From Iowa to Asheville and Back: An Accountable Care Perspective from the Trenches

New care team models are springing up across the country.

To address calls to improve the coordination of chronic care, new models for multidisciplinary care teams continue to be evaluated in areas across the country. One approach, accountable care organizations (ACOs), involves bringing doctors, hospitals, and other care providers together to deliver coordinated high-quality care to a panel of patients (eg, Medicare beneficiaries). Given the importance of medication therapy in the management of chronic conditions, pharmacists can be key members of the ACO care team. Given the typical geographic dispersion of an ACO’s patient population, community pharmacists are well-positioned to deliver services, such as medication therapy management (MTM), to address medication nonadherence and other medication issues at the time around hospital discharge and other transitions through the health care system.

This concept of team-based care isn’t new. Pharmacist-based care programs such as The Asheville Project have been referenced as innovative mechanisms to ensure quality patient care at reduced costs. As our profession moves onward with efforts to achieve provider status, the services that pharmacists provide will continue to be evidence for achieving the “triple aim” of improving the patient experience of care, improving the health of populations, and reducing the per capita cost of health care.

As a pharmacist who received training in Iowa followed by a residency in North Carolina, I have been fortunate to experience the commitment of our profession to successful implementation and integration of pharmacist services across the continuum of care into various models of care, including an ACO. Most recently, the Iowa Pharmacy Association (IPA), along with key partners at OutcomesMTM and the University of Iowa, with generous support by the McKesson Corporation, Community Pharmacy Foundation, and the National Association of Chain Drug Stores Foundation, have played an integral part in engaging community pharmacy in discussions on innovative practice models across Iowa. Since 2011, IPA has been working extensively with UnityPoint Health, the nation’s 13th-largest nonprofit health system, to integrate pharmacist services within its ACO model. IPA has coordinated meetings with UnityPoint Health executives and ACO implementation teams throughout 2011 and 2012. These meetings provided IPA staff with the opportunity to gauge initial interest in the inclusion of community pharmacists within their Pioneer ACO application. These meetings progressed over time to become opportunities to develop and help shape the model for community pharmacists within their Pioneer ACO centered in Fort Dodge, Iowa.

On December 19, 2011, UnityPoint Health—Fort Dodge was named one of the CMS-awarded Pioneer ACOs, covering an 8-county region in north central Iowa, including Trinity Regional Medical Center and Trimark Physicians Group. IPA’s collaboration with additional pharmacy stakeholders and partners at UnityPoint Health will study the effects of MTM services delivered in tandem by community pharmacists and health-system pharmacists in an integrated MTM program within the Pioneer ACO.

Twenty-eight community pharmacies throughout the rural 8-county region have agreed to participate in this project. The model developed by UnityPoint Health and IPA provides MTM services by utilizing both community pharmacists and ACO clinical pharmacists so that the MTM services will: (1) be coordinated by the ACO’s clinical pharmacists, (2) include a post—hospital discharge medication reconciliation MTM service for targeted patients, and (3) include follow-up MTM services to address ongoing drug therapy problems (eg, nonadherence) for older adult patients living in the community. The ACO believes that this mix of MTM services will reduce hospitalizations, hospital readmissions, emergency department (ED) visits, and per capita costs through a 2-year study period. Specific objectives of this project and evaluation are:

(1) Assess the effects of an integrated MTM program for ACO patients on all-cause hospitalization rates.

(2) Assess the effects of an integrated MTM program for ACO patients on 30-day hospital readmission rates.

(3) Evaluate the impact of an integrated MTM program on the incidence of adverse drug events that result in ED visits for ACO patients.

(4) Assess the effect of an integrated MTM program on per capita Part A and B Medicare costs for ACO patients.

(5) Characterize the types and frequencies of drug-related problems identified and resolved by the pharmacist-delivered MTM services for ACO patients.

This research is significant for our profession because it will study an integrated MTM program that coordinates services delivered by community pharmacists and clinical pharmacists within a Pioneer ACO. Findings from this study can be used by policy makers and other stakeholders for utilizing community pharmacists within the ACO model. Community pharmacists and pharmacies offer important access points for patients needing MTM services, especially older adults. This study is innovative in that it involves a Pioneer ACO and community pharmacies that serve a rural population. Patients in rural areas have unique access needs because the ACO hospital and physicians may be far away and fewer medical specialists may be available compared with metro areas. The integrated MTM program studied here will provide a test of how well community pharmacists can complement the MTM services being delivered by ACO personnel. If successful, this approach can provide evidence to support a helpful expansion of access to MTM services for ACO members and other ACOs in development.

Patient-Centered Care Team and Patient Population

As evidenced by the new analysis by Avalere Health, pharmacist services are improving care, and these services are aligning with the changing health care environment. From the earlier efforts of the Asheville Project, patient-centered care can have an impact, allowing for new roles for pharmacists to contribute to the improvement of quality and the reduction of costs and other health care services. Within an ACO model, overall coordination of MTM services can be completed by a pharmacist. For example, in complex cases, patients needing medication reconciliation after a hospital stay are likely to have questions about topics such as which medications to stop as they transition to managing their medication at home. A community pharmacist typically has a relationship with the patient that can support the discussions needed to ensure a smooth postdischarge transition. Similarly, community pharmacists are a good choice for addressing medication nonadherence, which tends to be multifaceted and persistent. That is, it typically takes multiple MTM visits to successfully overcome nonadherence. Often, patients will need to change their behaviors, and continued support from the community pharmacist would help toward behavior change. Through coordinated efforts with pharmacists across the continuum of care, MTM services can be a bridge across our profession to build the patient-centered care team.

A variety of MTM services can be available to ACO patients who have been identified through their screening processes to receive them. These include: (1) pharmacy consults for newly diagnosed chronic conditions, (2) peri-discharge medication reconciliation, and (3) ongoing medication management for chronic conditions (eg, nonadherence). Pharmacy consults for new chronic conditions should be patient education focused on the role of medications in managing the new condition. Peri-discharge medication reconciliation could either occur prior to discharge (ACO clinical pharmacist) or after the patient has returned home (community pharmacist), depending on pharmacist availability and patient factors. Ongoing medication management for chronic conditions will be conducted by community pharmacists to address ongoing drug therapy problems, such as medication nonadherence.

Each of the MTM services conducted by a pharmacist could include a medication therapy review, subsequent intervention and/or referral, documentation, and follow-up as needed. Some of the reviews will be targeted at specific medications, while other MTM services will address all of a patient’s medications (eg, medication reconciliation). The pharmacist’s intervention could involve solely the patient (eg, nonadherence), or a prescriber, or both depending on the problem(s) to be addressed. It is likely that some drug-related problems will require multiple follow-up MTM visits to be resolved, such as medication nonadherence.

As our profession evolves from hallmark programs like the Asheville Project, we need to take the core lessons learned from these efforts moving forward for the well-being of our patients and our profession. We are all health care professionals. We need to work with other health care professionals to resolve the dangers in our health care system. Through effective communication and by understanding where each health profession can make its best impact, we can achieve the “triple aim” as established by the Institute for Healthcare Improvement.

As pharmacists, we each bring a unique perspective to our profession. I encourage each pharmacist and student pharmacist I meet to pick their passion. Be the expert in an area of practice. However, that is not enough. Know your colleagues, and know what their passions are. As health care access points in our communities, we need to know the various resources available in the community in order to best take care of patients. That might mean contacting another pharmacy that has staff with expertise in an area of practice that is outside your comfort zone.

Finally, with any great idea comes ways to improve that initiative. As pharmacists participating in the Asheville Project, we continued to look for ways to improve the patient care experience through new services (eg, medication synchronization, collaborative practice agreements, coordinated care visits). With new payment and delivery models such as ACOs and Patient-Centered Medical Homes, pharmacists need to continue to be problem-solvers who look for a means to improve the system. For any program or service that you and your pharmacy provide, continue to look for methods to improve that service and experience for your patients.

Anthony Pudlo, PharmD, MBA, BCACP, is vice president of professional affairs at the Iowa Pharmacy Association. He is a part-time pharmacist at Hy-Vee. Dr. Pudlo served as regional clinical health manager at Kerr Health and as clinical coordinator at Kerr Drug. He earned his Doctor of Pharmacy and Master of Business Administration degrees from Drake University.