Community pharmacists possess an untapped potential for ensuring medication safety in the home, but their involvement is generally limited in most communities. The following excerpt from the IHI report, No Place Like Home: Advancing the Safety of Care in the Home, presents a collaborative initiative that partners pharmacists with providers to improve patient safety.
Background of the Problem
Medication safety issues represent a significant patient safety concern in the home setting, especially among patients with complex medication regimens for chronic illness. Community pharmacists, who interact frequently with these patients when they pick up their prescriptions, have the expertise to detect and address drug therapy problems and potential adverse drug events and therefore can be an important safeguard against medication safety events in the home. Historically, however, community pharmacists have generally had a limited role in coordinating care and ensuring patient safety.
Description of the Program
Community Care of North Carolina (CCNC), a patient-centered medical home partnership that serves the entire state of North Carolina, launched a Community Pharmacy Enhanced Services Network (CPESN® Network) in 2015 through a Health Care Innovation Award Round Two from the Center for Medicare & Medicaid Innovation. CCNC care management patients visit a community pharmacy an average of 35 times each year (compared with only three visits to a primary care provider). The CPESN approach brings together an extensive network of community pharmacies that provide enhanced medication management services to patients with complex medical and behavioral health needs. The services go beyond the traditional community pharmacy model of dispensing medications. The goal of CPESN is to increase care coordination with CCNC health care providers and thereby improve medication safety and patient outcomes.
The program includes these components:
Close collaboration of community pharmacists with CCNC care managers and other health care staff, who refer patients to CPESN pharmacies and collaborate with CPESN pharmacists to address patients’ medical, social, behavioral, and medication safety–related needs.
In-depth patient assessments are conducted by specially trained CPESN pharmacists in the community pharmacy or home setting to identify medication safety issues and barriers to care or medication adherence.
Enhanced medication management services, such as home delivery or programs to support medication synchronization (filling all prescriptions at the same time each month), are designed to promote medication adherence and safety. An electronic pharmacist care plan that uses Health Level-7 (HL7) standards has a uniform framework for communicating electronic health information and contains information about a patient’s medication regimen and the pharmacist’s recommendations in a form that can be shared with other health care team members.
There is a per member per month (PMPM) value-based payment model to CPESN-participating pharmacists based on patient adherence and risk-adjusted cost and utilization outcomes.
How the Program Works
CPESN pharmacies serve Medicaid and Medicare beneficiaries who have at least one chronic health condition. CPESN pharmacies identify eligible patients through referrals from CCNC health care providers or care coordinators, as well as through analysis of Medicaid and Children’s Health Insurance Program (CHIP) claims data.
After a patient is deemed eligible for CPESN support, a specially trained CPESN pharmacist conducts an initial in-depth, 60- to 90-minute assessment with the patient. The pharmacist may use laboratory, medical, and pharmacy claims data to review the patient’s health conditions and medications. The assessment focuses on identifying drug therapy problems, medication side effects, adverse events, and barriers to medication adherence. Assessments occur in person at the CPESN pharmacy, by telephone, or in the patient’s home.
Based on the assessment, the pharmacist works with the patient and, as relevant, CCNC staff to address any medical, social, behavioral, and medication safety–related needs. Possible steps may include enhanced medication management services, such as home delivery of medications or support for medication synchronization. Pharmacists may also work with CCNC staff to adjust medication regimens, develop strategies to support patient self-management, or refer the patient for behavioral health services or other home- or community-based services.
After the initial assessment, the CPESN pharmacist follows up with the patient at regular intervals (typically ranging from monthly to quarterly) on an ongoing basis, based on patient need. These follow-up assessments provide an opportunity to evaluate new medication safety problems and check on the status of previously addressed issues.
CPESN pharmacists document all findings from their initial and follow-up assessments in an electronic pharmacist care plan. The care plan is either made available via the CCNC electronic community health record or embedded in the workflow of the eight vendor systems commonly used by CPESN pharmacies. The care plan uses existing HL7 standards, thus facilitating integration with the electronic medical records used by other health care providers. The care plan details the patient’s medication regimen, the patient’s health concerns (including drug therapy problems and medication support needs), and the pharmacist’s recommendations and interventions.
Pharmacists receive a PMPM payment for their services under a value-based payment model developed specifically for CPESN pharmacies. The payment model adjusts PMPM payments based on performance on three Medicare Star adherence measures (antihypertensive, diabetes, and statin medications), as well as three risk-adjusted outcomes: total cost of care, inpatient hospitalizations, and emergency department visits. PMPM payments are contingent on pharmacists completing the electronic care plan.
Nationwide, 38 other networks representing 35 states have replicated the CCNC CPESN Network model.
CCNC has successfully scaled the CPESN model across North Carolina, a geographically and demographically diverse state. As of August 2017, the CCNC CPESN Network consisted of 227 pharmacies, which had collectively provided enhanced medication services to roughly 15,000 individuals. The program has served patients with a wide range of complex health conditions, demonstrated the feasibility of electronically exchanging information between pharmacists and other providers, and shown preliminary evidence of improved patient medication adherence.
Evidence includes the following:
ccording to an independent analysis of CPESN participants at baseline, more than 70 percent were Medicare-Medicaid dual-eligible, signifying a high level of social need. Moreover, CPESN participants had poorer health status and greater need for care than the general Medicare fee-for-service population. Finally, CPESN participants had higher expenditures, rates of acute care hospitalizations, and rates of outpatient emergency department visits relative to national and North Carolina averages for Medicare fee-for-service beneficiaries.
According to unpublished data from CCNC, CPESN pharmacists had exchanged more than 20,000 care plans with health care providers and payers as of June 2017.5
According to unpublished data from CCNC, baseline results showed 4 to 5 percent higher medication adherence rates (based on proportion of days covered greater than 80 percent) among patients served by CPESN pharmacies, compared with patients served by non-CPESN pharmacies.
To read other case studies and learn more about improving patient safety in the home, please download the No Place Like Home: Advancing the Safety of Care in the Home report.