Connecting the new healthcare team
The future of American health care could be summed up in one word — “connection.” To thrive in a fast-reforming healthcare system that demands better patient outcomes at a lower cost, pharmacies, physicians, hospitals, health systems, outpatient clinicians and diagnosticians are going to have to connect much more effectively, both with one another and with the patients they serve.
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This move to coordinated care is critically important to the nation’s overburdened and overly costly health system. “A growing body of evidence suggests that when physicians, nurses, pharmacists and other healthcare professionals work collaboratively, better health outcomes are achieved,” said Steve Anderson, president and CEO of the National Association of Chain Drug Stores. To that end, he said pharmacists are “partnering with healthcare providers work ing in nearby health systems and hospitals, serving as part of care teams to help improve patient health and outcomes.”
The nation’s pharmacy providers are helping to drive the change. Wielding advanced automation and data systems, they’re working hard to align their pharmacists’ patient-care and disease-prevention activities with the overall clinical efforts of hospital systems, physician groups and other health providers. In the process, they’re helping to build a new team-based, patient-focused model of coordinated community care.
“Integrated delivery models and team care are the wave of the future, and the way to ultimately control healthcare costs and deliver better care,” said Robert Thompson, recently retired EVP of pharmacy for Rite Aid. “We’re trying to have a broad range of capabilities to participate in that environment.”
In a growing number of stores and regions, “Rite Aid pharmacists and specially trained care coaches, located in Rite Aid pharmacies, work with the physician and patient on an ongoing basis to improve the patient’s overall health and self-management abilities. The care team members collaborate with the patient to establish health goals, eliminate barriers and create a personalized healthcare action plan in coordination with the patient’s physician,” noted a company spokesperson.
Through the company’s Health Alliance program, local and regional health systems are beginning to embrace the idea by enlisting Rite Aid stores in a network of extended care for post-discharge patients with chronic conditions, Thompson said.
“It takes a village,” added Jocelyn Konrad, Rite Aid’s current EVP of pharmacy. “We want to collaborate, whether it’s with other health professionals, employees, health plans — whatever that may be. We want to be part of that solution.”
Linking ‘the healthcare ecosystem’
This new health delivery paradigm is about being “a more integrated part of the healthcare ecosystem,” noted Brad Fluegel, SVP and chief strategy and business development officer for Walgreens Boots Alliance. “Across the spectrum, we’re trying to figure out how to help stitch together various parts of the healthcare system to deliver a better experience for the patients.”
“A lot of what we’ve been doing as we talk with health systems, health plans and others is making sure that we can connect our process and our data with theirs, so that we can help improve adherence rates, close gaps in care that patients might be experiencing and use our digital health tools to create incentives for patients and consumers to take better care of themselves and remain adherent,” Fluegel added.
Richard Ashworth, president of Walgreens pharmacy and retail operations, said the goal “is to leverage the assets that Walgreens brings — including our locational advantage and our core pharmacy capabilities — and to put those together with our other adjunct healthcare services … in partnerships with local health systems.”
Ashworth called those partnerships “one of the strategic pillars for our healthcare strategy.” And hospital-based health systems, he added, are “the crux of where care is really delivered, which is in the community, by hospitals and health systems and physicians.”
To that end, Walgreens and other pharmacy providers are positioning themselves as the community-based health resource for patients after their discharge from the hospital. It’s about extending and completing the web of patient care beyond the hospital or physician practice setting in a new “collaborative services model,” Ashworth said. “This means we take the assets we have and the infrastructure we have, and work together with the local health system to better coordinate care.”
Connecting the dots in health care can involve every aspect of a pharmacy organization. CVS Health, for instance, joined with the Department of Health and Human Services last year in a partnership involving both its pharmacies and its more than 1,100 MinuteClinic in-store clinics. The goal: To promote an online information resource for Americans that “provides recommendations from government-recognized clinical experts for the personalized preventive services patients should receive based on their age and gender,” according to the company.
“Many of these recommended preventive services are conveniently delivered at MinuteClinic, where we can coordinate with a patient’s primary care physician,” said Andrew Sussman, associate chief medical officer for CVS Health and MinuteClinic president and EVP.
This team-based, coordinated network of care will require advanced automation to capture and share patient data and electronic health records in systems that protect patients’ privacy, while still allowing all the members of their healthcare team — doctors, hospitals, clinicians and pharmacists — to share the information needed to make the best informed decisions on their behalf.
Pharmacies have been ahead of the automation and data-capture curve for decades. Their leadership in automated health information began with integrated pharmacy dispensing systems that link all stores within a pharmacy chain on a common information and record-keeping platform. And the rollout of electronic prescribing over the past 15 years strengthened those data connections, forging new links between pharmacies, prescribing physicians, health systems, health plan care coordinators and pharmacy benefit managers in a continuum of care.
All these connections are forging “a more connected and collaborative healthcare system with a technology-neutral platform that exchanges vast amounts of data across a disparate range of health technology systems,” said Tom Skelton, CEO of e-prescribing platform provider Surescripts.
“There is no question that healthcare is going digital,” said Skelton. “Providers … are sharing critical information to coordinate patient care. Just as we’ve witnessed continued growth in e-prescribing, so too have we seen the complexity of the healthcare system multiply, while patients and providers demand easier access to health information.”
Syncing monthly prescription refills to boost adherence, outcomes
With medication nonadherence leading to enormous health complications for millions of Americans — and generating staggering and needless cost spikes that add as much as $290 billion a year to the nation’s healthcare costs — the search for ways to get patients to take their prescription medicines as directed has become increasingly urgent.
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One of the most promising breakthroughs to boost adherence rates has been medication synchronization. Simply put, med sync refers to the process by which a chain or independent pharmacy will give their patients the option of converting all their maintenance prescription refills each month to a single, once-a-month dispensing and pickup cycle.
Syncing up all a patient’s prescriptions has become a proven tool for boosting adherence rates by making the refill process that much simpler. But it also yields other benefits, by giving pharmacies the tools to analyze patient compliance rates and other data on their patients for health plan payers.
Importantly, the program also gives those patients the opportunity for periodic, appointment-based counseling sessions with their pharmacist when they come in every month or two for their regularly scheduled prescription refill pickup.
One early innovator in med sync was Minnesota-based drug chain Thrifty White, which has enrolled thousands of patients to its synchronized monthly prescription refill system. By doing so, the chain has shifted those patients to appointment-based pharmacy care.
The program makes it easier for patients to comply with their medication regimens, said Tim Weippert, EVP of pharmacy. But it’s also served as a platform for monthly, face-to-face meetings between patient and pharmacist ranging from “a basic consultation…up to a full medication therapy management session,” he explained.
Rite Aid’s med sync program, called One Trip Refills, gives patients the “added convenience” of “picking up multiple medications once a month,” a Rite Aid spokesperson explained. But it also “provides us with an opportunity to interact with our patients and have meaningful conversations about their medication regimen, overall health and their individual needs and wellness goals.”
Targeting better patient outcomes through care transitions, adherence
Here’s a fact that keeps health plan administrators and anyone else responsible for budgeting health costs awake at night: 1-in-5 hospital patients ends up back in the hospital within 30 days of their discharge. And the biggest factors pulling them back all have to do with medications — either through medication errors, nonadherence or adverse drug events.
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That’s according to the Centers for Medicare and Medicaid Services, which put the cost of those revolving-door readmissions at $25 billion or more a year. Other estimates peg the cost as high as $44 billion, according to physician Stephen Jencks, a health consultant and senior fellow at the Institute for Healthcare Improvement.
Many of those costly trips back to the hospital could be avoided, said Jencks and other health experts, if there were better systems in place for transitioning patients from the hospital to the home or long-term care center — and improved coordination of care between the hospital and a local safety net of health providers, including pharmacies, clinics and physician groups.
In recent years, a number of pharmacy companies, big and small, have stepped up to prove that theory correct, developing innovative partnerships with local hospitals and health systems, all built around one fairly simple idea: getting the community pharmacist more actively involved in a patient’s transition from the hospital to the home, and helping them understand the critical importance of taking their medications as their doctors have prescribed. The results to date have been impressive, driving down 30-day hospital readmission rates about 50% for patients who have been part of these programs.
Plenty of factors are fueling the push for more coordination between hospitals, community pharmacies and other health entities. Among them is the critical need among public and private health plan payers to curb the staggering costs of hospital care.
“High-cost hospital care … is a major driver of national health expenditures,” said Karen Utterback, VP of strategy and business development for McKesson’s Extended Care Solutions Group. “If you want to tame national health expenditures … you must lower inpatient hospitalization rates.”
Also driving the transitions-in-care movement are the health reform dictates spawned by the Affordable Care Act of 2010, including the focus on quality of care and the shift in payments by Medicare and Medicaid from fee-for-service to outcomes-based reimbursements.
“With value-based hospital payment penalties now in place for excessive 30-day readmission rates, and a call for improved care coordination by the Affordable Care Act, improved models of care are necessary,” noted the American Journal of Managed Care.
“The ACA added force to new payment models that reward outcomes and penalize poor performance, such as high rates of readmission and hospital-acquired conditions,” agreed PricewaterhouseCoopers in a 2015 report on new health trends. “The ACA fueled this trend. For providers, the law took steps to change how Medicare pays for care by offering financial incentives and penalties that encourage better care coordination, higher-quality outcomes and less fragmentation.”
Indeed, the White House is pushing for federal health reimbursement changes “that would put as much as half of what it spends on Medicare into alternative payment models by 2018,” PwC’s Health Research Institute reported.
That shift away from fee-for-service to outcomes-based payments to hospitals is accelerating their urgent drive to discharge patients back into the community care setting more quickly and spread the risk burden among a team of community-based provider partners.
Pharmacists ‘at core of transitional care’
The stampede toward a more seamless transition of care between the hospital and the home is right in line with what Paul Abramowitz, CEO of the American Society of Health-System Pharmacists, called the “continued movement toward quality and coordinated delivery of care.”
“Studies have demonstrated that successful coordination and management of transition of care services lower costs by positively impacting hospital read mission rates,” Abramowitz said. “When pharmacists are involved, access is increased, quality is improved and costs are reduced.”
Anne Burns, VP of professional affairs for the American Pharmacists Association, agreed with that assessment. “We’re moving to a value-based healthcare system where providers, hospitals and other organizations are going to be paid based on their ability to both generate positive outcomes and control costs,” Burns said. “New care delivery models, such as patient-centered medical homes, are expanding across the country. Pharmacists are increasingly being incorporated into these models as members of inter-professional healthcare teams that collaborate and better coordinate the care of their patients.”
Even at this late stage, however — more than two years after full implementation of the Affordable Care Act, and well into the quality-and outcomes-based health payment reforms mandated by the ACA for Medicare — not enough attention is being given to the potential contributions that community pharmacy can make to reducing the readmission rate for patients transitioning from hospital to home.
“Ineffective care transition processes lead to adverse events and higher hospital readmission rates and costs,” according to a report from the Joint Commission’s Center for Transforming Healthcare. “One study estimated that 80% of serious medical errors involve miscommunication during the hand-off between medical providers.”
However, the commission noted, “readmissions within 30 days of discharge can often be prevented by providing a safe and effective transition of care from the hospital to home or another setting.” And among the collaborative-care activities that can have “very positive effects on transitions,” its report added, is “medication reconciliation, with the involvement of pharmacists.”
NEHI, a national health policy institute, agreed. In a study, the group found that a large percentage of hospital readmissions are caused by medication-related adverse events. “Medication management is at the core of advanced discharge planning and transitional care,” the health policy group reported. “This reflects three realities: adverse events are a major cause of avoidable hospital readmissions; more post-discharge adverse events are related to drugs than other causes; and lack of adherence to medications prescribed at discharge has been shown to be a driver of post-discharge adverse drug [events].”
NEHI urged the creation of integrated, multi-disciplinary healthcare teams — including community pharmacists — to improve post-discharge patients’ health and lower hospitalization costs.
Improved medication adherence reduces hospital readmissions
Much of the flow of patients back into the hospital can be traced to medication nonadherence. “The lack of adherence — not taking medications, not taking the right medications or taking the right medications the wrong way — is estimated to be the cause of nearly one-third of readmissions of patients with chronic medical illnesses,” Utterback noted.
The nonadherence problem goes far beyond the post-discharge patient population, however. When patients fail to take their medicines as prescribed, or don’t even have their prescriptions filled in the first place, it shortens lives for thousands of Americans and generates enormous extra health costs each year.
Poor medication adherence results in $290 billion of avoidable costs in the healthcare system, according to NEHI. And the breakdown in a patient’s planned medication therapy often occurs right after the doctor writes a prescription; according to NACDS, “25% of patients fail to pick up their initial prescriptions, leading to poor outcomes and preventable complications.”
It’s a problem that goes right to the heart of community pharmacy’s core competencies. Boosting adherence levels — both among post-discharge patients and among the total population — is an increasingly critical focus for pharmacy providers.
Chain and independent pharmacies around the country are stepping up efforts to partner with local hospital groups and health systems in a massive campaign to create a long-term, post-discharge safety net for patients after their release from the hospital. National pharmacy providers, such as Walgreens, CVS Caremark, Rite Aid, Walmart and others, all have long-term initiatives in place to align with hospital systems and help patients transition back into the community, as do such regional players as Thrifty White and Hy-Vee.
Walgreens’ WellTransitions program, launched in 2012 in partnership with local hospital systems in several markets, has shown solid results, yielding a 46% reduction in unplanned hospital readmissions within 30 days of discharge for patients who were part of an outcomes study, according to the company.
And Rite Aid has grown its Health Alliance transition-of-care partnership, which involves collaboration between some of its stores and several health systems around the United States. The program is reducing readmissions and improving patient outcomes through the formation of closer working relationships between post-discharge patients, physicians and Rite Aid pharmacists, said a company official, and through a careful tracking of all pharmacist-patient interactions and results.
With support from their wholesaler partners, many independents also are forming post-discharge patient-care networks. “As our country moves to a value-based model that rewards better outcomes, it’s critical for community pharmacists to demonstrate and measure how they can drive medication adherence and improved health,” said Doug Hoey, CEO of the National Community Pharmacists Association.
To help drive the transitions-of-care movement, several pharmacy companies have partnered with leading healthcare organizations and universities to conduct major research efforts on the success of such programs, including:
- A collaboration between Walgreens and the University of Mississippi’s School of Pharmacy and Medical Center to examine the impact of pharmacist-provided medication management on hospital readmissions. The project involves 20 local Walgreens pharmacies and the Mississippi division of Medicaid.
- A study of how pharmacists’ interventions and continuous care can reduce hospital readmissions among high-risk patients in Pennsylvania. Participants include Geisinger Health System, Weis Markets, Medicine Shoppe and Medicap pharmacies and Wilkes University College of Pharmacy and Nursing.
- An analysis of the impact of integrating electronic health information with pharmacist-provided medication management following a patient’s discharge from the hospital in several counties in Ohio. Partners include 45 Kroger pharmacies, the University of Cincinnati’s James L. Winkle College of Pharmacy, UC Health West Chester Hospital, Mercy Health Hospitals and the Greater Cincinnati Health Council.
- A study of emerging healthcare models — and their impact on patient outcomes — involves Thrifty White Pharmacy, Walgreens, the University of Iowa, University of Nebraska Medical Center, North Dakota State University, Blue Cross Blue Shield and OutcomesMTM.