Pharmacy Partnership to Improve Patient Outcomes Minnesota Rural Health Conference Session 2B Ryan M. Harden, MD MS Kendra Metz, Pharm D Sarah Nelson, MD June 25, 2018
Involved Partners
Involved Partners Kendra Metz, PharmD Thrifty White Pharmacy Ryan Harden, MD Medical Director, Gateway Family Health Clinic Assistant Professor University of MN Medical School Duluth Campus Sarah Nelson, MD Clinical Consultant, Healthy Northland Laura Palombi, PharmD, MPH Assistant Professor, University of MN Duluth College of Pharmacy
Objectives Describe development of interdisciplinary process Recognize involvement of EMR and workflows in referral/communication Describe outcomes and satisfaction through increased Medication Therapy Management (MTM) Describe ripple effect of partnership on improving patient care
Healthy Northland Collaboration of the Carlton, Cook, Lake, St Louis and Aitkin, Itasca, Koochiching Community Health Boards Community Wellness Grant - funding from CDC and MDH to prevent Obesity, Diabetes, Heart Disease and Stroke. Pharmacist as a team member in patient care and Bidirectional referral for MTM services
Carlton County Rural county just south of Duluth Population 35,500-41 people per square mile 13.7% below poverty line 17% over 65 5% Native American Indians - Fond du Lac reservation in the county Higher prevalence of chronic diseases than MN state average including HTN, heart disease, diabetes, tobacco use and obesity. Mental health issues and opioid addiction are major issues in the county
Carlton County Optimal health affected by rural health disparities and social determinants of health transportation fewer providers health conditions more serious by time diagnosed low income access to healthy food and places to be active Many people have multiple comorbidities requiring multiple medications
Project Overview Community Wellness Grant Project Goals: Bidirectional referral process for MTM (Medication Therapy Management) Improve patient outcomes - including, but not limited to DM and HTN
Thrifty White Pharmacy
Thrifty White Services Advancing community pharmacy through outcomesdriven strategy RxMedSync delivers adherence scores exceeding industry averages *Ateb "Med Sync Analysis December 2014" *Thrifty White 2016 RxMedSync Analysis. Time frame: 1/1/1616 12/31/16
2018 MedSync Study Study published by Harvard Medical School and Brigham and Women s Hospital Tracked 23,000 Medicare beneficiaries from 2011-2014 Evaluated Adherence, CV events, and resource use Key Outcomes 3% overall adherence improvement 9% decrease in hospitalization and emergency department visits 3% decrease in outpatient visits $26-42 billion annual cost savings *Medication Synchronization Programs Improve Adherence to Cardiovascular Medications and Healthcare Use. Journal of Health Affairs, January 2018
Keeping Our Community Healthy Immunizations Influenza, Pneumonia, Tetanus, Shingles, Hepatitis Health Screening Cholesterol, A1C, Blood Pressure Medicare Assistance Specialty Services accredited by three agencies licensed in all 50 states
Medication Therapy Management Drug Therapy Problems Unnecessary drug therapy Additional drug therapy required Drug therapy not effective Dosage too low Drug is causing an adverse reaction Dose too high Patient not willing or able to take therapy as directed
Clinical and economic outcomes of medication therapy management services: The Minnesota experience 285 intervention patients (MTM) 637 drug therapy problems resolved goals of therapy achieved increased from 76% to 90% Compared with control (no MTM) HEDIS improved HTN 71% vs 59% Cholesterol management 52% vs 30% Total health expenditures decreased per person J Am Pharm Assoc. 2008;48:203 211.doi: 10.1331/JAPhA.2008.07108
The Minnesota experience Patients receiving face-to-face MTM services provided by pharmacists in collaboration with prescribers experienced improved clinical outcomes and lower total health expenditures. J Am Pharm Assoc. 2008;48:203 211.doi: 10.1331/JAPhA.2008.07108
Patient Perspective of MTM Patient-perceived value of Medication Therapy Management (MTM) services: a series of focus groups collaboration of healthcare team resource for questions and education accessibility to the MTM pharmacist financial incentives for participation http://z.umn.edu/innovations 2012, Vol. 3, No. 4
Provider Perspectives of MTM Primary Care Providers experiences with Pharmaceutical Care-based Medication Therapy Management Services part of our team approach source of education for the patient and provider preventative health http://z.umn.edu/innovations 2012, Vol. 3, No. 1
Local Collaboration
Gateway Clinic Independent Primary Care Clinic 14 physicians, 5 mid-level providers Founded 1972 3 locations Moose Lake, MN Sandstone, MN Hinckley, MN
Interdisciplinary Care Team approach Pharmacy Physical Therapy Occupational Therapy Social Services Nursing
Interdisciplinary Care (continued) Pharmacy Immunizations Teaching Information on prescriptions Medication Therapy Management
The Problem Poor patient adherence No formal referral process to access pharmacy services Lack of follow-up for MTM
Barriers to Implementing MTM Referral Process Lack of staff time at Gateway Clinic Difficulties in configuring EMR Educating providers and nursing staff
Solution Designed bidirectional referral process to access pharmacy services Specifically MTM Built referral into Electronic Medical Record (EMR) - work around Educated providers at Monthly Group Practice Management Meetings
Electronic Medical Record EMR allows for referrals to providers or specialties Unable to refer to Pharmacy Thrifty White Pharmacy referral built into EMR as a provider
PHYSICIAN GENERATES CLINIC NOTE..
..ENTERS ASSESSMENT and PLAN
THIS SCREEN IS UNDER TREATMENT
GENERATES OUTGOING REFERRAL
REASON FOR REFERRAL
IT DEPARTMENT ADDED THRIFTY WHITE PHARMACY AS PROVIDER
SELECT THIS PROVIDER
ENTER NOTES TO PHARMACY SEND REFERRAL
ASSIGN TO RN
Referral generated RN prints off referral Patient takes referral to pharmacy to set up appointment for MTM Patient attends appointment for MTM Pharmacist documents MTM Prints off results of MTM Faxes results to clinic Results go into Physician Inbox/Pharmacy Folder
PHARMACY folder was added under CONSULT NOTES folder
Results Physician needs to sign off on MTM MTM results searchable in patient chart
Evaluation of process Many patients are still getting informal referrals Not all physicians referring for MTM Patient adherence concerns
Reasons for limited results Too many clicks to generate referral Informal referrals Many referrals weren t completed (requires patient action)
Solutions Simplification of referral process in EMR Notify Pharmacy of referrals (fax directly to pharmacy)
It made a difference to that one! Gateway Physician MTM referral 12/16 46 yo M LC History of heart surgery, depression Weight 395 BMI 46.7 Smoker A1c>14%, Trig 1,435, BP 160/78 Blurry vision, neuropathy, dental pain Perceived health poor
Medications pre and post MTM Medications Pre MTM Metformin 850 mg qd Lyrica 225 mg BID Zolpidem 10 mg qhs Duloxetine 60 mg BID Clonazepam 1 mg TID ASA 81 mg Nitro 0.4 mg SL prn Mg 400 mg Medication changes with MTM Metformin 1000 mg BID Victoza 0.6 mg, titrated to 1.8 mg daily - with training Atorvastatin 40 mg qd Lisinopril 10 mg daily Furosemide 20 mg BID Glucose testing TID Also enrolled in MedSync
1 month later Pt reports 100% compliance Average glucose 230 from 480 Working on smoking cessation Follow up MTM visit results: recommend add SGLT2 (Invokana 100 mg added 1-12-17) increase statin start bupropion (Bupropion SR 150 mg BID 1-11-17) Pharmacy provided immunizations (Tdap and Pneumovax)
4 months later LC perceives health as fair Improved vision and urinary frequency Depression improved Smoking only 2 cigarettes per day A1c 8.7% (14%) LDL 40 Trig 281(1,435) BP 120/80 (160/78) BMI 46 (46.7)
Clinic Pharmacy Partnership Has increased referrals between Gateway Clinic Sandstone and Thrifty White Sandstone Has resulted in Collaborative Practice Agreement Has resulted in the development of a Naloxone Protocol
Future plans with this project Present results to Group Practice Management Encourage formal referral process Send referrals to pharmacy directly to contact patient
Future collaborations Continue Collaborative Practice Agreement Naloxone Protocol Other projects as needs arise
Presenter Contact Information Ryan M. Harden, MD MS rharden@d.umn.edu Kendra Metz, Pharm D p754@thriftywhite.com Sarah Nelson, MD sarah@silvercliff.net
This is the end. Jim Morrison