Challenges and Solutions for Successful Integration of Pharmacy Services: What Lessons can be Learned from Integrated Behavioral Health? Casey E. Gallimore, PharmD Associate Professor, University of Wisconsin-Madison School of Pharmacy Kent A. Corso, PsyD, BCBA-D President, NCR Behavioral Health, LLC; Adjunct Faculty, Uniformed Services University Health Sciences/Department of Family Medicine Session # F7 CFHA 19 th Annual Conference October 19-21, 2017 • Houston, Texas
Transcript
Challenges and Solutions for Successful Integration of Pharmacy Services: What Lessons can be Learned from Integrated Behavioral Health?
Casey E. Gallimore, PharmD
Associate Professor, University of Wisconsin-Madison School of Pharmacy
Kent A. Corso, PsyD, BCBA-D
President, NCR Behavioral Health, LLC; Adjunct Faculty, Uniformed Services University Health Sciences/Department of Family Medicine
Faculty DisclosureDr. Corso has had a potentially relevant financial relationship
during the past 12 months of the following type:
Book Royalties:
Integrating Behavioral Health into the Medical Home Greenbranch Publishing2016
Conference Resources
Slides and handouts shared in advance by our Conference Presenters are available on the CFHA website at http://www.cfha.net/?page=Resources_2017
Slides and handouts are also available on the mobile app.
Learning Objectives
At the conclusion of this session, the participant will be able to:
• Describe how integration of behavioral health and pharmacy services within Medical Homes can support this model, consistent with the Quadruple Aim.
• Identify potential challenges to successful interdisciplinary integration of both behavioral health and pharmacy within the Medical Home.
• Develop solutions that overcome common barriers and facilitate successful and meaningful integration of interdisciplinary services within the Medical Home.
1. Ferrante JM, Balasubramanian B, Hudson SV, Crabtree BF. Principles of the Patient-Centered PCMH and preventive services. Annals of Family Medicine. 2010; 8:108-116
2. Crogan TW, Brown JD. Integrating mental health treatment into the patient centered PCMH. AHRQ Publication No. 10-0084-EF. Rockville, MD: Agency for Healthcare Research and Quality; 2010.
3. Ramalho de Oliveira D, Brummel AR, Miller DB. Medication therapy management: 10 years of experience in a large integrated health care system. J Manag Care Pharm. 2010;16:185-195.
4. Isetts BJ, Schondelmeyer SW, Artz MB, et al. Clinical and economic outcomes of medication therapy management services: the Minnesota experience. J Am Pharm Assoc. 2008;48:203-211.
5. Isetts BJ, Brummel AR, Ramalho de Oliveira D, Moen DW. Managing drug-related morbidity and mortality in the patient-centered PCMH. Med Care. 2012;50:997-1001.
6. Goldstone LW, DiPaula BA, Caballero J, et al. Improving medication-related outcomes for patients with psychiatric and neurologic disorders: value of psychiatric pharmacists as part of the health care team. Ment Health Clin. 2015;5:1-28.
Bibliography / Reference
7. Cobb CD. Optimizing medication use with a pharmacists-provided comprehensive medication management service for patients with psychiatric disorders. Pharmacotherapy. 2014;34:1336-1340.
8. Kozminski M, Busby R, Somma McGivney M, et al. Pharmacist integration into the PCMH: qualitative analysis. J Am Pharm Assoc. 2011;51:173-183.
10.Corso KA, Gage D. Nurses and psychologists advancing the Patient-Centered Medical Home model. Nursing Administration Quarterly. 2016; 40 (3): 192–201. DOI: 10.1097/NAQ.0000000000000176.
11.Scharf DM, Eberhart NK, Hackbarth NS, Horvitz-Lennon M, Beckman R., Han B et al., Evaluation of the SAMHSA primary and behavioral health care integration (PIBHCI) grant program. 2014: The RAND Corporation; Washington D.C.
Bibliography / Reference
Learning Assessment
A learning assessment is required for CE credit.
A question and answer period will be conducted
at the end of this presentation.
Patient-Centered Medical Home (PCMH)
▪Primary care model of healthcare reform
▪Integral component of the Patient Protection and Affordable Care Act (2010)
▪Supported by both the National Committee for Quality Assurance (NCQA) and the Agency for Healthcare Research and Quality (AHRQ)
▪Aims to boost quality, accessibility, and efficiency of primary care by increasing availability of services while managing costs1
Background
▪The PCMH model regards integrated behavioral healthcare (IBH) as critical for reaching its goals (IBH is required for PCMH recognition by NCQA)2
▪Although similar endorsements have not been made for other health specialties, there is an appetite for specialties beyond IBH in Medical Homes
▪Effective workflow models do not exist to direct how other specialties should be embedded in the PCMH along with IBH
▪With the current trend of increasing multiple specialties into the Medical Home, it can be challenging to develop effective workflow models, train patients and staff to use the services and avoid confusion, silos or duplication of efforts
Pharmacy Role in Medical Homes
▪Pharmacists are trained in principles of patient-centered, team-based medication management:▪ Collect S/O information necessary to understand medication history and clinical status of
the patient
▪ Assess information to understand clinical effects of the medication regimen in conjunction with patient’s overall health goals; identify and prioritize problems
▪ Develop patient-centered care Plan in collaboration with patient/care giver and other team members that is evidence-based and cost effective
▪ Implement care plan in collaboration with other team members and the patient/caregiver
▪ Follow-up on safety and effectiveness of care plan
▪Pharmacists may complete post-graduation training to specialize in areas such as ambulatory care or psychiatric pharmacy (residency and/or board certification)
Pharmacy Role in Medical Homes
▪Opportunity for pharmacy roles within the PCMH supporting safe, evidence-based and cost-effective medication use▪ Commonality of medication prescription in primary care
▪Studies of collaborative medication management (CMM) between pharmacists and primary care providers (PCPs):▪ Co-management of chronic conditions (diabetes, dyslipidemia, and hypertension)
▪ Associated with improved clinical outcomes, positive ROI; and reduced healthcare expenditures related to hospitalizations, physician time, and prescription costs 3-5
▪ Psychiatric pharmacist, PCP and patient co-management of psychotropic regimens
▪ Associated with increased adherence rates, patient medication knowledge and cost savings; positive ROI; and decreased adverse effects and polypharmacy 6,7
Pharmacy Role in Medical Homes
▪Problem: Few resources exist to assist practice managers in developing effective workflow models when pharmacists and other specialties are embedded in the PCMH
▪Opportunity: Examination of current pharmacist roles in primary care and how these can be applied and leveraged alongside IBH to benefit providers and patients
▪Goal: Identification of potential challenges and solutions for practice managers and other clinic leaders to integrate pharmacy and IBH into the PCMH in a manner that avoids confusion, silos or duplication of efforts while supporting pursuit of the Quadruple Aim
Challenges of Integration
▪Failed initiatives and poor integration can be fiscally costly and negatively impact the patient experience and morale of the care team
▪Proactively identifying and addressing potential challenges is vital to successful integration of a new specialty in the Medical Home:
▪ Workflow and logistics
▪ Establishing new professional relationships
▪ Under- or overutilization of the service
▪ Identification of qualified candidates
▪ Fiscal sustainability
▪ Ensuring a positive patient experience
Workflow and Logistics: Challenges
▪Pharmacy integration will likely involve incorporation onto established behavioral health teams and within existing models of care
▪Successful workflow models must compliment, not impede existing clinic processes to avoid decreased efficiency, negative impacts on patient care and provider, staff and patient frustration
▪Concern over complicating or slowing clinic workflow has been cited as one barrier to more extensive pharmacist integration into primary care practices, and should therefore be discussed prior to integration8
▪Have pharmacists shadow other integrated clinicians who are already established in the clinic, to gain an understanding of the opportunities for healthcare enhancement
▪Identify specific program goals (measurable, evidence-based, defined)
▪Identify outcome and process metrics to evaluate the program
Workflow and Logistics: Solutions
▪Conduct educational/feedback sessions to facilitate understanding of competencies, roles and responsibilities of all team members
▪Establish clear processes for workflow
▪Train all staff (i.e., pharmacists, other integrated clinicians, nurses, PCPs and administrative staff)
▪Focus on CQI: Build-in and conduct regular program evaluation
▪Refine workflow processes as necessary
Establishing Relationships: Challenges▪Team-based aspect of PCMH produces an interprofessional melting pot for education, training, and practice among previously “siloed” disciplines
▪Effective team-based care is dependent on effective interprofessionalclearly defined roles and responsibilities, mutual respect and shared values, and understanding the principles of teamwork and team dynamics9
▪The success of PCMH relies on effective communication, coordination and collaboration10
▪A growth curve exists for newly interacting and collaborating health professions
Establishing Relationships: SolutionsGoal: iterative approach to program development that re-shapes the culture to embrace and truly practice team-based care
▪Encourage open dialogue with clinicians about their interests in pharmacists and IBH to help develop and define clear roles and responsibilities for all team members
▪Perform a staff needs assessment to help refine roles and responsibilities and design a program the team needs
▪Provide ongoing training for all PCMH team members
▪Educate patients about the role of all team members in the PCMH via written materials, website references and standard introductory scripts
Establishing Relationships: Solutions
▪Facilitate interactions between team-members by positioning pharmacist workspace in a central location where patient care occurs (i.e. within the staffing room of a family medicine clinic)
▪Schedule pharmacists to present topic discussions at clinic meetings and in-services
▪Appoint pharmacists to quality improvement initiatives
▪Train pharmacists to proactively engage clinic personnel when opportunities arise to facilitate patient care
▪Work closely with clinical and administrative leadership to develop integrated programs that are economical and sustainable
Utilization of Services: Challenges
▪To realize benefits of pharmacy team members, processes must be created to ensure pharmacists are utilized frequently and appropriately
▪Under- or overutilization of services can result in poor productivity and program outcomes, patient and provider frustration, and poor cost efficiency
▪Program underutilization and poor standardization in treatment delivery model has been cited as a common challenge across federally-funded IBH integration programs, and the same should be anticipated for pharmacy service integration11
Utilization of Services: Solutions
Goal: include pharmacists in PCMH menu of services in manner that adds value via increased revenue, decreased/offset costs, prevention of high-risk patient incidents, improved clinical outcomes
▪Create multiple conduits between the pharmacist, other team members and the patient population (i.e. direct and indirect patient care roles)
▪Identify specific clinical criteria which will define the precise use of pharmacy resources (i.e., sole provider program for pain; medication reconciliation from inpatient and outpatient primary care)
Utilization of Services: Solutions
▪Ensure pharmacy clinicians are visible and available to team members
▪Encourage pharmacy team members to be proactive in identifying opportunities for intervention
▪Establish productivity goals for pharmacists, incentivizing patient contacts which are shared (co-treatment) and which are independent
▪Reward high performance and de-incentivize poor performance
ID of Qualified Candidates: Challenges
▪Hiring and training are important prerequisites to successful integration and effective workflow
▪Pharmacists, similar to other healthcare professionals, may vary in their abilities and goodness-of-fit to operate in a team-based primary care environment for several reasons:▪ Post-graduation training or job experience
▪ Comfort with and interest in mental health care
▪ Individual personality attributes
▪An individual who is a poor fit within the PCMH model may lead to stalled integration, poor utilization, wasted funding and lost confidence of team members
ID of Qualified Candidates: Solutions
Goal: identification of pharmacists qualified for integrated care roles
▪Target recruitment efforts at pharmacists who possess skill set that matches needs of integrated care team and clinic patient population:▪ Specialty training in psychotropic medication management (focus on
mental health care)
▪ Generalist training in ambulatory care for holistic approach to medication management (focus on range of chronic conditions)
▪Require residency training or comparable experience practicing in a dynamic and team-based environment as a minimum requirement
▪In small practices, identify mentors from other practices
ID of Qualified Candidates: Solutions▪In larger practices, consider developing a training program whereby pharmacists may train with an expert you’ve hired (e.g., practica, internship)
▪Interview to assess for personal attributes that are conducive to PCMH environment:
▪ Flexibility and adaptability
▪ Self-directedness
▪ Solid communication skills
▪ Experience/success working in teams
▪ Working knowledge of medical homes/primary care settings
Fiscal Sustainability: Challenges
▪Reimbursement mechanisms vary across health specialties, health care settings, and locations
▪Unclear and un-standardized productivity requirements for fiscal sustainability for certain health specialties
▪Lack of established payment systems for pharmacists in primary care:▪ Pharmacists are not recognized as providers under the Centers for Medicare and
Medicaid Services (CMS)
▪ Most federal and private payers do not include pharmacist services in their payment systems
▪ Reimbursement avenues for pharmacy services vary across states, practice settings, organizational structures and payers
Fiscal Sustainability: Solutions
Goal: develop specific business cases and pro forma that result in cost-effective integrated pharmacy services
▪When determining ROI for pharmacists and other integrated clinicians consider alternative measures in addition to direct revenue:
▪ Quality of care provided▪ Patient safety and risk management▪ Provider satisfaction and burn-out▪ Cost offset and cost savings
Fiscal Sustainability: Solutions
▪Research state/local reimbursement avenues for pharmacy services
▪ Utilize CMM or MTM billing codes for complex patients▪ Utilize the “incident to” model (can be used in physician’s offices with a
payers to inquire about reimbursement options for pharmacy services)▪ Research and apply for grant money for pilot programs or demonstration
projects▪ Collaborate with academic centers (pharmacist faculty, pharmacy
residents/students)
Patient Experience: Challenges
▪Integrating a new specialty such as pharmacy into the Medical Home can result in a poor experience if patient perspective is not considered
▪Sudden involvement of a new team member may result in confusion or mistrust for some patients
▪Frustration may occur if patient visit times are lengthened or if they are asked to attend more clinic visits when a new specialty is added to the team
Patient Experience: Solutions
Goal: ensure a positive experience is preserved when new specialties are integrated into the Medical Home
▪Evaluate impact of integrating pharmacists at the patient level by developing patient advisory panel▪ Identification of program goals related to a positive patient experience
▪ Development of patient educational materials about pharmacist team members
▪Facilitate co-treatment between team members (i.e. pharmacist and BHC or PCP)
▪Publish and disseminate patient education materials about using new services and collaborative patient care methods
Case Study
▪Scenario: ABC Clinic is a certified Patient Centered Medical Home that has elected to integrate clinical pharmacy services alongside behavioral health services. They are currently in the early stages of integration planning.
▪Goal: Review the profile of ABC Clinic and provide recommendations on how to successfully integrate pharmacy services by considering and preemptively addressing potential challenges.
Conclusions▪Integration of both pharmacy and BH within the Medical Home can facilitate achievement of the Quadruple Aim
▪While challenges to successful integration do exist, anticipating potential barriers and proactively developing a plan can minimize obstacles – we can learn from the challenges IBH has encountered over the years
▪Eventual development of a unifying model that defines exact roles and responsibilities of pharmacists within the PCMH alongside BH could yield consensus in strategies for successful integration of pharmacy services
