Any primary care practice can tell you the impact of adverse drug events (ADEs), but few can suggest how to reduce their $3.5 billion annual cost to the nation. One practice in Bloomington, however, enhanced the team-based patient-centered medical home (PCMH) model, improving medication management and patient health – and growing closer to the triple aim.
IU Health Southern Indiana Physicians added a key health professional to the PCMH: a pharmacist.
Regional Director of Pharmacy Michael Melby, MS, FASHP, IU Health South Central Region and CEO, HealthLINC, explained, ”If we proved our role to be indispensable in that office, we would be asked to serve on the team in future expansions of the model.”
Early in 2011, Melby loaned Jennifer Reiter, PharmD, an inpatient clinical pharmacist, to the ambulatory care setting at Southern Indiana Physicians for one year. She is still there, and two more co-located ambulatory clinical pharmacists were added since then. Their services to prevent ADEs, reduce ED visits and deliver drug therapy and chronic disease management netted $329,000 in revenue and savings during the first-year pilot – a three to one return on investment (ROI).
On sharing these results, Melby said, “I have presented the idea of community meds management to employers, administrators, payers, providers, TPAs and entrepreneurs. The idea meets with uniform positivity.”
Here’s how it works
Adverse drug events (ADEs) are a serious problem.
- 82% of American adults take at least one medication and 29% take five or more.
- 700,000 ED visits and 120,000 hospitalizations annually are due to ADEs.
- $3.5 billion is spent annually on the extra medical costs of ADEs.
- At least 40% of the costs of ambulatory ADEs are estimated to be preventable.
Source: Centers for Disease Control and Prevention
“We don’t dispense medications but serve like a consultant to the patients,” said Reiter. She reconciles medications a patient may have at home with new inpatient and outpatient prescriptions, identifies problems on admission and follows up after discharge, leaving messages for the physician.
“We call patients and see them when they visit the office, discussing their medications and checking with them when medications change,” Reiter explained. While diabetes patients, for example, see physicians every three months, the pharmacists see or talk to them every two-to-four weeks.
“We review their medications and glucose readings,” Reiter said. “If medications need changing or dosage adjusted, we make those modifications.” Hemoglobin A1C levels are down at the practice, and patients say the care is the best they’ve ever received. Cholesterol readings and vaccination rates also improved.
“Jennifer is an integral and essential part of our clinic and my daily practice. She provides follow-up that is challenging for a physician in a busy practice. I have made it a habit to refer all my patient's with HgbA1C greater than 8 percent to her,” said MacKenzie Lupov, MD. She recently helped one patient improve HgbA1C from 18.5 to 6.1 percent in four months.
The role of technology
Community medication management has succeeded elsewhere in the country. Community Care of North Carolina (CCNC) received an innovation grant in 2013 to expand and determine if its model could help accomplish the triple aim outside the state. CCNC visited 40 communities and chose Bloomington for its expansion, largely because of the success already documented by Reiter and others.
HealthLINC, Bloomington’s health information exchange, a partnership with HealthBridge, is critically involved, allowing practices and hospitals to send data to CCNC and helping caregivers coordinate their work. HealthLINC offers electronic alerts so ambulatory caregivers know when their patients visit the ED or are admitted.
Looking to the future
As the transformation of health care continues, many believe this model will become the norm. “Pharmacists are uniquely qualified to have a significant positive impact on the triple aim. Many physicians have already welcomed pharmacy to the care team and would not now practice any other way,” said Melby.
He noted many things have been tried to mitigate the ADE issue. So the promise of something that actually works meets with very little resistance.
Dr. Lupov said, “The future of medicine is really to make the primary care office more patient-centric, and Jennifer (Reiter) has helped us take a big step in that direction.”
Both agree pharmacists must partner with physicians in all high-risk transfer of care settings to ensure medication therapy is safe and effective. “Patients continue to experience too many problems with medication therapy for it to go any other way,” Melby concluded.
See more about the one-year pilot here.