Population health has always seemed like a unicorn to me. Every day I witness exactly what is required to positively impact outcomes for patients with chronic conditions.
There is no silver bullet, no patient portal, no app, no EMR system that will ever be more valuable than a familiar, caring voice asking how you are doing, how your medications are working, if you are taking your medications as prescribed and identifying barriers to medication access and adherence.
I can tell you with certainty that population health begins with a population of one: the one patient you are caring for at any given moment. It is not easy. Patients require a significant amount of handholding between physician visits to remain adherent to their complex medication regimens, in order to reduce the likelihood of becoming acute, to avoid going to the ER or being readmitted. At Curant Health we provide this kind of care because we know it is what's required to improve outcomes and lives. In addition, we provide care like this because it gives providers a documented view of what happens during those 360 plus days of the year the patient is not seen in the provider's office.
The role of the pharmacist is evolving in the team-based approach to medical care. Pharmacists are arguably the most under-utilized resource available to providers, and pharmacists have the highest capability to improve access to care, patient engagement, medication compliance, patient outcomes and to reduce overall healthcare spending at the same time. The pharmacist's ability to improve a hospital's overall performance and reduce Medicare readmissions rate penalties is also very real.
Access to care - increase time per patient interaction, remove clinical administrative burdens
Physicians have less time than ever to spend with patients. According to a study published in The Journal of General Internal Medicine, physician interaction with a patient lasts only eight minutes. The physician time crunch will get worse, as the Affordable Care Act continues to increase coverage access to millions of Americans. The effects of this time shortage are amplified for people suffering from chronic disease states, as they require significant explanation and care to fully understand their conditions and multiple medication therapies.
Outcomes for chronically ill patients suffer when those patients don't follow their prescribed therapies, and the adherence rates for this group are astonishingly low. According to Medication Adherence In America, a study conducted by the National Community Pharmacists Association (NCPA), Americans with chronic medical conditions received a mean grade of C+ on medication adherence; that means they averaged between 1 and 2 non-adherent behaviors in the past year. Even worse, 31% of the 1020 patients studied received a D or F, meaning they were almost entirely non-compliant with their prescribed therapies.
As physicians are forced to squeeze more patient visits into the day, clinical pharmacists serve as supplemental educators and counselors for patients. Internal research conducted by Vickie Andros, PharmD, Director of Clinical Services for Curant Health, revealed our clinical pharmacists spend 21 minutes with patients per interaction. This is more than double the average time physicians spend with their patients as highlighted by the study published in The Journal of General Internal Medicine.
Medication therapy management (MTM), when done in a thoughtful, comprehensive manner, is a powerful tool that directly engages patients to improve medication adherence. While conducting medication therapy management, clinical pharmacists spend time discussing medication issues and protocols with patients. These value-rich interactions, include discovery and patient education, identify previously unknown patient lifestyle factors, form closer relationships with pharmacy staff and lead to better medication adherence, improved outcomes, improved lives and lower overall cost of care.
The role of the pharmacist is also expanding into administered screening tests, wellness programs, vaccinations and educational events. These services are not only a convenience to patients, but also expand clinical reach beyond the traditional definition of "provider resources." More and more pharmacists are trained to take on specialized roles, as seen by the number trained to deliver vaccinations, up from 40,000 to 150,000 between 2007 and 2011. At Curant Health we are also cultivating the next class of pharmacists who will carry the load on prior authorizations to the benefit of all concerned. Their in-house management of the process from start through appeal means provider partners are able to focus on providing patient care. The clinical expertise of these pharmacists serves to expedite the complete approval process. This arsenal of knowledge and experience needed for successful completion of increasingly complex prior authorization requirements removes a critical barrier to patients' access to care.
Improving education and expanding the care team reach
Sending a chronically ill patient home with multiple new prescriptions expecting them to self manage and be adherent to their therapy has proven ineffective. The New England Healthcare Institute estimates that non-adherence to prescribed medication costs the U.S. health care system $290 billion each year. During the JP Morgan Healthcare Conference, one pharmaceutical manufacturer told my colleague Marc O'Connor that adherence to oral oncological therapies is 40%. In other words, 60% of even cancer patients are non-adherent to their treatments.
Studies also show that between 42-82% of patients have at least one discrepancy between discharge medications and those being taken prior to admission. One study highlighted that 10% of those discrepancies were serious.(1-6) There is an obvious opportunity for clinical pharmacists to provide additional patient education within these transition phases.
Moreover, about one-third of people over age 65 who take five or more medications experience some sort of adverse drug event, such as a bone-breaking fall, disorientation, inability to urinate or heart failure. Outpatient clinical pharmacists performing comprehensive MTM often resolve medication issues which may lead to non-adherence, possibly preventing catastrophic events such as these.
Pharmacists are among the most accessible members of a patient's care team. They are trained to educate patients and possess pharmacological expertise that most prescribers do not. Clinical pharmacists trained as experts in medication therapy management devote patient-focused time to address medication-related issues and optimize medication therapy.
The minimum level of patient engagement required to improve adherence levels
Medication adherence outside of the controlled environment of the hospital is an issue. Medication possession ratio (MPR) is one commonly accepted metric on adherence, but it only tells part of the story. The minimum required next step is: "You got your prescription filled. Now let's make sure you take your medication as prescribed."
Chronically ill patients, especially the sickest of the sick, need at least one dedicated care team member to provide frequent, sustained medication support and adherence counseling in order to ensure the patient's multiple medications work effectively and realize their full value.
The proof of value in your pharmacist teams: improving adherence to improve outcomes - including reducing hospital readmissions.
It is not easy, but in real world scenarios MTM and clinical pharmacists have proven effective in moving both components of the value equation, outcomes and costs, in the corresponding right directions. Pharmacists' services have demonstrated a reduction in hospital readmissions by 86% in one-quartile of a Medicare population(7). In a study we conducted with Purdue University and home care provider Amedisys, of 895 participants, 232 (26 percent) were considered to be in the "risk level 1" quartile for hospital readmittance. Hospital readmissions were reduced by 86 percent among this population who received medication therapy management through Curant Health within a 30-day period. Put another way, the group receiving MTM was three times more likely to remain out of the hospital after 60 days.
In a cohort of HIV patients on highly active antiretroviral therapy (HAART), consistent patient outreach to ensure adherence, along with customized prescription packaging improved adherence by 28% and patients demonstrating 95% adherence improved 69%. The result of which increased the number of patients whose viral loads are undetectable from 28% to 66% and whose overall healthcare costs decreased by $3,000 per patient per year.(8)
As hospital and healthcare leaders across the country continue to advance the shift away from fee-for-service to value-based care, the capabilities and value of clinical pharmacists supported by patient care coordinators should be leveraged by those in positions to do so. Moving forward, healthcare leaders should consider the proper use, engagement and role of accountability for each provider type (including clinical pharmacists) and ask, "Are all available resources being tapped to positively affect the outcomes and cost variables in the healthcare value quotient?" More specifically, "How do we collectively improve patients' quality of life by improving medication adherence?" When those things happen, quality of life and outcomes go up while waste goes down.
About the author
Patrick Dunham is Co-Founder and CEO of Curant Health. Founded in 2000, Curant Health treats tens of thousands of chronically ill patients throughout the United States every year through its enhanced medication therapy management protocols and supports its provider partners with its award-winning EHR, MedPlan™.
Footnotes
1. Moore C, Wisnivesky J, Williams S et al. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003; 18:646-51.
2. Schnipper JL, Kirwin JL, Cotugno MC et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006; 166:565-71.
3. Duggan C, Feldman R, Hough J et al. Reducing adverse prescribing discrepancies following hospital discharge. Int J Pharm Pract. 1998; 6:77-82.
4. Dickerson A, MacKinnon NJ, Roberts N et al. Drug-therapy problems, inconsistencies and omissions identified during a medication reconciliation and seamless care service. Healthc Q. 2005; 8 (Spec No):65-72.
5. Foss S, Schmidt JR, Andersen T et al. Congruence on medication between patients and physicians involved in patient course. Eur J Clin Pharmacol. 2004; 59:841-7.
6. Paquette-Lamontagne N, McLean WM, Besse L et al. Evaluation of a new integrated discharge prescription form. Ann Pharmacother. 2001; 35:953-8.
7. "A Randomized, Controlled Pragmatic Trial of Telephonic Medication Therapy Management to Reduce Hospitalization in Home Health Patients," Health Services Research, Volume 49, Issue 5, October 2014
8. "Effects of a Pharmacy-Care Program on Adherence and Outcomes," American Journal of Pharmacy Benefits, January/February 2012
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