University of Southern California (USC) pharmacist Steven Chen is confident that data from a nearly completed multimillion-dollar project will definitively show that clinical pharmacy services are cost-effective and improve patient outcomes.
“It’s practice-transforming,” Chen, chair of the USC School of Pharmacy’s Titus Family Department of Clinical Pharmacy and Pharmacoeconomics and Policy, said of the $12-million Centers for Medicare and Medicaid Services (CMS)–funded project’s findings.
Chen said the project demonstrated that clinical pharmacy services in the primary care setting led to marked reductions in mortality and 30-day hospital readmission rates among medically complex patients.
“Our readmissions data shows that you reap the benefits within six months,” Chen noted.
For patients with uncontrolled hypertension, early data presented by USC indicate that, access to clinical pharmacy services led to sustained average decreases of about 15 mm Hg in both systolic and diastolic blood pressure levels. Clinical pharmacy care also resulted in an average drop of about 20 percentage points in the proportion of patients whose glycosylated hemoglobin level exceeded 35% and a nearly equal increase in the proportion whose glycosylated hemoglobin level was less than 7%.
Chen said the clinical pharmacists were “very aggressive” with hypertension treatment and follow-up and had most patients at goal after two visits. For patients with conditions like diabetes or asthma, which require considerable self-management, reaching treatment goals generally took longer, he said.
Chen said he and his colleagues are now preparing their findings for publication.
The project was funded through a CMS Innovation Center grant [see August 1, 2013, AJHP News] and involved a collaboration between USC and AltaMed Health Services Corporation’s network of federally qualified health centers. These clinics serve an economically disadvantaged, largely Latino and nonelderly population in Southern California.
The CMS funding allowed 10 USC clinical pharmacy teams to provide comprehensive medication management (CMM) services to patients at the participating clinics.
Chen said that during the three-year grant period, clinical pharmacy teams identified more than 67,000 medication-related problems affecting 6000 AltaMed patients who were considered to be at high risk for poor health outcomes.
The most frequent intervention performed by the pharmacy teams was changing drug dosages or dosing intervals. Other common interventions included adding new medications to the treatment plan, ordering laboratory tests, discontinuing medications, and substituting medications.
Each team consisted of a clinical pharmacist, a pharmacy resident, and a clinical pharmacy technician.
“We thought this would give us the best yield for the money, and it did seem that that was the case,” Chen said.
All of the clinical pharmacy technicians spoke Spanish fluently and had completed training at one of three schools in the state that feature a standardized CMM curriculum created for the CMS-funded program.
In the primary care clinics, Chen said, the technicians were responsible for “the basic stuff,” such as working with patients to reconcile medication lists for later review by the pharmacist. The technicians used data from electronic health records to identify appropriate patients and enroll them in the program after consulting with the pharmacist.
“They also managed the patient assistance programs, and they checked in with patients every two months after they finished reaching treatment goals,” Chen said. He said these check-in contacts were critical for helping patients stay on track with their medication plan and determining whether they needed to return to the clinic for more help.
“By doing this, we were able to show that our improvement measures persisted,” Chen said.
He said that the tasks performed by the technicians, at roughly a third of a pharmacist’s salary, contributed to a 50% increase in average daily patient visits scheduled at the clinics.
“There’s a lot of excitement about utilizing technicians in this capacity,” Chen said. “All of our techs got jobs after the grant ended. And even during the grant, we had some great techs stolen from us.”
Chen said patients were selected for clinical pharmacy services on the basis of dozens of “triggers” involving prescribing data, laboratory test results, patient demographics, vital signs, and other characteristics that, when combined, “suggest gaps in medication-related quality or safety.”
Through a collaborative practice arrangement, the pharmacy teams were able to able to enroll each patient without first obtaining approval from a primary care provider (PCP).
“We thought we’d get some pushback, but the PCPs are so thankful that we’re taking these challenging patients and helping them,” Chen said. Within two months of the program’s start, he said, referrals from clinic physicians became the largest source of patient enrollment.
Chen said that although some published study results indicate that clinical pharmacy services give a positive return on investment and improve outcomes, much of that research hasn’t been very rigorous.
What’s missing, he said, are validated metrics for the assessment of comprehensive medication therapy management, including ways to quantify drug-related problems and how those problems are resolved.
The USC–AltaMed project compared a propensity score–matched set of patients who received clinical pharmacy services with patients who didn’t have access to those services. Chen said the study was designed and conducted with input from a USC health economist.
“It gives . . . a very accurate picture of the impact of clinical pharmacy on costs, on healthcare quality, on safety, on access and everything else,” Chen said of the study design.
The study also featured a telepharmacy component for some small clinics in the AltaMed network. That portion of the study is being continued through a nine-month extension period with leftover funding from the original grant. Chen said the findings from the telepharmacy project have been positive so far.
“We’re able to show, through patient surveys and data, that patients didn’t perceive it to be any different than in-person care. They were very comfortable with telehealth. And the outcomes achieved were right on par with what we did in person,” Chen said.
Sahar Ataii Dagher, the lead pharmacist for clinical pharmacy video telehealth services, said the technology is “a great way to extend the role of pharmacists” in primary care clinics.
Dagher said that before launching the telepharmacy service, she visited each clinic for several days to establish a personal relationship with the staff and work out the technical kinks for the service.
Once the service was established, patients would be seen by a clinic-based clinical pharmacy technician or medical assistant who was hired specifically for the telepharmacy program. That person performed medication reconciliation and any necessary point-of-care testing before bringing up Dagher on the video screen for her portion of the appointment.
Dagher said the clinic-based technician or medical assistant serves as her hands during the appointments and can help her examine medication bottles or perform other needed tasks.
She said that the office staff, as well as the patients, interact with and respond to her as if she were physically in the clinic.
“They would actually walk into the room and talk to me through the video as if I was sitting there,” Dagher said. “They felt comfortable enough that if they knew a patient was in there that they wanted to talk to me about, they would come in; and that happened quite often.”
Dagher said she expects USC to continue to provide telepharmacy services in clinic settings after the grant support ends. “It has been shown to be very effective,” she said.
The USC research team recently reported to the California Department of Public Health that preliminary data on the overall project indicate that pharmacy services generated a positive return on investment.
Martin Serota, chief medical officer for AltaMed, likewise said preliminary data show that the clinical pharmacy teams “improved patient satisfaction, provider satisfaction, clinical outcomes, and total costs of care.”
But he said AltaMed has had to make changes to the care delivery model now that the federal funding has ended.
“Unfortunately, in California, you can’t be reimbursed for clinical pharmacists’ services—at least not yet. So it’s not a financially sustainable model, even though it was an effective model,” he said.
Serota said AltaMed is now using nurse practitioners and physician assistants for face-to-face CMM interventions performed under the supervision of the clinics’ medical director or a clinical pharmacist. He described the nonpharmacist midlevel practitioners’ services as “revenue-generating” for the clinics, in contrast to care provided by clinical pharmacists.
He said the midlevel providers care for high-risk patients with diabetes, hypertension, and dyslipidemia and use “pretty much the same protocol [and] the same treatment algorithms that the clinical pharmacists had followed.”
A bill under consideration by California’s legislature would require Medi-Cal to cover CMM services by pharmacists and primary care physicians (see story).
If Medi-Cal does provide a reimbursement mechanism for clinical pharmacy services, Serota said, AltaMed would include pharmacists in its expansion of the CMM care model.
But he said the modified model appears to be working so far.
“Anything you do to provide special attention to this population seems to have an effect,” he said.