- Email: [email protected]
A pharmacist's contribution within a patient-centered medical home
EXPERIENCE
A pharmacist’s contribution within a patient-centered medical home Jamie L. McConaha, Gary W. Tedesco, Louis Civitarese, and Michele F. Hebda
Abstract Objectives: To evaluate the impact of a pharmacist embedded in a primary care physician (PCP) group practice to assist in achieving patient-centered medical home (PCMH) accreditation by increasing chronic care measures through the use of angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) medications in patients with concomitant diabetes mellitus (DM) and hypertension (HTN).
Jamie L. McConaha, PharmD, CGP, TTS, BCACP, CDE, Assistant Professor of Pharmacy Practice, Mylan School of Pharmacy, Duquesne University, Pittsburgh, PA Gary W. Tedesco, PharmD, Clinical Pharmacist, Medicare D Clinical Operations, CVS/Caremark, Pittsburgh, PA; at time of project completion, Academic Fellow, Mylan School of Pharmacy, Duquesne University, Pittsburgh, PA Louis Civitarese, DO, MMI, Physician, Preferred Primary Care Physicians, Carnegie, PA
Setting: PCP practice in Pittsburgh, PA. Practice description: 16 decentralized PCPs linked by electronic health record system. Practice innovation: An academically based pharmacist provided medication management services to the PCP group for patients with DM and HTN using criteria developed by the quality committee of the practice. Interventions: Using the electronic health records and inclusion criteria, a list of patients with concomitant DM and HTN and not currently taking ACEI or ARB medications was obtained. Patients were excluded based on predetermined criteria. Electronic messages were sent to PCPs responsible for the remaining patients. Results: Across the 16 participating office locations, 5,258 patients were diagnosed with DM and HTN. Of these, 4,304 were already being treated with an ACEI or ARB medication (81.9%). Of the remaining 954 patients, the pharmacist determined that 784 met at least one of the exclusion criteria (82.2%). Recommendations were sent for the remaining 170 patients, and the pharmacist received 150 responses (88.2%). Physicians agreed with the recommendation to initiate therapy in 82 patients (54.7%), and therapy was started in 56 of those patients (68.3%).
Michele F. Hebda, PharmD, TTS, Academic Fellow, Mylan School of Pharmacy, Duquesne University, Pittsburgh, PA Correspondence: Jamie L. McConaha, PharmD, Mylan School of Pharmacy, Duquesne University, 316 Bayer Learning Center, 600 Forbes Ave., Pittsburgh, PA 15282; [email protected] Disclosure: The authors declare no relevant conflicts of interest or financial relationships. Funding: The Mylan School of Pharmacy, Duquesne University, supported the development of the pharmacist practice with internal funding. Previous presentations: American Pharmacists Association Annual Meeting, Orlando, FL, March 29, 2014 Received June 13, 2014. Accepted for publication November 24, 2014. Published online in advance of print April 24, 2015.
Conclusion: This project showed the positive effect of a pharmacist in helping a PCP group address quality projects relating to PCMH accreditation and improvements in care that can affect Medicare star ratings. J Am Pharm Assoc. 2015;55:302–306. doi: 10.1331/JAPhA.2015.14119
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Journal of the American Pharmacists Association
patient-centered medical home
EXPERIENCE
T
he patient-centered medical home (PCMH) is a practice model that aims to make primary care comprehensive, patient centered, coordinated, team based, accessible, and focused on quality and safety.1 This model helps to ensure that the primary care physician (PCP) office is not the patient’s final destination, but rather the central location that facilitates patient-specific care. The PCMH is critical in achieving the Institute for Healthcare Improvement’s “Triple Aim,” which states that improvements to the health care system should strive for better care, better health, and lower costs.2 Major insurers are supporting the PCMH to control costs and improve patient outcomes and satisfaction. Additionally, federal health care reforms have pushed the concept of PCMH to a point where the health care system may begin to embrace and implement fully the PCMH model.3 The National Committee for Quality Assurance (NCQA) PCMH is a recognition program for improving primary care. This program, released in 2011 and revised in 2014, uses a set of standards to aid physicians and their teams in creating a practice that embodies PCMH. The NCQA PCMH 2011 includes six standards aligned with the core components of primary care. Each standard has a number of elements providing broad objectives for meeting the core components. Each element is then further delineated through more specific, measurable factors.4 To receive accreditation, a physician’s practice must reach a minimum score based on the “factors” of PCMH, which are contained within the standards and elements of the program. The patient–physician relationship is at the core of the PCMH model, but the physician is hard-pressed
Key Points Background: ❚❚
The National Committee for Quality Assurance requires that physician practices select, quantify, and improve upon chronic care measures to obtain patient-centered medical home accreditation.
❚❚
Initiating and maintaining patients with concomitant hypertension and diabetes on angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) therapy is one such chronic care measure that pharmacists can aid physician practices in meeting. Findings: ❚❚ The pharmacist’s efforts with this project opened communication between the physicians and pharmacists in this PCP practice, resulting in the addition of a pharmacist fellow position and future collaborative efforts.
Journal of the American Pharmacists Association
to meet the PCMH demands alone. The expanded services provided within a PCMH is most effective when delivered by a multidisciplinary team. PCMH standards focus on evidence-based care, and pharmacists are well positioned to make recommendations to the care team about the proper use of medications and the role of medications in disease management. With pharmacists included on the patient care team, numerous PCMHs have shown improvements in managing glycosylated hemoglobin, low density lipoprotein cholesterol, and blood pressure.5 Standard 6, Element A, Factor 2 of the 2011 NCQA accreditation guideline states that the practice must identify “at least three chronic or acute care clinical measures.” These clinical measures will become the primary foci of the practice with regard to the remaining accreditation criteria. Standard 6, Element C, Factor 1 further states the practice must “set goals and act to improve on at least three measures from Element A.”4 There are many ways pharmacists can be involved in improving chronic care measures for physician practices undergoing PCMH accreditation, including identifying patients eligible for pharmacotherapy according to evidence-based guidelines. One such set of guidelines, established by the American Diabetes Association (ADA), recommends that “pharmacological therapy for patients with diabetes and hypertension should be with a regimen that includes either an angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin receptor blocker (ARB).”6 However, the decision to start ACEI or ARB medication in patients with diabetes and hypertension must be patient-specific and guided by clinical judgment. Contraindications, precautions, intolerances, adverse drug reactions, patient preferences, comorbidities, and drug interactions may all confound the decision to initiate drug therapy. Pharmacists are in a prime position to help make clinical decisions such as adding one of these medications to a patient’s regimen.
Objective This project evaluated the impact of a pharmacist embedded in a PCP group practice to assist in achieving PCMH accreditation by increasing chronic care measures through the use of ACEI or ARB medication in patients with concomitant diabetes and hypertension.
Practice description This project took place in a large PCP group practice located in Pittsburgh, PA. The PCP practice employed 36 physicians in 19 practice locations and used an electronic health record (EHR) system. Of the 19 offices, 16 participated in this pilot project. Three offices were excluded because they were either new offices added after the project initiation or new to the EHR system. There were 63,554 full time patients in this PCP practice (defined as those who had an office visit in the last 2 years). j apha.org
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Of this number, 6,925 had a diagnosis of type I or type II diabetes mellitus (ICD-9 250) and 5,258 had diagnoses of both diabetes (DM) and hypertension (HTN; ICD-9 401). The project was completed by a pharmacist embedded in the PCP practice as part of the Academic Partners Program of the Mylan School of Pharmacy, Duquesne University. The Academic Partners Program, started in 2007, connects the resources of the school, including practice-based faculty, to the practice partner to improve the partner, patient, and organizational outcomes. This program also serves to enhance the school’s teaching, research, and service outcomes. Through this arrangement, the faculty clinician spends approximately 20 hours per week at the partner site engaging in clinical practice activities and teaching student pharmacists, residents, and fellows experientially. The pharmacist added to this particular PCP practice began on September 1, 2012, and was the group’s first and only pharmacist collaborator.
Practice innovation In fall 2012, three members of the medical group management team spearheaded the project of obtaining PCMH accreditation for the entire physician group practice. Based on the required NCQA PCMH elements, the management team provided suggestions for quality improvement projects to the practice’s quality committee. The quality committee was a physician-led steering committee that focused on developing quality improvement projects for the organization. The quality committee comprised six physicians, five managerial staff, and one ad hoc external physician who was a medical director from a neighboring hospital. One of the suggestions made to the quality committee by the PCMH steering group was to improve upon a Medicare star-rating measure the organization had struggled to meet: increasing the number of patients with DM and HTN treated with ACEI or ARB medication. The Centers for Medicare & Medicaid Services assigns an overall rating of 1 to 5 stars based on performance in nine quality measures. Contracts and quality bonus payments are awarded to physician practices for high and stable performance on these measures. By increasing the number of patients with DM and HTN treated with one of these medications, the PCP organization would improve its star rating, and also satisfy one of the 2011 NCQA PCMH accreditation criteria (Standard 6, Element C, Factor 1). The quality committee decided to prioritize the treatment of HTN in patients with DM. To accomplish this, the physicians suggested using a pharmacist on site. The pharmacist was asked to develop a proposal describing the method for identifying patients as appropriate candidates for ACEI or ARB treatment and providing recommendations to the physicians.
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Implementation This project was approved by the Duquesne University Institutional Review Board under an expedited review. To begin, the pharmacist presented a proposal, previously approved and endorsed by the quality committee, to the physicians and office managers at a monthly practice meeting. The pharmacist emphasized the importance of adhering to the quality measure of appropriate treatment of HTN in patients with DM for the attainment of PCMH accreditation. The pharmacist then asked the group for feedback on any exclusion criteria regarding patients perceived as inappropriate candidates for such treatment. The exclusion criteria resulting from this discussion included any documented drug allergy, intolerance, or previous adverse drug reaction to an ACEI or ARB medication, documented hyperkalemia on the most recent laboratory value (serum potassium level >5.0 mmol/L), age of 75 years or older, and a diagnosis of renal disease listed by the physician as an active problem. In addition, patients whose blood pressure was controlled (<130/80 mm Hg) with another antihypertensive medication with a compelling indication for treatment with that medication due to a cardiovascular comorbidity were excluded. Patients whose blood pressure was controlled by lifestyle measures alone without the presence of albuminuria were excluded. A consensus was reached among the physicians that the pharmacist would send patient recommendations using a “flag” or electronic communication within the EHR. Following this meeting, an EHR report containing a list of all patients with diagnoses of DM or HTN and not currently being treated with an ACEI or ARB medication was printed. The pharmacist, aided by student pharmacists, reviewed each patient chart to determine if the patient was an appropriate candidate for ACEI or ARB therapy. For those patients meeting inclusion criteria, a flag was sent to the physician. If the physician did not respond to this communication within 4 weeks, a reminder was sent for a total of 2 communications.
Documentation The pharmacist’s recommendations and physicians’ responses were documented in an Excel spreadsheet kept on a privacy-protected computer that complied with requirements of HIPAA, the Health Insurance Portability and Accountability Act. This spreadsheet included the patient medical record number, office location, presence of a documented allergy or intolerance to an ACEI or ARB, if the patient had previously taken an ACEI or ARB, presence of hyperkalemia or renal disease, blood pressure, and whether a recommendation had been made to the physician. The pharmacist documented reasons for patient exclusions as well as patient recommendations. The pharmacist followed the patient’s record in the EHR to determine if an ACEI or ARB was initiated or Journal of the American Pharmacists Association
patient-centered medical home
EXPERIENCE
documented the reason if the recommendation was not accepted. Dates of follow-up reminders and responses were documented.
Results The Duquesne pharmacist was added to the PCP practice on September 1, 2012, which coincided with the initial work of the PCMH steering committee. The pharmacist presented the project proposal at the January 2013 practice meeting and data collection began on February 1, 2013. The first round of physician recommendations was sent by July 30, 2013. Across the 16 participating office locations, 5,258 patients were diagnosed with DM and HTN. Of these, 4,304 were already being treated with an ACEI or ARB medication (81.9%), which left 954 patients with a concomitant diagnosis of DM and HTN not currently treated with an ACEI or ARB medication. Of these 954 patients, the pharmacist determined that 784 met at least one of the exclusion criteria (82.2%). Reasons for patient exclusion are listed in Table 1. For the remaining 170 patients, the pharmacist sent an electronic communication to the patient’s PCP for consideration. Of the 170 recommendations sent, the pharmacist received 150 responses (88.2%). Physicians agreed with the recommendation to initiate therapy in 82 patients (54.7%), and a note was placed in the chart as a reminder to discuss initiating therapy at the next office visit. Therapy was started in 56 of those patients (68.3%). Of the remaining 26 patients, 15 were pending until the patient’s next office visit, and 11 were not initiated because of several reasons including new hyperkalemia, transferred care, and patient refusal. Table 2 illustrates the reasons for which the PCP did not accept the pharmacist’s recommendations.
Evaluation Evaluation of the success of this project was determined not only through the practice’s achievement of PCMH accreditation, but more importantly from recognition by the quality committee of the pharmacist’s role in the practice. After the project was completed, the PCP practice was recognized by NCQA as a PCMH (i.e., the practice gained accredited PCMH status). Unfortunately, the practice did not obtain a sufficient number of points for the standard addressed to contribute to the accreditation status. While a small number of patients were started on ACEI or ARB medication, the exclusion criteria developed by the physician group resulted in many patients being disqualified from receiving ACEI or ARB medication intervention. Despite this, this project opened communications between the pharmacist and physicians in the PCP about other quality-improvement roles for the pharmacist (see “Barriers and opportunities” section). As this Journal of the American Pharmacists Association
Table 1. Reasons for patient exclusion from pharmacist review No. patients excluded Exclusion criteria (%; n = 784) Advanced age (75 years or older) 334 (43) Hypertension controlled with lifestyle measures alone and no albuminuria 108 (14) Hyperkalemia 69 (8.8) 65 (8.3) Othera Current beta-blocker treatment for comorbidity and blood pressure controlled 62 (7.9) Documented allergy or previous adverse drug reaction 60 (7.7) Patient already on an angiotensin converting enzyme inhibitor or angiotensin II receptor blocker medication 46 (5.9) Documented renal disease 40 (5.1) Some other reasons for patient exclusion included instances where the physician had already attempted to initiate therapy with these agents, the patient refused, the patient was currently taking a diuretic for edema and blood pressure was already controlled, patient was being treated for hypertension by a specialist, and the patient was no longer with the primary care practice.
a
Table 2. Physician reasons for not accepting pharmacist recommendations Reasons No. patients (%; n = 68) Blood pressure controlled by current medications and unwilling to change therapy/beta-blocker needed for comorbidity/blood pressure controlled by lifestyle measures alone 44 (65) Othera 8 (12) Previous adverse drug reaction not mentioned in problem list 4 (5.9) 3 (4.4) Challenging patientsb Hyperkalemia revealed through new laboratory results 3 (4.4) 2 (2.9) Agec Angiotensin converting enzyme inhibitor or angiotensin II receptor blocker medications initiated before receiving recommendations 2 (2.9) Renal disease discovered through new laboratory results 2 (2.9) Patient refusal, other more pressing conditions (such as cancer), cost, and smoker (medications worsen cough). b Prescribers did not accept the pharmacist’s recommendations in “challenging” patients. These could be patients who had other more pressing medical issues or who were too difficult to convince to try with these additional medications. c Although the pharmacist did not send recommendations for any patients older than 75 years, physicians chose not to accept the recommendations in two patients who were 74 years old and would be turning 75 within the next 6 months. a
project increased awareness of the pharmacist’s contributions to the PCP group practice, a full-time pharmacist fellow was added to the practice to assist the pharmacist in leading future quality improvement projects.
Discussion This project was initiated to help a PCP group practice j apha.org
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meet the PCMH accreditation factor of improving performance on a chronic care clinical measure. Specifically, the goal was to use the services of a clinical pharmacist to identify patients with DM and HTN eligible for treatment with ACEI or ARB medication who were not currently receiving such therapy. Only 17.8% of patients reviewed were determined by the pharmacist to be appropriate candidates for ACEI or ARB therapy. While the number of patients initiated on ACEI or ARB medication as a result of this project was not substantial enough to contribute to the PCMH accreditation scoring, the pharmacist-provided recommendations were clinically important to the providers and patients of the practice. Furthermore, the project shows that although third party payers measure the use of these medications as deemed appropriate by national clinical practice guidelines, appropriateness needs to be determined on a case-by-case basis. This study was conducted following release of the 2011 NCQA PCMH accreditation standards. A new set of guidelines was released in March 2014.7 Practices that had previously purchased the NCQA PCMH toolkit were required to submit their applications by March 30, 2015, to use the 2011 standards. The content addressed in the 2014 standards remains the same, making this project relevant to practices pursuing accreditation with the updated guidelines.
quires that the PCP practice provide information about new prescriptions to more than 80% of the patients, families, or caregivers.7 Through the pharmacist’s work on the treatment of HTN in patients with DM measure, the practice recognized that the pharmacist could be extremely useful in helping to meet this medication-related measure.
Barriers and opportunities
1. Defining the PCMH. Agency for Healthcare Quality and Research, U.S. Department of Health and Human Services. http:// pcmh.ahrq.gov/page/defining‐pcmh. Accessed January 21, 2014.
In an ideal PCMH setting, the pharmacist works alongside physicians and provides face-to-face clinical recommendations. But in a large, decentralized PCP practice such as this, it was not feasible for the one pharmacist, who also had academic obligations to the university, to be present physically in all 16 office locations. The solution to this barrier was to provide the pharmacist with remote EHR access. This allowed the pharmacist to review each patient chart and send recommendations from a central office location. Developing a trusting professional relationship with the physicians, however, was key to the success of this project and future projects. The pharmacist was able to accomplish this through attendance at monthly practice meetings, face-to-face project status updates to the quality committee, and actual time spent working in the PCP offices. As mentioned previously, this project resulted in later collaboration opportunities between the pharmacist, pharmacist fellow, and the physicians. One such project was the use of the pharmacist to help maintain the acquired PCMH accreditation through meeting Standard 4, Element C, Factor 3 of the 2014 PCMH update regarding medication management through the addition of a pharmacist telephonic intervention. This element re-
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Conclusion This project showed the positive effect of a pharmacist in helping a PCP group address quality projects relating to PCMH accreditation. While this practice has already achieved NCQA PCMH accreditation, this project is still being conducted for continuous quality improvement. Future reports will be used to identify new patients who may be candidates for treatment with ACEI or ARB medications. This endeavor, while conducted within an ambulatory PCP practice, could also be translated to practitioners in other care settings. The application integrating the pharmacist as a core team member of a PCMH and their ability to provide a comprehensive medication therapy review could be conducted remotely within any EHR system capable of electronic communication to the prescriber and further allow for other future PCMH standards to be met. References
2. Why the medical home works. Patient-Centered Primary Care Collaborative. http://www.pcpcc.org/content/why‐it‐works. Accessed January 27, 2014. 3. Nielsen M, Langner B, Zema C, et al. Benefits of implementing the primary care medical home: a review of cost and quality results. Patient-Centered Primary Care Collaborative. 2012. http:// www.pcpcc.org/guide/benefits‐implementing‐primary‐care‐ medical‐home. Accessed January 27, 2014. 4. Standards and guidelines for NCQA’s patient-centered medical home (PCMH) 2011. National Committee for Quality Assurance. 2011. http://www.coloradoafp.org/pdf/NCQA_2011_Standards. pdf. Accessed January 27, 2014. 5. Chisholm-Burns MA, Kim Lee J, Spivey CA, et al. US pharmacists’ effect as team members on patient care: systematic review and meta-analyses. Med Care. 2010;48(10):923–933. 6. Standards of medical care in diabetes—2013. American Diabetes Association. http://care.diabetesjournals.org/content/36/ Supplement_1/S11.full. Accessed January 27, 2014. 7. Patient Centered Medical Home (PCMH 2014) Standards Parts 1 & 2 Training. National Committee for Quality Assurance. 2014. http://www.ncqa.org/Programs/Recognition/RelevanttoAllRecognition/RecognitionTraining/PCMH2014Standards.aspx. Accessed August 30, 2014.
Journal of the American Pharmacists Association
A pharmacist’s contribution within a patient-centered medical home Jamie L. McConaha, Gary W. Tedesco, Louis Civitarese, and Michele F. Hebda
Abstract Objectives: To evaluate the impact of a pharmacist embedded in a primary care physician (PCP) group practice to assist in achieving patient-centered medical home (PCMH) accreditation by increasing chronic care measures through the use of angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) medications in patients with concomitant diabetes mellitus (DM) and hypertension (HTN).
Jamie L. McConaha, PharmD, CGP, TTS, BCACP, CDE, Assistant Professor of Pharmacy Practice, Mylan School of Pharmacy, Duquesne University, Pittsburgh, PA Gary W. Tedesco, PharmD, Clinical Pharmacist, Medicare D Clinical Operations, CVS/Caremark, Pittsburgh, PA; at time of project completion, Academic Fellow, Mylan School of Pharmacy, Duquesne University, Pittsburgh, PA Louis Civitarese, DO, MMI, Physician, Preferred Primary Care Physicians, Carnegie, PA
Setting: PCP practice in Pittsburgh, PA. Practice description: 16 decentralized PCPs linked by electronic health record system. Practice innovation: An academically based pharmacist provided medication management services to the PCP group for patients with DM and HTN using criteria developed by the quality committee of the practice. Interventions: Using the electronic health records and inclusion criteria, a list of patients with concomitant DM and HTN and not currently taking ACEI or ARB medications was obtained. Patients were excluded based on predetermined criteria. Electronic messages were sent to PCPs responsible for the remaining patients. Results: Across the 16 participating office locations, 5,258 patients were diagnosed with DM and HTN. Of these, 4,304 were already being treated with an ACEI or ARB medication (81.9%). Of the remaining 954 patients, the pharmacist determined that 784 met at least one of the exclusion criteria (82.2%). Recommendations were sent for the remaining 170 patients, and the pharmacist received 150 responses (88.2%). Physicians agreed with the recommendation to initiate therapy in 82 patients (54.7%), and therapy was started in 56 of those patients (68.3%).
Michele F. Hebda, PharmD, TTS, Academic Fellow, Mylan School of Pharmacy, Duquesne University, Pittsburgh, PA Correspondence: Jamie L. McConaha, PharmD, Mylan School of Pharmacy, Duquesne University, 316 Bayer Learning Center, 600 Forbes Ave., Pittsburgh, PA 15282; [email protected] Disclosure: The authors declare no relevant conflicts of interest or financial relationships. Funding: The Mylan School of Pharmacy, Duquesne University, supported the development of the pharmacist practice with internal funding. Previous presentations: American Pharmacists Association Annual Meeting, Orlando, FL, March 29, 2014 Received June 13, 2014. Accepted for publication November 24, 2014. Published online in advance of print April 24, 2015.
Conclusion: This project showed the positive effect of a pharmacist in helping a PCP group address quality projects relating to PCMH accreditation and improvements in care that can affect Medicare star ratings. J Am Pharm Assoc. 2015;55:302–306. doi: 10.1331/JAPhA.2015.14119
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Journal of the American Pharmacists Association
patient-centered medical home
EXPERIENCE
T
he patient-centered medical home (PCMH) is a practice model that aims to make primary care comprehensive, patient centered, coordinated, team based, accessible, and focused on quality and safety.1 This model helps to ensure that the primary care physician (PCP) office is not the patient’s final destination, but rather the central location that facilitates patient-specific care. The PCMH is critical in achieving the Institute for Healthcare Improvement’s “Triple Aim,” which states that improvements to the health care system should strive for better care, better health, and lower costs.2 Major insurers are supporting the PCMH to control costs and improve patient outcomes and satisfaction. Additionally, federal health care reforms have pushed the concept of PCMH to a point where the health care system may begin to embrace and implement fully the PCMH model.3 The National Committee for Quality Assurance (NCQA) PCMH is a recognition program for improving primary care. This program, released in 2011 and revised in 2014, uses a set of standards to aid physicians and their teams in creating a practice that embodies PCMH. The NCQA PCMH 2011 includes six standards aligned with the core components of primary care. Each standard has a number of elements providing broad objectives for meeting the core components. Each element is then further delineated through more specific, measurable factors.4 To receive accreditation, a physician’s practice must reach a minimum score based on the “factors” of PCMH, which are contained within the standards and elements of the program. The patient–physician relationship is at the core of the PCMH model, but the physician is hard-pressed
Key Points Background: ❚❚
The National Committee for Quality Assurance requires that physician practices select, quantify, and improve upon chronic care measures to obtain patient-centered medical home accreditation.
❚❚
Initiating and maintaining patients with concomitant hypertension and diabetes on angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) therapy is one such chronic care measure that pharmacists can aid physician practices in meeting. Findings: ❚❚ The pharmacist’s efforts with this project opened communication between the physicians and pharmacists in this PCP practice, resulting in the addition of a pharmacist fellow position and future collaborative efforts.
Journal of the American Pharmacists Association
to meet the PCMH demands alone. The expanded services provided within a PCMH is most effective when delivered by a multidisciplinary team. PCMH standards focus on evidence-based care, and pharmacists are well positioned to make recommendations to the care team about the proper use of medications and the role of medications in disease management. With pharmacists included on the patient care team, numerous PCMHs have shown improvements in managing glycosylated hemoglobin, low density lipoprotein cholesterol, and blood pressure.5 Standard 6, Element A, Factor 2 of the 2011 NCQA accreditation guideline states that the practice must identify “at least three chronic or acute care clinical measures.” These clinical measures will become the primary foci of the practice with regard to the remaining accreditation criteria. Standard 6, Element C, Factor 1 further states the practice must “set goals and act to improve on at least three measures from Element A.”4 There are many ways pharmacists can be involved in improving chronic care measures for physician practices undergoing PCMH accreditation, including identifying patients eligible for pharmacotherapy according to evidence-based guidelines. One such set of guidelines, established by the American Diabetes Association (ADA), recommends that “pharmacological therapy for patients with diabetes and hypertension should be with a regimen that includes either an angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin receptor blocker (ARB).”6 However, the decision to start ACEI or ARB medication in patients with diabetes and hypertension must be patient-specific and guided by clinical judgment. Contraindications, precautions, intolerances, adverse drug reactions, patient preferences, comorbidities, and drug interactions may all confound the decision to initiate drug therapy. Pharmacists are in a prime position to help make clinical decisions such as adding one of these medications to a patient’s regimen.
Objective This project evaluated the impact of a pharmacist embedded in a PCP group practice to assist in achieving PCMH accreditation by increasing chronic care measures through the use of ACEI or ARB medication in patients with concomitant diabetes and hypertension.
Practice description This project took place in a large PCP group practice located in Pittsburgh, PA. The PCP practice employed 36 physicians in 19 practice locations and used an electronic health record (EHR) system. Of the 19 offices, 16 participated in this pilot project. Three offices were excluded because they were either new offices added after the project initiation or new to the EHR system. There were 63,554 full time patients in this PCP practice (defined as those who had an office visit in the last 2 years). j apha.org
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Of this number, 6,925 had a diagnosis of type I or type II diabetes mellitus (ICD-9 250) and 5,258 had diagnoses of both diabetes (DM) and hypertension (HTN; ICD-9 401). The project was completed by a pharmacist embedded in the PCP practice as part of the Academic Partners Program of the Mylan School of Pharmacy, Duquesne University. The Academic Partners Program, started in 2007, connects the resources of the school, including practice-based faculty, to the practice partner to improve the partner, patient, and organizational outcomes. This program also serves to enhance the school’s teaching, research, and service outcomes. Through this arrangement, the faculty clinician spends approximately 20 hours per week at the partner site engaging in clinical practice activities and teaching student pharmacists, residents, and fellows experientially. The pharmacist added to this particular PCP practice began on September 1, 2012, and was the group’s first and only pharmacist collaborator.
Practice innovation In fall 2012, three members of the medical group management team spearheaded the project of obtaining PCMH accreditation for the entire physician group practice. Based on the required NCQA PCMH elements, the management team provided suggestions for quality improvement projects to the practice’s quality committee. The quality committee was a physician-led steering committee that focused on developing quality improvement projects for the organization. The quality committee comprised six physicians, five managerial staff, and one ad hoc external physician who was a medical director from a neighboring hospital. One of the suggestions made to the quality committee by the PCMH steering group was to improve upon a Medicare star-rating measure the organization had struggled to meet: increasing the number of patients with DM and HTN treated with ACEI or ARB medication. The Centers for Medicare & Medicaid Services assigns an overall rating of 1 to 5 stars based on performance in nine quality measures. Contracts and quality bonus payments are awarded to physician practices for high and stable performance on these measures. By increasing the number of patients with DM and HTN treated with one of these medications, the PCP organization would improve its star rating, and also satisfy one of the 2011 NCQA PCMH accreditation criteria (Standard 6, Element C, Factor 1). The quality committee decided to prioritize the treatment of HTN in patients with DM. To accomplish this, the physicians suggested using a pharmacist on site. The pharmacist was asked to develop a proposal describing the method for identifying patients as appropriate candidates for ACEI or ARB treatment and providing recommendations to the physicians.
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Implementation This project was approved by the Duquesne University Institutional Review Board under an expedited review. To begin, the pharmacist presented a proposal, previously approved and endorsed by the quality committee, to the physicians and office managers at a monthly practice meeting. The pharmacist emphasized the importance of adhering to the quality measure of appropriate treatment of HTN in patients with DM for the attainment of PCMH accreditation. The pharmacist then asked the group for feedback on any exclusion criteria regarding patients perceived as inappropriate candidates for such treatment. The exclusion criteria resulting from this discussion included any documented drug allergy, intolerance, or previous adverse drug reaction to an ACEI or ARB medication, documented hyperkalemia on the most recent laboratory value (serum potassium level >5.0 mmol/L), age of 75 years or older, and a diagnosis of renal disease listed by the physician as an active problem. In addition, patients whose blood pressure was controlled (<130/80 mm Hg) with another antihypertensive medication with a compelling indication for treatment with that medication due to a cardiovascular comorbidity were excluded. Patients whose blood pressure was controlled by lifestyle measures alone without the presence of albuminuria were excluded. A consensus was reached among the physicians that the pharmacist would send patient recommendations using a “flag” or electronic communication within the EHR. Following this meeting, an EHR report containing a list of all patients with diagnoses of DM or HTN and not currently being treated with an ACEI or ARB medication was printed. The pharmacist, aided by student pharmacists, reviewed each patient chart to determine if the patient was an appropriate candidate for ACEI or ARB therapy. For those patients meeting inclusion criteria, a flag was sent to the physician. If the physician did not respond to this communication within 4 weeks, a reminder was sent for a total of 2 communications.
Documentation The pharmacist’s recommendations and physicians’ responses were documented in an Excel spreadsheet kept on a privacy-protected computer that complied with requirements of HIPAA, the Health Insurance Portability and Accountability Act. This spreadsheet included the patient medical record number, office location, presence of a documented allergy or intolerance to an ACEI or ARB, if the patient had previously taken an ACEI or ARB, presence of hyperkalemia or renal disease, blood pressure, and whether a recommendation had been made to the physician. The pharmacist documented reasons for patient exclusions as well as patient recommendations. The pharmacist followed the patient’s record in the EHR to determine if an ACEI or ARB was initiated or Journal of the American Pharmacists Association
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documented the reason if the recommendation was not accepted. Dates of follow-up reminders and responses were documented.
Results The Duquesne pharmacist was added to the PCP practice on September 1, 2012, which coincided with the initial work of the PCMH steering committee. The pharmacist presented the project proposal at the January 2013 practice meeting and data collection began on February 1, 2013. The first round of physician recommendations was sent by July 30, 2013. Across the 16 participating office locations, 5,258 patients were diagnosed with DM and HTN. Of these, 4,304 were already being treated with an ACEI or ARB medication (81.9%), which left 954 patients with a concomitant diagnosis of DM and HTN not currently treated with an ACEI or ARB medication. Of these 954 patients, the pharmacist determined that 784 met at least one of the exclusion criteria (82.2%). Reasons for patient exclusion are listed in Table 1. For the remaining 170 patients, the pharmacist sent an electronic communication to the patient’s PCP for consideration. Of the 170 recommendations sent, the pharmacist received 150 responses (88.2%). Physicians agreed with the recommendation to initiate therapy in 82 patients (54.7%), and a note was placed in the chart as a reminder to discuss initiating therapy at the next office visit. Therapy was started in 56 of those patients (68.3%). Of the remaining 26 patients, 15 were pending until the patient’s next office visit, and 11 were not initiated because of several reasons including new hyperkalemia, transferred care, and patient refusal. Table 2 illustrates the reasons for which the PCP did not accept the pharmacist’s recommendations.
Evaluation Evaluation of the success of this project was determined not only through the practice’s achievement of PCMH accreditation, but more importantly from recognition by the quality committee of the pharmacist’s role in the practice. After the project was completed, the PCP practice was recognized by NCQA as a PCMH (i.e., the practice gained accredited PCMH status). Unfortunately, the practice did not obtain a sufficient number of points for the standard addressed to contribute to the accreditation status. While a small number of patients were started on ACEI or ARB medication, the exclusion criteria developed by the physician group resulted in many patients being disqualified from receiving ACEI or ARB medication intervention. Despite this, this project opened communications between the pharmacist and physicians in the PCP about other quality-improvement roles for the pharmacist (see “Barriers and opportunities” section). As this Journal of the American Pharmacists Association
Table 1. Reasons for patient exclusion from pharmacist review No. patients excluded Exclusion criteria (%; n = 784) Advanced age (75 years or older) 334 (43) Hypertension controlled with lifestyle measures alone and no albuminuria 108 (14) Hyperkalemia 69 (8.8) 65 (8.3) Othera Current beta-blocker treatment for comorbidity and blood pressure controlled 62 (7.9) Documented allergy or previous adverse drug reaction 60 (7.7) Patient already on an angiotensin converting enzyme inhibitor or angiotensin II receptor blocker medication 46 (5.9) Documented renal disease 40 (5.1) Some other reasons for patient exclusion included instances where the physician had already attempted to initiate therapy with these agents, the patient refused, the patient was currently taking a diuretic for edema and blood pressure was already controlled, patient was being treated for hypertension by a specialist, and the patient was no longer with the primary care practice.
a
Table 2. Physician reasons for not accepting pharmacist recommendations Reasons No. patients (%; n = 68) Blood pressure controlled by current medications and unwilling to change therapy/beta-blocker needed for comorbidity/blood pressure controlled by lifestyle measures alone 44 (65) Othera 8 (12) Previous adverse drug reaction not mentioned in problem list 4 (5.9) 3 (4.4) Challenging patientsb Hyperkalemia revealed through new laboratory results 3 (4.4) 2 (2.9) Agec Angiotensin converting enzyme inhibitor or angiotensin II receptor blocker medications initiated before receiving recommendations 2 (2.9) Renal disease discovered through new laboratory results 2 (2.9) Patient refusal, other more pressing conditions (such as cancer), cost, and smoker (medications worsen cough). b Prescribers did not accept the pharmacist’s recommendations in “challenging” patients. These could be patients who had other more pressing medical issues or who were too difficult to convince to try with these additional medications. c Although the pharmacist did not send recommendations for any patients older than 75 years, physicians chose not to accept the recommendations in two patients who were 74 years old and would be turning 75 within the next 6 months. a
project increased awareness of the pharmacist’s contributions to the PCP group practice, a full-time pharmacist fellow was added to the practice to assist the pharmacist in leading future quality improvement projects.
Discussion This project was initiated to help a PCP group practice j apha.org
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meet the PCMH accreditation factor of improving performance on a chronic care clinical measure. Specifically, the goal was to use the services of a clinical pharmacist to identify patients with DM and HTN eligible for treatment with ACEI or ARB medication who were not currently receiving such therapy. Only 17.8% of patients reviewed were determined by the pharmacist to be appropriate candidates for ACEI or ARB therapy. While the number of patients initiated on ACEI or ARB medication as a result of this project was not substantial enough to contribute to the PCMH accreditation scoring, the pharmacist-provided recommendations were clinically important to the providers and patients of the practice. Furthermore, the project shows that although third party payers measure the use of these medications as deemed appropriate by national clinical practice guidelines, appropriateness needs to be determined on a case-by-case basis. This study was conducted following release of the 2011 NCQA PCMH accreditation standards. A new set of guidelines was released in March 2014.7 Practices that had previously purchased the NCQA PCMH toolkit were required to submit their applications by March 30, 2015, to use the 2011 standards. The content addressed in the 2014 standards remains the same, making this project relevant to practices pursuing accreditation with the updated guidelines.
quires that the PCP practice provide information about new prescriptions to more than 80% of the patients, families, or caregivers.7 Through the pharmacist’s work on the treatment of HTN in patients with DM measure, the practice recognized that the pharmacist could be extremely useful in helping to meet this medication-related measure.
Barriers and opportunities
1. Defining the PCMH. Agency for Healthcare Quality and Research, U.S. Department of Health and Human Services. http:// pcmh.ahrq.gov/page/defining‐pcmh. Accessed January 21, 2014.
In an ideal PCMH setting, the pharmacist works alongside physicians and provides face-to-face clinical recommendations. But in a large, decentralized PCP practice such as this, it was not feasible for the one pharmacist, who also had academic obligations to the university, to be present physically in all 16 office locations. The solution to this barrier was to provide the pharmacist with remote EHR access. This allowed the pharmacist to review each patient chart and send recommendations from a central office location. Developing a trusting professional relationship with the physicians, however, was key to the success of this project and future projects. The pharmacist was able to accomplish this through attendance at monthly practice meetings, face-to-face project status updates to the quality committee, and actual time spent working in the PCP offices. As mentioned previously, this project resulted in later collaboration opportunities between the pharmacist, pharmacist fellow, and the physicians. One such project was the use of the pharmacist to help maintain the acquired PCMH accreditation through meeting Standard 4, Element C, Factor 3 of the 2014 PCMH update regarding medication management through the addition of a pharmacist telephonic intervention. This element re-
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Conclusion This project showed the positive effect of a pharmacist in helping a PCP group address quality projects relating to PCMH accreditation. While this practice has already achieved NCQA PCMH accreditation, this project is still being conducted for continuous quality improvement. Future reports will be used to identify new patients who may be candidates for treatment with ACEI or ARB medications. This endeavor, while conducted within an ambulatory PCP practice, could also be translated to practitioners in other care settings. The application integrating the pharmacist as a core team member of a PCMH and their ability to provide a comprehensive medication therapy review could be conducted remotely within any EHR system capable of electronic communication to the prescriber and further allow for other future PCMH standards to be met. References
2. Why the medical home works. Patient-Centered Primary Care Collaborative. http://www.pcpcc.org/content/why‐it‐works. Accessed January 27, 2014. 3. Nielsen M, Langner B, Zema C, et al. Benefits of implementing the primary care medical home: a review of cost and quality results. Patient-Centered Primary Care Collaborative. 2012. http:// www.pcpcc.org/guide/benefits‐implementing‐primary‐care‐ medical‐home. Accessed January 27, 2014. 4. Standards and guidelines for NCQA’s patient-centered medical home (PCMH) 2011. National Committee for Quality Assurance. 2011. http://www.coloradoafp.org/pdf/NCQA_2011_Standards. pdf. Accessed January 27, 2014. 5. Chisholm-Burns MA, Kim Lee J, Spivey CA, et al. US pharmacists’ effect as team members on patient care: systematic review and meta-analyses. Med Care. 2010;48(10):923–933. 6. Standards of medical care in diabetes—2013. American Diabetes Association. http://care.diabetesjournals.org/content/36/ Supplement_1/S11.full. Accessed January 27, 2014. 7. Patient Centered Medical Home (PCMH 2014) Standards Parts 1 & 2 Training. National Committee for Quality Assurance. 2014. http://www.ncqa.org/Programs/Recognition/RelevanttoAllRecognition/RecognitionTraining/PCMH2014Standards.aspx. Accessed August 30, 2014.
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