Thank you. Good afternoon. On behalf of the AHRQ Health Care Innovations Exchange I would like to welcome to you the Web event, "Innovative Roles of Pharmacists in Health Service Delivery." I'm a program analyst in AHRQ Center for Outcomes and Evidence. We're very excited about today's topic and glad to see that you share our enthusiasm. We'll be polling you to get a better feel for who has joined us today.
As some of you may be new to AHRQ's Health Care Innovations Exchange, I will just take a minute or two to give you an overview before I introduced the moderator. The Health Care Innovations Exchange is a comprehensive program designed to accelerate the development of innovations. This program supports the agency's mission to improve the safety, effectiveness, patient centeredness, timeliness, efficiently and equity of care.
The Innovations Exchange has the following components, searchable innovations that describe the activity, its impact, how the innovator developed it and other useful information for deciding whether to adopt the innovation. There are now over 400 profiles within the database. And new profiles and content are added every two weeks. We have searchable QualityTools. The innovations now post over 1400 practical tools that can help you assess, measure, promote, and improve the quality of healthcare. The new tools are also added every two weeks.
We have learning opportunities. Many resources describe the process of innovation and ways to enhance your approaches. Resources include expert commentaries, articles, and adoption guides. We also have networking opportunities. You can interact with organizations that have adopted innovations to learn new approaches to delivering care and developing strategies and share information. Posting comments on specific innovations is one way to connect. Types of comments include asking questions, or responding to questions about how an innovation works, and mentioning lessons learned.
This Web event is part of a series of learning events to support you in developing and adopting innovations in healthcare delivery. We invite you to look at archived materials from our most recent Web event. It could be found on our Web site listed on your screen. We hope you will join us for future events that will be announced on the Health Care Innovations Exchange Web site. Stay tuned for a Web event in June. We also welcome your thoughts on other topics to address. At the end of today's event you will be asked to complete a brief evaluation. Your comments will help us to plan future events that meet your needs, and you can also email your comments and ideas to us.
Before we get started I would like to give our panelists a sense of who we have in the audience today. You will see a polling question shortly; it will ask you what your primary role is.
Here we go. There are 48 of you who are a pharmacist, 5% physicians, 5% nurses; researchers 10%, policymakers 2%, and others 21%. We have a very nice cross section.
Today we do proudly present this Web event because we appreciate the importance of pharmacists and their growing and changing roles. The use of prescription medication has skyrocketed, yet improvements in healthcare quality have not kept pace. We tap into the skills and qualifications of clinical pharmacists today. With that very brief introduction I would like to introduce our moderator today, Carmen Kelly. Dr. Kelly is a pharmacist and officer in AHRQ. Dr. Kelly obtained her directorate from Howard. Currently, Dr. Kelly is a member of the Board of Visitors for the College of Pharmacy, Nursing and Allied Health at Howard University and a member of the Advisory Board of the Journal of the American Pharmacists Association. Carmen?
Thank you, Judi. The role of the pharmacist has evolved over the years to a more patient oriented practice. The model includes drug therapy to improve a patient's quality of life. In 2003, pharmacists were presented with another opportunity to optimize outcomes in Medicare, MMA. Participating insurers were to assist through MTM programs. The law describes it as a program of management that is designed to ensure that covered Part D drugs are appropriately used to optimize therapeutic outcomes to improve use and to reduce the risk of adverse events.
Given that, MTM is still a fairly new service. Few measures exist to establish effectiveness. As a result AHRQ continues to support research that will help to establish evidence for building programs. This includes a study currently being conducted to evaluate a medication management program in Medicare beneficiaries. Today, AHRQ has the unique opportunity to share examples of successful evidence-based pharmacist medication management programs.
Next slide, please. We will hear from Dr. Beverly Green. As well, we will hear from Dr. Santhi Masilamani. With that I would like to introduce Dr. Beverly Green.
Dr. Green is a practicing family doctor at Group Health. She is also an affiliate investigator conducting health services research. Dr. Green has over 20 years of experience. She is the author of many papers on hypertension and is an associate editor in charge of the American Journal of Preventive Medicine. Dr. Green?
Thank you. It's a pleasure to present today. I'm going to be talking about the effectiveness of a Web-based pharmacist intervention to improve blood pressure control. I have no disclosures. This study was funded by the NHLBI
Hypertension is the most common diagnosis made in primary care. Yet only about half of the patients with this diagnosis have a blood pressure below the recommended target. This is despite unequivocal evidence
We wanted to know whether a new model of care could be used to improve blood pressure control. We compared two interventions to usual care, the use of a home blood pressure monitor and the use of an existing Web site, this plus pharmacist care management.
The primary outcomes were change in systolic and diastolic blood pressure. Secondary outcomes were medication adherence.
The setting is Group Health. It's a practice in Washington State and Idaho. The study was conducted at ten Group Health medical centers in Western Washington. These centers used the Electronic Medical Record, Epic. It also has an attached portal, MyGroupHealth.
The study was based on the Chronic Care Model. The Chronic Care Model is designed by Ed Wagner and others at our institution. It's based on six domains. They are evidence-based decision support, clinical information systems, delivery system design, self-management support, the resources and policies of the community, and also the organization and policies of the healthcare systems. In this model, if each domain is optimized and integrated it leads to informed patients and improved outcomes.
For the study, patients had to have a diagnosis of hypertension and be on medications. They had no exclusionary health conditions. For this study, the pharmacist provided care. We called the patients with the diagnosis and asked if they had access to a computer, Internet and email. If they were willing to participate we invited them to two screening visits. They had to have uncontrolled hypertension at both visits.
Group 1: This is what patients normally receive at Group Health. If the patients in Group 1 were not already registered to use MyGroupHealth, we ensured they were. They received standard pamphlets. They were also told their blood pressure was not under control and to work with their physicians to improve their blood pressure control.
Group 2 also were registered if they were had not previously used the Web site. They received a home blood pressure monitoring kit and were trained in its use and they also received Web training. This includes secure messaging with their healthcare providers, refilling medications via the Web, viewing portions of their medical records, health information, and links to Group Health and community resources. They were encouraged ? they were also told that their blood pressure was not in control and were encouraged to message their physicians.
Group 3 received all of the same things that group 2 received; additionally they received Web-based pharmacist care. The clinical pharmacists provided the interventions. They were experienced pharmacists in care management registry database work, and using Electronic Medical Records. They had not done any Web-based interventions prior. Their training including two 1/2 day sessions, review of a database they were already using for their day-to-day work, and documentation of their encounters with patients in the Electronic Medical Record. We also provided training on patient centered communication styles.
The pharmacists were notified when a new patient was randomized to their group. They would email the patient; the patient could link to the Web site and sign in, where they would see the welcome message from the pharmacist. The pharmacists also notified the patient's physician by email. In addition, the pharmacists would plan a telephone call, review the patients' medication history with them and their allergies and adherence to medications using open-ended questions. They were also introduced to the action plan that would be used for Web communications.
This is an example of a Web communications action plan. The first component is the patient's blood pressure monitoring plan. The second component is a list of their medications, doses, and frequencies. The third is lifestyle changes. The patient received the standard pamphlet that reviewed changes that could be used to decrease blood pressure risks. They were asked during the call to choose at least one to work on. The fourth component was the assessment of the ongoing monitoring and instructions for the next step. Finally, there's a follow-up plan.
Ongoing pharmacist care occurred every two weeks for the first three months, or until the blood pressure is under control. There were continuing communications about adherence and lifestyle goals. If there were concerns, the care was transferred to the patient's physician.
Results. The study lasted 12 months.
Recruitment. We went to each center and attempted to contact every single patient that had hypertension and was on medications for that. About 20% did not have access to the Web. And of those people that were ? that we contacted about 1/3 agreed to a screening visit. At this visit over 60% had controlled blood pressure based on our criteria. Had we conducted this study now we would have used Electronic Medical Records to prescreen patients. At that time the Electronic Medical Record was new and we did not have enough measurements. About 2% had very high blood pressures and were not eligible. We assisted them in making appointments with their physicians.
This gives the demographics of the patient sample. They were mainly a middle aged group, similar race and ethnicity. They were fairly well-educated. The majority were employed full-time. Also almost all of the patients were overweight, only 7% had a normal BMI at baseline. Most of the patients had systolic blood pressure uncontrolled.
At 12 months there were improvements in blood pressure. There was a stepped decrease in the systolic blood pressure monitoring Web only compared to usual care. A net change occurred in the pharmacists' group, which was significant compared to the usual care and only group. For diastolic blood pressure monitoring, the changes were smaller.
At the time of randomization, we stratified by systolic blood pressure and had predesignated analysis of the group. In group 3, blood pressure was reduced to a greater degree with a net change of 13 millimeters in the pharmacists' group. The same was true of the diastolic blood pressure.
At 12 months all groups had improvements in blood pressure control. The pharmacists' group is the only group that had significantly improved, as compared to usual care. You can see this change was even wider in those with more severe hypertension.
The mean number of hypertension medications, the majority were only on one medicine. In the Web group they increased compared to usual care. We also expected and saw increased secure messaging, but we just looked at those that the patients initiated on their own. We found greater secure messaging in both groups, highest in the pharmacist's group. Primary care visits did significantly differ between groups.
There was no difference in groups in numbers of hospitalizations. There was a slight decrease in specialty care visits in the pharmacists' group.
Cost-effectiveness. Bringing patients into clinic and telling them that their blood pressure was not under control cost on average $10. The blood pressure monitor and Web training added $54. The cost of effectiveness of the intervention for each percentage of patients was $16.
Limitations. Our sample, our patients needed to have Web access, we found that was correlated with age and education. Our population is an insured group. We also don't know the optimal dose of pharmacist intervention. It's possible that a briefer intervention would have had the same results.
Our study supports a new model of care, bringing care out of the office and into patient's homes. More active participation by the patient in their care, and a new model of care based on team care that is integral to the new Medical Home. And using allied health professionals. This model is being used as Group Health as part of its implementation of the Medical Home in the care of patients with chronic conditions. At Group Health we work on getting patients to their targets for each of these chronic conditions.
In a study like this, it takes a lot of people to make it happen. I want to acknowledge that and thank the other members of my research team and the pharmacists and other people that were instrumental to making this study happen. Thank you very much.
Thank you, Dr. Green. The audience will have an opportunity to ask Dr. Green questions later in the program. At this time I would like to introduce our next speaker, Dr. Santhi Masilamani. Dr. Santhi Masilamani graduated from University of Oklahoma, received a BS in pharmacy. She completed a specialty residentially at Texas Tech. She established services for the indigent and were instrumental in establishing the ADA recognition program. The ambulatory clinical program received a network award under her direction. She is also an active member of AHSP, ACCP. Dr. Santhi Masilamani?
Hello, everyone. Thank you for the introduction. It's a great honor to be able to present some basic elements of medication therapy management and what we did in the community health program.
I wanted to describe some basic elements of MTM, as you are aware. They have been described by various organizations as having the components below. With healthcare dollars being spent in the ambulatory arena, focus on disease management became an important element for MTM. Medication reconciliation and the continuum of care became of paramount importance. And with chronic disease management following polypharmacy, another important element. Of course, patient counseling is an integral part of the care of the patient, that includes medication reconciliation. Patient counseling helps parameters to improve. Appointment coordination is also very important. Patients come in to see their physician, their clinical pharmacist, then they need to understand the importance of keeping their follow-up appointments. Above all, with many of our population becoming underinsured in the future patient assistance is very important. Switching medications to a lower cost, agent in the same class, to help patients who are not able to afford their care.
With those elements come certain features that many of us are aware of. Patient centered approach is very, very important to medication therapy management. Especially in an interdisciplinary environment. They determine their own goals and what their timeline is for their goals and that makes medication therapy management more achievable and sustainable and gets the goals to where the patient wants it. Communication is also an important feature, communications between providers is very important, what the clinical pharmacist does needs to be communicated to the physician, to the patient. What the patient does needs to come back to the clinical pharmacist and also the nurse that is in there with the social worker and many other members of the team, need to communicate together with the patient. The MTM features can be population-based or individualized. We did take trends in diseases and designed programs to address the trends. We also individualized each trend. If we were addressing diabetes we would individualize the care for the patient. It also needed to be flexible in all aspects, including appointment times, appointment frequency and medication types for the MTM to be successful. Of course, MTM features evidence-based medicine. Individualizing the literature to the patient and helping him or her understand their disease is an important feature of MTM. And promoting the program, what the MTM program that has been put into place with the patient, with the physician, with the institution, wherever the site is promotion becomes very, very important.
All those elements and features lead to patient safety. Safety includes improved disease parameters such as a lowered A1C, lower blood glucose, lower INR. It also improves adverse drug event reporting, with the providers noticing more from the patient, receiving more information from the patient, collaborating with the pharmacist to get the optimal regimen. That trend can be analyzed and used to reduce events further in a formalized program. It also improves patient satisfaction. When the patient notices that they're at the center of their care, and there's a team working together to improve their disease parameters there's improvement in patient satisfaction.
I went through the general elements of MTM and the features that we used as primary clinical pharmacists to present to the hospital, the health system, to show where we fit into the care of the patient. So what did that take? That took readiness from the health system. To add primary care pharmacist to the system, we talked about the MTM elements, we talked about the features, we talked about what that meant for the patient. But what did that mean for hospitals or health systems, or someone who will be funding the program?
In our case it was "Twas the Night Before JCAHO." It means that the hospital along with its community health centers needed to be prepared to answer questions. As you may be aware, many of the standards include medication management standards. There are about 27 standards; that's where the clinical pharmacist, MTM elements and features, and those that we described earlier fit in. So where was our hospital at that time? It was under probationary accreditation.
The hospital was preparing the elements and presenting it. Also the hospital is looking at reducing readmissions with the healthcare reform bill. Also the hospital is looking at appointments with physicians in the primary care setting, as well as the specialty setting at 6 months. The specialists had a wait time of 3 to 4 months, and primary care had more than four months of wait time.
There were people who did not come back because of the long wait times. Anything that patient might be walking in with, or maybe referred for, the patient may be referred for diabetes. The pharmacist will look at anything else that needs to be addressed on that patient's profile.
The hospital and the health system needed to be ready. They were ready. Then the leadership had a culture of patient safety. That led to MTM by clinical pharmacists. Then approval for FTEs, or enough pharmacists to staff one clinical pharmacist per community pharmacy.
What was the impact? Enough FTEs produced medication safety. Throughout the community health centers and the hospitals there was a team play of win-win; the pharmacists and the physicians and the nurses worked together to keep it consistent.
What does that mean in this complicated picture? We were noticed by the HHS administration and asked to participate in their collaborative. This now has about 600 participants, and many teams across the country are using this picture. In between the hospital and pharmacy services, patient self-management and the primary care home.
The clinical pharmacist is in the middle of the care, making sure that patient safety achieved, and making sure that everyone communicates appropriately to make sure that the patient's disease condition is improving. To show you the final results of that ?
We all know that outcomes are the best evidence for success of the program. In this slide you can see with the clinical pharmacist at each community health center and the hospital pavilions. These were the outcomes that we achieved. There was a tremendous increase in the percent at goal in INR.
Reduction in A1C across the system averaged about 2.54%. Total visits we're averaging 16 visits per pharmacist per day. Major bleeds and clots were zero. ER visit reductions were at 18% overall. And hospital admission reductions were at 36%. So this is our innovation, our clinical pharmacist at each of the community health centers. That concludes my presentation.
Thank you, Dr. Santhi Masilamani.
At this time our presenters will answer some questions. Dr. Green, can you expand on the cost-effectiveness for each percentage of patients?
The cost-effectiveness is dividing the cost of the intervention by the proportion of the unit of change. And the reason you want to use incremental cost-effectiveness is it allows you to compare it with other interventions directly.
Thank you. The next question is for both of our presenters. Have there been similar studies on patients from indigent populations, such as those that go to county facilities? And do you have plans to implement your innovation in another setting? Dr. Green?
Yes. I will start to say we were concerned about the patient population that did not have access to the Internet. I would think once you get to a institution ? or group of patients that don't have insurance that proportion will be higher. Some of the researchers on the team have looked at different ways to engage patients in Web-based interventions.
There are some interesting new promising ways to do that, such as the use of the cell phone, or proxies. Having a person assigned to ? a good friend or family member that might have access to a computer to assist the patient, or coming into the clinic and using a kiosk. One has to be cognizant that Web-based interventions are not for everyone, you still have to rely on other mechanisms to improve chronic conditions.
Thank you. Dr. Santhi Masilamani?
Yes. I have had several questions to duplicate the program at other settings. I was at a county facility and there is lots of interest in the private sector. We are looking at a similar program in another setting.
Thank you. Dr. Green, are you still using clinical pharmacists as part of your support group? If so, how are the increased costs covered?
That's a two-part question. After the intervention I think we tried to directly maintain the program. And have it going on in the clinics with pharmacists from additional clinics being recruited into similar work. That had varying amounts of success. We help patients with recruiting of patients. What I think has happened, which has been a more successful way to implement it, it has become part of the way that Group Health provides care in general.
Now they're using in the Medical Home model virtual visits. The idea of a team concept is being brought more actively into care management. In the case of medication management, often that's assigned to the pharmacist. So the answer would be now it's something that we use for chronic conditions in general. Of all of our patient encounters, about 30% are virtual, which is pretty amazing. About 55% are in-person. The rest are telephone encounters. Patients appreciate the virtual encounters. For conditions where it's just a matter of monitoring, Web-based is promising.
Thank you. The question is for both presenters. What were obstacles that you encountered? Dr. Santhi Masilamani?
We anticipated obstacles.The approach we used was that I was the primary pharmacist who went into the clinics first. The physicians themselves asked for that to be replicated. That was our approach, to go in and just show them what we can do, they expanded the program for us.
Thank you. Dr. Green?
I think when we actually applied for the grant we didn't know exactly ? we already had Web communications with patients. But we didn't have the EMR in place. It was fortunate that things rolled into place. Using the Electronic Medical Record would be far more efficient. I really think it was surprising how few obstacles we did have. The physicians and patients were very receptive. The complaint we got from a physician is one patient was doing too much secure messaging. There are ways to use filters in EMRs so you don't have to see all of those.
Thank you. Dr. Santhi, what was the average number of patients seen per day per pharmacist?
Our goal was 18 per day. It decreased over time to 14 visits per day.
Thank you. Dr. Green, how might this cost be justified? Does this merit reimbursement by payers?
I don't think we did the definitive study to say whether this is more or less cost-effective. I think that needs to be determined. For Web-based care in general that's not been answered. If you compared this type of care with pharmacists in-house care you ? or a physician, which I would expect to be much more expensive. Given we don't have that, is it reasonable cost for an organization to encumber? That business case is still being worked out. There are a lot of things happening around payment for pharmacist services. I think a lot more things need to happen if we're going to be serious about team-based care and ongoing comprehensive primary care for patients and improving quality.
Thank you. I believe this is the last question for Dr. Green. How do you anticipate expanding the program to a larger group of patients?
Well, there are a couple of things. We are considering disseminating ? translating this into other settings. We work in some rural areas. In terms of the cost of a blood pressure monitor, it's relatively inexpensive in you buy them in large quantities. You could have a program where you would lend the monitor. We feel that's a small cost to coming in for in-person visits.
Thank you very much. The last question I will address to Judi, the question is will the slides from today's presentation be made available after the call?
Thank you, Carmen. Yes, actually the slides and the text from this presentation will be available on the Health Care Innovations Exchange site. You will be able to access that shortly. I want to thank our presenters, and Carmen and our audience. This has been an informative learning opportunity for all of us. We do value your feedback. If you have more questions and you want to address questions or comments to our innovators you can go to the Innovations Exchange site, there's a comment section. We will get back to you.
As we're drawing to a close we would like to ask you to stay on a few more minutes and complete the evaluation that is about to appear. Again, remember if you have any comments that you can contact us. I want to thank everyone. This was a great hour. Hope to have some of our audience participate again. Thank you.