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Evidence-Based Medicine for Pharmacists in Patient-Centered Medical Home
Slide Presentation in Text Format

Monday, December 13, 2010

11:00-12:30pm, ET

  • On the top of the slide are the logos for the Department of Health and Human Services and the Agency for Healthcare Research and Quality (AHRQ).

 Slide 2

Development and Support

  • This Web conference was developed by the Agency for Healthcare Research and Quality’s (AHRQ) Effective Health Care Program with assistance from the American Pharmacists Association.

 

On the bottom of the slide is the logo for the Effective Health Care Program and the American Pharmacists Association.


Slide 3

Accreditation and CPE Information

  • The American Pharmacists Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education (CPE). This Web conference, Evidence-Based Medicine for Pharmacists in the Patient-Centered Medical Home, ACPE #202-999-10-270-L04-P, is approved for 1.5 hours of CPE credit (0.15 CEUs).

 

  • To obtain CPE credit for this Web conference, participants must participate in the entire Web conference and complete the online evaluation by December, 27, 2010. A voucher code and further instructions will be provided during the Web conference. In order to complete the online activity evaluation form, participants will need to have a valid Pharmacist.com user name and password. A Statement of Credit will be automatically generated upon achieving these requirements.


Slide 4

Accreditation and CPE Information

  • Target Audience: Pharmacists
  • ACPE Activity Type: Knowledge-based
  • Learning Level: Level 1


Slide 5

Learning Objectives

After participating in this Web conference, pharmacists will be able to:

  • Define the tenets of the patient-centered medical home and AHRQ’s role.
  • Describe the various patient-centered medical home models and list the numerous roles for pharmacists in a PCMH.
  • Discuss successful implementation strategies and potential barriers to the PCMH.
  • Recognize the Effective Health Care Program as an evidence-based resource for pharmacists.


Slide 6

Speakers

Sarah J. Shoemaker, Ph.D., Pharm.D., R.Ph., Moderator
Health Services and Policy Researcher
Abt Associates, Inc.
Cambridge, Massachusetts

Janice L. Genevro, Ph.D., MSW, The Patient-Centered Medical Home (PCMH) and AHRQ
Lead, Primary Care Implementation Team
Center for Primary Care, Prevention, and Clinical Partnerships
AHRQ
Rockville, MD

Images of Dr. Shoemaker and Dr. Genevro are on the left side of the slide next to their name and title. 


Slide 7

Speakers

Stephanie M. Hammonds, Pharm.D., The Role of Pharmacists in the Medical Home
Office of Pharmacy Affairs
Healthcare Systems Bureau
HRSA
Rockville, MD

Karen Williams, Pharm.D., M.B.A
Branch Chief for Quality Improvement (QI)
Office of Pharmacy Affairs
HRSA
Rockville, MD

Images of Dr. Hammonds and Dr. Williams are on the left side of the slide next to their name and title.


Slide 8

Speakers

Vince Willey, Pharm.D., The PCMH in Practice: The Pharmacist Experience
Associate Professor
Philadelphia College of Pharmacy
Philadelphia, PA

Scott R. Smith, Ph.D., R.Ph., M.S.P.H., How AHRQ’s EHC Program can support the Pharmacist’s Role in the PCMH
Director of Pharmaceutical Outcomes Research Programs
Center for Outcomes and Evidence
AHRQ
Rockville, MD

Images of Dr. Willey, and Dr. Smith are on the left side of the slide next to their name and title.


Slide 9

Disclosures

Sarah J. Shoemaker, Pharm.D., Ph.D., R.Ph., has no financial interests or relationships to disclose.

Janice L. Genevro, Ph.D., M.S.W., has no financial interests or relationships to disclose.

Stephanie M. Hammonds, Pharm.D., has no financial interests or relationships to disclose.

Karen Williams, Pharm.D., M.B.A., has no financial interests or relationships to disclose.

Vincent Willey, Pharm.D. has recently received research/grant support from AstraZeneca.

Scott R. Smith, Ph.D., R.Ph., M.S.P.H., has no financial interests or relationships to disclose.


Slide 10

AHRQ and the Medical Home: Building a Blueprint

Janice L. Genevro, Ph.D., M.S.W.
Center for Primary Care, Prevention,
& Clinical Partnerships
AHRQ

Slide 11

AHRQ Mission Statement  

To improve the quality, safety, efficiency, and effectiveness of health care for all Americans


Slide 12

What AHRQ does

  • Generates New Knowledge

 

  • Synthesizes Evidence
  • Supports Implementation


Slide 13

Primary Care

AHRQ recognizes that
revitalizing
the Nation’s primary care system
is foundational to achieving
high-quality, accessible, efficient health care for all Americans.

Slide 14

The Medical Home

AHRQ believes that the primary care medical home, also referred to as the patient-centered medical home (PCMH), advanced primary care, and the healthcare home, is a promising model for transforming the organization and delivery of primary care.


Slide 15

The Medical Home

  • A medical home not simply a place but a model of primary care that delivers care that is:
    • Patient-centered
    • Comprehensive
    • Coordinated
    • Accessible, and
    • Continuously improved through a systems-based approach to quality and safety


Slide 16

AHRQ’s Definition of the Medical Home

  • Key components
    • Patient-centered: Relationship-based with an orientation toward the whole person
    • Comprehensive Care: Team-based care that includes providers from multiple disciplines, including pharmacy
    • Coordinated Care: Clear, open communication and transfers of accountability, especially during care transitions
    • Superb access to Care: Responsive to patients’ preferences regarding access
    • Systems-based approach to quality and safety: Commitment to quality and quality improvement
    • Health IT, workforce development, and payment reform are critical to achieving the potential of the medical home
  • Full version is available at www.pcmh.ahrq.gov


Slide 17

AHRQ and the Joint Principles Closely Aligned

AHRQ

  • Patient-centered
  • Comprehensive
    • Team-based care
  • Coordinated
  • Accessible
  • Quality and safety
  • Health IT
  • Workforce development
  • Payment reform

AAFP, AAP, ACP, AOA

  • Personal physician
  • Physician directed practice
  • Whole person orientation
  • Care Coordination
    • Health IT
  • Quality and safety
  • Enhanced access
  • Payment


Slide 18

AHRQ PCMH Research   

  • Retrospective Evaluations
    • Health Partners (Minnesota)
    • WellMed (Texas)
  • Mixed Methods Evaluations
    • Transforming Primary Care Practice
      • 14 2-year awards
      • $600K per study
      • Awarded summer 2010
  • Establishing a Research Agenda
    • Co-funded with CWMF and ABIMF
    • Collaboration of SGIM, STFM, APA
    • Results published June 2010 in JGIM


Slide 19

Information for Decision Makers   

  • Foundational White Papers
    • Necessary but Not Sufficient:  The HITECH Act’s Potential to Build Medical Homes
    • Engaging Patients and Families in the Medical Home
    • Integrating Mental Health into the Medical Home

 

    • Address Policy and Research Issues


Slide 20

Coming Soon!
More White Papers and Briefs

  • Planned white papers for 2011:
    • Analysis of PCMH outcomes
    • Exploration of PCMH within the larger health care system
  • Upcoming series of briefs on the status of primary care in the US
    • Includes new analysis of the primary care workforce


Slide 21

Database of PCMH Literature

  • Database of published literature on the medical home
    • Over 500 citations
    • Searchable by PCMH domain, policy relevance, and outcomes
    • Includes a section on foundational documents and articles


Slide 22

Implementation Projects

  • National expert working group on using practice facilitators and practice coaching
    • Launching winter 2010


Slide 23

Implementation Projects  

  • Building a PCMH Information Model
    • Describe the PCMH in terms of the information flows and interactions between and among patients/consumers and other PCMH stakeholders
    • Develop new ‘functional use cases’
    • Examine current standards and existing ‘technical use cases’ in relation to the PCMH
    • Identify gaps
    • Began Summer 2010


Slide 24

Online PCMH Resource Center

On the slide is a screen image of the Patient Centered Medical Home Resource Center Web page on the Agency for Healthcare Research and Quality Web site.


Slide 25

PCMH.AHRQ.Gov

  • Targeted towards meeting the needs of Policy Makers and Researchers
  • Includes:
    • AHRQ definition of the medical home
    • Searchable article database
    • Foundational white papers
  • Will continue to grow and expand

 

Please visit and help us spread the word!


Slide 26

Principles for Pharmacists’ Services in PCMH

  • Developed by 9 pharmacy organizations
  • Essential principles:
    • Access to pharmacist services
    • Patient-focused collaborative care
    • Flexibility in PCMH design
    • Development of outcome measures
    • Access to relevant patient information
    • Effective health information technology
    • Aligned payment policies

 

Principles for Inclusion of Pharmacists’ Clinical Services in the Patient-Centered Primary Care Medical Home. (March 2009). http://www.accp.com/docs/misc/pcmh_services.pdf


Slide 27

Delivering Better, Safer Care in Communities Nationwide: The PSPC Performance Story

Stephanie M. Hammonds, Pharm.D.
Office of Pharmacy Affairs,
HRSA

Slide 28

How Reliable is our Care? 
A Function of System and Culture

Patient Safety and Clinical Pharmacy Services Collaborative (PSPC) Aim

Chaos 1:100 1: million
-Custom-crafted processes -Standard process
-Safety drills
-Alerts
-Loss of individual identity
-Defer to expertise
-Safety Culture
-Each Doc writes unique orders
                    á
Multi-disciplinary rounds
Protocols for high risk meds
                         á
                       CPS
-Anesthesia safety
-Airline industry
                      á

Autonomy                                                 Teamwork                         Highly Reliable Org’s

 

Slide 29

Let’s Improve Health Outcomes!
A Decade of “Calls for Action”
 
Primary Care Status Quo:

  • Physicians Rx patients, w/o collaboration
  • Accept Rx errors as ok, or not my problem
  • Tolerate non-adherence, poor outcomes

Calls us to lead “Significant Change”,
Target: Chronic Disease via Primary Care


Slide 30

PSPC Aim

To save and enhance thousands of lives a year by:
1.   Achieving optimal health care outcomes 
2.   Eliminating adverse drug events 
3.   Increasing clinical pharmacy services


Slide 31

PSPC Teams are Transforming and Improving Quality Delivery Systems  

This slide is a visual of how PSPC is working to improve the overall delivery system.  PSPC focuses on comprehensive primary care including transitions of care. The PSPC aims to integrate clinical pharmacy services into the patient-centered health home. 

On the left there is a traditional model which indicates that is not powerful enough to significantly improve outcomes, particularly for complex patients.  In an ideal world everyone would have a primary care physician. 


Slide 32

Models for Medical Home
“Doc alone with an Rx pad”

This slide shows the traditional model of care that is available.  The traditional model only covers basic episodic care, which leads to status quo outcomes.


Slide 33

Models for the Medical Home
Systems/Teams for Better Outcomes

This slide shows the advanced model.  This model illustrates that there needs to be a way to minimize the old standard of care, which is only visiting the doctor in his or her office.  The advance model shows that there are three levels that need to work together to result in better outcomes.  These three levels work to close the outcomes gap. 

  • Doctors office ó Basic Care, Episodic
  • Expanded Medical Home ó Preventive Planned Care
  • Comprehensive Health Home: Community Health Centersó Disparity


Slide 34

The “3T’s” Road Map to Transform US Health Care
The “How” of High-Quality Care

This is a diagram of the three Ts of transforming healthcare.


Slide 35

Acquiring and Advancing Knowledge to Achieve Better Outcomes

This is another diagram of the three Ts of transforming healthcare. One example illustrates an ace inhibitor.  T1 represents the basic biomedical research; someone discovers the chemical compound that can inhibit the angiotensin converting enzyme.  However, without the next step one will not be able to impact public health.  T2 is in the middle and has an image of a funnel that represents the clinical research trials that will eventually be marketed.  T3 shows that despite the clinical research, there is a huge backlog in systems-based performance improvement, which is leading to patients falling through the cracks.  This is represented by the boat neck on the diagram.  Currently, PSPC is at the boat neck.  The average patient in the PSPC population takes at least eight prescription drugs and has five chronic conditions, and sees multiple providers. 


Slide 36

Health Status Breakthroughs in High-Risk Patient Populations  

The PSPC high-risk patient population is characterized by:

  • 8 drugs per patient
  • 5 chronic conditions per patient
  • 3 providers per patient

The soundtrack for our patient’s health care stories?: Scary Music
30% of PSPC teams’ total patients are in this high-risk population


Slide 37

Health Status Breakthroughs for Multiple Populations of Focus (PoFs)

On this slide there is a pie chart showing the distribution of Teams by PoF.  The pie chart is divided into Anticoag (15%), Asthma (8%), BP (5%), Diabetes (54%), HIV/AIDS (13%), LDL (5%).

For each of these POFs, teams are working to bring patients from health status out of control to under control.


Slide 38

Imagine a future when:

Patients

  • Are in proactive, comprehensive medical homes
  • Receive indicated planned/preventive care
  • Understand what each med is intended to do
  • Safely use indicated Rx to achieve those goals
  • Are in a world class community of practice Health Professionals
  • Work collaboratively, with joy

PSPC is doing this, and WILL BLOW THE DOORS
OFF STAUS QUO!


Slide 39

A Map on the Road to Improvement

“Change Package”

  • Details the leading practices that together address the Aim and Goals of the improvement process.
  • Developed by harvesting lessons from high performing organizations that have achieved outstanding results.
  • Reviewed and vetted by a panel of national experts.
  • Serves as the catalogue of leading practices that teams adapt and use to accelerate the improvement process.


Slide 40

The PSPC Change package is organized into five strategies to achieve results

This slide has a pyramid with the top of the pyramid labeled as Patient Centered Care, the middle portion labeled Safe Medication Uses System, and the bottom portion labeled Integrated Care Delivery.  The free space on the left side of the pyramid is labeled Leadership Commitment, and the free space on the right side of the pyramid is labeled Measurable Improvement. 


Slide 41

Institute for Healthcare Improvement (IHI) Breakthrough Model for Improvement

This graph shows IHI methodology and how improvement cycles help with the acceleration to move further and faster than the status quo drift.


Slide 42

PSPC Performance Story
Patients with Health Status Out of Control
September 2009 (Baseline)

This slide shows a bar graph.  Each bar graph represents the patient in the team populations shown on slide 37.  100 percent of the patients had the status Out of Control.


Slide 43

Patients with Health Status now
“Under Control” vs. “Out of Control”
Through PSPC 2.0 (12 Months)

This slide is a graph of the teams shown on slide 42.   On this graph it is clear that patients receiving care from their respective teams showed dramatic improvements.


Slide 44

Health Status Breakthroughs

In just 12 months, 54% of patients brought their health status under control


Slide 45

Patient Safety Breakthroughs

Teams are working to drive rates of
potential adverse drug events (pADEs) and adverse drug events (ADEs) to ZERO

Average team improvement through PSPC 2.0

  • pADE rates fell 60%

      from an average of 0.86/pt to 0.34/pt

  • ADE rates fell 49%

from an average of 0.12/pt to 0.06/pt


Slide 46

PSPC Potential Impact at full scale up

CHC patient population expected to reach 40 million

  • Extrapolating from PSPC Data:
    • 12 million patients will need CPS
    • 5.4 million potential ADEs avoided
    • 720,000 actual ADE’s prevented
  • Savings Generated:
    • $8.7K/ preventable ADE


Slide 47

PSPC Spread
Number of… PSPC 1.0 PSPC 2.0 PSPC 3.0 (as of 11/1/10)
Teams 68 110 127
States 37 inc. PR 41 inc. DC and PR 43 inc. DC and PR
Community Health Centers 57 79 100
Colleges/Schools of Pharmacy 24 53 73

 

Slide 48

PCMH in Practice:  The Pharmacist Experience

Vincent Willey, Pharm.D.
Associate Professor of Pharmacy
Philadelphia College of Pharmacy

At the bottom of the slide there are logos for Quality Family Physicians and the Philadelphia College of Pharmacy.


Slide 49

Presentation Overview

  • Our PCMH practice
    • Pharmacist consultation
    • Patient scheduling and referral
    • Patient visit flow

 

  • Physician perspective
  • Implementation challenges


Slide 50

Practice Background

  • Three fulltime physicians
    • Privately owned practice
  • 9 staff
  • Medical assistants
    • No nurse practitioners, physician assistants or nurses
  • Practice started in 1999
  • Electronic medical record since inception
  • Phlebotomy on-site from national lab provider


Slide 51

Pharmacist Consultation

  • Collaboration with the Philadelphia College of Pharmacy

 

    • Pharmacists currently 2 full days per week
      • One full day and two half days
    • Started in July 2009
      • One pharmacist at one day per week

 

    • Second pharmacist added in January 2010
      • Two half days per week


Slide 52

Pharmacist Consultation Area

  • Specific patient education area

 

    • Not an exam room
    • Table and chairs to facilitate more relaxed atmosphere and more than one person
      • Significant others
      • Group visits


Slide 53

Patient Scheduling

  • Pharmacists’ schedule maintained in the same system as the physicians
  • Receptionists make appointments
  • Majority of patients specifically referred by the physician
  • One hour for new patients
  • Half an hour for follow-ups


Slide 54

Patients Currently Referred

  • Metabolic syndrome
    • Diabetes
    • Hypertension
    • Dyslipidemia
    • Most have multiple or all 3 conditions

 

  • ADHD/depression/anxiety/bipolar disorder
  • Others


Slide 55

Future Expansion of Patients

  • Asthma

 

  • Smoking cessation
  • Anticoagulation management

 

  • Pain management
  • “Complex” medication regimens


Slide 56

Patient Visit Flow- Initial Visit

  • Medication review
    • Update current list
      • Especially inquire regarding OTC and alternative meds

 

    • Review indications
      • Do they know why they are taking each?
    • Assess adherence


Slide 57

Patient Visit Flow- Initial Visit

  • Introduction
    • Who and what I do
    • Not just about medications
    • What do they want to get out of the session

 

  • Disease state education
    • Review of lab parameters and goals
    • Use EMR to show graphs for trends
    • Why we care about these numbers


Slide 58

Patient Visit Flow- Initial Visit

  • Diet review
    • Current diet