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Evidence-Based Medicine for Pharmacists in the Patient-Centered Medical Home (PCMH)

Webcast transcript, Monday, December 13, 2010

OPERATOR:  Good day, ladies and gentlemen, and welcome to today’s conference entitled Evidence-Based Medicine for Pharmacists in the Patient-Centered Medical Home.  If you get disconnected at any time from the Web conference, you may dial 888-632-5065 or 201-604-0318.  And, when prompted, please enter 57764940 followed by the pound sign.  Again, that code is 57764940 followed by the pound sign.

At this time, it is my pleasure to turn the floor over to Sarah Shoemaker.  Ma’am, the floor is yours.

SARAH SHOEMAKER:  Thank you.  Good morning, ladies and gentlemen, on behalf of the Agency for Healthcare Research and Quality, also known as AHRQ, welcome to today’s Web conference titled Evidence-Based Medicine for Pharmacists in the Patient-Centered Medical Home, held by AHRQ’s Effective Health Care Program.

My name is Sarah Shoemaker. I am a Health Services and Policy Researcher with Abt Associates in Cambridge, Massachusetts.  I am also a pharmacist.  I have been working with AHRQ’s Office of Communications and Knowledge Transfer to conduct outreach to pharmacists and make them aware of AHRQ’s evidence-based resources and engage them in AHRQ’s Effective Health Care Program, and I will be moderating today’s event.

Before we get started, I want to review some information about today’s Web conference technology.  If you are experiencing technical difficulties, there are a number of options for assistance. You can click on the Click Here for Web conference Help Link to be directed to a troubleshooting Web site to do a systems check, or you can open the Web conference FAQ document under the Downloadable Files button on the bottom of your screen.  You can also contact technical support by submitting your issue in the Ask Question box.

Under the Downloadable Files button, you will also find the slides for this event, which may be helpful for reviewing slide details, and a document with speaker biosketches.

Today’s Web conference includes closed captioning, the captioning that appears in a box below the slides through the Windows Media Player or Real Player buttons on the main page.  Finally, this presentation is being recorded and will be made available on the AHRQ Web site shortly.

This Web conference was developed by AHRQ’s Effective Health Care Program, with assistance from the American Pharmacists Association.  This Web conference is approved for one and a half hours of CPE [Continuing Professional Education] credit; to obtain credit, participants must participate in the entire conference and complete the online evaluation by December 27.  A voucher code and further instructions will be provided at the end of the Web conference.

In terms of learning objectives, at the end of today’s Web conference, we anticipate that each of you will be able to define the tenets of the medical home and AHRQ’s role; describe the various patient-centered medical home models; discuss successful implementation strategies and potential barriers to the medical home model; and recognize the Effective Health Care Program as an evidence-based resource.

Now, let me introduce our speakers.  We will first be hearing from Janice Genevro from AHRQ’s Center for Primary Care Prevention in Clinical Partnerships.  She will present AHRQ’s perspective and role in the patient-centered medical home and share with us a medical home resource available from AHRQ.

Then we will hear from Stephanie Hammonds and Karen Williams from the Health Resources and Services Administration, or HRSA, about their experiences with integrated models of care in their Patient Safety and Clinical Pharmacy Services Collaborative.

Next, we will hear from Vince Willey from the Philadelphia College of Pharmacy about his experience in a medical home practice, including the challenges.  And, last, we will hear from Scott Smith from AHRQ’s Center for Outcomes and Evidence about evidence-based resources that may help pharmacists in the medical home and other settings.

Finally, we have set aside time at the end of the call to take questions from the audience, which can be entered by the Ask Question button, which is located at the bottom of your screen.  When you click on the button, a box will appear requesting that you enter your question.  Once completed, press the Submit button.  Feel free to pose questions throughout the presentations, and we will try to answer as many questions as we can at the end during the moderated Q&A session.

The following are the disclosures the speakers have to claim.  So, without further ado, I'll turn it over to Janice Genevro from AHRQ.  Jan?

JANICE GENEVRO:  Good morning, everyone.  As Sarah mentioned, I work at the Agency for Healthcare Research and Quality.  I’m a Senior Scientist and Lead of the Primary Care Implementation Team in the Center for Primary Care Prevention and Clinical Partnerships.  I’ll be providing information–some information about the Agency for Healthcare Research and Quality in terms of the work that we do and our mission and also introduce you to AHRQ’s work in the patient-centered medical home and some online resources that we’ve developed that we will hope will be of great value to you.

AHRQ’s mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans, and, to do this, we work in three general areas.  First, we generate new knowledge, and this includes providing research support through grants and contracts.  We synthesize evidence, and we support implementation, and we are doing work in all three areas related to the patient-centered medical home.

In terms of our position on primary care, the Agency for Healthcare Research and Quality recognizes that revitalizing the nation’s primary care system is foundational to achieving high-quality, accessible, efficient health care for all Americas, so we understand that high-quality primary care is essential to supporting our mission and supporting good health care and good health care outcomes for all Americas.

Specifically in relation to the medical home, AHRQ believes that the primary care medical home, which is also referred to as the patient-centered medical home or PCMH, advanced primary care, and the health care home, is a promising model for transforming the organization and delivery of primary care.

AHRQ has developed our own definition of the medical home, and first of all, we wanted to point out that a medical home is not simply a place, but it’s a model of primary care that delivers high-quality care that’s patient-centered, comprehensive, coordinated, accessible, and continuously improved through a system-based approach to quality and safety.  And I’d like to talk a little bit more about each of these components and provide some specific information about our perspective on these.

So those are the key components of the medical home; our definition of the medical home, the first is that the medical home is patient-centered.  And this means that the primary care that’s delivered is relationship-based with an orientation toward the whole person.  It also involves partnering with patients and their families, which requires understanding and respecting each patient’s unique needs, cultures, culture values, and preferences.  The medical home practice actively supports patients in learning to manage and organize their own care at the level that the patient chooses.  Recognizing that patients and families are core members of the care team, medical home practices ensure that they are truly informed partners in establishing care plans.

Comprehensive care is also an essential and important aspect of the medical home.  The primary care medical home is accountable for meeting the large majority of each patient’s physical and mental health care needs, including prevention, wellness, acute care, and chronic care.

We’d like to highlight that providing comprehensive care requires a team of health care providers, including pharmacists.  But the care team also will include physicians, advanced practice nurses, physician assistants, nutritionists, social workers, educators, and care coordinators.

Although some medical practices may bring together large and diverse teams of care providers to meet the needs of their patients, many others, including smaller practices, will build virtual teams that link themselves and their patients to providers and services in their community.

Actually, I misspoke there, that was comprehensive care.

Moving on to coordinated care.  The primary care medical home is responsible, at least in our perspective, for coordinating care across all elements of the broader health care system.  This would include specialty care, hospitals, home health care, and community services and support.  This coordination is particularly critical during transition between sites of care, such as when patients are being discharged from the hospital, or moving from primary care to nursing home settings, or from nursing home settings back to primary care.  It’s also essential that medical home practices excel at building clear and open communication among patients and families in medical homes and members of the broader care team.

Next, the medical home needs to provide superb access to care.  The primary care medical home delivers successful services with shorter waiting times for urgent needs, enhanced in-person hours, around-the-clock telephone or electronic access to a member of the care team, and alternative methods of communication, such as e-mail and telephone care.  In–it’s especially important to note that the medical home and practice is designed to be responsive to patients’ preferences regarding access.

And, finally, in terms of a systems-based approach to quality and safety, the primary care medical home demonstrates a commitment to quality and–quality improvement by ongoing engagement in activities such as using evidence-based medicine and clinical decision support tools to guide shared decisionmaking with patients and families.

We also recognize that there are other aspects of the supporting environment that are needed to help make medical homes a success.  These include health information technology, workforce development, and payment reform, which we believe are critical to achieving the potential of the medical home.

The full version of AHRQ’s definition of the medical home is available at the link that’s there on your slide,, and I'll be talking a little bit more about that resource toward the end of my presentation.

We did want to highlight that the principles–the joint–the joint principles that were–that have been publicized by the American Academy of Family Physicians, the American Academy of Pediatrics, and the American Osteopathic Association and our principles are closely aligned.  You’ll see the crosswalk here between the elements of AHRQ’s definition of the patient-centered medical home and the joint principles.  Two things we wanted to highlight are that we have focused on team-based care as being a core element of comprehensive care, and, as I mentioned, we see pharmacists as being a critical element of team care.  And we have not focused on the notion that the primary care medical home needs to be directed by a physician or that there needs to be a personal physician as part of the medical home; rather the patient and family can relate directly to the team in the primary care medical home.

I’d like to talk a little bit about some of the research that AHRQ’s doing, and some other projects that we have under way to support the patient-centered medical home.  First, we have retrospective evaluations that are under way at two sites; these are being conducted at Health Partners in Minnesota and WellMed in Texas, which are two sites that have been leaders in the patient–the transformation movement to the patient-centered medical home.

We also have several mixed-method evaluations that are designed to understand how primary care practices have transformed to the medical home.  We’ve made 14 two-year awards, and those awards were made in the summer of 2010, they’re for two years, and so we’ll be able to get results and hopefully communicate those to the larger medical community in 2012.

We’ve also supported the development of a research agenda related to the primary care medical home; this was work that was co-funded with the Commonwealth Fund and the ADIM Foundation, it was a collaboration of professional societies. A meeting was held in late October 2009, and the results of this agenda were published in June 2010 in the Journal of General Internal Medicine and are available, I believe, to the general public for download.

And I don’t really know what that noise was or if everyone heard it, but we will move ahead.

AHRQ also has made a commitment to supporting the development of information for decisionmakers related to the primary care medical home as part of a larger project that we’ve undertaken.  We are publishing foundational white papers, and these are available to the general public on the Web site that I mentioned early–earlier.  The three papers that we started with were designed to address what we thought were core issues in the primary care medical home that there were information gaps.  The first is a paper regarding the HITECH Act’s potential to build medical homes, and this is called necessary but not sufficient.

The second paper addresses issues related to engaging patients and families in the medical home, including patient and family involvement in their own care and quality improvement and safety initiatives at the level of the individual primary care medical home and also engaging patients and families in larger policy and strategy issues related to the development and evaluation of the medical home.

Finally, the third initial white paper related to issues regarding integrating mental health services into the medical home.  These are specifically designed to address policy and research issues, and there are associated decisionmaker briefs that are three to four pages that highlight the central issues, and those will be available, we hope, in the beginning of 2011.

We also have another set of white papers and briefs that will be coming out.  We are looking at PCMH outcomes, there’s a lot of conversation about how successful the patient-centered medical home has been in delivering the kind of outcomes that the research and policy community and the general health care community are interested in, including improvement of care, improvement of health outcomes, and reduction of costs.  So we’re planning a paper that will provide information about outcomes of specific kinds of forerunner primary care mental home models.

We’ll also be looking at the patient-centered medical home within the larger health care system, looking at the medical neighborhood, and we have a particular brief coming out that looks at care coordination within the context of the patient-centered medical home and the accountable care organization.

We do have an upcoming series of briefs on the status of primary care in the United States. I've just learned, however, that the analysis of the primary care workforce paper has been delayed, but we will post that as soon as it’s available on the Web site that I mentioned.

In addition, the patient-centered medical home resource, online resource, has a database of published literature on the medical home that includes over 500 citations.  It’s searchable by domain, by policy, relevance and outcomes, and it includes a section on foundational documents and articles that, we hope, will be of value to you.

Finally, I'd like to talk about some implementation projects.  AHRQ has developed a toolkit on integrating the chronic care model and safety net settings.  This–the chronic care model was developed by Ed Wagner and colleagues, and there’s tremendous overlap between the elements of the chronic care model and the primary care medical home.  These toolkits are designed to help individual practices and health care systems make the transformation to providing the services that the medical home ideally offers.

We’ve also initiated a project to bring together a national expert working group on using practice facilitators and practice coaching to facilitate transformation to the patient-centered medical home.  This will be launched in winter 2010, and the primary product from this will be a toolkit on how-to guide to help practices make the transformation.

Then, very briefly, we also have some health IT products and projects related to the patient-centered medical home.  One of these specifically is designed to help describe the information flows and interactions between and among patients and consumers and other primary care medical home stakeholders, and it will be based on the development of some new functional use cases.  This began in the summer of 2010, and results from this will also be available within the next 18 months or so.

Finally, here is the online PCMH resource center that I mentioned.  Again, you can find it at; it has the foundational white papers, it will have policy briefs, it has the searchable citations database and will also be the repository for additional information that we develop over time as AHRQ increases its investment related to the patient-centered medical home.

This online resource is targeted toward meeting the needs of policymakers and researchers, it has information about our definition of a medical home, and I mentioned the database and the white papers.  It will continue to grow and expand, and we hope to be augmenting the information that will be available regarding implementation and information that will be of value to people who are actually providing patient-centered medical home–oriented care in the field.

And I think that’s it for me.

SHOEMAKER:  Thank you, Jan, for sharing us with–sharing with us AHRQ’s principles for the patient-centered medical home and making us aware of AHRQ resources.  I know we have a diverse audience of pharmacists from several settings, all of whom I’m sure could find valuable resources on AHRQ’s PCMH online resource.

Besides AHRQ’s principles and the joint principles developed by several physician organizations, we wanted to recognized that, in 2009, several pharmacy organizations developed principles for inclusion of pharmacists’ clinical services in the patient-centered medical home.  These principles include access to pharmacist services, patient-focused collaborative care, flexibility in the design of the medical home, development of outcome measures, access to relevant patient information, effective health information technology, and aligned payment policies.

In the pharmacy principles document, the organizations acknowledge several private and public sector success stories of pharmacist clinical services enhancing the safety and effectiveness of medication use.  One of the success stories is HRSA’s Patient Safety and Clinical Pharmacy Services Collaborative, which turns us to Stephanie Hammonds’s presentation.

STEPHANIE HAMMONDS:  Thank you, good morning.  My name is Stephanie Hammonds, and I work in the Quality Improvement Branch of the Office of Pharmacy Affairs at HRSA, the Health Resources and Services Administration.  My colleague and the Quality Improvement Branch Chief, Commander Karen Williams, regrets that she’s unable to be here today, a real trouper, she’s undergoing treatment for breast cancer, and today is her infusion day.

I’d also like to thank Dr. Mark Laufman at Northwestern University for his assistance with this presentation.

Our mission in the Office of Pharmacy Affairs is to provide clinical and cost-effective pharmacy services to enable participating entities to stretch scarce federal resources in order to serve more patients, expand their services, or offer additional services.

As part of this two-fold mission in conjunction with administering the 340B Discount Drug Program, HRSA launched the PSPC, the Patient Safety and Clinical Pharmacy Services Collaborative.  Using the Institute for Healthcare Improvement’s breakthrough series methodology, the Patient Safety and Clinical Pharmacy Services Collaborative achieves optimal patient health outcomes, eliminates adverse drug events, and provides sustainable access to clinical pharmacy services for ambulatory patients served by safety net providers.

Patients selected for interventions take an average of eight prescriptions, have five chronic health conditions or more, and are medically out of control.  Operating on a 12-month cycle, 54 percent of the selected patients improved to be medically under control, adverse drug events were reduced by 49 percent, and potential adverse drug events were reduced by 60 percent.  And I’ll provide more detail on how we do that over the next several slides.

This slide represents a systems prediction of the rate of error; currently, primary care providers operate in relative autonomy without any real system of care.  As a result, in chaotic fashion, there’s no way to predict an error rate.

In the middle, by using a systems-based approach, we were able to get a baseline measure on our rate of error.  And, on the right, by implementing clinical pharmacy services into these systems, this is where we can go.  With a highly reliable organization, error rates are extremely low.

In 2001, the landmark IOM [Institute of Medicine] report “To Err is Human” was published.  Then there was a call to reduce health disparities.  We’ve had a decade of calls to action, we’ve had a decade of hospital-focused work in patient safety, but outcomes remain largely unchanged.  The recent OIG report shows that we kill about 15,000 Medicare beneficiaries each month, as much as half from medication errors.  That’s 20 jumbo jets full of Medicare beneficiaries crashing, killing all passengers on board each month.

And still, we tolerate the status quo of the lone physician treating patients without team-based collaboration, we tolerate non-adherence and poor outcomes, and then we blame the patient.  Because of this, the needle is not moving, we’re not seeing a change despite a decade of asking for it.

So, instead of killing 7,000 Medicare beneficiaries, our goal is first to keep them all alive.  The PSPC aim is to save and enhance thousands of lives each year by achieving optimal health care outcomes, eliminating adverse drug events, and integrating clinical pharmacy services into primary care.

This is a visual of the aim that you saw on the previous slide, or we want to improve the overall delivery system.  So, with a focus on comprehensive primary care, including transitions of care, the PSPC aims to integrate clinical pharmacy services into the patient-centered health home.

Over on the left, you see the traditional model, which is not powerful enough to significantly improve outcomes, particularly for high-risk complex patients.  Everybody in an ideal world has a primary care doc, they leave the light on for you, they have their prescription pad, it’s basic episodic care with the same old outcomes.

So, looking to an advanced model, we want to minimize the old standard of care with the lone doc in his or her office.  And I know it doesn’t look like it on the left side, but it doesn’t look like an injection needle, but think of clinical pharmacy services as a shot in the arm to help us do what we need to do to get better outcomes.  These three levels of care turn the old system of care on its head and close the outcomes gap between expected and actual outcomes.

I think many of you have probably seen this diagram before of the three Ts to transform health care, so I won’t spend much time on it here.  But there’s another way to think of it; let’s use an ACE inhibitor as an example.  So, in T1, we have all the basic biomedical research, someone discovers the chemical compound that can inhibit angiotensin-converting enzyme.  But, without the next step, it’s useless to impact public health.

In T2 in the middle, what looks like a funnel, we have the clinical research trials, and somebody ultimately markets the product.  The patient takes their medication, but perhaps not the right way or perhaps without a good system in place. We failed them and never spent the time with them to make sure they understood how to take it the right way.  Then they get a cough, and they get all this inappropriate treatment for bronchitis or asthma, or perhaps nobody monitors their potassium, and they die of sudden cardiac death.

So what T3 shows is, despite the clinical research to market the drug that could save their life, we’ve got a huge backlog in a systems-based performance improvement.  The funnel has only been a bottleneck, and now patients are falling through the cracks, and these cracks are like the cracks in the wheels of a steam engine coming down the track, and it’s like watching a train wreck getting ready to happen.

So, a train wreck getting ready to happen.  Pretend you’re watching a movie, and you were watching a train wreck, and what’s the soundtrack?  You hear scary music.  Well, these are real data, this is the average patient in the PSPC population of focus takes at least eight prescription drugs, they’ve got at least five chronic conditions, and they see multiple providers.  We focus on the high-risk, high-cost medically complex patients, and what do we call them?  We call them our train wrecks.  Sadly, this could be the story of their life, and the scary music is their soundtrack.

So, although teams start with a population of focus, a small sample of patients to target for their quality improvements, our data have shown that as much as 30 percent of the patients in the safety net can be classified as high-risk.

So, teams start with a population of focus and track the metrics for one of their out-of-control health conditions.  However, the goal is to spread the improvement model to all core measures for all the patients.  Like to spend a minute here, and I’d like to point out that, even though the teams are tracking and reporting the measures for one condition, they are still taking care of the whole patient.  This one measure is a place to start their systems-based quality improvement effort.

Also note that over half of our teams focus on diabetes, perhaps as a low-hanging fruit.  But, as we know with diabetes, 96 percent of these patients have more–have other comorbidities.  And at the risk of sounding like a broken record, while teams might only track and report the HbA1c measures to HRSA, they are nevertheless providing comprehensive care for all the comorbidities to that patient.

So, we’re going to look to the future and think of Mr. Big Voice in the movies.  Imagine a time,  but the future is now, PSPC is already doing all of the things that you see here.  We have the potential to redesign and enhance medication reconciliation processes such that the patient is the driver at every encounter regardless of who provides care or where.  Imagine a time where patients review their medication lists with their providers at each office or ER visit, hospital discharge, consultant office pharmacy, or other to be sure that we’re all on the same page, and the patients actively challenge and manage changes.

So, imagine a present future where patients know what each med is intended to do, know that if–know if the goal is being met, they’re aware that they have a formulary, they have adopted a healthy skepticism, and can–and can challenge any change to their med list to ensure it is indeed an improvement, and actively seek advice and counsel regarding medication management from their clinical team.

So, instead of a clear and present danger, by putting names and faces on our aim, the PSPC is like a controlled building demolition, and we believe it’s going to blow the doors off the status quo.

So, the PSPC uses a change package, and you might ask, What is that?  During the first year of the PSPC, high-performing teams were studied for leading or best practices.  These best practices were then vetted by national experts and compiled for re-dissemination to other teams as one of the ways that we foster an all-teach, all-learn environment.  This document is a living, breathing document, and it’s updated as teams find new ways to break through challenges and spread clinical pharmacy services to more patients.

Think of the collaborative really as a single, all-encompassing strategy, one process that operates with three core components and two overriding principles. 

And here are some of our data from year two.  So, what you’re looking at, each bar on this graph represents the patient in one team’s population of focus.  If you’ll recall the pie graph that I showed you earlier with the 54 percent of teams focusing on diabetes in addition to those other disease states, teams selected patients whose health status was out of control.  So, by definition, at the beginning of the year, 100 percent of the patients are out of control.

So, here is the same graph, the same teams, the same patients across all the same disease states after 12 months in the PSPC.  But you can see that the patients receiving care from these teams have demonstrated dramatic improvements.