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©2015 The Advisory Board Company • advisory.com

Integrated Pharmacy Models

in Primary Care

Health Care Industry Committee

Summary

The health care industry has selected one phrase to describe growing efforts to improve the long-term health outcomes of

populations while lowering long-term costs: population health. Despite the consistency in terminology, hospital population

health strategies are anything but uniform, especially when it comes to how they incorporate pharmaceutical management.

Pharmaceuticals are one of the most powerful methods of improving long-term health outcomes, but only if the right patient

takes the right prescriptions at the right time. Increasingly, hospitals are bringing pharmacists and medication therapy

management services to the forefront of population health initiatives. The population health leaders spearheading these

initiatives, as well as their nursing and pharmacy allies, need your support to make the right investments and get the most

value out of your products.

This research brief profiles several advanced population health programs integrating pharmacy services directly into the

primary care setting. While the brief was originally produced for hospital population health managers, we believe the insights

are important for the pharmaceutical industry as well. By understanding how progressive hospitals are structuring innovative

pharmacy programs that incorporate your products, we believe you can better position your expertise in medication

management and patient education to augment your partners’ efforts.

©2015 The Advisory Board Company • 29994 advisory.com 2

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Program Director

Contributing Consultants

Research and Insights

Design Consultant

Sara Sanchez

Rebecca Tyrrell, MS

Tracy Walsh, MPH

Meridith Weiss, MPH

Stefanie Kuchta


Table of Contents

Research in Brief. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

A Checklist for Integrated Pharmacy Program Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Section 1: Five Programs You Can Learn From . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Profile #1: University of Michigan Health System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Profile #2: University of Southern California-AltaMed CMMI Pilot . . . . . . . . . . . . . . . . . . . . . 9

Profile #3: Hennepin County Medical Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Profile #4: University of North Carolina-MAHEC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Profile #5: University Connecticut CMS Demonstration Pilot . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Section 2: Action Steps and Cross-Program Insights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Key Insights from Integrated Pharmacy Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Core Components Grid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15


Research in Brief

Source: Advisory Board interviews and analysis.

The Research

Advisory Board researchers conducted a literature review of integrated pharmacy models in primary

care. Then we interviewed some of the best organizations with models demonstrating positive

clinical and financial outcomes to get actionable insights.

Here, we’ve profiled five organizations that represent a broad range of integrated pharmacy

models in terms of geographic location, patient population, and program scale. You’ll get an

overview of each program and its defining characteristics, as well as an in-depth look at each

organization’s approach to the six critical components of an integrated pharmacy program:

• Staffing and Deployment

• Patient Eligibility and Referral Processes

• Patient and Provider Engagement Strategies

• Care Coordination Processes

• Performance Metrics and Outcomes

• Financial Considerations

Finally, we recommend action steps to help your organization implement these best practice

models and advance an integrated pharmacy program.

The Challenge

Drug-related morbidity and mortality cost nearly $200 billion annually in the United States.

Integrating pharmacists into primary care can prevent avoidable spending by increasing patient

adherence, optimizing prescription regimens, and preventing medication-related complications. To

address these cost and quality opportunities, progressive health care systems are expanding the

role of the pharmacist as a central component of primary care transformation.


A Checklist for Integrated Pharmacy Program Development


Topics to Address Insights from Top Programs

Staffing and Deployment

Staffing ratios

Team composition

Pharmacist affiliation

Scheduling

Establish a pharmacy support role that performs

administrative, analytic, and patient outreach

functions

Patient Eligibility, Referral Processes

Physician referral protocols

Patient identification triggers

Referral conversion rates

Leverage comprehensive risk stratification criteria

to identify eligible patients

Patient and Provider Engagement Strategies Tactics for promoting provider acceptance

Tactics for increasing patient utilization

Institute mechanisms for interdisciplinary

collaboration between pharmacists and primary

care physicians

Care Coordination Processes

Pharmacist scope of practice

Templates and collaboration agreements

Range of pharmacy interventions offered

Graduation criteria

Use standardized intervention templates to

efficiently track and coordinate pharmacist

activities

Performance Metrics and Outcomes Operational metrics

Pharmacy program impact

Carefully select, monitor, and report clinical and

quality outcomes to facilitate buy-in and best

practice sharing

Financial Considerations

Funding source(s)

Financial impact

Sustainability planning

Measure program impact on total cost of care and

downstream utilization to demonstrate business

case


Five Programs You Can Learn From

See how five organizations have integrated pharmacists into their primary care

teams to improve patient outcomes and reduce avoidable health care spending

Section 1


Profiled Organizations Represent Varying Degrees of Program Scale

Source: Advisory Board interviews and analysis. 1) Medication Therapy Management.

Organization Background Program Overview

University

of Michigan

Health System

(UMHS)

990-bed academic medical center and

health system based in Ann Arbor,

Michigan, with an integrated pharmacist

model deployed at 15 primary care

clinics and four specialty clinics

• Partnership with department of pharmacy, college of pharmacy, and physician group practice

• Group practice model expanded from 3 to 15 primary care sites since 2009

• Pharmacy teams consist of pharmacist and pharmacy residents and students, with support from clinic

panel managers

• Supported by financial incentives from BlueCross BlueShield of Michigan and the creation of T codes to

reimburse non-physician providers for face-to-face and phone visits

University of

Southern California-

AltaMed Health

System CMMI Pilot

(USC-AltaMed)

Integrated pharmacy partnership

between the USC School of Pharmacy

and AltaMed Health System, a network

of 43 community clinics located in Los

Angeles and Orange counties,

California

• Engaged in a CMMI Challenge grant through July 2015 to assess the feasibility and impact of an

integrated pharmacist model across 10 primary care practice sites and 3 video telehealth locations

• Clinical pharmacy teams provide services directly to patients under a set of standardized, evidence-based

protocols

Hennepin County

Medical Center

(HCMC)

894-bed medical center based in

Minneapolis, Minnesota, offering

specialty and primary care MTM1

services at 16 ambulatory care sites

• Embeds 12 FTE pharmacists and two clinical pharmacy residents across 16 ambulatory clinic sites, the

Augustana skilled nursing facility, and the Harbor Light homeless shelter clinic

• Ambulatory MTM services have decreased average variable cost by approximately $2,000 per patient per

year

University of North

Carolina– Mountain

Area Health

Education Center

(MAHEC)

Family medicine residency training

program with seven family health

centers serving 16 counties in western

North Carolina

• Embeds 5.25 FTE pharmacists and two pharmacy residents across the system’s seven ambulatory sites

• Pharmacists work with UNC’s Department of Medicine to conduct Medicare Wellness visits, enabling

pharmacists to bill at a higher reimbursement rate

• Significant collaboration with community organizations, including a community pharmacy, medication

assistance program, and the regional aging council

University of

Connecticut CMS

Demonstration Pilot

CMS demonstration project to embed

pharmacists across five primary care

sites in Connecticut between July 2009

and May 2010

• Examines impact of the integrated pharmacy model for Medicaid polypharmacy patients

• Contracted with nine independent pharmacists at five primary care practices in Connecticut

• Program led by stakeholders from the University of Connecticut School of Pharmacy, the Connecticut

Pharmacists Association, and the Connecticut Department of Social Services

• Results included an estimated annual savings of $1,595 per patient


Profile #1: University of Michigan Health System

University of Michigan’s Close Partnerships Drive Credibility, Scaling Efforts

Source: University of Michigan Health System; Advisor Board interviews and analysis.

Case in Brief University of Michigan Health System

(UMHS)

• 990-bed system comprised of three hospitals,

40 outpatient locations with more than 120

clinics, and a medical group of 1,800

• In 2009, launched collaborative partnership

between College of Pharmacy, Department of

Pharmacy, and Faculty Group Practice to

create an integrated pharmacist model, now

deployed at 15 primary care clinics and 4

specialty clinics

• Through the BCBS of Michigan PCMH program,

UMHS developed new reimbursement process

for clinical pharmacy services, generating

revenue through use of T codes that allow non-

physicians to bill for services; currently,

pharmacists are participating in a multi-payer

demonstration project

UMHS Collaboration Across Groups to Support Pharmacy Model

Commercial Payer

• Provides initial funding for patient-centered medical home development (BCBS of Michigan)

• Offers financial incentives for quality performance

• Provides reimbursement for fee for service and enhanced E&M codes

College of Pharmacy

• Faculty make up the

core practitioner group

• Students support to enhance

patient care and outreach

Faculty Group Practice

• Provides infrastructure, funding

• Leverages existing relationships

to improve patient recruitment

Department of Pharmacy

• Standardizes processes;

promotes unity across sites

• Helps support cost of direct

patient care

• Partially funds pharmacist salaries

Staffing and

Deployment

Patient Eligibility,

Referral Processes

Patient and Provider

Engagement Strategies

Care Coordination

Processes

Performance Metrics

and Outcomes

Financial

Considerations

• Staffing ratio:

Variable based on

facility size, budget

allocation, and team-

based care readiness

• Team composition:

Pharmacist, pharmacy

residents and students;

outreach support from

clinic panel managers

• Patient caseload:

Avg. 6.5 patients/half-

day; goal of 5+/half-day

• Direct referral:

Variable based on

program maturity;

initially rely on registry

to drive volumes and

increasingly shift toward

provider referrals

• Clinical triggers:

Diabetes, hypertension,

polypharmacy, not on

evidence-based

medications

• Time to steady-state

referral volumes:

6 months

• Strategies: Building on

existing patient-provider

relationships,

positioning pharmacist

as an extension of the

PCP’s services and

network

• Collaboration

strategies: Single

medication list,

progress notes, and

medication plan shared

between pharmacists

and PCPs; pharmacist

conducts follow-up visit

after initial intake to

discuss medication

changes and action

steps for patient

• Clinical outcomes:

0.8% decrease in A1c

for patients with

baseline A1c>7% and

1.4% decrease for

those with baseline

A1c>9%

• Funding source: 70%

clinical pharmacy work

paid by health center,

30% subsidized;

increasingly shifting

more costs to clinic

• Other: Developed new

reimbursement process

for clinical pharmacy

• Financial outcomes:

Generated $154,831 in

revenue via T codes in

first year (2009)


Profile #2: University of Southern California-AltaMed CMMI Pilot

USC-AltaMed’s Pharmacy Care Managers Optimize Team Workflow

Source: University of Southern California, AltaMed Health System; Advisory Board interviews and analysis. 1) Based on 1 year pre- vs. 1 year post-enrollment; controlled evaluation anticipated by 2015.

Case in Brief University of Southern California-AltaMed CMMI

Pilot (USC-AltaMed)

• Integrated pharmacy partnership between the USC

School of Pharmacy and AltaMed Health System, a

network of 43 community clinics located in Los

Angeles and Orange counties, California

• Currently engaged in a CMMI Challenge grant

through July 2015 to assess the feasibility and

impact of an integrated pharmacist model across

10 primary care practice sites and three video

telehealth locations

• Clinical pharmacy teams provide services directly

to patients under a set of standardized, evidence-

based protocols

• Pharmacy Care Managers handle majority of

administrative work, enabling pharmacists to focus

more on patient care and leading to a 40%-50%

increase in visits per pharmacist per day

Staffing and

Deployment


Referral Processes



Care Coordination

Processes

Performance Metrics

and Outcomes

Financial

Considerations

• Staffing ratio:

1 clinical pharmacy

team per 4 FTE PCPs

and 8,000 patients


Pharmacist, pharmacy

resident, and clinical

pharmacy technician


350-725 per team;

average 14-22 patients

per day


≈50% of patients,

usually by primary care

physician

• Clinical triggers: Of

remaining 50%,

patients identified using

patient registry (e.g.,

A1c>9%, BP>140/90

mm Hg) or identified

following hospital

discharge


referral volumes:

4-6 months

• Strategies: Instituted

daily team huddles and

weekly interdisciplinary

team meetings; started

with practices that

already embrace team-

based care

• Collaboration

strategies: Developed

a set of collaborative

practice agreements

permitting pharmacists

to initiate, adjust, and

discontinue medications

for many chronic

conditions

• Process outcomes:

Between Oct 2012 and

Aug 2013, 19,696 Rx

problems identified

among 1,993 patients


Inpatient admissions

decreased 13.1%, ED

visits by 37.8%, and

observation visits by

50% (n=1,171)1

• Funding source:

Pharmacist teams are

employed by USC, but

program costs are

covered by CMMI grant

through July 2015

• Cost outcomes:

Projected savings

are $31.7M over three

years

Clinical Pharmacy Teams

Primary care team conducts daily huddles and weekly

interdisciplinary team meetings with clinical pharmacy teams

Clinical Pharmacists

• Target most

complex patients

• Manage caseloads

of 350-725 patients

Primary Care

Team

Resident Pharmacists

• Recruited from across

the nation, enrolled in

USC School of

Pharmacy's accredited

residency program

Pharmacy Care Managers

• Review patient registries

for proactive identification

• Conduct patient outreach

• Perform first steps of

medication review

• Prepare medication pill

boxes and lists to help

improve adherence


Profile #3: Hennepin County Medical Center

Multiple Referral Channels Boost Patient Volumes and Facilitate Scheduling

Source: Hennepin County Medical Center; Advisory Board interviews and analysis.

Case in Brief Hennepin County Medical Center

(HCMC)

• 894-bed medical center based in

Minneapolis, Minnesota

• Embedded 12 FTE pharmacists and

2 pharmacy residents across 16

ambulatory clinic sites, the

Augustana skilled nursing facility,

and the Harbor Light homeless

shelter clinic

• Ambulatory MTM services have

decreased average variable cost by

≈$2,000 per patient per year

Staffing and

Deployment


Referral Processes



Care Coordination

Processes

Performance Metrics

and Outcomes

Financial

Considerations

• Staffing: 12 FTE staff

pharmacists, two

pharmacy residents

across seven clinics


Pharmacy Support

Analyst (0.8 FTE)

conducts departmental

administrative, analytic,

and billing functions


Combined with use of

disease registry;

Pharmacy Support

Analyst generates a

weekly list of patients

with an upcoming

appointment who meet

clinical criteria


Physician referral,10+

medications, or asthma

diagnosis

• Provider engagement:

Long-standing inpatient

clinic pharmacy team

creates receptive

system culture

• Patient engagement:

Multiple forms of patient

notification, including

brochures, warm

handoffs, and

telephonic reminders;

MyChart patient

portal access

• Standardization:

In-house EMR

templates, but most of

pharmacist actions are

left to their clinical

discretion

• Process outcomes:

Two drug problems

identified on average

per patient visit


3.4% lower 30-day

readmission rate in

hospital clinic; 90% of

patients surveyed

would recommend

MTM services to a

family member or friend

• Funding source:

Approximately 10%

grant funded, 15%

reimbursed, 75% offset

by reductions in total

cost of care and

increased utilization of

community pharmacy

• Other considerations:

Increased in-network

utilization of HCMC

pharmacies by 15%

among patients who

see MTM pharmacists

Patient Identification Driven by Referrals, Reinforced by Data and Analytic Reports

Patient Outreach

Includes warm handoffs,

brochures on site, automated

reminders, and follow-up calls

for no-shows

Physician Referral

Primary care provider submits

referral order for pharmacist

consult through shared EMR

Data Registry Report

Pharmacy Support Analyst

generates weekly list of patients

with an upcoming appointment

who meet clinical criteria

Number of MTM visits

since January 2014 9,040

Avg. number of drug

therapy problems

identified per visit

2

Patient no-show rate;

comparable to other

ambulatory services

17%

Estimated cost

avoidance for HCMC

in 2013

>$2M


Profile #4: University of North Carolina–MAHEC

Shift from Grant Funding to Billable Services to Ensure Program Sustainability

Source: University of North Carolina; Mountain Area Health Education Center; Advisory Board interviews and analysis.

Case in Brief University of North Carolina-Mountain

Area Health Education Center (MAHEC)

• Family medicine residency training program

that is part of a statewide health education

center system; seven family health centers

serve 16 counties in western North Carolina

• MAHEC works closely with Mission

Hospital, an 800-bed tertiary care teaching

health system

• Pharmacists and pharmacy residents

provide MTM services within

disease-specific clinics and conduct

Medicare Wellness Visits and employee

wellness visits

• Adding a PGY2 residency program in

July 2015

Staffing and

Deployment


Referral Processes



Care Coordination

Processes

Performance Metrics

and Outcomes

Financial

Considerations

• Pharmacy team: 5.25

FTE pharmacists and 2

pharmacy residents

employed by MAHEC

and co-funded by UNC


4-5 per pharmacist on

average per half day

• Duration of visits:

15 min. for

anticoagulation teams,

30 min. for others


≈80% of referrals are

from PCPs


Automatic referrals for

key conditions (e.g.,

abnormal DEXA results

or hypertension scores

exceeding thresholds),

Medicare Wellness

Visits, employee

wellness visits


referral volumes:

Practice dependent

• Strategies:

Interprofessional

meetings monthly to

discuss shared

expectations and

quality indicators

• Standardization: EMR

templates for

documentation of

encounters, team

member

communication, and

quality indicators for

chronic illnesses


Improved utilization of

ACE inhibitors, beta

blockers for CHF

patients, inhaled

corticosteroids for

persistent asthma,

DEXA screening rates

• Funding source:

“Incident to” billing and

transitions in care

codes allow billing at

higher levels if

physician sees patient

with a pharmacist

• Other considerations:

In several states,

pharmacists may bill for

Medicare Wellness

Visits

• “Incident to” billing codes allow

pharmacists to start bringing in

revenue

• New transitions in care codes yield

higher reimbursement rates than

incident to billing

• Pharmacists bill for Medicare

Wellness Visits (WMVs), most

profitable service for program

• Employee wellness visits negotiated

with self-insured employer bring

additional revenue

“Quilt Approach” Shifts Funding Sources Over Time to Support Program Growth

Months to transition away

from grant funding

12–18 Initial target for billable

reimbursement

50% Approximate annual billing per

pharmacist for MTM services

$70K

Initial Grant Funding Early Billable Services Increasing Self-Sufficiency

Billable Services Replace Initial Grant Funding

• University support enables

program launch


Profile #5: University Connecticut CMS Demonstration Pilot

Connecticut CMS Demonstration Yields Positive Clinical Impact, ROI

Source: Smith M, et al., “In Connecticut: Improving Patient Medication Management in Primary

Care,” Health Affairs, 30(4):646-654; Advisory Board interviews and analysis.

1) n=917 reported drug problems.

Case in Brief University of Connecticut CMS

Demonstration Pilot

• CMS demonstration project examining

the impact of the integrated pharmacy

model on Medicaid patients with

polypharmacy needs receiving care

at five primary care practices in

Connecticut between July 2009

and May 2010

• Program led by stakeholders from the

University of Connecticut School of

Pharmacy, the Connecticut Pharmacists

Association, and the Connecticut

Department of Social Services

• Results included an estimated annual

savings of $1,595 per patient

Staffing and

Deployment


Referral Processes



Care Coordination

Processes

Performance Metrics

and Outcomes

Financial

Considerations

• Staffing:

Independent

pharmacists contracted

under a Shared Service

Model with the

Connecticut Pharmacist

Association’s network

• Patient volumes:

88 patients across 9

pharmacists (≈10

patients per pharmacist


None; relied on

proactive outreach with

patient registry

• Eligibility criteria:

Medicaid beneficiary;

receipt of primary care

services at one of the

selected sites; at least

one chronic condition;

3+ medications for

chronic conditions

• Strategy: Participating

PCPs were already

familiar with integrated

pharmacy model

• Application of

pharmacist

recommendation:

82% of prescribers

made at least one

change in patients’

therapies based on the

recommendation of the

pharmacist

• Encounters: 401

across 88 patients (avg.

of 4.6 per patient)

• Duration of visits:

Initial appointment of

60-75 minutes with a

pharmacist and up to 5

follow-up appts. at

monthly intervals, each

lasting 20-40 minutes

• Process metrics:

Pharmacists identified

917 drug therapy

problems and 3,248 Rx

discrepancies


Nearly 80% of the 917

identified problems

were resolved within

four sessions; patients

achieved 91% of their

treatment goals by their

final visit

• Funding source: CMS

grant, although cost

savings exceeded

contracting costs for

pharmacists

• Cost of pharmacist:

Contracted on a fixed-

fee basis, amounting to

$2-$3 per minute on

average for MTM

• Sustainability

planning: Estimated

ROI of 2.5x

Program Results

Problems classified as preventable

medication errors that required a pharmacist

to intervene1

76%

Drug therapy problems resolved after four

patient-pharmacist encounters1

Program Design

Shared Service Model

The Connecticut Pharmacists

Association, a network of independent

pharmacists available to work on a

contractual basis

Co-located Pharmacists

Nine pharmacists embedded part-time

within four FQHCs and one primary care

practice between July 2009 and May 2010

Complex Patient Management

Pilot offered up to five MTM visits with the

co-located pharmacist for 88 Medicaid

patients with polypharmacy needs

Estimated annual total cost savings

per patient $1,595

Total return on investment (ROI) 2.5x

Process Metrics

Clinical Outcomes

Cost Implications

80%


Action Steps and Cross-Program Insights

Understand key action steps and components for implementing an effective

integrated model

Section 2


Key Insights from Integrated Pharmacy Programs


Competency Area Insight Rationale Action Steps

Staffing and Deployment

Establish a pharmacy

support role that performs

administrative, analytic, and

patient outreach functions

• Increases pharmacist capacity for patient

visits, medication therapy management,

and other top-of-license tasks

• Calculate efficiencies gained through use of pharmacy

support to build business case for additional staff

• Clearly define responsibilities per role to prevent

redundancies and facilitate collaboration

Patient Eligibility, Referral

Processes

Leverage comprehensive

risk stratification criteria to

identify eligible patients

• Enhances efficiency in managing

patients with multiple comorbidities

• Creates scalable model for expanding

across multiple practices

• Determine data sources for mining patient information

• Identify relevant clinical, demographic, and psychosocial risk

factors such as use of 10+ medications, frequent ED use,

behavioral health diagnosis, etc.



Institute mechanisms for

interdisciplinary

collaboration between

pharmacists and primary

care physicians

• Builds trust between providers through

regular communication and empowers

top-of-license care

• Documents formal expectations for

coordination between pharmacists and

primary care providers

• Assess state regulations pertaining to pharmacist scope-of-

practice and the role of collaborative practice agreements

(CPAs); enlist pharmacist and physician champions to guide

creation of a template CPA

• Dedicate time for huddles, team meetings, or other

interdisciplinary forums

Care Coordination Processes

Use standardized

intervention templates to

efficiently track and

coordinate pharmacist

activities

• Identifies unmet patient needs and

potential areas for improvement

• Ensures standardized data capture to

assess program performance and build

physician buy-in

• Consult with pharmacists to build intervention checklist that

compiles information on daily activity (e.g., medication

problems identified, pharmacist recommendations, physician

response)

• Incorporate tool into organization’s EMR to enhance ease of

use

Performance Metrics and

Outcomes

Carefully select, monitor,

and report clinical and

quality outcomes to facilitate

buy-in and best practice

sharing

• Illustrates cost and quality improvement

benefits of the integrated model

• Facilitates learning across sites and

allows for effectiveness comparisons

• Clarify relevant process and outcome measures, as well as

desired program targets

• Utilize tracking systems to regularly report on program

performance

Financial Considerations

Measure program impact on

total cost of care and

downstream utilization to

demonstrate business case

• Supports financial sustainability planning

and program expansion beyond grant-

funded pilot

• Builds case to present to commercial

payers

• Identify program costs, including staffing, IT investments,

and training

• Estimate cost avoidance attributable to integrated model and

compare to overall program costs


Core Components Grid: Staffing and Deployment

Pharmacists Augment Team-Based Primary Care Models


Staffing Ratio Team Composition Pharmacist Affiliation Scheduling

University of

Michigan

Health System

(UMHS)

Variable based on facility size,

budget allocation, and practice

readiness for team-based care

Pharmacy team consists of

pharmacist, pharmacy residents and

students; clinic panel managers

support with patient recruitment and

outreach

Pharmacy teams are jointly

salaried by the department of

pharmacy services, college of

pharmacy, and faculty group

practice

1-6 half-day clinics per week

(varies by center); pharmacists

provide care to an average of 6.5

patients per half-day (5 is min.

target)

University of


AltaMed CMMI Pilot

(USC-AltaMed)

Approximately one clinical

pharmacy team per four FTE

primary care providers and

8,000 adult patients; caseload of

500 patients per team

Team includes a clinical pharmacist, a

pharmacy resident, and a pharmacy

technician serving as the pharmacy

care manager (e.g., reviews patient

registries, conducts patient outreach)

Clinical pharmacy team members

are employed by USC and

embedded within AltaMed clinics

Clinical pharmacy teams work 40

hours per week; each team sees

an average of 14-22 patients per

day (target is 20 patients per day)

Hennepin County

Medical Center

(HCMC)

12 FTE staff pharmacists

embedded across 16 clinic sites

in the ambulatory setting

0.8 FTE Pharmacy Support Analyst

covers administrative, analytic, and

billing functions for the department;

two pharmacy residents provide

additional weekend support

Pharmacists are employed by

HCMC and embedded within the

system’s ambulatory clinics

At least one pharmacist staffs

each clinic at any given time

during traditional clinic hours (8-5,

Mon-Fri), with overlap at the

positive care clinic1 and internal

medicine clinic

UNC-Mountain Area

Health Education

Center (MAHEC)

Expanded from 3 pharmacists

and 2 pharmacy residents to

5.25 FTE pharmacists and 2

pharmacy residents since 2011

Varies by practice site Faculty employed by MAHEC and

co-funded by UNC provide

pharmacy services 50%-60% of

the week while embedded within

the clinics

Faculty provide clinic services

50%-60% of the week;

pharmacists see 4-5 patients per

half day (10-11 per half day for

anticoagulation visits)

University of

Connecticut CMS

Demonstration Pilot

Approximately 10 patients per

pharmacist

Contracted with independent

pharmacists under a Shared Service

Model with the Connecticut

Pharmacists Association network

Pharmacists contracted on a

fixed-fee basis, with fees

amounting to $2-$3 per minute on

average for MTM

Between July 2009 and May

2010, pharmacists reported 401

encounters across 88 patients;

pharmacists conducted an

average of 4.6 visits per patient


Core Components Grid: Patient Eligibility, Referral Processes

Identify Patients through Combination of PCP-Referral and Data Analysis


Physician Referral Protocols Patient Identification Triggers Referral Conversion Rates

University of

Michigan

Health System

(UMHS)

Pharmacist screens disease registries to

proactively identify eligible patients for

outreach and minimize physician burden;

traditional physician referrals

Diabetes (A1c >8%), hypertension (>140/90 mm Hg),

polypharmacy (8+ medications), patients not on

evidence-based medications (e.g., statin use in

diabetes)

72% referral conversion when pharmacy team

performed outbound calls to promote

comprehensive medication reviews for retiree

population

University of


AltaMed CMMI Pilot

(USC-AltaMed)

Balance of direct referrals from care team

members (usually primary care

physicians) and patient identification

using clinical triggers from the patient

registry

More than 48 clinical triggers deployed (e.g.,

BP>140/90 mm Hg, acute care utilization for asthma

and no controller medication issued, A1c>9%, heart

failure on diuretics, frequent ED use, frequent

hospitalization, recent discharge)

Minimal referral challenges reported (i.e., few

patients decline pharmacy services)

Hennepin County

Medical Center

(HCMC)

Predominantly provider referrals

supplemented by weekly lists of patients

with upcoming appointments who would

benefit from a pharmacy session,

generated by support analyst

In addition to physician referrals based on clinic-

specific criteria, pharmacy screens for patients on 10+

medications or with a diagnosis of asthma

17% no-show rate for pharmacy appointments,

which is comparable to primary care clinic rate

UNC-Mountain Area

Health Education

Center (MAHEC)

Referrals from any team member, with

approximately 80% coming from PCPs;

patients were able to self-refer to drive

referral volumes at program outset

Automatic referrals for key conditions (e.g.,

osteoporosis patients referred by lab tech when DEXA

results are abnormal); diabetic and hypertensive

patients identified through disease registry; patients

most commonly referred for complex medication

regimens, diabetes management, medication

assistance, Medicare Wellness Visits, employee

wellness, osteoporosis, and pain

85%-90% referral conversion rate, with no-

show rate comparable to primary care clinic

rate

University of

Connecticut CMS

Demonstration Pilot

Proactive outreach using patient registry Medicaid beneficiary who previously received primary

care services at one of the selected sites; must have

at least one chronic condition and take three or more

prescription medications for chronic conditions

88 patients across four FQHCs and one private

practice met eligibility criteria


Core Components Grid: Patient and Provider Engagement Strategies

Anticipate Up to Six-Month Period Before Provider Referrals Reach Steady State


Tactics for Promoting Provider Acceptance Tactics for Increasing Patient Utilization

University of

Michigan

Health System

(UMHS)

• Train pharmacists to frame partnership discussions around how the

physician will benefit

• Emphasize pharmacist support as an opportunity to free up physician

time to focus on non-medication-related issues

• Frame pharmacy as an extension of PCP’s services and network

• Conduct all initial visits in person to build relationships before

transitioning to phone follow-up based on patient needs and

preferences

University of


AltaMed CMMI Pilot

(USC-AltaMed)

• Invest in program marketing and communication from the outset

• Conduct daily huddles and weekly interdisciplinary team meetings with

provider, case manager, and clinical pharmacist to support ongoing

communication for all patients

• Share results, data, and high-impact patient stories

• Use warm hand-offs from PCP and emphasize continuity

of care

• Staff bilingual clinical pharmacy technicians to promote culturally

competent care

• Incorporate awareness of psychosocial factors (e.g., housing stability,

social support) into all encounters, given safety net status

Hennepin County

Medical Center

(HCMC)

• Host presentations upon program launch to encourage pharmacists to

introduce themselves and the program

• Establish interdisciplinary staff meetings to introduce teams to

pharmacist role

• Encourage face-to-face meetings

• Enable patient communication through MyChart patient portal

UNC-Mountain Area

Health Education

Center (MAHEC)

• Identify a physician champion who supports PCMH concept, pharmacy

integration

• Conduct monthly interdisciplinary meetings with physicians,

pharmacists, nursing staff, and behavioral health to discuss shared

expectations and quality indicators

• Hold monthly pharmacy group meetings to discuss practice-related

issues

• Encourage patient self-referral at outset

• Personalize transitions using warm hand-offs

University of

Connecticut CMS

Demonstration Pilot

• Select primary care team with prior experience with integrated practice

models and an understanding of how to effectively utilize pharmacists

• Promote face-to-face meetings

• When possible, resolve medication problems without requiring patient

to make a separate appointment


Core Components Grid: Care Coordination Processes

Determine Criteria for Patient Graduation Early in Program Development

Source: Advisory Board interviews and analysis. 1) The positive care clinic is an interdisciplinary clinic for patients living with HIV/AIDS.

Pharmacist Scope of Practice Templates and Collaboration

Agreements

Range of Pharmacy

Interventions Offered Graduation Criteria

University of

Michigan

Health System

(UMHS)

In 2010, all PCMH pharmacists had

their scope of practice approved by

the UMHS credentialing committee to

include diabetes, hypertension,

hyperlipidemia management, and

polypharmacy management

Intervention checklists highlight evidence-

based guidelines per disease state and

track activities performed during visit;

pharmacists and PCPs share patient

medication lists, progress notes, and

medication plans; pharmacist-led follow-

up visits include discussion of medication

changes and action steps for patient

Providing leadership in chronic

care quality improvement

initiatives; evaluating and

optimizing treatment regimens

for diabetes, hypertension,

hyperlipidemia, and

polypharmacy

Patients are encouraged to

return to their PCP once

the pharmacist feels there

are no additional active

pharmacy interventions to

impact clinical outcomes

University of


AltaMed CMMI Pilot

(USC-AltaMed)

CPAs in place to provide physician

reassurance and give pharmacists

sufficient liberty to make impactful

changes for patients; starting January

1, 2014, SB493 expanded pharmacist

scope of practice, enabling the use of

CPAs under the televisit model across

three primary care clinics

Collaborative practice agreements permit

pharmacists to initiate, adjust, and

discontinue medications for many chronic

conditions

Changing dose or drug interval

(38%), conducting patient

education (38%), adding or

discontinuing medication (19%),

substituting medication (5%)

Clinical pharmacy teams

check in every two months

with patients who have

graduated to confirm that

chronic disease targets are

still being met

Hennepin County

Medical Center

(HCMC)

Every pharmacist on the MTM team

holds a specialty certification or board

certification; specialty pharmacists

have received training in oncology,

solid organ transplant, infectious

disease, asthma education, and/or

diabetes education

Co-location of pharmacists with the rest of

the care team facilitates routine

interaction; shared EMR streamlines

referrals and provider communication, and

contains intervention checklist templates

Conducting general medication

therapy management (e.g.,

reviewing medication therapy

regimens, performing disease

management coaching/support)

Pharmacists use clinical

judgment to determine

when patients should

graduate from the program

and discontinue pharmacy

services

UNC-Mountain Area

Health Education

Center (MAHEC)

All pharmacists are recognized as

clinical pharmacist practitioners by the

state board of pharmacy and practice

collaboratively with PCPs. The

expectation is that pharmacists will

become board certified within 1-2

years; MAHEC pays for review

courses and exams

Shared EMR templates standardize team

member communication, documentation,

and quality indicators; embedding

pharmacists at clinics more than one day

per week facilitates relationship building

and consistency; pharmacists ensure

access to community resources and assist

with transitions in care

General MTM, ensuring access

to community resources,

providing interprofessional

education, assisting patients with

care transitions, participating in

quality improvement initiatives,

conducting employee wellness

visits for chronic diseases

Patients are seen until drug

therapy issues are

resolved, with complex

patients often returning for

annual or biannual

checkups; anticoagulation

patients followed

indefinitely

University of

Connecticut CMS

Demonstration Pilot

Not available Standardized medication action plan and

summary report, including evidence-

based recommendations from the

pharmacist, used to guide pharmacist

interventions

Screening for inappropriate

medication choice, omission or

duplication, dosage issues, drug

interactions, adverse reactions,

adherence issues, and health

literacy or cost issues

Patients see the

pharmacist for maximum of

five visits


Operational Metrics Pharmacy Program Impact

University of

Michigan

Health System

(UMHS)

• Average number of patients per half-day clinic

ranges from 4.5-8.3

• 80% direct patient care, 20% clinical administration

• Average duration of appointment is 30 minutes

(reduced from initial 45 min)

• Glycemic control and diabetes-related care improved

• Increased goal attainment of many pay-for-performance process measures for the pharmacy-

managed population

University of


AltaMed CMMI Pilot

(USC-AltaMed)

• 15,540 patient visits for 3,001 patients over 12

months

• Daily visits of 14-22 patients per team

• Team patient panel size of 350-725

• Average appointment duration is 30-45 minutes

• Over 2 years, inpatient visits decreased 13.1% for participating patients

• ED visits decreased 37.8%

• Observation visits decreased 50%

• Average patient satisfaction score of 9.6/10 for surveyed patients

• 9.9 problems identified per patient on average, of which 43% were related to effectiveness,

27% to non-adherence, and 18% to safety issues

Hennepin County

Medical Center

(HCMC)

• Patient visit numbers tracked per FTE per clinic to

establish daily targets for pharmacists

• 17% no-show rate, on par with the rest of the

organization

• Pharmacists identified more than 3,500 adverse drug events; two drug problems identified on

average per patient visit

• 30-day readmission rate reduced by 3.4% in hospital clinic

• 90% of patients surveyed would recommend MTM services to a family member or friend

• Outpatient utilization increased by 40% and inpatient utilization decreased by 12%

UNC-Mountain Area

Health Education

Center (MAHEC)

• 4-5 patients per pharmacist per half day

• 10-11 anticoagulation patients per pharmacist per

half day

• 80% of referrals from PCPs

• 85%-90% of referred patients receive services

• Average appointment time is 15 min. for

anticoagulation teams, 30 min. for others

• Program tracks disease-specific clinical outcomes such as ACE inhibitor use for CHF patients

and inhaled corticosteroids for persistent asthma

• Appropriate use of calcium and vitamin D use increased from 30% to 99%

• DEXA screening for women increased from 25% to 80% and INRs in range improved

• Transitions in care program reduced 30 day readmission rate from 15.5% to 5.3%

• Reductions in A1c scores from 9.4 to 7.7 among pharmacy clinic patients since March 2014

• Pharmacists increase primary care physician capacity by conducting Medicare Wellness Visits

University of

Connecticut CMS

Demonstration Pilot

• Nine pharmacists worked with 88 Medicaid patients

• 401 total patient encounters

• Average of 4.6 encounters per patient

• Initial appointments 60-75 minutes, follow-up

appointments 20-40 minutes

• 82% of prescribers made at least one change to patients’ therapies based on pharmacist

recommendations

• Nearly 80% of drug therapy problems were resolved within four patient-pharmacist encounters

• 91% of patients achieved their treatment goals by the final visit (63% within first visit)

• Pharmacists identified 917 drug therapy problems and 3,248 medication discrepancies

Core Components Grid: Performance Metrics and Outcomes

Leverage Performance Outcomes to Increase Provider And Payer Buy-in



Core Components Grid: Financial Considerations

Most Programs Initially Rely on Grant Funding, Then Push for Reimbursement


Funding Source(s) Financial Impact Sustainability Planning

University of

Michigan

Health System

(UMHS)

• Majority of costs absorbed by UMHS

practice sites with support from Dept. of

Pharmacy and College of Pharmacy

• Commercial payer reimbursement

available, but varies by practice payer mix

• Currently, five payers contribute to

Pharmacy Services through capitated

payment and fee-for-service

• The PCMH model enabled use of T code billing

with BCBS of Michigan

• In its first year, the program generated

$154,831 in T code revenue

As model evolves, program costs are

increasingly shifted to practices; cost

breakdowns are practice dependent, but on

average, the practice covers 70% of program

cost and 30% is subsidized by the Dept. of

Pharmacy and College of Pharmacy

University of


AltaMed CMMI Pilot

(USC-AltaMed)

• Recipients of three-year, $12M CMMI

grant through July 2015

• AltaMed provides clinic infrastructure while

USC provides salaries for pharmacy teams

• Projected savings are $31.7M over three years

• Increase in drug spending (≈$400 per patient

per year) expected to be offset by reductions in

medical care spending

Sustainability plans range from expanding

patient panels, increasing billable activity

among pharmacists, and/or piloting the model

within risk-based or capitated payment

structures

Hennepin County

Medical Center

(HCMC)

• Approximately 15% of program costs are

covered by insurance reimbursements,

10% by grant funding, and 75% absorbed

by the system due to demonstrated

reductions in total cost of care and

increased utilization of community

pharmacy services, resulting in an overall

positive ROI

• For patients receiving pharmacy services,

HCMC has been able to decrease patient

total cost of care by over $2,000 per patient per

year

Exploring risk-based contracts under their

Hennepin Health Insurance Group, a county

plan that provides assistance for individuals

below the poverty level who are ineligible for

Medicaid; increasing payer contracting activity

to support MTM services

UNC-Mountain Area

Health Education

Center (MAHEC)

• “Quilt approach” consisting of combination

of grant funding and use of “incident to”

billing codes, transitions in care codes,

employee wellness visits negotiated with

self-insured employer, and Medicare

Wellness Visits

• Initial target for billable reimbursement to

cover 50% of program costs

• The transition away from grant funding took

≈12-18 months

• Each pharmacist bills approximately $70,000

annually for MTM services

• Billable reimbursement target is 50% of

program costs

Continuing to explore creative ways of billing for

services to shift away from grant funding;

recently procured 2-year grant to evaluate

financial sustainability of the integrated

pharmacy model in rural areas

University of

Connecticut CMS

Demonstration Pilot

• Part of a $5M grant from CMS to

Connecticut Medicaid

• Additional grant program elements

included e-prescribing and health

information exchange development

• Estimated annual savings of $1,595 per patient

• Savings exceeded program costs with

estimated ROI of 2.5x; calculations include the

cost of contracted pharmacists and

administrative inputs

The principal investigator of this demonstration

project subsequently joined the CMS Innovation

Center to guide pharmacy intervention

development for Comprehensive Primary Care

(CPC) initiative