BETHESDA, MD 12 Jun 2014—A not-for-profit health system in south central Pennsylvania is using a supercharged medical home model to care for some of its costliest patients, and clinical pharmacy services are an important part of that care.
"It's a very tight-knit team. Everyone has an equal say and opinion about what they think is going on with the patient," said Ambulatory Pharmacist Clinician Amber Jerauld of Lancaster General Health. "I feel like everyone's voice is heard, and they really value the pharmacist on this team."
The program, dubbed Care Connections, targets patients in the vertically integrated health care system who have complex medical and psychosocial issues that lead to high costs. Eligible patients have at least three medical problems, behavioral issues that may be a barrier to care, and a history of multiple recent hospital admissions.
Lancaster General Health President Thomas Beeman, in testimony before Congress in May, said the health system had previously determined that 480 "superutilizer" patients accounted for $36 million in hospital charges during 2008 and 2009.
The health system in 2011–12 enrolled a small number of patients into a pilot program that provided intensive team-based transitional care to stabilize the patients' health and resolve psychosocial issues before releasing them to their primary care provider (PCP).
"There was some positive data from the pilot program showing that we were able to decrease length of stay and number of hospitalizations and improve quality of care for the patients," said Jerauld, who participated in the pilot project.
Those positive findings led to the launch of Care Connections last August.
According to Beeman, inpatient visits for the pilot and Care Connections patients have decreased by 67% since 2011, inpatient days fell by 84%, and emergency department visits dropped by 26%. He said initial estimates based on limited data suggest that the services decreased per-member per-month costs by $670.
Jerauld said a pharmacy residency project also found improved medication adherence among 51 Care Connections patients. She attributed the improvements to the "high-touch" care and one-on-one education provided by the health care team.
Jerauld said 93 patients were actively enrolled in Care Connections in mid-May.
"We're hoping to have them from 90 to 120 days and then eventually transition them back to their PCP's office," said Jerauld, who works mornings for Care Connections and afternoons for LG Health Physicians Downtown Family Medicine, a National Committee for Quality Assurance–recognized level III patient-centered medical home.
About two dozen patients had been released from Care Connections through mid-May, and about 12 more were expected to return to their PCP's care in June, Jerauld said.
"The whole idea is not to keep these patients forever—that we can get them back on their feet and then eventually transfer them back to their previous PCP office. But we've found that [with] some of our patients, we're probably going to need to hold on to [them] because they are so complicated. It's not that their previous PCP can't take care of them, but they don't have all the resources to assist with so many of their barriers," she said.
When new patients are enrolled in Care Connections, Jerauld meets with them before they see a physician. She reviews their electronic medical record to identify drug–drug interactions, renal function issues that could affect medication dosages, therapeutic duplication, and other medication-related problems.
Patients are asked to bring their medications with them to their initial appointment, and Jerauld performs a detailed medication reconciliation to identify problems and suggest changes to the treatment plan.
"That way I can go to the provider and say 'OK, they're taking X, Y, and Z that we didn't know about. Or they're taking the wrong dose, or they don't have these medications,'" Jerauld explained.
She said the team convenes a "huddle" each morning to review the day's schedule and go over issues that may affect the patients' health.
"Many times, they don't know how to access certain kinds of transportation or know of certain community resources. Maybe they're not in the right insurance plan. Maybe they need a pillbox to help them take their medications in an organized manner. So, just trying to break down any barriers they have to care is what the entire team tries to do," Jerauld said.
She said the ability to visit patients in their homes is critical to the success of Care Connections.
"It's amazing what you find out when you actually go into the home and see what their living conditions are like," she said.
Jerauld recalled visiting one patient, now a success story, who had been struggling with her insulin regimen. The team was also unsure if she was taking her other medications correctly.
"Her husband was filling the pillbox for her, but we really didn't know if it was right," Jerauld said. "So I went out and was able to see the pills that are in her pillbox are pretty much correct. But she couldn't see well, so she was not drawing up her insulin appropriately; she was just kind of guessing."
Jerauld said the patient was switched to an insulin pen and taught how to use it properly.
"What you see and observe in the home is sometimes different from what you get in a regular office visit," Jerauld said. "You're actually seeing how they have everything set up in their home."
Jerauld said the team's patient care navigators have worked as paramedics or emergency medical technicians and are critical to the program's success.
"They do a lot of home visits; they try to coordinate transportation to make sure patients get to and from their appointments. They are looking at the medications in the home. They're developing that relationship with the patient. So they are a key to our team," Jerauld said.
She said the team's social workers counsel patients and ensure access to important community-based services that help patients manage their health and well-being.
Beeman stated that the program's clinical and social care is supported by an interconnected electronic health records system and related technologies. This includes telehealth components that allow Care Connections staff to connect with office resources while visiting patients in their homes.
The health system has announced its intent to seek outside funding to sustain Care Connections, and Jerauld said the leadership staff has applied for grants to expand the program.