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Memorial Hospital

Integrated-Comprehensive Medication Therapy and Chronic Disease Management Model for Optimizing Short and Long-Term Health Outcomes in a Community Hospital System

Britt A. Cummins, M.S., R.Ph., Craig Baker, Pharm.D., Memorial Medication Therapy-Disease Management Center Team

Pharmacotherapy is a cornerstone of therapy for many common chronic illnesses. The full benefits of medications are often not realized with the typical episodic approach to patient care due to issues with medication management, poor adherence, ineffective transitions of care (TOC), and fragmentation and lack of continuity. Although our hospital’s multidisciplinary approach to managing acutely ill inpatients significantly improved short-term outcomes, there was a failure to improve health and quality of life over the long-term.  We were making significant short-term improvements in getting patients well only to see them back in the hospital over-and-over again due to repeated disease exacerbations, adverse drug events, and medication errors at home. Pharmacy identified the need to reach outside the hospital to become more involved in patients’ long-term medication and chronic disease management. We developed an integrated, comprehensive model for medication therapy-chronic disease management for each patient’s movement across inpatient and outpatient health facilities and physician offices. The purpose was to achieve optimal long-term outcomes by managing medications and chronic diseases in an integrated fashion that minimized fragmentation and episodic reactive care.

This model utilizes clinical pharmacist-nurse practitioner-pharmacy technician-medication assistance teams in the hospital, TOC program, medication/disease management clinics, and primary care offices to provide well-coordinated, comprehensive care. Features include 1) eliminating gaps during TOC as patients move between inpatient and outpatient settings, 2) supporting physicians and other providers by providing up-to-date medication reconciliation and comprehensive drug reviews on an ongoing basis while coordinating all aspects of medication management, 3) providing highly individualized education, tools, and medication plans that facilitate optimal medication taking behaviors and adherence, 4) minimizing financial barriers with cost conscious decisions and use of medication assistance programs, and 5) working with patients longitudinally to improve and sustain healthy long term outcomes through effective medication and lifestyle strategies.

TOC clinic reduced 30-day readmission rates for the same diagnosis from 21% to 4% and all cause readmissions from 15.5% to 7% while seeing a $1.5 million net financial benefit over 30 months. Heart Failure Clinic decreased annual admissions by 82% with a $1.5 million net benefit over 27 months. COPD Clinic reduced annual admissions by 63.2% with a net benefit of $1.6 million/year in 2 years. Anticoagulation Clinic improved time in therapeutic range from 66.4% to 83.4% and achieved a hospitalization rate of 1.98/100 patient years (versus 13.9 for usual physician office model) and an emergency room visit rate of 0.33/100 patient years (versus 5.6 for usual physician office model). Net financial benefits were $2.8 million in 3 years.

This care model demonstrates an approach to medication-chronic disease management that reduces exacerbations and treatment failures, improves health outcomes, and achieves favorable financial results. Its uniqueness lies in the high level of integration and coordination of care that is often missing in today’s fragmented healthcare.

Memorial Hospital

Memorial Hospital

Pictured Left to Right: Callie Tackett, Laura Aumiller, Laura Couch, Britt Cummins, Craig Baker, Melannie Hunsicker, Mirasol Alexander, Jennifer Forbush

Not Pictured: Amy Brown, Robin Connelly, Joe Dula, Jeannie Kim, Samantha Wells