New London Hospital and Newport Health Center
The practice setting for our Population Health Pharmacy Service is predominantly ambulatory, split between two specific practice sites. There is an additional focus on transitions of care for patients admitted to the inpatient facility that are managed by one of New London’s primary care providers. Forty percent of clinic time is within Primary Care at a Rural Health Clinic (RHC). Sixty percent of clinic time is within Primary Care at a Physician-based clinic that is affiliated with our 25-bed Critical Access Hospital (CAH). Currently 1.2 total pharmacist FTEs are dedicated to staffing both practice sites, with additional allocated FTEs anticipated in the near future. Most patient interaction is face-to-face with clinic schedules built in the same way that traditional Primary Care provider schedules are built.
Though part of the same organization and only separated from one another by 15 miles, the two practice sites are very different from one another in both scope and socio-economic factors. The Newport Health Center, founded by New London Hospital in 1991, is a Rural Health Clinic, in federally-designated medically-underserved Sullivan County, NH. Newport’s population of 6,500 is the largest community within New London Hospital’s 15-town service areas and the median income level is below both NH and national levels. By contrast, New London Hospital, founded in 1918, is a 25-bed Critical Access Hospital (CAH). The residents of New London have median incomes above both NH and national levels. Both practice sites are fully embraced by their respective communities and have a large volume of voluntary donors that allow for many nontraditional wellness activities to be incorporated into the provided services.
New London Hospital is affiliated with Dartmouth-Hitchcock, a major tertiary care, academic medical center and is part of a much larger regional health system. Currently we serve as a site for pharmacy learners completing both introductory and advanced rotations. Pharmacy students, especially those engaged in their advanced practice rotations, are embedded in the clinics with their preceptor(s) to aid in both their learning experiences, as well as with the provision of patient care initiatives.
The Ambulatory Pharmacy Team serves the following clinical roles: diabetes education and management, diabetes prevention, anticoagulation services, hypertension education and management, continuous glucose monitoring, patient medication assistance services, and assistance with patient transitions of care.
Why was the pharmacy service developed?
Institutional metrics surrounding diabetes and anticoagulation were in need of improvement. The medical staff desired to provide expanded services including enoxaparin bridging and initiation/transition to novel anticoagulant agents. Additionally, the ADA-recognized diabetes education program lost its coordinator and was in jeopardy of losing its recognition. The institution was also starting to venture towards alternate payment models (e.g. ACO, risk-based payment models). .
What training, certification, credentialing, and practice agreement is utilized by the practice site?
Currently ambulatory pharmacists have board certification and work with board of pharmacy approved collaborative practice agreements. Advanced training, in terms of certificate programs, residencies, and fellowships is required in order to work in various, specific patient care fields.
What outcomes are being measured to evaluate the model's success?
Ambulatory Care clinic pharmacists manually track interventions and patient-specific best practice standard attainment manually in order to justify value and worth. All clinic patient encounters are coded and billed to both Federal and commercial payers through a variety of CPT codes. We have opted to not include an Advance Beneficiary Notification (ABN) process in order to improve access and limit patient no-shows. Financial aid services are available for patients that receive clinical services but are not reimbursed by their insurers.
We have also set up a pharmacy-based patient medication assistance program that providers can refer patients to who might be having difficulties affording their medication. This service allows patients to receive a pharmacy consult which focuses on medication changes to decrease patient out of pocket expense for their medications without compromising quality of care. In addition, patients are connected with federal, state, and commercial patient assistance programs in order to assist with the fiscal implications of their medications costs in order to improve patient compliance and outcomes.
How have you made this service sustainable?
The service is currently sustainable through a variety of mechanisms starting with billing and a subsequent constant stream of revenue. We are also tracking patient outcomes (e.g. hemoglobin A1c, use of ACE/ARB in diabetes, hospital readmission rates) and best practice standard attainment which will ultimately play a role in increasing facility revenue generation by impacting patient quality metrics within risk-based payment modalities.
Community outreach initiatives are also targeted for several purposes including, but not limited to, self-marketing in order to generate additional patient and provider utilization, and to assist with private donor contributions.
How did you gain support of administrators, providers, and other key stakeholders?
Institutional Administration has historically been in support and values the role and skills of the pharmacist. Increased provider buy-in is targeted in a number of different ways. While provider utilization and referral rates have continually trended upward, there is still an underlying culture that must be chipped away at in order to facilitate utilization by previously untapped providers. Fiscal reliability is important for all clinical programs and fiscal sustainability of any service needs to be pursued.
What are some lessons learned while implementing your practice model that you would like to share?
- Be patient but always look for opportunities to assist in clinical and wellness initiatives in order to increase buy-in. Try and identify clinical gaps or needs and explore how you might assist in filling that gap.
- Make the most out of the opportunities that you are presented. Helping a provider or patient might not inherently lead to increased utilization, but in small-town America, word of mouth can be a powerful ally.
- Document everything you do, from best practice standard attainment, to utilization, to medication reconciliation discrepancies rectified, to chart reviews.
- Track everything you do. Just because a service might not be tied to a patient encounter or revenue generated, there is still value in it. Track your curbside consults. Track your drug information questions answered.