Advocate Medical Group Southeast Center and Midwestern University Chicago College of Pharmacy
Advocate Medical Group - Southeast (AMG-SE) is part of the AMG subsidiary of the Advocate Health System, located in Chicago, Illinois. The AMG-SE center is a patient-centered medical home (PCMH) and accountable care organization (ACO), which is comprised of a multidisciplinary team structure and an outcome-based reimbursement model. The PCMH at AMG-SE is built on a multidisciplinary team structure, which includes primary care physicians, a cardiologist, three clinical pharmacists, a physician assistant, a nurse educator and a dietician.
At AMG-SE, the pharmacist can initiate, discontinue, or adjust medications for the listed disease states given patient results and tolerance. The pharmacist also provides medication reconciliation and education to improve patient adherence. Furthermore, the pharmacist orders and interprets laboratory values, orders appropriate medical referrals, and provides disease state and lifestyle education. The pharmacist schedules 8-15 patients daily for individual disease management visits, allocating 60 minutes for initial visits and 30 minutes for follow-up visits. In addition to chronic disease management clinic visits, the pharmacist is available for physician consults, medication recommendations and dosing and drug information questions.
Seventy-percent of patients at the site are under a full-risk global payment model through Medicare Advantage or commercial payers. The pharmacist is 50% co-funded by a college of pharmacy, spending four days each week in clinic and one day each week at the college. The portion of the pharmacist’s salary supported by AMG is covered through the capitated reimbursement model with pay-for-performance incentives, with a focus on preventative health care by meeting performance measures and decreasing costs. Patients are referred to the clinical pharmacist if they are at high risk for hospital admission or readmission, have complex medication regimens, a history of poor adherence, as well as other factors associated with a high cost of care.
AMG-SE is also a primary site for the Midwestern University postgraduate year-two (PGY-2) Ambulatory Care Residency Program, and 1 – 2 residents have clinical rotations at the site for 8 – 10 months each residency year.
Data collected prior to implementation
In 2008, AMG created a PCMH project team to improve outcomes at AMG-SE Center, which had suboptimal outcomes compared to other AMG centers. In the year prior to PCMH implementation, 36% of patients who were hospitalized at Advocate Trinity Hospital for a heart failure exacerbation were readmitted within 30 days of their hospital stay for a subsequent heart failure exacerbation. Over the year period, a risk cost of $2.4 million was estimated for 30-day readmissions. Many of these patients had a primary care physician at AMG-SE Center. A comprehensive care structure did not exist and there were minimal coordinated patient handoffs both between providers within the AMG Southeast Center and with the adjoining Advocate Trinity Hospital. A high rate of heart failure hospital readmissions and uncontrolled chronic care conditions led to a desire to implement the PCMH at the site to improve the quality of patient care and decrease hospitalizations. The initial goal of the PCMH pilot was to focus on patients diagnosed with heart failure.
What training, certification, credentialing, and practice agreement is utilized by the practice site?
Clinical pharmacists at the site have completed either a PGY-2 Cardiology Pharmacy Residency Program or a PGY-1 or PGY-2 pharmacy residency with an ambulatory care focus.
The clinical pharmacists created disease state management protocols, approved through AMG, for heart failure, diabetes, hypertension, hyperlipidemia, COPD, and asthma.
What outcomes are being measured to evaluate the model's success?
In the first 18 months, only 3 of the 150 high-risk patients managed by the clinical pharmacist for heart failure had a 30-day readmission for heart failure exacerbation Expansion of the clinical pharmacist’s role to include care for patients with diabetes, resulted in recognition of AMG-SE Center as a top AMG site for diabetes management in 2012. The recognition was based on results collected that demonstrated improvement in diabetes metrics and other disease state measures, including blood pressure control and cholesterol management. Other quality metrics also improved after the integration of a clinical pharmacist, including generic medication use, the number of patients on an angiotensin-converting enzyme inhibitor (ACEI) and a beta-blocker (BB) for heart failure management. The initial results of the PCMH pilot program led to the hiring of more clinical pharmacists at the AMG-SE Center and at other AMG sites.
How have you made this service sustainable?
At AMG-SE the focus was on reducing the cost of care for patients with heart failure. Inpatient admissions for heart failure and 30-day readmissions were tracked to assess the quality of the program. In the first 10 months, clinical pharmacist managed 111 patients with heart failure. In the 10 months prior to being managed by the clinical pharmacist, the patients were hospitalized 63 times for heart failure. After receiving care from the clinical pharmacist for 10 months, the same 111 patients were hospitalized 30 times, indicating a 50% decrease in hospitalizations in patients being followed by the clinical pharmacist. The average cost per heart failure hospitalization at the time was $8,500, indicating a potential cost avoidance of $280,000 for the 111 heart failure patients based on pre-/post-enrollment.
How did you gain support of administrators, providers, and other key stakeholders?
Through initiating and titrating medications based on ACC/AHA guidelines in a timely manner and the resulting improved outcomes for patients with heart failure, the pharmacist’s role became well accepted. The pharmacist made recommendations to the physicians regarding the management of other disease states, which led to physicians also referring patients to the pharmacist for management of diabetes, hyperlipidemia, COPD, asthma and hypertension, and the expansion of the collaborative practice agreement. The physicians at the site felt more comfortable allowing the pharmacist to prescribe under their name when the clinical pharmacist could provide evidence-based recommendations and demonstrate primary literature application. Providing comprehensive care and evaluating the appropriateness of all medications in an effort to manage co-morbid disease states further garnered physician trust and lead to the expansion of clinical pharmacy services at the clinic.
What are some lessons learned while implementing your practice model that you would like to share?
As the clinical pharmacist established value within the clinic, other challenges developed. Within 6 to 8 months, provider referrals grew to a point where demand could not be met. A mechanism was put in place to discharge stable patients with diabetes who had an A1c less than 7%;
Due to the high volume of patients referred to the clinical pharmacist, a second pharmacist was hired to assist in the workload. The cardiology-trained clinical pharmacist was able to easily gain prescriptive authority for cardiology disease states within a month of entering the position, which allowed for a more efficient transition between the APN and the pharmacist. Recognizing the different skills sets of pharmacists and building on each other’s strengths developed through post-graduate training and prior experience is an important piece of creating a team model.
With the identified need for additional high-level pharmacist practice to perform chronic disease management services, there is opportunity for training the type of pharmacist needed in this setting. A PGY-2 ambulatory care residency position was developed and approved at the site to facilitate the expansion of chronic disease management and to increase availability of services in order to reach out to more patients. Integration of a trainee into a successful model demonstrates to the resident the required level of services and the clinical pharmacist’s optimal role in providing comprehensive medication management. It encourages residents to develop the skill set required to identify opportunities for service growth and gain the ability to perform the requisite clinical pharmacist services. The PGY-2 resident at AMG-SE Center also gains exposure to an alternative payment model and an understanding of sustainability in developing clinical pharmacy services.