There is a growing body of research on the pharmacist’s role in population health management initiatives and the need for pharmacists to be involved in the development of personalized care plans, coaching, education and the delivery of patient-centered care.
As many population health efforts focus on complex patients with multiple chronic diseases, effective medication management can be key to these efforts, and pharmacists stand to play an integral role in improving medication use, adherence and outcomes, according to many healthcare leaders.
Leaders at Beth Israel Deaconess Care Organization (BIDCO), a value-based physician and hospital network and accountable care organization (ACO) in Massachusetts, have made efforts to give pharmacists a bigger role in preventive care to provide more intense medication management, with the aim of achieving improved outcomes in less time than traditional approaches.
BIDCO has 2,600 participating providers, both primary care providers and specialists, across its network and partners with seven community hospitals and one academic medical center, Beth Israel Deaconess Medical Center, a major teaching hospital of Harvard Medical School. About 20 percent of physicians in the ACO are independent, while the majority are employed by their respective organizations. BIDCO also is contracted with the Centers for Medicare and Medicaid Services (CMS) as a Medicare Shared Savings Plan (MSSP) participant.
Sarika Aggarwal, M.D., BIDCO’s chief medical officer, says the organization works with providers in five key areas. “We are their structure to do contracts with the payers, both commercial and government payers. We create the internal financing systems for all of our providers. We do administrative functions and we also have data analytics and a population health tool with a data warehouse across all our providers, and that is a pretty big feat because we have several different versions of electronic health record (EHR) systems. Finally, we create the population health strategy based on these value-based contracts that we have, so we create the clinical strategy and we execute on the strategy within the structure of BIDCO.”
Bill Gillis, CIO at BIDCO, will share more insights on the role of data and analytics to support risk-based contracts at the Health IT Summit in Boston on August 7 and 8 at the Courtyard Boston Downtown.
As part of a population health strategy, many healthcare organizations focus on behavioral changes to improve health outcomes. However, it can take months, if not years, before providers see measurable results from their efforts. In an effort to get pharmacists more involved in the organization’s population health work, BIDCO leaders deployed a unique “pharmacy first” approach specifically to its Rising Risk Management program.
“There is a lot of evidence that speaks to pharmacists having a much bigger role in population health, and especially in the chronic disease space. I think pharmacists, in the future, are going to be very valuable independent practitioners because they are able to effect the key pieces in population health—medication adherence, medical management and the quality management of these chronic diseases,” Aggarwal says.
When Aggarwal joined BIDCO in 2016, pharmacists participating in the ACO were helping to address quality gaps in care focusing on patients with chronic diseases and multiple medication regimens. At that time, a small pilot project focusing on improving medication management for diabetes patients was proving successful. “Given the size of our network and the size of our population, my vision was to touch a greater number of lives, so I wanted more patients to be enrolled in this program,” Aggarwal say. “I also knew that there was a whole behavioral management piece that needed to be added to the pharmacy piece. And, another key aspect is that I wanted the pharmacists to lead this because I thought they could bring all of this together.”
Beginning in 2017, BIDCO clinical leaders move forwarded with this “pharmacy-first” approach to its rising risk management program, which entailed risk stratifying the “rising risk” patients as well as hiring and training health coaches and engaging physicians in this work.
“We realized there was a lot of opportunity, really looking at our populations and focusing on which diseases we could have the biggest impact, and then thinking about the medication piece—how medications really fit into each one of these chronic diseases,” Jennifer Perlitch, BIDCO's rising risk, program manager, says. BIDCO leaders settled on five chronic diseases to focus on—diabetes, asthma, COPD (chronic obstructive pulmonary disease), cardiovascular disease and heart failure. “We spent a good amount of time focused on what our strategy would be and really structuring our interventions with these patients to incorporate what the patients wanted to work on, but also influencing them to focus on key pieces with regard to self-management that could really impact them now, as well as reduce the likelihood of disease progression and exacerbations or complications in the future,” Perlitch says.
Aggarwal says BIDCO leaders made a strategic decision to focus on “risking risk” rather than high-risk patients for this initiative. “If you really plot the morbidity score against the actual impact, which is in the utilization space and the total cost of care and in the quality space, the sweet spot opportunities, or the population that has the greatest impact, is not always those patients who have the highest morbidity scores. There is this space of patients that have some utilization, who have the chronic disease and who will belong to that future population, but are impactable now,” she notes.
And, with a focus on achieving improved health outcomes in months, not years, BIDCO leaders decided to move forward with a “boot camp-style approach,” Aggarwal says. “Our approach was to talk to these patients about the really basic pieces that they needed to know about their chronic disease, such as what are the warning signs and symptoms, what are the screenings that they need have for this disease, when do they need to seek care as well as medication adherence and medication management. It was a sort of boot camp, with a combination of pharmacists as well as health coaches, and then adding our case management to it when these patients had multiple other co-morbidities.”
Data and analytics were foundational to this work in order to generate an impact score to effectively risk stratify patients, Aggarwal says. “We spent a lot of time trying to understand the risk stratification, and our preliminary risk stratification in early 2017, it was really not quite as forward-thinking as we are now. It was really based on cost use data, along with chronic disease and co-morbidities. Our future risk stratification model incorporates all those variables but it also incorporates a lot of the clinical data and the census data, which includes social determinants, such as education, housing, employment and all those other pieces.”
BIDCO leaders also made a strategic decision to focus on those five chronic diseases across the network and care continuum. “That gives all the different stakeholders a common goal,” Aggarwal says.
“Pharmacy-first” approach drives results
Through this program, pharmacists engage patients for six to eight weeks and work in partnership with patients’ primary care physicians to monitor complex medication regimens to ensure patients’ take their prescription medication regularly and as prescribed. Pharmacists also screen patients’ medications, results, and reactions to reduce ineffective medicines, and avoid risky combinations. The pharmacists also proactively analyze and evaluate patient prescription habits, and use that information to work with primary care physicians on making recommended tweaks or changes to medication regimens that can have an immediate positive impact on patients’ quality of life and care, Perlitch says.
In 2017, the program enrolled about 100 patients over a six-month period of time. So far in 2018, program leaders have already exceeded that number of enrolled patients through the end of April, she notes. As a result of this “pharmacy-first” approach to effectively managing patients’ complex medication regimens, BIDCO program leaders have been able to impact patient outcomes rather quickly.
Sharing results with regards to diabetes patients enrolled in the program in 2017, Perlitch says of those patients, 89 percent achieved a decrease in their hemoglobin A1c, and of that 89 percent, 47 percent achieved HbA1c levels below BIDCO’s value-based contract threshold.
“Another metric we measured early in 2018, but with a very small population, was the number of patients that lost weight. So far, 42 percent of those patients have had a decrease of at least 5 pounds in their weight,” Perlitch says.
“We also have a couple of success stories with regard to COPD patients, as we’ve avoided a couple of emergency room visits,” she adds.
Aggarwal notes, “Our health coaches have been so successful in engaging patients that historically providers have hit the wall with and couldn’t move those patients. We have numerous success stories that really speak to this different approach and really meeting the patient where they are and working on manageable and attainable goals so that the patient is seeing that they can be successful.”
With the initial success of the initiative, program leaders can share some early lessons learned about giving pharmacists a large role in patient care to support population health efforts.
“I think the most important thing is getting the providers engaged and really demonstrating results, and then monitoring your successes,” Perlitch says.
Aggarwal adds, “I think having clinical champions of the program, just like all other programs, is very important. These clinical champions continue to bring others on board. Provider engagement also is predicated on giving actual pathways to them to engage. So, instead of saying, ‘we’ll give you these patients and can you call them,’ we speak to the providers about doing automatic referrals from multiple programs, such as our transitions of care program.”
Moving forward, BIDCO clinical leaders are focused on expanding the number of patients participating in the program.