PHARMACY

The Primary Care Team Pharmacist

A Vital Tool to Prevent Hospital Readmissions

BY SANDRA LEO, PharmD

The 21st century has brought many new challenges and opportunities to the world of health care, and they are not just due to the ongoing COVID-19 pandemic. As value-based and other alternative payment models have become more prevalent following passage of the Affordable Care Act in 2010, health systems are transitioning their focus to providing quality rather than quantity of care. Value-based programs have developed to incentivize health systems to improve quality measures and increase efficiency. As the face of reimbursement continues to evolve, so should practice in all areas of health care. Evolution of primary care practice models is no exception.

One area in which health systems continue to struggle is with hospital readmissions. Hospital readmission rates are a key player in determining reimbursement rates for large health systems and are associated with significant costs both to the patient and the health system. The Hospital Readmissions Reduction Program, a key part of the Medicare value-based purchasing program, penalizes hospitals up to 3% of their Medicare reimbursements based upon readmission rates for chronic conditions such as COPD, pneumonia and heart failure. Some of the most important and preventable contributors to hospital readmission are poor medication adherence and medication-related errors. Patients with multiple chronic conditions often have complex medication regimens, which can leave even the most medically literate patients daunted. Around 45% of Americans have more than one chronic condition, and about 20% take at least five medications on a daily basis. However, according to the World Health Organization (WHO), adherence to chronic therapy in developed countries is only around 50%. This difficulty is often compounded by the older age of this patient population and lack of health literacy.

For example, say hello to Bob. Bob, who to this point had enjoyed good health, was recently discharged from the hospital following an extended ICU stay. He was diagnosed for the first time with Type II diabetes. When he was discharged, Bob was given prescriptions for both long-acting and short-acting insulin pens (as well as new prescriptions for a beta blocker and an ACE inhibitor); he was not given any oral antihyperglycemic medications. He had never used any injectable medications, had no idea how to use them and was given no education regarding them. He faces a difficult time adjusting to a new phase of his life, including a level of self-care that he’s never had to face before. Following his hospital discharge, rather than starting to use these new insulin pens, he goes without any medication treatment for his diabetes because he does not want to risk using his insulin pens incorrectly.

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Physician/employer direct contracting

Exploring new potential

BY MICK HANNAFIN

With the continuing escalation of health care costs, large and midsized selfinsured employers are once again looking for an edge to manage their medical plan costs and their bottom line. They understand that they are ultimately funding health care as they pay for their population’s claims.

Many of these employers have employed the same overarching set of strategies: shop for a new carrier that is willing to lower the administrative costs or underprice the risk,

Physician/employer direct contracting to page 124 CAR T-cell therapy

Modifying cells to fight cancer

BY VERONIKA BACHANOVA, MD, PHD

University of Minnesota Health is now among the few selected centers in the nation to offer two new immunotherapy drugs for the treatment of diffuse large B-cell lymphoma. Both drugs—Yescarta and Kymriah—are part of an emerging class of treatments, called CAR T-cell therapies, that harness the power of a patient’s own immune system to eliminate cancer cells.

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CAR T-cell therapy to page 144

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System disconnections

During hospital stays, medications for chronic and other conditions are often changed, discontinued or added, leading to medication discrepancies (differences between what medications the patient takes after they are discharged and what their care team intends them to take), further intensifying the risk for readmission. Following hospital discharge, patients with medication discrepancies are twice as likely to be readmitted to the hospital within 30 days. A systemic review of nine studies published in 2018 found that rates of medication-related readmissions ranged from 3-64%, with a median value of 21%. This study further found that approximately 69% of these readmissions were avoidable if these medication discrepancies had been resolved. Transitions of care present a difficult and challenging time for the patient and the health system, but also a substantial opportunity to improve patient care and reduce readmission rates through changes in the primary care treatment model. In 2017, WHO targeted transitions of care (along with polypharmacy and high risk medications) as one of the three key action areas where interventions are needed to reduce medicationrelated harm. When moving from the acute setting to the community setting, communication and medication management can play a vital role in keeping our patients from readmission and may have a vast impact on reimbursement rates within our health systems.

Enter the pharmacist

The role of the pharmacist has vastly changed in recent years. No longer limited to the dispensing of medication, the incorporation of pharmacists

into clinical practice has greatly increased as team-based care has become the standard of practice. Nowhere has this been more evident than in clinical hospital practice, as pharmacists have taken lead roles in antibiotic stewardship, medication reconciliation and medication use evaluation. Multiple studies have shown that medication reconciliation performed by hospital-based pharmacists reduces hospital readmissions, with one major meta-analysis demonstrating a 19% reduction in all-cause readmissions.

As team-based care continues to evolve, utilization of pharmacists has become increasingly vital in primary care as well. With the advent of ambulatory care programs, such as medication therapy management (MTM), comprehensive medication management (CMM) and primary care medical home (PCMH) over the past twenty years, prevalence of pharmacists on the primary care team has grown greatly. MTM services specifically have not only been associated with improved clinical indicators, such as lowering blood pressure, lowering LDL, increasing rates of smoking cessation and lowering HgA1cs, but also with increasing patient adherence and quality of life. It has also shown significant financial benefits, with a return on investment (ROI) of $1.29 per $1 spent on MTM services.

With more clinical pharmacist incorporation into primary care, more information regarding their role and potential benefit has emerged. One metaanalysis published this year, which included 14 randomized control trials, studied the effects of pharmacist involvement on multidisciplinary teams, both in the acute and primary care setting, on the probability of hospital readmission. Compared to usual care, the utilization of multidisciplinary care teams that included pharmacists resulted in a 32% lower risk of hospital readmission. Another recent meta-analysis published in 2021 shows that pharmacist intervention in post-discharge care can reduce 30-day hospital readmission rates by 22% and decrease overall readmission rates by 13%. All of the studies included in the trial involved intervention by a pharmacist after hospital discharge and included communication that occurred between the pharmacist and the patient’s primary care provider. Subgroup analyses within this study further demonstrated that the effects of pharmacist intervention were more effective when the pharmacist was more actively involved, such as during a comprehensive medication review, and when the pharmacist was more actively involved with the care team through direct communication, (such as a face-to-face care discussion, as opposed to more indirect means, such as fax or email).

Let’s return to Bob. Bob has his follow-up appointment with his primary care provider a week following his hospital discharge. Before he meets with them, he connects with the ambulatory care pharmacist on the clinic team, who educates him regarding how to use his new insulin pens, discusses what his other new medications are used for and updates his medication list within his electronic medical record. In addition, that pharmacist meets with his primary care provider and discusses potential oral treatment options that may allow Bob to avoid needing injectable insulins. Any medications we use to treat patients only work as well as we are able to get patients to use them; in Bob’s case, he leaves feeling more confident he is able to understand how to use his medications and more capable of using them; his blood sugar is more well controlled as a result. Incorporation of a pharmacist CMM visit when a patient visits for a post-hospital discharge visit can help to dissolve these medication discrepancies, and in Bob’s case, may have helped to keep Bob out of the hospital again.

Important and preventable contributors to hospital readmission are poor medication adherence.

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Moving forward

So why is pharmacist involvement on the primary care team still a problem in some settings? One study from Australia may hold the answer. Although the study acknowledged that, within primary care settings, pharmacists are respected for their clinical insight and well-accepted into clinical practice by physicians, nurses and patients, this meta-analysis identified multiple barriers cited by key stakeholders on the primary care team. The most consistently recognized barrier in this study was lack of funding. However, as payment models become increasingly more value-based, the value of a pharmacist in primary care likely far exceeds their cost. While some studies have shown that MTM services are associated with cost savings, further studies about their economic impact in light of value-based care have become increasingly important and should be prioritized to continue improvement.

Pharmacists themselves identified another vital barrier—the absence of training programs for clinical pharmacists. Expanding pharmacy residency programs in ambulatory care also plays a role in developing the ambulatory

The Primary Care Team Pharmacist to page 304

3The Primary Care Team Pharmacist from page 28

care team and should be prioritized. Other barriers were identified as well, including lack of role clarity, lack of clinic space, overburden on the patient’s time and medical culture among staff. Education of our clinical staff may be important for MTM as well. Multiple articles mentioned in this Australian review suggest that unawareness on the part of medical staff played a role in pharmacist underutilization.

How do we build a better care team that uses pharmacists to their full extent? First, allow pharmacists to work at the top of their license. MTM visits are a perfect opportunity for optimization of medication therapy for chronic conditions when pharmacists are allowed to operate under a protocol with a provider. Similarly, pharmacists can be highly involved in the management and billing of services related to drug therapy management for specific conditions, including anticoagulation, immunizations, osteoporosis and smoking cessation. Second, we can clearly identify and delineate roles for pharmacists and educate our clinic staff regarding what this entails. As demonstrated in the Australian study, most clinic staff are not aware of what pharmacists can do. And lastly, we can include pharmacists in the discussions regarding the direction of treatment for individual patients. One of the most advantageous aspects of primary

medical home initiatives is the collaborative aspect of treatment decision making. Along with pharmacists, health professionals, such as nurses and social workers, may provide valuable insight into how to achieve the most effective care. Just like performing rounds on a hospital unit, collaborative discussions in clinic can help determine the treatment paths most likely for patients to adhere to. Utilization of pharmacists As reimbursement models in health care has become increasingly continue to evolve, so must primary care practice vital in primary care. models. The COVID-19 pandemic has presented unique challenges and heightened the urgency by which practitioners must integrate these new models into primary care to achieve the highest ideals of value-based care. As our health systems continue to be taxed by high levels of hospital admissions and face potential shortages of health care staff in the face of the current pandemic, primary care teams can play an important role in optimization of health care delivery. Pharmacists stand in a unique position to increase positive clinical outcomes and reduce provider burden, as well as add financial incentives to the health system. We just need to give them the opportunity. Sandra Leo, PharmD works in the Mille Lacs Health System as part of the University of Minnesota Post Graduate Pharmacy Residency Program. Prior to this, she worked as a research scientist in the area of Cytogenetics.

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