1. 1/14/2016 www.pharmacypracticenews.com/Article/PrintArticle?articleID=34496
http://www.pharmacypracticenews.com/Article/PrintArticle?articleID=34496 1/7
Policy
DECEMBER 15, 2015
Patient-Savvy Pharmacists Ready for
Medical Homes
Data, technology among tools of the trade
By Lynne Peeples
(/aimages/2015/ppn1215_001a_13765_300.jpg)
Chicago—The name might be deceiving
at first. A “medical home” does not refer
to a tangible building, house or hospital,
but rather an approach to providing
comprehensive, coordinated health care.
It’s a concept well aligned with the U.S.
health system’s evolving emphasis on
boosting the quality and efficiency of
care—a challenging goal that
pharmacists can help their organizations
achieve.
“We’re transitioning away from fee-for-
service toward a focus on patient
outcomes,” Tim Lynch, PharmD, MS, the regional senior director and pharmacy officer
at CHI Franciscan Health in Tacoma, Wash., told an audience during a session at the
American Society of Health-System Pharmacists (ASHP) Conference for Pharmacy
Leaders in October. In their workshop, Dr. Lynch and his colleague, Eric Wymore,
PharmD, MBA, the regional clinical pharmacy manager at CHI Franciscan Health,
discussed opportunities for pharmacists to use data, technology and their unique skill
sets to contribute to the success of these new patient-centered medical home
(PCMH) teams.

2. 1/14/2016 www.pharmacypracticenews.com/Article/PrintArticle?articleID=34496
http://www.pharmacypracticenews.com/Article/PrintArticle?articleID=34496 2/7
Less than half of attendees, according to a preworkshop survey, knew what a PCMH
was and had implemented one in their organization. What’s more, 42% reported that
pharmacists were not included in their primary care clinic or medical home model.
That gap indicates “there is a huge opportunity for pharmacists to get involved,” Dr.
Wymore said.
ADVERTISEMENT
First Steps
A quick look at the history of health care funding provides some context for the
potential roles of medical homes, as well as for the pharmacists inside those homes.
“In the 1900s, there was no such thing as health care insurance as we think of it
today,” Dr. Lynch explained. Patients back then simply paid for their medical services
as they occurred, he noted. That evolved during the middle of the 20th century, when
early plans had people pay a percentage of their salaries in advance of medical care.
During World War II, when there was great competition for employees, employers
enticed people to their companies by offering health care funding. Eventually, the
federal government became involved, and, by 1963, a majority of Americans were
covered by some form of health insurance.
Somehow, the model left taxpayers, providers and patients with a lot to be desired.
Today, the health care system incurs billions annually, partly due to the costs of
avoidable adverse drug events. Chronic disease treatment consumes as much as 75
cents of every health care dollar.
“Cuba pays far less for health care with equivalent life expectancy,” Dr. Lynch said.
“Are we getting a positive return on investment in the United States?”
A key problem in the past, according to Dr. Lynch, was payors reimbursing physicians
for providing care, regardless of quality. “In years past, there were fewer incentives to
do it right the first time,” he said. “But that is changing.”
The system is moving from a focus on volume to value, with no reimbursement for
poor quality or injuries due to error. That’s where the medical home can help, he and
Dr. Wymore explained. Under the roof of a medical home, a team can work together
to optimize population health—another concept emerging with health care reform,

3. 1/14/2016 www.pharmacypracticenews.com/Article/PrintArticle?articleID=34496
http://www.pharmacypracticenews.com/Article/PrintArticle?articleID=34496 3/7
reflecting an increased focus on the health outcomes of a group of individuals. A
medical home, for example, may cater to patients living in a specific region or those
being treated for a certain group of conditions.
“For patients with chronic conditions and complex medication regimens, there needs
to be a strong patient–physician–pharmacist relationship that is ongoing and a
continuous one,” said Marie Smith, PharmD, FNAP, the Henry A. Palmer Professor in
Community Pharmacy Practice and assistant dean for practice and public policy
partnerships at the University of Connecticut School of Pharmacy, in Storrs, who did
not attend the ASHP conference. “The pharmacist meets with patients or family
caregivers, and is an integrated member of the practice’s primary care team.
Medical homes will look very different depending on the context, explained Dr. Smith,
a thought leader on pharmacy’s role in medical homes and primary care practice
transformation. As a result, the roles of pharmacists may differ as well, according to
a 2013 paper she co-authored (Health Aff [Millwood] 2013;32[11]:1963-1970).
Some of a pharmacist’s key contributions, according to another paper she authored
in 2010, may include reviewing prescribed and self-care medications, including
resolving any medication-related problems and optimizing complex regimens, as well
as designing adherence programs and recommending cost-effective therapies
(Health Aff [Millwood] 2010;29[5]:906-913).
“Pharmacist integration in a patient-centered medical home can vary according to the
size of the practice and current medication-related workflows and processes,” she
added. “Generally speaking, larger PCMH practices or PCMHs that are part of ACOs
[accountable care organizations] may be more inclined to hire a clinical pharmacist,
whereas a smaller practice may prefer to contract for clinical pharmacist services
that focus on a subset of patients with complex medication regimens.”
Often, the first necessary step is for pharmacists to simply get their feet in the door.
That begins, explained Drs. Lynch and Wymore, with convincing the C-suite,
physicians and other health care staff of their value.
“A lot of providers don’t know what you can do,” Dr. Lynch said. “You want to partner
with providers familiar with what pharmacists are capable of.”
They both emphasized the importance of

4. 1/14/2016 www.pharmacypracticenews.com/Article/PrintArticle?articleID=34496
http://www.pharmacypracticenews.com/Article/PrintArticle?articleID=34496 4/7
(/aimages/2015/ppn1215_024a_13765_300.jpg)
Hang Nguyen, PharmD, BCACP counsels a
patient as part of CHI Franciscan Health’s
medical home initiative.Photographer: Chris
Willard
They both emphasized the importance of
educating providers and office staff of
pharmacists’ unique skills and
knowledge, which extend well beyond
what they might see in a community or
retail setting. “Providers are your best or
worst advocates,” Dr. Lynch said. “You’ve
got to win over physicians. Once you gain
their respect, they will tell others.”
The C-suite typically wants to see a
pharmacist’s value quantified, of course.
So, the next step might be showing them
the “positive return on investment for the
services you provide,” Dr. Lynch added.
“Look across your organization: Where are the gaps? Where are pharmacists uniquely
positioned to fill some of those gaps?”
Polypharmacy Initiative
Drs. Lynch and Wymore noted that one of the biggest factors in their success has
been earning this respect and acceptance within their organization. They highlighted
some of the progress they have achieved so far. In 2013, CHI Franciscan Health
launched a polypharmacy project, with the goal of creating a comprehensive process
to optimize drug therapy. Based on an internal medication reconciliation project, the
average patient arrived to the hospital taking 14 medications. This creates a lot of
opportunities for potential errors and bad outcomes, which was borne out by initial,
preliminary results of the polypharmacy program (sidebar).
Around the same time, CHI Franciscan Health also implemented a PCMH model,
focused on chronic disease management and care coordination for 715 patients
spread out among multiple clinics, Dr. Lynch noted. Just one pharmacist full-time
equivalent (FTE) was originally proposed. The team was able to identify and intervene
on the highest-risk patients, such as those older than 65 years of age and with three
or more chronic diseases or eight or more medications.
By convincing providers of a pharmacist’s value, they succeeded in doubling their
allocation to two FTEs. Still, with such limited pharmacist resources, the team needed
to prioritize their efforts.

5. 1/14/2016 www.pharmacypracticenews.com/Article/PrintArticle?articleID=34496
http://www.pharmacypracticenews.com/Article/PrintArticle?articleID=34496 5/7
Doing More With Less
Drs. Lynch and Wymore and their team initially targeted clinics where there was a
shortage of primary care providers, a larger number of providers, a strong physician
champion, strong clinic leadership and providers who were more familiar with clinical
pharmacists. To cover multiple clinics with limited pharmacist resources, they
identified clinics with high patient volume and a large proportion of high-risk patients.
After the first six months of the initiative, the pharmacists went from spending most
of their time processing refill requests and other administrative work to making
patient phone calls and performing anticoagulation, diabetes care and direct patient
care transition visits.
“Say yes to everything at first to get your foot in the door, then of course correct,”
advised Dr. Wymore.
As that trust builds, he said, providers will likely ask pharmacists to become involved
in more direct patient care and more complex cases.
Where To Start
Since most pharmacists are operating in the health-system setting, there is a need to
prioritize and get involved in population health management, added Dr. Wymore. This
presents another large opportunity for pharmacists to be involved as part of a
coordinated effort to improve outcome measures for patients. The CHI Franciscan
Health team chose to focus on diabetes and hypertension measures.
“We have developed a 40/30/30 practice model in order to help other team members
understand where the pharmacists intend to focus their efforts: 40% of their day is
spent on performing direct, face-to-face patient care visits; 30% of their day is spent
on population health outreach; and the remaining 30% of the day is for on-the-fly or
curbside consults,” Dr. Wymore said.
Based on their own experience and those of participants, a few other strategies
surfaced during the workshop, such as having pharmacists rotate between clinics
using set days or electronic schedules—which might enhance relationships with
providers—as well as identifying and utilizing various technologies.
“Traditional models of care, where you’re seeing the eyeballs of each and every

6. 1/14/2016 www.pharmacypracticenews.com/Article/PrintArticle?articleID=34496
http://www.pharmacypracticenews.com/Article/PrintArticle?articleID=34496 6/7
“Traditional models of care, where you’re seeing the eyeballs of each and every
patient, is just not always practical,” Dr. Wymore added.
Virtual Diabetes Project
In addition to phone calls, other forms of outreach such as Skype and email may also
help with continuing care. Through a collaborative virtual diabetes project with the
certified diabetes educator, CHI Franciscan Health provided iPads for a limited
number of study patients to monitor their glycated hemoglobin A (HbA ). So far,
they’ve seen a 2.2% improvement in HbA . That may not sound like much in absolute
terms, but according to data presented at the 72nd Scientific Sessions of the
American Diabetes Association, patients who reduced their HbA levels by nearly
one percentage point—from a mean of 7.8% to 7%—had a significant 45% decreased
risk for cardiovascular death (hazard ratio, 0.55; 95% CI, 0.49-0.63; P<0.001).
“Tracking outcomes is also critical in establishing your value on the team,” Dr.
Wymore said, who added that the virtual diabetes project “was run by our diabetes
educators; our pharmacists collaborated with the diabetes educators on these
patients.”
Dr. Smith noted the integrated teamwork of a medical home “requires face-to-face
patient encounters to build a trusted relationship.” But “once an established patient is
making good progress toward meeting their medication management goals, some
follow-up may be done with remote monitoring technology or virtual visits,” she said.
However, she added that some payors may not recognize virtual visits.
Who’s Going To Pay?
Reimbursement roadblocks also can broadly hinder pharmacists’ ability to join
medical home teams. “Even when physicians do want to add a pharmacist to the
health care team in a primary care office or outpatient clinic, the main barrier is lack
of a payment mechanism in a fee-for-service payment model,” Dr. Smith said.
“With the growth of ACOs and more value-based or risk-based payment models,” she
added, “clinical and administrative leaders are recognizing that adding pharmacists
to the health care teams can have a positive impact on quality improvement and cost
savings.”
1C 1C
1C
1C

7. 1/14/2016 www.pharmacypracticenews.com/Article/PrintArticle?articleID=34496
http://www.pharmacypracticenews.com/Article/PrintArticle?articleID=34496 7/7
Drs. Lynch, Wymore and Smith reported no relevant financial relationships.
Outcomes Data Not Yet In, But Benefits Still There
Tracking clinical outcomes for any new initiative is difficult, and the medication reconciliation project
initiated by CHI Franciscan Health in Tacoma, Wash., is a case in point. But that’s not to say there are
clear indications of benefit, according to the program coordinators.
“The data that we had done from our medication reconciliation pilot showed that many of our patients
were arriving at the hospital on more than eight medications,” they noted in a follow­up email. “That was
recognized as a risk factor for readmission, because taking multiple medications could indicate poor
control and lack of adherence. Increased readmissions were something that we were trying to reduce as
one of our strategic initiatives. The polypharmacy program rolled in nicely under the PCMH that was
taking place in the clinics and the care re­design with care management. Since we were working on
having a pharmacist review high­risk patients (e.g., over 65, on eight or more medications, recently
discharged), incorporating them in the PCMH was a natural fit.
The polypharmacy program was a jumping off point for our PCMH— this was the intention of including it
in our background. The program helped to propel our pharmacy services into the PCMH. There were not
additional outcomes beyond what was discussed.”
—L.P.