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Practice Models within Patient Centered Medical Home. Objectives. Describe Patient Centered Medical Home concepts Describe system redesign goals for providers and team members Explain how clinical pharmacy contributes in providing direct patient care

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Presentation Transcript
  • Describe Patient Centered Medical Home concepts
  • Describe system redesign goals for providers and team members
  • Explain how clinical pharmacy contributes in providing direct patient care
  • Present examples of pharmacy outcomes data from Medical Home Models
patient centered medical home
Patient Centered Medical Home

Replaces episodic care based on illness and patient complaints with coordinated care and a long term healing relationship

  • The Primary Care Team
    • Takes collective responsibility for patient care
    • Responsible for providing all the patient’s health care needs
    • Arranges for appropriate care with other specialties as needed 
  • Enhanced Access
  • Enhanced communication between
    • Patients
    • Providers
    • Staff
Focused on the principle that all redesign is guided towards

Removing Waste

Enhancing Value

Value is defined by the Veteran & Customer

The VETERAN first

The secondary customers next

Never on the system itself

Value changes as Veteran and Health care expectations evolve

Veteran Centered (each patient has their own)

Evidence Based (right care, right place)

Value is comprised of


Efficient/Costs (not solely financial)






System Redesign: Patient Center Care


renewed emphasis on skills of the primary care team
Renewed Emphasis on Skills of the Primary Care Team
  • Leadership
  • Teamwork
  • Teaching
  • Clinical expertise in Veteran-specific problems
    • Mental Health
    • Pain management
    • Military medicine
  • Knowledge of facility, VISN, and community resources
  • Systems Redesign
  • Clinical Microsystems
  • Change culture


McGinnis JM, Foege WH. Actual Causes of Death in the United States. JAMA 1993;270:2207-12.

Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual Causes of Death in the United States, 2000. JAMA 2004;291:1230-1245.

group health cooperative seattle
Group Health Cooperative – Seattle
  • One-year study provides some of the nation's first empirical evidence of the benefits of this new type of care. It compared 9,200 patients at Group Health's medical home to a control group. At one year, patients at the medical home:
    • Had 29 percent fewer emergency room visits, 11 percent fewer hospitalizations that primary care can prevent, and 6 percent fewer in-person visits.
    • Used 94 percent more e-mail, 12 percent more phone, and more group visits and self-management support workshops.
    • Patients received better health care, including needed screening tests, management of their chronic illnesses, and monitoring of their medications.
    • Reported, in a random-sample survey, higher ratings on six scales of patient experience.

September 2009 American Journal of Managed Care

key principles of the medical home
Key Principles of the Medical Home
  • Each member of the team works at their highest training level
    • Medication management goals can be delegated to Clinical Pharmacy Specialists, who are key members of PCMH
  • When possible care of the patient will be delivered by their team
  • Same day appointments will be available to care for acutely ill panel members decreasing ED visits
  • Improve provider throughput to improve time spent with direct patient care
Clinical Pharmacy SpecialistsIncrease the efficiency of physician-patient interactions & allow for greater patient access

Improved Quality & Efficiency of Care



clinical pharmacy specialist cps
Clinical Pharmacy Specialist (CPS)
  • Primary Care can utilize the Clinical Pharmacy Specialist in direct patient care roles. They are mid-level providers with a VA scope of practice and able to perform to the highest level of their profession.

* Managing patient’s drug therapy to goal

for chronic disease states and other specialty care

  • These positions are highly respected provider members with advance professional skills
cps scope of practice
CPS Scope of Practice

Scope of Practice allows CPS to:

  • CPS’s are granted medication prescribing & monitoring privileges based on a locally-defined scope of practice.
    • Prescribe medications includes: initiation, continuation, discontinuation, monitoring and altering therapy without co-signature
  • Work in concert with an attending physician
  • Evaluate medication therapy through direct patient care involvement
  • Perform physical measurements necessary to ensure appropriate patient clinical responses to drug therapy
  • Order consults, as appropriate, to maximize positive drug therapy outcomes and disease state management.
chronic disease medication management
Chronic Disease Medication Management
  • Chronic diseases have multiple drug therapy options to achieve therapeutic goals.
  • VA’s National Formulary and PBM/MAP Criteria for Use documents provide patient specific criteria
    • CPS and Clinical Pharmacists are well versed with the VA National Formulary and are VA experts on drug information, medication selection for specific diseases and medication safety (alerts and bulletins).
  • CPS have the advance skills necessary to provide Medication Management Services in Primary Care and Specialty Care
  • The Clinical Pharmacist plays a vital role in dual-care management, therapeutic interchange, and medication reconciliation
a routine day utilizing cps within the home model
A Routine Day: Utilizing CPS Within the Home Model
  • Patient Clinic Visits (via appointment package)
    • Managing Pharmacotherapy
    • Patient Education
    • Clinical Reminders
    • Physical Assessment
  • Medication Renewals
  • Precepting Pharm.D. Residents/Students
  • TeleHealth Follow-Up & Interventions
  • Quality Assurance, education and training
    • Medication Use Evaluations (MUEs)

Clinical Pharmacy Specialists Can Address:

        • Identification of absent therapies, sub-optimal doses, significant drug interactions
        • Medication adherence assessment
        • Provision and monitoring of cost effective and safe regimens
        • Dietary/Lifestyle recommendations
        • Participation in quality improvement initiatives
        • Provider education
        • Patient education
patient scheduling with and without the use of cps
Patient Scheduling:with and without the use of CPS

with PharmD

without PharmD

Courtesy of Dr. Rubin, D.O.

Chief of Primary Care Service

West Palm Beach VA Medical Center

jesse brown vamc primary care home model
Jesse Brown VAMC Primary Care Home Model
  • Primary Care Team Staffing
  • Each team:
      • 3 Primary Care Physicians
      • 1 Nurse Case Manager
      • 1 LPN
      • 0.5 Health Tech
      • 1 Clinical Pharmacy Specialist

Chronic Disease Management Role of CPS

  • Anticoagulation
  • Diabetes
  • COPD/Asthma
  • BPH
  • Hypertension
  • Hyperlipidemia
  • Medication Management
  • Therapeutic Drug Monitoring
jesse brown vamc home model
Jesse Brown VAMC Home Model

Standard Pharmacy Clinic Structure

  • 4.5 clinic days per week
  • 20 minute appointments
  • 16-18 appointment slots per day
  • (except Thursdays: ½ day clinic)
  • Referral Process
  • providers schedule directly into CPS clinic
  • review of patients who do not meet performance/therapeutic goals are scheduled
  • Referrals based on national formulary changes and national medication efficiency programs

Jesse Brown VAMC Home Model

Four Primary Care Teams

Data from 3/09 – 3/10;

source – VSSC cube and VISTA

jesse brown vamc home model1
Jesse Brown VAMC Home Model

Other Clinical Pharmacy Specialist Responsibilities

  • Medication Use Evaluations – QA program
  • Non-Formulary Consult Review
  • Assist with Formulary Conversions and Annual
  • Cost Savings Initiatives
  • Assist with facility performance measures/initiatives
  • Membership in various Local, VISN, and/or National
  • Groups/Committees
  • Research
  • Precept 4th Year Pharmacy Students (min 5 students/year)
  • Precept PGY-1 Pharmacy Practice Residents
jesse brown vamc home model2
Jesse Brown VAMC Home Model
  • CPS integrated in primary care at main station and four community based outpatient clinics (CBOC)
  • CPS reports to pharmacy service
  • Success of this integrated role has led to CPS expansion in specialty clinics throughout the medical center
  • Pharmacy continues to receive requests from medical staff to expand CPS services
jesse brown vamc home model3
Jesse Brown VAMC Home Model

Specialty Clinical Pharmacy Clinics

  • Intense Diabetes Management
  • Emergency Department
  • Geriatrics
  • Gastroenterology
  • Home Based Primary Care
  • Home Infusion Program
  • Infectious Diseases
  • Co-Infection – Hepatitis C
  • Mental Health
  • Nephrology
  • Pain
  • Pulmonary
  • Smoking Cessation
  • Urology
  • Women’s Health
jesse brown vamc home model4
Jesse Brown VAMC Home Model

Pharmacy Clinic Outcomes – Diabetes Management

Percentages given as a mean


jesse brown vamc home model5
Jesse Brown VAMC Home Model

Pharmacy Clinic Outcomes – Women’s Health

Multidisciplinary clinic model

Mean number of visits: 2.4 over 6 months

Values given as a mean



VA is a nationally recognized leader in Clinical Pharmacy Services.

The team based approach of the Patient Centered Medical Home provides the opportunity for this role and that of the other team members to become the standard of care.