American College of Clinical Pharmacy
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ACCP Report - March 2017

Highlights from the CMM Effectiveness and Implementation Grant: A Report from the Study Team


Each quarter, the ACCP Report features a column, written by the study team, to provide ACCP members with highlights and learnings from the Comprehensive Medication Management (CMM) project. The previous reports for March, June, and September 2016 can be found at www.accp.com/report/archives.aspx.

The report provides an update on study progress and concludes with Research Insights, which highlight a particular aspect of our work. The goal is to share the key learnings emerging from our efforts.

Study Updates

To revisit the aims of this study, visit www.accp.com/docs/report/0616.pdf.

As a key component of aim 1, we launched a demographic and baseline CMM survey to all lead pharmacists within each of our sites. The survey findings describe each site in greater detail as well as highlight the state of CMM within each practice. As a follow-up to the baseline survey, we completed several interviews with sites to learn more about their CMM practice model and currently have a series of focus groups and interviews under way to better understand the structural and system-level elements that support CMM delivery within their primary care practice or organization. Survey and interview findings will be forthcoming after all the data are collected and analyzed.

A key learning that emerged from our baseline work is the lack of a consistent, standardized practice of CMM across our sites. Despite pharmacists confirming that they are engaged in CMM and despite the existence of several guideline documents, standards of practice, and definitions of CMM in the literature, a consistent approach to CMM is lacking. As described in detail in the September 2016 ACCP Report column, our implementation science colleagues at the National Implementation Research Network advised us that an important first step in implementing and spreading an innovation is to "describe the core activities that allow an intervention or program to be teachable, learnable, doable, and measurable in practice; and promote consistency across practitioners at the level of actual service delivery." To that end, and as discussed in the September 2016 column, we applied a rigorous methodology to develop a CMM common language document for the patient care process. We have finalized that document and are now preparing for its release and widespread dissemination beyond our sites. The CMM common language document has also been translated into a CMM self-assessment tool, which we will make available for use throughout the profession. These tools will be forthcoming in the next few months. Having a common language for the CMM patient care process is critical as we seek to assess the fidelity of the CMM intervention (i.e., that the intervention is being implemented as intended). Our multifaceted approach to assessing fidelity will be highlighted in the next quarterly update in the ACCP Report.

Using the common language document, our study sites have identified areas for improvement in CMM delivery and are engaged in improvement work using Plan-Do-Study-Act (PDSA) cycles. The study team devoted significant time in fall 2016 to planning and training pharmacists on improvement cycles through a series of live webinars. These monthly webinars are designed to build pharmacist knowledge and share the lessons learned through practice rounds of rapid-cycle change. The early webinars introduced several tools and assessments to assist the sites with planning, implementing, and documenting their PDSA cycle work. In January 2017, we launched our rapid-cycle testing of CMM within the primary care practices. Each site formally identified an improvement team composed of three to five key individuals within the site's practice or organization who are dedicated to the improvement efforts and can help facilitate change within the practice. To support a site's use of the PDSA cycles, trained coaches (e.g., an implementation science expert and a pharmacist from the study team) provide monthly virtual coaching support to each site. These coaching calls are designed to address any concerns the sites may have, provide guidance when needed, and help the sites stay on track with their deliverables. Learnings from the PDSA cycles are captured by PDSA planning and tracking forms and run charts submitted by the site's implementation team before webinar sessions and after improvement cycles. PDSA cycle work will continue throughout the rest of the study, with the goal of helping sites improve on areas of CMM delivery and move toward a more consistent approach to CMM. Learnings will be captured throughout the year. Early learnings indicate that sites are finding the tools, resources, and coaching around improvement cycle work to be helpful and that the structured approach to quality improvement within each site is valuable.

One of the critical aims of the ACCP study is to leverage learnings around optimal implementation and best practices in CMM that yield consistent outcomes. The goal is to build a business case for payers and health care systems that facilitates better decision-making within new value-based payment models. As such, a payer and policy advisory board (PPAB) was created to provide insights and recommendations to guide the research team. Specifically, the PPAB is educating the team on environmental factors to consider, emphasizing key areas of focus in order to produce meaningful evidence that facilitates better decision-making. In October 2016, we held our first PPAB meeting in Washington, D.C. The PPAB consists of two national payers, including representation from America's Health Insurance Plans and two regional health plans and two representatives from provider-led accountable care organizations who are engaged in risk-based contracting with public and commercial payers. The following two themes emerged from the initial PPAB session, relative to embedding pharmacists into primary care clinics: (1) making the case: expanding medication optimization return-on-investment (ROI) analyses to inform the move to value-based payment and (2) defining the intervention to determine the impact—identifying specific pharmacist activities, fidelity, and best practices. We describe each of these themes in greater detail in the Research Insights section of this column.

Finally, Drs. Jen Carroll and Wilson Pace and the team with the American Academy of Family Physicians National Research Network and DARTNet have been instrumental in leading our efforts to conduct a formal evaluation of the impact of CMM on important outcomes (aim 4 of the study). This work is well under way within each site to determine data access capabilities, and the research team is formalizing the approach and analysis of this aim. Our CMM grant steering committee as well as our PPAB will play a key role in reviewing and validating our approach to this aim. This formal, retrospective evaluation is taking place this year.

Research Insights from Our PPAB

As described earlier, two key themes emerged from our meeting with the PPAB in October 2016. We outline each theme here and summarize insights from this meeting.

Theme 1: Making the Case: Expanding Medication Optimization ROI Analyses to Inform the Move to Value-Based Payment

One of the challenges facing the U.S. health care system is delivering high-value, effective therapies and clinical services that provide the best health outcomes. The Affordable Care Act (ACA) proposes numerous ways to extract greater value from the U.S. health care system framed around three core tenets of care: quality, access, and cost. The overriding emphasis and focus of payers and providers has been on controlling total health care spending and "bending the cost curve" as the ACA is being implemented. To achieve this objective, more efforts are being directed toward defining, delivering, and measuring "value," with "value" embedded as an integral part of health care and treatment decisions. The importance of medication management within population health is gaining traction, given the need to proactively manage and optimize medication use (especially for patients with chronic conditions), and quality metrics are being tied to reimbursement through public programs and commercial value-based contracts.

The transformation occurring in health care is opening up new opportunities to think and act in innovative and creative ways to bring about change. This shift to value provides significant opportunity for the profession of pharmacy to demonstrate the value of appropriate medication use on cost and quality. As a result, provider organizations are now executing risk-based contracts with payers that focus on achieving cost savings and quality improvement within defined patient populations. These new arrangements are driving the need for additional infrastructure in population health management, which includes investments in people, technology and analytics, and team-based care coordination processes. This begins with identifying the "metrics that matter" to achieve success and then building out interventions and processes to achieve those metrics.

The next step, and the purpose of this work going forward, is to assess how best to deploy resources in a cost-effective way that can directly improve clinical and economic returns back to the provider organization based on those investments. Although prior research has shown that medication management services produce positive clinical outcomes in the primary care setting, many questions remain. How are these resources (investments) measured relative to the improvement in quality measures, total cost of care reductions, and productivity gains within that care setting? As the impact of CMM is monetized, how does a provider organization then invest in and scale up those services? Once people and technology have been invested, how do CMM services get funded over time in "shared services" or "shared risk" contracts?

Specifically, the PPAB noted that we must (a) be able to first measure the specific pharmacist function(s) and then assess the key clinical and economic metrics that matter to that organization; (b) better define cost savings to include lowering the total cost of care, lowering operational costs of the provider organization, lowering per member per month cost for the health plan (payer), and lowering drug costs for the patient and health plan (payer); (c) produce varying ROI models depending on whether the organization is accountable for the cost of medications; (d) consider a new model of defining ROI relevant to payer and/or provider audiences and clinical ROI versus financial ROI; and (e) develop flexible ROI models that account for the patient population receiving CMM, with the goal of moving toward focusing pharmacist activity (e.g., CMM) on complex patients who drive 50% of cost versus spreading interventions across entire populations (i.e., what is the appropriate ratio of pharmacist interventions on target patients to produce downstream cost savings).

In summary, these PPAB insights are helping the study team reframe its original thinking about ROI—to be most effective, we must develop and validate flexible ROI models rather than work toward a static ROI model. The goal is to enhance payer and provider organization decision-making with investments in CMM services, which will in turn produce better clinical and economic performance within new value-based payment models. In doing so, we must account for the variability in payer, provider, and patient mix and develop flexible ROI models.

Theme 2: Defining the Intervention to Determine the Impact—Identifying Specific Pharmacist Activities, Fidelity, and Best Practices

As health care continues to transition toward value-based care, we must demonstrate the value-added role of the clinical pharmacist as an integral member of the health care team in optimizing medication use and improving patient care. This will require that we demonstrate our ability to articulate and carry out a consistent approach to optimizing medication use, build the business case that integrates medication optimization into value-based payment models across diverse care delivery systems, and, importantly, support practices in their ability to integrate these services into their workflow and business model.

Specifically, the PPAB noted the importance of explicitly defining CMM and ensuring it is consistently applied and can be replicated. This reinforced the work we proposed to do. The PPAB noted that the following are important considerations as we look to scale up and sustain the CMM service: (a) if CMM is to be integrated into emerging value-based care and payment strategies, it must be well defined, consistently delivered, and understood because payers and providers need to know what they are buying; (b) the pharmacist must assuredly be appropriately educated and trained in order to deliver a high-quality intervention; (c) the pharmacist's actions and the price to pay for them must be quantified; (d) the intervention must touch the right patients in order to reduce the total cost of care and have impact; and (e) the intervention must be scaled up in practices.

These insights from the PPAB reinforce the importance of having a consistent and standardized approach to the CMM patient care process and of assessing the fidelity of CMM. The work we are engaged in with the pharmacists and study sites was originally framed to address these insights. Having this aspect of our work validated by the PPAB was a key outcome of the meeting.

On behalf of the investigators and the study team, we hope these highlights are informative. Please feel free to reach out to Mary Roth McClurg at mroth@unc.edu or Todd Sorensen at soren042@umn.edu at any time with questions.