Large numbers of uninsured or underinsured people, overuse of resources, and lack of communication between health care providers characterize our current health care system. Non-adherence to medications is associated with 125,000 deaths per year, 10 percent of all hospital admissions, and an estimated $100 billion in direct and indirect health care costs. Research shows that proper use of medications can lead to improved health, enhanced quality of life, and increased productivity when directly linked to clinical quality outcome goals. 

The Patient Centered Medical Home (PCMH) model is an approach to providing comprehensive primary care in a setting that facilitates partnerships and communication between patients, their personal physicians, and other health care providers in a team approach to health care. This model addresses the lack of communication between health care providers and works to improve the quality, effectiveness, and efficiency of patient care, by building a relationship between the patient, his or her primary physician, and any specialist or other health care providers the patient needs.

However, only a few  PCMHs utilize pharmacists, who can play an important role in improving medication adherence, optimizing therapeutic outcomes, and promoting safe, cost-effective medication use.  This lack of relationship between PCMH providers and the pharmacist leaves the burden of comprehensive medication management on the patient who may or may not fully understand their medication regimen. Pharmacists have in-depth knowledge of drug effects and interactions and are able to give a more detailed understanding of the effects of drug therapy, making pharmacists an essential part of any PCMH. During the past 25 years, many studies have demonstrated that pharmacists participating in Patient Centered Medical Home Models (PCMH) in ambulatory clinic settings have made positive contributions to patient care quality, safe medication use, and improved medication adherence.

The Kennedy Pharmacy Innovation Center (KPIC) is actively engaged in the development of a sustainable business model where pharmacists, as a provider, are an integral part of the PCMH care team.

Partnering with Palmetto Primary Care Physicians (PPCP), the Kennedy Pharmacy Innovation Center (KPIC) created and tested a pilot program to evaluate sustainable business models with the pharmacist as a provider of Comprehensive Medication Management (CMM) and Medication Therapy Management (MTM). When KPIC and PPCP created the PCMH pilot project, it was designed to test whether a new interdisciplinary business model could improve quality of care, patient access, and ultimately lower health care costs.

October 2013, Paul Fleming, Pharm.D., was hired as the pharmacist in the PCMH pilot project in the PPCP North Trident location, which has five Family Practice Physicians and two Family Nurse Practitioners serving an estimated 20,000 patients. Among the services he provides are; drug therapy monitoring, providing drug information, pharmacokinetic consults, dosing recommendations, lectures and conferences for staff and health care professionals, providing patient disease and medication education, documenting patient interventions and outcomes, and preparing medication use evaluations when appropriate.   

As the one-year pilot drew to a close, the CMMC analyzed the data and found patient outcomes and satisfaction improved, provider productivity rose as physicians were able to focus on more complex cases, and the health care system saved about $700 per patient visit, according to industry standards of cost avoidance. PPCP has hired Dr. Fleming on a permanent basis to continue his work as part of the patient care team.

Increased Quality Outcomes and Satisfaction

Having a full-time pharmacist on-site is helping the PPCP Trident office provide a higher standard of care and the data show clear benefits for patients:

• More than 77 percent of previous uncontrolled patients diagnosed with diabetes  improved in their A1c measures
• More than 79 percent of previously uncontrolled patients diagnosed with high cholesterol  improved in their LDL-C measures
• More than 72 percent and 81 percent of previously uncontrolled patients diagnosed with hypertension saw improvements in their systolic (SBP) and diastolic (DBP) measures, respectively    
• Satisfaction survey results on a 5-point Likert scale showed patients (4.9) and staff (5.0) overwhelmingly willing to recommend/refer patients to see the pharmacist. In written comments, 15 percent of the patients said that they would change behavior based on the pharmacist’s coaching.

Increased Productivity and Health Care Savings

In addition to measures of patient quality, the CMMC also measured provider productivity, revenue, and cost avoidance - key components in determining the sustainability of the model.

• Increased Productivity (IP) benefiting the physician and the practice: This pilot saw an average revenue increase of more than 15 percent.   The revenue increase was created through the pharmacist opening up physician time for more new patients and allowing the physician to manage more complex patients within the same appointment time due to the pharmacist handling medication management for those patients.
• Revenue: Revenue was measured by evaluating the received payment for medication management provided by the pharmacist as a member of the care team. At the end of the pilot with the pharmacist’s patient visit capacity at 85 percent of his available appointment load, approximately 75 percent of pharmacist’s expenses were covered.  Additional value the pharmacist provided included helping the team create a foundation to close care gaps that could earn performance incentives and contributed to staff education and productivity.
• Cost Avoidance (CA) benefiting the patient and the payer: CA is calculated based on projected follow-up costs if no intervention had occurred. The CMMC used common industry measures for reporting the financial impact of the pharmacist’s clinical interventions (medication allergies prevented, medication reconciliations, changes of dose, counseling for self-care, lab evaluations and adverse effects identified and remedied) and found projected CA averaging more than $700 a patient visit during April, May, and June of 2014.

From August through October of 2021, KPIC conducted a pilot of a team-based care project in collaboration with the SC Pharmacy Association (SCPhA), Department of Health and Environmental Control (DHEC), Hawthorne Pharmacy and Fairfield Medical Associates.

The 12-week pilot embedded a Hawthorne pharmacist into Fairfield Medical Associates (FMA) 2 days a week. The pharmacist conducted Chronic Care Management (CCM) calls, participated in shared office visits with FMA providers, and initiated naloxone therapy in patients who met specific criteria set by the practice. 

Although, the collaboration between Hawthorne and FMA did not continue, the pilot was still a success since FMA decided to hire a pharmacist directly. Patti Fabel consulted with FMA’s practice manager during the first half of 2022 to help identify a pharmacist. In June of 2022, FMA decided to hire 2 pharmacists.

Over the next 2 years, in collaboration with the Center for Rural Primary Healthcare, Gene Reeder, Tessa Hastings and Patti Fabel will continue to work with FMA to demonstrate the value proposition of a pharmacist within a Rural Health Center.

From October 2021 through January 2022, KPIC conducted another pilot of a team-based care project in collaboration with SCPhA, DHEC, and Beaufort Jasper Hampton Comprehensive Health Services (or BJ Comp, an FQHC in the Lowcountry region.)

This 12-week pilot embedded a pharmacist already employed by BJ Comp, into their primary care team for 2 days per week to conduct Annual Wellness Visits (AWVs) and remote patient monitoring (RPM) for patients with hypertension.

By the end of this pilot, BJ Comp not only continued this model, but expanded it to include 2 pharmacists.

Patti Fabel continues to consult with the pharmacy team at BJ Comp, providing as needed assistance related to billing for pharmacist services.

Results from these 2 pilots along with 3 additional pilots conducted in the second half of 2022, will be presented at a national pharmacy meeting in 2023 and submitted for publication in a peer reviewed journal in 2023.