Implementation outcomes associated with a value-based care model of comprehensive medication management in community pharmacies.

OBJECTIVE: Although the delivery of comprehensive medication management (CMM) in community pharmacies has been shown to improve health outcomes, inconsistent adoption hinders the benefit patients receive. Our objective was to examine the implementation of a novel value-based care model and the impact of educational and coaching support for pharmacists on patient access to CMM. The underlying care model provides a payment for CMM services combined with incentives to document and improve clinical outcomes and patient engagement. DESIGN: Cross-sectional study. SETTING AND PARTICIPANTS: In addition to fee-for-service payments, performance-based incentives were provided to 12 participating pharmacy organizations to promote pharmacist documentation of clinical values (blood pressure and tobacco status for patients with vascular disease and additionally hemoglobin A1c [HbA1C] for patients with diabetes). To promote patient engagement, pharmacies that engaged a higher proportion of attributed patients received additional incentives. OUTCOME MEASURES: Implementation outcomes included penetration (the proportion of eligible patients who received CMM), adoption (variation in penetration across organizations), and fidelity (documentation of all required clinical values). Comparisons were made using t-tests and chi-square testing. RESULTS: Among 1240 eligible patients, 478 (35.8%) had documentation of any service by a participating pharmacist during a one-year implementation period. Using diabetes as an example, documentation was consistently highest for tobacco status (38.1%), followed by blood pressure (29.7%), and HbA1C (38.1%). CMM recipients on average were older, used more medication, and were more likely to have at least one comorbid condition than non-recipients. 41.8% of patients with vascular disease had documentation of both blood pressure and tobacco status while 24.4% of patients with diabetes had blood pressure, tobacco, and HbA1C documentation. CONCLUSIONS: Improving pharmacist access to a patient's medical records could help improve access to CMM services for patients under value-based care models that rely on patient targeting and clinical measurements.

Community pharmacists' experience relying on select implementation strategies in the delivery of comprehensive medication management.

OBJECTIVE: Implementation strategies are methods or techniques that facilitate adoption, implementation, and sustainability of a clinical program or practice. There has been a lack of widespread adoption of comprehensive medication management (CMM) in community pharmacies. The objective of this evaluation was to expand understanding of how select implementation strategies impacted pharmacists' experience implementing and delivering CMM in the community pharmacy setting. METHODS: A community pharmacy CMM initiative, Slice of Partners in Excellence (PIE), employed a number of implementation strategies and key elements from the Institute for Healthcare Improvement's Breakthrough Series to support increased engagement and delivery of CMM within a local payer's CMM program. The program provides incentives to pharmacies for providing CMM to select patients and achieving predetermined quality metrics. To evaluate pharmacists' experience with the implementation strategies and the impact it had on implementing and delivering CMM, a focus group and survey were conducted. RESULTS: Some of the implementation strategies were more frequently highlighted as generating value to participants (coaching, community-wide problem-solving) than others (monthly webinars). Pharmacists identified a need for more formal education regarding billing, documentation and patient engagement supports. Pharmacists expressed a desire for ongoing implementation supports extending beyond this initaitive. CONCLUSION: Understanding the types of implementation strategies that are deemed as influential by pharmacists delivering clinical services in the community pharmacy setting is critical to maximizing patient access to these services in the future.

Screening and Referral Care Delivery Services and Unmet Health-Related Social Needs: A Systematic Review.

INTRODUCTION: Unmet health-related social needs contribute to high patient morbidity and poor population health. A potential solution to improve population health includes the adoption of care delivery models that alleviate unmet needs through screening, referral, and tracking of patients in health care settings, yet the overall impact of such models has remained unexplored. This review addresses an existing gap in the literature regarding the effectiveness of these models and assesses their overall impact on outcomes related to experience of care, population health, and costs. METHODS: In March 2020, we searched for peer-reviewed articles published in PubMed over the past 10 years. Studies were included if they 1) used a screening tool for identifying unmet health-related social needs in a health care setting, 2) referred patients with positive screens to appropriate resources for addressing identified unmet health-related social needs, and 3) reported any outcomes related to patient experience of care, population health, or cost. RESULTS: Of 1,821 articles identified, 35 met the inclusion criteria. All but 1 study demonstrated a tendency toward high risk of bias. Improved outcomes related to experience of care (eg, change in social needs, patient satisfaction, n = 34), population health (eg, diet quality, blood cholesterol levels, n = 7), and cost (eg, program costs, cost-effectiveness, n = 3) were reported. In some studies (n = 5), improved outcomes were found among participants who received direct referrals or additional assistance with indirect referrals compared with those who received indirect referrals only. CONCLUSION: Effective collaborations between health care organizations and community-based organizations are essential to facilitate necessary patient connection to resources for addressing their unmet needs. Although evidence indicated a positive influence of screening and referral programs on outcomes related to experience of care and population health, no definitive conclusions can be made on overall impact because of the potentially high risk of bias in the included studies.

What is needed to sustain comprehensive medication management? One health plan's perspectives.

Implementation of comprehensive medication management (CMM) in the community pharmacy setting remains sporadic despite its prevalence in other pharmacy contexts. One health plan has been investing in CMM since 2010. Their experience and perceptions in the payer-provider partnership could offer unique insights into the sustainability of CMM in community pharmacy. As part of a broader academic-payer-provider partnership, perceptions of CMM sustainability were explored with key stakeholders in the health plan through a semistructured group interview. Five themes emerged: (1) distinction between CMM and other patient care opportunities, (2) building a CMM program that delivers value requires an investment in network development, (3) payment design influences sustainability, (4) lack of push from community pharmacies to pay for CMM, and (5) the importance of an ongoing facilitated learning and action collaborative. Given previously demonstrated positive return-on-investment, CMM in community pharmacies shows promise for being a sustainable practice model. However, increased reach and performance of networks, as well as number of payers in the market, will be critical to scaling CMM in the community pharmacy setting.

A Systematic Review of the Effect of Telepharmacy Services in the Community Pharmacy Setting on Care Quality and Patient Safety.

While community pharmacy-based telepharmacy services can expand medication access for underserved communities, the safety and quality of these services is uncertain. A systematic review was conducted in August 2020 exploring the effect of community pharmacy-based telepharmacy services on patient safety and care quality. Database searches identified 866 studies, of which six met the inclusion and the risk of bias measurement criteria. Medication dispensing errors, adherence, and patient satisfaction were the most frequently evaluated outcomes. Literature suggests no overall difference in medication safety and adherence, conflicting evidence on patient satisfaction, and insufficient evidence on inappropriate medication use in community pharmacy-based telepharmacies compared with traditional pharmacies. Due to the potential for high risk of bias, no definitive conclusions could be made about telepharmacy outcomes. Research with stronger study designs and more rigorous evaluation methodologies is needed to create conclusive evidence on the effectiveness of community pharmacy-based telepharmacy services.

Adaptations made to delivery of comprehensive medication management in the community pharmacy setting during COVID-19.

BACKGROUND: As a result of COVID-19, numerous adaptations were made to health care delivery, including comprehensive medication management (CMM) delivered in community pharmacies. OBJECTIVE: Identify and describe the adaptations that have been made to the delivery of CMM among community pharmacies due to COVID-19. METHODS: Community pharmacies participating in a CMM implementation and research initiative had regular coaching calls throughout COVID-19 and completed a survey of changes that occurred as a result of COVID-19. Coaching notes and survey results were summarized and mapped to the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) to systematically capture changes that occurred. RESULTS: A number of reactive adaptations were made to CMM delivery as a result of COVID-19, including increased virtual or remote delivery of CMM, delaying CMM visits to allow pharmacies to provide care directly related to the pandemic including COVID-19 testing and vaccines, wearing personal protective equipment (PPE) in visits, new ways of obtaining clinical patient information, and shifting CMM staffing models. CONCLUSION: Adaptations that occurred to CMM during COVID-19 allowed pharmacists to continue to serve their patients and meet public health needs.

Community pharmacists' perceptions of acceptability, appropriateness, and feasibility of a value-based care model for comprehensive medication management.

BACKGROUND: HealthPartners is an integrated health plan offering comprehensive medication management (CMM) under a value-based care model called Partners in Excellence (PIE). In PIE, participating organizations are incentivized to conduct CMM visits and are eligible for bonus payments if they achieve quality and engagement metrics. Engagement in PIE from community pharmacies has been lacking. Implementation science, specifically the assessment of implementation outcomes, provides key insights into the uptake of patient care services, such as CMM, into practice. OBJECTIVE: To evaluate the acceptability, appropriateness, and feasibility of the PIE program from the perspective of community pharmacists and pharmacy managers. METHODS: Semi-structured, one-on-one qualitative interviews were conducted with a group of 14 pharmacists and pharmacy managers participating in the PIE program. Interviews were coded inductively, and then codes were mapped to the implementation outcomes of acceptability, appropriateness, and feasibility. RESULTS: Twelve codes emerged from the interviews. Four codes (targeted conditions of PIE, achieving PIE metrics, comprehensiveness of PIE, and confusion and barriers) were mapped to acceptability; 3 codes (CMM documentation and billing, fitting CMM into limited time with patients, and community pharmacy's role in patient care) were mapped to appropriateness; and 1 code (collecting clinical patient information) was mapped to feasibility. Four codes (CMM payment model, targeting patients for CMM, personnel for CMM, and patient/provider buy-in of CMM) were considered a combination of more than 1 outcome. CONCLUSIONS: Although the acceptability, appropriateness, and feasibility of the PIE program was generally positive, participants cited a number of implementation challenges related to documentation and billing and producing a sustainable CMM model. The results shed light on how a value-based care model for CMM is perceived within community pharmacies and could inform the development and implementation of similar quality-based CMM programs. DISCLOSURES: This study was funded by the National Association of Chain Drug Stores (NACDS) Foundation and the UNC Eshelman Institute for Innovation. Pestka is affiliated with the University of Minnesota College of Pharmacy and reports grants from NACDS Foundation and UNC Eshelman Institute for Innovation for the conduct of the study; she has also received grants from UNC Eshelman Institute for Innovation and NACDS Foundation outside the submitted work. Stoa and Sorensen are also affiliated with the University of Minnesota College of Pharmacy. Blanchard is employed at the UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill. This work was presented as a virtual poster at the 2020 American College of Clinical Pharmacy Annual Meeting, October 19-30, 2020.

A mixed methods evaluation of the implementation of pharmacy services within a team-based at-home care program.

BACKGROUND: Sub-optimal medication use results in significant avoidable morbidity, mortality, and costs. Programs, such as comprehensive medication management (CMM), can help to optimize medication use, improve outcomes, and reduce costs. However, implementing programs like CMM can be challenging and differences in how CMM has been implemented may be responsible for observed heterogeneity in the outcomes associated with CMM. OBJECTIVE(S): Describe the implementation strategies utilized in implementing CMM telephonically within a team-based at-home care program and evaluate the implementation process. METHODS: The implementation of CMM was facilitated using various implementation strategies including: develop educational material and conduct training, change record system, audit and feedback, learning collaborative, quality monitoring, readiness assessment, and implementation team formation. The impact of these strategies as well as pharmacist and team member perspectives on the implementation of CMM were examined using mixed methods and guided by Proctor's conceptual model for implementation. RESULTS: The pharmacists felt that most of the implementation strategies used to facilitate consistent delivery of CMM were useful, but were unable to successfully implement all of them. Despite this, significant increases in fidelity to steps of the patient care process was achieved. The pharmacists felt that CMM was acceptable, appropriate for patient population, and feasible, but barriers (e.g., the telephonic and remote nature of the practice, the evolving nature of the program, and the difficulty in coordinating care between the patients primary care team and the care team affiliated with the program) affected the feasibility and organizational fit of CMM within this team-based, at-home care program. General pharmacy services, however, were seen as acceptable, appropriate, and feasible. CONCLUSION: Deliberately designing and utilizing a variety of implementation strategies can facilitate the implementation of CMM and significantly increase fidelity to the patient care process. To improve feasibility and organizational fit of CMM, additional barriers and challenges need to be addressed.

Ensuring intervention success: Assessing fit as an overlooked step of the implementation process.

Ensuring fit between a service and the implementing context is a critical but often overlooked precursor of implementation success. This commentary proposes five key considerations that should be evaluated when exploring fit: alignment with needs and metrics; alignment with organizational resources and capabilities; alignment with organizational priorities and culture; alignment with reimbursement mechanisms for long-term sustainability; and alignment with the regulatory environment. Successful uptake and implementation hinges on careful planning and, most importantly, appropriate fit between the service and the implementing environment.