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Geisinger at Home: A multidisciplinary primary care effort to care for
patients with high healthcare utilization
Margaret Bigart Pharm.D
Sarah Krahe Dombrowski Pharm.D, BCACP
Michael R. Gionfriddo Pharm.D, Ph.D
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Disclosures
• MRG is/has been a co-I on several grants funded by
pharmaceutical companies: AstraZeneca, Merck, Takeda, and
Regeneron.
• MRG has acted on behalf of Geisinger as a consultant on
shared decision making (SDM) and medication adherence for
Pfizer and the PhRMA Foundation, respectively.
• MRG has had honorarium paid to Geisinger to speak on SDM
to Hillcrest Medical Center (Tulsa, OK)
• MRG is a co-I on a grant sponsored by the PA DoH studying
prior authorization and a PI on a grant studying transitions of
care funded by NACDSF.
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Acknowledgement
• We would like to thank the Geisinger at Home teams
• We would like to thank Geisinger Health Plan which
funded this work through the Quality Pilot Fund
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Objectives
1) Define Comprehensive Medication Management and
list pharmacists’ essential functions
2) Identify the role of the pharmacist on home-based
primary care teams
3) Discuss the barriers and facilitators to integrating a
pharmacist into a home-based primary care team
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Problem
• 5% of patients account for 50% of costs
• Complex
• Polypharmacy
• Multimorbidity
• Psychosocial
• Traditional models of care fail to meet needs
Timely access
Better coordination of care
Address social determinants
Home based care for medically
complex and terminal conditions
Triple
Aim
× Fragmented & episodic care
× Climbing acute-care utilization
× Excessive post-acute care
× Poorly managed specialty drug
costs
Home Based Care
(team travels) Traditional Care
(patient travels)
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• Geisinger at Home (G@H) is a portfolio of services
designed to provide integrated clinical care that
manages patients with multi-morbid medical conditions
primarily within their homes by delivering:
• Home Based Medical Care
• Comprehensive medical care
• Community Based Palliative Care
• Palliative end of life care
• Mobile Integrated Health
• Acute care by mobile paramedics
Overall Strategy of Geisinger at Home
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G@H Target Populations
• Home-bound
• Advanced age
• Multiple chronic conditions with increasing complexity
• Advanced illness with limited life span
• Significant social gaps
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Geisinger at Home Team Regional
Medical Director
Advanced Practitioner
(AP)
Registered Nurses
(NCM)
Direct Care (3)
Acute Care (1)
Advanced Practitioner
Registered Nurses
Direct Care (3)
Acute Care (1)
Advanced Practitioner
Registered nurses
Direct Care (3)
Acute Care (1)
Advanced Practitioner
Registered Nurse
Direct Care (3)
Acute Care (1)
Social Worker Dietitian Pharmacist Behavioral Health Palliative Care Paramedic
Community Health Assistant (CHA)
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General G@H Workflow
• Patient identified by G@H or PCP referral
• Enrollment visit with AP/NCM
• Frequency of follow up visits are dependent on patient’s
current medical status and goals of care
• Generally, stable patients every 1-3 months
• Other team members follow with patient as needed via
phone or home visits
• Weekly team meetings
• Constant communication with team through TigerText,
Skype, electronic health record
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Comprehensive Medication
Management (CMM)
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Comprehensive Medication Management
Clinical pharmacist develops an individualized medication therapy care plan in collaboration with the patient and the health care team that achieves the intended goals of therapy with appropriate follow-up to ensure optimal medication use and outcomes.
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Comprehensive Medication Management
• Ensures each patient’s medications (prescription, nonprescription,
alternative, traditional, vitamins, or nutritional supplements) are
individually assessed
• Purpose
• Optimize medication use
• Appropriate indication
• Effective
• Safe
• Able to be adhered to
• Improve patient health outcomes
• Patient-centered
• Patient is an active participant
• Collaborative
• Pharmacists worked closely with healthcare team
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CMM Framework – Core Components of Care
• A Shared Philosophy of Practice
• Establishes the values and beliefs that guide the clinical pharmacist’s action and
behaviors as a member of an interdisciplinary, patient-centered care team and
serves to foster relationships built on trust
• The Patient Care Process
• Establishes the nature of work that occurs when a clinical pharmacist, working in
collaboration with the patient and the healthcare team, provides care to an
individual patient with the goal of optimizing medication use and improving the
quality of their health care.
• Essential to understand the ways in which various members of the team
contribute to the patient care process for optimizing medication use
• Practice Management
• Includes the structural and system level supports within a
practice related to practice management and operations
• Enables the efficiency, effectiveness, and sustainability
of CMM services
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CMM Essential Functions
Collect and Analyze Information
Assess the Information and Formulate a Medication Therapy Problem List
Develop the Care Plan
Implement the Care Plan
Follow up and Monitor
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Collect and Analyze Information
• Assure the collection of the necessary subjective and
objective information about the patient
• Conduct a review of the medical record to gather relevant
information
• Conduct a comprehensive review of medications and
associated health and social history with the patient.
• Analyze collected information in order to understand
the relevant medical/medication history and clinical
status of the patient.
• Analyze information in preparation for formulating an
assessment of medication therapy problems
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Collect and Analyze Information - Activities
Inquire as to whether the patient has any questions or
concerns for the visit.
Review social history (e.g., alcohol, tobacco, caffeine,
other substance use).
Review social determinants of health relevant to
medication use
Review past medication history, including allergies and medication adverse
effects.
Obtain and reconcile a complete medication list that
includes all current prescription and
nonprescription medications, and complementary and
alternative medicine
Review the indication for each medication.
Review the effectiveness of each medication.
Review the safety of each medication.
Review the patient’s adherence to his/her
medications using available resources
Review the patient’s medication experience
Determine the patient’s personal goals of therapy.
Review how the patient manages his/her medications
at home
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Assess the Information and Formulate a Medication
Therapy Problem List
• Assess and prioritize the patient’s active medical
conditions taking into account clinical and patient goals
of therapy.
• Assess the indication of each medication the patient is taking
• Assess the effectiveness of each medication the patient is
taking
• Assess the safety of each medication the patient is taking
• Assess adherence of each medication the patient is taking
• Formulate a medication therapy problem list
• Prioritize the patient’s medication therapy problems.
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Medication Therapy Problem Categories
Indication
Unnecessary medication
therapy
Needs additional medication
therapy
Safety
Adverse medication
event
Dosage too high
Needs additional monitoring
Effectiveness
Ineffective medication
Dosage too Low
Needs additional monitoring
Adherence
Nonadherence
Cost
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Prioritize Medication Therapy Problems
Chief Complaint
• Why is the patient being referred to pharmacist?
• What is going to kill/harm patient first?
What else is patient interested in?
What can wait?
1 2 3
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Develop the Care Plan
• Develop a care plan in collaboration with the patient and the
patient’s health care providers to address the identified medication
therapy problems.
• Identify the monitoring parameters important to routinely assess
indication, effectiveness, safety, and adherence.
• Review all medication lists to arrive at an accurate and updated
medication list.
• Determine and coordinate who will implement components of the care
plan
• Determine the type of follow-up needed, appropriate timeframe
patient follow-up, and appropriate mode for follow-up (e.g., in
person, electronically, by phone).
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Implement the Care Plan
• Discuss the care plan with the patient.
• Ensure patient understanding and agreement with the plan and goals of
therapy.
• Provide personalized education to the patient on his/her medications
and lifestyle modifications.
• Provide the patient with an updated, accurate medication list.
• Implement those recommendations that you as the clinical
pharmacist have the ability to implement.
• Communicate the care plan to the rest of the care team.
• Document the encounter in the electronic health record
• Communicate instructions for follow-up with the patient
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Follow up and Monitor
• Provide targeted follow-up and monitoring where needed, to monitor
response to therapy and/or refine the care plan to achieve patient
and clinical goals of therapy.
• Could be in person, electronically, or via phone
• To assess general status of care, monitor blood sugar or blood
pressure, adjust insulin, check INRs, provide education, etc
• Repeat a comprehensive medication management visit at least
annually, whereby all steps of the Patient Care Process are
repeated to ensure continuity of care and ongoing medication
optimization
• If the patient is no longer a candidate for CMM, ensure that a plan is
in place for continuity of care with other care team members
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CMM Essential Functions
Collect and Analyze Information
Assess the Information and Formulate a Medication Therapy Problem List
Develop the Care Plan
Implement the Care Plan
Follow up and Monitor
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CMM in Telehealth
• Clinical pharmacists participating in telehealth can remotely obtain
a complete medication history from the patient or caregiver by
identifying the patient’s current medications, medication-taking
behaviors, adherence, allergies, attitudes, and medication
experience.
• Advantages to telehealth
• Incorporates patient care services into geographically limited settings
• Increases efficient use of health care professionals’ time, resources, and
expertise.
• Promotes cost savings by decreasing hospitalizations, assisting in transitions
of care, or reducing transportation costs
• Additional considerations
• Technology capabilities, mode of transmission, level of security, need for
sharing of the patient’s information, limitations of telehealth encounters, after
hours/on-call expectations, and expected turn-around time for follow-up
communications
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Pharmacist’s Role
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Why are pharmacists a vital member of home
based care team?
Population with:
• Multiple complex disease states
• Multiple medications
Can result in:
• Medication therapy problems
• Increased hospitalizations and ER visits
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Pharmacist’s Role
Comprehensive Medication Management
Disease Management
Drug Information Questions
Acute Management
Clinician and Patient Education
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Application of CMM in G@H
• Identification of patients
• Pharmacist review
• Provider or Case Manager referral
• Add to pharmacist schedule
• Complete essential functions
• Communication with patient through phone call
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CMM Essential Functions- Workflow
Collect and Analyze Information
•Chart review, Patient interview
Assess the Information and Formulate a Medication Therapy Problem List
• Indication, Effectiveness, Safety, Adherence
Develop the Care Plan
•Prioritized list based on goals of care
•Dose/frequency adjustment, Discontinue/Add med, Mail order, Referral, Lab monitoring
Implement the Care Plan
•Collaboration with Geisinger at Home team
Follow up and Monitor
•Collaboration with Geisinger at Home team
•Home visits, phone call, lab review
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Disease Management
Chronic Kidney Disease
Coronary Artery Disease
Peripheral Artery Disease
Chronic Obstructive Pulmonary
Disease
Diabetes Hypertension
• Focus on high 6 disease states
• Closure of care gaps
• Lab monitoring
• Disease education
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Drug Information Questions
Medication safety
• Renal Dosing
• Hepatic Dosing
• Drug/Disease interactions
Dose adjustments
Deprescribing
Treatment Recommendations
Cost
• Formulary alternatives
• Medication assistance programs
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Acute Management
• COPD exacerbations
• Hyper/Hypoglycemia
• Antibiotic recommendations
• HF exacerbations
• Medication Acquisition
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Clinician Education
• Present at weekly team huddles
• Clinical Pearls
• Examples:
• Diuretic titration plans
• COPD guidelines
• Steroid induced hyperglycemia
• Medication use in the elderly
• Influenza treatment
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Future
• Telehealth
• Ipad video visits
• Medications reconciliation
• Disease management
• Assess device technique
• Utilization of dashboard
• Target specific populations
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Facilitating Implementation
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Assembling the Study Team
• Leadership Support
• Physician Director
• Pharmacy Director
• Implementation expertise
• Research expertise
• Representatives from practice
• CMM pharmacists
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Making it happen
• We are taking several steps to facilitate the
integration of pharmacists with Geisinger at Home
• Standardized training/credentialing process
• Standardized documentation
• Quarterly chart reviews
• Quarterly workshops for pharmacists
• Standardized roles/responsibilities
• Standardized workflows
• Population monitoring dashboards
• Understanding and Improving Readiness
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Standardized Training
• 6-8 week training in chronic disease management
• Anti-Coag
• Diabetes
• Asthma/COPD
• Heart Failure
• Hypercholesterolemia
• Hypertension
• CMM Webinar
• Readings on CMM
• Shadowing pharmacists and providers
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Standardized Documentation
• Developed standardized note templates with our EHR
vendor
• Templated format/language
• Automatically pulls in certain data
• Labs
• Medications
• Problem list
• Smart data elements
• “.dot phrases”
• Facilitates data collection and consistency of
documentation
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Chart Reviews
• Quarterly chart reviews by peers
• Standardized rubric
• Needs Improvement
• Acceptable
• Exceptional
• Teachable moment
• Open-ended comments
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Rubric
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Self-Assessments
• Quarterly self-assessments
• Extent to which following best-practice for CMM
• Please reflect on the last 10 CMM visits (emphasis is
placed on the comprehensive nature of the visit) that you
have conducted. For what percent of CMM visits did you
complete the following steps?
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Workshops
• Quarterly
• Geisinger at Home Pharmacists
• Pharmacist Regional Supervisors
• Research Team Members
• Agenda
• Administrative Updates
• Group discussions
• Case Studies
• Educational presentations
• Communicating with patients
• Telephonic communication
• Deprescribing
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Workflows and Roles/Responsibilities
• Mapping out current and future state
workflows/responsibilities
• Ensure a standardized process to care delivery
• Highlight gaps or opportunities to improve workflow
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Dashboards
• Redesigning population health dashboard
• Track overall enrollment
• Tabulate pharmacist workload (# of interventions)
• Monitor individual pharmacist patient panel
• Present relevant individual patient data
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Understanding and Improving Readiness
• Goal
• Improve the integration and sustainability of CMM into G@H
• Process
• Identify implementation team
• CMM Pharmacist and 3-5 G@H team members
• Take Readiness Assessment
• Identify Opportunities
• Develop and Execute QI Plan
• PDSA
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Readiness Assessment Example
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Preliminary Impact
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Next Steps
• Refine population health dashboard
• Support ongoing readiness work
• Develop predictive analytics
• Evaluate success of program
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Questions?
Michael R. Gionfriddo Pharm.D, Ph.D
Geisinger Health System
Center for Pharmacy Innovation and Outcomes
Forty Fort, PA 18708
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