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    Come together

    Providing whole-patient care in the primary care setting isn't impossible — it just takes a team approach


    Participants in MAHEC’s patient-centered medical home model include (from left): Ben Smith, PharmD; Bill Hitch, PharmD, BCPS, CPP; Gaye Colvin, MLIS, CQI coordinator; Kimberly Fordham, PharmD; Mollie Ashe Scott, PharmD, BCPS, CPP; Lisa Ray, MD, CCD. (PHOTOGRAPHY COURTESY OF STEVEN MCBRIDE)
    A shortage of primary care physicians, decreased reimbursement, and increased complexity of patient care can make caring for today's patients harder than ever. Despite these challenges, the Mountain Area Health Education Center (MAHEC) in Asheville, N.C., has found that providing whole-patient care in the primary care setting isn't impossible — it just takes a dedicated team approach and constant quality improvement.

    Through the center's patient-centered medical home, physicians, nurses, pharmacists, a dietician, and behavioral medicine specialists work together to meet the needs of each patient, whether the goal is to manage diabetes, to combat the effects of osteoporosis, or to find a way to help pay for a new medication.

    Residency training in family medicine

    As a family medicine residency training program dedicated to training and retaining healthcare students and residents, MAHEC is unique. Through its education program, pharmacy students and residents acquire first-hand experience working in collaborative environments such as MAHEC's anticoagulation clinic, osteoporosis clinic, and pharmacotherapy clinic. Pharmacists also assist with patient transitions into the hospital and back into the community.

    By allowing each medical professional to focus on what he or she does best, MAHEC has developed a full-service family practice in which all its team members are valued and respected for their individual skills and knowledge.

    NCQA and structural specifics

    According to the National Committee for Quality Assurance (NCQA), not all patient-centered medical homes are created equal. The nonprofit organization has developed an accreditation system that designates and recognizes 3 levels of patient-centered medical homes. Evaluation of each medical home depends on how well it meets NCQA standards.

    Table 1: Summary of PCMH 2011 Standards (6 standards/27 elements) Information printed with permission. "FAQs NCQA's Patient-Centered Medical Home [PCMH] 2011" National Committee for Quality Assurance, Washington, D.C. Available online at www.ncqa.org/tabid/1016/Default.aspx.
    While MAHEC was accredited according to 9 NCQA standards, in 2011 the organization defined the goals of patient-centered medical homes in 6 standards, including enhancing patient access and continuity of treatment, identifying and managing patient populations, planning and managing care, providing self-care and community support, tracking and coordinating care, and measuring and improving performance (Table 1).

    The standards were created as tangible and measurable ways to meet the 7 principles of a patient-centered medical home jointly developed in 2007 by the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Physicians, and the American Osteopathic Association. The more comprehensive the patient-centered medical home, the more points the practice will receive under NCQA's accreditation system. MAHEC has been designated a level III patient-centered medical home, the highest distinction given by the organization.

    Elements of success

    Lisa Ray
    Lisa Ray, MD, CCD, a MAHEC family physician, said that for each level of distinction, some elements of a patient-centered medical home are required and other elements are optional.

    Mollie Ashe Scott
    Mollie Ashe Scott, PharmD, BCPS, CPP, MAHEC director of pharmacotherapy, believes that the practice was able to secure the highest level of accreditation because of its solid model of team-based care, its large continuous quality-improvement program, and its focus on whole-patient care.

    "In primary care we are looking at the whole person, not just at their medical issues but also at their social issues and their psychosocial issues, as well as how that impacts their health, so you need to have that philosophy," she said.

    In addition, practices also need to have systems in place that can document quality and show quality improvement over time. "I think that's where pharmacists can help. I think our hospital colleagues especially are doing a lot with quality improvement in the hospital and ensuring safe use of medications. That translates very nicely to the outpatient system, where we just need to set up systems for population management," said Scott, who is also a clinical associate professor at the Eshelman School of Pharmacy and School of Medicine at University of North Carolina, Chapel Hill.

    One way MAHEC tracks quality improvement is through an electronic medical records system. For example, with these records the practice is able to assess diabetes population management through annually reviewing mean HbA1C scores, calculating the percentage of patients who have met A1C goals, determining the percentage of people who have a low-density lipoprotein score of less than 100, and reviewing quality indicators for medications. If an area of concern is observed, a clinic-wide intervention is developed to address the problem.

    Having systems in place to document quality improvement also benefits the process of application for accreditation. According to Ray, practices with procedures already in place that meet accreditation standards will have an easier time than practices that first need to create new policies or tracking methods.

    Even with a solid system established for documenting quality improvement, Ray said, the accreditation process can still be time-consuming. It requires considerable data collection and many staff interviews about current practices. According to her estimates, she spent roughly 3 hours a week for 9 months, working with another staff member, to complete the application.

    A focus on pharmacotherapy

    When it came to creating the specific clinics at MAHEC, the staff kept physician and patient needs in mind. The pharmacotherapy clinic was developed approximately 10 years ago, after physicians acknowledged that they could use extra help with diabetes management and medication assistance. Pharmacists who work in the pharmacotherapy clinic educate newly diagnosed patients about diabetes management.

    "We do a lot of insulin titration and insulin adjustment," Scott said. "It's kind of a second set of hands for the physicians. We'll see those patients about every 2 weeks to help assess their glucose patterns and adjust their insulin to get them to goal."

    Pharmacists also work closely with patients who may not be able to afford their prescribed medications. "We are in an area of the state where we have a large number of uninsured or underinsured patients, so dealing with affordability for younger patients as well as for seniors who are in the doughnut hole became a huge niche for us," Scott said.

    Managing osteoporosis

    The pharmacotherapy clinic isn't the only clinic filling a need within the practice. MAHEC also runs an osteoporosis clinic where physicians and pharmacists work hand-in-hand to assist patients who have abnormal dual-energy X-ray absorptiometry (DEXA) scans.

    The clinic was established after a pharmacy student working on a project found that health center patients with abnormal DEXA scores weren't always receiving appropriate follow-up. In response, MAHEC instituted a screening program to evaluate women over the age of 65 through use of the DEXA scan and established the clinic where Ray, who is also assistant clinical professor, School of Medicine, the University of North Carolina, Chapel Hill, interprets the DEXA scores, determines the diagnoses, assesses patients for risk factors, and develops initial treatment plans.

    After each initial plan is developed, the pharmacists conduct a dietary history, determine whether the patient needs to begin taking calcium and vitamin D supplements or needs to have previously established dosages adjusted, and evaluate the patient's current medications to determine whether any prescribed drugs are likely to increase the risk of falls.

    Since the program began, screening rates at MAHEC went from approximately 20% of women over the age of 65 receiving a DEXA scan to approximately 75%. Also, Ray said, the close collaboration has created an almost collegial environment for the team, in which staff members are able to learn from one another. "The patients get really comprehensive care," she said.

    Anticoagulation assistance

    When they aren't in the pharmacotherapy or osteoporosis clinics, Scott and her pharmacy residents can be found in one of the center's anticoagulation clinics. The center operates an on-site clinic and several off-site clinics at nearby retirement facilities.

    Kimberly Fordham
    Kim Fordham, PharmD, who is completing a 1-year residency at MAHEC, said that during shifts in the anticoagulation clinic she can see anywhere from 10 to 15 patients for 20 minutes each. During their visits, she assesses patients' status, verifies that there have been no changes to their regimens, checks for drug or food interactions, takes their international normalized ratios (INR), and determines medication or dietary changes that may be necessary.

    As part of MAHEC's focus on quality improvement, Fordham also recently completed a project assessing whether MAHEC anticoagulation patients were receiving equitable services, regardless of whether pharmacists or nurses oversaw their care.

    "It's real important to me that we're not just providing services when the patient is sitting in front of us, but we're thinking constantly about how we're going to keep them safe and make sure we are doing the right thing," she said.

    Other quality improvement efforts Fordham has assisted with include updating a policy and procedure manual for anticoagulation management services, and updating policies regulating frequency of INR checks. To help prevent unnecessary dose changes for the older population, new age-specific policies call for checking patients who are more than 65 years of age every 10 to 14 days, while those under the age of 65 will be rechecked in 5 to 7 days.

    Transitioning care

    Transitions can often pose challenges to patient management. At MAHEC, a care-team pharmacist, a physician, and 2 medical residents combine to make patient transitions as seamless as possible.

    Bill Hitch
    When MAHEC patients enter the hospital for primary care, Bill Hitch, PharmD, BCPS, CPP, works to make sure they are receiving the appropriate medications during their stay, updates the electronic medical record with any changes, and reviews the medications again when the patient is discharged. "We try to focus on looking at the meds during those transition points, trying to clean those up to make sure that patients are on the right medication and the right dose at the right time," he said.

    After a patient leaves the hospital, MAHEC policy calls for patients to be seen by their primary care physicians within 1 week of their hospital stays, at which time medication lists are again updated, if necessary.

    Community collaboration

    Many patients at MAHEC struggle with payment issues. Withnumerous medication assistance services available in Asheville, including a program at Mission Hospital, MAHEC has refrained from duplicating services. Instead, Scott and her team serve as a triage point for patients, matching their insurance, age, and medication needs with the most appropriate local resource.

    Ben Smith
    Ben Smith, PharmD, works in the medication assistance program as part of the Mission Hospital Outpatient Clinical Pharmacy Services. Collaborating with MAHEC has been a valuable experience for both organizations, he said. When patients are referred to the assistance program from the health center, they are contacted by a medication assistance specialist who verifies their eligiblity for the program and schedules a visit to the hospital, where they can learn about the program and meet with a pharmacist to resolve their medication needs. The staff at the hospital's medication assistance program can continue to collaborate with the health center by sending notes to MAHEC physicians and pharmacists sharing updates on patient progress.

    "It works out well for us to be able to fill that need but still communicate closely with MAHEC," Smith said.

    The MAHEC pharmacy staff realizes that drug cost may not be the only obstacle preventing patients from taking their medications. Mental health issues, such as depression, or other financial burdens may also influence whether patients are regularly using and refilling prescriptions. "The challenges that we come up with the most are dealing with psychosocial issues," Scott said.

    To combat these problems, MAHEC's behavioral medicine staffers also work with patients. Pharmacists too are trained to ask patients who have difficulty paying for their medications about other needs as well, such as heating, cooling, and food, and are able to refer patients to community resources that can help meet other such needs.

    "If you are trying to provide whole-patient care, doing what you can for the patient and getting them to the person who can meet that need when you can't do it has become really important to us," Scott said.

    Conquering challenges

    While the patient-centered medical home model has brought many benefits to MAHEC and improved patient care, it also brings its own set of challenges.

    Reimbursement is one of the biggest challenges faced by MAHEC pharmacists. Pharmacists at the health center bill for services in 2 ways. When they are working with a MAHEC employee who is part of a wellness program targeting diabetes, hypertension, or hyperlipidemia, they can be paid directly for their services. However, for all non-MAHEC employees, the clinic pharmacists use the "incident to" billing model for a private physician office and bill for services under the physician assigned to supervise for the day.

    This billing model works better in the anticoagulation clinic, where patient volume is high; in the pharmacotherapy clinic, where pharmacists see fewer patients for longer periods, it has been a challenge.

    "That's not covering our cost. It's a loss for us, but we continue to do it for 2 reasons. One is because we think it's an appropriate service for the patients and the mission of our practice, and number 2, it's a teaching clinic," Scott said.

    Scott said other common challenges for patient-centered medical homes include finding ways to document quality improvement and getting started on the initial application process.

    Despite the challenges, the staff at MAHEC agrees that the patient-centered medical home has benefited both practice and patients. "I think the patients get better care, because you've got all these different people looking at patients through different eyes, trying to figure out how to best meet their needs and help them succeed," Scott said.

    Jill Sederstrom is a freelance medical writer based in Kansas City.