Improving the Care of Dual Eligible Patients in Rural Federally Qualified Health Centers: The Impact of Care Coordinators and Clinical Pharmacists

Systematic literature review of the impact of psychiatric pharmacists

Introduction

Pharmacists focusing on psychotropic medication management and practicing across a wide variety of healthcare settings have significantly improved patient-level outcomes. The Systematic Literature Review Committee of the American Association of Psychiatric Pharmacists was tasked with compiling a comprehensive database of primary literature highlighting the impact of psychiatric pharmacists on patient-level outcomes.

Methods

A systematic search of literature published from January 1, 1961, to December 31, 2022, was conducted using PubMed and search terms based on a prior American Association of Psychiatric Pharmacists literature review. Publications describing patient-level outcome results associated with pharmacist provision of care in psychiatric/neurologic settings and/or in relation to psychotropic medications were included. The search excluded articles for which there was no pharmacist intervention, no psychiatric disorder treatment, no clinical outcomes, no original research, no access to full text, and/or no English-language version.

Results

A total of 4270 articles were reviewed via PubMed, with 4072 articles excluded based on title, abstract, and/or full text in the initial pass and 208 articles selected for inclusion. A secondary full-text review excluded 11 additional articles, and 5 excluded articles were ultimately included based on a secondary review, for a final total of 202 articles meeting the inclusion criteria. A comprehensive database of these articles was compiled, including details on their study designs and outcomes.

Discussion

The articles included in the final database had a wide range of heterogeneity. While the overall impact of psychiatric pharmacists was positive, the study variability highlights the need for future publications to have more consistent, standardized outcomes with stronger study designs.

Improvement in Clinical Outcomes and Access to Care With Pharmacist-Led Chronic Care Management Services at a Rural Family Medicine Clinic

Background: Chronic care management (CCM) can significantly impact the management of chronic diseases in rural patient populations. To date, few practice models have addressed its impact on clinical outcomes and access to care in rural practice settings. Objective: Implement a sustainable pharmacist-led CCM practice model while tracking clinical outcomes and healthcare access at a rural, medically underserved family medicine clinic. Methods: This study retrospectively examined data from the clinic's CCM program from October 2020 through May 2021 and included total clinical encounters at three- and 6-months intervals, as well as changes in clinical outcomes like A1c and systolic blood pressure (SBP) at three- and 6-months intervals. Results: Over an 8-month period, 46 patients were enrolled in pharmacist-led CCM services. Those with a CCM encounter or office visit within 3 months of enrollment showed a mean A1c reduction of 1.07% after 3 months (95% CI -1.70 to -.44, P = .0016), while those with an encounter or office visit within 6 months of enrollment displayed a mean A1c reduction of 1.64% after 6 months (95% CI -2.35 to -.92, P < .001). There was a 73.8% increase in total clinical encounters in the 6 months after CCM enrollment compared to the 6 months preceding it, signifying increased access to care. Conclusion: Patients with CCM encounters or office visits within the first 3-6 months experienced statistically significant reductions in A1c. Moreover, total clinical encounters markedly increased in the 6 months after enrollment, allowing for more frequent engagement between ambulatory pharmacists and traditionally challenging rural patients.

Financial reimbursement and productivity metrics for pharmacist-led chronic care management services in rural practice settings

BACKGROUND

The implementation of chronic care management (CCM) services has often been hindered by issues with reimbursement, raising concerns about sustainability. To date, little if any literature has examined the financial feasibility and sustainability of CCM services in rural practice settings.

OBJECTIVE

Assess financial reimbursement and productivity metrics for pharmacist-led CCM services at a rural, medically underserved family medicine clinic.

METHODS

This study retrospectively examined data from the clinic's CCM program from October 2020 through May 2021 and included total clinical encounters, minutes of pharmacist time spent on calls, CCM claims, work relative value units (wRVU), financial reimbursement, and overall personnel costs.

RESULTS

Over an 8-month period, 46 patients were enrolled in CCM services. Of the 49 CCM calls placed during this time, 31 (63.3%) were billable, though only 20 (64.5% of billable calls) were ultimately reimbursed. Approximately 37% of pharmacist "time-on-task" was not billable. Compared to the $643 required to cover pharmacist time on CCM calls, $822 of reimbursement was collected. This $179 profit, or 27.8% return-on-investment, is similar to results from more urbanized practices. Furthermore, services were "net productive" in wRVU generation, which may appeal to physician stakeholders interested in such targets.

CONCLUSIONS

Concerns about profitability and sustainability have prevented more widespread CCM implementation. In the present study, pharmacist-led CCM services achieved a 27.8% return-on-investment. Though rural-based CCM services may never attain significant profit margins, this data suggests they can still be financially self-sustaining and "net productive," all while providing high-quality patient care.

Association between sustained opioid prescription and frequent emergency department use: a cohort study

BACKGROUND

Chronic non-cancer pain (CNCP) is common among frequent emergency department (ED) users, although factors underlying this association are unclear. This study estimated the association between sustained opioid use and frequent ED use among patients with CNCP.

METHODS

Retrospective cohort study using a Canadian provincial health insurer database (Régie d'Assurance Maladie du Québec). The database included adults with both ≥1 chronic condition and ≥ 1 ED visit in 2012 or 2013. Inclusion in the study further required a CNCP diagnosis, public drug insurance coverage and 1-year survival after the first ED visit in 2012 or 2013 (index visit). Multivariable logistic regression was used to derive ORs of frequent ED use (≥5 visits in the year following the index visit) subsequent to sustained opioid use (≥60 days opioids prescription within 90 days preceding the index visit), adjusting for important covariables.

RESULTS

From 576 688 patients in the database, 58 237 were included in the study. Of these, 4109 (7.1%) had received a sustained opioid prescription and 4735 (8.1%) were frequent ED users in the follow-up year. Sustained opioid use was not associated with frequent ED use in the multivariable model (OR: 1.06, 95% CI 0.94 to 1.19). Novel associated covariables were benzodiazepine prescription (OR: 1.21, 95% CI 1.12 to 1.30) and polypharmacy (OR: 1.23, 95% CI 1.13 to 1.34).

CONCLUSIONS

Due to confounding by social and medical vulnerability, patients with CNCP with sustained opioid use appear to have a higher propensity for frequent ED use in unadjusted models. However, sustained opioid use was not associated with frequent ED use in these patients after adjustment.

Primary Care Physicians', Psychiatrists', and Oncologists' Coordination While Prescribing Medications for Patients With Multiple Chronic Conditions

OBJECTIVES

Coordination of medication prescribing is important in the care of patients with multiple chronic conditions (MCC) given the involvement of multiple providers and multiple medications used to manage MCC. The objective of this study was to identify physician and practice factors associated with physicians' coordination of prescribing for complex patients with MCC.

METHODS

Our cross-sectional study used a 33-item anonymous, online survey to assess physicians' coordination practices while prescribing for patients with MCC. We sampled primary care physicians (PCPs), psychiatrists, and oncologists across the United States. Coordination of medication prescribing was measured on a 7-point Likert-type scale. χ2, Fisher exact test, and binomial logistic regression, adjusted for factors and covariates, were used to determine differences in coordination of prescribing. Average marginal effects were calculated for factors.

RESULTS

A total of 50 PCPs, 50 psychiatrists, and 50 oncologists participated. Most psychiatrists (56%) and oncologists (52%) reported frequently coordinating prescribing with other physicians, whereas less than half of the PCPs (42%) reported frequently coordinating prescribing. Female physicians were 25% points more likely to report coordinating prescribing than male physicians (P = 0.0186), and physicians not using electronic medical records were 30% points more likely to report coordinating prescribing than physicians using electronic medical records (P = 0.0230). Four additional factors were associated with lower likelihood of coordinating prescribing.

CONCLUSIONS

Physician and practice factors may influence differences in coordination of medication prescribing, despite physician specialty. These factors can provide a foundation for developing interventions to improve coordination of prescribing practices for MCC.

Health Care Delivery Interventions for Hypertension Management in Underserved Populations in the United States: A Systematic Review

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Behavioral Health Screening and Care Coordination for Rural Veterans in a Federally Qualified Health Center

Many rural veterans receive care in community settings but could benefit from VA services for certain needs, presenting an opportunity for coordination across systems. This article details the Collaborative Systems of Care (CSC) program, a novel, nurse-led care coordination program identifying and connecting veterans presenting for care in a Federally Qualified Health Center to VA behavioral health and other services based upon the veteran’s preferences and eligibility. The CSC program systematically identifies veteran patients, screens for common behavioral health issues, explores VA eligibility for interested veterans, and facilitates coordination with VA to improve healthcare access. While the present program focuses on behavioral health, there is a unique emphasis on assisting veterans with the eligibility and enrollment process and coordinating additional care tailored to the patient. As VA expands its presence in community care, opportunities for VA-community care coordination will increase, making the development and implementation of such interventions important.

Impact of pharmacists on outcomes for patients with psychiatric or neurologic disorders

INTRODUCTION

Psychiatric and neurologic illnesses are highly prevalent and are often suboptimally treated. A 2015 review highlighted the value of psychiatric pharmacists in improving medication-related outcomes. There is a need to describe areas of expansion and strengthened evidence regarding pharmacist practice and patient care impact in psychiatric and neurologic settings since 2015.

METHODS

A systematic search of literature published from January 2014 to June 2019 was conducted. Publications describing patient-level outcome results associated with pharmacist provision of care in a psychiatric/neurologic setting and/or in relation to central nervous system (CNS) medications were included.

RESULTS

A total of 64 publications were included. There was significant heterogeneity of published study methods and data, prohibiting meta-analysis. Pharmacists practicing across a wide variety of health care settings with focus on CNS medication management significantly improved patient-level outcomes, such as medication adherence, disease control, and avoidance of hospitalization. The most common practice approach associated with significant improvement in patient-level outcomes was incorporation of psychiatric pharmacist input into the interprofessional health care team.

DISCUSSION

Pharmacists who focus on psychiatric and neurologic disease improve outcomes for patients with these conditions. This is important in the current health care environment as most patients with psychiatric or neurologic conditions continue to have unmet needs. Additional studies designed to measure pharmacists' impact on patient-level outcomes are encouraged to strengthen these findings.

Improving Chronic Disease Outcomes Through Medication Therapy Management in Federally Qualified Health Centers

INTRODUCTION

Appropriate management of chronic diseases, including proper use of medications, can lead to better disease control, decrease disease-related complications, and improve overall health. Pharmacists have been shown to positively affect chronic disease outcomes through medication therapy management (MTM). The primary objectives of this project are to increase the number of patients with (1) A1c in control and (2) blood pressure in control; secondary objectives are to (3) describe number and type of medication-related problems identified and resolved by pharmacists providing MTM in Federally Qualified Health Centers (FQHCs), (4) identify potential (pADEs) and actual adverse drug events (ADEs), and refer patients to diabetes self-management education classes, as needed.

METHODS

This multisite, prospective, descriptive pilot study engaged three FQHC sites with distinct models of established pharmacist MTM services to care for patients with uncontrolled diabetes and/or hypertension. Data were reported in aggregate regarding primary and secondary outcomes.

RESULTS

As of December 2015, 706 patients were enrolled in the project. Of the 422 with uncontrolled diabetes, 52.84% (n = 223) had an A1c <9%; 72 patients (17.06%) achieved an A1c between 8% and 9%, 19.19% (n = 81) of patients achieved an A1c <8% and ≥7%, and 16.59% (n = 70) of patients achieved an A1c <7%. The percentage of patients with blood pressure <140/90 mm Hg improved to 65.21%.

CONCLUSION

Pharmacist-provided MTM can improve chronic disease intermediate outcomes for medically underserved patients in FQHCs.

Health Services Utilization Among Fee-for-Service Medicare and Medicaid Patients Under Age 65 with Behavioral Health Illness at an Urban Safety Net Hospital

BACKGROUND

In 2011, fee-for-service patients with both Medicare and Medicaid (dual eligible) sustained $319.5 billion in health care costs.

OBJECTIVE

To describe the emergency department (ED) use and hospital admissions of adult dual eligible patients aged under 65 years who used an urban safety net hospital.

METHODS

This was a retrospective database analysis of patients aged between 18 and 65 years with Medicare and Medicaid, who used an urban safety net academic health center between January 1, 2011, and December 31, 2011. We compared patients with and without behavioral health illness. The main outcome measures were hospital admission and ED use. Chi-square and Wilcoxon rank-sum tests were used for descriptive statistics on categorical and continuous variables, respectively. Greedy propensity score matching was used to control for confounding factors. Rate ratios (RR) and 95% confidence intervals (CI) were determined after matching and after adjusting for those variables that remained significantly different after matching.

RESULTS

In 2011, 10% of all fee-for-service dual eligible patients aged less than 65 years in Massachusetts were seen at Boston Medical Center. Data before propensity score matching showed significant differences in age, sex, race/ethnicity, marital status, education, employment, physical comorbidities, and Charlson Comorbidity Index score between patients with and without behavioral health illness. Analysis after propensity score matching found significant differences in sex, Hispanic race, and other education and employment status. Compared with patients without behavioral health illness, patients with behavioral health illness had a higher RR for hospital admissions (RR = 2.07; 95% CI = 1.81-2.38; P < 0.001) and ED use (RR = 1.61; 95% CI = 1.46-1.77; P < 0.001). Results were robust after adjusting for characteristics that remained statistically significantly different after propensity score matching.

CONCLUSIONS

Adult dual eligible patients aged less than 65 years with behavioral health illness in the Medicaid fee-for-service plan had significantly higher rates of hospital admission and ED use compared with dual eligible patients without behavioral health illness at the largest urban safety net medical center in New England. Safety net hospitals care for a large proportion of dual eligible patients with behavioral health illness. Further research is needed to elucidate the systems-related and patient-centered factors contributing to the utilization behaviors of this patient population.

DISCLOSURES

This research was funded in part by a National Research Service Award (T3HP10028-14-01). The authors have no conflicts of interests to disclose. Cancino had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design were contributed by Cancino, Jack, and Burgess, with assistance from Cremieux. Cancino and Cremieux took the lead in data collection, along with Jack and Burgess, and data interpretation was performed by Jarvis, Cummings, and Cooper, along with the other authors. The manuscript was written primarily by Cancino, along with Jack and Burgess, and revised primarily by Cancino, along with the other authors.