Adopting Health Information Systems
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PHARMACY FORECAST 2017 POPULATION HEALTH MANAGEMENT
30 AM J HEALTH-SYST PHARM | VOLUME 74 | NUMBER 2 | JANUARY 15, 2017
Population Health Management: Improving the Community to Heal the Patient
Panelists (FPs) predicted that within the next five years, at least 75% of health systems will have formal pro- grams aimed at achieving the highest quality at the lowest cost for specific patient populations (Figure 1, item 1). This suggests that pharmacy practice leaders will need to give a lot of atten- tion to developing (and continuously refining) and enforcing data-driven treatment protocols for illnesses that are associated with substantial quality and cost issues.
COMMUNITY PARTNERSHIPS
Integral to managing popula- tion health is employing nonmedi- cal strategies to make communities healthier. About three fourths of FPs predicted that at least 50% of health systems will expand nonmedical sup- port services (Figure 1, item 2) and that at least 25% of health systems will heavily engage community leaders to manage nonmedical and social is- sues that affect health (Figure 1, item 3). This can be achieved by partner- ing with community governments to improve neighborhood walkability, make outdoor physical activities more accessible, promote healthy diets, eliminate smoking, ensure access to medical and mental health services, and reduce alcohol and substance abuse.2 Use of nontraditional support services that optimize caregiver labor costs (e.g., distance health programs using smartphone applications and video technology) is another impor- tant consideration.
MANAGING HIGH-RISK PATIENTS
As more states improve collabora- tive practice acts that allow pharma- cists to add, modify, and discontinue medications, more opportunities exist to expand the health system’s primary care footprint in community
Scott J. Knoer, M.S., Pharm.D., FASHP, Chief Pharmacy Officer, Cleveland Clinic, Cleveland, OH.
Address correspondence to Dr. Knoer ([email protected]).
Copyright © 2017, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/17/0102-0030.
INCENTIVIZED PATIENT WELLNESS
Population health management (PHM) continues to be a top stra- tegic initiative for health-system pharmacy leaders because evolving payment models incentivize patient wellness. Last year’s Pharmacy Fore- cast report included a chapter on PHM that focused on financial incentives.1 This year’s chapter offers an expanded perspective on PHM and emphasizes health-related behavioral and societal issues.
Many health systems are learning from their experience in self-insuring their employees and assuming fi- nancial responsibility for keeping them healthy. These lessons can be extrapolated to other populations as the health system enters into at-risk contracts with health-benefit plans. Some health systems are experiencing decreased healthcare expenditures and increased employee productiv- ity through wellness initiatives (e.g., premium reductions based on health- ful weight maintenance, compliance with disease management programs, regular exercise encouraged by free access to fitness centers and free pe- dometers, avoiding tobacco use).
ACHIEVING HIGHEST QUALITY AT LOWEST COST
A large majority (84%) of Forecast
pharmacies.3 Notably, 63% of FPs pre- dicted that over the next five years, it is at least somewhat likely that 50% or more of health systems will serve high-risk patients through formal programs with community phar- macies (Figure 1, item 4). Electronic health records can be used to iden- tify high-risk patients for pharmacist interventions, including education, blood pressure screening, medication adjustment, appointment facilita- tion, refill authorization, mail-order program enrollment, and compli- ance packaging programs such as for patients using multiple medications or those with dementia.
MANAGING MENTAL HEALTH
Last year, 70% of FPs predicted that at least 25% of health systems would integrate behavioral and mental health services with primary care. In this year’s survey, 67% of FPs predicted that at least 25% of health systems will achieve significantly improved out- comes from such integration within the next five years (Figure 1, item 5).
While it is generally beyond the pharmacy department’s ability to ensure that communities have ade- quate behavioral health services, the focus of pharmacy practice leaders is to ensure that pharmacists improve outcomes by participating in mental health teams in specialty and prima- ry care clinics. As pharmacists inte- grate into PHM models such as the medical home, they must have the expertise to manage mental health disorders (including depression, dementia, and schizophrenia) as ef- fectively as they manage hyperten- sion and metabolic disorders. Medi- cation nonadherence and untreated mental health symptoms guarantee increased visits to emergency rooms, productivity loss, and increased so- cietal costs.
PHARMACY FORECAST 2017POPULATION HEALTH MANAGEMENT
AM J HEALTH-SYST PHARM | VOLUME 74 | NUMBER 2 | JANUARY 15, 2017 31
Figure 1 (Population Health Management). Forecast Panelists’ responses to the question, “How likely is it that the following will occur by the year 2021 in the geographic region where you work?”
80%
60%
40%
20%
0% Very
Likely Somewhat
Likely Somewhat
Unlikely Very
Unlikely
1 At least 75% of health systems will have formal, assertive programs aimed at achieving the highest quality at the lowest cost for specific patient populations (e.g., oncology, diabetes, inflammatory and immune disorders) across the continuum of care.
43% 41%
14%
2%
80%
60%
40%
20%
0% Very
Likely Somewhat
Likely Somewhat
Unlikely Very
Unlikely
23%
53%
20%
3%
2 At least 50% of health systems will significantly expand their nonmedical support services (e.g., transportation, health education, counseling, patient engagement) to address factors related to poor health.
80%
60%
40%
20%
0% Very
Likely Somewhat
Likely Somewhat
Unlikely Very
Unlikely
30%
45%
22%
3%
3 At least 25% of health systems will be heavily engaged with community leaders in programs to manage the nonmedical/social determinants of health (e.g., environmental, cultural, and economic factors).
80%
60%
40%
20%
0% Very
Likely Somewhat
Likely Somewhat
Unlikely Very
Unlikely
17%
46%
27%
9%
4 At least 50% of health systems will serve high- risk patients (e.g., those with cancer, congestive heart failure, HIV) through formal programs with community pharmacies (e.g., for adherence coaching, patient monitoring) that they own or are in partnership with.
80%
60%
40%
20%
0% Very
Likely Somewhat
Likely Somewhat
Unlikely Very
Unlikely
19%
48%
28%
5%
5 Through the integration of behavioral health services with primary care, at least 25% of health systems will achieve significantly better outcomes related to comorbid conditions in patients who suffer from mental health disorders. 80%
60%
40%
20%
0% Very
Likely Somewhat
Likely Somewhat
Unlikely Very
Unlikely
66%
22% 12%
0%
6 At least 75% of health systems will have a major campaign aimed at improving the prescribing of opioids.
PHARMACY FORECAST 2017 POPULATION HEALTH MANAGEMENT
32 AM J HEALTH-SYST PHARM | VOLUME 74 | NUMBER 2 | JANUARY 15, 2017
STRATEGIC RECOMMENDATIONS FOR PRACTICE LEADERS
1. Leverage the pharmacy enter- prise to achieve optimal medi- cation adherence by high-risk patients. In pursuit of this goal, include risk-stratification tech- niques, telehealth applications, collaborative practice in clinics and community pharmacies, refill authorization, compli- ance packaging, and bedside discharge-prescription delivery.
2. If your institution self-insures its employees for healthcare coverage, use that program to pilot innovative pharmacy ser- vices (such as targeted disease state management) that can be offered to other health-benefit plans.
3. Create a pharmacy refill clinic that allows physicians to opti- mize their time with patients while improving medication- use safety, adherence, and outcomes.
4. Identify and implement ways for the pharmacy enterprise to actively contribute to your health system’s support ser- vices for high-risk patients, including efforts in telehealth, patient education, and motiva- tional interviewing for improv- ing adherence.
5. Assertively incorporate a behavioral health component into pharmacist patient care, including chronic disease management and prescription assistance programs.
6. Ensure that your pharmacy enterprise is actively addressing the opioid crisis through means such as an opioid stewardship program, effective opioid- diversion prevention, support of prescription-medication dis- posal programs, and promo- tion of improved public access to naloxone.
THE OPIOID CRISIS The United States is experiencing
an unprecedented increase in mor- bidity and mortality associated with the misuse and abuse of opioids.4 This epidemic results in substantial treatment costs, decreased workplace performance, and devastating effects on families and communities. Con- gressional recognition of this crisis led to bipartisan passage of the Compre- hensive Addiction and Recovery Act of 2016.5
Two thirds of FPs predicted that within the next five years, it is very likely that at least 75% of health sys- tems will have a major campaign aimed at improving the prescribing of opioids (Figure 1, item 6). These
efforts will probably include opioid stewardship programs based on pre- scribing guidelines for chronic pain issued by the Centers for Disease Con- trol and Prevention.6 It is important to partner with law enforcement, patient families, community pharmacies, and ambulance services to ensure nalox- one access and expanded drug take- back programs.
Diversion of controlled substanc- es can have a major financial impact on health systems, as reflected by the $2.3 million settlement paid to the United States by a major Boston insti- tution to resolve drug diversion allega- tions.7 In addition to focusing on retail pharmacy chains and wholesalers, the Drug Enforcement Administration
now targets health systems for diver- sion and compliance issues. A proac- tive health-system approach toward preventing diversion of controlled substances could integrate state- automated opioid reporting into elec- tronic health records to monitor and improve prescriber compliance.
Disclosures Dr. Knoer is a contributing editor of AJHP. He has declared no other potential conflicts of interest.
References 1. Shane R, Deculus CL. Population
health management: aligning incen- tives to transform care delivery. In: Zellmer WA, ed. Pharmacy forecast 2016–2020: strategic planning advice for pharmacy departments in hos- pitals and health systems. Bethesda, MD: ASHP Research and Education Foundation; 2015:9-12.
2. Community Commons. Community health needs assessment toolkit. http://assessment.communitycom- mons.org/CHNA/About.aspx (accessed 2016 Aug 20).
3. Knoer SJ, Luder DD, Hill JM et al. Lessons learned in updating and im- proving a state collaborative practice act. Am J Health-Syst Pharm. 2016; 73:1462-6.
4. Kolodny A, Courtwright DT, Hwang CS et al. The prescription opioid and heroin crisis: a public health ap- proach to an epidemic of addiction. Annu Rev Public Health. 2015; 36:559- 74.
5. Comprehensive Addiction and Recov- ery Act of 2016. www.congress.gov/ bill/114th-congress/senate-bill/524/ text (accessed 2016 Aug 20).
6. Centers for Disease Control and Pre- vention. CDC guideline for prescrib- ing opioids for chronic pain—United States, 2016. www.cdc.gov/mmwr/ volumes/65/rr/rr6501e1.htm (accessed 2016 Aug 20).
7. U.S. Department of Justice. MGH to pay $2.3 million to resolve drug diversion allegations (September 28, 2015). www.justice.gov/usao-ma/pr/ mgh-pay-23-million-resolve-drug- diversion-allegations (accessed 2016 Aug 20).
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