Impact of a centralized population health pharmacy program on value-based Medicare patients

Abstract

BackgroundMemorial Healthcare System (MHS) participated in the Centers for Medicare and Medicaid Services Bundled Payments for Care Improvement Advanced value-based program aimed to improve patient care and reduce health care costs. Challenges with medication therapy problems (MTPs) led to the development of a centralized tele-health population health pharmacy program. This innovative approach aimed to provide comprehensive postdischarge medication support and resolve MTPs during the 90-day risk period. ObjectivesThe program aimed to provide longitudinal medication support, resolve MTPs, and affect 90-day readmission rates. Practice descriptionMHS established uniform workflows, a pharmacy task force, and a dual pharmacy team approach with population health registered nurses (PHRNs). The population health pharmacists (PHPs) conducted postdischarge telephonic encounters to resolve MTPs longitudinally throughout the risk period. Practice innovationThe program used a centralized tele-health model with electronic health record–integrated tools. It targeted readmission rates up to 90 days, beyond the conventional 30-day period. PHPs collaborated with onsite transitions of care pharmacists, PHRNs, and health care professionals for coordinated patient care and MTP resolution. Evaluation methodsA retrospective analysis using descriptive statistics, a Kruskal-Wallis test, and multivariate regression models after stratifying patients into 4 groups were used to assess MTP resolution rates and differences in readmission rates. ResultsOver 7 months, PHPs completed 801 telephonic visits, identifying 433 MTPs with a 94% resolution rate. The program led to a statistically significant reduction in 90-day readmission rates from 35% to a range of 10%-17% (P < 0.01). ConclusionThe centralized tele-health population health pharmacy program improved patient outcomes, resolved MTPs, and reduced readmission rates. The program serves as a model for integrating pharmacists into value-based care initiatives.