Population health management: An independent physician organization approach.

Abstract

The role of clinical pharmacists and their impact on population health and value-based contracts within a multidisciplinary care management team are described. The Greater Rochester Independent Practice Association (GRIPA) has promoted high-quality, value-based care since its foundation 20 years ago. One of several ways that GRIPA enables its physicians to succeed in shared-savings agreements is by providing a community-based multidisciplinary care management team. The multidisciplinary team's primary goal is to help physicians manage the care of their most costly and complex patients. In addition, clinical pharmacists concentrate on lowering the amount of money spent on medications. The outcome goals for this team include (1) reducing hospitalizations, emergency room visits, and the use of unnecessary or inappropriate medications and (2) improving medication adherence and other measurable outcomes. Care management provided by clinical pharmacists for patients meeting GRIPA's high-risk criteria (≥2 inpatient or ≥3 emergency room visits in the 12 months before care management engagement) between 2013 and August 2015 resulted in a 42% decrease in 30-day readmissions, a 45% decrease in hospital admissions, a 16% decrease in emergency room visits, and a 20% decrease in annual medical charges. Through individualized pharmacy reviews and a unique approach to managing high-cost drugs, the clinical pharmacists at GRIPA have been successful in reducing hospitalizations and emergency room visits as well as promoting appropriate use of medications while reducing pharmacy waste. As part of a multidisciplinary team, clinical pharmacists are able to optimize medication use and engage patients and physicians to reduce medical and medication costs for contracted patients.