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Pharmacists within an ACO Primary Care Office

Pharmacist-Led Heart Failure Clinic

Medication Adherence

Transitions of Care

Physicians & Pharmacists Reducing Hospital Admissions

Chronic Care Management and the Healthcare Team

ARB Recall

Pharmacy Services Provided

Medication Therapy Management (MTM)

Core components include a comprehensive medication review, update of personal medication record,  medication action plan, intervention and/or referral, and documentation and follow-up

•Optimizes therapeutic outcomes for individual patients

•Identifies polypharmacy, preventable adverse drug events, medication adherence, and medication misuse

Annual Wellness Visits (AWV)

• Once yearly Medicare Part B benefit

• Assesses medical history and risk factors through the use of an health risk assessment

• Personalized prevention plan is created with patient

• Improves detection of omissions in preventative care

• Evaluates patient’s well-being, adherence, and medication optimization

• Generates substantial revenue

• Provides a way for pharmacists to support their salaries in a physician’s office

Chronic Disease State Management (CDSM)

• Assist patients in controlling their chronic diseases (e.g., diabetes, hypertension, hyperlipidemia) by providing education on lifestyle changes, monitoring, and medication adherence

• Development of standardized, evidence-based clinical protocols

• Initiate, modify, or discontinue medications through collaborative practice agreements

• Improve efficiency and increase quality and patient satisfaction and safety

• Enhanced coordination of care among diverse providers

• Easy to integrate

Chronic Care Management (CCM)

• Services provided outside of face-to-face patient visits for Medicare patients with ≥ 2 significant chronic conditions expected to last at least 12 months or until death

• Conditions pose a significant risk of death, acute exacerbation or decompensation, or functional decline

• Conditions include, but are not limited to, Alzheimer’s disease, arthritis, asthma, atrial fibrillation, cancer, COPD, depression, diabetes, heart failure, hypertension, ischemic heart disease, and osteoporosis

• Around-the-clock access to care management service and designated CCM practitioners

• Promotes continuity of care between members of CCM team

• Provides opportunities for the patient/caregiver to communicate through various means with the practitioner in compliance with HIPAA

Transitions of Care (TOC)

• Facilitate communication between hospital and outpatient providers

• Conduct medication histories and reconciliations for the inpatient and outpatient providers

• Assist in the discharge process and provide education to patients and their caregivers

• Reduction of preventable adverse drug events after discharge from the hospital

• Reduction of readmissions, an ACO quality measure

These services are provided in-person at primary care offices and telephonic through the MTM call center.

Reproduced from: Joseph et al. J Manag Care Spec Pharm, 2017 May;23(5):541-548.

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