Pharmacists within an ACO Primary Care Office
Pharmacist-Led Heart Failure Clinic
Physicians & Pharmacists Reducing Hospital Admissions
Chronic Care Management and the Healthcare Team
Pharmacy Services Provided |
Description |
Benefits |
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.