Apr 6, 2016 Drs. Steven Chen and Michael Hochman, of USC, presented as part of a seminar series on UCLA CTSI Dissemination, Improvement and Implementation Research.

1. Improving Healthcare Quality and
Safety While Reducing Costs Through
Clinical Pharmacy Service Integration
Steven W. Chen PharmD, FASHP, FCSHP, FNAP
Associate Professor and Chair
Titus Family Department of Clinical Pharmacy and Pharmacoeconomics and Policy
William A. Heeres and Josephine A. Heeres Endowed Chair in Community Pharmacy
Co-Chair Emeritus, HRSA Patient Safety & Clinical Pharmacy Services Collaborative
Michael Hochman, MD, MPH
Director
Gehr Family Center for Implementation Science
Keck School of Medicine of USC

2. Agenda
• Comprehensive Medication Management at
AltaMed Health Services
• The “Business Case” for Comprehensive
Medication Management
• The Gehr Family Center for Implementation
Science

3. Medication Safety Problems in U.S.
• 1.5 million people are injured each year
due to medications
• ~25% of ambulatory patients experience
adverse drug events
• 90% of chronic diseases require
medications as first-line therapy
• “…for every dollar spent on ambulatory
medications, another dollar is spent to
treat new health problems caused by the
medication.”
Institute of Medicine (IOM), To Err Is Human: Building a Safer Health System, Washington, DC: National Academy Press; 2000.

4. $12 Million USC / AltaMed CMMI Project: Specific Aims
UNIVERSITY OF
SOUTHERN CALIFORNIA
National Conference on Best
Practices and Collaborations to
Improve Medication Safety and
Healthcare Quality
Feb 20-21, 2014
Resident and
technician training
for expansion
Web-based pharmacist training
and credentialing
OUTCOME MEASURES
 Healthcare Quality
 Safety
 Total Cost / ROI
 Patient & provider
satisfaction
 Patient access
Telehealth clinical
pharmacy10 teams
Pharmacist + Resident +
Clinical Pharmacy Technician

5. USC Patient Targeting and Management Strategy
Clinical Pharmacy
Comprehensive
Medication
Management
Clinical pharmacy
tech “check-ins”
every 2 months
Yes
Unstable
No
Treatment Goal
Reached?
High cost patients
Frequent and recent
acute care utilizers
48 EHR-embedded triggers
to detect high risk patients
MD referrals

6. Outcome: Recruit high risk patients
• Enrolled 6,000 patients since Oct 2012
• Predominantly Hispanic, non-elderly women
• 3/4ths have hypertension, 36% uncontrolled
• 2/3rds have diabetes, 60% uncontrolled
• High rates of hospitalizations

7. Outcome: Improvement in Clinical Markers
125
130
135
140
145
150
155
Baseline 3 Months Most
Recent
Systolic Blood Pressure
72
74
76
78
80
82
84
86
88
Baseline 3 Months Most
Recent
Diastolic Blood Pressure
* Among those with uncontrolled hypertension at baseline

8. 0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
Less than 7 7 to 8 8 to 9 9 to 10 Greater than 10
A1C Levels
Baseline 6 months Most Recent
Outcome: Improvement in Clinical Markers

9. Outcome: Hospitalizations are declining

10. Control Group Selection
Propensity scoring to match CPS enrollees (treatments) to similar patients
receiving care at non-treatment clinics (controls) in three steps:
• Wave 1 treatment patients
• PACE treatment patients from Wave 2
• Non-PACE treatment patients from Wave 2
Covariates used to model the propensity score:
• Demographics
• Health status
• Utilization
• Other

11. Clinical results
HbA1C average change in 6 months, uncontrolled at baseline
BP % under control in 6 months, uncontrolled at baseline
-11%
-9.3%
Utilization results (Probit Analysis)
Readmissons per year per patient (6 month panel)
Readmissions per year per patient primarily attributed to
medications (6 month panel)
-16%
-33%
Summary of Difference-in-Differences Results
(Treatment – Control)
http://www.careinnovations.org/uploads/USC.C
EPC.pharm_webinar_FinalV.pdf

12. Untreated (Cohort) vs. Treated Patients,
USC CMMI Program
Mortality rates
- 25.7%
absolute
difference
0.01
0.009
0.008
0.007
0.006
0.005
0.004
0.003
0.002
0.001
0
1 2 3 6 9 12
Months after enrollment
Untreated Treated
Preliminary analysis, data on file
USC Schaeffer Center for Health Policy & Economics

13. Medication-Related Problems Identified Through
CMMI Clinical Pharmacy Program
67,169 problems among 5,775 patients (Avg 11.6 per patient)
9,222, 14%
22,229, 33%
13,352, 20%
14,059, 21%
8,267, 12%
Medication
Nonadherence
Safety Issues
Appropriateness /
Effectiveness
Misc
Insufficient Patient
Self-Management
http://www.careinnovations.org/uploads/USC.CEPC.pharm_webinar_FinalV.pdf, Updated July 2016

14. Top Actions Taken by Pharmacists to Resolve Medication-
Related Problems (excluding education)
2,665
3,847
4,230
5,554
14,981
Substitute Medication
Discontinue Medication
Order test
Add Medication
Change Dose or Drug Interval

15. Physician Satisfaction

16. Average score = 9.6
Average score = 9.7
Patient Satisfaction

17. Patient Engagement / Retention Keys
Engagement Retention
Make room for walk-ins / “warm hand-offs”  
PCP endorsement to targeted / enrolled patients  
Match team member language skills  
Clinical pharmacy technicians  
Align appointments  
Engage family and caregivers  
Consider selective home visits  
Extended hours / weekend clinics  
Transportation support if possible  
Flyers explaining program benefits in lay terms 
Consider peer-led group appointments 
Continuity of pharmacist / tech provider 

18. USC Pharmacy Program Recognitions
Clinical Pharmacy Impact
1. Innovation Challenge Finalist in the Let’s Get Healthy California Goal Area of “Lowering the Cost of
Care”! - January 26, 2016, Innovation Conference, Sacramento
2. Los Angeles Times article: http://www.latimes.com/local/great-reads/la-me-c1-pharmacists-clinics-
20150406-story.html
3. Selected for inclusion in the AHRQ Health Care Innovations
Exchange: https://innovations.ahrq.gov/profiles/pharmacy-teams-use-telepharmacy-provide-
medication-management-risk-patients-safety-net
4. Recognized as Exemplar Innovator, UCSF Center for Excellence in Primary Care and Center for
Care Innovations: https://innovations.ahrq.gov/profiles/pharmacy-teams-use-telepharmacy-provide-
medication-management-risk-patients-safety-net
5. Interviewed for article in California Healthcare Foundation’s Center for Health
Reporting: “Prescription for Success: Caring”- http://www.losangelesregister.com/articles/metcalfe-
597822-chen-eat.html
6. Cover story for Pharmacy Today: “Chen, colleagues provide MTM in L.A.’s most vulnerable
neighborhoods, (http://www.pharmacist.com/node/49949)relate
7. Pharmacy Times article: “Effectiveness of Clinical Pharmacy Services to be Tested”,
(http://www.pharmacytimes.com/news/Effectiveness-of-Clinical-Pharmacy-Services-to-Be-Tested)
8. Semi-Finalist, Harvard Business School / Harvard Medical School Health Acceleration Challenge -
https://openforum.hbs.org/challenge/hbs-hms-health-acceleration-challenge/refinement/good-
medicine-medication-therapy-management-and-saving-the-health-care-system-millions
9. Pinnacle Award, American Pharmacists Association: https://pharmacyschool.usc.edu/steven-chen-
receives-2013-pinnacle-award-in-washington-dc/
10. Innovator Award, Health Resources and Services Administration (HRSA) Patient Safety and Clinical
Pharmacy Services Collaborative (PSPC)

19. Agenda
• Comprehensive Medication Management at
AltaMed Health Services
• The “Business Case” for Comprehensive
Medication Management
• The Gehr Family Center for Implementation
Science

20. WHY DO THIS?
Clinical Pharmacy

21. WHY DO THIS?
Clinical Pharmacy

22. WHY DO THIS?
• Doctors don’t like to follow protocols …
• Pharmacists manage drug therapy better
through collaborative practice agreements!
Clinical Pharmacy

23. OVERCOMING ANXIETY
• Can pharmacists do this?
• Will they communicate?
• Why did I go to medical school?
Clinical Pharmacy

24. IMPACT
• Staff Satisfaction
• Patient Satisfaction
• Quality Goals
• Reduction in ER and Hospital Utilization
• Unexpected benefits:
- patient assistance programs
- help with medication errors
- staff education
Clinical Pharmacy

25. MAJOR CHALLENGE
Clinical Pharmacy

26. BUSINESS CASE
• Does clinic pharmacy save money?
• Is clinical pharmacy a high-value service?
• If yes, how do we pay for it?
Clinical Pharmacy

27. OPTIONS
• Billing policy changes
• Pay for performance
• Health Home Demonstration
• More risk-bearing, capitated payment
arrangements
Clinical Pharmacy

28. Our Team
28
David Goldstein, MD Michael Hochman, MD, MPH Rachel Lim
Welmoed van Deen, MD, PhD
Faculty
Rusha Modi, MD
Faculty

29. • Collaborate and partner with local health
systems
• Help implement best practices
• Develop sustainable innovations
• Advance knowledge in care delivery
Mission
29

30. • The “Triple Aim”
• Quality/Experience
• Population Health
• Efficiency
• Co-development with health systems
• Sustainable
• Scientifically important data
• Engages University and local communities
• Trainees can participate
Principles
30

31. Projects in Development
31
• Getting hospitalized patients out of bed
• Evaluating “Whole Person Care” waiver
• Medication assisted therapy for high utilizers
• Preventing readmissions from primary care
perspective
• Scaling Comprehensive Medication
Management

32. Gehr Innovation Awards
32