Telehealth medication management and health care spending in a Medicare Accountable Care Organization.

BACKGROUND: Value-based care is an opportunity for medication optimization services to improve medication management and reduce health care spending. The reach of these services may be extended through telehealth. However, as health care systems and payers grapple with the long-term financing of telehealth, real-world assessments are needed to evaluate the potential economic impact of pharmacy-driven telehealth services. OBJECTIVE: To evaluate the impact of a scalable pharmacist-driven telehealth intervention to improve medication management on health care spending for clinically complex patients who were enrolled in a Medicare Next Generation Accountable Care Organization. METHODS: Data for this pretest-posttest nonequivalent group design study came from Medicare claims from 2015 to 2020 and linked pharmacist care activity data derived from the electronic medical record. Patients in the intervention group were identified as those who received the telehealth medication management service. Patients in the control group were offered the service and refused or could not be contacted. The primary outcome was total medical spending over a 6-month period, and impact was assessed using a covariate-adjusted difference-in-difference model. RESULTS: There were 581 patients who received the intervention and 1,765 who served as controls. The telehealth intervention reduced total medical spending by $2,331.85 per patient over the first 6 months of the service ($388.50 per month; P = 0.0261). Across a range of estimates for the cost of service delivery, we find a return on investment of 3.6:1 to 5.2:1. CONCLUSIONS: The $388.50 monthly savings found in this study represent a substantial reduction in health care spending and emphasize the opportunity for telehealth delivery of medication management services to improve value as a part of alternative payment models. DISCLOSURES: This study was funded by the UNC Health Care Department of Pharmacy. Dr Urick has received personal fees from Pharmacy Quality Solutions and Cardinal Health. Drs Peters, Vest, Colmenares, Foushee, and DeFalco are employees of UNC Health Care Department of Pharmacy. Mr Easter received a Co-PI grant from NACDS Foundation to implement Community-based Value Care Initiative (CVCI) in a community pharmacy setting. He also received a grant to Eshelman School of Pharmacy. He has an individual consulting agreement with digital health company Truentity Health to provide go to market strategy for medication management services. He also has stock options from Truentity Health as a component of the consulting agreement. Dr Foushee has a leadership or fiduciary role at Member-At-Large and the Ambulatory Care Academy of the North Carolina Association of Pharmacists. At the time this work was conducted, Dr Urick, Dr Pathak, and Dr Blanchard were all employees of the UNC Eshelman School of Pharmacy.

Implementation outcomes associated with a value-based care model of comprehensive medication management in community pharmacies.

OBJECTIVE: Although the delivery of comprehensive medication management (CMM) in community pharmacies has been shown to improve health outcomes, inconsistent adoption hinders the benefit patients receive. Our objective was to examine the implementation of a novel value-based care model and the impact of educational and coaching support for pharmacists on patient access to CMM. The underlying care model provides a payment for CMM services combined with incentives to document and improve clinical outcomes and patient engagement. DESIGN: Cross-sectional study. SETTING AND PARTICIPANTS: In addition to fee-for-service payments, performance-based incentives were provided to 12 participating pharmacy organizations to promote pharmacist documentation of clinical values (blood pressure and tobacco status for patients with vascular disease and additionally hemoglobin A1c [HbA1C] for patients with diabetes). To promote patient engagement, pharmacies that engaged a higher proportion of attributed patients received additional incentives. OUTCOME MEASURES: Implementation outcomes included penetration (the proportion of eligible patients who received CMM), adoption (variation in penetration across organizations), and fidelity (documentation of all required clinical values). Comparisons were made using t-tests and chi-square testing. RESULTS: Among 1240 eligible patients, 478 (35.8%) had documentation of any service by a participating pharmacist during a one-year implementation period. Using diabetes as an example, documentation was consistently highest for tobacco status (38.1%), followed by blood pressure (29.7%), and HbA1C (38.1%). CMM recipients on average were older, used more medication, and were more likely to have at least one comorbid condition than non-recipients. 41.8% of patients with vascular disease had documentation of both blood pressure and tobacco status while 24.4% of patients with diabetes had blood pressure, tobacco, and HbA1C documentation. CONCLUSIONS: Improving pharmacist access to a patient's medical records could help improve access to CMM services for patients under value-based care models that rely on patient targeting and clinical measurements.

Scoping Review to Inform the Future Development of a Measure for Team-Based Care in Oncology.

PURPOSE: Team-based care is the delivery of health services to an individual by at least two health care providers working collaboratively to achieve optimal care. Participants on the National Cancer Institute and the ASCO Teams in the Cancer Care Delivery Project have defined 13 key principles to serve as the foundation for a successful team; however, it is unclear whether there exist measures of these key principles. METHODS: A scoping literature search was conducted for each key principle on PubMed and Embase to identify existing measures for key principles. Articles of interest were exported to a citation manager, Sciwheel, cataloged by the key principle. Existing measures were extracted via a two-stage screening process, with an abstract review followed by a full-text review. RESULTS: Fifteen unique measures were identified, with items extrapolated for 12 of the 13 key principles. Measures were not exclusive and could represent more than one key principle. The number of measures varied per principle from zero to five, with Team Composition and Diversity yielding no existing measure. CONCLUSION: The long-term goal is to compile and edit these measures, to create a comprehensive measure to be used in various team-based oncology care settings, and to address areas for improvement, ultimately optimizing patient care.

Readiness as a precursor of early implementation outcomes: an exploratory study in specialty clinics.

BACKGROUND: Readiness has been identified as an essential precursor of successful implementation. However, evidence supporting its value is sparse. Empirical studies exploring the relationship between the application of readiness interventions, readiness levels, and implementation outcomes are lacking. The purpose of this study was twofold: (1) to evaluate the effectiveness of a readiness intervention (based on increases in readiness levels, changes in early implementation outcomes (i.e., acceptability, appropriateness, feasibility, and intent to adopt), and qualitative insights into the types of perceived outcomes) and (2) to assess the role of readiness as a predictor of these early implementation outcomes. METHODS: Seven healthcare specialty clinics engaged in a structured process to assess and build readiness for implementing a comprehensive medication management (CMM) service over a 10-month period. A mixed methods approach, which included surveys with healthcare stakeholders at each clinic (N = 27) and interviews with the lead pharmacists (N = 7), was used to evaluate the effectiveness of the readiness intervention (aim 1). Survey data were also used to conduct multiple regression models to assess the role of readiness as a predictor of early acceptability, appropriateness, feasibility, and intent to adopt CMM (aim 2). RESULTS: Significantly higher readiness levels, as well as higher scores on acceptability, appropriateness, feasibility, and intent to adopt, were reported as a result of engaging in the readiness intervention. However, upon closer examination, the direction of this association seemed to be dependent on the type of clinic. Qualitative data on the types of perceived outcomes resulting from engaging in the readiness intervention provided further insights into the potential reasons for these findings. Furthermore, post-readiness levels predicted between 44 and 68% of the variance in the early implementation outcomes. When accounting for clinic membership, readiness remained critical for service acceptability, feasibility, and intent to adopt but not for appropriateness. CONCLUSION: These findings provide insights into the relationship between use of a readiness intervention, readiness levels, and early implementation outcomes. Engaging healthcare settings in a readiness intervention was beneficial in ways more complex than a simple positive linear relationship, highlighting the opportunity to broaden its purpose and expand definitions of readiness success. In addition, the importance of readiness levels in predicting early implementation outcomes, while critical, also seems to be highly dependent on context, particularly for appropriateness (fit).

Community pharmacists' experience relying on select implementation strategies in the delivery of comprehensive medication management.

OBJECTIVE: Implementation strategies are methods or techniques that facilitate adoption, implementation, and sustainability of a clinical program or practice. There has been a lack of widespread adoption of comprehensive medication management (CMM) in community pharmacies. The objective of this evaluation was to expand understanding of how select implementation strategies impacted pharmacists' experience implementing and delivering CMM in the community pharmacy setting. METHODS: A community pharmacy CMM initiative, Slice of Partners in Excellence (PIE), employed a number of implementation strategies and key elements from the Institute for Healthcare Improvement's Breakthrough Series to support increased engagement and delivery of CMM within a local payer's CMM program. The program provides incentives to pharmacies for providing CMM to select patients and achieving predetermined quality metrics. To evaluate pharmacists' experience with the implementation strategies and the impact it had on implementing and delivering CMM, a focus group and survey were conducted. RESULTS: Some of the implementation strategies were more frequently highlighted as generating value to participants (coaching, community-wide problem-solving) than others (monthly webinars). Pharmacists identified a need for more formal education regarding billing, documentation and patient engagement supports. Pharmacists expressed a desire for ongoing implementation supports extending beyond this initaitive. CONCLUSION: Understanding the types of implementation strategies that are deemed as influential by pharmacists delivering clinical services in the community pharmacy setting is critical to maximizing patient access to these services in the future.

What is needed to sustain comprehensive medication management? One health plan's perspectives.

Implementation of comprehensive medication management (CMM) in the community pharmacy setting remains sporadic despite its prevalence in other pharmacy contexts. One health plan has been investing in CMM since 2010. Their experience and perceptions in the payer-provider partnership could offer unique insights into the sustainability of CMM in community pharmacy. As part of a broader academic-payer-provider partnership, perceptions of CMM sustainability were explored with key stakeholders in the health plan through a semistructured group interview. Five themes emerged: (1) distinction between CMM and other patient care opportunities, (2) building a CMM program that delivers value requires an investment in network development, (3) payment design influences sustainability, (4) lack of push from community pharmacies to pay for CMM, and (5) the importance of an ongoing facilitated learning and action collaborative. Given previously demonstrated positive return-on-investment, CMM in community pharmacies shows promise for being a sustainable practice model. However, increased reach and performance of networks, as well as number of payers in the market, will be critical to scaling CMM in the community pharmacy setting.

Use of research evidence varied in efforts to expand specific pharmacist autonomous prescriptive authority: an evaluation and recommendations to increase research utilization.

BACKGROUND: An expanding body of literature shows that pharmacists' interventions improve health outcomes and are cost-saving. However, diverse state regulations of pharmacists' scope of practice create a discrepancy between what pharmacists are trained to do and what they legally can do. This study investigated how stakeholders utilized research evidence when developing expanded scope of practice policies in their respective states. METHODS: Using autonomous pharmacist prescriptive authority as a surrogate for general pharmacist scope of practice, a general policy document analysis was performed to understand the scope of practice landscape for pharmacists across the United States. Next, semi-structured interviews with policy-makers and pharmacy advocates were conducted to explore how the identified states in the policy document analysis utilized evidence during the policy-making process. Investigators analysed findings from the transcribed interviews through application of the SPIRIT Action Framework. Resulting codes were summarized across themes, and recommendations to researchers about increasing utilization of research evidence were crafted. RESULTS: Sixteen states with 27 autonomous pharmacist prescriptive authority policies were identified. Public health need and safety considerations motivated evidence engagement, while key considerations dictating utilization of research included perceptions of research, access to resources and experts, and the successful implementation of similar policy. Research evidence helped to advocate for and set terms for pharmacist prescribing. Barriers to research utilization include stakeholder opposition to pharmacist prescribing, inability to interpret research, and a lack of relevant evidence. Recommendations for researchers include investigating specific metrics to evaluate scope of practice policy, developing relationships between policy-makers and researchers, and leveraging pharmacy practice stakeholders. CONCLUSIONS: Overall, alignment of researcher goals and legislative priorities, coupled with timely communication, may help to increase research evidence engagement in pharmacist scope of practice policy. By addressing these factors regarding research engagement identified in this study, researchers can increase evidence-based scope of practice, which can help to improve patient outcomes, contain costs, and provide pharmacists with the legal infrastructure to practise at the top of their license.

Learning needs assessment for multi-stakeholder implementation science training in LMIC settings: findings and recommendations.

BACKGROUND: Despite significant progress in the field of implementation science (IS), current training programs are inadequate to meet the global need, especially in low-and middle-income countries (LMICs). Even when training opportunities exist, there is a "knowledge-practice gap," where implementation research findings are not useful to practitioners in a field designed to bridge that gap. This is a critical challenge in LMICs where complex public health issues must be addressed. This paper describes results from a formal assessment of learning needs, priority topics, and delivery methods for LMIC stakeholders. METHODS: We first reviewed a sample of articles published recently in Implementation Science to identify IS stakeholders and assigned labels and definitions for groups with similar roles. We then employed a multi-step sampling approach and a random sampling strategy to recruit participants (n = 39) for a semi-structured interview that lasted 30-60 min. Stakeholders with inputs critical to developing training curricula were prioritized and selected for interviews. We created memos from audio-recorded interviews and used a deductively created codebook to conduct thematic analysis. We calculated kappa coefficients for each memo and used validation techniques to establish rigor including incorporating feedback from reviewers and member checking. RESULTS: Participants included program managers, researchers, and physicians working in over 20 countries, primarily LMICs. The majority had over 10 years of implementation experience but fewer than 5 years of IS experience. Three main themes emerged from the data, pertaining to past experience with IS, future IS training needs, and contextual issues. Most respondents (even with formal training) described their IS knowledge as basic or minimal. Preferences for future training were heterogeneous, but findings suggest that curricula must encompass a broader set of competencies than just IS, include mentorship/apprenticeship, and center the LMIC context. CONCLUSION: While this work is the first systematic assessment of IS learning needs among LMIC stakeholders, findings reflect existing research in that current training opportunities may not meet the demand, trainings are too narrowly focused to meet the heterogeneous needs of stakeholders, and there is a need for a broader set of competencies that moves beyond only IS. Our research also demonstrates the timely and unique needs of developing appropriately scoped, accessible training and mentorship support within LMIC settings. Therefore, we propose the novel approach of intelligent swarming as a solution to help build IS capacity in LMICs through the lens of sustainability and equity.

Adaptations made to delivery of comprehensive medication management in the community pharmacy setting during COVID-19.

BACKGROUND: As a result of COVID-19, numerous adaptations were made to health care delivery, including comprehensive medication management (CMM) delivered in community pharmacies. OBJECTIVE: Identify and describe the adaptations that have been made to the delivery of CMM among community pharmacies due to COVID-19. METHODS: Community pharmacies participating in a CMM implementation and research initiative had regular coaching calls throughout COVID-19 and completed a survey of changes that occurred as a result of COVID-19. Coaching notes and survey results were summarized and mapped to the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) to systematically capture changes that occurred. RESULTS: A number of reactive adaptations were made to CMM delivery as a result of COVID-19, including increased virtual or remote delivery of CMM, delaying CMM visits to allow pharmacies to provide care directly related to the pandemic including COVID-19 testing and vaccines, wearing personal protective equipment (PPE) in visits, new ways of obtaining clinical patient information, and shifting CMM staffing models. CONCLUSION: Adaptations that occurred to CMM during COVID-19 allowed pharmacists to continue to serve their patients and meet public health needs.

Screening and Referral Care Delivery Services and Unmet Health-Related Social Needs: A Systematic Review.

INTRODUCTION: Unmet health-related social needs contribute to high patient morbidity and poor population health. A potential solution to improve population health includes the adoption of care delivery models that alleviate unmet needs through screening, referral, and tracking of patients in health care settings, yet the overall impact of such models has remained unexplored. This review addresses an existing gap in the literature regarding the effectiveness of these models and assesses their overall impact on outcomes related to experience of care, population health, and costs. METHODS: In March 2020, we searched for peer-reviewed articles published in PubMed over the past 10 years. Studies were included if they 1) used a screening tool for identifying unmet health-related social needs in a health care setting, 2) referred patients with positive screens to appropriate resources for addressing identified unmet health-related social needs, and 3) reported any outcomes related to patient experience of care, population health, or cost. RESULTS: Of 1,821 articles identified, 35 met the inclusion criteria. All but 1 study demonstrated a tendency toward high risk of bias. Improved outcomes related to experience of care (eg, change in social needs, patient satisfaction, n = 34), population health (eg, diet quality, blood cholesterol levels, n = 7), and cost (eg, program costs, cost-effectiveness, n = 3) were reported. In some studies (n = 5), improved outcomes were found among participants who received direct referrals or additional assistance with indirect referrals compared with those who received indirect referrals only. CONCLUSION: Effective collaborations between health care organizations and community-based organizations are essential to facilitate necessary patient connection to resources for addressing their unmet needs. Although evidence indicated a positive influence of screening and referral programs on outcomes related to experience of care and population health, no definitive conclusions can be made on overall impact because of the potentially high risk of bias in the included studies.

A Systematic Review of the Effect of Telepharmacy Services in the Community Pharmacy Setting on Care Quality and Patient Safety.

While community pharmacy-based telepharmacy services can expand medication access for underserved communities, the safety and quality of these services is uncertain. A systematic review was conducted in August 2020 exploring the effect of community pharmacy-based telepharmacy services on patient safety and care quality. Database searches identified 866 studies, of which six met the inclusion and the risk of bias measurement criteria. Medication dispensing errors, adherence, and patient satisfaction were the most frequently evaluated outcomes. Literature suggests no overall difference in medication safety and adherence, conflicting evidence on patient satisfaction, and insufficient evidence on inappropriate medication use in community pharmacy-based telepharmacies compared with traditional pharmacies. Due to the potential for high risk of bias, no definitive conclusions could be made about telepharmacy outcomes. Research with stronger study designs and more rigorous evaluation methodologies is needed to create conclusive evidence on the effectiveness of community pharmacy-based telepharmacy services.

Community pharmacists' perceptions of acceptability, appropriateness, and feasibility of a value-based care model for comprehensive medication management.

BACKGROUND: HealthPartners is an integrated health plan offering comprehensive medication management (CMM) under a value-based care model called Partners in Excellence (PIE). In PIE, participating organizations are incentivized to conduct CMM visits and are eligible for bonus payments if they achieve quality and engagement metrics. Engagement in PIE from community pharmacies has been lacking. Implementation science, specifically the assessment of implementation outcomes, provides key insights into the uptake of patient care services, such as CMM, into practice. OBJECTIVE: To evaluate the acceptability, appropriateness, and feasibility of the PIE program from the perspective of community pharmacists and pharmacy managers. METHODS: Semi-structured, one-on-one qualitative interviews were conducted with a group of 14 pharmacists and pharmacy managers participating in the PIE program. Interviews were coded inductively, and then codes were mapped to the implementation outcomes of acceptability, appropriateness, and feasibility. RESULTS: Twelve codes emerged from the interviews. Four codes (targeted conditions of PIE, achieving PIE metrics, comprehensiveness of PIE, and confusion and barriers) were mapped to acceptability; 3 codes (CMM documentation and billing, fitting CMM into limited time with patients, and community pharmacy's role in patient care) were mapped to appropriateness; and 1 code (collecting clinical patient information) was mapped to feasibility. Four codes (CMM payment model, targeting patients for CMM, personnel for CMM, and patient/provider buy-in of CMM) were considered a combination of more than 1 outcome. CONCLUSIONS: Although the acceptability, appropriateness, and feasibility of the PIE program was generally positive, participants cited a number of implementation challenges related to documentation and billing and producing a sustainable CMM model. The results shed light on how a value-based care model for CMM is perceived within community pharmacies and could inform the development and implementation of similar quality-based CMM programs. DISCLOSURES: This study was funded by the National Association of Chain Drug Stores (NACDS) Foundation and the UNC Eshelman Institute for Innovation. Pestka is affiliated with the University of Minnesota College of Pharmacy and reports grants from NACDS Foundation and UNC Eshelman Institute for Innovation for the conduct of the study; she has also received grants from UNC Eshelman Institute for Innovation and NACDS Foundation outside the submitted work. Stoa and Sorensen are also affiliated with the University of Minnesota College of Pharmacy. Blanchard is employed at the UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill. This work was presented as a virtual poster at the 2020 American College of Clinical Pharmacy Annual Meeting, October 19-30, 2020.

A mixed methods evaluation of the implementation of pharmacy services within a team-based at-home care program.

BACKGROUND: Sub-optimal medication use results in significant avoidable morbidity, mortality, and costs. Programs, such as comprehensive medication management (CMM), can help to optimize medication use, improve outcomes, and reduce costs. However, implementing programs like CMM can be challenging and differences in how CMM has been implemented may be responsible for observed heterogeneity in the outcomes associated with CMM. OBJECTIVE(S): Describe the implementation strategies utilized in implementing CMM telephonically within a team-based at-home care program and evaluate the implementation process. METHODS: The implementation of CMM was facilitated using various implementation strategies including: develop educational material and conduct training, change record system, audit and feedback, learning collaborative, quality monitoring, readiness assessment, and implementation team formation. The impact of these strategies as well as pharmacist and team member perspectives on the implementation of CMM were examined using mixed methods and guided by Proctor's conceptual model for implementation. RESULTS: The pharmacists felt that most of the implementation strategies used to facilitate consistent delivery of CMM were useful, but were unable to successfully implement all of them. Despite this, significant increases in fidelity to steps of the patient care process was achieved. The pharmacists felt that CMM was acceptable, appropriate for patient population, and feasible, but barriers (e.g., the telephonic and remote nature of the practice, the evolving nature of the program, and the difficulty in coordinating care between the patients primary care team and the care team affiliated with the program) affected the feasibility and organizational fit of CMM within this team-based, at-home care program. General pharmacy services, however, were seen as acceptable, appropriate, and feasible. CONCLUSION: Deliberately designing and utilizing a variety of implementation strategies can facilitate the implementation of CMM and significantly increase fidelity to the patient care process. To improve feasibility and organizational fit of CMM, additional barriers and challenges need to be addressed.

Measuring implementation of medication optimization services: Development and validation of an implementation outcomes questionnaire.

BACKGROUND: Implementation outcomes serve as progress and success indicators of the implementation process. They are also key antecedents to achieving the more traditional clinical outcomes typically associated with a service. Despite their importance, there are few implementation outcomes measures with appropriate psychometric properties, none of which have yet been adapted for medication optimization services. OBJECTIVES: This study aims to develop and validate the Implementation Outcomes Questionnaire (IOQ) to assess implementation of medication optimization services, starting with Comprehensive Medication Management (CMM). The resulting IOQ is a 40-item self-report instrument for six implementation outcomes, including adoption, acceptability, feasibility, appropriateness, penetration, and sustainability. METHODS: A three-phase approach was used to develop and validate the IOQ. Development of the instrument, Phase I, was informed by a targeted search of existing implementation outcomes measures in other fields, a review of suitableoptions options by an expert panel, and item adaptation. To assess content validity, Phase II, an internal vetting process was conducted using an adapted version of Rubio and colleagues' methodology. Evidence of reliability and construct validity, Phase III, was obtained through a pilot test with 167 pharmacists within 78 different care settings. RESULTS: Overall, the results supported the reliability and validity (both content and construct) of the IOQ, with further psychometric testing needed for adoption. The items' relevance, clarity, and alignment with each implementation concept were high, except for Penetration. As a result, the Penetration items were refined for further use. Best-fit models were identified for each outcome based on the MCFA analyses, thereby providing insights into the factor structures and interpretation for each measure. Cronbach' alphas indicated good internal consistency. CONCLUSIONS: This questionnaire is the first of its kind tailored to medication optimization services, starting with CMM. Access to this survey should facilitate measurement of implementation outcomes, thereby increasing the likelihood of achieving the desired clinical outcomes.

Ensuring intervention success: Assessing fit as an overlooked step of the implementation process.

Ensuring fit between a service and the implementing context is a critical but often overlooked precursor of implementation success. This commentary proposes five key considerations that should be evaluated when exploring fit: alignment with needs and metrics; alignment with organizational resources and capabilities; alignment with organizational priorities and culture; alignment with reimbursement mechanisms for long-term sustainability; and alignment with the regulatory environment. Successful uptake and implementation hinges on careful planning and, most importantly, appropriate fit between the service and the implementing environment.

Ensuring intervention success: assessing fit as an overlooked step of the implementation process

Ensuring fit between a service and the implementing context is a critical but often overlooked precursor of implementation success. This commentary proposes five key considerations that should be evaluated when exploring fit: alignment with needs and metrics; alignment with organizational resources and capabilities; alignment with organizational priorities and culture; alignment with reimbursement mechanisms for long-term sustainability; and alignment with the regulatory environment. Successful uptake and implementation hinges on careful planning and, most importantly, appropriate fit between the service and the implementing environment

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The Active Implementation Frameworks: A roadmap for advancing implementation of Comprehensive Medication Management in Primary care.

Implementation of evidence-based health services interventions is complex and often limited in scope. The Active Implementation Frameworks (AIFs) are an evidence-based set of frameworks to use when attempting to put into practice any innovation of known dimensions. This article describes the novel application of the AIFs to facilitate the implementation and improvement of Comprehensive Medication Management (CMM) in primary care practices to optimize medication use and improve care for patients.