Team-Based Approach to Care Management

Evidence-Based Diabetes Management, December 2014, Volume 20, Issue SP18

Senior Vice President, Health System Alliances, CVS Health

Chronic diseases are among the most prevalent and expensive of all health-related conditions. Nationwide, 75% of healthcare spending is attributable to the treatment of chronic diseases.1 In recent years, diabetes has gained prominence as one of the most concerning chronic diseases by virtue of increasing disease prevalence and cost burden. In 2012, 29.1 million Americans were diagnosed with diabetes, up from 25.8 million in 2010, costing an estimated $245 billion in direct medical expenses and reduced productivity.2 If not properly managed, the complications associated with diabetes progressively diminish overall health and can lead to comorbidities such as stroke, heart disease, kidney disease, vascular disease, amputations, and blindness.

Health systems, Accountable Care Organizations, healthcare plans, and healthcare providers are actively seeking cost-effective ways to mitigate the rise of chronic diseases. As the payment spectrum continues to evolve and move from volume- to value-based models, providers gain more influence over patient care management and decisions. Because chronic conditions such as diabetes can affect so many other aspects of health, a multitude of providers are involved in administering care. In the interest of coordination, a team-based approach is most effective in managing the inherent complexity of the disease. CVS Health is actively engaging with health systems across the country to help coordinate this comprehensive care for patients, offering chronic disease monitoring as well as clinical support, medication counseling, and wellness programs.

CVS Health has now engaged with more than 40 major health systems throughout the country to help support population health management and to provide low-cost, high-quality care alternatives. While providers are accountable for patient health outcomes, they do not have full visibility into their patients’ behavior outside their office or the hospital. These health-system collaborations aim to equip primary care providers (PCPs) with key information collected through CVS pharmacists that will assist them in making sound clinical decisions, such as reports on their patient population’s medication adherence. Through this team approach to patient care, CVS Health is supporting providers’ care plans, communicating critical patient care information, and enhancing connectivity to manage health in a more coordinated, affordable, and efficient way.

Poor adherence to medications and reduced access to primary care are 2 main drivers responsible for the increased incidence of complications accompanying manageable chronic diseases such as diabetes. CVS Health is well positioned to help address both of these causes—in collaboration with its affiliates—through various adherence interventions and low-cost, high-quality health services offered by MinuteClinic, which complement primary care.

Three key stakeholders are responsible for managing a patient’s medication adherence: the provider, the pharmacist, and the patient. Adherence to a medication regimen—critical for patients suffering from a chronic disease—means taking the same medication every day. Research shows, however, that many patients, even many of those with chronic conditions, do not take all the prescriptions essential to their medication regimen on a consistent basis.3 Only 50% of patients adhere to medications as prescribed by physicians, and less than 40% of patients remain adherent 2 years after the initiation of a medication.4 While predicting nonadherence is difficult, owing to its many associated causes, pharmacists are best equipped to quickly identify patients who are not taking a medication and could therefore be at risk. CVS Health has developed algorithms and processes to identify and connect with affiliates’ patients who are nonadherent or need additional counseling regarding their medications. Electronic Medical Record (EMR) integration facilitates communication and data sharing between providers and CVS Health without negatively impacting the work flow in the physician’s office.

CVS Health performs a comprehensive series of adherence interventions for its customers, including reminders to pick up, refill, and continue taking medications. Data regarding the number and type of interventions performed is then sent to providers in aggregate and condition-specific reports. Furthermore, CVS Health can identify patients who are deviating from their prescribed regimen and alert the provider. If a person with diabetes only fills and picks up 2 of the 3 medications prescribed, CVS Health will call to remind the patient to pick up the third medication and report the nonadherence directly to their provider’s EMR. These interventions and messages enable providers to access and review actionable information regarding their patients’ current adherence at the point of care.

Understanding the medications prescribed following a hospital transition can be difficult, particularly for patients with chronic diseases. A patient with diabetes, already on multiple medications for their condition before they go to the hospital for a surgery, may be sent home from the hospital with additional prescriptions. This patient may face obstacles both in obtaining this new medication and in understanding how it could impact their current medications. To ease the process, CVS/pharmacy can deliver new medications to a health system affiliate’s patient at their hospital bedside and offer education regarding the medication prior to discharge. A CVS pharmacist can follow up with the patient post discharge to ensure that they understand their medications and to encourage continuing care with their PCP. In addition, a pharmacist can review and reconcile the patient’s list of medications, ensuring that there are no safety concerns regarding drug interactions with existing medications. If the patient is identified as having an increased risk for complications or readmission, the healthcare system and CVS Health can coordinate an in-home pharmacist visit for the patient. All this information will then be reported back to the patient’s provider through the integrated EMR.

Patients with chronic diseases often need ongoing support to understand the medications they routinely take, and commonly rely on their local pharmacist. CVS pharmacists have the opportunity to connect more frequently with patients than other providers because patients visit the pharmacy more often than other healthcare settings. To optimize these touch points, CVS Health offers one-on-one pharmacist counseling for patients with common, but costly, chronic conditions.

Studies have shown that one-on-one counseling can significantly improve medication adherence for this population by delivering proactive, patient-specific interventions. Greater patient engagement and active pharmacy care can improve chronic disease management, and in turn, patients’ overall health.

A Retail Medical Clinic Adds Value to Patient Care

Often, patients with chronic conditions need routine screenings or tests to monitor their condition. CVS Health collaborates with affiliates to identify patients from their panel who would benefit from a reminder on an upcoming screening or test. A PCP identifies a patient with diabetes who is due for a foot exam or glycated hemoglobin test, and the CVS pharmacist delivers the reminder message to the patient when they come to the pharmacy to pick up a prescription. CVS Health’s retail medical clinic, MinuteClinic, is available to an affiliate’s patients for many of these services, simplifying the process for the patient. If the patient chooses to be seen at a MinuteClinic, the nurse practitioner will conduct the exam and report the results directly to the patient’s provider. For the patient, this simple integrated approach provides value through coordinated, lower-cost care; easy access to health maintenance testing; and coaching and coordination with their provider. For the provider, value is created through improved adherence, reduced hospital admissions, a coordinated team of pharmacist and nurse practitioner collaborators, and financial benefits from risk contract savings and quality.

Beyond improving pharmacy care and medication adherence, CVS Health is working to address the impact of other healthcare issues on patient outcomes, including the profound shortage of PCPs in the United States. This shortage is evident in the fact that 50% of patients seen at MinuteClinic locations report that they do not have a PCP. MinuteClinic provides patients access to convenient, quality, low-cost healthcare that is complementary to and supportive of the provider and patient care medical home. CVS Health currently operates more than 940 Joint Commission accredited clinics in 30 states, and plans to expand to 1500 clinics across 35 states by 2017, at which time 60% of the American population will be within 10 miles of a clinic. In addition to addressing the shortage of PCPs, MinuteClinic can help support the increased focus on wellness and prevention as part of the overall healthcare solution to managing chronic conditions such as diabetes. As an extension of the healthcare team, Minute-Clinic nurse practitioners and physician assistants offer joint clinical programs that target comorbidities, including hypertension and weight loss, as well as tobacco cessation programs list of PCPs accepting new patients is provided at the time of the visit in an effort to connect the patient to a medical home for long-term follow-up of chronic conditions and for other medical needs.

To further underscore its commitment to treating patients with chronic disease, CVS/pharmacy has removed cigarettes and all tobacco products from its stores nationwide.5 Tobacco products often cause or exacerbate chronic diseases. In addition, CVS Health has launched a national smoking cessation campaign that focuses on risk assessment, education, appropriate medication therapy, and long-term coaching. The various components of the treatment team—pharmacists, nurse practitioners, digital and online assets, and marketing resources—are employed in tandem to provide patients with the best opportunity to stop smoking. Smoking cessation collaboration is offered to major health-system affiliates as an important addition to their capabilities for preventing chronic diseases.

While chronic conditions have become some of the most prevalent and expensive health issues, they are also often the most preventable and manageable. Employing a team-based approach, providers can reduce the growth of complications from chronic diseases by collaborating with CVS Health to access a myriad of healthcare management products, services, and tools. Through a deep commitment to analytical research, access to data, and primary care augmentation through MinuteClinic, CVS Health is uniquely positioned to support providers in improving health outcomes and reducing medical costs.References

1. Chronic disease prevention and health promotion. CDC website. http://www.cdc.gov/chronicdisease/.Updated October 14, 2014. Accessed November 5, 2014.

2. National Diabetes Statistic Report, 2014. CDC website. http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf. Published June 10, 2014. Accessed November 5, 2014.

3. Yeaw J, Benner JS, Walt JG, Sian S, Smith DB. Comparing adherence and persistence across 6 chronic medication classes. J Manag Care Pharm. 2009;15(9):728-740.

4. Choudhry NK, Avorn J, Glynn RJ, et al. N Engl J Med. 2011;365(22):2088-2097.

5. Brennan TA. CVS Caremark quits for good: our decision to stop selling tobacco products. Am J Manag Care. 2014;20(SP7):SP220.