Pharmacists, nurses team up in Pittsburgh care transition project

(The Pharmacist) The pharmacist has a key role in a Pittsburgh Regional Health Initiative (PRHI) care transition project that recently won a $10.4 million Health Care Innovation Award from the CMS Medicare and Medicaid Innovation Center (CMMI).

“The grant will provide an opportunity to showcase the value that pharmacists can bring to accountable care,” Toni Fera, PharmD, consultant with PRHI, told She was formerly the APhA Foundation’s Director of Patient Self-Management Programs.

The Innovation Center announced May 9 its first round of 26 preliminary awardees to implement projects for people enrolled in Medicare, Medicaid, and the Children’s Health Insurance Program, especially those with high health care needs. The second round of awardees will be announced in early June.

The Pittsburgh project, Creating a Virtual Accountable Care Network for Complex Medicare Patients, was the only one to mention pharmacists in the CMMI announcement. The plan for the project is to create support centers staffed by pharmacists and nurse care managers to help small primary care practices offer their patients better integrated care in the service areas of seven hospitals in western Pennsylvania. The project builds on a PRHI-led physician–hospital pilot program.

For selected patients with chronic diseases who are admitted to the hospital and are at high risk for readmission, a pharmacist will collaborate with nurse care managers and other providers to prepare patients for their transition in care, meeting with patients and teaching them about their medications before discharge, according to Fera. After discharge, the pharmacist will contact the patient to assess continued adherence to the prescribed medication regimen and address any identified medication therapy problems.

As the program grows, patients will be referred to a Primary Care Resource Center pharmacist, who will provide comprehensive medication management follow-up as part of a hospital-based, virtual medical home.

The project will focus on approximately 25,000 Medicare beneficiaries with chronic obstructive pulmonary disorder, congestive heart failure, and coronary artery disease, as well as the general primary care population. It is expected to save an estimated $74.1 million over 3 years by reducing 30-day readmissions and avoidable disease-specific admissions, and create an estimated 26 new jobs, according to the CMMI announcement and a PRHI news release.

“It is well documented that pharmacists can play an important role in reducing readmissions, hospitalizations, and overall health outcomes via provision of medication education and chronic disease management, medication reconciliation, and ensuring use of evidence-based therapies,” Fera said. “Given the importance of medication adherence in the management of chronic diseases, we felt that pharmacists would be a vital member of a multidisciplinary care management team in a virtual medical home within an accountable care network.”