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Trinity Pioneer ACOMTM Program Results

Trinity Pharmacists Identify patients on high-risk medications or fit criteria for needing post-discharge follow-up.

MTM Referral Process – Trinity ACOHigh Risk Transition

of Care PatientsHigh Risk Chronic Care

Patients

Population Management Pharmacist High risk patients identified by review of claims data (high risk medications, multiple prescribers, not achieving quality measures; nonadherence).

Iowa Health ACO Pharmacists

(Triage High-risk Patients)

MTM-Trained Community Pharmacist Providers

Primary Activities

• Create linkages with case management & analytics• Identify and triage high risk MTM patients• Solve medication issues telephonically, if able• Send referrals to MTM-Trained community

pharmacists via OutcomesMTM platform

• Complete MTM activities for all referred patients• Assist with medication reconciliation• Assist with monitoring for pts started on high risk med

(ex: insulin, steroids, antiplatelets, warfarin)• Assist with improving medication adherence• Document activities in OutcomesMTM platform• Communicate with providers as needed

CommunicationPrimary Activities

OutcomesMTM

Referral

Unique Patients Served per Month (including referrals)

10.01.2013-06.30.2014

3

Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-140

20

40

60

80

100

120

349 Unique Patients Served

Unique Patients Served per Month

10.01.2013-06.30.2014

4

Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-140

10

20

30

40

50

60

70

80

90

100

ACO Referrals

Oct-1

3

Nov-1

3

Dec-1

3

Jan-

14

Feb-

14

Mar-1

4

Apr-1

4

May-1

4

Jun-

140

10

20

30

40

50

60

70

80

90

100

InforMed Patients

80/267 = 30.0% 269/543 = 49.5%

MTM Claims per Month (including referrals)

10.01.2013-06.30.2014

5

Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-140

20

40

60

80

100

120

140

160

180

Total # of MTM Claims= 850

MTM Claims per Month

10.01.2013-06.30.2014

6

Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-140

20

40

60

80

100

120

140

160

ACO Referrals

Oct-13Nov-13Dec-13 Jan-14 Feb-14 Mar-14 Apr-14May-14 Jun-140

20

40

60

80

100

120

140

160

InforMed Patients

MTM Claims Summary

7

Average 2.4 MTM claims per patient

10.01.2013-06.30.2014

Total # of Patients Total # of MTM Claims0

100

200

300

400

500

600

700

800

900

Top Reasons for MTM Services

8

10.01.2013-06.30.2014

Drug interaction

Dose too high

Dose too low

Cost-effective alternative

Adherence - Inappropriate admin/technique

Adverse drug reaction

Adherence - Underuse of medication

Unnecessary prescription therapy

Needs immunization

New or changed OTC therapy

Suboptimal drug

Needs drug therapy

New or changed prescription therapy

CMR - Complex drug therapy

0 50 100 150 200 250 300 350 400 450

Top Results for MTM Services

9

10.01.2013-06.30.2014

Increased dose

Decreased dose

Initiated cost effective drug

Altered administration or technique

Therapy failure

Altered adherence

Unable to reach prescriber after 3 attempts

Immunization administered

Changed drug

Discontinued therapy

Initiated new therapy

Unable to reach patient after 3 attempts

Prescriber refused recommendation

CMR - No drug therapy problems identified

CMR - Drug therapy problems identified

Therapy success

Patient refused

0 20 40 60 80 100 120 140 160 180 200

Top Pharmacy Performers

10

THRIFTY WHITE DRUG 049

EAGLE PHARMACY

FRIENDSHIP HAVEN PHARMACY

WALGREEN DRUG STORE 05361

Walmart 1526

DANIEL PHARMACY

HY-VEE DRUGSTORE 7035

WALMART 886

HY-VEE PHARMACY 1192

0 50 100 150 200 250 300 350

6

19

21

45

51

67

99

183

292

# MTM Claims

DISCUSSION

Feedback or topics from pharmacists

Prioritizing patients in cue Discharge patients vs. others

Communication from leadership team 1-on-1 visits Live group meetings

Expected project timeline