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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