Pharmacy Times

Asheville Project Thrives with Hospital Pharmacy at Its Hub

Author: Barry A. Bunting, PharmD

The Pharmacy Department of Mission Hospitals, a 700-bed, community hospital located in Asheville, NC, was instrumental in the development, implementation, and administration of the Asheville Project. Communities tend to look to their hospital(s) as resources for health care expertise, and this was the case with the development of the Asheville Project. Hospital pharmacy departments throughout the country might consider their own potential to be a catalyst for pharmacist-coordinated disease management programs in their communities, as Mission Hospitals was in ours.

When I reflect on why the Asheville Project flourished in our community, a major reason was that the hospital functioned as the hub of the program. It contributed developmental brainpower, arranged for pharmacist training, and brought the program to community pharmacists. This could, and should, be happening in other communities. Who better to do this than a hospital pharmacy department that has talented, motivated pharmacists with a reputation for clinical expertise within its walls?

Mission Hospitals? pharmacy department functions at a very high clinical level, but until the Asheville Project, the department had primarily focused on inpatient clinical services. Asheville offered pharmacists the opportunity to use those same talents to help patients in ambulatory areas. Hospital pharmacy departments have the potential to improve care outside the hospital, and there is a tremendous need to do so.

A Meeting of the Minds

The original Asheville demonstration project began as the brainstorm of key thought leaders in the state. Prominent among them were state pharmacy association and school of pharmacy leaders, as well as representatives from state government and industry. The idea was to determine if patients with medical conditions requiring chronic medications could benefit from regular face-to-face counseling with pharmacists, based on the premise that if pharmacists were given the opportunity to apply their clinical skills, patients would do better clinically, outcomes would improve, and possibly even result in lower total health care costs.

The group realized that it would be necessary to conduct a demonstration project to study the value of such services. The burden of proof was on the pharmacy profession to prove convincingly to purchasers of health care services, employers, government, insurance companies, and patients that pharmacists have knowledge and skills worth purchasing.

To test the idea, someone needed to ?give us a chance.? A purchaser of health care services, an employer, would need to be approached and agree to allow pharmacists to demonstrate whether, in fact, these services improved care and if improved care would lead to lower health care costs.

Daniel G. Garrett, RPh, MS, FASHP, then director of pharmacy at Mission Hospitals, took to heart the charge to find a payer to ?give us a chance? and approached the Risk Benefits Manager of the City of Asheville, John Miall, to see if the city would be willing to partner in a demonstration project where the city would offer a disease management program to their employees with diabetes, and the pharmacy department at Mission Hospitals would develop, implement, and administer the program in the community. In addition, the pharmacy department would provide expertise to determine program outcomes and publish results.

Hospital Pharmacists Take the Lead

Even after the agreement in principle was reached, many decisions still had to be made, involving a wide range of issues and stakeholders. In the area of pharmacists alone, we had to look at training, curriculum, recruitment, and development of a pharmacist network. We needed incentives to recruit patients and match them to pharmacists. Roles and relationships with the employer benefits staff had to be defined, as well as outreach to physicians and community diabetes educators. We also needed a plan for marketing, replication, and measuring outcomes. Pharmacy leadership at the hospital was responsible for fleshing out the demonstration project idea in these areas.

Although all of this sounds daunting, it was not impossible, and the administrative and clinical expertise that allowed this to happen in Asheville is available in many other communities with progressive hospital pharmacy departments. We have seen other communities implement similar programs without the direct involvement of their local hospitals; however, in our experience, it is much easier when they are involved.

One of the biggest challenges for a community that would like to initiate a project like this is figuring out how to get started. Once begun, it is much easier to sustain, but having a point person or a point organization is critical.

Yet why would a hospital, whose focus is primarily on acute care, be interested in a program that focuses on ambulatory care?

What?s in It for Us?

Hospitals need to realize there is actually something in it for them. In our case, Mission Hospitals? pharmacy department not only helped an employer in our community improve its employees? health, we also provided the services for our own hospital employees, improving their health and decreasing our hospital?s health plan costs. In fact, even if a hospital pharmacy department were only to provide disease management services for its own employees, this would make a lot of sense for the hospital. Furthermore, once they have put the pieces together for their own employees, they could easily market these services in the community, which is exactly what we have done. Mission Hospitals currently coordinates disease management programs for 7 employers in the region for diabetes, asthma, hypertension, hyperlipidemia, and depression and has helped other communities start similar programs in more than a dozen different states.

Another plus for our department is that we have gained inestimable value in the eyes of our hospital?s administration as a result of this program. We have been able to document that our efforts are helping the hospital save millions of dollars on health plan costs. While many employers, including hospitals, have experienced double-digit average annual increases in total health care costs over the last few years, Mission Hospitals has had a net decrease in total health care costs over the last 4 years.

Also a plus for hospital pharmacies is that this program provides another venue for them to use their staff ?s clinical skills, and they are actually getting paid for the services. We have been able to hire pharmacist staff based on our ability to fund their positions with disease management services. A disease management service also fits well with the overall national trend for more hospital services being offered in the outpatient setting. Here is another opportunity for pharmacists to work in outpatient clinic settings, and this fits very well with evolving medication therapy management programs.

Hospitals also need to look at this as an opportunity to become ?the good guy? in the community. Hospitals are continually hammered by payers for being the cause of rising health care costs. Yet when we?-together with our Asheville Project employers?-looked at the true drivers of rising health care costs, we found that most of the increases are due to people simply using more hospital services, rather than actual increases in the costs of the services.

When we were asked to help a local employer determine why it had a 30% increase ($7 million) in health care costs in 1 year, we discovered that 5% was indeed due to an increase in hospital charges. But the other 25% was strictly due to a significant increase in the number of trips to the hospital by employees.

When people come to the hospital, they get treated, and it will be expensive. Should US health care strategies for controlling costs include interventions that help keep people from needing expensive hospital services in the first place? Of course. It is exactly what this pharmacist-driven disease management approach does.

A Tangible Investment

Because of this program, our hospital administration is able to point to its key role in the Asheville Project as a tangible investment to improve the community?s health. The hospital is doing more than simply fixing people when they break; we are helping people keep from breaking and from needing our services. This is a great public relations move?a hospital driving programs that, when successful, actually keep people out of the hospital. We are not the bad guy anymore or at least viewed as less of a bad guy.

It may come as a surprise to many that there has been significant interest in the Asheville Project outside of pharmacy circles. We receive more calls from employers across the country than we do from the pharmacy community. Why? Because the Asheville Project illustrates that there is a better strategy for controlling health care cost than to continue to focus primarily on lowering payments to doctors and hospitals, as well as dispensing fees. It is a failed strategy. No matter how much services are discounted or fees cut, if people increasingly need hospital services, costs are going to go up.

The better strategy is to focus on prevention. In our case, a focus on using medications more effectively both improves health and decreases expensive hospital admissions.

In our community, there has been a significant collaboration between hospital pharmacy and community pharmacy practice. Many hospital pharmacies have already expanded clinical services into hospital ambulatory clinics, and with the recent experimentation with community pharmacy-based minute clinics, it appears that community pharmacy may be moving in a similar direction?both having realized that the future of pharmacy is in applying our clinical expertise to meet the growing need to improve ambulatory patient care.

The need is overwhelming, and there is room for everyone. Hospital pharmacy and community pharmacy must work together to pool our assets and resources around improving patient care. In our experience, when this happens, everyone wins.