A report from the Accountable Care Organization Research Network, Services, and Education (ACORNSEED).

After discussing the Basics of Accountable Care Organizations (ACO) and Medication Therapy Management and Annual Wellness Visit services, the third and last section of the Pharmacists in ACOs series will focus on 3 more integration strategies for pharmacists within the ACO setting, including chronic care management (CCM), chronic disease state management (CDSM), and transitions of care (TOC).
Q: What are CCM, CDSM, and TOC?
A: CCM is defined as non–face-to-face services provided to Medicare patients. Patients are eligible if they have 2 or more chronic conditions expected to last at least one year or until death. These chronic illnesses pose a significant risk of death, acute exacerbation or decompensation, or functional decline. The qualifying list of chronic conditions include, but are not limited to, Alzheimer’s disease, arthritis, asthma, atrial fibrillation, cancer, chronic obstructive pulmonary disease (COPD), depression, diabetes, heart failure, hypertension, ischemic heart disease, or osteoporosis.1
CDSM consists of performing disease state education to the patient or caregiver regarding his or her chronic condition(s), assessing health status, establishing patient-specific goals of therapy, identifying medication-related problems, creating a care plan, monitoring current conditions and progress to the goals of care, and documenting and tracking results of interventions provided.
TOC is the movement of a patient from one setting of care to another. For example, a patient is discharged from the hospital, then transferred to a skilled nursing facility (SNF), then returns home and follow-up with his/her primary care provider.3
Q: How can pharmacists help with CCM in an ACO?
A: Through CCM, pharmacists’ responsibilities are broadened as they play a central role in the multidisciplinary healthcare team. Pharmacists’ impact in improving medication adherence, serves as a vital factor of improved patient outcomes. This comes at a pivotal time because as the number of pharmacists continue to increase, the expansion of their contributions are necessary for the pharmacy profession to thrive.4 In addition, primary care providers do not have sufficient time to obtain, verify or discuss extensive medication lists with a patient during a routine office visit. Some important advantages of pharmacists in CCM are their accessibility to patients with chronic disease and the ability to help patients manage their complex medication regimens in a timely manner. In the primary care setting, including ACO physician offices, pharmacists have begun to collaborate with physicians on medication optimization, polypharmacy, and medication safety. This nonphysician health care professional also has the ability to assist with preventive interventions (ie, vaccinations, lipids, osteoporosis).5 Pharmacists can play a vital role on the CCM teams by assisting with the care of these patients and working to improve quality benchmark measures. Furthermore, if a physician or another qualified health care professional (eg, pharmacist) during clinical staff time spends at least 20 minutes per month with a CCM eligible patient and establishes, implements, revises, or monitors a comprehensive care plan, Medicare will pay for these services under the Medicare Physician Fee Schedule (PFS) using Current Procedural Terminology (CPT) code 99490.6 To bill for this fee, it is required to use a certified electronic health record (EHR) for CCM patient encounters and documentation, offer 24/7 access to staff who have EHR access, appoint a practitioner for each patient, and coordinate care with proper referral to and from the hospital, specialists, or other providers. To maintain CCM services, practices must obtain patients’ consent at least annually.7
Q: What is the role for pharmacists in CDSM within an ACO?
A: Pharmacists are well positioned to help patients control these chronic diseases by providing education on lifestyle changes, monitoring, and medication adherence. Prior studies have shown that pharmacist involvement in CDSM improves clinical outcomes and reduces direct and indirect health care costs.8-12
An important tool to consider when discussing pharmacist-led CDSM is the development of collaborative practice agreements (CPAs). These agreements create a formal practice relationship between a pharmacist and other health care providers, and specify what patient care services beyond the pharmacist’s typical scope of practice can be provided by the pharmacist.13 These patient care services can include modification of current drug therapy, initiation of new therapy, ordering of labs, or performing physical assessment of the patient. Collaborative practice agreements combine physicians’ expertise in disease diagnosis and pharmacists’ expertise in drug therapy and disease management to allow shared responsibility of patient outcomes.14 The extent of the services authorized under the CPA depends on state laws and regulations, which are highly variable between states, and the terms of the specific agreement itself.13
Q: What is the role of TOC pharmacists in ACOs?
A: An ACO may include hospitals, SNFs, primary care physicians and specialists, home health nursing, and hospices. If fragmented care and miscommunication result from poor transitions of a patient from one care setting to another, the inevitable outcome is an avoidable hospital readmission and increased financial cost to the health care system.15 Transitioning patients from an acute-care setting to their homes or a post–acute-care setting, or vice versa, has become a priority for hospitals and ACOs alike, as controlling the transition process can help lower unnecessary readmission rates and avoidable costs drastically. It has been shown that TOC pharmacists make an impact on optimizing clinical outcomes by providing discharge counseling and obtaining medication histories and reconciliations. This is accomplished by services such as follow-up phone calls or at-home visits within 72 hours of discharge, which has been proven to reduce readmissions.1Six Transitional Care Management Services can be performed at a primary care office to Medicare patients, and they are billable, depending on the complexity of the service provided. Pharmacists are able to bill under general supervision of a provider using CPT codes 99495 and 99496 for moderate medical complexity and high medical complexity patients, respectively. To bill for either, there must be communication with the patient or caregiver (can be telephonic) within 2 business days of discharge. The provider can bill 99495 if there is also a face-to-face visit within 14 days of discharge, and the higher code 99496 can be billed if the patient is seen face-to-face within 7 days of discharge. Services may be performed by the physician, other qualified health care professionals, or licensed clinical staff under his or her direction.17
Q: What is the future role of pharmacists in ACOs?
A: Because pharmacists can reach out to patents and share valuable information with other clinicians, they are in an ideal position to manage multiple aspects of patient care, improve health care quality, and decrease overall health care expenditures. Further integration of pharmacists into patient care teams will provide value to accountable care organizations. As more organizations realize the benefits of integrating pharmacists into patient care, programs involving pharmacists will become an increasingly common approach to improving health outcomes and reducing the financial burden on the health care system.
Tina Joseph, PharmD, BCACP, is Assistant Professor of Pharmacy Practice at Nova Southeastern University, College of Pharmacy, and member of ACORNSEED. Genevieve M. Hale, PharmD, BCPS, is Assistant Professor of Pharmacy Practice at Nova Southeastern University, College of Pharmacy, and member of ACORNSEED. Stephanie Gernant, PharmD, MS, is Assistant Professor of Pharmacy Practice at Nova Southeastern University, College of Pharmacy, and member of ACORNSEED. Cynthia Moreau, PharmD, is Assistant Professor of Pharmacy Practice at Nova Southeastern University, College of Pharmacy, and member of ACORNSEED. Yesenia Prados, PharmD, is Clinical Pharmacist of Pharmacy Practice at Nova Southeastern University, College of Pharmacy, and member of ACORNSEED. Renee Jones, PharmD, CPh, is Assistant Professor of Pharmacy Practice and Director of Preceptor Development at Nova Southeastern University, College of Pharmacy, and member of ACORNSEED. Matthew Seamon, PharmD, Esq, is Associate Professor and Chairperson of Pharmacy Practice at Nova Southeastern University, College of Pharmacy, and member of ACORNSEED.
  1. American College of Physicians. Chronic care management tool kit: what practices need to do to implement and bill CCM codes. ACP website. acponline.org/system/files/documents/running_practice/payment_coding/medicare/chronic_care_management_toolkit.pdf. Accessed October 3, 2016.
  2. American College of Clinical Pharmacy; Hume AL, Kirwin J, Bieber HL, et al. Improving care transitions: current practice and opportunities for pharmacists. Pharmacotherapy. 2012;32(11):e326-37. doi: 10.1002/phar.1215.
  3. Patwardhan A, Duncan I, Murphy P, Pegus C. The value of pharmacists in health care. Popul Health Manag. 2012;15(3):157-62. doi: 10.1089/pop.2011.0030.
  4. Manolakis PG, Skelton JB. Pharmacists’ contributions to primary care in the United States collaborating to address unmet patient care needs: the emerging role for pharmacists to address the shortage of primary care providers. Am J Pharm Educ. 2010. 15;74(10):S7.
  5. Thompson CA. CMS explains Medicare payment for chronic care management services. Am J Health Syst Pharm. 2015;72(7):514-515.
  6. Centers for Medicare & Medicaid Services. Chronic care management services cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf. Published May 2015. Accessed October 3, 2016.
  7. Edwards ST, Landon BE. Medicare’s chronic care management payment - payment reform for primary care. N Engl J Med. 2014;371(22):2049-2051.
  8. Yu J, Shah BM, Ip EJ, Chan J. A Markov Model of the cost-effectiveness of pharmacist care for diabetes in prevention of cardiovascular diseases: evidence from Kaiser Permanente Northern California. J Manag Care Pharm. 2013;19(2):102-114.
  9. Cranor CW, Bunting BA, Christensen DB. The Asheville Project: long-term clinical and economic outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc (Wash). 2003;43(2):173-184.
  10. Fera T, Bluml BM, Ellis WM. Diabetes ten city challenge: final economic and clinical results. J Am Pharm Assoc (2003). 2009;49(3): e52-e60.
  11. Schuessler TJ, Rusinger JF, Hare SE, Prohaska ES, Melton BL. Patient satisfaction with pharmacist-led chronic disease state management programs. J Pharm Pract. 2016;29(5):484-489. doi: 10.1177/0897190014568672.
  12. Greer N, Bolduc J, Geurkink E, et al. Pharmacist-led chronic disease management: a systematic review of effectiveness and harms compared with usual care. Ann Intern Med. 2016, [Epub ahead of print].
  13. Weaver KK. Policy 101: collaborative practice empowers pharmacists to practice as providers. Pharmacy Today. pharmacytoday.org/article/S1042-0991(15)30671-X/pdf. Accessed October 3, 2016.
  14. Academy of Managed Care Pharmacy (AMCP). Practice advisory on collaborative drug therapy management. AMCP website. amcp.org/WorkArea/DownloadAsset.aspx?id=14710. Accessed October 2, 2016.
  15. Kmetz, A. ACO care transitions: coaching, management, and coordination. Patient Safety and Quality Healthcare website. psqh.com/analysis/aco-care-transitions-coaching-management-and-coordination/#sthash.3BJlF032.dpuf. Published February 4, 2015. Accessed on October 1, 2016.
  16. Miller DA, Schaper AM. Implementation of follow-up telephone call process for patients at high risk for readmission. J Nurs Care Qual. 2015;30:63-70.
  17. Centers for Medicare & Medicaid Services. Transitional care management services. cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf. Published March 2016. Accessed on October 2, 2016.