ACO Embedding Pharmacists in Primary Care for Chronic Care Management

May 7, 2022
North Carolina-based Triad HealthCare Network is working with UpStream Health to establish an embedded model driven by pharmacy with nursing care support

Triad HealthCare Network (THN), the accountable care organization affiliated with Cone Health in North Carolina, is working with Greensboro, N.C.-based UpStream Health to embed pharmacists in primary care practices to improve chronic care management for Medicare and Medicare Advantage patients.

During the recent spring NAACOS conference, Norine Tamborino, R.N., director of strategic programs and projects for THN, described this new approach and the partnership with UpStream. The ACO has 1,300 providers in a combination of primary and specialty care, and 55 percent of those providers are independent. THN is responsible for about 170,000 lives in value-based contracts.

Over the past year, THN began to embed care managers in some primary care offices, Tamborino said. “They've done a wonderful job, but we needed more than that,” she said. “We had a few pharmacists from UpStream in some of our primary care offices, and we saw that it was really beginning to make a big difference, so in January of this year, we signed a partnership relationship with them to establish an embedded model driven by pharmacy with nursing care support as well. We began this at the same time as getting into the Direct Contracting model.”

Cone Health, THN and UpStream Healthcare have a five-year affiliation under which UpStream will provide physicians with the support and systems they need to provide chronic care management (CCM) services to their Medicare and Medicare Advantage patients. The partners said the affiliation would bring a growing team-based advanced primary care model to enable THN to preserve its independent and Cone Health Medical Group primary care physician base through value-based incentive payments while reducing Cone Health's financial risk.

Tamborino said that COVID taught them how fragile many of their patients are. “Even patients that we would have said are stable — as they began to lose their traditional supports of churches and family members and food services — who were afraid to come out to patients’ homes for fear that they would give them COVID — those patients who were otherwise stable were no longer stable,” she said. “Patients who we thought traditionally were OK probably weren't as OK as we thought.”

“UpStream Health supports our Direct Contracting patients as well as our Medicare Advantage populations,” she said. “It is an embedded model, led by pharmacy, so that's a change, but a good change. It gives us the ability to do something very, very different, and support our providers,” she added. The pharmacist can open communication with the patients around medication. “We focus on some key quality metrics and look at patient utilization as well,” she explained. In this model, the pharmacist is the lead. They spend about 90 minutes initially with the patient. “It is a big change for someone from the pharmacy team to sit down and walk through the medications — when you take them, your ability to access them, any of the challenges that you have. It's very different for patients to have that focus on their care needs.”

She said this approach started with UpStream’s founder, Fergus Hoban, who is Irish and would have a cup of tea with the patients and have these conversations. “I think we noticed that with the annual wellness visits, spending 45 minutes with a patient is transformative in terms of how much you learn during that time and how much that patient feels connected to you,” Tamborino said. This embedded model focuses on decreasing utilization, optimizing care, and closing quality gaps.

UpStream looks at about 4,000 patients per practice, and roughly 1,200 of them will be chronic care management patients, which means having two or more chronic conditions, she said. They have a contact center concierge service, where patients who are part of the chronic care group will be able to call with any concerns.

“The biggest thing, we hope, is that it will streamline care for the patient. It's a reminder, when you look at the list of how many people will be touching this patient, that it really does take a village to keep that patient at the center of care,” Tamborino said. “Ideally, it's making things easier for them and the provider, by being that one voice to decrease fragmentation and to really understand what the patient needs.”

She explained that this will give them the opportunity to understand someone not having transportation, struggling with depression, or not have enough food in their home. “It's only through those conversations and having a team that is really linked,” Tamborino said. “If you're getting a telephone call, not many of us want to talk to a stranger, right? But if that person showed up at their bedside when they were in the hospital, they're part of your care team. If you see them when you're at your doctor's office, you know that person. When you call the pharmacy, because this specialty doc just added a new medication and you're not sure how to take it, now you have a pharmacist you can dial who's going to be able to walk you through it and you're going to talk to them. They're also going to be the first people you call when you're in trouble.”

Tamborino said they are really just rolling this model out now so they don’t have any results to share yet, “but I do think the important thing is surrounding the patient with the right resources, making life easier for patients and the physician.”

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