Coordinated

Pharmaceutical Therapy
in Chronic Care

Five Innovative Programs

September 2000
The National Pharmaceutical Council

is an education association supported

by the leading research-based

pharmaceutical companies.

NPC conducts research on the

appropriate use of pharmaceuticals

and the clinical, fiscal and

economic aspects of pharmaceutical

care. The Council prepares education

and information resources for

public and private payers and health

care policy makers.

© 2000 by the National Pharmaceutical

Council. All rights reserved.
OVERVIEW

Numerous studies indicate the limitations of a component-
based, line item approach to the management of pharmaceuti-
cals. Although some savings in the drug budget may occur,
treatment outcomes may be compromised and overall expendi-
tures are often increased.
A much greater potential for improved treatment and overall
cost savings lies in the direction of improved coordination of
pharmaceutical care, especially for elderly and other chronic
care patients. These groups consume a disproportionate share
of health care expenditures, including pharmaceuticals. They
usually have several coexisting diseases and are at risk for
adverse consequences due to their compromised physiological
status, and for interactions of prescriptions from several physi-
cians. Their pharmacological needs require access to a broad
range of medications and an individualized approach to care.
Successful models of coordinated pharmaceutical care for
these and other patients at high risk for suboptimal treatment
must be identified. This collection of five diverse approaches
illustrates that coordinated pharmacotherapy can be imple-
mented effectively across a variety of health care organizations.
Many of the programs have resulted in improved outcomes
and/or reduced overall costs of care.
This report provides detailed descriptions of the development
and operation of these programs. These approaches may, with
appropriate modifications, be applicable at other care sites,
and can represent a blueprint for organizations wishing to
implement coordinated pharmaceutical care.

TA B L E O F C O N T E N T S

Overview ....................................................................................................................................................................................... 3

Introduction ................................................................................................................................................................................. 5

Case Studies

Protecting the Vulnerable Elderly During Transition from In-patient to Home Care
Crozer-Keystone Health System ................................................................................................................................................... 6

New Technologies in Burn Care Require Coordination of Pharmaceutical Therapy

Alta Bates Hospital Burn Care Center.........................................................................................................................................16

Coordination of Pharmaceutical Care in High-Risk Patients with Coagulation Disorders

Johns Hopkins Bayview Medical Center ......................................................................................................................................24

Centralized Accountability for Coordinated Pharmaceutical Care in a Multi-Specialty Clinic

Palo Alto Medical Foundation Clinic ..........................................................................................................................................32

Education Improves Medication Management, Regimen Knowledge, and Outcomes in HIV/AIDS Patients
San Francisco Department of Public Health...............................................................................................................................40

What the Case Studies Have Taught Us ....................................................................................................................................46

Coordinated Pharmaceutical Therapy in Chronic Care 3

INTRODUCTION
Pharmaceutical innovation has greatly improved treatment out-
comes and quality of life for many patients. However, the full
potential of pharmaceutical therapy is seldom reached due to the
prevalence of uncoordinated care. Chronic care patients, especial-
ly the elderly, are most affected by uncoordinated care due to the
complexity and multiplicity of their conditions and drug regimens,
and their reliance on multiple care providers.
The Need for Coordinated Pharmaceutical Care
As the pace of innovation in pharmaceuticals, diagnostics, and
medical practice quickens, the “practice gap” between the avail-
ability of important innovations and their most effective use is
widening. The advent of “disease management,” which has
brought many important advances beyond episodic and uncoordi-
nated care, has resulted in increased cooperation and informa-
tion-sharing among providers. However, additional coordination of
pharmaceutical care is often required because disease-by-disease
approaches may neglect interactions among diseases and their
treatments.
Additional factors contributing to the increased need for coordi-
nated pharmaceutical care include increased numbers of medical
specialists and sub-specialists, and the rising population of fragile,
elderly patients with comorbidities. Complicating the situation fur-
ther is the movement by patients through different services and
sites of care of newly merged health systems.
Principles of Coordinated Pharmaceutical Care
One impediment to the realization of coordinated pharmaceutical
care is the ambiguity regarding the definition of this concept and
its principles. In 1999, the National Pharmaceutical Council (NPC)
joined with the National Chronic Care Consortium (NCCC), an
alliance of the nation’s leading non-profit health systems, to articu-
late a vision and framework for coordinated pharmaceutical care,
and to outline some key principles. Ten of the most important
principles are as follows:
• Commitment, leadership, and support for coordinated phar-
maceutical care from upper management
• Alignment of financial incentives and clinical goals across sites
of care and service sectors
• Management by interdisciplinary teams of physicians, pharma-
cists, and other care providers
• Centralized responsibility and accountability for the totality of
pharmaceutical care for the individual patient
• A system for identifying patients at high risk for undiagnosed
disease and suboptimal therapy
• Ongoing assessment of drug regimens and proper prescribing
and use of drugs
• Centralized knowledge of the patient’s full medical history and
all currently prescribed medications
• Effective communication and feedback among care providers,
especially across sites of care
• Education and involvement of the patient in the treatment plan
• Evaluation of the effectiveness of coordinated care programs
These and other aspects of coordinated pharmaceutical care are
further described in a NPC/NCCC brochure entitled Integrating
Pharmaceutical Care: A Vision and Framework, which is
available free of charge from NPC (www.npcnow.org).
Case Studies
The challenge now is to put these principles into practice in the
real world of care delivery. Clearly, resource constraints limit what
can be accomplished in mounting new programs that may require
coordinating activities across sites of care, building teams, and
assembling patient-level databases. Despite this, a variety of innov-
ative coordinated care programs have sprouted up across the
country. Five of these programs are profiled here, as examples of
successful approaches taken by different types of provider organi-
zations. These programs embody many of the principles of coordi-
nated pharmaceutical care developed by NPC and NCCC.
These case study profiles were based on interviews with individu-
als who designed, championed, managed, or participated in the
programs. These individuals also provided written descriptions of
program details as well as information on program results. Their
sense of pride and accomplishment in launching these programs
was apparent during these communications. NPC is grateful for
their help in codifying this information. Through distribution of
this booklet, we hope to make these innovative programs more
widely known so that others may be encouraged to implement
programs of their own.
Contributors include: Sydney Hecker, MD, Robert Scheidtman, PharmD,
Bruce Bienenstock, MD, Lori Reisner, PharmD, Kathy Korbholz, Edward
Casey, RPh, Peter Daley, RPh, Alan J. Ross, Jerold T. Kaplan, MD, June
M. Buckle, ScD, Mary G. Meyers, RN, MS, Phillip Zieve, MD, Burt
Finkelstein, PharmD, Charles Twilley, PD, MBA, and Mathew Sharp.
Coordinated Pharmaceutical Therapy in Chronic Care 5
Case 1

Protecting the Vulnerable

E l d e r l y D u r i n g Tr a n s i t i o n f r o m
In-patient to Home Care

Crozer-Keystone Health System

D e l a w a r e C o u n t y, PA
w w w. c r o z e r. o r g
CONTENTS

Overview................................................................................. 8

Pharmaceutical Care Assessment Program.............................. 8

Disease Management and Home Care Create Program Need... 8

The Program’s Genesis............................................................ 9

An Innovative Partnership with a Pharmacy School................. 9

How the Program Works......................................................... 9
Rotation Training.............................................................. 9
The Pharmacy Risk Assessment – A Standardized Tool..... 11
In-Home Pharmaceutical Regimen Assessments............... 11
Intake and Planning.................................................... 12
Recommendation Documentation, Communication,
and Follow-up....................................................... 13
Program Results...................................................................... 13

Three Case Examples.............................................................. 14

Lessons Learned and Keys to Success...................................... 14

Physician and Nurse Manager Acceptance........................ 14
Anticipate Growth and Maintain Flexibility........................ 15
Assessment and Data Collection Tools............................... 15

The Crozer-Keystone Health System......................................... 15

Coordinated Pharmaceutical Therapy in Chronic Care 7

Overview
The Pharmaceutical Care Assessment Program at Crozer-Keystone
Health System provides a real world approach to delivering
coordinated pharmaceutical services to patients with complex
drug regimens. The Program’s focus is on serving elderly patients
during their time of greatest need: the transition from in-patient
care to home care. The Program is staffed through an innovative
arrangement with a nearby pharmacy school and provides
enhanced coordinated pharmaceutical services for no additional
cost to patients or the health care system.
This Program reflects many principles of coordinated pharmaceu-
tical care. Coordinated therapy for high-risk elderly patients is
provided during their transition from hospital to home care.
In-home visits allow patients and pharmacists to work together to
assess the patient’s pharmaceutical coordination requirements and
individual pharmaceutical needs. A complete medical history is
retrieved from the health system’s computer. A tailored treatment
plan is developed which considers the patient’s self-care capabili-
ties, medication regimens, and needs for education. Prescription
and non-prescription drug regimens are confirmed, patient
knowledge of drug regimens and diseases is determined, and
appropriate education is provided. A comprehensive drug
interaction and medication management review is also conducted.
The results of the visit are entered into Crozer’s computer system
to become part of the patient’s permanent medical record. After
the visit, a telephone follow-up is conducted to review any
medication or regimen changes, and to answer additional
questions. An interdisciplinary management team has integrated
the program into the operations of Crozer’s home care agencies.
Comprehensive education and training of the pharmacists making
in-home visits ensures a consistent standard of service.
Pharmaceutical Care Assessment Program
The Pharmaceutical Care Assessment Program was developed to
address pharmaceutical coordination issues for high-risk, elderly
patients transferring from inpatient facilities to home care status.
High-risk patients include those with multiple diseases and who
require multiple medications. Special attention is given to potential
interactions among prescribed medications and between these
medications and over-the-counter (OTC) products. Patients
entering any of Crozer-Keystone’s three home care programs are
eligible for this assessment program.
An initial pharmacy assessment is made by the home care
admitting nurse during the first visit to the home. Patients with
high-risk scores on a standardized risk assessment intake tool are
referred to the Program for a more complete in-home assessment
8 Coordinated Pharmaceutical Therapy in Chronic Care
by a pharmacist or board-eligible fifth year Doctor of Pharmacy
student. During this (voluntary) home visit, the patient’s pharma-
ceutical care plan, self-care capabilities, medication regimens, and
pharmaceutical education needs are assessed.
The results of the assessment and any pharmaceutical coordina-
tion recommendations are reported to the primary care nurse and
the patient’s admitting physician on a written form or through
Crozer-Keystone’s home care medical record system. The Program
team, consisting of the Program Preceptor (a clinical pharmacist
who is the Program manager) and all current pharmacy students,
reviews the results and recommendations and makes appropriate
regimen modifications and education interventions, or enrolls the
patient in additional disease management programs (see below).
Disease Management and Home Care Create Need
During the 1990’s, Crozer-Keystone, like most integrated delivery
systems, implemented a broad-based disease management and
wellness program offering individuals and their families the latest
treatment options, technology, education, and resources. Primary
care physicians are provided with updated information from spe-
cialists and specialty professional organizations regarding new
treatments, medications, and care guidelines for specific diseases.
Developing these disease management and wellness programs
spanning the entire care continuum highlighted the need for
increased focus on effective transitions between inpatient care
and home care. The multidisciplinary team that implemented the
congestive heart failure (CHF) program included physicians,
inpatient nurses, and home care nurses. The CHF team quickly
recognized the need for pharmaceutical coordination during the
transfer to home care.
Furthermore, in 1997, Medicare regulations required non-
pharmacy-trained health care professionals (e.g., physical,
speech, and occupational therapists) to provide a complete
assessment of patient care, including pharmaceuticals. These
regulations strengthen the need for pharmacy-trained personnel
to participate or intervene when necessary in cases where no
nursing involvement is present.
The Program’s Genesis
The CHF team, together with Edward Casey, RPh, Director of
Pharmacy Services, worked with one of Crozer-Keystone’s three
home care agencies to launch a pilot program, staffed by a phar-
macist from Crozer-Keystone and a pharmacy student from the
Philadelphia College of Pharmacy and Science.
The pilot program was, in part, a response to the launch and pro-
jected growth of Crozer-Keystone’s Medicare Risk program. Under
the program, the health system was assuming global financial
responsibility for an elderly patient population with many complex
medical and pharmaceutical needs. The pilot program fit the goals
and objectives of total quality improvement and cost management
required to build a successful Medicare Risk program.
In this pilot phase, a first-generation pharmaceutical care risk
assessment tool was used, and patient referrals and informal
assessments were conducted. The home care administrators
responded favorably, and there was evidence of positive clinical
impacts in the first twenty-five patients (see chart below). This
resulted in program expansion and improvement of the tools,
processes, and personnel to manage and conduct the program on
a larger scale.
Program expansion began with the addition of the Program
Preceptor, a full-time clinical pharmacist, with 50% of his time
allocated to the Program. Further expansion to all three of Crozer-
Keystone’s home care agencies required a substantial increase in
pharmacy staff resources. This need was met through a formal
partnership with the University of the Sciences in Philadelphia
(U.S.P.).
An Innovative Partnership with a Pharmacy School
Crozer-Keystone and the University of the Sciences in Philadelphia
agreed to support a rotation of U.S.P. pharmacy students through
the Program. This innovative partnership enabled both organiza-
tions to meet their goals, while providing patients with a substan-
tial benefit at no additional cost to the patient or the Health
System.
U.S.P. was pleased to provide its pharmacy students with the
opportunity to gain valuable experience in an ambulatory care
setting. The students work directly with patients in their homes
and gain insight into real-life drug therapy challenges faced by
patients with complex chronic diseases.

How the Program Works

R E S U LT S O F P I L O T P R O G R A M
Program Details
Total patients in pilot
Patients qualifying for program
(intake score >15)
Received home consults
Compliance problems
Received education
Drug-related admissions
Drug therapy recommendations
• Five meds discontinued at
$325/month (three for one pt.)
• One added drug treatment, one
change in drug regimen schedule,
and one request for lab tests
The Program is managed by the Program Preceptor, Peter Daly,
RPh, a clinical pharmacist who reports directly to the Director of
Pharmacy Services. Under Dr. Daly’s leadership, a management
Number of team representing all facets of the health system has effectively
Patients integrated the Program into the operations of Crozer-Keystone’s
25 three home care agencies. The Program is comprised of four main
components: rotation training, use of a pharmacy risk assessment
12 tool, in-home assessments, and recommendations and follow-up.
12
3 Rotation training
5 During the course of the year, ten groups of pharmacy students
2 rotate through the Program. Each group consists of three pharma-
9 cy students working under the direct supervision of the preceptor
for a total of ten weeks. Each pharmacy student is assigned to one
of Crozer-Keystone’s home care agencies.
Comprehensive pharmacy student orientation and training was
implemented to ensure a consistent standard of service. The
orientation consists of one day of intensive formal training, fol-
lowed by at least three days of observation with home care nurses,
hospice nurses, or physical therapists. The orientation session
covers a variety of administrative and technical topics.

Coordinated Pharmaceutical Therapy in Chronic Care 9

Administrative topics include:
• The Program’s mission, vision, and philosophy
• Risk and safety management strategies
• Clinical information systems
• Confidentiality guidelines
• Program documentation requirements
• Hospice program objectives and services
Technical topics include:
• Supportive care
Screening Tool
10 Coordinated Pharmaceutical Therapy in Chronic Care
• Heart Success Program
• Medication administration and medication errors
• Adverse drug reactions
• Pain management
• Intravenous and parenteral therapy at home
• Infection control
• Disease management guidelines for gastroesophogeal
reflux disease, asthma, arthritis, CHF pain management,
and other diseases
• Drugs to be used with caution in the elderly
Upon completion of the orientation, the student enters field
training under the supervision of the home care nurses and guid-
ance of the Preceptor. The student is required to complete ten
field visits to pass the rotation. Recommendations or changes in
patient therapy require prior discussion and/or approval of the
preceptor.
Pharmacy risk assessment:
a standardized intake screening tool
The interdisciplinary team that developed the Program also
developed a standardized intake screening tool to assist home
care nurses in assessing the patient’s pharmaceutical regimen
complexity and determining the need to refer a patient to the
Program.
The basic home care Pharmaceutical Care Assessment Screen
(PCAS) shown on page 10 uses eight primary categories to assess
a patient’s overall pharmaceutical regimen risk profile. Any patient
scoring fifteen or more total points is referred to the Program for
an in-home pharmacy assessment.
In-home pharmaceutical regimen assessments
Once the patient is referred to the Program, the pharmacy student,
with support from the Preceptor and other Program students,
completes an eleven-step patient assessment process, the schemat-
ic of which is shown below.
The objective of the assessment is to increase pharmaceutical
effectiveness by confirming prescription and non-prescription
drug regimens, assessing the patient’s knowledge of drug regi-
mens and diseases, and providing appropriate education when
warranted. In addition, a comprehensive drug interaction and
medication management review is conducted. Recommendations
are often made to modify existing regimens, change dosing, delete
unnecessary medications, add additional drugs, and simplify the
patient’s understanding of complex overall drug therapies.
The multi-step assessment process is comprised of three sets of
tasks: 1) intake and planning, 2) in-home assessment, and 3) rec-
ommendation, documentation, communication, and follow-up.
Coordinated Pharmaceutical Therapy in Chronic Care 11
1. Intake and planning necessary includes that person in the appointment. Once
scheduled, the student notifies the primary care nurse of the
a. The referral is logged into the program tracking system and
appointment date and time.
the patient is assigned to a pharmacy student or program
pharmacist.
d. If the patient refuses the visit, the student prepares a refusal
form and submits it to the Preceptor. The refusal is then
b. The pharmacy student uses the Health System’s Delta copied to the home care nurse making the referral and
computer system to retrieve a complete medical history and documented in the electronic medical record.
all patient demographic information.
e. Prior to the visit, the student prepares a patient review plan
c. The pharmacy student contacts the patient to schedule an
highlighting specific issues for discussion. Educational
in-home appointment for the pharmaceutical assessment.
materials are assembled and potential drug interactions are
The student inquires about anyone assisting the patient with
checked based on known existing prescriptions.
medication administration (friend, relative, etc.) and if

12 Coordinated Pharmaceutical Therapy in Chronic Care

2. In-home assessment
f. The student and patient meet in the patient’s home for about
one hour to complete the pharmaceutical assessment. The
student checks the contents of the medicine cabinet and the
patient’s pill box. They discuss the patient’s understanding of
each prescription, when it should be taken, what it is for,
special instructions, and potential adverse drug reactions.
The patient is also encouraged to discuss any side effects
experienced and to ask questions regarding medication regi-
mens.
g. The home visit is documented using a standardized
Pharmaceutical Care Assessment Form (see below). This
form includes demographic information, medical history,
medication lists, visit observations, and vital sign/lab report
results. The form is completed with a succinct list of priori-
tized problems and recommendations for regimen modifica-
tion, additional patient education, patient assistance, and
other pharmaceutical interventions.
h. The entire Program team meets weekly with the Preceptor to
review all assessment forms and recommendations. The
assessment is modified to reflect team conclusions, and a
final copy is delivered to the Preceptor and the home care
nurse.
A formalized tool, the Pharmaceutical Care Assessment Health Care
Communication Form supports the in-home assessment. This
form (shown on page 12) documents key patient data, medical
problems, all prescription and OTC medications, patient observa-
tions, and recommendations. Upon completion of the form, it is
P R O G R A M R E S U LT S
of patients
Referrals
Received home consults
• Required intervention
Recommendations made
Drug therapy recommendations
• Recommendations accepted
reviewed and approved by the Preceptor, and formal recommen-
dations are made to the patient’s home care nurse and physician.
3. Recommendation documentation, communication,
and follow-up
i. The home care nurse is informed, in person or by voice
mail, about the results of the visit, potential or existing prob-
lems, and important recommendations. Critical issues found
while the pharmacist is still at the home are communicated
to the primary care nurse and Preceptor via pager, and cor-
rective action is taken immediately.
j. The student records the patient visit and any recommenda-
tions directly into the Health System’s Delta computer system,
which communicates the results of the visit to all the patient’s
providers including his physician, nurses, etc. and becomes
part of the patient’s permanent medical record.
k. A follow-up telephone visit is conducted to review any
changes in medications or altered regimens and to answer
additional questions. The follow-up call is documented in a
report and submitted to the Preceptor and home care nurse.
Program Results
Although formal outcome studies measuring the cost benefits of
the Program have not yet been completed, process results and
anecdotal patient results indicate the program is effective. A study
of 166 referrals during the period January 1998 to February 1999
noted the following pharmaceutical regimen improvements result-
ing from the Program (see table below).
The acceptance of 33 patient-specific recommendations for
Number Percentage
of patients
166 100%
53 32%
51 96%
146 100%
118 81%
33 29%
Coordinated Pharmaceutical Therapy in Chronic Care 13
the 166 referrals indicates the intake assessment tool is working
effectively to select appropriate patients for the Program, and the
in-home pharmaceutical assessments are effectively identifying a
wide variety of therapy improvement opportunities.
During the three-month period from April 1, 1999 to June 30,
1999 the Program received 420 referrals. Compared to the 166
referrals received from January 1998 to February 1999, this
represents an annual growth rate of over 1,000%. The Program’s
dramatic growth during 1999 indicates an overwhelmingly positive
response from the home care nurses and primary care physicians.
As the Program advances in the future, Crozer-Keystone plans to
complete a comprehensive outcomes assessment and to constantly
monitor the effectiveness of the intake assessment tool and other
Program features.
Three Case Examples Provide Evidence of the Program’s
Effectiveness:
• Case 1. A 77-year-old woman was referred to the Program
due to her recent myocardial infarction and history of multi-
ple medications. During the home visit, the student noted a
duplication in therapy with clopidogrel plus aspirin ––
a combination that resulted in an increase in bruising. Also,
the patient was without a clinically indicated drug (ACE
inhibitor) proven to decrease morbidity and mortality in post
myocardial infarction patients. Furthermore, the patient, who
also has a history of asthma, was prescribed an antihyperten-
sive agent but was suffering from bronchoconstriction and
difficulty in breathing. The antihypertensive has been shown
to have bronchoconstrictive properties. The Program recom-
mended the duplicate drugs be removed from the patient’s
regimen and an ACE inhibitor added. The patient’s physician
agreed with the recommendations and implemented them
immediately, avoiding a potentially dangerous drug interac-
tion. The patient has not been re-admitted to the home care
program or hospital.
cian and resulted in improved pain control and decreased
nocturia, significantly improving the patient’s quality of life.
• Case 3. A 74-year-old woman with a history of chronic
airway obstruction, heart failure, bronchitis, and arthritis was
referred for an in-home pharmacy consult because her drug
therapy included multiple medications with possible
drug-drug interactions. During the visit, the student noted
several duplications of therapy such as for her pain control.
The patient was also prescribed two corticosteriod inhalants
while only one is clinically indicated for the treatment of
chronic airway obstructive disease. Furthermore, the patient
was prescribed guaifenesin/phenylpropanolamine and
amitriptyline. Concurrent use of these medications may result
in hypertension, cardiac arrhythmias, and tachycardia.
The Program recommended discontinuing four medications.
The recommendations were implemented, drastically
reducing the potential for adverse side effects (especially
falls) and potential drug interactions.
Lessons Learned and Keys to Success
Three essential lessons were learned as Crozer-Keystone imple-
mented this program over the course of four years.
Physician and nurse manager acceptance
A critical factor leading to implementation of the Program was the
support and acceptance of the health system’s physicians, and
particularly the primary care nurses (case managers) at the home
care sites. Gaining support was accomplished by leveraging other
health system programs like the CHF disease management
program. The leadership team of the CHF disease management
program helped identify the need for the Program; designed it to
fit the needs of the physicians and primary care nurses; and built
initial support for the implementation of pilots. The pilot program
was used to fine tune Program tools, demonstrate Program
effectiveness, and broaden the support base.

• Case 2. A 76-year-old woman, referred to the Program due

to “excruciating pain” from arthritis and spinal stenosis, was
noted to be suffering from inadequate pain control and
insomnia. The student suggested an immediate-release
narcotic for break-through pain control, combined with a
continuous-release narcotic for long-acting pain control. A
change in dosing schedule for the diuretic furosemide was
also suggested – the dose was to be given earlier in the day
instead of just prior to sleep to prevent frequent nocturia.
The recommendations were approved by the patient’s physi-

14 Coordinated Pharmaceutical Therapy in Chronic Care

Anticipate growth and maintain flexibility The Crozer-Keystone Health System
Pharmaceutical coordination programs that are well designed,
have physician and provider support, and target well-defined Crozer-Keystone Health System’s network of facilities and
patient needs are likely to experience phenomenal growth and physicians provides residents of Delaware County, Pennsylvania
create the potential for unmet demand. Maintaining initial success and surrounding communities with easy access to primary care
and momentum does not require anticipating every detail from the and specialty services. Crozer-Keystone consists of five hospitals with
outset, but rather a mindset that embraces flexibility and creativity. 1,088 licensed inpatient beds and 649 sub-acute and skilled nurs-
By effectively anticipating the potential growth of the Program, ing beds in its seven long-term care and transitional care units
Crozer-Keystone was able to expand capacity through creative operated by 1,128 medical staff. The health system includes 36 pri-
partnerships with pharmacy colleges, and through “controlled mary care sites staffed by 147 physicians
release” of the Program into the system’s two additional home conducting over 200,000 office visits annually.
care agencies. By maintaining positive momentum throughout its
growth, Crozer-Keystone ensured the Program’s long-term success.
In addition, Crozer-Keystone operates three centers for
occupational health, a sports club, and centers for family health in
Assessment and data collection tools
each of its primary service areas.
The importance of designing and utilizing consistent, effective
tools to perform home care intake and in-home pharmaceutical
assessments cannot be underestimated. Nurse case managers and
any other health care professionals opening a case can use the
intake tool as a guideline to make effective referral decisions.
Similarly, the structured format of the assessment form maintains
consistency of reporting, and guides inexperienced pharmacy
students to make comprehensive assessments and recommenda-
tions. Both tools can be used as a starting point for health systems
interested in implementing a similar program, and they can be
tailored to meet the specific needs of the health system, home care
program, and patients.

In summary, the Program provides a rational approach to

delivering coordinated pharmaceutical services to patients with
complex medication regimens. In-home visits allow patients and
pharmacists to work together in a comfortable, private setting to
assess the patient’s pharmaceutical needs and to take appropriate
corrective action. Through an innovative arrangement with
pharmacy schools, the Program can be implemented at little
or no cost to the health system or its patients.

Coordinated Pharmaceutical Therapy in Chronic Care 15

Case 2

N e w Te c h n o l o g i e s i n B u r n C a r e
Require Coordination of
Pharmaceutical Therapy

Alta Bates Hospital Burn Care Center

San Francisco Bay Area, CA
w w w. a l t a b a t e s . c o m
CONTENTS

Overview ............................................................................ 18

“Blended Medicine”........................................................... 18

Pharmaceutical Coordination in Burn Care........................ 18

Effective Dosage Levels in Pain Control ........................ 18
Effective Dosage Levels in Antibiosis............................. 19
Dietary Concerns and Impact of Diet on
Pharmaceutical Effectiveness ...................................... 19
Pharmaceutical Challenges in Discharge Planning........ 19

Coordinating Pharmaceutical Care..................................... 19

The Burn Coordinator is the Hub of the
Coordination Wheel ................................................. 20
Role of Pharmacists in Coordination............................ 20

Lessons Learned and Keys to Success................................. 20

Unique patient circumstances heighten need for
pharmaceutical coordination .................................... 20
Nurse Coordinator role
enables pharmaceutical coordination ......................... 21
Information and communication systems
leverage hospital-wide resources............................. 21
The Alta Bates Hospital....................................................... 21

Appendix: Advances in Burn Care ...................................... 22

Coordinated Pharmaceutical Therapy in Chronic Care 17

Overview
The Alta Bates Hospital Burn Care Center is located in the San
Francisco Bay area of Northern California. The Center employs
“blended medicine” with a core of multi-specialty professionals to
deliver coordinated services, including pharmaceutical care, to
burn patients. The blended medicine approach ensures the effec-
tive management of these high-risk, high-cost patients.
Coordination of pharmaceutical therapy enables the Center to take
full advantage of recent advances in burn care pharmaceutical and
service technologies. Coordinated therapy extends from emergent
care through inpatient and outpatient rehabilitation and into
extended care planning for the patient’s return to normal activities
of daily living (ADLs). The burn coordinator, discharge planner
and hospital clinical pharmacist provide a nucleus of professionals
focused on developing and implementing coordinated pharmaceu-
tical care processes to address the unique needs of burn care
patients. These processes include: establishing effective dosage
levels for pain control and antibiosis; managing relationships
between pharmacotherapy and diet; and discharge planning that
provides individualized pharmaceutical regimens.
Many key principles of coordinated pharmaceutical care are
evident in the operation of the Burn Center. High-risk burn
patients require complex, precise pharmaceutical therapy and
careful, ongoing assessment of drug regimens. The complexity of
pain control in these patients, plus their need for drugs
compatible with their nutritional status, necessitates a coordinated
approach to prescribing, dosage titration, and monitoring.
Coordination extends across service sectors. An interdisciplinary
team (including surgeons, nurse coordinators, therapists,
and the clinical pharmacist) develops and implements
coordinated strategies and shares information at weekly
“plan of therapy” sessions.
The clinical pharmacist takes responsibility for centralized
pharmaceutical care by overseeing pharmaceutical use and
maintaining communication with burn specialists to determine
effective dosage levels for optimal wound care. A data system
enables the pharmacist to monitor pharmaceutical use and
laboratory indices. Abnormalities associated with improper use
and dosages of medications are flagged for follow-up.
18 Coordinated Pharmaceutical Therapy in Chronic Care
“Blended Medicine”
The Burn Center is a six-bed facility occupying 3,000 square feet
within a 310-bed hospital. Eighty to one hundred patients are
treated yearly by a core of multi-specialty professionals, who draw
upon the resources of the hospital in their practice of “blended
medicine.” Although burn patients occupy a relatively small
percentage of hospital beds, these intensive care patients require
high levels of staff support and hospital resources.
Burn Center Director Jerold T. Kaplan, MD is trained in bacteriol-
ogy and orthopedics –– fields vital to managing burn patients.
Under Dr. Kaplan’s leadership, the Center has effectively imple-
mented a coordinated approach to pharmaceutical treatment that
extends from emergent care through inpatient and outpatient
rehabilitation and into extended care planning for the patient’s
return to normal activities of daily living.
The Center’s medical professionals and therapists rely on frequent
meetings and close communication to optimize patient care.
The charge nurse, occupational therapist, surgeon, and clinical
dietitian pool their efforts in a coordinated fashion. The charge
nurse and discharge planner play a central role in guiding
treatment and coordinating therapeutic regimens. This is the
essence of blended medicine.
Central to burn care and blended medicine is the coordinated use
of pharmaceuticals at every level of therapy. As a member of the
care team, the clinical pharmacist oversees pharmaceutical use
and dispensing, and maintains communication with burn special-
ists in determining effective dosage levels for optimal wound care.
Pharmaceutical Coordination in Burn Care
The introduction of improved pharmaceutical therapies for
controlling pain, treating infection, and restoring bodily functions
in the burn patient has raised four primary challenges in the
current management of burn patients.
Effective dosage levels in pain control
Pain control is idiosyncratic, varying from burn patient to burn
patient. In addition, the significant disruption of tissues and organ
systems in moderate second and third degree burns calls for
creative measures on the part of the physician. The use of various
adjuvant medications such as Phenergan or Vistaril, which
potentiate the effectiveness of narcotic analgesics, can serve to
reduce analgesic dosage levels. Lower levels of narcotic analgesics
and derivatives reduce the potential for habituation, which
requires increasingly higher dosage levels.
Titration of analgesic dosage levels must take into account the
patient’s vital signs, respiratory rate, hematological and respiratory
status, body language, idiosyncratic drug reactions, and
neuromental and neurologic status. The complexity and interde-
pendency of these issues requires a coordinated approach
to pharmaceutical prescribing, dosage titration, and monitoring.
Effective dosage levels in antibiosis
To achieve effective levels of antibiosis to prevent infection, one
must rely upon clinical wound examination as well as such time-
honored methods as antimicrobial susceptibility testing or disc
sensitivity testing. Proper wound culture methods are essential for
effective isolation and treatment of wound contaminants.
Coordination of pharmaceutical prescribing with wound culture
methods ensures that patients receive optimal antibiotic treatment
while minimizing the risk of antibiotic drug resistance.
Dietary concerns and impact of diet on
pharmaceutical effectiveness
Moderately to severely burned patients require more protein and
calories to compensate for what is sometimes the loss of ten percent
of body weight or more at the time of injury. A delicate balance
exists between intravenous fluid intake and protein intake as well.
The registered clinical dietitian and medical staff should take
electrolyte disturbances and fluid-volume disturbances into
account. Where intravenous nutrition is not effective,
hyper-alimentation remains an option at all times. The clinical
dietitian must remain vigilant in adjusting dietary needs for burn
victims with preexistent diabetes, liver disease, or hypertension to
ensure the continued effectiveness of their existing therapeutic
regimens during recovery from the acute burn trauma.
Pharmaceutical challenges in discharge planning
Oral medications may be used unless the patient has a venous
catheter in place for continuing intravenous home therapy. Such
patients require daily home nursing care and periodic alteration
of the intravenous site to avoid infection and skin maceration.
Hence, patients lacking the means for home care nursing must
sometimes make do with oral medications exclusively. Moreover,
the administration of topical wound medications and bandaging
often is beyond the scope of self-administered patient care.
Appropriate discharge planning integrates the pharmaceutical
needs of each patient with his or her individual self-care capacity,
financial constraints, and caregiver circumstances.
Lastly, oral analgesics are often substituted for intramuscular
analgesics at the time of discharge. The monitoring of analgesic
effectiveness and drug interactions is more problematic when
patients must monitor their own responses to oral medications
without recourse to vital signs and other indices of therapeutic
response.
Each of these issues heightens the need for coordinated pharma-
ceutical care, which considers each patient’s circumstances when
selecting and administering pharmaceutical regimens across the
rapidly changing care continuum. As the patient moves from
in-patient emergent care to outpatient rehabilitation and finally to
home care, the professional team must constantly assess a
complex, interdependent array of medical, social, psychological,
and financial considerations to ensure optimal pharmaceutical
treatment.
To ensure the availability of resources required to support this
effort, the Center Director insists that third party administrators
and reviewers provide these burn patients with all necessary ser-
vices and adequate rehabilitation time to recover from their
injuries. The Alta Bates Burn Care Foundation provides additional
support for medical care.
Coordinating Pharmaceutical Care
The Center fulfills the following therapeutic goals and commit-
ments regarding pharmaceutical care of burn patients:
• The appropriate use of pharmaceuticals in wound care
• The selective and specific use of medications
• The selection of appropriate doses of analgesics early on to
reduce drug dependency
• The reduction of antibiotic drug resistance through short-
term, aggressive therapy
• The coordination of pharmaceutical therapies throughout the
care continuum
The Center maintains close adherence to these principles of
therapy and provides for the specialized needs of its patients by
integration of pharmaceutical therapy through its well-coordinated
care team. Although burn patients require relatively few basic
medications (e.g., opiates, Benadryl, silver sulfadiazine, furacin,
and various antibiotics), drug interactions and iatrogenic
complications are possible. These complications can result from
the patient’s existing therapies for chronic conditions such as
diabetes, liver disease, arthritis, and hypertension. The focus of
the clinical pharmacist on the totality of drug therapy has
minimized such adverse events.
Coordinated Pharmaceutical Therapy in Chronic Care 19
The Burn Coordinator is the hub of
the coordination wheel
The Center is a model of multi-specialty or “blended care”
medicine. Core team members, including surgeons, nurse coordi-
nators, therapists, and the clinical pharmacist, meet weekly at
“plan of therapy” sessions to discuss therapeutic options for their
patients. These meetings also serve to keep all team members
absorbed and involved in individual patient care.
While these meetings ensure that all members are involved in
developing coordinated therapeutic plans for the patients, daily
pharmaceutical coordination is the responsibility of the Burn
Coordinator. At Alta Bates a specialized Nurse Coordinator (NC)
performs the burn coordinator function. The NC is responsible for
dressing changes, skin and wound care, tube feeding, and emer-
gent care for respiratory crises, in addition to responsibility for
coordinating all pharmaceutical care. Specialized wound care
training, and often ACL certification, enables the NC to maintain
control of these multiple tasks.
Along with the physician, the NC has the responsibility of titrating
intravenous, intramuscular, and oral medications to achieve effec-
tive pain control among patients with different pain thresholds.
The Burn Coordinator must also adjust for age and health status in
administering pain medications at effective dosage levels. Burn
severity and organ and body functioning impacted by the burn
trauma also influence drug dosing.
The NC assumes the role of discharge planner. The NC must
choose the proper setting for continuing burn care and rehabilita-
tion, whether at home, in a skilled nursing facility, or at a board
and care facility. The NC must wean the burn patients from
hospital care while acclimatizing them to an adequate level of
self-sufficiency in ADLs. This includes adequate self-care at home,
psychosocial adjustment, and ability to use assistive aids such as
casts, splints, crutches, canes, or wheelchairs. The most difficult
problem the NC faces is the lack of sufficient community safety
nets and resources available to the post-burn patient. Months of
painstaking burn care and rehabilitation can be reversed by an
absence of transitional services and housing for burn patients with
chronic and permanent after-effects of their injuries.
Role of pharmacists in coordination
The management of medications in burn therapy at the Center is
the province of the hospital’s clinical pharmacist. The pharmacist
is assisted by a software program that monitors hospital patients
for pharmaceutical use and laboratory indices, and that also
serves as a pharmaceutical screening device.
20 Coordinated Pharmaceutical Therapy in Chronic Care
When the computer notes systemic abnormalities associated with
medications, the pharmacist will “flag” the findings and send a
notation to the burn physician and to the patient's chart. The
pharmacist will suggest that the physician consult with him to
determine what adjustments in dosage may be necessary or
beneficial. Thus, the hospital’s coordinated information system
allows the pharmacist to effectively support the care team and
Nurse Coordinator in the Burn Center without being dedicated to
the Center on a full-time basis. The blended medicine model takes
full advantage of the spectrum of hospital resources without
significant cost to the Burn Center.
The clinical pharmacist also closely monitors changes in body
chemistry, noting renal, hematologic, hepatic, and auditory status
concurrent with antibiotic usage. The burn patient on aminoglyco-
side therapy to combat gram-negative organisms will have
frequent auditory testing. Changes in blood levels are noted
and flagged for the physician's attention. In addition, the
pharmacist monitors the concentration of the antiseptic furacin
used in topical wound care.
Lessons Learned and Keys to Success
Over the past ten years, the Burn Center has constantly evolved its
practices to incorporate a blended medicine approach to all burn
care. Through the efforts of the surgeons and nurse coordinators,
this coordinated approach to patient care incorporates each of the
critical components of burn care therapy. Three keys to success
enabled the effective coordination of pharmaceutical therapy into
the blended medicine approach.
Unique patient circumstances heighten need for
pharmaceutical coordination
Burn victims present many immediate and long-term chal-
lenges requiring a comprehensive approach to care coordina-
tion from emergent care to a variety of home care settings.
Many challenges were realized during the initial emergent care
stage, such as the fact that wound debridement and re-hydra-
tion take precedence over pharmaceutical issues. However,
overall treatment success relies, in part, on effective use of
pharmaceutical therapies. Therefore, it is critical to recognize
the interdependent role of pharmaceutical therapies and the
impact other patient circumstances may have on their effec-
tiveness. Explicitly recognizing these issues provides the basis
for developing a coordinated pharmaceutical therapy
approach and for complementing the blended medicine team
with appropriate pharmaceutical support.
 Nurse Coordinator role enables pharmaceutical
coordination
Recognizing the unique needs of burn care patients, a burn
center must centralize and clearly delineate responsibility for
coordinating all patient activities. Effective coordination of
pharmaceutical therapy relies on the coordinator being close
to the patient at all times and physically located on the Burn
Center ward. Although the Hospital’s clinical pharmacist pro-
vides support and expert input to the pharmaceutical coordi-
nation process, primary day-to-day responsibility is maintained
at the Burn Center and is coordinated by the Nurse
Coordinator. Clear delineation of the NC’s role as the coordi-
nator of therapeutic interventions ensures the pharmaceutical
therapies are monitored and adjusted in a coordinated fashion
with other patient-specific therapy and planning, such as
wound debridement, dietary changes, and discharge planning.
Information and communication systems leverage
hospital-wide resources
Information systems can extend the knowledge and expertise
of hospital personnel at low incremental costs. The systems at
Alta Bates Hospital support the coordination of the burn team
by monitoring patients and providing feedback to team
members. This is especially important for members who are
not full-time employees of the Burn Center. In particular, these
systems allow the Center to leverage the Hospital’s clinical
pharmacist as an integral member of the team, and also
convey his knowledge and support to others without his daily
presence at the Center.
In summary, Alta Bates Hospital and the Burn Center Director
recognized the unique needs of burn care patients and forged a
coordinated approach to treating these patients throughout their
recovery and transition back to activities of daily living. The
Hospital’s information systems and support departments facilitated
this approach through creative leveraging of the Hospital’s
resources. Through the efforts of the Burn Center Director and the
Nurse Coordinator, the Burn Center ensures these high-risk,
high-cost patients receive the highest quality care.
The Alta Bates Hospital
Alta Bates Medical Center has a 90-year history of providing
excellent medical care and services to the East Bay Area in
Northern California. Founded in 1905 by Nurse Alta Bates, the hos-
pital is located on three major campuses in Berkeley and Oakland,
and is the major referral center for the East Bay Medical Network.
Areas of excellence include :
• Burn Center
• Rehabilitation Services
• Occupational Health
• 24-hour Emergency Center
• Mental Health Services
• Bone Marrow and Kidney Transplant Programs
• Heart & Vascular Services
• Comprehensive Cancer Center
• Family Birth Center
• Perinatal Center
• Women and Infants Services
The 555-bed Medical Center has 2,700 employees and 900
physicians on staff. Its medical staff is distinguished by the fact that
more than 90% of its active physicians are board certified.
The Medical Center supports many community programs including
the East Bay AIDS Center, Adult Sickle Cell Anemia Program,
Mentoring Program for Teens, Primary Care Access Clinic, Breast
Health Access for Women with Disabilities, Audio Health Library,
and other free public health education classes.
Alta Bates Medical Center is part of the Alta Bates Health System,
a non-profit organization dedicated to serving the East Bay.
Its mission is to provide high-quality, accessible, affordable health
care in a comfortable setting for families. It is affiliated with Sutter
Health, which is comprised of 5,000 physicians and 25 hospitals in
Northern California.
Coordinated Pharmaceutical Therapy in Chronic Care 21
Appendix: Advances in Burn Care expand airways and dry respiratory tissues. Steroid inhalants such
as sodium medrol are used extensively to offset bronchospasm
Burn care medicine has advanced significantly from the field hos-
and airway compromise.
pitals and “Medevac” teams who cared for burn victims in the
Korean War. MASH team surgeons would debride burn sites, The progression beyond disc sensitivity methods for establishing
amputate when necessary, and skin graft when appropriate. At that effective Mean Inhibitory Concentrations (MICs) of antibiotics has
time a limited array of antibiotics was available to fight complicat- been startling. Today, modern laboratories can use an automated
ed wound infections. system which examines tube-dilutions of wound bacteria grown on
enriched media. Effective pharmaceutical dosage levels and
Gram-negative infection or wound sepsis were dreaded events.
identification of microorganisms is greatly accelerated. Hence,
Patients were bathed frequently with full body immersion as a pre-
effective wound debridement and irrigation has progressed in lock
lude to extensive debridement and topical care. Orthotists and
step with more effective pharmaceuticals.
prosthetists crafted bulky splints and braces in attempts to avoid
joint contractures and to restore joint mobility. Advances in orthopedics have been significant for total joint
replacement and reconstruction. Monoarthrodial and biarthrodial
Morphine, Demerol, and Percodan were the mainstays of pain
joint surfaces can frequently be salvaged through plastic and
control. Introduction of the sulfonamides in wound care antisepsis
metallic implants, which restore joint mobility and function.
marked a major stride in the treatment of partial and full thick-
Occupational therapists (OTs) have in many instances supplement-
ness burns. Topical Sulfamylon cream proved quite effective in
ed physiotherapists within burn centers. The OT tries to preserve,
wound surface antisepsis by combating various gram-positive and
maintain, or restore lost functional capacity and also serves as a
gram-negative surface wound contaminants including
monitor for standards of patient autonomy and self-determination.
Pseudomonas aeruginosa and some fungi.
Physiotherapists provided most of the post-burn rehabilitation,
using overhead slings and pulleys to mobilize the burn victim as
soon as possible. Strengthening and flexibility exercises were used
to preserve functional capacity and mobility.
Over the last 25 to 30 years, significant advances in burn care
have taken place. The sulfonamide derivative, silver sulfadiazine,
has largely supplanted Sulfamylon among sulfonamide-based
creams in topical wound care. This cream is well absorbed into
the tissues and facilitates wound decontamination so that effective
skin grafting and wound granulation can take place. It is partially
effective against superinfection and wound contaminants, includ-
ing many yeasts and fungi.
In addition, a powerful array of antibiotics, such as the aminogly-
cosides gentamycin, and tobramycin along with the penicillin
derivative Geopen (disodium carbenicillin), have been formulated
to combat the gram-negative wound contaminants such as
Pseudomonas and Bacteriodes. Extended spectrum antibiotics,
along with heparin locks and central venous therapy, have further
increased antibiotic effectiveness.
New medications in respiratory medicine have contributed signifi-
cantly to progress in dealing with burn after-effects or sequelae
such as smoke inhalation, pulmonary edema, atelectasis, pul-
monary obstruction, bronchospasm, and pneumonia.
Bronchodilating medications such as albuterol and Atravent

22 Coordinated Pharmaceutical Therapy in Chronic Care

Coordinated Pharmaceutical Therapy in Chronic Care 23
Case 3

Coordination of Pharmaceutical
Care in High-risk Patients with
Coagulation Disorders

The Johns Hopkins Bayview Medical Center

Baltimore, MD
w w w. j h b m s . j h u . e d u

Prepared by: June M. Buckle1, ScD; Mary G. Myers2, RN, MS;

Burt Finkelstein3, PharmD; Charles Twilley4, PD, MBA

1 Associate, Health Policy & Management, The Johns Hopkins University Department of
Health Policy and Management, School of Hygiene and Public Health. At the time this program
was developed, Dr. Buckle was Senior Director, Care Management and Outcomes Evaluation,
The Johns Hopkins Medical Center.
2 Director of Case Management.
3 Director of Pharmacy Services.
4 Clinical Coordinator of Anticoagulation Service
CONTENTS

Overview............................................................................. 26

Forging a New Approach to Care........................................ 26

The Care Management Program:

Framework and Governance .............................................. 26
The Care Management Executive Oversight Group........ 27
The Executive Quality Management Council.................. 27

Advances in Anticoagulation Therapy

Underlie the Need for Coordinated Care....................... 27

The Anticoagulation Service (ACS): An Example of

Successful Pharmaceutical Coordination ...................... 28
Goals........................................................................ 28
Coordinated Pharmaceutical Care............................ 28
Guidelines................................................................ 28
Comorbidities .......................................................... 29
New Patients............................................................. 29
The Case Manager.................................................... 29
Coordination of Anticoagulant Care Across Settings . 29
Evaluation of the Program........................................ 30
Impact of the Program............................................. 30

The Johns Hopkins Bayview Medical Center....................... 31

Coordinated Pharmaceutical Therapy in Chronic Care 25

Overview
The Johns Hopkins Bayview Medical Center in Baltimore,
Maryland has established an interdisciplinary care management
program that serves patients across the Center’s care delivery
settings. The goal is to provide a coordinated array of services and
continuity of care as patients move among services and providers.
To accomplish this, interdisciplinary teams were organized as part
of a general re-engineering of care processes and staff functions.
This enabled improved management of care by linking the core
functions of the various service entities.
As one of its initiatives, Hopkins Bayview initiated an anticoagula-
tion service (ACS) for high-risk in-patients and outpatients who
require close monitoring of medications and lifestyles. The ACS
provides continuity of pharmaceutical care, prevents sequellae,
and manages overall costs for high-risk patients with various
diagnoses, including atrial fibrillation, cardiomyopathy, congestive
heart failure, and other conditions requiring anticoagulation
therapy and services.
After one year of operation the patients in the ACS were better able
to attain and maintain therapeutic prothrombin levels. They
required fewer trips to the service and were regulated with less
frequent testing of prothrombin levels. A reduction of 20% in total
costs resulted from a decreased need for monitoring and blood
tests.
Several principles of coordinated pharmaceutical care are evident
in the operation of the anticoagulation service at Hopkins Bayview:
Top management was seriously committed to the coordination
and continuity of pharmaceutical care for all patients, especially
for those moving among services and providers. Management
aggressively abolished old structures to enable the linking of core
functions of the various services. Patients can now obtain therapy
without a trip to a distant, centralized department.
An interdisciplinary team of physicians, pharmacists and other
providers oversees and assumes centralized responsibility and
accountability for pharmaceutical treatment of anticoagulation
patients. The service’s longitudinal database enables continuous
monitoring of drug regimens, medical history, and all currently
prescribed medications. The service also provides education to
patients, providers, and caregivers.
The service coordinates pharmaceutical care for anticoagulation
patients across the continuum of services and treatment sites. For
example, the service works with Hopkins Home Care to enable
switches in anticoagulation therapy to be made at home that would
normally be performed in the hospital. Lastly, the service performs
research to determine the effectiveness of its programs.
26 Coordinated Pharmaceutical Therapy in Chronic Care
Forging a New Approach to Care
The Bayview staff now practices coordinated, patient-centered
care, within a care delivery system that puts patients at the locus of
all activities. A new acute-care hospital, the Bayview Pavilion, was
designed with this model in mind. The hospital offers a compre-
hensive, coordinated array of services on the patient care units
ranging from rehabilitation to X-ray to pharmaceutical services.
This efficient system not only improves staff productivity but also
allows patients to be treated without disruption or a trip to a
distant, centralized department for testing or therapy.
In order to achieve this coordinated status, the Johns Hopkins
Bayview Medical Center needed to “reinvent” itself. In doing so, it
was often necessary for major service departments to abolish old
structures and approaches. This was necessary to make room for
the development of new practice models made possible by linking
the core functions of the various service sectors.
Rethinking and redesigning work processes was necessary to
achieve dramatic improvements in critical measures of perfor-
mance including quality, cost, service, and efficiency. This
required managers to become change agents, and front-line staff
to become empowered to redesign their work environments. It
necessitated staff from various departments to form interdiscipli-
nary teams to resolve common patient-focused problems.
Redesign also included new approaches to coordinating care
management activities. For the pharmacy service this involved the
redesign and coordination of high-quality pharmaceutical care,
while selecting the most cost-effective approaches.
The new care management framework and its governance are
described below. An example is then provided of how an
interdisciplinary team was able to coordinate pharmaceutical care
to establish a successful service for anticoagulation patients,
especially those with complex medical needs.
The Care Management Program:
Framework and Governance
Care management at Bayview, and throughout Hopkins’ multi-
organizational system, is an interdisciplinary program focused on
wellness and health promotion and empowering patients through
self-care and education. The program reflects the belief that
prevention and early intervention produce higher quality care
while minimizing cost. Therefore, the program seeks to support
individuals at the least intense level of service and in the most
appropriate setting. This is accomplished while striving for quality
outcomes and assuring continuity of care across the continuum.
The program is designed to be applied to groups of patients as
well as individuals in a variety of health care delivery settings and
to create smooth transitions from one site of care to another.
Therefore, new roles and new services have been created and
provided, and mechanisms for evaluating quality- and value-based
care have evolved.
The Care Management Executive Oversight Group
The Oversight Group oversees the care management program,
which is an integral component of Bayview’s quality management
structure. Group members include physicians, case managers,
administrators, and representatives of all clinical departments
including laboratory, radiology, and pharmaceutical services. The
Group’s objectives include establishing strategic direction for care
management; integrating all clinical services into care processes;
developing guidelines and extended care pathways; overseeing all
clinical practice improvement initiatives; and evaluating outcomes
of care. The Group oversees the development of regular guideline
reports that coordinate the clinical and financial outcomes of care
for each condition under study.
The Executive Quality Management Council
The Oversight Group reports to the Council, the committee at the
highest level of the organizational structure that evaluates the
quality of clinical care. Council members include Bayview’s chief
executives (e.g., President, Chief Financial Officer, Vice President
for Medical Affairs, physician chiefs, administrators, and clinical
department directors). The Council oversees the coordination of
care across the continuum, secures resources to advance clinical
practice, and assures economies of scale across various commit-
tees in the organization. The Council receives regular reports from
the Oversight Group that reflect continuing progress towards
achieving improved clinical outcomes, patient satisfaction, and
coordination of new roles and services. Reports from the Council
are forwarded to the Board of Trustees.
As a result of the commitment of these top executives to the care
management program, a greater emphasis was placed on
advanced, independent service roles for health care professionals
designed to meet the special needs of high-risk patients. Therefore,
the activities of case managers (advanced practice nurses) and
pharmacists were integrated into the care management program to
manage high-risk populations of patients with specific chronic
conditions over time and care setting. The case managers focus on
specific conditions, such as congestive heart failure, and
pulmonary and neurological problems. They also participate in
guideline development, pharmaceutical care, and social services,
and are integral to the anticoagulation program described below.
Advances in Anticoagulation Therapy Underlie the Need
for Coordinated Care
The development of new medications, and new clinical knowledge
regarding the mainstay agents aspirin and warfarin, has facilitated
therapy for patients at risk for thromboembolism. Although
warfarin has long been used to prevent thromboembolic disease,
studies continue to discover and refine techniques to augment its
safety and effectiveness.
New drugs for acute-care therapy include the low molecular-
weight heparin agents, an advance over unfractionated heparin,
which requires intravenous administration. These agents, devel-
oped in the 1990s, are smaller pieces of the heparin molecule and
can be given by subcutaneous injection. They can usually be
administered once daily, in a weight-based dose, without subse-
quent monitoring or dose adjustment. Other advances include
thrombolytic agents (t-PA, streptokinase, and others) for heart
attacks, stroke, pulmonary embolism, and deep vein thrombosis;
and agents for heparin-induced thrombocytopenia (danaparoid
and recombinant hirudin).
However, therapeutic gains from these advances in acute-care
therapy can be offset by improper transition to oral, long-term
anticoagulant agents, mainly warfarin. Although warfarin is an
effective anticoagulant, it has a complex dose-response relation-
ship. Due to its narrow therapeutic index, significant changes in
clotting time can result from as little as a 15% change in dose.
Even slight underdosing can result in thrombosis, and too much
can lead to serious bleeding. The reported combined rate of
major hemorrhage and thrombosis is between 10% to 20%.
However, warfarin prevents 20 strokes for every bleeding episode
that occurs.
In addition, up to five days are required after any dose change
(or diet change affecting vitamin K levels) to reach the new
antithrombotic state. Elderly or debilitated patients often require
lower daily doses of medication; and drug interactions with
warfarin are not always known or predictable.
For these reasons, blood clotting time for patients on long-term
anticoagulation therapy must be closely monitored, and a variety
of tests have now become available for this purpose. One crucial
advance over the last decade is the standardization of prothrombin
time testing from one laboratory to another. In addition, the ability
to test for prothrombin times at home, using whole blood from
capillaries, now enables patient self-testing and self-management
of anticoagulant dose adjustments.
Despite the potential for improved therapy associated with these
new medications and tests, anticoagulant therapy is often inade-
quate – especially when care is not coordinated and prescribers
Coordinated Pharmaceutical Therapy in Chronic Care 27
and patients are not educated on best use of medications. For
example, an American College of Cardiology study reported a 30%
drop-off in compliance with anticoagulant therapy after one year.
Often, anticoagulation therapy is not prescribed, or is under-
dosed. Although warfarin is an effective anticoagulant in atrial fib-
rillation, one study reported that only 38% of women with this
condition were treated properly with warfarin. Since atrial fibrilla-
tion is a leading cause of stroke, coordination of pharmaceutical
treatment, involving both provider and patient participation, can
have a great influence on treatment outcomes and costs.
The Anticoagulation Service (ACS): An Example of
Successful Pharmaceutical Coordination
The ACS at Bayview was created in response to the need for coor-
dinated anticoagulation therapy. The Service was designed by an
interdisciplinary team led by members of Bayview’s Departments
of Medicine and Pharmacy. Phillip Zieve, MD and Burt Finkelstein,
PharmD, collaborated to gain full support for the team from the
medical staff and also gained the administration’s approval for
funding of a full-time pharmacist position.
Dr. Zieve is Physician Chief and Professor of Medicine at The
Johns Hopkins University, and a practicing clinical hematologist.
Dr. Finkelstein is Director of Pharmacy Services at Bayview. His
responsibilities include helping to define how pharmaceutical ser-
vices are managed across the System and overseeing the pharma-
ceutical requirements for all in-patients and ambulatory patients.
Dr. Finkelstein and the Clinical Coordinator of the ACS, senior
staff pharmacist Charles Twilley, PD, MBA, are empowered to lead
the interdisciplinary team as ACS services become increasingly
integral to the new practice model. The ACS is administered with
the philosophy that anticoagulation therapy is woven into patients’
lives; and with education, knowledge, and understanding about
their conditions, the patients will be able to better manage their
therapy.
Goals
The goal of the ACS is to serve high-risk anticoagulation patients
who require close monitoring of their medicines and lifestyles in
order to enhance quality of life and prevent sequellae. The ACS is
designed to further coordinate pharmaceutical care through care
management processes, including monitoring and consultative
services to physicians and health care providers. The Service
oversees continuity of care for the Medical Center’s outpatients
28 Coordinated Pharmaceutical Therapy in Chronic Care
and in-patients who require oral or parenteral anticoagulation.
Emphasis is on achieving maximum benefit while minimizing cost,
improving quality of life, and increasing patient and provider
satisfaction.
Pharmaceutical care management for this patient
population means:
• Providing monitoring and dose modifications for chronic
anticoagulated patients;
• Assuring optimal anticoagulation while minimizing
untoward effects;
• Assuring attainment of desired therapeutic outcomes,
with minimal adverse effects and sequellae using
evidence-based guidelines;
• Assisting in the transition from chronic oral to short-term
parenteral anticoagulation when medically indicated;
• Providing education to patients, caregivers, and providers;
• Conducting ongoing outcomes-oriented research;
• Providing coordinated pharmaceutical care across the
continuum of services.
Coordinated pharmaceutical care
Planning and designing the ACS program reflected Bayview’s
three-fold mission of patient care, education, and research.
Planning included developing interdisciplinary performance
improvement activities, contributing to the literature through
devising and maintaining a database, and creating coordinated
evidence-based practice guidelines. To further ensure coordina-
tion of pharmaceuticals in the care management processes, an
interdisciplinary team developed standards for documentation,
education, and accountability for pharmacotherapy.
Guidelines
Integrating pharmaceutical care necessitated that the ACS Clinical
Coordinator play a critical role in the development of evidence-
based therapy management guidelines that optimize functional and
medical outcomes and minimize disability progression. The coor-
dinator led the interdisciplinary guideline team, and worked with
the Medical Center’s Director of Guideline Development to ensure
that the guidelines were fully coordinated across care delivery
sites. The current literature was reviewed for standards of care,
and current medication practices were defined.
The ACS longitudinal database contains patient, clinical, satisfac-
tion, and financial information. Data are maintained on primary
and comorbid diagnoses, concomitant drug therapy, and recent
history of anticoagulant dosing for the conditions seen in the clinic
(e.g., atrial fibrillation, cardiomyopathy, congestive heart failure,
and other coagulopathies). From the database, reports about drug
usage practices and costs were presented to the interdisciplinary
team to identify opportunities for performance improvement. The
benefits of specific drugs were discussed (e.g., low molecular-
weight heparin) and drug protocols were reviewed before
determining the final evidence-based guideline.
Comorbidities
Among the elderly population with multiple comorbidities seen at
the clinic, coordinated pharmaceutical care plays an essential role
in identifying and managing issues of polypharmacy. Guidelines
address initiation and maintenance of therapy, assessment of inter-
actions among multiple medications, dosing modifications, acute
transition from oral to parental anticoagulation, chronic monitor-
ing of therapy, and treatment of supratherapeutic INR values. The
ACS collaborates closely with physicians of patients with multiple
comorbidities, who are often the patients at greatest risk.
New patients
The intensity of anticoagulant therapy for all new patients is deter-
mined by their primary care physician (PCP) or referring physi-
cian. If the desired therapeutic range is not specified, it is deter-
mined by the ACS physician consultant or the ACS pharmacist.
Each new patient and his family or caregiver meets initially with
ACS staff. At this time, relevant education materials about therapy
and initial laboratory values and their meanings are discussed. For
non-English speaking patients, the service facilitates access to
educational materials in the patient’s native language. For
providers, the ACS subscribes to the newsletter Anticoagulation
Forum, which can be e-mailed to all on-line providers as an
element of continuing education from the service.
Subsequent patient visits involve obtaining laboratory testing,
adjusting dosages, and providing follow-up care. Changes in thera-
py, in accordance with established guidelines, are conveyed to the
patient by telephone or in person when the patient is scheduled
for the next test. The ACS communicates with the patient frequently
on issues such as information on drug therapy, diet, and dose
changes based on altered health status. In addition, to ensure con-
tinuity of care, vacation planning is offered to patients who require
monitoring and who are leaving the area for an extended period.
A letter is provided so that the testing can be performed at any
facility.
The ACS also begins documentation for the medical records,
which are always available for review by providers. On-line ele-
ments of the electronic record give providers with security access
the ability to gather information across the health system. In addi-
tion to the ACS comprehensive database, documentation about the
clinical needs and responses to therapy is maintained for the
patient’s in-patient or outpatient medical record. Also maintained
are copies of other correspondence to the patient (e.g., reminder
letters, vacation letters) and correspondence to the PCP.
The case manager
When high-risk cardiac patients are admitted to the Medical
Center, they are either screened for automatic referral or are
referred by another professional to the cardiology case manager.
During the intake assessment, the case manager obtains a detailed
medication history and current usage calendar. If the patient has
been on outpatient anticoagulation therapy with complications in
management (i.e., unable to obtain a therapeutic prothrombin
time), the care manager makes an additional assessment to con-
sider current issues and lifestyle risk factors. For example, a
patient may be noncompliant with the standard medication regi-
men because it interferes with his or her work schedule. The case
manager also obtains information from the insurer about coverage
issues.
All of this information is then presented to the ACS pharmacist
who determines if the patient should receive the services of the
ACS. Specifically, he assesses if quality of care could be enhanced
and complications reduced if the patient were constantly moni-
tored, had further education about self-care, and had stable thera-
peutic values maintained. The case manager also presents her
findings to the patient’s PCP, orients him to the ACS service and
facilitates the PCP’s agreement to delegate anticoagulation manage-
ment to the ACS.
Coordination of anticoagulant care across settings
The ACS provides services that integrate pharmaceutical care
across the continuum of services provided by the system. For
example, the ACS works in concert with Hopkins Home Care when
a transition from warfarin to heparin is needed for a patient who
has developed deep vein thrombosis. Such cases usually require
brief hospitalization, but the ACS is able to perform this transition
in the patient’s home. The patient saves a minimum of $2,400 in
out-of-pocket expenses for hospital room and board since the
insurer will likely deny the procedure as an in-patient charge.
Coordinated Pharmaceutical Therapy in Chronic Care 29
Evaluation of the Program Impact of the Program
The ACS was evaluated one year after its inception, a critical step The results of integrating pharmaceutical care into care manage-
in determining early successes and future directions. Data were ment processes at the ACS have been well received by manage-
maintained on the number of patients visiting the ACS and the ment, and the Bayview cardiology service has plans to develop an
number of prothrombin time (pT) laboratory tests ordered. This integrated pharmaceutical service for patients with congestive
allowed comparison of quality and cost factors before and after heart failure. In addition, ideas are currently being formulated for
the patient entered the ACS (the intervention). The table below added services for Bayview’s population of frail, often elderly
presents the changes in monitoring, testing, and percentage of patients with multiple comorbidities. Since aggressive management
patients in the therapeutic range for the 300 patients remaining in of such patients decreases the potential for drug interactions,
the program after one year. close monitoring and patient education could improve quality of
life and decrease costs of care for these patients.
The table shows that the pre-intervention mean number of
prothrombin (pT) tests was 30 per patient per year. At the end of
year one, this figure dropped to 19. From a quality perspective,
patients were able to attain and maintain therapeutic levels,
decrease the number of trips to the anticoagulation service, and
be regulated with less frequent testing through close communica-
tion with the service. The table also shows that the total costs of
pT tests decreased by 36%, and other monitoring costs, including
additional laboratory testing (e.g., urinalysis), decreased by 74%
for an overall decrease in monitoring costs of 61%. In addition,
the average number of patients who were maintained in therapeu-
tic range increased by 14%.
The total cost savings per patient was $332.98, representing an
annualized savings of $115,212 for these 300 patients. Utilization
and costs for office visits, hospital and nursing admissions, emer-
gency services, and pharmaceuticals were not determined.

Program Results
A N N U A L P R E - A N D P O S T- I N T E R V E N T I O N VA L U E S F O R M O N I T O R I N G , T E S T I N G ,
A N D E F F E C T I V E N E S S O F A N T I C O A G U L AT I O N C A R E ( N = 3 0 0 )

Program Details Pre-Intervention Post-Intervention % Change

Avg. number of pT tests/patient 30 19 -36%
Cost of pT tests $431.96 $277.32 -36%
Other monitoring costs $241.56 $63.22 -74%
Total monitoring costs $673.52 $340.54 -61%
Avg. % patients in therapeutic range 43 57 +14%

30 Coordinated Pharmaceutical Therapy in Chronic Care

The Johns Hopkins Bayview Medical Center (JHBMC)
JHBMC has a long history of employing performance improvement
approaches when addressing systems issues, especially for chronic
care patients. The three-fold mission of JHBMC focuses
on excellence in patient care, teaching, and research. A
state-of-the-art, hospital-based outpatient facility was completed in
1999, ensuring that patients have access to and receive
quality care across the health care continuum.
The JHBMC offers a comprehensive array of clinical services for per-
sons with chronic conditions, including hospital, primary care, pre-
vention, and specialty care services to the Southeast Baltimore com-
munity, the greater Baltimore metropolitan
community, as well as an international population. JHBMC is
a full-service, 700-bed community teaching hospital and
long-term care facility housing Maryland’s only regional burn cen-
ter, and an area-wide trauma center; as well as centers
for renal dialysis, a neonatal intensive care, and a sleep
disorders center.
Johns Hopkins Geriatrics Center is one of the national
demonstration sites for the Program of All-Inclusive Care for
the Elderly (PACE). The Center provides residential and outpatient
day and respite care, home and office-based assessments, and
house calls. The National Institute on Drug Abuse and
the gerontology section of the National Institute of Aging are
also located on the campus.
JHBMC staff works closely with Johns Hopkins Bayview Physicians,
PA, a not-for-profit, multi-specialty practice whose physicians are
full-time faculty of Johns Hopkins School of Medicine. JHBMC is also
a major teaching site for the School
of Medicine, and has its own teaching programs in medicine and
geriatrics.

Coordinated Pharmaceutical Therapy in Chronic Care 31

Case 4

Centralized Accountability for

Coordinated Pharmaceutical
Care in a Multi-Specialty Clinic

Palo Alto Medical Foundation Clinic

Palo Alto, CA
w w w. p a m f . o r g
CONTENTS

Overview................................................................................. 34

Coordinating Pharmaceutical Care.......................................... 34

Managed Care Fuels Need to Coordinate Pharmaceutical Care 35

The Path to Pharmaceutical Coordination............................... 35

An Innovative Funding Model Leads to Implementation .......... 36

Quality Improvement and Pharmaceutical Coordination......... 36

Pharmaceutical Coordination through
Disease Management of Depression........................... 36
Pain, Lipid-lowering, and Anticoagulation Clinics............. 37
Frequent Visitor Program.................................................. 38

Benefits of Accountability for Pharmaceutical Coordination.... 38

Lessons Learned and Keys to Success...................................... 39

Focus on Pharmaceutical Coordination
to Achieve Competitive Advantage................................ 39
Link Pharmaceutical Utilization with Outcomes
to Enable Process Improvement................................. 39
Centralize Responsibility for Pharmaceutical Coordination
to Facilitate Process Improvement.............................. 39

The Palo Alto Medical Foundation........................................... 39

Coordinated Pharmaceutical Therapy in Chronic Care 33

Overview
This case study examines the driving forces that led to centralized
responsibility for pharmaceutical coordination at the Palo Alto
Medical Foundation Clinic, and how pharmaceutical coordination
is key to the effectiveness of various quality improvement projects.
Management’s assumption of responsibility for pharmaceutical
coordination has enabled an increased focus on the role of phar-
maceuticals in care improvement initiatives. Adding pharmaceuti-
cal coordination to these ongoing initiatives has resulted in perfor-
mance improvement throughout the Clinic’s patient population.
Many principles of coordinated pharmaceutical care are evident
in this case study:
The Clinic has aligned its financial incentives and clinical goals
through its focus on coordination of drug therapy. The Clinic
believes that although aspects of coordinated pharmaceutical care,
such as education and improved compliance, may result in
increased prescription use and costs, overall costs are likely to
decrease due to reduced use of services.
A key feature of this program is its emphasis on centralized
responsibility for pharmaceutical coordination. Top management
assumed this responsibility and assigned cross-service account-
ability for this function to a clinical pharmacist, who reports to
senior management.
Accurate pharmaceutical and clinical databases provide vital
support to the Clinic’s quality improvement programs. A robust
prescription database enables analysis of physician prescribing,
identification of areas for improvement, and the targeting of
follow-up education efforts. These databases remove the Clinic’s
dependency on its HMO contracting partners for critical
information.
The Frequent Visitor Program identifies high-risk patients who
require additional attention and a high level of provider coordina-
tion. Using the prescription database, a number of critical condi-
tions were identified, including asthma, depression, diabetes, and
other chronic diseases. The database also identifies patients who
would benefit from further pharmaceutical coordination efforts,
including patient education, counseling, and compliance support.
High-risk, chronic care patients are also served by disease-focused
clinics that provide ongoing education, counseling, and condition
monitoring. It is anticipated that these efforts will increase
medication compliance, identify drug interactions, and support
lifestyle habits that complement drug therapies.
34 Coordinated Pharmaceutical Therapy in Chronic Care
The disease-focused clinics are managed through a team
approach involving a combination of providers and educators,
including pharmacists, nurses, and physicians. Linking activities in
these clinics with each patient’s primary care physician ensures
maximum coordination of pharmaceutical therapies.
Physician education is provided by the clinical pharmacist, who
develops and delivers follow-up education to targeted physicians.
The pharmacist also maintains Clinic-wide physician education
programs. This education is essential to the success of the Clinic’s
disease management programs. Patient education is enhanced by
the Clinic’s web site, which provides answers to frequently asked
questions.
Coordinating Pharmaceutical Care
The Palo Alto Medical Foundation is a multi-specialty group
practice that operates three primary clinics in the Silicon Valley.
More than 186 physicians and 848 nurses and support staff
deliver pediatric, family practice, internal medicine, and OB/GYN
services. Over 50% of the Clinic patients are managed care
enrollees. The Foundation’s clinics (collectively referred to as
“the Clinic”) have implemented many initiatives designed to
coordinate and improve patient care. Coordinating pharmaceutical
care is an essential element of these efforts.
Several key factors underlie the Clinic’s success in pharmaceutical
coordination and resultant benefits. Top management has assumed
responsibility for pharmaceutical coordination, and has assigned
centralized, cross-service accountability for this function. This has
provided a framework for successful implementation of many
quality improvement programs. In addition, the linkage of phar-
maceutical utilization data with treatment outcomes data has
facilitated treatment process improvement. This linkage and other
elements of pharmaceutical coordination have provided knowl-
edge of drug utilization patterns and their relationships with treat-
ment outcomes and costs. This information is especially important
in projecting costs for contracts based on global capitation.
The impetus for the program and key stages of its evolution are
examined in this case study which describes the implementation of
Palo Alto’s depression disease management, anticoagulation, and
frequent visitor initiatives. Multi-specialty clinics like the Palo Alto
Medical Foundation are well-suited to leading the pharmaceutical
coordination effort with the assistance of their health plan
contracting partners and other health care industry participants.
The linchpin of the Clinic’s success in coordinating pharmaceuti-
cal care has been the centralized accountability for pharmaceuti-
cal coordination. This accountability rests with the Clinic’s clinical
pharmacist who reports to the Assistant Director of Health Plans, a described below). Implementation of other coordinated care
member of the senior management team. The clinical pharmacist programs, including clinical guidelines, education, and improved
is responsible for supporting all quality improvement initiatives compliance, may increase prescription use, although overall costs
that have pharmaceutical aspects across all three clinics. are likely to decrease due to reduced use of services. Increased
drug costs accompanied by lower overall costs may result from
This case study examines the driving forces that led to centralized
the Clinic’s coordinated programs for depression, pain, lipid, and
responsibility for pharmaceutical coordination, and how pharma-
coagulation disorders (see below). Underuse of medications,
ceutical coordination is key to the effectiveness of various quality
resulting in compromised outcomes, is common for all of these
improvement projects.
conditions.
The assumption of responsibility for pharmaceutical coordination,
By focusing on pharmaceutical coordination, the Clinic believes it
and assigning this responsibility to the clinical pharmacist, has
will increase its knowledge of pharmaceutical utilization issues,
enabled an increased focus on the role of pharmaceuticals in care
create more coordinated health care service models, and increase
improvement initiatives. In addition, the Clinic has assembled the
the overall effectiveness of care. The competitive advantage that is
prescription databases necessary for developing and monitoring
gained from this knowledge will help the Clinic estimate risk for
quality improvement initiatives. These databases remove the
the drug budget component of global risk arrangements in the
Clinic’s dependency on its HMO contracting partners for critical
future.
information. Adding pharmaceutical coordination to its ongoing
care improvement initiatives, and supporting them with a clinical
pharmacist, has resulted in accelerated performance improvement
The Path to Pharmaceutical Coordination
throughout the Clinic’s patient population.
In 1990, Medical Director Sydney Hecker, MD, and Director of
Pharmacy Robert Scheidtman, PharmD, began coordinating phar-
Managed Care Fuels Need to Coordinate maceutical care at the Clinic. They soon realized that the prescrib-
Pharmaceutical Care ing patterns of its physicians were extremely diverse and could not
be easily analyzed due to a lack of valid, useful prescribing data.
As managed care growth skyrocketed in Northern California in the
Although the Clinic received reports of physician prescribing pat-
1990s, the need to manage the quality and cost of medical care
terns from the various HMOs, the reports came intermittently; in
became increasingly important to the Clinic’s managed care
different formats; on small patient populations; and were based on
customers. Most California health plans eventually included a
comparisons to each HMO’s unique formulary. Therefore the
prescription benefit, and these plans sought to control
reports were inadequate for analyzing the true prescribing pat-
prescription spending through a host of benefit design features
terns of the Clinic’s physicians. Using the reports as a basis for
such as generic switching, restrictive formularies, and prior
coordinating pharmaceutical care throughout the Clinic proved
authorization. The health plans also asked the Clinic for assistance
ineffective and became the genesis for the Clinic’s current efforts.
in managing physician prescribing patterns. Thus, the Clinic was
driven by its customers to analyze, monitor, and alter prescribing, Hecker and Scheidtman set out to coordinate pharmaceutical care
believing that this would lower drug costs. using a three-pronged approach:
The Clinic does not directly benefit from any drug cost savings • Develop useful physician prescribing profiles based on a
that have accrued from these efforts; the financial risk for the database of reliable, complete, and timely prescribing data
pharmaceutical benefit is currently borne by the health plan, and for all patients served by the Clinic,
is managed by a PBM or the plan itself. Although global risk
• Create a prescribing guideline designed to meet the objective
contracts are increasingly common, the Clinic receives fixed
of delivering cost-effective, high-quality medical care, and
(capitated) payments only for professional services.
• Increase focus and accountability for coordinating pharma-
However, the Clinic realizes the value of taking responsibility for
ceutical care by creating a clinical pharmacist role as a
managing the total cost and quality of care, including pharmaceu-
resource for professional teams.
ticals. Thus, the Clinic is coordinating and managing pharmaceuti-
cal care despite its inability to benefit from any reductions in drug
costs. Such reductions may result from its programs targeting Hecker previously chaired a pharmacy and therapeutics commit-
inappropriate use of resources (e.g., the Frequent Visitor Program tee for an association of physician groups, and the committee

Coordinated Pharmaceutical Therapy in Chronic Care 35

developed an objective pharmaceutical guideline as a tool. Hecker
initially used this guideline to assist the Clinic in developing and
evaluating disease management programs. The guideline served as
a standard against which all pharmaceutical performance could
be measured, and effectively replaced the various formularies used
by the managed care plans to create physician-prescribing reports.
The Clinic subsequently developed its own guideline, specifically to
encourage and measure the quality of pharmaceutical prescribing
by the Clinic’s physicians.
Simultaneously, Scheidtman began building broad-based support
for creating a clinical position to coordinate pharmaceutical care
throughout the Clinic’s many quality improvement initiatives. This
position was ultimately filled with a clinical pharmacist, using an
innovative funding model that leveraged both public and private
funds.
An Innovative Funding Model Leads to Implementation
Although there was a groundswell of support for the clinical
pharmacist position and the need was clearly recognized,
garnering management approval for creating the position was
challenging since it was difficult to quantify the hard-dollar return
on the investment.
Scheidtman proposed creating the position with primary funding
from nine pharmaceutical company partners. These firms con-
tributed a total of $65,000 toward funding the clinical pharmacist
position. In addition, the Clinic struck a partnership arrangement
with the University of California San Francisco School of Pharmacy.
Under the arrangement, UCSF would place a clinical pharmacist at
the Clinic and assume responsibility for 50% of the salary. This
provided real-life experience in a medical group setting as part of
the UCSF curriculum. The combination of pharmaceutical compa-
ny funding and the partnership with UCSF allowed the Clinic to
create the position on a provisional basis. After the first year, the
return on investment from the position was clear, and manage-
ment approved the position on a permanent basis.
The clinical pharmacist has facilitated the coordination of
pharmaceutical care within this large clinic, especially through
activities associated with its disease management programs.
Such activities include:
• Networking with pharmaceutical company representatives to
identify the most recent clinical studies in the disease area
• Identifying, researching, and analyzing the most relevant
clinical and pharmacoeconomic studies in the disease area
• Analyzing practice patterns and interviewing physicians to
develop a primary care physician needs assessment
36 Coordinated Pharmaceutical Therapy in Chronic Care
• Assisting process improvement teams to develop
cost-effective, high-quality clinical guidelines tailored to the
needs of Clinic physicians
• Delivering follow-up education to targeted physicians
• Developing and delivering Clinic-wide physician education
programs
• Developing and maintaining a prescription database that can
be used to monitor the program’s effectiveness
Quality Improvement and Pharmaceutical Coordination
Pharmaceutical coordination is evident in the operation of three of
the Clinic’s quality improvement initiatives: disease management
programs, lipid-lowering and anti-coagulation clinics, and the
Frequent Visitor Program. These programs rely on the establish-
ment and maintenance of accurate clinical databases, analysis
of clinical patterns, management of care delivery teams, and
education of providers on pharmaceutical care. These functions
are best carried out within a framework of centralized account-
ability for pharmaceutical coordination.
Pharmaceutical coordination through disease
management of depression
The Clinic is implementing a number of disease management
(DM) programs as part of an overall effort to improve patient
care. These programs focus on complex patient populations that
require a high degree of service coordination to maximize the
quality and cost-effectiveness of care. The depression initiative
clearly demonstrates the value of DM programs that coordinate
pharmaceutical care.
The DM program for depression focuses on developing and imple-
menting a depression treatment guideline for patients in primary
care. Bruce Bienenstock, MD, head of the Clinic’s psychiatry
services, initiated the depression DM program by gaining approval
from the Quality Assurance and Clinical Improvement Board.
The proposed program included four primary components:
1) documentation of current treatment patterns and primary care
physician needs; 2) development of a depression treatment guide-
line; 3) education of primary care physicians on the guideline;
and 4) monitoring results.
Documenting current disease treatment patterns and primary care
physician needs enabled the clinical pharmacist, Dr. Lori Reisner,
to perform chart reviews and credibly discuss treatment alterna-
tives and education needs with the primary care physicians.
After numerous meetings with primary care physician groups,
Drs. Bienenstock and Reisner had a clear understanding of methods are applied in all disease areas to effectively coordinate
physician needs related to identifying and treating patients with pharmaceutical care for all Clinic patients. For example, the
depression in their practices. monitoring and measurement tools developed for the depression
program, particularly the prescription database, will be applied
This needs assessment assisted them in gathering information for
universally to all disease management programs.
guideline development. Such information included clinical studies,
reviews, AHRQ and other guidelines, and DM programs. These
were used to build an evidence-based treatment guideline for
Pain, lipid-lowering, and anticoagulation clinics
high-quality care, tailored to the needs of the Clinic’s primary care
physicians. As part of the Clinic’s ongoing effort to coordinate care for
high-risk, chronic conditions, disease-focused clinics are being
Dr. Reisner played an important role in assembling and assessing
developed to provide pain management, lipid-lowering, and
the information upon which the guideline was based.
anticoagulation services. The goal of these new clinics is to
Dr. Bienenstock said, “Dr. Reisner brought unique skills to the
provide education, counseling, and condition monitoring to
team and an ability to effectively interface with pharmaceutical
patients on an ongoing basis, relying heavily on proper pharma-
company representatives to gather clinical evidence.” In addition,
ceutical care. Therefore, coordinating pharmaceutical care within
her perspective added value to the analysis of various studies and
these clinics is anticipated to increase compliance with drug
algorithm options. The final algorithm summarized the preferred
regimens, to identify drug interactions, and to influence lifestyle
treatment regimen on one page, accompanied by a compendium
habits that complement drug therapies, thereby improving overall
of supporting facts and studies.
quality of care and reducing total system costs.
Although algorithm development is critical, the most important
Each clinic will be established by the clinical pharmacist and
step in the program was educating primary care physicians on the
managed by a combination of providers and educators, including
benefits of SSRI antidepressant medications and other recom-
pharmacists, nurses, and physicians. Linking activities in each of
mended treatment options. The clinical pharmacist delivered most
these clinics with each patient’s primary care physician will ensure
of the training on depression, as well as specific information
maximum coordination of the total care plan, including pharma-
delineating drug products, to the primary care physicians. The
ceutical coordination.
clinical pharmacist’s role as an educator is essential to successful
implementation of DM programs within the medical group setting.
Finally, no clinical performance improvement process is complete
without a thorough measurement and monitoring system in place.
Dr. Reisner oversees this system using a robust prescription data-
base developed by combining the numerous data feeds received
from its managed care partners.
After initiating a process to collect the data on a regular basis, Dr.
Reisner and a programmer designed an analysis tool to enable her
to monitor the DM program, using the prescription database to
analyze physician prescribing, identify areas for improvement, and
target follow-up education efforts. Using the physician prescribing
profiles from the database, together with the Clinic’s own pharma-
ceutical guideline and its depression guideline, she conducted
one-on-one education and training sessions with the primary care
physicians. In Phase II of the measurement program, the Clinic
will link guideline usage to clinical outcomes using its newly
implemented electronic medical record system.
In addition to depression, the Clinic is currently implementing DM
programs for several other chronic conditions, including diabetes,
asthma, and congestive heart failure. The clinical pharmacist plays
a key role in each of these efforts and ensures that consistent

Coordinated Pharmaceutical Therapy in Chronic Care 37

Frequent Visitor Program The clinical pharmacist enabled the care process improvement
teams to increase their performance by:
In 1997, Kathy Korbholz, Senior Administrator, ordered a report
listing a specific patient’s visits over a twelve-month period. She • Having better access to pharmaceutical prescribing data,
was alarmed to discover that the patient had made over 190
• Bringing an in-depth knowledge of pharmaceutical therapies
appointments during the period. The patient had cancelled and and their pitfalls to the team,
rescheduled over 50 visits and had seen 24 different physicians in
16 different departments. A chart review uncovered no chronic • Analyzing possible pharmaceutical-related causes for
medical problems, identified numerous tests, and provided no real frequent visits, and
answers. Believing she had stumbled across the rare patient, Ms. • Assisting the team to develop and deliver effective education
Korbholz nevertheless ordered a report for all patients having on pharmaceutical issues.
more than 20 visits during each of the past two years. The result-
ing report identified over 4,000 patients with more than 20 visits;
the original patient was relegated to page 12. Clearly, many Benefits of Accountability for
patients were not having their medical needs met despite extensive Pharmaceutical Coordination
use of Clinic services. Together with a care management team of
Focusing on pharmaceutical coordination and creating a clinical
physicians, administrators, nurses, and the clinical pharmacist,
pharmacist role charged with overseeing pharmaceutical coordi-
she set out to improve the coordination of care for these patients
nation has brought many benefits to the Clinic, including:
by initiating the Frequent Visitor Program.
• Developing a comprehensive prescription drug database
In 1997, over 4,200 patients, or 3.59% of all Clinic patients, were
that can be used to enable a variety of clinical improvement
identified as frequent visitors. They consumed approximately 20%
programs,
of the Clinic’s services. An analysis derived from the newly devel-
oped prescription database identified a number of critical areas • Facilitating and supporting the design, implementation, and
for attention, including patients with chronic diseases such as monitoring of disease management programs in diabetes,
asthma, depression, and diabetes. The analysis also identified asthma, and depression,
those patients who could benefit from further pharmaceutical
• Providing valuable pharmaceutical knowledge to all clinical
coordination efforts, including patient education, counseling, and
process improvement teams,
compliance support.
• Developing expanded roles for pharmacists by planning and
The Clinic instituted a number of programs in 1998 to better man-
founding pain, lipid-lowering, and anticoagulation clinics,
age frequent visitors, including:
and most importantly,
• Flagging patient charts to identify those requiring additional
• Achieving more effective pharmaceutical utilization
attention, continuity of provider, and a high level of provider
throughout the system.
coordination,
• Creating a frequent visitor check list to be completed
at each visit, The clinical pharmacist function and related pharmaceutical
coordination efforts are still in their infancy at the Clinic. These
• Building social support groups through “group visits” for
efforts form the platform for the many clinical improvement
patients with similar ailments, and
programs that are now operational. These programs are
• Posting answers to frequently asked questions on the Clinic’s successful in terms of process. Significant improvements in
web site to provide medical information without the need for clinical outcomes and patient satisfaction are expected and will
an office visit. be assessed.

38 Coordinated Pharmaceutical Therapy in Chronic Care

Lessons Learned and Keys to Success
During the course of the past three years, as the Clinic implement-
ed its pharmaceutical coordination program, three essential
lessons were learned:
Focus on pharmaceutical coordination to achieve
competitive advantage
A provider organization should focus on pharmaceutical coordina-
tion, even if it is currently not at risk for the drug budget. In doing
so, the organization will increase its knowledge of pharmaceutical
utilization issues, create more coordinated health care service
models, and increase the overall effectiveness of care. Such
organizations will be better prepared to understand and accept
financial risk for pharmaceutical care from HMO contracting
partners who are increasingly preferring global risk contracts.
Link pharmaceutical utilization with outcomes to enable
process improvement
Information is the key enabler in implementing almost any clinical
process improvement program. Analyzing and implementing phar-
maceutical treatment often requires a comprehensive prescription
database linked to outcomes and other patient information.
Although most clinics do not have timely access to such informa-
tion, as electronic medical records become more common in the
clinic setting, pharmacists and process improvement teams will be
better able to assess and implement improvement initiatives, edu-
cation efforts, guidelines development, and performance monitors.
The Clinic invested substantial time and resources to develop the
prescription database they needed to move these processes
forward. The Clinic will continue to improve utilization of informa-
tion by linking pharmaceutical use and protocol compliance to
outcomes and other service use. By the continued use of an elec-
tronic medical record, the Clinic will acquire additional knowl-
edge to further improve the coordination of pharmaceutical care.
Centralize responsibility for pharmaceutical
coordination to facilitate process improvement
Clearly identifying a person or department accountable for coordi-
nating pharmaceutical care can facilitate many clinical process
improvement programs. Once the Clinic created the clinical phar-
macist role and held the pharmacist accountable for pharmaceuti-
cal coordination efforts, other members of the organization sought
out her support and knowledge to help them with pharmaceutical
aspects of their process improvement initiatives. This accountabili-
ty not only aided in the coordination of pharmaceutical care, but
also enabled overall service coordination at the Clinic. The key is
not necessarily who is responsible for pharmaceutical coordina-
tion, but rather that responsibility is centralized and therefore
recognized throughout the health care system.
In summary, clear accountability, accurate and comprehensive
prescription data, and recognition of the importance of
outpatient pharmaceutical care can be achieved by creating a role
specifically responsible for coordinating pharmaceutical care.
At the Palo Alto Medical Foundation, this position was filled by a
clinical pharmacist and resulted in effective implementation of
a variety of innovative programs throughout the organization.
The Palo Alto Medical Foundation
The Palo Alto Medical Foundation for Health Care, Research &
Education is a not-for-profit, tax-exempt public charity nationally rec-
ognized for leadership in health care delivery. The Foundation pio-
neered the multi-specialty group practice of medicine and
outpatient services as ways to improve the quality and cost-effective-
ness of health care. The Foundation was one of the first
organizations in the country to embrace the concept of a coordinated
health care delivery system in a managed care setting as a superior
approach to improving health services.
In 1987, using community philanthropy, long-term financing, and a
multi-million dollar gift from its physicians, the Foundation acquired
the assets of the Palo Alto Clinic Partnership (founded in 1930).
Together with the former Palo Alto Medical Research Foundation
(founded in 1950) and a new education division, they created a
truly coordinated health care delivery system.
The Foundation operates three primary clinics in the Silicon Valley
with over 186 physicians and 848 nurses and support staff. In addi-
tion to the 69 researchers and staff at the Research Institute and the 17
educators in the education division, the Foundation employs over
1,100 health care professionals.
In 1993, the Foundation became an affiliate of the Sutter Health
System based in Sacramento, California. This allied the Foundation
with a very strong health system. Like the Palo Alto Medical
Foundation, Sutter is a not-for-profit organization comprised of more
than 30 health-related entities, including hospitals, other medical
foundations, an insurance company, and support organizations.
Through Sutter, the Foundation recently joined
with the California Health Care System to form a statewide health care
network, Sutter Health.
Coordinated Pharmaceutical Therapy in Chronic Care 39
Case 5

Education Improves Medication

Management, Regimen
Knowledge, and Outcomes in
HIV/AIDS Patients

San Francisco Department of Public Health

San Francisco, CA
w w w. d p h . s f . c a . u s
CONTENTS

Overview of the HIV/AIDS

Treatment Education Certification Program (TECP)........... 42

Complex Treatment Regimens for HIV/AIDS Patients............... 42

The Path to TECP Implementation........................................... 42

Elements of the Program......................................................... 43

Results and Benefits................................................................ 44

Knowledge Base of Counselors Improved ............................ 44
Improved Drug Therapy, Treatment Outcomes,
Quality of Life................................................................. 44

Expanding and Improving the Program................................... 45

Lessons Learned and Keys to Success...................................... 45

Additional Information on the Origins of TECP....................... 45

Coordinated Pharmaceutical Therapy in Chronic Care 41

Overview
The Treatment Education Certification Program (TECP),
sponsored by the San Francisco Department of Public Health,
enhances basic knowledge regarding HIV/AIDS care and
treatment. TECP is offered to non-medical service providers,
including treatment advocates, case managers, peer advocates,
mental health and substance abuse counselors, and others who
work directly with low-income HIV-positive clients. If necessary,
the trainees interact directly with the medical professionals
who provide care for these clients.
This training program enables these non-medical providers to
better assist their clients in meeting the challenges posed by their
complex therapeutic regimens. The program also helps these
providers in identifying inappropriate or conflicting drug
therapies.
The core of the program is a three-day course on HIV/AIDS, its
many comorbidities, and the complex treatment regimens faced by
these patients. Once certified, trainees provide patients with the
support and education necessary to ensure compliance with their
treatment regimens and to maximize the value of their pharma-
cotherapy. The trainees are not intended to replace the physician.
Rather, they provide a baseline of information, together with
emotional and practical support, for a complex patient population
with multiple social and physical challenges. Case reports indicate
that the program has been successful in improving pharmaceutical
therapy in HIV/AIDS patients. This innovative program demon-
strates how public health officials and not-for-profit programs can
be essential forces in the coordination of pharmaceutical care.
Several principles of coordinated pharmaceutical care are
exemplified in this program that serves clients who have multiple
coexisting diseases and who often receive prescriptions from
several physicians. Effective communication and feedback among
caregivers was an essential element of the program, and patients
were educated and involved in the treatment plan. Strong leader-
ship by individuals within participating organizations promoted
success and rapid acceptance of the program. In addition, the
peer-to-peer training fostered a sense of teamwork that built a
strong support network for the future.
42 Coordinated Pharmaceutical Therapy in Chronic Care
Complex Treatment Regimens for HIV/AIDS Patients
Dramatic progress in our ability to suppress HIV replication
through powerful new medications has resulted in widespread
optimism that HIV can become a long-term manageable disease.
However, with a multitude of antiretroviral drugs now available
and in development, HIV treatment regimens have become
increasingly complex.
In addition to receiving treatments designed to suppress HIV
replication, most patients are also treated for common clinical
manifestations of HIV disease, such as AIDS wasting, HIV-associat-
ed psychiatric disorders, pneumococcal infections, pneumocystis
carinii pneumonia, cytomegalovirus, and other bacterial infec-
tions. Many patients also require therapy for other comorbidities,
such as cardiac conditions, diabetes, and asthma. The combina-
tion of these regimens confronts the AIDS patient with one of the
most complex treatment regimens in medicine.
TECP was created in response to this challenge. Program partici-
pants help guide patients through prescribed drug regimens. TECP
also provides participants with the knowledge necessary to help
patients effectively use available pharmaceutical treatments, and
addresses the need to integrate education, treatment advocacy, and
support in the HIV/AIDS community. TECP ensures that patients
have qualified professionals to answer their questions regarding
treatment options, results, side effects, and appropriate usage.
The Path to TECP Implementation
TECP was made possible by federal funding provided to state and
local public health agencies under the Ryan White Comprehensive
AIDS Resources Emergency (CARE) Act. The funds provided to
San Francisco’s Department of Public Health were used to create
and support public health and wellness programs throughout the
city. The programs are administered through a complex array of
agencies. TECP is managed by two of these agencies, the Asian and
Pacific Islander Wellness Center (API) and Project Inform.
TECP was designed with three primary goals: 1) to initiate market-
ing, public relations, and advocacy effort within CARE program
managers and the general public; 2) to develop program
management tools; and, 3) to develop training curriculum and
resource materials.
API hired the program coordinator and master trainer and began
developing the marketing, outreach, and administrative materials.
Project Inform took primary responsibility for developing the cur-
riculum and training materials.
A three-fold approach was used to market the program to the
local Ryan White CARE-funded programs. First, a program Elements of the Program
brochure was posted at all Ryan White CARE-funded sites in San
The training curriculum and accompanying HIV Treatment
Francisco in order to attract interest from individual non-medical
Education Briefing Book include sections on: HIV treatment
providers. Second, TECP Coordinator Mathew Sharp visited
training philosophy; HIV pathogenesis; standards of care;
program managers of Ryan White CARE agencies to personally
anti-HIV treatments and therapies; opportunistic infections;
introduce them to TECP. This one-on-one outreach resulted in
research, clinical trials and access issues; compliance issues and
significant interest. Third, the program was marketed through the
strategies; strategies for working with multiply diagnosed clients
media. For example, on December 1, 1998 the San Francisco
and underserved populations; and sources for updated treatment
Chronicle ran a story on TECP, which extended interest in the
information.
program beyond the local agencies. These efforts resulted in a
strong demand for the training courses; training sessions were The three-day training course forms the centerpiece for TECP.
often over-enrolled. In addition, agencies outside the San Each three-hour course was attended by eighteen participants and
Francisco Department of Public Health’s purview became aware was led by Project Inform. The training course is augmented by
of TECP and enrolled their providers through a tuition-based pro- an annual treatment education update, provider work group
gram that was added to respond to the strong market demand. sessions and one-on-one consultations for participants who need
additional individualized training.
API also took the lead in developing tools necessary to effectively
manage the overall program, including tools for intake, screening, Five provider work group sessions, lasting three hours each, were
scheduling and follow-up with training course participants. API held during the year. Each session focused on a topic of interest
designed participant tracking systems, eligibility certification pro- that could not be covered in sufficient detail during the three-day
cedures, and all data entry forms used to monitor the progress of training. Each session also featured a guest lecturer from the
the program and individual program participants. San Francisco HIV/AIDS research and treatment community.
These work group sessions, together with the treatment education
updates and the core training sessions, form a powerful year-
Project Inform led all curriculum design efforts and, round training program.
together with API, managed the overall design of the
Individual tutoring was provided for participants having difficulty
three-day curriculum, including pre- and post-training
with the pace or volume of content covered in the training. These
certification examinations, instructional materials, and an
consultations focused on areas such as treatment options, HIV
HIV Treatment Education Briefing Book for distribution to
pathogenesis, and other complex topics. These tutoring sessions
all participants.
proved particularly valuable for participants who were having
difficulty passing the certification exam.
During the program design phase, Project Inform and API
conducted a focus group with a number of non-medical providers
to establish a baseline for program planning, evaluation, and
standards for certification, and to collect input for curriculum
design. In addition, a panel of advisors and experts was asked to
help guide overall program development, particularly the
curriculum.

Coordinated Pharmaceutical Therapy in Chronic Care 43

Results and Benefits
The program had positive effects on both the counselors and their
client patients.
Knowledge base of counselors improved
Analysis of the results from the first year of TECP demonstrates
that the program clearly improves the level of HIV/AIDS
knowledge in service providers. During TECP’s first year, nine
training sessions were held with a total of 152 participants.
The participants represented 41 agencies and clinics in the San
Francisco area, and they performed a wide variety of non-medical
jobs within the agencies as indicated in the figure below.
Profile of Participants
A total of 122 participants, or 80%, passed the certification exami-
nation. In addition to taking the final exam, participants complet-
ed a pre-test prior to the training session which was used to
measure changes in knowledge level. There was nearly a 90%
improvement in base-level knowledge about the disease and its
treatment alternatives. Ninety-two percent of participants rated
the course as very useful or better.
Improved drug therapy, treatment outcomes, quality of life
The most important measure of the program’s impact would be
the improved health and well being of the clients in contact with
TECP participants. This information proved difficult to obtain, due
to patient privacy concerns and technical issues associated with
measuring impact. However, the three case examples below
document improvements in the quality of life and treatment
outcomes and costs:
• Mr. A, a mid-twenties male patient of Pacific Islander descent is
diagnosed with AIDS and is prescribed a complex therapeutic reg-
imen including protease inhibitors in a cocktail. Mr. A does not
44 Coordinated Pharmaceutical Therapy in Chronic Care
speak English well, resulting in numerous unanswered (and un-
asked) questions regarding the regimens. Consequently, he was
incorrectly administering the cocktails and his retroviral load was
not improving. While waiting in the lobby of the Asian and Pacific
Islander Wellness Center, Mr. A began conversing with the front
reception area staff in his native language. He asked many of his
questions regarding the drug regimens and other related issues.
The reception staff, having been certified in TECP, were able to
properly identify potentially serious non-compliance issues and
direct Mr. A to a Center counselor who could more fully address
his concerns. This effort resulted in increased compliance with the
prescribed medications and details of the regimen leading to
reduced retroviral loads and improved overall health and well
being.
• Mr. B, a 37-year-old man diagnosed with AIDS, is currently
undergoing a complex treatment regimen of antiretroviral drugs,
including agents for the treatment of various AIDS-related events
such as Kaposi’s sarcoma and treatments for other non-AIDS relat-
ed events, such as asthma. During counseling sessions with a
TECP-certified social services counselor, Mr. B indicated concern
over his continued weight loss and the impact it was having on his
appearance. As a result of the TECP training, the counselor imme-
diately recognized that Mr. B might have been in the early stages of
AIDS-wasting syndrome. He recommended that Mr. B see his
doctor immediately to discuss augmenting his treatment regimen
to include a therapy specifically designed to delay or prevent the
onset and debilitating effects of wasting. Mr. B’s primary care
physician confirmed the lay recommendation and began an
aggressive prevention/treatment regimen that resulted in signifi-
cant improvement in Mr. B’s lean body mass and also increased
his ability to avoid serious AIDS-related events.
• Ms. C, a 32-year-old woman who recently relocated to the San
Francisco area and is currently being treated for AIDS, was meet-
ing with a TECP-certified counselor. The counselor noted the diffi-
culty Ms. C was having maintaining compliance with the multiple
pharmaceutical therapies she was currently taking. After a com-
plete “brown bag review,” the counselor determined that Ms. C
had been prescribed two overlapping antiretroviral therapy
cocktails and could be at risk for unexpected drug-drug interac-
tions. Upon the recommendation of the counselor, Ms. C’s medica-
tion profile was immediately reviewed by a clinical pharmacist at a
nearby institution, and it was deemed necessary that her physician
reassess and adjust the overall therapeutic regimen. As a result,
one of the overlapping regimens was discontinued, providing both
the health system and the patient substantial cost savings while
reducing the risk of dangerous side effects.
Expanding and Improving the Program
TECP will build upon its core strengths and expand to include
additional trainees. TECP’s success has spread to agencies and
organizations throughout the greater Bay Area and beyond;
therefore, TECP has created a tuition-based enrollment option for
providers from outside San Francisco.
TECP is also working with the federal government’s Health
Research and Services Administration (HRSA) to fund a national
rollout of TECP to cities and agencies throughout the country.
According to Mathew Sharp, TECP Project Coordinator,
“The foundation is in place to build a powerful nationwide
training program to teach non-medical providers to assist
HIV/AIDS patients with their treatment regimens.”
Lessons Learned and Keys to Success
Development and implementation of TECP has yielded insight
into many keys to success in building and integrating a training
program for counselors of patients with a complex chronic
medical condition.
First, chronic care patients with complex diseases, such as
HIV/AIDS, need knowledgeable service providers at every point of
contact within their sphere of influence. Often this advice is sought
in less formal venues than the physician’s office, including friends,
fellow patients, case managers, treatment advocates and others
working in the system. Providing potential contacts with the in-
depth knowledge and resources to answer these questions and
serve as a safety-net resource for HIV/AIDS patients improves
patient compliance with treatment regimens and quality of life.
TECP trainees can now answer routine questions with confidence
and recognize issues that are best handled directly by the patient’s
physician. TECP has given non-medical providers important base-
line information to help patients cope with the complex treatment
regimens resulting from their disease.
Second, successfully launching a training program like TECP
requires a focus on specific diseases and the challenges faced by
chronic care patients. TECP benefited greatly from San Francisco’s
strong HIV/AIDS community and a well-established network of
Ryan White CARE-funded organizations. Starting a similar program
in other communities where the agency network is not as strong
would present additional marketing and organizational challenges.
Similarly, other chronic conditions with less developed support
networks and patient communities would require additional
marketing and grass roots activism.
Third, strong leadership from within the organizations receiving
the training can promote success among participating organiza-
tions. The leadership provided by API and Project Inform was
from within the Ryan White CARE-funded agency community and
resulted in rapid acceptance of TECP. In addition, the peer-to-peer
training concept fostered a sense of teamwork that builds a strong
support network for the future. Combining this informal sense of
community with the formalized, ongoing training of the provider
work groups and treatment education updates builds a support
network of HIV/AIDS non-medical providers who can embrace
and lead continuous improvement throughout the non-profit
agency system.
Additional Information on the Origins of TECP
In San Francisco, the Ryan White CARE Act funds programs that
are administered by the AIDS Office of the San Francisco
Department of Public Health (SFDPH). The SFDPH has tasked the
San Francisco Ryan White HIV Health Services Planning Council to
assess community needs and prioritize services to be supported
with federal HIV/AIDS dollars. The 1998 efforts of the Planning
Council recognized the need to assist its more than 15,000
HIV/AIDS clients in gaining access to, interpreting, and evaluating
their treatment options so they can make informed choices.
In addition, the Planning Council wanted to hold its nearly 300
non-medical AIDS workers accountable for establishing and
maintaining a high standard of competence in a rapidly evolving
field. The Planning Council recommended funding a program
like TECP, and called for proposals from the area’s Ryan White
funded agencies.
The Asian and Pacific Islander Wellness Center, the largest
non-profit HIV/AIDS agency dedicated to Asians and Pacific
Islanders in the United States, together with Project Inform, the
nation’s leading HIV/AIDS treatment information and advocacy
source, developed a grant proposal for submission to the
Department of Public Health. The collaboration of these two
leading HIV/AIDS organizations fit the Planning Council vision
perfectly, and the Treatment Education Certification Program was
funded and launched in September of 1998. The collaboration
brought together Project Inform’s unique skills of treatment
advocacy and training program design with the day-to-day opera-
tional understanding of a large non-profit HIV/AIDS wellness
center. The combined expertise of these two organizations was
well suited to implementing this complex program across all 68
Ryan White agencies in the San Francisco Metropolitan Area.
Coordinated Pharmaceutical Therapy in Chronic Care 45
What the Case Studies Have Taught Us
The five programs profiled in this report provide insights on
successful strategies and approaches for achieving coordinated
pharmaceutical treatment.
Leadership and Management
A commitment by top management characterized many of these
successful programs. Management often acted on this commitment
by assigning accountability for the coordination function to an
individual or a team.
A “champion” with a vision of coordinated care, often the medical
director or staff pharmacist, is needed to spearhead the initiative
and, most importantly, to engage the interest and cooperation of
clinicians.
A pharmacist was often the key driver for the development and
implementation of the coordinated care process. The pharmacist
often worked in partnership with the “champion” (if he or she
was not the champion). Nurses often proved to be effective coor-
dinators of the day-to-day operation of the program. These new
roles for health care professionals provided added value for the
organization.
Partnerships
Successful partnerships between provider organizations and phar-
macy schools have resulted in win-win situations for both parties.
Pharmacy students or interns who assumed integral roles in pro-
gram implementation received valuable experience; the provider
organization received low-cost professional assistance in operating
the program.
Information Systems
Acquisitions of nursing homes, hospitals, and other sites of care
delivery by health systems have generally resulted in fragmented
information systems in which prescribing data are not linked to
treatment outcomes data. Although integration of medical charts
across sites and a fully computerized medical record are rare, this
has not prevented many of the case study sites from linking
enough information to implement an effective level of coordinated
pharmaceutical care.
Coordination Across Sites of Care
Specialty clinics within hospitals – e.g., for burn care or anticoag-
ulation – can be a central focus for coordination of pharmaceuti-
46 Coordinated Pharmaceutical Therapy in Chronic Care
cal care across care sites of the parent health system. These hospi-
tal-based clinics have extended coordinated services into the
ambulatory care setting and home care.
Education
The pace of progress in pharmaceutical technology has height-
ened the need for both provider and patient education. Educating
and providing feedback to physicians and patients is essential for
optimal use of advanced pharmaceutical technologies, such as
those for patients with HIV/AIDS.
Evaluation
Improvements in treatment outcomes and costs were noted in
those coordinated pharmaceutical programs that engaged in some
measurement of program effects. However, since such programs
often evolve as resources permit, rigorous and comprehensive
cost/benefit evaluations are rarely performed. In addition, recent
cutbacks in operating budgets make such evaluations less likely.
However, pharmacy professors or graduate students in search of
interesting, relevant research projects could perform such analy-
ses. Demonstration of a net economic gain to the organization will
help maintain support for the program and justify funding for
expansion.
Some of the evaluations that were done indicated that drug expen-
ditures may rise as a result of coordinated pharmaceutical care,
especially in those programs focused on reducing undertreatment
or improving medication compliance. However, in some of these
programs, increased drug costs were accompanied by lower over-
all costs as well as improved quality of care. This is illustrated in
the coordinated programs for depression, pain, lipid, and coagu-
lation disorders.
Competitive Advantage
Coordinated pharmaceutical care programs can be useful even to
those provider organizations not currently at risk for drug expen-
ditures. In addition to increasing the overall effectiveness of care,
improved pharmaceutical coordination will also help such organi-
zations enhance their knowledge of pharmaceutical utilization
patterns. Substantial competitive advantage may result from this
knowledge. In addition, improved knowledge of drug usage
patterns will help provider organizations entering global capitation
arrangements to better estimate drug budget risk.