Making Value-base Care Work
By Bruce Buckley

The A3 Collaborative, a yearlong value-based care initiative, has shared initial results and the numbers are impressive.

A 40% reduction in both 30-day hospital readmissions and one-year mortality, and more than $1 million in savings, are just some of the outcomes detailed in interviews with Pharmacy Practice News. Coupled with big gains in hepatitis C screening and a large uptick in cures as a result of more consistent HCV treatment, the results underscore the value of peer-to-peer learning, according to Toni Fera, PharmD, a health care consultant and member of the management team at the Alliance for Integrated Medication Management, one of the three “A’s” that launched the A3 Collaborative early last year. “The A3 Collaborative has been a percolator for innovation,” Dr. Fera said. “It has helped [provider teams] to realize that they’re on the right track and to keep moving forward.”

‘A Strong Value Story’

Felicity Homsted, PharmD, BCPS, the chief pharmacy officer at Penobscot Community Health Center, in Bangor, Maine, said participation in the A3 Collaborative was instrumental in helping to build “a strong value story” for the HCV and transitions of care (TOC) projects.

The value became apparent in research findings for the first year of the TOC program, she told Pharmacy Practice News. The 428 patients who opted into the program had a 40% lower 30-day readmission rate than the 435 patients who did not participate. Mortality also was 40% lower during the first year for the TOC group, Dr. Homsted said. Based on estimates from the Centers for Medicare & Medicaid Services, she noted, the costs saved for the avoided readmissions amounted to approximately $1.4 million.

The enhanced HCV program also achieved strong results. Before the launch, screening and treatment for the disease had been “sporadic,” Dr. Homsted said. But by developing an educational program for physicians and nurse practitioners, and turning on computer prompts across the system, HCV screening and treatment have become a practice standard. Looking at the data, “we have doubled our [HCV] screenings from 324 per quarter in 2017 to 643 in the most recent quarter,” she explained. “Treatment has gone from fewer than 10 cases per year to greater than 50.”

Patient outcomes also have improved. “Between 30 to 40 patients in the last year have been cured,” she noted, “whereas before it might have been two or three, and those were all sent external to the organization.”

From Hospital to Home

Jordan Haag, PharmD, BCPS, an ambulatory care pharmacist at Mayo Clinic, in Rochester, Minn., said its ambulatory care pharmacist leadership group saw the A3 Collaborative as an effective resource for helping to transition into the “value-based care environment, where we know that pharmacists have a significant impact on clinical and financial outcomes.” The group decided to focus its research and quality improvement efforts on transitioning patients from hospital to home. They began by analyzing how those transitions were working, with the goal of developing “a performance story” to share with A3 members and others who could benefit from the lessons learned.

The A3 Collaborative was a huge help in that effort, Dr. Haag noted. For example, the group provided tools that Mayo Clinic used to conduct a systemwide analysis of “the downstream implications” of their TOC efforts. It also provided reasources for measuring the number of patients affected and the resources needed to execute TOC-related changes.

Using those management tools, the Mayo Clinic team found that “if we focus on patients with a certain combination of high-risk medicines, we can make significant improvements in clinical outcomes.”

The team’s results were documented in a Mayo Clinic Proceedings article (Mayo Clin Proc 2018;2[1]:4-9). Clinic investigators reviewed outcomes from July 26, 2013, to April 1, 2016, among adult patients taking at least 10 medications at hospital discharge, including one or more high-risk medications. The patients either received or did not receive a post-discharge visit from a pharmacist immediately before a clinician visit. There were 502 patients in each group (pharmacist plus clinician and clinician only). The researchers found that patients in the pharmacist plus clinician group were significantly less likely to be readmitted 30 days after discharge than those in the clinician-only group (hazard ratio, 0.49; 95% CI, 0.35-0.69; P<0.001).

ASHP a Strong Supporter

Given the strong emphasis on outpatient pharmacy underpinning the A3 Collaborative, the fact that ASHP is a member is not surprising. “ASHP opted to support the collaborative in recognition that ambulatory care practice is a dynamic and growing patient care area,” said Melanie R. Smith, PharmD, BCACP, DPLA, the director of the ASHP Section of Ambulatory Care Practitioners. “The A3 Collaborative provides an opportunity for our members to elevate ambulatory care practices.”

The collaborative gave interdisciplinary team members the chance to share challenges and solutions with peer groups at ASHP’s 2017 Summer and Midyear Clinical Meetings. Educational webinars provided information on best practice models, and coaches offered technical assistance via monthly phone calls to help keep teams on track.

G. Benjamin Berrett, PharmD, BCPS, BC-ADM, the ambulatory primary care pharmacy manager at University of Utah Health, in Salt Lake City, told Pharmacy Practice News that joining the A3 Collaborative had meant the chance to develop a more comprehensive, standardized approach to medication management. The A3 Collaborative, he added, “was an opportunity to formulate a consistent framework—a kind of North Star for our practice across all of our clinics. Our pharmacists were doing great things, but they weren’t being done consistently throughout the clinics. There was so much variation between practices that it was really tough to establish value and determine the impact we were having.”

The A3 Collaborative experience helped clear that confusion. “Pharmacists in the clinics,” Dr. Berrett said, are now “moving toward a very consistent practice, but with plenty of flexibility in clinical decision making.”

The A3 Collaborative, now wrapping up its inaugural year, announced a new learning cycle for 2018-2019.

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