As AIMM’s closes it’s 2016 collaborative year and plans for the 2017 year, I am excited to share the accumulation of this year’s work and successes of our AIMM teams.  AIMM’s efforts spread across a number of partnerships this year, working with health care organizations and communities to foster wide-spread adoption of care delivery systems that integrate comprehensive medication management (CMM) services and specialized areas of focus such as transitions of care.  Our partners include:

  • Apexus, AIMM’s long standing partner, provides financial support for 340B organizations to participate in AIMM to develop CMM services for high-risk, medically complex patients.
  • Cardinal Health Foundation and it’s E3 Grant Program recipients across the country who are working to improve care transitions.
  • Empire Health Foundation working to integrate CMM services in rural communities across eastern Washington.
  • Iowa Healthcare Collaborative to bring CMM services to the state’s six Community Care Coalitions Centers established under the Iowa State Innovation Model initiative from the Centers for Medicare and Medicaid Services.
  • University of North Carolina Eshelman School of Pharmacy, with whom AIMM has partnered to contribute its years of experience supporting clinical pharmacy service development in a large national project focused on integrating CMM in primary care settings.

Read more about AIMM’s partners.

As described in a previous blog, AIMM deploys an innovative framework described as a “performance story” to track actionable results from participating teams.  The performance story is a progression of an organization’s efforts to achieve a defined aim and goals for the year.  It also provides teams with demonstrative results to share with senior leadership in a narrative format to highlight achievements toward integrated CMM services and improved patient health outcomes.

Performance stories are constantly being refined throughout the year with guidance from AIMM’s project development coaches.  AIMM coaches are quality improvement experts and provide ongoing consulting and assist a team in reaching their set aim and goal for the year. This framework also holds teams accountable to their commitment to reach set aims and goals.

Most recently, the Apexus 340B-sponsored teams celebrated their year-long performance results with one another in a celebratory learning event.  Teams used AIMM’s signature leadership style, which is introduced at the beginning of the year and honed all year long to articulate their results, successes to date, and preparations for the upcoming 2017 year. Below are team examples shared during the learning event, which illustrate the remarkable experience teams embark upon in the AIMM learning collaborative.

Initial Team Collaborative
Participating AIMM Teams in this collaborative are establishing their CMM services and working to get results quickly for a manageable population of high-risk patients.

Family Health Services – With a vision to provide CMM services, Family Health Services now offers clinical pharmacy services three days a week. Services have expanded from diabetes to include hypertensive patients and at the end of this year, 20% of patients are at goal (goal defined as A1C < 9). The team used this year to communicate the value of the pharmacy department across the health center and now, the pharmacy department is fully integrated within the medical clinic, and participate in provider meetings.  Pharmacy is recognized by the entire organization for the value it brings to patient care.

Community Health and Wellness Partners of Logan County (CHWPLC) – Setting an AIMM goal at the beginning of the year allowed the pharmacy department to evaluate services and make changes.  Before, there was minimal recognition for the impact the department was making on overall patient care, and goal setting has been key. Key measures are collected and it allows for evaluation and changes. Data collected supported the department’s request for an additional full-time pharmacist, which was approved this year.  CHWPLC pharmacy department has strong support from the CEO and that support has spread organization-wide. Pharmacy is integrated with providers, quality department and is part of sharing monthly communications.

Desert Senita Community Health Center – Engaging the health center staff to help the pharmacy department meet its goals was the aim for the pharmacy team this year. Their AIMM performance story was presented to leadership early on in the year, and then the department was invited them to present to the organization’s board of directors. The focus this year has been on its diabetes patient population, and engaging in a community coalition, partnering with a local school system and helping to establish bike rides for healthy living of its patients with diabetes. The pharmacy department has been recognized and celebrated by the center’s Chief Medical Director, and also invited to present its community program with the local chamber of commerce.  This past November, Desert Senita was the first federally qualified health center in Arizona to have a recognized diabetes prevention program!

Advanced Team Track
Participating AIMM Teams that are bringing their CMM successes to scale, spreading to a larger patient population and developing innovative payment models for service.

Marshfield Clinic – Providing CMM services for 2,350 patients in Marshfield’s affiliated health plan, the pharmacy department noted it was able to keep 100% of their diabetes and blood pressure patients from the 2015 AIMM year at clinical goal in 2016.  Another patient population group not at goal was added in 2016, and by the end of this year, notable improvement is seen in up to 40% of patients, with 70% improvement for patients’ blood pressure.  This year’s goals included system support and alignment, working with key leaders throughout the health system to improve documentation, enhanced dashboards and improved process for tracking data. The pharmacy department proudly shares that all clinicians work “at the top of their license.”  Pharmacy technicians are deployed for responsibilities that do not require a pharmacist, creating greater efficiencies.  For 2017, Marshfield pharmacy department will work to build interdisciplinary care teams and expand into a chronic care clinic.

Crescent Community Health Center – Working on barriers for patients was this year’s focus, including access to medication, mental health and social services. The final result will be pharmacy and behavioral health having integrated services within the clinic.  The pharmacy department received diabetes accreditation and is now seeking it at the state level to bill for Medicaid, which will provide more financial stability.  The pharmacy department communicates with providers and nurses and helps keep the patients focused on diabetes and blood pressure goals, moving away from acute care to long-term goal setting and self-management.

Zufall Health Center – Expanding clinical pharmacy service offerings has the pharmacy department’s one full-time pharmacist traveling to four of the center’s six sites. The diabetes program was accredited this year and now bills for diabetes education services. To provide additional support, the pharmacy department was able to hire a dietitian to help with patient care and work towards a goal to bring at least 85% of patients to clinical goal in diabetes (A1c <9;) and blood pressure (< 140/90).  Pharmacy students help with data collection and outcomes are shared with the Chief Medical Officer and the quality department.

AHN West Penn – Managing a wellness clinic with 1,800 patients, including employees, patients discharged from the hospital, and physician referrals.  A retrospective analysis of the clinic’s data from the year shows pharmacy interventions helped to identify 350 medication-related problems across all patient visits, and produced an average A1C reduction of 1.6% in these patients.  The pharmacy wellness program operates similar to a general internal medicine clinic in that any patient who comes to us, or is referred by a physician may have any type of health issue. A work flow has been developed, which allows services to be sustainable for 100 patients or 1,000 patients.  Standardized into the system is a set of questions that addresses CMS Star Rating measures, current diabetes guidelines to help uncover common medication problems, and a standardized care process.  This allows all the pharmacists to be applying the same methodology of care and scale services.

The AIMM performance story template allows organizations to capture the growth of a team, the systematic processes being developed, the leadership actions used to obtain necessary resources, and reflect executive support. These above examples are a sample of the success from our teams this year. AIMM looks forward to continue to celebrate team’s performance stories and achievements in the 2017 year.

If you are interested in joining the 2017 AIMM collaborative, click here.

Todd Sorensen, PharmD, FAPhA
Executive Director, AIMM