This blog post is part of a series written by Sampath Narayanan, CIO of ConcertoHealth, on the work his team is doing to improve population health outcomes.
As a risk-bearing provider partner managing dual-eligible Medicare/Medicaid members, ConcertoHealth’s focus is the subset of patients considered at most risk for worsening health. These patients are frail, elderly, or have been diagnosed with multiple chronic conditions. In fact, more than half of Concerto’s members have three or more chronic conditions.
There is additional complexity inherent in the management of the care of these members: Our data show that patients who are Medicaid recipients often exhibit low medication adherence, which can lead to higher readmission rates. In addition, higher utilization of multiple hospitals, emergency departments and specialists often results in numerous prescriptions (and prescribers).
In my last blog, I shared how Concerto presents patient data and encourages its primary care providers (PCPs) to leverage that information to address gaps in care. One of the most important gaps is around medications. In this post, I’ll discuss how Concerto’s medication management initiatives, supported by analytics, can prevent adverse events and readmissions, ensuring the highest levels of safety for our members.
At a fundamental level, we need to identify when a member has been prescribed an additional new drug, received a modified prescription, transitioned off a previously prescribed medication, or is not adhering to instructions. Most providers and care managers are challenged by incomplete medication records, often deferring to the member’s recollection and verbal descriptions to understand what they were, and are, actually taking. Since memory is often an unreliable source, we have undertaken several initiatives that help mitigate the risk of possible interactions and contraindications for our members.
As an analytics-intensive organization, we collect prescription and medication adherence data for our patients from a multitude of sources, including: primary care and care manager patient visits, hospital discharge summaries via HIEs, and claims from pharmacy benefit managers (PBMs).
PIR, Laboratory and Condition-Specific Reporting Initiatives
Our first initiative has been to include medication alerts in our proprietary Patient Intervention Report (PIR), a pre-visit preparation tool for providers, which I introduced in my last blog. The report flags any medications that are new, pose a high-risk, or are high-cost, so the PCP can assess their necessity, as well as their potential impact on the patient’s health. It also alerts the caregiver of adherence discrepancies identified by our analytics, such as discontinued medications or those that were prescribed but not picked up at a pharmacy; the caregiver can then advise the patient about the importance of, and instructions for, taking the prescribed medication.
There’s also an alert that prompts a Concerto pharmacist to assess a member’s medications list when 10 or more prescriptions are indicated as active. Pharmacists can coordinate with the PCP, specialists, and members to identify redundant and discontinued medications. This transparent, proactive approach keeps our clinical and non-clinical staff informed and, therefore, able to make decisions that are most appropriate for the care of the member.
The second initiative aims to correlate and present medication data received from various sources. With Patient3D, each member’s medication history is ultimately determined through a combination of data in the PCP’s EMR, which indicates what was prescribed and by whom, and data culled from claims, which show the prescriptions that were picked up. These two datasets are displayed adjacent to each other in Patient3D, giving the provider an opportunity to initiate a discussion with the member about their adherence behavior.
Concerto’s third medication management initiative focuses on reconciliation activities by our care managers and pharmacists. Medication reconciliation is a deliberate, concerted effort to resolve discrepancies between what active prescriptions the patient is taking according to our data, and what the member actually is taking, specific to dosage, route and frequency. Care managers and pharmacists connect directly with identified members to reconcile their list of medications and enter the updated information into the member’s record. Each updated list is then presented in Patient3D, along with details of who reconciled the information and when, so that all caregivers can benefit from accurate and current medication details.
We have developed several reports, as well as a dashboard for our pharmacists and care managers to use in tandem with the clinical data available in Patient3D. These laboratory-focused medication management reports and graphs enable our pharmacy and care management teams to closely monitor our members that are most at risk for a serious acute event or chronic problems related to heart and pulmonary health. By tracking the results of their laboratory blood panels, our pharmacy team can make sure any of our members with a history of heart problems are having their blood-coagulation levels measured by INR/PT laboratory tests, and that those levels are within a safe range. Because the report data is bolstered by medication adherence to a specific class drugs — Coumadin anticoagulants — we are also able to make sure that those with elevated or reduced coagulation are maintaining their health and mitigating adverse events through supplemental drug care.
Medication Management Reports
Medication management reports focus on the last refill for every medication prescribed to our members. They show how many refills and days-supply are remaining for each patient, and inform the provider as to whether the member is actively following the drug protocol or prescription dosing regimen as directed. Our pharmacy and utilization management teams use these reports to assess adherence to prescribed drugs and intervene when appropriate.
At a management level, our medication analytics dashboards enable our clinical and pharmacy leadership teams to track and analyze our population’s drug utilization pattern via a multitude of measures, such as: drug-spend by member, health plan and product type; drug-spend trends over time; medication supply and usage over time; usage of high-cost and high-risk medications; and utilization factors by generic and high-risk medications. These insights allow us to provide safe, quality care to our members, while working to minimize drug expenses, uncover fraud, waste or abuse, and recover unreimbursed costs from unapproved or illegal practices.
For my next blog, I will pivot on our member connection efforts from the medication reconciliation initiative above and discuss all the ways Concerto engages its members. I look forward to sharing how Concerto’s interactive portal and appointment reminders have contributed to better clinical outcomes, and how telemedicine and virtual reality are impacting the future of health care delivery.
This piece was written by Sampath Narayanan, CIO at ConcertoHealth, a provider of specialized primary care and clinical services that operates exclusively in value-based agreements.