Ballad Health Medical Associates

Practice Setting

Ballad Health is an integrated healthcare delivery system serving Northeast Tennessee, Southwest Virginia, Northwestern North Carolina and Southeastern Kentucky. It currently operates a family of 21 hospitals, over 40+ primary care clinics, a behavioral health hospital, an addiction treatment facility, long-term care facilities, home care and hospice services, retail pharmacies, and a comprehensive medical management corporation. Many Ballad Health primary care offices are accredited as Level 3 Patient-Centered Medical Homes, the highest level of recognition from the National Committee for Quality Assurance (NCQA).

Within this health system, there are four established Ambulatory Care Clinical Pharmacists serving eight different primary care clinics across the region, with remote pharmacy service capabilities expanding to over 20 practices. Each Clinical Pharmacist is embedded into 1-2 practice sites and serves approximately 8-12 primary care providers on average. The majority of our primary care providers are in a private-practice environment with physicians and mid-level providers, while other pharmacists serve in medical residency programs.

The Clinical Pharmacy team interacts with patients in a multitude of ways. The large majority of patient interaction occurs in shared visits with providers. Typically, patients who are new to the practice or have experienced a recent transition of care are identified for Clinical Pharmacy services as part of the provider visit. For these visits, a Clinical Pharmacist reviews all medications with the patient (and caregiver, if applicable) in the exam room for 15-30 minutes. The pharmacist then collaborates with the primary care physician, including recommending medications to add or discontinue, dosage adjustments, lab orders, or any other medication-related need. The physician or nurse practitioner then sees the patient and performs a complete physical exam and implements any changes agreed upon by both parties.

Additionally, patients with complicated disease states and medication regimens can be identified by providers, clinical staff, or self-identified by patients to see a Clinical Pharmacist during their visit. The Clinical Pharmacy team can also provide individual appointments for further follow-up and care between office visits with their primary care provider. For example, patients can be scheduled for individual appointments with a Clinical Pharmacist for diabetes management and education, complicated disease states, and/or polypharmacy visits.

Why was the pharmacy service developed? (Describe any compelling data collected prior to implementation)

The pharmacy department was able to identify a physician champion and a very forward-thinking practice administrator/AVP of Operations. These individuals knew Quality Metrics and Pay for Performance models were on the horizon and wanted the organization to be a leader in developing innovative practice models. This team came into contact with ETSU College of Pharmacy to draft a job description, feasible workflow and scope of practice for a Clinical Pharmacist in a primary care setting. The first three pharmacists were co-funded by the university but overtime payment for the positions were transitioned into being fully funded by the organization.

What training, certification, credentialing, and practice agreement is utilized by the practice setting pharmacist(s)?

All members of the Clinical Pharmacy team have completed a PGY2 in Ambulatory Care Pharmacy. The healthcare organization crosses state lines between Tennessee and Virginia and each state allowed for the development of a Collaborative Practice Agreement with providers allowing pharmacists to ordering medications, adjusting doses, and discontinuing medications under this agreement.

What outcomes are being measured to evaluate the model's success? (Clinical metrics, revenue, cost-savings, patient satisfaction, etc.)

The Clinical Pharmacy team documents all clinical interventions into a software program that automatically calculates an estimated cost savings to the healthcare system for a particular intervention.

Additionally, the quality metrics guided by Medicare are utilized in evaluation and justification for each Clinical Pharmacist position. Specifically, quality metrics related to statin utilization, Rheumatoid Arthritis medication use, osteoporosis medication use, immunization rates, adherence rates, ACE/ARB utilization, and other diabetes-focused metrics are included in these negotiations.

How have you made this service sustainable? (Include billing, reimbursement, etc.) 

While utilizing this software at Ballad Health Medical Associates, we have determined that cumulative estimates for each pharmacist average approximately $1.5-2M per year per pharmacist. On average, each pharmacist documents approximately 1200 interventions per year. While these estimates may be slightly over-inflated (the national average ROI is 4-5:1 based on previous studies performed in the primary care setting), the pharmacy team is simultaneously utilizing this software capability to track the provider name, patient name, and third-party payor.  At the end of every calendar year, our Clinical Pharmacy team submits a list of all interventions to a particular payor to calculate a true cost savings to the healthcare system and assist in salary negotiation and expansion, along with our quality metric reports on the specific measures listed above.

How did you gain support of administrators, providers, and other key stakeholders to implement your practice model?

For administrators, the focus was on identifying innovative ways to measure impact in terms of total cost savings to the healthcare system and performance on quality metrics. The pharmacy department meets frequently with administrators to ensure methods of documentation and outcome tracking are focused in the right areas.

For providers, the focus was on how to help them make their workflow more efficient while offering more comprehensive care to their patients. Instead of offering a service based on practice interests,  providers a “menu” of possible areas where they might utilize Clinical Pharmacy services. For example, some providers utilize services specifically in areas of diabetes management and transitions of care while other providers prefer to utilize services more significantly in controlled substance monitoring, drug information questions, Asthma/COPD, heart failure, mental health, and/or antibiotic selection. Early adopters were identified early on and the pharmacy department worked diligently to customize services based on practice style, patient panel, and workflow.

What are some lessons learned while implementing your practice model that you would like to share

If having a Clinical Pharmacist in a primary care setting is new to your region or organization, find a physician champion or early adopter and work as hard as possible to help him or her serve the patients. They will do the rest of the work for you.  When a physician stands up and says “I can’t take care of my patients fully without a Clinical Pharmacist,” it paints a different picture and moves administrators, payors, and other stakeholders to action.

Flexibility is also important.  In the beginning, it was assumed that the pharmacist’s role would be shaped by diabetes, hypertension, and lipids management.  However, the role was shaped by any chronic disease state that requires medication therapy. In the middle of an opioid epidemic, Clinical Pharmacists stepped up and asked providers how to be of assistance.  This opened the door for pharmacists to have a significant impact on their practices.

Change is inevitable; embrace it or be left behind.