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Scott Knoer, MS, PharmD, FASHPChief Pharmacy Officer October 27, 2017

This speaker has no potential of actual conflicts of interest

Leveraging the Pharmacy Enterprise to Improve Population HealthHow do I make my community healthier and my hospital successful? 

Pharmacist Learning Objectives 

• Understand population health management strategies 

• Describe how pharmacists can tie their practice to population health management initiatives across the Pharmacy Enterprise

Technician Learning Objectives 

• Understand population health management strategies 

• Describe how pharmacy technicians can tie their practice to population health management initiatives across the Pharmacy Enterprise

U.S. News & World Report’s “2017-18 Best Hospitals”

No. 2 on Best Hospitals Honor Roll

Rank Hospital Points Specialty

1 Mayo Clinic, Rochester, Minnesota 415 15

2 Cleveland Clinic 365 14

3 Johns Hopkins Hospital, Baltimore 363 15

4 Massachusetts General Hospital, Boston 358 16

5 UCSF Medical Center, San Francisco 303 15

U.S. News & World Report’s  “2017‐18 Specialties”

Rank Specialty Rank Specialty

1Cardiology &Heart Surgery

3 Orthopedics

2 Urology 5 Geriatrics

2 Nephrology 5 Gynecology

2Gastroenterology & 

GI Surgery6

Neurology & Neurosurgery

2 Rheumatology 7 Cancer

3Diabetes &

Endocrinology9 Ophthalmology

3 Pulmonology 16 Ear, Nose & Throat

Care of the sick, investigation of their problems, and further education of those who serve

- Cleveland Clinic Mission Statement

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• 53,000 Caregivers• 165 Acre Campus• 42 Buildings

• 1.9 M Unique Patients• 7.1 M Patient Visits• 220,059 Admissions

FHCFHC

Elyria FamilyHealth Center

Westlake FamilyHealth Center

FHCFHC

Lorain Family HealthAnd Surgery Center

FHCFHC

LakewoodFamily Health

Center

FHCFHC

Strongsville Family Health and Surgery Center

FHCFHC

Brunswick FamilyHealth Center

FHCFHC Wooster FamilyHealth Center

FHCFHC

Independence FamilyHealth Center

FHCFHCSolon FamilyHealth Center

FHCFHC

Chagrin Falls FamilyHealth Center

FHCFHC

Beachwood FamilyHealth and Surgery Center

FHCFHC

Willoughby HillsFamily Health Center

FHCFHC

HHFairview Hospital

Lutheran Hospital

HH

Ashtabula County Medical Center

HH

Euclid Hospital

HH

Hillcrest Hospital

HH

South PointeHospital

HH

Marymount Hospital

HH

ClevelandClinic

Integrated Health Systemserving 6 million patients

Akron General Medical Center

HH

HHAvon Hospital

HHMedina Hospital

FHCFHC

Stephanie Tubbs JonesFamily Health Center

Additional Locations

Cleveland Clinic FloridaWeston

Cleveland Clinic NevadaLou Ruvo Center for Brain Health (Las Vegas)

Cleveland Clinic CanadaToronto Health & Wellness Center

Cleveland Clinic Abu Dhabi, UAE

Cleveland Clinic London: 33 Grosvenor Place

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Provide patient focused pharmacy practice across the continuum of care through innovation, education, 

and research‐ Department of Pharmacy Mission Statement

Population Health ‐ Definition Consensus

“The health outcomes of a group of individuals, including the distribution of such outcomes within the group.” 

– Kindig and Stoddart 2003

Am J Public Health. 2003 March; 93(3): 380–383.

Achieving Population Health: IHI Triple Aim 

• Framework that describes an approach to optimizing health system performance. 

– Improving the patient experience of care (quality and satisfaction)

– Improving the health of populations

– Reducing the per capita cost of health care

Robert Wood Johnson Foundation, 2014

Comprehensive Health Management

Population Medicine

The design, delivery, coordination, and payment of high‐quality health care services to manage the Triple Aim for a population using the best resources we have available to us within the health care system. 

– Ninon Lewis, Institute for Healthcare Improvement

Popul Health Manag. 2017 Feb;20(1):74‐85.

Population Health Management

• “Population Health Management (PHM) the active process of strategically utilizing health determinant data for a defined cohort to design, coordinate, and deliver high-quality, cost effective, patient-centered care across the continuum, through optimizing communication, collaboration, and utilization of available resources with the goal of creating and sustaining health.” ‐ Felicity Homsted

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NEED FOR CHANGE

• Economics

• Reform

• Demographics

• Technology

• Disruptors

• Transparency

• Consumerism

Health Care’s Burning Platform

U.S. Aging Population

United States Census Bureau. International Data Base. (URL in ref list).22

0

5

10

15

20

25Total Population

Millions

Age

Age of the United States 1980, 2010

1980

2010

Anderson, G. Chronic Care: Making the Case for Ongoing Care. Robert Wood Johnson Foundation and Johns Hopkins Bloomberg School of Public Health.  February 2010: 1‐43. (URL in ref list).

Chronic Diseasefd

Number of people with Chronic Conditions (millions)

Munro, D. 2012 – The Year In Health Care Charts. Forbes. Dec 20, 2013. (URL in ref list).

Cost of Care by Age

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$2,963Difference between US & Switzerland’s health spending per capita.

$912 BTotal dollars saved if the US could lower its health spending per capita to Switzerland’s

California HealthCare Foundation. Health Care Costs 101: Slow But Steady. 

Transforming Care Delivery

Acute Health Population Health

Sick Healthy

Individual Patient Populations

Single Encounter with Patient Holistic, Long Term Relationships

Episodic Care Care Continuum

Individual Provider Care Team

In‐Office Care Multi‐Modal Touches

Volume‐BasedVolume‐Based Value‐BasedValue‐Based

PaymentPayment Fee‐for‐ServiceFee‐for‐Service Outcomes BasedOutcomes Based

FocusFocus Acute EpisodesAcute Episodes Bundles & PopulationsBundles & Populations

Role of the ProviderRole of the Provider

Single EpisodesSingle Episodes Care ContinuumCare Continuum

InformationInformation RetrospectiveRetrospective Real‐time & PredictiveReal‐time & Predictive

The Reimbursement Shift 

Fundamentally new orientation & capabilitiesFundamentally new orientation & capabilities

POPULATION(S) HEALTH

CLEVELAND CLINIC APPROACH

• Access

• Documentation 

• Telemedicine

• Care Paths

• Team Based Care

• Data Analytics

• Care Coordination

• Network Contracting

Capabilities for Success Fragmented, Variable and Discontinuous Care

Recovery and Rehab

SNF

Outpatient Rehab

HC

Home

Wellness / FitnessCenter

Retail Pharmacy

PhysicianClinics

Diagnostic /Imaging Center

Urgent Care

Surgery Center

Community‐Based Care

Acute CareHospital

IRF

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Integrated, Coordinated and Data‐driven Care

Care paths and outcomes Distance Health Infrastructure

Cost and value analysis

Recovery and Rehab

Inpatient Rehab

Skilled NursingFacility

Outpatient Rehab

Home CareHome

Wellness / FitnessCenter

Retail Pharmacy

PhysicianClinics

Diagnostic /Imaging Center

Urgent Care

Family Health & Surgery Center

Community‐Based Care

Acute Care

Hospital

Longitudinal Data

Home

Integrated Care: Value‐Based and Patient‐Centered

• Personalized

• Patient‐focused

• Integrated

• Continuous

• Right care, place and time

• Primary and Specialty Care

• Transcends time, physical location

2014 2015 2016 2017 2018 2019 2020

Payment at Risk

0.5Million

1.3Million

Preserve/Strengthen the Core & Stimulate Growth

Specialty Care

Prevent Illness

OUR CORE GROWTH

Goal: NE Ohio and SE Florida Communities – improve 

health and decrease overall cost of care

Goal: Provide highest quality/low 

cost provider, driving volumes

Vision for Cleveland Clinic and Healthcare 34

Medical Neighborhood

VOLUMEVOLUME VALUEVALUEFee for ServiceFee for Service OutcomesOutcomes

VOLUMEVOLUME

Promote Well‐Being(Stimulate growth)

Promote Well‐Being(Stimulate growth)

Specialty Care(Preserve/strengthen the core) 

Specialty Care(Preserve/strengthen the core) 

Vision for Cleveland Clinic and Healthcare 35

Our Double Opportunity

Vision for Cleveland Clinic and Healthcare 36

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How do we act on it?

What’s the best that can happen?

What will happen next?

Why is this happening?

What actions are needed?

What were the key drivers?

How many, how often, where?

What Happened?

Sophistication of Analytics

Competitive Advantage

StdReports

AdhocReports

DataExploration

AlertsScorecards

StatisticalAnalysis

Forecasting

PredictiveAnalysis

Optimization

Proactive Decision Making

Reactive Decision Making

Adapted From:. Copyright © 2012, SAS Institute Inc. All rights reserved. ANALYZE YOUR DATA, TRANSFORM YOUR BUSINESS DAN SOCEANU, SENIOR DATA MANAGEMENT SOLUTIONS ARCHITECT, SAS

Support with Analytics Adapting to Change

Touch$$

Different Touch$

High Touch$$$$$

1,117per month

2014 2015 20172016

Express Care Online

2012 2013 2014 2015 2016 2017

1,1271,127

12,29612,296

45%

Increase Shared Medical Appointments

2007 2009 2011 2013 2015 2017

136,600

6,500

43%

Increase Express and Urgent Care Visits  Oscar Health Insurance

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Projected FTE Physicians, Most Plausible Scenario, 2006-2025

Dill, M. & Salsberg, E. The Complexities of Physician Supply and Demand: Projections Through 2025. Association of American Medical Colleges. Nov 2008: 1‐94. (URL in ref list).

Physician Shortage

Shortage of about 160,000 physicians in 

2025

Increase in Pharmacist Training

Increase in Post Grad Pharmacist Training Pharmacy Population Health Goals 

• Improve patient access and experience

• Optimize physician time

• Improve quality

–Achieve treatment goals

–Prevent adverse drug events

• Decrease costs

Pharmacy in Population Health Vision

• Pharmacist in all ambulatory clinics

• Manage medication therapy

–Get uncontrolled patients to goal

–Keep chronic patients healthy

–Adherence–Educate–Monitor

–Adjust medications

Ohio Consult Agreement

• Pharmacist consult agreement

–Rules with expanded scope

• Improves patient care

– Improves efficiency

– Improves scope

–Eases administrative burden

– Improves patient access

–Refill Authorizations

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Scope of Practice

• Comprehensive Medication Management 

• Medication Review

–Medicare D ‐MTM

–Hospital discharge medication reconciliation

–Polypharmacy review

–Adherence assessment and counseling

–Refill Authorization if seeing patients

High Risk (Top 5%)

Pharmacy Med Reconciliation

< 5 Day Follow Up

Warm Handoff

Transitional Care Coordination

High Risk Strategy 

Pharmacist ActionsAssemble the Right Team

40 FTE

Current Pharmacy Presence: 22.2 FTE 

Primary Care

– 2 FTE Main Campus

– 1.5 FTE Beachwood

– 1 FTE Solon

– 1 FTE Independence

– 1 FTE STJ

– 1 FTE Wooster

– 1 FTE Lorain

– 1 FTE Strongsville

– 1 FTE Fairview

– 1 FTE Marymount

– 1 FTE  Akron General

– 0.5 FTE Hillcrest

– 0.2 FTE South Pointe

Specialty

– 3 FTE Oncology

– 2.5 FTE Pain 

– 1.3 FTE Endocrine 

– 1 FTE Transplant

– 1 FTE HIV

– 0.2 FTE Heart Failure

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Pharmacist Involvement

Primary Care Consults

• Diabetes

• Hypertension

• Care gaps

• Hospital discharge medication reconciliation 

• Non‐adherence, cost minimization  

Specialty Clinics

• Heart failure

• Endocrine

• Pain

• Transplant

• HIV

Visit Structure

• Embedded in clinics

• Physician referral to pharmacist

–Treatment resistant, nonadherent patients

–Diabetes and HTN 

• Face‐to‐face, virtual, or telephonic encounters–New: 60 min.

–Follow‐up: 30 min.

Mean change in BP from baseline = -16/-9 mmHg, p<0.0004

57.6%

• Achieve goal in high % of consulted patients• Opportunity for long-term follow-up to sustain improvement

Outcomes: Hypertension Outcomes: Diabetes

• DM seen with HgbA1c >9% by population management (n=65)

–Reduction in A1c (mean): ‐2.1% 

–(p < 0.001)

– Improved % of patients with HgbA1c <9% from 14% to 65% 

–(p = < 0.001)

Initiatives in the Pipeline

• Mental health 

• Opioid stewardship 

• Neurology

• Rheumatology

• Dermatology– Methotrexate monitoring

– Accutane

• Pharmacogenomics

Future priorities

• Leverage broader prescriptive authority–Less recommending, more doing

• Free up physician time

–See new or worsening control patients (diagnosis)

• Accessibility–Virtual visits–Telephonic visits–Asynchronous visits

• New areas

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Get to the Strategy Table

• Who is leading your PHM strategy?

– Medicine

– Strategy office

• Are there workgroups?

– Invite yourself

– Have advocates get you invited

• Do you own your EHP?

Population Health Management has one common universally accepted definition 

•T 

•F

To effectively manage populations, health‐systems should focus primarily on acutely ill patients requiring specialty care?

•T

•F

Effective interdisciplinary team care where all Caregivers practice at the top of their license is critical to successfully managing populations of patients?

•T

•F

Pharmacy’s role in PHM is a given so you should wait until your hospital administration and physician leadership asks you for help?

•T

•F

Questions?