Integrating Pharmaceutical Care: A Vision And Framework

Integrating Pharmaceutical Care: A Vision and Framework Written by Deborah Paone Richard Levy Richard Bringewatt

National Chronic Care Consortium

National Pharmaceutical Council

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The National Chronic Care Consortium and The National Pharmaceutical Council

The National Chronic Care Consortium (NCCC) and the National Pharmaceutical Council (NPC) jointly developed this vision and framework for integrated pharmaceutical care.

The National Chronic Care Consortium The NCCC is an alliance of the nation’s leading nonprofit health systems and serves as a national operational laboratory for developing and testing models and methods to improve care for people with chronic conditions. The NCCC also serves as a national resource center in transforming delivery systems to improve quality and reduce costs of standard operating procedures used by purchasers, payers, and providers. National Chronic Care Consortium 8100 26th Avenue South Suite 120 Bloomington, MN 55425 (612) 858-8999 Fax: (612) 858-8982 www.nccconline.org

The National Pharmaceutical Council NPC is an educational association supported by the leading researchbased pharmaceutical companies. NPC demonstrates and communicates the scientific, clinical, and societal value of evidence-based healthcare, including pharmaceuticals. NPC works with public and private sector partners to implement research and demonstration projects related to the optimal use of pharmaceuticals.

Contents Executive Summary..............................................................3 Introduction ......................................................................... 4 Section 1: The Need for Integrated Pharmaceutical Care Pharmaceutical Care Challenges ............................... 6 The Changing Role of Pharmacy Services .............. 8 The Nature of Chronic Conditions ........................... 9 Section 2: Implementing Integrated Pharmaceutical Care The Vision ................................................................... 12 The Framework: A Systems Solution..................... 15 Benefits of Integrated Pharmaceutical Care ......... 19 Case Studies ................................................................ 20 Taking Action.............................................................. 24

National Pharmaceutical Council 1894 Preston White Drive Reston, VA 20191-5433 (703) 620-6390 Fax: (703) 476-0904 www.npcnow.org.

Integrating Pharmaceutical Care: A Vision and Framework

References .......................................................................... 26 © Copyright 1999 by the National Chronic Care Consortium and the National Pharmacetical Council. All rights reserved.

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Executive Summary Chronic disease is widespread in the United States, particularly among the elderly, and is accompanied by complex clinical and psychosocial dimensions. The elderly are especially at risk for receiving ineffective treatment or suboptimal care, which leads to adverse consequences. This situation is produced in part by a fragmented healthcare system that often ignores the need to integrate pharmaceutical care with other aspects of chronic conditions. Multiple medications are often prescribed and managed separately and are not coordinated across disease states or care settings. Additionally, the financial incentives of service sites and providers often are not aligned with the objective of using pharmaceuticals to manage overall treatment outcomes and costs. This fragmentation of care increases the potential for suboptimal prescribing, drug interactions and adverse effects, duplicate prescriptions, and noncompliance with treatment regimens. In light of these problems—and since pharmaceuticals are the central element in the treatment of chronic care patients—it is important to consider an approach to pharmacotherapy that is focused on the totality of care. Integrated pharmaceutical care is not about an increase or decrease in use of pharmaceuticals; it is about enabling appropriate pharmaceutical management as an integral component of primary, acute, and long-term care services. This paper describes a systems-based model for pharmaceutical care that is based on the belief that the full value of pharmaceutical therapy is best achieved when care is organized around the person, focuses on disability prevention and health maintenance, and extends smoothly across settings, across providers, and over time. The model specifies support for the program by senior management and a multidisciplinary team approach to the ongoing management, coordination, and evaluation of medicines. Care decisions are supported by information systems that track prescriptions and provide feedback on the results of therapy. In keeping with this model, selection of pharmaceuticals and treatment plans are tailored to the needs of individual patients and based on overall treatment outcomes and cost. Selection criteria also include the medication’s ability to improve the performance of daily activities, slow the progression of disability and dependence, and facilitate compliance. Selection also recognizes ethnic and cultural differences among patients, especially attitudes and beliefs about medications that may make the difference between successful and unsuccessful treatment. Since this model of pharmaceutical care is responsive to the prevailing characteristics of chronic disease, it should result in improved clinical outcomes, quality of life, and patient satisfaction. Additionally, the inherent efficiencies of this approach may be especially attractive to provider organizations that assume overall risk for a defined population group. This paper presents examples of organizations’ successes in implementing pharmaceutical integration, along the lines of the model. The NCCC and NPC also have tools available that specify criteria and measures for integrated pharmaceutical care and help organizations to assess their current extent of integration. These may be useful in assisting organizations in strategic planning for pharmaceutical integration.

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The National Chronic Care Consortium and The National Pharmaceutical Council

Introduction The National Chronic Care Consortium (NCCC) and the National Pharmaceutical Council (NPC) jointly developed this vision and framework for integrated pharmaceutical care. This vision and framework are based on the belief that the full value of pharmaceutical care in the treatment of chronically ill patients is best achieved in a truly integrated setting. The concepts in this paper derive from the commitment of both organizations to an integrated, population-based, and holistic approach to healthcare. The cost efficiencies and potential for improved care inherent in an integrated approach will become important as payers increasingly demand that provider organizations deliver quality care while assuming overall risk for populations. Integration is not about an organization’s contractual or ownership arrangements. Rather, it is a way of organizing and implementing the care process. Integration methods can be adapted to a wide range of delivery systems, alliances, and partnerships. As the NCCC and NPC conceive it, integrated care is organized around the individual, focusing on health maintenance and disability prevention across time and settings. Individuals and populations served by a healthcare system organized according to these principles will enjoy better clinical, social, and cost outcomes. Integrated healthcare differs from disease management, especially in its application to chronic illness. The term “disease management” has been applied to many activities that represent important advances beyond episodic and uncoordinated care. But a disease-bydisease approach may neglect interactions between diseases and often does not address the potential for overall health management offered by a population-based approach. Health management involves prevention, diagnosis of undetected disease, and minimization of disease risk. It requires the alignment of economic incentives and a sharing of the financial risks among all providers and service sectors in the system (Gevirtz et al.,1999). The NCCC defines people with serious and persistent chronic conditions as those who “…possess one or more biological or physical conditions where the natural evolution of the condition(s) can significantly impact a person’s overall quality of life, including an irreversible inability to perform basic physical and social functions” (Bringewatt, 1995). These individuals represent the highest-cost, fastest-growing segment of the population served by healthcare organizations. Unfortunately, the current cure-oriented healthcare system is not designed to serve these patients. Current administration and financing programs perpetuate a fragmented, institution-based approach. Chronic care patients have sustained needs but are served by “…a system of care that is in fragile equilibrium. Even slight perturbations in their support system can have direct consequences and also secondary or compensatory effects” (Soumerai et al., 1994). A more population-based, integrated approach is required to provide needed stability and optimal care for these patients. Since pharmaceuticals are a key treatment strategy for most chronic care patients, this paper discusses the need for and the value and characteristics of a system where pharmaceuticals are fully integrated into overall patient care.

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Section 1:

The Need for Integrated Pharmaceutical Care Pharmaceutical innovation has greatly improved treatment outcomes and quality of life for patients with many chronic conditions, including HIV/AIDS, diabetes, depression, psychosis, ulcer, and cardiovascular disease. However, there is evidence that medication management in the chronic care population could be improved. This section examines current pharmaceutical care challenges, explores the evolution of pharmacy services, and reviews the characteristics of chronic conditions. It is these characteristics of chronic conditions need to drive the delivery of pharmaceutical care.

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Pharmaceutical Care Challenges Medications have become the most common therapeutic intervention in modern healthcare (Evans et al., 1994) and represent a major form of treatment for elderly individuals and others with chronic conditions. Although the elderly comprise 12 percent of the population, they account for 34 percent of total pharmaceutical expenditures (Mueller et al., 1997). There are several significant challenges to providing pharmaceutical care for older adults and people with chronic conditions.

Component Management Perhaps the most important factor contributing to suboptimal use of medications in the chronic care population is that—even in “integrated” healthcare systems— medications are often managed separately from other elements of care, and drug therapy is not coordinated across disease states or care settings. Some observers call this “component management,” with a characteristic focus on just one piece of healthcare at a time (Cohen and Naughton, 1995). Component management of drug therapy, where selection of pharmaceuticals occurs without knowledge of the overall effect on the patient, can result in compromised clinical outcomes and increased use of medical services (Horn et al., 1998; Levy and Cox, 1999; Soumerai et al., 1991, 1994). This lack of coordination also increases the potential for drug interactions, duplicate prescriptions, noncompliance, suboptimal prescribing, and over- and under-treatment. Additionally, the financial incentives of the various sites or providers often are not aligned. There is rarely an overarching goal that drives care decisions.

Underuse and Overuse of Pharmaceuticals There is evidence that many older adults may be taking too many prescription and over-the-counter medications. While the appropriate medications may have significant positive effects, polypharmacy (multiple medications, e.g., eight or more) can lead to an increased incidence of drug-to-drug interactions, more adverse drug events, a decrease in medication compliance, and, potentially, a decline in quality of life (Stewart and Cooper, 1994). Underuse of pharmaceuticals in chronic care patients with multiple concurrent illnesses also has been documented. One disease may be neglected if another disease receives primary attention. For example, one study found that older patients with diabetes, pulmonary emphysema, or psychotic syndromes received as many as 60 percent fewer prescriptions or other treatments for concurrent but unrelated diseases (estrogen replacement therapy, lipid lowering medications, and medical treatment for arthritis, respectively) compared with patients with only one disease (Redelmeier et al., 1998). Such problems may be widespread since it is estimated that more than 40 percent of people with chronic illness have more than one chronic condition (Robert Wood Johnson Foundation, 1996).

Inappropriate Prescribing and Adverse Reactions Problems of inappropriate prescribing and adverse reactions among the elderly have been well-documented (Baum et al., 1984; Stewart and Cooper, 1994; Wilcox et al., 1994; General Accounting Office, 1995). The incidence of adverse drug reactions is high—estimates vary from five percent to 35 percent. Medication use in older adults Integrating Pharmaceutical Care: A Vision and Framework

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tends to rise with age (Stewart et al., 1991), and age-related changes in physiology can alter the effectiveness, time course, or side effects of many drugs (Lindley et al., 1992). Additionally, the use of multiple medications, especially by patients with several conditions, can increase the risk of adverse effects. Studies of adverse drug events occurring in patients admitted to tertiary hospitals revealed that drug errors can be due to a physician ordering the wrong dose or choosing the wrong medication. More often, however, injuries result from systems problems arising from the complex interactions among individuals, as well as from problems in dealing with sophisticated technologies (Leape et al., 1995; Hendee, 1998).

Lack of Coordination of Information There is also the problem of coordinating information. A patient may go to several different specialists, and these physicians may each prescribe a medication for the symptom or problem that they are treating. Unfortunately, these physicians may have incomplete information about the full set of medications that the patient is taking. In addition, there may be problems in getting timely information to the right provider. In a study of adverse drug events in two hospitals, many errors were due to incomplete or inaccurate patient information. Results of laboratory tests, current medications, or information about the patient’s condition were sometimes not easily accessible when needed, which resulted in prescribing errors. Pharmacists, too, sometimes lacked critical information that would have allowed them to stop an improper order (Leape, et al., 1995).

Adherence to Medication Regimens Adherence to medication regimens can be a major problem for chronic care patients. The regimens may require frequent administration of several different medications. Older people with cognitive difficulties may be less able to follow medical advice, ask for clarification, or actively participate in self care. Due to their frailty, older people can be particularly susceptible to the physical, social, and psychological consequences of nonadherence to medication regimens (Balkrishnan, 1998). Medication adherence rates for the elderly range from 26 percent to 59 percent (Balkrishnan, 1998). Some studies have shown that the greater the number of medications prescribed for elderly patients, the greater the rate of noncompliance (Col et al., 1990; Coons et al., 1994). Consequences of elderly patients’ nonadherence to medication therapy include reduced effectiveness or treatment failure, disease progression, emergence of resistant bacteria, medication overdose, unnecessary medical expenses, and hospitalizations (Greenberg, 1984). In one study, approximately 11 percent of hospital admissions in an elderly population were related to medication noncompliance (Col et al., 1990).

Balancing Costs The last few years have witnessed a significant increase in the number of medications available and a rise in the relative proportion of medication costs compared to total healthcare expenditures. This is clearly a concern to healthcare providers and plans. There is some evidence, however, that the strategic employment of newer pharmaceuticals can leverage overall treatment costs. When they offer substantial therapeutic advantages over existing therapies, new medications may reduce utilization and costs of other services, and reduce overall costs associated with disability and labor (see for example Cystic Fibrosis Foundation, 1993; Fagan et al., 1998; Legg et al., 1997a, b; Peters, 1993; Stocker, 1996).

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The National Chronic Care Consortium and The National Pharmaceutical Council

The Changing Role of Pharmacy Services Within the last decade we have seen an evolution in the organization of pharmacy services within healthcare institutions. The number of stand-alone facilities has diminished, as the number of larger multiorganizational systems and alliances has increased. Many multiorganizational healthcare systems began as hospitals or physician groups and grew through mergers and acquisitions of other local healthcare facilities. Often, each new facility added to the system brought its own management structures and procedures for selecting, ordering, distributing, and evaluating pharmaceuticals. It was not uncommon for the pharmacy services departments at each institution to operate relatively independently from one another for years. To realize the operating efficiencies and clinical improvements made possible by consolidation, many of these newly integrated systems are beginning to integrate pharmacy operations across service sectors. One challenge to planners seeking operational efficiencies is to assure that an adequate range of drugs for individuals or groups of patients with specific clinical needs is available at a given site. With the evolution in healthcare systems has come a change in the role of pharmacists working in these systems. Traditionally, pharmacy was a hospital ancillary service; pharmacists ordered and dispensed medications, managed a formulary for a hospital or physician group, reinforced instructions to patients on prescribed medications, and occasionally consulted or advised clinicians (Ogden et al., 1997). Pharmacists, especially hospital pharmacists, have been advocating for a greater clinical role in “a more integrated approach for drug distribution and provision of services” (Pierpaoli et al., 1986). While the physician remains the primary decisionmaker regarding therapy for individual patients, the advent of complex healthcare systems has given rise to a greater role for pharmacists in the management of pharmaceuticals. Integrated pharmaceutical care means new roles for pharmacists. In 1997, pharmacists in integrated health systems (including managed care organizations) were found to be spending approximately 45 percent of their time on dispensing functions, 30 percent on clinical activities, and 21 percent on administrative responsibilities (Reeder et al., 1998). These pharmacists reported that they are increasingly able to participate in activities representing elements of integrated pharmaceutical care. Such activities include report card development, populationbased decisionmaking, quality performance assessment, physician education, medication compliance monitoring, use of pharmacoeconomic data for formulary decisionmaking, and patient counseling. Pharmacists also were often included on interdisciplinary teams for ambulatory patients (Reeder et al., 1998). Case studies that highlight the expanded institutional roles of pharmacists are presented on pages 20 to 23.

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The Nature of Chronic Conditions The NCCC defines people with serious and persistent chronic conditions as those who “…possess one or more biological or physical conditions where the natural evolution of the condition(s) can significantly impact a person’s overall quality of life, including an irreversible inability to perform basic physical and social functions” (Bringewatt, 1995). Chronic diseases are multidimensional, involve psychosocial factors, and are interdependent with other acute or chronic diseases the patient may have. Further, chronic diseases are often disabling and continue over long periods of time. To reduce costs and increase quality over the long term, management infrastructures must be more responsive to these characteristics. Since pharmaceuticals play such a large role in the treatment of chronic care patients, the organization of pharmacy services must take these characteristics into account. Because current healthcare policy, regulation, and payment methods were designed with short-term medical problems in mind, people with chronic diseases and disabilities remain one of the most challenging groups served by healthcare providers. These characteristics of chronic conditions need to drive the delivery of pharmaceutical care.

Multidimensional Most care delivery organizations are organized primarily to stabilize body chemistry through pharmaceutical and medical technology. However, chronic illness also includes functional, emotional, social, and environmental concerns. Effective care requires attention to these nonmedical dimensions. Thus, selection of pharmaceuticals for individual patients should take into account the effect on a person’s function, attitude, and lifestyle. Pharmaceutical regimens should be prescribed with an understanding of a person’s views about healthcare and with a realistic expectation of adherence to the regimen.

Interpersonal Chronic conditions often affect every aspect of a person’s life and identity. The power of personal values, the influence of family and friends, and the importance of community are strong factors in the health and function of each individual. Healthcare providers and systems need to understand these influences and provide support for family caregivers. Recognition by providers of language barriers and cultural differences among patients, especially regarding attitudes and beliefs about drug therapy, can make the difference between successful and unsuccessful treatment.

Disabling Medical concerns generally dominate care decisions, but from the patient’s perspective the primary issue of chronic illness is retaining function. Accordingly, treatment needs to be focused on preventing, delaying, or minimizing the progression of disability. This requires an understanding of the natural evolution of

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Chronic Care Facts Individuals with chronic conditions represent the highestcost, fastest-growing segment of the population served by healthcare organizations. • In 1995, an estimated 99 million people in the United States had a chronic condition, characterized by persistent and recurring health problems lasting for an extended period of time. • Though people with chronic conditions represent only 20 percent to 30 percent of the entire population served by a healthcare system, they incur more than 70 percent of the costs. • Chronic conditions are the leading cause of illness, disability, and death in the United States today, and are responsible for 90 percent of all morbidity and 80 percent of all deaths. • Chronic conditions constitute 70 percent of the nation’s personal healthcare expenditures. • In 1987 dollars, the average annual per capita cost for persons with one or more chronic condition was $4,762. • In the next 25 years, the number of Americans with chronic conditions will increase by approximately 35 million.

chronic conditions, the risk factors associated with next-phase disability progression, and those pharmaceutical and other interventions which reduce the probability of future care needs. Providers should assess treatment outcomes in terms of functional status as well as health status, and payment systems should support both. Improved payment systems that reward disability prevention encourage the use of pharmaceuticals, which improve function. Such drugs, especially those that improve mobility or cognitive ability, can slow disability progression and improve function and quality of life.

Interdependent The needs of chronic care patients are highly interrelated, yet financing and delivery of care often occurs through a plethora of isolated contracts, regulations, providers, and staff. Often scant attention is given to how multiple but uncoordinated interventions affect cost and care outcomes. Multiple diseases are common in chronic care patients, and interrelationships among diseases often complicate care management. Optimal prescribing for these patients requires input from an interdisciplinary team of caregivers. Contracts with provider networks or alliances should include incentives that enable practitioners who serve the same person to work together in achieving common cost and quality outcomes.

Ongoing Unfortunately, policymakers and payers focus primarily on reducing costs care component by care component, as if hospitals, home health agencies, nursing homes, and pharmacy services were unrelated businesses, with no sense of the cumulative effects of ongoing chronic care interventions on cost and quality over time. Current training and compensation for providers is often focused on responding to a medical circumstance or crisis event, disregarding care needs that extend over time. The ongoing nature of chronic conditions must be acknowledged through a more longitudinal perspective on the management, cost, and evaluation of the pharmaceutical care provided to people with chronic conditions.

(Source: Chronic Care in America, A 21st Century Challenge, Robert Wood Johnson Foundation, 1996)

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Section 2:

Implementing Integrated Pharmaceutical Care Pharmaceutical care is central to the overall treatment and ongoing management of chronic conditions, and therefore pharmaceutical services must be organized and delivered in concert with the continuum of care. Integrated pharmaceutical care is not about an increase or decrease in use of pharmaceuticals; it is about enabling appropriate pharmaceutical management as a integral component of primary, acute, and long-term care services. This section provides a vision for integrating pharmaceutical care and includes a framework for organizations to create a systems solution in addressing care challenges. This section also describes the benefits of integrated pharmaceutical care, provides examples of organizations’ successes, and offers steps for moving ahead.

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The National Chronic Care Consortium and The National Pharmaceutical Council

The Vision Optimal care of the chronically ill in both public and private-pay programs requires moving from reducing costs for defined programs to exploring incentives and oversight functions that can enable the establishment of a new generation of care in keeping with the nature of chronic illness. The NCCC and NPC’s vision for the healthcare delivery system of the future is one where care is organized around the multidimensional needs of the person, is focused on disability prevention, and extends across time, place, and setting. For people with chronic conditions, the coordination of services in this way is not a luxury but a necessity. The organization, management, and delivery of pharmaceutical care should support the goal of continuity of care—this is particularly important for older adults and those with chronic conditions who require care from several providers. Consider the characteristics of chronic conditions listed below and how the healthcare delivery system can reorganize pharmaceutical care to mirror these characteristics.

Characteristics of Chronic Conditions

Implications for Pharmaceutical Care

Multidimensional The illness affects the whole person.

➤ The choice of medications should recognize

Interpersonal The illness affects and is affected by family and friends.

➤ The overall effects of pharmaceutical

Disabling The illness can significantly affect a person’s ability to carry out the most basic daily activities.

➤ Pharmaceutical treatment should seek to

Interdependent Care is often complicated by interrelationships among multiple conditions.

➤ Medications given for one disease can

Ongoing The illness does not disappear after a few office visits or a hospitalization.

➤ Medication records should follow the

Integrating Pharmaceutical Care: A Vision and Framework

psychological and social factors as well as biological and lifestyle factors. Medication regimens should be monitored to determine overall effects on these dimensions. treatment should enhance, or at least not impede, a person’s ability to perform social roles and to derive benefits from family/ friend relationships. prevent, delay, or minimize disability prevention and should not impair performance of important activities of daily living or result in further dependence. enhance or minimize the effects of medications given for another disease. Thus, the course of treatment should take into account comorbidities and drug interactions. patient across sites and providers. Continuity of care should be supported through communication processes and team management. Improving the health and well-being of a person over the long term should be a goal of pharmaceutical care.

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The NCCC and NPC have recognized two important aspects of providing optimal pharmaceutical care within a care delivery system. First is the organization of pharmacy services within and across care delivery sites, which influences how pharmaceuticals are ordered, distributed, and evaluated. This includes an infrastructure that allows the organization to track prescriptions and treatment outcomes. Second are the processes whereby medications are prescribed, used, monitored, and determined to be effective for a given patient or group of patients. This includes a feedback loop to prescribers and other care managers to monitor effectiveness and evaluate the need for modification of the treatment.

Integrated Pharmaceutical Care Principles Healthcare organizations may wish to adopt the following principles for integrating or reorganizing their pharmaceutical care services. 1. Pharmaceutical care is an integral part of any continuum of services offered by a healthcare organization. 2. The effect of pharmaceutical care, in combination with other services or treatments, optimizes functional and medical outcomes of those served and prevent, delay, or minimize disability progression. 3. Pharmaceutical care policy/practice supports continuity of care across settings. Settings and providers pursue a common set of pharmaceutical care objectives to optimize cost, quality, and satisfaction outcomes. 4. High-risk patient groups warrant special attention by the healthcare system related to medication use, prescribing patterns, efficacy of pharmaceuticals, and compliance. 5. Outcomes associated with an integrated pharmaceutical care approach are measured. 6. Pharmaceutical care decisions are integral to comprehensive care plans. Care plans take into account the multidimensional nature of clients served. 7. The approach to pharmaceutical care for an individual responds to the changing dynamics of a person’s condition. 8. People who are responsible for deciding, ordering, distributing, administering, monitoring, and evaluating pharmaceutical care are expected to function as part of a common care team. 9. Clients and their families are important partners in medication management. The healthcare organization promotes this role through information, training and education on self care, wellness, disease characteristics, and proper use of medications.

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10. The structure of pharmacy services and how they are organized within a multiorganizational delivery system promotes cross-site communication and decisionmaking on pharmaceutical care across the system. 11. Leadership and support from the highest management and governance levels of the organization is necessary to ensure that the quality of pharmaceutical care is high. 12. Pharmaceutical information is a part of a comprehensive set of information on clients to understand medical, functional, and psychosocial needs. 13. All necessary information on medications is available to practitioners across settings when they need it, with appropriate safeguards to maintain client confidentiality. 14. Financial incentives of providers related to pharmaceutical care are aligned to promote and optimize cumulative clinical and economic outcomes across the system. 15. The system takes a long-range view when determining the cost effectiveness of pharmaceuticals. 16. The healthcare system is aware of rules and regulations of public and private purchasers related to pharmaceutical care and of limitations in the pharmacy benefits of clients’ health insurers. The healthcare system works to minimize adverse effects and maximize positive opportunities arising from these rules, regulations, and benefit structures.

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The Framework: A Systems Solution Integrated pharmaceutical care must be part of a systems solution. Simply changing practice guidelines or creating new protocols will not achieve the desired patient care results. The problems are systemic and intertwined; therefore, basic changes are required in the infrastructure and organization of the healthcare delivery system, as well as in clinical practice. NCCC’s vision of an integrated approach to care, including pharmaceutical care, involves four components of integration: governance/management of the organization, clinical management of patients, information systems, and financing through payment and reimbursement systems.

Governance and Management Many senior executives of healthcare organizations are encumbered by organizational structures, governing bodies, and system performance measures that are out of step with future care requirements and expectations. Meeting the chronic care challenge requires redefining the governance and management of health systems to reflect a new vision of care. This includes changing board composition, accountability measures, reporting relationships, and staff performance incentives. In pharmaceutical care, this translates to leadership and support for an integrated approach across the various sites of care in the system to ensure that ongoing patient needs are met. Thus, the structure and organization of pharmacy services would promote cross-site communication and decisionmaking about pharmaceutical care across the system. There must be accountability for how pharmaceuticals are managed and provided to customers, at the highest level of system governance, with special emphasis on chronic care populations. Other characteristics of an integrated system related to governance and management of pharmaceuticals include • A management structure that includes assignment of responsibility for providing caregivers with the tools required for an integrated pharmaceutical approach • Management and clinical leadership that ensures necessary training in an integrated approach to pharmaceutical care • An emphasis on the use of pharmaceuticals in primary and secondary prevention to prevent clients from becoming high-risk patients • Considerations of epidemiological factors in the care of individuals, including demographics, disease incidence, and prevalence in populations and subpopulations, especially in high-risk patients • A structure for systemwide monitoring of medication effectiveness and treatment outcomes • Evaluations of new drugs or treatment regimens and a review of existing drugs, policies, and procedures for effectiveness

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Clinical Management The goal of integrated care management is that care provided in different settings at different times and by different professionals to support common patient and system goals. To achieve this, organizations need to establish seamless continuums of care, including the full spectrum of primary, acute, and long-term care services. If providers create and implement care plans that recognize the multidimensional aspects of disease, patients moving between care settings will not experience discontinuity. Practitioners will understand the risk factors associated with disease and disability progression and will develop protocols that prevent, delay, or minimize disability progression and the future need for high-cost services. Key characteristics of an integrated approach to pharmaceutical care management include • Effective methods for population-based management of conditions, particularly where therapy depends heavily on pharmaceuticals • Care plans that account for the multidimensional nature of clients served • Early identification of changes in a person’s condition, diet, lifestyle, or use of nonprescription drugs that could affect response to prescribed medications— these changes are monitored and prescribed treatments are altered if necessary. • Prospective identification of high-risk individuals—upon identification, pharmaceutical therapy is initiated or changed to avoid adverse outcomes • Prescribers and pharmacists function as part of a care team. • Providers and care managers work effectively to avoid delays or interruptions in providing pharmaceutical treatment and are supported in managing pharmaceutical care across settings/sites of care and over time. • Providers inform patients about pharmaceutical options and understand the effects of prescribed medication and its interaction with diet, exercise, and nonprescription drugs. Patients are actively involved in choosing a course of treatment. • Providers actively seek patients’ perspectives in evaluating the effectiveness of pharmaceutical care. Satisfaction with specific pharmaceutical regimens is assessed, and this information is used in prescribing decisions and modifications to treatment protocols. • Providers and care managers regularly monitor compliance with medication regimens. For clients at risk for noncompliance, the clinical team works with the client and caregivers to modify the regimen or address the issues underlying noncompliance. • The organization educates staff on health beliefs and cultural norms of various ethnic, culturally defined, and age groups, especially regarding beliefs about the role of pharmaceuticals in maintaining or improving health status.

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Information Systems The potential of information systems technology far exceeds applications that most healthcare organizations have in place today. Although organizations may collect key clinical, demographic, service use and financial data on an individual patient or set of patients, this information resides in different databases and at separate sites. In general, organizations are not currently able to link the data sets —and thus they cannot accurately identify the outcomes or costs of any specific chronic disease or disability over the course of treatment. Providers often cannot access important information in “real time” when it would be most useful in decisionmaking. Pharmaceutical care information may be incomplete or may reside in the separate database of each service sector (inpatient, hospital, physician clinic, ambulatory care, home health agency, nursing facility, or retail pharmacy). The need to measure outcomes of care is more urgent than ever. The ability to track and coordinate pharmaceutical use as patients move across the system is a necessary component of integrated care. This ability is also necessary if new therapies and care approaches are to be appropriately evaluated and used to achieve optimal care and cost savings. Unfortunately, most delivery organizations have not yet linked their pharmacy data with patient-level information from other services, such as hospital admissions, laboratory data, and office visits. The ability of health plans to link this data is important for implementation of fully integrated pharmaceutical care. In an integrated system, pharmaceutical care information would be part of a comprehensive database that would help providers understand clients’ medical, functional, and psychosocial needs. All necessary information on medications would be available to practitioners across settings with appropriate safeguards to maintain client confidentiality. Key characteristics of an integrated information system include • The ability to integrate medical cost and utilization data with pharmacy data and to track and report aggregate trends in outcomes over time and across settings • The ability to generate client-specific reports showing care over time—for example, a record of the client’s entire medication profile shown over time and across settings • The ability of all care providers and prescribers to access necessary medication information • The ability to identify potential drug interactions and to trigger actions by physicians and other prescribers proactively Full and immediate integration of information systems is not a realistic objective for most organizations. It is a lengthy and expensive process, which should be undertaken incrementally. A key step for integrating pharmaceutical care, however, is the ability to link patient-level prescription data with utilization data for other services. The cost of making this link may not be as high as implementing a fully computerized patient record.

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Financing Services for people with chronic conditions are financed by multiple public and private sources, each using a different approach to program administration. Unfortunately, the current financing and administration of government-sponsored programs often have the unintended effect of locking in place a fragmented, institution-based, cure-oriented approach to care. Medicare, Medicaid, and many other programs frequently provide disincentives for third-party payers and providers to take a holistic, longitudinal approach to chronic care. Even within managed care programs, costs and quality of care are often managed through a series of cost or discount-based subcontracts with providers—reducing the potential for shared incentives or common goals across sites of care. Proper management of chronic conditions will require a shift in the focus of financing and an alignment of incentives to achieve benefits that are cost-effective to purchasers of care. Key characteristics of an integrated approach to pharmaceutical financing include • The healthcare system’s contracts and provider payment methods include incentives for providers to manage pharmaceuticals across settings and over time, basing reimbursement on providers’ ability to impact care and cost outcomes according to system-wide cumulative care and cost goals. Contracts with aligned financial incentives for medication management across sites of care cover an increasing proportion of the healthcare organization’s patient population. • The philosophy of integrated pharmaceutical care is extended to contract negotiations with payers and other providers to work toward continuity of care. Risk contracts and contracts with outside vendors are reviewed by management and modified where possible to ensure effective cross-site communication and medication management. • An evaluation of pharmacy costs and other treatment options in relation to their effectiveness over the long-term. Thus, the purchase cost or per dosage cost for a given medication is considered only one aspect of the total value of the medication in evaluating treatment options. Other issues to consider include ease of use for the patient, history of patient compliance with the medication, total treatment costs over a longer time interval (e.g., one to five years), research on effectiveness compared to other drugs or treatments, provider satisfaction, patient satisfaction, potential side effects, and likelihood or potential of drug interactions. • The design of the pharmacy benefit would seek to minimize adverse clinical effects and maximize positive opportunities arising from rules or limitations of the benefit.

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Benefits of Integrated Pharmaceutical Care Integration of pharmaceutical care with all other care decisions will improve the effectiveness of therapy in many ways. Providers will diagnose disease and identify related conditions at an earlier stage so that appropriate therapies can be prescribed sooner to prevent further deterioration. Interdisciplinary teams of clinicians and pharmacists and electronic systems that give warning signals at the time of prescribing will avoid waste and increase satisfaction. Patients who receive better education about their medications should understand the reasons and the directions for their therapy more fully—leading to increased compliance and improved clinical outcomes. Caregivers will improve their communication and feedback. This will enhance the efficiency of treatment and allow the care provider team to better monitor the effectiveness of therapy. In turn, this will enable more timely alterations in therapy for individuals and targeted patient groups. Healthcare organizations also will realize the benefits of an integrated approach. A Blue Cross/Blue Shield survey examined how health plans were responding to increasing pharmaceutical costs and how they were planning to improve their capabilities over time. The most successful health plans were found to be working toward a fully integrated patient care approach. In such plans, reporting structures and staffing allowed for interaction and communication between pharmacy and other clinical staff, and integrated data capabilities allowed timely access to data from disparate settings (Boland, 1998). In theory, a healthcare organization with integrated pharmaceutical care will • Target high-risk patient groups, especially those requiring multiple medications, for enhanced management to avoid problems such as adverse drug-to-drug or drug-to-disease reactions, over or undertreatment of comorbid conditions, and noncompliance with regimens. • Provide information to patients and their families and allow them to be partners in their own healthcare. • Consider the multidimensional needs and characteristics of patients when choosing a course of treatment, establishing pharmaceutical policies, and structuring drug benefits. • Evaluate pharmaceutical care and track effects. • Consider the cost of a particular drug or course of treatment as only one factor in selection of medications; other factors include clinical effectiveness across a variety of patients, compliance issues, side effects, ease of administration, and effect on systemwide costs. • Make information about medications accessible—with appropriate safeguards— to all providers in all sites of care to support effective decisionmaking. • Arrange and manage pharmacy services to support care goals through cross-site communication and interdisciplinary team management.

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Case Studies This paper presents concepts and issues in true delivery system integration. But putting these concepts into practice in the real world can be challenging. Hearing about other organizations’ experiences regarding barriers and processes for improvement can be useful for organizations wishing to implement their own programs. Below are descriptions of current programs that are representative of best practice prototypes. Common themes in these examples include development of systems approaches to reduce unnecessary drug use and adverse effects; management of pharmaceutical care by interdisciplinary teams; strategic use of pharmacists; coordination of information; development of computerized decisionsupport systems; and implementation of an information-based technique for improving the quality of pharmaceutical care.

Improving Care Processes An Interdisciplinary Team Approach to Care At Johns Hopkins Bayview Medical Center, an interdisciplinary team approach, together with Clinical Practice Improvement (CPI) techniques have changed the way care is delivered and evaluated. CPI creates a dynamic environment for improving the process of care, including pharmaceutical care. It involves developing a consensus of practitioners on the process used for treatment of a given disease (e.g., drug selection, dosages, timing of administration), measurement of treatment outcomes, and feedback to the practitioners. Outcomes include effectiveness of treatment, complications, long-term medical outcomes, patient functional status, patient satisfaction, and overall treatment costs. A CPI team evaluates this information and makes fact-based recommendations on improvements in the process. The modified process is then implemented, evaluated, and fed back to the practitioners. Continuous quality improvement is possible by repeating this sequence. Physicians respond favorably to this evidence-based, non-judgmental approach to improving quality of care (Buckle et al., 1999; Horn, 1995).

Reducing Adverse Drug Effects In 1988, LDS Hospital, a division of multihospital Intermountain Health Care (IHC) in Salt Lake City, implemented a process-of-care approach to the management of infectious disease. With a focus on the complete continuum of care, the program uses a computer-assisted decision support system based on practice guidelines derived from a consensus of local physicians. The guidelines were programmed into a hospital information system as rules, algorithms, and predictive models. The LDS antibiotic management process extends far beyond initial product selection and includes choosing the correct dose and the correct route and timing of administration for the individual patient. It also takes into account such factors as current physiological functional status, decisions to obtain cell cultures, laboratory tests, and duration of therapy. LDS Hospital evaluated the effects of this integrated care program seven years after implementation and found that adverse drug events associated with antibiotics were reduced by 30 percent and mortality declined. In addition, expenditures for Integrating Pharmaceutical Care: A Vision and Framework

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antibiotics decreased from 25 percent of total costs in 1988 to 13 percent, although the number of patients receiving antibiotics increased from 32 percent to 53 percent. Trend analysis showed that antimicrobial resistance patterns have been stable (Evans et al., 1998). Since the trial, IHC has implemented the program in many of its large hospitals, emergency rooms, and outpatient clinics. The antiinfectives program has been a model for disease management applications in other specialties, including diabetes, anticoagulants, congestive heart failure, and coronary artery bypass surgery.

Evidence-Based Prescribing Challenged by the growth in the size and complexity of healthcare delivery systems and the increase in pharmaceutical costs, organizations have worked to optimize the value of pharmaceutical therapy. HealthNet, a 1.4 million member California HMO, established a data-intensive, computerized decision support system that allowed providers to practice evidence-based prescribing, often using state-of-theart medications. Using company-wide patient care data, HealthNet analyzed and provided feedback to its medical groups on treatment patterns in 13 disease groups accounting for 50 percent of drug use. This information enabled HealthNet to realize overall cost savings and quality improvement, often through the use of more costly medications (Cunningham, 1997).

A Population-Based Approach One large-scale intervention that integrated computers, pharmacists, and physicians was shown to be promising for improving prescribing patterns and supporting a population-based approach to geriatric care. Focusing on an ambulatory elderly population, an independent medical advisory board consisting of geriatric specialists in pharmacy, medicine, and nursing adopted the “gold standard” Beers criteria for seniors to identify drugs or drug combinations that are inappropriate for the elderly. These included long-acting sleeping and anti-anxiety agents, shortacting barbiturates, anticholinergic antidepressants, certain narcotic analgesics, prescriptions exceeding maximal dosages for the elderly, nonsteroidal antiinflammatory drugs for patients with ulcers, and beta-blockers for patients with chronic obstructive pulmonary disease. Using the online database, provider prescribing patterns were evaluated for a total of 23,269 older patients receiving prescription drugs from a large pharmacy benefits manager during a 12-month timeframe. Potentially inappropriate drug use was identified. Computer alerts triggered telephone calls to the physicians by pharmacists with training in geriatrics. During these calls, the pharmacists provided information on the principles of geriatric pharmacology and on quality of care, based on best practices. The telepharmacy intervention yielded a contact rate with physicians of 56 percent. About one quarter of all alerts were accepted by physicians—with a range of 40 percent for one type of drug to two percent for another. (Monane et al., 1998)

Reorganizing Pharmaceutical Care A Functional Integration Team Fairview Health Services, a regional healthcare system in Minnesota, grew from a single hospital to a vertically-diversified multiorganizational healthcare system by acquiring, building, and consolidating hospitals and developing hospital-based home care and senior services. However, separate facilities within the

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organizationcontinued to operate largely independently of each other, including in the provision of pharmaceutical care. In 1991, the system’s management was restructured to bring the hospital services together in one division and the non-hospital services in another division, known as Continuum Services. In 1995, the many outpatient and retail pharmacies owned and operated by Fairview participated in a systemwide Medication Management Task Force to increase quality and control costs by integrating medication management from the time a decision was made to use a drug to the time it was administered. In 1997, Fairview began to critically review several key functions, including how they organized pharmacy services across the system and how they delivered pharmaceutical care. They established a “functional integration team” of professionals across the system; this team’s recommendations resulted in a more centralized management structure and changes to certain aspects of ordering, distributing, and monitoring medication use. A major focus was to bring the patient, physician, and pharmacist together to better manage pharmaceutical care (NCCC Member Information).

A Risk Reduction Program As part of its quality improvement and performance monitoring program, Lancaster Health Alliance in Pennsylvania used a transdisciplinary leadership team to review practices at its 30-bed transitional care unit (TCU). The team discovered that many TCU residents were taking a large number of medications—outside of a range considered to be a benchmark for this population. Residents were averaging 15 medications per day, with a range of between 10 and 22 medications daily. Furthermore, the use of antipsychotic medications seemed high. The leadership team began a Risk Reduction Program and launched a multipronged approach to addressing polypharmacy; this approach included highlighting the role of clinical pharmacists in physician education, researching and publishing geriatric dosage guidelines, presenting data on polypharmacy and its effects, and working with nurses and nursing leaders to address dosage adjustment and improve inservice education. The team then focused attention on the use of antipsychotic medications. A clinical pharmacist with knowledge of the elderly provided leadership in planning and oversight, helping to guide appropriate use. Nursing and physician staff participated in educational sessions. The organization also established a performance improvement monitoring process for effectiveness and appropriateness of psychoactive medication use. Subsequently, the clinical pharmacist collaborated with the chairman of the Department of Psychiatry to develop systemwide standards for antipsychotic drug use in the geriatric population, using data gathered from the subacute care study. Results were dramatic. Overall medication use dropped to an average of 8.1 medications per resident per day, and the number of residents on psychoactive medications dropped from 15 to three over a 22-month period. Furthermore, there was a reduction in the use of restraints (from five people with restraints to zero use of restraints after November 1997). Unexpected positive outcomes included the reduction in the number of medication errors seen within the unit, perhaps due to fewer medications being given, and a heightened awareness of medication dispensing and administration on the unit. (Fridy, 1998) Integrating Pharmaceutical Care: A Vision and Framework

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Changing Organizational and Reporting Structures In the 1980s, Sharp HealthCare, a regional healthcare system in San Diego, grew from a single hospital to a group of hospitals and then to a hospital system with medical clinics and other facilities. However, like Fairview Health Services, the organization operated more as a collection of individual facilities than as a single system of care. Beginning in 1994, management worked to reengineer the organizational and reporting structures with the objective of creating an integrated system. This process allowed staff pharmacists to move into unconventional roles and to participate as decisionmakers in clinical care. Sharp created a steering committee to oversee the development and refinement of a systemwide approach to pharmaceutical care. Functional teams reporting to the steering committee worked to standardize policies and procedures. As of 1996, Sharp was working toward creating a systemwide Pharmacy and Therapeutics Committee to review guidelines for drug use and evaluate formularies (Rizos et al., 1996).

Involving Pharmacists in Care Delivery Pharmacists and Physician Partnerships A pilot project at Allina Health System in Minnesota has shown positive results among older adults seen at one of two clinics; these results included reducing polypharmacy and improving effectiveness of medications by selecting medication regimens designed for easy compliance and by identifying other user-friendly methods for elderly patients. The program partnered pharmacists with primary care physicians and targeted patients with congestive heart failure. A total of 167 patients were enrolled during a four month to 10 month timeframe. Results included • Improvement in laboratory values in patients receiving anticoagulation therapy • Decreased risk of cerebrovascular events in patients receiving hyperlipidemia therapy • Changes in medication, dosage, or reduction in number of medications due to comprehensive medication review by pharmacist/physician team • Increased number of low-income patients receiving assistance in meeting medication needs through pharmaceutical company free drug programs Despite recommendations which increased drug costs, many recommendations resulted in cost savings—not including the potential cost savings and improved patient satisfaction from reducing the risk of cardiac events. Allina plans to continue the work at its Senior Health Clinic, tracking outcomes for a greater length of time and potentially adding an additional site (NCCC Member Information).

An Integrated Approach to Medication Management A pilot program at the Sepulveda Veterans Affairs Medical Center in California offers an example of the use of pharmacists in an integrated approach to medication management. Pharmacists made home visits to evaluate medications for a group of frail older people. Patients were found to be taking a mean of 4.7 medications, although a mean of 6.0 were prescribed. Evaluations also revealed consumption of many potentially unnecessary medications (found in 70 percent of subjects) and multiple problems with the medication regimens (e.g., incorrect drug frequency or dosage, expired medications, medication omissions). Follow-up after the visit, which included patient counseling and recommendations to the prescriber, showed a significant decrease in medication problems (Hsia Der et al., 1997).

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Taking Action Integrated pharmaceutical care is not going to happen immediately. Change, particularly systems reform, is an ongoing process. The following tasks may be helpful in transforming pharmaceutical care to be more commensurate with problems of chronic disease and disability.

1. Review current practices. Examine how your system organizes pharmaceutical services and delivers pharmaceutical care, paying particular attention to care continuity across settings/programs. Conduct a base analysis of current practices on sources of information, including patients, physicians, pharmacists, and other key constituents, as well as data on drug use, adverse drug events, and other key statistics. If a patient group is particularly at risk for high medication use (e.g., frail elderly diabetics), consider focus groups or one-on-one patient interviews to better understand pharmaceutical issues from the client perspective.

2. Identify strengths and challenges. Identify key strengths and problem areas in pharmaceutical care within the organization. Prioritize areas of focus. Adopt short-term and long-term goals.

3. Examine best practices. Examine best practices and innovations in pharmaceutical care for your key focus areas. Conduct a literature search and telephone interviews or site visits to other organizations.

4. Select initiatives. Select one or two initiatives that have broad support and defined, measurable goals. Initiatives may be focused on building the organization’s infrastructure (e.g., improving cross-site transfer of pharmacy data over several settings in real time) or on delivering pharmaceutical care more effectively (e.g., for a defined frail older adult client base, building interdisciplinary teams of care providers that include a pharmacist trained in working with older adults).

5. Provide appropriate resources. Ensure that the pharmaceutical care initiative is appropriately financed.

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6. Track progress. Ensure that progress is tracked through accurate data collection.

7. Communicate results. Make sure your organization communicates the results of your efforts across the organization. For long-term efforts, communicate interim findings.

8. Evaluate your success. Evaluate the success of your pharmaceutical initiatives to determine if they should be expanded, modified, or dropped. Identify key learnings and apply them to future efforts.

9. Determine next-stage priorities. With input from key stakeholders, determine your next steps in moving toward the vision of integrated pharmaceutical care.

Integrated Pharmaceutical Care Toolbox The NCCC and NPC have developed a toolbox to assist healthcare organizations in examining and evaluating their current pharmaceutical care practices. Integrating Pharmaceutical Care is a toolbox designed to allow a multiorganizational healthcare system to analyze its own progress toward integrated pharmaceutical care—across settings and facilities—according to certain guiding principles and measurable objectives. The toolbox provides a framework and lays out a suggested process for conducting a self-assessment. The centerpiece of this toolbox is the Criteria and Measures for Integrated Pharmaceutical Care. Working with a group of physicians, pharmacists, and administrators, the NCCC and the NPC developed these criteria and measures to define targets for healthcare organizations to use in moving toward a more integrated approach to providing pharmaceutical care. For more information about this toolbox, call the NCCC at (612) 858-8999.

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Hsia Der, E., L.Z. Rubenstein, and G.S. Choy. “The Benefits of In-home Pharmacy Evaluation for Older Persons.” Journal of the American Geriatrics Society 45 (2): 211–214 (1997). James, B., Executive Director for Health Care Delivery Research, Intermountain Health Care. Interview with staff of the President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry, January 9, 1998. Leape, L., et al. “Systems Analysis of Adverse Drug Events.” Journal of the American Medical Association 274 (1): 35–43 (1995). Legg, R.F., et al. “Cost-effectiveness of Sumatriptan in a Managed Care Population.” American Journal of Managed Care 3 (1): 117–122 (1997). Legg, R.F., et al. “Cost benefit of Sumatriptan to an Employer.” Journal of Occupational and Environmental Medicine 39 (7): 652–657 (1997). Levy, R.A. and D. Cocks. Component management fails to save health care system costs, the case of restrictive formularies. Second edition. Reston, VA: The National Pharmaceutical Council, 1999. Lindley, C.M., M.P. Tully, V. Paramsothy, and R.C. Tallis. “Inappropriate Medication is a Major Cause of Adverse Reactions in Elderly Patients.” Age and Aging 21 (1992): 294–300. McLaughlin, T.J., et al. “The Effect of Comorbidity on Use of Thrombolysis or Aspirin in Patients with Acute Myocardial Infarction Eligible for Treatment.” Journal of General Internal Medicine 12 (1997): 1–6. Monane, M., et al. “Improving Prescribing Patterns for the Elderly Through an Online Drug Utilization Review Intervention.” Journal of the American Medical Association 280 (14): 1249–1252 (1998). Mueller, C., C. Schur, and J. O’Connell. “Prescription Drug Spending: The Impact of Age and Chronic Disease Status.” American Journal of Public Health 87 (10): 1626–1629 (1997). National Health Information. “HIV Treatment Strategies Must Shift to DM Focus.” Healthcare Demand and Disease Management 4 (10): 145–160 (1998). Ogden, J.E., A. Muniz, A.A. Patterson, D.J. Ramirez, and K.W. Kizer. “Pharmaceutical Services in the Department of Veterans Affairs.” American Journal of Health System Pharmacists 54 (1997): 761–765. Peters, W.P. “Comparative Effects of GM-CSF and PBPC chemotherapy.” Blood 81 (7): 1709–1719 (1993). Pierpaoli, P.G., R.W. Anderson, W.N. Kelly, A. Linggi, and L.D. Pelham. “Strategic Planning for Clinical Services: Panel Discussion.” American Journal of Hospital Pharmacists 43 (9): 2174–2177 (1986). Reeder, C.E., C.M. Kozma, and C. O’Malley. “ASHP Survey of Ambulatory Care Responsibilities of Pharmacists in Integrated Health Systems.”American Journal of Health System Pharmacists 55 (1998): 35– 43. Redelmeier, D.A., H.T. Siew, and G.L. Booth. “The Treatment of Unrelated Disorders in Patients with Chronic Medical Diseases.” New England Journal of Medicine 338 (21): 1516–1520 (1998). The Robert Wood Johnson Foundation. Chronic Care in America, a 21st Century Challenge. The Robert Wood Johnson Foundation: Princeton, 1996. Soumerai, S.B., D. Ross-Degnan, J. Avorn, T.J. McLaughlin, and I. Choodnovsky. “Effects of Medicaid Drug-Payment Limits on Admission to Hospitals and Nursing Homes.” New England Journal of Medicine 325 (1991): 102–107. Soumerai, S.B., T.J. McLaughlin, D. Ross-Degnan, C.S. Casteris, and P. Bollini. “Effects of Limiting Medicaid Drug Reimbursement Benefits on the Use of Psychotropic Agents and Acute Mental Health Services by Patients with Schizophrenia.” New England Journal of Medicine 331 (1994): 650–655. Stewart, R.B., M.T. Moore, F.E. May, R.G. Marks, and W.E. Hale. “A Longitudinal Evaluation of Drug Use in an Ambulatory Elderly Population.” Journal of Clinical Epidemology 44 (12): 1353–1359 (1991). Stewart, R.B. and J.W. Cooper. “Polypharmacy in the Aged: Practical Solutions.” Drugs and Aging 6 (1994): 449–461. Stocker, M.A. Quotation from Michael A. Stocker, President and CEO of Empire Blue Cross and Blue Shield (NY). Wall Street Journal July 12, 1996. Wilcox, S.M., D.U. Himmelstein, and S. Woolhander. “Inappropriate Prescribing for the CommunityDwelling Elderly.” Journal of the American Medical Association 272 (1994): 292–296.

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Acknowledgements The NCCC and NPC acknowledge the contributions of Jean Polatsek who reviewed this document and the staffs of the NCCC and NPC who provided support for its publication.

Authors Richard J. Bringewatt is President and CEO of the National Chronic Care Consortium (NCCC). Mr. Bringewatt developed the “chronic care network” strategy that is central to the NCCC’s work and assumed the lead role in developing the NCCC. During his 29-year career, Mr. Bringewatt has developed and managed numerous healthcare programs including establishing a multidisciplinary clinic, a senior HMO, and a variety of other primary, acute, and long-term care programs for the chronically ill. He has also provided leadership in health systems policy development at the county, state, and federal levels. A national expert on chronic care, Mr. Bringewatt has provided testimony on Medicare reform before the United States House Ways and Means Committee and has consulted with many of the nation’s leading demonstrations in chronic care. Richard Levy, Ph.D., is Vice President of Scientific Affairs for the National Pharmaceutical Council (NPC) and is responsible for research planning, development, and coordination. His current research interests center on issues related to achieving optimal value of medications. Specific research areas include the role of pharmaceuticals in organized healthcare systems, issues in geriatric pharmacotherapy, patient noncompliance with medications, and clinical and economic aspects of pharmaceutical benefits programs. Dr. Levy has spent more than 30 years teaching, writing, and conducting research in universities and private industry and is the author of more than 70 publications in pharmacology and health services research. Deborah Paone serves as the National Chronic Care Consortium's Senior Research Associate, providing leadership in developing practice-based products and resources on systems integration across the full continuum of primary, acute, and long-term care settings/services. Ms. Paone serves as consultant to the State of Minnesota on their dually eligible demonstration (Minnesota Senior Health Options). She also works with member committees on operational and strategic issues in coordinating care across settings and over time.

National Chronic Care Consortium National Chronic Care Consortium 8100 26th Avenue South Suite 120 Bloomington, MN 55425 (612) 858-8999 Fax: (612) 858-8982 www.nccconline.org Integrating Pharmaceutical Care: A Vision and Framework

National Pharmaceutical Council National Pharmaceutical Council 1894 Preston White Drive Reston, VA 20191-5433 (703) 620-6390 Fax: (703) 476-0904 www.npcnow.org.

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