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Todd SorensonLeveraging trust for behavior change: Interdisciplinary team connects with hard-to-reach patients, addresses medication and SDOH problems



By Todd D. Sorensen, PharmD, FAPhA, FCCP, Professor and Senior Executive Associate Dean for Strategic Initiatives and Faculty Affairs, College of Pharmacy at the University of Minnesota, and Executive Director of Alliance for Integrated Medication Management (AIMM)

September 14, 2022

Patient trust can be difficult to cultivate, but it’s essential to ensure patients receive the right medicine in the right amount at the right time. That applies to any patient, but it’s especially true for individuals without a relationship with a provider.

Medication Care Coordination (MCC), a care coordination initiative in rural Washington State, has found a way to earn patient trust and connect them with pharmacists and physicians.

MCC, which serves older adults in the eastern part of the state, brings together pharmacists and care coordinators to address medication-related problems and social determinants of health that impair patients’ ability to achieve the intended benefits of their medications. It’s designed to support and supplement the primary care provider’s care plan.

The Empire Health Foundation funds the collaborative effort. Participants include Aging and Long-Term Care of Eastern Washington, Rural Resources Community Action and Medication Review, Inc. (MRI). The Washington State University School of Pharmacy, which is providing academic resources, has already generated several journal articles based on the early pilots.

My organization, the Alliance for Integrated Medication Management—better known as AIMM—is facilitating the initiative’s leadership agenda, coordinating strategic program design, and providing implementation and program evaluation support.

Identifying the problem

Compared to those in more urban areas of the state, the people living in rural Eastern Washington tend to be older, with higher rates of chronic conditions. As a result, they are taking many prescription—and over the counter—medications. To quote one of the pharmacists, their medications have become more of a problem than a solution. On average, participants took 15 medications and had nine chronic conditions. (See here.)

Because their medications were not actively managed and optimized, these individuals were at serious risk. That’s not a surprise. The health care system simply isn’t designed to deliver the coordinated, patient-centered care these patients need to manage their chronic conditions and medications. They need access to medication management services integrated with primary care, and they need someone to help them overcome their barriers to care.

Empire Health Foundation decided to find a solution. It convened a steering committee of institutional and community providers to help guide the development of a system to meet the needs of these difficult-to-reach patients. What emerged was MCC.

Community-based advocate

Community-based care coordination is a powerful tool. That’s why the centerpiece of MCC is a community-based care coordinator who visits individuals in their homes, building trust and serving as their advocate. This care coordinator connects the patient remotely with pharmacist and the primary care provider. Because the patient trusts the care coordinator, they are more likely to trust the pharmacist and provider—think of it as a halo effect.

Over a three-to-six-month period, this team addresses medication-related problems and the related social barriers. They don’t merely solve the problem: They bolster the patient’s own skills, confidence and knowledge to better self-manage their care.

Expanded role for clinical pharmacists

The intervention may begin with medication problems, but it becomes clear that the issues are much more complex: They may have housing problems, mental health issues or other challenges that interfere with taking their medication appropriately.

Clinical pharmacists, specially trained for the program, spend as much time as they need with patients, allowing them to delve more fully into the social factors that could be affecting a person’s medication use. It’s important to stress that clinical pharmacists take a whole-person approach that looks at all the medications and all the conditions together, adding, modifying and changing medications based on resolving drug therapy problems in their totality.

Once the pharmacist identifies the mediation problems, they can develop strategies and recommendations for resolving them. Working with the patient across multiple visits, the clinical pharmacist can minimize or even eliminate medication therapy problems. It takes time: These problems run much deeper than a lack of adherence or polypharmacy. Pharmacy problems include dosage issues (too high or too low), unnecessary therapy, inappropriate medications, inadequate therapy, adverse reactions and medications that simply don’t work.

Just as important, because they work in concert with the trusted care coordinator, and because they meet with the patient over several virtual sessions, they make the patient feel more empowered about their medication regimens; they help them understand what medications they’re taking and why it’s important that they take them. Again, it’s about trust.

As a result, patients appreciate the program. They are not merely satisfied; they’re grateful for the time everyone has taken to help them understand their medications. Some are even recommending the program to friends, family members and neighbors.

Supporting physicians

Physicians want to reach these people; this program helps them connect effectively. The coordinator has already built trust on the front end. Like the clinical pharmacist, the physician can leverage that trust and connect much more quickly with the patient. This approach also gives physicians the insights they desperately need, but often don’t get, such as Where does the patient keep their medicines? and What are they actually taking?

The future is interdisciplinary

By fully engaging physicians and patients, MCC’s interprofessional teams resolve medication-related problems and improve patient quality of life, including reduced hospitalizations and better A1C numbers.

In 2021 of the 199 clients referred, 99 enrolled and 59 completed the program. Of those who “graduated” in 2021, 93% met personal goals, 80% resolved medication barriers, 90% percent accepted provider recommendations, 93% showed improved patient activation and 73% showed improved quality of life.[1] In fact, MCC received a 2022 Aging Innovations Award from USAging.

As we reorganize the health care experience, we need to ensure it’s done in a patient-centered, systematic and coordinated way—and especially in terms of medication use—we must approach this in a more rational way than it has been in the past.

We believe the way to lower health care costs and improve patient outcomes for high-risk patients is to provide access to comprehensive medication management services through an integrated, interdisciplinary team of health care providers. MCC is an important step in that direction.

For further information, listen to the recent GTMRx podcast.

[1.] Aging Innovations and Achievement AWARDS SHOWCASE, USAging 2022

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