BETHESDA, MD 12 November 2009—For more than a year, a rural health system in central Minnesota has been offering select patients a medical home, complete with a pharmacist.
Lakewood Health System, with its main campus just east of 4.5-square-mile Staples, started its patient-centered medical home in early 2008.
Hospital-based clinical pharmacist Julie Moriak has been providing ambulatory care pharmacy services to Lakewood’s medical home patients from the start.
The medical home operates out of the Staples Clinic, on the middle floor of the large building at the health system’s main campus, Moriak said. On the top floor is the 25-bed critical-access hospital, and on the basement, or lowest, floor are the ancillary service departments.
In addition to the 25 medical beds, the health system has 10 licensed behavioral health beds and 100 licensed beds for skilled nursing or long-term care.
Medical home patients taking 10 or more medications have sort of an unwritten referral, thanks to the physician in charge, to see the team pharmacist at a mutually convenient time, Moriak said.
Family medicine physician John Halfen, who heads the program, is also the health system’s medical director.
Moriak said she interviewed about 35 medical home patients, most of them elderly, in the past year. The youngest was about 45 years old, and the oldest was age 90 or so.
Hypertension has been her patients’ most common disease, she said, with diabetes a close second and congestive heart failure in third.
Not all of her patients take 10 or more medications. Moriak said she periodically scans the clinic’s electronic medical records to identify additional patients whose medication regimen may need a pharmacist’s intervention.
Medicare Part D sponsors and the state of Minnesota pay Lakewood’s pharmacy department for the medication therapy management (MTM) services that Moriak provides to plan enrollees and certain low-income residents, she said.
But those patients, she estimated, constitute only about 10% of her clientele.
The health system has been absorbing much of the cost of her providing services to medical home patients.
"Lakewood Health System has a very firm belief in the medical home," Moriak explained.
The program’s physician in charge, she added, "is pretty adamant about continuing to have pharmacy services available for patients."
Tim Rice, president of the health system and a hospital administrator for about 35 years, said medical home patients have consistently commented on how the program improves their access to services.
"If you really focus on what is right for patients and right for services, the money usually takes care of itself," he said.
Rice said health systems provide a lot of services, such as spiritual care and health education, that do not always get reimbursed.
Moriak said her director, Brian Hinman, determines the days when she can be at the clinic.
With that information, she then checks the clinic’s electronic medical record system for when certain patients have upcoming appointments.
Her clinic-designated days will decrease in number soon, however, when another hospital pharmacist starts maternity leave, she said.
The pharmacy department, she said, has 5.2 full-time-equivalent pharmacists, including the director, and 5.6 full-time-equivalent technicians.
According to a report Lakewood submitted to Minnesota’s Office of Rural Health and Primary Care, the health system embarked on the medical home program for several reasons. Administrators were in favor of the idea. Physicians were interested in the medical home and dissatisfied with the health care system as it was. The clinic had implemented a new electronic medical record system with "untapped capabilities." And the patient population was limited and "devoted."
A patient enrolling in the medical home, the report states, must meet one of the health system’s criteria: three or more diagnoses requiring treatment; four or more prescription medications; severe illness; chronic illness; illness requiring visits every two months or less; or lack of insight into health care because of age or intelligence.
The patient also must be willing to see the same health care provider for routine matters.
In September 2008, when a subcommittee of the National Advisory Committee on Rural Health and Human Services came onsite, the health system said nearly 300 patients had enrolled in the 11-physician medical home program.
Some of the medical home patients who receive attention from Moriak do not actually meet with her.
Moriak said clinic physicians have stopped her in the hallway to ask for assistance with specific patients. After examining the records, she makes recommendations.
The 2002 graduate of the University of Minnesota College of Pharmacy said she had pushed for clinical responsibilities ever since joining the health system’s hospital pharmacy department straight out of school.
"I just kept putting enough little hints here and there . . . that Dr. Halfen, who was doing the medical home, heard that I wanted to do clinical services," Moriak said. "So he contacted my director, Brian, and asked for me to be a part of the medical home program."
By having access to the clinic’s electronic medical record system, Moriak said, she can determine before the first encounter with a patient which medications have been tried already. She can find out the kinds of procedures that have been done and the surgical and family histories.
"I like to say that I have an advantage over the general, run-of-the-mill MTM pharmacist in the community because I am using the clinical electronic medical record," Moriak said.
She also credited her health system’s environment, where she can relatively easily talk directly with another health professional.
"If I have a question about a patient," Moriak said, "I can go get it answered right away . . . . If I want to make a change or I want to make a recommendation, I can do it face-to-face."
