A Team-based Care Approach to Reach Rural, Underserved Virginia Patients
Submission Date: August 2018
State/Territory Submitted on the Behalf of: Virginia
States/Territories Involved: Virginia
Domain Addressed:Health Systems Strategies
Public Health Issue:Successfully treating high blood pressure, a common health condition in the United States, often requires prescription medication dispensed by a pharmacist.
Blood pressure control improves when pharmacists use a team-based approach to work collaboratively with primary care providers to provide chronic care management (CCM).
The 6,000 residents of rural Emporia, Virginia, lack many health services such as chronic care management for hypertension and diabetes.
Program Action:NACDD, in coordination with the CDC Division for Heart Disease and Stroke Prevention, works with a Virginia team to accelerate team-based care using the Pharmacist Patient Care Process (PPCP) to manage high blood pressure. CCM and the PPCP are similar methods for promoting team based care, for enhancing the connections between primary care providers and pharmacists, and for improving patient outcomes.
Virginia’s quality improvement organization, Health Quality Innovators (HQI), used insurance claims, Medicare Part D data, and other analytics to identify areas of the state with high potential healthcare needs related to chronic disease, such as Emporia.
HQI enlisted a local independent pharmacy, A&B Pharmacy, and a primary care practice, Emporia Medical Associates, to implement a CCM pilot for selected patients with diabetes and high blood pressure.
The Virginia Department of Health (VDH) provided regular information updates to support and expand the pharmacy activities. As the pilot progressed, community health workers began to work with patients to connect them with local resources for disease management.
Impact/Accomplishments:A&B Pharmacy and Emporia Medical Associates saw an 8% increase in medication reconciliation, an 11% increase in use of tobacco cessation services, and a 6% increase in the number of patients receiving chronic care management through provision of the following services: monthly check-in calls; guidance on healthy eating and active living; medication reconciliation/synchronization; help with tracking blood glucose and blood pressure; and opportunities to ask questions one on one with the pharmacist.
All participating patients reported improvement in health outcomes related to healthy eating and exercise. HQI’s posted videos highlight the work as described by the A&B registered pharmacist and certified pharmacy technician.
As a result of this effort, the Virginia Pharmacy Association, VDH, and HQI established formal partnerships. The Virginia Pharmacy Association will help other community pharmacies implement the PPCP to promote consistency and measurability in pharmacists’ service delivery.
VDH will partner with HQI and the Virginia Pharmacy Association to disseminate an implementation guide to help other primary care/pharmacy partners expand this work.
This project provided baseline data and outcomes that were used to support two VDH applications for CDC funding to continue and expand this work.
Program Areas:Health Equity and Cultural Competency
State Contact Information:
VA
Kayla Craddock, MPH
Virginia Department of Health, Quality Improvement Supervisor
804-864-7871
kayla.craddock@vdh.virginia.gov