Making the Rounds

Even before the US Supreme Court ruled the Affordable Care Act (ACA) constitutional in June, the Hackensack Alliance Accountable Care Organization (ACO) was well on its way to implementing the fundamental changes required of the ACA—President Obama’s landmark attempt to change the way healthcare is distributed and reimbursed in the United States.

For the Hackensack Alliance ACO and the 104 doctors who have signed on with the organization, meeting the test set forthby the ACA began in April, 2012. That was when the Medicare Shared Savings Program (MSSP) signed a contract with Hackensack Alliance ACO to share in the millions of dollars the ACO could save by delivering better healthcare services at lower prices to the 14,000 Medicare patients within the ACO network. “In the first 5 quarters we have saved in excess of $14.5 million,”said Dr Morey Menacker, president and chief executive officer of Hackensack Alliance ACO, in a telephone interview.

Hackensack Alliance administrators had targeted savings of between $5 million and $10 million across the 20 disciplines practiced by healthcare professionals with privileges at 685-bed flagship Hackensack University Medical Center (UMC) in Hackensack, NJ, and the 2 other northern New Jersey hospitals within the Hackensack University Health Network: 128-bed HackensackUMC at Pascack Valley in Westwood, NJ, and the 365-bed HackensackUMC Mountainside in Montclair, NJ (Table 2). Even using the most aggressive estimate, savings have exceeded Menacker’s expectations by about 50%. The amount saved would have been even reater had the MSSP contract included Medicare Part D, which covers prescription medication, Menacker said. How Hackensack Alliance ACO and the 3 hospitals under its auspices far exceeded its savings target offers a case study in what one ACO has done to lower costs and improve services.

Nurse Navigators

Menacker said one of the first things Hackensack Alliance managers did was to make the 20 hospital practice areas patient-centered medical home (PCMH) compliant. Once that was sealed, the ACO then went off and trained the staff to become PCMH compliant.

Because the PCMH model is grounded in care coordination and communication among the different healthcare disciplines, each PCMH was required to have an electronic medical system, which the ACO then linked to a population management software program capable of gathering data from the separate electronic medical systems. Gathering the data allowed the ACO to target the top 10% highest cost patients for intervention using the concept of “nurse navigators” embedded within the PCMH setting, he said.

Nurse navigators at Hackensack University Medical Center (UMC) play a similar role to that of account managers in a large corporation. Like account managers responsible for every part ofthe client relationship across multiple departments, nurse avigators are charged with overseeing the patient’s relationship with the array of services within the healthcare system: the primary care physician, the hospital, the pharmacist, and the physical therapist.

At the end of the day, these special nurses supervise the inpatient population to make sure the care they receive is “seamless.” “A big problem is that patients go from home to the hospital and all the medications get changed because they don’t have the formulary with them,” Menacker said. “We’ve created 2 major interventions that have been dramatically successful in that area.”

One intervention involves following patients to make sure their medication reconciliation is complete, he said. The second intervention allows hospitals to supply patients with 30 days’ worth of medication, and patients are told to toss out what is left in their medicine cabinet. Nurse navigators, meanwhile, get in touch with hospital pharmacists and retail pharmacies to tell them about the changes.

With the bulk of the ACO’s patient population being 65 years or older, many on limited budgets, giving them the fewest medications at the lowest cost is essential, said ACO director Denise Patriaco. “We continually speak to them,” she said. “We have the nurse navigators come in for high-tech, hightouch with the patients. We ask, ‘Did you take your meds this morning? Tell me what you took?’ Patients need to be aware of what they are taking and why they are taking it.”

The number 1 cause of hospital readmittance is medication noncompliance, so the ACO follows up with a barrage of calls, from the day of discharge right through to subsequent office visits with primary care doctors and specialists, she said.

The average cost of a visit to the emergency department (ED) for more than 8000 patients in the United States was $2168.¹ Keeping patients out of the ED simply by reminding them to take their medication is the best way to zap hospital costs out of the system, literally at the price of a pill.

Hackensack UMC in Hackensack last year alone had 92,182 ED admissions, 12,532 inpatient surgeries, and 2.93 million outpatient visits, according to hospital statistics (Table 1).

Making the Rounds

Because Medicare Part D was not part of the MSSP contract with Hackensack Alliance, it is hard to say exactly how much the ACO’s stricter pharmacy management procedures have contributed to overall savings. It is safe to say, however, that no ACO can hope to achieve the kind of big savings delivered by Hackensack without implementing reforms around the pharmacy piece of the healthcare equation.

Medication Therapy Management (MTM) techniques show treatment costs for patients were lower by as much as $5500 per patient than for patients in the control group,² and more than 7 out of 10 physician visits resulted in at least 1 prescription medication, according to a 2006 study.³

Not long ago, it was the doctors who were best known for making the rounds and visiting dozens of patients on different hospital floors. Doctors still do that, but it is now much more common to see pharmacists making the rounds as well.

“In my experience pharmacists have not traditionally come to the floor and talked to patients,” Patriaco said.

At Hackensack UMC, though, pharmacists are just as likely as nurses to be appearing at patients’ bedsides and talking to nurses and doctors. Nor does the pharmacist’s role end at discharge following the all-important medical reconciliation.

Pharmacists, she said, “are calling nurses and physicians all day long” to make sure patients are on the proper blood thinners, and if they are on more than 1, how they got there, who made the decision, and why.

With 2014 full- and part-time registered nurses, 2 licensed practical nurses, and 401 doctors and dentists at Hackensack UMC (Table 2), pharmacists have a full plate coordinating medications among the patients served by the physicians and nurses.

Once primarily a dispenser of medication in the correct doses, the pharmacist has morphed into an equal of the practicing nurse and the doctor, with all the privileges and responsibilities that access to the hospital’s emergency medical records system can provide.

Menacker said that with Hackensack Alliance on the verge of signing new contracts with commercial insurers, it is likely Hackensack UMC will have to hire more pharmacists or consultants to help with MTM, Menacker said.

Commercial insurers typically take a closer look than Medicare at slashing the pharmacy portion of the total medical spending pie, and Hackensack Alliance is ready to make sure Hackensack UMC leans on all their PharmD’s for help.

“Doctors and the healthcare system can reduce the use of pharmacy dramatically if doctors talk and discuss the options with patients and doctors talk to other experts—nurses and pharmacists— instead of just writing a script,” Menacker said.

As Hackensack Alliance grows beyond its original Medicare population and inks commercial contracts, the ACO will look to “wrest control” of the formulary from the insurance carriers since Part D is not part of the ACO’s MSSP contract, he said.

Placing the formulary in the hands of the healthcare providers— the hospitals or nursing care facilities—only makes sense “because they know what the patients need,” he said.

Touch and Tech

Elderly patients who suffer from memory lapses often forget to take their pills, or take them at the wrong time, or take them in the wrong order or doses. Particularly if patients consume a regimen of multiple prescription drugs for chronic conditions, it is not uncommon for them to mix pills.

Following a successful pilot at Hackensack UMC with software vendor Health Recovery Solutions, high-risk patients will be provided a tablet computer to keep them on track during the critical 30-day post discharge period, said Rohan Udeshi, chief operating officer of Health Recovery Solutions.

The latest 4G tablets come with integrated glucose meters and pedometers. Data medication compliance, vital signs, physical activity, and side effects are all recorded and shared with the patient’s pharmacist, doctor, and nurse navigator.

“The tablet is loaded with reminder times,” said Udeshi. “All these data are collected and we crunch the data and alert clinicians when they need to follow up with the patient.”

Keeping patients on track with their pharmacy regimen through access to the electronic medical records is considered critical to avoiding readmission, and patients can use the tablet to record and transmit progress to their nurse navigators, Udeshi said.

Hackensack Alliance administrators originally thought the tablet would work as a hospital readmission prevention tool, but it has since developed into an ideal disease management tool and the 30-day usage period has recently been extended to 60 days, Patriaco said.

“The tablet goes with patients wherever they go,” Menacker said. “It will act as an alarm clock. There’s ongoing reconciliation that automatically gets forwarded to the nurse navigator. As home care comes to the house, they enter the vitals into the tablet and forward the data to the nurse navigator.”

A 50-patient randomized blind trial found an 8% readmission rate after 30 days for the patients using the tablets. The control group that received the usual care suffered a readmission rate of 28% after 30 days, Udeshi said.

“We’ve really made a difference,” said Menacker.

Quality Measures

The “dramatic changes” in Hackensack’s ability to oversee medication compliance among the highest risk population is critical to meeting quality measures laid down by Centers for Medicare & Medicaid Services as part of the MSSP contract, Menacker said. With 5 quarters worth of experience, “It’s a little early” to be able to track exactly how rigorously Hackensack Alliance is meeting the pharmacy quality standards set by CMS, Menacker said, but Medicare’s announcement that Hackensack Alliance had saved more than $14.5 million was enough for him.

For the first time, doctors and nurses at Hackensack UMC will be rated based on the quality metrics, he said. “This will also apply to the pharmacist.”

Under MSSP, ACOs have to report on a total of 33 quality-related performance measures, and Hackensack Alliance is reporting on each of the government’s ACO measures: Nos. 12, 30, 31, and 33, all of which are specific to pharmacy and drug therapy.

The 4 measures range from medication reconciliation after discharge, to cholesterol management for patients with cardiovascular conditions, to beta-blocker and Warfarin therapy for patients with heart failure, to angiotensin-converting enzyme inhibitor and cholesterol-lowering therapy for patients with heart diseaseto bronchodilatory therapy for patients with chronic obstructive pulmonary disease, to osteoporosis management in women suffering from fractures.⁴

Every patient will need a good reason as to why they are on a particular dose of medication, and every step in the MTM process will be documented in Hackensack UMC’s electronic medical system, which was scheduled to undergo a major integration overhaul with Hackensack Alliance in October, Patriaco said.

“The job of the ACO is to look at how hospitals are spending the money,” she said. “Our job is to drive down costs and keep really close track of high-risk patients who have developed highrisk diseases and to keep them healthy and happy. The more support they have the better off they are and the lower the costs.” Author Disclosure: The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Address correspondence to: E-mail: info@ajmc.com.1. Abrams L. How much does it cost to go to the ER? The Atlantic. http://www.theatlantic.com/health/archive/2013/02/how-much-does-it-cost-to-go-to-theer/273599/. Published February 28, 2013. Accessed September 25, 2013.

2. Barlas S. Pharmacists want a more explicit role in ACOs. PT. 2011; 36(10):685- 687. Published October 2011. Accessed September 21, 2013.

3. Academy of Managed Care Pharmacy. Pharmacists as vital members of accountable care organizations: illustrating the important role that pharmacists play on health care teams. Published 2011. Accessed September 20, 2013.

4. Academy of Managed Care Pharmacy. Pharmacists as vital members of accountable care organizations: illustrating the important role that pharmacists play on health care teams. Published 2011. Accessed September 24, 2013.