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Leveraging Pharmacist-Led Chronic Care Management (CCM) Services to Decrease Acute Care Stays for Diabetic Patients

Dr. Cynthia C. Nwaubani, BCGP, CMTM

As the national healthcare model has transitioned from volume-based to value-based care, the role of the physician has also shifted. In the value-based care model, physicians are held accountable to deliver the best outcome at the lowest cost. The role of the physician has been redefined to include stewardship of the healthcare economy. November is Diabetes Awareness Month; we will examine the significance of this shift and the impact on the diabetic patient. The American Diabetes Association reports an annual cost of $327B for diagnosed cases of diabetes. One of seven healthcare dollars spent is on diabetic care. Because a significant portion of this spend is derived from costs of acute care, redesigning care delivery to keep diabetic patients out of acute care has been a focus of private and public payers. Chronic care management services—reimbursable by the country’s largest payer, Medicare—were borne from those efforts.

Because complex chronic conditions, such as diabetes, require significant care between office visits—developing a comprehensive patient-centered care plan, care coordination, transitions of care management and increasing access to care via telehealth and 24/7/365 clinician availability are elements of CCM.   

PharmD Live’s CCM services were designed to prevent acute care stays through effective management of the chronic condition. Here’s how PharmD Live’s CCM services are implemented:  

A dedicated clinical PharmD Live pharmacist collaborates with the physician to create a comprehensive care plan, using a patient-centric approach. Patient education and disease-state management plays a paramount role in care. The clinical pharmacist addresses the patient’s ongoing adherence to the care plan, ensures referrals are made to specialists for diabetes-related care (such as podiatrists for foot exams), identifies root cause of shifting bloodwork trends, addresses impact from social determinants of health and ensures diabetes supplies are stocked. Clinical pharmacists rely on PharmD Live’s software, with an advanced clinical rules engine which ensures consistent, timely care and real time communication with practice electronic health records (EHR). PharmD Live  pharmacists provides services virtually, telephonically or via home visit.

PharmD Live tracks quality metrics and provides streamlined billing reports to practice administrators. PharmD Live, a telehealth company committed to improving patient outcome and helping physicians earn quality bonus payments and avoid financial penalties, serves as a seamless extension of physician practices. To fortify your value-based care strategy, schedule a capabilities presentation with Ellery Plowman.