Striking Gold: How Washington State is Empowering the Care Team Evolution

The days of the gold rush are long gone, but Washington State still “strikes gold” when it comes to advances in policies and payment models that are enabling clinicians to work as a team, improving access to care for patients throughout the state.

Data Brief

New Data: Clinician Perspectives & Prescribing Patterns Reveal Opportunities for Care Team Evolution

Striking gold in this context relates to a patient’s ability to find accessible, more affordable care from a collaborative care team. But what makes Washington State different and able to support clinical care teams? As they say, for leading healthcare policy – we must go west.

Healthcare’s Modern-Day Trailblazers

Since 1979, pharmacists in Washington State have been recognized as healthcare providers through scope of practice laws that provided prescriptive authority and flexible collaborative practice agreements. And nearly a decade ago, Washington was the first state to require private health plans to reimburse pharmacists, just as they would for care services provided by a physician.

The state’s policy change accelerated a transformation in how care is delivered and has paved the way for more accessible care for patients.

Primary care in health systems across the state regularly include the expertise of pharmacists, physicians, nurse practitioners and physician assistants, all working together to provide accessible and more comprehensive patient care. And these services are sustainable because pharmacists are compensated for much of the care they provide, just like physicians.

Alaa “Ali” Salama, RPh, Board Certified Medication Therapy Management Specialist (BCMTMS), is a pharmacist working in this type of primary care setting as the Ambulatory Care Pharmacy Services Manager at Confluence Health, serving patients in northern central Washington (between Seattle and Spokane).

It’s considered a rural area and Ali noted that the provider shortage is effectively doubled in rural areas, resulting in less accessible care for patients.

This map shows the PCP shortage areas in Washington State (in blue), according to an analysis. The area in the green circle is where Confluence Health is helping to make care more accessible by including pharmacists who provide clinical services as part of patient care teams.

To combat this challenge, Ali has led efforts to advance the capabilities of clinical care teams, “we're trying to open access as much as we can in the primary care setting. We came up with the idea of involving the pharmacist because there is a shortage of care providers in general, nationwide. For the rural areas as well, it can be really difficult to retain or recruit physicians or advanced practice providers.”

It’s what led to a pilot program where pharmacists could, “help with the gap and basically free up the other provider’s time to see either new patients or work with more complex cases,” said Ali. “Our pharmacists have the capacity to see the patient if needed, every other week or every three weeks, depending on their condition versus other providers,” which wouldn’t be more frequent than three to six months.

He added that pharmacists support medication management, including making medication changes and adjustments for patients and can see patients with greater frequency. He also shared that this collaborative care in the primary care setting has led to stronger, trusted relationships between pharmacists and patients.

The Next Frontier in Patient Care

Ali said, “when it comes to medication management, I think the pharmacist has a great expertise to add to the team.”

Confluence Health’s team of pharmacist providers are focused mainly on patients with medication heavy disease states like diabetes, hypertension and heart failure. Pharmacists are a valuable addition to the care team because they have capacity to spend the time with patients who need it and lend their expertise to monitoring their established medication regimens and ensuring it is truly the best option for the patient.

He also shared that by having the “pharmacist within the care setting, they have the ability to make a decision to change therapy or adjust medication plan. These changes are relayed to the provider within the EHR.”

In Surescripts study, pharmacists prescribed a variety of medications to treat chronic and acute conditions, most commonly diabetic therapies as well medications used to treat mental health conditions.

He recalled what that process would have looked like prior to the policy changes that permit this collaboration today, noting that it would require the pharmacist to call the physician's office, explain the concern and the recommended change. But there was a lack of trust between clinicians -- a critical component that is strengthened within the care team model.

“The care that the pharmacist can provide is beneficial for the patient. It's beneficial as well for the health plan. [This model] can save a lot of unnecessary expenses because basically, if the patient is not able to access their regular provider for a routine visit or when something has come up regarding their medication condition, they have to wait at least 2-3 weeks or a month to see their regular provider. Therefore, the next step the patient will take is to go to an urgent care or the emergency room.

He noted the expense is much greater for the health plan – especially when the patient’s needs could have been addressed during a routine visit with more accessible providers.

“Controlling patients' hypertension, diabetes or heart failure can prevent more serious conditions or more serious development of their disease in the future years.”

Jumping On the Bandwagon

Community pharmacies in Washington state are also jumping on the bandwagon, so to speak, and striking gold for patients with more accessible care at an overall lower cost.

In a study, pharmacy researchers at Washington State University looked at care provided by a pharmacist for minor health issues, (urinary tract infections, shingles, animal bites and headaches, etc.) in a drugstore, grocery store or other retail setting, and found that costs were significantly lower – an average of about $278 less when treated in pharmacies compared to patients with similar conditions treated at “traditional sites” of primary care, urgent care or emergency room settings. Follow-ups with pharmacy patients showed that almost all their illnesses had resolved after the initial visit with a pharmacist.

The researchers also found that for an uncomplicated case of urinary tract infection, normally treated with antibiotics, a first visit to an emergency room cost on average $963, a primary care physician’s office, $121 — at the pharmacy, the average was $30.

The model in Washington State has yielded real results and it’s due to the trail-blazing policies, payment models and in Ali’s case, the technology within the health system setting, that is truly empowering clinical care teams to serve patients in a more meaningful, collaborative way.

But there’s another frontier that has yet to be fully explored.

“We [pharmacists] document in the EHR in the same way as other providers. This ensures the care team is on the same page. If there are any changes with the plan, changes to medication, a need to share lab results or look further into the therapy plan, this is all documented and available in the chart,” added Ali.

He notes that on a federal level Medicare still does not recognize pharmacists as a provider and so there is no reimbursement in place for care provided to Medicare patients, which is an expense to the health system. “However, the services that the pharmacists are providing are the most needed among the [Medicare] population who are on multiple medications and have many questions about their therapy.”

He also pointed to advancing health intelligence sharing and improving the ability for clinicians to communicate between different technologies and have access to the same clinical information. He said it ensures greater accuracy of the information and less time is needed to chart notes or retrieve needed information.

According to a recent survey, better access to clinical information is a key priority for clinicians, 85% of pharmacists and 57% of other clinicians said that they would place a high priority on connecting both pharmacists and prescribers with centralized information about their patients.

There’s no doubt that the final frontier for care team collaboration in any setting is access to technology that provides secure health intelligence sharing. It’s this combination of policy and technology that can help clinicians return their focus to the patients in their care and it’s how we can help healthcare heal itself.