Thursday, September 3, 2009

Team Play - Including the entire care team to improve outcomes

The Ashville Project demonstrates how non-physicians care providers can become highly valuable members of a care team who contribute to dramatic improvements in cost, quality, and outcomes.

I was recently made aware of a demonstration project that has the potential to go viral (ok, maybe that is a strong use of the term) in the quest to dramatically increase health value. I was asked to gather some information on the Ashville Project, a coopaboration (cooperative collaboration) involving adding pharmacist as a core part of the core team. I was very impressed by what I learned and thought the findings (while several years old now) would prove valuable to those interested in care team and care coordination.

Description of Project

Pharmacists are highly specialized, highly educated, and highly influential health care providers who have not historically participated in direct patient care in a meaningful way. On average, patients with chronic medical conditions see their pharmacist 5 times more than then they see their health care providers. These interactions provide significant opportunities for education, encouragement, and increased compliance with medical regiments while improving patient self empowerment and satisfaction with their health care experience.

In 1996, a large cohort of pharmacist across North Carolina embarked on a project to better coordinate their services while attempting to establish the value of the cognitive and coaching services they could provide. Their demonstration project involved having the pharmacist assume a coaching and advocacy role with patients. They received specific training for this expansion of their historical role, worked directly with patients to ensure understanding and compliance with their medical regimens, and followed the outcomes of participants assiduously to ensure efficacy of the program. They were paid directly by the self insured employer a flat fee ($300 / year) to provide these services while at the same time the employer waived the cost of all co-pays, medications, and supplies related to the targeted condition (diabetes).

Patients were provided the opportunity to meet with pharmacists at no cost to set and monitor treatment goals and to receive diabetes education, home glucose meter training, and information about adherence to their regimen. Pharmacists also performed physical assessments of patients’ feet, skin, blood pressure, and weight. Appropriate lipid management was a key component of the educational intervention. In addition, pharmacists referred patients to their physician, as needed. As an incentive to participate, patients received a free home blood glucose monitor and a waiver of co-payments for diabetes-specific drugs and supplies.


The Asheville Project was able to demonstrate tangible benefits and significant costs savings for patients, providers, and employers. Surveys indicated that patients felt more in control of their lives and were healthier. The pharmacists and diabetes educator agreed that the caring and supportive environment fostered by the project made patients comfortable with the process and facilitated their developing the skills necessary to self-manage their diabetes. Managers indicated that the program led to reduced medical costs and lower absenteeism.


The Ashville Project was highly successful in increasing compliance while improving the target clinical objectives. Mean A1c decreased (i.e., improved) at every follow-up. Additionally, at every follow-up, 57.7% to 81.8% of patients were improved, compared with baseline. Further, the number of patients with optimal A1c values (i.e., A1c < 7%) increased. At the first follow-up, 24.3% more patients had optimal A1c values, and increases of 27.2% and 18.2% were noted at the second and third follow-ups, respectively.

Mean LDL−C decreased (improved) at every follow-up, although the magnitude of the change was small. The percentage of patients with improved LDL-C values was 50.0% to 66.7% at each follow-up. At the first six follow-ups the percentage of patients with optimal LDL-C increased, with a range from 2.4% to 20.9% increase over baseline.

Mean HDL-C increased (improved) at every follow-up. Similar to LDL-C outcomes, 53.3% to 75.0% of patients experienced improved HDL-C at every measurement. We also observed an increase in the number of patients achieving optimal HDL-C8values at each time.


Analyses of insurance and prescription claims indicated that mean total amount paid for all diagnoses decreased at each followup year. Most of the decrease in total costs was accounted for by a shift from insurance claims for emergency department, inpatient, and physician office visits to prescription claims. Mean costs for insurance claims decreased by $2,704 PPPY in the first follow-up year and by $6,502 PPPY in the fifth follow-up year. During the same periods, mean prescription costs increased significantly, by $656 to $2,188 PPPY, with diabetes-related prescriptions accounting for more than half of the increase. Logistic regression suggested that in the first year of the program patients with type 1 diabetes were less likely than those with type 2 diabetes to see a 10% decrease in total medical costs. The payers realized decreases in total direct medical costs that ranged from $1,622 to $3,356 PPPY.

In addition to these direct savings, indirect costs such as absenteeism were also affected. The mean number of days of sick time used for group 1 decreased at every follow-up year, compared with baseline. Data were available
for 37 patients for the years 1996 through 2001. During the baseline year the mean number of sick days was 12.6 days PPPY. There was a mean decrease of 6.6, 4.1, 5.3, 4.9, and 6.2 days PPPY in each subsequent year. The group 1 employer has estimated the value of increased productivity to be $18,000 per year.

Replicating the Model

The economics and financial model of the Ashville Project have been replicated in many other settings throughout the United States with success. In order for the project to be successful it requires a collaborative team approach, alignment of incentives, financial commitment from employers and/or payers, and agreement on which outcomes will be measured to demonstrate success.


The key factors identified in the programs success were the decisive influence the waived co-payments for diabetes medication and related supplies had as an incentive for patients to participate, the opportunity for patients to establish ongoing relationships with caring and knowledgeable health care professionals, and the improvements in self-management of diabetes brought about by the continuity of seeing the same provider on a regular basis. The program appears to demonstrate a significant return on investment by directly reducing cost of urgent and emergent care settings, which is seen in increasing cost reductions over time (despite increasing prescription costs during the same time). Demonstration projects provide preliminary evidence that these results can be replicated in other settings.

For me, the key learning is how other members of the care team, who are often latent or unaware of their potential impact, can be utilized to share their knowledge, insights, and expertise to achieve significantly greater health value. Think what will happen when all of our providers are working together to incrementally and seamlessly add value to the overall care delivery process.
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