Audio Transcript
[0:00] Host: Hello, and thank you for joining us for this edition of the Valuable Insights podcast. A series dedicated to sharing value-based success stories and best practices. I am your host Sholeh Killingsworth and, in this episode on medication adherence, we will be talking to Dr. William Torkildsen, a primary care physician at Port Isabel Health Clinic in Port Isabel, Texas. And Ricky Cruz, LVN, an embedded care coordinator for CareAllies. Thanks for being here today. I appreciate you both taking the time to share your story.
[0:05] Cruz: Sure, thanks for having us.
[0:07] Torkildsen: Yeah, Thanks for inviting us, and this should be a fun discussion.
[0:09] Host: Great. To get us started, Dr. Torkildsen, can you tell us a little bit about your physician organization and what drove your organization to launch this initiative around medication adherence?
[00:53] Torkildsen: So, we have five independent physician associates -- associations along the Texas border. We consolidated the five individual IPAs into one unit called Valley Organized Physicians, which is also an IPA. How this evolved for us was, we decided that we wanted to establish care coordination in VOP.
[01:20] Torkildsen: So, we’re – we are the Texas border -- which is its own particular culture -- but it has tremendous care coordination needs, and we wanted to establish a standardized care coordination process across VOP, with as little fragmentation as possible. So, we established a basic structure for integration and collaboration. And then, as our infrastructure improved and our thought processes progressed and we applied that relationship to our medication adherence problem. Some physician offices in the past haven’t really taken ownership of compliance. And I think that's -- that’s a tactical error. We have very good medical therapy for hypertension, diabetes, and atherosclerosis. We spend a lot of time managing patients with these problems and trying to adjust their medicines, and titrate their medicines appropriately, and sometimes we don’t really realize how infrequently some of our patients are taking their medications. So, our outcomes aren't always what we wanted, but I think a big part of it is because our patients aren't taking their medicines correctly. And it happens a lot. So, I think -- I think the focus to get good adherence is a huge health care issue.
[0:38] Host: So, seeing as this is a huge health care issue, I understand VOP implemented a process in 2016 around adherence that you refer to as your Medication Adherence Tracker. Can you give us an overview of the process?
[03:05] Torkildsen: We get a list that is updated every two to three weeks. Usually about every 2 weeks. And those are the patients that need their refills now or needed it a few days ago, or will need them within the next week. We try to keep the list short so we try to restrict it to a two-week window. And then my staff -- my care coordinator delegates which of those patients are going to be called and patients are called and reminded to have their refills. And then, and then they receive follow-up phone calls to make sure they have picked up their medications and we track it.
[03:46] Torkildsen: So we use pharmacy claims as our end point. And so the medication ad tracker identifies, for each office, how many patients were called and how many refills or pharmacy fills were achieved, assuming that that touchpoint resulted in a pharmacy closure.
[04:11] Torkildsen: So, for instance, I have a patient, he is a week late on his Lisinopril. Call him up, and he says oh, I just haven't had time. I don't have a co-pay or whatever it is, and, at that point in time, we make sure to encourage them how important it is that they go pick that up, and then we track them to see if they have picked it up and if they keep showing up on the tracker as not picking it up, then we have to intensify that dialogue. Most people have gotten the message, during their office visits that this is just a little reminder from us -- sometimes a big reminder -- that they need to go pick up their medications. Definitely 90-day refills make a difference, and the other thing that makes the big difference is synchronizing, asking the pharmacist to synchronize their medications. So if they are on three or four or five medicines, and they are all 90-day fills, to pick them all up at the same time every 90 days. Rather than going back and forth back and forth to the pharmacy. That drives most patients crazy.
[05:23] Torkildsen: So I think, synchronizing -- the 90-day fills and synchronizing the fills makes a big difference for adherence. And then if we can -- if you can get a pharmacy -- the other item -- big ticket item is getting a pharmacy to work with you, and do some of the heavy lifting, with regards to calling the patients or reminding them of their refills. Even if you need to share your adherence tracker with them, on an individual basis, I think anything -- I think that will decrease some of the workload on our offices. And I am seeing more and more big and large pharmacies that are willing to do that.
[06:07] Host: That’s great to hear, thank you, Dr. Torkildsen. Now Rickie, can you further expand upon the process for the medication adherence tracker, and how your team of Embedded Care Coordinators (or ECCs) play a role in helping to kick start these types of initiatives within physician offices?
[06:20]Cruz: Absolutely. As Dr. Torkildsen mentioned, a targeted list identifying patients who are currently either non-adherent to their therapies or have been identified as having only filled the medication once is included. The medications included in the list are those for chronic conditions, we have diabetes, hypertension, and cholesterol. We receive this listing from the CareAllies pharmacy team, and our ECC team filters the report by provider then we print it and pass it along to the primary care physician, or PCP’s, office staff. It’s distributed every 2 weeks, which allows the office staff to document outcomes directly onto the report, outcomes may include: patient agreed to refill the medication, the patient was unable to be reached, the medication was changed by the provider, etc. The report is returned back to our ECC team every 2-3 weeks, and the outcomes are then logged into what we call the Medication Adherence Tracker or MAT for short.
[07:19]Cruz: For the initiative to flow smoothly and efficiently, each PCP should have what we like to call a practice coordinator, or a point of contact, that we, the embedded care coordinator, or ECC, are able to connect with. This is typically a Medical Assistant, nurse, a mid-level provider such as a Nurse Practitioner or Physician assistant. We also make sure that the Primary care physician is in the know and a part of these conversations and the process.
[07:45]Cruz: Our team must communicate the information, both timely and accurately, so the PCP or staff can act quickly to make an intervention. We typically have an open dialogue with the point of contact in the physician's office, who will share any barriers or concerns that we are able to further escalate to a pharmacist if needed. It really is an all-hands-on-deck approach that the patients are really positively responding to.
[08:11]Cruz: We evaluated the 2016 adherence outcomes, using a formula called PDC, or proportion of days covered, to see if improvements were made in medication adherence after we first rolled the initiative out. We identified around 3500 unique non-adherent patients in South Texas who required a PCP intervention. We found that of those that did receive an intervention, they were 20 times more likely to fill their prescription after the intervention and 3 times more likely to be considered adherent by the end of the year, or in other words, compliant with their medication for over 80% of the year. We feel confident the initiative has been a success, and this is why we have continued it till this day, along with having other markets adopt the process.
[08:53] Host: Impressive results. And Dr. Torkildsen, despite the fact that this has been such a success, I know incorporating a new initiative like this into an established office workflow can be challenging. How has your office adapted to these changes?
[09:07] Torkildsen: It's -- It’s been a slow process. It has taken -- it takes a while for things to change in a medical office. It's patience realizing that our whole team is concerned about medication adherence and so bringing that into our daily dialog during the office visits and capturing that information on the chart has been our biggest challenge. But it -- now that it is kind of in everybody's mindset as an important issue.
[09:42] Torkildsen: It’s a gradual change. It doesn't happen overnight. It requires persistence on the part of the office staff. And then persistence from the ECC's always being there with a timely report that's well developed and easy to understand. So the process has works better with time. We have some offices that say they don't have time to be calling the patients and we have kind of been more resistant than other practices so, at that point in time, we asked our physician leaders, and our board members to intervene with the PCP's and have meaningful dialogue and they usually have an impact. Wouldn't you think Ricky?
[10:30] Cruz: Absolutely. For sure, Dr. Torkildsen.
[10:32] Host: So Rickie, you and your team have participated in carrying out this initiative with Dr. Torkildsen and his colleagues for a few years now – based on your observations, what would you say are the key components to their success?
[10:46] Cruz: So, the biggest key for success is really going to be establishing that open line of communication. It’s really going to fall back from the ECC to whoever they identified as that office go-to. your office superstar if you will -- so whoever is really going to be open to communicating to you, working the report, understanding the reports. so we really want them -- them being the office, the physician -- whoever is making those outreaches to open up that line and see why they are not picking up the medication. Is it an intolerance that they have to it? A lack of education as far as why they are on the medication? Or is it a cost issue? So, really, the successful offices have that open line. They understand the process.
[11:26] Host: So Dr. Torkildsen, since the process itself is so important, what advice would you give your colleagues looking to implement this type of process?
[11:34] Torkildsen: I think the leadership from the ECC has been a huge factor in this success because that's the boots-on-the-ground information and dialogue that our PCP offices get on a regular basis. That’s the contact with the outside world, so to speak. And the training for the ECC has -- has been, pretty much, standardized, so our messaging is similar throughout our market. Developing the mindset in the office and the structure so that these functions that are necessary can be carried out.
[12:21] Torkildsen: And, like I say, the leadership part on this needs to come from the physician. He's the one -- he or she is the one that is going to have to direct to the office and say, yes I want this done. Because it's not going to happen until we have that -- until that message comes out from the physician to their staff. I think that our patients need leadership, that's why they chose us to be their PCPs. And I think it's appropriate that we should be expected to take a leadership and an ownership position in a patient's medication adherence.
[12:58] Torkildsen: It is easy to not take your medicines for a day or two - skip a day here, skip a day there, and all of a sudden, you are stockpiling a ton of medicines in the medicine cabinet but if they know, each and every time that they come into our offices, that we are wanting to look at their -- the dates on their bottles and their refills and wanting to know that they are really taking their medicines, it becomes important to them. But for years it wasn't -- we didn't act like it was important to us. We kind of looked at the medicine bottles, sometimes, the higher-functioning practices did but we didn't always dive down into the refills like we do now. So as our patients start to realize that this is important, and it is important to us then it will matter -- then it will matter to them. So the office culture that gets developed around this process is as important as the process itself. It takes a village.
[13:50] Host: It definitely sounds like it, so I’m glad to hear the effort has been worth it. So with that, I want to thank you Dr. Torkildsen and Rickie for joining us today to share your story on this edition of the Valuable Insights podcast.
