The Pharmacists’ Patient

Care Process Approach

An Implementation Guide for Public Health Practitioners
Based on the Michigan Medicine Hypertension Pharmacists' Program
 The Pharmacists’ Patient Care Process Approach

Acknowledgments
Contributing Authors
Centers for Disease Control and Prevention RTI International
Mark Rivera Cindy Soloe
Erika Fulmer Alexa Ortiz
Julia Jordan Mihaela Johnson
Sharada Shantharam Benjamin Yarnoff
Kara MacLeod Laura Arena
Jeffrey Michael Durthaler Kate Ferriola-Bruckenstein

The authors wish to thank Hae Mi Choe, Amy Vereecke, and Carol Becker from the Michigan Med-
icine Pharmacy Innovations and Partnership team, who provided important guidance throughout
the project and reviewed earlier sections of this document.

Financial Disclosure/Funding: This work was supported in part by a contract (Contract Number
200-2014-61263) from the Centers for Disease Control and Prevention.

Suggested Citation: Centers for Disease Control and Prevention. The Pharmacists’ Patient
Care Process Approach: An Implementation Guide. Atlanta, GA: U.S. Department of Health and
Human Services; 2021.
Contents
1. Introduction 1
1.1 Background 2
1.2 Program Overview 3
1.3 Why Consider the Pharmacists’ Patient Care Process (PPCP)? 5
2. Starting a Hypertension Pharmacists Program 6
3. Core Elements of the Michigan Medicine Program 7
3.1 Core Element: Implementation Model 7
3.2 Core Element: Infrastructure and Capacity 10
3.3 Core Element: Partnership with Community Pharmacies 14
3.4 Core Element: Leadership Support 19
3.5 Core Element: Sustainability Planning 21
4. Program Monitoring and Evaluation 22
5. Conclusion 26
5.1 Overall Strengths of the Michigan Medicine Program 26
5.2 Key Recommendations for Program Implementation and Maintenance 27
References 29
Appendix A. Glossary of Key Terms 32
Appendix B. Michigan Medicine Checklist for Partnering with Community-Based Pharmacies 34
Appendix C. Resources 36
Appendix D. Michigan Medicine Program Logic Model 38

Commonly Used Acronyms

AHA: American Heart Association HEDIS: Healthcare Effectiveness Data and
Information Set
BPA: best practice alert
NCQA: National Committee for Quality
CDC: Centers for Disease Control and Prevention Assurance
CPA: collaborative practice agreement PCP: primary care physician
DHDSP: Division for Heart Disease and PPCP: Pharmacists’ Patient Care Process
Stroke Prevention
SOAP: subjective, objective, assessment,
EHR: electronic health record and plan
 The Pharmacists’ Patient Care Process Approach

Michigan Medicine Hypertension Pharmacists' Program

 Introduction | 1

Pharmacists’ Patient Care

Collect Process (PPCP) Framework
Follow-up:
1. Introduction
• Com
ate
Monitor Assess The goal of this implementation guide is to
• C labor

and
unicate •

Patient-
Evaluate support public health practitioners’ engagement
ol

Centered
Care of pharmacists in hypertension management through
Do
c u m e nt the Pharmacists’ Patient Care Process (PPCP). In this
guide, we share lessons from an evaluation of a PPCP
Implement Plan implementation through the Michigan Medicine
Hypertension Pharmacists' Program (hereafter
referred to as the Michigan Medicine Program).

This document is intended for public health

Figure 1. Pharmacists’ practitioners and health care professionals who
Patient Care Process (PPCP)
are interested in implementing a hypertension
pharmacists' program rooted in the PPCP.

The PPCP, endorsed by the Joint Commission of Pharmacy Practitioners (2014), is

recommended as a standard health care approach for patients with chronic condi-
tions, including hypertension. The PPCP uses a team-based care approach, incorpo-
rating pharmacists as part of a multidisciplinary team to improve patients’ quality of
care. Incorporating pharmacists in patient care is an important consideration because
their involvement has been shown to improve long-term blood pressure control
(Hwang, Gums, & Gums, 2017) and decrease racial and socioeconomic disparities
(Anderegg et al., 2016).

Throughout this guide, we draw on examples of PPCP implementation as illustrated

by the Michigan Medicine Program. This guide includes three primary sections:

» Starting a Hypertension Pharmacists' Program

» Core Elements of the Michigan Medicine Program

» Program Monitoring and Evaluation

Readers may find it helpful to consult the list of commonly used acronyms at the
beginning of the guide, the glossary of key terms in Appendix A, and the list of
references at the end of the guide.

The Pharmacists’ Patient Care Process Approach

 Introduction | 2

1.1 Background
Hypertension is a major risk factor for heart disease and stroke, two of the
leading causes of death in the United States (Fryar et al., 2017; Centers for
Disease Control and Prevention [CDC], 2017a; CDC, 2017b; Merai et al., 2016).
Based on application of the 2017 American College of Cardiology/American
Heart Association (AHA) Hypertension Guideline (Whelton et al., 2018), 47%
of U.S. adults have hypertension (CDC, 2021). Of adults diagnosed with hyper-
tension, only about 1 in 4 have their blood pressure under control (<130/80 mm
Hg) (CDC, 2021). Hypertension is costly, for both individuals and health systems.
For example, an individual in the United States with hypertension is estimated
to incur nearly $2,000 more in annual health care expenditures than someone
without hypertension (Kirkland et al., 2018). The annual cost of hypertension to
the United States is estimated to fall within a range of $131 billion to $198 billion
(Wang, 2017; Kirkland, 2018).

Given the prevalence and health-related burden of hypertension, CDC’s Division

for Heart Disease and Stroke Prevention (DHDSP) used a systematic screening
and assessment methodology (Leviton & Gutman, 2010) to identify promising
interventions that reduce death and disability due to heart disease and stroke
by improving blood pressure control. The Michigan Medicine Program was
selected for a rigorous evaluation to assess its effectiveness and to identify
aspects of this program that might be replicated. The Michigan Medicine
Program was selected because an evaluability assessment showed they have
fully implemented the PPCP, successfully expanded the program to provide
services to patients in community-based locations through a partnership with
Meijer Pharmacy, and demonstrated promising outcomes and the availability
of program data.

The Pharmacists’ Patient Care Process Approach

 Introduction | 3

1.2 Program Overview

Michigan Medicine began embedding pharmacists in primary care clinics
in 1999 to provide direct care to patients with diabetes, hypertension, and
hyperlipidemia. This umbrella pharmacist program, originally implemented in
one primary care clinic using collaborative practice agreements (CPAs) which
delineated roles and supported effective collaboration between physicians and
pharmacists and was expanded over time to all 14 primary care clinics, including
select specialty clinics within Michigan Medicine.

In 2016, health system leaders at Michigan Medicine reviewed Healthcare

Effectiveness Data and Information Set (HEDIS) measures and determined that
goals related to hypertension in adults were not being met (Vordenberg et al.,
2019). In response, Michigan Medicine began implementing quality improve-
ment strategies to improve the process for identifying, treating, and monitoring
hypertension in ambulatory care clinics and community-based settings. The
Michigan Medicine Program is the result of incorporating pharmacists into both
ambulatory care clinics and the community settings.

* Michigan Medicine Program

• A structured and standardized approach for
pharmacists to work with patients to address
hypertension through implementation of
the PPCP.
• Originally established within Michigan
Medicine ambulatory care clinics.
• The program was expanded to provide patients
with access to pharmacists at community-based
locations through a partnership with Meijer, a
regional supermarket with retail pharmacy.

The Pharmacists’ Patient Care Process Approach

 Introduction | 4

The Michigan Medicine Program have pharmacists who provide direct patient
care using the PPCP (Figure 1) to engage them in developing and implementing
strategies to manage their hypertension.

Central to the Michigan Medicine Program is a hypertension best practice

alert (BPA), which prompts physicians to refer patients who have two consecutive
elevated blood pressure readings during a clinic visit to see a pharmacist. The
hypertension BPA is currently implemented in 8 Michigan Medicine primary care
clinics and selected specialty clinics.

The program initially included only services provided by pharmacists within

Michigan Medicine ambulatory care clinics and was expanded based on growing
evidence that many patients find community-based pharmacists more accessible
and these pharmacists can improve patient outcomes (Vordenberg et al., 2019;
CDC, 2012; Cranor, Bunting, & Christensen, 2003). In 2016, Michigan Medicine
began partnering with Meijer, a regional supermarket with retail pharmacy.

* Best Practice Alert

• At Michigan Medicine, if a medical assistant
records an elevated blood pressure reading in
a patient’s electronic health record (EHR), the
medical assistant receives an alert to repeat
measurement by taking a second blood
pressure reading 5 minutes later.
• If the second reading is also elevated, the
physician can refer the patient to follow-up
with a pharmacist by signing a referral order.

The Pharmacists’ Patient Care Process Approach

 Introduction | 5

The partnership started with two Meijer (i.e., » More patients maintained their blood
community-based) pharmacy locations and pressure control. Participating patients
then expanded to a third in 2018 and fourth maintained blood pressure control for
in 2020. Meijer community-based pharma- more days within 3 months of starting
cists have become contracted employees of the program than patients who did
Michigan Medicine. not participate.
» More revenue through quality
incentives. Improvements in blood
1.3 Why Consider the pressure control provided the Michigan
Pharmacists’ Patient Care Medicine Program an opportunity to
generate revenue through quality incentive
Process (PPCP)? programs that offer higher insurance
CDC’s evaluation of the Michigan Medicine reimbursement for meeting certain high
Program included an examination of patients’ blood pressure quality benchmarks.
EHR data and discussions with program staff. » Improved hypertension medication
CDC identified the following clinical and management. Patients in the program
health system benefits that resulted from received better medication management
implementing the PPCP: as evidenced by more frequent adjust-
» More Michigan Medicine Program ments to their hypertension medications
patients, across clinic or community than those not in the program.
settings, achieved blood pressure » Increased primary care physician (PCP)
control. Patients who participated in availability to see patients. Delegation of
the program were more likely to achieve hypertension patient care responsibilities
blood pressure control within 3 and 6 from physicians to pharmacists frees up
months of starting the program than physician time. Patients who participated
those who did not participate.1 in the program had significantly fewer
visits with their PCP, thus allowing more
* Participants time for those PCPs to see other patients.
BP control BP control BP control
at baseline at 3 months at 6 months

0% 66.3% 69.1% More information about the Michigan

Medicine–Meijer partnership is
Non-participants provided in Section 3.3.
3.3
BP control BP control BP control
at baseline at 3 months at 6 months

0% 42.4% 56.5%
1 Note that the reported values are not reflective of blood pressure control rates for all of Michigan Medicine. Instead, participants and non-participants were selected because
their blood pressure was not under control, thus 0% were under control at baseline.

The Pharmacists’ Patient Care Process Approach

 Starting a Hypertension | 6
* Potential Program Benefits Pharmacists' Program
» More patients achieving and maintaining
hypertension control
» Increased achievement of quality
benchmarks
» Improved medication management
among patients with hypertension
» Increased PCP availability to see patients

2. Starting a Hypertension Pharmacists'

Program
Factors that facilitate effective program start-up include securing leadership support,
fostering physician buy-in, and establishing pharmacist privileges necessary to
provide effective patient care.

» Secure Health System Leadership Support. As described under the “Leadership

Support” core element (Section 3), securing support from health system lead-
ership is essential for starting a successful hypertension pharmacists' program.
Ensure that key leaders understand the value of the program, are willing to
advocate for it, and can provide financial support. Such leaders are well posi-
tioned to launch the program.

» Foster Referring Physician Buy-In. As described under the “Infrastructure and

Capacity” core element (Section 3), hypertension pharmacists' program success
depends on engaging physicians who will refer patients to the program. Ensure
that referring physicians understand the program’s benefits and are confident
that pharmacists will add value to patient care. In turn, physicians are more
likely to support program implementation.

» Provide Pharmacist Access to Patient's EHRs. As described under the

“Infrastructure and Capacity” core element (Section 3), establishing a means
for pharmacists to access patient's EHRs can be very helpful. Access to patient's
EHRs allows pharmacists to prepare for and document encounters with their
patients, ensures strong communication of patient care plans with other health
care providers, and facilitates delivery of high-quality patient care.

The Pharmacists’ Patient Care Process Approach

In considering these facilitators and
the program’s core elements de-
Core Elements of the Michigan Medicine Program | 7
scribed in Section 3, readers are
encouraged to think about the unique
characteristics, needs, and assets of
their particular organizational setting.
These considerations can inform
appropriate tailoring of the program
to best fit within the specific
organizational context.

3. Core Elements of the

Michigan Medicine Program
The Michigan Medicine Program is guided by core elements that are not mutually
exclusive but highlight important features of the program. The five core elements:

1. PPCP implementation model

2. Infrastructure and capacity

3. Partnership with community pharmacies

4. Leadership support

5. Sustainability planning

3.1 Core Element: Implementation Model

The PPCP model promotes a patient-centered, consistent approach to care
delivery and can be applied to managing patients’ hypertension in any pharmacy
practice setting (CDC, 2016).

As noted in Figure 1, the PPCP includes five steps: (1) collect necessary informa-
tion about the patient to understand their medical history and clinical status,
(2) assess the information collected and analyze the clinical effects of the patient’s
current therapy to identify problems and achieve optimal care, (3) develop an indi-
vidualized patient-centered care plan, (4) implement the care plan in collaboration
with other health care professionals and the patient, and (5) monitor and evaluate
the effectiveness of the care plan and modify it as needed (Joint Commission of
Pharmacy Practitioners, 2014). This model represents an effective approach for
identifying and working with patients to manage hypertension.

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 Core Elements of the Michigan Medicine Program | 8

Michigan Medicine’s Implementation of the PPCP

Michigan Medicine based the implementation of their hypertension pharmacy
program on the PPCP. Patients with two consecutive elevated blood pressure
readings are referred by their PCP for follow-up care with a pharmacist. For
patients referred to the program during a clinic visit, scheduling of the pharma-
cist appointment occurs at the conclusion of their visit. Each subsequent phase of
the program is described below.

Collect. After a patient is scheduled to meet with the pharmacist but before a
meeting occurs, the ambulatory care clinic- or community-based pharmacist
reviews the patient’s EHRs for current diagnoses, medication allergies, medical
history, current medications and medication history, current symptoms, lifestyle
factors, and risk factors for cardiovascular disease.

Assess. After collecting and reviewing the information, the pharmacist meets
with the patient, assess their status, and fill in any information gaps. During this
appointment, the pharmacist captures missing patient information, including
degree of medication adherence, medication side effects, cost-related concerns
about medications, blood pressure goals, health perceptions, and priorities. The
pharmacist then assesses the patient’s current medication therapy plan to ensure
its appropriateness, effectiveness, safety, and adherence in the context of their
clinical laboratory results, current lifestyle, and health goals.

* PPCP Model Aims

» Reduce barriers to care by making
health care more accessible
» Improve care through a consistent,
team-based approach
» Improve patient engagement through
patient-centered care
» Address comorbidities through tailored
lifestyle recommendations

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 Core Elements of the Michigan Medicine Program | 9

Plan and Implement. The ambulatory care clinic or community-based phar-

macist develops an individualized medication and lifestyle plan for the patient
based on the collected data and their assessment. The pharmacist implements
the plan and works with other health care providers and the patient during
follow-up visits to consider modifications as needed. Plans may include lifestyle
modification recommendations; medication therapy management; and the
coordination of referrals to other specialists, such as clinic dietitians, social
workers, and behavioral health specialists.

Follow Up: Monitor and Evaluate. The ambulatory care clinic or community-
based pharmacist monitors patient medication appropriateness, effectiveness,
safety, adherence, lifestyle, and health goals and suggests changes when
appropriate. Ongoing monitoring may occur through in-person patient visits.

Potential evaluation topics include the following:

» Ongoing Program Cost Estimates.

Michigan Medicine reported that the majority of
ongoing monthly costs of providing pharmacists'
program services to address all chronic diseases
were allocated to staffing, primarily covering time for
5.2 full-time equivalent (FTE) of pharmacists across
14 primary care clinics and a smaller proportion
covering clinical program director and administrative
staff time. A small proportion of spending was
attributed to indirect costs. The program cost
estimates reflect the additional resources needed to
operate the Michigan Medicine Program within an
existing health care system.

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 Core Elements of the Michigan Medicine Program | 10

» Ambulatory Care Clinic-Based Pharmacist Services.

The majority of the ambulatory care pharmacist time was spent providing
services to new and returning patients (80%) with smaller portions (20%)
spent on coordinating with other health care professionals, conducting
chart reviews, and handling other administrative activities. The labor costs
for the ambulatory care pharmacists were spread across 14 primary care
clinics for managing chronic diseases, including hypertension. On average
each month, pharmacists at these 14 clinics had 401 in-person visits and
517 follow-up phone consultations with patients as part of the program.

» Community-Based Pharmacist Coverage and Services.

The costs covered by the contracts between Michigan Medicine and Meijer
community-based pharmacies provided a flat rate that covered pharma-
cists’ time to provide program services across four pharmacies. On average
each month, Meijer pharmacists had 80 in-person visits, at their community
pharmacy locations, with patients as part of the program.

3.2 Core Element: Infrastructure and Capacity

Elements of infrastructure and capacity that support effective hypertension
pharmacists' program implementation include a staffing plan, official agree-
ments that support effective team-based care, and designated equipment and
facilities. A clear staffing structure can ensure that the team has the collective
capacity to develop, manage, and implement the program. Program implemen-
tation is supported by a team-based approach in which PCPs, pharmacists, and
specialists (if needed) work together to provide appropriate and timely support
to patients with hypertension. CPAs serve to clarify patient care roles and
functions and support effective collaboration between physicians and phar-
macists. Finally, ensuring the availability of designated equipment and facilities
for pharmacists is important for meeting with patients and supporting them in
managing their hypertension through implementation of the PPCP.

Michigan Medicine’s Infrastructure and Capacity

Staffing Structure. The staffing structure for the hypertension pharmacists'
program includes a core management team, data quality staff, and clinical
staff. Table 1 provides a description of the roles and responsibilities for each
staffing category.

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 Core Elements of the Michigan Medicine Program | 11

Table 1. Michigan Medicine Staffing Categories and Descriptions

Staffing
Description
Category
Core • Comprise staff with clinical and administrative expertise who understand the nuances of the program
Management and are committed to its success.
Staff • Include three key roles: program director, program manager, and ambulatory care clinic manager.
– As noted in Section 3.4, the program director drives the program, providing the vision for
implementation, serving as a champion, and taking on primary responsibility for fostering buy-in
from leadership and others with a strategic interest in the program to support implementation
and sustainability.
– The program manager coordinates the day-to-day implementation, fosters communication among
program leadership and staff, and provides data-based feedback to clinics to encourage performance
improvements.
– The ambulatory care clinic manager helps program leadership understand the operations within a clinic
and informs how the hypertension pharmacists' program is incorporated into a clinic’s existing practices.
Data Quality • Comprise staff who have access to and expertise with clinical and other data.
Staff • Ensure the underlying program data are accurate and available.
• Support the program manager in providing ongoing performance feedback to participating clinics
(e.g., reports of percentages of patients in a clinic following the recommended workflow).
Clinical Staff • Comprise physicians (and their teams) and pharmacists at both ambulatory care clinics and
community pharmacy locations.
• Pharmacists at both ambulatory care clinics and community pharmacy locations and referring physicians
collaborate to provide timely and effective patient-centered care; this collaboration represents the
foundation for the success of the hypertension pharmacists' program.
• Physicians remain primarily responsible for a patient’s care, and when it is determined to be beneficial, they
may refer eligible patients for follow-up care with a pharmacist. In turn, physicians use the EHRs to review
ambulatory care clinical pharmacists’ medication changes and to approve community pharmacist
recommendations for medication changes.

» Staff Effort to Start the Michigan Medicine Program.

The Michigan Medicine primary care clinic–based hypertension
pharmacists' program was primarily launched by a single clinical
pharmacist who served as program director, advocate, and administrator
during the start-up phase. Level of effort for this role was about 60%, or
0.60 full-time equivalent.

Support for a Team-Based Approach

Consistent with the PPCP model, Michigan Medicine adopted a team-based
approach that involved PCPs and pharmacists (both ambulatory care and
community-based) jointly providing patient services. Not only does a team-
based approach foster better communication and coordination of care, it has
also been shown to encourage active engagement of patients in their own
care (Proia et al., 2014). Furthermore, delegation of certain patient care respon-

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 Core Elements of the Michigan Medicine Program | 12

Ambulatory Care Clinic Start-Up

Investment Reflects
• 12 months to plan and implement
the program.
• Effort to launch two to four participating
clinic sites.
• Dedicated time from staff already employed
at existing clinics.

sibilities from physicians to other qualified providers such as pharmacists can

help address the projected shortage of PCPs and can free up physician time to
address other priorities (U.S. Department of Health and Human Services, 2013).

Collaborative Practice Agreements. It is essential to establish a formal un-

derstanding between physicians and pharmacists with respect to patient care
management privileges. CPAs between Michigan Medicine ambulatory care
pharmacists and clinic providers allow pharmacists to provide disease and med-
ication management services to patients outside of traditional provider-based
clinic visits. These pharmacists can then initiate, modify, and discontinue medica-
tion therapies using predefined protocols for patients with hypertension, type 2
diabetes, and/or hyperlipidemia. Physicians sign off on the medication changes
that ambulatory care pharmacists make, but the changes can be implemented
before that sign-off occurs. Michigan Medicine hired Meijer pharmacists as con-
tractors. Under this arrangement, a Michigan Medicine physician reviewed and
was required to sign off on each medication change prior to implementation.

Designated Equipment and Facilities. Michigan Medicine leadership noted

the importance of having the equipment and facilities necessary to provide ade-
quate hypertension management care to patients. Specifically, they emphasized
the importance of having a private area in which to maintain calibrated blood
pressure monitoring equipment and underscored the importance of a robust
EHR system and information technology support.

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 Core Elements of the Michigan Medicine Program | 13

It is important to keep in mind that CPA policies that define

the scope of practicing pharmacists vary by state (CDC, 2013).

» Ambulatory Care Clinic Equipment and Facilities Costs.

Before implementing the hypertension pharmacists' program, Michigan
Medicine had infrastructure, such as facilities, equipment, and an EHR system,
already in place as part of their normal clinic operations. Health systems or
other entities hoping to establish a hypertension pharmacists' program that
do not have existing infrastructure or equipment will need to estimate and
plan for covering costs related to these components.

* Additional CPA Resources

Additional CDC resources to support and
guide the use of CPAs:
» Pharmacy: Collaborative Practice
Agreements to Enable Collaborative
Drug Therapy Management
» Advancing Team-Based Care
Through Collaborative Practice
Agreements *

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 Core Elements of the Michigan Medicine Program | 14

3.3 Core Element: Partnership with Community

Pharmacies
Forming partnerships with community-based pharmacies can extend hyperten-
sion care services in locations that are convenient for patients. Once a potential
community partner is identified, collaboration with organization leadership to
clarify and document roles and responsibilities will help solidify understanding
and engagement. Collaboration might be achieved through meetings between
health system, program, and community pharmacy leadership to inform the
content for documentation, including contracts and CPAs (see Section 3.2).

* Implementation Insight
When feasible, have designated space and reserved blood
pressure monitoring equipment to ensure that pharmacists have
the privacy and resources needed to effectively engage with
patients and implement the PPCP.

» Implementing a Community-Based Pharmacy Partnership.

Efforts and costs to implement a Michigan Medicine partnership with
community-based Meijer pharmacies were primarily attributed to Michigan
Medicine program staff labor (i.e., administrative oversight, project coordi-
nation, and pharmacist training provided by health system staff ). No infra-
structure costs were reported for launching the community-based program
component, because Meijer had infrastructure, such as facilities and tele-
phones, in place already. Furthermore, Meijer pharmacists were given access
to the existing Michigan Medicine EHR system to help facilitate their contri-
butions to patient management and effective collaboration with referring
physicians. Health systems and community pharmacies without these infra-
structure components in place may incur additional start-up costs.

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 Core Elements of the Michigan Medicine Program | 15

Additional factors that can facilitate successful engagement of community-

based pharmacies through a hypertension pharmacists' program include
providing training and ongoing support for participating pharmacists and
ensuring EHR access.

» Training and Ongoing Support. This factor is necessary to fully integrate

community-based pharmacists into a hypertension pharmacists' program
and to standardize care across the program. Training can ensure that
community-based pharmacists have a thorough understanding of the
program, which, in turn, can foster greater trust between pharmacists and
referring physicians and, ultimately, support high-quality patient care.

» Access to Patient's EHRs. For community-based pharmacists, this factor

is essential to fully integrating them into a hypertension pharmacists'
program. Access to EHRs allows community-based pharmacists to view
patient information and use communication tools they need to participate
seamlessly as members of the provider team.

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 Core Elements of the Michigan Medicine Program | 16

Michigan Medicine’s Partnership with

Community-Based Pharmacies
Michigan Medicine began partnering with Meijer to extend services in commu-
nity-based locations. Patients referred to the program during a clinic visit are
given the option to see a pharmacist in a Michigan Medicine clinic or at a Meijer
community-based pharmacy. The intended benefits of the partnership for
patients, Meijer, and Michigan Medicine are noted in Figure 2. Also, a checklist
of considerations for partnering with a community-based pharmacy, based on
Michigan Medicine’s approach, is provided in Appendix B.

Figure 2. Benefits of the Michigan Medicine and Meijer Partnership

Benefit to
Patients

Provides
access to care
in locations
convenient to
patients

Extends care Michigan Aligns with

Benefit to services for Michigan Meijer’s values to Benefit to
Medicine
Michigan Medicine patients serve members of
& Meijer Meijer
Medicine at additional their surrounding
locations Partnership community

The partnership with Meijer was officially established through a contract that
allows Meijer community-based pharmacy sites to be paid a single flat rate that
covers all of their pharmacists’ time to see patients as part of the hypertension
pharmacists' program. Additionally, Meijer pharmacists as a group have a CPA
with Michigan Medicine providers. The agreement allows Meijer pharmacists
to recommend medication changes for the patients they see. However, unlike
participating pharmacists based in a Michigan Medicine clinic, physicians must
approve Meijer pharmacists’ recommended medication changes before they are
implemented. The typical time frame for physician approval is within 24.

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 Core Elements of the Michigan Medicine Program | 17

Training and Ongoing Support for Community-Based Pharmacists

Once the contract with Meijer was established, Michigan Medicine provided
targeted training and ongoing support for community-based pharmacists to
ensure that they were effectively integrated into the program. Michigan
Medicine designated a seasoned ambulatory care pharmacist within the
program as the point person to work with the Meijer community-based
pharmacists to train them:

» Understand the ambulatory care approach;

» Navigate the EHR system;

» Effectively communicate with referring providers through patient notes;

» Understand and comply with system policies and procedures; and

» Hone other skills needed to maximize their contribution to team-based care

of patients with hypertension.

The trainer developed tailored materials to support the integration of Meijer

community-based pharmacists into the Michigan Medicine system, including
a clinical protocol compliance competency worksheet and a SOAP2 note
competency assessment. Thorough training helped ensure a standard program
workflow across ambulatory care and community-based pharmacists, create
positive interactions, and build trust between referring physicians and
community-based pharmacists. Additional ongoing support and supervision
are provided through bimonthly video conferences between community-based
pharmacists and a team of two Michigan Medicine physicians affiliated with the
hypertension pharmacists' program. During these video conferences, Meijer
pharmacists can bring cases for discussion, and the team will review and provide
feedback to the pharmacists to help support quality program delivery.

Establishing Access to Patient's EHRs for External Pharmacists

Program leadership identified pharmacists’ access to EHRs as essential to
effective implementation. Even though Michigan Medicine had negotiated
and established EHR access for ambulatory care pharmacists, additional effort
was necessary to acquire this access for Meijer community-based pharmacists.
2
This acronym stands for “subjective, objective, assessment, and plan.” This is a standard charting plan used in clinical
settings based on the medical model of practice. It includes recording a patient’s condition and status.

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 Core Elements of the Michigan Medicine Program | 18

Initially, program leaders had to address concerns within Michigan Medicine

before issuing EHR access privileges to providers outside the health care system.
Communication with system leaders led to the solution of onboarding Meijer
community-based pharmacists as Michigan Medicine contracted employees.

As contracted employees, Meijer community-based pharmacists were given EHR

privileges that allowed them to access patient records, communicate directly with
referring physicians, and recommend medication changes for the patients they
saw. They were provided with Michigan Medicine laptop computers that allowed
secure access to EHRs, which, in turn, allowed them to acquire the information
needed to serve patients fully and collaborate effectively as members of the
health care team. Giving Meijer community-based pharmacists employee status
ensured that they would be accountable for complying with all health system
policies and procedures.

Program leaders noted that approval for Meijer pharmacists to be hired as

contracted employees with EHR privileges paved the way for implementing the
community-based pharmacy component of the program.

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 Core Elements of the Michigan Medicine Program | 19

3.4 Core Element: Leadership Support

Acquiring leadership support at multiple levels of a health system can
encourage adoption of the hypertension pharmacists' program and ensure that
the program remains a priority. Levels of leadership to consider engaging may
include executive, clinical, and day-to-day operational. Leaders at each of these
levels help ensure that the program is supported, implemented, and sustained.

Michigan Medicine Engagement of Leadership

The Michigan Medicine Program director met with Michigan Medicine executive
leadership, referring physicians, and clinic administrators, and staff to garner
support for the program. The director met with representatives at each of these
levels to share how the program was affecting quality and patient outcomes.
The director’s role in pursuing these connections, advocating for the program,
and framing the potential benefits in ways that were compelling to each level of
leadership was noted as an essential facilitator in obtaining support.

* The Importance of
Institutional Knowledge
The Michigan Medicine Program director’s
institutional knowledge, understanding of
quality improvement processes, and grasp
of the potential importance of the program
to leaders at different levels within the
health system were critical to establishing
and sustaining leadership support.

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 Core Elements of the Michigan Medicine Program | 20

For example, in approaching different leaders, the program director

understood that:

» Executive Michigan Medicine leaders need to see how the program can
support the health system in achieving quality benchmarks to encourage
their support for initial financial investment in the program and promotion
of clinical staff buy-in;

» Clinical staff in both ambulatory care clinic and community settings need to
see the potential benefits to patients (e.g., improved patient outcomes) and
feel confident that patient information will be protected in order for them to
support the program through patient referrals; and

» Operational staff need to see how and why the program is integrated into
clinical processes so that they can support effective implementation.

Establishing partnerships with community-based

pharmacies requires engagement of community-based
pharmacy leadership to develop a shared understanding
of roles and responsibilities.

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* Sustaining the Core Elements of the Michigan Medicine Program | 21
PPCP Approach
Those interested in implement-
ing a PPCP-based hypertension
pharmacists' program can work 3.5 Core Element: Sustainability Planning
with payers and health care Planning for sustainability early can support longevity of the
providers to explore and discuss hypertension pharmacists' program. Identifying factors that will
available payment models that promote sustainability and incorporating them into implemen-
can sustain the program. tation are important steps. Furthermore, conveying these factors
(and efforts to support them) to anyone who provides support
to the program can help them see the viability of a hypertension
pharmacists' program and the value of continued investment.

Sustainability at Michigan Medicine

Michigan Medicine Program leadership identified the factors in
Table 2 as important to facilitating hypertension pharmacists'
program sustainability.
Table 2. Factors Supporting Sustainability of the Michigan Medicine Program
Sustainability Factor Description
Dedicated Staff • Engage clinical and community staff and others responsible for program management
and implementation in the program’s planning.
(See Section 3.2, Table 1)
• Support community pharmacy engagement in patient care management through
CPAs and contracts.
• Foster strong communication and program buy-in among members of the healthcare
team through regular data-driven feedback.
Designated Clinical Space • Allocate private clinical space and designate equipment (e.g., blood pressure monitors)
and Equipment to support quality engagement with patients in clinic and community-based settings. If
these resources are not already available, incorporate them into program cost planning,
(See Section 3.2, Designated Equipment
because they are necessary for sustaining the program.
and Facilities)
Shared Pharmacist–Physician • Secure EHR access for pharmacists to support communication with other practitioners
EHR Access in both clinic and community settings (including referring PCPs) and to facilitate deliv-
ery of high-quality patient care.
(See Section 3.2, Collaborative
Practice Agreements)
Ongoing Funding • Establish CPAs to enable privileges for Michigan Medicine pharmacists. These agree-
ments can tie pharmacist services into the Blue Cross Blue Shield of Michigan (BCBSM)
(See Section 3.2, Infrastructure and
reimbursement model, which recognizes pharmacists as care managers.
Capacity)
• Require partner clinics (in both ambulatory care clinic and community-based settings)
to pay a portion of a pharmacist’s salary to facilitate full engagement in the program.
Leadership Support • Seek leadership support in both clinic and community-based settings by sharing
program information with leaders, including updates on the services that pharmacists
(See Section 3.4, Leadership Support)
are providing in clinics and how these services affect patient outcomes, achievement of
quality benchmarks, and other factors that might facilitate buy-in.

Find more resources to guide implementation and support sustainability in Appendix C.

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 Program Monitoring and Evaluation | 22
* Monitoring and
Evaluation Resources
See the following CDC website for
resources that may support effective
program monitoring and evaluation.

Evaluation Guides & Toolkits *

4. Program Monitoring and Evaluation

Program monitoring and evaluation provide three primary benefits:

» Enabling measurement of progress toward program goals;

» Identifying opportunities for program improvement; and

» Demonstrating program effectiveness.

In this section, we include a brief overview of core concepts and issues to

consider when evaluating a hypertension pharmacists program.

Program evaluation requires a systematic approach that can support program

improvement and accountability. The CDC Framework for Program Evaluation in
Public Health provides a structured approach to program evaluation (CDC, 1999;
https://www.cdc.gov/eval/framework/). The framework comprises a series of
steps that outline the essential elements of effective program evaluation.

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 Program Monitoring and Evaluation | 23

Engage Others
Early in the evaluation planning process, engage those with strategic interest
in the program to identify appropriate evaluation questions and define the
most meaningful program- and patient-level outcomes to assess the program’s
impact. Their early involvement may increase support for the evaluation as
it is implemented and to act on evaluation findings. In addition to the core
implementation team (i.e., program director and management staff ), consider
engaging clinical staff (e.g., pharmacists, physicians), health system leadership,
patients, and other people and organizations invested in the program, the evalu-
ation’s results, and how those results might be used.

Describe the Program

Start by gaining a thorough understanding of the program, its costs, and
how program activities are intended to link to outcomes of interest. Then
develop a logic model that depicts key components of the program, how
those components relate to one another, and how they relate to the intended
outputs and outcomes. The Michigan Medicine Program Logic Model is included
in Appendix D.

Focus the Evaluation

Using the program logic model, as well as other pertinent
information gathered about the program, develop evaluation
* Logic Model questions and then an overall evaluation design. Select evalua-
Resources tion questions that align well with program objectives. Evaluation
Visit the CDC Program questions might focus on program processes, outcomes, and/or
costs. Process evaluation questions can support understanding
Performance and
of how a program is being implemented. Outcome evalua-
Evaluation Office
tion questions can help explore a program’s effects on specific
website for logic
outcomes. Cost or economic evaluation questions help identify,
model resources.
measure, and assess the costs of starting and implementing a
program. Evaluators need to assess the types of data required
to address each evaluation question in a way that those with a
strategic interest in the program will find compelling. Table 3
provides the overarching evaluation questions and corresponding
data sources used to guide the evaluation of the Michigan
Medicine Program.

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 Program Monitoring and Evaluation | 24

Table 3. Sample Evaluation Questions and Corresponding Data Sources

Process/Implementation Interviews EHR Data Cost Data
• What are the key factors that affect implementation of the program? ®
• What is needed to support sustainability of the program? ® ®
• To what extent is the program transferable and replicable? ®
Outcomes/Effectiveness
• What is the reach of the program? ® ®
• To what extent does the program improve patient outcomes? ® ®
• To what extent does the program improve organizational outcomes? ® ®
Cost
• What are the costs and savings associated with implementing
the program? ®

Gather Credible Evidence

Gathering evidence that will be seen as credible requires planning. Identify the
indicators, methods, and sources of information that will be used to address
each of the proposed evaluation questions. Specify an approach for collecting
the data (e.g., conducting primary data collection, relying on already available
data, such as patients’ EHRs) and for analyzing the information (e.g., pre-post,
control vs. comparison).

Data collection for the Michigan Medicine Program evaluation

included a review of quantitative data (EHRs and cost) and
qualitative data (e.g., transcripts of interviews).

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 Program Monitoring and Evaluation | 25

Justify Conclusions
Regardless of whether an evaluation is conducted to show program effective-
ness, help improve the program, or demonstrate accountability, analysis and
interpretation of findings is an important step. Once analysis is complete, it is
important not only to interpret the evaluation data to determine the extent to
which the program was effective at achieving outcomes of interest but also to
describe any contextual factors that might have influenced the findings and to
describe any data limitations. It is important to engage those with a strategic
interest in the program during this process, because they can help review the
data, provide additional context, and identify potential uses of the findings. CDC
engaged key contacts from the Michigan Medicine Program in the development
of the evaluation data collection, analysis approaches, and understanding the
full context of the findings.

Ensure Use and Share Lessons Learned

The ways in which evaluation results will be used and disseminated can be
considered before the evaluation period ends. Program data can be used to
address evaluation questions and also be shared in real time with the program
team to inform immediate program improvements. For example, Michigan
Medicine Program’s leadership team monitors BPA data and provides regular
feedback to clinic teams to ensure the BPA system has the intended effect on
referrals to the program.

Sharing lessons learned is a key step in evaluating a program because it can help
inform the field and build the evidence for using a particular strategy. When
disseminating findings, consider multiple communication channels, such as
evaluation reports, executive summaries, fact sheets/briefs, newsletter articles,
formal and informal presentations, and journal publications. Finally, and perhaps
most importantly, use the evaluation findings to identify ways to further improve
the hypertension pharmacists' program.

The Michigan Medicine Program team has disseminated program evaluation findings
through internal and external communication channels, including peer-reviewed
publications (e.g., Vordenberg et al., 2019).

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 Conclusion | 26
* Pharmacy Resources
Additional CDC resources to support
integration of pharmacists into clinical care:

Pharmacy Resources *

5. Conclusion

5.1 Overall Strengths of the Michigan

Medicine Program
The Michigan Medicine Program has shown promise in providing
patient-centered care, improving blood pressure management among
program participants, and supporting the health system in achieving
quality benchmarks. Core elements of the program are implementation
of the PPCP model, infrastructure and capacity, partnership with
community pharmacies, leadership support, and sustainability planning.
Incorporating all five of these core elements has supported Michigan
Medicine in providing high-quality, patient-centered care to patients
with hypertension. Some strengths of this program include how it:

» Promotes patient-centered care based on the PPCP, an evidence-

based approach that incorporates pharmacists as part of a multidis-
Readers are encouraged ciplinary team to improve quality of care;
to consider the context » Demonstrates early and effective engagement of health system
of their organizational leadership to support adoption, implementation, and sustainability;
setting and adapt this
program as appropriate. » Includes use of official agreements (CPAs for ambulatory care
pharmacists and contracts for community-based pharmacists) to
establish necessary privileges (e.g., access to EHRs) and support
effective collaboration between pharmacists and physicians; and

» Engages community-based pharmacy partners to expand program

accessibility and convenience for patients.

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 Conclusion | 27

5.2 Key Recommendations for Program Implementation and Maintenance

This evaluation resulted in the following key recommendations for implementing the PPCP
based on the Michigan Medicine Program and similar approaches:

» Consider an approach with a standardized these services affect patient outcomes,

scope of services that includes all five steps and how they support achievement of
of the PPCP as described in “Using the quality benchmarks.
Pharmacists’ Patient Care Process to Manage
» Identify and address barriers to acquiring EHR
High Blood Pressure” (CDC, 2016).
access for pharmacists early on to support
» Ensure that the team includes a program delivery of high-quality patient care and facili-
director with applied institutional knowledge, tate effective communication and collabora-
understanding of quality improvement tion between pharmacists and physicians.
processes, ability to leverage relationships,
» Allocate private clinical space that supports
and willingness to be persistent in champi-
proper blood pressure measurement
oning the program.
and designate equipment (e.g., blood
» In addition to a strong program director, pressure monitors).
ensure that the team includes program
» Use formal agreements (e.g., CPAs, contracts)
administration staff (e.g., managers), data
to establish a clear understanding of roles
quality staff to monitor implementation,
and responsibilities for physicians and
and clinical staff (e.g., pharmacists,
pharmacists with respect to patient care
referring PCPs).
management privileges.
» Engage health system leaders at the
» Provide ongoing training and support for
executive, clinical, and operational levels by
community-based pharmacists to support
demonstrating the value of the program in
their understanding of and integration
ways that are relevant and compelling to
into the larger program.
their roles and responsibilities.
» When considering this model, assess
» Develop tools (e.g., BPAs) to support
program costs (e.g., staffing, infrastructure)
physician referrals to the program and
and compare these with potential options
a plan for delivering timely, data-driven
for reimbursement. Identify and continually
feedback (i.e., referral activity) regarding
explore opportunities to support expansion
their implementation of these tools. of reimbursement (e.g., onboarding of
» Foster ongoing leadership buy-in by additional payers) and requirements for
providing updates on the services that obtaining quality incentives to support
pharmacists are providing in clinics, how program sustainability.

In addition to the above recommendations for program implementation and maintenance, the
following are barriers and potential solutions identified through the Michigan Medicine Program eval-
uation that may also be helpful for planning purposes.

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 Conclusion | 28

Michigan Medicine Program Barriers and Solutions

•Communicate program benefits (e.g., quality of care, patient

access) to physicians
•Share data to demonstrate to physicians that the model is
Gaining improving clinic efficiency
– physician
buy-in to + “...if you encounter a provider who’s never worked with a clinical pharmacist,
they might not understand the role...but there’s so much data out there...
the program
that you can easily provide that to them and educate them on the impact
of clinical pharmacists....”
—Michigan Medicine Pharmacist

• Automate physician reminders through the best practice alert (BPA)

Obtaining • Hold face-to-face meetings to remind physicians about

– physician
referrals to + program benefits
“Another barrier is just [referrals] getting lost in the shuffle of all the other
the program things we have to do. So just bringing it up to the forefront repeatedly....”
—Michigan Medicine PCP

• Educate leadership about how access will support quality of

patient care
Providing
• Ensure that approvals in accordance with governance procedures
Meijer
– pharmacists
access to
+ are obtained
“Coming to them with this totally new idea just took a lot of conversation
patient's EHRs and making sure we had the proper checks and balances with our
external pharmacists....”
—Michigan Medicine Program Leader

Patient • Use postcards/text messages to explain appointment location

confusion • Encourage patients to use their patient portal to access appointment
about the
– location of
appointments
+ “We created postcards to give to patients, and we also built in that they can
use their portal to cancel and reschedule appointments.”
when referred —Michigan Medicine Program Leader
to Meijer

• Explain that access to patient's EHRs supports high-quality care

Patient • Explain that access enables communication among entire team
concern of providers
– about
Meijer + “We communicated well at the outset [to patients] that the pharmacist is
going to be in their record, and that that’s what makes the program strong.”
access
to EHRs —Michigan Medicine PCP

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 References | 29

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May 18, 2021.

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Joint Commission of Pharmacy Practitioners. Pharmacists’ Patient Care Process. May 29,
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Kirkland EB, Heincelman M, Bishu KG, Schumann SO, Schreiner A, Axon RN, et al. Trends
in healthcare expenditures among U.S. adults with hypertension: national estimates,
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Proia KK, Thota AB, Njie GJ, Finnie RK, Hopkins DP, Mukhtar Q, et al. Team-based care and
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Vordenberg SE, Lindell V, Sheerer K, Settles A, Fan AL, Serlin DC, et al. Improving
hypertension control through a collaboration between an academic medical center
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Wang G, Zhou X, Zhuo X, Zhang P. Annual total medical expenditures associated with
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The Pharmacists’ Patient Care Process Approach

 References | 31

For more information, please contact:

Centers for Disease Control and Prevention

1600 Clifton Road NE
Atlanta, GA 30333
Telephone: 1-800-CDC-INFO (232-4636)
TTY: 1-888-232-6348
E-mail: [email protected]
Web: www.cdc.gov
Publication date: June 2021

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 Appendix A | 32

Appendix A. Glossary
Note: This glossary consists of terminology and definitions as used in this guide. Program
implementers may consider using other terms that work for their key audiences.

Key Term Definition

Best Practice Alerts (BPAs) A BPA is an alert in the EHR system that automatically notifies clinic staff when a patient has an
elevated blood pressure reading.
Electronic Health Records EHRs or EMRs are digital versions of patients’ paper charts that provide real-time patient records.
(EHRs)/Electronic Medical
Records (EMRs)
Evaluation Evaluation is defined by CDC as a systematic approach to collecting, analyzing, and using
data to determine the effectiveness and efficiency of programs and to inform continuous
program improvement.
Logic Model A logic model is a planning tool that clarifies and graphically displays a program’s or evaluation’s
planned goals, activities, and short- and long-term outcomes or impacts. Logic models help
summarize key program elements, provide a rationale for program activities, and clarify
intended outcomes. They can be used to communicate and/or interpret outcomes.
National Committee for HEDIS, a tool created by NCQA, measures performance on dimensions of health care service
Quality Assurance (NCQA) and delivery. Health care plans across the United States report on a number of HEDIS measures,
Healthcare Effectiveness which include 80 measures across five domains of care to facilitate the comparison of
Data and Information performance among health care plans. Michigan Medicine Program leadership considered NCQA
Set (HEDIS3)
HEDIS blood pressure measures when developing their program.

Pharmacists’ Patient Care The PPCP is recommended as a standard health care approach for patients with chronic con-
Process (PPCP) ditions, including hypertension. As noted in Figure 1, the PPCP includes five steps: (1) collect
necessary information about the patient to understand their medical history and clinical status,
(2) assess the information collected and analyze the patient’s therapy to identify problems and
achieve optimal care, (3) develop an individualized patient-centered care plan, (4) implement the
care plan in collaboration with other healthcare professionals and the patient, and (5) monitor
and evaluate the effectiveness of the care plan and modify it as needed (Joint Commission of
Pharmacy Practitioners, 2014).

3
https://www.ncqa.org/hedis/measures/controlling-high-blood-pressure/ *

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 Appendix A | 33

Appendix A. Glossary of Key Terms continued

Key Term Definition
Quality Benchmark Quality benchmarks allow continual measuring and comparing of performance metrics within a
healthcare organization and across health care organizations. For example, because better care
can improve health outcomes and reduce costs, the Medicare Shared Savings Program rewards
participating organizations for meeting quality performance benchmarks. These quality perfor-
mance benchmarks are established by the Centers for Medicare & Medicaid Services and are valid
for 2 years.
Qualitative Data Qualitative data are usually in the notes or transcripts and answer questions that are descriptive
(explain why or how); common qualitative analytical methods include participant observation
and content, thematic, and pattern analysis.
Quantitative Data Quantitative data are numerical in nature and answer questions that are quantifiable (specify
how much or to what extent); commonly used quantitative analytical methods include descrip-
tive statistics, one- and two-tailed t tests, correlations, cross-tabulations, and multiple regression
or other advanced statistical models.
Team-Based Care A team-based care model is based on a multidisciplinary team comprising the patient, the
patient’s PCP, and other professionals such as nurses, pharmacists, dietitians, social workers, and
medical assistants, who coordinate comprehensive disease management plans.

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 Appendix B | 34

Appendix B. Michigan Medicine Checklist for

Partnering with Community-Based Pharmacies

Community Pharmacy BP Clinic Implementation

I. Contract
a. Draft contract and send to internal legal department for approval
b. Send draft contract to community pharmacy for review and edits
c. Once finalized for both parties, contract is signed and executed
II. Collaborative practice agreement (CPA)
a. Draft CPA for community pharmacist scope of practice
b. Obtain appropriate governance approvals
c. Circulate CPA for medical director/staff signature(s)
III. Compliance
a. Gather documentation for each community pharmacist
i. HIPAA training
ii. License review (monthly)
iii. Curriculum vitae/resume
iv. Fraud waste and abuse training
v. Office of Inspector General exclusion search
b. MySAM exclusion review
c. Other institutional requirements
IV. Electronic health record system build
a. Create scheduling template for clinic hours at each community clinic location
b. Add new pharmacist providers to EHR access
c. Provide HIPAA-compliant laptops for community clinics to use for patient visit
documentation and physician outreach

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 Appendix B | 35

V. Clinic resources
a. Blood pressure machine (3 reading average)
b. HIPAA-compliant laptop
c. Manual BP cuffs (multiple size cuffs)
d. Patient reference materials
VI. Training
a. Clinical hypertension module
i. Case studies and protocol
b. Hypertension and telephone encounter workflows
c. Hypertension note template
d. Mock appointments and review
VII. Competency
a. Complete all required training
b. Score 100% on clinical protocol and SOAP note competency exams
c. Establish bimonthly meetings with community blood pressure program medical
director(s) to review patient cases
VIII. Referring clinic training and go-live
a. Train clerical and clinical staff at community blood pressure referring clinics on
how to identify appropriate patients, how to schedule at community clinic, and
what to expect for documentation and follow-up
IX. Patient and physician surveys
a. Community pharmacists provide private space for new and returning visit patients
to complete patient satisfaction surveys to be placed in locked box and picked up
by medical center staff
b. Distribute electronic physician satisfaction surveys to evaluate awareness and
satisfaction of community blood pressure pharmacists

2020 © The Regents of the University of Michigan

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 Appendix C | 36

Appendix C. Resources
This appendix includes a selection of links to resources that may be helpful in developing,
implementing, and evaluating a hypertension pharmacists' program model.

General Resources
Best Practices • This resource provides scientific evidence behind eight strategies for managing hypertension
and lowering cholesterol levels. https://www.cdc.gov/dhdsp/pubs/guides/best-practices/
index.htm
• This resource provides the 2019 American College of Cardiology/American Heart Associa-
tion guidelines for the primary prevention of cardiovascular disease. https://www.acc.org/
latest-in-cardiology/ten-points-to-remember/2019/03/07/16/00/2019-acc-aha-guideline-on-
primary-prevention-gl-prevention
• This resource provides blood pressure screening recommendations from the U.S. Preventive
Services Task Force. https://www.aafp.org/afp/2016/0215/p300.html
Community–Clinical • This resource provides a framework for creating linkages between community pharmacists and
Linkages physicians. https://www.cdc.gov/dhdsp/pubs/docs/ccl-pharmacy-guide.pdf
Collaborative Practice • The two resources below provide an introduction to CPAs. The first item is a course accredited
Agreement (CPA) by the Accreditation Council for Pharmacy Education, and the second item is a brief webinar.
– Course: http://elearning.pharmacist.com/products/5399/pharmacist-collaborative-
practice-agreements-who-what-why-and-how
– Webinar: https://naspa.us/introduction-collaborative-practice-agreements-brief-webinar/
• The course and webinar offer an overview of the impact of CPAs and considerations for imple-
mentation. CPAs are used to support team-based care through collaboration between physi-
cians and pharmacists. Through CPAs, pharmacists are granted privileges to provide disease
and medication management services to patients outside of traditional provider-based clinic
visits. https://www.cdc.gov/dhdsp/pubs/docs/Best_Practice_Guide_CDTM_508.pdf
Evaluability Assessment • This resource was created by CDC and provides tools and resources needed to conduct
evaluability assessments. https://www.cdc.gov/eval/tools/evaluability_assessments/index.html
Evaluation Resources • CDC’s Division for Heart Disease and Stroke Prevention (DHDSP) has developed evaluation
tools and resources to assist state health departments, tribal organizations, communities, and
partners in their programmatic and evaluation efforts. Although many of the tools and
resources were developed primarily for use by DHDSP-funded programs, they may also be of
interest to entities not funded by DHDSP or entities working in other chronic disease areas.
https://www.cdc.gov/dhdsp/evaluation_resources/guides/index.htm

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 Appendix C | 37

Appendix C. Resources continued

General Resources
Evidence-Based Practices • This manuscript describes a conceptual framework for planning and improving
evidence-based practices. The framework is an intersection of public health impact and
quality of evidence to look at a continuum of evidence-based practices—from emerging, to
promising, to leading, to best practices. https://www.cdc.gov/pcd/issues/2013/13_0186.htm
• This resource was created through the Million Hearts initiative and provides a list of process
improvements developed for ambulatory clinical settings to improve hypertension control.
https://millionhearts.hhs.gov/files/HTN_Change_Package.pdf
• This resource was also created through the Million Hearts initiative and compiles
evidence-based strategies for clinicians to aid in efforts to improve hypertension control.
https://millionhearts.hhs.gov/files/MH_HTN_Clinician_Guide.pdf
Pharmacists and Health • This website provides general information about pharmacists’ use of health information
Information Technology technology. http://www.pharmacyhit.org/
Pharmacists’ Patient Care • The PPCP is used to prevent and manage hypertension through team-based care. This
Process (PPCP) resource offers guidance, tools, and examples for how pharmacists can help improve patient
outcomes associated with hypertension. https://www.cdc.gov/dhdsp/pubs/docs/
pharmacist-resource-guide.pdf
Pharmacy-Based • This website provides DHDSP resources to help communities and health systems implement
Medication Adherence pharmacy-based interventions to improve medication adherence for cardiovascular disease
Interventions prevention. https://www.thecommunityguide.org/findings/cardiovascular-disease-
tailored-pharmacy-based-interventions-improve-medication-adherence?deliveryName=USC-
DCCG_25-DM18589
Professional • This website provides general information about the American Society of Health-System
Organizations Pharmacists. This professional organization represents pharmacists serving as patient care
providers in acute and ambulatory settings. https://www.ashp.org/
Team-Based Care • This resource is designed to advance team-based care by integrating community pharmacists
alongside prescribers, supported through formalized relationships through CPAs.
https://www.cdc.gov/dhdsp/pubs/docs/CPA-Team-Based-Care.pdf

The Pharmacists’ Patient Care Process Approach

Appendix D. Michigan Medicine Program Logic Model
Michigan Medicine Hypertension Pharmacists’ Program Logic Model

Inputs Activities Outputs Outcomes Impact

Core Team Identify and refer patients prompted by best practice alert
• Pharmacy Innovations and Partnerships team • Identified through elevated BP (two readings) * • No. of patients identified
• Clinic pharmacists during PCP visit • No. of patients referred (to clinic and
• Referred to pharmacists and appointment community pharmacies)
• Trained Meijer pharmacists
• Primary care providers scheduled at check-out
• Medical assistants
In-person 30-minute meeting with patients to collect
Additional Team Members the following:
• Advanced practice providers (e.g., PAs, NPs) • Diagnoses, allergies, medical history
*
• Clinic dietitians • Current and past medications—adherence, • No. of appointments
• Social workers side effects, and cost • Patient data (some in discrete fields and some
• Behavioral health specialists • Current symptoms in case notes)
• Lifestyle factors
• Panel managers
• Risk factors for CVD
Short-Term Outcomes (up to 1 year)
Leadership Support • BP and BP goals
• Executive leadership • Patient perceptions and priorities Patient-level outcomes:
• Clinic leadership • Improved BP control
• Meijer leadership Assess Number and type • Increased disease and treatment knowledge
• Evaluate drug therapy through direct patient • Medication modification needs identified • Increased patient satisfaction
Partners interview and EHR review • Lifestyle modification needs identified • Improved access to health care providers
• Blue Cross Blue Shield of Michigan • Order labs to assess efficacy and safety of • Labs ordered • Timelier follow-up with health care providers
medication on behalf of physicians, as needed
Program Materials/Tools Systems-level outcomes:
• Collaborative practice agreements Plan • Increased access to pharmacists among
• Clinical protocols • Determine appropriate treatment to achieve goal patient population
using Specific, Measurable, Achievable, Realistic, * • No. of plans developed, documented in EHRs • Strengthening of relationships between
• Home BP monitoring tools and *
patient portal and Timely goal approach • No. of plans communicated (to patients PCP and pharmacists Achieve optimal hypertension
• Coordinate as needed with care team and providers) • More efficient use of resources control and management utilizing
• Patient education materials
• Document and communicate findings and • Improved quality ratings team-based care
Staff Training recommendations in EHR using standardized
note template
• Clinic team orientation and follow-ups Long-Term Outcomes (1 year or longer)
• Clinical pharmacist onboarding protocol
• Meijer pharmacist onboarding protocol Implement Patient-level outcomes:
• Physicians respond to BPA
• Decreased cardiovascular disease
Funding • Clinic and Meijer pharmacists:
• University of Michigan Medical Group - Provide lifestyle modification recommendations Systems-level outcomes:
- Reinforce medication adherence • No. of responses to BPA
• Clinics * • Improved quality ratings
- Document plans in EHR • No. and type of medications prescribed/modified
(for each method) • Increased use of team-based care
IT - Clinic pharmacists only: • Michigan Medicine serves as leader in field
• No. of referrals made to other team members
• EPIC (MiChart) • Make referrals to dietitians, social workers, et al. across the state
• Best practices alert • Make medication modifications
• Tableau dashboards • Meijer pharmacists only:
• Patient portal - Recommend medication modifications
• No. of follow-up appointments
Quality Improvement Evaluate/follow • No. of patient care plans/medications adjusted
• Pharmacist credentialing process • Follow up (in-person, telephone) until 2 visits at goal * • No. and type of medications prescribed/modified
• Weekly report on medical assistant workflow • Evaluate drug effectiveness, make changes • No. of referrals made to other team members
• Monthly report on clinic BP control as necessary • Frequency of use of home BP monitoring tools
• Meijer patient satisfaction surveys • Document information in EHR (routed to • Patient tenure in the program
• Quality improvement analysis patient’s PCP)
• Use home BP monitoring tools (e.g., patient • Time to goal blood pressure
• Periodic evidence review portal) for ongoing assessment.

*
• No. of new locations for current partners
Expand the community BP program
• No. of new partnering community pharmacists

Share the model (clinic and community BP program) • No. of pharmacists trained through 9/17/19
• Presentations * various mechanisms
• Publications • No. of presentations made
• Consultations/technical assistance • No. of publications made
• Training (ad hoc and through formal mechanisms) • No. of consultations made

The Pharmacists’ Patient Care Process Approach