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Fierce Collaborators

AACP Article

The Federally Qualified Urban Health Network provides a model for collaboration that includes pharmacists as part of primary care teams serving low-income populations.

By Joseph A. Cantlupe

Nearly a decade ago, a group of 10 federally qualified health centers in Minneapolis-St. Paul was competing for dollars and patients in a big way. Their relationship was “fiercely competitive,” according to a Dartmouth College study. Over the years, however, they bonded together to provide high-quality care to low-income and medically underserved populations and formed one of the nation’s first safety net Accountable Care Organizations (ACOs). These once “fierce competitors” were now “fierce collaborators,” the Dartmouth researchers noted.

For a long time, the full network lacked pharmacists and student pharmacists, although some were at individual clinics. That has changed, and it’s making a big difference in providing care. While each of the clinics had pharmacy positions, only recently did the entire network begin to include pharmacists and pharmacy residents. Their actions have gone a long way to improve their multidisciplinary framework, improve medication management and ease the burden on the physician. With the service of pharmacists, these clinics have seen major improvements in caring for patients, many of whom have comorbidities such as diabetes and hypertension.

Known as the Federally Qualified Urban Health Network (FUHN), the collaboration model includes at least eight clinics with multiple service sites. Its clinics serve about 60,000 patients, of which 27,000 are Medicaid patients. The clinics, in particular, have worked closely with the University of Minnesota College of Pharmacy, their students and their residents, said Dr. Todd Sorensen, professor and senior executive associate dean for strategic initiatives and faculty affairs at UMN. They have reported “significant improvements in quality measures when pharmacists are part of the primary care team,” he said.

Under the program, with value-based agreements with Minnesota Medicaid and the managed care plans, cost savings and additional revenue stemming from those agreements have driven the expansion of pharmacists into primary care services, Sorensen said. The network structure that manages these ACO agreements has made integration of pharmacists one of their top priorities in part because of the significant impact on quality measures they have seen, he added. The ACOs are groups of doctors, hospitals and other healthcare providers who come together voluntarily to give coordinated high-quality care to their Medicare patients, according to the Centers for Disease Control and Prevention. When an ACO succeeds in delivering high-quality care and spending healthcare dollars more wisely, the ACO will share in the savings it achieves for the Medicare program.

Improved Care With Pharmacists’ Involvement

UMN began developing relationships with Federally Qualified Health Centers that eventually came to form FUHN two decades ago. The collaboration started with a grant from the Health Resources and Services Administration (HRSA) to establish clinical pharmacist services in three FQHCs. The collaboration has been maintained over 20 years through FQHC residency positions affiliated with UMN’s PGY1 residency program, hosting student APPEs as well as efforts to expand clinical pharmacy services to additional clinics in the network. Clinic officials have praised the collaboration and its impact on patient care, Sorensen noted. In addition, the FUHN program has had fiscal benefits through the Medicaid program, with money shared back with the project. “They are looking to expand this over time,” he said.

UMN recently received a $1.5 million Agency for Healthcare Research and Quality grant in collaboration with FUHN to implement and evaluate strategies to improve medication use in care transitions of patients who receive primary care in FUHN-affiliated FQHCs. Dr. Joel Farley is the principal investigator, leading a team of researchers and practitioners from the College of Pharmacy, UMN School of Public Health and FUHN. The effort directly targets cost savings goals established by FUHN’s value-based agreements with Minnesota Medicaid. The FQHCs are community-based healthcare providers that receive funds from the federal HRSA Health Center Program to provide primary care services to underserved areas. A strict set of requirements must be met, including fees based on ability to pay, and they must be overseen by a governing board that includes patients.

The FUHN clinics serve more than 60,000 patients—the overwhelming number of whom are poor and from diverse communities. Nearly half are served in languages other than English. “It’s the savings/new revenue that is coming from those agreements that are driving the expansion of pharmacists into their primary care services.”

Dr. Todd Sorensen

The FUHN clinics serve more than 60,000 patients—the overwhelming number of whom are poor and from diverse communities. Nearly half are served in languages other than English. “It’s the savings/new revenue that is coming from those agreements that are driving the expansion of pharmacists into their primary care services,” Sorensen explained. In turn, capacity has grown for pharmacy resident and student pharmacist experiences that engage them in learning about social determinants of health, pricing programs and insurance impacts, he said.

The possibilities for economic benefits of such programs are endless, advocates say. Other similar pilots described average annual savings per patient exceeding $1,000 a year in overall medication claims when a pharmacist had a face-to-face meeting with a patient in the primary care practice. Physician-pharmacist collaborative models have produced a 504 percent return on investment, according to a National Academy of Medicine on High Quality Primary Care report.

Indeed, pharmacists, residents and students have played key roles in providing care and improving outcomes, said Colleen McDonald Diouf, chair of the FUHN Board of Directors. She also serves as the CEO of the Community-University Health Care Center at the University of Minnesota. “We have many providers, some of whom were challenged, and burned out and fatigued, and now they have someone on their team who is managing and supporting those patients who need more care,” she said.

Pharmacists have been brought in to work closely with different clinics, some of whose patients may have similar healthcare issues but require different approaches to care due to cultural or language barriers. Diabetes and hypertension are among the top issues for the patients, though that may differ in each community, Diouf said. “Our mission is to help communities become healthier, to reach folks not served by mainstream healthcare because of a multitude of reasons: structural racism, poverty, trauma or having disproportionate rates of chronic diseases,” she added. “We are health centers that grew from the communities we serve, each with unique approaches. We build upon each health center’s strengths.”

A recent grant to FUHN via one of its health plan partners supported an initiative where a pharmacy resident designed and implemented a program in which a clinical pharmacist and a community health worker pair provided medication management services that helped patients with diabetes control their hemoglobin A1C, Diouf said. In 2019, the program demonstrated that clinics were able to significantly improve the number of patients achieving an A1C measurement at goal. Contributions by clinical pharmacists have played a significant role, she pointed out.

Before pharmacists became involved, the clinics “didn’t have pharmacy team members to help with those medications. We had a lot of sick people at our clinics. But it’s an example of what FUHN does best—it takes the best practice from a community health center and spreads it out to other health centers.”

Colleen McDonald Diouf

Before pharmacists became involved, the clinics “didn’t have pharmacy team members to help with those medications. We had a lot of sick people at our clinics. But it’s an example of what FUHN does best—it takes the best practice from a community health center and spreads it out to other health centers,” Diouf said. “We worked really hard to get funding to do the pilot projects with the (Minnesota) College of Pharmacy.”

Dr. Swetha Pradeep, a clinical pharmacist with FUHN, said she started working with the program in 2019 after completing her residency and works at three clinics: Neighborhood HealthSource, Native-American Community Clinic and Southside Community Health Services. “What is unique about this practice is its population health approach,” Pradeep said. “Rather than relying solely on medical provider referrals to the pharmacist, we take a proactive approach in identifying patients not meeting a clinical quality goal. Not meeting this quality goal is a ‘ticket in the door’ to see the pharmacist.”

Pharmacists apply the comprehensive medication management model when assessing patients, ensuring that all of a patient’s medication needs—including indication, effectiveness, safety and convenience—are addressed. Collaborative practice agreements with primary care providers add efficiency to the team’s services. Of note, Pradeep added, “Many of our patients have challenges with medication access or affordability. I can help navigate insurance formularies and cost-savings programs for patients.”

Delivering on a Promise

Bringing pharmacy and physician teams together to improve care represents a longtime goal for Sorensen. While this has been a challenge previously, shifts to value-based payment have created new opportunities for the adoption of team-based care. This was a priority theme when Sorensen served as AACP President in 2019–20. His focus for the AACP standing committees was to establish strategies that would advance physician-pharmacist collaborations as a strategy to support pharmacy practice transformation.

The AACP 2020–21 professional affairs standing committee focused its report on pharmacists’ unique role and integration in healthcare settings, said Dr. Gina Moore, chairwoman of the committee and associate dean for administration and operations and associate professor at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences. Among other tasks, the committee identified studies that showed positive outcomes from patient care services provided by pharmacists in non-primary care settings. They included healthcare team satisfaction, drug savings, improvement in patient medication adherence, patient satisfaction and a reduction in hospital readmissions. The report showed that regulatory barriers have held back the pharmacy profession from “practicing at the top of their license,” the committee said.

Other workplace issues must be overcome, Moore said. “There is a considerable knowledge gap when it comes to other providers knowing what pharmacists can do and the synergies that can be tapped into. Luckily, in primary care practices, particularly in federally qualified health centers and in clinics in which interdisciplinary care is practiced, pharmacists tend to practice at the top of their scope of licensure and make considerable impact on patient care.”

However, the committee noted that “while the challenges can be numerous, the integration of pharmacists into the healthcare model continues to expand and the profession needs to continue to facilitate overcoming these barriers.” Sorensen is starting to see a realization of the impact of pharmacist involvement stemming from the FUHN program. “I have known many of the CEOs and leaders across the network for 20 years,” he said. Those collaborations are the foundation for an increased pace of growth of pharmacist integration with the primary care team now that quality of care and clinical outcomes are increasingly driving organizational investments and decisions.

Joseph A. Cantlupe is a freelance writer based in Washington, D.C.

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