Message from the Directors
The USC Titus Center for Medication Safety and Population Health’s first year offered an exceptional number of challenges and opportunities.
As the entire healthcare system continues to recover from the COVID-19 pandemic, it is more critical than ever to leverage the expertise of all healthcare team members. Suboptimal medication therapy remains a major cause of avoidable patient harm and healthcare costs; contributors include a diminishing and overburdened primary care workforce, fragmented health information systems, misaligned financial incentives and insufficient support for pharmacists to practice at the top of their licensed potential.
An acute need persists for innovation, including evidence-based interventions that are scalable, sustainable and accessibly delivered to the right places by the right people at the right time. In fact, accessibility remains an essential element to improving health equity, especially for technology-enabled services. Improving accessibility requires that we address the social needs of underserved patients and empower them to engage in self-management. Generating and disseminating new evidence on effective and accessible care is the key focus of all the Titus Center’s efforts in research, practice development, education and advocacy.
All of our activities must be driven by quality evidence. Earlier this year, we added Yuna Bae-Shaaw, PharmD, PhD, a research assistant professor at the USC Mann School of Pharmacy and Pharmaceutical Sciences, to the analysis team. This appointment has allowed us to rapidly expand our research activity pipeline. We report here some early findings as we near completion on the first two rigorous evaluations of patient cohorts enrolled in the California Right Meds Collaborative (CRMC) at two different health plans.
We have submitted proposals and letters of intent for approximately $9 million in new funding, while continuing work under the current $3 million 1817 Wellness grant from the Centers for Disease Control and Prevention (CDC), which supports CRMC and other partner programs. That CDC grant was obtained thanks to collaboration with the Los Angeles County Department of Public Health. About a dozen other analysis projects are in the planning stages or already underway. We also recently convened our first Advisory Board mini-retreat to solicit guidance and suggestions. Finally, our first annual Titus Center Symposium in October successfully brought together thought leaders and practitioners to share progress and ideas across the spectrum of center activities.
Our flagship enterprise, CRMC, continues to grow in patient enrollment—within current health plans and with new health plans joining. Two international healthcare organizations are also seeking to partner with us. The CRMC network now includes over two dozen pharmacies in three counties. They collaborate with four different health plans covering more than 8 million lives. Through these partnerships, CRMC is bringing value-based comprehensive medication management (CMM) to underserved communities throughout California and beyond. Our key partners are community pharmacies, managed by USC and supported by a rigorous continuous quality improvement process.
Another major contributor to CRMC’s success is the clinical pharmacy technician certification program, which enables pharmacy technicians to fulfill essential clinical CMM support roles. In many instances, these technicians act as the key culturally and linguistically aligned team link with patients. CMM delivered through CRMC has made remarkable improvements in the health of the most vulnerable patients, driven in part by a strong focus on closing the loop on social needs. CRMC recently expanded to partner with Healthcare In Action, a traveling comprehensive health program for unhoused individuals (a care delivery innovation often referred to as “street medicine”). Meanwhile, our training program has expanded to include the Psychiatry for Population Health Pharmacists Collaborative in recognition that mental health illnesses are common comorbidities among our patients.
Seeking to advance policy and practice, our team members also serve on local, regional, and national committees and organizations addressing major gaps in the management of common chronic conditions. These include the American Heart Association, Be There San Diego, California Chronic Care Coalition, California Pharmacists Association, CDC, Covered California, Get The Medications Right Institute, Los Angeles County Department of Public Health, Right Care Initiative and several programs supported by the National Institutes of Health.
The Titus Center was made possible by a generous bequest following the passing of Susie Titus, BS ’58, a great friend of USC Mann for many years. Her support, along with that from her late brother DeWight Titus, PharmD ’58, has been instrumental in advancing our clinical service mission. Their generosity has enabled our faculty, staff, partners and graduates to impact countless lives.
We also are indebted to Dean Vassilios Papadopoulos for his ongoing support and guidance of the center and related initiatives. Finally, the vision for this center was originally developed in collaboration with the late Kathy Johnson, PharmD, MPH, PhD, a great friend, mentor and leader.
Steven
Chen,
Pharm.D., FASHP, FCSHP, FNAP
Director, USC Titus Center for Medication Safety and Population Health
Associate Dean for Clinical Affairs
Professor, Titus Family Department of Clinical Pharmacy
William A. Heeres and Josephine A. Heeres Chair in Community Pharmacy
D. Steven Fox, MD, MPhil
Associate Director and Research Head, USC Titus Center for Medication Safety and Population Health
Fellow, USC Schaeffer Center
Research Assistant Professor, Department of Pharmaceutical and Health Economics
Mission and Vision
Vision
Achieve equitable health and community well-being through highquality, evidence-driven clinical practice
Mission
Optimize population health outcomes by promoting outpatient pharmacy practice and clinical service delivery models that:
• Are grounded in evidence
• Recognize social determinants of health
• Facilitate maximum patient access
We will advance this mission through targeted research, service delivery, stakeholder education, and policy advocacy
A special thank you to Bill and Josephine Heeres. Their generous support, guidance, and mentorship continues to be invaluable in our efforts to advance the role of community pharmacy as local hubs for healthcare and social services.
Meet the Titus Center Team
Steven Chen, Pharm.D, FASHP, FCSHP, FNAP
Director, USC Titus Center
D. Steven Fox, MD, MPhil
Associate Director and Research Head, USC Titus Center
Jessica Abraham, PharmD, APh
Director of Population Health
Michelle Chu, PharmD, BCACP, APh
Assistant Professor of Clinical Pharmacy
David Dadiomov, PharmD, BCPP
Assistant Professor of Clinical Pharmacy
Thuy Tien Nguyen, PharmD
Clinical Affairs Intern
Yuna H. Bae-Shaaw, PharmD, PhD
Research Assistant Professor
Shaden Daas, MPH
Project Manager
Connie Kang, PharmD, BCPS, BCGP
Assistant Professor of Clinical Pharmacy
Lisa McDonald Reyes, MPH
Associate Director of Continuing Education Office of Continuing
Anneliese Wilkins
Quality Improvement Specialist
Advisory Board, USC
Titus Center and Caliornia Right Meds
Collaborative
We are indebted to our esteemed Advisory Board members, who provide guidance and insights on:
• Current and developing real-world challenges to achieving optimal health outcomes, with an emphasis on equity
• Innovative approaches to improving quality of care and patient safety
• Improving efficiency and efficacy of health interventions
• Reducing cost of care from health plan / payer and consumer perspectives
• Quality improvement approaches and resources
• Facilitating aligned and productive partnerships for advancing the mission of the Titus Center and CRMC
2022 Advisory Board Members:
HEALTH PLAN LEADERSHIP
Kristin Gericke, PharmD, Director of Pharmacy
CalOptima Health
Ed Jai, PharmD, Senior Director and Chief Pharmacist
Inland Empire Health Plan
Sharon Jhawar, PharmD, Director of Pharmacy
SCAN Group Health Plan
Alex C. Kang, PharmD, MBA, APh, BCPS, BCACP, Director of Clinical Pharmacy
L.A. Care Health Plan
Salina Wong, PharmD, Senior Director, Clinical Pharmacy Programs
Blue Shield of California
MEDICAL LEADERSHIP
Michael Hochman, MD, MPH, CEO Healthcare In Action
Tony Kuo, MD, MSHS, FAACP, Director, Division of Chronic Disease and Injury Prevention
Los Angeles County Department of Public Health
Mark Loafman, MD, MPH, Chair of Family and Community Medicine
Cook County Health
MEDICAL LEADERSHIP (cont.)
Jessica Nunez de Ybarra, MD, MPH, Community Health Medical Administrator
California Department of Public Health
HEALTH SYSTEM PHARMACY LEADERSHIP
William A. Heeres, PharmD, Chairman Emeritus and Community Pharmacy Specialist
USC School of Pharmacy Board of Councilors
Rita Shane, PharmD, Vice President and Chief Pharmacy Officer Cedars-Sinai Health System
Lindsay Valenzuela, PharmD, APh, BCACP, Associate Vice President Population Health Integration Desert Oasis HealthCare
PROFESSIONAL ORGANIZATIONS
Susan Bonilla, CEO California Pharmacists Association
Sang-Mi Oh, Senior Vice President/ Executive Director Los Angeles County American Heart Association
PATIENT ADVOCACY
Elizabeth Helms, President and CEO California Chronic Care Coalition
Partnerships
The Titus Center collaborates with a broad group of local, regional, and national stakeholders to fulfill our mission. These include:
Health Plans
Our health plan partners in the California Right Meds Collaborative (CRMC)— including Blue Shield of California, Healthcare In Action (a unit of SCAN Group Health Plan that delivers care to unhoused individuals), Inland Empire Health Plan and L.A. Care Health Plan— team with our network of community pharmacies to offer a variety of services, including comprehensive medication management (CMM). Clinical services are supported by value-based payments and CRMC works closely with health plan staff to drive outcomes efficiently through a rigorous continuous quality improvement process. In addition, health plans invest time and resources into educating our network of pharmacies on how to identify and assist patients with resources for social needs. We are listed as a vendor under Covered California and are exploring strategies for educating and incentivizing participating health plans to partner with us. We also are expanding into international partnerships with countries that face challenges that could be addressed by expanding the role of pharmacists.
If you want to go fast go alone; if you want to go far go together.
Government Health Agencies
The Los Angeles County Department of Public Health (LACDPH) and California Department of Public Health (CDPH) are close collaborators in our mission to spread the availability of CMM. Our team serves on multiple committees with both entities, including a CDC 1817 Wellness grant with LACDPH; CDPH Cardiovascular Disease and Prevention Program post-stroke CMM pilot program; CDPH Prevention Forward Program; CMM Statewide Implementation Task Force; L.A. County Healthy Brain Initiative; and L.A. County Hypertension Task Force. We also work closely with the L.A. County Department of Health Services, LAC+USC Medical Center and L.A. County Department of Mental Health on projects funded by the National Institutes of Health, practice advancement and training opportunities, and other scholarly opportunities.
Other Government Agencies
The offices of the Los Angeles County Public Defender and Alternate Public Defender have been collaborators on developing innovative clinical and social services for the county’s highest-risk patients coping with mental health and substance use disorders. The partnerships have gained the support of the Los Angeles County District Attorney to seek funding mechanisms for these novel services.
Federally Qualified Health Centers
Through CRMC, we partner with over a dozen Federally Qualified Health Centers to facilitate collaborations with our network of community pharmacies.
National and Regional Organizations
Our professional organization partners are leaders in care-delivery transformation and advocacy. They include the American Heart Association, Be There San Diego, California Pharmacists Association, CDC National Hypertension Roundtable, Get The Medications Right Institute and Right Care Initiative. We share our work through these organizations and are connected to other organizations that have the potential to advance our mission.
Community Pharmacies
At the core of our mission is optimizing population health through accessible, evidence-based interventions that address both health and social needs. Our network of CRMC community pharmacy partners includes pioneers and leaders who have operationalized this mission, resulting in best-practice models for adaptation.
Participating pharmacies include:
• Acton Vale Pharmacy
• Bellwood Pharmacy
• Courtyard Pharmacy
• Desert Hospital Outpatient Pharmacy
• Bellwood Pharmacy
• Echo Pharmacy
• Econo Pharmacy
• Inland Pharmacy
• Kanan Pharmacy
• Manchester Professional Pharmacy
• Pacific Oak Pharmacy
• Parkview Medical Plaza Pharmacy
• Playa Pharmacy
• The Prescription Shop
• Quality Home Infusion
• Sierra Pharmacy
• University-owned pharmacies at Loma Linda University and Western University
• Vermont V.O. Pharmacy
• West Alondra Pharmacy
Annual Symposium Highlights
The USC Titus Center hosted our inaugural annual symposium on October 29, 2022. Access to healthcare services has been a recurring and common concern among virtually all stakeholders—including health plans, health systems, government healthcare and public health— particularly for the most vulnerable and underserved patients. As a result, for the symposium we developed the theme “Extending the Healthcare System Into the Community for the Most Vulnerable Patients.” Our goals were to:
• Provide an update on health equity in Los Angeles County
• Share best practices for delivering high-value, community-based healthcare services
• Provide payer perspectives on value and health equity
• Discuss methods for driving quality improvement
• Compare the value of rigorous impact analyses versus quality improvement data
To accomplish these goals, our symposium included the following topics and speakers:
KEYNOTE
A powerful keynote session was delivered by Tony Kuo, MD, MSHS, director of the Division of Chronic Disease and Injury Prevention at the Los Angeles County Department of Public Health. Kuo provided a comprehensive overview of health equity challenges in the county.
BEST PRACTICES FOR DELIVERY OF HEALTHCARE SERVICES IN THE COMMUNITY
• Florian Rader, MD, Joseph E. Ebinger, MD, and Ciantel Adair Blyler, PharmD, from the Cedars-Sinai Smidt Heart Institute provided an update on the well-known Black barbershop-based hypertension program, including cost analyses and feasibility for remote services.
• Michael Hochman, MD, CEO of Healthcare In Action, discussed the multidisciplinary medical program that travels to unhoused individuals.
Healthcare In Action operates at multiple locations in Southern California and partners with health plans, hospitals and health systems.
• Steven Chen, PharmD, provided an update on the California Right Meds Collaborative (CRMC), while Janice Cooper, PharmD, shared the perspective of a frontline CRMC pharmacist, describing CRMC as enabling her to help patients at a level that could never be accomplished previously. Michelle Chu, PharmD, provided an overview of how CRMC manages social needs in the course of delivering comprehensive medication management (CMM), including engagement of pharmacy technicians in the provision of culturally and linguistically aligned services.
VALUE IN HEALTHCARE
• Alex Kang, PharmD, and Edward Jai, PharmD, provided perspectives from L.A. Care Health Plan and Inland Empire Health Plan on the value payers seek from healthcare services and the importance of ensuring equity.
• Anneliese Wilkins shared the CRMC process for driving quality from CMM, including quality improvement tools, report cards and subsequent training.
• Steven Fox, MD, and Yuna Bae-Shaaw, PharmD, PhD, discussed the importance of having reliable data to conduct rigorous impact analyses, which provide a more accurate and comprehensive perspective of the impact of a clinical intervention versus quality improvement reporting.
We were pleased to have a large group of both frontline pharmacists and pharmacy leaders in attendance. We aimed for participants to leave “in action”—that is, ready to seek partnerships to provide high-value, community-based clinical services, consider joining our collaborative and work with our Titus Center health economists to conduct rigorous analyses of established clinical pharmacy programs.
PROGRAMS
The California Right Meds Collaborative
Launched in 2020, the California Right Meds Collaborative (CRMC), an initiative of the USC Mann School of Pharmacy and Pharmaceutical Sciences, is a consortium of health plans, pharmacies, medical providers, county public health, academic medicine and professional organizations in California that provides comprehensive medication management (CMM) services to vulnerable, high-risk patients.
CRMC’s mission is to create a network of pharmacists that provides CMM in alignment with health plan and health system priorities, supported by value-based payments. This mission is even more critical since the onset of COVID-19, with patients with common chronic conditions at higher risk of harm and death when infected. In addition, healthcare quality measures, already poor before COVID-19, have become worse, resulting in more patients suffering from complications of chronic diseases. Furthermore, the gap in health disparities between underserved and well-insured populations has widened.
Community pharmacies were identified so that CRMC can leverage their accessibility (location and extended hours), staffing that is often culturally and linguistically aligned with the local community, and high degree of public trust. Through rigorous training and continuous quality improvement, patient health and satisfaction are improved along with patient safety, access and provider
satisfaction. Key enablers include a sustainable, value-based payment model and addressing both health and social needs.
A CDC 1817 Wellness grant, secured through a partnership with the L.A. County Department of Public Health, supports the administration of CRMC in Los Angeles County. Four health plans, covering over 8 million lives, are currently engaged and more health plans are seeking to join in 2023, including two international organizations.
USC Mann has decades of experience partnering with safety-net clinics in delivering high-impact CMM, along with a Round 1 Center for Medicare and Medicaid Innovation (CMMI) Healthcare Innovation Award and a subsequent best practice for delivering CMM via telehealth. Experience from these programs has informed strategy, training, continuous quality improvement processes, focus on social needs, patient and provider engagement, and valuebased payment methodology.
“CRMC is a scalable solution for persistently poor health outcomes across the state and the nation,” says Steven Chen, PharmD, CRMC director, associate dean for Clinical Affairs, and the William A. and Josephine A. Heeres Chair in Community Pharmacy. “It deploys an evidence-based intervention, CMM, that is accessible in the neighborhoods
where patients live, supported by health plans through a value-based payment. USC ensures optimal results from CRMC through broad training, including providing CMM services, managing social needs, securing patient and provider engagement, and prioritizing cultural competency and sensitivity, the latter being critically important given Southern California’s diverse population.”
The Advisory Board for the USC Titus Center and CRMC is comprised of health
plan, medical, pharmacy, professional organization and patient advocacy leaders who provide insights, advice and broad perspectives to advance the mission of CRMC.
CRMC leadership is provided by a team of USC faculty and staff as well as executive leadership groups of pharmacists, physicians, senior healthcare leaders, academic leaders and other stakeholders from various entities involved in CRMC (including health plans, health systems and universities).
CRMC procedures are customized to the unique needs of each health plan, but generally consist of:
• a stringent vetting process for participating pharmacies
• targeting, engaging and enrolling high-risk patients
• physician/medical group engagement and partnership
• extensive training/coaching on pharmacist skills and critical patient management skills, including cultural sensitivity, motivational interviewing, shared decision-making and addressing social determinants of health
Over 270 pharmacists received training on CMM in 2022, which was conducted remotely until our spring 2022 Learning Session in partnership with the California Pharmacists Association’s Western Pharmacy Exchange in Las Vegas, which was hybrid (in person and remote).
CRMC hosts summer fellows who are heavily engaged in training and coaching CRMC pharmacists as well as developing continuous quality improvement tools, and USC Mann residents conduct research projects supporting CRMC’s goals and growth.
During the COVID-19 lockdowns, CRMC was in jeopardy because the health plans originally agreed to pay exclusively for inperson CMM services. However, because of USC Mann’s successful completion of a CMMI Healthcare Innovation Award that included a well-refined video telehealth CMM arm, CRMC was able to prepare participating pharmacies to deliver remote CMM, which the health plans agreed to reimburse.
The growth of CRMC has drawn the attention of national, state and local healthcare leaders. The impact of CRMC has been shared with the American Society of Health System Pharmacists, California Department of Public Health, California Pharmacists Association, California State Board of Pharmacy, CDC, CMMI, Covered California, Get The Medications Right Institute, Los Angeles County Department of Public Health, Los Angeles County Department of Health Services, Right Care Initiative and other key stakeholder groups. CRMC is listed as a vendor for the state of California, thanks to a collaborative effort with the California Chronic Care Coalition and the California Pharmacists Association.
CRMC Stakeholder Value Summary
PATIENT
Drug Cost Savings
Total Healthcare Costs
Patient Satisfaction
↓ out-of-pocket $ (↑ generic drug use)
NA
Convenient access to a trusted provider, culturally and linguistically aligned; off-hours and weekend availability
Provider Satisfaction
NA
FRONT-LINE PROVIDER
DHCS/HEALTH PLANS/PAYERS
↑ generic and preferred drug use
Beneficial for capitation / full risk or incentive payments tied to acute care utilization
Maximum ROI when targeting high-risk/ high-cost patients; shared risk/valuebased payments
Quality of Care in Collaboration with Medical Providers
patient health literacy, self management skills
Improved patient retention and patient satisfaction surveys
↓ burnout, ↑patients seen, medication management shifted to pharmacist
Improves measures tied to performancebased incentives, resulting in ↑ reimbursement
Improved patient enrollment / retention, marketing opportunities
↑ provider retention, ↑ Rx adherence
Improves impact measures for key rankings, e.g., HEDIS, Medicare Stars
Patient Safety
↓ medication-related harm, liability and costs through close monitoring and safe medication titration
WHAT’S UNIQUE ABOUT THE CALIFORNIA RIGHT MEDS COLLABORATIVE?
1. Sustained through value-based payments by health plans, centered around population health priorities
2. Learning format based on a proven national collaborative model, the Institute for Healthcare Improvement (IHI) Breakthrough Series for Collaboratives
3. Merged with the USC Psychiatry for Population Health Pharmacists Collaborative to advance skills of pharmacists in managing mental illnesses, a common comorbidity for high-risk vulnerable patients
4. Draws from over 30 years of CMM experience, including the USC Center for Medicare and Medicaid Healthcare Innovation Award (CMMI HCIA) and extensive work with underserved patients, including in Los Angeles’ Skid Row
5. Utilizes a stringent vetting process to qualify pharmacies to join a carefully curated network of community pharmacies for CMM delivery, thus driving enough volume to participating pharmacies to sustain a full-time, dedicated clinical pharmacist and technician
6. Supported by a CDC 1817 Wellness grant through a partnership with Los Angeles County Department of Public Health, supporting several key CRMC team members
7. Leverages strong statewide public health partnerships, including the American Heart Association, California Pharmacists Association and Right Care Initiative
8. Facilitates collaborative partnerships with clinics, Federally Qualified Health Centers and physicians financially incentivized to improve outcomes
9. Experience and expertise from several California schools of pharmacy
10. Culturally sensitive training incorporating patient engagement methods, such as motivational interviewing and shared decisionmaking
11. Includes training of clinical pharmacy technicians to support CMM services
12. Whole-person care pharmacy experience in L.A. County (CMS 1115 waiver)
13. Video telehealth expertise vetted through CMMI HCIA grant and private health systems
14. Community pharmacies prepared to serve as health and social services hubs, closing the loop on social needs with support from health plans
15. Incorporates experience working with a barbershop-based hypertension program from Cedars-Sinai managed by pharmacists, including a rigorous continuous qualityimprovement process
16. Aligned with current legislative efforts in California aimed at improving patient health outcomes
CRMC 2022 Clinical pharmacy technician training took places at USC Mann, enabling pharmacy technicians to provide critical services to support successful comprehensive medication management.
How CRMC Drives Optimal Results From CMM
Alignment With Health Plan Priorities
The foundation of CRMC is our health plan partnerships. By optimizing medication therapy for patients at greatest risk for harm and/or acute care utilization, the collaborative ensures that the value and return on investment to health plans is maximized. Although initially focused on Medicaid due to greater health disparities, CMM provides similar benefits for all highrisk populations.
Value-Based
Full payment for services requires attainment of treatment goals established by participating health plans, reducing financial risk to payers and shifting it to CMM providers.
Continuous quality improvement
By closely tracking process and outcome measures, CRMC ensures that every patient safely and efficiently reaches treatment targets.
Accessible, heavily trained, addressing social needs
With 90% of people living within two to five miles of a community pharmacy, the mission of the collaborative is to create networks of community pharmacies that are easily accessible in local neighborhoods. Network pharmacies are carefully vetted and extensively trained using the IHI Breakthrough Series Collaborative Process to provide CMM as well as connect patients with locally accessible resources to address social needs.
Early impact results suggest that CRMC is working: After five CMM visits, A1c is reduced an average of 3.3 points for patients with uncontrolled diabetes; systolic blood pressure is reduced by 34mmHg for patients with uncontrolled hypertension; and statin utilization is increased for patients with diabetes from 42% to 89.4%. These and other findings have led health plan partners to expand enrollment eligibility to more high-risk patient subgroups and increased interest from other health plans in joining CRMC.
California Right Meds Collaborative Timeline
September 2019
Early 2019 September 2019 June 2020
•Formalized partnerships with health plans
• Developed value-based payment program
• Curated network of pharmacies for participation
•Received grant from LAC DPH to support CRMC LAC
• Soft launch of CRMC with Fall 2019 Learning Session focused on health plan and CDC priorities
• Scheduled bi-monthly webinars and coaching for pharmacy network
• Finalized QI dashboards / rep ort cards
JulyAugust 2020
• Piloted CMM delivery program among 5-10 pharmacies for each health plan
• Identified FQHCs/clinics and physicians to work closely with community pharmacies to support CMM services
September 2020 Late 2020 Early 2021 Mid 2021
•Fall 2020 Learning Session with topics focused on:
▪ Preparing community pharmacies to deliver CMM
▪ Developing value-based payment model
▪ Applying quality improvement tools & methods
▪ Building collaborating with physicians and patients
•Scale-up spread of CMM services with additional pharmacies in health plan partnerships
• Summer 2021 Learning Sessions focused on:
▪ Health plan strategies for funding CMM services
▪ Insights on the value health plans are seeking from adding a clinical pharmacist in the healthcare team
• Launch of Psychiatry for Population Health Pharamacists
• CRMC listed as vendor under Covered California
2022
• Engangement with additional health plans, pharmacies, and health systems
• Spring 2022 Learning Session hosted in collaboration with CPhA's Western Pharmacy Exchange
▪ Integrating psych medications in CMM
▪ Approach to patients with substance use disorder in the community setting
▪ Health plan opportunities
POPULATION HEALTH PROGRAMS
The USC Virtual Pharmacist Care Center (VPCC)
The U.S. is seeing exponential growth of chronic diseases such as diabetes, heart failure, high cholesterol and hypertension. According to the CDC, 6 in 10 adults have at least one chronic disease; 4 in 10 have at least two. Chronic diseases are our country’s leading cause of death and disability and the leading drivers of $3.8 trillion in annual healthcare costs.
Half of the prescription medications taken every year in the U.S. are used improperly and adverse effects from medications are estimated to be the fourthleading cause of death in the U.S. Additionally, 75% of hospital readmissions among seniors in the U.S. are avoidable, primarily through better use of medications. Close attention to medications by qualified clinical pharmacists can address the $528.4 billion of avoidable annual spending due to misuse or suboptimal use of medications.
Medication therapy management (MTM) assesses and evaluates an individual’s complete medication therapy, rather than focusing on a single medication. The Centers for Medicare and Medicaid Services (CMS) provides detailed measures for health plans to adhere to in order to remain compliant. CMS has made MTM a Star measure, which further incentivizes health plans to put medication management at the forefront of care for patients.
Comprehensive medication management (CMM) ensures that each patient’s medications are individually assessed to determine that each is appropriate, effective, safe given the patient’s comorbidities and other medications, and able to be taken as intended.
Established in 2013, USC’s Virtual Pharmacist Care Center (VPCC) partners with health plans, pharmacies, health systems, pharmacy benefit managers and other professional institutions to optimize medication use and safety while decreasing healthcare costs. USC VPCC exceeds CMS-mandated goals through its interventions on medication adherence and completion of comprehensive medication reviews. A team led by experienced clinical pharmacists, pharmacist residents, interns and technicians achieves excellent patient and provider satisfaction through provision of clinical pharmacy services provided remotely using video and telephone visits.
USC VPCC also serves as a learning site for USC Mann students and residents, who are precepted to excel at providing high-quality patient care.
VPCC Services
• Alternative therapy
• Anticoagulation management
• Comprehensive medication management (CMM)
◦ Diabetes (CDC HEDIS measure), hypertension (CBP HEDIS measure), dyslipidemia (SPC/SPD HEDIS measures), asthma (AMR HEDIS measure), COPD, heart failure and more
• Comprehensive medication review (CMS Part D measure)
• Medication adherence (CMS Part D measure)
◦ Non-insulin diabetes medications
◦ Cholesterol medications (statins)
◦ Hypertension medications (reninangiotensin system antagonists)
• Medication reconciliation post-discharge (CMS Part C measure)
• Statin use in persons with cardiovascular disease (CMS Part D measure)
• Statin use in persons with diabetes (CMS Part D measure)
• Targeted medication review
• Transitions of care: Post-discharge follow up for high-risk patients to prevent 30-day readmissions and manage uncontrolled chronic conditions
◦ Advanced heart failure, diabetes, hypertension, anticoagulation, COPD, asthma, hyperlipidemia and other chronic conditions
◦ Collaboration with the patient’s provider
◦ CMM
◦ Post-discharge medication reconciliation
Summer 2022 CRMC Fellow Get Together: An open invitation for current and past CRMC fellows to connect with everyone in person to share wisdom/advice on career and pharmacy profession and enjoy delicious food. Our fellows from 2020 to 2022 were present; some are working as clinical pharmacists or pharmacy residents; others are on clinical rotations or still taking didactic classes at the school. Everyone made great memories.
CRMC Fellows
As we continue to expand our collaborative, we want to grow future generations of pharmacists who are ready for success in advanced pharmacy practice, team-based care and the new era of telemedicine. CRMC fellowships provide education and inspiration through 10-week, full-time, immersive experiences as CRMC team members.
Fellows learn all aspects of CRMC, from program development and CMM to working with health plans and valuebased payment. Mentored by a primary preceptor from the CRMC team, fellows take on longitudinal projects working with USC experts in clinical care, managed care, community pharmacy, public relations, population health and health plans. Some fellowship projects have directly impacted and shaped
CRMC processes, including pharmacy workflow, patient outreach scripts for clinical pharmacy technicians and a practice guide for health plans.
In summer 2022, our fellows moderated group discussions during the Learning Session, presented on guideline updates, provided support to new pharmacies joining the collaborative and expanded our social media coverage to help disseminate our work.
“ Reflections From CRMC Fellows
“I am truly grateful for the opportunity to network with different pharmacists in the Southern California area. My favorite part of this fellowship was visiting over 10 pharmacies and helping them implement CMM services.”
Teny
Khachadourian, USC Mann Class of 2025
“This fellowship is truly an expansion of my understanding of the scope of practice in pharmacy. I learned a lot about developing projects that align with the mission of reducing the burden of chronic disease by advancing the role of pharmacists in the healthcare system, and collaborating with health plans to advocate for the expansion of pharmacists as members of the healthcare team, such as designing value-based programs targeting specific diseases’ cohorts, creating an algorithm to enroll eligible patients to implement CMM services and providing assistance on the medication management platform.”
Charles Teng, USC Mann Class of 2024
“The team embraced me as a member of their workforce and always guided me in the right direction. I learned a great deal about comprehensive medication management, business partnerships and pharmacy/insurance relationships. CRMC has a great team and inspiring leaders who contributed to my positive experience at CRMC.”
Shayanne
Casapao, USC Mann Class of 2025
Grants and Honors
CDC 1817 Wellness Grant for Diabetes Care
The Titus Center’s five-year 1817 Wellness grant from the CDC Division of Diabetes Translation, which we received in October 2018, supports programs to improve health outcomes for people diagnosed with diabetes and devise new, evidence-based approaches to increase the reach and effectiveness of population health strategies in underserved communities where diabetes is prevalent. The grant focuses on eight different strategies, including bidirectional referrals. With this grant, CRMC has partnered with L.A. Care to serve patients across L.A. County.
CDC Telehealth Evaluation
CRMC’s CMM was one of three telehealth programs selected by the CDC Division for Heart Disease and Stroke Prevention (DHDSP) for evaluation. In partnership with NORC, a leading policy research institution at the University of Chicago, DHDSP aims to evaluate telehealth’s role in improving access to care among populations at risk of hypertension driven by disparities in economic and social status—social determinants of health. Selection of our program was a significant recognition: In 2021, the CDC conducted a systematic screening and assessment, soliciting nominations from nearly 200 organizations throughout the U.S. Following the call for nominations and initial review, six finalist organizations were selected to participate in assessments, of which only three
telehealth strategies, including CRMC’s CMM, were chosen for the full, rigorous evaluation. Those three strategies were chosen based on each program’s overall goals and priorities, strategy, design, potential impact, organizational evaluation capabilities and data systems, sustainability of the strategy, and replicability and transferability of the strategy.
The objectives of the evaluation of CRMC’s CMM program are to: (1) qualitatively and quantitatively describe the implementation of USC’s telehealth CMM program; (2) assess clinical outcomes associated with the telehealth CMM program; and (3) measure the implementation and operating costs of the telehealth CMM program overall and per enrolled patient. The results of the evaluation will be used to inform further replicability of CRMC’s CMM program, promote scaling the intervention into a wider range of settings and expand our current evidence base for what works in telehealth. The study plan was approved by the University of Chicago’s internal review board in September 2022, under the title “Rigorous Evaluation of Telehealth Strategies to Address Hypertension Management and Control,” and is currently collecting qualitative data from CRMC leaders and participating providers. The
analysis of clinical and process data will begin as soon as the final datause agreement has been executed among USC, L.A. Care and Inland Empire Health Plan.
Impact
Health Outcome Analyses
A number of health outcome analyses are in progress. Here we report some initial findings from the first year of two CRMC programs—one at L.A. Care, focused on better management of patients with poorly controlled type 2 diabetes, the other at Inland Empire Health Plan (IEHP), focused on patients with poorly controlled asthma. Those results focus on process measures (CRMC screening, problems identified and services delivered to eligible patients).
A rigorous analysis of program outcomes, including measures of clinical control and any associated reduced use of medical resources (e.g., ER visits and hospitalizations) is pending. In order to credibly attribute patient improvements to the CRMC intervention itself, rather than unrelated factors, the analysis of outcome measures will compare treated patients’ outcomes before and after CRMC care versus outcomes for clinically and geographically similar patients, during the same time period, who were not offered the CRMC intervention. Those comparison group “difference-in-difference” analyses are pending final execution of data-sharing agreements.
Asthma Management in Partnership With IEHP
The asthma management program enrolled IEHP plan members with poorly controlled asthma (one or more hospitalizations or ER visits within one year). The impact analysis examined patients who had one or more CMM visits between December 1, 2021, and June 30, 2021. Preliminary analysis showed that, among 76 patients who participated in CRMC’s CMM program, ACT scores increased by 2.2 points on average from the baseline of 12.1 (p <0.05), with an overall improvement in the percentage of patients with well-controlled asthma from 31% at baseline to 70%.
Overall, these preliminary results suggest a significant clinical benefit from the CRMC interventions. They also illustrate the difficulties of delivering treatment—even to eligible patients. For L.A. Care patients with type 2 diabetes, of the 9,224 patients who appeared eligible, only 1,193 were successfully contacted and only 207 had at least one CRMC clinical treatment visit. Those difficulties in patient outreach are far from unique to the CRMC program. As we set out on the second year of these programs, a key focus was improving patient tracking and outreach.
Diabetes Management in Partnership with L.A. Care
Nearly 25,500 patients enrolled in L.A. Care health plans were screened for eligibility to participate in the diabetes management program with CRMC. The eligibility was based on formal diagnosis of type 2 diabetes and level of disease control. Hemoglobin A1c greater than 9% within 30 days or greater than 11% within 90 days of eligibility assessment was considered eligible. Of those screened, 9,244 patients met the eligibility criteria and 3,070 patients were reached out to. Of 1,193 patients who were successfully contacted and solicited for participation in the CRMC program to manage their diabetes, 440 were enrolled into the program.
We are currently evaluating the impact of the CRMC program on patients who enrolled and had one or more CMM visits between December 1, 2020, and December 31, 2021. Preliminary analysis showed that, for 207 people who received one or more CRMC visits, hemoglobin A1c declined by an absolute average of 1.15 points from the baseline level of 11.39% (p <0.05), keeping in mind that A1c reductions usually require an average of three cycles of A1c followup tests (typically nine months involving nine to 10 visits) for optimal A1c control. Further analysis will examine the impact on healthcare resource utilization such as inpatient stays, ER visits and urgent care visits.
25,428 Screened for eligibility
9,244 Met eligibilty criteria
3,070 Attempted to contact
1,193 Successful contact
440 Enrolled
Policy
The Titus Center is in the initial stages of our policy outreach and advocacy efforts. Essential to our advocacy approach is gathering and generating rigorous evidence regarding the benefits of specific health services delivery approaches. We will only advocate for process and policy changes that are supported by evidence that shows that a policy approach will improve clinical outcomes (especially outcomes that matter to patients), reduce harm, accelerate attaining clinical goals and/or improve efficiency.
Our first several analyses—including the two CRMC programs for diabetes and asthma described in the prior section—examine the impact of pharmacist-directed chronic medication management, usually in partnership with patients’ physicians via a collaborative management agreement. Increasingly strong evidence is accumulating that properly trained pharmacists can efficiently and effectively manage medications for chronic conditions such hypertension, hypercholesterolemia, heart failure, asthma, COPD and type 2 diabetes mellitus.
While rigorous evidence is the cornerstone of policy change, it is only a first step. Evidence must not only be rigorous, but also specifically address key stakeholder concerns. Not all evidence that should change clinical practice does so. Barriers to practice change can only be overcome through understanding and addressing those barriers, which in turn requires
partnership with relevant stakeholders. Toward that end, we have partnered with multiple local, regional and national organizations to advance advocacy efforts aligned with our mission. These organizations include:
• American Heart Association
• California Chronic Care Coalition
• California Department of Public Health
• California Pharmacists Association
• California Society of Health-System Pharmacists
• CDC National Hypertension Control Roundtable
• Cedars-Sinai Smidt Heart Institute
• Get The Medications Right Institute
• Los Angeles County Department of Public Health
• Los Angeles County Hypertension Task Force
Our health plan partners have also provided testimony in support of policy changes impacting pharmacy practice. Partnership efforts are already producing results, as detailed elsewhere in this report. The landscape is changing, driven by healthcare quality (and efficiency) incentives at the health plan level, and by growing recognition at the policy level that innovative health services delivery models will be a necessary part of bridging primary care gaps, which are most acute for historically disadvantaged groups and may be filled most effectively by culturally aligned providers embedded in the community.
Moving forward, we plan to deepen and broaden our policy efforts. The accumulated evidence already supports greater use of pharmacists in CMM. However, a key barrier is that many states do not fully recognize pharmacists as healthcare practitioners with the right to bill payers directly for clinical services. We will work to effect changes in those policies, consistent with the evidence. Likewise, we are beginning to gather evidence to show how effectively licensed pharmacy technicians can fill the role of community health workers, bridging social and cultural gaps to the broader healthcare system. Finally, while our initial policy efforts have focused on the role that pharmacists can play— including providing CMM for a range of conditions—our interest lies in advancing all innovations that improve patient health and medication safety. We are committed to remaining a learning, evolving organization.
Stakeholder Testimonials
Patients
“My A1c was 9.6 [when I started the CRMC program]. One month ago, it was 8.4. It’s just amazing how someone comes into your life and changes it. I would recommend [CRMC] to anyone.”
Dana Prince, patient of CRMC pharmacist Christal
“I was diagnosed with asthma, a condition that was totally unfamiliar to me. [Natalie] has guided me with the best and correct practices to manage this diagnosis. I hope that all clinics have this care for their patients. Thank you!”
Rodriguez,
Pham
Juana
patient of CRMC pharmacist Natalie Valadez
By the Numbers (infographics)
Stakeholder Testimonials
Physicians
“The clinical pharmacists are fully integrated into our clinic, so that they help us side by side with our physicians. This added benefit not only assists our patients but also the community we are serving. Thank you!”
Gemma Kim, MD, Chief Academic Officer, Designated Institutional Officer and Chief of Medical Staff, Desert Regional Medical Center
“It’s been a wonderful experience both for us as providers and also for our patients. Phenomenal! We were able to improve the outcome. The pharmacy team works in unison with us, which helps us all together.”
Vidhya Koka, MD, Founder and Chief Medical Officer, SJ Medical Group
Stakeholder Testimonials
“While we have the clinical skills, having the broad reach that CRMC does is what’s going to propel us to another level. We are really happy with the result. This program really shows how well we can take care of our patients. Come join and let’s do this together.”
Alex Kang, PharmD, MBA, APh, BCPS, BCACP, Director of Clinical Pharmacy, L.A. Care Health Plan
“It has been a holy grail. We are actually at 1.4 million plus members. We would affect an order of magnitude of our members, as you can see from the results, in a way that would optimize care and decrease morbidities and mortalities significantly—a 12:1 return on investment.”
Edward Jai, PharmD, Senior Director and Chief Pharmacist, Inland Empire Health Plan Health Plans
