Carolina Community Health Partnership (CCHP) Pharmacy Team
“In a rapidly evolving health care system with increased demands for results and personalized care, the pharmacist is a critical partner in the provision of care. The skill set of the pharmacist provides a unique opportunity to deliver optimal medication utilization to manage acute and chronic diseases as well as many other roles that are beyond an outdated view that limits pharmacy practice to the distribution of medication. The pharmacist is uniquely positioned to provide disease state management through appropriate medication therapy management that has been demonstrated to improve patient outcomes and decrease overall health care costs. This role is more important than ever as the environment is demanding new practice and payment models that are required to further optimize care and outcomes while addressing the unsustainable increases in health care costs. While the role of the pharmacist on the health care team for optimal management of medication has been appreciated, the positive impact on wellness, outcomes, and overall health care costs through a full scope of practice highlights the significant contribution pharmacists make and can make in the ever-changing health care system.”
NC Med J. 2017;78(3):165-167
Carolina Community Health Partnership (CCHP) is the local affiliate network of Community Care of North Carolina (CCNC) that serves Cleveland and Rutherford counties. CCHP pharmacists and pharmacy technicians work with Care Managers to create strong relationships with patients, providers, and community pharmacists. Typical pharmacy-related services encompass the major tenets of the Pharmacists’ Patient Care Process.
The Pharmacists’ Patient Care Process (see illustration below), as outlined by the Joint Commission of Pharmacy Practitioners, entails collecting and assessing patient-specific care data, creating and implementing a multidisciplinary care plan, and monitoring and evaluating the results. Pharmacists must work closely with patients and providers to ensure that goals are specific, measurable, attainable, relevant, and timely.
Pharmacists joined Community Care of North Carolina (CCNC) network teams in 2007 in response to concerns about medication-related issues among high-risk, blind, aged, and/or disabled patients. Network goals emphasize improving patient outcomes while decreasing overall health care costs and this subset of patients accounts for a disproportionate share of poor outcomes and high costs. Pharmacists’ primary responsibilities include medication management services, education, coordination, roll-out, and oversight of pharmacy benefits for the Network.
Medication management services encompass a broad-array of strategic interactions at various points along the care continuum. Ultimately, these interactions are designed to improve overall care quality and to reduce preventable hospital readmissions and emergency department (ED) visits. Nurse Care Managers complete medication reconciliations as part of their comprehensive health assessments and pharmacists review these medication lists, looking specifically for potential problems that need to be communicated back to the appropriate provider. Primary components of the CCNC Care Model include:
Chronic care medication management, which focuses on working with patients that are identified and referred to CCNC for medication management
Transitional care medication management, which focuses on identifying and clarifying medication list discrepancies for patients following discharge from an acute care facility
Care Managers and pharmacists also conduct home visits when necessary to further clarify and communicate care issues.
On a local level, our pharmacists and pharmacy technicians assist patients and providers by providing services like:
- Meeting with and advocating for patients in whatever setting necessary to meet patient needs
- Typically includes home visits, clinic visits, hospital visits, community encounters, and agency appointments
- Growing relationships with Department of Social Services (DSS) of Cleveland and Rutherford counties to better serve patients in transition programs such as foster care
- Establishing relationships with community agencies to meet critical needs (food/clothes/shelter/medications) in times of crisis
- Initiating, coordinating, and reviewing information necessary for medication reconciliations by nurse care managers
- Obtaining medication lists from clinics, pharmacies, and community agencies to reconcile into one list shared back to all providers
- Coordinating and facilitating specific patient care needs, such as obtaining replacement insurance cards and medical devices (glucometers)
- Providing educational support for community-based initiatives through collaborative partnerships with Health Educators at Cleveland County Health Department
- Helping coordinate and speak at community educational programs on various topics, such as smoking cessation, medication take-back programs, and opioid misuse
- Establishing relationships with network hospitals to assist with transitional care
- Working closely with pharmacists and pharmacy technicians that perform medication reconciliation at local hospitals
- Working with multidisciplinary team to address care concerns for dialysis patients to reduce readmissions and emergency department visits
- Working with network clinics to establish chronic pain management care paths to improve quality and safety
- Helping clinics carry out North Carolina Division of Health Benefits (NCDHB) processes for prescribing preferred medications for Medicaid patients
- Providing ongoing educational support for hospital-based community education programs
- Teaching diabetes medication class to patients attending diabetes management programs at local hospitals
- Providing educational support for hospital-based initiatives
- Assisting with implementation of clinical initiatives at local hospitals
- Presenting topics of interest annually for medical staff at both hospitals
- Providing educational support for community-based initiatives
- Helping coordinate and speak at community continuing education programs on various topics, such as chronic pain, opioid misuse, diabetes, and chronic obstructive pulmonary disease (COPD)
Our team works closely with community-based organizations to provide patient education around important medication-related topics such as adherence, safety, disposal, and outcomes. Helping patients engage in their own care and equipping them to carry out their care plans is a vital part of the CCHP Pharmacy Team’s role in the multidisciplinary care process.
If you would like information about who we are and what we do, please feel free to contact us.
|Carolina Community Health Partnership (CCHP) Pharmacy Team|
|Kassi George, CPhT
|Dana Friday, RPh
|Tom Martin, PharmD, BCPS, CDE
Network Clinical Pharmacist