UMass Medical School pharmacists, clinical services staff support medically complex individuals through Community Case Management collaboration

September 01, 2016

A Massachusetts family is saving nearly $500 a year on a medication for an ill child, thanks to the collaboration between UMass Medical School’s clinical pharmacists and its Community Case Management Program.

The family had been paying monthly copays for an appetite stimulant prescribed to the child. Clinical Pharmacy Services, a unit within UMass Medical School's Commonwealth Medicine division, conducted a medication review and discovered the copay could be covered by the state Medicaid program, MassHealth. 

“The pharmacy had billed the medication to the primary insurance but the family had been paying $40 per month for the copay,” said Nicole Trask, PharmD, consultant pharmacist for Clinical Pharmacy Services. “We helped the pharmacy appropriately bill the copay from the primary insurance to MassHealth, which resulted in an annual cost savings of $480 for the family.”

The Community Case Management Program, a partnership between MassHealth and Commonwealth Medicine, coordinates community long-term services and supports (LTSS) for 838 MassHealth members with complex medical needs and their caregivers. Pharmacists in Clinical Pharmacy Services provide operational and clinical services to CCM to ensure those members have access to pharmacy services.

The work being done by CCM and Clinical Pharmacy Services enables individuals with complex chronic health problems to live at home instead of in an institution and makes sure the services they receive are medically necessary, which saves money for MassHealth.

CCM was established in 2003 to coordinate community services for medically complex children and young adults age 22 or younger. In 2013, MassHealth expanded CCM to members of all ages who qualify.  Clinical Pharmacy Services has been consulting with CCM since 2006.

 “We’re authorizing services that are medically necessary for complex populations living in the community, while making sure we avoid duplicating services,” said Kerri Ikenberry, RN, BSN, director of clinical services in Disability & Community Services, a unit within Commonwealth Medicine.

Another example of the collaboration helping patients involves a MassHealth member who was in line at a local pharmacy. When she was told her prescription would be denied by MassHealth, she contacted CCM from her place in line and CCM asked Clinical Pharmacy Services to review the medication. The Clinical Pharmacy Services pharmacist called the pharmacy where the woman was waiting and assisted them with billing the prescription, which was then filled the same day.

 “We’re making sure MassHealth members don’t go without the medications they need,” Trask said.

CCM assesses MassHealth members with complex medical needs to determine whether they qualify for in-home continuous skilled nursing care, and authorizes and coordinates the services.  In addition to nursing care, services may include a personal care attendant, oxygen and respiratory equipment, medical supplies and therapy services. The CCM team includes nurse clinical managers, physical therapists, occupational therapists, respiratory therapists and social workers. CCM nurse clinical managers reach out to CPS pharmacists for assistance with billing issues at the pharmacy, assistance with the medication prior authorization process, and medication reviews to provide insight into members’ needs.  

Clinical Pharmacy Services does about 30 consults a month for CCM, with a high of 45 in January, Trask said.

“Clinical Pharmacy Services pharmacists and pharmacy residents are the patient’s advocate in obtaining medications through the MassHealth program,” said Bonnie Greenwood, PharmD, BCPS, director of clinical programs for Clinical Pharmacy Services.

CCM’s outreach to MassHealth members with complex medical needs has made a difference by helping vulnerable populations.

“CCM acts as a single entry point for members to MassHealth,” Ikenberry said. “Providing service coordination for this medically fragile population has been well-received by both MassHealth members and providers of long-term services and supports.”

The work Clinical Pharmacy Services does with CCM also provides an effective educational tool for the program’s pharmacy residents.

“This is an example of how we’re teaching the next generation of pharmacists to work with patients,” Greenwood said.

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