The Pharmacy Care Network How Expanding The Care Continuum Improves Patient Care and Delivers Financial Benefits Mike Sanborn, President and CEO Baylor Health Carrolton

Introduction The Role of Pharmacy in a Continuous Care Model – Ambulatory & Retail – Inpatient Care – Home Health & Skilled Nursing – Clinic Food for Thought Next Steps 1

The Role of Pharmacy in a Continuous Care Model PharmacyClinic Home Health & Skilled Nursing Hospital Medication Therapy Management Comprehensive Medication Reconciliation Transitions with Medication Therapy Management Coordinated Prescribing & Specialty

Ambulatory & Retail Pharmacy Revenue Opportunity Patient Fill & Adherence Employee scripts – Savings incentives – Self Insured Medication Therapy Management Health Maintenance – Immunizations, Screenings, etc. 3 $ $$ Pharmacy data helps improve adherence and patient outcomes Your Pharmacy Network $

Ambulatory & Retail Pharmacy Impact on Readmissions Patient Monitoring – Disease state management – Medication management – Reduce adverse reactions and side effects – Increase adherence 4 *According to a study by the federal Agency for Healthcare Research and Quality. 4M avoidable readmissions annually 69% stem from failed drug therapy Local retail pharmacists can offer significant expertise in retail management !

Inpatient Pharmacy The Current Value-Based Purchasing Landscape Hospital PerformanceReadmissions Clinical Process of Care (45% of total performance) Outcomes (25% of total performance) Patient Experience of Care (30% of total performance) Unfilled prescriptions AMI-7a Fibrinolytic Therapy Received within 30 Minutes of Hospital Arrival SCIP-Inf-2 Prophylactic Antibiotic Selection for Surgical Patients MORT-30-AMI Acute Myocardial Infarction (AMI) 30- day mortality rate Communication with Nurses Patient comprehension AMI-8a Primary PCI Received within 90 Minutes of Hospital Arrival SCIP-Inf-3 Prophylactic Antibiotic Discontinued within 24 Hours After Surgery End Time MORT-30-HF Heart Failure (HF) 30-day mortality rate Communication with Doctors Medical information or test results not provided HF-1 Discharge Instructions SCIP-Inf-4 Cardiac Surgery Patients with Controlled 6 a.m. Postoperative Serum Glucose MORT-30-PN Pneumonia (PN) 30-day mortality rate Responsiveness of Hospital Staff Family lack of knowledge to provide adequate care PN-3b Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital SCIP-Inf-9 Urinary Catheter Removed on Postoperative Day 1 or Postoperative Day 2 (**new for 2014**) Pain Management Patient follow up with doctor PN-6 Initial Antibiotic Selection for CAP in Immunocompetent Patient SCIP-Card-2 Surgery Patients on Beta- Blocker Therapy Prior to Arrival Who Received a Beta-Blocker During the Perioperative Period Communication about Medicines Adverse events SCIP-Inf-1 Prophylactic Antibiotic Received within One Hour Prior to Surgical Incision SCIP-VTE-1 Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered Cleanliness and Quietness of Hospital Environment Medication reconciliation SCIP-VTE-2 Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxes within 24 Hours Prior to Surgery to 24 Hours After Surgery Discharge Information Clear discharge instruction Overall Rating of Hospital

Inpatient Pharmacy The Current Value-Based Purchasing Landscape Hospital PerformanceReadmissions Clinical Process of Care (45% of total performance) Outcomes (25% of total performance) Patient Experience of Care (30% of total performance) Unfilled prescriptions AMI-7a Fibrinolytic Therapy Received within 30 Minutes of Hospital Arrival SCIP-Inf-2 Prophylactic Antibiotic Selection for Surgical Patients MORT-30-AMI Acute Myocardial Infarction (AMI) 30- day mortality rate Communication with Nurses Patient comprehension AMI-8a Primary PCI Received within 90 Minutes of Hospital Arrival SCIP-Inf-3 Prophylactic Antibiotic Discontinued within 24 Hours After Surgery End Time MORT-30-HF Heart Failure (HF) 30-day mortality rate Communication with Doctors Medical information or test results not provided HF-1 Discharge Instructions SCIP-Inf-4 Cardiac Surgery Patients with Controlled 6 a.m. Postoperative Serum Glucose MORT-30-PN Pneumonia (PN) 30-day mortality rate Responsiveness of Hospital Staff Family lack of knowledge to provide adequate care PN-3b Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital SCIP-Inf-9 Urinary Catheter Removed on Postoperative Day 1 or Postoperative Day 2 (**new for 2014**) Pain Management Patient follow up with doctor PN-6 Initial Antibiotic Selection for CAP in Immunocompetent Patient SCIP-Card-2 Surgery Patients on Beta- Blocker Therapy Prior to Arrival Who Received a Beta-Blocker During the Perioperative Period Communication about Medicines Adverse events SCIP-Inf-1 Prophylactic Antibiotic Received within One Hour Prior to Surgical Incision SCIP-VTE-1 Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered Cleanliness and Quietness of Hospital Environment Medication reconciliation SCIP-VTE-2 Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxes within 24 Hours Prior to Surgery to 24 Hours After Surgery Discharge Information Clear discharge instruction Overall Rating of Hospital

7 Driving Results Interviews with top/bottom 5% hospitals for AMI mortality Among other factors, top performers heavily engage pharmacists, those at the bottom don’t. In high performing hospitals: – “pharmacists were closely integrated into care processes, and they actively informed and influenced clinical decisions.” Curry LA, et al. Ann Intern Med. 2011;154:

Inpatient Pharmacy Impact on Readmissions Intake Medication Reconciliation – Pharmacist or technician real- time engagement through EHR Discharge Medication Reconciliation Discharge With Medication In Hand – Counseling with patient and family – Tech with iPad uses Facetime with pharmacist Comprehensive pharmacy management - from intake to discharge and beyond

Inpatient Pharmacy Clinical Initiatives Formulary management Indigent support programs – Pharmacy assistance programs recover medication and devices – 340B offers significant outpatient cost reduction Informatics – Streamline automated utilization and order-set process in EHR – Beware of automated over-prescribing Value analysis team – Comprehensive study should include pharmacy costs to determine lower cost options – Focus on total care cost Shortage management – Shared communications of availability within the health system 9

10 Pharmacist Value Economic effects of pharmacists on health outcomes Meta-analysis of 126 publications – Subdivided into several different kinds of analyses Future studies should build on the literature and focus on using pharmacists’ expertise in medication therapy to increase access to health care, maximize the quality time providers spend with patients, and improve the quality of care delivered in an efficient and cost-effective manner. Chisolm-Burns MA, et al. Am J Health-Syst Pharm. 2010;67:

Pharmacist Impact on Heart Failure VBP and Core Measures 11 Pharmacist-managed heart failure medication education and discharge instruction “Significant reduction in 30-day all cause readmissions, increase in rate of ACEI/ARB prescribing at discharge for LVSD, and positive impact on patient satisfaction” Warden BA, et al. Am J Health-Syst Pharm. 2014;71:134-9

Home Health and SNF Transitions with Medication Therapy Management Outreach on medication coordination and reconciliation Good marketing and relations with health system Care coordination with primary care physician – Understand expectations for post-hospital care 12 Positive relations with local SNF’s demonstrates health system ease of doing business

Clinic Pharmacy Services The Growing Specialty Market Convergence of health systems with clinics Significant growth projected Opportunity to source purchasing through hospital Become a provider or partner to control costs and quality – Better quality than white bag/brown bag – Significant 340B opportunity 13 Improve quality and coordination of care

Clinic Pharmacy Services Helping to Manage Disease Complex disease state management – Diabetes, anti-coagulation, heart failure, etc. High touch increases patient satisfaction Drug selection Prescription capture to improve medication adherence 14

Additional Food for Thought Re-evaluate compounding expenses Harmonize your formulary with your provider network Specialty pharmacy is a growing business Medication Therapy Management services – New revenue – Volume needed – Outcomes will demonstrate more opportunity PBM evaluation – Evaluation of alternatives 15

…And the Pharmacist’s Role in ACOs

Benefits of Future State Pharmacy services leveraged as clinical, strategic and financial asset Incorporation into care teams Drives patient adherence and satisfaction Reduces readmissions Pharmacy leaders now lead an effective, coordinated pharmacy enterprise across system Better relationships and coordination of care across the continuum 17

Next Steps How you can engage your pharmacy team – Meet with your pharmacy leaders – What are the first feasible steps pharmacy can take to support the changing dynamics of your health system? – What resources are needed to support long-term goals? – Are vendors and GPOs partnering to deliver value and support your goals? 18

Thank you 19