Chronic Disease Management Pharmacy Services: Moving the Needle on Outcomes

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Chronic Disease Management Pharmacy Services: Moving the Needle on Outcomes



With a 248-bed hospital, 45 outpatient clinics, and four outpatient pharmacies, Southern Ohio Medical Center (SOMC) offers a wide-range of healthcare services across seven counties in rural Ohio and Kentucky. Its mission: “We will make a difference.”

When it comes to caring for patients living with chronic conditions, this mission takes on added importance and added challenges.

Like many other non-profit hospitals in rural and urban areas alike, SOMC’s community faces a high prevalence of chronic diseases. Many members of the community live at or below the federal poverty level, making medication affordability a significant barrier to care. In fact, SOMC’s most recent Community Health Needs Assessment identified “cost of prescriptions” and “skipping/stretching prescriptions” as top opportunities for health improvement.

“If patients can’t afford things like inhalers or insulin, they ration them. If they ration them, they have a higher likelihood of being hospitalized,” Sarah Porter, DO, ACOFP, Senior Medical Director of Family Medicine explains.


A Holistic Approach to Chronic Disease Management

Against this all-too-common backdrop, SOMC knew that achieving its population health goals for patients with chronic conditions would require a holistic approach—one that addressed how to improve medication access and management.

“Pharmacists bring a valuable skillset and perspective to care teams,” explains Rory Phillips, RPh, MBA, Director of Pharmacy & Respiratory Services. “With access to dispensing data and the electronic health record, they are uniquely positioned to work with providers to proactively address barriers to adherence and to monitor therapy effectiveness.”

“’Teamwork’” is one of SOMC’s strategic values, and we believed a multi-disciplinary approach that included pharmacy would help improve the health of our community over the long haul,” affirms Valerie DeCamp, DNP, RN, A-GNP-C, NE-BC, Vice President of Clinical Integration and Chief Quality Officer.

Consequently, SOMC decided to partner with CPS to offer chronic disease management (CDM) pharmacy services to its patients with diabetes, asthma, COPD, and hyperlipidemia. The service has been implemented in four clinics at SOMC so far, with plans to expand to 15 more by the end of 2021. And no wonder: Within the first six months, average A1c levels for SOMC’s highest-risk patients fell by double-digit percentages.

Here’s how SOMC leaders describe the impact the services are having on patients, providers, and the health system:


Q: Why did SOMC launch CDM pharmacy services?

First and foremost, we launched these services because chronic disease is such a big issue in our community, says Phillips.

Dr. Porter explains, “CDM had been on our radar for quite some time, but we were struggling to make much headway. Our A1c lists were always about the same. About 1 in 10 of our patients had A1c levels that were super high, and we just couldn’t do anything about it because of the financial aspect.”

SOMC had implemented other initiatives focused on managing chronic disease in the past, including a partnership with a telehealth company. But these initiatives failed to move the needle.

“So, we asked ourselves, “How can pharmacists make a difference with our data insight and skillset?’” says Phillips.

Phillips believed SOMC’s specialty pharmacy services offered a care model that could be replicated to drive not only better adherence but also a better patient experience.

“Our patients with asthma, COPD, diabetes, and hyperlipidemia faced many of the same challenges with their therapies as our patients who require specialty medications,” he elaborates. “We found success tackling these barriers with our specialty pharmacy services, so we decided to work with our partner CPS to offer similar services to our patients with more common chronic conditions.”


Q: How do the services work?

SOMC’s CDM pharmacy services take a holistic approach. “Our pharmacists and pharmacy liaisons work locally at SOMC to support patients at every step of their medication journey,” explains Dr. DeCamp.

Pharmacy liaisons help patients with medication access and adherence. A core focus is on working to secure financial assistance for patients who qualify. They also conduct monthly refill coordination calls, during which they screen patients for barriers to adherence.

Pharmacists’ responsibilities include managing medication education, providing counseling, and monitoring clinical outcomes. “Our pharmacists provide additional support to patients identified as high-risk,” notes Dr. Porter. “They counsel these patients on a monthly basis, monitor therapy effectiveness via home glucose tests, and recommend dosage modifications or other therapeutic changes to providers.”

All patients’ prescriptions are dispensed by SOMC’s community pharmacies, and patients can either pick up their medications at one of four convenient locations or have them delivered to their home.

An advanced technology platform underpins the services. It integrates with SOMC’s electronic health record to identify eligible patients and to auto-deploy advanced clinical protocols and risk-stratification models. It even auto-triggers pharmacist interventions based on the data pharmacy liaisons document during their monthly refill coordination calls.

SOMC’s CDM pharmacy services are possible because of the 340B Drug Pricing Program, which was established in 1992 to help safetynet providers stretch limited resources to better serve their vulnerable communities.

“340B savings enable us to offer these vital services to our patients in order to improve adherence and outcomes,” explains Phillips.


Q: What clinical results have you achieved?

Patients with diabetes enrolled in SOMC’s CDM pharmacy services have a 91% average proportion of days covered (PDC), a common measure of adherence. This is significantly higher than the average PDC found in national studies for patients with diabetes, which ranges from 36% to 81%.1

In addition, SOMC has seen:

  • an average 18.7% decline in A1c levels within six months for enrolled patients who started with an A1c over 10.
  • an average 9.3% reduction in A1c levels for enrolled patients who started with an A1c under 10.

By contrast, Phillips adds, A1c levels dropped only 3.4% among SOMC patients not using SOMC’s chronic disease management pharmacy services.

“Our results show that better adherence translates into better clinical results,” explains Porter. “When patients have the support they need to start and stay on their therapies, we see their health outcomes improve.”


Q: How do these services fit into your overall population health strategy?

“Patients are often embarrassed when they can’t afford their medications, so they fall out of healthcare except when something acute happens. Our CDM pharmacy services allow us to level the playing field for all of our patients,” replies Dr. Porter.

Agrees Phillips, “Our mission is to make a difference in our communities, and our cardinal value is to honor the dignity and worth of each person. This program fundamentally addresses barriers to access and provides the foundation to further SOMC’s mission, values, and population health goals.”

Like many health systems, SOMC is focused on the transition toward value-based care (VBC). “Our goal is to provide the best care as efficiently as we can, and we’ve definitely seen our outcomes improving with CDM pharmacy services,” says Dr. DeCamp.

She adds that CDM pharmacy services also support SOMC’s five strategic values: safety, quality, service (patient satisfaction), finance, and teamwork. “I was in awe when I first saw the results. I’m excited that we can truly make a difference for our patients. We have something concrete we can offer, and we can see those results. That’s why we do what we do.”


Q: What do you recommend other health systems focus on to increase success?

Take a collaborative approach to increase your odds of success with CDM pharmacy services, Phillips recommends. Let a partner like CPS bring the people, expertise, and technology to the table and manage day-to-day operations.

“CPS provided a proven approach. We’d worked with CPS to implement our specialty pharmacy services, and we knew they would work side-by-side with us to develop a program that achieved results for our patients,” said Phillips.

Dr. Porter also recommends focusing on provider engagement: “Collaborate with providers to develop clinic workflows and communicate proactively with the care team about patients. You have to build our trust by showing us results.”


Q: What other benefits to the provider or patient satisfaction have you seen so far?

Phillips emphasizes that providers feel they have a helpmate now, another clinician who will help their patients reach their goals. Furthermore, the program “takes away barriers for patients.”

Dr. Porter illustrates with the following story:

One of my patients is a gentleman with Type 2 diabetes whose A1c typically runs about 11. His son has diabetes as well—Type 1. Both patients need insulin, but the father would go to a non-SOMC pharmacy and purchase insulin only for his son. He didn’t get it for himself because he couldn’t afford it.

When we launched our CDM pharmacy services, he was one of the first to enroll. And by his next visit, his A1c levels were so much better! Why? Because he’d been compliant with his medicine. It touched my heart when he told me, “Dr. Porter, I just cried and cried when I got my medication from the pharmacy. And I didn’t even have to go to the pharmacy; they brought it to me!”

Says Dr. Porter, “This program has the potential to really change the face of trust for our patients.”


Interested in learning more about SOMC’s journey establishing CDM pharmacy services? Click here.


  1. Tan, E., Yang, W., Pang, B., Dai, M., Loh, F. E., & Hogan, P. (2015). Geographic Variation in Antidiabetic Agent Adherence and Glycemic Control Among Patients with Type 2 Diabetes. Journal of Managed Care & Specialty Pharmacy, 21(12), 1195–1202.

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