Dear Director Kimsey:

            ExactCare Pharmacy appreciates the opportunity to submit recommendations to the Department of Medical Assistance Services (DMAS) on the use of increased federal match dollars for Medicaid Home and Community-Based Services (HCBS) under the American Rescue Plan Act (ARPA).

ExactCare Pharmacy is a full-service closed door, long-term care pharmacy that does business in the Commonwealth of Virginia. ExactCare focuses on providing poly pharmacy and medication management services to high-risk, medically complex patients on multiple medications, generally 8+ medications. These patients typically qualify for SNF placement based on their complex needs and meet certain patient qualification criteria.

The population of beneficiaries choosing to receive long-term care services from home is growing. This trend was only exacerbated by the onset of the COVID-19 public health emergency (PHE). As a result of the COVID-19 PHE, many in the health care industry rapidly evolved their service delivery models to provide care to institutional-level patients in a home setting. Many of these patients are elderly, disabled, low-income, and chronically ill individuals who require ongoing support with activities of daily living. This includes support with medication management to improve adherence.

Comprehensive pharmacy services are often an underused and underdeveloped healthcare solution for patients with chronic conditions. Studies have shown that holistic models of ongoing medication management coupled with high-touch care coordination and management activities can improve adherence and thereby the quality of life of patients and prevent costly medical expenses.[1] These types of services can also play a significant role in ongoing efforts to rebalance the delivery of care away from the institutional setting and towards home and community-based locations.

To meet these ends, ExactCare Pharmacy encourages DMAS to consider the following recommendations when determining the use of the increased HCBS funding under ARPA:

• Adopt enhanced care coordination to integrate care models that can more effectively address the needs of complex populations.
• Incorporate chronic care pharmacy management services into transition care planning prior to the transition from an institutional setting to home or community-based setting.

Adopt enhanced care coordination to integrate care models that can more effectively address the needs of complex populations

A significant portion of patients interact with multiple health care providers across various care settings, which can result in fragmented delivery and lack of continuity among health care teams. Care teams, including primary care physicians, specialists, and pharmacists, are best equipped to deliver high-quality care and provide effective treatment recommendations when working as a coordinated care team. Complex-care patients, in particular those who take 8+ medications prescribed by a variety of providers and need assistance in a variety of ADLs, pose a unique challenge to care coordination.

Pharmacists and pharmacies are in a unique position to competently provide robust care coordination for this population at a lower cost to the health care system. For example, ExactCare Pharmacy works closely with a patient’s care team to implement a high-touch approach that includes home-visits, comprehensive medication reviews, patient education, medication reconciliation, medication compliance packaging, and electronic reminders and trackers for complex care patients. This effort has resulted in improved medication adherence that reduces overall health care utilization (fewer days in hospitals and nursing homes) and costs[2], while increasing patient quality of life as seen in world class patient satisfaction.

            We therefore recommend that DMAS consider ways to expand the scope of HCBS services and funding to include the management of care at home by a broader range of providers, including pharmacists.

Incorporate chronic care pharmacy management services into transition care planning prior to the transition from an institutional setting to home or community-based setting

Moments of transition from institutional sites of care are highly prone to medication management errors due to a lack of communication between providers, missed patient follow-up, inadequate patient education, incomplete medication reconciliation, and the absence of patient involvement in medication management. Inconsistent care coordination contributes to relatively high readmission rates within 30 days of discharge.[3]

            As part of a more holistic approach to transitions of care, DMAS could consider investing in community transition programs that include medication reconciliation at discharge as an explicit component/service. When coupled with other aspects of a high-touch approach like ongoing medication reviews, patient education, and electronic reminders and trackers, medication reconciliation can lead to significant total cost of care reductions.    

ExactCare Pharmacy appreciates your consideration of these recommendations. Please feel free to contact Sarah Fenwick, SVP, Network Contracting, at sfenwick@exactcarepharmacy.com or (216) 369-2200 ext. 5067  if there is any further information we can provide or if you have any questions about our recommendations.

Sincerely,

Sarah Fenwick

SVP, Network Contracting

ExactCare Pharmacy