Plan monitors meds to identify treatment gaps
Data go hand-in-hand with disease management
Pharmacy data are an integral part of case management of chronically ill patients covered under Horizon/Mercy, with headquarters in Trenton, NJ.
The case managers monitor pharmacy data to find out if members have been prescribed the proper medicine for their conditions and to make sure the prescriptions are filled and refilled on a regular basis.
"Pharmacy data are essential to disease management success. It’s a real barometer for compliance and noncompliance," says Pamela Persichilli, RNC, director of clinical operations for Horizon/ Mercy.
Horizon/Mercy covers more than 273,000 members, representing about 42% of New Jersey’s total managed care market for the publicly insured.
In addition to a number of programs for pregnant women and children, the plan currently has disease case management programs for congestive heart failure, diabetes, asthma, and sickle cell disease.
The case managers in the health plan’s disease management programs work with the pharmacy team to monitor whether patients have filled their medication prescription.
They can log into the pharmacy database, enter the ICD-9 codes for a particular disease state, and receive a list of members with the diagnosis and a profile of their medication, including who ordered it and when the prescriptions were filled.
They also check the pharmacy list against the list of members who have been identified through hospitalization and emergency department visits to make sure that no one falls through the cracks.
A case manager may run a pharmacy profile and realize the member is not on a diuretic or isn’t taking cardiac medicine. In these cases, they coordinate with the primary care physicians and educate them.
If they find high-risk patients who have not had their prescription filled, they call the physician and educate the physician if necessary.
For instance, if the pharmacy profile shows that someone with congestive heart failure isn’t on a diuretic or isn’t taking cardiac medicine, the case managers make sure the physician has prescribed them. They make sure that all members in their diabetes management program are getting their prescriptions for ace inhibitors filled.
"It means either they aren’t taking it every day or they just haven’t gotten around to getting it prescribed and don’t realize the problem with missing a day or two," says Giavanna Ernandes, RN, MSN, APNC, Horizon/Mercy’s team leader for disease management.
Most of the time if the case manager calls the member about a prescription, the member says he or she hasn’t gotten around to having it filled, she adds.
The case managers can log onto the pharmacy system and look at the member profiles as often as they need to. They follow up to make sure the prescriptions have been filled regularly.
Pharmacy data are an integral part of case management of chronically ill patients covered under Horizon/Mercy, with headquarters in Trenton, NJ.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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