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The Rx VBHC Series: SESSION 4 Part 2 | EXECUTION | Implementing MAB in High & Low Risk Populations on Medications

The Rx VBHC Series: SESSION 4 Part 2| EXECUTION | Implementing MAB in High-Risk Populations - African Americans with Diabetes & Lower-Risk Populations on medications


The first four sessions included:

  • Introduction - the Smith Family and their challenges with the current healthcare system

  • SESSION 1: Dr. Sam, the Director of Pharmacy and one of the first leaders to adopt the prescription strategy

  • SESSION 2: Details of the Medication A.R.E.A.S. Bundle (MAB) Prescription Strategy

  • SESSION 3: The mental framework to help Providers and Team Members incorporate MAB into clinical practice

  • SESSION 4: PART 1: Implementing Effective Efficiencies . Building a Collaborative Pharmacist Care Delivery Model . Creating an Economic Engine (Reimbursement)

  • NOW in SESSION 4 Part 2, we will make MAB real in higher-risk populations with multiple chronic conditions (MCC) and lower-risk populations on medications.





(excerpts from the Medication A.R.E.A.S. Bundle Handbook)


A.  Implementing MAB in High-Risk Populations - African Americans with Diabetes (Case Study)


1.   The Background


     According to the American Hospital Association's 2017 Environmental Scan, studies have shown that if Americans manifesting chronic conditions could achieve “six normal” ranges (for low- density lipoprotein cholesterol, blood pressure, blood sugar, waist-to- height ratio, stress management, and tobacco toxins) with or without medication, there would be a subsequent reduction in chronic disease by 80% to 90% over 10- to 30-year periods. If 65% of individuals achieved the six normals, the nation would save over $600 billion in healthcare spending per year.

     Diabetes is one of the most prominent of all the chronic conditions that if treated effectively would make a significant difference in health outcomes and total healthcare costs. In the United States, type 2 diabetics now represents nearly 10% of healthcare expenditures due to the increased hospitalizations and complications, including amputation, blindness, kidney failure, heart attack, stroke, uncontrolled hypertension, sexual dysfunction, and vascular dementia.

     Experts predict that if major steps are not taken to manage this disease, by 2050, 120 million to 180 million Americans will have diabetes—a sixfold to tenfold increase in the US population. These statistics, coupled with the poor quality of life, the adverse outcomes, and the economic burden associated with the complications of uncontrolled diabetes, requires that the prevention and effective management of diabetes become and remain a national priority for now.

     One of the ethnic groups that are disproportionately affected by diabetes is the African American population. According to the American Diabetes Association, they have higher incidences of end-stage renal disease, more likely to be hospitalized and die from diabetes, higher likelihood of developing diabetes retinopathy, and overall complication risks, compared to non-Hispanic Whites.


2.    The CASE STUDY: Implementing MAB using the BSMART Checklist in our select population


     In the SAFER Healthplan, 18% of the total population with type 2 diabetes were adult African Americans. Of this group of African Americans, 15% were enrolled in the care management program based on the care management’s criteria (see chapter 7 of the Medication A.R.E.A.S. Bundle Handbook).

     The effective management of diabetes is multifaceted, comprised of education, nutritional management, exercise, and medications. Using the BSMART Checklist, let us implement MAB (alongside the other components of diabetes management) in our high-risk populations to help reverse or minimize some of these complications, decrease progression of the disease, improve the care and health of the population, and contribute to reducing the total cost of care burden associated with diabetes.


  • BARRIERS: To better understand the MAB barriers in the African American group, three focus groups were set up with patients from the care management group. These were the most common barriers identified:

    • Lack of understanding of diabetes and the need for medications

    • They were not sure if the best medications had been prescribed for their conditions

    • Some had experienced negative side effects from other medications

    • Co-pays for medications were too high

    • Challenges of getting an up-to-date prescription list, primarily due to the use of multiple pharmacies

    • Challenges between brand and generic names of medications

    • Some did not trust nutritional plans as they were not reflective of what they were used to eating

    • The labs were not open at the hours convenient for them which prevented them from getting their lab tests done.

These barriers were then incorporated into the barrier questionnaire used by the care managers for each diabetes patient enrolled in the care management program. All the patients had their readiness assessment done and scored between 3 to 8 - these were dealt with individually with the care manager.

  • SOLUTIONS: Once the barriers were identified and the readiness assessment completed, the care manager (CM) tailored each patient’s action plan with interventions related to the identified barriers and focused on these following solutions:

    • Education: The CM educated patients about diabetes and the importance of the medications in treating diabetes. The CM also focused on the value and benefit of their medications as well as the markers of the disease (for example, HgbA1c lab tests and blood glucose self-monitoring tests), instead of just the symptoms of the disease, as predictors for how well they were doing.

    • Diet: The CM worked with dietitians to modify the diet tools used to teach patients about their diabetic diets. These new tools incorporated general foods eaten by African Americans, in addition to the suggested foods featured in the booklets.

    • Office hours: The CM team worked with the lab to open earlier and close later by staggering shifts.

    • Adherence tools: The CM recommended adherence tools to keep patients on track, such as pillboxes, medication apps, and telephone reminders.

    • Action plan: The CM gave patients updated written action plans that summarized their visits and conditions, outlined their prescriptions, provided them with a reconciled and most up-to-date medication list, a list that reflected their goals and targets, a list of key contacts if the patients had questions or issues, and detailed future appointments.

  • MOTIVATION: The providers and CMs of these patients used several techniques to motivate their patients to be engaged and more adherent to their therapies and action plans including motivational interviewing, education, financial incentives, social networking, storytelling, and feedback at each visit (virtual and in-person). See Handbook for details.

  • A.R.E.A.S. TOOLS: Tools are incredibly important to help patients remember when and how to take their medications, to remember if they have taken their medications, to remind them of the importance of taking their medications, to prevent patients from having adverse outcomes when taking their medications, to empower patients to self-manage their conditions, and to help reduce a complex regimen. The following tools helped the African American group stay on track – pillboxes, storytelling CD to listen to at home, written information about the medications, a reconciled list of all their medications, follow-up management, the medication app for the patients with a smartphone or tablet, reminder calls, and side effect management tips.

  • RELATIONSHIPS: The patients felt their healthcare team and CMs encouraged, empowered, empathized, and educated them at every point of contact and gave them the tools and resources needed to improve their health and quality of life successfully.

  • TRIAGE: The patients were enrolled in the care management program and health education classes. The patients were also encouraged to join the community support group and enroll at the local gym at a significant discount.


3.      THE RESULTS (abbreviated):

Nine Months Later, sixty percent of the patients had HbA1c less than 7 and more than eighty percent had a HbA1c of less than 9 by doing the following:

  • Addressing Barriers with targeted Solutions:

    • After their barriers were identified and addressed: 85% were taking their medications as prescribed

    • More than 70% had access to fresh fruits and vegetables from their farmer’s markets

    • They increased their knowledge of their disease

    • One to two days a week, an evening clinic was established, and the lab opened earlier and closed later to accommodate the needs of all patients who had access challenges during the day

    • More than 45% consistently exercised more than 60 minutes per week, and more than 90% consistently exercised for 30 minutes a week

    • More than 95% had a diabetes screening in the last nine months

    • Less than 3% of the population had readmission (significantly less than before).

  • The results from the Motivation techniques, A.R.E.A.S. tools, Relationships formed, and Triage process can be found in Chapter 7 of the handbook.


4.      The African American Diabetic Group Economic, Clinical, and Humanistic Outcomes (ECHO)

  • Economic outcomes: lower cost prescriptions; lower readmissions, contributing to lowering the associated penalties for the hospital; eventual reduction in disease progression; and increased healthier lifestyles and healthier communities, resulting in eventual economic advantages for the patients and organization.

  • Clinical outcomes: Improvement in diabetes, hypertension, and cholesterol quality measures; positive impact on Medicare Stars, HEDIS, and other quality measures related to diabetes; and positive impact on the readmission rate. These outcomes will eventually contribute to the new Quality Payment Program (MACRA / MIPS / APMs) 

  • Humanistic outcomes (care experience): Improved patient satisfaction scores reflected in CAHPS survey and improved patient satisfaction scores reflected in pharmacy survey.


B. Core SMART Actions to Address Low-Risk Populations on Medications

Due to the significant number of patients with multiple chronic conditions, it would be virtually impossible to spend an extensive amount of time on every patient using the Barrier Questionnaire in the BSMART Checklist to implement MAB. The Extensive BSMART Checklist is primarily reserved for moderate- to high-risk patients or in practice settings where the providers or team members can effectively do this. However, there are core SMART actions that every provider and qualified team member can use for lower-risk patients to address the most common MAB barriers. The most common barriers that occur in most patients on medications include: patients not understanding or accepting their conditions, unreconciled medication lists, lack of engagement around treatment plans, unaffordability of medications, and perceived or actual side effects.

So, at each point of contact with lower-risk patients, providers and qualified team members should focus on the following core SMART actions when prescribing or consulting on a medication to address the most common MAB barriers and optimize patients’ medication management and health outcomes. SMART represents Solutions to the most common barriers mentioned above . Motivation . AREAS Tools . Relationships . Triage.

  • Four Solutions that will address the most common barriers in patients on medications:

    • Reconciled List: Always provide patients with a reconciled and most up-to-date reconciled list of their medications

    • Affordability: Always address financial issues because of the increasing cost of medications for most patients and over 40% of patients with healthcare coverage have higher out-of-pocket costs due to having high-deductible health insurance.

    • Value: Always emphasize and reinforce the value and benefit of therapy. Evidence shows that patients who understand their disease condition and the purpose of their medications are more likely to be adherent and report less side effects and issues.

    • Educate: Focus on the markers of the disease, instead of symptoms, as predictors for how well patients are doing (many diseases have no symptoms), provide side effect management tips, and set goals.

  • Motivate: At each point of contact across the continuum, it is important to encourage, empower, empathize (when necessary), and educate patients and caregivers.

  • A.R.E.A.S. Tools: Provide tools such as pillboxes and apps for self-monitoring and self-management.

  • Relationships: Maintain a healthy, positive relationship with patients.

  • Triage: Direct patients and caregivers to online resources and other healthcare services such as health education and nutrition classes where they can learn more about the disease process, treatment options, nutritional plans, blood sugar monitoring, exercise plans, and other strategies to promote better health.

So, leverage the BSMART Checklist to implement MAB in higher-risk patients across the continuum which will contribute to making the triple aim of better care, better health, and better costs, a reality for these patients.

And use the above core SMART actions in lower-risk patients when consulting them about their medications.  These core actions will address the most common MAB barriers in lower-risk patients in a very short period of time (two minutes on average) and will contribute to effective medication management, leading to a decrease in progression and complications of the disease, improve the care and health of the population, and help reduce the total cost of care.


In Session 5 of this 10-Part Series, we will discuss the following in detail:

  • Performance Measure Mania – its impact and challenges

  • Addressing Measure Mania

  • Successful and best practices that address multiple measures and reduce initiative overload

  • The Medication A.R.E.A.S. Bundle (MAB) Prescription: Reducing Initiative overload

  • MAB Impacting the National Quality Strategy (NQS)

  • Making Measures Meaningful


More information about the MAB Rx Strategy can be found at:


My hope and goal is to provide you with a prescription strategy that will make a difference in the lives of patients with multiple chronic conditions – the most frequent and expensive users of healthcare, contribute to making healthcare value a reality for all, and give you a competitive advantage in this new era of value-based healthcare!





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