Start: June 2018

Funder: Gordon and Betty Moore Foundation


Over the last decade, pioneering health care organizations have sought tailored approaches to improve health outcomes for individuals with complex medical, behavioral health, and social needs. However, there are significant gaps in the field, including the issue of medication complexity, a concept encompassing the number of medications an individual is prescribed (polypharmacy), challenges around adherence, risk of medication errors, failure to accomplish treatment goals resulting from inadequate or inappropriate drug regimens, and avoidable complications or harm caused by drug interventions (aka, adverse drug events or ADEs), among others.

The Community Management of Complex Care Innovation Lab, led by the Center for Health Care Strategies (CHCS) through support from the Gordon and Betty Moore Foundation, is a national initiative aimed at identifying community-based strategies to improve medication safety among low-income populations, particularly those with complex medical, behavioral, and social needs. The 14-month initiative will support opportunities to:

  1. Implement community paramedicine efforts to improve medication management, reduce unnecessary utilization, and improve medication safety;
  2. Use pharmacy data to create targeted interventions aimed at patients who are taking high-risk medications or complex combinations of medication;
  3. Repurpose community pharmacies to provide enhanced medication management services such as home visits, health education, and patient education; and
  4. Tailor and disseminate electronic health record (EHR) medication reconciliation, patient education, and tools to promote safe medication use and adherence.

The Innovation Lab includes five competitively selected sites with existing community-based medication management programs for individuals with complex needs. The pilot sites, representing a range of delivery systems and populations, will enhance and expand programs with a focus on reducing medication errors and improving outcomes. The pilot sites are:

  • Northwestern University Health Literacy & Learning Program (HeLP) Lab, Chicago, IL, will tailor and disseminate electronic health record-based medication reconciliation, patient education, and regimen surveillance tools, guided by the Universal Medication Schedule, and assess the efficacy of the tools among patients with multiple chronic conditions.
  • Pharmacy Society of Wisconsin, Madison, WI, will work with members of the Wisconsin Pharmacy Quality Collaborative to increase provision of comprehensive medication reviews (CMR) to Medicaid members through technician product verification workflow efficiencies, CMR coaching workgroups, and targeted marketing to pharmacists, prescribers, community groups, and the media.
  • ThedaCare Health System, Appleton, WI, will include in-home medication review in its Community Paramedic Program; partner with two local pharmacies to provide enhanced medication management services; and use a Virtual Health model to link the community paramedic, pharmacist, and patient during in-home visits.
  • Towncrest Pharmacy, Iowa City, IA, will establish a system to flag patients at risk of medication-related problems in clinical documentation and match them with appropriate interventions, such as adherence monitoring, patient education, medication counseling, or training.
  • University of Minnesota College of Pharmacy and Fairview Health Services, Minneapolis, MN, will enhance comprehensive medication management with the aim to reduce readmissions by advancing care coordination at discharge, including post-discharge care plan coordination between physicians and pharmacists for people recently hospitalized for acute behavioral health needs.

Participants in the multi-site demonstration and evaluation will test and scale new ways to address medication complexity among populations with complex needs. Each pilot site will receive tailored, expert technical assistance and participate in a peer learning collaborative to exchange and accelerate solutions across sites. CHCS will distill lessons from the sites’ innovative medication management efforts and share emerging best practices nationally.