Atlantic General Hospital

Medication Therapy Management targets adherence to reduce readmissions and lower costs.

The challenge

Build on the progress already made with Atlantic General’s patient-centered medical home (PCMH) to further strengthen medication adherence and decrease hospital readmissions.

Our solution

Partner with PHS to create a pharmacy-driven medication therapy management (MTM) program within the PCMH.

The outcome

Better patient care for enrolled patients.


lower readmissions 


fewer emergency department (ED) visits


adherence (vs. 79% national average)

Stronger financial results

  • Total revenue nearly 29% over goal
  • Avoided ~$100 in cost per patient by reducing ED visits
  • Revenue per Rx 20% over goal
  • Gross profit nearly 69% over goal
  • Avoided ~$5,000 in cost per patient by preventing readmission

Atlantic General Hospital

Atlantic General Hospital is a 62-bed acute care facility in Berlin, Maryland, serving more than 117,000 patient visits per year from people in Maryland, Virginia and Delaware. Part of the Atlantic General Health System, this non-profit hospital gives back to its community through community health services and health fairs, health literacy programs for children, charity care and more. 

Atlantic General Hospital launched its patient-centered medical home (PCMH) model in 2011 to help reduce readmissions. A PCMH is a concept, not a specific place. It signifies a team of healthcare professionals, guided by the primary care provider, that provides comprehensive, coordinated care for the patient over their lifetime. This model actively embraces input and participation from the patient and the patient’s family.

The Atlantic General Hospital nurse-led collaboration of clinicians—including physicians and case managers—focuses on serving higher-risk patients. Engaging more frequently and directly with these patients over the long term improves outcomes and lowers costs. Building on the PCMH’s progress, Atlantic General wanted to do even more to reduce readmissions.

The challenge: Increase medication adherence and capture data to show results

Medication nonadherence is widely recognized as a primary cause of readmissions in hospitals and health systems across the country. Atlantic General believed nonadherence was playing a key role in its own readmissions but lacked the data to prove it. To gain long-term support for an innovative program to improve adherence, the hospital needed to show a direct link to readmissions and provide hard data to measure program results. 

Research conducted by Mayo Clinic in 2011 indicates that 50 percent of patients nationwide don’t take medications as prescribed, and it’s estimated that non-adherence is responsible for 11 percent of hospital readmissions across the country.1 Further, medication mismanagement creates an estimated 1.5 million adverse events each year and $177 billion in avoidable costs.2 

Our solution: Create a pharmacy-driven MTM program 

Atlantic General wanted to follow a proven strategy to increase adherence: create a medication therapy management program (MTM) within the PCMH. The hospital advanced the MTM concept by creating a pharmacy-driven MTM with community outreach at its heart. With this innovative model, a pharmacist visits patients at home to perform MTM services in person.

To help create its MTM clinic, Atlantic General turned to Pharmacy Healthcare Solutions (PHS). PHS consultants were instrumental in developing the hospital’s ambulatory pharmacy, AGHRx RediScripts. PHS continues to manage the pharmacy on the hospital’s behalf.

Setting up the MTM program required reallocating just 10 percent of an existing pharmacist’s time to directly support the PCMH. Karan Bealla, MTM Pharmacist, joined the PCMH care team to manage the new MTM clinic. This allowed nurses to focus more effectively on their nonpharmaceutical responsibilities. While the PCMH has hundreds of patients, there are only five nurses to serve them.

“From a resource allocation and focus perspective, adding an MTM Pharmacist to the PCMH care team just makes sense,” said Jeff Kukel, PharmD and Pharmacy Manager of AGHRx RediScripts Pharmacy. “The MTM Pharmacist supplements the PCMH staff and helps our hospital more effectively identify and lower barriers to proper medication management and adherence.”

Targeting the right patients

All PCMH patients are considered for referral to the MTM clinic. These patients require more assistance to help manage their disease states, have a history of readmissions and high utilization of healthcare resources. Each case is reviewed by a care coordinator to determine if a referral is necessary.

To identify those who would benefit most from the in-home MTM service, patients are stratified based on their history of readmission and causes of it. “Patients determined to be ‘highest risk’ are invited to join, but others can opt-in as well,” Kukel said.

What happens during an in-home patient visit?

“First, we review prescribed medications with the patient and then set up the ‘pill box,’” said Karan Bealla, MTM Pharmacist. “This organizes the medication regimen and makes it easier to understand which medications to take when.”

Bealla also develops an action plan with the patient that includes specific goals aimed to help support adherence. Finally, she establishes a quarterly visit schedule. “The first visit may be in the patient’s home, while future visits could be at AGHRx RediScripts, if the patient has transportation to get there,” she said.

The outcome: Higher adherence, lower costs

Once the MTM Pharmacist began visiting patient homes, subsequent data collection confirmed the hospital’s suspicions. The substantial reduction in readmissions as a direct result of the program is proof of the strategy’s value.

The MTM Clinic produces numerous benefits for Atlantic General and its patients, including:

  • Improved medication adherence and patient outcomes
  • Substantially lower hospital readmissions and ER visits
  • Enhanced patient satisfaction
  • Deeper community engagement
Patients enrolled in the MTM program had fewer readmissions, dropping from 9 in the prior year to 1 after actively participating in the program, an 89 percent reduction. The cost avoidance benefits of preventing readmissions are significant as well: approximately $5,000 per patient. The change in emergency department (ED) visits was also dramatic: enrolled patients had 91 ED visits in the prior year and only 11 visits after taking part in the program, an 88 percent reduction. Preventing needless use of the ED also avoids about $100 in costs per patient visit.

“We presented the financial benefits of our pharmacy-driven MTM to the hospital’s executive leadership,” Kukel said. “When they saw the results we achieved with limited resources, they gave us the go-ahead to expand the program.”

In the first year, 10 percent of Bealla’s time was dedicated to home visits. The balance was spent working at the hospital’s ambulatory pharmacy. In the second year, her time commitment increased significantly. “Because of the program’s success, I now spend half my time working with the program,” she said.

Creating your own pharmacy-driven MTM program

Based on Atlantic General’s experience, follow these steps:

  1. Understand which financial, operational and patient care objectives matter most to your healthcare organization.
  2. Assess how much emphasis your executive leadership places on lowering hospital readmissions (this is typically the #1 reason why a pharmacy-based, community-focused MTM program is put into place).
  3. Develop your pharmacy-driven MTM program to begin addressing readmissions rates. Set baseline metrics and track performance over time.
  4. Pilot the program first (just as Atlantic General did)—start small, use data analytics for proof of concept and expand service as results increase support among executive leadership.

As hospital ambulatory pharmacists reveal the value of visiting patients in their homes, they demonstrate how pharmacists can serve a far greater role than filling prescriptions. The hospital ambulatory pharmacy can be a critical component of a provider’s comprehensive strategy to lower costs and improve patient care.

1Case Management Society of America. “Medication Adherence: WHO cares?” www.ncbi.nlm.nih. gov/pmc/articles/PMC3068890
2American Pharmacists Association.