Partnership in Medication Adherence Creates 5-Star Impact at Community Health Care in Ohio

Contributors

“It was, hands-down, the easiest onboarding of anything we’ve ever done at CHCI.” That’s Shannon Smith’s assessment of how quickly and collaboratively Stellus Rx worked to implement medication adherence support for Community Health Care’s Medicare Advantage lives. And Smith would know—she has spent her career helping CHCI serve tens of thousands of patients throughout Ohio and today serves as the medical group’s Chief Operating Officer.

But it’s not just Stellus Rx’s agility of implementation that has stood out to Smith and the CHCI team, it’s also the rapid advancement in adherence performance. “We were hitting mostly 3-Stars or 4-Stars in the triple-weighted adherence measures,” said Smith. “Stellus Rx turned that around in a year, where we’re now hitting 4-Stars or 5-Stars in the same measures across all payers.”

In this interview, we explore how CHCI’s partnership model for medication adherence has freed up resources and attention for new clinical initiatives that enhance CHCI’s mission-driven care delivery.

Can you give us a snapshot of Community Health Care (CHCI) and your approach to patient care?

Shannon Smith: So, some of the things we truly try to highlight: We’re very mission-focused and collaborative with our patients. Patient care can’t be directed only by what the physician wants a patient to do. It has to be bidirectional, so we work with our patients to come up with a plan together. We’ve found that’s the most effective way to achieve the best outcomes.

And so far, that approach has helped sustain and grow CHCI as an independent, physician-owned practice for nearly 40 years now. We have 18 family practice locations and will add a 19th location in September. CHCI also offers pediatrics, women’s care, physical therapy and behavioral health … serving more than 80,000 patients across Ohio, all tied to our mission of providing care that’s comprehensive and compassionate.

When you talk about collaborative care, what does that mean for CHCI? What’s essential for delivering that type of care in a way that works operationally for you?

Shannon Smith: It’s looking at each patient individually and working to connect what they need and what resources are available to them. Since our locations are so spread out from one another, that means we also have a lot of diversity in patient needs, including different social determinants of health that influence care decisions. Frankly, that’s one of our biggest barriers. We have care managers embedded in each one of our offices that are either LPNs or RNs, and they spend a lot of time working with patients to address those social determinants of health—we’re talking basics, like the affordability of food, transportation, medication.

And it’s because we want to continue to take such a personalized approach with each patient—and because we’re continually working on different initiatives that raise the quality of care we deliver—it’s crucial for us to have the right partners in place to extend the team-based care we deliver, in ways that are consistent with our mission.

So turning, then, to medication adherence and the role that plays as part of patients’ overall care experience … how does CHCI think about the challenges with adherence, and what have been the keys to overcoming those challenges?

Shannon Smith: To start, I think it’s important to consider the complexity of the data. We have lists of quality metrics from each payer that we’re looking at all the time. And they’re similar from payer to payer, but there are small-but-significant differences that we have to be mindful about. That’s a lot to dig into and keep watch over throughout the course of a year.

Then there’s the capacity and bandwidth component. Performance in the triple-weighted adherence measures is definitely huge for us … but how do we reach out to those patients? How do we make time? And then even if we reach the patient at the right time, how do we ensure we have the right expertise to help patients remove whatever barriers stand between them and adherence, whether that’s education about specific medications or how to reduce out-of-pocket costs … the list goes on.

The partnership we’ve built with Stellus Rx immediately addresses both of these pain points for us. Having a clinical pharmacist actually reach out to patients is huge. Stellus Rx pharmacists know the medications inside and out. They have access to what’s covered in patients’ prescription drug benefit and what’s not, what patients can expect with side effects and how to get through them. They talk to patients about the importance of taking their medications; they educate patients and reinforce the messages that patients receive from their physicians at CHCI.

It’s been a relief to have all of that moved from our plates and to be able to trust a partner to extend the level of quality and service that CHCI always works to provide.

Prior to your work with Stellus Rx, how was CHCI addressing medication adherence measures?

Shannon Smith: Previously, nonadherence was part of our district managers’ set of responsibilities. Each district manager was assigned a payer and would identify patients who were nonadherent. We would do chart dives, send messages to the provider about what the patient might need, try to put in notes for upcoming appointments. We would reach out to patients, but we’re not pharmacists, so that wasn’t well received from patients. And I think that ties to the patient education piece and the pharmacist expertise piece.

Patients often stop taking their medications because they don’t see immediate results—or maybe the only immediate effects they see are the cost of the medication and side effects. So they were missing that expert voice who could walk them through why these medications are so important.

And our results showed it. We were hitting mostly 3-Stars or 4-Stars in the triple-weighted adherence measures. Stellus Rx turned that around in a year, where we’re now hitting 4-Stars or 5-Stars in the same measures across all payers.

Implementation of new solutions into existing practice workflows can be tricky, especially for an organization like CHCI that has so many geographically dispersed locations. What can you share about Stellus Rx’s implementation process at your practice?

Shannon Smith: It was, hands-down, the easiest onboarding of anything we’ve ever done at CHCI. Through the entire process, the Stellus Rx team seemed to be about, “What will make this easiest for your team?” And that’s everything from how Stellus Rx integrated with our EMR to preferences for how Stellus Rx’s pharmacists communicate with our providers. I couldn’t be more grateful for how easy it was to get implemented and up and running.

Post-onboarding, our teams have found a great working rhythm together, with the Stellus Rx team putting actionable notes on patient telephone encounters directly into our EMR, making sure our physicians have the full information they need to take the next steps in the care of our patients. It’s to the point where our physicians are asking for more communication and earlier—not just to make sure we achieve performance in our adherence measures, but to do even more to help our patients.

You mentioned earlier about the additional bandwidth created for your team as a result of Stellus Rx’s work. What additional insights can you share about how your team is working today and what they’re able to focus on as a result of your partnership with Stellus Rx?

Shannon Smith: It’s expanded our ability to address all the other initiatives we have in place. With each payer, we have all kinds of other quality measures we’re working on: colorectal cancer, breast cancer screening, all the other diabetic measures. We have a huge diabetic eye initiative that we’re doing … kidney health for diabetic patients … blood pressure control and repeating blood pressures in the office … a heart failure initiative … a COPD initiative … a dementia initiative.

And in each of these, the district managers have direct involvement. So they’re ensuring that we’re calling patients, scheduling appointments, annual wellness visits. They’re managing the day-to-day with projects and staffing, with accountability for all of this. So having Stellus Rx step in to support medication adherence has given them more time to focus on plates that were already close to overflowing.

And to this point, we’ve talked about the practice and provider impact you’ve seen. Have there been examples of patient impact as well?

Shannon Smith: One of our physicians got a message from a Stellus Rx pharmacist about a patient who was overdue on picking up his medications. The pharmacist saw in the patient’s chart that the patient had been a no-show for his last three appointments and was checking to see if something more was going on.

Typically, when we have patient no-shows, we outreach the patient by phone and mail. Well, this patient wasn’t responsive to any of our outreach attempts, which was very unlike him. So the next step was to reach out to the patient’s emergency contact, which happened to be his pastor. The pastor had not heard from the patient, either, which triggered a home visit by the patient’s physician and one of our care managers.

It turns out the patient’s health had declined and he was essentially confined to his home. He has a hard time seeing and doesn’t drive, so he hadn’t been out of the house much, hadn’t been able to attend church, hadn’t been able to receive or take his medications, hadn’t been able to go to the grocery store. All of his food was expired.

Seeing all of this, we’ve been able to set him up with additional resources to help him—things like transportation services, different types of medication packaging; his care manager will be checking on him more regularly. This patient will receive more of the care he needs and have a better chance at a healthier life all because a Stellus Rx pharmacist saw something abnormal and was able to alert us to that information in time for us to act. It shows what a partnership like ours can do.

Published: July 30, 2025