Physician perceptions of integrating advanced practice pharmacists into practice

Impact of pharmacist-provided Medicare annual wellness visits and chronic care management on reimbursement and quality measures in a privately owned family medicine clinic

PURPOSE

Improvement in patient outcomes from collaboration between pharmacists and physicians in ambulatory clinics has been well documented. Barriers to payment have made widespread growth of these collaborations slow. Medicare annual wellness visits (AWVs) and chronic care management (CCM) provide an opportunity for pharmacist-physician collaborations that are directly revenue generating. The objective of this study was to evaluate the impact of pharmacist-led AWVs and CCM on reimbursement and quality measures in a private family medicine clinic.

METHODS

This was a retrospective observational study in which the rate of reimbursement for AWVs and CCM was compared before and after implementation of pharmacist-provided services. Claims data were reviewed for Current Procedural Terminology codes and reimbursement applicable to AWVs and CCM. Secondary outcomes included the total number of AWV and CCM appointments, Healthcare Effectiveness Data and Information Set (HEDIS) measure completion rates, and average change in quality ratings. Outcomes were analyzed utilizing descriptive statistics.

RESULTS

Reimbursement from AWVs increased by $25,807.21 in 2018 and $26,410.01 in 2019 compared to 2017. Reimbursement from CCM increased by $16,664.29 in 2018 and $5,698.85 in 2019. In 2017, 228 AWVs and 5 CCM encounters were completed. After implementation of pharmacist services, the number of CCM encounters increased to 362 in 2018 and 152 in 2019 and the number of AWVs totaled 236 and 267, respectively. Completed HEDIS measures and star ratings increased during the study.

CONCLUSION

Pharmacist provision of AWVs and CCM addressed a gap in care by increasing the number of patients who received these services while also increasing reimbursement in a privately owned family medicine clinic.

Factors influencing clinical pharmacists' integration into the clinical multidisciplinary care team

Objectives: To investigate the factors influencing clinical pharmacists' integration into the clinical multidisciplinary care team, using interprofessional collaboration between clinical pharmacists and physicians as the focus. Methods: Through stratified random sampling, a cross-sectional questionnaire survey was conducted among clinical pharmacists and physicians in secondary and tertiary hospitals in China from July to August 2022. The questionnaire, comprising the Physician-Pharmacist Collaborative Index (PPCI) scale to reflect the collaboration level and a combined scale to measure influencing factors, was made available in two versions for clinical pharmacists and physicians. Multiple linear regression was adopted to analyze the association between the collaboration level and influencing factors, as well as the heterogeneity of the significant factors in hospitals of different grades. Results: Valid self-reported data from 474 clinical pharmacists and 496 paired physicians were included, who were serving in 281 hospitals from 31 provinces. In terms of participant-related factors, standardized training and academic degree, respectively, exerted significant positive effects on the perceived collaboration level by clinical pharmacists and physicians. In terms of context characteristics, manager support and system construction were the main factors for improving collaboration. In terms of exchange characteristics, clinical pharmacists having good communication skills, physicians trusting others' professional competence and values, and both parties having consistent expectations had significant positive effects on collaboration. Conclusion: The study provides a baseline data set on the current level and associated factors of clinical pharmacists' collaboration with other professionals in China and other countries with a related health system, providing references for individuals, universities, hospitals, and national policymakers to facilitate the development of clinical pharmacy and multidisciplinary models and further improve the patient-centered integrated disease treatment system.

A descriptive analysis of primary care providers' interest in clinical pharmacy services

Background

Various clinical pharmacy services exist to improve the health outcomes of patients. However, there are numerous barriers to their implementation and execution, especially in outpatient settings. As pharmacists design and implement clinical pharmacy services in outpatient settings, they often do not consider the needs of providers until after service development.

Objectives

The purpose of this study was to assess primary care providers' (PCPs') perceptions of clinical pharmacy services and their clinical pharmacy support needs.

Methods

A web-based survey was distributed via email to PCPs across North Carolina (NC). Survey dissemination was completed in two phases. Data analysis consisted of mixed methods - quantitative and qualitative. Descriptive statistics were used to analyze demographic differences within each phase as well as the ranking of medication classes/disease states by providers. Qualitative data analysis through inductive coding was done to assess provider perceptions of clinical pharmacy services.

Results

The response rate of the survey was 19.7%. Providers with previous experience with a clinical pharmacist rated overall services as positive. 62.9% of PCPs (N = 80) provided their perception of the positive attributes (pros) of clinical pharmacy services. 53.5% of PCPs (N = 68) provided their perception of the negative attributes (cons) of clinical pharmacy services. The top three medication classes/disease states that providers indicated they would value clinical pharmacy services for were: comprehensive medication management (CMM), diabetes medication management, and anticoagulation medication management. Of the remaining areas assessed, statin and steroid management ranked the lowest.

Conclusions

The results from this study demonstrated that clinical pharmacy services are valued by PCPs. They also highlighted how pharmacists can best contribute to collaborative care in outpatient settings. As pharmacists, we should aim to implement the clinical pharmacy services that PCPs would value most.

Health Economic Analysis of Pharmacist-Led Annual Wellness Visits

Objective To quantify the financial and clinical implications of pharmacists completing Medicare Annual Wellness Visits (AWV). Design Retrospective, observational, population-based health economic analysis utilizing electronic medical record data. Setting A single family-practice clinic within a Missouri-based not-for-profit community health system. Patients/Participants Medicare patients in their second year of coverage who had not been seen for an AWV within the previous 12 months. Intervention Patients attended a subsequent AWV conducted by a licensed ambulatory care pharmacist between July 1 and December 31, 2021. The pharmacist completed all necessary visit requirements and helped facilitate completion of preventive screenings. Main Outcome Measures Primary outcomes measured were financial implications of pharmacists completing AWVs. The primary objective was to quantify the direct and indirect financial benefits for a health system incorporating pharmacist-led AWVs. Direct revenue was calculated based on the number of visits completed multiplied by the reimbursement rate paid to the health care system by the Centers for Medicare & Medicaid Services (CMS). Indirect revenue was estimated based on the number and type of interventions completed by the patient. The secondary outcome measured was the clinical impact of pharmacist-led AWVs through quantifying preventive care service needs and completion of these services. Alongside these measures, the number of medication discrepancies and drug interactions were also measured and cost avoidance estimated. Annual cost in salary of a pharmacist was considered, but additional cost of overhead was beyond the scope of the study. Results Thirty-nine AWVs were completed. Two hundred six recommended screenings, labs, and immunizations were identified, of which 24% were completed. The pharmacists were also able to identify 205 medication issues. These visits generated $4,593.42 in direct revenue. Recommended preventive care generated $2,161.71 in indirect revenue. Conclusion Pharmacist-led AWVs are financially beneficial to the health care system and increases the number of completed AWVs while avoiding demand for additional physician time.

Physicians' and advanced practice providers' perceptions of the impact of embedded clinical pharmacists on the work environment in ambulatory care clinics

PURPOSE

Clinical pharmacists are recognized as valuable team members in primary care clinics due to the variety of patient care services they provide. This study examined nonpharmacist healthcare providers' perceptions of how embedded clinical pharmacists impact the work environment in ambulatory care clinics.

SUMMARY

This was an exploratory mixed methods study consisting of semistructured interviews and a subsequent survey. Participants included attending and resident physicians, and advanced practice providers (APPs) practicing in clinics with an embedded clinical pharmacist. Coded interview transcripts were analyzed to identify themes that were used to develop a survey. Interview participants were not asked to complete the survey. Survey responses were analyzed utilizing descriptive statistics. Subgroup analysis assessed for differences in responses based on provider type, gender, clinical practice area, years of practice, and pharmacy services utilization. Fourteen physicians and APPs participated in the semistructured interviews, and 43 other providers completed the survey. In the interviews, participants stated the clinical pharmacist contributed positively in terms of work environment, workload, work-related stress, and burnout. The major themes identified were sharing patient care responsibilities, saving provider time, and being a knowledgeable resource. Survey responses were consistent with interview statements; however, the positive impact differed between nonusers and moderate to high utilizers of clinical pharmacy services. The main barrier to collaborating with clinical pharmacists was their limited availability.

CONCLUSION

Embedded clinical pharmacists positively impact the work environment in ambulatory care clinics by reducing provider workload, work-related stress, and burnout. Participants also noted clinical pharmacists are a trusted resource for patient care and drug information questions.

Moving beyond professionalism: Pharmacy students understanding of professionalism and professional identity

INTRODUCTION

Professional identity is who we are in the context of our chosen profession, a complex and dynamic process. The purpose of this study was to describe pharmacy students' understanding of the terms professionalism and professional identity and the elements of formal and informal curricular activities that may contribute to professional identity formation.

METHODS

This anonymous cross-sectional survey was administered to pharmacy students in years one through five at all 10 Canadian pharmacy schools with the help of local Canadian Association of Pharmacy Students and Interns representatives. Students were first asked to define professionalism and professional identity and then were provided with a definition of professional identity to support their statements as to what experiences were meaningful in its development. Both an inductive and deductive approach were used for thematic analysis of written responses alongside descriptive statistics.

RESULTS

A total of 172 students responded. Most students were from the University of Alberta and were evenly distributed through years one through four of pharmacy. Key themes emerged of the traditional view of professionalism, expanding the six tenets defined by the American College of Clinical Pharmacy to include responsibility and accountability. Pharmacy students' definitions of professional identity more often included facets of professionalism, but when prompted acknowledged teaching related opportunities, professional development, and role-modelling as playing a key role in professional identity development.

CONCLUSIONS

Most pharmacy students were unable to formally define professional identity; however when prompted they did understand what it was and which experiences nurtured its development.

Evaluating the role and value of a clinical pharmacist in a concierge primary care clinic

OBJECTIVE

To understand the perceived role and value of the clinical pharmacist in a southern Arizona concierge primary care practice (CPCP) by employees.

METHODS

Semistructured face-to-face interviews were conducted with health care team members employed by the CPCP site in December 2019 and January 2020 for this study. The interviews were audio recorded, transcribed, and thematically analyzed using an inductive approach with ATLAS.ti (version 7). A qualitative assessment was performed by 2 independent reviewers to identify the themes, which included clinical, economic, and humanistic outcomes.

RESULTS

Eleven CPCP employees were interviewed: physicians (n = 2), a nurse practitioner (n = 1), medical assistants (n = 4), and administrative staff (n = 4). The perceived role and value of the clinical pharmacist in this CPCP varied by employee position; yet, all expressed the pharmacist's positive impact on patient care. Five themes were identified. The most common pharmacist roles identified included providing medication knowledge to providers, preventing abuse of controlled substances, monitoring clinical response to medications and adverse drug events, aiding in prior authorizations, educating patients, and providing patient-centered care.

CONCLUSION

These results demonstrate that the integration of a clinical pharmacist into a CPCP can be valuable. This study highlights that the pharmacist was positively received by the physicians and staff. This further supports the value of the pharmacist as a key interprofessional health care team member. Further study is warranted to assess the longitudinal impact of pharmacists' services in a CPCP.

The Evolving Role and Impact of Integrating Pharmacists into Primary Care Teams: Experience from Ontario, Canada

The movement to integrate pharmacists into primary care team-based settings is growing in countries such as Canada, the United States, the United Kingdom, and Australia. In the province of Ontario in Canada, almost 200 pharmacists have positions within interdisciplinary primary care team settings, including Family Health Teams and Community Health Centers. This article provides a narrative review of the evolving roles of pharmacists working in primary care teams, with a focus on evidence from Ontario, as well as drawing from other jurisdictions around the world. Pharmacists within primary care teams are uniquely positioned to facilitate the expansion of the pharmacist’s scope of practice, through a collaborative care model that leverages, integrates, and transforms the medication expertise of pharmacists into a reliable asset and resource for physicians, as well as improves the health outcomes for patients and optimizes healthcare utilization.

Awareness and perceptions of advanced practice pharmacists among health care providers in New Mexico

OBJECTIVE

The purpose of this study was to evaluate health care provider awareness and perceptions of the 2 types of advanced practice pharmacists (APPhs) in New Mexico: pharmacist clinicians (PhCs) and community pharmacists with independent prescriptive authority (iRPhs).

METHODS

A cross-sectional electronic survey was administered to health care providers in New Mexico to describe awareness and perceptions of APPhs and benefits and barriers to collaborative practice with APPhs.

RESULTS

A total of 5905 providers received the emailed survey, and 634 (11%) completed the survey, with 68% of the respondents indicating that they were not aware of the 2 types of APPhs in New Mexico. The top benefits of working with a PhC identified by the respondents were access to medication knowledge, enhanced clinical outcomes, and increased access to patient care. The barriers to employing a PhC at their practice included cost, difficulty in billing for services, and limited reimbursement. Importantly, 80% of the respondents felt that PhCs should be recognized as providers for insurance reimbursement. Awareness of iRPhs varied by prescriptive authority service, ranging from 34% for tuberculin skin testing to 84% for adult vaccinations. Overall, 80%-92% indicated that iRPhs should be reimbursed, depending on the prescriptive authority service.

CONCLUSION

Provider awareness of APPhs in New Mexico was low; however, the willingness to refer patients to APPhs for clinical services was high. Cost, difficulty in billing for services, and reimbursement for PhC services were the primary identified barriers to adding a PhC into practice. Most of the respondents indicated that both types of APPhs should be granted provider status and reimbursed by third-party payers for their services.

Medicare Annual Wellness Visits: A Scoping Review of Current Practice Models and Opportunities for Pharmacists

OBJECTIVE

To explore the existing practice models and practice opportunities surrounding pharmacist-delivered Medicare Annual Wellness Visits (AWVs), with the goal of improving patient access through advanced pharmacy-based health services.

DATA SOURCES

English-language articles published in peer-reviewed journals from January 2011 to March 2018 were reviewed by searching PubMed and Google Scholar databases using permutations of terms such as "pharmacist/pharmacy," "Medicare," "Annual Wellness Visit," "develop/development," and "implement/implementation."

STUDY SELECTION AND DATA EXTRACTION

Original articles reporting resources (inputs), processes, and programmatic outcomes (uptake and delivery, interventions made, financial models, satisfaction) of pharmacist-delivered AWV services were retained.

DATA SYNTHESIS

Eight articles describing 6 unique studies representing current pharmacist-delivered AWV practices were included in the final review. All identified articles used observational study designs and were published in peer-reviewed journals from 2014 to 2017. Five studies utilized staff (in-house) pharmacists working in internal or family medicine clinics via collaborative practice agreements; one study described a model for outsourcing AWV services through a community pharmacy. Pharmacists completed 37 to 300 AWVs and performed both medication- and non-medication-related interventions, with a mean of 3.5 to 5.4 interventions/patient. Quarterly revenue ranged from $3750 to $22 340 (USD), with 40 pharmacist-hours required for initial program development.

IMPLICATIONS FOR PATIENT CARE AND CLINICAL PRACTICE

This scoping review will serve as a guide for pharmacists wishing to implement AWV services in their own practices.

CONCLUSIONS

There is opportunity for ambulatory/community pharmacists to expand their practices to include AWV services in states that allow collaborative practice agreements. Interprofessional collaboration between physicians and pharmacists can optimize and aid adoption of pharmacist-delivered AWV services.

Development and reliability assessment of a tool to assess community pharmacist potential to influence prescriber performance on quality measures

OBJECTIVE

To develop and assess the reliability of a tool that measures community pharmacist potential to influence prescriber quality measure performance.

METHODS

Multidisciplinary, health care subject matter experts were convened to determine the criteria that evaluate the community pharmacist's ability to influence quality measure performance and a scoring mechanism. The draft tool was reviewed by investigators and subject matter experts in various health care professional settings to assess face validity and make refinements. Interrater reliability was assessed by 2 independent reviewers using a random 20% sample of the 2017 Merit-based Incentive Payment System (MIPS) measure set. Absolute agreement and kappa statistics were calculated, and the tool was iteratively refined based on the results. The tool was then applied to the full 2017 MIPS measure set by 2 reviewers, and interrater reliability was assessed.

RESULTS

The quality measure impact tool-community pharmacy (QMIT-CP) comprised 5 criteria, which assessed the quality measures of the community pharmacist's influence potential. The criteria evaluated whether the quality measures: (1) addressed the use of medications or immunizations; (2) included a condition treatable by medications; (3) treated patients in an outpatient setting; (4) included outcomes; and (5) evaluated whether relevant measure data were available to community pharmacists. All criteria used a dichotomous scale, and the summed scores were used to categorize the pharmacist's influence potential as "high" (4-5), "moderate" (2-3), or "low" (0-1). Kappa statistics ranged from "substantial agreement" (≥0.6) to "almost perfect agreement" (≥0.8) for individual QMIT-CP criteria and overall pharmacist influence potential categorization.

CONCLUSIONS

The QMIT-CP is a reliable tool to identify quality measures and assess the high, moderate, or low influence potential that community pharmacists may have. The QMIT-CP can be used to support innovative team-based care and enhance value-based contracting by identifying relevant measures that community pharmacists have the potential to influence.

Looking Back at US Pharmacy’s Past to Help Discern Its Future

Objective: To review specific literature that aimed to predict the future of US pharmacy, beginning in the late 1980s. Data Sources: Articles were identified from searching MEDLINE, CINAHL, Google Scholar, and references of relevant articles. The following combinations of search terms were used: future, pharmacy, prediction, and forecast. Study Selection and Data Extraction: The following inclusion criteria were applied: (1) full-text commentary, review, or original research and (2) focused predominantly on the pharmacy in the United States. Data on predictions for the future of pharmacy were extracted. Data Synthesis: We selected 3 articles published between 1988 and 2006, with each aiming to project the future for the following decade. We examined each prediction in light of the current knowledge. Relevance to Patient Care and Clinical Practice: Educators, practitioners, and other stakeholders should consider reflecting on the changes in pharmacy for the past 3 decades and applying both historical and emerging trends to improve patient care and sustain practice in the third decade of the 21st century and beyond. Conclusion: Most of the predictions for the future of pharmacy from the past 3 decades materialized, with some still in progress (reimbursement for pharmacy services), whereas others manifested in unexpected ways (transition from shortage to excess of pharmacists). Current forces shaping pharmacy include, but are not limited to, growing spending and use of specialty drugs, automation of pharmacy operations, growth of pharmacy in the digital health enterprise, and growing consumer interest in the use of analytical pharmacy that tests drugs before dispensing.

Expansion of pharmacist practice in oral oncolytic therapy with a collaborative practice agreement

INTRODUCTION

Collaborative practice agreements have been utilized to expand pharmacist roles and improve patient care outcomes. A need to reduce the time providers spend reviewing oral oncolytic prescriptions for therapy continuation or dose adjustments was identified in the oncology clinics of a community health system. A collaborative practice agreement was created to decrease turnaround time for processing oral oncolytic prescriptions, improve provider satisfaction, and decrease patient prescription costs.

METHODS

A three-month pilot was initiated to evaluate feasibility and provider satisfaction by comparing two provider groups. An additional three months of data were collected post-collaborative practice agreement implementation to evaluate impact. Primary endpoints included: interventions, turnaround time, and patient cost savings. A survey was conducted to determine provider satisfaction.

RESULTS

The mean turnaround time for pharmacist interventions in the pilot group (n = 54) was 7 min, compared to 3311 min in the control group (n = 87), which was statistically significant (p < 0.0001). Two interventions in the pilot group resulted in patient cost savings due to dose rounding by a pharmacist. The mean turnaround time of the post-collaborative practice agreement group (n = 197) was 6 min, which was statistically significant when compared to the control group (p < 0.0001).

CONCLUSION

Turnaround time was significantly shorter for prescriptions in the pilot and post-collaborative practice agreement groups compared to the control group. Provider satisfaction increased as the collaborative practice agreement resulted in less time reviewing oral oncolytic prescriptions. Patient costs were also reduced during the pilot phase due to dose rounding by pharmacists.

Pharmacist-Led Annual Wellness Visits: A Review

Objective:

To summarize findings of pharmacist involvement with Medicare Annual Wellness Visits (AWV), including the number of pharmacist interventions, patient/provider satisfaction, and billing models.

Data Sources:

A literature search was conducted using PubMed, ScienceDirect College Edition Journals Collection-Health and Life Sciences, Cochrane Library, CINAHL, Medline, and Academic Search Complete, including dates between January 01, 2011, and November 05, 2018.

Study Selection:

Search was limited to full-text, peer-reviewed articles, published in English which were relevant based on identification of a pharmacist’s role in AWV. Search terms included “Medicare annual wellness visits” and “Pharmacists.”

Data Extraction:

A data extraction tool was used to collect study authors, year published, study design, description of intervention, objectives, primary outcome measures, model of care, clinic setting, location, results, number of patients, and overall effect.

Results:

Of the 139 returned citations, 11 met inclusion criteria. Of the practice settings, 7 (72.72%) utilized a collaborative practice agreement for conducting AWV. Six (54.54%) of the studies measured financial outcomes, 3 (27.27%) measured satisfaction of students/patients/physicians, 2 (18.18%) measured clinical outcomes, and finally 4 (36.36%) measured number and types of interventions. Review revealed that 6 (54.54%) articles had more medication-related interventions than nonmedication-related interventions. Studies evaluating finances as it relates to AWVs had various findings including 38% return on investment, higher reimbursement for pharmacist-led visits, and an increase in revenue.

Conclusion:

In a variety of outpatient health centers, AWV were conducted by pharmacists, had a positive impact on patient care, and had high satisfaction rates between patients and physicians.

Preparing Pharmacists for Collaborative/Integrated Health Settings

Pharmacy practice is changing to accommodate the need for pharmacists to be better team members in newly emerging collaborative care and integrated health systems. Pharmacy schools could lead this change by educating students to be effective participants in these relatively new models of care. Schools are encouraged to follow the approach outlined in the recent guidance published by the Health Professions Accreditors Collaborative (HPAC) for interprofessional practice and education (“the new IPE”). This approach includes articulating an IPE plan, establishing goals, assessing student achievement of the necessary IPE competencies, developing educational plans that are multi-faceted and longitudinal, and modifying the existing assessment/evaluation process to ensure the quality of the IPE effort. These curricular decisions should be based on existing and new research on the effectiveness of IPE on student’s attitudes, knowledge, skills, and behavior. A key decision is how to create effective interactions between pharmacy students and those of other professions. Educational emphasis should be directed toward team building skills, not just individual competencies. The pharmacy faculty probably need to enhance their teaching abilities to accommodate this change, such as learning new technology (e.g., simulations, managing online exchanges) and demonstrating a willingness to teach students from other professions.

Creating a Pharmacotherapy Collaborative Practice Network to Manage Medications for Children and Youth: A Population Health Perspective

Children with special health care needs (CSHCN) use relatively high quantities of healthcare resources and have overall higher morbidity than the general pediatric population. Embedding clinical pharmacists into the Patient-Centered Medical Home (PCMH) to provide comprehensive medication management (CMM) through collaborative practice agreements (CPAs) for children, especially for CSHCN, can improve outcomes, enhance the experience of care for families, and reduce the cost of care. Potential network infrastructures for collaborative practice focused on CSHCN populations, common language and terminology for CMM, and clinical pharmacist workforce estimates are provided. Applying the results from the CMM in Primary Care grant, this paper outlines the following: (1) setting up collaborative practices for CMM between clinical pharmacists and pediatricians (primary care pediatricians and sub-specialties, such as pediatric clinical pharmacology); (2) proposing various models, organizational structures, design requirements, and shared electronic health record (EHR) needs; and (3) outlining consistent documentation of CMM by clinical pharmacists in CSHCN populations.