The pharmacists' role in the Patient-Centered Medical Home (PCMH): a white paper created by the Health Policy Committee of the Pennsylvania Pharmacists Association (PPA)

Acceptance rate of clinical pharmacists' recommendations-an ongoing journey for integration

Introduction: Multidisciplinary expert team collaboration in the clinical setting, which includes clinical pharmacist involvement can facilitate significant improvements in outcomes and optimize patient management by preventing drug-related problems (DRP). This type of collaboration is particularly valuable in patients with multi-morbidity and polypharmacy such as diabetic foot patients. Evidence regarding the successful integration of a new clinical pharmacist, without previous experience into a unit is still scarce. Therefore, this study aimed to describe and evaluate the actual successful integration process of the clinical pharmacist into a diabetic foot unit by measuring the change in recommendation acceptance rate over time. Methods: A prospective, exploratory treatment effectiveness study based on the recommendation acceptance rate of a new clinical pharmacist introduced into the diabetic foot unit was conducted over a 9- month period. The clinical pharmacist identified medical and drug-related problems (DRP) or any discrepancies in the prescribing and administration of medications. Each identified DRP was documented and formulated as a recommendation by the clinical pharmacist. The main outcome measure was the acceptance rate of recommendations over time. Results: A total of 86 patients, of which 67% were men, averagely aged 66.5 (SD 11.8) years were evaluated. Calculated BMI was 30.2 (SD 6.2). The average number of medical diagnoses was 8.9 (SD3.2), and 11.1 (SD 3.7) prescribed drugs for each patient. Cardiovascular disease was presented by 95% (n = 82) of the patients and 33% of them (n = 28) had uncontrolled hyperglycemia. Averagely, 3.3 (SD 1.9) DRPs were identified pre patient. The efficacy-related DRP recommendation acceptance rate increased over the study period from 37.8% in the first 4 months to 79.4% after a period of 4.75 months. Safety-related DRP recommendation acceptance rate increased from 56% to 67.6%. Conclusion: Improved clinical outcomes and optimized pharmacologic patient management may be achieved by the successful integration of a clinical pharmacist into the team. This study provides evidence of the increasing recommendation acceptance rate of integrated, pharmacist-driven comprehensive medication management in an unexperienced unit. To overcome challenges, team members should collaborate to fully integrate the clinical pharmacist into the team-based structure and utilize proper strategies to minimize and transcend barriers.

Pharmacists' role in detection and evaluation of adverse drug reactions: Developing proactive systems for pharmacosurveillance

PURPOSE

To identify current challenges in detection of medication-related symptoms, and review technology-based opportunities to increase the patient-centeredness of postmarketing pharmacosurveillance to promote more accountable, safer, patient-friendly, and equitable medication prescribing.

SUMMARY

Pharmacists have an important role to play in detection and evaluation of adverse drug reactions (ADRs). The pharmacist's role in medication management should extend beyond simply dispensing drugs, and this article delineates the rationale and proactive approaches for pharmacist detection and assessment of ADRs. We describe a stepwise approach for assessment, best practices, and lessons learned from a pharmacist-led randomized trial, the CEDAR (Calling for Detection of Adverse Drug Reactions) project.

CONCLUSION

Health systems need to be redesigned to more fully utilize health information technologies and pharmacists in detecting and responding to ADRs.

Pharmacist documentation of gaps in care identified during diabetes coaching

OBJECTIVES

1) To identify the number of gaps, type of gaps, and contributing factors to gaps in diabetes care reported by pharmacists in the Diabetes Gaps in Care Portal (Gaps Portal). 2) To understand how pharmacists used the Gaps Portal and the implications for quality diabetes care.

DESIGN

The Alliance for Patient Medication Safety developed an online Gaps Portal as a tool for pharmacists to identify and document gaps in care when managing patients with diabetes.

SETTING

Pharmacists from across the United States in community pharmacy and ambulatory care settings who were engaged in diabetes coaching activities participated.

MAIN OUTCOME MEASURES

Pharmacists entered gaps in diabetes care into the Gaps Portal from April 2016 to June 2017. Descriptive statistics were used to determine the type and number of gaps and contributing factors. A qualitative analysis of pharmacist interviews was conducted to identify themes related to pharmacist perceptions of the portal.

RESULTS

Ten pharmacists entered 528 gaps in diabetes care (n = 469; 565 encounters). The most common category of gaps in diabetes care was drug therapy (n = 420/528; 79.6%). Of the drug therapy gaps reported, the most common gap occurred in patients with or at risk for atherosclerotic cardiovascular disease and not on a high-intensity statin (122/420), followed by those not on a moderate statin (106/420). Themes focused on during interviews included integration of diabetes coaching and documentation, impact of Gaps Portal on workflow, and prioritization of gaps.

CONCLUSION

Pharmacists most commonly identified drug therapy gaps, predominantly pertaining to statin use, which coincides with a change in the guidelines for statin use in diabetics. Telephone interviews indicated that the Gaps Portal template served as a useful checklist to identify gaps in care during diabetes coaching activities and that the Gaps Portal was useful for reporting and monitoring purposes.

Are community-based pharmacists underused in the care of persons living with HIV? A need for structural and policy changes

OBJECTIVE

To describe community pharmacists' perceptions on their current role in direct patient care services, an expanded role for pharmacists in providing patient care services, and changes needed to optimally use pharmacists' expertise to provide high-quality direct patient care services to people living with human immunodeficiency virus (HIV) infections.

DESIGN

Cross-sectional study.

SETTING

Four Midwestern cities in the United States in August through October 2009.

PARTICIPANTS

28 community-based pharmacists practicing in 17 pharmacies.

INTERVENTIONS

Interviews.

MAIN OUTCOME MEASURES

Opinions of participants about roles of specialty and nonspecialty pharmacists in caring for patients living with HIV infections.

RESULTS

Pharmacists noted that although challenges in our health care system characterized by inaccessible health professionals presented opportunities for a greater pharmacist role, there were missed opportunities for greater level of patient care services in many community-based nonspecialty settings. Many pharmacists in semispecialty and nonspecialty pharmacies expressed a desire for an expanded role in patient care congruent with their pharmacy education and training.

CONCLUSION

Structural-level policy changes needed to transform community-based pharmacy settings to patient-centered medical homes include recognizing pharmacists as important players in the multidisciplinary health care team, extending the health information exchange highway to include pharmacist-generated electronic therapeutic records, and realigning financial incentives. Comprehensive policy initiatives are needed to optimize the use of highly trained pharmacists in enhancing the quality of health care to an ever-growing number of Americans with chronic conditions who access care in community-based pharmacy settings.

Collaborative drug therapy management and comprehensive medication management-2015

The American College of Clinical Pharmacy (ACCP) previously published position statements on collaborative drug therapy management (CDTM) in 1997 and 2003. Since 2003, significant federal and state legislation addressing CDTM has evolved and expanded throughout the United States. CDTM is well suited to facilitate the delivery of comprehensive medication management (CMM) by clinical pharmacists. CMM, defined by ACCP as a core component of the standards of practice for clinical pharmacists, is designed to optimize medication-related outcomes in collaborative practice environments. New models of care delivery emphasize patient-centered, team-based care and increasingly link payment to the achievement of positive economic, clinical, and humanistic outcomes. Hence clinical pharmacists practicing under CDTM agreements or through other privileging processes are well positioned to provide CMM. The economic value of clinical pharmacists in team-based settings is well documented. However, patient access to CMM remains limited due to lack of payer recognition of the value of clinical pharmacists in collaborative care settings and current health care payment policy. Therefore, the clinical pharmacy discipline must continue to establish and expand its use of CDTM agreements and other collaborative privileging mechanisms to provide CMM. Continued growth in the provision of CMM by appropriately qualified clinical pharmacists in collaborative practice settings will enhance recognition of their positive impact on medication-related outcomes.

Pharmaceutical Role Expansion and Developments in Pharmacist-Physician Communication

Expanded clinical pharmacist professional roles in the team-based patient-centered medical home (PCMH) primary care environment require cooperative and collaborative relationships among pharmacists and primary care physicians (PCPs), but many PCPs have not previously worked in such a direct fashion with pharmacists. Additional roles, including formulary control, add further elements of complexity to the clinical pharmacist-PCP relationship that are not well described. Our objective was to characterize the nature of clinical pharmacist-PCP interprofessional collaboration across seven federally funded hospitals and associated primary care clinics, following pharmacist placement in primary care clinics and incorporation of expanded pharmacist roles. In-depth and semistructured interviews were conducted with 25 practicing clinical pharmacists and 17 PCPs. Qualitative thematic analysis revealed three major themes: (1) the complexities of electronic communication (particularly electronic nonformulary requests) as contributing to interprofessional tensions or misunderstandings for both groups, (2) the navigation of new roles and traditional hierarchy, with pharmacists using indirect communication to prevent PCP defensiveness to recommendations, and (3) a preference for onsite colocation for enhanced communication and professional relationships. Clinical pharmacists' indirect communication practices may hold important implications for patient safety in the context of medication use, and it is important to foster effective communication skills and an environment where all team members across hierarchies can feel comfortable speaking up to reduce error when problems are suspected. Also, the lack of institutional communication about managing drug formulary issues and related electronic nonformulary request processes was apparent in this study and merits further attention for both researchers and practitioners.

A Qualitative Assessment of the Practice Experiences of Certified Diabetes Educator Pharmacists

OBJECTIVE

To describe the practice experiences of Certified Diabetes Educator (CDE) pharmacists in Saskatchewan and determine what impact the CDE designation has had on their personal practices.

METHODS

A qualitative research approach was used. All pharmacists in Saskatchewan were e-mailed about the study, and eventually, a purposive sampling method was used to select a range of CDE pharmacists. Semistructured, in-person interviews were performed. An interview guide was developed to assess the work activities performed, the benefits of becoming a CDE and the challenges and resultant solutions that optimize their CDE designations. All interviews were transcribed verbatim and coded using deductive thematic analysis to identify the main themes that described the experiences of respondents, with the aid of QSR NVivo.

RESULTS

A total of 14 CDE pharmacists from various communities and work settings chose to participate. All of the participants indicated they were engaging in increased diabetes-related activities since becoming CDEs. All participants indicated they were happy with their decisions to become CDEs and described numerous benefits as a direct result of achieving this designation. Although some solutions were offered, participants still face challenges in optimizing their role as CDEs, such as devoting enough time to diabetes management and remuneration for providing diabetes services.

CONCLUSIONS

CDE pharmacists in Saskatchewan report performing enhanced diabetes-related activities subsequent to becoming CDEs and that obtaining this designation has had a positive impact on their personal practices. A larger, cross-country study is necessary to determine whether these results are consistent amongst all pharmacists in Canada.

Assessing student pharmacists' ability to identify drug-related problems in patients within a patient-centered medical home

OBJECTIVE

To quantify, describe, and categorize patient drug-related problems (DRPs) and recommendations identified by fourth-year (P4) student pharmacists during a live medication reconciliation activity within a patient-centered medical home (PCMH).

METHODS

Fourth-year student pharmacists conducted chart reviews, identified and documented DRPs, obtained live medication histories, and immediately provided findings and recommendations to the attending physicians. Documentation of DRPs and recommendations were analyzed retrospectively.

RESULTS

Thirty-eight students completed 99 medication reconciliation sessions from June 2011 to October 2012 during their advanced pharmacy practice experience (APPE). The students obtained 676 patient medication histories and identified or intervened on 1308 DRPs. The most common DRPs reported were incomplete medication list and diagnostic/laboratory testing needed. Physicians accepted 1,018 (approximately 78%) recommendations.

CONCLUSION

Student pharmacists successfully identified and reduced DRPs through a live medication reconciliation process within an academic-based PCMH model. Their medication history-taking skills improved and medication use was optimized.

Pharmacists as an underutilized resource for improving community-level support of breastfeeding

With their highly visible roles in the community, frequent interactions with soon-to-be and new parents, and knowledge of medication safety, pharmacists can be a key component in breastfeeding promotion and support. A review of the literature showed that pharmacists have poor knowledge but positive attitudes toward breastfeeding and that pharmacy practices are variable and mostly guided by personal experience. A review of 58 health professional organizations' English-language infant feeding/breastfeeding policy statements showed that no US pharmacists' association has a position statement, as exists for professional pharmacist organizations in Canada and Australia. We explored pharmacists' interactions with mothers before and after birth and possible opportunities to expand pharmacists' roles in the promotion and support of breastfeeding. Barriers to meeting unmet needs of breastfeeding mothers were identified in order to plan strategies for implementing programs to address these barriers. Through input obtained from pharmacy and breastfeeding experts and from information available in the published literature, good matches between unmet needs and capabilities were identified in (a) provision of health promotion resources and public awareness campaigns, (b) assistance with purchase of breastfeeding products and pumps, and (c) provision of information, support, and referral related to commonly encountered difficulties as well as medication use during lactation. Absence of adequate breastfeeding knowledge was identified as a crucial barrier. Leveraging pharmacists to address unmet preventive health needs is especially important as we strive to align resources to support healthy behaviors in our current health care delivery environment.

Potential cost avoidance of pharmacy students' patient care activities during advanced pharmacy practice experiences

OBJECTIVES

To evaluate the potential cost avoidance of student interventions documented by fourth-year (P4) student pharmacists during advanced pharmacy practice experiences (APPEs) in outpatient and inpatient settings.

METHODS

The school-wide Web-based intervention database was retrospectively analyzed to review characteristics of interventions documented during the 2011-2012 APPE cycle. Potential cost avoidance for interventions was derived from a comprehensive literature review and adjusted to 2011 dollars based on the consumer price index for medical care.

RESULTS

Eighty-seven students (71% of the graduating class) documented 5,775 interventions over 36 weeks, with an estimated potential total cost avoidance of $908,800. The intervention categories associated with the greatest cost avoidance were prevention of adverse drug events, provider education, and patient education.

CONCLUSIONS

Fourth-year student pharmacists and their preceptors had a positive impact, contributing to potential cost avoidance in both the inpatient and outpatient pharmacy settings.

Design of a trial to evaluate the impact of clinical pharmacists and community health promoters working with African-Americans and Latinos with diabetes

BACKGROUND

Given the increasing prevalence of diabetes and the lack of patients reaching recommended therapeutic goals, novel models of team-based care are emerging. These teams typically include a combination of physicians, nurses, case managers, pharmacists, and community-based peer health promoters (HPs). Recent evidence supports the role of pharmacists in diabetes management to improve glycemic control, as they offer expertise in medication management with the ability to collaboratively intensify therapy. However, few studies of pharmacy-based models of care have focused on low income, minority populations that are most in need of intervention. Alternatively, HP interventions have focused largely upon low income minority groups, addressing their unique psychosocial and environmental challenges in diabetes self-care. This study will evaluate the impact of HPs as a complement to pharmacist management in a randomized controlled trial.

METHODS/DESIGN

The primary aim of this randomized trial is to evaluate the effectiveness of clinical pharmacists and HPs on diabetes behaviors (including healthy eating, physical activity, and medication adherence), hemoglobin A1c, blood pressure, and LDL-cholesterol levels. A total of 300 minority patients with uncontrolled diabetes from the University of Illinois Medical Center ambulatory network in Chicago will be randomized to either pharmacist management alone, or pharmacist management plus HP support. After one year, the pharmacist-only group will be intensified by the addition of HP support and maintenance will be assessed by phasing out HP support from the pharmacist plus HP group (crossover design). Outcomes will be evaluated at baseline, 6, 12, and 24 months. In addition, program and healthcare utilization data will be incorporated into cost and cost-effectiveness evaluations of pharmacist management with and without HP support.

DISCUSSION

The study will evaluate an innovative, integrated approach to chronic disease management in minorities with poorly controlled diabetes. The approach is comprised of clinic-based pharmacists and community-based health promoters collaborating together. They will target patient-level factors (e.g., lack of adherence to lifestyle modification and medications) and provider-level factors (e.g., clinical inertia) that contribute to poor clinical outcomes in diabetes. Importantly, the study design and analytic approach will help determine the differential and combined impact of adherence to lifestyle changes, medication, and intensification on clinical outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01498159.