Development and integration of pharmacist clinical services into the patient-centered medical home

doi:10.1331/JAPhA.2012.10206

Journal of the American Pharmacists Association

Volume 52, Issue 5, September–October 2012, Pages 661-667

https://doi.org/10.1331/JAPhA.2012.10206 Get rights and content

Abstract

Objectives

To describe the development of pharmacist clinical services within a primary care physician practice using a standardized business plan, the extent of clinical pharmacy service integration into the patient-centered medical home (PCMH), and the clinical changes in the pharmacist's patient cohort.

Setting

A two-physician primary care/occupational care practice in Pittsburgh, PA, from May 2007 to December 2011.

Practice description

Pharmacist-led clinic receives physician referrals for medication management, adherence, and disease management services.

Practice innovation

Pharmacist practice in a primary care setting with emphasis on integration of clinical services into the medical home model designed by the American Academy of Family Physicians.

Main outcome measures

Characterization of the patient's pharmacist and services provided by the pharmacist. Glycosylated hemoglobin (A1C), body mass index (BMI), low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, total cholesterol, triglycerides, and blood pressure.

Results

The top five primary referral reasons were diabetes self-management, weight management, medication adherence, hypertension, and dyslipidemia management. Improvements in clinical parameters were demonstrated for lipids and A1C at 1 and 2 years after baseline. Statistically significant improvements in BMI also were observed.

Conclusion

The pharmacist developed and integrated clinical services into a primary care practice, became an integral member of the clinical team in the two-physician PCMH, and improved patient outcomes.

Section snippets

Objectives

We describe one type of pharmacy practice model located in a PCMH. The concept is not new, as academic pharmacists and others have been working in primary care settings for years. However, few published references exist about pharmacist clinical services offered in a medical home. The current work describes (1) the development of pharmacist clinical services within a primary care physician practice using a standardized business plan, ⁷ (2) the extent of clinical pharmacy service integration

Practice description

A long-standing relationship between the Duquesne University Mylan School of Pharmacy (Pittsburgh, PA) and the Duquesne University Rangos School of Health Sciences physician assistant program was the connection for developing a pharmacy practice within a primary care medical practice. The medical practice consists of two physicians who are adjunct clinical professors at the Rangos School and familiar with teaching physician assistant students experientially. The practice uses one full-time

Business concept

Widespread integration of clinical pharmacy services into the outpatient care environment or medical home has not occurred, primarily because current reimbursement methods are inadequate. Nonetheless, many in the profession see the mandate for pharmacist clinical services in primary care as a necessity to improve patient outcomes through optimal medication use. In March 2009, a group of pharmacy organizations issued a document presenting seven principles for the integration of clinical services

Results

The pharmacists’ practice was implemented in May 2007. The practice has one full-time and one part-time physician seeing approximately 100 patient visits per week for a total of about 5,000 patient visits per year. The breakdown of office visits by insurance class is atypical of a primary care practice located in southwestern Pennsylvania: Blue Shield, 37.5%; commercial (Aetna, United, Health America, and UPMC), 21.3%; Medicaid, 3.0%; and Medicare, 4.7%. Our patient panel for a 0.3-FTE

Practice outcomes: Building blocks of the medical home

From our experiences in this medical home practice, clinical pharmacy services can be integrated into the four building blocks of the PCMH as described by AAFP. ¹⁵ A physician practice will achieve NCQA accreditation as a PCMH when criteria within each building block are met. The pharmacist can use the criteria in each building block to develop clinical pharmacy services within the PCMH. As more primary care practices achieve accreditation, alternate reimbursement methods from payers in both

Limitations

The clinical outcomes were characterized as modest. The major limitation of the current findings was that they involved a nonrandomized single-cohort study design of a subset of patients who chose to participate in our collaborative care model. Other limitations included missing or unreported clinical data and diminishing cohort sizes over time. Consistent follow-up with our patients was not achieved. Patients referred for weight management were the most likely to drop out. Typically, these

Conclusion

A clinical pharmacy service was implemented in a primary care practice working toward accreditation as a PCMH. The practice was established using business principles for developing services and a timeline for planning. Educating physicians regarding types of patients who benefit from pharmacy services and developing trusting relationships provided the foundation for our practice to survive 3 years and counting. A variety of clinical services were implemented using the AAFP medical home model

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There are more references available in the full text version of this article.

Cited by (33)

Utilizing diagnostic pharmacists to support Family Medicine Walk-In clinics during the COVID-19 pandemic
2022, Journal of the American Pharmacists Association
Citation Excerpt :
Pharmacists in various clinical emergency department roles have also been described.20,21 Other reports have taken a broader approach with pharmacists managing multiple chronic diseases in the primary care setting such as hypertension, hyperlipidemia, diabetes, and metabolic syndrome.22-24 There is also one published paper from 1977 describing the use of a pharmacist with diagnosing privileges.
During the coronavirus 2019 (COVID-19) pandemic, physician focus shifted from continuity of care to pandemic duties. However, patients still required in-person visits for acute or chronic complaints. Specially trained pharmacists were utilized to alleviate Family Medicine Walk-In (FMWI) provider shortages.
To describe the innovative practice utilizing diagnostic pharmacists in FMWI, evaluate their impact on provider time, compare workload with traditional advanced practice providers (APPs), and evaluate type of visits and medications prescribed.
Pharmacists at an Indian Health Service medical center staffed FMWI 2.5 days per week to alleviate provider shortages during the COVID-19 pandemic. The privileged pharmacist had a diagnostic scope like APPs. Non-privileged pharmacists provided care to patients utilizing current protocols and were required to present all new complaints to providers.
The facility utilized pharmacists that have completed or were progressing through the local diagnostic training program to alleviate provider shortages.
The absolute number of visits by pharmacists was determined and the number of provider hours shifted to pharmacy estimated. The number of visits by provider type was calculated and compared. ICD-10 codes were evaluated for purpose of visits. New prescriptions written by pharmacists were categorized and reimbursement rates determined.
Pharmacists were responsible for 677 visits during 88 clinic days, with an estimated 338 provider hours shifted to pharmacists. Pharmacists saw 5.8 patients per day, APPs 5.2, and physicians 5.7. Pharmacists primarily evaluated hypertension, diabetes, musculoskeletal, and infectious disease complaints. New prescription categories included pain management, endocrine, cardiovascular, and infectious disease. The single billable pharmacist was reimbursed $77,945.
Diagnostic pharmacists in FMWI have allowed providers to shift to other pandemic duties and demonstrate similar workload as APPs. Most visits and prescriptions fall within known pharmacist practice. Pharmacists in this setting pay for the existence of this position and remain integrated in FMWI.
Access to clinical pharmacy services in a pharmacist-physician covisit model
2021, Research in Social and Administrative Pharmacy
Citation Excerpt :
Medication management services provided by pharmacists have demonstrated positive clinical impact in a variety of settings,1–6 including primary care.7,8
A pharmacist-physician covisit model in which patients see both a pharmacist and physician on the same day was established in a primary care practice. Previously, patients were seen in a referrals-based model in which providers referred patients for clinical pharmacy services on a different day.
To assess access to clinical pharmacy services in a pharmacist-physician covisit model compared to a referrals-based model.
A retrospective chart review was completed for patients who were seen by physicians on pre-specified half-days of clinic before and after implementation of the covisit model. Covisit model half-days between June 29, 2018 and September 30, 2018 and matched half-days from 2015 were included. Charts were reviewed to determine if patients scheduled to see the physician would benefit from clinical pharmacy services, including being seen for chronic disease management, eligible for a Medicare Annual Wellness Visit (AWV), prescribed medications that required counseling, had an adverse medication-related event, or had adherence concerns. Those eligible for clinical pharmacy services were further reviewed to determine if the patient interacted with a pharmacist within three months of their visit.
Prior to implementation of the covisit model, 123 patient visits were completed on the pre-specified half-days. Of these, 61 patients (49.6%) were deemed eligible for clinical pharmacy services. In the covisit model, 149 patients were seen by the physician, of which 69 patients (46%) were eligible for clinical pharmacy services. More patients in the covisit cohort went on to interact with a pharmacist (56 patients, 81% vs. 10 patients, 16%, adjusted OR = 32.98, 95% CI [8.89–122.39]). The most common reasons patients were identified for clinical pharmacy services were eligibility for AWV, hypertension, and diabetes.
A pharmacist-physician covisit model significantly increased accessibility to clinical pharmacy services compared to a referrals-based model.
Family physician perceptions of barriers and enablers to integrating a co-located clinical pharmacist in a medical clinic: A qualitative study
2020, Journal of the American Pharmacists Association
Citation Excerpt :
Despite externally funded pharmacists, physicians cite the opportunity cost of losing a consult room to the pharmacist as a potential barrier. Integrating clinical pharmacists into a patient’s primary health care team improves medication safety and patient outcomes.1-6 Clinical pharmacists provide patient care that optimizes medication therapy and promotes health, wellness, and disease prevention, which can decrease drug costs, hospital admissions, and specialist visits when they are integrated into the primary health care team.7,8
Pharmacists from The University of British Columbia Pharmacists Clinic provide comprehensive medication management services once to twice a month through the co-location model at multiple general practice clinics beginning from 2014 and consistently since 2016. For some of the clinics, this was the first experience with a co-located allied health professional. The objective of this study was to examine the perspectives of physicians who had a relatively long-standing relationship with a co-located pharmacist to identify barriers and facilitators to integrating a clinical pharmacist.
A qualitative research methodology was used to gain the perspectives of physicians. Data were collected through convenience sampling and one-on-one semistructured interviews. In-person or telephone interviews were conducted from August 12, 2019, to September 10, 2019, and audio was recorded with the participants’ consent. The recorded interviews were transcribed, and a thematic analysis with an inductive approach was used to analyze the data.
Eight physicians from 4 general practice clinics were interviewed. Analysis of the interviews identified 6 themes that contained barriers or enablers to the integration of a co-located pharmacist: (1) electronic medical record (EMR) use, (2) identifying patients and the referral process, (3) workload and logistics, (4) patients’ willingness, (5) impact of in-person communication, and (6) shifting physicians’ perspectives. The enablers included the use of an EMR to proactively identify patient referrals, a dedicated pharmacist workspace, a physician champion, and intentional scheduling of in-person physician-pharmacist case conferences. The barriers included identifying patients for referral, the lack of EMR interoperability, pharmacist availability, physician colleagues who were less committed to team-based care, and financial implications despite externally funded pharmacists.
The physician participants perceived several barriers and enablers to the integration of a pharmacist into their practice. The themes identified can be used to inform physicians and pharmacists on the integration process for team-based primary care.
The degree of integration of non-dispensing pharmacists in primary care practice and the impact on health outcomes: A systematic review
2018, Research in Social and Administrative Pharmacy
A non-dispensing pharmacist conducts clinical pharmacy services aimed at optimizing patients individual pharmacotherapy. Embedding a non-dispensing pharmacist in primary care practice enables collaboration, probably enhancing patient care. The degree of integration of non-dispensing pharmacists into multidisciplinary health care teams varies strongly between settings. The degree of integration may be a determinant for its success.
This study investigates how the degree of integration of a non-dispensing pharmacist impacts medication related health outcomes in primary care.
In this literature review we searched two electronic databases and the reference list of published literature reviews for studies about clinical pharmacy services performed by non-dispensing pharmacists physically co-located in primary care practice. We assessed the degree of integration via key dimensions of integration based on the conceptual framework of Walshe and Smith. We included English language studies of any design that had a control group or baseline comparison published from 1966 to June 2016. Descriptive statistics were used to correlate the degree of integration to health outcomes. The analysis was stratified for disease-specific and patient-centered clinical pharmacy services.
Eighty-nine health outcomes in 60 comparative studies contributed to the analysis. The accumulated evidence from these studies shows no impact of the degree of integration of non-dispensing pharmacists on health outcomes. For disease specific clinical pharmacy services the percentage of improved health outcomes for none, partial and fully integrated NDPs is respectively 75%, 63% and 59%. For patient-centered clinical pharmacy services the percentage of improved health outcomes for none, partial and fully integrated NDPs is respectively 55%, 57% and 70%.
Full integration adds value to patient-centered clinical pharmacy services, but not to disease-specific clinical pharmacy services. To obtain maximum benefits of clinical pharmacy services for patients with multiple medications and comorbidities, full integration of non-dispensing pharmacists should be promoted.
Integration of pharmacists into patient-centered medical homes in federally qualified health centers in Texas
2017, Journal of the American Pharmacists Association
Citation Excerpt :
CommUnityCare PCMHs use the “co-visit model,” where recommendations and modifications are shared with the referring provider on the same day as the patient’s physician visit. This model has also been used by other PCMHs, although the consultation may be provided by a pharmacist or nurse practitioner in some practices.23,24 The main difference between the PCMH and UC clinics in the present study is the availability of co-visits in the PCMH clinics as opposed to only pharmacist-only visits in the UC clinic.
To describe the integration and implementation of pharmacy services in patient-centered medical homes (PCMHs) as adopted by federally qualified health centers (FQHCs) and compare them with usual care (UC).
Four FQHCs (3 PCMHs, 1 UC) in Austin, TX, that provide care to the underserved populations.
Pharmacists have worked under a collaborative practice agreement with internal medicine physicians since 2005. All 4 FQHCs have pharmacists as an integral part of the health care team. Pharmacists have prescriptive authority to initiate and adjust diabetes medications.
The PCMH FQHCs instituted co-visits, where patients see both the physician and the pharmacist on the same day. PCMH pharmacists are routinely proactive in collaborating with physicians regarding medication management, compared with UC in which pharmacists see patients only when referred by a physician.
Four face-to-face, one-on-one semistructured interviews were conducted with pharmacists working in 3 PCMH FQHCs and 1 UC FQHC to compare the implementation of PCMH with emphasis on 1) structure and workflow, 2) pharmacists’ roles, and 3) benefits and challenges.
On co-visit days, the pharmacist may see the patient before or after physician consultation. Pharmacists in 2 of the PCMH facilities proactively screen to identify diabetes patients who may benefit from pharmacist services, although the UC clinic pharmacists see only referred patients. Strengths of the co-visit model include more collaboration with physicians and more patient convenience. Payment that recognizes the value of PCMH is one PCMH principle that is not fully implemented.
PCMH pharmacists in FQHCs were integrated into the workflow to address specific patient needs. Specifically, full-time in-house pharmacists, flexible referral criteria, proactive screening, well defined collaborative practice agreement, and open scheduling were successful strategies for the underserved populations in this study. However, reimbursement plans and provider status for pharmacists should be established to sustain this model of care.
Perceptions of pharmacists' integration into patient-centered medical home teams
2015, Research in Social and Administrative Pharmacy
Citation Excerpt :
Proposed expansion of pharmacists' roles on PCMH teams have included providing medication therapy management, medication reconciliation, designing adherence programs, recommending cost-effective therapies, and tracking patient and population level outcomes.6,7 Several pharmacists have engaged in the work of integrating into existing or helping form new PCMHs.8–19 While these many experiences have highlighted the abilities of pharmacists to engage in PCMH, only one has rigorously explored factors enabling pharmacists' integration.8
Patient-centered medical homes (PCMHs) are a newer paradigm of health care service delivery. Team-based care that includes pharmacists has been implemented in several countries. Subsequently studies have successfully identified challenges and barriers with team-based care. Research on pharmacists' integration into PCMH is warranted to help bridge knowledge from earlier studies exploring team-based care. In 2010, the Department of Veteran Affairs (VA) began a national PCMH implementation, operationalized as “Patient-Aligned Care Teams” (PACTs). The VA's national PACT implementation presents an opportunity to describe other persistent barriers to effective coordination between primary care and pharmacy providers.
To identify perceived barriers and facilitators to pharmacist integration into VA PACTs from the perspective of non-pharmacist team members.
Semi-structured interviews were conducted as part of a formative evaluation of PCMH implementation. Participants were from VA medical centers and community-based outpatient clinics in the Midwestern United States and included physicians, nurses, associated health care professionals, and health system administrators.
In working toward pharmacy service integration, role clarity and work activities were influenced by team member attitudes toward and previous experiences with pharmacists. Interviewees reported that coordination with pharmacists was hindered if communication placed extra burdens on other team members. Interviewees reported collaboration was easier when pharmacists were onsite, but that technology helped facilitate off-site access to pharmacy services. Finally, some team members characterized pharmacist integration as essential while others failed to integrate pharmacists at all.
Non-pharmacist members of PACT teams reported some reluctance in pharmacists' integration. They attributed this reluctance to knowledge deficits, limited participation in PACT training by pharmacists, an imbalance in effort expended for pharmacists' integration, and coordination or communication challenges. While there may be unique opportunities for pharmacists to improve patient care through participation in PCMHs, work remains to improve other health professionals' knowledge of and attitudes toward pharmacists' roles on health care teams.

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: Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria.

: Funding: The Duquesne University Mylan School of Pharmacy supported the development of the pharmacist practice with internal funding.

: Previous presentations: American College of Clinical Pharmacy Spring Practice and Research Forum, April 5–9, 2008, Phoenix, AZ, and American College of Clinical Pharmacy 2008 Annual Meeting, October 19–22, 2008, Louisville, KY.

View full text

ExperienceDevelopment and integration of pharmacist clinical services into the patient-centered medical home

Abstract

Objectives

Setting

Practice description

Practice innovation

Main outcome measures

Results

Conclusion

Section snippets

Objectives

Practice description

Business concept

Results

Practice outcomes: Building blocks of the medical home

Limitations

Conclusion

J Am Pharm Assoc

J Am Pharm Assoc

What we do: the patient-centered medical home

Role of pharmacists in the medical home

Am J Health Syst Pharm

Why pharmacists belong in the medical home

Health Aff (Millwood)

NCQA patient-centered medical home: a new model of care delivery

Patient-centered medical home

Preventing medication errors: quality chasm series

Planning in pharmacy organizations

Experience
Development and integration of pharmacist clinical services into the patient-centered medical home