PCMHs: Why You Need A Pharmacist on Your Team

While it may sound obvious, much of medical care involves medication.  In fact, medication accounts for 80% of the way in which practitioners prevent and treat disease. While medications can sometimes cause adverse reactions, the benefit of medication in improving health outcomes is overwhelming. 

With increasingly complex and costly medication regimens, patients often require support and guidance. Pharmacists provide counseling to help patients understand the purpose of their medications, develop a schedule for taking medications, achieve medication adherence, and become aware of the potential for drug interactions and side effects. 

How many times have you heard patients relying on family, friends, and the media for their medical information? Pharmacists are a much more reliable option for filling this void in patient information and their presence in an office practice has been associated with higher levels of patient satisfaction.

Patient-centered medical homes (PCMHs) often include pharmacists as part of the interdisciplinary team to support both patients and providers. Physician office practices utilize pharmacists to provide comprehensive medication reviews, select optimum doses, address polypharmacy, and work directly with patients. In these collaborative models, pharmacists improve access to care and alleviate some of the demand on physicians for chronic disease management.

In North Carolina, Clinical Pharmacist Practitioners (CPPs), in a collaborative practice agreement with one or more physicians, provide medication and disease-state management, prescribe medication, and order laboratory tests. This allows pharmacists to “work at the top of their license” and contribute directly to patient care as a provider in the office practice setting (1).

Placing pharmacists in settings like this has been shown to both improve health care quality and lower costs. In one study, patients who received pharmacist-provided medication management had a 19% higher rate of ambulatory care visits and a 52% lower rate of hospitalizations than other patients in the PCMH (2). 

In another study of two pharmacists embedded in four PCMHs (3) found this approximate breakdown of the pharmacists’ time:

  • Approximately 25% of the pharmacists’ time was spent providing face-to-face services to patients

  • Another 40% of their time involved population health (writing of policies and clinical protocols), chart review, and documentation

  • Phone outreach and follow-up accounted for about 20% of the time

  • Consultation with the providers and staff accounted for 15% of the time

Drug therapy interventions were in the following areas:

  • Nonadherence (51%)

  • Adverse reactions (14%)

  • Dose too low (11%)

  • Needs additional drug therapy (7%)

  • Unnecessary drug therapy (7%)

  • Needs different drug product (6%)

  • Dose too high (5%)

Pharmacists are increasingly providing Medicare Annual Wellness Visits in combination with comprehensive medication reconciliation and reviews (4,5). They provide referrals to other providers such as physical therapists, audiologists, and nutritionists, as well as to social service agencies. They provide education related to advanced directives and home safety, they perform screening for fall risk, depression, and impaired cognition, and they provide needed immunizations, refills, and medication therapy adjustments. During annual wellness visits in 53 patients, the pharmacist identified 139 medication- related problems including suboptimal medication use, insufficient therapeutic monitoring, and under-treatment of a chronic condition. Revenues exceeded the cost of the pharmacist by 38% (5,6).

In two Veteran Administration Medical Centers, clinical video telehealth has been utilized by pharmacists to deliver anticoagulation services and diabetes management for patients at a distance from the medical center (7,8). Patients followed by the telehealth anticoagulation service had equivalent outcomes compared to the standard of care at six months. In patients with diabetes, the goal HbA1c was increased from zero at baseline to 38% at six months. Pharmacists were able to provide disease management services in primary care using telehealth, lowering healthcare costs and maintaining or improving patient outcomes. Patient satisfaction survey results were positive (> 4.5/5 point scale).

It is estimated that 40% of hospital admissions are related to medication therapy problems. Medication therapy problems are a major cause of morbidity and mortality and occur more commonly during health care transitions, often at the time of hospital discharge. If considered to be a disease, medication therapy problems would rank as the fifth leading cause of death in the United States. A recent meta-analysis of 32 studies demonstrated a 32% reduction in readmissions using pharmacy-supported interventions in care transitions compared with standard care (9).

Pharmacists provide an array of services to patients and practitioners in an office practice:

  1. Medication reconciliation and review – This works best face-to-face with prescription bottles as a separate visit or before the patient’s visit with the primary care provider. Medication related issues can be discussed with the primary care provider and adverse reactions, refills, cost issues, and therapeutic recommendations can be addressed. Pharmacists advise on polypharmacy and “deprescribing” medications that are not needed or are ineffective. Some pharmacists are performing the Medicare Annual Wellness Visits described above in conjunction with a medication reconciliation and review prior to a provider visit, thus bringing dollars into the practice.

  2. Adherence counseling – Using motivational interviewing, the pharmacist can explore reasons for poor adherence. An explanation of medication indications, discussion of potential side effects, and use of medication organizers, bubble packing, and adherence apps may help improve adherence. The community pharmacy providing adherence packaging may need an updated medication list and information to obtain prescription transfers or new prescriptions, especially during care transitions. Resolving difficulty with medication access may involve care management, financial counselors, patient assistance programs, and the community pharmacy.

  3. Chronic disease management – Common areas for pharmacist intervention include diabetes, hypertension, hyperlipidemia, anticoagulation, asthma/chronic obstructive pulmonary disease, smoking cessation, depression/anxiety, osteoporosis, and pain management. Disease state management involves patient education, assessing patient outcomes, reviewing and adjusting medications, ordering labs, and coordinating care. Multiple disease states may be addressed and multiple visits may be needed. Referrals to the pharmacist can be made through the electronic medical record or by introducing the pharmacist during the provider’s visit with the patient. This allows for a “warm handoff” and face-to-face time to schedule the follow-up appointment with the pharmacist.

  4. Collaboration with other professionals in the clinic – Besides physicians and mid-level practitioners, examples of other collaborating professionals may include dieticians, patient navigators, and behavioral health clinicians. A pharmacist-behavioral health clinician team may be useful to monitor patients with depression and other behavioral health issues.

  5. Immunizations – Pharmacists may evaluate, order, and/or administer immunizations.

  6. Providing refills – The pharmacist in a practice can be a conduit for community or hospital pharmacists who have questions about prescriptions or need refill authorization.

  7. Patient specific consultation and drug information – Examples include use of medications in patients who are pregnant or breastfeeding, adjustment of medications in impaired renal function, management of drug interactions, and more.

  8. Practice innovation and protocol development – Examples may include guideline-based therapies that may be new for a practice. Pharmacists may develop clinical protocols, such as how to select patients for transition from warfarin to direct acting oral anticoagulants.

  9. Utilization of population health data to identify high risk patients – The electronic medical record can be searched to identify patients affected by medication safety alerts or patients who may benefit from pharmacy intervention. Including the pharmacist in the practice’s quality assurance activities can help improve metrics.

  10. Practice updates on new studies and disease guidelines – Reviews can be emailed to practitioners or presented at staff meetings to update the practice on medication-related issues such as new therapeutic modalities, FDA bulletins and recalls, newly published studies, and disease guidelines.

Pharmacy is the third largest health care profession and often times, pharmacists are vastly underutilized. Pharmacists spend two to four years completing their undergraduate work, four years in a doctoral program, and may spend one or two more years in a practice-based residency program or fellowship. Pharmacists who work in office practices often attain Board Certification in pharmacotherapy or ambulatory care practice (10). It is advisable to ask about these types of credentials when bringing a pharmacist into an office practice.

Pharmacists have been proven to improve the metrics of a practice. Pharmacist provided care helps a practice comply with HEDIS and CMS star measure metrics. A report to the US Surgeon General in 2011 demonstrates a monetary return on investment ranging from 2.8-to-1 to 12-to-1 (11, 12).

The greatest limitation remains reimbursement. In most states, pharmacists are not able to charge commercial payers for office visits at a level above a nurse visit. By participating in Medicare Annual Wellness Visits, improving the efficiency of the practice, reducing hospitalizations, and improving disease-specific metrics, pharmacists can develop models that provide sufficient means for reimbursement.

“We hear clearly from physicians and other providers an enthusiastic welcome and appreciation of pharmacists in collaborative team-based care. Many are championing these practices. Another voice is that of the patient. This voice you will hear loudest and, I predict, will long remember.” – Terry Mcinnis, MD (10).

Emtiro Health’s clinical pharmacists have a wealth of knowledge and experience in integrating pharmacists into PCMHs and Patient–Centered Specialty Practices (PCSPs). Whether your need is chronic disease management, addressing medication adherence or improving metrics, our team is ready to discuss opportunities to embed a pharmacist in your practice.

References

  1. Scott MA, Hitch B, Ray L, Colvin G. Integration of the pharmacist into a patient centered medical home. J Am Pharm Assoc 2011; 51:61- 66.

  2. Romanelli RJ, Leahy A, Jukes T, Ishisaka DY. Pharmacist-led medication management program within a patient-centered medical home. Am J Health-Syst Pharm 2015; 72:453-459.

  3. Castelli G, Bacci J, Dombrowski SK, Osborne M, et al. Pharmacist-delivered comprehensive medication management within Family Medicine practices: An evaluation of the SCRIPT Project. Fam Med 2018; 50: 605-612.

  4. Warshany K, Sherrill CH, Cavanaugh J, et al. Medicare annual wellness visits conducted by a pharmacist in an internal medicine clinic. Am J Health-Syst Pharm 2014; 71:44-49.

  5. Woodall T, Landis SE, Galvin SL, et al. Provision of annual wellness visits with comprehensive medication management by a clinical pharmacist practitioner. Am J Health-Syst Pharm 2017; 74:218-223.

  6. Park I, Sutherland SE, Ray L, Wilson CG. Financial implications of pharmacist-led Medicare annual wellness visits. J Am Pharm Assoc 2014; 54:435-440.

  7. Maxwell LG, McFarland MS, Baker JW, Cassidy RF. Evaluation of the impact of a pharmacist-led telehealth clinic on diabetes-related goals of therapy in a Veteran population. Pharmacother 2016; 36:348-356.

  8. Singh LG, Accursi M, Black KK. Implementation and outcomes of a pharmacist-managed clinical video telehealth anticoagulation clinic. Am J Health-Syst Pharm 2015; 72:70-73.

  9. Rodrigues CR, Harrington AR, Murdock N, et al. Effect of pharmacy-supported transition-of care interventions on 30-day readmissions: a systematic review and meta-analysis. Ann Pharmacother 2017: 51:866-89.

  10. Capps KH (ed). Get the medications right: a nationwide snapshot of expert practices. Health2Resources; 2016.

  11. Giberson S, Yoder S, Lee MP. Improving patient and health system outcomes through advanced pharmacy practice: a report to the U.S. Surgeon General. Washington, DC: Office of the Chief Pharmacist, US Public Health Service; 2011.

  12. Watanabe JH, McInnis T, Hirsch, JD. Cost of prescription drug–related morbidity and mortality. Ann Pharmacother 2018: 52:829-37.

Brea Neri