Embedding Pharmacists with Physicians

“From 1999 to 2009, we had two other practices adopt my practice model. Then in 2009, when the Patient-Centered Medical Home was introduced to the University of Michigan Medical Group and Blue Cross Blue Shield of Michigan incentivized our health system to develop this team-based care model, I used that opportunity to expand our program across all primary care sites,” Choe said. “Then BCBSM approached me and asked if I’d be interested in scaling our model outside of our health system, across the state. That came with the creation of Michigan Pharmacists Transforming Care and Quality Initiative. I was financially supported by BCBSM to work with physician organizations around the state to emulate our practice model. We now have pharmacist programs similar to ours in 21 of 42 physician organizations across the state.”

Stepping outside of academic walls and joining with other organizations on a similar mission showed Choe how great the need was for pharmacists in community physician practices and gave her a new appreciation for what pharmacists can do. She used her experience to craft the module, detailing six steps to collaborating with pharmacists, answering commonly asked as well as murkier questions surrounding integrations, providing downloadable tools and resources, as well as outlining case studies describing different approaches toward collaboration for inspiration.

The module may be geared toward physicians, but its content provides direction and support for pharmacists and colleges of pharmacy looking to integrate, too. “Faculty members who are charged with developing a clinical practice in ambulatory care so that they can provide innovative practice sites for their students during their clerkship rotations can certainly reference this module to gain insights into practical steps to take and tools to use to start the practice,” Choe said. “Students who have been trained and exposed to this type of innovative model could then go out when they graduate and replicate and scale that type of practice, so I think it’s kind of like planting the seed.”

Striving to prepare pharmacists to run a productive practice in outpatient clinical environments, Choe created what she calls a crash course mock clinic that puts pharmacists right in the hot seat, in front of simulated patient instructors, trying to reconcile what patients say versus what physicians’ notes indicate, exposing them to elements that are critical to run an efficient clinic. She hopes colleges as a whole put appropriate emphasis on ambulatory or community-based care in their curriculum and would like to see a united vision for training students to service this “burning need.”

Extending a Physician’s Reach

The Ohio Northern University HealthWise program started as a wellness clinic for employees. Under Director Dr. Michael Rush, assistant clinical professor of pharmacy practice at the ONU College of Pharmacy, HealthWise has grown to become the clinical brand for the college, expanding services to include a retail community pharmacy, medication therapy management call center, drug and health information call center and a mobile health clinic that travels to rural, underserved areas providing access to healthcare through free screenings, health education and care coordination.

But in the beginning, when HealthWise was only a wellness clinic, one physician took notice. He was pleased with the results he was seeing in his patients, who were also ONU employees going to the clinic, so he reached out to the college and asked if they could work with him a few days a week to provide care for his patients with diabetes.

That was 2010, the beginning of the college’s partnership with the family medicine practice. Rush and the collaborating physician integrated pharmacists into the practice following the process that Choe laid out in her STEPS Forward module:

Decide how the practice can benefit from including a pharmacist.

The pharmacist complements the physician practice, focusing on patient education; medication use to prevent, cure and manage disease; and improving patient outcomes. Many publications demonstrate the improved outcomes for chronic diseases when pharmacists collaborate with physicians.

Identify the roles pharmacists can have in a physician practice setting.

These include assessing patients by gathering accurate medical and medication histories; consulting with physicians to create disease management plans; educating patients about their health, disease and medications; and empowering patients to take responsibility for their own health through knowledge and support. Pharmacists bring value in managing medication therapy for patients with chronic diseases, such as high blood pressure, diabetes, and asthma or COPD. Pharmacists also monitor patient progress in between office visits to help patients meet therapy goals and adhere to treatment. Patients with chronic disease who reach treatment goals for those diseases help to improve the quality ratings of the practice and increase practice reimbursement.

Find your pharmacist or pharmacy technician match.

Physician practices that are interested in collaborative relationships with pharmacists can turn to schools or colleges of pharmacy or partner with hospitals or community pharmacies to identify clinicians. Although Choe’s model is one in which pharmacists are embedded in the medical practice, other models include physicians collaborating with pharmacists who are not located at the practice but may be at hospitals, community pharmacies or other clinical care settings in the community.

Prepare and set expectations for your team and patients.

It’s important to establish a workflow in the practice so that patients receive care from the appropriate healthcare provider without experiencing long wait times or appointment times.

Determine the resources the pharmacist needs and the impact on the physician’s workflow.

Common needs for a pharmacist incorporated into a medical practice include space for appointments with patients; access to the electronic health record and billing and scheduling systems; access to drug information resources; and private space for consultation with physicians.

Measure impact.

The practice can track health outcomes, provider and patient satisfaction with the pharmacy service and changes in health literacy. For example, in the family medicine clinic the team tracked laboratory data and found improvements for patients with diabetes in hemoglobin A1c concentrations and blood glucose concentrations. Patients also expressed that they felt more comfortable managing their condition after working with the pharmacist.

The collaboration is excellent training ground for future physicians and pharmacists. Both medical students and pharmacy students need experiential education, and learners can be integrated in the collaborative practice model to expand the work of the providers and improve patient care. In Rush’s practice, student pharmacists or pharmacy residents attend to patients with Rush providing supervision and consultation.

“I think pharmacists are going to play a greater role in providing primary care in the future,” Rush said. “The physician shortage will increase through 2030, and pharmacists are generally easily accessible and well trained to help patients understand their health risks, engage in prevention and wellness activities and serve as an interface for patients with other healthcare providers in a complementary way. Colleges of pharmacy must continue to recognize the important public health role of the profession as they train pharmacists, particularly preparing them to be entry points into the healthcare system and providing primary care with a focus on health education, disease prevention and wellness. There will come a time not too far down the road where the fee-for-service model that we’re used to seeing for billing will be less common and we’ll begin to see more of a fee-for-performance model, where the physician and other providers involved in a patient’s care are reimbursed based off of the outcomes of the patient. When that day comes, that will only re-emphasize the importance of having a pharmacist on your team.”

Community Pharmacists Making the Call

Early in her faculty career, Dr. Melissa Somma McGivney, associate dean for community partnerships and associate professor at the University of Pittsburgh School of Pharmacy, was embedded into a physician office practice. There, she saw that the physicians trusted her because she was right there with them. When she realized that they did not see community pharmacists in the same way, she became devoted to connecting pharmacists and physicians to care for patients no matter where they are.

McGivney recognizes that there are patients—high-risk, high-need, highly connected to the healthcare team—who can greatly benefit from the pharmacist working directly in the practice with the physician, but she and her colleagues have also identified patients who need the expertise of a pharmacist who are not highly connected to their healthcare team. These individuals might not have strong health insurance, so they wait until a critical moment to seek help and end up in the emergency room or hospitalized, but they are connected to a community pharmacy with an accessible pharmacist. McGivney and her team have focused on how to position that community pharmacist to be highly connected to the local physicians.

Through a series of grant-funded research projects, McGivney and her colleagues have created different tools that they are continuing to test. The main crux of their work is trying to meaningfully connect a pharmacist who is already working with a physician, though the two might not see it yet. “We’ve learned that it’s really about mutual patients, that’s an important term that we’ve begun to use. When a patient has prescriptions filled at a pharmacy, that patient has chosen that pharmacist and chosen that prescriber, so when you talk about connecting them and making things better together, that really resounds with physicians,” McGivney said. “It becomes a different conversation when you start talking about the things you already have in common. This isn’t a health plan telling the physician something has to happen, this is, ‘Your patient chose you. Your patient chose me, the pharmacist. We are both responsible for this patient, so how do we help our patient?’”

One of their research projects has exposed interesting findings regarding dispensing data (a.k.a. billing data). Through that data, a pharmacist can find out who the high prescribers are for a particular pharmacy and see what their patient population looks like based on prescription claims. “We have worked with pharmacies to create an infographic, a really simple one-pager that pharmacists can take to a physician’s office and talk to prescribers about their mutual patients,” McGivney said. “The infographic may just be a tool, but it’s an excuse to start a conversation.”

That conversation may go like this: “One of our recent graduates went to a family physician with the infographic and said, ‘OK, we have over 60 mutual patients, and over 20 of them are on an antidepressant or antianxiety agent,’” McGivney said. “The physician was surprised and said, ‘I didn’t realize this. What can we do?’ So one step the pharmacist and physician took was getting those patients on a medication synchronization program, because it’s hard sometimes when you have depression or anxiety to always remember to get your medications. Medication synchronization becomes like a support system in a sense, with the pharmacist doing an outbound call every month to check on the patients and make sure they get their prescriptions. That’s a simple example, but one that became very meaningful for that pharmacist and that physician, and we believe, those patients.”

A second research project recognizes the school’s desire to share this opportunity with other pharmacists, so McGivney and her team are developing a toolkit that will be disseminated to pharmacists across the country later this year, as part of a Community Pharmacy Foundation grant. McGivney feels schools can make a real impact by looking at high-performing, experiential learning sites and connecting those sites with faculty to figure out how the school can do research that advances the practice.

The University of Pittsburgh has also been integral in developing the Pennsylvania Pharmacists Care Network, a clinically integrated network with over 100 community pharmacies in the state providing advanced patient care services. The school serves in a leadership capacity, a quality assurance capacity and a research capacity within the group. With similar networks developing nationwide, McGivney sees abundant partnership opportunities for schools of pharmacy in the development phase, the research phase and also in an educational capacity with the pharmacies that tend to be high-performing and open to working with students.

“I deeply believe that what we as pharmacists contribute that’s so unique is our knowledge and understanding of medications and how medications impact individuals and populations, and how we can work to really make it better for people,” McGivney said. “As we continue to evolve in healthcare, we need to be part of the team, and that happens through logistics. Some of that might be the pharmacist physically positioned closer to the physician, or through technology that enables pharmacists and physicians to collaborate better, or through legal channels that take away the barriers for us to collaborate, but that need for us to be an active member of that team is clear. Patients need someone to help them navigate the complexities of medication use, so from an academic standpoint, it’s our responsibility to prepare our students to be active, clinically minded individuals no matter where they practice.”

Nimble and Creative Models of Care

The University of Colorado Skaggs School of Pharmacy has had faculty and pharmacy residents embedded in federally qualified health centers or community health clinics working alongside physicians for years. Dr. Gina Moore, assistant dean for clinical and professional affairs and associate professor, said what they’re starting to see that’s new are the Comprehensive Primary Care Plus (CPC+) funds, and that’s creating more positions for their pharmacists.

CPC+ is a national primary care medical home model that aims to strengthen primary care through payment reform and transformation in the delivery of care. Clinics working with the school have been awarded CPC+ funds and medical directors have chosen to allocate a portion of those funds for clinical pharmacy services.

“We’ve hired three new positions this year with those CPC+ dollars,” Moore said. “They’re PGY2-trained ambulatory care pharmacists. One was hired for our geriatric clinic. We already have pharmacists in the geriatric clinic but this new position focuses on transitions of care. Another hire was for a brand new internal medicine clinic that never had clinical pharmacy services before, and the other hire is a hybrid model providing clinical pharmacy services for some of our smaller clinics, the WISH Clinic, which is comprehensive care for women, as well as for a family practice.”

Moore said the geriatric clinic reached out to the school, recognizing the need for a pharmacist’s skills to help treat its patients’ complex needs. With other partnerships, the school moved slowly, integrating into a physician practice by starting an anticoagulation clinic, where the physician quickly realized the potential of pharmacists and asked the school how they could find more funding for pharmacists to help the practice with other disease states. “Integrating pharmacists has been relatively easy because the physicians have really bought into the value of the clinical pharmacists,” Moore said. “We probably get more demands than we can fill.”

The challenge is the funding, which leads to innovative thinking, such as a new project at the University of Colorado where physicians and providers in primary care can consult with specialists via the electronic health record. Clinical pharmacists are on the list of specialists, so physicians can consult with them on questions about drugs or drug regimens. “It’s great that physician practices recognize the need, so I think we have to be nimble and creative with some of the models of care,” Moore said.

Moore thinks having access to the electronic medical record may be an embedded pharmacist’s most important resource. Having a template for the pharmacist’s patient notes provides ongoing documentation in the medical record of any changes to the medication regimen. Electronic health records are also key for measuring impact.

“A lot of times you can track clinical outcomes via the electronic health record and that’s really important to understand, particularly as we move to value-based reimbursement, that your practice can document the better care that comes with a clinical pharmacist,” Moore said. “It’s better for the pharmacist and for the physician audience to understand things like, how many changes did the pharmacist really make? How important was that? Did they really identify patients, perhaps with compromised renal function that needed a dosage adjustment to their medication? Oftentimes, physicians might think, ‘I get along just fine, I’ve done this for years,’ but then when they see the changes that a pharmacist can make to really improve that patient’s medication regimen, they truly understand the impact that that pharmacist is having.”

Athena Ponushis is a freelance writer based in Ft. Lauderdale, Florida.