Kathleen Gannon Longo is a Contributing Editor.

Kathleen Gannon Longo

At the Shoshone Pharmacy in Shoshone, ID, a patient arrives to pick up his prescription. The technician asks him to wait, explaining that the pharmacist would like to discuss potential drug interactions with him. The patient is ushered into a private room where he sits across from a 20 inch video screen. Before long, the pharmacist, who is at another pharmacy, appears on the screen, and the discussion commences.

Telepharmacy scenarios, like that take place regularly at Shoshone Pharmacy, and are becoming more common at chain, retail, and health-system pharmacies nationwide.

Currently, 23 states allow telepharmacy, though requirements vary, according to the National Association of Boards of Pharmacy. Several other states have telepharmacy pilot programs in place.

“Telepharmacy can help bring back pharmacy services to areas that are underserved, such as rural areas,” says Lisa Schwartz, PharmD, senior director, professional affairs, NCPA.

In fact, the first state laws surrounding telepharmacy started with a pilot program in North Dakota in 2001. The program brought pharmacy services to 80,000 citizens in medically underserved, remote, and rural communities. Following the success of the pilot program, the North Dakota Board of Pharmacy established permanent rules in 2003 that allowed telepharmacy to be practiced on a broader scale.

In Idaho, the Shoshone pharmacy operates as a satellite pharmacy to R&R Pharmacy in Jerome, ID, about 18 miles away. Shoshone serves a community of 1,500 people who were previously without pharmacy services. While a community of only 1,500 wouldn’t justify a fully-staffed pharmacy, the staffing by technicians, along with the videoconferencing, ensures that those in the community are not deprived of pharmacy care.
	How it Works
	The pharmacy is set up like a regular pharmacy, but is staffed by technicians, explains Jason Reading, PharmD, owner of the two pharmacies. Prescription orders are transmitted to the pharmacist at the main pharmacy for verification. “We have a good system of checks and balances in place,” says Reading. “Setting up a remote pharmacy makes sense from a business standpoint, from a pharmacy professional standpoint, and from a patient care standpoint.”

From a business standpoint, a satellite location can bring a pharmacy up to capacity in terms of filling prescriptions. “If a pharmacy has the capacity to fill 300 scripts a day, but is only filling 200 based on patient volume, why not get paid for the additional 100 scripts?” he says. From a professional standpoint, a pharmacy staffed by technicians frees the pharmacist to perform clinical interventions.

In addition to Shoshone Pharmacy, Reading recently opened a small satellite pharmacy at North Canyon Medical Center in Gooding, ID, about 26 miles from Jerome. It operates mainly as a discharge pharmacy, but provides other services to the community, such as immunizations. As a further reach toward the provision of patient care, Reading recently placed a pharmacist on site at a local medical clinic with physicians, which would not have been possible had the remote pharmacies not been staffed by technicians.
	In the Chains
	In chain pharmacies, CVS Health has innovated by allowing patients to consult with a healthcare provider via a mobile device through the CVS App. The MinuteClinic Video Visits are geared to patients ages two and older who use the app seeking treatment and advice for a minor illness, minor injury, or a skin condition, according to the company.

After completing a health questionnaire through the app, patients are matched to a board-certified community-based healthcare provider in their state, who reviews the questionnaire and proceeds with the video-enabled visit via the patient’s smartphone. When relevant, the physicians call prescriptions into the patient’s pharmacy or refer patients to providers in their community. The program, which has been in place since August, has recently expanded.
	Hospital Telepharmacy
	Videoconferencing can be a powerful tool in a discharge setting, says Brian Roberts, CEO of PipelineRx, a San Francisco-based provider of cloud-based telepharmacy services, primarily in the hospital setting. In addition to allowing pharmacists to consult with patients, videoconferences may take place between nurses and pharmacists, and physicians and pharmacists. Videconferencing may also be arranged with pharmacists once a patient is home, helping to ensure continuity of care, he says.

“While some health system pharmacists may find outsourcing to be threatening, it is empowering,” Roberts says. Rather than eliminate pharmacists, pharmacists are deployed to other areas of the hospital. “Pharmacists are able to work at the top of their game,” he says.

In the inpatient setting, telepharmacy usually involves order entry from a remote site, generally during the hours when the regular pharmacists aren’t on duty. Delta County Memorial Hospital, in Delta, CO, a 50-bed rural hospital, has 24/7 pharmacy coverage since pharmacists from PipelineRx process orders overnight. “We’re able to offer outstanding seamless care when the pharmacy staff is not able to be physically present,” says Philip Neary, PharmD, a clinical pharmacist at the facility.

The remote pharmacists also perform services such as pharmacokinetics, renal assessments, therapeutic interchanges, and IV to oral changes. The overnight pharmacists also check for duplication of therapies, do medication reconciliations, check for patient allergies, and evaluate laboratory results. The PipelineRx platform allows the hospital to collect data, perform clinical interventions, and track cost-savings, says Neary. “These are all activities we might not have been able to justify at a smaller facility.”
	In a similar scenario, at Memorial Hospital of Salem County in Salem, NJ, telepharmacists take over when the inpatient pharmacy closes at 10:30 pm., says Jon Margolin, MS, director of pharmacy at the facility. In addition, the telepharmacists answer questions from nurses and other practitioners. “Basically, the remote pharmacists mimic what we do during the day,” says Margolin. “The screening they do allows us to catch more errors in real time. This is huge.”

Margolin hopes telepharmacy will allow the hospital’s pharmacists to expand the services they provide. “It is our goal for pharmacists to be more involved in inpatient counseling, discharge counseling, and be able to go on rounds and respond to hospital emergency codes with other members of the healthcare team,” he says. 
	Pushing Back on Telepharmacy
	Convincing directors of pharmacy in hospital settings to use telepharmacy can be a challenge, says Roberts. “They tend to have more of an entrepreneurial approach. They want the pharmacy to grow bigger with the hiring of more staff, but bigger is not necessarily better.”

There is resistance in the retail setting, as well, says Reading. “There are those who say we’re killing the profession by staffing the pharmacies with technicians, but the concept lets pharmacists expand their capabilities,” he says.

Patient resistance can also be a barrier to telepharmacy. While patients don’t seem to mind talking to pharmacists via a video screen, they do sometimes get upset if they must wait, Reading says. “They don’t see the inside of the pharmacy where the pharmacist is; they just see the video screen so it’s easy to assume the pharmacist is sitting there with his feet up,” he explains. “The technicians need to be careful how they talk to the patient when they bring them into the video room.”

Reimbursement for telepharmacy services, and lack of it in many cases, is another barrier. Currently, many of the telehealth payment models involving pharmacists have been implanted in managed care organizations such as Kaiser Permanente.

As the private sector shifts away from fee-for-service in favor of value-based care, there is likely to be increased interest from insurance payers to explore telehealth models, according to the study, “Pharmacists providing care in the outpatient setting through telemedicine models: a narrative review,” published in Pharmacy Practice in 2017.

Legislation is another impediment to telepharmacy. “Since the telepharmacy concept is still in its early growth stages, in many cases, the legislation is not keeping up with the technology,” says Neary.

Roberts agrees. “Our pharmacists are licensed in multiple states and work across multiple sites,” he says. “We need to comply with individual state regulations, some of which are more stringent.” Some states, for example, require that a call center be set up; others require that prescriptions be saved for seven years.  

On the health system side, telepharmacy is still an underpenetrated market, so has plenty of room to grow, says Roberts. Currently, it is in about 20% of U.S. hospitals, he says.

Down the road, he sees the technologies expanding to nursing homes, psychiatric facilities surgery centers, and hospital outpatient pharmacies. The technology will also be used more across the individual hospitals in a system. “Orders may be shared across a hospital with a blend of services and technology,” Roberts says. “Telepharmacy is here to stay.” 

Kathleen Gannon Longo is a contributing editor.

Articles

Adoption of video conferencing technologies improve dispersal and communication to patients and healthcare professionals alike.

Telepharmacy Business Model Allows Satellite Operation and Increased Patient Convenience

Work hours can be long for pharmacists working in a retail or hospital setting. As an employee, a pharmacist may feel that he or she is stuck with whatever hours or shifts that management gives them. But it doesn’t need to be that way.

Pharmacists need to realize that they hold the power when negotiating for better hours, says Alex Barker, PharmD, founder of 

, which provides motivational career counseling to pharmacists in all practice settings. “The more indispensable you are, the more likely you are to have a major bargaining chip when negotiating,” says Barker.

Related article: The Drug Topics 2017 Pharmacist Salary Survey

Whether a pharmacist is looking to reduce long days and overtime, or to realign their current hours to meet personal needs, they must justify their request by providing information that will demonstrate how the requested revision will benefit the organization, he says.  “Simply going to a manager or director and asking for a change in hours is a poor approach.”

Take for example, a pharmacist who works five days a week, and on three of those days he spends an extra two hours earning overtime, says Barker. That pharmacist can ask to officially be assigned those extra working hours on those three days, and in return, eliminate one day from his workweek.

One argument should be: The pharmacist would be saving the retail store-or hospital-a significant amount of money by absorbing those extra hours at the overtime rate into their regular pay scale.

Another argument that can be made: “In some cases, the extra hours could be a justification for letting a store or a clinic remain open later in the evening,” says Barker.

Barker describes a pharmacy client who wanted to work more days, but fewer hours each day. “She positioned the negotiation in such a way that if she worked more days, she could provide coverage during the busy hours of the store.” In the end, she didn’t get the exact arrangement she wanted, but it was close enough to satisfy both parties, he says.

Beyond the benefits of reduced overtime pay or better hours, pharmacists should look for a correlation between patient safety and the requested work schedule, as that is always an issue that weighs on managers’ minds, Barker says.

For example, the pharmacist in the previous scenario could have argued that having more pharmacists on hand during busy hours would reduce the likelihood of dispensing errors.

Anna Legreid Dopp, PharmD, director of clinical guidelines and quality improvement at 

, agrees that pointing to patient safety and patient care is important when discussing work hours. She suggests providing data that validates the positive effects on patient care and patient safety that such a change would provide.

But, where pharmacy hours are concerned, she noted that some pharmacists thrive on the extra hours and aren’t necessarily looking for a reduction.

Barker notes that unions representing pharmacists can be a resource for pharmacists in negotiating hours. In dealing through a union, pharmacists should remember that unions generally want things to be fair, so if you’re part of a large organization, look around and see what other pharmacists may have that you don’t. “For example, how are other hospitals handling pharmacists’ schedules?” he offers.

But it’s important to consider that “every union rep is going to be different and some may fight harder than others,” Barker added.

Related article: The 25 Cities with the Highest Pharmacist Salaries

Safety is an issue among the 700 pharmacy staff members represented by Illinois-based 

. The membership includes retail pharmacists, chain pharmacists, students, interns, and graduate students.

“A chain pharmacist may be forced to work at least one 12-hour shift a week, and pharmacists find it difficult, if not impossible, with their current work flow to take a break,” says a spokesperson for the union, noting that this raises safety concerns.

"In any bargaining situation, having members stand strong and demand a change is important,” says the spokesperson. Beyond that, “Legislative intervention would even the playing field by requiring all retailers to do the same thing and impose penalties [for noncompliance].”

, which represents healthcare workers in Florida, New Jersey, New York, Massachusetts, and Washington, DC, representative Lauren Vallone is involved in collective bargaining negotiations with the more than 2,000 hospital and retail pharmacists represented in the union. Vallone agrees with Barker in that negotiating may often involve reducing a workweek or, in some cases, adding days to a workweek.

“It can be an issue of age,” Vallone says. Longer 12-hour days may be more difficult for the older worker, whereas a younger member of the pharmacy workforce may find such a schedule to be good.

Vallone has found that in most of the collective bargaining sessions in which she has participated, “the members get what they need.” In addition to negotiating hours, the union has negotiated issues such as how many flu shots a pharmacist can administer and still be expected to safely fill the required number of prescriptions.

ASHP has recently made a commitment to supporting the well-being of the pharmacy workforce and reducing burnout, which can stem from working long hours.

The organization is leading the pharmacy effort associated with the National Academy of Medicine’s 

Action Collaborative on Clinician Well-Being and Resilience

, which addresses the serious consequences of burnout among healthcare providers.

“We feel it can benefit both pharmacists and patients and can help pharmacists to feel their best and do their best,” says Aretha Hankinson, director of advocacy communications at ASHP.

Related article: Balancing Act: Dealing with Stress in the Pharmacy

For hospital pharmacists, stress and burnout on the job can be caused by internal and external factors, says Christina Martin, PharmD, MS, director of membership forums at ASHP. External factors can include personal elements such as family issues or personal financial situations. Internal factors can include long hours leading to stress, onerous rules and regulations, increased oversight, inspections, audits, high employee turnover, and drug shortages.

 “The goal of the initiative is to raise awareness of these issues, provide the education, and get the discussion going on the organizational level,” says Dopp.

Overall, pharmacists should never be afraid to ask for different work hours, says Barker. “The worst thing that could happen is a manager will say “No’. There is little or no consequence that comes from asking, and if you’re rejected, it doesn’t mean you’ll be rejected the next time.”  

What does and doesn’t work for pharmacists trying to improve their working conditions.

Negotiating Better Hours: A Guide for Pharmacists

As the summer winds down, pharmacists need to gear up for students returning to school in September. Ensuring that children have the right medications for attention deficit hyperactivity disorder (ADHD) is a top priority.

More than 5 million children have an ADHD diagnosis, according to the 2016 National Survey of Children’s Health, a parent-focused 

 conducted by the U.S. Census Bureau on behalf of HHS. Included in the total are 2.2 million children aged 6 to 11 and 2.9 million adolescents aged 12 to 17. Two out of three of children who are diagnosed take a medication (62%), and nearly one out of three receive a combination of medication and behavioral treatment (32%).

Many families don’t notice ADHD symptoms as much in the summer, when children are very active, and they 

 on medications, says Jake Olson, PharmD, owner of Skywalk Children’s Pharmacy in Milwaukee. This shifts as parents “restart their child’s therapies as the child heads back to school.”

Agreeing with Olson, Jim Cox, director of pharmacy at 

., a 38-store regional grocery/pharmacy chain in Minnesota, says ADHD is the primary area in which those pharmacies see an increase in prescriptions as students return to school. ADHD becomes more evident as summer sports and activities wind down, he says. “In many cases, we’ll dispense more than one bottle, one for the child to have with him in school and one to keep at home,” he said.

 in Vernon, TX, says she sometimes needs to order extra supplies of drug products for ADHD as the demand increases in September.

Common prescription drugs for the treatment of ADHD, according to Christopher Nadeau, PharmD, a fourth-generation pharmacist at 

 in Lewiston, ME, are a combination of stimulant drugs, which are also Schedule II drugs, and nonstimulant drugs (See Fig. 1). These drugs can be supplemented with over-the-counter items.

In addition to prescription drugs, Olson says Skywalk recommends nutritional 

 for ADHD. Since ADHD therapies can have the side effect of a reduced appetite, the pharmacists may recommend an appetite stimulant, he says. Additionally, melatonin may be recommended to help with sleep problems, another side effect.

In Maine, Nadeau has a different approach. “I generally don’t recommend OTC products as much as I do lifestyle changes,” says Nadeau. “I usually suggest that the patient gets ample time for physical activity and develops good sleep habits. This has helped a few of my patients lower their dose, or get off the medication altogether.”

Related article: Acetaminophen Use in Pregnancy Linked to ADHD

Bayer says Hillcrest Pharmacy doesn’t dispense many OTC products for ADHD. It is generally more cost-effective for parents to request a prescription drug, which can be covered by insurance, she says.

Nadeau says that, from what he has seen in his pharmacy, providers may be seeking alternative treatments before writing a prescription for an ADHD drug; he has seen an overall decrease in the number of prescriptions written. “Many ADHD medications are Schedule II narcotics, which have been scrutinized extensively over the last few years,” he says. He also points out that there are now more resources for families, such as counseling.

The pharmacist can serve as a catalyst in ensuring that a child is properly diagnosed with ADHD. Cox says parents may reach out to pharmacists based on symptoms they’ve seen in their child. Pharmacists can then encourage parents to take their children to a physician for diagnosis. Olson notes that a child’s teacher may often be involved in helping to secure a diagnosis as well.

Nadeau says that he refers students and families to resources in the community, when applicable.

How pharmacists can help students get the treatments they need.

What You Need to Know About ADHD Medications

The pharmacist’s role is expanding as the healthcare arena moves from fee-for-service to value-based payments.

“Physicians are warming to the idea of working alongside pharmacists in their practice settings. In fact, not only are they warming to it, many physicians are carving out a pharmaceutical piece of part of their risk-sharing agreements,” says Susan Cantrell, RPh, CEO of the Academy of Managed Care Pharmacy (

Medicare accountable care organizations (ACOS) do not directly include pharmacists and medications, but appropriate medication management is necessary to ensure success of value-based arrangement, Cantrell explains. “Therefore, we are seeing a trend where physicians are trying to integrate pharmacists and medication management to achieve good outcomes,” she says.

Related article: How to Manage Medication Risks

Medication therapy management (MTM) is one of the biggest areas in which physicians increasingly rely on pharmacists, says Lucinda Maine, PhD, RPh, executive vice president and CEO of the American Association of Colleges of Pharmacy (

). “As physicians need to meet expectations around quality-based metrics, they are finding they can move those quality needles when a pharmacist provides MTM.”

In some cases, pharmacists embedded in practices or hospital pharmacists are meeting with patients prior to physician visits and conducting thorough medication reviews and assessments. “This relieves the physician of doing that part of the care plan,” she says. “Once physicians sees the value of the pharmacist, they don’t want to practice any other way.”

Community pharmacists are also experiencing role changes, as they too are providing medication management across the continuum of care. Some community pharmacists are partnering with nearby hospitals to more thoroughly counsel patients regarding medication and adherence. The expanding role of pharmacy technicians and robotics should also liberate these pharmacists to take on more of these tasks, says Maine.    

Here's more on how the role of pharmacists is changing in various practice settings.

Community pharmacy is the biggest area in which pharmacists can be better used because they have such frequent interactions with patients, says Marilyn Stebbins, PharmD, vice chair for clinical innovation, University of Southern California San Francisco (UCSF) School of Pharmacy. “Most people visit a retail pharmacy more than 20 times a year; this is where the pharmacist’s impact is the greatest,” she says.

Pharmacists are offering vaccinations, blood pressure screenings, and counseling on specific disease states such as diabetes. “In the retail setting, MTM, and not dispensing, should be the priority,” says Stebbins. “In this way, pharmacists can help improve outcomes and show their value.”

Related article: How Pharmacists Can Team Up with Physicians to Improve Care

Community pharmacists are also experiencing a growing role as hospitals look to them as a resource to improve adherence and reduce readmissions, a key metric in many value-based payment arrangements. One example is the “Meds to Beds” program at UCSF. Pharmacists from two retail pharmacies on the hospital campus meet with patients before they leave the hospital. The pharmacists explain their discharge medications and then follow up with patients to ensure they are compliant. The program has had good results, says Stebbins.

In both the retail and the hospital setting, specialty pharmacy is another model in which pharmacists are expanding their skills. Specialty pharmacies focus on high-risk patients who need intensive monitoring and intervention, explains Gary Matzke, PharmD, professor, Virginia Commonwealth University School of Pharmacy. Walgreens, for example, has pharmacies dedicated to oncology and HIV, where pharmacists perform extensive medication reviews and work closely with the patient to ensure compliance. The specialty pharmacy “contracts with pharmaceutical companies to ensure the providence of product care,” Matzke adds.

 reports that 3,257 pharmacists are currently certified as ambulatory care specialists. The specialty ranks third in numbers, behind geriatric pharmacy (4,432) and pharmacotherapy (21,771).

Related article: It's Time for Pharmacists to Carve Out a New Role

Ambulatory care encompasses pharmacy practice in clinical settings that could include ambulatory care clinics, physicians’ offices, retail pharmacies, and pharmacies affiliated with long-term care facilities, says Ernest Wright, senior manager of operations-BPS. In long-term care, pharmacists may also be certified through BPS as Geriatric Pharmacy Specialists.

“When the ambulatory care specialty certification was first offered in 2011, it went through a season of growth and resulted in many pharmacists being rapidly certified,” says Wright. Today, growth is still “pretty steady.”

Pharmacists are also finding new roles in hospitals and physician practices as these organizations take on value-based models such as 

). PCMHs are models of care that put patients at the forefront and build relationships between patients and their healthcare team. The end goal is to optimize outcomes as payers look to reward value.

), for example, the Pharmacy Department and the Department of Family Medicine, developed prototype PCMH models within two already-established primary care offices. Pharmacists at both sites, Care Point Gahanna and Care Point Lewis Center, work in the physicians’ offices as members of the healthcare team. “The pharmacists have separate appointments with the patients where they obtain medication history, conduct patient interviews, make medication adjustments, order labs, if necessary,” says Bella Mehta, PharmD, professor of clinical pharmacy and family medicine at OSU.

“While the original prototypes didn’t set out to measure long-term clinical outcomes, both sites found the pharmacists valuable and went on to hire full-time pharmacists,” says Mehta. “This is the highest compliment you can get.” 

Related article: Automation Drives New Role for Hospital Pharmacists

, a seven-hospital health system, brought together hospital pharmacists, clinical pharmacists, community pharmacists, and physicians. The project, Improving Health of At-Risk Rural Patients, sought to “improve the clinical status of the patients as well as reduce health service utilization, such as hospitalizations and emergency room visits,” explains Matzke.

A grant from the CMS Center for Medicare and Medication Innovation supports the placement of pharmacists in clinics on the hospital campus. The project was a collaboration between Carillon and Virginia Commonwealth University.

The pharmacists working in the clinics identified high-risk patients at hospital discharge, and from that point, coordinated among the clinic, the patient’s primary care physician, and the community pharmacist. High-risk patients were those with multiple disease states who were taking four or more long-term medications.

Related article: Telepharmacy: New Jobs, Expanded Opportunities

“We saw significant improvement in all clinical and utilization end points,” says Matzke. In looking at end points, blood pressure improved in participating patients, as well as cholesterol levels and A1c levels. “And many of the clinical results as well as the degree of hospital utilization were significantly better in the pharmacist group than in the retrospective control group that received usual care,” he adds.

Senior care is another area in which pharmacists are using their MTM skills to improve patient outcomes. “With the current demographics-with the baby boomers getting older and living longer-this generation is remaining a vital active member of the community,” explains Lynette Bradley-Baker, RPh, PhD, vice president for public affairs and engagement at AACP. “Subsequently, pharmacists are being asked to provide care in nursing homes and long-term care facilities.” In these settings, “MTM is critical to controlling chronic disease management,” she says.

A program at UCSF called “Care at Home” has the pharmacist addressing the needs of the older homebound patient via an e-visit. “It isn’t home healthcare, per se, but involves elderly, frail patients at higher risk who receive most of their healthcare in their home,” Stebbins explains. The program is a collaboration between the School of Pharmacy and the School of Nursing. “Through videoconferencing, the patient can receive a pharmacy consult at home,” she explains. “Additionally, the pharmacist may visit the home with the nurse practitioner, examine the patient’s medications and where they’re kept, and make recommendations.

In the managed care setting, more pharmacists are getting involved in utilization management programs for patients covered by Medicare Part D, says Cantrell. Ensuring proper usage can help curb costs, therefore helping organizations reach cost-based metrics in value-based arrangements.

Broken down further, pharmacists may be involved in population health management initiatives, in which healthcare organizations attempt to improve outcomes and reduce costs of care associated for groups of patients within specific disease states and demographics. “Pharmacists are involved in evaluating trends, evidence, and data to determine appropriate treatments, including medications, or preventative measures that will improve health among the patient population at a macro level to be implemented by individual clinicians, says Cantrell.”

Related article: Precision Medicine: A New Role for Pharmacists

In addition to offering these services in traditional managed care settings, such as ACOs, the managed care pharmacist is finding a new site in the in the physician’s office, says Cantrell. Placing these pharmacists in a doctor’s office, “allows them to be visible and lets the public see how they can improve patient care,” she says.

Reimbursement for the provision of pharmacy services has long been a concern.  Although, Cantrell says, “as the healthcare arena is moving toward paying for value, we’re seeing things move in the right direction for pharmacists.”

Currently, pharmacists may bill for MTM services under Medicare Part D, but, says Stebbins, it is not automatic. “Not every Medicare Part D Plan allows pharmacists to bill; it is on a contractual basis.” In individual states, billing for services is contingent upon provider status, but Stebbins notes that while California is one of the most progressive states in recognizing the value of pharmacists, “pharmacists aren’t being paid, in most cases. The payment models need to be worked out.”  

Related article: How to Get Paid for Pharmacy Services

One innovative payment model in California was established by Inland Empire Health Plan, a Medicaid managed care plan. Inland Empire implemented a pharmacy network, designed to provide targeted care to patients with chronic illness and allows pharmacists to bill for MTM services. This pay-for-performance program evaluates pharmacies on a set of seven quality metrics and provides bonuses to high quality pharmacies.

Pending federal legislation would allow pharmacists to bill for services under Medicare Part B. Once that is approved, pharmacists will be able to embrace their new roles, says Mehta.

Some private insurers are also allowing pharmacists to bill, in some instances, says Matzke. But, he adds that adequate reimbursement doesn’t have to be dependent on billing for services. In a clinic, for example, “payment to the pharmacist is carved out of the payment that comes to the practice as a whole.” If the pharmacist is valued and can increase efficiency, Matzke says, the pharmacist will be appropriately compensated. Lack of provider status shouldn’t hold pharmacists back from stepping up to the plate and providing optimal patient care.

1. National Committee for Quality Assurance. Overview of PCMH. Available at http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh/why-pcmh/overview-of-pcmh. Accessed April 19, 2018.

2. University of North Carolina Eshelman School of Pharmacy. Achieving Better Quality and Lower Costs in Medicaid through Enhanced Pharmacy Services. Center for Medicaid Optimization through Practice and Policy. Available at https://pharmacy.unc.edu/files/2015/03/Achieving-Quality-and-Lowering-Cost-in-Medicaid-through-Enhanced-Pharmacy-Services_CMOPP-white-paper_April-2017.pdf.  Accessed April 20, 2018.

Physicians are looking to pharmacists to help satisfy value-based metrics. Here’s how it’s changing pharmacists’ roles.

Top Ways Pharmacists’ Roles Are Changing

Pharmacists have a role in the chronic disease state management of patients with cardiac disease.

Since the push from Medicare and Medicaid, as well as from private payers, to manage complex disease states, health-care teams are managing these diseases, in large part through ambulatory clinics. The role of the pharmacist in this type of environment, says Norman P. Tomaka, BS Pharm, MS, a Media Liaison to 

 is to “ensure patients are compliant with their cardiac medications to help prevent readmissions and other untoward outcomes.”  But pharmacists in other settings have a role to play, too. In many hospitals, for example, pharmacists meet directly with patients to discuss medication regimens.    

The value of the pharmacist as a member of the cardiac health-care team has been clearly documented. The 2017 

Hypertension Clinical Practice Guidelines

 from the American Heart Association (AHA) and the American College of Cardiology (ACC) recommend a team-based approach, which includes pharmacists,  in the treatment of hypertension. “There is high-quality evidence demonstrating that team-based models, particularly with pharmacists and nurses, improve hypertension treatment and control,  says Eric McLaughlin, PharmD, BCPS, FASHP, FCCP, who coauthored the guidelines as APhA’s representative. “With the formal recommendation to use a team-based approach for the care of hypertension patients, there would be an expanded role and opportunities [for pharmacists],”  says MacLaughlin in a written release.

A study conducted in the cardiology unit of a university-affiliated hospital demonstrated that correction of drug-related problems (DRPs) by physicians after a pharmacist’s advice caused a significant decrease in mortality as analyzed by propensity-score (PS) matching. A total of 1,541 interventions were suggested by the clinical pharmacist in the study group; 1,416 (92%) of them were accepted by the cardiology team. All-cause mortality was reduced from 1.7% during Phase I (preintervention) to 1.0% during Phase II (postintervention). The difference was statistically significant (P=0.0074).

The pharmacist is valued as a member of the health-care team in treating patients with cardiac disease,” says Brittany Todd, PharmD, BCBS, CLS, Clinical Pharmacy Specialist in the Clinical Pharmacy Cardiac Risk Service (CPCRS), at Kaiser Permanente Colorado (KPCO) in an interview with Drug Topics. 

At the facility, a team of clinical pharmacists and clinical pharmacy specialists manage most patients with atherosclerotic disease (ASCVD). “At KPCO, our providers know of the Clinical Pharmacy Cardiac Risk Service and rely on us for long-term management of their patients with ASCVD,”  says Todd. “As pharmacists, we work closely with our primary care providers, cardiologists, neurologists, and cardiac rehab nurses to ensure all parties are on the same page with patient care.” [see Table 1]

“Within CPCRS, we are able to manage multiple disease states,” Todd continues. “Pharmacists ensure appropriate management of dyslipidemia, hypertension, diabetes, and smoking cessation. We order labs and instruct patients to follow up in clinics regarding blood pressure or any uncontrolled issue,” she says.

“We work off a Collaborative Drug Therapy Management document that outlines what we can and cannot do,” Todd says. The physician representatives for KPCO review this document annually to ensure that pharmacists manage their patients appropriately based on guidelines, evidence-based medicine, and safe practices. Because of the protocol, “we make therapy changes. We simply notify the physician of any therapy changes we made,” she says.

“I feel our providers understand what a pharmacist brings to the table-medication expertise-and truly appreciate our role,” Todd says.

A collaboration between a pharmacy and a hospital in Virginia is serving the needs of cardiac patients as they transition from hospital to discharge. Bremo Pharmacy, which also has a long-term care and community pharmacy in its group, is situated right in 

Up next: What this means for hospital and community pharmacy

Pharmacists spend time at each patient’s bedside prior to discharge to ensure that the patient understands their medication regimen. Mary Curtis, PharmD, is assigned to the cardiac unit. “We educate the patient on their medications and potential side effects,” she says. Our goal is to send the patient home on appropriate therapy and lower our readmission rates.”

Pharmacists also “meet” with patients via FaceTime at Parham Doctors’ Hospital, also in Richmond.

The program is expanding to include a pharmacist’s intervention up to the patient’s first postdischarge physician visit. The pilot program, which is focusing on high-risk patients, started in January. The emphasis,  says Curtis, is on chronic care management. “By the time the patient goes back to the doctor, we will have provided the physician with a postdischarge medication reconciliation, and other pertinent information,” Curtis says. This gives the cardiologist a heads-up on what to expect before the patient arrives for their appointment.

Reversal Agents for Direct-Acting Oral Anticoagulants

After that first physician visit, the patient is welcome to continue having their prescriptions filled at Bremo, if they choose Curtis says.

Curtis explains that the Bremo pharmacists do not work within a collaborative drug therapy agreement, but feels that pharmacists and physicians have a strong relationship. “The physician can open the door to help the patient accept the pharmacist as a member of the health-care team,” she says. 

Community pharmacists are making a difference as well, says Tomaka. Many community pharmacists provide blood pressure screenings, as well as counsel patients on lifestyle issues, such as diet and exercise. Others have smoking cessation programs.

Tomaka cites an example from his own experience as a community pharmacist when he encouraged a patient to have a blood pressure reading in the pharmacy. It was determined that the patient was having an adverse reaction to a new medication, and the proper adjustment was made. In another instance, a patient was encouraged to take a blood pressure medication at a different time of day to avoid a side effect that was affecting quality of life.

Clinical Challenge: Treating Nasal Congestion with Concomitant Hypertension

The community pharmacist is in a good position to counsel patients on lifestyle issues, Tomaka says. A good resource for the pharmacist is the American Heart Association’s 

At Kaiser, Todd agrees that lifestyle issues are important. “We do focus quite a bit on therapies since we are pharmacists, but with each call (or at least we try), we talk about lifestyle. This includes a heart-healthy diet, weight loss, and exercise,” she says. “A unique part of what we do is allow time with patients to really get into the why. Many patients with ASCVD are told to take meds, lose weight, etc. This is overwhelming and they are never taught why it is so important. We are able to develop relationships with these patients since we follow them long-term,” she says.

Curtis agrees. “It’s important for a patient to understand their meds, as well as to understand why lifestyle issues, such as diet and exercise are important. As a pharmacist, to give guidance to a patient, and to come to the point where you see that patient feeling better, is very rewarding.”

1. Zhai X, Gu Z, Liu X. Effectiveness of the clinical pharmacist in reducing mortality in hospitalized cardiac patients: a propensity score-matched analysis. Ther Clin Risk Manag. 2016;12:241-250.

When it comes to cardiac disease, pharmacists in all practice settings can make a difference.