As pharmacists struggle to practice at the top of their licenses and become a recognized and integral part of a care team, these goals are coming to fruition in patient-centered medical homes (PCMHs).
The Agency for Healthcare Research and Quality’s definition of a PCMH emphasizes a care team that includes pharmacists, physicians, advanced practice nurses, physician assistants, nurses, nutritionists, social workers, educators, and care coordinators as key elements. The team provides comprehensive and coordinated care centered around the patient.
The American College of Clinical Pharmacy (ACCP) believes that clinical pharmacists should enhance the care provided by collaborating professionals by sharing their pharmacotherapeutic expertise—rather than serving as a substitute or extender.
Daniel Aistrope, PharmD, BCACP, director of clinical practice advancement for ACCP, considers comprehensive medication management (CMM)—a clinical service that includes an individualized care plan to achieve the intended goals of therapy with appropriate follow-up to determine actual patient outcomes—to be the primary responsibility of a pharmacist in a PCMH.
Aistrope provides support and consultation to members across the country seeking to develop and advance clinical pharmacy services integrated into team-based medical practices, including the implementation of CMM.
According to the ACCP, patients who could benefit from CMM include those who:
- Have not reached or are not maintaining their intended therapy goal.
- Are experiencing adverse effects from their medications.
- Have difficulty understanding or following a medication regimen.
- Need preventive therapy.
- Are often readmitted to the hospital.
“It’s one thing to put therapy problems on paper, but another to bring solutions to reality through team-based care,” Aistrope says. “Optimizing medication therapy is a primary goal in a medical home.”
Pharmacists in PCMHs
Five clinical pharmacists who practice in PCMHs shared their experience with Drug Topics. They have many of the same responsibilities, benefit from many of the same advantages of the setting, and face similar challenges.
In general, their duties include reviewing patients’ medical profiles, reconciling medications, evaluating lab results, assessing the appropriateness of drugs, finding drug-related problems, educating patients, developing a care plan, and following up.
Many PCMHs rely on population management tools to resolve pharmacy-related problems, including registries that:
- Highlight how well patients as a whole and as individuals are achieving certain quality measures and reaching medication goals.
- Find possible pitfalls, such as patients not on appropriate effective medications or who are nonadherent to a drug regimen.
- Identify patients with certain chronic diseases to uncover medication intolerance, side effects, and trouble with polypharmacy.
“These tools help with adherence and indicate if medications need adjustment,” says Liza W. Claus, PharmD, assistant professor and clinical pharmacist at the University of Colorado Anschutz Campus in Aurora.
Kelly Cochran, PharmD, clinical associate professor at the University of Missouri-Kansas City School of Pharmacy and a clinical pharmacist at the University of Missouri General Internal Medicine Clinic in Columbia, serves in a consulting role as part of a collaborative team of primary care physicians, behavioral health professionals, nurse care coordinators, and a dietitian.
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The interpersonal and interdisciplinary approach enhances the level of care, Cochran says, and enables the team to better understand patient problems—including social determinants of health—and help solve them. Her team lacks a social worker, which Cochran believes would be a valuable resource, along with additional providers.
Similar to clinical pharmacists in other medical homes, Cochran has access to EHRs, lab data, and patient medical histories, which most community pharmacists do not. She says the information enables her to make ongoing changes in medication therapy.
She and other clinical pharmacists in her practice are part of a collaborative practice agreement with one or more physicians that allows them to assume professional responsibility for performing patient assessments; order medication-related laboratory tests; select, initiate, and monitor medications; and adjust medication regimens.
Medical Home versus Community Pharmacists
“There’s a big difference in the work that pharmacists can do in a medical home compared to a typical community pharmacy setting,” says Daniel Rehrauer, PharmD, of HealthPartners in Minneapolis. “Working in a medical home, you have access to medical records and work side by side with other members of a care team. If I am working with a patient on a medication issue and discover the real problem is diet related, I can walk down the hall and talk to the dietician or just send a referral. That is much more difficult to do in a community pharmacy setting. With that being said, there are opportunities for community pharmacists to make inroads and form partnerships with local providers,” he says.
“The medical home, however, is what will allow organizations to have success in these new payment models and to spend more time on providing care than on figuring out payment,” he says.
Liza W. Claus, PharmD, of the University of Colorado Anschutz Campus in Aurora, draws some similarities between her role in a medical home with that of a community pharmacist. “Both are concerned with medication safety and appropriateness and counsel patients using a medication for the first time or having trouble with a particular drug,” she says.
“One key difference is the location” Claus says. A clinic with close proximity to other providers “creates a physically integrated team giving pharmacists the ability to manage therapy under collaborative protocols.”
Kyle Turner, PharmD, of University of Utah Health, says community pharmacists optimize medications for patients, but their emphasis is on how to take drugs to boost adherence, while in his role in a PCMH, he also manages a patient’s entire drug regimen. “For us, medication therapy management is a marathon, not a sprint,” he says.
One big difference, says Allyson Schlichte, PharmD, of Fairview Uptown Clinic in Minneapolis, is her ability to form relationships with prescribers, which was missing when she served as a community pharmacist. On the other hand, she believes that community pharmacists touch patients more than she does in the clinic and that they are able to reinforce how to take certain medications appropriately.
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