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Wells C, Warren AC, Scott MA. Development and implementation of ambulatory care pharmacy services at an internal medicine clinic. Am J Health Syst Pharm 2024; 81:e528-e534. [PMID: 38613410 DOI: 10.1093/ajhp/zxae102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Indexed: 04/14/2024] Open
Abstract
PURPOSE This report describes the step-by-step process that led to expansion of ambulatory care pharmacy services at a newly established internal medicine clinic within a patient-centered medical home in North Carolina. SUMMARY Implementation of clinical pharmacist services at the clinic was led by a postgraduate year 2 (PGY2) pharmacy resident and guided by the 9 steps described in the book Building a Successful Ambulatory Care Practice: A Complete Guide for Pharmacists. After a needs assessment and review of the demographics and insurance status of the clinic's target population, it was determined that pharmacist services would focus on quality measures including diabetes nephropathy screening, diabetes eye examination, blood glucose control in diabetes, discharge medication reconciliation, annual wellness visits, and medication adherence in diabetes, hypercholesterolemia, and hypertension. Clinic appointments were conducted under 3 models: a pharmacist-physician covisit model, a "floor model" of pharmacist consultation on drug information or medication management issues during medical resident sign-out sessions with supervising physicians (medical residents could also see patients along with the pharmacist at a covisit appointment), and a covisit model of stacked physician and pharmacist appointments. The pharmacist's services were expanded from 2 half-day clinic sessions per week initially to 5 or 6 half-day clinic sessions by the end of the residency year. CONCLUSION By the fourth quarter of the first PGY2 residency year in which ambulatory care pharmacy services were provided in the clinic, the clinical and financial impact of those services justified the addition of a second full-time pharmacist to the clinic team.
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Affiliation(s)
- Casey Wells
- Department of Pharmacotherapy, Mountain Area Health Education Center, Asheville, NC
- Practice Advancement and Clinical Education, University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Anne Carrington Warren
- Department of Pharmacotherapy, Mountain Area Health Education Center, Asheville, NC
- Practice Advancement and Clinical Education, University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, USA
| | - Mollie Ashe Scott
- Department of Pharmacotherapy; Mountain Area Health Education Center, Asheville, NC
- Practice Advancement and Clinical Education, University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, NC, USA
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Lum ZK, Tan JY, Wong CSM, Kok ZY, Kwek SC, Tsou KYK, Gallagher PJ, Lee JYC. Reducing economic burden through split-shared care model for people living with uncontrolled type 2 diabetes and polypharmacy: a multi-center randomized controlled trial. BMC Health Serv Res 2024; 24:760. [PMID: 38907254 PMCID: PMC11193226 DOI: 10.1186/s12913-024-11199-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 06/12/2024] [Indexed: 06/23/2024] Open
Abstract
BACKGROUND Interprofessional collaborative care such as a split-shared care model involving family physicians and community pharmacists can reduce the economic burden of diabetes management. This study aimed to evaluate the economic outcome of a split-shared care model between family physicians and community pharmacists within a pharmacy chain in managing people with uncontrolled type 2 diabetes and polypharmacy. METHOD This was a multi-center, parallel arm, open label, randomized controlled trial comparing the direct and indirect economic outcomes of people who received collaborative care involving community pharmacists (intervention) versus those who received usual care without community pharmacist involvement (control). People with uncontrolled type 2 diabetes, defined as HbA1c > 7.0% and taking ≥ 5 chronic medications were included while people with missing baseline economic data (such as consultation costs, medication costs) were excluded. Direct medical costs were extracted from the institution's financial database while indirect costs were calculated from self-reported gross income and productivity loss, using Work Productivity Activity Impairment Global Health questionnaire. Separate generalized linear models with log link function and gamma distribution were used to analyze changes in direct and indirect medical costs. RESULTS A total of 175 patients (intervention = 70, control = 105) completed the trial and were included for analysis. The mean age of the participants was 66.9 (9.2) years, with majority being male and Chinese. The direct medical costs were significantly lower in the intervention than the control group over 6 months (intervention: -US$70.51, control: -US$47.66, p < 0.001). Medication cost was the main driver in both groups. There were no significant changes in productivity loss and indirect costs in both groups. CONCLUSION Implementation of split-shared visits with frontline community partners may reduce economic burden for patient with uncontrolled type 2 diabetes and polypharmacy. TRIAL REGISTRATION Clinicaltrials.gov Reference Number: NCT03531944 (Date of registration: June 6, 2018).
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Affiliation(s)
- Zheng Kang Lum
- Department of Pharmacy and Pharmaceutical Sciences, Faculty of Science, MD1, Tahir Foundation Building, National University of Singapore, 12 Science Drive #06-03, Singapore, 117549, Singapore
| | - Jia Yeong Tan
- Keat Hong Family Medicine Clinic, Trilink Healthcare Private Limited, 2 Choa Chu Kang Loop, Singapore, #03-02, Singapore
| | - Cynthia Sze Mun Wong
- Bukit Batok Polyclinic, National University Polyclinics, 50 Bukit Batok West Ave 3, Singapore, 659164, Singapore
| | - Zi Yin Kok
- Keat Hong Family Medicine Clinic, Trilink Healthcare Private Limited, 2 Choa Chu Kang Loop, Singapore, #03-02, Singapore
| | - Sing Cheer Kwek
- Bukit Batok Polyclinic, National University Polyclinics, 50 Bukit Batok West Ave 3, Singapore, 659164, Singapore
| | - Keith Yu Kei Tsou
- Bukit Batok Polyclinic, National University Polyclinics, 50 Bukit Batok West Ave 3, Singapore, 659164, Singapore
| | - Paul John Gallagher
- Department of Pharmacy and Pharmaceutical Sciences, Faculty of Science, MD1, Tahir Foundation Building, National University of Singapore, 12 Science Drive #06-03, Singapore, 117549, Singapore.
| | - Joyce Yu-Chia Lee
- Department of Clinical Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University of California, 101 Theory, Suite 100, Irvine, CA, 92697, USA.
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Carson D, Preston R, Hurtig AK. Innovation in Rural Health Services Requires Local Actors and Local Action. Public Health Rev 2022; 43:1604921. [PMID: 36189186 PMCID: PMC9516414 DOI: 10.3389/phrs.2022.1604921] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 09/02/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives: We examine the role of “local actors” and “local action” (LALA) in health service innovation in high-resource small rural settings and aim to inform debates about the extent to which communities can be empowered to drive change in service design and delivery. Methods: Using an adapted roles and activities framework we analyzed 32 studies of innovation projects in public health, clinical interventions, and service models. Results: Rural communities can investigate, lead, own and sustain innovation projects. However, there is a paucity of research reflecting limited reporting capacity and/or understanding of LALA. Highlighting this lack of evidence strengthens the need for study designs that enable an analysis of LALA. Conclusion: Innovation and community participation in health services are pressing issues in small rural settings where population size and distance from health infrastructure make service delivery challenging. Current reviews of community participation in rural health give little insight into the process of innovation nor understanding of how local actors produce improvements in innovation. This review outlines how communities and institutions can harness the essential role of LALA in supporting health innovations.
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Affiliation(s)
- Dean Carson
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
| | - Robyn Preston
- School of Health, Medical and Applied Sciences, Central Queensland University, Rockhampton, QLD, Australia
- *Correspondence: Robyn Preston,
| | - Anna-Karin Hurtig
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
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Caron O, Fay AE, Pressley H, Seamon G, Taylor SR, Wilson CG. Four models of pharmacist‐integrated office‐based opioid treatment. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2022. [DOI: 10.1002/jac5.1607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Olivia Caron
- Mountain Area Health Education Center (MAHEC) Family Health Center, 123 Hendersonville Rd Asheville North Carolina USA
| | | | - Haley Pressley
- University of North Carolina (UNC) Eshelman School of Pharmacy Chapel Hill North Carolina
| | - Gwen Seamon
- MAHEC Family Health Center Asheville North Carolina
| | | | - Courtenay Gilmore Wilson
- Department of Family Medicine, Mountain Area Health Education Center (MAHEC) Asheville North Carolina
- Department of Research, UNC Health Sciences at MAHEC Asheville North Carolina
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy Chapel Hill North Carolina
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Gonzalvo JD, Kenneally AM, Pence L, Walroth T, Schmelz AN, Nace N, Chang J, Meredith AH. Reimbursement outcomes of a pharmacist‐physician co‐visit model in a Federally Qualified Health Center. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1416] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Jasmine D. Gonzalvo
- College of Pharmacy Purdue University, Eskenazi Health Indianapolis Indiana USA
| | | | | | | | | | | | - Juan Chang
- Eskenazi Health Indianapolis Indiana USA
| | - Ashley H. Meredith
- College of Pharmacy Purdue University, Eskenazi Health Indianapolis Indiana USA
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Expanding pharmacists' roles: Pharmacists' perspectives on barriers and facilitators to collaborative practice. J Am Pharm Assoc (2003) 2020; 61:213-220.e1. [PMID: 33359117 DOI: 10.1016/j.japh.2020.11.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 11/30/2020] [Accepted: 11/30/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The pharmacy profession is shifting from transactional dispensing of medication to a more comprehensive, patient-centered model of care. Collaborative practice agreements (CPAs) extend the role of a pharmacist to initiate, monitor, modify, and discontinue drug therapies and provide other clinical services. Although collaborative practice has been shown to improve health system efficiency and patient outcomes, little is known about how pharmacists perceive CPAs. To explore pharmacists' perspectives of CPAs, including barriers and facilitators to CPA implementation. METHODS Semistructured key informant interviews were used to elicit information from licensed pharmacists practicing in a variety of settings in Arizona. Thematic analysis was used to identify key qualitative themes. RESULTS Seventeen interviews of pharmacists with (n = 11, 64.7%) and without (n = 6, 35.3%) CPAs were conducted in April-May 2019. The pharmacists saw their role in CPAs as supportive, filling a care gap for overburdened providers. A heightened sense of job satisfaction was reported owing to increased pharmacist autonomy, application of advanced knowledge and clinical skills, and ability to have a positive impact on patients' health. Challenges to the implementation of CPAs included liability and billing issues, logistic concerns, some experiences with provider hesitancy, and lack of information and resources to establish and maintain a CPA. The barriers could be overcome with conscious team-building efforts to establish trust and prove the worth of pharmacists in health care teams; strategic engagement of stakeholders in the development of CPAs, including billing and legal departments; and mentorship in the CPA creation process. CONCLUSIONS The pharmacists in this study enjoyed practicing collaboratively and had overall positive perceptions of CPAs. As health worker shortages become more dire and pharmacy practice evolves to expand the role of pharmacists in providing direct patient care, CPAs will be an important tool for restructuring care tasks within health systems.
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Ulrich IP, Lugo B, Hughes P, Doucette L, Creith BB, Flanagan S, Gilmer B. Access to clinical pharmacy services in a pharmacist-physician covisit model. Res Social Adm Pharm 2020; 17:1321-1326. [PMID: 33153913 DOI: 10.1016/j.sapharm.2020.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 09/28/2020] [Accepted: 10/05/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND 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. OBJECTIVE To assess access to clinical pharmacy services in a pharmacist-physician covisit model compared to a referrals-based model. METHODS 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. RESULTS 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. CONCLUSIONS A pharmacist-physician covisit model significantly increased accessibility to clinical pharmacy services compared to a referrals-based model.
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Affiliation(s)
- Irene Park Ulrich
- Mountain Area Health Education Center; UNC Eshelman School of Pharmacy; UNC School of Medicine; 123 Hendersonville Road, Asheville, NC, 28803, USA.
| | - Brunilda Lugo
- UNC Health Sciences at the Mountain Area Health Education Center, USA.
| | - Phillip Hughes
- UNC Health Sciences at the Mountain Area Health Education Center, USA.
| | - Lorna Doucette
- UNC Eshelman School of Pharmacy, UNC Gillings School of Global Public Health, USA.
| | | | | | - Benjamin Gilmer
- Family Medicine Faculty Physician, Mountain Area Health Education Center, UNC School of Medicine, USA.
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The design and evaluation of a pilot covisit model: Integration of a pharmacist into a primary care team. J Am Pharm Assoc (2003) 2020; 60:491-496. [DOI: 10.1016/j.japh.2019.11.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 10/21/2019] [Accepted: 11/16/2019] [Indexed: 11/21/2022]
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Tripicchio K, Urick B, Easter J, Ozawa S. Making the economic value proposition for pharmacist comprehensive medication management (CMM) in primary care: A conceptual framework. Res Social Adm Pharm 2020; 16:1416-1421. [PMID: 31918964 DOI: 10.1016/j.sapharm.2020.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 12/15/2019] [Accepted: 01/01/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Comprehensive medication management (CMM) is a patient care process provided by clinical pharmacists in primary care settings that ensures optimal use of medications with timely follow-up. Despite widespread evidence that shows CMM improves clinical and medication-related outcomes, pharmacist-delivered CMM services often fail to be adopted into U.S. primary care settings. OBJECTIVE This study presents a conceptual framework linking outcomes of pharmacist-delivered CMM services in primary care settings to financial benefits for health plans providing coverage of CMM services and primary care practices investing and implementing CMM. METHODS A critical review of the literature was performed in PubMed and the gray literature to identify financing opportunities that justify the coverage of CMM by third-party health plan administrators or the implementation of CMM by primary care practices. Financing elements that could be impacted by pharmacist-led CMM outcomes, namely higher achievement of medication-related quality measures and reduction of total costs of care, were recorded and utilized to develop the conceptual framework. RESULTS The framework suggests that CMM provides economic benefits to both health plans and primary care practices by increasing market competitiveness, direct revenue, and quality bonuses. Health plans may benefit from higher plan quality ratings, lower premiums and plan bids, increased shared savings, and quality bonus payments. Primary care practices may achieve increased negotiating power through accreditation recognition and patient satisfaction, increased revenue through shared savings and fee-for-service reimbursement, and achievement of quality bonus payments. CONCLUSIONS The alignment of economic benefits from CMM advances a strong value proposition for greater adoption of CMM coverage by health plans and implementation in the U.S. primary care system. Through broader CMM implementation, pharmacists can work alongside physicians in advanced care models and play a vital role in shaping the primary care practice transition to value-based care.
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Affiliation(s)
- Kristen Tripicchio
- Division of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC, 27599, USA.
| | - Benjamin Urick
- Division of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC, 27599, USA
| | - Jon Easter
- Division of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC, 27599, USA
| | - Sachiko Ozawa
- Division of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC, 27599, USA; Department of Maternal and Child Health, University of North Carolina Gillings School of Global Public Health, 135 Dauer Drive, Chapel Hill, NC, 27599, USA
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Strengthening the evidence-base on payment models for pharmacist-provided services. J Am Pharm Assoc (2003) 2019; 59:5. [DOI: 10.1016/j.japh.2018.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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