AMCP Spring 2014
Integrating Pharmacists Into New Care Delivery Models
For the past few years, new care delivery models have evolved, spurred through innovation and, of course, new payment methods. The opportunities for pharmacists in these care delivery models are characterized by the spectrum of integration represented by the models themselves, according to Marie Smith, PharmD, professor and assistant dean for practice and public policy partnerships, University of Connecticut School of Pharmacy, Storrs, Connecticut.

The most basic of these models is the patient-centered medical home (PCMH), which was actually started in the 1960s, reminded Dr Smith. The model promotes access, emphasizes care coordination, and encourages the transformation to health information technology and e-prescribing in a primary care practice.
The medical neighborhood represents a subtle difference from the PCMH, said Dr Smith. Rather than consisting of solely primary care, it includes the specialists and subspecialties in a particular geographic area. “Pharmacists in the community must become more of a part of the medical neighborhood, as the resident expert in medication management.”
           
Advanced primary care practices are a more advanced version of the PCMH, according to Dr Smith. “If a medical home is termed ‘level 3,’ it means little about change,” she said. In advanced primary care practices, “there is an active movement to look at advanced primary care. It’s looking at the workflow redesign, the processes of risk stratification, and being accountable to a transformation process.”

Accountable care organizations (ACOs) marry care redesign and payment reform, taking a population health view and accepting risk-based payment. The ACO represents real opportunity in team-based care, according to Dr Smith, but it is not the most integrated of the new delivery models. That designation goes to the community-based health team, which Dr Smith did point can be more virtual than it is real. “It is hard to spot sometimes, but we know them when we see them. It involves care transitions, such as home care, and involves social workers and social determinants of health (eg, affordability, filling basic care needs).”
           
The success of any of these new delivery models is dependent on the use of team-based care. “One accepted definition of team-based care makes no mention of a health care professional’s place of work or who they are. It does specify that they work seamlessly, working around patients’ needs,” said Dr Smith, “and emphasize a shared responsibility for care, which continues over time and between visits. It exists in only a few places today. But this is what we’re striving for.”
           
Many opportunities exist in the community for pharmacists to work as part of interdisciplinary teams and care transition teams, and the model of community-based care itself makes this possible. The pharmacist sits in the center of the model, with medication therapy management and medication management expertise, with medical specialists, providers, and community services surrounding them, tapping into pharmacy expertise.
           
Team-based care involving the pharmacist depends on the integration of the pharmacist into the primary care workflow, which should include pre-appointment planning, coincident referral (ie, a pharmacist located in the medical office, seeing referred patients during the office visit), follow-up referral (by appointment only), targeting patient consults at home or high-risk patient centers, and conducting e-consults. “All of these practices require that the pharmacist have access to patient medical information and the ability to share recommendations with providers. This implies EMR/HIT with ‘read and write’ access,” said Dr. Smith.
She listed 3 levels of pharmacy collaboration: (1) coordinated care, where communication is emphasized regarding prescription orders, and pharmacists as drug information resources are sometimes utilized; (2) co-located care, where the pharmacist is a team member based in the provider office (maybe not full time) and has access to the EMR system, and (3) integrated care (with full collaboration), with at least some level of authority and responsibility for medication therapy management (MTM). Practitioners routinely refer patients to pharmacist colleagues for MTM.
           
“I don’t think we have it figured out yet,” said Dr Smith. We need measures that are different than those seen in HEDIS to monitor performance of team-based pharmacists, like closing gaps in care around medication use.”
           
If we move ahead, do we have enough pharmacists to engage in this direct patient management? Dr Smith said that an RPh license is not the only credential required. We also need a credentialing system to handle the direct patient care/population health/integrated care-team role. Getting direct provider status is essential to being able to participate in these new payment models.

To close, Dr Smith quoted Calvin Coolidge, who said, “We cannot do everything at once, but we must do something at once.” 
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