This report describes the initial implementation of pharmacist-performed comprehensive medication management as part of an interdisciplinary care team at an accountable care organization’s primary care offices.
Pharmacist-performed comprehensive medication management (CMM) has shown improved patient outcomes in a variety of settings, leading to an increased interest in the implementation of clinical pharmacist—performed CMM within interdisciplinary care teams. This report describes the initial 3 months of implementing clinical pharmacy into interdisciplinary care teams in primary care clinics, including the workflow of the clinical pharmacist, typical activities performed, and recommendations. The findings indicated positive provider and patient satisfaction. Areas of opportunity were identified to improve provider acceptance rate of pharmacists’ recommendations and enhance pharmacist-provider relationships.
The American Journal of Accountable Care. 2020;8(1):8-11. https://doi.org/10.37765/ajac.2020.88356
Medication misuse, underuse, and overuse is estimated to contribute to $300 billion in healthcare costs.1 Comprehensive medication management (CMM) is the standard of care to ensure that medications (including prescription, nonprescription, alternative, and traditional medications, as well as vitamins and nutritional supplements) are individually assessed to determine that each medication is appropriate for the patient, is effective for the medical condition, is safe given the comorbidities and other medications being taken, and can be taken by the patient as intended. Clinical pharmacists are trained to provide CMM and create an individualized care plan describing goals of therapy, how to achieve them, and necessary actions for follow-up. By working in an interdisciplinary team, pharmacists can positively affect patient satisfaction and clinical outcomes.2
With a projection of 5 billion prescriptions dispensed and 80% of treatment plans containing medications in 2021, it is imperative that patients receive optimal medication regimens.2,3 The World Health Organization states that medication adherence for chronic diseases averages only 50% in developed countries, resulting in poor health outcomes and increased healthcare costs.2 Pharmacist-driven CMM can help improve medication adherence along with other clinical outcomes. A retrospective study assessing pharmacist-performed medication therapy management found higher rates of medication adherence, lower glycated hemoglobin levels, and lower low-density lipoprotein levels in patients with type 2 diabetes who received medication therapy management.4 Similarly, a study assessing the effect of a collaborative pharmacist—primary care provider team approach to medication therapy in patients with hypertension found a reduction in systolic blood pressure (BP) at 6 and 9 months compared with usual care.5
Overall, pharmacist-performed CMM has shown improved patient outcomes in a variety of settings. This report describes the initial implementation of pharmacist-driven CMM into an interdisciplinary care team at an accountable care organization (ACO)’s primary care offices for ambulatory patients.
Implementation of pharmacist-driven CMM was performed at a health system that cares for more than 300,000 patients in northern Kentucky and participates in an ACO. The organization is composed of 30 primary care offices, with 50% of patients cared for under a value-based performance program. This report focused on 4 primary care offices staffed with physicians, nurse practitioners, medical assistants (MAs), a social worker, and a care coordinator. Practices were chosen based on interest in ambulatory pharmacy services at their site and opportunity for improvement in quality measures. Each practice serves approximately 10,000 patients, with approximately 2000 visits per month. Four pharmacists participated in the CMM implementation, each spending one 8-hour day per week at 1 of 4 offices. All pharmacists hold a doctor of pharmacy degree and are licensed to practice pharmacy in the state of Kentucky. Three of the 4 pharmacists were enrolled in a postgraduate year 2 program at the time of implementation—2 in programs for ambulatory care and 1 in a program for community administration. The remaining pharmacist, who holds board certification in ambulatory care and has more than 17 years of experience, was employed as an ambulatory pharmacist.
CMM was performed by an ambulatory care pharmacist based on recommendations by the American College of Clinical Pharmacy.6 Pharmacists either met with patients face-to-face or spoke with them via telephone between August 20, 2018, and November 30, 2018. The Figure depicts the typical workflow of pharmacy visits. Usually, patients were seen by pharmacists on the same day as their appointment with the primary care provider. However, providers or pharmacists were able to schedule an appointment with the pharmacist only. If the patient was unable to come to the office, the pharmacist could conduct a telephone visit. Patients were roomed by an MA who received standardized training upon hiring. If BP was elevated, the MA was responsible for repeating BP measurement per office policy. Pharmacist recommendations were discussed with the patient’s primary care provider prior to making changes to medication therapy. The pharmacist documented all interventions, assessments, recommendations, and activities performed in the electronic health record and routed it to the provider. Pharmacists were individually responsible for ensuring follow-up with their patients. Voluntary patient satisfaction surveys were created based on the work of Moon et al7 (used with permission); they were either given to the patient to complete at their visit and return to the front desk, or mailed to them within 1 month of CMM with an addressed return envelope to be returned by mail. A voluntary provider satisfaction survey was sent to prescribers via email in January 2019. Pharmacists recorded types and number of interventions, number of recommendations accepted, activities performed, amount of time spent with patients, and total time spent on encounters.
During this 3-month initial implementation period, pharmacists spent an average of 18.8 minutes face-to-face with each patient and 72 minutes total per patient. They provided 836 (5.72 per patient) recommendations, of which 311 (2.13 per patient) were accepted (37.4%) (Table). The most accepted recommendations included ordering laboratory tests (46.5%), discontinuation of medication therapy (37.7%), and administration of immunization (35.3%). Some common activities performed by pharmacists included medication reconciliation, monitoring laboratory test results, and providing education. Pharmacists also utilized assessment tools such as the Patient Health Questionnaire 9, COPD [chronic obstructive pulmonary disease] Assessment Test, Generalized Anxiety Disorder 7-item scale, and American Urological Association Symptom Score Questionnaire.
Approximately one-third (35%) of patient satisfaction surveys were returned, similar to rates in previous published reports (eAppendix [available at ajmc.com]).7 More than 90% of patients agreed that the clinical pharmacist helped them understand why they are taking their medications, make sure that their medications are safe, and feel confident managing their medications. Many patients provided positive comments, including “This is a wonderful service and will help decrease drug interactions and problems” and “She did a very good job of explaining things and helping with questions and concerns.” Approximately 47% of prescribers completed the satisfaction survey. Of those, 93% agreed that patients benefited from seeing the pharmacist. Providers made several positive comments, including “Having a pharmacist available for consultation is very helpful particularly in the complex geriatric and/or diabetic patient.”
The acceptance rate for the pharmacist’s recommendations was lower than published rates in other studies.8-10 Ambulatory pharmacy services had not been previously implemented within the organization, making provider engagement low. Frequently, patients cancelled the appointment with their provider and rescheduled for a date outside of the follow-up time frame. This contributed to the low acceptance rate because providers typically wanted to wait until the next office visit before making changes to medication therapy. Lack of standardized follow-up may have also accounted for some of these patients being missed by the pharmacist at their rescheduled appointment date.
Patient and provider satisfaction surveys indicated a positive experience for both groups. We might have expected provider satisfaction to be low due to the low percentage of recommendations accepted by providers. However, this may be because providers with a positive or negative experience through acceptance of recommendations were more likely to complete the survey than providers who did not accept recommendations from the pharmacists.
Low provider engagement in the early stages of implementation likely played a large role in the low rate of recommendation acceptance. To improve the relationship between pharmacists and providers, pharmacists are now a part of the provider meetings, at which they present medication-related topics. Pharmacists are also now working 2 days per week at their assigned primary care office, increasing face-to-face time with providers and creating stronger relationships. The pharmacy team has become a key participant in all provider meetings for the health system through continuing education presentations, updates on pharmacy impact on value-based performance measures, and updates on medication-related changes in the health system and healthcare as a whole. Through these changes, the relationship between pharmacists and providers has strengthened and provider engagement has increased.
To create a more standardized follow-up process, the pharmacy team is now utilizing the Epic iVent tool to document interventions. This allows the team to track its interventions and return to any interventions that remain open. The team also documents interventions in an Epic Patient Outreach encounter, which allows the pharmacists to document a follow-up date and run daily reports to see which patients need follow-up that day.
The organization has grown to include 7 ambulatory care pharmacists who are each responsible for 1 to 2 value-based performance contracts in which they identify patients in the contract with care gaps and work with the patient and provider to close the gap if appropriate. This has been helpful in creating a more meaningful impact on the health system’s performance in regard to its value-based performance contracts.
There is increased interest in the implementation of clinical pharmacists into interdisciplinary care teams in ambulatory care. In this report, we have described the initial 3 months of implementing clinical pharmacy into an interdisciplinary care team in primary care clinics, including the workflow of the clinical pharmacist, typical activities performed, and recommendations. Other organizations planning to implement pharmacists in the primary care setting may utilize this information to anticipate and mitigate barriers such as low provider engagement, lack of standardized follow-up, and patients missing appointments. Patient and provider satisfaction were considered in this study and, to date, no provider surveys have measured the satisfaction of providers with integrated ambulatory pharmacist services in the primary care setting.
Overall, pharmacist-performed CMM as part of an interdisciplinary care team resulted in positive patient and provider satisfaction. With the large focus on value-based performance outcomes, implementation of pharmacist CMM services may be of interest to organizations looking to improve such outcomes.
Author Affiliations: St. Elizabeth Healthcare (ECHS, SMF), Edgewood, KY; James L. Winkle College of Pharmacy, University of Cincinnati (ALH), Cincinnati, OH.
Source of Funding: None.
Author Disclosures: Dr Hatfield Sapp is employed as an ambulatory pharmacist. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: Concept and design (ECHS, SMF, ALH); acquisition of data (ECHS, SMF); analysis and interpretation of data (ECHS, SMF, ALH); drafting of the manuscript (ECHS, SMF, ALH); critical revision of the manuscript for important intellectual content (ECHS); statistical analysis (ECHS, ALH); provision of study materials or patients (ECHS, SMF); administrative, technical, or logistic support (ECHS); and supervision (ECHS, SMF, ALH).
Send Correspondence to: Emma Caitlin Hatfield Sapp, PharmD, BCACP, St. Elizabeth Healthcare, 20 Medical Village Dr, Ste 103, Edgewood, KY 41017. Email: firstname.lastname@example.org.
1. Blouin RA, Adams ML. The role of the pharmacist in health care: expanding and evolving. N C Med J. 2017;78(3):165-167. doi: 10.18043/ncm.78.3.165.
2. The patient-centered medical home: integrating comprehensive medication management to optimize patient outcomes: resource guide, 2nd ed. Patient-Centered Primary Care Collaborative website. pcpcc.org/sites/default/files/media/medmanagement.pdf. Published June 2012. Accessed December 2, 2017.
3. Aitken M, Kleinrock M, Lyle J, Nass D, Caskey L. Medicines use and spending shifts: a review of the use of medicines in the U.S. in 2014. IQVIA website. iqvia.com/-/media/iqvia/pdfs/institute-reports/medicines-use-and-spending-shifts-in-the-us-in-2014.pdf. Published April 2015. Accessed August 10, 2018.
4. Skinner JS, Poe B, Hopper R, Boyer A, Wilkins CH. Assessing the effectiveness of pharmacist-directed medication therapy management in improving diabetes outcomes in patients with poorly controlled diabetes. Diabetes Educ. 2015;41(4):459-465. doi: 10.1177/0145721715587563.
5. Hirsch JD, Steers N, Adler DS, et al. Primary care—based, pharmacist-physician collaborative medication-therapy management of hypertension: a randomized, pragmatic trial. Clin Ther. 2014;36(9):1244-1254. doi: 10.1016/j.clinthera.2014.06.030.
6. CMM in Primary Care Research Team. The patient care process for delivering comprehensive medication management (CMM): optimizing medication use in patient-centered, team-based care settings. American College of Clinical Pharmacy website. accp.com/docs/positions/misc/CMM_Care_Process.pdf. Published July 2018. Accessed September 15, 2018.
7. Moon J, Kolar C, Brummel A, Ekstrand M, Holtan H, Rehrauer D. Development and validation of a patient satisfaction survey for comprehensive medication management. J Manag Care Spec Pharm. 2016;22(1):81-86. doi: 10.18553/jmcp.2016.22.1.81.
8. Lee AJ, Boro MS, Knapp KK, Meier JL, Korman NE. Clinical and economic outcomes of pharmacist recommendations in a Veterans Affairs medical center. Am J Health Syst Pharm. 2002;59(21):2070-2077. doi: 10.1093/ajhp/59.21.2070.
9. Carter BL, Bergus GR, Dawson JD, et al. A cluster randomized trial to evaluate physician/pharmacist collaboration to improve blood pressure control. J Clin Hypertens (Greenwich). 2008;10(4):260-271. doi: 10.1111/j.1751-7176.2008.07434.x.
10. Smith SM, Hasan M, Huebschmann AG, et al. Physician acceptance of a physician-pharmacist collaborative treatment model for hypertension management in primary care. J Clin Hypertens (Greenwich). 2015;17(9):686-691. doi: 10.1111/jch.12575.