Expanding Pharmacist Role in Patient-Centered Medical Home

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Expanding Pharmacist Role in Patient-Centered Medical Home 

Expanding the Role of the Pharmacist in the Patient-centered Medical Home, University of Washington

The patient-centered medical home (PCMH) has been characterized as a model of health care delivery that facilitates comprehensive and coordinated care. PCMH services are intended to be continuous, team-based, and actively involve patients and their caregivers [30]. The contributions of pharmacy faculty and pharmacists to the team in areas such as: collaborative drug therapy management; health information technology; personalized medicine; and the integration of advocacy and community-engagement learning activities into the professional curriculum are essential toward improving the quality of care, cost-effectiveness, and the patient experience [16]. Relationships established by University of Washington faculty with community partners and sustained through their teaching, research and service are described in four activities that support and strengthen the PCMH model.

Collaborative Drug Therapy Management

One of the underpinnings of a patient-centered medical home is the interprofessional team’s effectiveness in providing coordinated and integrated care. Collaborative drug therapy agreements protocols help facilitate achievement of this goal. In 2003, the American College of Clinical Pharmacy published a position paper on the involvement of pharmacists in Collaborative Drug Therapy Management (CDTM).  Included in this paper was a discussion of the evidence supporting CDTM, as well as future areas of research [31].

Currently there are over 1000 active CDTM protocols in the State of Washington that allow pharmacists to: provide immunizations; manage anticoagulant, high blood pressure, or diabetes therapy; provide tobacco cessation counseling; and provide pain management services.  Harborview Medical Center [HMC] is one of many practice settings where CDTM protocols are readily employed. HMC provides ambulatory care services through multiple primary and specialty care clinics. Pharmacists play a critical role on interprofessional teams in all seven primary care clinics and in many of the specialty clinics as well.   A description of the practice model was published by ASHP in “Collaborative Drug Therapy Management Handbook [32].”

With the current pay-for-performance incentives, clinical pharmacists are full participants in quality improvement initiatives within their clinics and provide leadership for medication-related measures. As compare to non-pharmacist care teams, those with a pharmacist have shown improved HgA1c, blood pressure and lipid management in diabetic patients; improved adherence to evidence-based therapy in patients with congestive heart failure; enhanced adherence to antiretroviral therapy in HIV+ patients; and reduced hospitalization/ER visits for children with asthma.

Pharmacists also participate in public health initiatives including the management of the smoking cessation program and are involved in health literacy projects including translating patient information sheets into multiple languages. Pharmacists bill for services using the facility fee portion of a clinic charge based on time and intensity. These visits require documentation in the medical record, which includes time spent on patient education. In order to bill for services, the pharmacists undergo the same credentialing process as physicians that includes a scope of practice document and source verification of their education, training, licensure and credentials.

Due to the pharmacist practice model and active engagement between University of Washington faculty and HMC administration HMC clinics are very popular APPE and IPPE sites. A recent IPPE project had P2 student pharmacists participating in the HMC-wide medication reconciliation program. Student pharmacists conducted patient interviews to obtain complete medication histories and entered the information into the electronic medical record in preparation for medication reconciliation to go live.

In 2007, a 2-year pharmacy administration residency program was created in concert with the Master in Health Administration degree to address the impending pharmacy leadership gap. Graduates of the program have successfully entered health-system leadership roles immediately following completion of the program. Additionally, HMC has developed a comprehensive 4-year internship program that is structured to coordinate pharmacy practice activities with the intern’s didactic content which enables the interns to staff as pharmacists and provide integral clinical services during their P4 year. The program also has a leadership track that provides additional mentoring and support for pharmacy leadership activities.

Health Information Technology Research

The University of Washington (UW) School of Pharmacy and The Everett Clinic have been collaborating on medication safety projects since 2001. The Everett Clinic, the largest independent medical group in Washington State, developed a comprehensive, homegrown electronic health record beginning in 1995. In 2003 they added the electronic prescribing module to improve medication safety and invited investigators at the University of Washington to collaborate in measuring this effect. Clinical pharmacists employed at The Everett Clinic led major aspects of electronic prescribing implementation including software design, system implementation and physician training.

Investigators at the UW School of Pharmacy obtained support from several grants (American Society of Health-System Pharmacists Research & Education Foundation, Merck Foundation, University of Washington Royalty Research Fund, and two grants from the Agency for Healthcare Research and Quality) to characterize medication errors before implementation of electronic prescribing and to explore the impact of electronic prescribing on medication errors and adverse drug events. Results revealed that implementation of the electronic prescribing system resulted in a 55% reduction in medication errors (from 18% to 8%); a reduction in adjusted odds of 70% [33][34]. These same investigators at the School of Pharmacy continue their efforts in this field with three projects evaluating the impact of clinical decision support tools, provided in the context of electronic prescribing. The first project, being conducted at The Everett Clinic, evaluates the impact of clinical decision support tools on prescriber adherence to guidelines for appropriate laboratory monitoring for specified medications. The second evaluates the impact of presentation of patient-specific pharmacogenomic biomarker results on physician prescribing patterns. The third evaluates the impact of a new method of alerting clinical pharmacists to out-of-range laboratory values on time to addressing this important medication safety issue. The latter two projects are being conducted at UW Medical Center. In a different setting, others have shown that pharmacist-led interventions significantly increase the frequency of appropriate laboratory monitoring for medications [35].

The clinical pharmacists at The Everett Clinic continue to play an instrumental role in providing population-based pharmaceutical care as employees of a physician group practice [36]. They have led disease management programs, guided the local pharmacy and therapeutics committee, implemented target drug programs and prescription to over-the-counter switches. They have negotiated pharmacy budgets with health plans and led patient assistance programs.

Personalized Medicine

The University of Washington recently founded the Northwest-Alaska Pharmacogenomics Research Network (NWA-PGRN), addressing pharmacogenomic research in American Indian and Alaska Native (AI/AN) and rural Pacific Northwest populations [37].  It is one of the 14 centers in the nation funded by the National Institutes of Health (NIH) and involves multiple campus units including, the Department of Pharmaceutics, the Department of Bioethics and Humanities, the Center for Genomics and Healthcare Equality, the Institute for Public Health Genetics, the Deep Sequencing EXOME Project, the Center for Ecogenetics and Environmental Health, the School of Pharmacy and the School of Law. The NWA-PGRN partners are the Confederated Salish Kootenai Tribes, the Center for Alaska Native Health Research, the Yukon Kuskokwin Health Corporation, the Montana Cancer Institute Foundation, the University of Montana, University of Alaska (Fairbanks), Group Health Research Institute, the Puget Sound Blood Center, the Southcentral Foundation and the University of Washington.

The formation of the NWA-PGRN was a result of earlier collaboration among faculty in the Institute of Public Health Genetics. http://depts.washington.edu/phgen/

Also beneficial to this collaboration were existing relationships between American Indian and Alaska Native populations and faculty and students actively participating in the PGRN.

The NWA-PGRN is a multi-disciplinary program that will encompasses five areas of emphasis: 

  1. consultation and qualitative research to support community-university research partnerships and identify potential barriers and facilitators for use of pharmacogenomics in healthcare;
  2. discovery and characterization of novel variation among AI/AN people for genes that contribute to the disposition and pharmacological response of the drugs warfarin, tamoxifen and tacrolimus; 
  3. demonstration that genetic testing predicts individual differences in warfarin, tamoxifen and tacrolimus disposition and response in AI/ANs, and assessment of whether unique dietary factors modify genotype-phenotype associations related to warfarin and tacrolimus; 
  4. assessment of whether pharmacogenomic testing provides unique advantages in rural populations, including AI/AN communities, due to differences in therapeutic monitoring; and
  5. identification of methods for identifying adverse drug reactions occurring in rural populations, as a basis for potential future pharmacogenomic research.

Creating advocates and engaged citizens

Engaging students in solving real-world challenges provides the foundation for them to become change agents and patient advocates.  Key elements in the activities described below are 1) raising awareness of healthcare issues, and practices or policies in need of improvement; 2) creating an environment that enables students to feel that they can be a change agent, 3) understanding the viewpoints of all the stakeholders, 4) requiring students to "champion" and take ownership of their change efforts, 5) bringing about a positive outcome or reviewing and revising strategies if the outcome is not achieved.

Fix the Law Project

For nine years, PharmD. students at the University of Washington have participated in the “Fix the Law Project.” Student groups identify a “broken law” and participate in policy analysis to propose a change to the law.  This project has been positively received, with the students’ background research and proposed language being included into revised laws and policy at the state and federal level [38]. 

Leadership and Practice Advancement APPE

The development of leadership and practice APPEs provide students with opportunities to create new patient care practice models, involving interprofessional teams.  As part of a leadership APPE, two students worked with a faculty member to develop, implement and then evaluate a MTM service at a community clinic.  One of the deliverables of this rotation was constructing a website that provided MTM and Collaborative Drug Therapy Agreement (CDTA) resources for student use. Templates were created so that students and pharmacists can easily learn the process to create a CDTA and modify it to fit their practice setting. 

The website includes patient encounter worksheets, disease specific encounter guides, and other clinical references that would assist students and practitioners in developing Medication Therapy Management Services (MTMS).  MTMS marketing materials specifically targeted for providers and patients are provided, as well as CDTA templates. A CDTA workshop was provided to all students prior to entering their APPEs and a presentation is planned for pharmacists at the Washington State Pharmacists Association’s Annual Meeting.

The author would like to acknowledge the contributions of Cindi Brennan, Wylie Burke, Cyndy Clegg, Beth Devine, Don Downing, Tom Hazlet, and Ken Thummel to this case study.

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