Commentary Consultant Pharmacists, Advanced Practice Nurses, and the Interdisciplinary Team Barbara Resnick
A
lthough in geriatrics we are better than many other clinical disciplines in terms of providing interdisciplinary care to older adults, I hope that we will continue to recognize how much more could actually be done. Before addressing the relationship between advanced practice nurses (APNs) and consultant pharmacists in real world settings, I want to review teamwork in geriatrics in general. It is critical to define what we mean by team, what type of team, and what the goals are of this teamwork.
individuals actually implement the care. The individuals providing the care/delivering the intervention might be trained by another discipline. Is there a best approach? From a logical, patientcentered perspective, it is clearly the interdisciplinary team that is the ideal. This approach allows us to get to know each other and the skill sets that each brings to the care situation. More important, it allows for discussion about who might be the best person to facilitate the interventions that will achieve the patient-centered goal. With this type of collaboration and trust, redundancy in care and fragmentation of service could be avoided.
I see the consultant pharmacist as a hidden treasure in the interdisciplinary team, particularly in the field of geriatrics.
Team Approaches to Care A multidisciplinary team involves individuals from several disciplines being involved in care, but not focusing on or providing this care together. Each discipline evaluates the patient/patient situation from his or her perspective and provides a report (written or oral) to other team members or to the patient only. This is the most efficient way to work as a “team,” but is not always in the best interest of the patient—or the most satisfying for the team members. An interdisciplinary team approach assumes that there is interaction among the different disciplines. The interdisciplinary team should certainly include the patient as part of the team. Team members should be working toward a common goal, and the focus is on group effort, not individual input. This approach also assumes communication among the team members, with this communication ideally being real-time and verbal, versus written or electronic. Transdisciplinary teamwork is based on the idea that one individual can perform the care required under the supervision of individuals from other disciplines. Input comes from multiple disciplines, but only one or two
Where Are We in Geriatrics Today? Despite the requirement initiated in 1996 by the Joint Commission, which stated that long-term care residents must be cared for in the context of interdisciplinary teams, there are many policies and initiatives that serve as barriers to—and even contradict—a true interdisciplinary team approach. Financial barriers are some of the most evident. Although there is some hope regarding reimbursement initiatives for some team members from the Centers for Medicare & Medicaid Services, we all are well aware that the hours spent in team meetings are not really compensated for among all disciplines. There is also limited use of technology to facilitate team meetings (e.g., webinars). In addition, there are professional concerns in interdisciplinary teams: Individuals from one discipline may not trust the skill set of another discipline. In some instances, one discipline, or an individual within a certain discipline, may enter the team feeling that he or she is not an equal member and thus withhold the sharing of information and opinions.
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Commentary Advanced Practice Nurses and Relations with Consultant Pharmacists While I can speak accurately only from my perspective, I believe APNs are open to the interdisciplinary team approach and willing to work with all members of the team. Medicare’s billing framework even requires that APNs practice in a collaborative arrangement with a physician colleague(s). In a good collaborative relationship, there is trust as well as shared roles and responsibilities to provide optimal care to the resident. Likewise, APNs have a good understanding of the skills and knowledge of our nursing colleagues and thus are able to easily understand and appreciate the care-related interventions they bring to the team. I see the consultant pharmacist as a hidden treasure in the interdisciplinary team, particularly in the field of geriatrics and long-term care, where polypharmacy is endemic. I believe my advanced practice colleagues generally agree (Table 1). While individual consultant pharmacists have a wide range of experiences and skills, we came up with 13 things we appreciate receiving from consultant pharmacists on our practice. Conversely, we have experienced some frustrations that focus mostly on consultant pharmacists who do not engage in direct conversations with APNs or team members, and thus we are unable to get questions and concerns answered. Another common frustration is working with a consultant pharmacist who does not sufficiently review the patient’s chart for all aspects of a case to understand decisions that might have occurred in specific situations. For example, the chart may contain explanations of why a dose reduction was not tried or why a medication was started. Some primary care providers believe that the consultant pharmacist does not know the patient/resident, has not performed a physical exam, or discussed patient/ resident goals with the patient/resident and/or family, and thus should not offer recommendations in terms of patient management. However, I believe that the consultant pharmacist provides an important, objective review of medications based on current evidence. This is critical and allows the provider, if he or she is willing to listen, the opportunity to have another chance to consider if the treatment is currently appropriate, being implemented
150
Table 1. Consultant Pharmacist Activities That Advanced Practice Nurses Appreciate Advanced practice nurses appreciate it when consultant pharmacists: 1. Not only review charts and write notes about patients, but also are willing to talk with the prescriber directly if there is something of concern 2. Include references in their notes to support recommended changes so that the provider can evaluate the evidence for the recommended change 3. Introduce themselves as the consultant pharmacist and establish a relationship with members of the health care team 4. Make medication suggestions in a way that helps advanced practice nurses understand these recommendations 5. Talk to nurses about the residents so the nurses do not review the charts in a vacuum 6. Review written notes by the prescriber and/or other consultants 7. Demonstrate an understanding of the regulatory environment in nursing facilities 8. Get to know the residents, especially those who are long-stay residents 9. Participate in quality assurance activities 10. Engage proactively in cost-saving and quality initiatives 11. Participate in resident discharges and transitions of care related to medication management 12. Participate in resident teaching 13. Monitor high-risk medications such as warfarin safely, and of value for the resident. Often, the reviews provided by the consultant are a blessed safety check on an item that could be easily forgotten (e.g., rechecking laboratory work or considering weaning a patient off of a medication after a set period of time). In 2007, the American Society of Consultant Pharmacists (ASCP) established a policy statement delineating the physician-consultant pharmacist roles and collaboration in the nursing facility. Although I was disappointed to see that neither APNs nor physician assistants
The Consultant Pharmacist march 2014 Vol. 29, No. 3
Commentary were included in that policy statement, it does a good job of delineating the way this relationship should work. The statement does not, however, maintain a consistent interdisciplinary team approach. For example, it states: • The physician has the ultimate responsibility to determine the need and desired therapeutic goals for medications. I would recommend a revision that says: After reviewing input from all members of the interdisciplinary team, the physician has the ultimate responsibility to determine the need and desired therapeutic goals for medications. The policy also states: • Facilities should establish policies to identify those disciplines (physicians, midlevel providers, consultant pharmacists, and any other health care practitioners) [who] are permitted to make recommendations regarding medications and should inhibit other unauthorized individuals from requesting the physician to order specific medications or from recommending to nurses they ask physicians to do so. I found this statement to be in contrast to the current focus on patient-centered care. I thought about how often I have taken recommendations from patients and families on optimal ways to manage pain or depression in a resident or discussed their requests for use of alternative medications or a new drug they recently saw advertised. I would certainly recommend reconsideration of this statement to be more reflective of team care and a patientcentered approach. Outside of the long-term care setting, consultant pharmacists are also involved in interdisciplinary, multidisciplinary, or transdisciplinary work and interact with midlevel providers. There are, for example, team approaches to treatment of patients with dementia, in cardiac clinics, in intensive care units, and in oncology clinics, among other settings.1-6 The opportunities for how consultant pharmacists could be incorporated into these types of teams are endless. In some instances, the pharmacist may serve as the leader of the team and other times in which the pharmacist is a member of the team.
152
In addition to clinical opportunities, there are ways for pharmacists to work with colleagues from other disciplines in educational endeavors in traditional academic settings as well as ongoing continuing education opportunities. I personally have had the opportunity to engage pharmacists in teaching a pharmacology course with me for APNs, helped to facilitate placement of pharmacy students in clinical placements with older adults, and presented numerous formal and informal continuing education sessions with consultant pharmacists. I found these experiences to be invaluable because the pharmacists brought a level of medication knowledge and management expertise in certain areas, while the nursing students and faculty brought patient-related challenges and issues from other real-world experiences.
I believe that the consultant pharmacist provides an important, objective review of medications based on current evidence.
Next Steps: Where We Need to Go from Here As an APN I welcome the opportunity to work with pharmacy colleagues in clinical and teaching endeavors. Given the current health care environment, there is a critical need to explore ways in which the health care team can work together to improve relations; assure accessible health care for all; and provide high quality, cost-effective care. I truly believe that will require new ways for team members to communicate, trust, and better “divide and conquer” the many health care challenges we face. To improve access to care, we need to expand the services pharmacists can provide in local pharmacies. Why is it that all 50 states do not yet allow pharmacists to give immunizations? With the epidemic of diabetes, maybe pharmacists could provide blood glucose and lipid screenings and refer and/or manage hyperglycemia? Why not use every pharmacy visit as an opportunity to monitor blood pressures and provide ongoing oversight of medication
The Consultant Pharmacist march 2014 Vol. 29, No. 3
Consultant Pharmacists, Advanced Practice Nurses, and the Interdisciplinary Team
management by the pharmacist? This might help with adherence for those who are hypertensive. Likewise, if a pharmacist is available to do discharge medication teaching in the acute care setting, why must the nurse do it? This might free up the nurse to perform other care-related activities that require his or her skill set. Maybe the pharmacist can take more of a leading role in the medication management of diabetes, hypertension, and asthma during primary care visits, and APNs can focus more on other behavioral interventions (encouraging exercise) and, for example, spend time in the evaluation of skin, eyes, vision, and renal function among diabetics. Currently, there is an increasing recognition and appreciation of the complexity of care among those with multimorbidity. I believe there would be a real advantage to having a pharmacist evaluate these patients and carefully review their medication profiles for drug-disease and drug-drug interactions. The consultant pharmacist could carefully consider how a drug for one medical problem might be negatively impacting the progression of a second medical problem (e.g., the impact of a nonsteroidal anti-inflammatory drug being used for arthritis on hypertension). Further, the consultant pharmacist could recommend alternative treatments. The last area in which I believe pharmacy and APNs have opportunities to work together is in the area of policy. For those of us working in long-term care settings, there are national and state-based issues that arise that ideally are best addressed with an interdisciplinary team approach. The ordering and management of narcotics in nursing facilities is one excellent example where policy initiatives are needed at an interdisciplinary level to facilitate change. Likewise, we need to work together to expand the scope of practice among our disciplines to optimize the care that patients can receive. I certainly hope that ASCP feels comfortable reaching out to organizations such as the Gerontological Advanced Practice Nurses Association or interdisciplinary groups in which APNs have been involved, such the American Geriatrics Society,
the Gerontological Society of America, and the American Medical Directors Association to support advocacy efforts and facilitate change. In conclusion, I am certain we have come a long way from our isolated silos and the days when other providers perceived pharmacists as only counting pills and putting them in a bottle. My hope is that as we move into this new care environment under the Affordable Care Act we will begin to learn together in academic settings (pharmacy students taking physical examination courses with nursing and medicine; nursing and medical students taking pharmacology courses with pharmacy students) and thereby start the process of truly working together as an effective interdisciplinary team. One day I anticipate our children and our children’s children will wonder how we ever practiced in any other way. Barbara Resnick, PhD, CRNP, is professor and the Sonya Ziporkin Gershowitz Chair in Gerontology, University of Maryland School of Nursing, Baltimore, Maryland. Consult Pharm 2014;29:149-53. © 2014 American Society of Consultant Pharmacists, Inc. All rights reserved. Doi:10.4140/TCP.n.2014.149.
References 1. Debar L, Kindler L, Keefe FJ et al. A primary care-based interdisciplinary team approach to the treatment of chronic pain utilizing a pragmatic clinical trials framework. Transl Behav Med 2012;2:523-30. 2. Packard K, Herink M, Kuhlman P. Pharmacist’s role in an interdisciplinary cardiac rehabilitation team. J Allied Health 2012;41:113-7. 3. Durán-García E, Fernandez-Llamazares CM, Calleja-Hernández MA. Medication reconciliation: passing phase or real need? Int J Clin Pharm 2012;34:797-802. 4. Bouwmeester C. The PACE program: home-based long-term care. Consult Pharm 2012;27:24-30. 5. Valgus J, Jarr S, Schwartz R et al. Pharmacist-led, interdisciplinary model for delivery of supportive care in the ambulatory cancer clinic setting. J Oncol Pract 2010;6:1-4. 6. Erstad B, Haas CE, O’Keeffe T et al. Interdisciplinary patient care in the intensive care unit: focus on the pharmacist. Pharmacotherapy 2011;31:128-37.
The Consultant Pharmacist march 2014 Vol. 29, No. 3
153
A
lthough in geriatrics we are better than many other clinical disciplines in terms of providing interdisciplinary care to older adults, I hope that we will continue to recognize how much more could actually be done. Before addressing the relationship between advanced practice nurses (APNs) and consultant pharmacists in real world settings, I want to review teamwork in geriatrics in general. It is critical to define what we mean by team, what type of team, and what the goals are of this teamwork.
individuals actually implement the care. The individuals providing the care/delivering the intervention might be trained by another discipline. Is there a best approach? From a logical, patientcentered perspective, it is clearly the interdisciplinary team that is the ideal. This approach allows us to get to know each other and the skill sets that each brings to the care situation. More important, it allows for discussion about who might be the best person to facilitate the interventions that will achieve the patient-centered goal. With this type of collaboration and trust, redundancy in care and fragmentation of service could be avoided.
I see the consultant pharmacist as a hidden treasure in the interdisciplinary team, particularly in the field of geriatrics.
Team Approaches to Care A multidisciplinary team involves individuals from several disciplines being involved in care, but not focusing on or providing this care together. Each discipline evaluates the patient/patient situation from his or her perspective and provides a report (written or oral) to other team members or to the patient only. This is the most efficient way to work as a “team,” but is not always in the best interest of the patient—or the most satisfying for the team members. An interdisciplinary team approach assumes that there is interaction among the different disciplines. The interdisciplinary team should certainly include the patient as part of the team. Team members should be working toward a common goal, and the focus is on group effort, not individual input. This approach also assumes communication among the team members, with this communication ideally being real-time and verbal, versus written or electronic. Transdisciplinary teamwork is based on the idea that one individual can perform the care required under the supervision of individuals from other disciplines. Input comes from multiple disciplines, but only one or two
Where Are We in Geriatrics Today? Despite the requirement initiated in 1996 by the Joint Commission, which stated that long-term care residents must be cared for in the context of interdisciplinary teams, there are many policies and initiatives that serve as barriers to—and even contradict—a true interdisciplinary team approach. Financial barriers are some of the most evident. Although there is some hope regarding reimbursement initiatives for some team members from the Centers for Medicare & Medicaid Services, we all are well aware that the hours spent in team meetings are not really compensated for among all disciplines. There is also limited use of technology to facilitate team meetings (e.g., webinars). In addition, there are professional concerns in interdisciplinary teams: Individuals from one discipline may not trust the skill set of another discipline. In some instances, one discipline, or an individual within a certain discipline, may enter the team feeling that he or she is not an equal member and thus withhold the sharing of information and opinions.
The Consultant Pharmacist march 2014 Vol. 29, No. 3
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Commentary Advanced Practice Nurses and Relations with Consultant Pharmacists While I can speak accurately only from my perspective, I believe APNs are open to the interdisciplinary team approach and willing to work with all members of the team. Medicare’s billing framework even requires that APNs practice in a collaborative arrangement with a physician colleague(s). In a good collaborative relationship, there is trust as well as shared roles and responsibilities to provide optimal care to the resident. Likewise, APNs have a good understanding of the skills and knowledge of our nursing colleagues and thus are able to easily understand and appreciate the care-related interventions they bring to the team. I see the consultant pharmacist as a hidden treasure in the interdisciplinary team, particularly in the field of geriatrics and long-term care, where polypharmacy is endemic. I believe my advanced practice colleagues generally agree (Table 1). While individual consultant pharmacists have a wide range of experiences and skills, we came up with 13 things we appreciate receiving from consultant pharmacists on our practice. Conversely, we have experienced some frustrations that focus mostly on consultant pharmacists who do not engage in direct conversations with APNs or team members, and thus we are unable to get questions and concerns answered. Another common frustration is working with a consultant pharmacist who does not sufficiently review the patient’s chart for all aspects of a case to understand decisions that might have occurred in specific situations. For example, the chart may contain explanations of why a dose reduction was not tried or why a medication was started. Some primary care providers believe that the consultant pharmacist does not know the patient/resident, has not performed a physical exam, or discussed patient/ resident goals with the patient/resident and/or family, and thus should not offer recommendations in terms of patient management. However, I believe that the consultant pharmacist provides an important, objective review of medications based on current evidence. This is critical and allows the provider, if he or she is willing to listen, the opportunity to have another chance to consider if the treatment is currently appropriate, being implemented
150
Table 1. Consultant Pharmacist Activities That Advanced Practice Nurses Appreciate Advanced practice nurses appreciate it when consultant pharmacists: 1. Not only review charts and write notes about patients, but also are willing to talk with the prescriber directly if there is something of concern 2. Include references in their notes to support recommended changes so that the provider can evaluate the evidence for the recommended change 3. Introduce themselves as the consultant pharmacist and establish a relationship with members of the health care team 4. Make medication suggestions in a way that helps advanced practice nurses understand these recommendations 5. Talk to nurses about the residents so the nurses do not review the charts in a vacuum 6. Review written notes by the prescriber and/or other consultants 7. Demonstrate an understanding of the regulatory environment in nursing facilities 8. Get to know the residents, especially those who are long-stay residents 9. Participate in quality assurance activities 10. Engage proactively in cost-saving and quality initiatives 11. Participate in resident discharges and transitions of care related to medication management 12. Participate in resident teaching 13. Monitor high-risk medications such as warfarin safely, and of value for the resident. Often, the reviews provided by the consultant are a blessed safety check on an item that could be easily forgotten (e.g., rechecking laboratory work or considering weaning a patient off of a medication after a set period of time). In 2007, the American Society of Consultant Pharmacists (ASCP) established a policy statement delineating the physician-consultant pharmacist roles and collaboration in the nursing facility. Although I was disappointed to see that neither APNs nor physician assistants
The Consultant Pharmacist march 2014 Vol. 29, No. 3
Commentary were included in that policy statement, it does a good job of delineating the way this relationship should work. The statement does not, however, maintain a consistent interdisciplinary team approach. For example, it states: • The physician has the ultimate responsibility to determine the need and desired therapeutic goals for medications. I would recommend a revision that says: After reviewing input from all members of the interdisciplinary team, the physician has the ultimate responsibility to determine the need and desired therapeutic goals for medications. The policy also states: • Facilities should establish policies to identify those disciplines (physicians, midlevel providers, consultant pharmacists, and any other health care practitioners) [who] are permitted to make recommendations regarding medications and should inhibit other unauthorized individuals from requesting the physician to order specific medications or from recommending to nurses they ask physicians to do so. I found this statement to be in contrast to the current focus on patient-centered care. I thought about how often I have taken recommendations from patients and families on optimal ways to manage pain or depression in a resident or discussed their requests for use of alternative medications or a new drug they recently saw advertised. I would certainly recommend reconsideration of this statement to be more reflective of team care and a patientcentered approach. Outside of the long-term care setting, consultant pharmacists are also involved in interdisciplinary, multidisciplinary, or transdisciplinary work and interact with midlevel providers. There are, for example, team approaches to treatment of patients with dementia, in cardiac clinics, in intensive care units, and in oncology clinics, among other settings.1-6 The opportunities for how consultant pharmacists could be incorporated into these types of teams are endless. In some instances, the pharmacist may serve as the leader of the team and other times in which the pharmacist is a member of the team.
152
In addition to clinical opportunities, there are ways for pharmacists to work with colleagues from other disciplines in educational endeavors in traditional academic settings as well as ongoing continuing education opportunities. I personally have had the opportunity to engage pharmacists in teaching a pharmacology course with me for APNs, helped to facilitate placement of pharmacy students in clinical placements with older adults, and presented numerous formal and informal continuing education sessions with consultant pharmacists. I found these experiences to be invaluable because the pharmacists brought a level of medication knowledge and management expertise in certain areas, while the nursing students and faculty brought patient-related challenges and issues from other real-world experiences.
I believe that the consultant pharmacist provides an important, objective review of medications based on current evidence.
Next Steps: Where We Need to Go from Here As an APN I welcome the opportunity to work with pharmacy colleagues in clinical and teaching endeavors. Given the current health care environment, there is a critical need to explore ways in which the health care team can work together to improve relations; assure accessible health care for all; and provide high quality, cost-effective care. I truly believe that will require new ways for team members to communicate, trust, and better “divide and conquer” the many health care challenges we face. To improve access to care, we need to expand the services pharmacists can provide in local pharmacies. Why is it that all 50 states do not yet allow pharmacists to give immunizations? With the epidemic of diabetes, maybe pharmacists could provide blood glucose and lipid screenings and refer and/or manage hyperglycemia? Why not use every pharmacy visit as an opportunity to monitor blood pressures and provide ongoing oversight of medication
The Consultant Pharmacist march 2014 Vol. 29, No. 3
Consultant Pharmacists, Advanced Practice Nurses, and the Interdisciplinary Team
management by the pharmacist? This might help with adherence for those who are hypertensive. Likewise, if a pharmacist is available to do discharge medication teaching in the acute care setting, why must the nurse do it? This might free up the nurse to perform other care-related activities that require his or her skill set. Maybe the pharmacist can take more of a leading role in the medication management of diabetes, hypertension, and asthma during primary care visits, and APNs can focus more on other behavioral interventions (encouraging exercise) and, for example, spend time in the evaluation of skin, eyes, vision, and renal function among diabetics. Currently, there is an increasing recognition and appreciation of the complexity of care among those with multimorbidity. I believe there would be a real advantage to having a pharmacist evaluate these patients and carefully review their medication profiles for drug-disease and drug-drug interactions. The consultant pharmacist could carefully consider how a drug for one medical problem might be negatively impacting the progression of a second medical problem (e.g., the impact of a nonsteroidal anti-inflammatory drug being used for arthritis on hypertension). Further, the consultant pharmacist could recommend alternative treatments. The last area in which I believe pharmacy and APNs have opportunities to work together is in the area of policy. For those of us working in long-term care settings, there are national and state-based issues that arise that ideally are best addressed with an interdisciplinary team approach. The ordering and management of narcotics in nursing facilities is one excellent example where policy initiatives are needed at an interdisciplinary level to facilitate change. Likewise, we need to work together to expand the scope of practice among our disciplines to optimize the care that patients can receive. I certainly hope that ASCP feels comfortable reaching out to organizations such as the Gerontological Advanced Practice Nurses Association or interdisciplinary groups in which APNs have been involved, such the American Geriatrics Society,
the Gerontological Society of America, and the American Medical Directors Association to support advocacy efforts and facilitate change. In conclusion, I am certain we have come a long way from our isolated silos and the days when other providers perceived pharmacists as only counting pills and putting them in a bottle. My hope is that as we move into this new care environment under the Affordable Care Act we will begin to learn together in academic settings (pharmacy students taking physical examination courses with nursing and medicine; nursing and medical students taking pharmacology courses with pharmacy students) and thereby start the process of truly working together as an effective interdisciplinary team. One day I anticipate our children and our children’s children will wonder how we ever practiced in any other way. Barbara Resnick, PhD, CRNP, is professor and the Sonya Ziporkin Gershowitz Chair in Gerontology, University of Maryland School of Nursing, Baltimore, Maryland. Consult Pharm 2014;29:149-53. © 2014 American Society of Consultant Pharmacists, Inc. All rights reserved. Doi:10.4140/TCP.n.2014.149.
References 1. Debar L, Kindler L, Keefe FJ et al. A primary care-based interdisciplinary team approach to the treatment of chronic pain utilizing a pragmatic clinical trials framework. Transl Behav Med 2012;2:523-30. 2. Packard K, Herink M, Kuhlman P. Pharmacist’s role in an interdisciplinary cardiac rehabilitation team. J Allied Health 2012;41:113-7. 3. Durán-García E, Fernandez-Llamazares CM, Calleja-Hernández MA. Medication reconciliation: passing phase or real need? Int J Clin Pharm 2012;34:797-802. 4. Bouwmeester C. The PACE program: home-based long-term care. Consult Pharm 2012;27:24-30. 5. Valgus J, Jarr S, Schwartz R et al. Pharmacist-led, interdisciplinary model for delivery of supportive care in the ambulatory cancer clinic setting. J Oncol Pract 2010;6:1-4. 6. Erstad B, Haas CE, O’Keeffe T et al. Interdisciplinary patient care in the intensive care unit: focus on the pharmacist. Pharmacotherapy 2011;31:128-37.
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