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Expansion of inpatient clinical pharmacy services through reallocation of pharmacists Amanda J. Sowell, Pharm.D., Department of Pharmacy, Palmetto Health Richland, Columbia, SC. Emily C. Pherson, Pharm.D., Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD. Virna I. Almuete, Pharm.D., Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD. Jennifer V. Gillespie, Pharm.D., M.B.A., Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD. Vi Gilmore, Pharm.D., Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD. Megan Jensen, Pharm.D., Department of Pharmacy, Anne Arundel Medical Center, Annapolis, MD. Ravi Nehra, Pharm.D., Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD. Kimberly M. Durand, Pharm.D., Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD. Todd W. Nesbit, Pharm.D., M.B.A., Department of Pharmacy, Academic Division, Johns Hopkins Health System, Baltimore, MD. Meghan D. Swarthout, Pharm.D., M.B.A., Department of Pharmacy, Johns Hopkins Health System, Baltimore, MD. Leigh E. Efird, Pharm.D., M.P.H., Department of Pharmacy, New York Presbyterian Hospital, New York, NY.

Purpose. The redesign of an inpatient pharmacy practice model through reallocation of pharmacy resources in order to expand clinical services is described. Methods. A pharmacy practice model change was implemented at a nonprofit academic medical center to meet the increasing demand for direct patient care services. In order to accomplish this change, the following steps were completed: reevaluation of daily tasks and responsibilities, reallocation of remaining tasks to the most appropriate pharmacy staff member, determination of the ideal number of positions needed to complete each task, and reorganization of the model into a collection of teams. Data were collected in both the preimplementation and postimplementation periods to assess the impact of the model change on operational workflow and clinical service expansion. Results. The mean ± S.D. times to order verification were 17 ± 52 minutes during the preimplementation period and 21 ± 70 minutes in the postimplementation period (p < 0.001). During the 3 months before and after implementation of the model change, the mean number of medication reconciliations performed increased from 114 to 144. After implementation of the model change, total interventions increased 194%. Notably, there was a 736% increase in the number of interventions focused on facilitating safe discharge. Conclusion. A pharmacy practice model change was successfully implemented by reallocating existing pharmacist and technician roles and increasing incorporation of pharmacy residents and students. This change led to an expansion of direct patient care coordination services without negatively affecting the operational responsibilities of the pharmacy or the need to hire additional staff. Keywords: discharge coordination, patient education, pharmaceutical services, Pharmacy Practice Model Initiative/Practice Advancement Initiative, transitions of care, workflow Am J Health-Syst Pharm. 2017; 74:e474-81


Address correspondence to Dr. Sowell ([email protected]). This article will appear in the November 1, 2017, issue of AJHP. Copyright © 2017, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/17/0000-e474. DOI 10.2146/ajhp160231


he traditional medicationdispensing role of the inpatient pharmacist has changed over time to include providing direct patient care services and participating as an active member of the healthcare team. Residency training has driven this transition by providing pharmacists the skills necessary to collaborate with multidisciplinary teams to create medication therapy management plans, develop institutional policies,


and participate in research related to pharmacy practice. Incorporating pharmacists into the multidisciplinary team is supported by growing evidence demonstrating the value of the acute care and medication safety services that pharmacists provide and by national pharmacy organizations and other healthcare disciplines.1-3 The collaboration of hospitalists and pharmacists in the inpatient setting is supported by the American Society

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of Health-System Pharmacists and the Society of Hospital Medicine.1 With the implementation of the Patient Protection and Affordable Care Act and the resulting financial penalties for excessive 30-day hospital readmissions, pharmacists have an opportunity to translate their skills and services into cost savings for their institutions. Several hospitals have found success in reducing readmissions by using multidisciplinary teams focused on providing coordinated transitional care services, with pharmacists identified as key providers for several of these services.4-9 Studies evaluating medication reconciliation have found that pharmacists performed this activity more accurately compared with other healthcare professionals, and additional studies demonstrated that medication adherence improved after pharmacist-provided discharge medication counseling.10,11 A systematic review by Kaboli et al.2 found that when pharmacists rounded on medical teams, there were decreases in the occurrence of preventable adverse drug events, number of patient transfers to higher levels of care, and medication expenditures and an increase in pharmacists’ job satisfaction. Despite the positive impact that pharmacists have demonstrated, pharmacy departments across the United States continue to struggle with ways to deploy pharmacists into roles that are not primarily tied to drug distribution. In 2010, ASHP launched the Pharmacy Practice Model Initiative, now called the Practice Advancement Initiative, which set forth the goal of changing hospital pharmacy models to allow pharmacists to improve the health and well-being of patients by serving in direct patient care roles.12 The initiative encourages pharmacists to describe the optimal pharmacy practice model, identify core clinical services to consistently provide, and determine the tools, resources, and actions needed to implement the optimal practice model with an emphasis on redeploying existing resources.

KEY POINTS • Daily responsibilities and tasks should be allocated to pharmacy team members in a way that allows each person to practice at the top of his or her license and training. • Protected time for additional, institution-specific training may allow pharmacy team members to perform more efficiently in newly assigned roles. • It is key to ensure that operations related to inpatient drug distribution are not adversely impacted when expanding clinical pharmacy services.

Background Johns Hopkins Hospital (JHH) is a nonprofit academic medical center with 1,192 licensed acute care beds and 50,594 annual inpatient admissions. In 2011, JHH’s readmissions prevention task force implemented care coordination rounds on a single hospitalist unit for pilot testing. These care coordination rounds used a multidisciplinary approach to identify and provide patients with the education, resources, and follow-up care that the task force felt were necessary to prevent a readmission after hospital discharge. The department of pharmacy, in partnership with this task force, created a bundle of services related to safe hospital transitions. These pharmacy services included pharmacist attendance at multidisciplinary rounds, patient medication education, medication reconciliation, postdischarge follow-up telephone calls, referral for a home-based medication management program, and discharge prescription planning and delivery.13,14 After this multidisciplinary approach was implemented on the pilot unit, JHH received the Health Care Innovation Award from the Centers for Medicare

and Medicaid Services. This 3-year award allowed for the implementation of the broad resources needed to improve the quality and effectiveness of healthcare delivered to patients, in part by expanding the same services offered on the pilot unit to the rest of the institution. Multidisciplinary care coordination teams were therefore deployed to more hospital units, and the pharmacy services became an integral piece of care coordination. This award provided a total of 5 pharmacist full-time equivalent (FTE) employees to support the expansion institutionwide. These pharmacists were then allocated to 1 of 5 inpatient pharmacy divisions within our institution. The largest division—the adult inpatient pharmacy (AIP)—serves the needs of medical, surgical, psychiatry, obstetric, adult emergency, acute rehabilitation, neurology, and neurosurgery patients across 483 beds on 33 nursing units and patient care areas. The hospital units served by this pharmacy division were prioritized to receive the institution’s first multidisciplinary care coordination teams, as these units discharge the most patients. The AIP was allocated 3 of the 5 pharmacist positions provided by the award, but the division still did not have enough pharmacists to provide a consistent presence on each of the newly developed care coordination teams. The AIP needed to reevaluate and change the current pharmacy practice model in order to support the institution’s care coordination expansion without increasing the number of FTEs. Former practice model. The title and role of each pharmacy staff member in the AIP were dependent on his or her training background. The pharmacists in the AIP provide care as a part of 12 multidisciplinary teams.13 The AIP staff comprised clinical specialists (postgraduate year 1 [PGY1] and postgraduate year 2 [PGY2] residency training required), point-ofcare pharmacists (PCPs) with or without a PGY1 residency or equivalent, current PGY1 and PGY2 residents, and pharmacy technicians. Residents


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DESCRIPTIVE REPORT were used monthly either as PCPs (if the goal of the rotation was to gain operational experience) or limited clinical specialists (if the goal of the rotation was to gain acute care clinical experience), but their availability was not consistent. Of the 3 award-funded pharmacists, 2 had already been integrated into the workflow of the former practice model for several months before the decision was made to change the practice model. The third awardfunded pharmacist was not hired until after the practice model was changed. With 2 of the award-funded pharmacists included, the former practice model maintained the daily operations of the pharmacy with 13 weekday daytime pharmacist positions (9 PCPs and 4 clinical specialists). With this staffing model, only 5 of the 12 multidisciplinary care coordination teams could be consistently covered. Model change strategy. Before implementation of care coordination teams at JHH, the AIP division completed a month-long model change pilot. The main objectives were to increase communication among pharmacists, elevate technician responsibilities, and provide consistent clinical services to more patients. Two pharmacy teams were created to care for approximately 120 patients. Each team consisted of a clinical specialist, 2 PCPs, and a pharmacy resident. In the pilot phase, 3 of the 4 team members rounded with a multidisciplinary team and performed acute care clinical services (e.g., documenting insulin dosing recommendations, assisting with antimicrobial stewardship). It is important to note that any pharmacist placed into this rounding position had PGY1 training or equivalent. The fourth team member was responsible for verifying medication orders, assessing parenteral nutrition orders, and communicating problem medication orders to the rounding pharmacists. Any team member could be placed into this order verification position, but it was most commonly a PCP. During this time a new pharmacy technician role was created to prepare



medications previously made only by pharmacists, troubleshoot requests to replace doses, address automated dispensing cabinet (ADC) needs, and improve medication delivery times for emergent medications. Informal feedback from staff highlighted achievement of the intended objectives. The pilot demonstrated that eligible PCPs could be separated from order verification responsibilities to be allowed protected time for rounding and performing direct patient care activities without negatively affecting daily operations. The testing period also showed that expansion of the PGY1 residency program was possible because it created more rotation experiences and precepting opportunities in a team-based structure.

Methods When developing the current model, the goal was to create or adjust team member roles so we could fully utilize each person’s level of training and spend more time providing clinical services. Feedback from pharmacy staff was most important to consider throughout implementation of the new model. A weekly team meeting was established to share concerns about the new model change, elicit group opinions for problem solving, and provide updates. The steps for operationalizing this model change are described below. Assessment of responsibilities. The first step of redesigning the practice model for the entire division was for pharmacy leadership to meet with staff to evaluate the current and anticipated tasks and responsibilities of all pharmacy team members. Tasks determined to no longer add value to the operations of the department were eliminated. For example, it was discovered that a pharmacist spent 30 minutes every morning sorting printed reports for monitored drugs and delivering these reports to the mailbox of the pharmacist assigned to review them. The automatic print function for these reports was discontinued, and each pharmacist


was provided electronic access to the necessary reports. Examples of essential tasks for evaluation included triaging replacement medication dose requests, reviewing patient medication profiles, compounding select sterile preparations by pharmacists (e.g., intravitreal injections, cassettes for short-expiration continuous infusion medications), monitoring warfarin, managing pharmacist call-outs, assessing total parenteral nutrition (TPN) orders, reviewing patient allergy reports, and assessing the use of broad-spectrum antibiotics. Once a final list of tasks was created, each task was categorized as technical, operational, clinical, or leadership related. Reallocation of pharmacy roles and responsibilities. To clearly reflect the reallocation of roles and responsibilities, position titles were changed to indicate each team member’s training. Clinical specialists were renamed team leaders, and PCPs with PGY1 training or the equivalent were renamed care coordination pharmacists (CCPs). Technicians, residents, and PCPs with no additional residency training retained the same title as under the former model. The next step in the model change was to reallocate each identified task to the most appropriate position (Figure 1). Technical tasks such as triaging incoming telephone calls, processing replacement-dose requests from the nursing units, and compounding select time-consuming sterile products were reallocated from PCPs to pharmacy technicians. All clinical tasks such as rounding with a multidisciplinary care coordination team, providing pharmacy services, monitoring warfarin, assessing an order for TPN, and precepting residents and students on an advanced pharmacy practice experience rotation were now shared between the team leaders and CCPs. Precepting students on an introductory pharmacy practice experience rotation and operational tasks, such as medication order verification and dispensing, became the responsibility of the PCPs alone. Leadership tasks (e.g.,


After Model Change

Before Model Change

Manage Call Outs

Coordinate Coverage

Restricted Antibiotic Approval Bundle of Services

Precept APPE Students Precept Residents

Warfarin Monitoring TPN Orders

Point-of-Care Pharmacist

Verify Precept IPPE Medication Students Orders



Answer Compound Medication Nursing Unit Select Sterile Delivery to Calls Products Floor

Point-of-Care Pharmacist


Team Leader

Care Coordination Pharmacist

Round With Team

Clinical Specialist

Figure 1. Roles and responsibilities of pharmacists before and after the model change. APPE = advanced pharmacy practice experience, TPN = total parenteral nutrition, IPPE = introductory pharmacy practice experience.

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DESCRIPTIVE REPORT managing staffing call-outs, finding coverage for care coordination teams without a pharmacist assigned to them for the day) became the responsibility of the team leaders. Development of new roles and responsibilities. A division-specific training program was created to promote the development of clinical skills related to staff members’ new roles and responsibilities.13 All CCPs and any PCPs interested in participating were granted protected time on the schedule for training, which was to be completed with a team leader for a 2- or 6-week period. PCPs who were interested in rounding with a multidisciplinary care coordination team underwent the 6-week training and could advance to a CCP position if deemed competent by the team leader. For those PCPs not interested in a rounding role but who wanted to participate in other direct patient care activities, a new flex position (FP) shift was created. This weekday, daytime shift was available for the PCPs who successfully completed the 2-week training that focused on providing pharmacy services (excluding rounding with a multidisciplinary care coordination team), and those who qualified rotated through this shift. This new role served a dual purpose, allowing the PCP an opportunity to practice and maintain his or her newly developed clinical skills and increasing the number of patients receiving pharmacy services. Restructuring the division. Based on the reassignment of tasks from PCPs to technicians and CCPs, it was determined that day-shift order verification responsibilities could be accomplished with fewer PCP positions. The number of medication orders for a given patient unit and the physical location of that unit were taken into account when deciding how to combine units for the purpose of order verification. The location was important, as most of the pharmacists verifying orders would be decentralized in order to maintain a pharmacy presence on the nursing units. To bet-



ter coordinate and manage these new and changing roles, the division was divided into 4 teams. Each team became responsible for managing the operational and clinical needs of its patients under the guidance of the team leader. Each pharmacy team member was assigned to a primary floor or multidisciplinary care coordination team in order to establish and maintain relationships with multidisciplinary staff and maximize the efficiency and familiarity of work. Increasing the number of CCPs within the division increased the preceptor pool and the number of advanced practice student rotations that our institution could offer. Students became integral team members by further extending the pharmacy presence at rounds under the guidance of their preceptor. Preceptors could delegate valuable, time-intensive tasks to students, such as documenting warfarin recommendations and assisting with the completion of the pharmacy services with an emphasis on collecting medication histories and performing patient education. When on rotation within our division, pharmacy residents were added to the schedule as PCPs or CCPs, depending on the goal of the rotation. To create a consistent presence of residents within our division, we worked with program directors to schedule at least 1 resident every month. A gap analysis was performed to determine the optimal number of pharmacists needed for this model change. Endpoints, including time to order verification, number of medication overrides from ADCs, number of pharmacist interventions, and HCAHPS scores, were compared before and after the change to evaluate the success of the new model.

Results The ideal number of positions in the new practice model was 18. Four teams were created (each with 1 team leader, 2 CCPs, and 1 PCP) to manage the order verification and care coordination needs of patients. The 4 team


leaders and 8 CCPs would allow the 12 multidisciplinary teams to have a pharmacist consistently assigned to them. It was determined that 5 PCPs would be needed to continue providing safe operational services for the division (4 PCPs assigned to a team, and 1 PCP remaining central to all teams as a coordinator). This ratio of pharmacists to orders was similar to that of our evening shift. Finally, 1 PCP would be scheduled to work the FP shift daily to provide additional assistance to the division where needed. Gap analysis. Ultimately, we maintained a similar number of consistently scheduled positions before and after the model change (13 versus 14, respectively). The additional position in the new model was achieved by consistently scheduling a pharmacy resident on an institutional rotation every month. Although unable to increase FTEs to meet our ideal number of positions (18), we were able to expand consistent clinical coverage from 5 to 9 of the 12 multidisciplinary care coordination teams. This expansion was achieved by collapsing 9 PCP positions to 5, converting 4 PCP positions to CCP positions, retaining the 4 team leaders, and scheduling a monthly resident. Consistent pharmacy service coverage of all 12 multidisciplinary teams was the eventual goal, but it was recognized that this would likely require hiring additional staff. In the interim, cross-coverage was still necessary, and it was the responsibility of the respective team leader to arrange coverage for any multidisciplinary care coordination team that did not have an assigned pharmacist. Time to order verification. The time to order verification was compared before (August 1–October 31, 2013) and after (February 1–April 30, 2014) the model change (preimplementation and postimplementation, respectively). Completed medication orders verified only during the 8-hour day shift were evaluated, since this was the only shift affected by the model change. The time from order placement by the provider and final

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verification by the pharmacist was calculated. The mean ± S.D. times to order verification were 17 ± 52 minutes during the preimplementation period and 21 ± 70 minutes in the postimplementation period (p < 0.001). Totals of 2,083 orders (3%) in the preimplementation period and 3,011 (5%) in the postimplementation period were verified more than an hour after the time of order placement. The mean ± S.D. times to complete order verification for these orders were 170 ± 231 minutes preimplementation and 172 ± 279 minutes postimplementation (p = 0.76). The most common orders taking prolonged times for verification were for TPN (13%), pregnancy and lactation status (3%), and 0.9% sodium chloride flush solutions (3%). Medication overrides. ADCs are used on nursing units to create more timely access to medications and decrease the workload for pharmacy. Under the usual workflow, a nurse may obtain a medication from the ADC once the pharmacist has verified the medication order. Medications included on an override list may be released from the machine before pharmacist verification in the event of an urgent need for patient care. The same 3-month time frame as the time to order verification preimplementation and postimplementation was used to assess whether collapsing PCP positions resulted in more ADC overrides. Again, only differences during the day shift were assessed. The mean ± S.D. numbers of overrides per month were 474 ± 78 before the model change and 410 ± 38 after the change (p = 0.27). Care coordination interventions. The reallocation of pharmacists’ positions described above allowed for considerable expansion of the number of patients receiving medication reconciliation, patient education, and postdischarge follow-up telephone calls. During the 3 months before and after implementation of the change model, the mean number of medication reconciliations performed increased from 114 to 144, patients who received education in

creased from 56 to 85, and postdischarge follow-up telephone calls increased from 18 to 29. Survey scores. In order to evaluate the impact of the increased amount of medication education provided with the model change, the scores for questions within the medication communication domain of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey were assessed. These questions target a patient’s understanding of the purpose and adverse effects of medications. Mean scores for those questions were compared. Although we were unable to directly link pharmacists’ interventions to these data, the observed trends were positive. When evaluating all of the units covered by the AIP after the model change, an overall 2.3% increase in the topbox percentile was achieved for the medication communication domain of HCAHPS. When comparing these units to the national HCAHPS database, the mean units increased from the 41st to the 48th percentile with the expansion of the pharmacy team. Acute care pharmacist interventions. To track the types of interventions made during hospitalization, pharmacists at JHH have historically documented interventions for 1 week per quarter and subsequently categorized those interventions based on their perceived impact (e.g., improved safety, efficacy, or knowledge; facilitated discharge; decreased drug cost). The pharmacist could select

more than 1 of the above categories to describe the interventions’ impact. These interventions are then extrapolated to project what the number of interventions would be for that particular quarter. A 2-quarter time frame (6 months) before and after the model change was selected to assess the impact of the model change on the number of interventions made. These time periods did not match those of the preimplementation and postimplementation periods used to characterize the previous data due to the extrapolated nature of the data and our inability to review this information on a monthly basis. After implementation of the model change, total interventions increased 194%. Notably, there was a 736% increase in the number of interventions focused on facilitating safe discharge (Table 1).

Discussion While this model change was not focused on the cost of care, we anticipate it may translate into cost benefits based on the findings of other studies. Bond and colleagues15 demonstrated potentially substantial cost savings with pharmacists’ participation in medical rounds and pharmacistprovided drug histories, both of which are components of our pharmacy services. They also found that increased staffing with clinical pharmacists was associated with a decrease in the total cost of care and suggested that cost savings were greatest between 1.11 and 3.23 clinical pharmacists per 100

Table 1. Results of Acute Care Pharmacist Interventions Before and After Implementation of a Model Change Before Implementation

After Implementation

% Increase

Total interventions




Improved drug safety




Improved efficacy




Improved provider knowledge





Facilitated discharge




Decreased drug cost





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DESCRIPTIVE REPORT beds. With the model change in our division, we were able to increase our number of consistent clinical pharmacists per 100 beds from 0.83 to 1.86. Training challenges. Providing a 2- or 6-week division-specific training program created challenges with scheduling, as all pharmacists undergoing training were full-time employees who needed to be removed from the workflow to allow protected training time. Only a few consecutive days of training could be granted to each pharmacist at a time, and training had to be staggered so that only 1 pharmacist was removed from the regular schedule at a time. It therefore took several months to fully train all pharmacy staff in their new roles, and continuity and reinforcement of training were challenging. In addition, the provision of training pharmacy staff was the responsibility of the team leaders and a select few CCPs, which became a large time burden when added to the other tasks assigned under the new model. The 6-week training was offered to PCPs without residency experience who were interested in becoming a CCP. Progression to a CCP was not guaranteed but determined by the team leaders based on evaluation of the PCP’s performance during training. The evaluation criteria used for this training were loosely based on the ASHP Residency Learning System Outcome R2 for PGY1 residents, which states that the learner must “provide evidencebased, patient-centered medication therapy management with interdisciplinary teams,16” as this was considered a critical skills set needed for a rounding pharmacist to be successful. It was acknowledged that some provider services care for specialized patient populations (i.e., cystic fibrosis, lumen disorders, and liver diseases) and not all CCPs had experience with these diseases or working with services such as urology or general surgery. Not having dedicated pharmacists in these areas previously, team leaders had to spend time rounding on these services first to determine the



activities and issues that future CCPs should target. Workload challenges. With the consolidation of PCP positions, adapting to an increased volume of orders per pharmacist was a challenge for the PCPs. The PCPs rotated positions and covered different floors throughout the week, but the number of orders doubled for some positions. PCPs scheduled for a “higher volume” position had to learn to prioritize their day and reach out to colleagues or the team leader if the order volume became unmanageable. Although order volume per PCP increased for the day shift, the total number of orders verified during the day shift across 5 PCPs was comparable to the order volume experienced by the 4 PCPs on the evening shift, which was not affected by the model change. To alleviate the workload for the day shift, PCPs were no longer required to focus on timeconsuming activities such as warfarin monitoring and documentation and parenteral nutrition assessment. After implementation of the new model, feedback regarding the structure of the new FP shift indicated that this PCP often had idle time in the mornings while waiting for care coordination activities to be assigned after rounds. To utilize this time more efficiently, the FP shift pharmacist was trained how to identify new overnight admissions and tasked with starting medication reconciliation for these patients. Coverage challenges. The complexity of ensuring and communicating coverage was another challenge as vacations, compensation days for weekend staffing, and unexpected absences often left gaps in the schedule. Ultimately, the team leaders were responsible to ensure that all patient care and order verification needs were covered each day for their team. If a PCP was unexpectedly out, the pharmacist in the FP shift was often used to cover the order verification needs for the team. If a CCP was out, a team leader was responsible for covering the clinical needs of the team.


For planned absences, the individual pharmacist was responsible for securing his or her own coverage and notifying the division of the coverage plan via e-mail. Given the complexity of this algorithm, the PCPs were frequently unsure of who to contact when issues arose. To help simplify this, the PCPs were instructed to contact the team leader for ultimate resolution. Feedback on mitigating the complexity of this coverage model eventually led to the creation of a pairing system where 2 CCPs or team leaders would cover for each other for scheduled days off and vacation time. The pharmacist in charge of making the schedule was aware of the pairs and would try not to schedule those pharmacists to be off on the same day. Communication challenges. Communication between all members of the pharmacy team was a significant challenge identified early in the implementation of the new model. When a problem order arose, PCPs often had difficulty identifying the care coordination team and pharmacist to which a patient had been assigned. This issue was mostly due to the inefficiency of the order verification software, which only sorts patients by location, and 1 nursing unit may admit patients from several care coordination teams. This barrier created the additional step of logging into a separate computer system to determine the assigned team. We anticipate this issue may be alleviated as our institution migrates to a new physician order-entry system with capabilities to integrate order verification and patient chart review. Understanding the new pharmacist roles in the AIP was a challenge for many colleagues outside of the division and the department. Pharmacists outside the AIP were often unsure who was scheduled for a particular service from day to day. To help with this issue, the general AIP schedule was shared with those members of the pharmacy department who required access, and the team leaders also served as a resource to help identify the CCP for the individual teams.

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Before the model change, the PCP was visible in a decentralized workspace on the unit, and the nursing staff had readily consulted this pharmacist. The model change reduced the availability and visibility of the decentralized PCP, so education about the new model structure and which pharmacist to contact was provided for the nursing staff. Ultimately, the model change allowed more pharmacists to attend daily multidisciplinary rounds and monthly nursing unit safety meetings. This increased pharmacist participation created a venue for CCPs and team leaders to foster new relationships with nursing staff, assist with any pharmacy-related issues on the units, and increase daily communication. Over time, nurses realized that CCPs and team leaders could be very instrumental in both operational and clinical aspects of patient care.

Conclusion A pharmacy practice model change was successfully implemented by reallocating existing pharmacist and technician roles and increasing incorporation of pharmacy residents and students. This change led to an expansion of direct patient care coordination services without negatively affecting the operational responsibilities of the pharmacy or the need to hire additional staff.

Disclosures The project described was supported by grant 1C1CMS331053-01-00 from the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services. The authors have declared no other potential conflicts of interest.

Previous affiliations At the time of writing Dr. Sowell was affiliated with the Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD.

Additional information The content of this paper is solely the responsibility of the authors and does not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. The research presented was conducted by the awardees. Findings may or may not be consistent with or confirmed by the findings of the independent evaluation contractor.

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8. Farley TM, Shelsky C, Powell S et al. Effect of clinical pharmacist intervention on medication discrepancies following hospital discharge. Int J Clin Pharm. 2014; 36:430-7. 9. Cawthon C, Wilia S, Osborn CY et al. Improving care transitions: the patient perspective. J Health Comm. 2012; 17(suppl 3):312-24. 10. Nester TM, Hale LS. Effectiveness of a pharmacist-acquired medication history in promoting patient safety. Am J Health-Syst Pharm. 2002; 59:2221-5. 11. Lipton HL, Bird JA. The impact of clinical pharmacists’ consultations on geriatric patients’ compliance and medical care use: a randomized controlled trial. Gerontologist. 1994; 34:307-15. 12. American Society of Health-System Pharmacists. Executive summary. Am J Health-Syst Pharm. 2011; 68:107985. 13. Gilmore V, Efird L, Fu D et al. Implementation of transitions-of-care services through acute care and outpatient pharmacy collaboration. Am J Health-Syst Pharm. 2015; 72:737-44. 14. Pherson EC, Shermock KM, Efird LE et al. Development and implementation of a postdischarge home-based medication management service. Am J Health-Syst Pharm. 2014; 71:157683. 15. Bond CA, Raehl CL, Franke T. Clinical pharmacy services, pharmacy staffing, and the total cost of care in United States hospitals. Pharmacotherapy. 2000; 20:609-21. 16. American Society of Health-System Pharmacists. Residency accreditation. (accessed 2015 Apr 14).


Expansion of inpatient clinical pharmacy services through reallocation of pharmacists.

The redesign of an inpatient pharmacy practice model through reallocation of pharmacy resources in order to expand clinical services is described...
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