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Integration of pharmacists into team-based ambulatory care practice models Zachary A. Weber, Jessica Skelley, Gloria Sachdev, Mary Ann Kliethermes, Starlin Haydon-Greatting, Binita Patel, and Samantha Schmidt Am J Health-Syst Pharm. 2015; 72:745-51
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he provision of healthcare in the United States is undergoing dramatic changes due to the escalating healthcare costs in our country. New models of healthcare based on patient-centeredness, coordination of information, and multidisciplinary care teams are emerging in response to the triple aim of improving the patient experience, increasing patient quality of care, and decreasing healthcare costs.1 Many people agree that pharmacists are critical members of care teams, with a variety of roles focusing on medication use, including direct patient care, population management activities (e.g., immunization, annual wellness screening), and education of other team members.2-8 Benefits of integrating pharmacy services into direct patient care are well documented in the literature in a wide range of studies evaluating various disease states and practice models.1,9-15 One meta-analysis examined 30 randomized trials and concluded that pharmacist-directed care improved the management of major cardiovascular risk factors in outpatients, with demonstrated reductions in blood pressure, total cholesterol, and low-density lipoprotein cholesterol.10 Another meta-analysis (of 298 studies) concluded that
pharmacist-provided direct patient care led to improvements in a wide range of therapeutic and humanistic endpoints, including patient outcomes in chronic disease states such as diabetes and hypertension as well as patient safety.9 Pharmacists’ initiatives have been able to reduce costs for health systems in a multitude of areas, including initiatives to decrease readmission rates by ensuring improved transitions of care for high-risk patients and to establish generic drugs on hospital formularies.1 While there are a number of examples of successful pharmacist integration into patient care teams, numerous ambulatory care clinical
Zachary A. Weber, Pharm.D., BCPS, BCACP, CDE, is Clinical Assistant Professor of Pharmacy Practice, Purdue College of Pharmacy, Indianapolis, IN. Jessica Skelley, Pharm.D., BCACP, is Assistant Professor of Pharmacy Practice, McWhorter School of Pharmacy, Samford University, Birmingham, AL. Gloria Sachdev, Pharm.D., is Clinical Assistant Professor, Primary Care, Purdue College of Pharmacy, and Adjunct Assistant Professor, School of Medicine, Indiana University, Indianapolis. Mary Ann Kliethermes, B.S., Pharm.D., is Vice-Chair of Ambulatory Care and Associate Professor, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL. Starlin Haydon-Greatting, M.S., B.S.Pharm., FAPhA, is Director of Clinical Programs, Illinois Pharmacists Association Patient Self-Management Programs, Spring-
pharmacy practitioners are still uncertain about how to best integrate themselves into a multidisciplinary outpatient team or overcome barriers they may face. The emphasis on developing and expanding ambulatory care practice models and the continued interest in this area of pharmacy practice were highlighted by the inaugural ASHP Ambulatory Care Conference and Summit in March 2014. To address this need, a survey was developed by the ASHP Section of Ambulatory Care Practitioners Section Advisory Group (SAG) on Compensation and Practice Sustainability and directed toward pharmacists who have successfully integrated into innovative team-based models of care. The goals of this article are to present the results of the SAG survey with the aim of learning from the experience of practices that have successfully incorporated pharmacists and to provide tips and advice for practitioners looking to accomplish similar integration. Survey method and results. In order to reach a large number of
field. Binita Patel, Pharm.D., M.S., is Director of Ambulatory/Retail Pharmacy, Froedtert Health, Milwaukee, WI. Samantha Schmidt is Postgraduate Year 1 Resident, McLeod Regional Medical Center, Florence, SC; at the time of writing she was a Pharm.D. student, Lloyd L. Gregory School of Pharmacy, Palm Beach Atlantic University, West Palm Beach, FL. Address correspondence to Dr. Weber ([email protected]). The authors have declared no potential conflicts of interest. Copyright © 2015, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/15/0501-0745. DOI 10.2146/ajhp140576
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pharmacists who have successfully achieved team integration, the survey was sent to members of the American College of Clinical Pharmacy’s Ambulatory Care Practice and Research Network via its e-mail listserver and to members of the ASHP Section of Ambulatory Care Practitioners via the ASHP Connect website. The survey was introduced to respondents as a vehicle for gathering information for development of a manuscript to highlight ambulatory care practices that have successfully incorporated pharmacists. In addition to collecting information on practice characteristics, the survey explored reasons why existing practitioners felt they were successful, as well as barriers they may have encountered or continue to face in establishing their practice sites. A secondary focus was to seek advice from these practitioners, based on their experiences, on strategies or tips for overcoming these barriers. A total of 51 pharmacists from 24 states responded to the survey. Data on integration models and practice site characteristics, as reported by survey respondents, are presented in Table 1. The collected data on the composition of patient care teams indicate a diverse mix of multidisciplinary team members, with large percentages of respondents reporting that teams include registered nurses (65%, n = 33), family practice physicians (59%, n = 30), nurse practition ers (59%, n = 30), social workers (59%, n = 30), internal medicine physicians (45%, n = 23), and dieticians (43%, n = 22). The surveyed pharmacists and their teams reported serving patients across a wide age range, with a large majority (90.6%) reporting that they serve populations of adult patients only and 32% indicating that their patients typically range in age from 45 to 64 years. The patient populations served are also diverse, including White/Caucasian (43.8% of respondents), Black/AfricanAmerican (28.3% of respondents), 746
Asian (4.7% of respondents), and Hispanic/Latino (15.7% of respondents) patients. Pharmacists reported that care teams are frequently assisted by support personnel; large percentages of respondents indicated the use of support staff in performing patient check-in (90%), scheduling patient appointments (80%), drawing samples for laboratory tests (67%), and following up on patient no-shows (55%), thus allowing time for pharmacists to prioritize other clinical responsibilities. The survey data indicate that the services most commonly performed by pharmacists in integrated models include drug information (92% of respondents); medication reconciliation (90%); provider education (84%); collaborative drug therapy management (76%); ordering, interpreting, and monitoring of laboratory tests (75%); shared visits with other healthcare providers (73%); and prospective or retrospective chart review (69%) (Table 2). The majority of responding pharmacists (90%) indicated that patient encounters are documented using electronic medical record (EMR) notes with encounter codes. Some of the most interesting survey results were the respondents’ free-text comments about how they were able to successfully integrate into multidisciplinary care teams and the barriers encountered in developing or promoting a new service. Statements of similar intent or advice were grouped by theme; these observations and recommendations, presented below (in lightly edited form) along with suggestions by the authors of this article, can serve as points of focus for pharmacists working to establish integrated models of teambased care. Obtaining “buy-in” from stakeholders. The surveyed pharmacists reported that identifying and securing supportive practice partners were crucial first steps toward team
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integration: Gaining support from key physicians and other personnel allowed for initial success and sustained support. Hospital or healthcare system administrators’ support provides continued opportunities for sustaining and expanding pharmacy services. Administrative and supportive personnel are essential to the daily workflow and success of the pharmacist in the clinic. Nursing, clerical staff, and other healthcare personnel can be used to promote the service to other providers and patients and also to aid in identifying patients who may benefit from the new pharmacy service. Recommendations of survey respondents included the following: • “Establish relationships with providers, administrators, and nurses who can model effective use of clinical pharmacy services for those in the practice who have not collaborated with a clinical pharmacist in the past or those who are slow to embrace this approach to team-based care.” • “Develop a physician champion. . . . Start with the needs of the clinic and health system (including what is ‘hot’ for integration based on health system or hospital goals) and reach out to others who have experience.”
Cooperative team member. Pharmacists’ participation as cooperative team members was identified by survey respondents as an essential aspect of successful ambulatory care service development. Respondents indicated that they were able to integrate themselves into the multidisciplinary team and identify roles in which they could be most helpful. Recognizing and assisting with identified areas of need for the team or patient population (which may be outside of the pharmacist’s specialized practice area) promoted buy-in from team personnel. Being a team member also included making sure the role of the pharmacist (i.e., what is expected and how he or she can help providers, other healthcare
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personnel, and patients) was clearly defined. The surveyed pharmacists recommended being visible, available during clinic hours, actively involved in all aspects of the service, and proactive in providing assistance: • “When starting practice activities, be willing and open to assisting with small tasks as a mechanism to encourage nurses and providers to begin to seek your assistance, and then recognize the point at which you have established yourself and can focus more on higher-level delivery of clinical pharmacy services.” • “I recommend that the pharmacist ‘identify’ first with the clinic staff/ team and, second, with the pharmacy department. Pharmacists in a clinic will only be successful if their work aligns directly with the clinic’s strategic plan, which may be different than the pharmacy department’s focus.”
Document services and outcomes. Appropriate documentation was frequently cited as being paramount to the success of service integration. Many surveyed pharmacists emphasized the necessity of documenting all patient encounters and recommendations to healthcare personnel or patients in the medical record. To show the benefits of a new or expanded service, pharmacists must collect, analyze, and report relevant outcome or performance measures related to the services they provide. Documentation patterns should align with daily responsibilities as much as possible to ensure that critical information is not overlooked, delayed, or miscommunicated. Respondents indicated that pharmacists should • “Document outcomes, report results regularly, and show the administration and providers the impact being made by services being provided consistently.” • “Track everything your organization deems valuable: clinical outcomes, pa-
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Table 1.
Integration Models and Practice Characteristics Reported by Survey Respondentsa No. (%) Respondents (n = 51)
Question and Response Options Which of the following integration models best describes your practice? Full employee of the organization A partnership between the organization and the place of employment (e.g., college or hospital affiliation with practice site using a cofunded or independent-contractor model) Organization that services several practices in a geographic area Contracted by a practice site or payer to provide services for specific patients Other In what type of clinic/practice do you currently work?b Hospital-based outpatient clinic Patient-centered medical home (PCMH) Private practice physician clinic Federally qualified healthcare center Accountable care organization (ACO) Managed care integrated system Community pharmacy Other How long have you been at your current clinic/practice site? 10 yr How did you enter into your current position? Established current practice Joined a current practice as an additional provider Took over for a previous provider Other What is your practice workflow for seeing patients?b Referral based Shared visit (pharmacist and physician or other team member see patients simultaneously) Shared visit (physician and pharmacist see patient on same day but separately) Independent visit (patient not referred) Group visit See all patients in the practice (e.g., PCMH) How are your services being reimbursed or paid for?b Fee-for-service “incident to” billing (noninstitutional) Cost avoidance College affiliation Facility fee (facility affiliated with healthcare institution) MTM billing codes Grant Capitated payments Pay for performance
29 (57)
16 (31)
1 (2)
1 (2) 4 (8)
24 (47) 16 (31) 9 (18) 6 (12) 4 (8) 1 (2) 1 (2) 12 (24) 5 (10) 11 (22) 9 (18) 10 (20) 16 (31) 34 (67) 11 (22) 4 (8) 2 (4) 44 (86) 34 (67)
29 (57) 18 (35) 16 (31) 10 (20)
19 (37) 19 (37) 15 (29) 14 (27) 11 (22) 8 (16) 7 (14) 7 (14)
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Table 1 (continued)
Question and Response Options What types of outcome measurements are you using to evaluate your services?b Disease state intermediate outcomes Patient satisfaction Medication adherence Hospitalizations and/or ED visits Readmission(s) Adverse drug events NCQA recognition measures Patient engagement CMS physician quality reporting measures Medicare “star ratings” (i.e., adherence to certain medications and appropriate use of medications in the elderly) ACO measures National Quality Strategy measures Other
No. (%) Respondents (n = 51)
45 (88) 24 (47) 21 (41) 19 (37) 16 (31) 15 (29) 13 (25) 8 (16) 8 (16)
• “Define what your end practice should look like, and understand that it may take time and hard work to get there.” • “Small progressive changes in your ambulatory care site are still victories toward making large strides in improving patient care.”
6 (12) 5 (10) 3 (6) 4 (8)
Overcoming integration barriers. Survey respondents identified difficulties in obtaining a buy-in from key stakeholders within a healthcare organization as the most prevalent hurdle to overcome when implementing a new ambulatory care pharmacy service. Their suggestions on ways to overcome this barrier to success included the following:
a MTM = medication therapy management, ED = emergency department, NCQA = National Committee for Quality Assurance, CMS = Centers for Medicare and Medicaid Services. b Survey participants were instructed to choose all applicable response options.
tient satisfaction, and time to manage the really complex patients, qualityimprovement reports—whatever makes your service viable for the long term that no other discipline can offer.”
Open communication. Knowledge and recognition of a new ambulatory care pharmacy service—and, ultimately, its success—can only occur if people are aware of its existence. Survey respondents recommended that pharmacists joining integrated teams accurately represent themselves to other clinicians in their practice setting—and persons outside of it who have an influence on the practice. Communication should start in the form of a written business plan, followed by marketing of the service; such communications should accurately convey the proposed goals of the new service and ideas for achieving them. Once the new service has been implemented, it is important to continue the communication strategies to convey program successes, using all forms of communication necessary (including oral and written forms) for 748
appropriate and thorough reporting. Survey respondents’ suggestions on effective communication included the following: • “Leave your ego at home. Integrating yourself among physicians requires establishing yourself with them so that they can’t do without you and your services.” • “Be your own advocate. Share what a great job you are doing; you are the expert at telling your own story.” • “Open communication between all team members [is key]. If they don’t know what you are doing for their patients and why, they are less likely to see you as a valued member of the team.”
Patience and perseverance. Pharmacists starting a new service will likely not be overwhelmed with patients or work as the service is being established. Following the previously discussed suggestions for success will allow for continued expansion of a service. Even if the pharmacist is taking over an existing service or coming in as an additional
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provider, it is important to get to know other team members and introduce them to the benefit that can be provided through pharmacist involvement. Survey participants offered the following suggestions:
• “[I] spent time ‘rounding’ with physicians during ambulatory care visits and provided recommendations within pharmacy’s scope to assist physicians in understanding our role and how we can enhance physician care.” • “[In my practice there is] more buy-in from nonadministrative physicians than from physicians administratively in charge. We kept constant ‘parallel dialogues’ with both administration and the people in the trenches.” • “Be a critical part of the team in all of your actions. Demonstrate your value such that the team can’t imagine how they cared for patients without you. Starting with those most open to working with a clinical pharmacist, I collected my interventions and shared those back with the team in a concise, clear format on a regular basis.”
Compensation and sustainability issues. Respondents stressed the importance of pharmacists being able to financially support themselves and contribute financially to their
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organization to ensure the success and sustainability of a new ambulatory care service. While many pharmacists with faculty roles or commitments within academia might not be paid directly by their practice sites, justification of their service comes through cost savings for the institution. Even if the pharmacist has an academic position, business plans for new ambulatory care services should explain how the services will be financially supported and advantageous for the clinic. Survey participants offered some helpful advice on addressing these issues: • “[My] institution had no experience with billing for clinical pharmacy services. We overcame this by partnering with pharmacy administration and key billing and hospital administrators to describe the service, provide examples from other academic medical centers, and identify areas of mutual understanding and how to move forward.” • “Set parameters for success [and] monitor them. Leverage successes into other areas.” • “[At my practice site within] a federally qualified health center, pharmacists are not recognized as providers. We are working to implement a system to allow for incident-to billing, whereby a provider (a physician) will come in and touch base with each patient so that we may bill for our visits.”
Additional information related to pharmacist reimbursement opportunities is available from the ASHP Section of Ambulator y Care Practitioners website (www. ashp.org/menu/PracticePolicy/ ResourceCenters/Ambulatory-Care). Challenges in defining the pharmacist’s role. According to a number of survey respondents, they often encountered unfamiliarity regarding the benefit they can bring to a service or team. Providers, healthcare personnel, and patients are all still learning about ambulatory care
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pharmacists and what role they can play in a healthcare team. Providing historical evidence of successful ambulatory care practice models, demonstrating proficiency with patient care in collaborative settings, and a willingness and availability to help in any way needed are methods recommended for enhancing awareness. Survey participants offered the following tips and suggestions: • “We were faced with a lack of understanding of the role of a clinical pharmacist in the outpatient clinic setting. We overcame this by building relationships with a physician champion, modeling these interactions, and utilizing [medication recommendation] opportunities to get our foot in the exam room door and then maximizing those opportunities by providing clinical recommendations.” • “There is confusion on the part of the patients and the providers about what you are there to do. Patients will say, ‘I already have a pharmacist.’ or ‘There’s a pharmacy here now?’ And providers will say, “We’re so glad you’re here . . .
but what are you doing here?’ If you highlight what you can do, make sure it is not at the expense of what providers ‘cannot’ do. It can be intimidating for providers if you try to say that they need a pharmacist because things are not being done effectively. It puts them at fault and creates a negative atmosphere. You need to present yourself as providing an extra service that can help improve health outcomes and thus is a benefit for providers and patients.”
Documentation hurdles. Doc umentation and outcome assessment were also identified as common challenges to be overcome during the implementation of a new ambulatory care pharmacy service. Survey respondents offered comments and tips on ways to overcome this hurdle: • “We use an EMR, but it took a few tries to get standardized templates that [could be] used by all pharmacists within our institution.” • “If you are documenting in the patient record details of your patient
Table 2.
Services Provided in Integrated Models, as Reported by Survey Respondentsa
Service Drug information Medication reconciliation Provider education Ordering, interpreting, and monitoring laboratory tests Shared visits with other healthcare providers Prospective or retrospective patient chart review Patient education (including sessions outside of scheduled clinic visits) Medication therapy management Access services or care coordination Refill authorization Research/clinical trials Preventive care or wellness screenings NCQA or PQRS reporting Immunizations Formulary management
No. (%) Respondents (n = 51) 47 (92) 46 (90) 43 (84) 38 (75) 37 (73) 35 (69) 34 (67) 30 (59) 29 (57) 27 (53) 23 (45) 18 (35) 16 (31) 14 (27) 12 (24)
NCQA = National Committee for Quality Assurance, PQRS = Physician Quality Reporting System.
a
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care visit, make sure other members of the team know where to find that note in the medical record, so everyone is on the same page and knows what the patient was told.” • “Finding the right system to capture data [is crucial]. Additionally, keep detailed records of quality measures, patients being seen, and potential billing revenues to supplement proposals for additional FTEs [fulltime equivalents] as your practice expands.”
Time management challenges. Many ambulatory care pharmacists have other roles or responsibilities in addition to their clinical services. These roles can include faculty or administrative positions, distributive functions, rounding services, and many others. Due to potential competing obligations, ambulatory care pharmacists might not be able to provide face-to-face contact with patients at their ambulatory care clinic on a full-time basis. As pharmacistmanaged services gain success, more patients are likely to be seen; this could further increase patients’ desire for more contact time with the pharmacist in a clinic setting. Pharmacists should do their best to balance competing obligations while still maintaining a focus on direct patient care responsibilities (as applicable); full dedication to practice activities that take place outside the clinic setting is equally important. Survey respondents recommended that pharmacists be forthcoming with collaborating physicians and healthcare personnel about the full job description and responsibilities of an ambulatory care pharmacist and about how much time has been allocated to a new clinic or service. Utilizing pharmacy students or residents can also help offset certain tasks that might not require the full attention of the pharmacist in charge. Relevant observations and tips noted on survey responses included the following: 750
• “We tried a variety of different methods to get patients into pharmacy appointments and learned lessons along the way (prospectively identifying patients for referrals was the most successful).” • “As your clinical responsibility expands and your practice develops, you may be faced with decisions on where your time is most valuably spent. Always keep in mind your vision for patient care for the practice site and where your services will have the largest impact on patient care.” • “Always be looking for opportunities to make patient care more effective and efficient. If you are improving outcomes and saving money, you will find a welcome reception for your services.” (This focus on results can also help provide justification for hiring technicians or additional pharmacist personnel to help alleviate time constraints.)
Discussion. Published resources for developing an ambulatory care pharmacy service provide a variety of information related to practice models, financing and reimbursement considerations, and documentation of patient encounters.3-22 Despite this available information, practitioners are still encountering difficulties and have lingering questions about the most effective techniques for promoting the success of a new service. Practical advice from successful pharmacists can add to the existing literature on this topic and provide useful guidance to practitioners embarking on this journey. For practitioners considering the development of an ambulatory care service, the advice provided by the SAG survey responses may assist in targeting their activities and preparing for aspects of daily practice likely to pose the greatest difficulty. Although the number of survey responses was relatively low, the respondents’ experiences provide a guide to understanding the key elements of integrating ambulatory
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care pharmacy services into multidisciplinary practices. Additional guidance on establishing a successful ambulatory care practice is available in the literature.16,18,19 The advice of respondents to the SAG survey echoes recommendations conveyed in the proceedings of the ASHP Ambulatory Care Summit in March 2014.23 The four domains that were the focus of the summit were (1) defining ambulatory care pharmacy practice, (2) patient care delivery and integration, (3) sustainable business models, and (4) outcomes evaluation. Other useful references provide recommendations on demonstrating the value of comprehensive medication management and pharmacist services; planning and implementing an ambulatory care pharmacist service; generating a profit or cost-avoidance margin that allows for service sustainability and expansion; and measuring, applying, and improving quality-improvement principles.24-27 The survey responses, stories, and aforementioned summit proceedings provide themes and considerations that practitioners view as the most salient to their pursuit of successful ambulatory care practices while also highlighting hurdles that may need to be overcome to foster the success, sustainability, and expansion of new practice sites. The Patient Protection and Affordable Care Act of 2010 paved the way for the development of payment models that focus on achieving patient value rather than simply boosting patient volume.28 The result has been a tremendous opportunity for the growth and expansion of ambulatory care pharmacy services in all practice settings. Developing financially sustainable services begins with pharmacists and their healthcare teams—within health systems, hospitals, physician practices, health plans, nursing homes, and any other organization working toward achieving the aims of improving the patient
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care experience, increasing quality of care, and decreasing healthcare costs. The introduction of recent legislation affecting healthcare payment and reimbursement, along with proposals regarding recognition of pharmacists as providers, has led to an exciting time of growth and opportunity for ambulatory care pharmacy services. References 1. Nigro SC, Garwood CL, Berlie H et al. Clinical pharmacists as key members of the patient-centered medical home: an opinion statement of the Ambulatory Care Practice and Research Network of the American College of Clinical Pharmacy. Pharmacotherapy. 2014; 34:96-108. 2. Giberson S, Yoder S, Lee MP. Improving patient and health system outcomes through advanced pharmacy practice. A report to the U.S. Surgeon General (revised, December 2011). www.accp. com/docs/positions/misc/improving_ patient_and_health_system_outcomes. pdf (accessed 2014 Mar 7). 3. Nichol A, Downs GE. The pharmacist as physician extender in family medicine office practice. J Am Pharm Assoc. 2006; 46:77-83. 4. Kozminski M, Busby R, McGivney MS et al. Pharmacist integration into the medical home: qualitative analysis. J Am Pharm Assoc. 2011; 51:173-83. 5. Hogue MD, Bugdalski-Strutrud C, Smith M et al. Pharmacist engagement in medical home practice: report of the APhA– APPM Medical Home Workgroup. J Am Pharm Assoc (2003). 2013; 53:e118-24. 6. McFarland MS, Davis KJ, Wallace JL. Utilization of home telehealth monitoring with active medication management by clinical pharmacists in poorly controlled diabetic patients. Pharmacotherapy. 2012; 32:420-6.
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7. Berdine HJ, Skomo ML. Development and integration of pharmacist clinical services into the patient-centered medical home. J Am Pharm Assoc (2003). 2012; 52:661-7. 8. Von Muenster SJ, Carter BL, Weber CA et al. Description of pharmacist interventions during physician-pharmacist co-management of hypertension. Pharm World Sci. 2008; 30:128-35. 9. Chisholm-Burns MA, Kim Lee J, Spivey CA et al. U.S. pharmacists’ effect as team members on patient care. Med Care. 2010; 48:923-33. 10. Santschi V, Chiolero A, Burnand B et al. Impact of pharmacist care in management of cardiovascular disease risk factors. Arch Intern Med. 2011; 171:1441-53. 11. Cripps R, Gourley G, Venugopal D, McFarland MS. An evaluation of diabetes related measures of control after 6 months of clinical pharmacy specialist intervention. J Pharm Pract. 2011; 24:332-8. 12. Ponniah A, Anderson B, Shakib S et al. Pharmacists’ role in the post-discharge management of patients with heart failure: a literature review. J Clin Pharm Ther. 2007; 32:343-52. 13. Lee JK, Grace KA, Taylor AJ. Effect of a pharmacy care program on medication adherence and persistence, blood pressure, and low-density lipoprotein cholesterol: a randomized controlled trial. JAMA. 2006; 296:2563-71. 14. Carter BL, Rogers M, Daly T et al. The potency for team-based care interventions for hypertension. A meta-analysis. Arch Intern Med. 2009; 169:1748-55. 15. Carter BL, Ardery G, Dawson JD et al. Physician and pharmacist collaboration to improve blood pressure control. Arch Intern Med. 2009; 169:1996-2002. 16. Kliethermes MA, Brown TR. Building a successful ambulatory care practice: a complete guide for pharmacists. Bethesda, MD: American Society of HealthSystem Pharmacists; 2012. 17. Isetts BJ, Schondelmeyer SW, Artz MB et al. Clinical and economic outcomes of medication therapy management services: the Minnesota experience. J Am Pharm Assoc. 2008; 48:203-11.
18. Stubbings J, Nutescu E, Durley SF, Bauman JL. Payment for clinical pharmacy services revisited. Pharmacotherapy. 2011; 31:1-8. 19. Harris IM, Baker E, Berry TM et al. Developing a business model for pharmacy services in ambulatory settings. Pharmacotherapy. 2008; 28:285. 20. Smith MA, Giuliano MR, Starkowsi MP. In Connecticut: improving patient medication management in primary care. Health Aff. 2011; 30:646-54. 21. Devine EB, Hoang S, Fisk AW et al. Strategies to optimize medication use in the physician group practice. J Am Pharm Assoc. 2009; 49:181-91. 22. Centers for Medicare and Medicaid Services. Medicare accountable care organization (ACO) quality data. https:// data.medicare.gov/Physician-Compare/ Accountable-Care-Organization-ACOQuality-Data/ytf2-4ept (accessed 2014 Mar 7). 23. American Society of Health-System Pharmacists. Proceedings of the ASHP Ambulatory Care Summit. Am J HealthSyst Pharm. 2014; 71:1345-7. 24. Helling DK, Johnson SG. Defining and advancing ambulatory care pharmacy practice: it is time to lengthen our stride. Am J Health-Syst Pharm. 2014; 71:134856. 25. Epplen KT. Patient care delivery and integration: stimulating advancement of ambulatory care pharmacy practice in an era of healthcare reform. Am J HealthSyst Pharm. 2014; 71:1357-65. 26. Sachdev G. Sustainable business models: systematic approach toward successful ambulatory care pharmacy practice. Am J Health-Syst Pharm. 2014; 71:1366-74. 27. Kliethermes MA. Outcomes evaluation: striving for excellence in ambulatory care pharmacy practice. Am J Health-Syst Pharm. 2014; 71:1375-86. 28. Government Printing Office. Patient Protection and Affordable Care Act. www. gpo.gov/fdsys/pkg/BILLS-111hr3590enr/ pdf/BILLS-111hr3590enr.pdf (accessed 2014 Mar 7).
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Integration of pharmacists into team-based ambulatory care practice models Zachary A. Weber, Jessica Skelley, Gloria Sachdev, Mary Ann Kliethermes, Starlin Haydon-Greatting, Binita Patel, and Samantha Schmidt Am J Health-Syst Pharm. 2015; 72:745-51
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he provision of healthcare in the United States is undergoing dramatic changes due to the escalating healthcare costs in our country. New models of healthcare based on patient-centeredness, coordination of information, and multidisciplinary care teams are emerging in response to the triple aim of improving the patient experience, increasing patient quality of care, and decreasing healthcare costs.1 Many people agree that pharmacists are critical members of care teams, with a variety of roles focusing on medication use, including direct patient care, population management activities (e.g., immunization, annual wellness screening), and education of other team members.2-8 Benefits of integrating pharmacy services into direct patient care are well documented in the literature in a wide range of studies evaluating various disease states and practice models.1,9-15 One meta-analysis examined 30 randomized trials and concluded that pharmacist-directed care improved the management of major cardiovascular risk factors in outpatients, with demonstrated reductions in blood pressure, total cholesterol, and low-density lipoprotein cholesterol.10 Another meta-analysis (of 298 studies) concluded that
pharmacist-provided direct patient care led to improvements in a wide range of therapeutic and humanistic endpoints, including patient outcomes in chronic disease states such as diabetes and hypertension as well as patient safety.9 Pharmacists’ initiatives have been able to reduce costs for health systems in a multitude of areas, including initiatives to decrease readmission rates by ensuring improved transitions of care for high-risk patients and to establish generic drugs on hospital formularies.1 While there are a number of examples of successful pharmacist integration into patient care teams, numerous ambulatory care clinical
Zachary A. Weber, Pharm.D., BCPS, BCACP, CDE, is Clinical Assistant Professor of Pharmacy Practice, Purdue College of Pharmacy, Indianapolis, IN. Jessica Skelley, Pharm.D., BCACP, is Assistant Professor of Pharmacy Practice, McWhorter School of Pharmacy, Samford University, Birmingham, AL. Gloria Sachdev, Pharm.D., is Clinical Assistant Professor, Primary Care, Purdue College of Pharmacy, and Adjunct Assistant Professor, School of Medicine, Indiana University, Indianapolis. Mary Ann Kliethermes, B.S., Pharm.D., is Vice-Chair of Ambulatory Care and Associate Professor, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL. Starlin Haydon-Greatting, M.S., B.S.Pharm., FAPhA, is Director of Clinical Programs, Illinois Pharmacists Association Patient Self-Management Programs, Spring-
pharmacy practitioners are still uncertain about how to best integrate themselves into a multidisciplinary outpatient team or overcome barriers they may face. The emphasis on developing and expanding ambulatory care practice models and the continued interest in this area of pharmacy practice were highlighted by the inaugural ASHP Ambulatory Care Conference and Summit in March 2014. To address this need, a survey was developed by the ASHP Section of Ambulatory Care Practitioners Section Advisory Group (SAG) on Compensation and Practice Sustainability and directed toward pharmacists who have successfully integrated into innovative team-based models of care. The goals of this article are to present the results of the SAG survey with the aim of learning from the experience of practices that have successfully incorporated pharmacists and to provide tips and advice for practitioners looking to accomplish similar integration. Survey method and results. In order to reach a large number of
field. Binita Patel, Pharm.D., M.S., is Director of Ambulatory/Retail Pharmacy, Froedtert Health, Milwaukee, WI. Samantha Schmidt is Postgraduate Year 1 Resident, McLeod Regional Medical Center, Florence, SC; at the time of writing she was a Pharm.D. student, Lloyd L. Gregory School of Pharmacy, Palm Beach Atlantic University, West Palm Beach, FL. Address correspondence to Dr. Weber ([email protected]). The authors have declared no potential conflicts of interest. Copyright © 2015, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/15/0501-0745. DOI 10.2146/ajhp140576
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pharmacists who have successfully achieved team integration, the survey was sent to members of the American College of Clinical Pharmacy’s Ambulatory Care Practice and Research Network via its e-mail listserver and to members of the ASHP Section of Ambulatory Care Practitioners via the ASHP Connect website. The survey was introduced to respondents as a vehicle for gathering information for development of a manuscript to highlight ambulatory care practices that have successfully incorporated pharmacists. In addition to collecting information on practice characteristics, the survey explored reasons why existing practitioners felt they were successful, as well as barriers they may have encountered or continue to face in establishing their practice sites. A secondary focus was to seek advice from these practitioners, based on their experiences, on strategies or tips for overcoming these barriers. A total of 51 pharmacists from 24 states responded to the survey. Data on integration models and practice site characteristics, as reported by survey respondents, are presented in Table 1. The collected data on the composition of patient care teams indicate a diverse mix of multidisciplinary team members, with large percentages of respondents reporting that teams include registered nurses (65%, n = 33), family practice physicians (59%, n = 30), nurse practition ers (59%, n = 30), social workers (59%, n = 30), internal medicine physicians (45%, n = 23), and dieticians (43%, n = 22). The surveyed pharmacists and their teams reported serving patients across a wide age range, with a large majority (90.6%) reporting that they serve populations of adult patients only and 32% indicating that their patients typically range in age from 45 to 64 years. The patient populations served are also diverse, including White/Caucasian (43.8% of respondents), Black/AfricanAmerican (28.3% of respondents), 746
Asian (4.7% of respondents), and Hispanic/Latino (15.7% of respondents) patients. Pharmacists reported that care teams are frequently assisted by support personnel; large percentages of respondents indicated the use of support staff in performing patient check-in (90%), scheduling patient appointments (80%), drawing samples for laboratory tests (67%), and following up on patient no-shows (55%), thus allowing time for pharmacists to prioritize other clinical responsibilities. The survey data indicate that the services most commonly performed by pharmacists in integrated models include drug information (92% of respondents); medication reconciliation (90%); provider education (84%); collaborative drug therapy management (76%); ordering, interpreting, and monitoring of laboratory tests (75%); shared visits with other healthcare providers (73%); and prospective or retrospective chart review (69%) (Table 2). The majority of responding pharmacists (90%) indicated that patient encounters are documented using electronic medical record (EMR) notes with encounter codes. Some of the most interesting survey results were the respondents’ free-text comments about how they were able to successfully integrate into multidisciplinary care teams and the barriers encountered in developing or promoting a new service. Statements of similar intent or advice were grouped by theme; these observations and recommendations, presented below (in lightly edited form) along with suggestions by the authors of this article, can serve as points of focus for pharmacists working to establish integrated models of teambased care. Obtaining “buy-in” from stakeholders. The surveyed pharmacists reported that identifying and securing supportive practice partners were crucial first steps toward team
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integration: Gaining support from key physicians and other personnel allowed for initial success and sustained support. Hospital or healthcare system administrators’ support provides continued opportunities for sustaining and expanding pharmacy services. Administrative and supportive personnel are essential to the daily workflow and success of the pharmacist in the clinic. Nursing, clerical staff, and other healthcare personnel can be used to promote the service to other providers and patients and also to aid in identifying patients who may benefit from the new pharmacy service. Recommendations of survey respondents included the following: • “Establish relationships with providers, administrators, and nurses who can model effective use of clinical pharmacy services for those in the practice who have not collaborated with a clinical pharmacist in the past or those who are slow to embrace this approach to team-based care.” • “Develop a physician champion. . . . Start with the needs of the clinic and health system (including what is ‘hot’ for integration based on health system or hospital goals) and reach out to others who have experience.”
Cooperative team member. Pharmacists’ participation as cooperative team members was identified by survey respondents as an essential aspect of successful ambulatory care service development. Respondents indicated that they were able to integrate themselves into the multidisciplinary team and identify roles in which they could be most helpful. Recognizing and assisting with identified areas of need for the team or patient population (which may be outside of the pharmacist’s specialized practice area) promoted buy-in from team personnel. Being a team member also included making sure the role of the pharmacist (i.e., what is expected and how he or she can help providers, other healthcare
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personnel, and patients) was clearly defined. The surveyed pharmacists recommended being visible, available during clinic hours, actively involved in all aspects of the service, and proactive in providing assistance: • “When starting practice activities, be willing and open to assisting with small tasks as a mechanism to encourage nurses and providers to begin to seek your assistance, and then recognize the point at which you have established yourself and can focus more on higher-level delivery of clinical pharmacy services.” • “I recommend that the pharmacist ‘identify’ first with the clinic staff/ team and, second, with the pharmacy department. Pharmacists in a clinic will only be successful if their work aligns directly with the clinic’s strategic plan, which may be different than the pharmacy department’s focus.”
Document services and outcomes. Appropriate documentation was frequently cited as being paramount to the success of service integration. Many surveyed pharmacists emphasized the necessity of documenting all patient encounters and recommendations to healthcare personnel or patients in the medical record. To show the benefits of a new or expanded service, pharmacists must collect, analyze, and report relevant outcome or performance measures related to the services they provide. Documentation patterns should align with daily responsibilities as much as possible to ensure that critical information is not overlooked, delayed, or miscommunicated. Respondents indicated that pharmacists should • “Document outcomes, report results regularly, and show the administration and providers the impact being made by services being provided consistently.” • “Track everything your organization deems valuable: clinical outcomes, pa-
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Table 1.
Integration Models and Practice Characteristics Reported by Survey Respondentsa No. (%) Respondents (n = 51)
Question and Response Options Which of the following integration models best describes your practice? Full employee of the organization A partnership between the organization and the place of employment (e.g., college or hospital affiliation with practice site using a cofunded or independent-contractor model) Organization that services several practices in a geographic area Contracted by a practice site or payer to provide services for specific patients Other In what type of clinic/practice do you currently work?b Hospital-based outpatient clinic Patient-centered medical home (PCMH) Private practice physician clinic Federally qualified healthcare center Accountable care organization (ACO) Managed care integrated system Community pharmacy Other How long have you been at your current clinic/practice site? 10 yr How did you enter into your current position? Established current practice Joined a current practice as an additional provider Took over for a previous provider Other What is your practice workflow for seeing patients?b Referral based Shared visit (pharmacist and physician or other team member see patients simultaneously) Shared visit (physician and pharmacist see patient on same day but separately) Independent visit (patient not referred) Group visit See all patients in the practice (e.g., PCMH) How are your services being reimbursed or paid for?b Fee-for-service “incident to” billing (noninstitutional) Cost avoidance College affiliation Facility fee (facility affiliated with healthcare institution) MTM billing codes Grant Capitated payments Pay for performance
29 (57)
16 (31)
1 (2)
1 (2) 4 (8)
24 (47) 16 (31) 9 (18) 6 (12) 4 (8) 1 (2) 1 (2) 12 (24) 5 (10) 11 (22) 9 (18) 10 (20) 16 (31) 34 (67) 11 (22) 4 (8) 2 (4) 44 (86) 34 (67)
29 (57) 18 (35) 16 (31) 10 (20)
19 (37) 19 (37) 15 (29) 14 (27) 11 (22) 8 (16) 7 (14) 7 (14)
Continued on next page
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Table 1 (continued)
Question and Response Options What types of outcome measurements are you using to evaluate your services?b Disease state intermediate outcomes Patient satisfaction Medication adherence Hospitalizations and/or ED visits Readmission(s) Adverse drug events NCQA recognition measures Patient engagement CMS physician quality reporting measures Medicare “star ratings” (i.e., adherence to certain medications and appropriate use of medications in the elderly) ACO measures National Quality Strategy measures Other
No. (%) Respondents (n = 51)
45 (88) 24 (47) 21 (41) 19 (37) 16 (31) 15 (29) 13 (25) 8 (16) 8 (16)
• “Define what your end practice should look like, and understand that it may take time and hard work to get there.” • “Small progressive changes in your ambulatory care site are still victories toward making large strides in improving patient care.”
6 (12) 5 (10) 3 (6) 4 (8)
Overcoming integration barriers. Survey respondents identified difficulties in obtaining a buy-in from key stakeholders within a healthcare organization as the most prevalent hurdle to overcome when implementing a new ambulatory care pharmacy service. Their suggestions on ways to overcome this barrier to success included the following:
a MTM = medication therapy management, ED = emergency department, NCQA = National Committee for Quality Assurance, CMS = Centers for Medicare and Medicaid Services. b Survey participants were instructed to choose all applicable response options.
tient satisfaction, and time to manage the really complex patients, qualityimprovement reports—whatever makes your service viable for the long term that no other discipline can offer.”
Open communication. Knowledge and recognition of a new ambulatory care pharmacy service—and, ultimately, its success—can only occur if people are aware of its existence. Survey respondents recommended that pharmacists joining integrated teams accurately represent themselves to other clinicians in their practice setting—and persons outside of it who have an influence on the practice. Communication should start in the form of a written business plan, followed by marketing of the service; such communications should accurately convey the proposed goals of the new service and ideas for achieving them. Once the new service has been implemented, it is important to continue the communication strategies to convey program successes, using all forms of communication necessary (including oral and written forms) for 748
appropriate and thorough reporting. Survey respondents’ suggestions on effective communication included the following: • “Leave your ego at home. Integrating yourself among physicians requires establishing yourself with them so that they can’t do without you and your services.” • “Be your own advocate. Share what a great job you are doing; you are the expert at telling your own story.” • “Open communication between all team members [is key]. If they don’t know what you are doing for their patients and why, they are less likely to see you as a valued member of the team.”
Patience and perseverance. Pharmacists starting a new service will likely not be overwhelmed with patients or work as the service is being established. Following the previously discussed suggestions for success will allow for continued expansion of a service. Even if the pharmacist is taking over an existing service or coming in as an additional
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provider, it is important to get to know other team members and introduce them to the benefit that can be provided through pharmacist involvement. Survey participants offered the following suggestions:
• “[I] spent time ‘rounding’ with physicians during ambulatory care visits and provided recommendations within pharmacy’s scope to assist physicians in understanding our role and how we can enhance physician care.” • “[In my practice there is] more buy-in from nonadministrative physicians than from physicians administratively in charge. We kept constant ‘parallel dialogues’ with both administration and the people in the trenches.” • “Be a critical part of the team in all of your actions. Demonstrate your value such that the team can’t imagine how they cared for patients without you. Starting with those most open to working with a clinical pharmacist, I collected my interventions and shared those back with the team in a concise, clear format on a regular basis.”
Compensation and sustainability issues. Respondents stressed the importance of pharmacists being able to financially support themselves and contribute financially to their
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organization to ensure the success and sustainability of a new ambulatory care service. While many pharmacists with faculty roles or commitments within academia might not be paid directly by their practice sites, justification of their service comes through cost savings for the institution. Even if the pharmacist has an academic position, business plans for new ambulatory care services should explain how the services will be financially supported and advantageous for the clinic. Survey participants offered some helpful advice on addressing these issues: • “[My] institution had no experience with billing for clinical pharmacy services. We overcame this by partnering with pharmacy administration and key billing and hospital administrators to describe the service, provide examples from other academic medical centers, and identify areas of mutual understanding and how to move forward.” • “Set parameters for success [and] monitor them. Leverage successes into other areas.” • “[At my practice site within] a federally qualified health center, pharmacists are not recognized as providers. We are working to implement a system to allow for incident-to billing, whereby a provider (a physician) will come in and touch base with each patient so that we may bill for our visits.”
Additional information related to pharmacist reimbursement opportunities is available from the ASHP Section of Ambulator y Care Practitioners website (www. ashp.org/menu/PracticePolicy/ ResourceCenters/Ambulatory-Care). Challenges in defining the pharmacist’s role. According to a number of survey respondents, they often encountered unfamiliarity regarding the benefit they can bring to a service or team. Providers, healthcare personnel, and patients are all still learning about ambulatory care
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pharmacists and what role they can play in a healthcare team. Providing historical evidence of successful ambulatory care practice models, demonstrating proficiency with patient care in collaborative settings, and a willingness and availability to help in any way needed are methods recommended for enhancing awareness. Survey participants offered the following tips and suggestions: • “We were faced with a lack of understanding of the role of a clinical pharmacist in the outpatient clinic setting. We overcame this by building relationships with a physician champion, modeling these interactions, and utilizing [medication recommendation] opportunities to get our foot in the exam room door and then maximizing those opportunities by providing clinical recommendations.” • “There is confusion on the part of the patients and the providers about what you are there to do. Patients will say, ‘I already have a pharmacist.’ or ‘There’s a pharmacy here now?’ And providers will say, “We’re so glad you’re here . . .
but what are you doing here?’ If you highlight what you can do, make sure it is not at the expense of what providers ‘cannot’ do. It can be intimidating for providers if you try to say that they need a pharmacist because things are not being done effectively. It puts them at fault and creates a negative atmosphere. You need to present yourself as providing an extra service that can help improve health outcomes and thus is a benefit for providers and patients.”
Documentation hurdles. Doc umentation and outcome assessment were also identified as common challenges to be overcome during the implementation of a new ambulatory care pharmacy service. Survey respondents offered comments and tips on ways to overcome this hurdle: • “We use an EMR, but it took a few tries to get standardized templates that [could be] used by all pharmacists within our institution.” • “If you are documenting in the patient record details of your patient
Table 2.
Services Provided in Integrated Models, as Reported by Survey Respondentsa
Service Drug information Medication reconciliation Provider education Ordering, interpreting, and monitoring laboratory tests Shared visits with other healthcare providers Prospective or retrospective patient chart review Patient education (including sessions outside of scheduled clinic visits) Medication therapy management Access services or care coordination Refill authorization Research/clinical trials Preventive care or wellness screenings NCQA or PQRS reporting Immunizations Formulary management
No. (%) Respondents (n = 51) 47 (92) 46 (90) 43 (84) 38 (75) 37 (73) 35 (69) 34 (67) 30 (59) 29 (57) 27 (53) 23 (45) 18 (35) 16 (31) 14 (27) 12 (24)
NCQA = National Committee for Quality Assurance, PQRS = Physician Quality Reporting System.
a
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care visit, make sure other members of the team know where to find that note in the medical record, so everyone is on the same page and knows what the patient was told.” • “Finding the right system to capture data [is crucial]. Additionally, keep detailed records of quality measures, patients being seen, and potential billing revenues to supplement proposals for additional FTEs [fulltime equivalents] as your practice expands.”
Time management challenges. Many ambulatory care pharmacists have other roles or responsibilities in addition to their clinical services. These roles can include faculty or administrative positions, distributive functions, rounding services, and many others. Due to potential competing obligations, ambulatory care pharmacists might not be able to provide face-to-face contact with patients at their ambulatory care clinic on a full-time basis. As pharmacistmanaged services gain success, more patients are likely to be seen; this could further increase patients’ desire for more contact time with the pharmacist in a clinic setting. Pharmacists should do their best to balance competing obligations while still maintaining a focus on direct patient care responsibilities (as applicable); full dedication to practice activities that take place outside the clinic setting is equally important. Survey respondents recommended that pharmacists be forthcoming with collaborating physicians and healthcare personnel about the full job description and responsibilities of an ambulatory care pharmacist and about how much time has been allocated to a new clinic or service. Utilizing pharmacy students or residents can also help offset certain tasks that might not require the full attention of the pharmacist in charge. Relevant observations and tips noted on survey responses included the following: 750
• “We tried a variety of different methods to get patients into pharmacy appointments and learned lessons along the way (prospectively identifying patients for referrals was the most successful).” • “As your clinical responsibility expands and your practice develops, you may be faced with decisions on where your time is most valuably spent. Always keep in mind your vision for patient care for the practice site and where your services will have the largest impact on patient care.” • “Always be looking for opportunities to make patient care more effective and efficient. If you are improving outcomes and saving money, you will find a welcome reception for your services.” (This focus on results can also help provide justification for hiring technicians or additional pharmacist personnel to help alleviate time constraints.)
Discussion. Published resources for developing an ambulatory care pharmacy service provide a variety of information related to practice models, financing and reimbursement considerations, and documentation of patient encounters.3-22 Despite this available information, practitioners are still encountering difficulties and have lingering questions about the most effective techniques for promoting the success of a new service. Practical advice from successful pharmacists can add to the existing literature on this topic and provide useful guidance to practitioners embarking on this journey. For practitioners considering the development of an ambulatory care service, the advice provided by the SAG survey responses may assist in targeting their activities and preparing for aspects of daily practice likely to pose the greatest difficulty. Although the number of survey responses was relatively low, the respondents’ experiences provide a guide to understanding the key elements of integrating ambulatory
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care pharmacy services into multidisciplinary practices. Additional guidance on establishing a successful ambulatory care practice is available in the literature.16,18,19 The advice of respondents to the SAG survey echoes recommendations conveyed in the proceedings of the ASHP Ambulatory Care Summit in March 2014.23 The four domains that were the focus of the summit were (1) defining ambulatory care pharmacy practice, (2) patient care delivery and integration, (3) sustainable business models, and (4) outcomes evaluation. Other useful references provide recommendations on demonstrating the value of comprehensive medication management and pharmacist services; planning and implementing an ambulatory care pharmacist service; generating a profit or cost-avoidance margin that allows for service sustainability and expansion; and measuring, applying, and improving quality-improvement principles.24-27 The survey responses, stories, and aforementioned summit proceedings provide themes and considerations that practitioners view as the most salient to their pursuit of successful ambulatory care practices while also highlighting hurdles that may need to be overcome to foster the success, sustainability, and expansion of new practice sites. The Patient Protection and Affordable Care Act of 2010 paved the way for the development of payment models that focus on achieving patient value rather than simply boosting patient volume.28 The result has been a tremendous opportunity for the growth and expansion of ambulatory care pharmacy services in all practice settings. Developing financially sustainable services begins with pharmacists and their healthcare teams—within health systems, hospitals, physician practices, health plans, nursing homes, and any other organization working toward achieving the aims of improving the patient
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care experience, increasing quality of care, and decreasing healthcare costs. The introduction of recent legislation affecting healthcare payment and reimbursement, along with proposals regarding recognition of pharmacists as providers, has led to an exciting time of growth and opportunity for ambulatory care pharmacy services. References 1. Nigro SC, Garwood CL, Berlie H et al. Clinical pharmacists as key members of the patient-centered medical home: an opinion statement of the Ambulatory Care Practice and Research Network of the American College of Clinical Pharmacy. Pharmacotherapy. 2014; 34:96-108. 2. Giberson S, Yoder S, Lee MP. Improving patient and health system outcomes through advanced pharmacy practice. A report to the U.S. Surgeon General (revised, December 2011). www.accp. com/docs/positions/misc/improving_ patient_and_health_system_outcomes. pdf (accessed 2014 Mar 7). 3. Nichol A, Downs GE. The pharmacist as physician extender in family medicine office practice. J Am Pharm Assoc. 2006; 46:77-83. 4. Kozminski M, Busby R, McGivney MS et al. Pharmacist integration into the medical home: qualitative analysis. J Am Pharm Assoc. 2011; 51:173-83. 5. Hogue MD, Bugdalski-Strutrud C, Smith M et al. Pharmacist engagement in medical home practice: report of the APhA– APPM Medical Home Workgroup. J Am Pharm Assoc (2003). 2013; 53:e118-24. 6. McFarland MS, Davis KJ, Wallace JL. Utilization of home telehealth monitoring with active medication management by clinical pharmacists in poorly controlled diabetic patients. Pharmacotherapy. 2012; 32:420-6.
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7. Berdine HJ, Skomo ML. Development and integration of pharmacist clinical services into the patient-centered medical home. J Am Pharm Assoc (2003). 2012; 52:661-7. 8. Von Muenster SJ, Carter BL, Weber CA et al. Description of pharmacist interventions during physician-pharmacist co-management of hypertension. Pharm World Sci. 2008; 30:128-35. 9. Chisholm-Burns MA, Kim Lee J, Spivey CA et al. U.S. pharmacists’ effect as team members on patient care. Med Care. 2010; 48:923-33. 10. Santschi V, Chiolero A, Burnand B et al. Impact of pharmacist care in management of cardiovascular disease risk factors. Arch Intern Med. 2011; 171:1441-53. 11. Cripps R, Gourley G, Venugopal D, McFarland MS. An evaluation of diabetes related measures of control after 6 months of clinical pharmacy specialist intervention. J Pharm Pract. 2011; 24:332-8. 12. Ponniah A, Anderson B, Shakib S et al. Pharmacists’ role in the post-discharge management of patients with heart failure: a literature review. J Clin Pharm Ther. 2007; 32:343-52. 13. Lee JK, Grace KA, Taylor AJ. Effect of a pharmacy care program on medication adherence and persistence, blood pressure, and low-density lipoprotein cholesterol: a randomized controlled trial. JAMA. 2006; 296:2563-71. 14. Carter BL, Rogers M, Daly T et al. The potency for team-based care interventions for hypertension. A meta-analysis. Arch Intern Med. 2009; 169:1748-55. 15. Carter BL, Ardery G, Dawson JD et al. Physician and pharmacist collaboration to improve blood pressure control. Arch Intern Med. 2009; 169:1996-2002. 16. Kliethermes MA, Brown TR. Building a successful ambulatory care practice: a complete guide for pharmacists. Bethesda, MD: American Society of HealthSystem Pharmacists; 2012. 17. Isetts BJ, Schondelmeyer SW, Artz MB et al. Clinical and economic outcomes of medication therapy management services: the Minnesota experience. J Am Pharm Assoc. 2008; 48:203-11.
18. Stubbings J, Nutescu E, Durley SF, Bauman JL. Payment for clinical pharmacy services revisited. Pharmacotherapy. 2011; 31:1-8. 19. Harris IM, Baker E, Berry TM et al. Developing a business model for pharmacy services in ambulatory settings. Pharmacotherapy. 2008; 28:285. 20. Smith MA, Giuliano MR, Starkowsi MP. In Connecticut: improving patient medication management in primary care. Health Aff. 2011; 30:646-54. 21. Devine EB, Hoang S, Fisk AW et al. Strategies to optimize medication use in the physician group practice. J Am Pharm Assoc. 2009; 49:181-91. 22. Centers for Medicare and Medicaid Services. Medicare accountable care organization (ACO) quality data. https:// data.medicare.gov/Physician-Compare/ Accountable-Care-Organization-ACOQuality-Data/ytf2-4ept (accessed 2014 Mar 7). 23. American Society of Health-System Pharmacists. Proceedings of the ASHP Ambulatory Care Summit. Am J HealthSyst Pharm. 2014; 71:1345-7. 24. Helling DK, Johnson SG. Defining and advancing ambulatory care pharmacy practice: it is time to lengthen our stride. Am J Health-Syst Pharm. 2014; 71:134856. 25. Epplen KT. Patient care delivery and integration: stimulating advancement of ambulatory care pharmacy practice in an era of healthcare reform. Am J HealthSyst Pharm. 2014; 71:1357-65. 26. Sachdev G. Sustainable business models: systematic approach toward successful ambulatory care pharmacy practice. Am J Health-Syst Pharm. 2014; 71:1366-74. 27. Kliethermes MA. Outcomes evaluation: striving for excellence in ambulatory care pharmacy practice. Am J Health-Syst Pharm. 2014; 71:1375-86. 28. Government Printing Office. Patient Protection and Affordable Care Act. www. gpo.gov/fdsys/pkg/BILLS-111hr3590enr/ pdf/BILLS-111hr3590enr.pdf (accessed 2014 Mar 7).
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