Research in Social and Administrative Pharmacy j (2015) j–j

Original Research

Knowing the patient: A qualitative study on care-taking and the clinical pharmacist-patient relationship Megan B. McCullough, Ph.D.a,*, Beth Ann Petrakis, M.P.A.a, Christopher Gillespie, Ph.D.a, Jeffrey L. Solomon, Ph.D.a, Angela M. Park, Pharm.D.b, Heather Ourth, Pharm.D.c, Anthony Morreale, Pharm.D.d, Adam J. Rose, M.D., M.Sc.a,e a

Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Hospital (152), 200 Springs Road, Bedford, MA 01730, USA b New England VERC, VA Boston Healthcare System, 150 South Huntington Avenue, Jamaica Plain, MA 02130, USA c Clinical Pharmacy Practice Program and Outcomes Assessment, Pharmacy Benefits Management Services, Department of Veterans Affairs, 110 Timber Ln, Ackworth, IA 50001, USA d Clinical Pharmacy Services and Healthcare Services Research, Pharmacy Benefits Management VACO, Department of Veterans Affairs, 1644 Crespo Dr., La Jolla, CA 92037, USA e Department of Medicine, Section of General Internal Medicine, Boston University, School of Medicine, 72 East Concord St., Boston, MA 02118, USA

Abstract Background: Previous studies have found clinical pharmacists (CPs) and clinical pharmacy specialists (CPSs) in direct patient care have positive effects across various patient outcomes. However, there are also other kinds of care-taking occurring in pharmacy-run clinic appointments that produce value for patients. Objective: To identify and characterize how CPs/CPSs in direct care clinics develop and practice caretaking behaviors which advance the pharmacist-patient relationship. Methods: Semi-structured CP/CPS interviews were conducted once per year for two years (46 year 1, 50 year 2) along with direct observations of clinical pharmacy work as part of an anticoagulation improvement intervention. Participants were from Veterans Health Administration (VHA) medical centers and VHA community-based outpatient clinics in the Northeastern U.S. Interviews were transcribed verbatim and thematically analyzed using NVIVO 10 software. Results: It was found that CPs/CPSs practice “knowing the patient” in ways related to, but distinct from this practice in the nursing literature. For CPs/CPSs, knowing the patient occurred over time, and it produced familiarity and trust between CPs/CPs and patients. A reciprocal relationship developed in which patients came to rely on CP/CPSs for other types of assistance. Patterns of knowing the patient and being known by the patient manifested in three distinct ways: 1) identifying the patient’s unmet needs, 2) explaining other medications, and 3) helping the patient navigate the system.

Conflict of interest: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. * Corresponding author. Tel.: þ1 781 687 4503. E-mail address: [email protected] (M.B. McCullough). 1551-7411/$ - see front matter Published by Elsevier Inc. http://dx.doi.org/10.1016/j.sapharm.2015.04.005

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Conclusion: This research identifies an action, knowing the patient, whereby CPs use their knowledge of the patient to deliver individualized care. This study contributes to the developing literature on pharmacistpatient relationships and pharmacist-patient communication. Published by Elsevier Inc. Keywords: Knowing the patient; Pharmacist-patient communication; Pharmacist-patient relationship; Patient care; Time; Clinical pharmacy services

Research on provider-identity formation among clinical pharmacists (CPs) and clinical pharmacy specialists (CPS) and the integration of CPs/CPSs into multidisciplinary teams has shown that CPSs’ skills and abilities are still not particularly well understood by other providers in many health care organizations. This does not limit the contributions of CPSs to patient care, but it may limit how measureable and acknowledged those contributions are.1–3 Prior research in this area demonstrates that while CPSs are valued for their medication expertise, there is still little knowledge among other health care providers that they have two distinct roles; that of being an independent direct care provider in a pharmacy-run clinic, and being a member of a collaborative health care team.4 While there are tools in development to measure CPSs contribution to care, the results from these quantitative tools have yet to be fully analyzed and published.5 A growing body of literature has described the contributions of outpatient clinical pharmacy to patient care, including comprehensive medication management, patient counseling, and health professional education with the intent of improving patient processes of care and clinical outcomes.6–9 Indeed, literature in pharmacy notes that incorporating direct patient care by pharmacists would be an appropriate and effective enhancement for US health care.8 Due to the great variability and heterogeneity of research studies, it is difficult at this time to definitively measure and assess CPS contributions to patient outcomes.10 Nevertheless research supports the contention that outpatient pharmacists are valuable contributors in medication management, patient counseling and education, as well as provider education.9 For clinical pharmacy to have an even greater impact on patient care, more research is needed on how clinical pharmacists and clinical pharmacy specialists interact and communicate with patients. There is a modest but growing body of research on pharmacist-patient communication. A recent review of forty-one studies of patient-pharmacist

interactions suggested that communication was marked by more biomedical than patient-centered speech on the part of pharmacists.11 However, it is important to note that these studies were primarily conducted in community pharmacies, the majority of which were located outside of the U.S. Therefore, it is unclear to what extent these results would apply to CP/CPSs in the U.S. Moreover, there may be other kinds of communication and care-taking that occur during appointments. The U.S. Department of Veterans Affairs has been a leader in the development and expansion of direct patient care in pharmacy-run clinics for disease state management.12,13 Anticoagulation care clinics (ACCs) were one of the first pharmacy-run disease state management clinics in the US and in the Veterans Administration. This study of CP/CPS practice in Veterans Health Administration (VHA) anticoagulation clinics is a qualitative study focusing on everyday clinical practices of care-taking and pharmacist-patient interaction in pharmacy-run clinics. This study’s objective is to identify and characterize how CP/ CPSs in direct care clinics develop and practice care-taking behaviors that advance the pharmacist-patient relationship and further pharmacist-patient communication. Scope of practice and VHA anticoagulation care In the U.S., pharmacists operate through collaborative practice agreements that create formal relationships between pharmacists and physicians or other providers that allow pharmacists to provide care to patients and expanded services for the health care team.14 Within the VA context, CPs have a scope of practice that generally goes beyond a collaborative practice agreement. With a VA scope of practice, the CP functions autonomously performing the medication management activities included in their scope of practice but they also work collaboratively with the health care team for the overall care of the Veteran.15 The scope of practice ensures that each is appropriately credentialed

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and the scope includes prescriptive privileges whereby a CP can initiate, modify, and continue medication regimens and well as assess patients.15 Once clinical pharmacists are using these privileges greater than 25% of the time, they may be eligible to become a Clinical Pharmacy Specialist (CPS). This paper uses the term CPS to designate a clinical pharmacist with a scope of practice. CP designates clinical pharmacists who engage in clinical decision making but perhaps do not have prescriptive privileges; their recommended medication changes are signed by the CPS or other provider or they have a very specific scope of practice which limits what they can write prescriptions for. In VHAs, CPs/CPSs deliver anticoagulation (warfarin) care in usually one of the following three models of care: face-to-face, telephone and point-ofcare. In a face-to-face appointment a patient would go to their local community-based outpatient clinical (CBOC) or VA medical center and have their blood drawn by the lab and then go up to the anticoagulation clinic and wait for the CP/CPS to call them. The CP/CPS would then conduct the patient interview face-to-face and conclude the visit by making a dose change or keeping the does as it is based on the patient’s INR reading (international normalized ration) which measures the time it takes blood to clot after the addition of a tissue factor.16 Then the CP/CPS would schedule the patient’s next anticoagulation appointment. In a telephone clinic, the patient gets their blood drawn at a VA facility or at a lab near their home that has an agreement with the VA. When the CP/CPS gets the patient’s INR results, the CP/CPS calls the patient, tells them what their INR reading was, conducts the patient interview and concludes with any dosing changes if there are any. Point of care is very similar to a face-to-face appointment. The only difference is that instead of going to the lab for a blood test to find out their INR value, a patient is tested by a point of care machine in the clinic. The patient interview begins right away and when the machine indicates that the reading is in, and then the patient interview continues with the reading then incorporated into the discussion. The appointment ends with dosing directions and scheduling the next appointment. Methods The research data presented and analyzed in this study are part of a four-year (2012–2016) implementation study designed to introduce an evidence-based performance measure: percent time in therapeutic range (TTR) with warfarin, and then

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study how this evidence-based practice was or was not adopted at ACCs located in the Northeastern U.S. The VHA locations included 8 VA medical centers and approximately 6 VA community based outpatient clinics (CBOC) associated with the VA medical centers. The Anticoagulation Improvement Intervention (ACCII), as is typical in implementation science studies, includes an ongoing mixedmethods evaluation. The qualitative portion of the evaluation includes yearly semi-structured interviews and direct observations of clinic operations, clinical practice and patient care. The purpose of this qualitative evaluation is to gather a broad range of anticoagulation staff and pharmacy leaders’ opinions, thoughts and concerns about the implementation, the evidence-based practice, change, and patient care. The qualitative team used this information both to study the reasons why the intervention is or is not working, as well as to feedback aggregated information to the intervention team in real time to help them to more effectively promote change. In parallel, the research team is analyzing the ongoing quantitative data about TTR and related process of care measures to monitor progress and improvement. While the larger study has produced a substantial amount of data to address multiple research questions, this paper, sought to understand the pharmacist-patient relationship. Subjects Study participants included CP/CPSs across medical centers in the New England Veterans Integrated Service Network 1 (VISN) (see Table 1). The qualitative team recruited a purposive sample of all VISN pharmacy staff that worked in ACCs to assess the work processes, work environment, duties and responsibilities, patient care, patient-pharmacist interactions and the professional context of frontline pharmacy staff.17 The team interviewed and observed the same staff at the beginning of the Table 1 Participants and interview length a

# CP interviews Male Female Average interview length

Year 1

Year 2

47 13 34 40:30

50 12 38 45:11

a CP interviews include clinical pharmacists (CP), hybrid pharmacists, and clinical pharmacy specialists (CPS) and some CPS/managers. Several pharmacy managers/administrators were included because they also work as frontline providers in anticoagulation clinics.

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improvement project (fall 2012–spring 2013) and one year into the improvement project (fall 2013– spring 2014). The Bedford VA Medical Center IRB approved this study. Written informed consent was obtained for every participant, both for interviewing and direct observations. Interviews and direct observations This study collected two types of data for this study: semi-structured qualitative interviews, and direct observations of clinical practice. Semistructured interviews are a staple of qualitative research in health services because interviews help researchers identify and explain complex real-world social actions and social beliefs. These methods are increasingly recognized as important in pharmacy research, particularly in the area of pharmacistpatient interactions.18,19 Direct observation, sometimes called nonparticipant observation, is used to study processes, procedures, activities or people acting in specific roles. Individuals are often unaware of their behaviors, so that interviews must be complemented by direct observation. Direct observation adds new contextual dimensions to traditional methods such as database analyses, surveys and interviews. Direct observation is an important research methodology because it helps researchers to understand human behavior in context and several recent pharmacy studies have used this method to great effect in studies focusing on pharmacist-patient communication.20–22 Data were collected over two years, with one visit per year at each of the 16 ACC sites. The 16 sites included CBOCs as well as centralized ACCs based at VA Medical Centers. The interviews were guided by questions that focused on aspects of clinical pharmacy practice and the experience of delivering patient care as a CP/CPS.17 This included asking CP/CPSs questions about their perceptions of their interactions with patients (see Appendix A). Qualitative semi-structured interviews were conducted with all staff that wished to participate. All interviews were audio-recorded and transcribed verbatim. For this study, observation involved learning what pharmacists were doing (interactions and behaviors), why they were doing such tasks, what impact such actions had, and the meaning of such actions to participants.17,23,24 Either during or after observation, detailed field notes were systematically written down by the research team.25 Direct observations were carried out in ACC clinics for the entire length of the interviewing visit, which usually lasted 2–3 h at CBOCs and

6–8 h at larger ACCs based at medical centers. Generally, two researchers visited an ACC and took turns interviewing the CP/CPSs while the other researcher engaged in direct observation. Observations ranged from approximately 2 h at small sites (with only 1 or 2 pharmacists) to 6 h at larger sites (with 3 or more pharmacists). While not every CP/CPS was observed, an effort was made to observe CP/CPSs in year 2 that were missed in year 1 (see Appendix B). Data analysis The qualitative team developed an emergent thematic analysis that allowed for an iterative approach to identifying patterns in the interview data focusing on pharmacist-patient interactions.26 Themes are recurrent unifying comments or statements about the subject of investigation, such as CP/CPSs talking about how they take care of patients, have gotten to know patients over time, come to care about patients, etc.27 In the formation of the codebook, the qualitative team met to review discrepancies. Differences were resolved through in depth discussion and negotiated consensus. Qualitative interview transcripts were formatted and imported into NVIVO 10 software for data management, coding and analysis, and then coded by the qualitative team. A subset of interviews, 8 CP/CPS interviews each year (one from each medical center), were independently double-coded to assess inter-coder reliability.28 Direct observation notes were read independently by the qualitative team. The qualitative team then applied the code book from the interviews to the direct observation notes. For this study, two members of the qualitative team reviewed codes that focused on pharmacist-patient interaction and pharmacist care-taking behavior. Researchers identified three types of care-taking behavior and sorted each piece of data (observational and interview-based) into one of the three categories as part of developing a theory of pharmacistpatient interaction. Data that exemplified how patients come to know CP/CPSs, seeking to have other medications explained and asking for assistance navigating the VA health care system, involved both direct observation notes and interview data. The research team triangulated and then synthesized their analysis of interview data and direct observation data in order to forge a data-driven portrait of pharmacist care-taking in local practice settings. The team then checked the results with study’s expert panel of clinical

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pharmacists (authors AP, AM and HO) who reviewed the data and the results. They affirmed their concurrence with the results. Results Anticoagulation care often covers many years of a patient’s life, and appointments happen monthly or more often. CPs/CPSs have contact with the same patients for an extended period of time in AC clinics. Therefore the qualitative team found that the relationship between patients and CPs/CPSs is temporal in nature; patients and CP/CPSs learn to know each other over time, and CPs/CPSs come to understand patients as a people with distinct feelings, behaviors and emotions.29 Time brings familiarity, and this breeds a specific kind of relationship dynamic between CP/CPSs and patients. The team also found that as a result of knowing the patient, CP/CPSs then employ an individualized intervention such as identifying patient’s unmet needs. According to nursing literature on knowing the patient, an individualized intervention is the result of time, familiarity, and trust acting together so that a provider comes to see the patient as person and therefore individualizes an intervention to meet the needs of the patient.29 As the CP/CPS comes to know his/her patient, the patient also comes to know the CP/CPS and then patients ask CPs/ CPSs to explain other medications and help them navigate the VA health care system (see Fig. 1). Identifying unmet needs CP/CPSs in anticoagulation clinics deliver care to the same patients every four or so weeks for years, since patients are often on warfarin (also known by its brand name, Coumadin) long-term. This frequent contact enables CP/CPSs to form close relationships with patients, and sometimes to become their most trusted health care provider. As one pharmacist remarked, “. well I think a big part of working with patients is the relationship, like a personal relationship that you have .” In their interviews many CP/CPSs noted that they had identified a patient’s unmet need for care. For example, a CP/CPS recounts, “I know the patients that tend to miss doses, that I’ll probably have to call the daughter because they’re very forgetful, there’s a question of undiagnosed Alzheimer’s . I’m just thinking about patients that I know have had problems. But I know them because I’ve been here for ten plus years and . that there’s a patient-provider relationship there.” CP/CPSs may take an even more active role on

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behalf of their patients if they deem it necessary. The following is a typical example: “. I would say in Coumadin clinic, we see these guys so often, that we know ’em better than their primary care provider . .we’re seeing these guys . on a regular basis. And I could name multiple instances where . [an] old guy comes in, he has mental status changes, you send ’em to urgent care, it’s a UTI or something like that . Or a lotta times . you know the guy. If it’s a guy that never says he has any problems whatsoever and never complains about nothing, and then he’s saying . he took a pretty good fall and had some bruising and might have hit his head, you get him to come into Urgent Care, you know? . You get to know ’em the best and you’re like the triage guy when you see ’em in clinic kind of .”

Here a Clinical Pharmacist sums up the ways CPs/CPSs can identify unmet patient needs and try to link patients to appropriate care. Another example of CPs/CPSs linking patients to appropriate care is shown in the following quote: “I had a patient’s son call me today who was coming in for his Coumadin visit but mentioned how his father’s leg was swelling and he had a cut on his leg, so I discussed with his primary care and made an appointment for him in the nurse clinic to be evaluated, and then for them [primary care] to decide what to do further.” This family was coming in any way for AC care, but due to the CP/CPS’s actions, this patient now would also be seen by primary care. Additionally, sometimes more serious issues in the lives of patients are spotted by CPs/CPSs. For example, many CPs/CPSs note in interviews that changes in a patient’s mental competency are often first noticed first CPs/CPSs in the AC clinic. One CP/CPS stated, “Oh, there’s great continuity . we’re seeing people so frequently, you could see differences. We have a patient, we’ve been seeing for many years and he definitely had cognitive decline, gradual over time and, his PCP (primary care provider) didn’t pick up on it at all because he’s [PCP] seeing him [patient] every six months, whereas we’re seeing him [patient] so frequently, you could see a change and, . we alerted him [PCP] to it and . all the appropriate follow up and services and what not have gone on, and he’s actually involved in the geriatric clinic now because of this, and is . doing really well.”

This kind of action on the part of CP/CPSs is not unique. Many CP/CPSs stated that when they noticed a patient’s mental competence change to the point they appeared unable to take care of

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Fig. 1. Results.

themselves, they alerted primary care, who then informed key personnel about patients that needed certain kinds of services. The qualitative team notes that CP/CPSs still struggle to solicit and engage with feedback from the patients and they often did not privilege the patient’s perceptions about their own treatment or needs. For example, when a CP/CPS identified an unmet need for a patient, the CP/CPS did not often solicit the patients’ perspective on this situation or ask if the patient wanted assistance, but rather the CP/CPS acted to alert other providers about the patient’s situation with little consultation with the patient. There are numerous small ways CPs/CPSs attempt to respond to their patient’s needs and requests for assistance that may only tangentially be related to the ACC. These kinds of good “customer services” also include making sure they listen to lonely patients, because for these patients, human connection is an unmet need. For example, here a CP/CPS tries to make a small amount of extra time for, “when you have the lonely gentleman who has nobody to talk to who sits in here for 20 min and as much as you try and gently [hand motions about moving along] .” Identifying a patient’s unmet needs means that CPs/CPSs noted mental decline, listened to the lonely patient, noted other complications that needed medical attention, and engaged in relationship building. These are actions that CPs/CPSs carried out frequently for their patients that went beyond routine AC care. Explaining other medications CP/CPSs can spend part of an anticoagulation appointment answering questions not only about warfarin, but also about other medications. To a certain extent, this can be viewed as part of ACC work; the CP/CPS has to know what other medications a patient is on in order to manage warfarin

properly. However in the course of managing warfarin, a CP/CPS receives many questions from patients about other medications, sometimes without any direct relevance to the management of warfarin. The team directly observed several instances of patients remarking that they did not understand why they were on certain medications and wanted to better understand both the medicine and the reason why they were on it. As one CP/CPS points out, “They come in and you know it’s not only their INR results they’re following up on because they know that we’re pharmacists. They also ask many other questions that have to do with their medications .” In this manner, CPs/CPSs often provided further patient education. Furthermore, patients in the warfarin management interview were observed bringing up other medical issues or complaining of side effects that they attributed to warfarin but were not warfarin related. In these cases, CPs/CPSs looked at a patient’s medications, explained about possible side effects from their other medications and sometimes encouraged patients to go see their primary care providers or specialists for further medical care and assistance with what was bothering them. Additionally, patients know the phone number of the ACC and have favorite CP/CPSs that they like to contact for assistance. They may do this whether or not they have an ACC appointment. As one CP/CPS says, “Other examples, patients calling in with medications, new medications or interactions, or questions or problems, so anything in addition to just the scheduled patients .” Patients also call into the ACC occasionally when they have non-ACC related questions. Patient information-seeking from CP/CPSs is an everyday occurrence. It was observed regularly in direct observations of clinics and reported in CP/CPS interviews. CP/CPSs are glad to help, and value

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the fact that patient’s trust them. For example, the qualitative team observed an AC patient wait until the end of the encounter to tell the CP/CPS that he felt dizzy when he took his medications. The CP/CPS carefully solicited from the patient what medications he was taking and at what time of day, thereby building a portrait of how this patient approached his own care. The CP/CPS made only one recommendation which was to eat food before taking one of the medications and then the CP/CPS stated that the patient really needed to make an appointment with his provider to discuss the dizziness further. Additionally, ACC appointments are also used by patients as a way of obtaining help in managing their medications. For example, one CP/CPS remarked, “There are . other patient teaching issues. Sometimes they’ll have patients who need what we call a brown bag med reconciliation visit. They bring in every bottle in their cabinet. They put it in a bag and bring it in and we go over it. Sometimes patients will have been in the hospital or have a lot of providers and things get a little mixed up and they ask us to sort that out.” This happens frequently during AC appointments. Patients are not trying to better understand how their medications work or do not work with warfarin; rather they are trying to just understand their medications. This kind of task does not pertain directly to AC care. Another CP/CPS discussed a certain patient that he thought was representative of a circumstance he often faced in the ACC:” . you know I asked him [the patient] to actually bring in his pill bottles and I could see that they were you know old and accumulating.” The CP/CPS took the time to figure out what was going on and to convince the patient to get rid of expired prescriptions. CP/CPSs acknowledged the time this takes but most CP/CPSs echoed the following sentiment. “you know, no matter what’s going on . they [patients] know how to get in touch with us and we can help ’em with different things . I think it’s really important.” Helping patients navigate the system Navigating the VA can sometimes be confusing for patients. The team observed that patients also use ACC appointments to try to get help managing their care in other ways. First and foremost, at the end of appointments, patients were observed asking CPs/CPSs to look up when they had other appointments. Patients also enlisted CP/CPSs to assist them in navigating the VA bureaucracy because it can be confusing for patients and it may be difficult for

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patients to find the correct channels from which to solicit information. In other words, patients knew they had an appointment coming up but were not sure with whom, or they knew they had a specialty appointment in eye care but were not sure when. A CP/CPS explains what this kind of care-taking looks like, “. They [patients] drop by . .I may have five to ten people stop a day and have something that needs to be done. They have something to tell me. They have a change in one of their medications. They may need to change their appointment. They may have a problem getting one of their medications from the pharmacy. They may have a question about an appointment they have some other place . [or] a problem they’ve had getting a hold of their provider; they need their . blood pressure medications, it’s whatever, I’m available. They know where I am.” In clinic observations, patients were sometimes observed to ask CPs/CPSs about how to get to see a specialist or how to get travel reimbursed. For example, a CP/CPS reports, “. I had two patients and both of which had issues, but they weren’t necessarily ACC issues. The first couple, he’s 90 something, and she’s [his wife] trying to take care of him, she’s legally blind, but of the two, she’s got the mental faculties, he’s got the physical faculties and together they, they work, and they do. They drive in . and they needed to see . the agent cashier because they needed a form to submit with their financial form for the VA and, you know what? Giving them directions, in this facility, to get someplace wasn’t gonna work and the cashier is not that far, so, you know what? . I said . let me take you over there and so I walked them over.”

Sometimes patients asked CPs/CPSs to look up phone numbers or directions to other areas of the medical center. CPs/CPSs answered what they could and most seemed to have acquired enough general knowledge to direct a patient to where he or she could find more information to answer his or her questions. What was significant here was the sheer volume of requests for assistance and how comfortable patients felt asking CPs/CPSs. CPs/CPSs also did let patients know when they did not have answers for them or when the patient needed to see another provider, and patients seemed to accept this. Discussion As mentioned previously, recent work in the VA has focused on quantifying and characterizing the interventions CPs/CPSs make on behalf of patients.5

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This is important work that shows great promise. However, qualitative research methods can identify and describe kinds of care that may be hard to measure and characterize, but which nonetheless adds a great deal to patient care. Such an investigation can help us to understand what is occurring within the patient-pharmacist relationship. This study identified that long-term relationships help CPs/CPSs know the patient as a person and that this knowing leads pharmacists to make individualistic, personalized interventions.29,30 This is especially apparent in the strategy categorized as identifying a patient’s unmet needs (e.g., when patients ask directly for help), or there is an indirect expression of need (e.g., the loss of cognitive function identified by the CP/ CPS).31 The team also identified that the time and familiarity that develops over the course of anticoagulation care creates a reciprocal relationship in which patients come to know their pharmacists. Nursing literature does not identify or discuss this reciprocal relationship wherein the provider knows the patient and then the patient comes to know the provider. This relationship results in patients asking pharmacists to explain other medications, and in helping patients navigate the VA system. Each of these care-taking actions arises from a CP/CPS’s perceptions of patients and assessment of what a patient needs and what CP/CPSs, given their scope of practice and the demands of their daily work, can provide. In other words, the strategies result from how the CP/CPS knows their patients and how their patients come to know and trust them. The qualitative research team observed that in addition to their formal duties managing anticoagulation, CPs/CPSs working in the ACC often deliver many kinds of other care and guidance to patients as well, some of which is not related to ACC work, but all of which has value. Many other providers, especially primary care providers and nurses, also engage in similar informal caretaking activities on behalf of patients. This study’s findings about pharmacists do not claim that these care-taking activities above and beyond expected patient care are only performed by CPs/CPSs. However, findings from interviews and direct observation indicate that CP/CPSs engage in a number of these care-taking behaviors, possibly because they see patients so frequently, and therefore may be highly trusted. Patient-centered communication can be understood as centering the appointment on the patient’s perspective, active listening on the part of the provider, open-ended questions by the provider, and making sure the patient’s voice is being heard

and understood.32–34 CPs/CPSs offered patient care and responded to the ways they interpreted patient needsdthis was how they “knew” the patient. Time and familiarity did enhance CP/CPS responses to patients. Sometimes, of course, time is limited, but other times, more back-and-forth with the patient could perhaps have made the knowing the patient more patient-centered. Work on pharmacists in South Africa provides a very rich example of how crucial it has become for pharmacists to be trained to communicate better with patients in HIV/AIDS treatment especially as it may be CPs/ CPSs who see the patient more than other providers.35 It is essential for patient adherence that pharmacists and patients build relationships so that CP/CPSs are better able to educate the patient in part because of a relationship based on trust.33–36 The present study broadens the understanding of how CP/CPSs incorporate care-taking into clinical practice. The team observed that many CP/CPSs often have known and interact with their anticoagulation patients over a long period of time. They learn to see patients as individuals and they grow to know their patients’ feelings and behaviors. The role of the longitudinal relationship in building trust is also discussed in the nursing literature on “knowing” the patient.29,31 Familiarity also plays a role in the pharmacist-patient relationship. Most CP/CPSs in this study referred to themselves using their first names and thereby cueing patients that their position vis-a-vis the CP/CPS is not the same as it might be between a patient and doctor or a patient and a nurse. Primary care physicians are almost always called, “Doctor.” Small actions such as the mutual use of first names may enhance familiarity between CPS and patient. This study begins to unpack what it means for a clinical pharmacist to “know” the patient, a concept that has been well explored in literature about nursing.29–31 This study suggests that CP/ CPSs “know” and care for patients in a way that is distinct from nursing. For example, in disease-state management, CPs/CPSs see the same patients over and over again in ACC but also in diabetes clinics and hypertension clinics, among many others. CPs/CPSs see patients across different clinic domains but also across years, which is different than the time period discussed for, say, oncology nurses.29 Time is a precious commodity in health care, and the fact that CPs/ CPSs and patients come to know each other so well could be a valuable resources. If capitalized upon, the pharmacist-patient relationship could help facilitate health interventions such as

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increasing greater adherence to medication by patients. The dimension of time is an important part of building provider-patient relationships for CPs/ CPSs in outpatient care and this needs further study. Additionally, CPs/CPSs are in an excellent position to use the dynamic of time to improve the patient experience of care. With some adaptations and more of an awareness of their own patient knowledge, CPs/CPSs are in a position to make their clinical practice more patientcentered. Further study about clinical pharmacist “knowing” the patient, and related kinds of care taking, will extend these findings. Limitations This study focused on acts of care-taking in the context of anticoagulation. The amount of caretaking tasks provided on behalf of patients may vary depending upon whether or not a CP/CPS is acting as a direct provider versus a member of a health care team, such as might happen in primary care. Additionally, since this study was conducted in pharmacy-run anticoagulation clinics, the same kinds of care-taking behaviors might not be observed in other pharmacy-run clinics. In the context of ACC care, pharmacists have prolonged contact with their patients and this can foster a more familiar relationship over time. This kind of informal care-taking by CP/CPSs may thus be somewhat less frequent in contexts other than the ACC. Furthermore, the re-occurrence of appointments between patients and CP/CPSs bring the dimension of time into this relationship. Through many appointments, ongoing interactions and the slightly more informal approach taken, many patients learn to trust CP/CPSs through long-term experience with them. Finally, a more exact accounting of the number of care-taking actions carried out by CPs/CPSs is also needed; perhaps a future quantitative time motion study would further support and extend the qualitative findings of this study. Conclusion Within the framework of ACC appointments, CP/CPSs learn to know their patients through time and familiarity. They learn to understand a patient’s behavior, perceptions and feelings and use this knowledge to engage in individualized interventions because they come to see the patient as a person; to see patients within the context of their lived experiences. This study identified how CP/CPSs know the patient and therefore employ the individualized intervention of identifying a patient’s unmet needs.

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This study also identified that a reciprocal relationship exists wherein patients come to know and trust CP/CPSs. Within the context of this pharmacistpatient relationship, patients come to ask for explanations of other medicines and ask for help navigating the VA health care system. Clinical pharmacy training has promoted improved patient-centered communication skills over the past few decades. Nevertheless, there are distinct ways that clinical pharmacists know and care for their patients in pharmacy-run clinics in ways that are intangible (i.e., hard to measure and count) but add value for patients. These ways of knowing the patient and how such knowledge manifests in clinical pharmacy practices should be further studied. It opens up a new stream of possible research which can examine the kinds of care-taking that pharmacists perform. Further research would help elucidate how this relationship could be leveraged into more effective communication between pharmacists and patient. This can open up new avenues of increasing adherence for patients through pharmacist-centered efforts. Acknowledgments Many thanks to the clinical pharmacists who have given generously of their time as well as shared with the research team their knowledge of clinical pharmacy care. Laurie Radwin’s expert feedback and generosity is also noted and appreciated. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the U.S. government. Funding is from Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development SDP 12-249 (Rose, PI).

References 1. Pottie K, Haydt S, Farrell B, et al. Pharmacist’s identity development within multidisciplinary primary health care teams in Ontario; qualitative results from the IMPACT project. Res Social Adm Pharm 2009;5:319–326. 2. Farrell B, Ward N, Dore N, Russell G, Geneau R, Evans S. Working in interprofessional primary health care teams: what do pharmacists do? Res Social Adm Pharm 2013;9:288–301. 3. Patterson BJ, Solimeo SL, Stewart KR, Rosenthal GE, Kaboli PJ, Lund BC. Perceptions of pharmacists’ integration into patient-centered medical home teams. Res Social Adm Pharm 2015;11:85–95.

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4. McCullough MB, Solomon JL, Petrakis BA, et al. Balancing collaborative and independent practice roles in clinical pharmacy: a qualitative research study. Ann Pharmacother 2015;49:189–195. 5. Hough A, Vartan CM, Groppi JA, Reyes S, Beckey NP. Evaluation of clinical pharmacy interventions in a Veterans Affairs medical center primary care clinic. Am J Health Syst Pharm July 1, 2013;70:1168–1172. 6. Isetts B, Brummel A, dO DR, Moen D. Managing drug-related morbitity and motrality in the patientcentered medical home. Med Care; 2012:997–1001. 7. Farris K, Cote I, Feeney D, et al. Enhancing primary care for complex patients: demonstration project using multidisciplinary teams. Can Fam Physician; 2004::998–1003. 8. Chisholm-Burns MA, Kim Lee J, Spivey CA, et al. US pharmacists’ effect as team members on patient care: systematic review and meta-analyses. Med Care 2010;48:923–933. 9. Nkansah N, M O, Yu C, et al. Effect of outpatient pharmacists’ non-dispensing roles on patient outcomes and prescribing patterns. Cochrane Database Syst Rev 2010;(7):CD000336. http://dx.doi.org/10. 1002/14651858. pub2. 10. Viswanathan M, Kahwati LC, Golin CE, et al. Medication therapy management interventions in outpatient settings: a systematic review and metaanalysis. JAMA Intern Med 2015;175:76–87. 11. Murad M, Chatterly T, Guirguis L. A meta-narrative review of recorded patient-pharmacist interactions: exploring biomedical or patient-centered communication. Res Social Adm Pharm 2014;10:1–20. 12. Clause S, Fudin J, Mergner A, et al. Prescribing privileges among pharmacists in Veterans affairs medical centers. Am J Health Syst Pharm June 1, 2001;58:1143–1145. 13. Morreale A, Ourth H, Groppi J. The Clinical Pharmacy Specialist’s Growing Provider Role in VA. U.S. medicine, 2013. This year in federal medicined outlook, http://www.usmedicine.com/agencies/depart ment-of-veterans-affairs/the-clinicalpharmacy-specia lists-growing-provider-role-in-va/; 2013. 14. CDC, Collaborative Practice Agreements and Pharmacists’ Patient Care Services: A Resource for Pharmacists www.cdc.gov/dhdsp/pubs/docs/Translational_Tools_ Pharmacists.pdf; Accessed 01.04.15. 15. Affairs DoV, ed. VA Handbook 5005, Part II, Staffing, Appendix G-15, Licensed Pharmacist Qualification Standard; 2008. 16. Rose AJ, Ozonoff A, Berlowitz DR, Henault LE, Hylek EM. Warfarin dose management affects INR control. J Thromb Haemost 2009;7:94–101. 17. Bernard HR. Research Methods in Anthropology: Qualitative and Quantitative Approaches. 4th ed. Lanham, MD: AltaMira Press; 2006. 18. Anderson C. Can we use quantitative methods to characterize pharmacy consultations with people with depression? Res Social Adm Pharm 2014;10:595–597. 19. Bradley EH, Curry LA, Devers KJ. Qualitative data analysis for health services research: developing

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Appendix A Interview guide year 1 & 2dlisting questions that elicited data on patients and CP care-taking Year

Question

Presence of data on patients

1 1 2 2

Tell me about the work in the ACC? Walk me through a day in the ACC? Since the last time we talked, tell me how ACC work is going? Now that the Anticoagulation Management Algorithm has now been officially released as a guideline, can you tell me your thoughts about it? Has your model of ACC care changed? (Why?/Why not?) - How is that going?

X X – X

Tell me about your workload and work flow? How many patients do you see in a session? Do you ever need to stay late to finish your work? Are patients ever left over until the next day? If so, how many patients, and how does that happen? In thinking about your work, work flow and the ACC environment, what are one or two things that you would like to change – even if this is not included in the currently proposed changes? What part of your job gives you the most professional satisfaction? Have the changes to ACC care enhanced or taken away from your job satisfaction? What aspects of your job do find most challenging? (example?) Tell me about a memorable patient? Are patients ever lost to follow-up? - How often does this occur? - How is ACC staff alerted to this issue? - How is it addressed?

X X – X

2 1/2 1/2 1/2 1/2 1/2

1/2 2 1 1 1

–

X

X X X X X

2 1 1 1/2

Patient tracking and loss to follow-updhas this improved at your site? Do you think the patients have noticed any changes in their care? Have they noticed any changes in their follow up intervals if they are out of range Can you describe for me the kind of team work and support system you have among your fellow ACC staff? - Do staff help each other out? How? - How do you communicate with each other

– X X –

1

I’d be interested in learning from you what you know about the proposed changes to ACC care in VISN 1, can you describe what you know? - How did you find out about these changes? - What do you think of these proposed changes? - How might the proposed changes affect your work here?

X

1 1

What’s been challenging or problematic about the proposed changes? How do you think these changes will continue to play out, both for yourself, your patients and for your ACC? Thinking about your work practices, what do you think will be lost if these changes take place? (Please describe, give an example) What do you think will be gained by the proposed changes? In thinking about your work, work flow and the ACC environment, what are one or two things that you would like to change – even if this is not included in the currently proposed changes? Is there anything I should have asked that I did not? Any last thoughts or comments?

X X

1 1 1/2

1/2

X X X

X

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Appendix B Direct observation on pharmacist-patient interactions List of actions and communication interactions to keep in mind as researchers observed care in VHA anticoagulation clinics. Notes were typically taken following the sequential action in the appointment. Data was later divided into thematic categories during data analysis. 1. How does the appointment begin? How is patient greeted? Asking about family Taking time to listen to stories, riddles, etc. 2. How does the clinical pharmacist (CP) talk about the INR result? Using lay terms? Biomedical terms? Does the patient appear to understand? 3. What kinds of questions does the CP ask in the patient interview? Does it cover all questions in the new standardized ACC patient interview guidelines? 4. If there is an issue about being out of range, like the patient is taking a new herbal supplement, what is the CP’s approach to eliciting information from the patient? How does the CP ask questions about a patient’s every day activities? If the CP does not do this, please note that these kinds of activities are not happening. Does the CP engage in constant education of the patient, i.e., reminders about alcohol use or food (Vitamin K) consumption? 5. Giving new dosing instructionsdare these explained well? 6. What is the relationship like between CP and patient? Does the CP take time to explain things? How well does the CP know the patient? How well does the CP listen to the patient? How does the CP respond to patient questions? 7. Accommodationsdare any made? Should some be made? 8. Making the next appointment: If no outstanding issues, is scheduling based on other appointments, taking into account Veterans travel time to VA and the expense? If there are outstanding issues, like being out of range, are travel issues considered over algorithmic management?

How well was the new algorithm explained and how well did CP explain why patient might need to return to clinic sooner? 9. What is done for traveling Veterans: Considering patient appointment & lab needs because patient was traveling/on vacation Making connections at other VAs so patients can have labs drawn while away. 10. What happens beyond the ACC appointment if anything? What do patients ask CP for? Appendix C Qualitative Coding Schema on pharmacist-patient relationship Codes applied to each interview. Year 1 1. ACC workflow 2. Algorithm 3. Barriers to change 4. Challenges of ACC work 5. Clinical practices A) Clinical thinking 6. Communication A) With patients 7. Job satisfaction 8. Model of Care A) Face to face B) Telephone C) Point of care D) Letter 9. Providers perceptions of patients A) Complex patients B) Easy patients C) Memorable patients 10. 11. 12. 13.

Perceptions of patients likes and dislikes Patient satisfaction Self-efficacy What might be lost through change

Year 2 1. ACC work flow 2. Algorithm 3. Barriers to change 4. Challenges of ACC work 5. Clinical judgment

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6. Communication 7. Job satisfaction 8. Model of Care A) Face to face B) Telephone C) Point of care

10. Patients A) Complex patients B) Easy patients C) Care-taking D) Memorable patients E) Communication with patients

9. What might be lost

11. Pharmacistsidentity

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