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Pharmacists’ roles in patientcentered medical homes APhA–APPM: Bella Mehta and Mary Ann Kliethermes APhA–APRS: Leticia R. Moczygemba and Dawn Andanar APhA–ASP: Lauren E. Bode
APhA–APPM
Optimizing medication use through team-based care The Patient Protection and Affordable Care Act (ACA) identifies the need to improve the quality and efficiency of health care in the United States.1 In transforming the delivery of health care, ACA promotes wellness and prevention within patient-centered medical homes Mehta (PCMHs), a teambased model of care. The legislation includes pharmacists as part of the health care workforce as part of a change from a model of treating chronic Kliethermes disease to a model that focuses on preventive medicine, health promotion, disease prevention, and patient self-management.1 New and emerging health care models including PCMHs, accountable care organizations (ACOs), medical neighborhoods, and community-based health centers are currently being created, tested, implemented, and disseminated in response to the pressing need to control health care costs and improve the quality of care patients receive in the United States. Reports from the Institute of Medicine (IOM) over the past 15 years have detailed the prevalence and high cost of problems in the U.S. health care system, including those related to medication use.2,3 Recommendations from IOM to resolve the
identified problems and the passage of ACA are further accelerating the transformation of health care delivery and the role that health professionals (including pharmacists) can play.1,4 Pharmacists can be critical players in PCMHs, helping patients make the best use of medications. Applying their knowledge and skills, pharmacists are drug-therapy experts on the health care team, promoting optimal medication therapy management as a key element of success in new models of care. Pharmacists are assisting integrated teams in ensuring optimal medication management and educating patients as active participants in their own health. As a result of the work of early adopters in providing pharmacists’ patient care services, the role of pharmacists within integrated
teams is becoming better understood and defined. This role has recently been highlighted by a number of authors and organizations. A theme issue of this journal, published in March/April 2011, featured articles on pharmacists and PCMHs.5 Beginning in September 2013, the American Pharmacists Association released a series of eight ACOs briefs focused on emerging health care models.6 Key publications have also described the essential elements of care provided by pharmacists, the substantial contributions pharmacists can make to improving the quality and safety of patient care in PCMHs, and the need for integrating pharmacists into ACOs.7,8 In a 2013 position paper, the American College of Physicians stated that well-functioning teams will assign responsibilities of patient care to midlevel providers such as clinical pharmacists.9 Additionally, the Patient-Centered Primary Care Collaborative, which comprises more than 1,000 multidisciplinary stakeholder organizations, has advocated for new models of team care, including pharmacists
The Association Report column in JAPhA reports on activities of APhA’s three academies and topics of interest to members of those groups. The APhA Academy of Pharmacy Practice and Management (APhA–APPM) is dedicated to assisting members in enhancing the profession of pharmacy, improving medication use, and advancing patient care. Through the APhA-APPM Special Interest Groups (SIGs), the Academy provides members a mechanism to network and support the profession by addressing emerging issues. To access a listing of APhA-APPM SIGs, visit www.pharmacist. com/apha-appm. The mission of the APhA Academy of Pharmaceutical Research and Science (APhA– APRS) is to stimulate the discovery, dissemination, and application of research to improve patient health. Academy members are a source of authoritative information on key scientific issues and work to advance the pharmaceutical sciences and improve the quality of pharmacy practice. Through the three APhA–APRS sections (Clinical Sciences, Basic Pharmaceutical Sciences, and Economic, Social, and Administrative Sciences), the Academy provides a mechanism for experts in all areas of the pharmaceutical sciences to influence APhA’s policymaking process. The mission of the APhA Academy of Student Pharmacists (APhA–ASP) is to be the collective voice of student pharmacists, to provide opportunities for professional growth, to improve patient care, and to envision and advance the future of pharmacy. Since 1969, APhA–ASP and its predecessor organizations have played a key role in helping students navigate pharmacy school, explore careers in pharmacy, and connect with others in the profession. The Association Report column is written by Academy and section officers and coordinated by JAPhA Executive Editor L. Michael Posey of the APhA staff. Suggestions for future content may be sent to [email protected].
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providing medication management.10 In a 2011 white paper, the Agency for Healthcare Research and Quality identifies pharmacists as a critical component of the medical neighborhood.11 Although there has yet to be a simple or standard process for integrating pharmacists into these new models, there is clear evidence of need and support from a variety of stakeholders. Pharmacists are contributing to patient care in PCMHs/ACOs by managing patients’ acute medication needs and assisting in the management of medications used for chronic conditions. These services include optimizing complex medication regimens; performing comprehensive medication reviews to identify, prevent, and minimize drug-related problems; developing care coordination with the patient and other team members, including patient education and medicationadherence strategies; providing ongoing monitoring, transitions of care, and follow-up; assisting with quality measurement; and ensuring adherence to evidence-based medicine. Pharmacists may see patients in separate appointments, during group visits, or in conjunction with other team members. Innovation is at the core of developing the new models of care so that the desired outcomes of quality, efficiency, and reduced cost are achieved. These new models of care enable pharmacists to practice at the “top of their license,” and opportunities are available and growing in communities throughout the country. These opportunities are available to pharmacists practicing in a variety of settings, including community pharmacy, ambulatory care clinics, and hospital-based practices. As each of these models evolve, pharmacists need to reach out not only within their organizations but also to other providers and health care groups in their community to advocate for inclusion of pharmacy services. To achieve the triple aim of better care for patients, better health 220 JAPhA | 5 4 :3 | M AY /JUN 2014
for populations, and reduced health care costs, patients and the health care industry need pharmacists to be fully integrated into PCMHs and ACOs. Bella Mehta, PharmD, FAPhA Coordinator, APhA–APPM Medical Home/ ACO SIG Associate Professor of Clinical Pharmacy College of Pharmacy Ohio State University Columbus [email protected] Mary Ann Kliethermes, BS, PharmD Coordinator-elect, APhA–APPM Medical Home/ACO SIG Vice Chair of Ambulatory Care and Associate Professor Chicago College of Pharmacy Midwestern University Downers Grove, IL [email protected]
References 1. Affordable Care Act. www.hhs.gov/healthcare/rights/law/index.html. Accessed April 28, 2014. 2. Institute of Medicine. Preventing medication errors: quality chasm series. www.nap. edu/openbook.php?record_id=11623. Accessed April 28, 2014. 3. Institute of Medicine. To err is human: building a safer health system. www.nap.edu/ openbook.php?record_id=9728. Accessed April 28, 2014. 4. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. www.nap.edu/openbook. php?record_id=10027. Accessed April 28, 2014. 5. Special features: patient-centered medical homes. J Am Pharm Assoc. 2011;51(2):156-211. 6. American Pharmacists Association. APhA accountable care organization (ACO) briefs. www.pharmacist.com/apha-accountablecare-organization-aco-briefs. Accessed April 23, 2014. 7. Smith M, Bates DW, Bodenheimer T, et al. Why pharmacists belong in the medical home. Health Aff. 2010;29(5):906-913. 8. Smith M, Bates DW, Bodenheimer TS. Pharmacists belong in accountable care organizations and integrated care teams. Health Aff. 2013;32(11):1963-1970. 9. Doherty RB, Crowley RA. Principles supporting dynamic clinical care teams: an American College of Physicians position paper. Ann Intern Med. 2013;159(9):620-626. ja p h a .org
10. Patient-Centered Primary Care Collaborative. www.pcpcc.org. Accessed April 28, 2014. 11. Taylor EF, Lake T, Nysenbaum J, et al. Coordinating care in the medical neighborhood: critical components and available mechanisms. pcmh.ahrq.gov/page/coordinating-care-medical-neighborhood-criticalcomponents-and-available-mechanisms. Accessed April 28, 2014.
APhA–APRS
The need for research to advance the pharmacist’s role in patientcentered medical homes The aging population, rise in chronic disease burden, and increase in the number of insured individuals as a result of the Affordable Care Act have contributed to a need to transform primary care from a physiciancentric to a teambased delivery model.1–3 This transformation Moczygemba can be facilitated by health care professionals, such as pharmacists, practicing at the top of their license. Given that pharmacists, as compared with physicians and Andanar nurses, are expected to be in adequate supply in the near future, there is an opportunity for pharmacists to expand their roles in team-based primary care.4,5 The patient-centered medical home (PCMH) model aims to deliver comprehensive, patient-centered, teambased, coordinated, accessible care with a focus on quality and safety.6 The PCMH has come to the spotlight for the potential to not only improve the quality of health care delivered to patients, but also to reduce health care costs. The PCMH model was first introduced in 1967 by the American Academy of Pediatrics and
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re-emerged as a health care reform strategy to combat the current disjointed health care system by delivering team-based patient care. In 2007, a coalition of medical associations released the Joint Principles for the Patient-Centered Medical Home, which defined key principles in the medical home model, such as an ongoing relationship with a personal physician who cares for the patient in all stages of life and team-based care that is integrated and coordinated across all settings of the health care system and places an overall emphasis on quality and safety. To ensure the same level of care across medical homes, the National Committee for Quality Assurance adopted standards in 2011 focused on enhanced access and continuity of care, managing patient populations and care, providing self-care support, tracking and coordinating care, and measuring and improving performance. Since 2007, a number of professional health care organizations and health systems have endorsed and adopted the PCMH model in the primary care setting. Despite the evolution of the PCMH concept, questions abound regarding the clinical and economic impact of PCMHs, staff mix of care teams, defined roles and responsibilities of team members, and PCMH payment models. Although there has been support for pharmacists to be a key member of PCMHs and primary care teams,7,8 progress toward making this a reality is ongoing. A recent study describing staffing patterns for primary care practices in the Centers for Medicare & Medicaid Services (CMS) Comprehensive Primary Care Initiative indicated that only 9.3% of the 204 practices classified as a PCMH included a pharmacist as part of the team. Regardless, there is emerging evidence that positive outcomes are achieved when pharmacists are integrated with PCMHs.9 In particular, reductions in total health care cost growth and greater achievement of 222 JAPhA | 5 4 :3 | M AY /JUN 2014
treatment goals have been reported with pharmacist involvement, compared with usual care.10,11 From a research perspective there is much opportunity to apply rigorous scientific methods to evaluate the impact of PCMHs, as well as further define and establish pharmacists’ roles. The Agency for Healthcare Research and Quality (AHRQ) commissioned the development of the PCMH Research Methods Series to guide researchers in conducting rigorous studies to measure the implementation and impact of PCMHs.12 In particular, AHRQ identified eight challenges to consider when evaluating PCMHs, including “describing the changes implemented, identifying barriers and facilitators to implementation, accounting for the practice- and health care systemlevel contextual factors, shortening the time frame needed for largescale evaluations, deciding when randomly assigning practices to become a PCMH model is viable, drawing accurate conclusions from small samples, integrating qualitative and quantitative findings from implementation and impact evaluations, and analyzing the findings to determine whether an intervention worked and what factors contributed to its success.”13 These challenges can guide a research agenda for the pharmacy profession to consider while building the evidence base for how to best integrate pharmacists into PCMHs. There is also an opportunity for pharmacy researchers to collaborate with practitioners—as well as researchers in medicine, nursing, and other health professions—to share ideas and expertise in research methods with a goal of developing robust studies that measure the impact of PCMHs. Another consideration for pharmacy researchers is to develop a defined set of core measures to use when evaluating pharmacist services in a PCMH. This would allow comparisons across various settings and ja p h a .org
populations and be easier for stakeholders such as payers and policymakers to interpret study findings. The PCMH model is a promising approach to redefining primary care and expanding the role of the pharmacist in the primary care setting. The pharmacy profession must rise to the challenge of conducting robust evaluations to assess clinical and economic outcomes related to the integration of pharmacists in PCMH teams. Leticia R. Moczygemba, PharmD, PhD Assistant Professor School of Pharmacy Virginia Commonwealth University Richmond Dawn Andanar, PharmD Community Pharmacy Practice Resident Virginia Commonwealth University Richmond [email protected]
References 1. Ghorob A, Bodenheimer T. Sharing the care to improve access to primary care. N Engl J Med. 2012;366(21):1955-1957. 2. Kirch DG, Henderson MK, Dill MJ. Physician workforce projections in an era of health care reform. Annu Rev Med. 2012;63:435445. 3. Sommers BD, Swartz K, Epstein A. Policy makers should prepare for major uncertainties in Medicaid enrollment, costs, and needs for physicians under health reform. Health Aff. 2011;30(11):2186-2193. 4. Brown DL. A looming joblessness crisis for new pharmacy graduates and the implications it holds for the academy. Am J Pharm Educ. 2013;77(5):90. 5. Knapp K, Schommer JC. Finding a path through times of change. Am J Pharm Educ. 2013;77(5):91. 6. Agency for Healthcare Research and Quality. Defining the PCMH. pcmh.ahrq.gov/page/ defining-pcmh. Accessed April 28, 2014. 7. Patient-Centered Primary Care Collaborative. The patient-centered medical home: integrating comprehensive medication management to optimize patient outcomes. www.pcpcc.org/sites/default/files/media/ medmanagement.pdf. Accessed April 28, 2014. 8. Giberson S, Yoder S, Lee MP. Improving patient and health system outcomes through advanced pharmacy practice: a report to the U.S. Surgeon General. www.usphs.gov/
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corpslinks/pharmacy/documents/2011adva ncedpharmacypracticereporttotheussg.pdf. Accessed April 28, 2014. 9. Peikes DN, Reid RJ, Day TJ, et al. Staffing patterns of primary care practices in the comprehensive primary care initiative. Ann Fam Med. 2014;12(2):142-149. 10. Isetts BJ, Brummel AR, de Oliveira DR, et al. Managing drug-related morbidity and mortality in the patient-centered medical home. Med Care. 2012;50(11):997-1001. 11. Nielsen M, Olayiwola JN, Grundy P, et al. The patient-centered medical home’s impact on cost and quality: an annual update of the evidence, 2012-2013. www.milbank.org/ uploads/documents/reports/Patient-Centered_Medical_Homes_Impact_on_Cost_ and_Quality.pdf. Accessed April 28, 2014. 12. Agency for Healthcare Research and Quality. Evidence and evaluation PCMH research methods series. pcmh.ahrq.gov/ page/evidence-and-evaluation. Accessed May 8, 2014. 13. Agency for Healthcare Research and Quality. Expanding the toolbox: methods to study and refine patient-centered medical home models. pcmh. ahrq.gov/sites/default/files/attachments/ ExpandingtheToolkit_031513comp.pdf. Accessed April 28, 2014.
APhA–ASP
A new model with old roots Patient-centered medical homes (PCMHs) are nearly universally touted as a new way forward for Bode health care and a new paradigm for patient care. An appealing aspect on first glance is that the model is so simple in concept: all health care needs met in one place. When I first learned of this model as a first-year student pharmacist, I remember wondering why we had not been doing this all along. But it’s the way things used to be—when health care meant one physician’s office on Main Street and perhaps an apothecary just next door. There are undeniable benefits to having multiple services under one roof, but the novel aspect of the PCMH model is the return of the older concept of patient-focused, unfragmented health care. PCMHs are not just convenient for the patient; this model is the safest and perhaps
most humanizing way to properly care for people in an increasingly disjointed health care system. A new role for pharmacy What is radically new in this form of health care is the profession of pharmacy. PCMHs, as a new paradigm for patient care, can also be a new paradigm for our profession, creating a new standard of medical care in which access to pharmacist’s clinical services is as routine as a physical exam. We know from personal experience and hundreds of clinical studies that when pharmacists take a larger role in patient care, patients have better outcomes and reduced health care expenses. Consequently, the provision of pharmacy services in a PCMH should mean more than having an onsite outpatient pharmacy. Proximity may satisfy the desire for convenience, but it does not make patients safer and healthier. PCMHs are the ideal outlet for departing from the model of pharmacy that sets pharmacists between prescribers and patients as gatekeepers tasked with keeping out
Call for Volunteers:
Editorial Advisory Board, JAPhA The publisher and editors of the Journal of the American Pharmacists Association invite interested APhA members from pharmacy practice, research, education, industry, and related fields to apply for 10 available positions on the JAPhA Editorial Advisory Board (EAB). The term of service is 3 years, beginning at APhA2015 in San Diego. Responsibilities of EAB members are to: Act as a core group of peer reviewers for submitted manuscripts. Serve as consultants to the editors about proposed changes or new directions in journal content and format or in the processes (e.g., peer review) and policies associated with journal production. Participate on ad hoc subcommittees to examine specific questions and suggest solutions. Provide feedback and suggestions on journal contents and policies as required or requested. Current EAB members are not eligible for reappointment until the year after completion of their terms (e.g., an EAB member whose term expires in 2015 would be eligible for appointment to a new term in 2016). Interested individuals should complete the application form at www.surveymonkey.com/s/FT82XPP and send a current curriculum vitae to Executive Editor L. Michael Posey at [email protected] by October 31, 2014.
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medications that may cause harm. In a PCMH, pharmacists are part of the team with the physician and patient—not only preventing harm, but maximizing benefit. Under the current “gatekeeper” model, pharmacists are positioned to catch an interaction between trimethoprim/sulfamethoxazole (TMP/ SMX) and warfarin before it harms the patient. As a student pharmacist, I am drawn to PCMHs as a future practice site where our role is to also evaluate whether warfarin is the best choice of anticoagulant for that patient’s atrial fibrillation and whether or not an antibiotic is indicated at all. New training for student pharmacists Working in these new models of patient care in the future necessitates new models in pharmacy training today to ensure that graduating doctors of pharmacy are team-ready and focused on patient care. These ideals are reflected in the Accreditation Council for Pharmacy Education’s (ACPE) 2016 draft standards,
which brings up the more relevant question of how to meet these goals. While the education gap between pharmacy and medicine has closed considerably over the past 30 years, student pharmacists are outpaced by their medical counterparts in one significant way. Every medical student has 2 years of comprehensive, patient-focused clinical experiences, whereas each student pharmacist has perhaps 9 months. While time spent does not guarantee the desired attitude, it is not unreasonable to suggest a correlation between the two. To create patient-centered professionals, students should train in a patient-centered curriculum that is rich with patient care experiences. Similarly, to create team-ready professionals, students should train extensively in interprofessional health care teams. Expanded experiential education can help us as student pharmacists prepare for increased patient care roles in settings such as the PCMH and also help us as practitioners advance the profession of pharmacy.
A new practice Many student pharmacists are optimistic about the opportunities available to them in new models of care. Indeed, some view PCMHs as a sort of promised land, where a pharmacist spends most of the day interacting with practitioners and patients. Where a decade of higher education serves to improve health and advance patient care. Where team-based care is not a buzzword but an actuality. As a future pharmacist, my final thought regarding PCMHs is simply this: We need more of them. Lauren E. Bode 2016 PharmD candidate College of Pharmacy University of Tennessee Health Science Center Region III Delegate APhA–ASP [email protected] doi: 10.1331/JAPhA.2014.14515
CALL FOR SUBMISSIONS
JAPhA SEEKS PUBLISHABLE LANDSCAPE OR NATURE PHOTOGRAPHS Do you have one or more photographs from a recent trip that you would like to share with your colleagues in pharmacy? The JAPhA editors are seeking color photographs for the front cover of the journal and for inclusion at the ends of Science & Practice articles. The photographs should be artistic, high-quality shots of nature, landscape, or city scenes containing no identifiable people. If you have photographs that might fit this bill, e-mail the images to the Editor at [email protected]. If your submission is chosen for inclusion, the editors will contact you for a high-quality image and the necessary permissions to use your work in the Journal.
14-065 Call for Photographs RIGHT.indd 1
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Journal of the American Pharmacists Association
Pharmacists’ roles in patientcentered medical homes APhA–APPM: Bella Mehta and Mary Ann Kliethermes APhA–APRS: Leticia R. Moczygemba and Dawn Andanar APhA–ASP: Lauren E. Bode
APhA–APPM
Optimizing medication use through team-based care The Patient Protection and Affordable Care Act (ACA) identifies the need to improve the quality and efficiency of health care in the United States.1 In transforming the delivery of health care, ACA promotes wellness and prevention within patient-centered medical homes Mehta (PCMHs), a teambased model of care. The legislation includes pharmacists as part of the health care workforce as part of a change from a model of treating chronic Kliethermes disease to a model that focuses on preventive medicine, health promotion, disease prevention, and patient self-management.1 New and emerging health care models including PCMHs, accountable care organizations (ACOs), medical neighborhoods, and community-based health centers are currently being created, tested, implemented, and disseminated in response to the pressing need to control health care costs and improve the quality of care patients receive in the United States. Reports from the Institute of Medicine (IOM) over the past 15 years have detailed the prevalence and high cost of problems in the U.S. health care system, including those related to medication use.2,3 Recommendations from IOM to resolve the
identified problems and the passage of ACA are further accelerating the transformation of health care delivery and the role that health professionals (including pharmacists) can play.1,4 Pharmacists can be critical players in PCMHs, helping patients make the best use of medications. Applying their knowledge and skills, pharmacists are drug-therapy experts on the health care team, promoting optimal medication therapy management as a key element of success in new models of care. Pharmacists are assisting integrated teams in ensuring optimal medication management and educating patients as active participants in their own health. As a result of the work of early adopters in providing pharmacists’ patient care services, the role of pharmacists within integrated
teams is becoming better understood and defined. This role has recently been highlighted by a number of authors and organizations. A theme issue of this journal, published in March/April 2011, featured articles on pharmacists and PCMHs.5 Beginning in September 2013, the American Pharmacists Association released a series of eight ACOs briefs focused on emerging health care models.6 Key publications have also described the essential elements of care provided by pharmacists, the substantial contributions pharmacists can make to improving the quality and safety of patient care in PCMHs, and the need for integrating pharmacists into ACOs.7,8 In a 2013 position paper, the American College of Physicians stated that well-functioning teams will assign responsibilities of patient care to midlevel providers such as clinical pharmacists.9 Additionally, the Patient-Centered Primary Care Collaborative, which comprises more than 1,000 multidisciplinary stakeholder organizations, has advocated for new models of team care, including pharmacists
The Association Report column in JAPhA reports on activities of APhA’s three academies and topics of interest to members of those groups. The APhA Academy of Pharmacy Practice and Management (APhA–APPM) is dedicated to assisting members in enhancing the profession of pharmacy, improving medication use, and advancing patient care. Through the APhA-APPM Special Interest Groups (SIGs), the Academy provides members a mechanism to network and support the profession by addressing emerging issues. To access a listing of APhA-APPM SIGs, visit www.pharmacist. com/apha-appm. The mission of the APhA Academy of Pharmaceutical Research and Science (APhA– APRS) is to stimulate the discovery, dissemination, and application of research to improve patient health. Academy members are a source of authoritative information on key scientific issues and work to advance the pharmaceutical sciences and improve the quality of pharmacy practice. Through the three APhA–APRS sections (Clinical Sciences, Basic Pharmaceutical Sciences, and Economic, Social, and Administrative Sciences), the Academy provides a mechanism for experts in all areas of the pharmaceutical sciences to influence APhA’s policymaking process. The mission of the APhA Academy of Student Pharmacists (APhA–ASP) is to be the collective voice of student pharmacists, to provide opportunities for professional growth, to improve patient care, and to envision and advance the future of pharmacy. Since 1969, APhA–ASP and its predecessor organizations have played a key role in helping students navigate pharmacy school, explore careers in pharmacy, and connect with others in the profession. The Association Report column is written by Academy and section officers and coordinated by JAPhA Executive Editor L. Michael Posey of the APhA staff. Suggestions for future content may be sent to [email protected].
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providing medication management.10 In a 2011 white paper, the Agency for Healthcare Research and Quality identifies pharmacists as a critical component of the medical neighborhood.11 Although there has yet to be a simple or standard process for integrating pharmacists into these new models, there is clear evidence of need and support from a variety of stakeholders. Pharmacists are contributing to patient care in PCMHs/ACOs by managing patients’ acute medication needs and assisting in the management of medications used for chronic conditions. These services include optimizing complex medication regimens; performing comprehensive medication reviews to identify, prevent, and minimize drug-related problems; developing care coordination with the patient and other team members, including patient education and medicationadherence strategies; providing ongoing monitoring, transitions of care, and follow-up; assisting with quality measurement; and ensuring adherence to evidence-based medicine. Pharmacists may see patients in separate appointments, during group visits, or in conjunction with other team members. Innovation is at the core of developing the new models of care so that the desired outcomes of quality, efficiency, and reduced cost are achieved. These new models of care enable pharmacists to practice at the “top of their license,” and opportunities are available and growing in communities throughout the country. These opportunities are available to pharmacists practicing in a variety of settings, including community pharmacy, ambulatory care clinics, and hospital-based practices. As each of these models evolve, pharmacists need to reach out not only within their organizations but also to other providers and health care groups in their community to advocate for inclusion of pharmacy services. To achieve the triple aim of better care for patients, better health 220 JAPhA | 5 4 :3 | M AY /JUN 2014
for populations, and reduced health care costs, patients and the health care industry need pharmacists to be fully integrated into PCMHs and ACOs. Bella Mehta, PharmD, FAPhA Coordinator, APhA–APPM Medical Home/ ACO SIG Associate Professor of Clinical Pharmacy College of Pharmacy Ohio State University Columbus [email protected] Mary Ann Kliethermes, BS, PharmD Coordinator-elect, APhA–APPM Medical Home/ACO SIG Vice Chair of Ambulatory Care and Associate Professor Chicago College of Pharmacy Midwestern University Downers Grove, IL [email protected]
References 1. Affordable Care Act. www.hhs.gov/healthcare/rights/law/index.html. Accessed April 28, 2014. 2. Institute of Medicine. Preventing medication errors: quality chasm series. www.nap. edu/openbook.php?record_id=11623. Accessed April 28, 2014. 3. Institute of Medicine. To err is human: building a safer health system. www.nap.edu/ openbook.php?record_id=9728. Accessed April 28, 2014. 4. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. www.nap.edu/openbook. php?record_id=10027. Accessed April 28, 2014. 5. Special features: patient-centered medical homes. J Am Pharm Assoc. 2011;51(2):156-211. 6. American Pharmacists Association. APhA accountable care organization (ACO) briefs. www.pharmacist.com/apha-accountablecare-organization-aco-briefs. Accessed April 23, 2014. 7. Smith M, Bates DW, Bodenheimer T, et al. Why pharmacists belong in the medical home. Health Aff. 2010;29(5):906-913. 8. Smith M, Bates DW, Bodenheimer TS. Pharmacists belong in accountable care organizations and integrated care teams. Health Aff. 2013;32(11):1963-1970. 9. Doherty RB, Crowley RA. Principles supporting dynamic clinical care teams: an American College of Physicians position paper. Ann Intern Med. 2013;159(9):620-626. ja p h a .org
10. Patient-Centered Primary Care Collaborative. www.pcpcc.org. Accessed April 28, 2014. 11. Taylor EF, Lake T, Nysenbaum J, et al. Coordinating care in the medical neighborhood: critical components and available mechanisms. pcmh.ahrq.gov/page/coordinating-care-medical-neighborhood-criticalcomponents-and-available-mechanisms. Accessed April 28, 2014.
APhA–APRS
The need for research to advance the pharmacist’s role in patientcentered medical homes The aging population, rise in chronic disease burden, and increase in the number of insured individuals as a result of the Affordable Care Act have contributed to a need to transform primary care from a physiciancentric to a teambased delivery model.1–3 This transformation Moczygemba can be facilitated by health care professionals, such as pharmacists, practicing at the top of their license. Given that pharmacists, as compared with physicians and Andanar nurses, are expected to be in adequate supply in the near future, there is an opportunity for pharmacists to expand their roles in team-based primary care.4,5 The patient-centered medical home (PCMH) model aims to deliver comprehensive, patient-centered, teambased, coordinated, accessible care with a focus on quality and safety.6 The PCMH has come to the spotlight for the potential to not only improve the quality of health care delivered to patients, but also to reduce health care costs. The PCMH model was first introduced in 1967 by the American Academy of Pediatrics and
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re-emerged as a health care reform strategy to combat the current disjointed health care system by delivering team-based patient care. In 2007, a coalition of medical associations released the Joint Principles for the Patient-Centered Medical Home, which defined key principles in the medical home model, such as an ongoing relationship with a personal physician who cares for the patient in all stages of life and team-based care that is integrated and coordinated across all settings of the health care system and places an overall emphasis on quality and safety. To ensure the same level of care across medical homes, the National Committee for Quality Assurance adopted standards in 2011 focused on enhanced access and continuity of care, managing patient populations and care, providing self-care support, tracking and coordinating care, and measuring and improving performance. Since 2007, a number of professional health care organizations and health systems have endorsed and adopted the PCMH model in the primary care setting. Despite the evolution of the PCMH concept, questions abound regarding the clinical and economic impact of PCMHs, staff mix of care teams, defined roles and responsibilities of team members, and PCMH payment models. Although there has been support for pharmacists to be a key member of PCMHs and primary care teams,7,8 progress toward making this a reality is ongoing. A recent study describing staffing patterns for primary care practices in the Centers for Medicare & Medicaid Services (CMS) Comprehensive Primary Care Initiative indicated that only 9.3% of the 204 practices classified as a PCMH included a pharmacist as part of the team. Regardless, there is emerging evidence that positive outcomes are achieved when pharmacists are integrated with PCMHs.9 In particular, reductions in total health care cost growth and greater achievement of 222 JAPhA | 5 4 :3 | M AY /JUN 2014
treatment goals have been reported with pharmacist involvement, compared with usual care.10,11 From a research perspective there is much opportunity to apply rigorous scientific methods to evaluate the impact of PCMHs, as well as further define and establish pharmacists’ roles. The Agency for Healthcare Research and Quality (AHRQ) commissioned the development of the PCMH Research Methods Series to guide researchers in conducting rigorous studies to measure the implementation and impact of PCMHs.12 In particular, AHRQ identified eight challenges to consider when evaluating PCMHs, including “describing the changes implemented, identifying barriers and facilitators to implementation, accounting for the practice- and health care systemlevel contextual factors, shortening the time frame needed for largescale evaluations, deciding when randomly assigning practices to become a PCMH model is viable, drawing accurate conclusions from small samples, integrating qualitative and quantitative findings from implementation and impact evaluations, and analyzing the findings to determine whether an intervention worked and what factors contributed to its success.”13 These challenges can guide a research agenda for the pharmacy profession to consider while building the evidence base for how to best integrate pharmacists into PCMHs. There is also an opportunity for pharmacy researchers to collaborate with practitioners—as well as researchers in medicine, nursing, and other health professions—to share ideas and expertise in research methods with a goal of developing robust studies that measure the impact of PCMHs. Another consideration for pharmacy researchers is to develop a defined set of core measures to use when evaluating pharmacist services in a PCMH. This would allow comparisons across various settings and ja p h a .org
populations and be easier for stakeholders such as payers and policymakers to interpret study findings. The PCMH model is a promising approach to redefining primary care and expanding the role of the pharmacist in the primary care setting. The pharmacy profession must rise to the challenge of conducting robust evaluations to assess clinical and economic outcomes related to the integration of pharmacists in PCMH teams. Leticia R. Moczygemba, PharmD, PhD Assistant Professor School of Pharmacy Virginia Commonwealth University Richmond Dawn Andanar, PharmD Community Pharmacy Practice Resident Virginia Commonwealth University Richmond [email protected]
References 1. Ghorob A, Bodenheimer T. Sharing the care to improve access to primary care. N Engl J Med. 2012;366(21):1955-1957. 2. Kirch DG, Henderson MK, Dill MJ. Physician workforce projections in an era of health care reform. Annu Rev Med. 2012;63:435445. 3. Sommers BD, Swartz K, Epstein A. Policy makers should prepare for major uncertainties in Medicaid enrollment, costs, and needs for physicians under health reform. Health Aff. 2011;30(11):2186-2193. 4. Brown DL. A looming joblessness crisis for new pharmacy graduates and the implications it holds for the academy. Am J Pharm Educ. 2013;77(5):90. 5. Knapp K, Schommer JC. Finding a path through times of change. Am J Pharm Educ. 2013;77(5):91. 6. Agency for Healthcare Research and Quality. Defining the PCMH. pcmh.ahrq.gov/page/ defining-pcmh. Accessed April 28, 2014. 7. Patient-Centered Primary Care Collaborative. The patient-centered medical home: integrating comprehensive medication management to optimize patient outcomes. www.pcpcc.org/sites/default/files/media/ medmanagement.pdf. Accessed April 28, 2014. 8. Giberson S, Yoder S, Lee MP. Improving patient and health system outcomes through advanced pharmacy practice: a report to the U.S. Surgeon General. www.usphs.gov/
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corpslinks/pharmacy/documents/2011adva ncedpharmacypracticereporttotheussg.pdf. Accessed April 28, 2014. 9. Peikes DN, Reid RJ, Day TJ, et al. Staffing patterns of primary care practices in the comprehensive primary care initiative. Ann Fam Med. 2014;12(2):142-149. 10. Isetts BJ, Brummel AR, de Oliveira DR, et al. Managing drug-related morbidity and mortality in the patient-centered medical home. Med Care. 2012;50(11):997-1001. 11. Nielsen M, Olayiwola JN, Grundy P, et al. The patient-centered medical home’s impact on cost and quality: an annual update of the evidence, 2012-2013. www.milbank.org/ uploads/documents/reports/Patient-Centered_Medical_Homes_Impact_on_Cost_ and_Quality.pdf. Accessed April 28, 2014. 12. Agency for Healthcare Research and Quality. Evidence and evaluation PCMH research methods series. pcmh.ahrq.gov/ page/evidence-and-evaluation. Accessed May 8, 2014. 13. Agency for Healthcare Research and Quality. Expanding the toolbox: methods to study and refine patient-centered medical home models. pcmh. ahrq.gov/sites/default/files/attachments/ ExpandingtheToolkit_031513comp.pdf. Accessed April 28, 2014.
APhA–ASP
A new model with old roots Patient-centered medical homes (PCMHs) are nearly universally touted as a new way forward for Bode health care and a new paradigm for patient care. An appealing aspect on first glance is that the model is so simple in concept: all health care needs met in one place. When I first learned of this model as a first-year student pharmacist, I remember wondering why we had not been doing this all along. But it’s the way things used to be—when health care meant one physician’s office on Main Street and perhaps an apothecary just next door. There are undeniable benefits to having multiple services under one roof, but the novel aspect of the PCMH model is the return of the older concept of patient-focused, unfragmented health care. PCMHs are not just convenient for the patient; this model is the safest and perhaps
most humanizing way to properly care for people in an increasingly disjointed health care system. A new role for pharmacy What is radically new in this form of health care is the profession of pharmacy. PCMHs, as a new paradigm for patient care, can also be a new paradigm for our profession, creating a new standard of medical care in which access to pharmacist’s clinical services is as routine as a physical exam. We know from personal experience and hundreds of clinical studies that when pharmacists take a larger role in patient care, patients have better outcomes and reduced health care expenses. Consequently, the provision of pharmacy services in a PCMH should mean more than having an onsite outpatient pharmacy. Proximity may satisfy the desire for convenience, but it does not make patients safer and healthier. PCMHs are the ideal outlet for departing from the model of pharmacy that sets pharmacists between prescribers and patients as gatekeepers tasked with keeping out
Call for Volunteers:
Editorial Advisory Board, JAPhA The publisher and editors of the Journal of the American Pharmacists Association invite interested APhA members from pharmacy practice, research, education, industry, and related fields to apply for 10 available positions on the JAPhA Editorial Advisory Board (EAB). The term of service is 3 years, beginning at APhA2015 in San Diego. Responsibilities of EAB members are to: Act as a core group of peer reviewers for submitted manuscripts. Serve as consultants to the editors about proposed changes or new directions in journal content and format or in the processes (e.g., peer review) and policies associated with journal production. Participate on ad hoc subcommittees to examine specific questions and suggest solutions. Provide feedback and suggestions on journal contents and policies as required or requested. Current EAB members are not eligible for reappointment until the year after completion of their terms (e.g., an EAB member whose term expires in 2015 would be eligible for appointment to a new term in 2016). Interested individuals should complete the application form at www.surveymonkey.com/s/FT82XPP and send a current curriculum vitae to Executive Editor L. Michael Posey at [email protected] by October 31, 2014.
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medications that may cause harm. In a PCMH, pharmacists are part of the team with the physician and patient—not only preventing harm, but maximizing benefit. Under the current “gatekeeper” model, pharmacists are positioned to catch an interaction between trimethoprim/sulfamethoxazole (TMP/ SMX) and warfarin before it harms the patient. As a student pharmacist, I am drawn to PCMHs as a future practice site where our role is to also evaluate whether warfarin is the best choice of anticoagulant for that patient’s atrial fibrillation and whether or not an antibiotic is indicated at all. New training for student pharmacists Working in these new models of patient care in the future necessitates new models in pharmacy training today to ensure that graduating doctors of pharmacy are team-ready and focused on patient care. These ideals are reflected in the Accreditation Council for Pharmacy Education’s (ACPE) 2016 draft standards,
which brings up the more relevant question of how to meet these goals. While the education gap between pharmacy and medicine has closed considerably over the past 30 years, student pharmacists are outpaced by their medical counterparts in one significant way. Every medical student has 2 years of comprehensive, patient-focused clinical experiences, whereas each student pharmacist has perhaps 9 months. While time spent does not guarantee the desired attitude, it is not unreasonable to suggest a correlation between the two. To create patient-centered professionals, students should train in a patient-centered curriculum that is rich with patient care experiences. Similarly, to create team-ready professionals, students should train extensively in interprofessional health care teams. Expanded experiential education can help us as student pharmacists prepare for increased patient care roles in settings such as the PCMH and also help us as practitioners advance the profession of pharmacy.
A new practice Many student pharmacists are optimistic about the opportunities available to them in new models of care. Indeed, some view PCMHs as a sort of promised land, where a pharmacist spends most of the day interacting with practitioners and patients. Where a decade of higher education serves to improve health and advance patient care. Where team-based care is not a buzzword but an actuality. As a future pharmacist, my final thought regarding PCMHs is simply this: We need more of them. Lauren E. Bode 2016 PharmD candidate College of Pharmacy University of Tennessee Health Science Center Region III Delegate APhA–ASP [email protected] doi: 10.1331/JAPhA.2014.14515
CALL FOR SUBMISSIONS
JAPhA SEEKS PUBLISHABLE LANDSCAPE OR NATURE PHOTOGRAPHS Do you have one or more photographs from a recent trip that you would like to share with your colleagues in pharmacy? The JAPhA editors are seeking color photographs for the front cover of the journal and for inclusion at the ends of Science & Practice articles. The photographs should be artistic, high-quality shots of nature, landscape, or city scenes containing no identifiable people. If you have photographs that might fit this bill, e-mail the images to the Editor at [email protected]. If your submission is chosen for inclusion, the editors will contact you for a high-quality image and the necessary permissions to use your work in the Journal.
14-065 Call for Photographs RIGHT.indd 1
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