December 2019, Volume XXXIII, No 9
Comprehensive medication management
Expanding the primacy care interprofessional team
magine a typical day in your primary care clinic. You are two patients behind schedule. Two of your practice partners are out of the office, and you are covering their inbox. Refill requests are pouring in, and your new medical assistant is not quite up to speed. Your next patient is one of your most complicated; you have struggled to make progress through a list of many medications in your 20-minute visits. You inherited this patient from a recently retired provider and have not had a chance to dig through their medical history, but you do know that none of their chronic conditions are at goal. Your coffee is cold. You have already missed two of your child’s hockey games, and after checking your watch, doubt you will make it home for dinner … again.
A recipe for burnout—and a strategy
Provider burnout is a well-documented issue within primary care. With shortened appointment times, higher patient loads, and increased provider responsibility due to shifts towards value-based care, the burden carried by primary care providers is heavy. In an environment where budgets are tight and expectations to quickly improve health outcomes are high, where might we look to improve provider work-life balance and reduce burnout? Recent research has demonstrated that adding a pharmacist to the primary care team can be one strategy.
As health care has evolved, so too has the profession of pharmacy. Pharmacists are doctorate-trained health professionals with a minimum of six years of education (most have a bachelor’s degree prior to completing a four-year Doctor of Pharmacy program) and optional postgraduate training. While the majority of pharmacists in retail or other outpatient settings enter the workforce immediately following completion of their degree, many pharmacists now complete one or two years of postgraduate residency training. Nearly 50% of graduates from the University of Minnesota College of Pharmacy now complete a residency and pursue a wide variety of career opportunities. While pharmacists have long been a core member of interprofessional teams in hospital settings, a similar role is now emerging more frequently in primary and specialty care clinics. In fact, more than 150 clinics in Minnesota currently have pharmacists integrated into the interprofessional care team.
Comprehensive medication management
Most of these clinic-based pharmacists deliver a service referred to as “comprehensive medication management (CMM).” In this practice model, pharmacists evaluate patients on an appointment basis, collect information regarding their medications and overall health, ensure that all of a patient’s medication-related needs are addressed using a defined assessment process, develop and implement care plans, and follow up with patients to ensure that the goals of therapy are achieved. These actions are done in collaboration with the patient’s primary care provider (PCP) and other team members.
The value of physician-pharmacist collaboration extends beyond just revenue.
While there is some potential financial benefit to pharmacists practicing in the primary care setting, payment opportunities have not developed as quickly as the efforts to integrate pharmacists into medical practices. Reimbursement for services is often low and may not cover the expense organizations incur to employ a pharmacist in this setting. However, the value of physician-pharmacist collaboration extends beyond just revenue. Evidence suggests that physician-pharmacist collaborations have a net positive impact on each of the three elements of the Institute for Healthcare Improvement’s Triple Aim: to improve health care quality through optimizing patient satisfaction, promote the health of populations, and reduce the per-capita cost of patient care.
Adding an “aim”
As burnout has emerged as a significant issue in health care, the Triple Aim has been updated to the “Quadruple Aim” to encompass the importance of improving provider “work-life,” including clinical work, professional satisfaction, and burnout. This new focus creates an opportunity to consider the factors that lead to medical provider burnout. A recent study published in the Journal of the American Board of Family Medicine explored this issue with PCPs in Minnesota health systems that have adopted an integrated model with pharmacists, and has identified a positive correlation.
Two themes surfaced from interviews with PCPs. These primary care providers indicated that working alongside pharmacists offering CMM resulted in:
As a result of this unique collaboration with a pharmacist, the PCPs described seven outcomes that impacted their work-life:
A pharmacist can add complementary skills to the primary care team in numerous ways. Having a pharmacotherapy expert easily accessible within a clinic can improve efficiency and enhance professional learning. Pharmacists are well-versed in evidence-based guidelines, and understand clinical nuances in medication selection, cost, and insurance coverage. Questions related to medication coverage and selection can be relayed through the pharmacist, allowing the provider to finish documentation or move on to another patient; this saves time for the provider during the course of their day. Additionally, a patient with many medication questions could be referred to the pharmacist for CMM services, leaving open an appointment slot for patients with other medical needs, thereby improving access to care. The pharmacist’s approach to patient care is unique, and because of this, medication-related problems that could have been overlooked may be discovered and subsequently resolved by the pharmacist.
Clinic-based primary care pharmacists are not practicing independently. As members of the health care team, trust is built between providers and pharmacists whereby the burden of care for the most complex patients can be shouldered together. In the study, PCPs viewed pharmacists as a collaborative partner. In most settings that have adopted this model, pharmacists operate under a collaborative practice agreement that establishes the parameters in which a pharmacist can start, stop, or adjust medications. These are often less prescriptive than a protocol and allow pharmacists to apply evidence-based guidelines and their knowledge of pharmacotherapy to help develop a treatment plan that achieves the desired outcomes of therapy. This partnership and collaboration led to PCPs feeling supported and reassured, even stating that they felt “less burned out.”
In the study, providers also mentioned several areas where pharmacist-provided CMM improved their own work-life and reduced burnout. Pharmacists were noted to decrease workload for providers through sharing patient care and communication responsibilities. Pharmacists assisted with refill requests and inbox messages, leaving PCPs more accessible for other activities; PCPs believed this increased their own and their patients’ satisfaction. PCPs described an increased sense of satisfaction, perceiving that their patients were receiving more comprehensive, quality care. They felt this led to an increased sense of support when care was shared amongst the team, leading to increased confidence in their clinical decisions through consultations with a pharmacist, including reduced fear of malpractice suits.
A pharmacist can add complementary skills to the primary care team in numerous ways.
Importantly, providers felt a decreased sense of mental exhaustion when they collaborated with pharmacists. Complex patients often have many medication-related problems, and the providers believed the pharmacists’ assessment led to simplification and organization of the patient’s medications. Not only were the pharmacists able to resolve many medication-related problems for the patient, but the organization of the pharmacists’ assessment led to an easier discovery of any unresolved needs to be addressed by the primary provider.
While these are positive and impactful outcomes, there are barriers to pharmacist and provider collaboration. Insurance coverage might limit patient ability to see pharmacists for CMM visits. Secondly, the strength of this collaborative partnership is based on a trusting relationship. Without a trusting relationship between both pharmacist and provider, it may be difficult to collaborate and improve patient health and outcomes. It is important to note that clinic-based primary care pharmacists are embedded within the primary care team, allowing development of a strong working relationship. These aren’t pharmacists working at dispensing pharmacies or insurance companies offering recommendations via fax machine; these are pharmacists working alongside providers, seeing the same patients, and working within the same electronic health record. Finally, patient understanding of the role of a pharmacist in their primary care visits may be limited. While all of these limitations exist, acknowledging the evolving health care team and the importance of team-based care on outcomes and quality cannot be understated.
The scenario at the opening of this article could be re-written with examples provided from the study. Your day starts as you scan your schedule and see that your extremely complex patient is coming in. You feel a sense of relief when you notice that the patient has a visit scheduled with your clinic-based primary care pharmacist immediately prior to the patient’s visit with you. The pharmacist gives you a warm handoff—she has cleaned up the medication list, resolved a patient’s concern about a potential side effect of an existing medication, and recommended a newer antiglycemic medication covered by the patient’s insurance that would likely help the patient reach his A1c goal.
After your discussion with the pharmacist, you’re pleased that you’ve learned a bit more about this newer medication. Your visit with the patient runs smoothly and you notice that the patient is also satisfied with this team-based care. Now, you are on time to see your next patient and also feel better about your work and your day. Because of the help with frequent follow ups and more complex patients, your patients are happy, you are on time, and you’ll likely make it home for dinner. This collaboration with the pharmacist, compounded over time, could certainly improve not only patient care and quality outcomes, but your work-life balance and burnout.
Kyle Walburg, PharmD, is a second-year pharmaceutical care leadership resident at the University of Minnesota College of Pharmacy, North Memorial Camden Family Medicine Clinic.
Sara Massey, PharmD, is a second-year pharmaceutical care leadership resident at the University of Minnesota College of Pharmacy, MOBE, LLC
Kylee Funk, PharmD, BCPS, is an assistant professor at the University of Minnesota College of Pharmacy.
Randy Seifert, PharmD, is professor and associate dean at the University of Minnesota College of Pharmacy.
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