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﷯ cover story two A changing role of pharmacy Collaborating on multiple fronts By Sarah Derr, PharmD ﷯illions of Americans lack adequate access to primary health care, and many are not able to see their clinician on a regular basis due to multiple factors, which may include lack of insurance coverage; social determinants of health that limit transportation, mobility, or flexibility in work schedules; and strained financial resources. For these patients—and patients in general—pharmacists can provide invaluable assistance if they are incorporated into care teams. This pharmacist-clinician collaboration is key to providing the best patient care in our changing health care system. Adding a pharmacist to the care team can reduce the risk of adverse drug reactions and can lower costs. By having patients manage chronic disease states with their pharmacists, physicians and other providers are freed up to spend more time with complex patients who truly need their expertise. An evolving field The pharmacy profession has evolved greatly over the course of the last two decades. Pharmacists remain committed to providing information and access to prescription medications for patients; however, their scope of practice now also includes health wellness testing, chronic disease management, and medication management services. Additionally, Minnesota pharmacists can administer most vaccinations, and recent legislation will allow pharmacists to administer subcutaneous and intramuscular medications in the pharmacy to assist with mental health and opioid/alcohol use disorder. Pharmacists can be found in nearly all practices of health care, including, but not limited to, inpatient and outpatient care, community and chain pharmacies, long-term care, specialty medication practices, toxicology, and nuclear pharmacy. Pharmacists act as a part of the patient care team by assisting other health care professionals to ensure each medication a patient takes is indicated, effective, safe, and convenient. Pharmacists are well versed in preventative care, patient counseling, motivational interviewing, and health and wellness. They know how to manage chronic diseases such as hypertension, diabetes, and hypercholesterolemia. Pharmacists can manage treatment plans initiated by providers, order laboratory tests, and adjust medication through adding, changing, and discontinuing medications. ﷯ According to a study in the United Kingdom, 5% of emergency department presentations, and 13% of presentations to general practitioners, represent minor ailments that could be managed in community pharmacies. Another study evaluated the effects of pharmacist care on heart failure, a leading cause of hospitalizations. One review of 2,000 patients from 1998 to 2007 found a 29% reduction in all-cause hospitalization and a 31% reduction in heart failure hospitalizations. New roles for the pharmacist Some examples of current pharmacy practice areas: Inpatient care. Currently, inpatient pharmacists serve on the health care team to review medications on rounds and make suggestions regarding patient care. Additionally, they provide patients and providers with information about medications and check for drug-drug, drug-food, and drug-disease interactions. Challenging medications—for example, antibiotics such as gentamicin and vancomycin—require difficult dosing calculations, which pharmacists can assist with to ensure patient safety. In response to a rise in strains of antibiotic-resistant bacteria, pharmacists in the inpatient setting have stepped into antimicrobial stewardship. By creating a plan and an antibiogram (which shows the hospital’s history of which microbes have been resistant to which antibiotics), pharmacists can assist in preventing further increases in bacterial resistance. Additionally, pharmacists serve on the pharmaceutical and therapeutics committee to determine which medications will be on formulary at the health system. This is extremely helpful, as there have been many recent drug shortages and pharmacists are aware of which medications are available. Many pharmacists or student pharmacists assist with medication history at intake and review the medication to ensure that the patient is on the right medications at all stages: what they were taking prior to admission, while they are in the hospital, and before they go home or move to another care center. ﷯ Ambulatory care. Minnesota is well known for embedding ambulatory care pharmacists within clinics, where they see patients, typically in one-on-one interactions. These pharmacists offer medication therapy management services to assist patients in better understanding their medications. These pharmacists spend anywhere from 30–60 minutes with a patient at each visit. They review the full patient medication list and check for indicated, effective, safe, and convenient medications, supplements, over-the-counter medications, and herbals. Additionally, they review the patient’s diagnosis and labs to ensure that medications are working appropriately and to see if any additional therapy is needed. Typically, this is done through a Collaborative Practice Agreement with the physicians, physician assistants, and nurse practitioners practicing in the clinic. Pharmacists can also assist with warfarin and insulin therapy adjustments. One study found that pharmacist-run services saved $647,024 by preventing hospital admissions and emergency department visits. A cost effectiveness evaluation indicated that discharge counseling by pharmacists had a cost savings in 48% of scenarios, but all scenarios were cost effective at a low willingness-to-pay value. High-risk elderly patients appeared to benefit most from this service. A study of medication therapy management programs with 186 patients through Blue Cross and Blue Shield of Minnesota found reductions in health care costs per person of 31.5%, from $11,965 to $8,197. Prescription claims increased 19.7%. The total cost of medication therapy management services was estimated at $49,490, but total health care expenditures for all patients were reduced by 31.5%, from $2,225,540 to $1,524,703. The return on investment was $12.15 per $1 of MTM services provided. This cost reduction can be seen in Figure 1. ﷯ Figure 1. National Association for Chain Drug Stores. Pharmacies: Improving Health, Reducing Costs. Community. Community pharmacists can also assist with chronic disease management and reviews of full patient medication lists, following up on work performed in the ambulatory care setting. Simple lab tests, such as glucose screenings and cholesterol checks performed at the pharmacy, allow patients to check their labs between clinic visits. This can also help flag an issue to share with the patient’s clinician. In-pharmacy blood pressure checks, PHQ-9, and GAD assessments can ensure that the patient’s medication therapy is effective. Pharmacists are also uniquely positioned to assist with the more than 300,000 over-the-counter medications now available. Community pharmacists also play a key role in assisting patients with medication adherence, which correlates with positive health outcomes. It is estimated that 20% to 50% of patients may not be adherent with their medications. Nonadherence is associated with disease progression, therapy failure, and hospitalization. A study found that 33% to 69% of medication-related hospital admissions are due to poor medication adherence. As the patient comes in on at least a monthly basis to refill a prescription, this is a great opportunity for pharmacists to assess adherence, to intervene if there is an issue, and to contact the clinician if there is great concern regarding adherence. On the national level, the Community Pharmacy Enhanced Services Network (www.cpesn.com) offers resources to help pharmacies assess their higher levels of services to patients in the outpatient setting. These services may include chronic care management, immunizations, medication delivery, medication administration, and more. Minnesota is in the process of building its own CPESN. ﷯ Pharmacists’ Patient Care Process The process of pharmacist care is guided through the Joint Commission of Pharmacy Practitioners (JCPP). To ensure consistency in any practice setting where pharmacists provide patient care, the JCPP developed the Pharmacists’ Patient Care Process. Steps in that process, in order, call for pharmacists to: Collect Assess Plan Implement Follow Up: Monitor and Evaluate At the center of this process is the patient, as well as collaboration, communication, and documentation. Each step is vital to pharmacist-provided patient care. Learn more at https://jcpp.net/patient-care-process/. Moving forward Communication is the biggest barrier for pharmacists to collaborate with other health care professionals. One communication challenge is reaching out and having the opportunity to share what pharmacists can do to assist in caring for patients as a part of the health care team. The reason for this is that pharmacists often have little time to present on the benefits of utilizing a pharmacist to clinicians and, additionally, often are communicating via phone or fax with nurses rather than directly with clinicians. Another barrier is not having access to the electronic medical record (EMR), especially for community pharmacists who could assist with ensuring that the patient’s therapy is effective and safe. Even having read-access only to the EMR allows pharmacists to provide better care. There are examples across the country (North Carolina and Iowa) who have read-only access or access to the EMR to write notes for clinicians. I encourage health systems and clinicians to reach out to local pharmacies to see how their local pharmacist could assist. ﷯ By incorporating the pharmacist on your care team, you will free up more time to care for your complicated patients. Reach out to your local pharmacists and discuss what opportunities exist for you to work as a team. In addition, encourage your patients to talk to their local pharmacist and better understand their services and how they can assist the patient. Sarah Derr, PharmD, currently serves as the Executive Director at the Minnesota Pharmacists Association. Dr. Derr completed her residency in ambulatory care at Fairview Health Services, then served as the inaugural executive fellow at the Iowa Pharmacy Association and the Medication Management Pharmacist for the Iowa Healthcare Collaborative. ﷯
﷯ cover story two A changing role of pharmacy Collaborating on multiple fronts By Sarah Derr, PharmD ﷯illions of Americans lack adequate access to primary health care, and many are not able to see their clinician on a regular basis due to multiple factors, which may include lack of insurance coverage; social determinants of health that limit transportation, mobility, or flexibility in work schedules; and strained financial resources. For these patients—and patients in general—pharmacists can provide invaluable assistance if they are incorporated into care teams. This pharmacist-clinician collaboration is key to providing the best patient care in our changing health care system. Adding a pharmacist to the care team can reduce the risk of adverse drug reactions and can lower costs. By having patients manage chronic disease states with their pharmacists, physicians and other providers are freed up to spend more time with complex patients who truly need their expertise. An evolving field The pharmacy profession has evolved greatly over the course of the last two decades. Pharmacists remain committed to providing information and access to prescription medications for patients; however, their scope of practice now also includes health wellness testing, chronic disease management, and medication management services. Additionally, Minnesota pharmacists can administer most vaccinations, and recent legislation will allow pharmacists to administer subcutaneous and intramuscular medications in the pharmacy to assist with mental health and opioid/alcohol use disorder. Pharmacists can be found in nearly all practices of health care, including, but not limited to, inpatient and outpatient care, community and chain pharmacies, long-term care, specialty medication practices, toxicology, and nuclear pharmacy. Pharmacists act as a part of the patient care team by assisting other health care professionals to ensure each medication a patient takes is indicated, effective, safe, and convenient. Pharmacists are well versed in preventative care, patient counseling, motivational interviewing, and health and wellness. They know how to manage chronic diseases such as hypertension, diabetes, and hypercholesterolemia. Pharmacists can manage treatment plans initiated by providers, order laboratory tests, and adjust medication through adding, changing, and discontinuing medications. ﷯ According to a study in the United Kingdom, 5% of emergency department presentations, and 13% of presentations to general practitioners, represent minor ailments that could be managed in community pharmacies. Another study evaluated the effects of pharmacist care on heart failure, a leading cause of hospitalizations. One review of 2,000 patients from 1998 to 2007 found a 29% reduction in all-cause hospitalization and a 31% reduction in heart failure hospitalizations. New roles for the pharmacist Some examples of current pharmacy practice areas: Inpatient care. Currently, inpatient pharmacists serve on the health care team to review medications on rounds and make suggestions regarding patient care. Additionally, they provide patients and providers with information about medications and check for drug-drug, drug-food, and drug-disease interactions. Challenging medications—for example, antibiotics such as gentamicin and vancomycin—require difficult dosing calculations, which pharmacists can assist with to ensure patient safety. In response to a rise in strains of antibiotic-resistant bacteria, pharmacists in the inpatient setting have stepped into antimicrobial stewardship. By creating a plan and an antibiogram (which shows the hospital’s history of which microbes have been resistant to which antibiotics), pharmacists can assist in preventing further increases in bacterial resistance. Additionally, pharmacists serve on the pharmaceutical and therapeutics committee to determine which medications will be on formulary at the health system. This is extremely helpful, as there have been many recent drug shortages and pharmacists are aware of which medications are available. Many pharmacists or student pharmacists assist with medication history at intake and review the medication to ensure that the patient is on the right medications at all stages: what they were taking prior to admission, while they are in the hospital, and before they go home or move to another care center. ﷯ Ambulatory care. Minnesota is well known for embedding ambulatory care pharmacists within clinics, where they see patients, typically in one-on-one interactions. These pharmacists offer medication therapy management services to assist patients in better understanding their medications. These pharmacists spend anywhere from 30–60 minutes with a patient at each visit. They review the full patient medication list and check for indicated, effective, safe, and convenient medications, supplements, over-the-counter medications, and herbals. Additionally, they review the patient’s diagnosis and labs to ensure that medications are working appropriately and to see if any additional therapy is needed. Typically, this is done through a Collaborative Practice Agreement with the physicians, physician assistants, and nurse practitioners practicing in the clinic. Pharmacists can also assist with warfarin and insulin therapy adjustments. One study found that pharmacist-run services saved $647,024 by preventing hospital admissions and emergency department visits. A cost effectiveness evaluation indicated that discharge counseling by pharmacists had a cost savings in 48% of scenarios, but all scenarios were cost effective at a low willingness-to-pay value. High-risk elderly patients appeared to benefit most from this service. A study of medication therapy management programs with 186 patients through Blue Cross and Blue Shield of Minnesota found reductions in health care costs per person of 31.5%, from $11,965 to $8,197. Prescription claims increased 19.7%. The total cost of medication therapy management services was estimated at $49,490, but total health care expenditures for all patients were reduced by 31.5%, from $2,225,540 to $1,524,703. The return on investment was $12.15 per $1 of MTM services provided. This cost reduction can be seen in Figure 1. ﷯ Figure 1. National Association for Chain Drug Stores. Pharmacies: Improving Health, Reducing Costs. Community. Community pharmacists can also assist with chronic disease management and reviews of full patient medication lists, following up on work performed in the ambulatory care setting. Simple lab tests, such as glucose screenings and cholesterol checks performed at the pharmacy, allow patients to check their labs between clinic visits. This can also help flag an issue to share with the patient’s clinician. In-pharmacy blood pressure checks, PHQ-9, and GAD assessments can ensure that the patient’s medication therapy is effective. Pharmacists are also uniquely positioned to assist with the more than 300,000 over-the-counter medications now available. Community pharmacists also play a key role in assisting patients with medication adherence, which correlates with positive health outcomes. It is estimated that 20% to 50% of patients may not be adherent with their medications. Nonadherence is associated with disease progression, therapy failure, and hospitalization. A study found that 33% to 69% of medication-related hospital admissions are due to poor medication adherence. As the patient comes in on at least a monthly basis to refill a prescription, this is a great opportunity for pharmacists to assess adherence, to intervene if there is an issue, and to contact the clinician if there is great concern regarding adherence. On the national level, the Community Pharmacy Enhanced Services Network (www.cpesn.com) offers resources to help pharmacies assess their higher levels of services to patients in the outpatient setting. These services may include chronic care management, immunizations, medication delivery, medication administration, and more. Minnesota is in the process of building its own CPESN. ﷯ Pharmacists’ Patient Care Process The process of pharmacist care is guided through the Joint Commission of Pharmacy Practitioners (JCPP). To ensure consistency in any practice setting where pharmacists provide patient care, the JCPP developed the Pharmacists’ Patient Care Process. Steps in that process, in order, call for pharmacists to: Collect Assess Plan Implement Follow Up: Monitor and Evaluate At the center of this process is the patient, as well as collaboration, communication, and documentation. Each step is vital to pharmacist-provided patient care. Learn more at https://jcpp.net/patient-care-process/. Moving forward Communication is the biggest barrier for pharmacists to collaborate with other health care professionals. One communication challenge is reaching out and having the opportunity to share what pharmacists can do to assist in caring for patients as a part of the health care team. The reason for this is that pharmacists often have little time to present on the benefits of utilizing a pharmacist to clinicians and, additionally, often are communicating via phone or fax with nurses rather than directly with clinicians. Another barrier is not having access to the electronic medical record (EMR), especially for community pharmacists who could assist with ensuring that the patient’s therapy is effective and safe. Even having read-access only to the EMR allows pharmacists to provide better care. There are examples across the country (North Carolina and Iowa) who have read-only access or access to the EMR to write notes for clinicians. I encourage health systems and clinicians to reach out to local pharmacies to see how their local pharmacist could assist. ﷯ By incorporating the pharmacist on your care team, you will free up more time to care for your complicated patients. Reach out to your local pharmacists and discuss what opportunities exist for you to work as a team. In addition, encourage your patients to talk to their local pharmacist and better understand their services and how they can assist the patient. Sarah Derr, PharmD, currently serves as the Executive Director at the Minnesota Pharmacists Association. Dr. Derr completed her residency in ambulatory care at Fairview Health Services, then served as the inaugural executive fellow at the Iowa Pharmacy Association and the Medication Management Pharmacist for the Iowa Healthcare Collaborative. ﷯

﷯ cover story two A changing role of pharmacy Collaborating on multiple fronts By Sarah Derr, PharmD ﷯illions of Americans lack adequate access to primary health care, and many are not able to see their clinician on a regular basis due to multiple factors, which may include lack of insurance coverage; social determinants of health that limit transportation, mobility, or flexibility in work schedules; and strained financial resources. For these patients—and patients in general—pharmacists can provide invaluable assistance if they are incorporated into care teams. This pharmacist-clinician collaboration is key to providing the best patient care in our changing health care system. Adding a pharmacist to the care team can reduce the risk of adverse drug reactions and can lower costs. By having patients manage chronic disease states with their pharmacists, physicians and other providers are freed up to spend more time with complex patients who truly need their expertise. An evolving field The pharmacy profession has evolved greatly over the course of the last two decades. Pharmacists remain committed to providing information and access to prescription medications for patients; however, their scope of practice now also includes health wellness testing, chronic disease management, and medication management services. Additionally, Minnesota pharmacists can administer most vaccinations, and recent legislation will allow pharmacists to administer subcutaneous and intramuscular medications in the pharmacy to assist with mental health and opioid/alcohol use disorder. Pharmacists can be found in nearly all practices of health care, including, but not limited to, inpatient and outpatient care, community and chain pharmacies, long-term care, specialty medication practices, toxicology, and nuclear pharmacy. Pharmacists act as a part of the patient care team by assisting other health care professionals to ensure each medication a patient takes is indicated, effective, safe, and convenient. Pharmacists are well versed in preventative care, patient counseling, motivational interviewing, and health and wellness. They know how to manage chronic diseases such as hypertension, diabetes, and hypercholesterolemia. Pharmacists can manage treatment plans initiated by providers, order laboratory tests, and adjust medication through adding, changing, and discontinuing medications. ﷯ According to a study in the United Kingdom, 5% of emergency department presentations, and 13% of presentations to general practitioners, represent minor ailments that could be managed in community pharmacies. Another study evaluated the effects of pharmacist care on heart failure, a leading cause of hospitalizations. One review of 2,000 patients from 1998 to 2007 found a 29% reduction in all-cause hospitalization and a 31% reduction in heart failure hospitalizations. New roles for the pharmacist Some examples of current pharmacy practice areas: Inpatient care. Currently, inpatient pharmacists serve on the health care team to review medications on rounds and make suggestions regarding patient care. Additionally, they provide patients and providers with information about medications and check for drug-drug, drug-food, and drug-disease interactions. Challenging medications—for example, antibiotics such as gentamicin and vancomycin—require difficult dosing calculations, which pharmacists can assist with to ensure patient safety. In response to a rise in strains of antibiotic-resistant bacteria, pharmacists in the inpatient setting have stepped into antimicrobial stewardship. By creating a plan and an antibiogram (which shows the hospital’s history of which microbes have been resistant to which antibiotics), pharmacists can assist in preventing further increases in bacterial resistance. Additionally, pharmacists serve on the pharmaceutical and therapeutics committee to determine which medications will be on formulary at the health system. This is extremely helpful, as there have been many recent drug shortages and pharmacists are aware of which medications are available. Many pharmacists or student pharmacists assist with medication history at intake and review the medication to ensure that the patient is on the right medications at all stages: what they were taking prior to admission, while they are in the hospital, and before they go home or move to another care center. ﷯ Ambulatory care. Minnesota is well known for embedding ambulatory care pharmacists within clinics, where they see patients, typically in one-on-one interactions. These pharmacists offer medication therapy management services to assist patients in better understanding their medications. These pharmacists spend anywhere from 30–60 minutes with a patient at each visit. They review the full patient medication list and check for indicated, effective, safe, and convenient medications, supplements, over-the-counter medications, and herbals. Additionally, they review the patient’s diagnosis and labs to ensure that medications are working appropriately and to see if any additional therapy is needed. Typically, this is done through a Collaborative Practice Agreement with the physicians, physician assistants, and nurse practitioners practicing in the clinic. Pharmacists can also assist with warfarin and insulin therapy adjustments. One study found that pharmacist-run services saved $647,024 by preventing hospital admissions and emergency department visits. A cost effectiveness evaluation indicated that discharge counseling by pharmacists had a cost savings in 48% of scenarios, but all scenarios were cost effective at a low willingness-to-pay value. High-risk elderly patients appeared to benefit most from this service. A study of medication therapy management programs with 186 patients through Blue Cross and Blue Shield of Minnesota found reductions in health care costs per person of 31.5%, from $11,965 to $8,197. Prescription claims increased 19.7%. The total cost of medication therapy management services was estimated at $49,490, but total health care expenditures for all patients were reduced by 31.5%, from $2,225,540 to $1,524,703. The return on investment was $12.15 per $1 of MTM services provided. This cost reduction can be seen in Figure 1. ﷯ Figure 1. National Association for Chain Drug Stores. Pharmacies: Improving Health, Reducing Costs. Community. Community pharmacists can also assist with chronic disease management and reviews of full patient medication lists, following up on work performed in the ambulatory care setting. Simple lab tests, such as glucose screenings and cholesterol checks performed at the pharmacy, allow patients to check their labs between clinic visits. This can also help flag an issue to share with the patient’s clinician. In-pharmacy blood pressure checks, PHQ-9, and GAD assessments can ensure that the patient’s medication therapy is effective. Pharmacists are also uniquely positioned to assist with the more than 300,000 over-the-counter medications now available. Community pharmacists also play a key role in assisting patients with medication adherence, which correlates with positive health outcomes. It is estimated that 20% to 50% of patients may not be adherent with their medications. Nonadherence is associated with disease progression, therapy failure, and hospitalization. A study found that 33% to 69% of medication-related hospital admissions are due to poor medication adherence. As the patient comes in on at least a monthly basis to refill a prescription, this is a great opportunity for pharmacists to assess adherence, to intervene if there is an issue, and to contact the clinician if there is great concern regarding adherence. On the national level, the Community Pharmacy Enhanced Services Network (www.cpesn.com) offers resources to help pharmacies assess their higher levels of services to patients in the outpatient setting. These services may include chronic care management, immunizations, medication delivery, medication administration, and more. Minnesota is in the process of building its own CPESN. ﷯ Pharmacists’ Patient Care Process The process of pharmacist care is guided through the Joint Commission of Pharmacy Practitioners (JCPP). To ensure consistency in any practice setting where pharmacists provide patient care, the JCPP developed the Pharmacists’ Patient Care Process. Steps in that process, in order, call for pharmacists to: Collect Assess Plan Implement Follow Up: Monitor and Evaluate At the center of this process is the patient, as well as collaboration, communication, and documentation. Each step is vital to pharmacist-provided patient care. Learn more at https://jcpp.net/patient-care-process/. Moving forward Communication is the biggest barrier for pharmacists to collaborate with other health care professionals. One communication challenge is reaching out and having the opportunity to share what pharmacists can do to assist in caring for patients as a part of the health care team. The reason for this is that pharmacists often have little time to present on the benefits of utilizing a pharmacist to clinicians and, additionally, often are communicating via phone or fax with nurses rather than directly with clinicians. Another barrier is not having access to the electronic medical record (EMR), especially for community pharmacists who could assist with ensuring that the patient’s therapy is effective and safe. Even having read-access only to the EMR allows pharmacists to provide better care. There are examples across the country (North Carolina and Iowa) who have read-only access or access to the EMR to write notes for clinicians. I encourage health systems and clinicians to reach out to local pharmacies to see how their local pharmacist could assist. ﷯ By incorporating the pharmacist on your care team, you will free up more time to care for your complicated patients. Reach out to your local pharmacists and discuss what opportunities exist for you to work as a team. In addition, encourage your patients to talk to their local pharmacist and better understand their services and how they can assist the patient. Sarah Derr, PharmD, currently serves as the Executive Director at the Minnesota Pharmacists Association. Dr. Derr completed her residency in ambulatory care at Fairview Health Services, then served as the inaugural executive fellow at the Iowa Pharmacy Association and the Medication Management Pharmacist for the Iowa Healthcare Collaborative. ﷯
﷯ cover story two A changing role of pharmacy Collaborating on multiple fronts By Sarah Derr, PharmD ﷯illions of Americans lack adequate access to primary health care, and many are not able to see their clinician on a regular basis due to multiple factors, which may include lack of insurance coverage; social determinants of health that limit transportation, mobility, or flexibility in work schedules; and strained financial resources. For these patients—and patients in general—pharmacists can provide invaluable assistance if they are incorporated into care teams. This pharmacist-clinician collaboration is key to providing the best patient care in our changing health care system. Adding a pharmacist to the care team can reduce the risk of adverse drug reactions and can lower costs. By having patients manage chronic disease states with their pharmacists, physicians and other providers are freed up to spend more time with complex patients who truly need their expertise. An evolving field The pharmacy profession has evolved greatly over the course of the last two decades. Pharmacists remain committed to providing information and access to prescription medications for patients; however, their scope of practice now also includes health wellness testing, chronic disease management, and medication management services. Additionally, Minnesota pharmacists can administer most vaccinations, and recent legislation will allow pharmacists to administer subcutaneous and intramuscular medications in the pharmacy to assist with mental health and opioid/alcohol use disorder. Pharmacists can be found in nearly all practices of health care, including, but not limited to, inpatient and outpatient care, community and chain pharmacies, long-term care, specialty medication practices, toxicology, and nuclear pharmacy. Pharmacists act as a part of the patient care team by assisting other health care professionals to ensure each medication a patient takes is indicated, effective, safe, and convenient. Pharmacists are well versed in preventative care, patient counseling, motivational interviewing, and health and wellness. They know how to manage chronic diseases such as hypertension, diabetes, and hypercholesterolemia. Pharmacists can manage treatment plans initiated by providers, order laboratory tests, and adjust medication through adding, changing, and discontinuing medications. ﷯ According to a study in the United Kingdom, 5% of emergency department presentations, and 13% of presentations to general practitioners, represent minor ailments that could be managed in community pharmacies. Another study evaluated the effects of pharmacist care on heart failure, a leading cause of hospitalizations. One review of 2,000 patients from 1998 to 2007 found a 29% reduction in all-cause hospitalization and a 31% reduction in heart failure hospitalizations. New roles for the pharmacist Some examples of current pharmacy practice areas: Inpatient care. Currently, inpatient pharmacists serve on the health care team to review medications on rounds and make suggestions regarding patient care. Additionally, they provide patients and providers with information about medications and check for drug-drug, drug-food, and drug-disease interactions. Challenging medications—for example, antibiotics such as gentamicin and vancomycin—require difficult dosing calculations, which pharmacists can assist with to ensure patient safety. In response to a rise in strains of antibiotic-resistant bacteria, pharmacists in the inpatient setting have stepped into antimicrobial stewardship. By creating a plan and an antibiogram (which shows the hospital’s history of which microbes have been resistant to which antibiotics), pharmacists can assist in preventing further increases in bacterial resistance. Additionally, pharmacists serve on the pharmaceutical and therapeutics committee to determine which medications will be on formulary at the health system. This is extremely helpful, as there have been many recent drug shortages and pharmacists are aware of which medications are available. Many pharmacists or student pharmacists assist with medication history at intake and review the medication to ensure that the patient is on the right medications at all stages: what they were taking prior to admission, while they are in the hospital, and before they go home or move to another care center. ﷯ Ambulatory care. Minnesota is well known for embedding ambulatory care pharmacists within clinics, where they see patients, typically in one-on-one interactions. These pharmacists offer medication therapy management services to assist patients in better understanding their medications. These pharmacists spend anywhere from 30–60 minutes with a patient at each visit. They review the full patient medication list and check for indicated, effective, safe, and convenient medications, supplements, over-the-counter medications, and herbals. Additionally, they review the patient’s diagnosis and labs to ensure that medications are working appropriately and to see if any additional therapy is needed. Typically, this is done through a Collaborative Practice Agreement with the physicians, physician assistants, and nurse practitioners practicing in the clinic. Pharmacists can also assist with warfarin and insulin therapy adjustments. One study found that pharmacist-run services saved $647,024 by preventing hospital admissions and emergency department visits. A cost effectiveness evaluation indicated that discharge counseling by pharmacists had a cost savings in 48% of scenarios, but all scenarios were cost effective at a low willingness-to-pay value. High-risk elderly patients appeared to benefit most from this service. A study of medication therapy management programs with 186 patients through Blue Cross and Blue Shield of Minnesota found reductions in health care costs per person of 31.5%, from $11,965 to $8,197. Prescription claims increased 19.7%. The total cost of medication therapy management services was estimated at $49,490, but total health care expenditures for all patients were reduced by 31.5%, from $2,225,540 to $1,524,703. The return on investment was $12.15 per $1 of MTM services provided. This cost reduction can be seen in Figure 1. ﷯ Figure 1. National Association for Chain Drug Stores. Pharmacies: Improving Health, Reducing Costs. Community. Community pharmacists can also assist with chronic disease management and reviews of full patient medication lists, following up on work performed in the ambulatory care setting. Simple lab tests, such as glucose screenings and cholesterol checks performed at the pharmacy, allow patients to check their labs between clinic visits. This can also help flag an issue to share with the patient’s clinician. In-pharmacy blood pressure checks, PHQ-9, and GAD assessments can ensure that the patient’s medication therapy is effective. Pharmacists are also uniquely positioned to assist with the more than 300,000 over-the-counter medications now available. Community pharmacists also play a key role in assisting patients with medication adherence, which correlates with positive health outcomes. It is estimated that 20% to 50% of patients may not be adherent with their medications. Nonadherence is associated with disease progression, therapy failure, and hospitalization. A study found that 33% to 69% of medication-related hospital admissions are due to poor medication adherence. As the patient comes in on at least a monthly basis to refill a prescription, this is a great opportunity for pharmacists to assess adherence, to intervene if there is an issue, and to contact the clinician if there is great concern regarding adherence. On the national level, the Community Pharmacy Enhanced Services Network (www.cpesn.com) offers resources to help pharmacies assess their higher levels of services to patients in the outpatient setting. These services may include chronic care management, immunizations, medication delivery, medication administration, and more. Minnesota is in the process of building its own CPESN. ﷯ Pharmacists’ Patient Care Process The process of pharmacist care is guided through the Joint Commission of Pharmacy Practitioners (JCPP). To ensure consistency in any practice setting where pharmacists provide patient care, the JCPP developed the Pharmacists’ Patient Care Process. Steps in that process, in order, call for pharmacists to: Collect Assess Plan Implement Follow Up: Monitor and Evaluate At the center of this process is the patient, as well as collaboration, communication, and documentation. Each step is vital to pharmacist-provided patient care. Learn more at https://jcpp.net/patient-care-process/. Moving forward Communication is the biggest barrier for pharmacists to collaborate with other health care professionals. One communication challenge is reaching out and having the opportunity to share what pharmacists can do to assist in caring for patients as a part of the health care team. The reason for this is that pharmacists often have little time to present on the benefits of utilizing a pharmacist to clinicians and, additionally, often are communicating via phone or fax with nurses rather than directly with clinicians. Another barrier is not having access to the electronic medical record (EMR), especially for community pharmacists who could assist with ensuring that the patient’s therapy is effective and safe. Even having read-access only to the EMR allows pharmacists to provide better care. There are examples across the country (North Carolina and Iowa) who have read-only access or access to the EMR to write notes for clinicians. I encourage health systems and clinicians to reach out to local pharmacies to see how their local pharmacist could assist. ﷯ By incorporating the pharmacist on your care team, you will free up more time to care for your complicated patients. Reach out to your local pharmacists and discuss what opportunities exist for you to work as a team. In addition, encourage your patients to talk to their local pharmacist and better understand their services and how they can assist the patient. Sarah Derr, PharmD, currently serves as the Executive Director at the Minnesota Pharmacists Association. Dr. Derr completed her residency in ambulatory care at Fairview Health Services, then served as the inaugural executive fellow at the Iowa Pharmacy Association and the Medication Management Pharmacist for the Iowa Healthcare Collaborative. ﷯