For weeks, the primary care physician had been adjusting her patient's medications, seeking the right mix to treat his COPD. He wasn't improving, so he was back again for another appointment. But this time he wasn't seeing his doctor. His visit was with a clinical pharmacist.
And that pharmacist was the first provider who asked the patient not if he was taking his medication, but how, says Mark Holtan, specialty pharmacy manager at Hennepin County Medical Center, a teaching hospital and network of primary care clinics in Minneapolis.
According to the instructions the patient was given, he was to “inhale one capsule daily." But as the clinical pharmacist discovered, the patient had been putting the capsule in his mouth, rather than in his inhaler. With a small but crucial correction in his understanding, the patient improved immediately, and was able to stop taking several other medications altogether.
As team-based care redefines the scope of allied health professions, clinical pharmacists are moving beyond filling prescriptions to providing direct care to patients and expertise in prescribing to physicians.
“There are so many touch points where pharmacists can contribute to addressing gaps in care," says Anne Burns, vice president, professional affairs at the American Pharmacists Association. “This is an exciting trend."
It's a shift with far-reaching implications: Pharmacists are uniquely qualified to make a dent in the 700,000 deaths and $21 billion dollars attributed to preventable medication errors each year. And every $1 spent on medication management systems saves $12 in downstream per-patient costs.
Joining the primary care team
At the Henry J. Austin Health Center (HJAHC), the community health center in Trenton, New Jersey, diabetes is the second most common diagnosis. But many of HJAHC's providers didn't feel comfortable initiating insulin therapy or adjusting medications without sufficient time to properly educate patients.
So, in 2014, in collaboration with Rutgers University's Ernest Mario School of Pharmacy (EMSOP) and the Nicholson Foundation, HJAHC launched a clinical trial to measure the impact of embedding clinical pharmacists into diabetes care teams.
The 230 patients in the experimental group, which were recruited between September 2014 and October 2016, had regular appointments with a pharmacist along with their usual doctor visits. Hour-long initial meetings on diabetes and medication education were followed by visits for medication monitoring and adjustments. Early results show the group improved A1c levels by 80 percent over the control group.
As it expands the program to more patients, HJAHC's pharmacists are providing disease-state management for a variety of conditions, freeing physicians to see a higher volume of patients who must be seen by a doctor.
“We are reducing hospitalizations, preventing strokes, and using more cost-effective medications," says pharmacy director Caitlin McCarthy. “And our patients aren't seeing expensive endocrinologists for something that can easily be managed in primary care."
As part of its commitment to embedding pharmacists in primary care teams, EMSOP is providing ongoing salary support for the health center's clinical pharmacists, covering half the pharmacists' salary. In turn, as clinical assistant professors, the pharmacists offer EMSOP students onsite learning at HJAHC's clinics.
Addressing barriers to health
Pharmacists also are evolving into care coordinators for clinical teams. At Mission Health Partners, the accountable care organization in North Carolina, clinical pharmacists see patients at home and partner with community health workers to remove barriers to medication adherence and craft medication plans that fit patients' lives. They work closely with Mission's community paramedics, another allied health profession expanding its scope, sharing in-home consultations for high-risk patients.
Hennepin's pharmacists likewise often help patients fill weekly pill boxes and set cell phone reminders, among other aids. The pharmacists are uniquely positioned to identify barriers to better health. “If I tell a patient 'take this medication with food,' and they say, 'I don't have food,' then I need to work out a way to get them food," says Holtan.
At Hennepin, 33 staff clinical pharmacists round daily with clinical teams, identifying patient-specific safety issues and reconciling medications on admission and discharge. “We're the safety net for our patients and our providers," says Jon Jancik, Hennepin's clinical pharmacy manager.
In 2009, the first year Hennepin launched the program, pre-discharge medication reconciliation by a pharmacist correlated with a 30 percent reduction in 30-day readmission rates and savings to the system some $587,000.
CVS Health, the pharmacy giant, is enabling clinical pharmacists at its MinuteClinics to work at the top of their licenses with data-driven care guidelines. With real-time access to a massive data set of both health and consumer behavior information, CVS generates algorithm-based treatment plans for chronic diseases managed through medication.
“We're never going to replace the primary care doctor, and we don't want to," says Troyen Brennan, M.D., chief medical officer for CVS, “but there's a lot more care that can be rendered by nurse practitioners and pharmacists than has ever been the case in the past."
Lia Novotny is a frequent contributor to athenaInsight.