Collaborative Drug Therapy Management by Pharmacists - 2003

American College of Clinical Pharmacy, Raymond W. Hammond, PharmD, FCCP, Amy H. Schwartz, PharmD, Marla J. Campbell, PharmD, Tami L. Remington, PharmD, Susan Chuck, PharmD, Melissa M. Blair, PharmD, Ann M. Vassey, PharmD, Raylene M. Rospond, PharmD, FCCP, Sheryl J. Herner, PharmD, and C. Edwin Webb, PharmD, MPH

Disclosures

Pharmacotherapy. 2003;23(9) 

In This Article

Requirements for Collaborative Drug Therapy Management

For pharmacists to participate effectively in CDTM, the following conditions should exist: a collaborative practice environment; access to patients; access to medical records; a defined level of education, training, knowledge, skills, and abilities; documentation of clinical activities; and payment for pharmacists' activities.

To promote the development of CDTM agreements with providers, the pharmacy profession needs to correct the misperception among some audiences that pharmacists have limited clinical training and experience. The profession must educate and convince the public, legislators, and health care practitioners about pharmacists' professional qualifications and expertise. Without support from these groups, support for collaborative practice arrangements will be limited.

When developing CDTM, the pharmacist's scope of practice should be defined clearly, delineating routine and nonroutine professional duties and responsibilities. Other health care providers, such as nurse practitioners and physician assistants, may be involved in CDTM agreements. Clear and consistent communication between each of these providers can help alleviate turf battles and promote a collaborative environment. Better understanding of the various skill sets and knowledge of different practitioners is essential so that roles and responsibilities are understood. For example, pharmacists are well suited for drug therapy management responsibilities, especially with respect to chronic disease states. Nurse practitioners and physician assistants may better serve patients through activities in screening, triage, and treatment of acute illnesses. The role of these physician extenders cannot be understated. Interaction and mutual support between these individuals and pharmacists are important, as is consistent and active communication with physicians.

Direct communication with patients is imperative for pharmacists to function successfully as drug therapy managers. In addition to an established agreement with a physician, a pharmacist-patient relationship is a key element of CDTM. In this relationship, the patient grants the pharmacist responsibility to perform services and the pharmacist promises competency in the performance of these services. Physicians and patients should understand that this relationship complements, rather than replaces, the physician-patient relationship.

The pharmacist must have access to medical records that include the patient's medical history, problem lists, progress notes, laboratory and procedure results, and drug history. The CDTM agreements also should address patient privacy and confidentiality issues. Pharmacists working in a health-system environment may have easy access to computerized medical records. Other practice settings may involve obstacles to access that need to be overcome. This is one area where pharmacy organizations can facilitate CDTM by promoting and assisting with the sharing of medical information through support of new technologies.

Pharmacists are uniquely trained for the task of CDTM. The American Council on Pharmaceutical Education (ACPE) implemented revised accreditation standards for professional degree programs in pharmacy in 1998. Pharmacy education now consists of at least 2 years of a college prepharmacy curriculum, followed by a 4-year professional program with extensive training in pharmacology and pharmaceutical sciences, biomedical sciences, therapeutics, physical assessment, and clinical experiential training. Successful completion of this curriculum leads to the Doctor of Pharmacy (Pharm.D.) degree, now the sole degree offered by U.S. colleges and schools of pharmacy. Specific areas and examples of core curricula required under the ACPE standards for Doctor of Pharmacy programs can be found on the ACPE Web site (http://www.acpe-accredit.org/).

Most pharmacy curricula now include active learning and problem-based learning components, which develop students' abilities to critically analyze data (i.e., critical thinking) and improve skills in providing individualized drug therapy management services. Additional training in patient interviewing, counseling, and patient assessment have resulted in competency to collect patient data, enhance patient adherence to a therapeutic plan, and monitor drug therapy for response to therapy and avoidance of adverse effects. Experiential training has been incorporated into the early years of the educational process to help students apply didactic learning to patient care. Advanced experiences demonstrating interdisciplinary and collaborative practice further enhance clinical skills and foster the concept of working as part of a health care team.

Many pharmacists complete postgraduate residencies and fellowships to obtain advanced clinical training. Generalized and disease- or discipline-specific programs are available. Some pharmacists who graduated from professional programs with a bachelor's degree in pharmacy (i.e., before the national shift in the pharmacy education curriculum) have obtained the necessary knowledge, skills and abilities through nontraditional Doctor of Pharmacy programs, postgraduate education, or various types of certificate programs that help them to achieve the necessary competencies for a specific disease state.

Pharmacists may pursue additional voluntary credentials that can highlight their ability to provide CDTM and other patient care services. The Board of Pharmaceutical Specialties offers board certification for the following pharmacy specialties: nuclear pharmacy, nutrition support, oncology, pharmacotherapy, and psychiatric pharmacy. The American Society of Consultant Pharmacists offers certification in geriatric pharmacy. In the late 1990s, the National Association of Boards of Pharmacy, as part of the National Institute for Standards in Pharmacist Credentialing, developed disease state management certification examinations for anticoagulation, asthma, diabetes mellitus, and hyperlipidemia. This process was stimulated as a result of the establishment of a Mississippi Medicaid project, which was initiated several years before to evaluate the delivery of targeted disease and drug therapy management services to Medicaid recipients. In addition, pharmacists can obtain certification as diabetes educators or asthma educators in programs established for a wide range of health professionals interested in advanced skills.

All of these credentials can help to identify those pharmacists who are qualified to provide CDTM. Ultimately, of course, the credentials or specific education and training requirements for an individual collaborative practice agreement should be determined by the collaborating practitioners at the practice site.

Timely and appropriate documentation of all activities related to CDTM is essential to both quality and professional acceptance. Policies and procedures should be in place to ensure that the documentation is shared appropriately and available to other providers caring for the patient. Conformity with the Health Information, Portability and Accountability Act (HIPAA), regulations, and guidelines for patient privacy and confidentiality should be incorporated into the plan. Pharmacists engaged in CDTM should meet all relevant standards for quality assurance and adhere to the same measures of quality as other health professionals in the practice setting. Supervision and quality improvement activities are site specific and will differ greatly among settings and health systems. Mechanisms to measure and ensure quality should be developed as an integral part of the CDTM agreement. Measuring adherence to practice guidelines and comparing patient outcomes to benchmark data or literature reports is essential and should be identical to the process developed for other health care professionals. Pharmacists should be able to provide at least the same quality of care and achievement of outcomes as other providers.

Several national pharmacy organizations, including ACCP, continue to seek recognition of pharmacists as providers of patient care services within both federal and private health care payment systems. Appropriate payment for pharmacists' CDTM and other direct patient care services will be a logical result of this recognition. Without reform of the payment system for pharmacists' services, which is based almost exclusively on the sale of drugs, the inclusion of CDTM will be difficult, if not impossible, to accomplish. All practitioners within a given practice setting must be able to generate revenue sufficient to support the direct and indirect costs of their practice activities, including salaries, staff support, supplies, technology support, and other expenses.

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