Pharmacists as Direct-Care Providers

An Expert Interview With Vincent J. Willey, PharmD

Elizabeth McGann, DNSc, RN

January 04, 2012

January 4, 2012 — Editor's note: Improved outcomes are associated with pharmacist-led medication therapy management programs. The role of the pharmacist in the medical home, as a direct-care provider, encompasses consultations with patients about their prescription and nonprescription medications, making recommendations tailored to individual needs, and collaboration with the members of the healthcare team to optimize medication therapy goals.

"The Pharmacists' Role in the Medical Home" was featured as a podium presentation at the American Society of Health System Pharmacists (ASHP) 46th Midyear Clinical Meeting & Exhibition, the largest international gathering of pharmacists focusing on improving patient care, held on December 4 to 8, 2011, in New Orleans, Louisiana.

To find out more about the role of the pharmacist in the medical home, Medscape Medical News interviewed Vincent J. Willey, PharmD, associate professor of pharmacy and vice chair of the Department of Pharmacy Practice and Pharmacy Administration at the Philadelphia College of Pharmacy, University of the Sciences, in Pennsylvania.

Dr. Willey's pharmacy practice experience spans the areas of community pharmacy, long-term-care consulting, home infusion, and ambulatory care clinical services. Dr. Willey maintains an ambulatory care practice in an independent physician office with a focus on overall cardiovascular risk reduction in patients with diabetes, hypertension, and dyslipidemia. He has published more than 30 original research manuscripts, presented at numerous medical, pharmacy, and research conferences. Dr. Willey is a member of the editorial advisory board of the Journal of Managed Care Pharmacy. His research interests are focused on dyslipidemia management and the role of the pharmacist in the medical home concept.

Medscape: What is the medical home concept?

Dr. Willey: The medical home is a patient-centered, team-based primary care model of healthcare. The Agency for Healthcare Research and Quality (AHRQ) has identified 5 key functions/attributes for the medical home: patient-centered care, comprehensive care, coordinated care, superb access to care, and a systems-based approach to quality and safety.

These attributes allow for much of a patient's care to be provided within a single site, with overall coordination occurring there, and when outside services, such as specialist care or hospitalization, are required.

The medical home team is typically led by a primary care physician. However, in the medical home, their role is evolving from being the primary interface for care of the patient to coordinating the efforts of a team that may include nurse practitioners, physician assistants, nurses, social workers, and pharmacists.

Medscape: What is the pharmacist's role in the medical home?

Dr. Willey: The pharmacist may play multiple roles within the medical home. Primarily, the pharmacist can play a central role around the appropriate use of medications. This should begin with a comprehensive review of all the medications a patient is taking. Although this sounds like a fundamentally simple process, it is an area where many errors occur.

Patients who encounter multiple transitions of care often have several changes in medications of which the primary care physician is unaware. In addition, many healthcare providers focus only on prescription medications, but the majority of patients now take multiple over-the-counter medications, vitamins, and natural/herbal supplements. These nonprescription medications can cause adverse effects and drug interactions that are important for the healthcare team to be aware of in the overall care of the patient.

Pharmacists can then perform a systematic assessment of all medications that a patient is taking to optimize therapy goals. This process is often referred to as medication therapy management and focuses on 4 key components: appropriateness, effectiveness, safety, and adherence. After this assessment, the pharmacist can formulate a personalized medication care plan that can be integrated into the overall care of the patient.

In addition, the pharmacist may be involved with disease state education, laboratory and clinical testing, and therapeutic lifestyle change education, focusing on issues such as proper nutrition and activity goals. For example, a fellow presenter at the ASHP midyear meeting, Michael J. Cawley, PharmD, RRT, CPFT, focused his remarks on the involvement of pharmacists with spirometry services as part of their role in assisting in the care of patients with respiratory diseases.

Medscape: Are there provisions in the Patient Protection and Affordable Care Act that pertain to pharmacy services in the medical home?

Dr. Willey: Yes. Several provisions in the Act refer to the creation of programs that support the implementation of medication therapy management services provided by pharmacists. These programs would have pharmacists work within healthcare teams to focus on patients with chronic diseases to improve quality of care and reduce costs. Other programs focusing in on the creation of comprehensive healthcare teams and caring for patients in their own homes have listed pharmacists as potential team members.

Medscape: Can you describe a typical interaction with patients and other healthcare professionals in the medical home model?

Dr. Willey: In the medical home model in which I currently practice, patients with certain chronic diseases — diabetes, hypertension, dyslipidemia, metabolic syndrome, asthma, COPD, various psychiatric disorders (such as ADHD, depression, anxiety) — are referred to the pharmacist by the primary care physician. Typically, these patients are not at their therapeutic goals, need additional education, and/or have trouble with their medications. Patient visits are scheduled directly with the pharmacist, and are seen in the physician office in a specifically designed consultation area.

The pharmacist provides services such as medication education, disease state education, appropriate nonpharmacologic counseling such as recommendations on diet and activity, objective testing such as spirometry or specialized rating scales for psychiatric disorders, and recommendations for medication therapy optimization to the physicians. These recommendations include both medication changes and testing required for appropriate medication monitoring. The physician always sees the patient during the visit, at which time the recommendations are discussed. The services provided to the patient are tailored to their individual needs and specified care plans are developed and implemented.

Medscape: Are there parts of the country where having a pharmacist at the point of care has begun to take hold?

Dr. Willey: There are many places around the country where pharmacists are being utilized at the point of care. Many of these are large integrated health systems such Kaiser Permanente, Geisinger Health System, and various university-based healthcare systems. The Veterans Administration has utilized pharmacists to provide direct patient care services in the outpatient setting for decades. There are also increasing numbers of smaller primary care practices bringing on pharmacists to work in their office with their patients.

Medscape: How do you think this new model of care will affect patient self-administration of medications and adherence?

Dr. Willey: I believe the medical home has a huge role to play in these areas. Nonadherence is a well-established problem in the treatment of chronic diseases, but what is not well established is how to improve the situation. There are many factors that go into adherence, but a key factor is the patient's perceived need for the treatment. The information exchange and 2-way dialogue that needs to occur for the patient to understand fully and to buy into their prescribed therapy is very difficult to accomplish in the traditional primary care model.

A team-based individualized approach to the patient such as that provided in the medical home model offers a better infrastructure to accomplish this goal. In addition, as self-administration of medications becomes increasingly complex due to situations such as multiple therapies and complex delivery devices, education efforts in these areas becomes even more important.

Medscape: Is there evidence to show improved patient outcomes?

Dr. Willey: Multiple projects have demonstrated the benefits and improved outcomes associated with pharmacist-led medication therapy management programs. The Ashville Project is probably the most comprehensive of these evaluations.

The Ashville Project was a community pharmacy-based care management project performed in Ashville, North Carolina, in patients with asthma, diabetes, high cholesterol, and hypertension. Positive clinical, economic, and humanistic outcomes associated with the pharmacists' interventions were observed. Overall, research to determine the optimal models for the medical home and the utilization of the pharmacists in these models is still in the beginning stages.

Medscape: What resources are available to healthcare providers who are interested in finding out more about this topic?

Dr. Willey: The Agency for Healthcare Research and Quality has developed the Patient Centered Medical Home Resource Center Web site, which serves as an excellent repository of information. It not only includes information generated by AHRQ, but also provides links to many other interested stakeholders, such as the Centers for Medicare and Medicaid Services and the Health Resources and Services Administration. The Integrating Comprehensive Medication Management to Optimize Patient Outcomes guide has been developed by the Patient-Centered Primary Care Collaborative. This resource provides an excellent overview and practical considerations regarding the implementation of these services.

Medscape: What were the 2 most significant aspects of your presentation?

Dr. Willey: The 2 most significant aspects were the important role that pharmacists can play as direct providers in the medical home model and how pharmacists can best approach physicians to integrate themselves into the patient care teams. This new role for pharmacists is a way to expand the reach of their patient-care services and to improve patient outcomes.

Dr. Willey has disclosed no relevant financial relationships.


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