Collaborative Drug Therapy Management: Case Studies of Three Community-based Models of Care

Margie E. Snyder, PharmD, MPH; Tara R. Earl, PhD, MSW; Siobhan Gilchrist, JD, MPH; Michael Greenberg, JD, MPH; Holly Heisler, MPH, MBA; Michelle Revels, MA; Dyann Matson-Koffman, DrPH, MPH, CHES

Disclosures

Prev Chronic Dis. 2015;12(3) 

In This Article

Discussion

To our knowledge, this is the first study of its kind to examine real-life examples of CDTM implementation in various community settings. Our results demonstrate that models for CDTM can be tailored to the needs of the pharmacists, the practitioners, and the patients they serve on the basis of the level of trust, training, and familiarity among practitioners. Even when state law allows practitioners and pharmacists to determine the scope of CDTM services,[1,3] compensation mechanisms and legal requirements for certification and training and existing informal collaborative relationships limited pharmacists' options or interest in expanding the array of CDTM elements offered.

A consortium, which was convened by the American Pharmacists Association Foundation (APhAF) and charged with developing strategies to advance pharmacist patient care services, identified 7 principles for optimizing the role of pharmacists in patient care.[18] These principles resonate with the emergent themes from these case studies. The consortium reported that successful collaborations are established mutually by the collaborating health professionals on the basis of trust and demonstrated competence in a regulatory context that allows practitioners to establish the scope of the agreement.[18] A 2011 survey of pharmacists also found that trustworthiness and professional interaction are predictive of established collaborative care relationships with physicians, whereas trustworthiness and role specificity are predictive of newly established collaborations.[19] Each site reflects different levels of maturity in CDTM, and establishing trust over time through repeated professional interactions and the demonstrated value of pharmacist patient care services was a critical factor.

Informal collaboration between pharmacists and providers established trust and added value to patient care services, but it also resulted in some pharmacists reporting little need to enter into CPAs to perform more advanced patient care services, particularly given the logistics of these agreements and the limited compensation for CDTM services. Even though the case studies were conducted in states with permissive scope of practice laws that allow the practitioners to set the terms of the CPAs, some administrative and procedural legal requirements affected the study participants' capacity to engage in CDTM, primarily because the costs and time commitment were considered burdensome.

One of the most common challenges for pharmacists and pharmacies reported by the sites and supported in the literature is the lack of sustainable compensation mechanisms.[8,18,20] The APhAF consortium reported this challenge and stated that a scalable, sustainable, and financially viable business model is necessary for the successful implementation of pharmacist patient care services.[18] Giberson et al describe several federal and state CDTM models that are successful because pharmacists are compensated for the patient care services they provide, but they explain that the private sector has yet to incorporate these models, in part because pharmacists lack recognition as providers under federal law.[8] Furthermore, a survey of pharmacist clinicians practicing CDTM in 2 states suggested that CDTM is a business loss: respondents billed on average $6,500 per month for their services, far less than the average cost of hiring a pharmacist clinician.[20] This highlights potential compensation challenges, even when states have tried to reduce financial barriers to expanding the provision of pharmacist services. These case study sites are funded by grants and private and public payer reimbursement for some services, including Medicare Part D and immunization fees, but not all services. A lack of sustainable compensation for pharmacist patient care services and the need for recognition of pharmacists as providers were reported across the sites. Therefore, although evidence indicates that expansion of pharmacists' roles through CDTM could greatly benefit public health,[4–6,8] new compensation models are needed for individual practices to implement CDTM.

The Task Force recommendations for team-based care involving pharmacists and nurses to improve cardiovascular disease risk factors underscore the results of this study. The Task Force recommendations are based on recent literature summarizing examples of collaborative models of hypertension management, including models that involved pharmacist interventions. Notably, the Task Force found larger improvements in hypertension control when pharmacists were team members, and medication adherence was greater when team members could change antihypertensive medications independent of or with approval of the primary care provider. However, the Task Force noted the need for appropriate reimbursement mechanisms for team members that may improve the perceived "benefit to barrier" ratio reported here and encourage more pharmacists to participate in hypertension control CPAs as an alternative to informal collaborations with providers.[7]

This study has several limitations. The sites selected might not be representative of all community-based CDTM practices. For example, Kerr Drug pharmacists served patients participating in a research study. El Rio is an FQHC where pharmacists, physicians, and other providers practice in a relatively closed setting. Furthermore, time and resource constraints prevented full transcription of audio recordings and analysis via formal data-coding procedures. Finally, the number of sites was small. It is not known whether visiting more sites would have identified additional themes.

As health care delivery systems increasingly adopt models of team-based care, such as CDTM, business and practice models and policies need to adapt accordingly. Although pharmacist interventions positively affect hypertension and other chronic diseases, these case studies highlight challenges and varying approaches to implementing CDTM. Pharmacists, other providers, and decision makers can use these findings when considering collaborative practice models to expand the pharmacist's role in team-based care, link patient care in clinical settings with community-based services, and improve health outcomes. Results of this study will be available as guidance documents on CDC's website.

Comments

3090D553-9492-4563-8681-AD288FA52ACE

processing....