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Integrated Pharmacist Services in Medical Practices

This piece was originally published in the July/August issue of the Tarrant County Physician.

By Jennifer Fix, PharmD, MBA, BCGP, BCACP
Steven Hauf, B.A., CPhT, PharmD Candidate (2020)

Introduction by Monte Troutman, DO, TCMS Publications Committee:

Hello colleagues. Although I have been a member of the Tarrant County Medical Society (TCMS) for many years, this is my first time to submit any writings to the Tarrant County Physician publication.  TCMS asked for a member of the Texas College of Osteopathic Medicine (TCOM) and a member of the TCU School of Medicine at UNTHSC to join their Publications Committee (PC). I don’t know how to say no, so I joined. 

The PC wanted an insight into changes in medical education and how these changes impact the current state of healthcare. I felt that I could contribute since I have been a full-time faculty member at TCOM for over thirty-five years. Yes, I have seen dramatic changes in how our medical students are taught. I hope that I can contribute in a way that shows these dramatic changes will have a positive impact. 

One of the changes in medical education is the emphasis on the team approach concept. Physicians and students in training are now taught to be a member of a team that cares for patients. One of the members of the team are our pharmacists. I chose a new friend and colleague to write the first of I hope many articles that provide insight into the team approach. Dr. Jennifer Fix is a valuable member of the faculty of the School of Pharmacy. She is now embedded in our clinical practice of gastroenterology at the Health Science Center. I didn’t realize the service and help that she and the pharmacy students could offer our practice. Not only helping our gastroenterologists but also our clinical staff. I believe “invaluable” is the term that best describes their contribution to the team. The best part of their presence is that our medical students get to see the pharmacist in action. Yes, this is new concept and our students learn the value of teamwork with our pharmacist colleagues. Please read and enjoy and learn!     

“Put me in coach!”  It was at the American Association of Colleges of Pharmacy (AACP) Annual Meeting that clinical pharmacist and professor, Dr. Jennifer Fix, most recently heard this line from one of the keynote speakers as he talked about the ability, desire, and willingness of pharmacists to serve alongside physicians in integrated medical practices.  The CDC says that, “pharmacists have long been identified as an underutilized public health resource. Pharmacists are well positioned to help out with improving chronic disease management and make a difference when they are actively engaged as part of a team-based care approach.”1,2 

Pharmacists working in accordance with a physician’s referral in providing face-to-face, in-office services for chronic health condition management, education, and medication optimization is likely to be something you would hear most pharmacists express as a short-term goal for the profession and something pharmacy schools have implemented into their curriculum.  Todd Sorenson, PharmD, President of the American Association of Colleges of Pharmacy has declared his bold aim which is “that by 2025, fifty percent of primary care medical practices will have integrated comprehensive medication management (CMM) services into their care model; and those services will be delivered in collaboration with pharmacists.”  

The Health Science Center (HSC) in Fort Worth, part of the University of North Texas System, is widely recognized for its work in Inter-professional Education (IPE) – and is already ahead of this 2025 goal laid out by Dr. Sorenson. HSC has pharmacists integrated into several of their medical practice sites.  Through collaborations with health-related programs at Texas Wesleyan University, Texas Christian University, Texas Women’s University, and University of Texas at Arlington, HSC medical students from both the Texas College of Osteopathic Medicine and The Texas Christian University/UNTHSC School of Medicine participate in IPE events alongside pharmacy, nurse practitioner, physical therapy, nursing, nutrition, and social work students.3  Graduates of the School of Pharmacy located at the HSC in Fort Worth, receive a Doctor of Pharmacy degree (PharmD). Prior to graduation, though, these student pharmacist interns must complete three years of coursework followed by experiential rotations. Among these rotations are opportunities for the pharmacist intern to experience an ambulatory care setting in which they can put their education into practice in managing patients with common chronic diseases alongside their preceptor, a clinical pharmacist with collaborative agreements with physicians to enhance patient care. Most pharmacists working in medical practices have completed one to two years of post-graduate residency to develop their skills and many have also completed Board Certification in Ambulatory Care Pharmacy recognized by the Board of Pharmaceutical Specialties.4

One example of this collaborative practice between physician and pharmacist includes patients referred by a physician for a clinical pharmacist comprehensive medication therapy consult where pharmacists are engaged to identify, address, and solve drug therapy problems. In a 2018 study titled “Drug Therapy Problem Identification and Resolution by Clinical Pharmacists in a Family Medicine Residency Clinic,” the researchers conducted a retrospective chart review and found that half of the drug related problems (DRPs) found were resolved the same day.  The most common DTP category identified in this study was the need for additional drug therapy (41.6%), followed by the need for additional monitoring (14.5%), suboptimal adherence (9.9%) dose too low (9.4%), adverse drug reaction (7.3%), unnecessary therapy (6.7%), ineffective drug therapy (5.5%), and dose too high (5.1%).5 While physicians are capable of handling such issues, pharmacists are extensively trained to identify and respond to these specific problems and their expertise should offer peace of mind to the physicians they work with, who will know that the medications have been evaluated by these medication experts. 

Pharmacists can enhance outcomes and enhance quality of care as well as the overall patient experience.

While pharmacists used to be found only in corner drug stores or hospital basements, this is no longer the case.  Pioneering physicians who have already integrated pharmacists into their medical practices have done so by establishing the scope of practice for the clinical pharmacist that they oversee by defining the details of a Collaborative Practice Agreement (CPA) and agreeing on a list of disease states and drug classes that they would permit the pharmacist to initiate, stop, or modify. The CPA is submitted to the State Board of Pharmacy for review and acceptance. In Texas, pharmacists are authorized to sign non-controlled substance prescription drug orders established through a CPA.6  The National Alliance of State Pharmacy Associations show that CPAs can “decrease the number of phone calls required to authorize refills or modify prescriptions, thus allowing each member of the health care team to complement the skills and knowledge of the other member(s), effectively facilitate patient care, and improve patient outcomes.”7  In addition to medication reconciliation, clinic-based pharmacists, upon collaboration with the physician, are also able to provide disease state specific modifications in existing treatment regimens, provide drug therapy education, process refills, assist with navigating insurance challenges, obtain medical, surgical, social, and vaccine histories, and much more.  Given the opportunity, pharmacists can enhance outcomes and enhance quality of care as well as the overall patient experience. 

Through physician acceptance and implementation of pharmacist integration, medical practices continue to equip themselves for evolving payer regulations and their ability to meet patient care benchmarks. For instance, the Centers for Medicare and Medicaid Services (CMS) have a new “Meaningful Measures” framework initiative to identify the highest priorities for quality measurement and improvement.8 This initiative outlines quality topics for the core issues related to the highest quality of care and better patient outcomes that are directly related to CMS strategic goals, every one of which pharmacists are educated on and are well-suited for assisting the practice in meeting these goals. These measures include quality priorities such as; reducing harm caused in the delivery of care, strengthening family engagement as partners in care, promoting effective communication and coordination of care, collaborating with communities to promote best practices of healthy living, and making care affordable. 

Billing models for clinic pharmacists continue to evolve, but the baseline billing codes are recognized for Medication Therapy Management.  According to the American Society for Hospital Pharmacist Billing Guide, 99605 is recognized for Medication therapy management service(s) provided by a pharmacist, individual, face-to-face with patient, initial 15 minutes, with assessment, and intervention if provided; initial encounter; 99606 is used for a subsequent encounter; and  99607 can be used to bill for each additional 15 minutes.9 

In summary, we believe that the integration of pharmacist services into medical practices is important and could potentially be an essential key to meeting quality measures that enhance overall practice reimbursement while offering physicians a partner to assist them in meeting the needs and improving the care of patients with common chronic disease states.

References
1. Advancing Team-Based Care Through Collaborative Practice Agreements. A Resource and Implementation Guide for Adding Pharmacists to the Care Team. Center for Disease Control and Prevention (CDC). https://www.cdc.gov/dhdsp/pubs/docs/CPA-Team-Based-Care.pdf. Accessed July 30, 2019.

2. CDC releases practical guide for pharmacists to establish collaborative practice agreements. American Pharmacists Association (APhA). https://www.pharmacist.com/article/cdc-releases-practical-guide-pharmacists-establish-collaborative-practice-agreements. Published 2017. Accessed July 27, 2019.

3. Interprofessional Collaborations. Interprofessional Education and Practice. https://www.unthsc.edu/interprofessional-education/interprofessional-collaborations-ipe/. Accessed April 8, 2020.

4. Ambulatory Care Pharmacy. Board of Pharmacy Specialties. https://www.bpsweb.org/bps-specialties/ambulatory-care/#1517761118361-6c02bae3-f5a01517779729021. Accessed April 10, 2020.

5. Macdonald, D., Chang, H., Wei, Y., & Hager, K. D. (2018). Drug Therapy Problem Identification and Resolution by Clinical Pharmacists in a Family Medicine Residency Clinic. INNOVATIONS in Pharmacy, 9(2), 4. doi: 10.24926/iip.v9i2.971.

6. TexasStateBoardofPharmacy.PharmacistsAuthorizedtoSignPrescription Drug Orders for Dangerous Drugs Under a Drug Therapy Management Protocol of a Physician. Texas State Board of Pharmacy Web site. http://www.tsbp.state.tx.us/ files_pdf/DTM.pdf. Accessed July 27, 2019.

7. Collaborative Practice Agreements: Resources and More. National Alliance of State Pharmacy Associations https://naspa.us/resource/cpa/. Published 2017. Updated June 8, 2017. Accessed July 27, 2019.

8. Meaningful Measures Framework. Center for Medicare and Medicaid Services (CMS). https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/CMS-Quality-Strategy.html. Published 2019. Updated July 22, 2019. Accessed July 30, 2019.

9. Ambulatory Care. ASHP. https://www.ashp.org/-/media/assets/ambulatory-care-practitioner/docs/sacp-pharmacist-billing-for-ambulatory-pharmacy-patient-care-services.pdf. Accessed April 10, 2020.

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