Embedding Pharmacists Into the PracticeCollaborate with pharmacists to improve patient outcomes

How can a pharmacist help me in my practice?

Pharmacists may optimize drug therapy according to agreed upon protocols by escalating therapy, deescalating therapy, substituting medications with safer and/or less costly alternatives, managing drug interactions, improving patient and team education and medication adherence, all in accordance with state laws for pharmacists. Pharmacists may also perform medication reconciliation for the most challenging patients with multiple comorbidities.

What is the difference between a clinical pharmacist and a retail or community pharmacist?

Clinical pharmacists optimize medication therapy and promote overall wellness and disease prevention.² Within an ambulatory care clinic environment, clinical pharmacists manage chronic medical conditions, improve medication use and management and address medication adherence. Pharmacists provide medication therapy evaluations and recommendations to patients, physicians and other health care professionals.

A community or retail pharmacist works in retail and chain pharmacies located in drug and grocery stores. They may also own an independent pharmacy. They interact directly with the public but tend to have limited interaction with providers at a practice.⁴,¹⁵ Some community pharmacists also perform Medication Therapy Management (MTM), immunization services and patient counseling on various medications.

What does it mean to embed a pharmacist?

Quiz Ref IDEmbedding a pharmacist means fully integrating him or her within your care team and giving the same access to the medical record as other members of the team. Pharmacists will work closely with you and may see patients on their own clinic schedule for disease-specific management.

How does a pharmacy technician help me in my practice?

Pharmacy technicians can help streamline medication preauthorization and perform medication histories. While pharmacy technicians’ roles are more limited than those of a pharmacist, they often perform pre-visit medication histories and refill medications by protocol. Pharmacy technicians become a part of the care team much like medical assistants and other ancillary support staff.

How can pharmacists improve the outcomes of my patient population?

A pharmacist with access to your population data and medical records can look at your entire patient population to determine practice needs. For example, they could analyze your practice’s panel to identify patients who are not reaching A1c goals and then implement a practice-wide effort to improve goal attainment.

Quiz Ref IDHow can pharmacists improve the outcomes of individual patients?

Together, physicians and pharmacists can develop protocols to optimize drug therapy to achieve clinical outcomes. The pharmacist can identify medications that are no longer needed (deescalating therapy), which leads to fewer medication interactions and side effects, and can reduce costs and save time. Pharmacists can also perform “brown bag medicine reviews,” which involve patients packing up all of their medications and bringing them to a visit with the pharmacist. The pharmacist then goes through the bag and reviews all the medications to identify older and possibly discontinued medications, duplicate therapies, medications filled by another physician that the practice may not have been aware of. Pharmacists can also focus on improving medication adherence by identifying and resolving barriers for patients.

Can I create collaborative practice agreements for tasks like escalating therapy?

Yes, if your state law allows this. Use clinical care guidelines and evidence-based protocols as the foundation for the delegated protocols.

How can pharmacists help my patients with uncontrolled hypertension?

A pharmacist can teach a patient how to monitor their blood pressure at home and promote medication adherence. If collaborative agreements are allowed by state law, they may be able to adjust therapy to achieve blood pressure goals. The module toolkit contains an example of a delegated protocol for blood pressure treatment.

How can pharmacists help my patients with diabetes?

Physicians may find it helpful to co-manage certain patients with a pharmacist, such as patients with diabetes. For example, pharmacists can provide education, optimize lifestyle choices and titrate medication doses by protocol based on home glucose readings (depending on state law) for patients on insulin. Some practices have found that A1c levels improve in co-managed patients.

How can a pharmacist help educate the care team?

By being on site, the pharmacist can serve as a resource to the entire care team by providing updates regarding new medications, generic availability, guideline updates or other prescribing information. The pharmacist can inform the team about medications that are no longer recommended for geriatric patients or point out medications within a therapeutic class that are now available as generics.

If I cannot embed a pharmacist into my practice, how can I collaborate with community pharmacists that my patients know and trust?

Give your patients copies of their chart or portions of their chart such as medication lists, visit summaries, lists of medical conditions and basic labs, to share with their community pharmacist. If you use OpenNotes, include a request in the note that the patient speak with their pharmacist about various issues and bring a copy of the note with them to the pharmacy.

Our practice has just received access to patients’ medication refill data. How can the practice best utilize this data?

The pharmacist can review the medication refill data while performing medication history or reconciliation with the patient. For example, a patient may initially state they are taking a medication but if the pharmacist sees that the prescription has not been filled for several months, she can address this with the patient in a non-judgmental manner. This process may also uncover barriers to adherence, such as cost, confusion or concerns about the medication’s safety.

What skills or qualities should I look for in a pharmacist that I want to embed in my practice?

• Quiz Ref IDExperience in ambulatory care through residency/post-graduate training or in a patient-facing setting, such as another clinic

• Training in or have a desire to learn patient care techniques, such as motivational interviewing, medication therapy management and/or complex care management

• Empathy and compassion

• Ability to communicate with ease using plain language with patients and clinical language with the care team

Some of these same skills and qualities, such as listening with empathy and compassion and the ability to communicate with ease and in plain language, are also things you want to look for in a pharmacy technician.¹⁴

How can I encourage patients to work with the embedded pharmacist?

Create an introductory letter or biography of the embedded pharmacist to share with patients. Display a picture and description of the pharmacist’s services in the practice and/or on your practice’s website. A quick “meet and greet” during a patient’s visit with a physician can be the most influential approach to encourage patients to work with a new team member. Then, schedule the patient for a separate visit with the pharmacist if needed.

How do I determine the embedded pharmacist’s schedule?

There is no standard schedule for an embedded pharmacist. A practice of 10 physicians may have a need for a pharmacist onsite for one day a week. Another practice of only two physicians might also identify a need to have a pharmacist in the office two days a week.

How do I decide where to begin to use the pharmacist’s skills?

You may wish to develop a list of patients who could benefit from pharmacy services such as those with polypharmacy needs, uncontrolled diabetes or hypertension or those requiring anticoagulation management. Work with your electronic health records team to create a list of all complex patients for the pharmacist to risk stratify.

How much visibility does a newly embedded pharmacist need?

Initially, you will want to have the pharmacist physically in your office. This will help them develop relationships with patients, staff and other physicians. Start with fewer hours and build up. Consider scheduling pharmacist clinics for a half-day each week. As use increases, you can adjust the amount of time the pharmacist spends in the practice.

Can a pharmacist do virtual visits?

In-person interactions are useful initially to develop relationships with patients, the physicians and the care team. Once the pharmacist has established trust, they may be able to practice virtually as well, if allowed under applicable law. Virtual visits can be vital for reaching homebound patients.¹⁴ In some practices, embedded pharmacists often conduct a significant percentage of their visits over the phone to minimize travel to the clinic for patients.

What is the appropriate number of daily patient visits for an embedded pharmacist?

The number of patients per day will vary depending on the complexity of patients and type of services. However, once embedded pharmacists are up and running, it is reasonable to expect them to provide care to 10 to 16 patients per day either by phone or with in-person visits.

Michigan Medicine Patient Centered Medical Home (PCMH) pharmacists average 13 patients per day, with 45 percent of these visits occurring in the clinic and 55 percent in the form of phone consults. Phone consults are only done with established patients.

What type of agreements do I need to have in place with the pharmacist?

If you embed a clinical pharmacist, he or she may work as an independent contractor or an employee. The type of relationship the clinical pharmacist has with your practice will be outlined in the formal agreement between the two parties. These agreements need to comply with all federal and state laws and be drafted by competent legal counsel. If your practice is part of a larger organization, it is best to coordinate through the overarching administration.

How should I reorganize clinic and/or office space for the pharmacist’s needs?

You don’t have to overhaul your space when you embed a pharmacist. All they need is a private space with a desk, a phone and an exam room. The pharmacist can take advantage of any open exam room that gives privacy. They will need access to a computer in the exam room as well as common equipment such as blood pressure monitors. The pharmacist or pharmacy technician should be co-located with other team members and attend the daily huddle.

How are an embedded pharmacist’s services reimbursed by private payers?

Review agreements with payers carefully to determine your options. Commercial health plans that focus on medication adherence and medication reconciliation during transitions of care may provide opportunities to reimburse care management services. Legal and coding specialists should be consulted as well.

Does billing for services as “incident to” capture pharmacist services?

The Centers for Medicare & Medicaid Services (CMS) defines “incident to” services as those services that are furnished incident to physician professional services in the physician’s office (whether located in a separate office suite or within an institution) or in a patient’s home.⁹ This gives non-physician practitioners, such as pharmacists, a potential mechanism for billing for their services that relate to the physician’s care plan.¹³

CMS guidance indicates that pharmacists can bill Medicare for services as “incident to” physician services if certain requirements are met. Services must be within the pharmacist’s scope of practice as dictated by the state’s Pharmacy Practice Act, among other requirements.⁵,⁶,⁹,¹⁰ Check with your local CMS carrier for guidance.

Not all commercial health plans will reimburse for “incident to” services, so be sure to check your contracts before attempting to bill.

What is a Medication Therapy Management (MTM) program?

MTM programs focus on efficacy, safety and cost by improving medication use, reducing the risk of adverse events, preventing drug interactions, improving medication adherence and finding cost-effective treatment regimens. MTM is a covered benefit for all Medicare Part D beneficiaries who meet defined eligibility criteria.⁷ A pharmacist’s services under MTM include annual comprehensive medication review and quarterly targeted medication review.

Are all MTM programs the same?

No, there is no one checklist for delivering MTM. Check with CMS, the commercial health plans you contract with and local retail or community pharmacies to confirm if they offer MTM and what services their MTM programs cover. MTM can take place in a face-to-face visit or over the phone. There is no time restriction for delivering portions of this program. Payment depends on the contracted rate for the activity.

Does a physician need to sign or review the pharmacist’s notes and medication changes? Does that change if we are sharing notes with patients?

Scope of practice for pharmacists varies by state law and your organization’s policies. It is discouraged to establish a precedent where the pharmacist sends the physician all of their notes as this could increase the physician’s workload needlessly. Work together for several months and identify the types of notes that should be flagged for a physician’s signature or as an FYI. For instance, one practice asked the pharmacist to include one to two lines at the top of a significant note that summarizes the major changes for the physician. This summary captures changes in a patient’s condition or the addition of a new medication. Follow this same advice if you are sharing notes with patients by participating in a program such as OpenNotes.

What’s the most efficient way to involve the pharmacist in managing incoming requests and messages to the practice?

Decide what types of messages should flow directly into the pharmacist’s inbox or in-basket. These could include specific medication questions or problems and general guidance on treatment options. Next, assign the pharmacist to a specific clinician’s team pool. The team can redirect those notes that require the pharmacist’s attention. Refill requests should go to the team pool in-basket first. The medical assistant assigned to the team pool can then queue up that prescription for the pharmacist to review and approve per the collaborative practice agreement, if applicable under state law. This diverts the refill request from the physician’s in-basket to increase efficiency and productivity for the entire team. If your practice has a licensed practical nurse or registered nurse, they may also perform medication refills based on protocol instead of the pharmacist.

Does the physician always need to refer patients to the pharmacist?

Nuances of payment often determine who must refer patients to the pharmacist. For example, if you are billing Medicare for the pharmacist’s service as “incident to” a physician’s service, a physician will have to make the referral.⁸

How do we know if patients are reacting positively to the pharmacist?

You can measure patient feedback and experience the same way you evaluate other patient satisfaction indicators: through a survey, informal conversations or direct discussions with your patient. Some practices add a question or two on their patient satisfaction surveys about the pharmacist’s services. Practices with embedded pharmacists have discovered that being able to schedule phone visits and provide frequent follow-up, as well as the pharmacist’s accessibility, are great patient satisfiers.