At University of Michigan Northville Health Center, working with a pharmacist who is onsite and fully integrated into the care team brings tangible benefits to providers and patients. Even before Northville was designated a patient-centered medical home, the providers saw value in developing a well-rounded team to serve their elderly population with complex medical needs. An embedded pharmacist has practiced alongside physicians for the last seven years and his role has grown with the practice, which has added three new physicians over that period.
One of the first conditions the pharmacist tackled was diabetes. By evaluating the practice's quality and patient data, he was able to identify those patients who had poorly controlled diabetes. The pharmacist then approached each patient's physician to determine how he could help. “Initially, there was a little hesitancy on the part of the physicians. We had been managing these patients, so it became a question of, ‘What can you help me with and what do I feel comfortable with?'” said Audrey Fan, MD, medical director at Northville. “We discovered that for a patient who was poorly controlled, an interim visit with the pharmacist meant that their diabetes was under better control when I saw the patient at their routine follow-up than they would have been otherwise. This allowed me to spend more time on the patient's other concerns.”
Face-to-face interactions between physicians and the pharmacist were essential for this arrangement to function, both at the outset and to ensure sustainability of the programs the pharmacist developed. These interactions helped both sides appreciate the nuances of care being provided and simplified charting, since everyone had access to the same platform. Trust was established that translated into genuinely warm handoffs of patients from the physician to the pharmacist.
At Northville, the ideal arrangement has been to have the pharmacist build a patient panel. The primary referrers to the pharmacist are physicians, but physician assistants and the dietician can also refer patients with the physician's approval. Eventually, as part of a system-wide initiative to address gaps in care, the group built in an automatic referral system for specific patients. For example, if the medical assistant noted an elevated blood pressure when checking vital signs, the patient was automatically referred, with physician approval, to the pharmacist for a recheck and further evaluation.
The pharmacist is introduced to patients in several ways. First, the practice created a short printed biography that included the pharmacist's picture and described what services he offered. This bio is available in the exam rooms to hand out at the end of visits. Second, physicians and team members verbally explain to patients how the pharmacist can help them. Lastly, providers sometimes introduce the patient and pharmacist through a warm handoff. The physicians emphasize to the patient that they provide care as a team and that the pharmacist can help physicians deliver on their promise of high-quality care. In a small practice, this is easy to do and is often the most effective way to help patients become comfortable with the pharmacist as a new team member.
At Northville, it took some time for the pharmacist to ramp up his projects and patient panel. The schedule evolved from one half-day in the clinic seeing five to six patients to three full days in the clinic following up with eight to 10 patients each half-day. In addition, some of the initial face-to-face time was converted to telephone visits for follow-up, especially for patients with diabetes, because it was very easy to gather measurements over the phone to evaluate the response to treatment. During downtimes, the pharmacist helps the practice comprehensively assess quality. He pulls patient lists and reviews charts to assess measures for diabetes and chronic kidney disease to see if patients are on track. With delegated protocols, he is able to update medications and improve metrics.
Today, the pharmacist's role has expanded to include medication reconciliation and evaluation for elderly patients. Using a combination of familiarity with Beers Criteria for Potentially Inappropriate Medication Use in Older Adults1, knowledge of drug-drug interactions, ability to readily identify less costly alternatives to medications that help patients bridge gaps in their prescription coverage and delegated protocols, the pharmacist is able to assist with medication management, including the ability to discontinue, adjust or add medications as needed with physician input and approval.
Physicians and patients at Northville are very satisfied with the pharmacist and pharmacy services offered. Physicians have been able to shift patients so that their schedule can accommodate more complex cases that require their expertise. Patients report that they like working with the pharmacist so much that they don't want to stop seeing him when they reach their treatment goals. Patients are huge fans of the pharmacist and appreciate being able to see how Northville prides itself on delivering care as a team.
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