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Embedding Pharmacists into the Practice in Ann Arbor, MI: A Case Study

Started in 1999 by Hae Mi Choe, PharmD, at a single primary care practice, the University of Michigan Medical Group's embedded pharmacist program has since expanded to include 14 sites and 11 pharmacists and is now both robust and successful.

“Pharmacists have extensive knowledge and training in disease management and education, but physicians weren't fully aware of these skills. I knew I could be a valuable contributor to the team, but I needed to find a way to incorporate myself into the practice and demonstrate that value,” says Dr. Choe. At the time, diabetes prevalence was increasing in Michigan, but the complexity of treatment regimens and the condition itself prevented management programs from keeping pace. She saw an opportunity to work with providers in her clinic to create and implement a diabetes management program.

Dr. Choe developed a program that focuses on therapeutic management and lifestyle education services for patients with diabetes. She viewed the program as a way to enhance and supplement the care that patients were already receiving from their physicians. Initially, she took the initiative in establishing relationships with the physicians and introducing herself to patients. Her gregarious personality and enthusiasm opened the door for her to demonstrate her competence and capabilities. The physicians soon started referring their patients to her. It took a year to build up a patient panel that she co-manages with the physicians.

Warm handoffs and a quick three-sentence introduction were instrumental to her success. “All the physician needed to say was: ‘I have an excellent pharmacist who works with me in the clinic. She can really help you with your high blood sugar levels and medications. Schedule an appointment with her on your way out,’” said Dr. Choe. “That 30-second introduction from the physician went a long way toward making patients feel comfortable with me.”

She started out seeing three to four patients per half-day at the time of the program launch. Her patient panel grew to an average of eight patients per half-day within the first year after launch. Eventually, she was seeing approximately 18 patients a day, but Dr. Choe acknowledges that this is likely not going be the norm for most clinics. Over time, Dr. Choe's responsibilities expanded to include training medical assistants and nurses to help them prepare refill requests and answer patient questions. Training topics included a review of common drug names and classes and overviews of recently-approved medications, their indications, mechanisms of action and common side effects. These trainings were very well-received and became part of the value proposition as the program expanded to other sites.

Dr. Choe also took on the task of evaluating the practice's quality performance to identify opportunities to improve care. She gathered and shared data on baseline practices (e.g., proportion of patients with glycemic or blood pressure control), and explained to her physician colleagues why it was important to address them. This fed into larger quality improvement (QI) efforts that prompted Dr. Choe to start a weekly QI huddle. The huddles include a physician, a medical assistant, a clerical staff member, a nurse and a clinic manager. In these 15-minute huddles, held every Thursday, the group has been able to pinpoint problematic workflows and formulate new ones to improve process and quality. Together, they have developed and implemented an asthma action plan, a controlled substance tracking program and an emergency room follow-up process.

Becoming an integrated team member was not without its challenges. Creating awareness about what pharmacists can and should do was the first hurdle to clear. Dr. Choe overcame this barrier by setting appropriate expectations, educating her colleagues and reinforcing the incremental improvements that they were witnessing.

“Hae Mi was very proactive from the start. She took the time to learn how we practiced day to day, and ran her ideas past us to see if they could be implemented. She focused on determining on how things would work in the real world, rather than just in the abstract. She made sure that the interventions actually made a difference, and when they didn't, she modified them, or started over.” -- David A. Cooke, MD, FACP, Michigan Medicine East Ann Arbor Health Center and Burlington Back and Pain Center

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