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Embedding Pharmacists into the Practice in Milwaukee, WI: A Case Study

Physicians, advanced practice providers and internal medicine residents in the busy Froedtert & Medical College of Wisconsin Internal Medicine Clinic (Froedtert clinic) handle hundreds of refill requests daily. To streamline this process, the clinic implemented standardized rooming protocols to help medical assistants capture accurate medication lists in the EHR during office visits. They also initiated a refill protocol to allow staff to refill medications on the medication list for patients who had been seen in the clinic within the last 12 months. The team tracked the time from refill request to completion against a goal of two business days. Despite these efforts, refill turn-around time ranged from seven to 10 days.

The team studied this performance gap and learned that:

  1. When refill requests were not met within two business days, second and third requests for the same medication quickly doubled and tripled the number of incoming requests

  2. Medical assistants who were entering paper requests into the EHR and performing at-visit medication reconciliation sometimes did not have the sophisticated medication knowledge to enter medications with complete and accurate directions in the EHR

  3. Even when explicitly asked to bring their medication lists with them to their first visit, many new patients did not come to clinic with a complete and accurate list

The Froedtert clinic's pharmacy partners in the hospital saw an opportunity to showcase the pharmacy services located onsite. Together they explored the potential for pharmacy technicians to assist with medication refills in the clinical practice. Initially, the pharmacy provided financial support and was willing to fund two positions for the clinic: one position to manage refills and one position to call new patients to prep the chart for medications, allergies and immunizations before the visit. The second position allowed for coverage for refills when the first position was out of office, so that the practice didn't fall behind on medication reconciliation and refills. Both technicians could access refill data, which improved the accuracy of medication reconciliation. Neither technician required training beyond basic EHR and clinic orientation.

Even though the pharmacy technicians were onsite for a full day when the clinic was open and were co-located with the nurses, they were not initially incorporated into the care team. During the clinic day, they managed an inbasket dedicated to refills. The team learned that having the pharmacy technician doing calls before new visits allowed them to explain their clinic processes, including the process for refills, and decreased the no-show rate for new visits. Both pharmacy technicians enjoyed their work, liking the ability to be more connected with patients and providers. Within one month, the practice was able to meet their two-day refill turn-around time goal, which is a significant driver of patient satisfaction in the practice. Additionally, the nurses' work could be appropriately shifted to their skills: before the addition of the pharmacy technicians, 35 percent of the nurse encounters were for refills; this dropped to 10 percent after the pharmacy technicians joined the clinic. Physician involvement in refill encounters dropped from 16 percent to 14 percent after hiring the pharmacy technicians. Overall, the number of monthly refill encounters decreased by 6 percent.

Providers appreciated the pharmacy technicians, noting smaller numbers of inbox messages about refills and having the ability to forward “nuisance medication questions” to someone who could answer them more quickly. Providers found that the pharmacy technicians were the best team members to confirm adherence, determine fill dates and rectify medication questions with pharmacies. In other settings, it could make sense for pharmacy technicians to handle pre-authorizations, but the practice already had an insurance verifier who works with the pharmacy on these tasks.

Over time, the Froedtert clinic found that they could meet their refill goals with only one pharmacy technician on staff. While making this change saved money on the second technician's salary, it did so at the expense of meeting priority goals, such as improving no-show rates, and providing coverage for the pharmacy technician when she took paid time off. Other primary care clinics in the hospital network see value in offering pharmacy services and are starting to emulate the pharmacy technician model in their clinics.

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