Practice Notes

Pharmacists and ambulatory care teams: An expanding role

Tiffany Chan

In 2009, Hennepin County Medical Center (HCMC)—a level I trauma center based in Minneapolis—began assigning pharmacists to review prescriptions and medication instructions for patients awaiting discharge to skilled nursing facilities. Having this second layer of medication reconciliation (physicians conducted an initial reconciliation when writing their discharge orders) enabled pharmacists to check that patients had complete instructions, flag concerns, and work with physicians to resolve any discrepancies.

The results shocked the system: About 30% of the errors that the pharmacists corrected were significant enough to have led to ED visits or extra hospitalization. With pharmacists reviewing prescriptions, ED visits among those patients decreased by 30%, hospitalizations by 42%, and cost of care by about $2,500 per patient.

A service delivery innovation

HCMC's 2009 pilot was so successful that the Agency for Healthcare Research and Quality documented it as a service delivery innovation.

HCMC leaders moved quickly to use their new knowledge to improve inpatient care more broadly. Today, pharmacists at HCMC round with medical teams in the hospital, working with physicians to validate discharge orders before patients return home or transfer to home care. This has proven highly effective, leading HCMC to the next step: deploying pharmacists in the ambulatory space.

Adding pharmacists to ambulatory care teams

Now, a team of pharmacists manages medication therapy, visiting patients both in ambulatory practices and at home. HCMC is using these pharmacists to:

  • Support primary care providers. HCMC currently staffs one ambulatory pharmacist for every five or six physicians. These pharmacists review medication orders, consult with physicians, and help educate patients and ensure compliance with drug regimens. To support its current ACO involvement, HCMC plans to add pharmacy services to every primary care clinic joining the system.

  • Manage care transitions in long-term care settings. HCMC recently installed a pharmacist in a long-term care facility to help ensure that patients understand and follow medication regimens, and to coordinate care with the primary care physicians. So far, preliminary data suggests a reduction in ED visits and hospitalizations.

  • Administer care in medication-management clinics. HCMC recently incorporated pharmacists into a large anticoagulation clinic, formerly run exclusively by nurses. Pharmacists now also provide medication management through a collection of eight off-site clinics within family practice or internal medicine offices.

Justifying the cost of pharmacy care

One study's findings suggest that every $1 spent on medication therapy management (MTM) generates $12 in savings. In HCMC’s experience, that return may be even larger.

In areas where HCMC provides MTM in conjunction with pharmacist-driven pre-discharge medical reconciliation, the health system has seen more than a 30% reduction in the 30-day readmission rate.

Although pharmacists are an expensive resource, they're an investment well worth considering, especially for groups that are taking on substantial risk.

  • Is your group considering incorporating pharmacists or other clinical staff into your ambulatory care team? Share your questions and concerns with us by emailing or leaving a comment at the end of this post.

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