By: Fred Gebhart
Just as hospital pharmacists moved out of the basement and into direct patient care in the 1980s and 1990s, outpatient pharmacists are moving out from behind the counter and into medical practices.
“There is a demand for pharmacists from the physician side in ambulatory care,” says Elizabeth Cuevas, MD, director of the Primary Care Transformation for Residency Clinics at Allegheny Health Network, a nonprofit eight-hospital academic medical system with facilities in Western Pennsylvania and Western New York. Allegheny is putting pharmacists into about 250 different practices that are part of its accountable care organization (ACO), a payment model in which the health system receives higher reimbursement if it improves quality and reduces costs.
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“We’ve used our pharmacists for improved medication management, medication reconciliation, patient education and outreach, symptom management, disease management, and making sure patients are actually taking their meds,” says Cuevas. “Pharmacists have a natural role in practices.”
Allegheny isn’t alone in placing pharmacists in physician practices and ambulatory care clinics. Integrated health systems and larger group practices nationwide are moving in the same direction.
In the ideal arrangement, pharmacists are embedded in practices with 5 to 10 physician and nonphysician practitioners, explains John Kennedy, MD, chief medical officer of AMGA, formerly the American Medical Group Association. “For smaller practices or areas that may be more remote, you can use telemedicine or share remote [pharmacist] support as long as you have a shared electronic health record.”
Allegheny is using embedded pharmacists and shared services, depending on the size and location of the practices. Practices with one or two providers usually can’t support a full-time pharmacist, but they can benefit by sharing the services of a pharmacist, according to the health system.
A group of small practices that are relatively close to each other might share a pharmacist who rotates through the different offices, for example. More distant locations might do better with video and data links to a central pharmacist.
Either way, pharmacists are part of the care team and their salaries are covered by the practice. Regardless of the specific arrangement, the goal is the same—to incorporate pharmacists into team-based patient care.
Starting in the Hospital
Allegheny’s decision to put pharmacists on patient care teams can be traced back 30 years, to when inpatient physicians began working with clinical pharmacists. Then, Michael Korczynski, PharmD, BCAP, came on board as manager for Clinical Services, Pharmacy – Ambulatory Care.
“I had come from Kaiser Permanente and the VA, so I was familiar with an autonomous role for pharmacists,” Korczynski says. “But it was a foreign concept here.”
Even so, in the years before Korczynski started at Allegheny, its physicians and pharmacists had built up a strong relationship working together on the inpatient side, he says. “I started an anticoagulation service and working with a primary care practice. Physicians quickly latched onto the new-to-them services.”
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Changes in physician education also helped foster physician acceptance of pharmacists on care teams, says Kennedy. Most younger physicians train with pharmacists on inpatient care teams. Once they join a practice, they expect the same access to a medication specialist, he says. Practices and health systems that can offer a pharmacist in the office have a hiring advantage as the physician shortage grows.
What Pharmacists Offer
Putting a pharmacist in the office brings quality and financial advantages, which is critical in value-based reimbursement models, such as Allegheny Health’s ACO.