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Hi Timeless Autonomy Community,
This week, we have a guest post for Timeless Autonomy readers by the awesome Dr. Jackie Boyle, PharmD. She’s sharing about her experience as a pharmacist working in primary care and the value of pharmacists in this space.
It’s no surprise that I believe pharmacists can and should play a strong role in value-based, advanced primary care. I love talking to Jackie about her work in this space. Enjoy!
Dana
One last thing! I'm building a course for my healthcare professional colleagues who want more for their careers. Want to join the waitlist?
In Dr. Strauss’ recent post on the future of primary care, I appreciated her call to action directed at healthcare providers (pharmacists included!) who are “head in the sand” sometimes, not seeing the forest through the trees. Changes are popping up in the landscape of healthcare payment policy, including the shift towards more funding in primary care, in-home care, and value-based care.
These changes are, or may soon be, the opportunities of a lifetime for pharmacy professionals.
Additionally, there is a primary care shortage worsening by the year. Pharmacists are ready and qualified to help…put us in, Coach!
The looming primary care shortage noted by the Health Resources & Services Administration describes that Health Professional Shortage Areas currently have a shortfall of 13,052 practitioners, with 15 million patients living in Medically Underserved Areas. Considering these numbers, pharmacists and other providers should be engaged as solutions to the shortage, working at the top of their scopes of practice and licenses.
Many are raising their hands to jump in and help address the burgeoning needs in managing the health of patient populations across the country. With longer lifespans, a large baby boomer population, more complex medication options, and complex disease management needs, pharmacists are poised and trained to help expand access to care, lower the total cost of care, and address care quality challenges. This is duly noted by the timeless 2011 U.S. Surgeon General’s Report.
While many pharmacy associations such as the American Society of Health-System Pharmacists have described the role of pharmacists in primary care and the myriad of services that pharmacists can provide in this setting, it is interesting (but not unexpected) to see that not all primary care offices have embedded pharmacists into their practice. Many times, patients were surprised when I walked into their room and announce that I was the pharmacist on the care team.
Patient: “Are you going to give me my medications?”
Me: “No, I’m actually here to see what medications you absolutely need, if they are working, and what we might be able to get you off of. I’m also here to make sure you understand the reason you are taking the medications and how to take them properly.”
Let’s take the process of medication reconciliation as one responsibility a pharmacist may have in primary care.
Creating an optimal medication list is akin to solving a complex puzzle to which I didn’t always have all the pieces. I needed to engage the patient to solve the puzzle.
A successful pharmacist/patient primary care encounter can identify and resolve some important patient safety risks, engage patients in managing their care, and identify barriers to medication compliance. Pharmacists in primary care look for answers to the following questions as they review and reconcile medications:
1) Do I have all the puzzle pieces?
a. Patients may have multiple prescribers and fill their medications at multiple locations. This could be due to their insurance practices, due to convenience, or due to necessity.
b. Are any medications missing from the puzzle? If so, the medication list would not be complete.
c. It is very common that patients are taking over-the-counter medications or herbal supplements that are not documented on their medication lists. Leaving these off a medication list renders it incomplete and prone to many patient safety risks.
d. Another omission could be caused by a prescription that was never filled by the patient – we may inadvertently assume they are taking something that was prescribed which appears on their medication list actively, when the patient has never filled the medication at any pharmacy to begin with.
2) Are there any duplicate puzzle pieces?
At times, I would discover that patients inadvertently were taking medications that were intended to be interchanged (new prescription received, but old prescription continued) or duplicate medications with different doses (new prescription, but old prescription continued again). As you might imagine, many patient safety risks were able to be resolved when we discovered these issues.
3) Are there puzzle pieces that don’t fit together?
Drug-drug and drug-supplement interactions can be overlooked. Many patients are taking over-the-counter medications or herbal supplements that are not documented on their medication lists. Or, clinical inertia has potentially led to medications being prescribed to treat side effects of other medications, rather than the side effect being recognized earlier and another medication option chosen if available.
4) Are all the puzzle pieces in the puzzle box and are they organized appropriately?
At times, I found medications were missing/unaccounted for because of reasons such as:
The patient didn’t have a viable means or strategy for organizing their medications at home,
Or their pillbox was unfilled or was missing necessary medications,
Or the pillbox was filled inappropriately,
Or the storage method left the medications at risk of becoming ineffective or unsafe to consume,
Or the medications were organized throughout the day in a way that didn’t align with the patient’s lifestyle, and therefore adherence was compromised.
These are but a few of the issues that I encountered during routine medication reconciliation visits. One could imagine how complex the puzzle can be with 20, 30, even 40 medications/over-the-counters/herbal supplements on a patient’s medication regimen!
A team effort is ideal to address medication management comprehensively and achieve optimal patient safety and health outcomes, reduce avoidable urgent and emergent medical care and hospital admissions, and reduce unnecessary healthcare spend. Pharmacists are the right professionals to engage patients and collaborate directly with other members of the care team to help manage medical care with the clinical care team in the primary care setting.
Pharmacy professionals as primary care team members
While the American Medical Association (AMA) outlined this practice in their Steps Forward model, there still is a long road ahead to normalizing this part of the integrated model of primary care.
One major obstacle to widespread adoption is creating and sustaining viable financial models that support pharmacy team integration into practice settings. In fee-for-service payment models, pharmacists are not revenue-producing team members.
Pharmacists are not recognized as healthcare providers under the Social Security Act. They aren’t able to bill for their patient-facing care delivery, despite the unequivocal value they provide. There are a few key federal bills (HR 1770 and S.1491) that are aiming to change that.
Value-based care payment models, a growing reimbursement mechanism (particularly in primary care), should create the momentum and the right incentives needed to first make the practice of embedded pharmacy professionals more common. Demonstrating value in this way may hopefully lead to elevating the pharmacist to provider status in the next few years.Thanks for reading!
Dr. Jackie Boyle, PharmD
If you want to learn more, I encourage you to connect with me at [email protected].
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