Clinical and Health Affiars
The Expanding Role of Minnesota Pharmacists in Primary Care
By Anusha Raju, Pharm.D., Lindsay A. Sorge, Pharm.D., Jody Lounsbery, Pharm.D., and Todd D. Sorensen, Pharm.D.
■ Changes to pharmacy education have paralleled changes in the role pharmacists play in primary care. Today, pharmacists are often members of the health care team, providing medication management services to help patients control chronic illnesses and working to prevent adverse drug events by educating and guiding prescribers. This article describes the role of pharmacists today and what they are doing to improve outcomes related to patient care.
The Doctor of Pharmacy degree has been the sole professional degree conferred by pharmacy schools in the United States since 2001. Previously, pharmacy graduates earned a four-year bachelor’s degree. Then, training emphasized the clinical issues associated with the dispensing of medications in community pharmacies or hospitals. In response to the growing complexity of medication use in the United States, pharmacy education requirements changed. Now, earning a degree requires four years of training following at least two years of undergraduate studies. Students also must do more than a year of field work. Doctor of Pharmacy students learn to assess a patient’s drug-related needs; identify, resolve, and prevent drug-related problems; and ensure that the goals of therapy are achieved by developing a care plan and conducting follow-up evaluations at appropriate times. They also learn to work as part of interprofessional teams.
The University of Minnesota Academic Health Center’s 1Health initiative, which was launched in 2010, offers one way for students from each of the health professions programs to learn to work together. Nearly 900 students from the College of Pharmacy, Medical School, Center for Allied Health, School of Dentistry, School of Nursing, School of Public Health, and College of Veterinary Medicine are involved in the first phase of 1Health. The goal is to teach them how to rely on each others’ skills and talents in order to optimize patient care. (More about 1Health is available at www.ahc.umn.edu/1health/.)
The change in pharmacy education coincided with a significant expansion of the role of pharmacists in health care. Pharmacists now provide a variety of clinical services in a number of settings including primary care clinics. The scholarly work of faculty at the University of Minnesota College of Pharmacy, strong collaborations within the practice community, and an innovative health care environment have made Minnesota a leader in integrating pharmacists into primary care teams. This article describes the role pharmacists play and how their involvement has led to improvements in patient outcomes.
Playing a New Role
Today, more than 100 clinical pharmacists work in primary care clinics across Minnesota. Organizations in the Minneapolis/St. Paul metro area that have incorporated pharmacists into their clinic-based care models include Fairview Health Services, HealthPartners, Hennepin County Medical Center, and University of Minnesota Physicians. Park Nicollet Health Services and Allina Hospitals and Clinics are currently developing programs. Outside the metro area, Mayo Clinic, Essentia Health, and several small rural health systems have established clinical pharmacy programs in their outpatient clinics.1
Within these organizations, pharmacists work directly with patients. They also create and maintain medication- related information systems, implement medication use policies and procedures, lead quality-improvement initiatives focused on medication use, and provide medication education to physicians and other clinic staff.
As members of a primary care team, pharmacists conduct one-on-one visits with patients in order to evaluate their medications in relation to their medical conditions and treatment goals. Patients are frequently referred to a pharmacist by a primary care provider; systematic review of clinic records using predetermined criteria targeting patients at high risk for poor medication outcomes also can lead to a referral. Through collaborative practice agreements—formal protocol-based agreements between a physician and a pharmacist—pharmacists in Minnesota can initiate therapy, alter doses, and order laboratory tests within predefined practice protocols.
One of the forces driving the trend of integrating pharmacists into primary care is the national emphasis on improving care for chronic diseases such as diabetes and heart diseases—diseases that if poorly controlled drive up health care costs. Recent data show that management goals for these diseases are not being met. As of 2009, only 33.9% of Medicaid patients with diabetes had achieved desirable HgbA1c levels.2 The percentage of both Medicare and Medicaid beneficiaries with controlled hypertension is less than 60%. Similar results have been reported for cholesterol management.2 According to MN Community Measurement, which publicly reports clinics’ scores on a number of health measures, the overall percentage of patients with adequate control of diabetes, heart disease, and hypertension is far from desirable in Minnesota.3 Controlling these conditions means that patients must make lifestyle changes and take medications. By providing medication management services, pharmacists can help ensure that patients make progress toward their goals.
Another role for pharmacists in primary care is helping to prevent adverse drug events. Adverse drug events have a significant impact on the cost of health care, as an estimated 700,000 emergency department visits and 120,000 hospitalizations in the United States each year are the result of ADEs and about $3.5 billion is spent annually to care for patients who have experienced ADEs. Among patients age 65 and older, 87% of hospitalizations are associated with their not taking prescription drugs properly. At least 40% of ADEs in the outpatient setting are considered preventable.4,5 Pharmacists can work to reduce ADEs by educating physicians and other providers about medications and advising them while they are making prescribing decisions.
Improving Outcomes, Reducing Costs
Including pharmacists in interprofessional teams has been shown to improve outcomes for several chronic conditions. Carter et al. examined the effect of collaboration between physicians and pharmacists on hypertension management and found that this partnership resulted in patients achieving significantly better mean blood pressure control.6 Similar outcomes have been seen in the management of diabetes, cardiovascular disease, and asthma.7-9 A 2010 meta-analysis of 298 studies strongly supported the positive impact of clinical pharmacy services; specifically, measures such as medication adherence, patient knowledge, and quality of life were shown to have improved significantly.10 Other studies evaluating pharmacist-led interventions in primary care show a significant reduction in overall hospital admissions. In a meta-analysis of patients in primary care, Royal et al. found an odds ratio of 0.64 for the reduction in hospital admissions when a pharmacist was involved in the primary care setting compared with when one was not.11 A 2009 survey suggested that organizations that included pharmacists in the care management team saw improvements in quality of care/outcomes and patient and medical provider satisfaction.12
Health care payers have begun to recognize the benefit of pharmacists’ contributions in medication management for chronic diseases. The Medicare Prescription Drug Improvement and Modernization Act of 2003 established medication management services as a core benefit of Medicare Part D.13 In Minnesota, the state’s Medical Assistance program, HealthPartners, and several self-insured employers have incorporated medication management services into their benefit packages.14,15
A 2003 study of Fairview Health Services pharmacists who work collaboratively with primary care providers found that 5,780 drug therapy problems were resolved for 2,524 patients. In addition, patients were more likely to achieve their therapeutic goals. At the beginning of the study, 74% of patients seen by clinical pharmacists were achieving their treatment goals; by the conclusion of the study, 89% were achieving them.16 These improvements were attributed in part to the fact that Fairview clinical pharmacists have broad collaborative practice agreements that allow them to conduct comprehensive medication evaluations and work with primary care staff to revise treatment plans. A more recent cost-benefit analysis involving Blue Cross and Blue Shield of Minnesota beneficiaries found that medication management services reduced their annual per beneficiary costs from $11,965 to $8,197. The cost of medication management services averaged $92.50 per pharmacist encounter, resulting in $12 saved for every $1 in service costs.17
Acknowledging the benefits pharmacists can bring to a primary care team, the state of Minnesota has included pharmacists in its definition of a health care home. To be certified as a health care home, a clinic need only have a primary care provider and a care coordinator; however, specialists may be included in the team when appropriate, and pharmacists are included in the program’s definition of “specialist.” They are currently involved in about half of the state’s 138 certified health care homes.18,19
Conclusion
Pharmacists perform a number of functions in health care. They can work jointly with physicians to manage chronic conditions, improve medication use systems, serve as a resource for drug information, and educate physicians and patients about medications. Studies have shown that including a pharmacist on the primary care team improves outcomes in patients with chronic conditions such as diabetes, hypertension, and asthma. Their involvement also reduces the incidence of adverse drug events and, thus, the cost of care. As health care leaders and payers better understand the contributions they make, it is likely that the number of pharmacists working collaboratively with primary care physicians will continue to grow in the future. MM
Anusha Raju and Lindsay Sorge are pharmaceutical care leadership residents at the University of Minnesota College of Pharmacy. Jody Lounsbery is an assistant professor in the University of Minnesota College of Pharmacy and faculty for the North Memorial Family Medicine Residency Program. Todd Sorensen is a professor and director of the Ambulatory Care Residency Program at the University of Minnesota College of Pharmacy.
References
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2. National Committee for Quality Assurance. The State of Health Care Quality: Reform, the Quality Agenda and Resource Use. 2010. Available at: www.ncqa.org/Portals/0/State%20of%20Health%20Care/2010/SOHC%202010%20-%20Full2.pdf. Accessed August 31, 2011.
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12. American Pharmacists Association. Medication Therapy Management Digest: Perspectives on the Value of MTM Services and their Impact on Health Care. April 2009.
13. Public law no. 108-173: Medicare Prescription Drug, Improvement, and Modernization Act of 2003. Available at: www.gpo.gov/fdsys/pkg/PLAW-108publ173/pdf/PLAW-108publ173.pdf. Accessed on August 31, 2011.
14. Minnesota Department of Human Services. Medication Therapy Management Services. 2006.
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17. Isetts BJ, Schondelmeyer SW, Artz MB, et al. Clinical and economic outcomes of medication therapy management services: the Minnesota experience. J Am Pharm Assoc. 2008;48(2):203-11.
18. Minnesota Department of Health. Health Care Homes (aka Medical Homes) Available at: www.health.state.mn.us/healthreform/homes/index.html. Accessed August 31, 2011.
19. Minnesota Administrative Rules. Health Care Homes. Chapter 4764, Parts 4764.0010-0070: Available at: www.revisor.mn.gov/rules/?id=4764&view=chapter. Accessed August 31, 2011.