Pharmacists supporting population health in patient-centered medical homes.

Abstract

The integral role of pharmacists in supporting population health initiatives in the patient-centered medical home (PCMH) model of care is described. Population health initiatives focus on the health outcomes of a group of patients; in the PCMH model, such groups of patients, known as panels, may be defined as patients assigned to a care team or provider. The basic characteristics of the PCMH model include physician-led, team-based practice; coordinated and integrated care within the PCMH and in the patient's community; provision of safe, evidence-based, high-quality care; incorporation of health information technology and continuous quality improvement strategies into panel identification, documentation, and care processes; improved access to care (e.g., through expanded scheduling and innovative communication methods); and value-based payments for participating healthcare professionals. Pharmacists can assist in management of patient panels to help achieve quality and performance metrics through activities typically including comprehensive medication reviews, identification of medication-related problems, and development of care plans and individualized treatment goals. Pharmacists practicing in PCMH settings focus on evaluating and optimizing medication regimens, including therapy initiation and dosage adjustment, to achieve targeted therapeutic outcomes and prevent adverse events. Pharmacists' role in population health management varies according to the PCMH characteristics and setting. Pharmacists support population health in the PCMH by improving medication use, quality, and safety. Pharmacists' impact on PCMH quality measures and health outcomes of their patient panels should continue to be evaluated.