Ambulatory Care Clinical Pharmacist Research Articles

Cost-benefit analysis with return on investment of clinical pharmacists in the Military Health System.

The Defense Health Agency comprises more than 700 military medical, dental, and veterinary facilities and provides care to more than 9.6 million beneficiaries. As medication experts, pharmacists identify opportunities to optimize medication therapy, reduce cost, and increase readiness to support the Defense Health Agency's mission. The Tripler Pilot Project and the Army Polypharmacy Program were used to establish a staffing model of 1 clinical pharmacist for every 6,500 enrolled beneficiaries. No large-scale cost-benefit study within the military health care system has been done, which documents the number of clinical interventions and uses established cost-avoidance (CA) data, to determine the cost-benefit and return on investment (ROI) for clinical pharmacists working in the medical treatment facilities. To validate the patient-centered medical home staffing model across the military health care system using the Tripler Pilot Project results to provide a cost-benefit analysis with an ROI. The secondary goal is to describe the interventions, staffing levels, and US Department of Defense-specific requirements impacting the provision of clinical pharmacy. A retrospective analysis of 3 years of encounters by clinical pharmacists in which an intervention was documented in the Tri-Service Workflow (TSWF) form as part of the electronic health record was completed. The analysis used 6 steps to assign CA intervention types and to prevent duplication and overestimation of the ROI. The absolute number of clinical pharmacists was determined using workload criteria defined as at least 20 encounters per month for at least 3 months of each calendar year. The number of clinical pharmacist full-time employees (FTEs) was determined by dividing the number of total active months by 12 months. Attrition was calculated comparing the presence of a unique provider identification between calendar years. The ROI range was calculated by dividing the CA by the total cost of clinical pharmacists using the variables' raw and extrapolated CA based on percentage of documentation template usage and the active clinical pharmacist calculation (absolute and FTE-based). Between January 1, 2017, and December 31, 2019, a total of 1,069,846 encounters by clinical pharmacists were documented in the electronic health record. The TSWF Alternative Input Method form was used by pharmacists to document 616,942 encounters. Forty-three percent of TSWF documented encounters had at least 1 CA intervention. The absolute number of clinical pharmacists associated with a documented encounter in any medical treatment facility ranged from 404 in 2017 to 374 in 2018 and the clinical pharmacist FTEs ranged from 324 in 2017 to 314 in 2019. Annual attrition rates for clinical pharmacists ranged from 15% to 20% (58 to 81 clinical pharmacists) annually. The total CA range was $329,166,543-$534,014,494. The ROI range was between $2 and $4 per dollar spent. This analysis demonstrated that ambulatory care clinical pharmacists in the Military Health System bring value through a positive ROI. Our study also identified a potential shortage of clinical pharmacists within the Air Force and Navy branches impacting medication management. This can have a negative impact on the readiness of service members, one of the leading priorities of the US Department of Defense.

908. Dismantling Barriers to Hepatitis Elimination: Automated Hepatitis C Screening with Care and Cure by a Primary Care Based Team

BackgroundLiver cancer rates are rising in the US, viral hepatitis accounting for more than 65% of the cases. Yet more than half of viral hepatitis infections remain undiagnosed. In response to the rise in HCV due to the opioid epidemic, the Centers for Disease Control and Prevention began recommending a one-time HCV test for all adults in 2020. Screening, linkage to care (LTC) and access to HCV curative therapy must be scaled up to reach the WHO goal of eliminating hepatitis by 2030.MethodsIn 2018, automated HCV screening utilizing electronic medical record protocols began in the emergency department (ED) based on the date of birth. Drug testing and peer recovery consults were added as eligibility criteria. Screening became universal and expanded to the inpatient units in 2020. Patient navigators (PN) received alerts of positive results and worked with patients to arrange LTC, one site being a primary care-based practice (PCP) where internists provided HCV care and support from ambulatory care clinical pharmacists.ResultsFrom Mar 2018 to Mar 2021, 50,873 people were screened for HCV, with 977 (1.9%) testing HCV Ab+, and 259 (0.5%) had confirmed infection by reflex HCV RNA. LTC 86.6% of patients, and 128 (49.4%) were newly diagnosed. Universal screening led to 35,482 testings from Jan 2020-Mar 2021. People born out of the 1945-65 birth cohort made up 75.8% of the screened and 39.1% of the infected. The PCP evaluated 47 HCV patients, initiated therapy in 38; 36 required prior authorization and 15 needed financial assistance. Treatment breakdown was: 29 (76.3%) glecaprevir/pibrentasvir, 6 (15.8%) sofosbuvir/velpatasvir & 3 (7.9%) ledipasvir/sofosbuvir. Pharmacist intervention with prior authorizations and financial assistance significantly reduced the cost (table 1). Thus far, 35 achieved cure with undetectable HCV RNA at 12 weeks.Table 1. The Cost of Treatment before and after Pharmacist Assistance ConclusionAutomated universal testing was an effective and seamless way to scale up HCV screening. Warm handoffs from a PN were important for engaging patients in care. A team approach assisted with removing barriers in therapy access, including prior authorization, specialist requirements, and financial assistance. Novel strategies utilizing ED and hospitals for testing with coordination to PCP are needed to find the missing millions and achieve hepatitis elimination.Disclosures Su Wang, MD MPH, Gilead Sciences (Grant/Research Support)Gilead Sciences (Grant/Research Support)

Bridging health disparities: a national survey of ambulatory care pharmacists in underserved areas.

Background:There is a shortage of primary care medical providers, particularly in rural communities and communities of racial and ethnic minority groups. Clinical pharmacists can help fill gaps in care among these vulnerable populations.Objective:To identify characteristics of ambulatory care pharmacists that pursue and maintain employment within underserved areas.Methods:An original survey was distributed nationwide to ambulatory care clinical pharmacists in underserved settings. Respondent characteristics were analyzed using descriptive statistics.Results:Of the 111 completed surveys, a majority of respondents were White, non-Hispanic, female, with English as their only spoken language. A majority of pharmacists completed a clinical experience or specialized training focused on underserved care prior to their position. The top three motivators for pharmacists accepting their clinical position as well as staying at their job were passion for caring for underserved populations, the presence of a faculty appointment, or the freedom and flexibility of advanced clinical roles.Conclusions:With a large majority of our respondents identifying as White and unilingual, there remains a large opportunity to increase diversity in the clinical pharmacy ambulatory care workforce caring for underserved populations. There is an observed correlation between early experiential or specialized training in underserved care and pharmacists pursuing employment in these areas. Thus, one potential long-term strategy to diversify and grow the ambulatory care clinical pharmacist workforce in underserved settings is for clinical practice sites to partner with colleges of pharmacy to recruit and maintain quality individuals who can meet the needs of diverse patient populations as well as expand student and resident training opportunities in underserved settings.

Perceptions of the Value of Clinical Pharmacy Medication Review for Women During Early Pregnancy.

The benefit of continuing medications to prevent or treat illness is often overlooked, since pregnant women tend to overestimate the teratogenic risk of medications. Pharmacists can serve as a resource to prescribers and pregnant women with their knowledge of the appropriate use and management of medications during pregnancy. Little information exists on the value women place on pharmacists' medication management during pregnancy. To assess pregnant women's perceptions of an ambulatory care clinical pharmacist (CP) medication review service during early pregnancy that provided education regarding the risks and benefits of medication use during pregnancy. This was a qualitative study of pregnant women using semistructured telephone interviews performed between December 12, 2018, and January 18, 2019, and conducted in an integrated health care delivery system. Potential participants were identified from CP encounter records. Consented English-speaking women aged ≥ 18 years participated in an up to 30-minute interview within 1 week of the CP encounter. Interviews were professionally transcribed and coded line by line using the constant comparison method with grounded theory used to gain insight into participants' perspectives. 62 women were invited to participate in semistructured telephone interviews of whom 24 (39%) completed the interview. Three main themes emerged from the qualitative analysis: satisfaction with the service, comfort with medication use during pregnancy, and connectedness to the health care team. Overall, the CP medication review and education service was perceived positively by the participants. Participants reported satisfaction in the quality, timeliness, and convenience of the service and found it beneficial to have their medications reviewed early during pregnancy to assist in medication use decisions before their first obstetric visit. CP medication review provided a comforting, valuable service for women during early pregnancy when medication-taking decisions can feel exigent. This study was funded by Kaiser Permanente. The authors have nothing to disclose. Preliminary results were presented at the Mountain States Conference for Residents and Preceptors, May 2019, in Salt Lake City, UT.

Ambulatory care practice in the COVID-19 era: Redesigning clinical services and experiential learning.

The coronavirus disease (COVID‐19) has created a variety of challenges for health care professionals, including ambulatory care clinical pharmacists. High‐quality remote and minimal‐contact care has become a necessity. Ambulatory care clinical pharmacists around the nation have adjusted their practice. In many cases, this included implementation of telehealth programs for comprehensive medication management. The redesign of ambulatory care Advanced Pharmacy Practice Experiences (APPE) also required quick adaptation. In this paper, we describe the clinical practice and experiential education challenges encountered by an ambulatory care clinical pharmacist workgroup in a COVID‐19 “hotspot,” with an emphasis on solutions and guidance. We discuss how to adapt ambulatory care clinical pharmacy practices including methods of minimal‐contact care, reimbursement opportunities, tracking outcomes, and restructuring ambulatory care APPE. As ambulatory care clinical pharmacists continue to expand the services they provide in response to COVID‐19, we also describe opportunities to promote pharmacists as providers during times of pandemic and into the future.

Workload evaluation of clinical pharmacists in the ambulatory care setting

AbstractIntroductionInpatient clinical pharmacists' roles and contributions to team‐based care are well established; however, there is limited evidence describing the activities and processes for the delivery of care by ambulatory care clinical pharmacists.ObjectivesThe primary objective was to measure time spent on daily activities that comprise the workload of clinical pharmacists providing direct patient care services in an integrated ambulatory care setting.MethodsA prospective, ethnographic, and observational pilot study was conducted at six pharmacist‐integrated multidisciplinary ambulatory care clinics. Clinical pharmacist participants were observed for up to three nonconsecutive clinic workdays. Participant demographics, site characteristics, and self‐reported engagement in direct patient care activities were collected. Workload was evaluated through direct observation of time spent on daily clinical and administrative activities. Time allocated, visit type, number of disease states assessed, and use of clinical support staff were collected for each visit. Results were stratified based on participant engagement in targeted, dual, or comprehensive medication management (CMM) visits, in which one, two, or three or more disease states were assessed, respectively. The primary outcome was analyzed using descriptive statistics.ResultsTen clinical pharmacists were observed for a total of 26 clinic workdays. Of prespecified activities, clinical pharmacist participants spent the most time documenting care activities, spending a mean (SD) of 6.6 (6.7), 8.0 (8.2), and 7.6 (7.7) minutes after targeted, dual, and CMM visits, respectively. There was a large variation in the distribution of prespecified clinical and administrative activities among participants. Years of practice experience, postgraduate training, board certification(s), duration of practice at the site, and site characteristics did not affect the distribution of time spent on activities (P > .05).ConclusionsThis evaluation articulates the daily activities that contribute to the work of ambulatory care clinical pharmacists and may serve as the foundation to perform more comprehensive evaluations of their contributions to patient outcomes.

Role of the Ambulatory Care Clinical Pharmacist in Management of a Refugee Patient Population at a University-Based Refugee Healthcare Clinic.

The International Family Medicine Clinic (IFMC) at University of Virginia Health System serves refugees and special immigrants in Virginia. The IFMC comprises an interprofessional team including a clinical pharmacist. A retrospective chart review of electronic medical records was performed. Adult refugee patients who attended a scheduled clinical pharmacist visit between October 6, 2015 and December 31, 2016 were included. The primary outcome was to characterize interventions made by a clinical pharmacist. Secondary outcomes included describing chronic disease states experienced by certain refugee populations and the clinical impact of pharmacist interventions in diabetes management. 80 refugee patients attended 275 clinical pharmacist visits. On average, visits lasted 30min. Numerous patient interventions were made, including initiation of 68 new medications, discontinuation of 49 medications, and 66 medication dose changes. An average A1c reduction of 1.8% (p < 0.001) was noted. The clinical pharmacist can play an important role in refugee healthcare.

Implementation and barriers to uptake of interactive voice response technology aimed to improve blood pressure control at a large academic medical center

ObjectivesBlood pressure control among patients with hypertension is a widely recognized quality metric, but many large health systems fail to reach targets set by the Healthcare Effectiveness Data and Information Set. We developed an interactive voice response (IVR) system called the “Mobile You Blood Pressure Program” at a large academic medical center and linked it to the health system’s electronic health record (EHR). The goal of the program was to capture home blood pressure readings in the EHR and to alert ambulatory care clinical pharmacists automatically of readings below or above clinical thresholds through direct messaging in the EHR. The goal of this report is to describe implementation of IVR, initial patient participation rates, and pharmacist-identified barriers to patient enrollment. SettingAmbulatory care clinical pharmacist specialists’ practice in 14 clinics in family medicine and internal medicine at Michigan Medicine, an academic health system serving more than 24,000 patients with a diagnosis of hypertension. Practice DescriptionThis study describes implementation and initial patient enrollment in IVR linked to the EHR for home blood pressure monitoring. EvaluationWe tracked the number of hypertensive patients enrolled and IVR call completion rates between September 2017 and February 2018. We also assessed pharmacist-identified barriers to patient enrollment during 2 separate 2-week intervals in January and February 2018. ResultsBetween September 1, 2017, and February 28, 2018, a total of 71 patients were enrolled from 14 clinics. Patients were scheduled for 1-3 IVR calls per week focusing on medication adherence and blood pressure control. A total of 936 IVR phone calls were made, with 488 (52%) calls completed. Access to a validated home blood pressure monitor was the largest pharmacist-identified barrier to patient enrollment. ConclusionsThe IVR Mobile You Blood Pressure Program represents a new application of digital technology within our health system. Pharmacist-identified barriers to patient participation included access to a validated home blood pressure monitor.

Asthma clinics combine pediatric care, pharmacy student education.

The primary care network operated by Nationwide Children’s Hospital in Columbus, Ohio, is giving pharmacy students practical experience in treating children who have asthma and helping to extend pharmacists’ role on ambulatory care teams. Cheryl Maslouski, ambulatory care clinical pharmacist

Creation of the System That Support Ambulatory Care Clinical Pharmacist

Creation of the System That Support Ambulatory Care Clinical Pharmacist

Questions for pharmacist providers in clozapine clinics: Ott and Williams

HOW LONG HAVE YOU BEEN PRACTICING IN YOUR CLINIC? WAS IT YOUR IDEA, OR SOMEONE ELSE'S? Dr. Ott: My clinic has been in operation since May 2009. I was invited by the attending psychiatrists to be a part of the launch, as well as a continuing team member for the clinic with a collaborative practice agreement. My role continues to grow as our research program expands, studies often include me as a co-investigator with similar study responsibilities to our physicians, including research and clinical visits and rating scales.

The IMPROVE study: background and study design. Impact of Managed Pharmaceutical Care on Resource Utilization and Outcomes in Veterans Affairs Medical Centers.

An ongoing study of the impact of ambulatory care clinical pharmacists on patient outcomes at selected Veterans Affairs medical centers (VAMCs) is described. The IMPROVE (Impact of Managed Pharmaceutical Care on Resource Utilization and Outcomes in Veterans Affairs Medical Centers) study will examine the effects of referring patients at high risk for drug-related problems to a pharmacist-managed monitoring program. Nine study sites from diverse geographic locations and small and large urban areas have been selected. Investigators visited each site to evaluate the structure of care, observe pharmacist-patient interactions, and assess the level and documentation of pharmacists' activities. A coordinating center will collect and process patient-specific data from the study sites to identify high-risk patients. It is expected that 500 intervention patients and 500 control patients from the nine VAMCs will complete all portions of the study. Intervention patients will be scheduled for medication assessments by ambulatory care pharmacists and will be monitored by pharmacists for at least 12 months. The coordinating center will track refill histories for intervention patients. Investigators will assess the activities performed by ambulatory care pharmacists to determine predictors of successful patient outcomes. The two groups will be compared with respect to change from baseline in quality of life and satisfaction with health care providers. A cost-benefit analysis will be undertaken to determine the impact of pharmaceutical care relative to total patient care costs. The main outcome results of the IMPROVE study are expected to be available in 1999. The IMPROVE project will be the first study of the impact of ambulatory care clinical pharmacists on patient outcomes.

Salary survey of ambulatory care clinical pharmacists.

To determine salary and selected fringe benefits of members of the Ambulatory Care Practice and Research Network of the American College of Clinical Pharmacy, we developed a self-administered questionnaire that surveyed demographic information, schooling and training, academic appointments, yearly salary (as of February 1, 1995), source of salary, outside income, annual raise, vacation time, financial support for continuing education, and board certification. Ninety-nine surveys were returned (return rate 46%). Respondents were mostly women (58%), their average age was 34 years (range 25-51 yrs), and they had a median of 5 years in the work force. Most respondents (67%) had residency training, whereas only 21% had fellowship experience. Board certification was reported by 46%. The median salary was $53,500 (average $55,861, range $35-90 k), with progression for academic rank. The last salary increase averaged 3.7%. Most (93%) respondents received an average of $1509 for travel. The survey represents a young work force. The salaries vary but show progression for accomplishment.

Medication Noncompliance

Dr. Mason is an assistant professor of clinical pharmacy, Idaho State University College of Pharmacy, Pocatello, Idaho, and ambulatory care clinical pharmacist, VA Medical Center, Boise, Idaho. At the time of the study, Dr. Mason was assistant professor of clinical pharmacy, University of Arkansas for Medical Science, and director of pharmacy education for AHEC South Arkansas.