Medical School

Emerging Pharmacy Practice Models in Healthcare Delivery

Pharmacy Symposium 2016
“We are clearly in a transitional state within healthcare,” said George MacKinnon, PhD, RPH, founding dean of the Medical College of Wisconsin Pharmacy School, “We also realize as an emerging School of Pharmacy, we want to be at the table helping to solve the problem of health care delivery and the majority of you that have been involved with healthcare realize it’s a team approach. It’s a team game.”

This team approach to healthcare was the topic of discussion at MCW’s first annual Pharmacy School Symposium, titled Emerging Pharmacy Practice Models in Healthcare Delivery. Four pharmacists, Daniel Buffington, PharmD, MBA, Diane K. Reist, PharmD, RPh, Gary Matzke, PharmD, and Bill Lee, MA, RPh were invited to speak about their experiences implementing innovative care models. The topics discussed included the pharmacist role within the interdisciplinary care team to improve patient outcomes, new models of care that include collaborative practice and addressing financial concerns regarding these models of care. The symposium attracted a wide audience consisting of pharmacists, pharmacy residents, physicians, administrators and community leaders.

Dr. Buffington, President and CEO of Clinical Pharmacology Services, Inc.,  was the first speaker of the morning, talking about his involvement with an Interdisciplinary Clinical Pharmacology Practice Model implemented at his company in collaboration with the University of South Florida College of Medicine. Interdisciplinary care is characterized by a collaboration between multiple practitioners, including pharmacists, physicians, nurses, physical and occupational therapists and other health care providers depending on the patients needs.

Through his development of the program, Dr. Buffington realized “The majority of training curriculum for pharmacists had reached a point that it was training people to be employees and not practitioners.” Graduating PharmD students are being prepared for a much different role than physicians graduating from medical school.

All the speakers recognized there was a lack of knowledge among healthcare providers and payers concerning the role that a pharmacist can play as a member of an interdisciplinary care team. Terms such as Medication Therapy Management (MTM) and Medication Reconciliation or “Med Rec” are often overused and misunderstood.

Dr. Buffington explained today’s pharmacists need to have skill sets and demonstrate the ability for physical assessment and chronic care monitoring, “We have some gaps in terms of chronology of training and skill sets. There’s a lot of messaging that pharmacy has to do with, surrounding MTM and I want to share with you today the ways and strategies we’ve tried to work with that.”

MTM is a global service description, covering everything a pharmacist does outside of dispensing the medication for the patient, which is very diverse. MTM services can differ in intensity and also differ between providers. Nursing homes, the Intensive Care Unit, Medical Teams, Managed Care/Call Centers, and Community Pharmacies all offer unique services.

“Med Rec is probably more over used and less understood than MTM,” said Diane Reist, PharmD, RPh, “Medication reconciliation is not just getting a list of the patient’s medications.” Dr. Reist is a Clinical Pharmacy Specialist in Transitional Care at the University of Iowa Hospitals and Clinics. She served on an integrated disciplinary care team as part of a research project funded by a $12.5 million Centers for Medicare and Medicaid Services (CMS) and Center for Medicare and Medicaid Innovations (CMMI) grant focusing on providing transitional care to rural Iowans.

Dr. Reist explained the process of medication reconciliation comprises of at least five steps: developing a list of current medications and medications to be prescribed, comparing the medications on the two lists, making clinical decisions based on the comparison and communicating the new list to the appropriate caregivers and the patient.

In order to implement MTM and medication reconciliation effectively, improved medical records and data management systems need to be shared with the full team of practitioners to improve patient outcomes. “How can you make a decision about what the best therapy is for a patient if you don’t know what’s been tried before and what’s happened before? And if the patient was willing and able to obtain that medication and take it?” Dr. Reist questioned.

The National Transitions of Care Coalition has developed some common essential data elements that should be included in all medication reconciliation forms and systems nationwide. These include patient demographics, primary care physician, prescription medications, other over the counter medications, herbal remedies, dietary supplements and time-limited medications and validation of accuracy.

Gary Matzke, PharmD and William Lee, MA, RPh, collaborated on the Improving Health of At-risk Rural Patients (IHARP) Program with Carillion Clinic in rural southwest Virginia. They also saw the need to share comprehensive patient records among health care providers. “Through a training program for our network of community pharmacists, we provided them full electronic access to the Epic electronic health record for our patients. And I’ve talked to some groups of pharmacists in the past, that’s what we’ve always said we don’t have,” said Dr. Matzke,. 

The IHARP program was a $4.1 million CMS funded grant project that focused on improving care of at risk patients in rural areas who take at least four medications and have two or more chronic conditions. In order to enhance medication-related health outcomes, seven pharmacists were integrated within the healthcare team at 21 primary care clinics.

“Our goal was to transform hospital pharmacy practice, primary care pharmacy practice, community pharmacy practice and link all those things together,” said Dr. Matzke

Lee and Dr. Matzke experienced successes within the IHARP program. The data from the project showed a healthcare cost avoidance of over 3 million dollars associated with the resolution of medication related problems.

“I think the cost savings and the prevention of unnecessary re-admissions, admissions and ER visits really provides the basis for the expansion of the pharmacist into the medical home environment,” said Lee

Dr. Reist and Dr. Buffington reported successes in their practice models as well. “We were really focusing on trying to reduce re-admissions but we actually reduced the length of stay and reduced the cost of care while the patient was still in the hospital, so that was kind of a bonus that we were very excited about,” said Dr. Reist

Even with positive outcomes for the patients involved, all of the pharmacists encountered challenges. One of the main issues to implementing innovative practice models is reimbursement for pharmacists’ services. Traditionally, pharmacists would get reimbursed from a mark-up on the product, the medication, but not directly for their cognitive services. That model is changing, but is still in need of reform. Dr. Buffington explained that a legislative change is required to include pharmacists in the Part B Medicare Eligible provider status.

“Provider status is a pathway to assure pharmacists capacity to be reimbursed by Medicare, who happens to be the single largest healthcare payer in the country,” said Dr. Buffington.

In addition, there were issues of non-compliance among patients, especially in the rural areas. “Non-compliance was a huge part of the problem in this area of the country (rural Southwest Virginia) and one of the biggest reasons, for about 35%, was patients couldn’t afford their meds,” said Dr. Matzke. Over 65% of the patients involved in the IHARP program had Medicare Part D, but some still could not afford the required co-pays. Carillion Clinic had to dramatically increase their medical assistance program support staff to be able to get the medications for these patients.

Regardless of the challenges ahead, the consensus of the morning was the future of pharmacy lies in innovative practice models, with the pharmacist involved as a direct patient care provider. “In fact all of what we look at as advanced or alternate practice models: accountable care organizations, patient centered medical homes and many new models that will be announced in the next year or two really require the skills that a pharmacist brings as a specialist over medication management and clinical pharmacology to the practice setting,” said Dr. Buffington.   

The MCW Pharmacy School hopes to contribute to the future of pharmacy practice and innovative care by graduating pharmacists that have the skills and expertise to practice at the top of their license. “Our pharmacy school curriculum aims to prepare the next generation of pharmacists through an innovative curriculum that will prepare graduates to be practice ready and team ready pharmacists through our doctor of pharmacy program,“ explained John Raymond, Sr., MD, President and CEO of MCW. The MCW Pharmacy School will matriculate its first class of doctor of pharmacy students in 2017.

What Excites You About the New MCW Pharmacy School?

The MCW Pharmacy School hosted its first annual Pharmacy Symposium in June 2016. We spoke with some of our speakers and attendees and asked, "What excites you about the new MCW Pharmacy School" Hear what they had to say...