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Establishing Pharmacotherapy Services in a Primary Care Clinic

Dec 26, 2010

Melissa Max, Pharm.D., far right, counsels a patient while a Harding University pharmacy student observes.

How did you get involved with the university’s partnership with ARcare?
It’s part of my responsibilities as a faculty member. The partnership was already in place when I joined the Harding staff in October of 2008. The idea was to put a faculty member in the clinic, and I started by going to the clinic one day a week to conduct patient reviews. It all began very simply. I developed a rapport with Bonnie Dillard, APN, the nurse practitioner involved with the clinic, and she was open to many of the things I suggested.  If I saw anything potentially problematic, like drug interactions or dosing issues, I wrote my concerns down and brought them to her. I didn’t even start with charting in an electronic medical record.

Why did you decide to focus on cardiovascular care?
We wanted to reach the greatest number of patients possible. Based on the number of patients who weren’t at goal for blood pressure, lipid management, and diabetes management, we determined the need for a cardiovascular focus.

What kind of criteria did you develop for providing care?
We wanted to start with high-risk patients, so they had to have at least two chronic disease states and be taking at least five medications. Most of them were taking between seven and nine medications. The program stresses evidence-based medicine, and I use evidence-based guidelines for any recommendations I make. We chose LDL cholesterol and blood pressure for our outcome measures.

What are the nuts and bolts of the program?
The program focuses on identifying potential adverse drug events and addressing concerns early, before a problem develops. Once we identify the patients at risk, we send them a letter of introduction explaining that we want to offer them pharmacy services. We follow established standards of care. For example, if it is necessary to add a medication for blood pressure or a statin for lipids, we follow up to make sure the patient got the appropriate lab work.

How did you develop a rapport with the ARcare staff?
I focused on collaboration, and how my work is not a challenge to theirs but an enhancement. For instance, Bonnie was seeing 30 patients a day. By concentrating on cardiovascular care and seeing fewer patients, I could focus and use my training. It takes a secure person to let someone come in and look over his or her shoulder, and when we started seeing improvements in patients, I explained how those markers show the value of working together. Bonnie’s support was important. I wouldn’t have been able to do any of this without getting her buy-in.

Do you have any advice for pharmacists who would like to partner with clinics?
If you are a faculty member or staff pharmacist, get the support of your leadership. Try to partner with a clinic that is focused on patient safety. Since health care is moving toward pay-for-performance, more clinics will be concentrating on safety and outcomes. Also, be strong clinically. Stay up-to-date on treatment guidelines, so you can bring value to the patients. And finally, remember to be tactful. As pharmacists, we are very focused on the drugs. But it’s important to also work on the total patient presentation. If you are working with other providers who know their patients very well, they can help you by giving you information and background before you meet with a patient. Be ready to put the time in to develop relationships with both patients and providers.

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