ASHP InterSections ASHP InterSections

From left, PMG Pediatric Pharmacy Specialist Kari Bishop, Pharm.D., discusses improvements in the EHR system related to adult and pediatric heparin infusions with Pharmacy Anticoagulation Specialist Linda R. Kelly, Pharm.D., PhC, CACP.

IF THEY TAKE A MOMENT to look, patients who fill prescriptions after visiting one of the ambulatory care clinics in Albuquerque’s Presbyterian Medical Group (PMG) will see that the name on the medication bottle belongs to a pharmacist.

“When I write a prescription, it’s not checked or approved by a physician because I’m recognized as a healthcare provider by my state and my health system,” said Robert Rangel, Pharm.D., BCPS, PhC, director of pharmacist clinicians and anticoagulation services with PMG, noting that state laws dictate the limits of collaborative practice.

“That changes the perception among patients and colleagues about pharmacists’ abilities to care for patients, and it means that we’re recognized as advanced practitioners.”

Independent Prescribing

Collaborative practice agreements (CPAs) under which pharmacists write prescriptions are no longer isolated experiments. But most require a physician or nurse practitioner to review and sign off on every order. That’s where PMG breaks new ground: Any of the 14 clinical pharmacists practicing in ambulatory care can independently prescribe any medication used in the scope of a primary care visit as well as manage a spectrum of common chronic disease states. Right now, that list includes diabetes, elevated lipid levels and cardiovascular disease, hypertension, asthma and COPD, and even psychiatric and thyroid conditions.

Robert Rangel, Pharm.D., BCPS, Ph.C.

The current CPA emerged from an earlier version at PMG’s anti-coagulation clinic, where pharmacists had wide latitude to adjust warfarin regimens and counsel patients. Improved clinical outcomes, such as a reduction in thromboembolic events, opened the door to the current, far more expansive CPA. This new practice agreement covers 15 primary care clinics, two cardiology clinics in greater Albuquerque, and one rural clinic with plans to expand to other parts of New Mexico. All of the more than 100 PMG physicians participate in the agreement.

“We’ve seen again and again that when you put a pharmacist in a clinic, even if they’re doing something small to begin with, sooner or later they’ll be asked to do more,” said Dr. Rangel.

The effectiveness of PMG’s ambulatory care practice reveals what pharmacists could do for patients if they were granted healthcare provider status under Medicare Part B, according to Joseph M. Hill, ASHP director of federal legislative affairs.

“This story is so great because it reinforces our message that pharmacist-provided care expands patient access and is cost effective,” Hill said, noting that the collaborative nature of PMG’s CPA mirrors the evolution of new care delivery models.

Charting Improvements in Fundamental Quality Measures

Three years ago, PMG restructured its budget so that the medical group, not the pharmacy department, paid the salaries of the ambulatory care pharmacists. A year later, the chain of command shifted; now, PMG ambulatory care pharmacists report to the director of the medical group rather the pharmacy director. The impact was huge, recalled Dr. Rangel.

“We’d been working and living in the medical group’s clinic but following a different management hierarchy. We didn’t feel like we were really a part of the medical group, and they felt the same way about us. We were still outsiders,” said Dr. Rangel.

The administrative shake-up solidified the unit and led to a collegial, supportive environment. “It really sealed the deal,” said Dr. Rangel.

Pharmacists at PMG clinics help patients manage a variety of chronic conditions, including diabetes.

The CPA’s success resulted from a lot more than just managerial and financial reshuffling. Once clinical pharmacists entered the scene, across-the-board improvements in fundamental quality measures followed, such as tighter A1c control for diabetic patients and improved blood pressure and lipid levels for cardiovascular patients. “We see better numbers for all three of them when pharmacist clinicians work in ambulatory care,” said Dr. Rangel.

Though their colleagues are accustomed to the presence of pharmacists in the outpatient clinics, patients are still getting used to the idea. Many express surprise when a pharmacist walks into the exam room to chat. “The majority of patients still see pharmacists as just drug dispensers,” said Dr. Rangel. “We still have a long way to go to change that perception. However, we are getting the word out, and it is making a difference.”

Expanding Scopes of Practice for Hospital Pharmacists

Linda Kelly, Pharm.D., CACP, PhC, a pharmacy anticoagulation specialist, anticipates that a CPA will emerge on the inpatient side at PMG. “I practice to the limit of my professional license in the outpatient clinics because of the CPA, but we haven’t yet defined a comparable role for clinician pharmacists on the inpatient side,” she said.

Setting comparable scopes of practice for clinical pharmacists throughout the organization will blur the lines between inpatient and outpatient care and create a more patient-centered care model, Dr. Kelly asserts. It just makes sense, she explained, that patients receive the same level of care from pharmacists wherever they practice in the organization.

“I already conduct medication management and offer prescribing recommendations for inpatients, but I can’t write orders independently,” she said. “Expanding our role to include prescribing is a logical next step.”

Dr. Rangel cautions that pharmacists tread carefully – but confidently – when seeking to expand their roles within a health system. “We were fortunate because we had already established relationships and a solid track record in the anti-coagulation clinic,” he said. “If we had walked into a clinic and said, ‘We’re here to manage your patients with chronic diseases and write prescriptions,’ we’d have hit forceful push back.”

“It was a slow process. We used our experience in the anticoagulation clinic as our introduction, and that made the transition much easier.”

Dr. Rangel suggests starting small, finding a niche, and letting the momentum build naturally.

“If I were starting from scratch, I’d ask the medical group what they need and how we can help… maybe managing diabetic or hypertensive patients,” he said. “Often members of the care team welcome that kind of offer. And as trust builds, demand for your services will almost certainly grow.”

–By Steve Frandzel