Gone are the days when health-system pharmacists just verified doctors’ medication orders and correctly dispensed them from the confines of the hospital basement. As more physicians enter specialty practice, HSPs are stepping in as “physician extenders” who develop optimal pharmacotherapy treatment plans based on the practitioner’s medication goals. This new role gives HSPs more responsibility to improve patient care and outcomes, while also making evidence-based pharmacotherapy more cost-effective.
It also means that continuing education planners have to be prepared to meet today’s HSPs’ constantly changing informational gaps in ways that go beyond knowledge-based symposia at pharmacy society meetings. Today’s HSPs need education that will improve their competency, performance, and lifelong learning.
In the Emergency Department
The Department of Veterans Affairs has long led the advancement of ambulatory care pharmacists, demonstrating their significant impact in improving outcomes for an array of disease states. HSPs’ move into the emergency departments of hospitals is informed by the VA experience, as well as several reports—including one by the Institute of Medicine—highlighting the epidemic of adverse drug events in the ED and signaling that these incidents can be prevented by instituting appropriate medication-management programs.
Physicians and HSPs have long collaborated in ambulatory care, but today’s HSP now provides on-the-spot clinical services in the ED and beyond. These include medication reconciliation, clinical consultation and education, reviewing medication orders for appropriateness prior to administration, discharge medication counseling, assisting medical staff in emergent resuscitative efforts, and coordinating patient care transfers to inpatient clinical pharmacists.
On the Care Team of Chronic Conditions
It’s widely known that HSPs collaborate with the healthcare team to design, implement, and manage pharmacotherapeutic regimens of patients with chronic disease. Less widely known is that they also regularly involve the chronic patient in all healthcare decisions and develop long-term compassionate provider-patient relationships. HSPs know it’s critical to work with patients to meet their predefined goals of care, reduce medication misadventures, and improve medication compliance.
Bradley A. Boucher, PharmD, FCCP, FCCM, with the University of Tennessee Health Science Center, understands that some hold outdated ideas about the HSP’s role. He says, “HSPs interact directly or impact indirectly far more patients than traditionally expected, particularly with acute or chronic patients who often require more vigilant screening, monitoring, and adjustment.”
Data from a recent survey conducted by Pharmacy Learning Network, a continuing education platform dedicated to the specific educational needs of HSPs, supports this observation. When asked “How many patients requiring inpatient glucose management do you impact on a monthly basis?” respondents were conservatively estimated to have had an impact on almost 8,000 patients per month.
A study conducted at a county hospital’s outpatient clinic in El Paso, Texas, evaluated pharmacist-managed diabetes mellitus. Under a collaborative drug therapy agreement, patients were referred to a clinical pharmacist who provided diabetes education, managed patients’ medications, ordered laboratory tests, managed patient visits, and referred patients to other healthcare providers when necessary. Among the pharmacist-
managed patients, there was an average 0.7 percent reduction in HbA1c and a 26.4 mg/dL average reduction in blood glucose.
In Transition to Outpatient Care/Discharge
Perhaps one of the most critical and complicated roles HSPs play is ensuring a safe transition from the hospital to the outpatient setting. HSPs review the inpatient pharmacotherapy plan and help the medical team determine an appropriate strategy to ensure post-discharge continuation of care. They also provide one-on-one discharge medication counseling with patients and their families to review new medications and changes to existing medications.
Discharge planning is an intricate, often-overlooked area full of potential pitfalls. It also is one of HSPs’ most pressing educational gaps: A recent survey reported only 17.4 percent of hospitals provide discharge counseling to patients on complex or high-risk medication regimens.
Educational planners would provide a service by focusing on the varying levels of discharge assessment and accompanying interventional practices HSPs must navigate daily, such as changing IV medications such as antibiotics to orally available alternatives, ensuring the patient is discharged on optimal evidence-based pharmacotherapy, and, most importantly, reviewing the patient’s pre-admission medications to prevent duplication of therapy, drug interactions, adverse reactions, or improper drug selection.
At the Hub of Quality
The issue of cost must, eventually, rear its head in any discussion of healthcare, and HSPs are often in the forefront of the perceived battle between superior healthcare and cost-effectiveness. However, as Boucher puts it, “Pharmacists are uniquely positioned to advance the two central healthcare goals of improving quality care and reducing costs.” He goes on, “Extensive documentation exists showing improved outcomes and reductions in overall costs within a variety of practice settings (e.g., intensive care units, anticoagulation clinics, etc.) when clinical pharmacists serve in these capacities.” Boucher was addressing the new CMS Hospital Value–based Purchasing Program, but similar results have been found in myriad CMS, Joint Commission, and other quality initiatives.
As external catalysts, these initiatives have only begun to reveal a tremendous need for quality initiative tools and resources for clinical pharmacists in the inpatient and transitional setting. Commercial supporters have already begun to align funding goals in this direction. QI continuing professional education is the new performance-improvement continuing medical education, but because health systems are closed in nature, it’s more likely we’ll see an assessment of QI CPE’s effectiveness than has been the case with PI-CME to date.
On P&T Committees
Because pharmacists are pharmacokinetics and pharmacoeconomics experts, they play an active role in formulary management and drug safety policy, and are integral members of a healthcare system’s pharmacy and therapeutics committee.
The HSP role on the P&T committee includes performing evaluations on the clinical, economic, and logistical data of medications the system is considering adding or deleting from the formulary, reporting identified adverse drug events, serving as advisers on policies pertaining to the safe use of medications, and reviewing the appropriateness of requests for patient-specific pharmacotherapy that fall outside the facility’s
The educational needs of HSPs in this role are much more like those you might see tackled in a typical managed-care activity, where the clinical benefits of therapy are balanced by the economic analysis of treatment.
The Pharmacy Care Model
The American Society of Health-System Pharmacists conducted a pharmacy practice model summit in Dallas in November 2010. This landmark summit produced several key recommendations that could throw open the basement doors and formally present HSPs as patient care practitioners. These recommendations include ensuring that all patients have access to care provided by a pharmacist; holding HSPs responsible and accountable for outcomes associated with medication therapy; ensuring that pharmacists who provide drug therapy are appropriately board-certified within their specialty (e.g., pharmacotherapy, oncology, or psychiatry); and ensuring that sufficient health-system medication-management–related resources are dedicated to HSPs.
The pharmacy care model proposed at the ASHP summit is the future of hospital-system pharmacy, paving the way for HSPs to become direct medication-care providers, further improve patient outcomes, and manage healthcare costs. For this to occur, HSPs must be provided the necessary tools to succeed in their expanding role.
Innovative educational designs targeted specifically to HSPs—focused on those issues that arise daily as these healthcare professionals balance maintaining up-to-date pharmacotherapy knowledge; patient assessment, monitoring, and education; and fiscal responsibility in pharmacotherapeutics—are not only necessary, but invaluable. The incentive of concentrating education in this area has the potential to go beyond HSPs; because of the reach and impact of these professionals, the benefit that is immediately relayed to individual patients may eventually translate into considerable gains in societal health outcomes.
Randolph V. Fugit, PharmD, BCPS, is an internal medicine clinical specialist at the Denver Veterans Affairs Medical Center and Clinical Assistant Professor of Clinical Pharmacy Practice at the University of Colorado Health Sciences Center. He serves as advisory chair for Pharmacy Learning Network.
Stephen M. Chavez, BBA, is the senior director of educational services for Pharmacy Learning Network, a North American Center for Continuing Medical Education Initiative.
Kristin Ciszeski is the Pharmacy Learning Network’s senior director of educational programming.
Pharmacy Learning Network provides accredited CPE education targeted specifically to the needs of HSPs. For more information, visit PharmacyLearningNetwork.com.
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