Provider, pharmacist collaborations increase patient check-ins
A model that incorporated a pharmacist into a patient’s office visit increased the mean number of daily check-ins for new patient appointments and all visit-type appointments, according to a retrospective analysis.
“Implementing this collaborative model between pharmacists and physicians in the outpatient setting has the potential to increase the provider’s availability,” M. Thomas Bateman Jr, PharmD, clinical assistant professor of pharmacy practice and administration at Rutgers’ Ernest Mario School of Pharmacy, told Healio Primary Care. “While our goal was to use this availability for providers to meet with more patients, other practices might use this increased availability to spend more time with complex patients or procedures, to complete administrative responsibilities, or other tasks specific to their practice.”
The model, which was described in a report that was published in The American Journal of Managed Care, included the following:
- Registration staff checks in the patient.
- A medical assistant records vital signs and conducts screening questionnaires.
- A clinical pharmacist collects details of the patient’s current illness, medical and psychiatric histories and conducts medication reconciliation during a 15-minute consultation.
- Via EHRs or face to face, the pharmacist offers the primary care provider an assessment and recommended plan.
- The provider performs a 15-minute patient exam.
- A nurse distributes discharge paperwork and instructions.
The model was implemented on 1 day of the week when the provider and pharmacist were simultaneously at a location that researchers dubbed “site A.” The model was later expanded so that the pharmacist worked with an additional medical provider at location dubbed “site B” on 3 days of the week. At both sites, the provider was a nurse practitioner; site As practiced family medicine and site Bs practiced adult internal medicine.
According to the researchers, at site A, the mean number of new patients who checked in for appointments increased from 1.42 to 4.1 daily (P < .01). The mean number of new patients whose appointments were canceled at that site increased from 0.33 to 3.57 daily (P < .01). Statistically significant increases were observed in the mean number of check-ins for all visit types, with a change in the daily average from 11.9 to 15.67 (P < .01), and the mean number of cancellations for all visit types increased from 5 to 9.71 daily (P < .01).
At site B, the researchers reported statistically significant decreases in the mean number of new patient appointments checked in and canceled, from 2.89 to 1.83 daily (P < .01) and 2.61 to 1.37 daily (P < .01), respectively. All other check-ins and cancellations remained relatively stable after the model’s implementation and no other changes were statistically significant.
The researchers reported throughout the model’s implementation at site A that there was an average of 2.38 new patients checked in daily for appointments with the pharmacist, which comprised 39.34% of the total checked-in visits. At site B, there was an average of 1.42 new patients checked in daily for appointments with the pharmacist, which comprised 40.11% of the total checked-in visits.
“Scheduling was the largest barrier encountered while implementing this collaborative pharmacist/provider model,” Bateman said. “Our practice’s scheduling system never completely synced the pharmacist and provider’s schedules as intended, which led to frequent instances of new patients being scheduled for the provider and the patient being omitted from the pharmacist’s schedule.”
He attributed the scheduling problem to the scheduling tool’s inefficiencies and staff error.
“This barrier can be overcome by having a properly functioning scheduling system, by establishing clearly defined days for which the pharmacist and provider will be available for collaborative new patient appointments and by having appropriate staff education and training regarding the scheduling of new patients,” Bateman continued.
Patients responded positively to the model, especially when they learned the pharmacist was adding to their care and not replacing the provider, according to Bateman.
“One key to success is to have the pharmacist enter the room, introduce themselves, welcome the patient to the office for their first visit, explain that by seeing a clinical pharmacist in office today their choice in retail pharmacy will not be affected and ensure that the patient understands they will still be seen by their provider following this brief visit with the pharmacist,” he said.
The model closely aligns with the Veterans Health Administration recommendation that one clinical pharmacy specialist be incorporated into the interdisciplinary team for every three groups of veterans that are assigned to care from a provider to improve medication management in the primary care setting, study co-author Caitlin McCarthy, PharmD, clinical assistant professor of pharmacy practice and administration at Rutgers’ Ernest Mario School of Pharmacy, told Healio Primary Care.
Perspective
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The model described in the article reinforces something we have been working toward in primary care for many years now — team-based primary care. The idea is that a team of professionals can care for a patient together better than any one professional can alone.
The authors describe the model of a shared office visit. In their report they partner in-person pharmacist visits with the primary care physician visit, but a number of other combinations exist using medical assistants, registered nurses, diabetes educators, community health workers, pharmacists, social workers, nutritionists and others.
Overall, the concept of team-based care, having a family physician-led team partner with a patient to help them achieve their best outcomes based on what the patient values in life is powerful. It empowers each member of the team to work to the top of their license and deliver the patient the support structure they need to thrive. As most family physician offices move toward using the Patient-Centered Medical Home approach, they have adopted similar strategies using a wide range of team members.
At both Temple Family Medicine and General Internal Medicine, we partner with our medical assistants to deliver advanced diabetes care during our routine office visits, including using telemedicine to get virtual ophthalmology consults on diabetic retinal exams done in the office during the patient’s visit with me. It saves the patient time, helps me manage their care more efficiently during their visit and most importantly, helps the patient access the services needed to remain well.
In a previous job, I tried to partner my family medicine practice with pharmacists to optimize care by improving medication reconciliation at the time of the office visit. Truthfully, it was a real challenge and ultimately wasn’t sustainable despite showing some value to the practice metrics. Patients use a wide range of pharmacies and frequently change due to a host of reasons. This makes partnering with their personal pharmacist challenging. We tried to work around that situation by hiring a pharmacist for the practice, but it was cost-prohibitive to sustain. As we tried to expand our team to add other in-person services, we found that patients were frustrated by the extension of the office visit. They felt as though they were being given less face time with their physician, and that was something they valued highly.
The idea of thinking outside the traditional face-to-face visit time as the only place to engage patients is outdated. At Temple, we have been exploring using telemedicine to engage patients just before their in-person visit to address some routine screening items such as medication reconciliation, depression screening and identification of barriers to care such as social determinants of health. Practices will need to adapt models like the one shared in the article to best fit the needs and abilities of their practice.
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This is a really interesting model. Having access to a clinical pharmacist and working closely with them would provide a lot of benefits, even outside of what this specific study looked at, as far as being able to consult on the most complex patients, including those who are on multiple medications or who have complex allergies. But specifically, with this model, the biggest benefit is the accuracy of reconciling new patient medications and getting a detailed history of their medication when we first see them.
One question that I had upon reading this study was, from an office efficiency standpoint, how did they implement the model? The idea of splitting the typical 30-minute visit for a new patient into two 15-minute sessions, which frees up the physician to be able to see an additional patient, is really a clever way for it to be more likely practical for an office setting. From a feasibility standpoint, we would need to look to detail the potential costs vs. the efficiency gains. But overall, it could be a great benefit to both the entire care team as well as the patient.
These types of creative solutions and ways of maximizing everyone’s skillset within the health care team are important and something that, historically, have not received enough attention. This is where medicine is heading. Having the ability to consult with people who are experts in their specific areas to provide maximum patient benefit is a fantastic way of approaching patient care in the primary care setting..
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