Bigger role for pharmacists can help primary care docs

Pharmacists can be a useful and cost-effective addition to primary care practices, IHPI member Hae Mi Choe, PharmD, said here American College of Physicians annual meeting.

Pharmacists "can assess and address barriers to medication adherence," said Choe, who is director of pharmacy innovations and partnerships at the University of Michigan Medical Group in Ann Arbor. Medication non-adherence is the largest avoidable cost in the health system, and drug-related morbidity costs the nation an estimated $290 billion annually, she said.

"It's amazing what patients tell us that they don't want to tell you," she said to the physicians in the audience. "What's preventing Mrs. Jones from taking her medications? Did she fall into the [Medicare] 'donut hole' in the middle of the year, so now her medication costs $200 instead of $20? [Finding out] what the barrier is where Mrs. Jones is not adhering to therapy is one of the key areas where we can provide value." Pharmacists at Choe's institution also are trained in motivational interviewing, so they can learn why a patient is being non-adherent and recommend strategies to overcome it.

Important Conversations

In addition to educating patients on how a drug works, pharmacists can also discuss why a patient needs to take a particular medication, said Choe. For example, "Mrs. Jones says, 'I don't want to take that medication because I read it's going to ruin my kidney' ... She doesn't understand if she doesn't take medication to treat her hypertension, to treat her diabetes, her kidney could get damaged through that. So trying to make that association ... is equally as important."

Although pharmacists aren't trained to do complete physicals, they can do limited parts of a physical assessment such as blood pressure monitoring or a diabetic foot exam, as well as order lab tests and medical equipment such as a glucometer, she said. "We also facilitate referrals to [specialists such as] dietitians, ophthalmologists, and cardiologists."

At the University of Michigan Medical Group, 11 embedded pharmacists -- worth 5.2 clinical full-time equivalents -- and two PGY-2 ambulatory care specialty residents are providing care across 14 primary care clinics, she explained. "We have pharmacists [at each clinic] 1-3 days a week, depending on the size of the clinic." The pharmacists have full access to patients' electronic health records (EHR) "so we can put our notes in there and doctors can see what we did," said Choe. There is also a patient "dashboard" that pharmacists can look at to "drill down" on patients who are not achieving their diabetes or hypertension goals, for example.

The medical group's pharmacists also have special credentialing privileges allowing them to prescribe medications. "They have a broad scope of practice as long as there is delegation by a physician ... They can evaluate and optimize a patient's therapeutic regimen" and provide medication management to achieve therapeutic goals.

The pharmacists' disease management services are focused on diabetes, hypertension, and hyperlipidemia, she explained. "These [conditions] probably cut through all of our payer metrics, so we knew that would be a good place to start our program," she said.

But they needed to build up a panel of patients because "we don't want to have pharmacists waiting for Mrs. Jones to show up at their door. So we do a lot of proactive outreach," looking through the medical group's disease registries to find patients who aren't taking their medications, said Choe. Initially, the pharmacists schedule patients for a 30-minute in-person or phone visit to get a good feel for their issues, with an in-person visit being the first choice.