Pharmacists in Primary Care: Lessons Learned from Integrated Behavioral Health

Today’s innovative healthcare environment encourages healthcare providers to experiment with different integration strategies for pharmacists because they have much to offer toward improving one of the most common treatments in primary care—prescribing medications. Increasingly, pharmacists are providing services in primary care within the Patient-Centered Medical Home (PCMH) model. But although integrated behavioral healthcare (IBH) has been touted as critical for reaching PCMH goals, the same endorsement has not been made for other health specialties, including pharmacy.(1)

Methods for pharmacist integration within the PCMH can be developed by applying to current pharmacy practice models what we’ve learned from the IBH literature over the last 35 years.(2-4) This article reviews various facets of program development and sustainment, challenges, and potential solutions for primary care practice managers and other hospital or clinic leaders.

Primary Care Today

The PCMH model was forged through the collaboration of several professional organizations, culminating in 2007 as a primary care model of healthcare reform. It remains an integral component of the Patient Protection and Affordable Care Act (2010) and is supported by both the National Committee for Quality Assurance (NCQA) and the Agency for Healthcare Research and Quality. The aims of the PCMH are to boost quality, accessibility, and efficiency of primary care by increasing availability of services while managing costs.(5,6)

Clinics often are organized around small multidisciplinary teams that conduct proactive management of the patient population in order to meet the aims of the PCMH model.(5,6) Among the various disciplines that could add value to the PCMH, it is difficult to know which specialties might be most beneficial. Given that IBH is required for PCMH recognition by NCQA, medical practice managers may be inclined to launch an IBH program first, and may not fully appreciate the benefits of integrating other health specialties, particularly pharmacists. Many practice managers also may be deterred by the tenuous process of hiring, training, spending money, and allocating space for additional integrated clinicians, especially when these clinicians undoubtedly will prompt changes to existing operations within the practice.

Benefits of Integrating Clinical Pharmacists into the Patient-Centered Medical Home

Trained as drug therapy experts, pharmacists are poised to assume a role within the PCMH, sharing responsibility for safe, evidence-based, and cost-effective medication use.(7) As early as the 1990s, pilot programs explored the use of pharmacists in primary care settings for these purposes. Two such pilot programs, conducted at Group Health Cooperative of Puget Sound, focused on integrating pharmacists into multidisciplinary teams.(8,9) Although the pharmacist team member was well received by patients and fellow team members, and clinical and cost outcomes improved, the programs failed to thrive. Similar to the fate of some ill-prepared IBH pilot sites,(3) these two pharmacy programs did not evolve to become a sustainable and standard practice model for pharmacists.

Since that time, the literature has increasingly addressed the use of pharmacists within the PCMH, particularly the rationale behind such integration.(10-12) Studies have examined collaborative medication management between pharmacists and primary care providers (PCPs) for chronic conditions such as diabetes, dyslipidemia, and hypertension.(13) Overall, collaborative pharmacy services have been associated with improved clinical outcomes, positive return on investment (ROI), and reduced healthcare expenditures related to hospitalizations, physician time, and prescription costs.(13-15) Collaborative pharmacist management of psychiatric comorbid conditions also has been studied within primary care. Here pharmacists trained as psychiatric specialists work directly with patients and PCPs to manage psychotropic regimens and address challenges associated with prescribing within primary care settings (e.g., adverse effects, drug interactions, nonadherence, suboptimal dosing and monitoring, and polypharmacy).(16,17) Such collaborative services also have demonstrated positive results, including increased adherence rates, patient medication knowledge, and cost savings; positive ROI; and decreased adverse effects and polypharmacy.(16,17)

Challenges of Integrating Clinical Pharmacists into the Patient-Centered Medical Home

Although the evidence indicates that pharmacists add value within the PCMH, very few resources exist to assist practice managers to develop effective workflow models when pharmacists and other specialties are embedded in the PCMH. Managers may benefit from tools to help prevent a failed initiative, because poor integration can be fiscally costly and have a negative effect on both the patient experience and the medical staff’s morale. Many additional challenges are associated with integration. Table 1 describes some of these challenges and offers suggestions for overcoming each.

Workflow and Logistics

Successful workflow models must complement, not impede, existing clinic processes. Concern over complicating or slowing workflow is one barrier to pharmacist integration, and should, therefore, be discussed prior to integration.(18) Having the pharmacist shadow other team members can reveal solutions for incorporating pharmacists into the existing workflow. Ideally, integration will result in increasing workflow efficiency over time; enhanced efficiencies may include pharmacists providing patient education, and conducting or documenting medication histories so IBH providers and PCPs spend less time on these activities. Having the pharmacist answer questions about medications, monitor side effects, support medication adherence, and perform follow-up also can optimize IBH provider and PCP time and allow the patient access to the appropriate expertise.

Underutilization or Overutilization

Under- and overutilization both lead to poor cost efficiency. A goal of integration is for the PCMH to include pharmacists in its menu of services in a way that adds value via increased revenue, decreased or offset costs, prevention of high-risk patient incidents, or improved clinical outcomes, including patient and provider satisfaction and treatment adherence. However, none of these benefits can be realized without processes that ensure pharmacists are used frequently and appropriately. A recent study cited program underutilization and poor standardization in treatment delivery models as the common challenges across 56 federally funded IBH integration programs.(3) Logic would predict that the same challenges would occur across integrated pharmacist programs without informed implementation practices. Proactive management may help both IBH and integrated pharmacy programs avert such problems. One key is creating multiple conduits between the pharmacist, other team members, and the patient population. Explicit clinical pathways and other organized ways of ensuring appropriate resource utilization can keep IBH and pharmacy programs delivering services that move the PCMH practice toward its program goals and fulfillment of the Quadruple Aim.(19)

Identification of Qualified Candidates for Clinical Pharmacist Positions

Hiring and training the right staff members are important prerequisites to successful integration and effective workflow. Certain personal attributes may make or break the integration process.(18) Pharmacists who are flexible, self-directed, and functional within teams, and who possess solid knowledge of primary care or PCMH settings are ideal candidates for positions within PCMHs. This mirrors expert consensus in the IBH field.(4) Hiring pharmacists or IBH providers without these attributes may lead to stalled integration, poor utilization, and wasted funding.

Identification of pharmacists qualified for an integrated IBH role also is key to success. The College of Psychiatric and Neurologic Pharmacists has called for more extensive integration of board-certified psychiatric pharmacists (BCPP) within PCMHs.(11) Although pharmacists with specialty training in psychotropic medications would be ideal, the limited availability of such specialists reduces the feasibility of this approach. In 2014 there were only 804 BCPPs in the United States; in order to meet needs of the ever growing number of PCMHs, therefore, integration of generalist trained pharmacists should also be explored.(20)

Establishing New Professional Relationships

Although the PCMH holds great potential and promise for improved patient care and outcomes, it also becomes an interprofessional melting pot for education, training, and practice among previously “siloed” disciplines. Such diversity and change presents unparalleled educational opportunities but also some unique management challenges. It is unrealistic to expect pharmacists to step into team-based care without adequate training or experience. Fortunately, patient care practices and interprofessional education are now components of the accreditation standards for Doctor of Pharmacy (PharmD) programs. Today pharmacists are trained to be practice-ready to deliver patient-centered care, and team-ready to participate actively in team-based care.(7) Pharmacist residency training in settings that afford additional experience working in team-based care or comparable experience practicing in dynamic and team-based environments could be considered minimum requirements for hiring a pharmacist.

An iterative approach to program development and oversight is vital to reshaping the culture so it embraces and truly practices team-based care. Ongoing training for all PCMH staff also is central to successful iterations. Especially during the beginning stages of program integration, an open dialogue with clinicians about their interests in pharmacists and IBH can help managers develop clear roles and guidelines for all team members. One suggestion to facilitate such dialogue is performance of a needs assessment to help design a program the staff needs (or perceives they need). The outcome of a needs assessment can provide insight into subsequent staff training.

Fiscal Sustainability Issues

Productivity requirements and fiscal sustainability for specialized professionals also present a challenge. Starting with a needs assessment and business case analyses can help leadership devise the clinical role and business rules that will be most beneficial to the PCMH (i.e., those methods of integration that help them strive for the Quadruple Aim).(19) For example, providing extra assistance to those patients who are on four or more medications may deliver the most clinical improvement and financial savings. Likewise, lowering the risk associated with those on chronic opioid therapy may improve safety while also limiting costs of inadequate care, sentinel events, and lawsuits. Individual business plans will most likely follow the trend of other initiatives in today’s healthcare landscape—where the benefit lies in reaching the Quadruple Aim rather than in generating direct revenue for the sake of profit.(19)

Most federal and private payers do not include pharmacist services in their payment systems.

Although each clinic’s business case analyses will drive productivity requirements, consider that an IBH provider that treats eight patients per day may account for that IBH provider’s entire salary, while treating 10 patients/day would cover the overhead costs associated with the IBH provider’s employment.(4) It is important to develop similar rubrics for pharmacists. Unfortunately, lack of established payment systems presents a significant barrier. Although legislation has been introduced to recognize pharmacists as providers under the CMS, currently they are not. Consequently, most federal and private payers do not include pharmacist services in their payment systems, and reimbursement avenues for pharmacy services vary across states, practice settings, organizational structures, and payers. Generating revenue for pharmacy services will likely require that practice managers develop pro forma at the individual PCMH level to secure ROI.

Overall, paying for clinical pharmacy and IBH services is questioned only due to the historical misconception that these services are ancillary. In reality, they are necessary to achieving the Quadruple Aim.(19) Researching state and local laws regarding integrated documentation and sharing of information, and contacting payers to inquire about establishing payment for IBH and pharmacy services are potential starting points for determining fiscal sustainability. It is important to predicate these discussions on the financial and clinical benefits of such integrated health professionals within the PCMH.(4) Finally, rather than considering direct revenue as the sole ROI, cost offset and cost savings, as well as risk management could also be considered. Medication mismanagement often results in higher costs—financially, legally, and clinically.

Ensuring a Positive Patient Experience

The impact of integrating new specialties into the PCMH also should be evaluated at the patient level to ensure a positive experience is preserved. For example, adding pharmacy into the workflow may mean patients have longer appointments (consisting of visits to multiple providers’ offices) or an increased total number of appointments. Polling patients before and following integration may help the clinic identify and proactively address these issues.

Another suggestion for ensuring the patient’s experience with team-based care is positive is to provide cotreatment. One current barrier to this format may be pharmacists’ lack of experience and comfort with cotreating patients. Behavioral health clinicians, by contrast, often conduct co-led group therapy appointments in training or in the workplace. Empowering IBH clinicians to train PCPs and pharmacists on how to implement this type of care could help overcome this barrier.

Final Recommendations

The type of service delivery model used by IBH and pharmacy will directly and indirectly determine the workflow, templates, access, productivity, and the nature of collaboration between the PCMH team and its integrated health professionals (e.g., IBH providers and pharmacists). Specific methods of teamwork also may be determined by the population served, funding sources, payment models, and revenue streams. Without clearly identified roles for integrated pharmacists, none of these business and operational planning and implementation can occur. Future research should outline the various roles and models for integrating pharmacists, while defining the coinciding responsibilities of pharmacists within the PCMH. This would enable practice managers to further develop workflow models of collaboration between the integrated specialties (e.g., IBH providers and pharmacists), develop pro forma, and conduct other business analyses on the program. The result would be a sustainable model for team-based care in which PCPs would be able to utilize these specialists to assist patients without demanding more of the PCPs’ time. Collectively, these results can help primary care practices methodically and purposefully advance the PCMH model and pursue the Quadruple Aim.

References

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2. Robinson PJ, Reiter JT. Behavioral Health Consultation and Primary Care: A Guide to Integrating Services, 2nd ed. Geneva, Switzerland: Springer International Publishing; 2016.

3. Scharf DM, Eberhart NK, Hackbarth NS, et al. Evaluation of the SAMHSA Primary and Behavioral Health Care Integration (PIBHCI) Grant Program. Washington, DC: The RAND Corporation; 2014.

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9. Robinson P, Del Vento A, Wischman C. Integrated treatment of the frail elderly: the group care clinic. In: Blount S, ed. Integrated Care: The Future of Medical and Mental Health Collaboration. New York: Norton; 1998.

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14. Isetts BJ, Schondelmeyer SW, Artz MB, et al. Clinical and economic outcomes of medication therapy management services: the Minnesota experience. J Am Pharm Assoc. 2008;48:203-211.

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17. Cobb CD. Optimizing medication use with a pharmacists-provided comprehensive medication management service for patients with psychiatric disorders. Pharmacotherapy. 2014;34:1336-1340.

18. Kozminski M, Busby R, Somma McGivney M, et al. Pharmacist integration into the medical home: qualitative analysis. J Am Pharm Assoc. 2011;51:173-183.

19. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12:573-576.