Four Year Evolution of a Multi-Site, Collaborative, Pharmacotherapy
Clinical and Outcomes Research Department in a Community-Based
Primary Care Medical Group
Ginger A. Woodford, Pharm.D.
Providence Medical Group
Providence Medical Group (PMG) has ten clinic offices and
is the largest community-based primary care group in the Portland
The PMG Pilot Pharmacy Project was conducted in collaboration
between the Providence Inpatient Department of Pharmacy and
PMG Physician Leadership. Pilot goals included improving patient
outcomes, improving physician/patient satisfaction, and increasing
drug cost savings.
The pilot project was implemented from 1997-1998. The first
steps were to establish relationships within the PMG and develop
an electronically-published drug information mailing to establish
an identity within the medical group.
After an analysis of the literature, clinic site visits,
and discussions with physicians a "Pharmacotherapy Clinic"
model was developed. Upon referral from a physician, the pharmacist
would meet with a patient in the physicians office for
an individual visit. Service would be provided based on the
level and purpose of the referral. The level of service would
include any one of three pharmacy interventions: patient education,
consultation, or collaborative drug therapy management. The
purpose of the referral could be any medication related issue
such as management of chronic disease, complex drug regimens,
or cost of medications. The pharmacists would review all of
the patients medications, assess the patient, provide
education, screen for adverse drug reactions and interactions,
and optimize the regiment based on the patients needs
according to collaborative guidelines. At the end of the visit
the patient would be scheduled for laboratory work and/ or
follow-up appointments with the pharmacist. A progress note
would be entered into the medical record and co-signed by
During the pilot project, positive data was collected and
reported on number and source of physician referrals, patient
satisfaction in several domains, clinical outcome data and
drug cost savings. A $60,000 annual cost savings was estimated
based on discontinuation of unnecessary medications or substitution
of less expensive, equally effective medications. The results
from this pilot project supported the full time hiring of
a pharmacist position and two additional clinical pharmacy
specialists to expand the program.
The Pharmacy Department Expanded from 1998-2000. Since two
additional pharmacists were hired, the once a week Pharmacotherapy
Clinic was expanded to all nine primary care clinics. In addition,
other cost- savings measures were implemented including a
sample room initiative, indigent care program, physician prescribing
feedback reports which allows physicians to assess their individual
performance in the dominant drug classes, and a counter-detailing
and education program. In the midst of this the primary care
specialty residency program was accredited.
In general the pharmacist activities included clinic and
other responsibilities. The pharmacist had patient care responsibilities
in the clinic three times a week and worked in collaboration
with physicians. The main goals included increasing physician
access, increasing patient satisfaction, decreasing drug costs,
and decreasing the number of hospitalizations. Other activities
that the pharmacists were involved with are risk management,
disease management, and physician education programs. The
pharmacists also act as an industry liaison. Goals in these
areas include decreasing costs, increasing quality of care,
and decreasing the number of hospitalizations.
The Pharmacy Departments 2001 staffing status include
four clinical pharmacists and one primary care pharmacy resident.
Activities include: patient care, outcomes research, physician/student
education, risk management, and industry liaison.
The Pharmacotherapy Clinic visit rates have increased from
1999 to 2001 with more than 6000 total patient visits since
the start of the program. From a retrospective review, physicians
predominantly selected collaborative intervention as the level
of referral. The most common reasons for referral were diabetes,
hypertension, and hyperlipidemia. In many cases, the pharmacist
identified issues that required intervention in addition to
the primary referral such as the management of refractory
pain in an elderly patient referred for hypertension. From
studies conducted in the Pharmacy Department, there is growing
evidence that supports the idea that interventions directed
at helping patients become better self-managers improve outcomes
across a range of chronic illnesses.
To determine the impact of initiatives aimed at decreasing
medication costs an analysis was conducted comparing estimated
annual drugs cost using a severity-adjusted, validated model
with the actual drug cost. The result for the year 2000 showed
a total savings of $536,825.
A physician satisfaction was conducted and showed that physicians
find the activities of education, patient care, and disease
management by the pharmacists as valuable.
In the past four years, an innovative clinical pharmacy practice
has sustained growth in a community-based primary care medical
group. These pharmacy activities provide benefit to patients,
providers, health systems, insurers, and the pharmacy profession.