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

Portland, Oregon

Providence Medical Group (PMG) has ten clinic offices and is the largest community-based primary care group in the Portland Metropolitan area.

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 physician’s 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 patient’s medications, assess the patient, provide education, screen for adverse drug reactions and interactions, and optimize the regiment based on the patient’s 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 the physician.

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 Department’s 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.