Pharmaceutical Care Clinics: An Innovation
in Collaborative Medication Therapy Management
Leigh Ann Ramsey, Pharm.D., BCPS, H. Joseph Byrd, Pharm.D.,
FASHP, Barbara G. Wells, Pharm.D., FCCP, BCPP, John Randall,
M.B.A., R.Ph., Elizabeth H. Hood, Pharm.D., Charmaine D. Rochester,
Pharm.D., CDE, James J. Pitcock, Pharm.D., Lisa M. Murphey,
Pharm.D., Margaret B. Pitcock, Pharm.D., and T. Kristopher
University of Mississippi Medical Center
Pharmacy practice has evolved from a focus on the responsible
dispensing of medications to a patient-oriented profession
concerned with the optimum use of pharmaceutical products
in the management of disease states. The University of Mississippi
is contributing to the development of disease management through
innovations at dedicated Pharmaceutical Care Clinics. Pharmacists
in these clinics educate patients on proper drug administration,
monitor responses to pharmacologic agents through physiologic
and laboratory assessments, and initiate and modify medication
regimens based upon collaborative drug therapy protocols.
These protocols outline the practice parameters for each clinic
and provide delegated prescriptive authority. Disease states
currently managed in these clinics include asthma, diabetes,
anticoagulation and dyslipidemias.
Description of the Program
The Pharmaceutical Care Clinics are housed in the University
of Mississippi Medical Center (UMMC) ambulatory care facility,
a renovated shopping mall. The first protocol-driven clinic
opened in 1998, providing outpatient management of anticoagulation
disorders. The Asthma Clinic, which opened later that year,
addresses the community need to curtail overutilization of
emergency care and decrease the risk for asthma-related mortality.
The backbone of the clinic is a collaborative protocol, and
care is fleshed out by disease specific education, identification
of goals, and development of individualized management plans
empowering patients to self-adjust drug therapy.
Due to the high prevalence of diabetes in Mississippi, the
Departments of Pharmacy and Medicine at UMMC partnered to
assemble the Diabetes Management Clinic (DMC) in May 1999
as the third component of the Pharmaceutical Care Clinics.
The DMC utilizes a multidisciplinary team, including a supervising
physician, pharmacists, certified diabetes educators, and
nurse practitioners to provide individualized care for patients
with diabetes. Pharmacists, as part of this healthcare team,
are primarily responsible for drug therapy management.
The fourth Pharmaceutical Care Clinic, the Lipid Management
Clinic, opened in November of 2000. This clinic is patterned
after the DMC with regard to the structure, with pharmacists
participating in medication therapy management under protocol
with a supervising physician.
Summary of Actions
In 1998, Mississippi became the first state to secure government
reimbursement for pharmaceutical care through the Division
of Medicaid in the areas of asthma, diabetes, dyslipidemia,
and anticoagulation therapy. For Medicaid reimbursement, pharmacists
are required to obtain a Medicaid provider number, establish
a treatment protocol with referring physicians, and become
credentialed through the National Institute for Standards
in Pharmacist Credentialing (NISPC) disease state certification
Pharmacists are paid a flat fee of $20 for each 15 to 30 minute
patient encounter. A pharmacist can be reimbursed for up to
12 visits per year per patient for all disease states managed.
These pharmaceutical care visits are in addition to the annual
allotment of fully reimbursed physician visits provided by
Medicaid. No restrictions exist as to the number of patients
a pharmacist can manage.
The Pharmaceutical Care Clinics are staffed by six full-time
pharmacists, who have been granted a doctorate in pharmacy
and completed post-graduate residencies. At present, the six
participating pharmacists hold 21 credentials in the various
disease states. As part of an academic institution, the Pharmaceutical
Care Clinics provide an optimal venue for pharmaceutical outcome
research. The Clinics serve as model practice sites for pharmacy
students, resident trainees, international scholars, as well
as for community pharmacists interested in expanding their
practices to include collaborative drug therapy management.
Summary of Outcomes
Preliminary economic analyses of our experience with pharmaceutical
care reveal that substantial cost savings can be realized
through asthma disease management. An evaluation of this pharmacy
intervention in 75 patients followed for one year demonstrated
a 39 per cent decrease in emergency department visits and
47 per cent decrease in hospital utilization for bronchospastic
decompensation, resulting in a cost savings of $99,283.18.
Twenty-one Medicaid enrollees were similarly evaluated utilizing
beneficiary data retrieved from the Division of Medicaid.
The number of Emergency Department visits decreased by 28
per cent after Asthma Clinic management. Although the number
of hospitalizations did not decrease, the hospital costs decreased
by 48 per cent. The overall cost savings was $55,755 and the
annualized rate of cost savings per Medicaid beneficiary was
Data derived from the Diabetes Management Clinic confirms
the benefit of collaborative pharmaceutical care. At entry,
patients had an average A1c of 9.9 per cent; however, after
one year of collaborative care, the average A1c of the pharmacist-managed
patients had fallen to 7.7 per cent. This beneficial impact
was consistent across the cohort, as only 3 percent of patients
experienced an increase in their A1c level. More significantly,
approximately 40 per cent of the patients attained the American
Diabetes Association’s (ADA) goal for glycemic control:
an A1c of less than 7.0 per cent. Of note, the majority of
patients were not newly diagnosed, but had a mean duration
of diabetes of 9.6 years. Their poor baseline glucose control
suggests a failure of traditional diabetes management. Likewise,
Anticoagulation Clinic patients more frequently achieve desired
therapeutic goals than those receiving usual care. Data from
the newly instituted Lipid Clinic is currently being reviewed.
Healthcare is in transition and new models of delivery will
likely be accompanied by a broader pharmacoeconomic perspective,
one that does not isolate drug costs, but views the cost of
pharmaceutical care in the overall context of medical care.
The financial constraints faced by health plan administrators
have caused them to limit physician access for enrolled populations,
which has created a need for non-physician involvement in
patient care. This need is of particular concern in chronic
diseases accompanied by complex drug regimens that may lead
to patient confusion, poor outcomes, and increased costs of
care. Pharmacists have extensive knowledge of pharmacology
and drug and disease interactions and are uniquely qualified
to assist in medication therapy management. Over the last
five years, the University of Mississippi has been a leader
in establishing the role of pharmacists in disease state management.
Our initial successes will pave the way for dissemination
of programs that will allow pharmacists to enhance patient
compliance, diminish the risk of adverse events, and improve
overall patient care.