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 Harrell, Pharm.D.

University of Mississippi Medical Center

Jackson, Mississippi

Introduction

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 program.

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 $2,655.

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.

Conclusion

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.