The Report of the 2019-2020 Professional Affairs Standing Committee: Pharmacist Integration with Primary Care Practices

INTRODUCTION AND COMMITTEE CHARGES

According to the Bylaws of the American Association of Colleges of Pharmacy (AACP), the Professional Affairs Committee is to study issues associated with professional practice as they relate to pharmaceutical education, and to establish and improve working relationships with all other organizations in the field of health affairs. The Committee is also encouraged to address related agenda items relevant to its Bylaws charge and to identify issues for consideration by subsequent committees, task forces, commissions, or other groups.

AACP President Todd Sorensen’s focus for the 2019-2020 AACP standing committees was centered on AACP Strategic Goal 3.4: Pharmacy advancement and transformation.¹ The 2019-20 Professional Affairs Committee (PAC) was charged to:

1. Describe the leadership role of schools of pharmacy in advancing interprofessional practice, with an emphasis on physician-pharmacist collaborative relationships.

2. Establish an inventory of resources that can support school efforts to grow collaborative partnerships between pharmacists and physicians.

3. Determine gaps that exist in the resources required to support schools in efforts to facilitate expansion of interprofessional partnerships. Specifically, evaluate the presence of resources that assist with articulating the value proposition for physician-pharmacist collaborations across the dimensions of quality, cost, patient experience and health care provider wellbeing (the Quadruple Aim).

4. Define strategies and draft an action plan for AACP’s role in facilitating member school efforts to accelerate the development of interprofessional practices within their geography of influence.

Members of the 2020 PAC included faculty representing multiple disciplines from various colleges and schools of pharmacy and professional staff representation from the American Pharmacists Association (APhA), the American Society of Health-Systems Pharmacists (ASHP) and the National Community Pharmacists Association (NCPA). The PAC also a family medicine physician representing the American Academy of Family Physicians (AAFP).

Background

The PAC spent considerable time discussing its charges, the process to address the charges, and the potential implications for the profession and pharmacy academia. The PAC initially focused on the physical integration of the pharmacist into primary care practices as the primary physician-pharmacist collaborative partnership that would be addressed by its charges. The PAC determined that its work generated to address charges one, two and three would serve as the basis for charge four (the strategies and draft action plan for AACP’s role in facilitating member school efforts to accelerate the development of interprofessional practices within their geography of influence). The PAC also decided to combine charges two and three and to address the Quadruple Aim via three subcommittees ([1] quality of patient care, [2] cost of care, and [3] the patient experience and provider wellbeing).

After conferring with President Sorensen, the PAC generated the following purpose statement to guide its work to address its charges: The 2019-2020 AACP Professional Affairs Committee will provide guidance to AACP and its member colleges and schools of pharmacy on contributing to the pharmacy workforce by creating positions focused on the pharmacist contributing to value-based interprofessional practice and patient care, recognizing a variety of care models. This workforce contribution will focus on integrating the pharmacist with physician-based patient care practices so that patient’s medication management needs are fulfilled, that health care quality metrics are addressed, and that physicians, pharmacists and other health care providers are able to meet the needs of patients in a more efficient, effective, and sustainable manner.

The PAC conducted its work via teleconference and other electronic means to address its charges. The draft action plan, along with the draft action plans from the other 2019-2020 AACP standing committees, served as part of the basis for the work that was conducted during the in-person meeting of the committees January 9-10, 2020 in the Washington, DC metropolitan area.

The PAC draft action plan contained the following items:

• The PAC to create, execute and evaluate a survey to AACP members to determine the gaps (needs) of colleges and schools of pharmacy to integrate pharmacists with physician-based practices;

• AACP to provide development support to colleges and schools of pharmacy and identify model relationship frameworks for colleges and schools of pharmacy to pursue;

• AACP to collect and communicate specific examples of how pharmacists could be incorporated with physician-based clinic practices (ie, chronic disease management, polypharmacy, reduction of ED utilization, INR management, pharmacogenomics, as well as different models of incorporation - telehealth, electronic consults via the EHR, etc.); and

• AACP to provide draft language/agreements to assist department chairs to integrate pharmacists within physician-based practices (eg, ‘plug and play’ contracts based on national best practices).

The PAC in-person meeting in January 2020 allowed for multiple committee conversations that generated a more strategic focus of the committee charges. In response to how the PAC could address their charges that could contribute to President Sorensen’s Bold Aim for the profession (By 2025, 50% of primary care physicians in the U.S. will have a formal relationship with a pharmacist), the committee developed the following goal:

Create multi-stakeholder demand for the integration of pharmacists with primary care practices in collaboration with other national organizations.

During this meeting, the PAC determined that multiple models integrating the pharmacist with primary care practices needed to be identified and communicated within and outside of the profession and pharmacy academia. In response to the committee charges, purpose statement and goal, the initial draft action plan items were revised to the following action items:

• Conduct focus groups at the 2020 AACP Interim Meeting;

• Conduct semi-structured telephone interviews with select focus group participants from the 2020 AACP Interim Meeting;

• Identify models of pharmacist integration in primary care practices;

• Identify opportunities to converse with non-academic pharmacist groups to identify and create awareness of models of pharmacist integration in primary care practices;

• Creation of an inventory of models of pharmacist integration in primary care practices (in coordination with national pharmacy and non-pharmacy groups); and

• Dissemination of the inventory of models of pharmacist integration in primary care practices (via stories, resources, and other avenues) within and outside of the pharmacy profession utilizing multiple mechanisms.

  Table 1 provides a listing of the current AACP policy statements that pertain to the PAC charges. Upon review and based on the committee’s work, the committee is proposing revisions to the following policy statements:

• Pharmacy education has the major responsibility to assist the profession to accomplish its mission for society. In keeping with the transition of health care from the acute care to the ambulatory care environment, pharmacy education must continue its efforts to encourage and assist the profession to provide clinical pharmacy services in the ambulatory environment (Source: Professional Affairs Committee, 1990) be revised to

  ○ Pharmacy education has the major responsibility to assist the profession to accomplish its mission for society. In keeping with the transition of health care from the acute care to the non-acute care environment, pharmacy education must continue its efforts to encourage and assist the profession to provide clinical pharmacy services in the non-acute care environment.

• AACP should encourage member institutions, in concert with practitioners, to expand clinical pharmacy in the community so that clerkships in community practices will be more meaningful to students, and even inspirational, so that such practices will be emulated when they enter the profession (Source: Policy Development Committee, 1982) be revised to

  ○ AACP should encourage member institutions, in concert with practitioners, to expand clinical pharmacy in the community so that the experiential education in community practices will be more meaningful to students, and even inspirational, so that such practices will be emulated when they enter the profession.

• AACP believes that pharmacy faculty have a responsibility to use their experience to examine and document the effectiveness of pharmacist-provided pharmaceutical care as an essential element of primary care (Source: Professional Affairs Committee, 1994) be revised to

  ○ AACP believes that pharmacy faculty have a responsibility to use their experience to examine and document the effectiveness of the Pharmacist Patient Care Process as an essential element of primary care.

• AACP support residencies and certificate programs that develop advanced clinical and administrative knowledge and skills in the delivery of comprehensive pharmacy services in the ambulatory care practice (Source: Professional Affairs Committee, 1989) to be revised to

  ○ AACP support residencies and certificate programs that develop advanced clinical and administrative knowledge and skills in the delivery of comprehensive pharmacy services in all health care practice settings.

• AACP supports the establishment of a recognized triad relationship among the schools/colleges of pharmacy, boards of pharmacy, and state pharmacy associations for the successful advancement of pharmacy practice and the role of pharmacists in interprofessional patient and health care practices (Source: Professional Affairs Committee, 2013) be revised to

  ○ AACP supports the establishment of a recognized triad relationship among the schools/colleges of pharmacy, boards of pharmacy, and state pharmacy associations for the successful advancement of pharmacy practice and the role of pharmacists as recognized health care providers within interprofessional and multidisciplinary health care practices.

• AACP supports the position that pharmacist-provided medication therapy management core elements are an essential and integral component of primary care (Source: 2009-10 Argus Commission as revision to Professional Affairs Committee, 1994) be revised to

  ○ AACP supports the position that pharmacist-provided comprehensive medication management is an essential and integral component of primary care.

• Administrators, faculty members and student pharmacists at all colleges and schools of pharmacy share responsibility for stimulating change in pharmacy practice consistent with the Vision for Pharmacy in 2015 developed by the Joint Commission of Pharmacy Practitioners (Source: Argus Commission, 2009) be revised to

  ○ Administrators, faculty members and student pharmacists at all colleges and schools of pharmacy share responsibility for stimulating change in pharmacy practice consistent with the Vision for Pharmacy developed by the Joint Commission of Pharmacy Practitioners.

This report has the following purposes: (1) to provide background on the current literature and resources available related to the committee charges; (2) to describe the rationale for and the results from the focus groups conducted at the 2020 AACP Interim Meeting; (3) to communicate the results of an initial inventory of models that integrate pharmacists with primary care practices; and (4) to devise a general plan to continue the work of the 2020 PAC.

Current Literature and Resources Related to the Committee Charges

Pharmacy practice transformation and the expansion of the role of the pharmacist has been happening across the country for many years in many different practices in a variety of ways.^2,3,4,5,6 Many colleges and schools of pharmacy have initiated and/or are participating in mechanisms (eg, pharmacy practice transformation centers, consortia to address changes in pharmacy practice) that address the changing needs of the pharmacy profession. One of the roles that academic pharmacy has had is integrating their pharmacist faculty members, pharmacy residents, and student pharmacists into primary care practices. This integration is not new and in fact, the American Medical Association (AMA) has developed a module to encourage its expansion.⁷ Yet the financial sustainability of pharmacists within these practices still remains a challenge.^8,9,10 While the work of colleges and schools of pharmacy and their partners is often a local phenomenon, AACP has a role to support these efforts. The work of the PAC has the potential to influence value-based care, interprofessional practice and pharmacy workforce development.

The Leadership Role of Colleges and Schools of Pharmacy in Advancing Interprofessional Practice

While colleges and schools of pharmacy have embraced interprofessional education, schools must be mindful of the relationship of education to interprofessional practice.¹¹ Foundational to the PAC charge is the belief that colleges and schools’ engagement in a leadership role advancing interprofessional practice and fostering collaborative relationships with physicians is essential for success. What does this leadership role look like? In a review of the literature, few references articulate this role. Frankel and colleagues outlined a comprehensive list of educational and program structure strategies to advance practice in Canada.¹² Adams and colleagues discussed roles in advancing practice collaboratively with community pharmacies and described strategies related to training, development, support, relationship building, and research.¹³ As the role for advancing interprofessional practice with emphasis on physician-pharmacist collaborative relationships is moving forward, exploring leadership frameworks may provide a structure to inform the various roles. Kouzes and Posner’s work on “The Leadership Challenge” identified five practices of exemplary leadership that may encompass these roles. The practices include; Model the Way, Inspire a Shared Vision, Challenge the Process, Enable Others to Act, and Encourage the Heart.¹⁴ The five practices provide a framework for action by colleges and schools of pharmacy and AACP to address this charge.

To “Model the Way,” colleges and schools of pharmacy should examine their values and identify how current actions that advance interprofessional practice align with these values. To “Inspire a Shared Vision,” colleges and schools of pharmacy should assess their vision statements and strategic plans for the presence of interprofessional practice themes that will drive future advancement. To “Challenge the Process,” colleges and schools of pharmacy should create ways to continue debating, improving, and experimenting through their actions and relationship development with medical schools and the broader health care community. To “Enable Others to Act,” colleges and schools of pharmacy should identify organizations and supporters and foster relationships to broaden and resource the efforts to advance interprofessional practice. To “Encourage the Heart,” colleges and schools of pharmacy should recognize faculty, preceptors, partners, and students for their work and contribution in advancing interprofessional practice. As a professional pharmacy organization, AACP must provide support to members and member institutions that equip people and organizations to engage in these roles. In addition, AACP must continue to foster collaborative working relationships with educational and practice-related professional organizations in medicine to foster collaborative work across our organizations.

The following section provides information regarding the physician-pharmacist collaborative relationship the potential effect on aspects pertaining to the Quadruple Aim: improving population health, reducing costs, enhancing the patient experience and improving the work life of health care providers.¹⁵

The Quality of Patient Care

Physician-pharmacist collaborative relationships can contribute to a significant improvement in quality across a variety of inpatient and outpatient practices. The diversity of physician-pharmacist collaborative relationships that have existed in the health-system/hospital setting has been recognized to improve patient outcomes and provide increased value to the health care system for many years.¹⁶ A recent partnership between a managed care payor, an academic medical center, and physician practices throughout the state of Michigan was designed to increase the presence of clinical pharmacists in a sustainable fashion with the goal to increase quality measures related to diabetes, hypertension, and hyperlipidemia with expanded services from the initial implementation period.¹⁷ Initial results to date include significant decreases in chronic disease-related hypertension measures and hemoglobin A1C levels as compared to control groups.¹⁷ Other similar pilots described an average annual savings per patient exceeding $1000 a year in overall medication claims when a pharmacist had a face-to-face meeting with a patient in the primary care practice (PCP) and has produced an 504% return on investment (ROI) based on the impact of physician-pharmacist collaborative models.¹⁸

While increasing the presence of pharmacists in ambulatory care and clinic practices has increased physician-pharmacist collaborations, the majority of practicing pharmacists are in community practices, including chain and independent locations. Physician-pharmacist collaborations in community practices also have an impact on quality of patient care. Pharmacists from an independent pharmacy who were integrated in a PCP improved quality measures including immunization, cancer screening, and hemoglobin A1C levels.¹⁹ These models are excellent examples of how the physician-pharmacist relationship can have tangible impact on the quality of care provided to patients.

The Cost of Care

While there are good reports of cost savings associated with pharmacists providing clinical services,^20,21,22 the data is often associated with the value pharmacists bring to patient care as opposed to additional revenue for the health care system.^17,23 With increased utilization of value-based models and contracts,²⁴ many primary care practices have utilized pharmacist services to improve health care quality metrics and realize better reimbursement to the primary care practice.

Pharmacists may bill for direct patient care visits, but this is typically done at the “incident-to” level.^25,26 This means the service must be performed under the physician’s direct supervision. This remains a barrier in that pharmacists bring a unique skill set for medication management and direct supervision is not necessary. However, coordinated care and a means for shared documentation remains a cornerstone of interdisciplinary care.

The fact that mid-level providers such as advanced nurse practitioners and physician assistants may often be hired at a lower rate than a pharmacist, often offers further challenges for health care systems with hiring decisions. Pharmacists will need to clearly document their value and often look for creative models in which they can offer their services to provide benefit to patients, providers, and the health care system.²⁷

The Patient Experience and Provider Well-Being

The patient experience is not only a part of the triple aim²⁸ and quadruple aim,¹⁵ but is also an important benchmark for clinical (eg, patient satisfaction, treatment adherence, improved outcomes) and business (eg, greater efficiency, meeting plan and government requirements, greater patient retention) outcomes.²⁹ Provider wellbeing has become an increasing concern for health care providers and health care practices.^30,31 Due to the demands that providers are experiencing it has been recommended that the established Triple Aim be revised to become the Quadruple Aim. The fourth aim of improving the work life of health care providers supports the original aim of enhancing the patient experience, improving population health, and reducing costs.¹⁵

The National Academies of Medicine identified that implementing team-based care reduces clinician burnout.³² Studies have indicated that primary care providers report high satisfaction with and perceived benefits of clinical pharmacy³³ and that primary care providers recognize that collaborating with pharmacists on comprehensive medication management leads to decreased mental exhaustion, satisfaction that patients are receiving better care, and decreased workload.³⁴ Pharmacists participating in comprehensive medication management have the opportunity to practice at a high-level, increasing the likelihood of their professional satisfaction. Future work of colleges and schools of pharmacy should focus on the clear articulation of the pharmacist’s ability to improve provider satisfaction through the provision of complementary services that improve patient care and provider well-being.

2020 AACP Interim Meeting Focus Groups

The PAC collaborated with the 2020 AACP Strategic Engagement Committee to conduct two 1-hour focus groups during the AACP Interim Meeting on February 9 and 10, 2020. Invitations were sent to potential focus group participants based upon known state or regional collaborations (state associations collaborations for the Strategic Engagement Committee and physician-pharmacist collaborative relationships for the PAC) involving colleges and schools of pharmacy. Each committee had 30 minutes to address their questions during the focus group. The PAC focused on asking questions pertaining to the role of academic pharmacy with physician-pharmacist collaborative relationships in primary care practices, the elements needed for these types of relationships, and sustainability efforts regarding these types of relationships. Each focus group was recorded in order to capture the content of the discussion and there were ten different schools represented in the focus groups (five in each focus group). The PAC focus group interview guide is provided in Appendix I.

Information obtained during the focus group on the PAC topics included:

Role of Academic Pharmacy with Physician-Pharmacist Collaborative Relationships

• Provide for the placement of faculty members to advance pharmacy practice and efficiency in primary care practices;

• Supply experiential training locations and experiences for student pharmacists and pharmacy residents;

• Expose students, residents, pharmacists and other health care providers to new roles for pharmacists and the patient care services they can provide;

• Grant opportunities to expand interprofessional education and interprofessional practice; and

• Supply implementation frameworks and measurement.

Elements needed for Physician-Pharmacist Collaborative Relationships

• Colleges and schools of pharmacy have to be willing to go to the administrators and business managers of primary care practices to discuss the costs and value of pharmacist integration models;

• The business case or data (eg, improve patient outcomes, quality measures) has to be made for pharmacist integration and sustainability in primary care practices. The data being presented should align with the priorities of the primary care practice;

• It is valued when the pharmacist-provided services save the physician’s time (eg, improvement of the quality of work life, improving work efficiency);

• These types of relationships are based on value—the physician, other health care providers, management and patients do see the value being brought by the pharmacist-provided services as they positively influence the level of patient care; and

• The evaluation of the pharmacist-provided services, both qualitative and quantitative, is useful and brings credibility to the collaborative relationship and the practice.

Physician-Pharmacist Relationships Sustainability Efforts

• Integrating pharmacists into primary care practices is often not difficult—it is getting the financing to support the pharmacists to provide the patient care services;

• Colleges/schools of pharmacy often have to provide pharmacist services in primary care practices at their own expense (and there are various cost share models to accomplish this), but oftentimes the practice is able to cover the costs after their value has been established; and

• Being able to write an effective business plan for pharmacist-provided services is crucial for the sustainability of these relationships.

CALL TO ACTION

The time to act is now. Our patients, our physician colleagues, and the health care system benefit from pharmacist collaboration with primary care practices. AACP, in coordination with other professional organizations, will need to provide models of successful pharmacist integration through vignettes, billing practices, and sample practice agreement templates to further enable pharmacist integration across the country.