The concept of clinical pharmacy has evolved from the passions of a handful of graduates with doctorate-level practice degrees in the early 1990s to an entirely new standard of care, with 100% of graduates with advanced degrees and direct patient care experience today.
Technology and robotic automation have assisted in transitioning pharmacy practice beyond managing prescriptions to also directly managing patients and residents. Pharmacists have three evolving roles as a result of the drive toward value-based care.
In-home medication care specialists
Medication reconciliation perhaps is the most daunting task of the care transitions process. Over the course of a healthcare event, numerous clinicians, including hospitalists and specialists, often unfamiliar with the patient / resident, prescribe medications. These medications most often are based on facility formularies that may or may not align with what the patient or resident was taking before the episode or event. Pharmacists as in-home specialists (regardless of where a person’s “home” is) have proven to be more effective than other healthcare professionals in reconciling all medication lists into one comprehensive plan.
Pharmacists can help by:
- Discussing with the patient or resident the medication profile in its totality, to increase knowledge and thus concordance;
- Conducting a thorough medication safety review that considers all prescribed medications and over-the-counter drugs;
- Assisting with de-prescribing and optimizing administration times;
- Making recommendations to prescribers for alternatives to reduce the medication burden;
- Identifying monitoring parameters to help avoid medication-related problems;
- Clearly mapping out for patients and residents which medications to take, why and how to take them to avoid interactions;
In-home measures can drastically reduce the 30-day readmission rates.
The formulary medication selection process often is based on market share/rebate incentives. Patients and residents often can be affected by business-focused contracts that result in reduced medication selection. So they may be prescribed medications that are not optimally co-administered — especially because obtaining nonformulary agents can result in delays in medication access and high co-payments.
Pharmacists can assist in the medication selection process (before dispensing occurs), helping physicians and facility medical directors find alternatives to medications that might cause drug-drug interactions or drug-drug-gene interactions. And, with pharmacogenomic data, prescribing becomes even more precise. Further, pharmacists can help avoid unintentional overdose and competitive inhibition drug interactions by providing guidance about medication administration times.
Pharmacists, who are medication experts, can help facilitate the prescribing process, especially when care coordination is lacking among providers. Involving pharmacists may even help drive the paradigm shift from formulary- and rebate-based prescribing toward a system that prioritizes medication outcomes.
Managers of medication benefits
The Program for All-Inclusive Care for the Elderly for Medicare / Medicaid dual-eligible beneficiaries is a prime example of value-based care that demonstrates how aligning incentives can eliminate the “silo effect” of Medicare Part D, which often is a cost-driver for Medicare Part A and B.
In many PACE organizations, pharmacists are able to proactively and prospectively collaborate with PACE and specialist prescribers to help optimize medication-related outcomes. In this high-risk population, pharmacists can identify whether a newly prescribed medication regimen increases a person’s risk for preventable adverse drug events. With the pharmacist in a real-time role, utilization, drug expenditures and total costs of care have been demonstrated to decrease and stabilize.
The science of “de-prescribing” is boldly confronting the problem of overprescribing. Pharmacists can advocate for both patients / residents and their insurers by optimizing regimens. This means ensuring the fewest medications required to manage chronic conditions while preserving their annual and lifetime medication benefits. Regardless of a medication’s cost, if it is the wrong medication for the patient or resident, then we’ve paid too much for it.
A systematic, prospective and personalized approach to the prescribing process can provide savings while improving clinical and economic outcomes, including patient / resident and provider satisfaction.
Overall, as value-based care moves from fee-for-service to fee-for-value, the pharmacist’s role will continue to evolve into one of responsibility for medication outcomes, as well as for the accuracy and timeliness of access.
Orsula Knowlton, PharmD, MBA, co-founded Tabula Rasa HealthCare with Calvin H. Knowlton, Ph.D. She is president and chief marketing/new business development officer. TRHC, based in Moorestown NJ , offers a suite of cloud-based software solutions to help healthcare organizations, prescribers and pharmacists better manage the medication-related needs of those in their care.
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