Putting Pharmacies in Clinics: An Innovative Approach to Improving Medication Adherence

The Practice Advancement Initiative (PAI) from the American Society of Health-System Pharmacists seeks to “transform how pharmacists care for patients by empowering the pharmacy team to take responsibility for medication-use outcomes.” Many of the PAI’s transformational goals involve the use of advanced technology, rethinking training programs, and the efficient use of pharmacy technicians. However, other goals involve commonsense ideas, such as the following:

• Promoting team-based approaches to health care
• Enabling pharmacists to optimize their time with patients across the continuum of care
• Empowering pharmacists to take responsibility for patient outcomes
• Positioning pharmacists to promote health and wellness, and prevent adverse medication outcomes

Many hospitals have already achieved these goals by incorporating clinical pharmacy services, which have proved to be effective at reducing the incidence and severity of adverse medication-related events. Since there were 36.5 million hospital stays in 2012,¹ this is good news for a large number of those hospitalized patients. However, in 2010 (the most recent year for which data are available), there were over 1 billion visits to primary care and other specialty offices.² Therefore, a true innovation in pharmacy practice would be to bring the PAI’s goals directly into the clinic environment, where the vast majority of people go for their health care needs.

This article discusses how this goal can be achieved by incorporating point-of-care pharmacies within clinics. An additional benefit of this point-of-care concept is that it can “empower” pharmacists to truly engage with patients to help them adhere to their medications. Adherence to medications is a good place to begin because every physician who prescribes medications should be deeply concerned about the following findings³:

• Nearly 75% of adults are nonadherent in one or more ways
• Almost one-third stop taking their medications earlier than instructed
• Nearly half said they had forgotten to take a prescribed medication
• Nearly one-third had not filled their prescriptions
• Nearly one-fourth had taken less than the recommended dosage
• More than 1 in 10 had substituted an OTC medication instead of filling the prescription they were given

The costs of nonadherence are significant, not only to patient outcomes, but also to overall health care expenditures. The following facts should also concern physicians who have to practice in a new age in which fee-for-service is being replaced with value-based compensation and readmissions reduction programs:

• Nonadherence increases the likelihood of hospitalization for patients with diabetes by 77%, with high blood pressure by 45%, and with high cholesterol by 35%⁴
• Nonadherence is estimated to cause approximately 125,000 deaths per year in the United States⁵
• Nonadherence is responsible for at least 10% of hospital admissions⁵
• Nonadherence has been estimated to cost the US health care system between $100 and $289 billion annually in direct costs⁵

What can physicians do to ensure that patients fill their prescriptions and take the right amount at the right time? Perhaps the solution lies within the clinic itself.

Point-of-Care Pharmacies

At PharmRx Group, we believe that a successful medical team has 3 members, each with a critical role: physician, pharmacist, and patient. Success is based on the premise that the physician and the pharmacist work cooperatively with the patient to devise a treatment plan that effectively manages their medical condition. Is there any better way to accomplish this than by placing the pharmacist directly at the point of care? By placing a pharmacist and a pharmacy directly within the clinic’s walls?

Survey results show that 86% of patients would talk to their pharmacist about their medications, and more than 80% believed the pharmacist could help them correctly adhere to their prescriptions.³ Therefore, doesn’t it make sense to bring this critical role directly within the walls of the clinic? To actually improve medication adherence rates, however, a point-of-care pharmacy has to offer more than the simple “innovation” of convenience. The true innovation lies in bringing the power of technology and the discipline of medication therapy management (MTM) to the clinic environment.

Medication Therapy Management

The goal of point-of-care pharmacies is to enhance medical outcomes by increasing the level of collaboration between physicians and pharmacists. Physicians will always have the primary responsibility for patient care, diagnosis, and medication prescription. However, by closely collaborating with an in-house pharmacist, physicians can take advantage of the specialized knowledge pharmacists have for MTM. This joint approach not only helps patients thoroughly understand their medications, but also allows the physician and the pharmacist to collaboratively monitor, review, and modify the medications based on the patient’s response.

The true benefits of MTM’s core components (ie, medication therapy review, personal medication records, medication action plans, intervention/referral, and documentation/follow-up) flow from the requirement for extensive, personalized engagements between pharmacists and patients. Whether it is the review of the benefits and complications of every medication, the compilation of in-depth medication profiles, or the creation of easy-to-follow medication plans, all aspects of MTM are designed to help patients adhere to their medication therapies.

Point-of-care pharmacies bring all of this into the clinic so MTM can become an integral part of each patient’s ongoing treatment. This fosters a closer collaboration between physicians and pharmacists, not only because they are in the same office, but also because all of the reviews, profiles, plans, and follow-up reports of the MTM are easily accessible to every member of the health care team. This means the benefits of MTM are applicable not only after a prescription is written, but also as part of every recurring patient visit and every review of treatment options.

The Benefits of Point-of-Care Pharmacy Services

When diligent pharmacists are an integral part of a clinic’s team, patients benefit from a truly “innovative” and inclusive approach to all aspects of their treatment and care. The primary goal and achievable benefit is improved adherence to medication therapies. This is of obvious benefit to patients and physicians; however, it is not the only significant benefit worth mentioning. Let us start with benefits that accrue for patients and physicians:

• Improved adherence to medication therapies
• An additional watchdog

Improved Adherence to Medication Therapies

It might seem obvious, but it is worth stating that improving adherence to medication does lead to better outcomes and lower costs. For example, a study of patients with diabetes determined that improved adherence led to a 13% reduction in hospitalizations and emergency department visits, whereas lower adherence led to a 15% increase.⁶ Another study of osteoporotic women determined that the risk reductions for fractures ranged from 20% to 45% for those adhering to their medications.⁷ In regard to cost savings, a study determined that adherence reduced average annual medical spending by $8881 for patients with congestive heart failure, $4337 for patients with hypertension, $4413 for patients with diabetes, and $1860 for patients with dyslipidemia.⁸

Acknowledging this begs the question: can enhanced patient—pharmacist interactions improve medication adherence? The study results released so far prove the answer is yes. For example, studies conducted by the National Community Pharmacists Association determined that medication synchronization programs could increase adherence from 37% to 81% for respiratory therapies and from 67% to 92% for cardiovascular therapies, as well as reduce first-fill abandonment by 90%.⁹ The synchronization involved pharmacists working with patients to have all of their prescriptions filled on the same day each month, as well as patients setting up scheduled visits and discussions with their pharmacists. In a similar manner, Thrifty White Pharmacy’s synchronization program improved adherence to chronic disease therapies to between 18% and 26% and added 84 extra days of therapy a year.¹⁰ Finally, the National Association of Boards of Pharmacy reports that counseling by pharmacists increased the adherence rate of elderly patients taking 3 or more medications by 43% and of patients suffering from heart failure by 46%.¹¹

Such improved adherence rates are of obvious benefit to patients in regard to better medical outcomes and fewer trips to the hospital. The enhanced patient—pharmacist interactions that make this possible form the core of MTM. Bringing these interactions into clinics is one way to ensure that patients gain this benefit.

Point-of-care pharmacies can also directly benefit physicians who incorporate them into their clinics. Physicians have always cared about the success of their medical therapies, but now the outcomes of those therapies are being used by insurance companies and the Centers for Medicare & Medicaid Services as metrics for value-based compensation. This trend will soon include private, employee-based insurance as some of the largest insurers intend to incorporate value-based compensation into 75% of their contracts by 2020.¹² Therefore, anything that can be done to improve outcomes and reduce hospitalizations (such as enhanced adherence to medication therapies) is critical to a clinic’s success.

An Additional Watchdog

Pharmacists placed within clinics perform an important watchdog role by preventing potential medication errors, which could affect patients and physicians. In addition, physicians can immediately consult with the pharmacist if they have questions regarding medications, optimal regimens, potential adverse interactions, or the availability of new medications. All of this benefits patients because problems can be resolved immediately, before they leave the clinic. It benefits physicians by reducing medication errors and reducing potential liabilities for misuse of medications, such as opioids.

Benefits to Patients

• A complete information environment
• Maximum convenience

A Complete Information Environment

Patients trust physicians for their ability to diagnose illness and prescribe appropriate medications. Unfortunately, patients often leave the exam room with only the most basic information about those medications. A point-of-care pharmacy directly addresses this problem by allowing patients to leave the exam room and immediately meet with a personal pharmacist. The goal of these personal sessions is to provide patients with all the information they need to correctly adhere to their prescribed medications. This means the pharmacist will create a profile of the patient’s medication history, answer questions about prescriptions, discuss potential adverse effects, and provide an action plan to guide the patient through the total regimen. This complete information environment is designed to give patients the best chance of a successful outcome.

Maximum Convenience

Patients typically have to make 2 trips for their medical needs: one to their clinic for diagnosis and prescription and another to a pharmacy to receive their medications. If there are problems with a prescription, patients face extended wait times while the remote pharmacist attempts to contact their physician. Point-of-care pharmacies change all that by providing both services within the 1 clinic location. This 1-stop convenience not only saves patients time, but also ensures that all problems are resolved before they leave the clinic.

Benefits to Physicians and Clinics

• Help with the bottom line
• Competitive advantages that help clinics become best-of-class providers

Help with the Bottom Line

As mentioned above, any improvement in overall patient outcomes, combined with associated reductions in complications, hospitalizations, and health care expenses, helps physicians and clinics with value-based compensation rates. However, a point-of-care pharmacy can also help in more basic ways. Point-of-care pharmacies offering prescription support services can reduce the workload commonly assumed by clinic staff. They can handle most of the call-answering duties regarding refills and medication-related questions, as well as respond to prescription reminder apps that allow patients to submit refill requests. Handing off these tasks to an in-house pharmacy can allow a clinic to redirect its staff to serve more patients and, therefore, improve the clinic’s bottom line.

Providing Competitive Advantages

When you think about it, isn’t the most convenient place for a pharmacy within a clinic, where all of a patient’s medication questions are top of mind? Clinics that offer personalized pharmacy services would be a 1-stop location for most of a patient’s needs in regard to consultation and medication. These clinics would stand above their competitors in regard to the range of services they offer and, more important, in regard to the convenience they offer their patients. Improved medical outcomes, personalized pharmacy services and maximized convenience are all factors that drive patient/customer loyalty. Amid all the advertising options that clinics can employ, few are as effective as the positive word-of-mouth advertising spread by a clinic’s patients to their friends and family. After all, clinics are businesses, and all businesses need competitive advantages.

Conclusion

The innovative concept behind point-of-care pharmacies is really quite simple: maximize the benefits pharmacists can provide by maximizing their engagement with patients. The most logical place to make this happen is where 1 billion health care visits take place each year: the clinics. But it is not just about numbers, it is also about environment. The privacy of clinic meeting rooms is conducive to the extensive patient—pharmacist consultations at the core of MTM. These personal interactions allow pharmacists to help patients adhere to their medications. Improved adherence leads to improved outcomes, which lead to healthier patients, higher value-based compensation rates, and successful best-of-class clinics. Point-of-care pharmacies provide these benefits to physicians and their clinics and, most important, to their patients by simply letting pharmacists do more of what they do best—help patients achieve the best possible outcomes from their medication therapies.

This article is published in collaboration with the Directions in Pharmacy CE Conference program.

Michael Russin cofounder of PharmRx Group.

References

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