Collaborative Health Care: The Essential Role of Pharmacists in Multidisciplinary Teams

For a number of years now, one of the most successful and transformational trends in health care has been the collaborative approach, where multidisciplinary teams of providers work together, each according to their specialty, to deliver comprehensive patient care. This approach improves patient outcomes considerably,^1,2 particularly as we face increasing complexities in health care systems, the disease complexities of a continuously aging population, and the ever-present concern of rising costs. However, health care systems are rising to the challenge, and they are recognizing the vital role of pharmacists on these teams.

Pharmacists doing rounds with physicians in a hospital. Image Credit: Marilyn Bulloch, PharmD, BCPS, FCCM, SPP, of Auburn University Harrison School of Pharmacy

Adding a pharmacist to a high-risk, specialized patient group such as what we would find in intensive care or oncology is a fairly-well established practice, but the number of teams utilizing pharmacists in less acute or specialized settings is also increasing.^3,4 This positive shift toward collaborative teams, each contributing diverse expertise, enhances productivity, reduces duplication, and improves communication.

There are multiple ways that pharmacists can contribute to multidisciplinary care teams. For example, pharmacists improve medication safety, enhance therapeutic efficacy, expand medication access, reduce health care costs, and provide patient education and counseling.

Improving Medication Safety

One of the most crucial ways that pharmacists can improve medication safety is by being present during times when patients are most vulnerable. One example is certainly during transitions of care, when a patient is moving from one level of care to another. This can include proceeding from home to hospital, back to home or to a nursing home or rehabilitation facility. These different settings are staffed by different professionals and transitioning from one setting to another can often create confusion, which can lead to medication errors. When pharmacists are on a multidisciplinary care team, they can perform medication reconciliation, create an accurate medication list, and reduce the probability of medication errors.

Pharmacists can also improve medication safety by making accurate dosing recommendations based on a variety of patient-specific factors, such as age, weight, kidney function and how different drug therapies may interact with each other. In addition, they can help with therapeutic drug monitoring (TDM) for medications that have a narrow therapeutic window, which are medications that have a small “window” between the minimum effective dose and the minimum toxic dose. TDM involves measuring specific drug levels in a patient’s bloodstream to ensure individualized dosing and therapeutic effectiveness while reducing the risk of adverse effect (AE).

Pharmacists also play a crucial role in minimizing the “prescribing cascade.” Occasionally a patient with a need for complex drug therapies will find themselves caught in a prescribing cascade, where one medication produces an AE that is treated with another medication, which produces an AE that is treated with yet another medication, and so on. A careful pharmacist who is acting as a critical member of that patient’s health care team can help investigate these effects, get to the bottom of the issue, recommend discontinuation or dose reduction of the culprit drug and help eliminate all the extraneous medications. Lastly, an important job pharmacists perform is to recommend de-prescribing medications that are no longer needed for the patient, whether this is because aspects of the patient’s condition have been resolved or because certain drug therapies supersede others.

Enhancing Therapeutic Efficacy

In order to enhance therapeutic efficacy, pharmacists make evidence-based recommendations to optimize treatment. After having considered all specific patient factors, they can help monitor and evaluate the effectiveness of the treatment. It’s as simple (and vital) as keeping the ultimate goal of the drug therapy at the forefront and continuously discerning whether that goal has been met.

One example of a pharmacist enhancing a drug’s efficacy occurs when an infectious diseases pharmacist within a multidisciplinary team assists their team with therapeutic drug monitoring for aminoglycosides to ensure that the drug levels remain within the therapeutic range for the infection being treated. If the levels fall below this range, the pharmacist can recommend dosage adjustments to achieve the appropriate therapeutic level. After these adjustments, they can continue to monitor both the drug levels and the patient's symptoms to ensure optimal therapeutic efficacy.

Expanding Medication Access

There are a number of ways that pharmacists can help expand access to medications for hospitals and patients alike. Certain high-cost medications, for example, may not be continually stocked by hospitals. If a care team is in need of a medication like this, the pharmacists can anticipate, then coordinate procurement of these very specialized, high-cost medications. Additionally, pharmacists can assist patients in various ways, such as helping them navigate insurance systems and advocating for necessary treatments through prior authorization. They can also assist patients facing financial difficulties by directing them to affordable prescription programs such as GoodRx or other programs which offer generic medications for as low as $4 a month. Additionally, pharmacists can help patients get essential medications through patient assistance programs, which are programs that help patients access medications at little or no cost. These programs are most commonly sponsored by pharmaceutical manufacturers, but they can also be sponsored by the government or other agencies. It is no surprise that many patients are not aware of programs like these when they have their hands full navigating the health care system itself, not to mention their illness.

Reducing Health Care Costs

Pharmacists can contribute to lowering overall institution costs by leveraging their expertise to help reduce medication expenses. A prime example of this occurs in hospital settings, where pharmacists should be well-versed with the hospital formulary—its preferred list of medications that guides purchasing decisions. This knowledge allows them to eliminate redundancies, determine which drugs with similar benefits to stock while promoting evidence-based, cost-effective practices to their team. Pharmacists can also alleviate the financial burden on patients by working to prevent prescribing cascades and thoroughly assessing the necessity of each medication. By optimizing medication use and preventing AEs or complications, pharmacists can ultimately help reduce the overall cost burden on the health care system.

Patient Education and Counseling

Patient education and counseling is the bread and butter of pharmacists. It is crucial to help patients have a better understanding of why they’re taking the medication, how the medication can actually help with their disease state and how to properly take the medication. This obviously happens every day in the community pharmacy setting, but when a pharmacist is on a multidisciplinary team, they tend to work very closely with the patient, so they have a better chance of emphasizing the importance of adherence. Pharmacists can also anticipate and address any medication concerns, such as when a drug will make a patient feel worse before they feel better. When these issues are addressed with the team pharmacist and reinforced by the community pharmacist, the message is stronger and the patient is much more likely to have positive outcomes.

Challenges and Concerns

About the Author

Diana Cao, PharmD, BCPS, BCCP, FCSHP, is an associate professor and chair of the Department of Pharmacy Practice at the Marshall B. Ketchum University College of Pharmacy (MBKU COP). She worked as a lead critical care pharmacist and was on faculty at the Loma Linda University School of Pharmacy and California Northstate University College of Pharmacy prior to joining MBKU COP. She is a Board Certified Pharmacotherapy Specialist (BCPS), Board Certified Cardiology Pharmacist (BCCP), and a fellow of the California Society of Health-System Pharmacists (FCSHP).

There are some challenges that pharmacists face in taking on a larger role in multidisciplinary health care teams. The first centers on perceptions and awareness. In this case some health care providers may not fully recognize the pharmacist’s ability to contribute to patient care—perhaps still associating them primarily with dispensary roles—and as a result, under-utilize their skills, which hinders their integration within the team.

Another challenge is competing priorities and resource limitations. Often when pharmacists are integrated into a multidisciplinary care team, it is in addition to an already heavy workload, or there is a lack of physical workspace that is close enough to the other team members. Proximity is often fundamental to the effectiveness of a team, and this can be even more true in a hospital setting.

The Importance of Leadership

Successful integration of pharmacists into the multidisciplinary care team will require strong leadership support. Adding a pharmacist to the team affects all other health care professionals on that team, so it is essential to have clear communication across different departments. This is especially important when it comes to clarifying roles, responsibilities, and expectations of different team members.

Strong leadership can help make clear why changes being made to the team represent an advantage for the team and the health care system in general. Leadership can also provide resources, training and support, so that each member of the team and their professional expertise is utilized fully and efficiently. Effective leadership is crucial for integrating pharmacists into multidisciplinary teams and enabling them to contribute meaningfully to the team's success.

REFERENCES

1. Lee H, Ryu K, Sohn Y, Kim J, Suh GY, Kim E. Impact on Patient Outcomes of Pharmacist Participation in Multidisciplinary Critical Care Teams: A Systematic Review and Meta-Analysis. Crit Care Med. 2019 Sep;47(9):1243-1250. doi:10.1097/CCM.0000000000003830.

2. Ruiz-Ramos J, Hernández MH, Juanes-Borrego AM, Milà R, Mangues-Bafalluy MA, Mestres C. The Impact of Pharmaceutical Care in Multidisciplinary Teams on Health Outcomes: Systematic Review and Meta-Analysis. J Am Med Dir Assoc. 2021 Dec;22(12):2518-2526. doi:10.1016/j.jamda.2021.05.038.

3. Byrne A, Byrne S, Dalton K. A pharmacist's unique opportunity within a multidisciplinary team to reduce drug-related problems for older adults in an intermediate care setting. Res Social Adm Pharm. 2022 Apr;18(4):2625-2633. doi:10.1016/j.sapharm.2021.05.003.

4. Kelepouris E, St Peter W, Neumiller JJ, Wright EE. Optimizing Multidisciplinary Care of Patients with Chronic Kidney Disease and Type 2 Diabetes Mellitus. Diabetes Ther. 2023 Jul;14(7):1111-1136. doi:10.1007/s13300-023-01416-2.