Initiative to build pharmacists into care team benefits patients

Kristen Cook, PharmD, with Drew Prescott, PharmD, at Nebraska Medicine’s Midtown Health Center

A UNMC College of Pharmacy strategic initiative, in collaboration with Nebraska Medicine, has resulted in improved patient outcomes in management of common chronic conditions, including uncontrolled type 2 diabetes, across the metro Omaha area. 

UNMC and Nebraska Medicine’s PCMH Pharmacy program now encompasses 12 ambulatory care pharmacists at 14sites in Omaha and Bellevue.  

What is PCMH (Patient Centered Medical Home) pharmacy? Pharmacists take leading roles, under collaborative practice agreements with supervising physicians, in drug management and patient counseling to treat chronic conditions. 

Kristen Cook, PharmD, clinical associate professor of pharmacy practice, has practiced for years as a PCMH pharmacist at the Nebraska Medicine Midtown Clinic that began in 2013. In 2016, Nebraska Medicine expanded PCMH to all metro Omaha primary care locations, covered by just four pharmacists. 

“I remember saying to our team back then that it was my goal to get a full-time pharmacist in every single clinic,” said Stephen Mohring, MD, Nebraska Medicine’s PCMH medical director and assistant professor of general internal medicine at UNMC. 

Fellowship

The PCMH team has expanded into training fellows, creating a post-graduate year two residency in ambulatory care. It also provides an exceptional experiential training experience for dozens of pharmacy students each year, Dr. Knoell said. 

Anthony Donovan, PharmD, was the program’s first fellow, working with Dr. McAdam Marx. “He really did a lot of the roll-up-the-sleeves and hands-on work,” managing data and gleaning meaningful statistics, she said. 

Dr. Donovan, a Kearney Health Opportunities Program (KHOP) alum, is now ambulatory pharmacist program coordinator at Nebraska Medicine. 

In 2017, the UNMC College of Pharmacy identified ambulatory care as an area for growth, to better reach patients, better prepare future pharmacists and further develop its clinical research portfolio. The college’s goal to further build strength in this area has meshed well with Nebraska Medicine’s commitment to the PCMH model. 

“It really is a partnership,” said Andrea Keifer, PharmD, Nebraska Medicine ambulatory care pharmacy manager. 

“It’s what (PCMH pharmacists) bring to a team that includes a physician plus other team members as needed, such as a dietitian, social worker and/or a nurse care manager to address the needs of the patient. The pharmacist is just one vital component of that team.” 

The collaborative practice agreement was “completely novel” at the program’s outset, Dr. Mohring said, “to allow our pharmacists to co-manage patients in the primary care space.” 

The result, among patients with uncontrolled type 2 diabetes, for example, has been improved prescription adherence, improved A1C values (a measurement of blood sugar in diabetes patients) and fewer emergency department visits. 

“You can track numbers to see if these interventions led by pharmacists are making a difference, not just within individuals but across populations,” said Daren Knoell, PharmD, chair of pharmacy practice and science. “And the data is overwhelmingly positive. They are routinely and positively impacting thousands of patients and making them healthier.” 

“Their outcomes are better,” said Carrie McAdam Marx, PharmD, who was recruited to UNMC to help lead its pharmacotherapy health services research. “Research also shows that patients whose care team includes a pharmacist often cost less to payers and health systems because we’re keeping patients out of the hospital and emergency rooms, thereby saving overall cost.  

“But it’s also better for the patient.” 

When pharmacists are working at the top of their scope of practice, patients are more likely to have their medications work most effectively. 

“What we’re seeing is that patients’ A1C’s when the pharmacist manages it (in diabetes care), is dropping well over 2 percentage points,” Dr. McAdam Marx said. 

“And that is outstanding because drug therapy alone will probably drop it about one (point).” 

When patients see that, they tend to step up their game, too. 

Research shows patients are more engaged with their overall diabetes management with PCMH pharmacy. 

“When the patients have a pharmacist they feel connected to in the clinic, who is reaching out to them on a regular basis, it helps them understand their health care team is part of their community and their health is valued by the team,” Dr. Cook said.  

“The PCMH pharmacists are great at building these relationships that result in better health outcomes and take pride in how well they know their patients.”  

From a physician’s perspective, “There is almost never a day that goes by that the care I deliver isn’t better because of pharmacy in our primary care clinics,” Dr. Mohring said. 

“There is not a single more successful intervention in the collective lives of our primary care patients than the addition of pharmacists in our clinics.” 

It’s not just the pharmacists’ expertise in medications but also their rapport with patients that leads to these PCMH successes, Dr. Keifer said.  

“If a patient sees a provider every six months, for example for diabetes, it’s hard to make a lot of headway as far as therapy adjustments. So that’s where the pharmacist is checking on that patient every one to two weeks, to review their blood sugar readings, make some adjustments and provide other recommendations.  

“It’s those high touches in between the appointment with their primary care provider that make a difference,” Dr. Keifer said. 

The PCMH pharmacy program has been so successful in diabetes management, it’s since been expanded into Hepatitis C treatment, HIV pre-exposure prophylaxis (PrEP), tobacco cessation and Covid therapies, said Kyle Skiermont, PharmD, Nebraska Medicine’s vice president of pharmacy and therapeutics and the college of pharmacy’s assistant dean for clinical affairs. 

Said Dr. Keifer, “The pharmacists do ask a lot of questions, trying to understand what has happened in the past, what has worked well, really trying to understand the patient situation so they can devise the best plan.” 

Dr. Knoell said the PCMH pharmacists are “cohesive,” meeting regularly to share experiences, trade insights and offer new ideas. But beyond anecdotes, the team now also has a wealth of data upon which to draw. 

“We’ve built up an infrastructure network for information sharing, for practice elevation as well as scholarship,” Dr. Knoell said. 

“This is a flourishing area.” 

A two-year pilot program funded by Diabetes Care Foundation of Nebraska is bringing some of the strategies used in the UNMC PCMH pharmacy model to Hastings and Wayne, Nebraska, as well. 

2 comments

  1. Charles Fritch, M.D. says:

    Great and promising program. Congratulations !!- Charles Fritch, M.D. FACS.

  2. Michele Balas says:

    Fantastic idea. Such a wealth of information

Comments are closed.

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