New specialty forges sustained relationships between pharmacists and patients to manage complex medication regimens.

By Alex McEllistrem-Evenson, Editor, Health Workforce News

When the Board of Pharmaceutical Specialties (BPS) approved a petition to recognize Ambulatory Care Pharmacy Practice as an official specialty in June 2009, there was little fanfare outside of the profession. Despite the fact that many pharmacists have informally “specialized” in the care of ambulatory patients for more than twenty years, the concept itself is still relatively unknown. The first new specialty recognized by BPS in 13 years is notable, however, in terms of its significance to health workforce issues both by way of its applicability to current trends and hot topics as well as ways in which it differs from most of the other five pharmacy specialties recognized by BPS.

According to the petition, submitted jointly by the American Society of Health-System Pharmacists (ASHP), American College of Clinical Pharmacy (ACCP), and the American Pharmacists Association (APhA), Ambulatory Care Pharmacy Practice “is the provision of integrated, accessible health care services by pharmacists who are accountable for addressing medication needs, developing sustained partnerships with patients, and practicing in the context of family and community. This is accomplished through direct patient care and medication management for ambulatory patients, long-term relationships, coordination of care, patient advocacy, wellness and health promotion, triage and referral, and patient education and self management.”

In layperson’s terms, these pharmacists are certified experts in optimizing and managing the medications for patients with complex needs and who are also ambulatory (meaning they are not admitted to a hospital, long-term care, or similar inpatient facility). Dr. Stuart T. Haines, one of eight co-authors of the BPS petition, states that any specialty “focuses on patients with complex drug therapy needs. The Ambulatory Care specialty focuses on the special needs of people who have multiple concurrent illnesses and taking multiple medications,” and who often administer these drugs themselves or with the assistance of a caregiver at home.

“We’re talking about people with multiple diseases for which there are multiple medications,” he continues. “It gets complex because there is significant potential for adverse effects, drug interactions, and difficulties with medication adherence. Often these patients are cared for by multiple physicians. So there’s not a single person who may be looking out for the drug therapy needs of that patient.”

This is where the Ambulatory Care Pharmacy specialist comes in. The role these pharmacists play (and will play in an official capacity, starting in 2011) is a unique combination of technical expertise and direct, sustained primary patient care.

“There are different practice models as to how this is done,” states Haines, who is both a professor at the University of Maryland School of Pharmacy and a Clinical Pharmacy Specialist with the VA. “Typically these pharmacists serve in a direct patient care role, making decisions about drug therapies and adjustments to these therapies. An ambulatory care pharmacy specialist may be assigned to a patient to help manage a certain therapy because the physician can maximize his or her expertise by seeing other patients or because the therapy requires extensive, ongoing monitoring. In some situations, they’re consulted by physicians, nurse practitioners, or physician assistants to give recommendations for particularly difficult cases.”

“Sometimes the patient is seen by the pharmacist for a fixed period of time, three or four visits,” he adds. “In other cases, like with anticoagulation therapy or diabetes management, the relationship with the patient lasts for many years – perhaps the rest of the patient’s life.”

This sustained relationship is something many patients tend to associate with their family physician rather than their pharmacist, and it points to a continuing evolution within the profession as a whole surrounding the increased emphasis upon coordinated care models, sometimes referred to as “medical homes.”

“I think this is the future,” muses Haines. “I think people believe that having a medical home for patients is great. Patients and providers like it better, providers interact with the patients more effectively, they help meet their needs. It works; this is a model that works.”

“The problem,” elaborates Haines, “is the payment structure in many private insurance plans and even Medicare. It doesn’t reward a medical home. It rewards you to go find as many physicians in as many different locations as you like. That’s costly and it doesn’t foster communications between people.”

As a practicing pharmacist, Haines finds the concept of a medical home exciting. “The pharmacist has a special place there. There’s a lot of cost issues related to medications that pharmacists can address. Many chronic illnesses are treated with medications and some of the medications are very tricky to work with, require a lot of monitoring, a lot of patient education, and the one person whose trained to do that well is the clinically trained pharmacist.”

In Haines’ opinion, having board-certified specialists in Ambulatory Care pharmacy increases the likelihood that pharmacy can alleviate some of the burden on primary care physicians. “Our purpose as a specialty is to help take care of patients,” states Haines. “That’s ultimately the goal. If there are more of us around that can monitor patients on complex drug therapies one can envision how that would free up somebody from having to do that – right now, it’s either not being done at all or not being done by a person whose training is specific to managing drug therapies. That doesn’t mean physicians don’t care about this; they do, they just have a lot of other things on their plates. So having someone concentrate improves the quality of care and may alleviate some burden from primary care physicians.”

“With the appropriate payment structures in place, I think Ambulatory Care Pharmacy specialists will be a part of most practices because primary care physicians will recognize the value,” remarks Haines. “If they’ve got all of this drug therapy monitoring to do, which there is very time-consuming, they’ll want to offload it to someone they can trust, who they believe is competent. There’s no question that pharmacists with this kind of training are as good at managing these drug therapies as a primary care physician. They’re probably going to be better at it because they’ve been specifically trained to do it and dedicate their efforts to doing it well.”

Along with the concept of the patient-centered medical home, a high degree of focus in the health workforce world is trained on the federal money being directed towards Health Information Technology (HIT), via the economic stimulus bill. Proponents of HIT argue, among a host of other things, that instituting uniform electronic health records will provide a virtual “safety net” for physicians, alerting them of possible dangerous drug interactions, incorrect dosages, and providing immediate access to each patient’s complete medical history.

In short, HIT promises to manage many areas under the purview of the certified Ambulatory Care Pharmacy specialist. Haines agrees: “Health IT certainly can do those things. It’s an important ingredient in the whole quality improvement initiative.”

Haines is quick, however, to clarify that he doesn’t view this as a threat to the utility of the Ambulatory Care Pharmacist. “Someone’s got to put in those algorithms and alerts, make sure the alerts are effective, and take care of all the things that go into the HIT or electronic health records system,” he observes. “Those will be Ambulatory Care Pharmacy Specialists. That’s one role, to be involved in Health IT and to make sure that these systems make a difference. There’s only so many of us that work in the discipline. There’s not enough of us to be available at every patient encounter.”

“Health IT is absolutely a critical ingredient because the Ambulatory Care Pharmacy Specialist will need to focus on the patients with the most complex issues,” continues Haines. “What Health IT can’t do, at least not yet, is to work directly with a patient and make some value judgments and decisions about what works best for them. HIT can help provide advice to the physician seeing the patient at the time about a potential drug interaction, that’s true: sometimes we need to outright avoid the interaction. Other times, however, we recognize a drug interaction but decide to push forth anyway because the potential benefits outweigh the risks. HIT systems can’t tell physicians if it’s worth the drug interaction in a particular patient’s case and then follow that particular patient over time to make sure that the effects of whatever drug interaction that has occurred is minimized. That takes a judgment call and that’s where ambulatory care pharmacists can play an important role.”

“Even though you’re alerted to a potential problem doesn’t mean you can evaluate it, judge it, and manage it. With complex patients, that’s often what you’re doing. You’re managing risk; you’re making decisions about what the best mix of medications might be. In my position at the VA we spend a lot of time looking for things that we can discontinue. Often when you have people with multiple chronic illnesses, medications are continually being added to the regimen, but few are stopped. You get to the point where there are 15 or 20 meds, and we ask whether we really need to have all of these, if can we consolidate some things. No health IT system is going to be able to tell you how to make those judgment calls.”

Regardless of ways in which this particular specialty may augment some of these topics dominating debate regarding health care policy, Haines is quick to clarify that this wasn’t the primary motivation for seeking BPS certification. “Our goal is to ensure that those people who are practicing ambulatory care pharmacy specialists are doing a good job. By creating the credential, you have some assurance that these people are well-trained and competent. That’s the primary motivation, to certify those who are capable and to limit the possibility that others who are not so capable from managing these complex patients’ medication needs.”

If establishing a formal-certification procedure results in an increased role for and presence of clinical pharmacists in primary care, it would seem that we are all better off as a result.