If a health care facility is considering introducing or expanding ambulatory pharmacy services, it is important to note that depending on the population intended for service, such an endeavor can involve several different kinds of pharmacy practice. With this in mind, appropriate planning will allow targeted ambulatory pharmacy services to not only deliver increased patient satisfaction, but also impact the facility’s bottom line and improve readmission rates.
The University of Wisconsin Hospital and Clinics (UW Health) operates 12 retail ambulatory pharmacies and depending on the location and specialty of each individual clinic, its patient population can vary widely. For example, while the oncology pharmacy does fill medications other than chemotherapy, approximately 90% of that pharmacy’s business involves pre- and post-treatments or oral oncology treatments and therefore requires pharmacists and technicians with experience working with cytotoxic drugs. Likewise, the pharmacists at the children’s hospital pharmacy must contend with growth hormones, specialty age- and weight-based compounding, and children’s chemotherapy, so their aptitude and experience must be in line with these tasks.
Finding the Best Ambulatory Pharmacists
Given the breadth of pharmacy practice types in the ambulatory setting, the successful ambulatory pharmacist must be able to multi-task and solve problems quickly. An ambulatory pharmacist may need to advise a patient on how to manage an adverse event, then switch to another patient and assist him or her on navigating a prior authorization system, then switch again to help a provider with formulary management.
Furthermore, invariably, ambulatory pharmacists need to enjoy or at least be experienced in speaking directly with patients, as direct interactions, such as OTC recommendations, are quite common. Patients often come to ambulatory pharmacists as a first-line health care provider. While we do not make blind recommendations, and the vast majority of such inquiries are directed to the patient’s primary care physician, it is our obligation to help our patients to a reasonable extent, and this can often involve some degree of counseling.
Facilitating Transfers in Care
At UW Health, we have a new program where we assign a technician to be our transition-in-care specialist who talks to newly admitted patients about their plans upon discharge, and then helps to facilitate test claims and prior authorizations ahead of time. This ensures that if a patient leaves with a prescription regimen of specialized medications, financial coverage has been already determined and discharge will not be delayed due to insufficient funding for medications or unfinished authorization paperwork.
Further to this, when a doctor sends a prescription to one of our ambulatory pharmacies, we can view allergies and disease states, and input insurance information and personal information accessed directly from the UW Health EMR. When patients arrive at one of our ambulatory pharmacies, their information is already entered and the medication pick-up process moves quickly.
In order to perpetuate patient safety, following the establishment of care for a patient through one of our ambulatory pharmacies, we offer a mail service for higher-risk patients, such as transplant recipients or those with HIV, to provide active support in making sure those patients come in for follow-up lab tests or for monitoring, as well as ensure they are adhering to their medication schedules.
Customer Service and Staffing
While all pharmacy practitioners are fundamental custodians of customer service, in the ambulatory setting, there is a direct service aspect that must be taken seriously for the business to grow. Accordingly, we have established a goal turnaround time of approximately ten minutes per prescription. This includes greeting the patient, filling the prescription, performing pharmacist verification, resolving any insurance issues, performing any necessary counseling, and cashing the patient out.
This kind of metric helps us establish staffing for each location. The standard retail model does not fit our unique areas of operation, mainly because our patients’ disease states tend to be complicated and specialized. As such, we dispense less atenolol and amoxicillin and more medications for multiple sclerosis and rheumatoid arthritis; products that have specific needs such as refrigeration or require injection technique education.
We also serve as a resource for our providers, who call with formulary issues, such as the compatibility of medications dispensed from our pharmacy with their clinic medications, or if they are mixing a vaccine that does not look right. These consultations occur every day at our ambulatory pharmacies.
Expanding Ambulatory Services
Last year, UW Health began providing influenza vaccines and began offering herpes zoster and pneumococcal vaccinations this year. One of our goals may be to expand our immunization program to include travel vaccinations in the next year. We also offer an antibiotic call-back program, where we call patients 48-72 hours after initiation to make sure they are complying with their regimen and are not experiencing side effects. Similarly, we have an oncology program involving medications that cause tolerance issues, so we only dispense a two-week supply and then we follow up regularly. Such medications can be very expensive, so the last thing we want is for patients to be non-compliant or to throw them out. Thus, we dispense in smaller amounts and provide direct, personalized follow up. Ultimately, we recognize the need to take care of our patients outside of the hospital in order to keep them from coming back to the hospital, unnecessarily.
Carrie Boeckelman, RPh, is a manager of ambulatory and community pharmacy services at University of Wisconsin (UW) Hospital and Clinics. She also is a clinical instructor at UW School of Pharmacy and is a preceptor for the Health System Pharmacy Administration Residency and Master’s Program at UW Hospital. Carrie received her BS in pharmacy from the University of Wisconsin, Madison.
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