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Allocating Clinical Pharmacists in the Ambulatory Care Setting


September 2013 - Vol. 10 No. 9 - Page #38

For many health care systems, scheduling and staffing pharmacists can be a challenge to efficient and productive workflow. Some practitioners prefer to work in the same environment perpetually, while others enjoy gaining experience in different areas of pharmacy practice to advance specific skill sets and overall pharmacy knowledge. Furthermore, many facilities staff employees at specific times and in specific places to take advantage of an individual’s specialized training or to balance spikes and lulls in workflow. 

Regardless of the reasons behind allocation of pharmacy resources, the process must be handled in such a way that efficiencies are gained, workload is properly managed, and operations remain transparent. One way to address these issues is to employ computer software to build, track, and maintain an allocation and scheduling model that places the most qualified practitioners in the ideal areas, and in the proper numbers, to meet patient acuity demands. 

Pharmacist Allocation in the Acute Care Setting
In 2010, a team led by the pharmacy department at the University of North Carolina (UNC) Hospitals and Clinics developed and deployed a new tool dubbed pCATCH to objectively validate the allocation of clinical pharmacist resources in our acute care practice care model.1

The term pCATCH—resembling an acrostic—identifies the five elements of the program that affect the allocation of pharmacist resources. These elements consist of the following:

  • The average daily Census for each clinical service
  • A gauge of patient Acuity using proprietary normative data from a contract benchmarking database firm and operational benchmarking solution to calculate a UNC service-specific pharmacy intensity score for each MS-DRG (Medicare severity diagnoses related group)
  • Teaching involvement of residents and student learners as well as the service’s ability to support specialty residency programs and added qualifications of board of pharmacy specialties
  • Annualized medication Cost data (drug expenditures) for each service
  • High priority medications that require specialized knowledge and more intensive monitoring by a clinical pharmacist

Acute Care versus Ambulatory Staffing
This unique tool has been in use at UNC Hospitals and Clinics for the past three years and has provided clinical and administrative leadership with an objective method to validate the allocation of pharmacist resources among acute care clinical services. From a macro perspective, the tool also is used for annual planning and to project the future allocation of awarded acute care clinical pharmacist resources in a generally accepted manner.

Effective utilization of pharmacist resources in the ambulatory care setting is generally not as developed as it is in the acute care setting. However, due to growing operational and regulatory focus on improving transitions of care, reducing preventable readmissions, shifting patient care to the outpatient setting when possible, and credentialing and recognizing pharmacists as patient care providers—a major focus of national pharmacy associations—the number of pharmacists practicing in the ambulatory care setting will continue to expand, as will the types of clinics in which they practice. This will induce facilities to create or acquire automated solutions to manage staffing in this setting.

Pharmacists as Clinical Practitioners
The state of North Carolina has been proactive in encouraging pharmacists to practice in the ambulatory care setting. The North Carolina Board of Pharmacy and North Carolina Medical Board acknowledge and allow clinical pharmacist practitioners (CPPs) to provide drug therapy management under the direction or supervision of a licensed physician who has provided written instructions for a patient and disease-specific drug therapy. CPP management may include ordering, changing, or substituting therapies and ordering tests, within agreed-upon management protocols.2 

Through the use of this credential, UNC Hospitals has expanded the number of its pharmacists practicing in the ambulatory care setting to almost 20. The following credentials are required for CPP registration2:  

  • Certification (BCPS, CGP) or ASHP residency including two years clinical experience, or
  • PharmD degree with three years experience, plus completion of one NCCPC or ACPE certificate program, or
  • BS degree with five years experience, plus completion of two certificate programs

Once registered, pharmacists can be assigned to practice in hospital-owned clinics and they can bill a facility fee for patient visits. CPPs also practice in physician-owned clinics, seeing and billing patients as both incident to and independent of physician visits. Currently, the UNC pharmacy department has pharmacists managing patients in the following clinics: endocrinology, cardiology, anesthesiology, geriatrics, solid organ transplantation, family medicine, internal medicine, bone marrow transplantation, oncology, and palliative care. Anticipated future expansion into other clinics including rheumatology, psychiatry, hepatology, neurology, and pediatric bone marrow transplant are planned concurrent to ongoing recruitment initiatives both internally and externally; we are looking for practitioners who can ensure the continued advancement of pharmacy practice for all patients within North Carolina.

Pharmacist Allocation in the Ambulatory Setting
Given the number of pharmacy practitioners currently working in the ambulatory setting at UNC, the planned growth over the next few years, and the variety of clinics where pharmacists are present, it is important to ensure that those clinics with the greatest need for pharmacist services are addressed first and that the workload is standardized and equivalent across clinics. 

Reflecting on past experiences with pCATCH in the acute care setting, we are engaged in further research to validate the applicability of the above-identified five elements in the ambulatory care setting. We expect these elements to become a part of future resource allocation models as ambulatory pharmacy practice and the assignment of clinical pharmacy practitioners continues to expand. Building on the initial findings of pCATCH for the acute setting, we are now applying them to the ambulatory setting as follows: 

1. Annual Number of Patient Clinic Visits (Census)
As with pCATCH in the acute care setting, the measurement of patient volume though a particular ambulatory care clinic is critical to the assessment of whether an advanced practicing pharmacist presence is required.

2. Patient Acuity
Using a combination of the number of prescribed medications and concurrent chronic patient conditions will likely form the backbone of patient acuity determinations.

3. Patient Care Education (Teaching)
We gauge teaching as it relates not to residents and students (as in the acute care model) but to teaching the patient. This metric will aim to account for medication regimens that may require more intense patient education, such as those for chronic conditions.

4. Acquisition Cost of Medications
Taking into consideration the billing structure and clinic efficiencies related to the care of the patient, the normalized acquisition cost of medication spend should be considered in ambulatory care pharmacist allocation models.

5. High Priority Medications
Medications including those with narrow therapeutic indices, those that may require pharmacist practitioner longitudinal drug monitoring and follow up, as well as high-risk medications, must be closely reviewed, tracked, and reconciled.

Conclusion
While additional research and model valuation and validation are required, the intent of this program is to summon pharmacy leadership to foster an effective and cost-efficient approach to applying finite pharmacist resources in the ambulatory care setting. Establishing a credible, reliable, and clearly defined method by which to perform this task should be a priority for any facility that seeks to expand the practice experience of its pharmacists and continue to present opportunities for pharmacists to practice to the top of their license. n

References

  1. Granko RP, Poppe LB, Savage SW, et al. Method to determine allocation of clinical pharmacist resources. Am J Health-Sys Pharm. 2012;69(16):1398-1404.
  2. Dennis BH. An overview of the clinical pharmacist practitioner in NC. North Carolina Association of Pharmacists Web site. Accessed March 26, 2013. Available at:http://www.ncpharmacists.org/displaycommon.cfm?an=13

Robert Granko, RPh, MBA, is an associate director of pharmacy at the University of North Carolina Hospitals. He graduated with his BS in pharmacy from Long Island University School of Pharmacy. Robert received his PharmD from the University of North Carolina at Chapel Hill and his MBA from Pfeiffer University School of Graduate Studies.

Jacob Holler, PharmD, MS, BCPS, is an acute care pharmacy manager at Henry Ford Hospital in Detroit, Michigan. He graduated from the University of Michigan College of Pharmacy and completed the Health System Pharmacy Administration residency program at University of North Carolina Hospitals.

Stephen F. Eckel, PharmD, MHA, BCPS, FAPhA, FASHP, is an associate director of pharmacy at UNC Hospitals, as well as a clinical associate professor in the division of practice advancement and clinical education and the division’s vice chair for graduate and postgraduate education. In addition, he is director of graduate studies and is in charge of the two-year MS in pharmaceutical sciences with a specialization in health-system pharmacy administration. Stephen received both his BS and PharmD from the University of North Carolina at Chapel Hill and his MHA from the UNC School of Public Health.

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