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Creating a Workflow for Medication Therapy Management

Heather Rickertsen works at Mercy Family Pharmacy in Dubuque, Iowa as a consulting and dispensing pharmacist.

Her patient care activities include an anticoagulation clinic, immunizations, Iowa Medicaid Pharmaceutical Care Management1, Medication Therapy Management (MTM), employee health screenings and medication reconciliation. Dr. Rickertsen is committed to the idea that “pharmacist provided patient care services are required for patients to safely and effectively use their medications.” She outlines a beneficial system in which pharmacists can efficiently provide care to patients utilizing various pre-existing tools.

Identify Barriers

It is important to begin by identifying barriers that exist to providing patient care services. Patients tend to view pharmacists only as medication providers. In addition, pharmacists often fail to see themselves as patient care service providers, lacking the confidence to do more for their patients beyond dispensing. Once this stereotype is overcome, pharmacists can work towards better patient care management (PCM) and MTM. Pharmacists also have a limited amount of time that they can devote to patient counseling, and their pharmacy design may be not be conducive to provision of patient care. Some common barriers are summarized below.

Barriers from the patient perspective:

  • Patients view pharmacists as medication providers rather than as health care providers.
  • Patients do not think they need the service because their doctor takes care of all of their needs.

Barriers from the pharmacist perspective:

  • Lack of confidence in ability to provide services. 
  • Lack of information - Not understanding the complete picture – no doctor’s chart – gaps in the information available to the pharmacist. Must depend largely on what patient communicates to you.
  • Time required to provide these services can seem prohibitive.
  • Fear of making final decision for an action plan and being flexible when that plan needs to change.

Barriers from the pharmacy technician perspective:

  • Do not feel as comfortable talking to patients. Pharmacy technicians sometimes do not have the same personal relationship with patients. Pharmacists can work to foster relationships between technicians and patients by developing scripts for technicians to handle questions and gather more information.
  • Pharmacy technicians may not be comfortable selling these services and may tend to accept the patient’s initial resistance.

From the provider’s perspective:

  • Fear of interference with the provider- patient relationship. Pharmacists must try to help providers understand that you are on the same team, working toward the same goal. Try to help them recognize how important pharmacist/physician communication is. Recognize that often the communication from the pharmacist to the physician may not be reciprocated.
  • Often billable services for the pharmacist may result in both direct and indirect costs for the physician. Pharmacists may try to share some costs with physicians through services like immunizations to encourage a collaborative effort.

Needs Assessment

The next step is to perform a needs assessment. Rickertsen describes a four step process:

  1. Identify services that may qualify for reimbursement through the various programs. Look at the number of patients you have that might have these needs.
  2. Perform an environmental analysis by examining what types of issues may be present in the pharmacy. Is there a common problem of non-adherence among patients or are they having a hard time finding payment? Also, the staff should identify payable patient services that could be beneficial to the patient population. These could include PCM/MTM, immunizations, anti- coagulation and disease state management.
  3. Identify human and physical resources needed to perform the services. This could include but are not limited to relationships with providers, educational requirements, labs access, electronic medical records, and outside participant involvement. One source of outside patient involvement is the patient’s family and friends. It is important that they have a concrete support group outside of the pharmacy.
  4. Think about and plan the logistic. How will the workflow be designed and what are the staffing requirements? Determine a workflow that will maximize access for patients. Be cautious of making any service feel elite – anyone should feel welcome.

Pharmacists’ goals should be to determine how programs can be made consistent and systematic so that they can be used at anytime. It is also important to look at factors that interrupt the service such as vacation time or maternity leave. The pharmacy must identify what Rickertsen calls “high alert areas” which are opportunities in the workflow that might cause a break in the service. Once these “high alert areas” are identified, it must be determined whether they are one-time or common issues. If they are just one-time issues then the pharmacy should work out a plan to prevent the issue from happening again. If they are common issues that come up often then the pharmacy should work to develop a process or a change in the process to eliminate these common issues.

For Rickertsen and Mercy the needs assessment was initially a formal process, acting in the step by step manner as mentioned above. Now the needs assessment continues as a less formal ongoing process that is situation driven. Issues constantly arise that need to be dealt with and new performance standards result. Continuous improvement is the goal.

Pharmacists and Their Team

Pharmacists can create diversified teams of professionals to help them care for patients. By diversifying the pharmacy team as it relates to skills and experience, pharmacists can develop patient care programs that are capable of offering a broad base of services and expertise. Think beyond the pharmacy when identifying your team. Relationships and communication with other providers will be vital to the success of many of your patient care services.

Within the pharmacy, team members should be allowed to focus on their areas of strength while learning new skills from others within the group. Pharmacists must recognize and acknowledge the talents and contributions of all team members. However, the team can also serve as a burden to the pharmacist and pharmacy as a whole. With a variety of people working in the pharmacy there is bound to be a variety of personalities, many of which do not get along with each other. Another issue that arises with a variety of people working is that they do not always work at the same time or the same place. A pharmacist could work one day and perform multiple patient interviews, but not work the next day when the pharmacy technician is reviewing the paperwork and entering information. In this scenario it becomes difficult for the technician to ask for clarification or pose questions. It is important to maintain open communication among all the members of the pharmacy staff.

Rickertsen and her team meet once a month to discuss issues and develop solutions. Most often one technician and one pharmacist will work on a problem together. This builds communication and trust among the team members. Another barrier often faced by the pharmacy team is the “high maintenance patient.” Some patients come to the pharmacy only willing to see a particular pharmacist. If that pharmacist happens to be unavailable, the patient may refuse to meet with other pharmacists. The group should convey a team approach to the patient so that if one pharmacist is not available, the patient will feel comfortable meeting with another pharmacist.

Pharmacy Technicians

Rickertsen asserts that that for pharmacists to establish effective workflow for services, they must be prepared to utilize staffing resources. Too often pharmacists feel that they must to do all the work themselves. Instead, pharmacists must utilize their staff – including technicians, other pharmacists, office staff, practice residents, and student pharmacists. Pharmacy technicians can be given new roles in assisting with patient services. By providing technicians with the skills required, they will gain the confidence required to work more independently and effectively, improving the efficiency of the workflow. Communication is also a key to the success of the pharmacy technician. Technicians often serve as the communication coordinator for the pharmacy practice. They can call patients and remind them of their visits or alert them of a change in their medication regime. Technicians can also communicate with other health care providers through faxing physician letters or obtaining laboratory values. Whether it is with patients, physicians or other pharmacists, pharmacy technicians are a cornerstone to the MTM communication process.

Pharmacy technicians can also aid in the process by scheduling patients, performing chart maintenance, completing quality assurance and workflow coordination, and identifying new patients. These are all tasks the pharmacist can delegate to their pharmacy technicians after providing the appropriate training and guidance, leaving more time for the pharmacists to work on providing quality patient care services.

The Role of Interns and Student Pharmacist

Pharmacy interns (student pharmacists who are employed by the pharmacy) can play a valuable role in the delivery or development of patient care services. Interns are encouraged to communicate upfront about what they hope to learn during the rotation so that sites can incorporate them into the process based on their interest and skill level. Pharmacists should communicate with patients so that they become comfortable with interns’ involvement in their care. This will help the interns develop skills and will also help patients learn to be flexible with who provides the service.

Another essential part to the pharmacist’s team is the student pharmacists that they often have on Introductory (IPPE) and Advanced Pharmacy Practice Experiences (APPE). These students are often with the pharmacy for only a limited period of time, so it is important that the student takes full advantage of their time spent in the pharmacy. Rickertsen mentions that most often IPPE and APPE students do not feel comfortable with the routine until about the third or forth week, and by this time the rotation is almost over. Her suggestion is that students should come to the site with ideas of what they want to accomplish during the rotation. This way, the student can get started right away and take full advantage of the experience. She also mentions that patients often enjoy working with student pharmacists. Some patients specifically ask if there are students around in the pharmacy. IPPE and APPE students are usually involved in drug therapy issues and patient write-ups, but there are a variety of areas in which the students can gain knowledge and enhance their rotation experience as well as play an integral role in the patient care process.

Continuous Improvement

A commitment to continuous improvement is essential to successful patient care services. Once the processes are in place, there must be a commitment across the team to follow through on the procedures that have been established. These processes include workflow associated with the patient services themselves, but may also includes other areas such staff development and education One of the key measures of improvement is patient satisfaction. The patient must believe that the program is beneficial. Patients may also want to save money and have better control of their disease or condition. Adverse reactions and multiple visits are fears, so patients want the reassurance that the pharmacist and their team will do all they can to prevent this.

Next, the quality of the program(s) is important. Are the pharmacists adhering to treatment guidelines, or are they leaving out essential steps? Patient outcomes should be reviewed and measured. What parameters must be established to measure outcomes? Are the programs successful? If not, then the team needs to work on modifying the program to result in greater success. Finally, look at efficiency. If inefficiencies exist, such as redundancy, analyze and modify the process to work toward optimal efficiency and greatest outcome for the patients.

Quality and effectiveness of programs can be measured by identifying quantifiable aspects of the program and documenting process. Rickertson and her staff examine a variety of benchmarks to determine the progress of the programs.

Benchmarks include:

  • Number of patient appointments
  • Number of patients visited
  • Number of cancelled or no-show patients
  • Number of hours spent with patients
  • Average time spent with patient
  • Changes in blood pressure
  • Changes in glucose
  • Changes in hemoglobin A1C
  • Changes in lipid profile

Business expansion also needs to be a part of the continuous improvement model. New marketing ideas should be put into action to bring in patients and to get physicians and other pharmacists involved. Needs for new services should also be examined through SWOT (Strengths, Weaknesses, Opportunities and Threats) analysis. A thorough SWOT analysis will help any business match their strengths to available opportunities for growth. Any new activities should be measured and monitored to determine their worth against cost and effort to implement.