- Email: [email protected]
Building Working Relationships With Providers
PHARMACY ADMINISTRATION AND MANAGEMENT
Building Working Relationships With Providers Before pharmacists can benefit from collaborative practice agreements, they must first build stronger working relationships with physicians.
Recently, much attention has been focused on collaborative practice agreements (CPAs) as a way for pharmacists to integrate their services into physicians’ practices. Although 40 states had authorized some form of collaborative drug therapy management as of January 2003, few pharmacists have engaged in these relationships. In this session, William R. Doucette, PhD, and Randal P. McDonough, PharmD, MSPharm, encouraged pharmacists to view CPAs as a relatively late stage in the collaborative process and to concentrate initially on developing strong working relationships with physicians. “If a pharmacist approaches a physician about signing a collaborative practice agreement without having first engaged in relationship development, the physician is likely to view the collaboration with skepticism,” said Dr. Doucette. “It’s a lot like walking up to a total stranger on the street and asking if the person wants to get married!” To help pharmacists build closer professional ties with physicians, the speakers presented their five-stage model of a collaborative working relationship (CWR).1 The model provides a framework to help pharmacists advance their professional relationships with physicians and ultimately enter into successful CPAs, if they desire. Strengthening the professional bond between pharmacists and physicians offers many benefits, the speakers noted. When pharmacists and physicians share responsibility for patient care, drug therapy monitoring is increased, timelier exchange of patient information can occur, and drug therapy problems can be resolved more quickly. In addition, because physicians are a major resource for patient referrals, these collaborations are crucial for expanding pharmaceutical care services.
Based on presentations by Randal P. McDonough, PharmD, MSPharm, and William R. Doucette, PhD, associate professors, University of Iowa College of Pharmacy, Iowa City. S44
Supplement to the Journal of the American Pharmacists Association (www.japha.org)
Stages of the CWR Model The development of working relationships between pharmacists and physicians typically moves through a series of stages, advancing from brief interactions on routine matters to mutually beneficial partnerships in which both parties have clearly defined roles and patient-care responsibilities (see Figure 1). Stage 0: Professional Awareness. In this pre-relationship stage, pharmacists and physicians tend to have stereotypical views of each other, characterized by brief exchanges of a discrete nature. For example, the pharmacist may call the physician with a refill request or to clarify a dosage. Typically, the pharmacist has not yet thought about building the relationship. Likewise, the physician may see little value in the pharmacist’s services and no need to collaborate. Stage 1: Professional Recognition. In this stage, pharmacists begin to make physicians aware of the services they can provide. Usually, pharmacists must take the initiative to build awareness of their skills and desire to collaborate. To promote professional recognition, the pharmacist can regularly provide useful information to the physician, such as feedback on patients’ adherence or periodic updates on patients’ medication histories. As physicians come to expect such value-added services, they begin distinguishing that pharmacy from others, setting the stage for a trial of services. Stage 2: Exploration and Trial. During this stage, a physician begins to test the pharmacist’s abilities, usually by referring one or more patients on a trial basis. Dr. McDonough cautioned that physicians may initially send their most difficult patients so they can more fully gauge the pharmacist’s competence. Pharmacists must be ready to deliver on their promise of high-quality service and demonstrate a high degree of proficiency. “The pharmacist needs to do an outstanding job,” said Dr. Doucette. “Remember, a first impression is a lasting impression.” Because commitment between providers is limited during this stage, relationships tend to be fragile and easily dissolved. Stage 3: Professional Relationship Expansion. If earlier stages of the relationship have been successful, the pharmacist can September/October 2003
Vol. 43, No. 5, Suppl. 1
W orking Relationships PHARM ACY ADM INISTRATION AND M ANAGEM ENT
expand the scope of the collaboration, such as by providing care for more patients or offering additional services. During this stage, communication becomes more bilateral, as physicians become more willing to initiate interactions or suggest ways to expand the collaboration. However, as the relationship grows, so does the potential for conflict. Avoiding conflict with the physician is not always the best approach, Dr. Doucette said. Instead, negotiating a resolution that is satisfactory to both parties may strengthen the relationship. Stage 4: Commitment to Collaboration. As the collaboration becomes more firmly established, physicians begin to depend on the knowledge and skills that pharmacists bring to the CWR. Pharmacists likewise become more reliant on the clinical information that physicians provide to help them manage patients’ drug therapy. During this stage, pharmacists must be careful not to take the relationship for granted, but strive to improve the quality and scope of their services and communication. Careful documentation of patient care, periodic analysis of clinical outcomes, continuous quality improvement, and clear channels of communication are vital for the ongoing success of the collaboration. Once the relationship has reached the final stage in the model, the pharmacist and physician may decide to formalize their relationship by entering into a CPA. This written, signed agreement clearly defines the patient care process, the responsibilities of each provider, the outcomes that will be collected, and the method of reimbursement. A CPA can enhance the image of the pharmacy practice and provide a guaranteed patient base if both providers adhere to the agreement. Before the CPA is finalized, it is important to give the physician ample time to provide input on the agreement to ensure his or her full commitment, Dr. McDonough advised.
Strategies to Advance Collaborations Dr. McDonough recommended several strategies for advancing professional collaborations, beginning with face-to-face meetings with physicians to acquaint them with pharmacy services and determine their patient-care needs. To gain access to busy physicians and useful information about their practices, pharmacists should try to get to know key contacts in the office, such as nursing staff, office manager, and receptionist. Before the first meeting, try to learn as much as possible about the practice and the patient populations it serves. During the meeting, focus the discussion on ways the pharmacy can provide solutions to the identified patient care needs in the practice. If initial efforts to develop a collaboration are not successful, be persistent. Often, physicians need more time and additional information before they agree to collaborate with pharmacists, especially if they have not had similar experiences in the past. A major roadblock to successful collaborations is a lack of confidence among pharmacists in their ability to provide patient-care services. However, once pharmacists begin to perform interventions, even on a small scale, their confidence invariably grows as Vol. 43, No. 5, Suppl. 1
September/October 2003
Figure 1. Model for Pharm acist–Physician Collaborative W orking Relationships Commitment to the Collaborative Working Relationship Stage 4
Professional Relationship Expansion Stage 3
Exploration and Trial Stage 2
Professional Recognition Stage 1
Professional Awareness Stage 0
they see the positive impact of their recommendations. “Become an interventionist,” urged Dr. McDonough. “Demonstrate what you can do and show how you can work with physicians to improve patient care and benefit both practices.”
Summary Developing strong professional collaborations with physicians can improve patient outcomes and benefit both the physician’s and the pharmacist’s practices. n The five-stage CWR model provides a framework to guide pharmacists in advancing their professional relationships with physicians. n To develop successful collaborations, pharmacists must be ready to take the initiative and tailor their services to the needs of physicians in their communities. n Once the professional relationship is well established, entering into a CPA can enhance the image of the pharmacy and ensure a more predictable base of patients. n
Reference 1. McDonough RP, Doucette WR. Developing collaborative working relationships between pharmacists and physicians. J Am Pharm Assoc. 2001;41:682–92.
Supplement to the Journal of the American Pharmacists Association (www.japha.org)
S45
Building Working Relationships With Providers Before pharmacists can benefit from collaborative practice agreements, they must first build stronger working relationships with physicians.
Recently, much attention has been focused on collaborative practice agreements (CPAs) as a way for pharmacists to integrate their services into physicians’ practices. Although 40 states had authorized some form of collaborative drug therapy management as of January 2003, few pharmacists have engaged in these relationships. In this session, William R. Doucette, PhD, and Randal P. McDonough, PharmD, MSPharm, encouraged pharmacists to view CPAs as a relatively late stage in the collaborative process and to concentrate initially on developing strong working relationships with physicians. “If a pharmacist approaches a physician about signing a collaborative practice agreement without having first engaged in relationship development, the physician is likely to view the collaboration with skepticism,” said Dr. Doucette. “It’s a lot like walking up to a total stranger on the street and asking if the person wants to get married!” To help pharmacists build closer professional ties with physicians, the speakers presented their five-stage model of a collaborative working relationship (CWR).1 The model provides a framework to help pharmacists advance their professional relationships with physicians and ultimately enter into successful CPAs, if they desire. Strengthening the professional bond between pharmacists and physicians offers many benefits, the speakers noted. When pharmacists and physicians share responsibility for patient care, drug therapy monitoring is increased, timelier exchange of patient information can occur, and drug therapy problems can be resolved more quickly. In addition, because physicians are a major resource for patient referrals, these collaborations are crucial for expanding pharmaceutical care services.
Based on presentations by Randal P. McDonough, PharmD, MSPharm, and William R. Doucette, PhD, associate professors, University of Iowa College of Pharmacy, Iowa City. S44
Supplement to the Journal of the American Pharmacists Association (www.japha.org)
Stages of the CWR Model The development of working relationships between pharmacists and physicians typically moves through a series of stages, advancing from brief interactions on routine matters to mutually beneficial partnerships in which both parties have clearly defined roles and patient-care responsibilities (see Figure 1). Stage 0: Professional Awareness. In this pre-relationship stage, pharmacists and physicians tend to have stereotypical views of each other, characterized by brief exchanges of a discrete nature. For example, the pharmacist may call the physician with a refill request or to clarify a dosage. Typically, the pharmacist has not yet thought about building the relationship. Likewise, the physician may see little value in the pharmacist’s services and no need to collaborate. Stage 1: Professional Recognition. In this stage, pharmacists begin to make physicians aware of the services they can provide. Usually, pharmacists must take the initiative to build awareness of their skills and desire to collaborate. To promote professional recognition, the pharmacist can regularly provide useful information to the physician, such as feedback on patients’ adherence or periodic updates on patients’ medication histories. As physicians come to expect such value-added services, they begin distinguishing that pharmacy from others, setting the stage for a trial of services. Stage 2: Exploration and Trial. During this stage, a physician begins to test the pharmacist’s abilities, usually by referring one or more patients on a trial basis. Dr. McDonough cautioned that physicians may initially send their most difficult patients so they can more fully gauge the pharmacist’s competence. Pharmacists must be ready to deliver on their promise of high-quality service and demonstrate a high degree of proficiency. “The pharmacist needs to do an outstanding job,” said Dr. Doucette. “Remember, a first impression is a lasting impression.” Because commitment between providers is limited during this stage, relationships tend to be fragile and easily dissolved. Stage 3: Professional Relationship Expansion. If earlier stages of the relationship have been successful, the pharmacist can September/October 2003
Vol. 43, No. 5, Suppl. 1
W orking Relationships PHARM ACY ADM INISTRATION AND M ANAGEM ENT
expand the scope of the collaboration, such as by providing care for more patients or offering additional services. During this stage, communication becomes more bilateral, as physicians become more willing to initiate interactions or suggest ways to expand the collaboration. However, as the relationship grows, so does the potential for conflict. Avoiding conflict with the physician is not always the best approach, Dr. Doucette said. Instead, negotiating a resolution that is satisfactory to both parties may strengthen the relationship. Stage 4: Commitment to Collaboration. As the collaboration becomes more firmly established, physicians begin to depend on the knowledge and skills that pharmacists bring to the CWR. Pharmacists likewise become more reliant on the clinical information that physicians provide to help them manage patients’ drug therapy. During this stage, pharmacists must be careful not to take the relationship for granted, but strive to improve the quality and scope of their services and communication. Careful documentation of patient care, periodic analysis of clinical outcomes, continuous quality improvement, and clear channels of communication are vital for the ongoing success of the collaboration. Once the relationship has reached the final stage in the model, the pharmacist and physician may decide to formalize their relationship by entering into a CPA. This written, signed agreement clearly defines the patient care process, the responsibilities of each provider, the outcomes that will be collected, and the method of reimbursement. A CPA can enhance the image of the pharmacy practice and provide a guaranteed patient base if both providers adhere to the agreement. Before the CPA is finalized, it is important to give the physician ample time to provide input on the agreement to ensure his or her full commitment, Dr. McDonough advised.
Strategies to Advance Collaborations Dr. McDonough recommended several strategies for advancing professional collaborations, beginning with face-to-face meetings with physicians to acquaint them with pharmacy services and determine their patient-care needs. To gain access to busy physicians and useful information about their practices, pharmacists should try to get to know key contacts in the office, such as nursing staff, office manager, and receptionist. Before the first meeting, try to learn as much as possible about the practice and the patient populations it serves. During the meeting, focus the discussion on ways the pharmacy can provide solutions to the identified patient care needs in the practice. If initial efforts to develop a collaboration are not successful, be persistent. Often, physicians need more time and additional information before they agree to collaborate with pharmacists, especially if they have not had similar experiences in the past. A major roadblock to successful collaborations is a lack of confidence among pharmacists in their ability to provide patient-care services. However, once pharmacists begin to perform interventions, even on a small scale, their confidence invariably grows as Vol. 43, No. 5, Suppl. 1
September/October 2003
Figure 1. Model for Pharm acist–Physician Collaborative W orking Relationships Commitment to the Collaborative Working Relationship Stage 4
Professional Relationship Expansion Stage 3
Exploration and Trial Stage 2
Professional Recognition Stage 1
Professional Awareness Stage 0
they see the positive impact of their recommendations. “Become an interventionist,” urged Dr. McDonough. “Demonstrate what you can do and show how you can work with physicians to improve patient care and benefit both practices.”
Summary Developing strong professional collaborations with physicians can improve patient outcomes and benefit both the physician’s and the pharmacist’s practices. n The five-stage CWR model provides a framework to guide pharmacists in advancing their professional relationships with physicians. n To develop successful collaborations, pharmacists must be ready to take the initiative and tailor their services to the needs of physicians in their communities. n Once the professional relationship is well established, entering into a CPA can enhance the image of the pharmacy and ensure a more predictable base of patients. n
Reference 1. McDonough RP, Doucette WR. Developing collaborative working relationships between pharmacists and physicians. J Am Pharm Assoc. 2001;41:682–92.
Supplement to the Journal of the American Pharmacists Association (www.japha.org)
S45