- Email: [email protected]
Establishing pathways for access to pharmacist-provided patient care
COMMENTARY
Establishing pathways for access to pharmacist-provided patient care Jon C. Schommer, William R. Doucette, and Lourdes G. Planas
Jon C. Schommer, PhD, Professor, College of Pharmacy, University of Minnesota, Minneapolis, MN.
Abstract Objective: To describe the pathways being established for access to pharmacist-provided patient care and supply recommendations for the next steps in this process. Data sources: A series of reports published by the American Pharmacists Association regarding pharmacist-provided patient care services. Summary: Community pharmacies and integrated health organizations have emerged as the two predominant pathways for patient access to pharmacist-provided patient care. We view these two pathways as complementary in helping cover patients’ entire medication therapy needs as they traverse acute and chronic health care services. However, gaps in access to pharmacist-provided care remain, especially during transitions in care. Conclusion: In further establishing pathways for access to pharmacist-provided patient care, we propose that the application of collaboration theory will help close gaps that currently exist between health care organizations. Such an approach carries risk and will require trust among participating organizations. This approach is also likely to require updating and contemporizing pharmacy practice acts and other statutes to allow pharmacists to practice at maximum capacity within new models of care. To perform their new roles and create sustainable business models to support these new functions, pharmacists will need to be paid for their services. To this end, changes will need to be made to payment and documentation systems, incentives, and contracting approaches to develop proper reimbursement and accounting for pharmacists’ new roles.
William R. Doucette, PhD, Professor, College of Pharmacy, University of Iowa, Iowa City, IA. Lourdes G. Planas, PhD, Assistant Professor, College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma, OK. Correspondence: Jon C. Schommer, PhD, University of Minnesota College of Pharmacy, 308 Harvard St., SE, Minneapolis, MN 54455; schom010@umn. edu Disclosure: The authors declare no relevant conflicts of interest or financial relationships. Received February 16, 2015. Accepted for publication June 4, 2015.
J Am Pharm Assoc. 2015;55:664–668. doi: 10.1331/JAPhA.2015.15029
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Downloaded From: http://japha.org/ by Chris Baumle on 01/12/2016
Journal of the American Pharmacists Association
PHARMACIST-PROVIDED PATIENT CARE
A
ccording to a report from the National Governors Association Center for Best Practices, “The critical role that medication management plays in treating chronic diseases suggests that the integration of pharmacists into chronic care delivery teams has the potential to improve health outcomes.”1 Recent development and expansion of pharmacist-provided patient care has been documented by a series of reports published by the American Pharmacists Association.2–10 Findings from these reports show that pharmacists are (1) coordinating medication care for patient-centered medical homes and primary care teams, (2) serving as the health care professionals responsible for ensuring optimal medication therapy outcomes, (3) leading transitions of care coordination, (4) leading chronic disease management teams, and (5) providing access to immunizations.
Objective The objective of this commentary is to describe the pathways being established for access to pharmacist-provided patient care and to supply recommendations for the next steps in this process.
Key Points Background: ❚❚
❚❚
The critical role that medication management plays in treating chronic diseases suggests that the integration of pharmacists into chronic care delivery teams has the potential to improve health outcomes. Pharmacists are (1) coordinating medication care for patient-centered medical homes and primary care teams, (2) serving as the health care professionals responsible for ensuring optimal medication therapy outcomes, (3) leading transitions of care coordination, (4) leading chronic disease management teams, and (5) providing access to immunizations.
Findings: ❚❚
❚❚
❚❚
Community pharmacies and integrated health organizations have emerged as the two predominant pathways for patient access to pharmacist-provided patient care. We view these two pathways for pharmacistprovided patient care as complementary in helping cover patients’ entire medication therapy needs as they traverse acute and chronic health care services. In further establishing pathways for access to pharmacist-provided patient care, we propose that the application of collaboration theory will help close gaps that currently exist between health care organizations.
Journal of the American Pharmacists Association
Downloaded From: http://japha.org/ by Chris Baumle on 01/12/2016
COMMENTARY
Access to pharmacist-provided patient care Community pharmacies and integrated health organizations have emerged as the two predominant pathways for patient access to pharmacist-provided patient care. Community pharmacies (e.g., independent, mass merchandiser, national chain, regional chain, and supermarket pharmacies) serve geographically defined communities, typically offer easy access without an appointment, are aligned with the procurement of prescription drugs, and employ the services of trusted pharmacists physically located within the community.10 Pharmacists working in this setting are central to the medication use process and are the most frequently encountered health professionals for many patients. In addition to access and convenience (e.g., in-person, telephonic, and online services), community pharmacy settings afford the opportunity to coordinate self-care behaviors that overlay prescribed therapies, including the use of over-the-counter drugs and nutritional supplements. For patients under the care of multiple prescribers, community pharmacies are ideal for improving continuity and coordination of care across providers and settings. Because many patients frequently and regularly visit community pharmacies, these settings are also ideal for improving the quality, safety, efficiency, and effectiveness of prescribed chronic care treatments. Integrated health organizations (e.g., acute care/inpatient hospitals, ambulatory care clinics, health system outpatient clinics, long-term and managed care facilities, physician’s offices) serve patient populations with targeted needs, often employ embedded pharmacists practicing within a team-based care model, are aligned with payer goals for meeting quality metrics and payfor-performance targets, and have been expanded based on evidence for showing that pharmacists are capable of solving problems.10 The integration of pharmacists into care teams is vital for establishing access to pharmacistprovided care at such sites. Pharmacists working at integrated health organizations are central to addressing medication use in acute care, disease management, and targeted outcome situations. Further, pharmacists in these settings help optimize the use of resources, provide unique expertise, and facilitate continuous qualityimprovement efforts for organizations.
Analysis We view these two pathways for pharmacist-provided patient care as complementary in helping cover patients’ entire medication therapy needs as they traverse acute and chronic health care services.11–15 However, gaps in access to pharmacist-provided care remain, especially during transitions in care. For example, a patient who is being discharged from a hospital will soon be interacting with his or her community pharmacist, at which point care would be enhanced by the sharing of informaj apha.org
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PHARMACIST-PROVIDED PATIENT CARE
tion between hospital and community pharmacists. The pharmacist’s role is central in the medication experience domain. We propose that pharmacist-to-pharmacist referral involving communication between different pharmacy and health care settings is a necessary next step for creating the access to pharmacist-provided patient care that is so profoundly needed in the health care system. It should be noted that the two pathways described here are not mutually exclusive and that there are some pharmacies and other organizations already serving as innovators in closing these gaps.11 However, we propose that the typical patient still encounters gaps in care and endures duplication of effort by pharmacists who do not have complete information at the time patient care services are provided. To enhance access to and reach the full potential of pharmacist contributions to patient care, there is a need to (1) update and contemporize pharmacy practice acts and other statutes in light of pharmacists’ new roles, (2) develop payments for these services that are commensurate with cost of provision and resultant value, (3) formalize pharmacist-to-pharmacist referrals so that pharmacists working in different systems have complete information and are able to collaborate, and (4) coordinate various segments of health care so that patients view them as seamless and patient-centered. Most of these recommendations are consistent with those recently made by the National Governors Association’s report on expanding pharmacists’ roles. The association suggested that states should address variation in their laws governing collaborative practice agreements, recognition of professional services and related payment issues, and access to health information technology systems.1 We believe that new models for pharmacist-provided patient care are likely to emerge over time. One example would be pharmacists taking full responsibility and being held accountable for quality and performance outcomes associated with medication management once the need for medication is identified. Thus, pharmacists would be responsible for all of the medication therapy needs of patients and would make referrals to other practitioners when pharmacy services are needed. Under this model, pharmacists would be considered primary chronic care service providers. This change could profoundly help patients who are using medications for chronic conditions by improving the continuity of their care. We propose that collaboration theory16–20 will be useful for the next steps that need to be taken in leading change and further establishing pathways for access to pharmacist-provided patient care. This approach can help close gaps that currently exist between organizations in the health care system by leading to the creation of strategic alliances and new processes of care.
Next steps Collaboration theory provides guidance on “how joint 666 JAPhA | 5 5:6 | NOV /DE C 2 0 1 5
ja p h a.org
Downloaded From: http://japha.org/ by Chris Baumle on 01/12/2016
decision-making among autonomous, key stakeholders of an interorganizational domain can be used to resolve planning problems of the domain and/or manage issues related to the planning and development of the domain.”20 Working together enables participating organizations to create and capture mutual advantages that translate into positive return on investment and more efficient management. Collaboration theory consists of five elements: 1. Collaborative performance systems 2. Information sharing 3. Decision synchronization 4. Incentive alignment 5. Integrated processes The practical application of collaboration theory has been realized in the past by product supply chains16 and the travel sector,20 with multiple organizations working together to fill gaps, achieve efficiencies, and create extra value for all participants. We believe that a similar approach could prove successful in the current health care environment. Collaborative performance systems are used to devise and implement performance metrics that guide collaborating organizations to improve overall performance.16 This process resolves the related issues of who should be involved in determining the mutual objective and what performance objectives should be specified with respect to the shared goal. It is assumed that use of this process will enhance each participating organization’s profit, return on investment, and cash flow. For example, current and future quality care indicators could be used to assess the performance of a collaborative system, which could affect the costs of care and payments to the providers involved. Because many health care performance metrics are associated with medication use, collaboration between pharmacists and other health care team members is essential. Information sharing denotes access to private data in all partners’ systems, enabling monitoring of the progress of service provision as customers pass through each process in the overall system.16 This includes data acquisition, processing, representation, storage, dissemination, status metrics, cost data, and performance data. Such access to information enables participating organizations to elicit a bigger picture of the situation that takes into account important factors for making effective decisions. For example, health information exchanges can be created to serve as a vital platform for providing coordinated care and for collecting information essential to continuous quality improvement initiatives to enhance outcomes of care. Decision synchronization can be defined as the extent to which participating organizations are able to orchestrate critical decisions for optimizing overall performance. This includes reallocating decision rights to synchronize planning and execution to match capacity Journal of the American Pharmacists Association
PHARMACIST-PROVIDED PATIENT CARE
for service provision with demand for services. The effectiveness of decision synchronization can be judged based on how it affects response toward fulfilling customer demands (logistical benefits) and efficiency for participating organizations (commercial benefits). For example, community pharmacists often identify information that is important to the success of medication therapy after the medication has been prescribed. Closer synchronization of drug selection and regimen overview is likely to improve medication management and outcomes. One way this could be accomplished is to have the pharmacist select the most appropriate medication for the patient’s health needs and financial situation using a collaborative practice agreement. Incentive alignment refers to the process of sharing costs, risks, and benefits among participating organizations. This motivates entities to act in a manner consistent with their mutual strategic objectives, including making decisions that are optimal for the overall domain and revealing truthful private information.16 Incentive alignment covers estimating costs, risks, and benefits, as well as formulating incentive schemes such as pay for performance and pay for effort.16 The assumption is that the actions of individual organizations are based on the expectation that they will result in mutual benefit, as well as benefit to the individual organization. For example, a collaborative system including hospitals, clinics, and community pharmacies could have payments linked to the quality and costs of care they jointly provide for a panel of patients. Integrated processes refer to the extent to which participating organizations design efficient processes that deliver services to customers in a timely manner at reduced costs.16 Explicit description of these processes allows organizations to synchronize the entire sequence of integrated work activities required to deliver services that fulfill customer needs. Flexibility is needed to respond to the variety of customer requirements at minimum costs with respect to supply capacity. To achieve this, participating organizations can redesign the distribution system, service offerings, production processes, and management systems to be cost effective and flexible to match supply with different conditions of customer demand. An example would be closer coordination across provider types when patients are hospitalized and then discharged. Sharing complete information and designing full integration during transitions of care would enhance care decisions, proving beneficial to both providers and patients.
Recommendations In further establishing pathways for access to pharmacist-provided patient care, we propose that the application of collaboration theory will help close gaps that currently exist between health care organizations. Such an approach carries risk and will require trust among Journal of the American Pharmacists Association
Downloaded From: http://japha.org/ by Chris Baumle on 01/12/2016
COMMENTARY
participating organizations. This approach is also likely to require updating and contemporizing pharmacy practice acts and other statutes to allow pharmacists to practice at maximum capacity within new models of care.1 To perform their new roles and create sustainable business models to support these new functions, pharmacists will need to be recognized with payment for their services. To this end, changes will need to be made to payment and documentation systems, incentives, and contracting approaches to develop proper reimbursement and accounting for pharmacists’ new roles.1
Conclusion These recommended changes are likely to result in new rules, technologies, and practices that grow beyond the boundaries of a specific collaborative context and are adopted broadly by other organizations throughout the whole domain.18 In our opinion, this next transformational step to establishing pathways for access to pharmacist-provided patient care is necessary and will likely result in desired outcomes for the whole pharmacy profession. Those who provide leadership for creating collaborative performance systems, information sharing, decision synchronization, incentive alignment, and integrated processes will help the pharmacy profession achieve its next great success. We propose that leadership will need to be involved at multiple levels, including national, state, professional, academic, and organizational. Also essential to making such advances will be pharmacist engagement and further education, especially regarding practice within collaborative systems. References 1. Isasi F, Krofah E. The expanding role of pharmacists in a transformed health care system. Washington, DC: National Governors Association Center for Best Practices; 2015. 2. American Pharmacists Association. Medication therapy management digest: perspectives on MTM service implementation. Washington, DC: American Pharmacists Association; 2008. 3. American Pharmacists Association. Medication therapy management digest: perspectives on the value of MTM services and their impact on health care. Washington, DC: American Pharmacists Association; 2009. 4. American Pharmacists Association. Medication therapy management digest—perspectives on 2009: a year of changing opportunities. Washington, DC: American Pharmacists Association; 2010. 5. Schommer JC, Planas LG, Johnson KA, Doucette WR. Medication therapy management digest—tracking the expansion of MTM in 2010: exploring the consumer perspective. Washington, DC: American Pharmacists Association; 2011. 6. Schommer JC, Doucette WR, Johnson KA, Planas LG. Positioning and integrating medication therapy management: an analysis of data from MTM environmental scans (2007–2010) and the future of MTM roundtable event. Washington, DC: American Pharmacists Association; 2012.
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7. Schommer JC, Doucette WR, Johnson KA, Planas LG. Positioning and integrating medication therapy management. J Am Pharm Assoc. 2012;52(1):12–24.
13. Shoemaker SJ, Ramalho de Oliveira D. Understanding the meaning of medications for patients: the medication experience. Pharm World Sci. 2009;30(1):86–91.
8. Schommer JC, Planas LG, Johnson KA, Doucette WR. Medication therapy management digest: pharmacists emerging as interdisciplinary health care team members. Washington, DC: American Pharmacists Association; 2013.
14. Shoemaker SJ, Ramalho de Oliveira D, Alves M, Ekstrand M. The medication experience: preliminary evidence of its value for patient education and counseling on chronic medications. Patient Educ Couns. 2011;83(3):443–450.
9. Schommer JC, Planas LG, Doucette WR. Medication therapy management digest: the pursuit of provider status to support the growth and expansion of pharmacist’s patient care services. Washington, DC: American Pharmacists Association; 2014.
15. Sanchez LD. Medication experiences of Hispanic people living with HIV/AIDS. Inov Pharm. 2010;1(1):6.
10. Schommer JC, Planas LG, Doucette WR. Patient care services provided by pharmacists—the environmental scan of providers (and payers): establishing pathways for access to pharmacistprovided patient care. Washington, DC: American Pharmacists Association; 2014. 11. Brummel A, Lustig A, Westrich K, et al. Best practices: improving patient outcomes and costs in an ACO through comprehensive medication therapy management. J Manag Care Spec Pharm. 2014;20(12):1152–1158. 12. Cipolle, RJ, Strand LM, Morley PC. Pharmaceutical care practice: the patient-centered approach to medication management services, 3rd ed. New York, NY: McGraw-Hill Companies; 2012:109–116.
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16. Simatupang TM, Sridharan R. An integrative framework for supply chain collaboration. Int J Logist Manag. 2005;16(2):257– 274. 17. Gajda R. Utilizing collaboration theory to evaluate strategic alliances. Am J Eval. 2004;25(1):65–77. 18. Lawrence TB, Hardy C, Phillips N. Institutional effects of interorganizational collaboration: the emergence of proto-institutions. Acad Manage J. 2002;45(1):281–290. 19. Savage GT, Bunn MD, Gray B, et al. Stakeholder collaboration: implications for stakeholder theory and practice. J Bus Ethics, 2010;96(1):21–26. 20. Jamal TB, Getz G. Collaboration theory and community tourism planning. Ann Tourism Res. 1995;22(1):186–204.
Journal of the American Pharmacists Association
Establishing pathways for access to pharmacist-provided patient care Jon C. Schommer, William R. Doucette, and Lourdes G. Planas
Jon C. Schommer, PhD, Professor, College of Pharmacy, University of Minnesota, Minneapolis, MN.
Abstract Objective: To describe the pathways being established for access to pharmacist-provided patient care and supply recommendations for the next steps in this process. Data sources: A series of reports published by the American Pharmacists Association regarding pharmacist-provided patient care services. Summary: Community pharmacies and integrated health organizations have emerged as the two predominant pathways for patient access to pharmacist-provided patient care. We view these two pathways as complementary in helping cover patients’ entire medication therapy needs as they traverse acute and chronic health care services. However, gaps in access to pharmacist-provided care remain, especially during transitions in care. Conclusion: In further establishing pathways for access to pharmacist-provided patient care, we propose that the application of collaboration theory will help close gaps that currently exist between health care organizations. Such an approach carries risk and will require trust among participating organizations. This approach is also likely to require updating and contemporizing pharmacy practice acts and other statutes to allow pharmacists to practice at maximum capacity within new models of care. To perform their new roles and create sustainable business models to support these new functions, pharmacists will need to be paid for their services. To this end, changes will need to be made to payment and documentation systems, incentives, and contracting approaches to develop proper reimbursement and accounting for pharmacists’ new roles.
William R. Doucette, PhD, Professor, College of Pharmacy, University of Iowa, Iowa City, IA. Lourdes G. Planas, PhD, Assistant Professor, College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma, OK. Correspondence: Jon C. Schommer, PhD, University of Minnesota College of Pharmacy, 308 Harvard St., SE, Minneapolis, MN 54455; schom010@umn. edu Disclosure: The authors declare no relevant conflicts of interest or financial relationships. Received February 16, 2015. Accepted for publication June 4, 2015.
J Am Pharm Assoc. 2015;55:664–668. doi: 10.1331/JAPhA.2015.15029
664 JAPhA | 5 5:6 | NOV /DE C 2 0 1 5
ja p h a.org
Downloaded From: http://japha.org/ by Chris Baumle on 01/12/2016
Journal of the American Pharmacists Association
PHARMACIST-PROVIDED PATIENT CARE
A
ccording to a report from the National Governors Association Center for Best Practices, “The critical role that medication management plays in treating chronic diseases suggests that the integration of pharmacists into chronic care delivery teams has the potential to improve health outcomes.”1 Recent development and expansion of pharmacist-provided patient care has been documented by a series of reports published by the American Pharmacists Association.2–10 Findings from these reports show that pharmacists are (1) coordinating medication care for patient-centered medical homes and primary care teams, (2) serving as the health care professionals responsible for ensuring optimal medication therapy outcomes, (3) leading transitions of care coordination, (4) leading chronic disease management teams, and (5) providing access to immunizations.
Objective The objective of this commentary is to describe the pathways being established for access to pharmacist-provided patient care and to supply recommendations for the next steps in this process.
Key Points Background: ❚❚
❚❚
The critical role that medication management plays in treating chronic diseases suggests that the integration of pharmacists into chronic care delivery teams has the potential to improve health outcomes. Pharmacists are (1) coordinating medication care for patient-centered medical homes and primary care teams, (2) serving as the health care professionals responsible for ensuring optimal medication therapy outcomes, (3) leading transitions of care coordination, (4) leading chronic disease management teams, and (5) providing access to immunizations.
Findings: ❚❚
❚❚
❚❚
Community pharmacies and integrated health organizations have emerged as the two predominant pathways for patient access to pharmacist-provided patient care. We view these two pathways for pharmacistprovided patient care as complementary in helping cover patients’ entire medication therapy needs as they traverse acute and chronic health care services. In further establishing pathways for access to pharmacist-provided patient care, we propose that the application of collaboration theory will help close gaps that currently exist between health care organizations.
Journal of the American Pharmacists Association
Downloaded From: http://japha.org/ by Chris Baumle on 01/12/2016
COMMENTARY
Access to pharmacist-provided patient care Community pharmacies and integrated health organizations have emerged as the two predominant pathways for patient access to pharmacist-provided patient care. Community pharmacies (e.g., independent, mass merchandiser, national chain, regional chain, and supermarket pharmacies) serve geographically defined communities, typically offer easy access without an appointment, are aligned with the procurement of prescription drugs, and employ the services of trusted pharmacists physically located within the community.10 Pharmacists working in this setting are central to the medication use process and are the most frequently encountered health professionals for many patients. In addition to access and convenience (e.g., in-person, telephonic, and online services), community pharmacy settings afford the opportunity to coordinate self-care behaviors that overlay prescribed therapies, including the use of over-the-counter drugs and nutritional supplements. For patients under the care of multiple prescribers, community pharmacies are ideal for improving continuity and coordination of care across providers and settings. Because many patients frequently and regularly visit community pharmacies, these settings are also ideal for improving the quality, safety, efficiency, and effectiveness of prescribed chronic care treatments. Integrated health organizations (e.g., acute care/inpatient hospitals, ambulatory care clinics, health system outpatient clinics, long-term and managed care facilities, physician’s offices) serve patient populations with targeted needs, often employ embedded pharmacists practicing within a team-based care model, are aligned with payer goals for meeting quality metrics and payfor-performance targets, and have been expanded based on evidence for showing that pharmacists are capable of solving problems.10 The integration of pharmacists into care teams is vital for establishing access to pharmacistprovided care at such sites. Pharmacists working at integrated health organizations are central to addressing medication use in acute care, disease management, and targeted outcome situations. Further, pharmacists in these settings help optimize the use of resources, provide unique expertise, and facilitate continuous qualityimprovement efforts for organizations.
Analysis We view these two pathways for pharmacist-provided patient care as complementary in helping cover patients’ entire medication therapy needs as they traverse acute and chronic health care services.11–15 However, gaps in access to pharmacist-provided care remain, especially during transitions in care. For example, a patient who is being discharged from a hospital will soon be interacting with his or her community pharmacist, at which point care would be enhanced by the sharing of informaj apha.org
N OV/D EC 2015 | 55:6 |
JAPhA 665
COMMENTARY
PHARMACIST-PROVIDED PATIENT CARE
tion between hospital and community pharmacists. The pharmacist’s role is central in the medication experience domain. We propose that pharmacist-to-pharmacist referral involving communication between different pharmacy and health care settings is a necessary next step for creating the access to pharmacist-provided patient care that is so profoundly needed in the health care system. It should be noted that the two pathways described here are not mutually exclusive and that there are some pharmacies and other organizations already serving as innovators in closing these gaps.11 However, we propose that the typical patient still encounters gaps in care and endures duplication of effort by pharmacists who do not have complete information at the time patient care services are provided. To enhance access to and reach the full potential of pharmacist contributions to patient care, there is a need to (1) update and contemporize pharmacy practice acts and other statutes in light of pharmacists’ new roles, (2) develop payments for these services that are commensurate with cost of provision and resultant value, (3) formalize pharmacist-to-pharmacist referrals so that pharmacists working in different systems have complete information and are able to collaborate, and (4) coordinate various segments of health care so that patients view them as seamless and patient-centered. Most of these recommendations are consistent with those recently made by the National Governors Association’s report on expanding pharmacists’ roles. The association suggested that states should address variation in their laws governing collaborative practice agreements, recognition of professional services and related payment issues, and access to health information technology systems.1 We believe that new models for pharmacist-provided patient care are likely to emerge over time. One example would be pharmacists taking full responsibility and being held accountable for quality and performance outcomes associated with medication management once the need for medication is identified. Thus, pharmacists would be responsible for all of the medication therapy needs of patients and would make referrals to other practitioners when pharmacy services are needed. Under this model, pharmacists would be considered primary chronic care service providers. This change could profoundly help patients who are using medications for chronic conditions by improving the continuity of their care. We propose that collaboration theory16–20 will be useful for the next steps that need to be taken in leading change and further establishing pathways for access to pharmacist-provided patient care. This approach can help close gaps that currently exist between organizations in the health care system by leading to the creation of strategic alliances and new processes of care.
Next steps Collaboration theory provides guidance on “how joint 666 JAPhA | 5 5:6 | NOV /DE C 2 0 1 5
ja p h a.org
Downloaded From: http://japha.org/ by Chris Baumle on 01/12/2016
decision-making among autonomous, key stakeholders of an interorganizational domain can be used to resolve planning problems of the domain and/or manage issues related to the planning and development of the domain.”20 Working together enables participating organizations to create and capture mutual advantages that translate into positive return on investment and more efficient management. Collaboration theory consists of five elements: 1. Collaborative performance systems 2. Information sharing 3. Decision synchronization 4. Incentive alignment 5. Integrated processes The practical application of collaboration theory has been realized in the past by product supply chains16 and the travel sector,20 with multiple organizations working together to fill gaps, achieve efficiencies, and create extra value for all participants. We believe that a similar approach could prove successful in the current health care environment. Collaborative performance systems are used to devise and implement performance metrics that guide collaborating organizations to improve overall performance.16 This process resolves the related issues of who should be involved in determining the mutual objective and what performance objectives should be specified with respect to the shared goal. It is assumed that use of this process will enhance each participating organization’s profit, return on investment, and cash flow. For example, current and future quality care indicators could be used to assess the performance of a collaborative system, which could affect the costs of care and payments to the providers involved. Because many health care performance metrics are associated with medication use, collaboration between pharmacists and other health care team members is essential. Information sharing denotes access to private data in all partners’ systems, enabling monitoring of the progress of service provision as customers pass through each process in the overall system.16 This includes data acquisition, processing, representation, storage, dissemination, status metrics, cost data, and performance data. Such access to information enables participating organizations to elicit a bigger picture of the situation that takes into account important factors for making effective decisions. For example, health information exchanges can be created to serve as a vital platform for providing coordinated care and for collecting information essential to continuous quality improvement initiatives to enhance outcomes of care. Decision synchronization can be defined as the extent to which participating organizations are able to orchestrate critical decisions for optimizing overall performance. This includes reallocating decision rights to synchronize planning and execution to match capacity Journal of the American Pharmacists Association
PHARMACIST-PROVIDED PATIENT CARE
for service provision with demand for services. The effectiveness of decision synchronization can be judged based on how it affects response toward fulfilling customer demands (logistical benefits) and efficiency for participating organizations (commercial benefits). For example, community pharmacists often identify information that is important to the success of medication therapy after the medication has been prescribed. Closer synchronization of drug selection and regimen overview is likely to improve medication management and outcomes. One way this could be accomplished is to have the pharmacist select the most appropriate medication for the patient’s health needs and financial situation using a collaborative practice agreement. Incentive alignment refers to the process of sharing costs, risks, and benefits among participating organizations. This motivates entities to act in a manner consistent with their mutual strategic objectives, including making decisions that are optimal for the overall domain and revealing truthful private information.16 Incentive alignment covers estimating costs, risks, and benefits, as well as formulating incentive schemes such as pay for performance and pay for effort.16 The assumption is that the actions of individual organizations are based on the expectation that they will result in mutual benefit, as well as benefit to the individual organization. For example, a collaborative system including hospitals, clinics, and community pharmacies could have payments linked to the quality and costs of care they jointly provide for a panel of patients. Integrated processes refer to the extent to which participating organizations design efficient processes that deliver services to customers in a timely manner at reduced costs.16 Explicit description of these processes allows organizations to synchronize the entire sequence of integrated work activities required to deliver services that fulfill customer needs. Flexibility is needed to respond to the variety of customer requirements at minimum costs with respect to supply capacity. To achieve this, participating organizations can redesign the distribution system, service offerings, production processes, and management systems to be cost effective and flexible to match supply with different conditions of customer demand. An example would be closer coordination across provider types when patients are hospitalized and then discharged. Sharing complete information and designing full integration during transitions of care would enhance care decisions, proving beneficial to both providers and patients.
Recommendations In further establishing pathways for access to pharmacist-provided patient care, we propose that the application of collaboration theory will help close gaps that currently exist between health care organizations. Such an approach carries risk and will require trust among Journal of the American Pharmacists Association
Downloaded From: http://japha.org/ by Chris Baumle on 01/12/2016
COMMENTARY
participating organizations. This approach is also likely to require updating and contemporizing pharmacy practice acts and other statutes to allow pharmacists to practice at maximum capacity within new models of care.1 To perform their new roles and create sustainable business models to support these new functions, pharmacists will need to be recognized with payment for their services. To this end, changes will need to be made to payment and documentation systems, incentives, and contracting approaches to develop proper reimbursement and accounting for pharmacists’ new roles.1
Conclusion These recommended changes are likely to result in new rules, technologies, and practices that grow beyond the boundaries of a specific collaborative context and are adopted broadly by other organizations throughout the whole domain.18 In our opinion, this next transformational step to establishing pathways for access to pharmacist-provided patient care is necessary and will likely result in desired outcomes for the whole pharmacy profession. Those who provide leadership for creating collaborative performance systems, information sharing, decision synchronization, incentive alignment, and integrated processes will help the pharmacy profession achieve its next great success. We propose that leadership will need to be involved at multiple levels, including national, state, professional, academic, and organizational. Also essential to making such advances will be pharmacist engagement and further education, especially regarding practice within collaborative systems. References 1. Isasi F, Krofah E. The expanding role of pharmacists in a transformed health care system. Washington, DC: National Governors Association Center for Best Practices; 2015. 2. American Pharmacists Association. Medication therapy management digest: perspectives on MTM service implementation. Washington, DC: American Pharmacists Association; 2008. 3. American Pharmacists Association. Medication therapy management digest: perspectives on the value of MTM services and their impact on health care. Washington, DC: American Pharmacists Association; 2009. 4. American Pharmacists Association. Medication therapy management digest—perspectives on 2009: a year of changing opportunities. Washington, DC: American Pharmacists Association; 2010. 5. Schommer JC, Planas LG, Johnson KA, Doucette WR. Medication therapy management digest—tracking the expansion of MTM in 2010: exploring the consumer perspective. Washington, DC: American Pharmacists Association; 2011. 6. Schommer JC, Doucette WR, Johnson KA, Planas LG. Positioning and integrating medication therapy management: an analysis of data from MTM environmental scans (2007–2010) and the future of MTM roundtable event. Washington, DC: American Pharmacists Association; 2012.
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COMMENTARY
PHARMACIST-PROVIDED PATIENT CARE
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