- Email: [email protected]
Pharmacist and Nurse Practitioner Collaboration in Nurse-managed Health Clinic
BRIEF REPORT
Pharmacist and Nurse Practitioner Collaboration in Nurse-managed Health Clinic Kylee A. Funk, PharmD, BCPS, Alexandra Paffrath, PharmD, and Jane K. Anderson, DNP, FNP, ANP ABSTRACT
Medication therapy problems, such as incorrect dosing, adverse drug reactions, and decreased adherence, result in harm to patients and increases in costs. In the literature, there are many examples of pharmacistphysician partnerships aimed to optimize patients’ medication use. As more nurse-managed health clinics continue to open, it is important for the nurse practitioner to consider partnership opportunities. In this report we describe an interprofessional “teamlet” consisting of a pharmacist and nurse practitioner as a model of collaborative care. Keywords: collaborative care, interprofessional team, medication management, nurse-managed health clinic, pharmacist Ó 2017 Elsevier Inc. All rights reserved.
BACKGROUND
F
or many patients, optimal medication use is an essential component of receiving the best care possible. The Institute of Medicine asserts that “Pharmaceuticals are the most common medical intervention, and their potential for both help and harm is enormous. Ensuring that the American people get the most benefit from advances in pharmacology is a critical component of improving the national health care system.”1(p13) However, it can be difficult to ensure that patients are receiving an optimized medication regimen. Patients commonly struggle with medications for various reasons. For example, some patients may not take medications as directed due to lack of education about the medication or disease it is treating, others may have difficulty affording or obtaining their medication, and still others may experience side effects that limit their ability to take the prescribed medication. These types of medication problems, among many others, impact the Triple Aim2—a concept that originated with the Institute for Healthcare Improvement with a goal to decrease overall health care costs, improve the patient’s experience, and optimize health care for the www.npjournal.org
population—by harming the patient and increasing their costs of care. To illustrate this point, drugrelated morbidity and mortality accounts for annual costs of > $200 billion in the United States—which is a greater cost than that spent on all medications annually.3 Our primary care clinic is a nurse practitioner‒ managed health clinic. Three nurse practitioners (NPs) provide about 1.5 full-time equivalents of care and 1 clinical pharmacist provides 0.4 full-time equivalent of care. We have taken a proactive approach to optimizing medication management through a partnership of NPs and clinical pharmacists. In our clinic, patients are seen in a variety of ways: through individual appointments with the NP; individual appointments with the clinical pharmacist; or through a co-visit with both the NP and pharmacist. For any patient with complex medication needs (these needs could be recognized by any member of our clinic, including the scheduler, medical assistant, or any provider), we attempt to perform a co-visit when the patient establishes care with our clinic. A patient visit through this partnership is illustrated in the case described. The Journal for Nurse Practitioners - JNP
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CASE REPORT
A 30-year-old woman, “Sue,” with a history of asthma, seasonal allergies, and depression with psychotic features, presented to the clinic with a chief complaint of diarrhea after recent antibiotic use for treatment of a sinus infection. The NP and pharmacist were the providers of Sue’s primary care and conducted a co-visit with Sue. An outside psychiatrist managed her mental health needs. At this visit, the chief complaint was addressed by stopping the antibiotic as sufficient treatment length was achieved. After the patient’s chief complaint was resolved, the pharmacist led the assessment of all the patient’s current medications. Each medication was evaluated for indication, effectiveness, safety, and convenience. Through this interview, the pharmacist and NP learned of several problems and worked with the patient on resolution: Asthma. When the pharmacist asked Sue about inhaler use, it became evident that there were gaps in understanding of her inhalers and she was using her controller inhaler as a rescue inhaler. As a result, Sue reported frequent nighttime awakenings and coughing with exertion. The NP identified that Sue’s asthma was severe, persistent, and poorly controlled, and may have been contributing to her frequent sinus infections. The patient was instructed on the appropriate use of inhalers and an asthma action plan was developed. The categorized the medication therapy problem as an inappropriate adherence. Allergies. The pharmacist asked Sue about her use of a steroid nasal spray and learned that the patient thought therapy was discontinued as she no longer had refills. With this, the patient reported frequent episodes of congestion and nasal discharge, which likely exacerbated her allergies, leading to frequent sinus infections. Refills of the nasal steroid spray were provided. The pharmacist categorized the medication therapy problem as non-adherence with need for education. Depression. When asked about medication changes, the pharmacist identified that Sue was experiencing dry mouth, which was likely e2
The Journal for Nurse Practitioners - JNP
associated with a recent dose increase in aripiprazole as prescribed by her psychiatrist to improve depressive symptoms. Sue stated she did not mention dry mouth to her psychiatrist out of concern that her discomfort would not be concerning to her psychiatrist. The patient was referred to dentistry due to oral health concerns from persistent dry mouth. The pharmacist categorized the medication therapy problem as adverse drug reaction. At follow-up, 1 week later, Sue reported appropriate adherence to both her nasal spray and inhalers and noted that her residual allergy symptoms had resolved. Some nasal drainage continued but no other side effects were mentioned. Sue was pleased with this control and noted that, with resolution of these symptoms, she could now exercise, and was no longer having nighttime awakenings. She had not yet presented for follow-up with dentistry or discussed dry mouth with her psychiatrist. THE PHARMACIST’S ROLE
The pharmacist’s role in primary care is expanding. In our clinic, comprehensive medication management (CMM) is practiced by the pharmacist. CMM by a pharmacist is considered a standard of practice by pharmacy organizations and is funded through certain government payers and private payers.4 CMM has several key components including: assessing each medication a patient is taking for indication, effectiveness, safety, and convenience; creating a care plan in coordination with the patient and the patient’s providers; and conducting follow-up visits with the patient to ensure that medication-therapy problems are resolved.3 CMM is a service that is distinct from, and complementary to, that of a primary care provider. CMM can help unveil medication adherence problems, medication interactions, and in general can increase patient satisfaction, as the practice helps to tailor a patient’s medication regimen to their individual goals and needs. In Sue’s case, when the pharmacist reviewed each medication, several issues were uncovered that may not have been identified or likely would not have been discovered as quickly in a routine primary care Volume
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Issue
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visit. Specifically, when the pharmacist reviewed the effectiveness of Sue’s nasal spray, it was clear that she was no longer taking the medication. Also, when the effectiveness of the inhalers was reviewed, it was apparent that the controller and rescue inhaler were not being used correctly. In addition, when the pharmacist reviewed the safety of aripiprazole, it was evident that the patient was experiencing potential side effects of the medication, but was hesitant to mention these side effects out of concern for how it would be received by her psychiatrist. In our clinic, the pharmacist and NP routinely perform co-visits on more complex patients. Throughout the pharmacist’s relationship with the patient, a comprehensive review of all the patient’s medications will take place. In Sue’s case, for example, when she established care with the clinic, acute concerns and a general medical history were addressed in a co-visit. The pharmacist then conducted a comprehensive medication review, as described in this case, in conjunction with Sue’s follow-up visit. THE NP’s ROLE
The NP’s role in primary care continues to become more significant; more than 80% of NPs are certified to practice in an area of primary care.5 In fact, NPs are choosing to practice in primary care at a much higher rate than physicians or physician assistants.5 NPs evaluate, diagnose, and treat patients in a comprehensive fashion.5 In our clinic, NPs serve as the patient’s primary care provider. In January 2015, legislative changes were enacted in the state of Minnesota that removed the requirement that NPs prescribe medications under a collaborative agreement with a physician.6 This legislation removed barriers and now allows the NPs in our clinic to perform to their full scope of practice. In addition, because the clinic is new and developing, the leadership and providers within the clinic have the luxury of creating new practice models and establishing partnerships with other professionals in new ways. INTERPROFESSIONAL TEAM OF NPs AND PHARMACISTS
Pharmacists have generally partnered and collaborated with physicians to provide comprehensive medication www.npjournal.org
management. Care provided to the patient in the context of a physician-pharmacist partnership has resulted in decreased overall costs and improved care based on multiple outcomes.7 As the role of NPs continues to expand in primary care, it is important for every NP to consider partnerships in clinical practice. Literature to date has mainly outlined the NP and pharmacist “teamlet” by focusing on specific conditions, such as tobacco abuse,8 heart disease,9 and diabetes.10 The interventions undertaken by these teams have demonstrated clinical improvements.8-10 The practice model of a teamlet consisting of an NP and pharmacist practicing in primary care has not been well documented. However, we believe the NP-pharmacist collaboration in this setting will likely be successful given: (1) improvements in care have been demonstrated with physician-pharmacist teams7; and (2) studies have suggested interprofessional models of care are likely to lead to improved care.11 Although the NP and pharmacist have some overlap in their professional expertise, their approach to patient visits is much different. The NP’s holistic approach to the health of each patient and the clinical pharmacist’s approach of assessing and optimizing the patient’s entire medication regimen set both of these providers apart from others. Both functions are important and independently have been shown to lead to improved patient outcomes. We believe that the collaboration we have described in using this teamlet approach provides an important and distinct feature for our patients. At our newly opened clinic, we do not yet have the patient volume to document outcomes from the care of the NP-pharmacist interprofessional team. However, we have found that our patients refer others to our clinic because of our model and we believe our collaboration has given us greater efficiency and enjoyment of our own work. In addition, the stories of patients like Sue, who achieved better health because she was cared for by our team, help us to move forward and continue to develop our model. References 1. Institute of Medicine. Informing the Future: Critical Issues in Health. 4th ed. Washington, DC: National Academies Press; 2007:13. 2. Berwick DM, Nolan TW, Whittington J. The Triple Aim: care, health, and cost. Health Aff. 2008;27(3):759-769. http://dx.doi.org/10.1377/hlthaff.27.3.759.
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3. Patient-centered Primary Care Collaborative. The patient-centered medical home: integrating comprehensive medication management to optimize patient outcomes. Resource Guide, 2nd ed. 2012. https://www .pcpcc.org/sites/default/files/media/medmanagement.pdf/. Accessed August 18, 2016. 4. American College of Clinical Pharmacy. McBane SE, Dopp AL, et al. Collaborative drug therapy management and comprehensive medication management—2015. Pharmacotherapy. 2015;35(4):e39-50. http://dx.doi.org/ 10.1002/phar.1563 5. American Association of Nurse Practitioners. NP infographic. https://www .aanp.org/images/about-nps/npgraphic.pdf/. Accessed August 18, 2016. 6. Minnesota Board of Nursing. APRN Scope of Practice Bill signed and effective January 1, 2015. http://mn.gov/health-licensing-boards/nursing/resources/ news/news- detail.jsp?id¼272-131175/. Accessed August 29, 2106. 7. Giberson S, Yoder S, Lee MP. Improving Patient and Health System Outcomes Through Advanced Pharmacy Practice. A Report to the US Surgeon General, Office of the Chief Pharmacist. Washington, DC: US Public Health Service; 2011. 8. Afzal Z, Pogge E, Boomershine V. Evaluation of a pharmacist and nurse practitioner smoking cessation program. J Pharm Pract. [epub ahead of print]. 9. Reilly V, Cavanagh M. The clinical and economic impact of a secondary heart disease prevention clinic jointly implemented by a practice nurse and pharmacist. Pharm World Sci. 2003;25(6):294-298. 10. Diggins K. Family nurse practitioner/pharmacist collaborative medication counseling in patients with diabetes. J Nurse Pract. 2014;10(9): 741-744. 11. Grumbach K, Bodenheimer T. Can health care teams improve primary care practice? JAMA. 2004;291(10):1246-1251.
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Kylee A. Funk, PharmD, BCPS, is an assistant professor at the University of Minnesota College of Pharmacy in Minneapolis and clinical pharmacist at the University of Minnesota Nurse Practitioners Clinic. She can be reached at [email protected]. At the time of writing, Alexandra Paffrath, PharmD, was an ambulatory care pharmacy resident at the University of Minnesota Nurse Practitioners Clinic. Dr. Paffrath currently practices as a clinical pharmacist in Fairview Health Systems. Jane K. Anderson, DNP, RN, ANP-C, FNP-C, is a clinical assistant professor in the School of Nursing at the University of Minnesota in Minneapolis and Clinical Director at the University of Minnesota Nurse Practitioners Clinic. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/17/$ see front matter © 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2017.04.001
Volume
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Issue
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2017
Pharmacist and Nurse Practitioner Collaboration in Nurse-managed Health Clinic Kylee A. Funk, PharmD, BCPS, Alexandra Paffrath, PharmD, and Jane K. Anderson, DNP, FNP, ANP ABSTRACT
Medication therapy problems, such as incorrect dosing, adverse drug reactions, and decreased adherence, result in harm to patients and increases in costs. In the literature, there are many examples of pharmacistphysician partnerships aimed to optimize patients’ medication use. As more nurse-managed health clinics continue to open, it is important for the nurse practitioner to consider partnership opportunities. In this report we describe an interprofessional “teamlet” consisting of a pharmacist and nurse practitioner as a model of collaborative care. Keywords: collaborative care, interprofessional team, medication management, nurse-managed health clinic, pharmacist Ó 2017 Elsevier Inc. All rights reserved.
BACKGROUND
F
or many patients, optimal medication use is an essential component of receiving the best care possible. The Institute of Medicine asserts that “Pharmaceuticals are the most common medical intervention, and their potential for both help and harm is enormous. Ensuring that the American people get the most benefit from advances in pharmacology is a critical component of improving the national health care system.”1(p13) However, it can be difficult to ensure that patients are receiving an optimized medication regimen. Patients commonly struggle with medications for various reasons. For example, some patients may not take medications as directed due to lack of education about the medication or disease it is treating, others may have difficulty affording or obtaining their medication, and still others may experience side effects that limit their ability to take the prescribed medication. These types of medication problems, among many others, impact the Triple Aim2—a concept that originated with the Institute for Healthcare Improvement with a goal to decrease overall health care costs, improve the patient’s experience, and optimize health care for the www.npjournal.org
population—by harming the patient and increasing their costs of care. To illustrate this point, drugrelated morbidity and mortality accounts for annual costs of > $200 billion in the United States—which is a greater cost than that spent on all medications annually.3 Our primary care clinic is a nurse practitioner‒ managed health clinic. Three nurse practitioners (NPs) provide about 1.5 full-time equivalents of care and 1 clinical pharmacist provides 0.4 full-time equivalent of care. We have taken a proactive approach to optimizing medication management through a partnership of NPs and clinical pharmacists. In our clinic, patients are seen in a variety of ways: through individual appointments with the NP; individual appointments with the clinical pharmacist; or through a co-visit with both the NP and pharmacist. For any patient with complex medication needs (these needs could be recognized by any member of our clinic, including the scheduler, medical assistant, or any provider), we attempt to perform a co-visit when the patient establishes care with our clinic. A patient visit through this partnership is illustrated in the case described. The Journal for Nurse Practitioners - JNP
e1
CASE REPORT
A 30-year-old woman, “Sue,” with a history of asthma, seasonal allergies, and depression with psychotic features, presented to the clinic with a chief complaint of diarrhea after recent antibiotic use for treatment of a sinus infection. The NP and pharmacist were the providers of Sue’s primary care and conducted a co-visit with Sue. An outside psychiatrist managed her mental health needs. At this visit, the chief complaint was addressed by stopping the antibiotic as sufficient treatment length was achieved. After the patient’s chief complaint was resolved, the pharmacist led the assessment of all the patient’s current medications. Each medication was evaluated for indication, effectiveness, safety, and convenience. Through this interview, the pharmacist and NP learned of several problems and worked with the patient on resolution: Asthma. When the pharmacist asked Sue about inhaler use, it became evident that there were gaps in understanding of her inhalers and she was using her controller inhaler as a rescue inhaler. As a result, Sue reported frequent nighttime awakenings and coughing with exertion. The NP identified that Sue’s asthma was severe, persistent, and poorly controlled, and may have been contributing to her frequent sinus infections. The patient was instructed on the appropriate use of inhalers and an asthma action plan was developed. The categorized the medication therapy problem as an inappropriate adherence. Allergies. The pharmacist asked Sue about her use of a steroid nasal spray and learned that the patient thought therapy was discontinued as she no longer had refills. With this, the patient reported frequent episodes of congestion and nasal discharge, which likely exacerbated her allergies, leading to frequent sinus infections. Refills of the nasal steroid spray were provided. The pharmacist categorized the medication therapy problem as non-adherence with need for education. Depression. When asked about medication changes, the pharmacist identified that Sue was experiencing dry mouth, which was likely e2
The Journal for Nurse Practitioners - JNP
associated with a recent dose increase in aripiprazole as prescribed by her psychiatrist to improve depressive symptoms. Sue stated she did not mention dry mouth to her psychiatrist out of concern that her discomfort would not be concerning to her psychiatrist. The patient was referred to dentistry due to oral health concerns from persistent dry mouth. The pharmacist categorized the medication therapy problem as adverse drug reaction. At follow-up, 1 week later, Sue reported appropriate adherence to both her nasal spray and inhalers and noted that her residual allergy symptoms had resolved. Some nasal drainage continued but no other side effects were mentioned. Sue was pleased with this control and noted that, with resolution of these symptoms, she could now exercise, and was no longer having nighttime awakenings. She had not yet presented for follow-up with dentistry or discussed dry mouth with her psychiatrist. THE PHARMACIST’S ROLE
The pharmacist’s role in primary care is expanding. In our clinic, comprehensive medication management (CMM) is practiced by the pharmacist. CMM by a pharmacist is considered a standard of practice by pharmacy organizations and is funded through certain government payers and private payers.4 CMM has several key components including: assessing each medication a patient is taking for indication, effectiveness, safety, and convenience; creating a care plan in coordination with the patient and the patient’s providers; and conducting follow-up visits with the patient to ensure that medication-therapy problems are resolved.3 CMM is a service that is distinct from, and complementary to, that of a primary care provider. CMM can help unveil medication adherence problems, medication interactions, and in general can increase patient satisfaction, as the practice helps to tailor a patient’s medication regimen to their individual goals and needs. In Sue’s case, when the pharmacist reviewed each medication, several issues were uncovered that may not have been identified or likely would not have been discovered as quickly in a routine primary care Volume
-,
Issue
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2017
visit. Specifically, when the pharmacist reviewed the effectiveness of Sue’s nasal spray, it was clear that she was no longer taking the medication. Also, when the effectiveness of the inhalers was reviewed, it was apparent that the controller and rescue inhaler were not being used correctly. In addition, when the pharmacist reviewed the safety of aripiprazole, it was evident that the patient was experiencing potential side effects of the medication, but was hesitant to mention these side effects out of concern for how it would be received by her psychiatrist. In our clinic, the pharmacist and NP routinely perform co-visits on more complex patients. Throughout the pharmacist’s relationship with the patient, a comprehensive review of all the patient’s medications will take place. In Sue’s case, for example, when she established care with the clinic, acute concerns and a general medical history were addressed in a co-visit. The pharmacist then conducted a comprehensive medication review, as described in this case, in conjunction with Sue’s follow-up visit. THE NP’s ROLE
The NP’s role in primary care continues to become more significant; more than 80% of NPs are certified to practice in an area of primary care.5 In fact, NPs are choosing to practice in primary care at a much higher rate than physicians or physician assistants.5 NPs evaluate, diagnose, and treat patients in a comprehensive fashion.5 In our clinic, NPs serve as the patient’s primary care provider. In January 2015, legislative changes were enacted in the state of Minnesota that removed the requirement that NPs prescribe medications under a collaborative agreement with a physician.6 This legislation removed barriers and now allows the NPs in our clinic to perform to their full scope of practice. In addition, because the clinic is new and developing, the leadership and providers within the clinic have the luxury of creating new practice models and establishing partnerships with other professionals in new ways. INTERPROFESSIONAL TEAM OF NPs AND PHARMACISTS
Pharmacists have generally partnered and collaborated with physicians to provide comprehensive medication www.npjournal.org
management. Care provided to the patient in the context of a physician-pharmacist partnership has resulted in decreased overall costs and improved care based on multiple outcomes.7 As the role of NPs continues to expand in primary care, it is important for every NP to consider partnerships in clinical practice. Literature to date has mainly outlined the NP and pharmacist “teamlet” by focusing on specific conditions, such as tobacco abuse,8 heart disease,9 and diabetes.10 The interventions undertaken by these teams have demonstrated clinical improvements.8-10 The practice model of a teamlet consisting of an NP and pharmacist practicing in primary care has not been well documented. However, we believe the NP-pharmacist collaboration in this setting will likely be successful given: (1) improvements in care have been demonstrated with physician-pharmacist teams7; and (2) studies have suggested interprofessional models of care are likely to lead to improved care.11 Although the NP and pharmacist have some overlap in their professional expertise, their approach to patient visits is much different. The NP’s holistic approach to the health of each patient and the clinical pharmacist’s approach of assessing and optimizing the patient’s entire medication regimen set both of these providers apart from others. Both functions are important and independently have been shown to lead to improved patient outcomes. We believe that the collaboration we have described in using this teamlet approach provides an important and distinct feature for our patients. At our newly opened clinic, we do not yet have the patient volume to document outcomes from the care of the NP-pharmacist interprofessional team. However, we have found that our patients refer others to our clinic because of our model and we believe our collaboration has given us greater efficiency and enjoyment of our own work. In addition, the stories of patients like Sue, who achieved better health because she was cared for by our team, help us to move forward and continue to develop our model. References 1. Institute of Medicine. Informing the Future: Critical Issues in Health. 4th ed. Washington, DC: National Academies Press; 2007:13. 2. Berwick DM, Nolan TW, Whittington J. The Triple Aim: care, health, and cost. Health Aff. 2008;27(3):759-769. http://dx.doi.org/10.1377/hlthaff.27.3.759.
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3. Patient-centered Primary Care Collaborative. The patient-centered medical home: integrating comprehensive medication management to optimize patient outcomes. Resource Guide, 2nd ed. 2012. https://www .pcpcc.org/sites/default/files/media/medmanagement.pdf/. Accessed August 18, 2016. 4. American College of Clinical Pharmacy. McBane SE, Dopp AL, et al. Collaborative drug therapy management and comprehensive medication management—2015. Pharmacotherapy. 2015;35(4):e39-50. http://dx.doi.org/ 10.1002/phar.1563 5. American Association of Nurse Practitioners. NP infographic. https://www .aanp.org/images/about-nps/npgraphic.pdf/. Accessed August 18, 2016. 6. Minnesota Board of Nursing. APRN Scope of Practice Bill signed and effective January 1, 2015. http://mn.gov/health-licensing-boards/nursing/resources/ news/news- detail.jsp?id¼272-131175/. Accessed August 29, 2106. 7. Giberson S, Yoder S, Lee MP. Improving Patient and Health System Outcomes Through Advanced Pharmacy Practice. A Report to the US Surgeon General, Office of the Chief Pharmacist. Washington, DC: US Public Health Service; 2011. 8. Afzal Z, Pogge E, Boomershine V. Evaluation of a pharmacist and nurse practitioner smoking cessation program. J Pharm Pract. [epub ahead of print]. 9. Reilly V, Cavanagh M. The clinical and economic impact of a secondary heart disease prevention clinic jointly implemented by a practice nurse and pharmacist. Pharm World Sci. 2003;25(6):294-298. 10. Diggins K. Family nurse practitioner/pharmacist collaborative medication counseling in patients with diabetes. J Nurse Pract. 2014;10(9): 741-744. 11. Grumbach K, Bodenheimer T. Can health care teams improve primary care practice? JAMA. 2004;291(10):1246-1251.
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Kylee A. Funk, PharmD, BCPS, is an assistant professor at the University of Minnesota College of Pharmacy in Minneapolis and clinical pharmacist at the University of Minnesota Nurse Practitioners Clinic. She can be reached at [email protected]. At the time of writing, Alexandra Paffrath, PharmD, was an ambulatory care pharmacy resident at the University of Minnesota Nurse Practitioners Clinic. Dr. Paffrath currently practices as a clinical pharmacist in Fairview Health Systems. Jane K. Anderson, DNP, RN, ANP-C, FNP-C, is a clinical assistant professor in the School of Nursing at the University of Minnesota in Minneapolis and Clinical Director at the University of Minnesota Nurse Practitioners Clinic. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/17/$ see front matter © 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2017.04.001
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2017