The Role of the Pharmacist
Poor communication and care coordination are barriers that impede medication management across settings of care. Clinical pharmacy services that provide primary care, medication review with patients upon discharge, and follow up in the ambulatory setting and appropriately document these critical services in the patient’s medical record can significantly reduce harm, eliminate waste, and improve patient outcomes. Innovative pharmacist-coordinated disease state management programs as a health care or medical home have been shown to result in significantly improved patient outcomes while demonstrating cost savings and improved patient satisfaction.
Examples of Transformational Change in Pharmacy Practice
Below are highlights of the important role pharmacists play in improving care coordination:
Medication Reconciliation: Northwestern Memorial Hospital determined its initial medication reconciliation compliance rate was 40%. Meanwhile 86% of prescription medication discrepancies originated in patients’ medication histories, which impacted inpatient orders. 
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A multidisciplinary team supported by hospital leadership, created the Medications at Transitions and Clinical Handoffs (MATCH) initiative to weave medication reconciliation into all points of patient care. In addition to enhancing the hospital’s electronic medical record system, the MATCH initiative implemented mandatory, multidisciplinary training to ensure that physicians were aware of medication histories prior to writing orders, nurses and pharmacists validated medication histories against active orders, and pharmacists participated as the final points of reconciliation. As a result, medication reconciliation compliance rates rose above 90%.
For additional details, please contact ASHP.
Medication History and Reconciliation Program: Initially, 80 percent of Community Health Network’s patients had at least one unresolved medication issue on their admission histories. Read more
A multidisciplinary team instituted a successful medication history and reconciliation program that, partnering with the IT department, developed an innovative approach to notifying pharmacists of new admissions, which allowed for more timely completion of medication histories. The new process also implemented electronic documentation by pharmacists in the medical record, thereby immediately alerting other hospital staff to availability of an updated medication history. This program significantly reduced unresolved medication issues. During the first nine months following implementation of the new process, pharmacists documented medication histories for more than 21,000 patients. Involving pharmacists in medication histories decreased unreconciled medications by a remarkable 73%.
For additional details, please contact ASHP.
Diabetes Care Collaborative Practice: In another study, pharmacists at two primary care clinics provided diabetes education, initiated or adjusted insulin therapy, and ordered pertinent laboratory tests to monitor patients’ response to therapy. Read more
Pharmacists also scheduled patient appointments with physicians, dietitians, social workers and psychologist, when appropriate. Patient—pharmacist interactions occurred face-to-face and by telephone. HbA1c concentrations were decreased from 11.1% to 8.9% (p=0.00004). After subtracting the cost of the pharmacists’ services and medical center charges for the appointment, the study saved the medical center a total of $103,950.
See Coast-Senior EA., Kelley CL, Kelley CL, et al. Management of patients with type 2 diabetes by pharmacists in primary care clinics. Ann Pharmacother 1998;32:636-41.
Pharmacist-Run Hypertension Clinic: Another study randomized patients with uncontrolled hypertension to usual care managed by a physician or to physician—pharmacist management in a pharmacist-run hypertension clinic for a period of one year. Read more
Pharmacists provided patient education, made treatment recommendations, and provided follow-up utilizing an evidence-based treatment algorithm. While significant reductions in blood pressure were seen in both groups, the intervention group with pharmacist involvement resulted in a significantly greater reduction in blood pressure (p<0.01) and significantly more of these patients reached their blood pressure goal (p<0.02). In addition, average visit costs per patient were significantly lower for the intervention group ($160 vs $195, p=0.04).
See Borenstein JE. Physician-pharmacist comanagement of hypertension: a randomized, comparative trial. Pharmacotherapy. 2003;23(2):209-16.
Relevant ASHP Best Practices
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