Indiana University Health - Mooresville Primary Care and Methodist Internal Medicine

Practice setting

Indiana University Health has more than 20 ambulatory care pharmacists working in the outpatient setting. The majority of pharmacists practice in the primary care setting, though several practice in specialty clinics such as HIV, cystic fibrosis, pulmonary hypertension, and hepatitis C, etc. IU Health also has a PGY2 ambulatory care residency program and the residents rotate through the various clinical settings. The IU healthcare system is part of an ACO. It has a health plan for employees and as well as members of the general community.

Pharmacists are employed through the hospital pharmacy department and are contracted out to the IU Health Physician group. Pharmacists may split time between a variety of clinics. The number of physicians and patient volume varies with each site. The more established physician groups generally have a larger patient volume (e.g. 15 – 25 patients/day) while newer clinics have smaller volume (e.g. 4 – 8 patients/day). The disease states encountered include complex diabetes, anticoagulation management, polypharmacy, and osteoporosis. Pharmacists are working to establish new service lines as needed. Patients are seen mostly through individual patient appointments and are either referred directly by providers or auto-referred via population health registries.

Why was the pharmacy service developed?

IU Health pharmacy service lines were developed in order to support the primary care providers within the health system. Pharmacists have been involved in the ambulatory care space in some capacity within the system for over 10 years. Each additional service line brought to ambulatory care pharmacists is developed with the intent to help meet a need of the system, be it a direct goal for the ACO/health plan, or just to collaborate in order to provide the best care possible.

What training, certification, credentialing, and practice agreement is utilized by the practice site?

Most ambulatory care clinical specialists are board certified in Ambulatory Care practice (BCACP), although it is not a requirement. A few pharmacists have additional credentials, such as the Certified Diabetes Educator (CDE). There is not a standard for post graduate training currently because the program has been in existence for over 10 years and several of pharmacists switched from the inpatient world when the outpatient needs arose. The trend with new hires places emphasis on residency training and experience.

Currently, IU Health does not credential pharmacists. Pharmacists practice under system-wide collaborative drug practice agreements, which closely mimics accepted practice guidelines in the corresponding area. Protocols are in place in a variety of areas, including but not limited to anticoagulation, cardiovascular risk reduction, diabetes, dyslipidemia, hypertension, COPD, chronic pain, osteoporosis, tobacco cessation, migraine. Even with protocols, there is ample space to exercise clinical judgment; the pharmacist-physician relationships supports this practice.
 
What outcomes are being measured to evaluate the model's success?

A variety of metrics are tracked for IU Health clinics. INR range, A1C, blood pressure, statin therapy, aspirin therapy, smoking cessation rates, cost-savings to patient, and safety outcomes are examples of what is followed to help show the benefit that pharmacists bring to the team. Revenue is also tracked for all of our sites.

How have you made this service sustainable?

Currently, pharmacists bill "incident to" level 1 visit (99211) for visits as able. Different codes are used for the provision of Medicare Annual Wellness Visits, smoking cessation counseling, INR home monitor training, continuous glucose monitor placement/interpretation and spirometry. There is practice buy-in for part of the pharmacists' salary, as well as partial funding through the hospital's pharmacy budget. The pharmacy department is working with the billing and compliance officers and regional MAC to develop a model where pharmacists are able to bill at the level of service provided in order to generate more funds to support the pharmacists' role in clinics.  

How did you gain support of administrators, providers, and other key stakeholders?

The pharmacy manager works with the physician group leadership to determine where pharmacist services are needed and which practices would be most able to sustain these positions. Based on how highly-utilized a pharmacist is in the practice, some have been able to build a case for additional FTEs.

What are some lessons learned while implementing your practice model that you would like to share?

Starting a new clinic site exciting but is not always a walk in the park. This process is very involved and there are many moving parts. Each clinic differs and what works at one place, will not always work at the next. It is important to go in with a plan but to also be flexible based upon the needs of the practice. It is also imperative to incorporate seamlessly into the practice model in place. Be sure to utilize clinic staff to do clerical work, point of care testing, and vitals to ensure that pharmacists practice at the top of their license.