Collaborative practice agreements let pharmacists prescribe meds
Is prescribing in your future? The likelihood appears to be growing. The imperative to handle ambulatory patients cost-effectively is driving a trend for pharmacists to prescribe, especially in cases where patients’ needs are primarily for drug therapy maintenance. Some 17 states allow pharmacists to order medications, and that number is sure to grow as collaborative practices between phys-icians and pharmacists spread.
Those collaborative practices are evolving from the many pharmacist-run outpatient clinics mushrooming across the health care industry. Experts predict collaborative prac- tices will grow rapidly as managed care companies see the savings and good outcomes to be reaped by putting pharmacists in charge of managing their chronically ill patients. Even academia has responded to this trend by developing physical assessment and diagnostic courses for pharmacists.
Nowhere are pharmacist prescribing and collaborative practices more cutting edge than in the Veterans Administration. Either by administrative protocol or simply by an agreement between a physician and a pharmacist, VA pharmacists are increasingly stopping or starting meds, recommending or changing drug therapy, setting up prescribing guidelines, or even admitting and discharging patients. The VA system has been so successful its pharmacists are increasingly lecturing on the system’s methods to pharmacists across the United States and overseas.
"If any of us were to gaze into our crystal balls, I think it still would have been not so much if this will happen but when," says Steven Cano, MS, director of pharmacy at Fallon Healthcare Systems in Worcester, MA. "If you look at the health care profession, the traditional roles we’ve come to accept are being blurred. I think the leaders in our various professions are always looking out 20 to 30 years and have found that the distinct roles are no longer needed as much as flexibility. Managed care is certainly an influence, and you’re seeing change in pharmacy school curriculums as everybody needs to do a little bit of everything. Pharmacists need a prescriptive role, and we’re prepared to let go of some of the things we’ve been doing."
VA systems leading the way
A 1995 VA directive from headquarters in Washington, DC, opened the door for clinical pharmacists, but the degree of pharmacist input still is decided within each hospital. Arguably the most progressive setup within the VA system and easily outpacing non-VA systems is the West Palm Beach (FL) VA Medical Center.
There, outpatient teams of two PharmDs with physicians, nurse practitioners, dietitians, and support staff make up pharmacotherapy clinics covering a range of patient problems from hypertension to diabetes. They are housed under one roof, with the clinical PharmDs considered the primary caregivers.
Under the West Palm pharmacotherapy clinic structure, PharmDs can prescribe, change, or adjust a medication without a physician cosigning. PharmDs also can approve a nonformulary drug if a formulary drug has failed. The only things these pharmacists cannot prescribe are controlled substances.
In the Coumadin (warfarin) clinic, which is run solely by staff pharmacists, they have prescription authority on dosages and drug therapy, which requires a clinical pharmacist to cosign.
"The doctors refer disease states to us, and we will take complete care of that patient. If we decide to change a medication, we do it on our own," says Donna Beerhle, PharmD, ambulatory care pharmacotherapy specialist. "Patients come in and are originally seen by a doctor, and if, for example, a patient has uncontrolled diabetes, the doctor will put that in the plan notes and refer the patient to a PharmD for follow-up and management of that disease."
If patients develop comorbidities while in therapy, they are referred to the clinic for re-evaluation, she says. The 100-bed hospital sees about 14 to 18 patients a day in the phar-macotherapy clinics, and staff shoot for half-hour appointments each.
"At first the clinic was so busy with clinical pharmacists just seeing the Coumadin patients," Beerhle explains. Then it was decided the staff pharmacists could see Coumadin patients as well, because they also wanted to be involved. "The system makes sense because a lot of times the doctors don’t have time to look at each patient’s history of meds, but we do. We also do some physical assessment, but we don’t diagnose," she adds. For example, a pharmacist might don a stethoscope to listen to a patient’s lungs. Once patients’ disease states are under control, the hospital’s clinical pharmacists can discharge them from the hospital and/or to their own primary doctor.
Beerhle agrees that her liability is greatly increased in the collaborative practice setting, but she accepts that liability as "part of the territory. Being in the VA system, we didn’t have to bump heads with too many people, but the extent of what we’re doing here is unique. Any time a physician or someone has been skeptical or a little bit hesitant, once they’ve worked with us they completely refer their patients to us, and the hospital has been tremendously supportive of pharmacy," she says.
She has lectured on the hospital’s collaborative practices to groups of U.S. pharmacists and at Florida meetings of the American Society of Health-System Pharmacists, and she has presented programs to pharmacy groups in London and Ireland. More stops are planned for the future.
At the James A. Haley Veterans Hospital in Tampa, FL, clinical pharmacists also act as primary providers, running a hypertension, lipid, and Coumadin clinic, says assistant director of pharmacy Kim Mowrey, PharmD. "Coumadin is the No. 1 adverse drug event in this center," she explains. "It has a lot to do with patients going to our clinic and then going to another doctor, who puts them on another drug. Then it’s usually an interaction problem," she says. About 400 Coumadin patients visit the clinic, where 15-minute appointments are the goal.
"Physicians are not really trained in adjusting Coumadin," Mowrey says. "There usually is an overdose or an underdose, and that’s really how our clinic came about. In the clinic, we investigate every adverse event to see if it could have been prevented." he says.
Clinical pharmacists Mowrey has eight on staff devoted to different areas initiate prescribing patterns and will refer patients to a physician or clinic director. Also under the Coumadin clinic protocol, every patient on the drug must have an appointment in the clinic before being discharged, and all outpatients routinely go through the clinic.
The Tampa VA used the ASHP anticoagulation center training on an in-house basis to help establish its Coumadin clinic. Like the West Palm Beach VA, the Tampa VA does not use warfarin generics. The weeklong training course was especially beneficial in preparing his staff to counsel patients.
The Tampa VA set up its hypertension clinic as a chronic disease maintenance program that includes an initial patient meeting with a cardiologist, who then sets up that patient’s program with the pharmacy. Clinical pharmacists can follow up up on medication decisions.
"Liability was an issue early on, but after the physicians and the clinic directors became familiar with how the pharmacists were treating patients, and finding out that we’re often more conservative, it’s really not an issue anymore," Mowrey explains. He also says the clinical pharmacist capabilities have become a good recruiting tool for the VAs. None of his clinical pharmacists dispenses.
Catching up in other settings
While the VA system may be leading the charge in collaborative practice, managed care facilities and traditional acute care hospitals are establishing their own inroads. Community pharmacists, on the other hand, are finding it harder to set up similar programs without the basic availability of a physician on site.
At Scott & White Hospital in Temple, TX, pharmacists manage patients and prescribe medications in the anticoagulation, lipids, and women’s health clinics, says Barry Browne, PharmD, coordinator of drug information services. Although a medical director oversees the clinics, the pharmacists are charged with managing their care. Texas law allows pharmacist to prescribe by protocol. (See state law summaries, p. 5.)
"I don’t think of PharmD specialists as physician extenders," Browne says. "I think our clinical practices are collaborative endeavors and collaborations with physicians." He adds that Scott & White is looking at expanding the programs to include osteoporosis, diabetes, and refill clinics.
At a managed care facility in Long Beach, CA, the Harriman Jones Medical Group, clinical pharmacists follow a similar protocol-driven approach. The prescribing guideline protocol was established by pharmacists and physicians and focuses on drug uses, duration, dosing, and interactions. The pharmacists double-check physicians who fail to follow the guidelines, and they prompt interventions and counsel physicians and patients on drug changes.
Patients who initially come into the anticoagulation clinic consult with a pharmacist and communicate to the staff any drug changes an outside doctor may prescribe. Regular blood work and checkups every six weeks are urged.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content