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Ambulatory Care Pharmacy – Lessons Learned in the Clinic

Ambulatory Care Pharmacy

Last week, I participated in an ambulatory care pharmacy roundtable.  It was really interesting and there was all sorts of different discussions from everything to board certification, residency, and the credentialing process.

Over the last 2+ years or so, I had the opportunity to grow an ambulatory care pharmacy practice. At the roundtable, I was able to share some of the lessons I learned. I was also able to share very rewarding experiences.  It wasn’t always easy, but I was able to work with some truly inspiring healthcare professionals.  I couldn’t be more grateful for the opportunity. Having a pharmacist placed within a clinic is a growing trend.  The payment shift away from fee for service to value based payments is a large component of why there are becoming more pharmacists within a clinic. We also provide a lot of value 🙂 I have since moved on from the ambulatory care pharmacy role, but I wanted to share with you some important things I learned along the way.

Patience

For me, the clinic had never had a pharmacist before.  There is absolutely a learning curve in trying to figure out what the providers needed from me and what I needed from them.  In addition, working with the nursing staff to get a good workflow was something that needed to be ironed out as well. This takes time and patience.  It takes times to build trust as well.

Meetings (Also see Recognition below)

I wasn’t always able to attend meetings, but I feel strongly that you should do what you can to attend clinic staff meetings that are applicable to your work.  From these meetings, you get to learn what is really important to your colleagues and administration. It is also a really great time to interact and develop strong relationships with your teammates.  They have to trust you. Another important aspect of attending meetings is to identify weaknesses or areas where the clinic needs to improve.  For example, if your clinic does poorly in their diabetes quality numbers, this is an area where you can speak up and tell them how you can help them improve.  Reporting and tracking of these quality numbers will likely happen at clinic meetings and if you aren’t there, you can’t help step up and address the problem.

Recognition

While a humble team player is always desired, you must recognize that your team needs to believe that you are providing value.  I remember a few meetings where I received praise from providers for help on various projects.  I believe this was important to increase the confidence of other providers who may be on the fence to seek a pharmacist’s help.

A couple of powerful examples I remember happening at meetings:

  1. A provider had previously worked with a clinical pharmacist in the hospital and stated that it made their job so much easier.  They strongly urged the other providers in the clinic to use the resource.
  2. I had worked to help improve D5 criteria and remember one provider mentioned that they had tried to get the patient to take a statin for years and that I did it in 15 minutes.

Billing Codes and Reimbursement

No matter what strategy you are using in your ambulatory care pharmacy practice, I think it is critical to understand how the clinic makes money.  Because pharmacists are not providers, we cannot bill like a nurse practitioner, physician assistant, or physician.  I hope we can get that changed, but that is the reality at this time.  However, it is important to remember what we can do.  We can provide value by improving quality numbers.  We can also do “incident to” billing. Transitional care codes, chronic care management and E/M codes can all be billed by “incident to”.  Some states give Medicaid patients an MTM benefit that can be billed as well.  Understanding billing/cost savings strategies is going to be important.  I would also encourage you to recognize how physicians/providers are paid as well as if patient access is a problem. If you can save providers time by helping solve medication related problems, this may allow them to see more patients, thus leading to more revenue for the clinic. If you haven’t read Blair’s blog on some of this stuff, you should. I believe she also has a handy free PDF of revenue generating services for clinical pharmacists.

Document What You Are Doing

You will get asked a ton of drug information questions and curbside consults.  I wasn’t always consistent, especially right away, but I think it is highly valuable to document those questions and the time spent helping providers. To document these questions, I used a simple spreadsheet.  This is another good way to demonstrate that you are helping make providers lives easier.

Ambulatory Care Pharmacy Clinical Literature

There is a growing list of clinical literature out there that demonstrates the value of an ambulatory care pharmacist.  Recognize that this may help you make the initial case for having a pharmacist in the clinic. If you are in those early stages, a good place to start might be the ASHP Ambulatory Care Self-Assessment Tool.

Internal Data

Clinical literature and external data can be helpful to make an initial case for an ambulatory care pharmacist. However, you must recognize that we have to track internal data and demonstrate our value once placed in a clinic.  Be sure you are clear on what you are trying to improve.  Are you looking to improve diabetes scores, hypertension, improve access, or reduce hospitalizations?  Whatever you are trying to do, be clear about this and track it.

Be Accessible

Having an open door or being in the middle of the clinic can be really helpful in gaining traction.  I’ve talked to other pharmacists who have had their office way in the corner or even on a separate floor from the main group of providers that they are supposed to work with.  Being as close to the action as possible can help you build credibility, increase referrals, and make sure you are not forgotten about!

No Shows

Coming from long term consulting, I never had a no show 🙂 That is something I had to adjust to in ambulatory care pharmacy.  Even if a provider gave me a referral, it was by no means a guarantee that the patient would show up.  Don’t take it personally, it happens.

Fear

When you are the only one in your profession within the clinic will have days of weakness, uncertainty, and definitely fear.  It’s ok, it happens.  Keep kicking down the door to new opportunities for pharmacists.

Advice

If you have worked, or are currently an ambulatory care pharmacist within a clinic, feel free to leave a comment below with any other advice that you can share from your experience.

Written By Eric Christianson

October 28, 2018

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