Ambulatory Care Toolkit

What is ambulatory care pharmacy practice?
The Board of Pharmacy Specialties (BPS) offers the following definition for ambulatory care pharmacy practice, which was developed by a joint task force of the American Pharmacists Association (APhA), the American Society of Health-System Pharmacists (ASHP) and the American College of Clinical Pharmacy (ACCP):

"Ambulatory care pharmacy practice is the provision of integrated, accessible health care services by pharmacists who are accountable for addressing medication needs, developing sustained partnerships with patients, and practicing in the context of family and community. This is accomplished through direct patient care and medication management for ambulatory patients, long-term relationships, coordination of care, patient advocacy, wellness and health promotion, triage and referral, and patient education and self-management. The ambulatory care pharmacists may work in both an institutional and community-based clinic involved in direct care of a diverse patient population.”

Getting Started

Pharmacists wishing to get started in an ambulatory care practice should consider following these steps.

Conduct Background Research and Create a Plan

  • Meet with physicians, other providers and administrators to identify ideas, needs and wants and develop top-level buy-in for ambulatory pharmacy services. 
  • Determine whether privileging at the institution is an option for obtaining prescriptive authority or whether pursuing a collaborative practice agreement is the preferred method for providing ambulatory services.
    • Develop a proposal that includes the benefits of the service, details for implementing the service, resources required, budget, proposed timeline and marketing ideas (see Business Model below).
Plan for Your Practice's Success
  • Develop a strategic plan for your practice.
  • Determine documentation procedures.
  • Develop protocols giving consideration to privileging or collaborative practice agreements and related legal factors.
  • Consider billing factors and meet with billing manager.
Obtaining an NPI number
Advance Ambulatory Care Pharmacy Practice
  • Document interventions and demonstrate value. Consider clinical value, humanistic value, and financial impacts in the strategy.
  • Maximize utilization of pharmacy technicians to increase efficiency and patient satisfaction. 
  • Leverage demonstrated value to expand services.
  • Consider incorporating pharmacy students and pharmacy residents into the practice.
Additional Resources for Getting Started

Business Model and Communication Resources

ASHP identified that developing a sustainable business model, determining which services yield a return on investment, and identifying payment mechanisms for valuable services are key challenges for ambulatory care practice. Ambulatory care services should be at least cost neutral or, ideally, generate a margin of profit that allows for service expansion.

Primary Care Provider Shortage
The literature demonstrates a significant shortage of primary care providers. The following articles may be useful background information when developing your business model: Business Considerations
ASHP recommends the following approach for designing and implementing an ambulatory care pharmacy service: (1) conduct a needs assessment; (2) consider a strengths, weaknesses, opportunities, and threats (SWOT) analysis; (3) conduct a gap and feasibility analysis; (4) consider financial opportunities; (5) consider interest of stakeholders (c-suite); (6) develop a business plan; (7) implement the service; and (8) measure outcomes.The links below provide additional information to help you conduct some of these steps:

Billing in the Ambulatory Care Setting
Compensation is necessary for sustainability of ambulatory care practices. The following resources will help you identify different billing opportunities for your practice area. Incorporation of Support Personnel
Staffing considerations may need to include support personnel including students and residents. The following links provide examples of how to incorporate technicians, students, and/or residents into a practice model.
Communication
In an ambulatory care practice, communication is vital to sustained success. Communication may occur through a variety of venues, including written, verbal or electronic.

 

Clinical Practice Resources

Creating an Ambulatory Care Pharmacy Practice
In order to build a sustainable ambulatory care pharmacy practice, a variety of factors must be in place. Outlined below are some of the elements that need to be considered.

Practice Assessment
For those currently working in an ambulatory care environment, ASHP's Ambulatory Care Self Assessment Tool can help identify ways to improve your practice.

 

Collaborative Practice Agreements
Collaborative practice agreements (CPAs) allow specific duties typically carried out by a prescriber to be conducted by a collaborating pharmacist. State laws vary greatly in terms of how CPAs can be utilized. In Michigan, the “delegation of authority” provision allows physicians to delegate certain functions to pharmacists. The specifics of what and how those functions are delegated are determined by the parties involved. CPAs may allow pharmacists to initiate, change or discontinue certain medications under an agreed upon protocol. Examples of CPAs can be found in these resources:

 

Documentation
Documentation is a key component of providing patient care services in order to communicate with other healthcare providers and bill for services. The resources below can be tailored to the needs of your practice.

 

Patient Medication Access
For a variety reasons, patients may have trouble affording their medications. Pharmacists working in an ambulatory care environment often work with patients and other healthcare providers to identify affordable medication options.

 

Patient Assessment
The following tools can assist with patient assessment in a variety of areas.

  • Medication Adherence Assessments 
    The most common indirect methods for measuring medication adherence include patient self-report, pill count and pharmacy refill records. Each method has strengths and weaknesses.
    • Patient Self Report

  • Health Literacy Assessment
    Understanding how well a patient understands health information is important so that you can tailor your information to the appropriate level.
    • Pharmacy Health Literacy Toolkit
      • This online database developed by the Agency for Healthcare Research & Quality (AHRQ) contains health literacy tools specific to pharmacy including a pharmacy staff assessment tool, information about implementing ‘universal precautions’ in the pharmacy, and how to create a patient-friendly pill card.

 

Outcomes

Applying quality-improvement principles to ambulatory care pharmacy practice is necessary for effectiveness. Ambulatory care pharmacists must be aware of quality improvement initiatives in order to prove value and sustain growth of services

Evaluating Outcomes
Measures of your patient care outcomes must be (1) meaningful, (2) feasible, and (3) actionable. The following resources will help you identify possible quality metrics.

Advocacy and Provider Status

State and national pharmacy associations are actively engaged in advocacy on Capitol Hill pushing for "provider status." The Pharmacy and Medically Underserved Areas Enhancement Act (H.R.592 and S.314) is bipartisan legislation that will amend section 1861(s)(2) of the Social Security Act to include pharmacists on the list of recognized healthcare providers. 

MPA Advocacy
  • MPA's Advocacy page includes pharmacists' accounts of grassroots involvement in Michigan to inspire pharmacists to be involved. These stories describe the type of relationships formed with legislators and how that makes a difference.
ASHP Advocacy
  • ASHP offers resources to see if your legislators are bill supporters, read about recent news regarding provider status and assist you in contacting your legislators. 
APhA Advocacy
  • APhA's advocacy page includes useful background information and helpful hints for contacting and interacting with legislators. Additional tips regarding approaches to written and face-to-face interactions are presented here. The Pharmacists Care Toolkit is available and includes several detailed fact sheets, background on the campaign and pertinent talking points.
Patient Access to Pharmacists’ Care Coalition (PAPCC)
  • PAPCC is a unified group of stakeholders working jointly to ensure that patients have access to pharmacist-delivered clinical services as part of their healthcare team.
ACCP's Medicare Coverage Initiative
  • ACCP has established a comprehensive initiative that will pursue legislative and regulatory changes to the Medicare program and relevant sections of the Social Security Act (42 USC and relevant sections, primarily Section 1861) to recognize the direct patient care services of qualified clinical pharmacists as a covered benefit under the Medicare program. Their February 2014 Update explains how they differ from the approach of other organizations.

Transitions of Care Model Resources

Each time a patient enters the healthcare system for a specific encounter, a medication history and reconciliation should take place. These may also be needed throughout the encounter as transitions occur. Upon change in encounter setting or level of care, care coordination should take place at the earliest opportunity. Specific examples of care coordination include follow-up appointment scheduling, coordination of discharge medications to all providers including the outpatient pharmacy, and resolution of any medication-related insurance coverage issues.

Key Elements for successful Transitions of Care (*Adapted from Project BOOST®)
  1. Institutional support (time, equipment, informatics and personnel)
  2. Engagement of patients and their families (breaking down barriers including language and health literacy issues as well as cultural differences)
  3. Connection to other ongoing quality and patient safety initiatives (CMS core measures, HCAHPS)
  4. Specific aims, or goals, that are time-bound, measurable and achievable
  5. Standardized discharge pathways that highlight key medications and any medication changes, important follow-up, self-management instructions and any pending tests
  6. Institution-specific policies and procedures
Resources to support implementing successful Transitions of Care Programs

There are many factors that need to be evaluated before and during the implementation of a transitions of care program to increase the likelihood of success. The following documents are a collection of available tools to guide the practice.

Transitions of Care Models

There have been many successful transitions of care models that have documented improvements in various measurements such as the reduction in medication errors and fewer readmissions. Examples of these programs in different settings are highlighted below.

Areas for Improving Transitions of Care

Transitions of care models need constant review and assessment to ensure quality, safety and efficacy. The following links provide recommendations on opportunities to improve pharmacy's role in transitions of care practices.

Other References