"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.”
Pharmacists wishing to get started in an ambulatory care practice should consider following these steps.
Conduct Background Research and Create a Plan
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:
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:
In an ambulatory care practice, communication is vital to sustained success. Communication may occur through a variety of venues, including written, verbal or electronic.
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.
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 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.
The following tools can assist with patient assessment in a variety of areas.
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
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.
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.
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.
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.
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.
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.