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:

• Journal Article: Do we really need more physicians? Responses to predicted primary care physician shortages.
• Report: Remaking Primary Care: From Crisis to Opportunity
• Report: Projecting the Supply and Demand for Primary Care Practitioners Through 2020

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:

• • Needs Assessment
    • Utilize ASHP’s Ambulatory Care Self-Assessment Tool

• • SWOT Analysis
    • Conducting a SWOT analysis involves analyzing your organization’s strengths and weaknesses (internal evaluation) and the environmental opportunities and threats (external evaluation).
    • Example SWOT analysis: MTM Service

• • Financial Opportunities: Return on Investment (ROI)
    • Feature Article: Data Prove the Point: Pharmacists Provide Value at Tripler in Hawaii
    • Feature Article: A New Place on the Continuum: Hospital-Owned Outpatient Pharmacies are Filling a Critical Niche

• • Financial Opportunities: Cost avoidance
    • Journal Article: Cost-avoidance and Qualitative Analysis of Clinical Pharmacy Interventions by Psychiatric Pharmacy Residents at State Psychiatric Facilities.
    • Journal Article: Economic Effects of Clinical Pharmacist Interventions: A Literature Review.

• • Justification of Services to Stakeholders: C-Suite Talking Points
    • Video: “Who is the medication expert in the white coat?”

• Building a Business Plan
  • Book: ACCP Ambulatory Care Survival Guide, 3rd edition
  • Book: Building a Successful Ambulatory Care Practice

Billing in the Ambulatory Care Setting
Compensation is necessary for the sustainability of ambulatory care practices. The following resources will help you identify different billing opportunities for your practice area.

• • ACCP Resources
    • Issue Brief: Outpatient Team-Based Care Payment Methods

• • ASHP Resources
    • FAQ: Pharmacist Billing for Ambulatory Pharmacy Patient Care Services in a Physician-Based Clinic and Other Non-Hospital Based Environments

• • APhA Resources
    • Website Toolkit: Getting your MTM Business Started
    • MTM Billing Codes (Note: There are limitations on when and how these codes can be used. Please see the references for additional details.)
      • G9002 – Clinic visit lasting ≤ 45 minutes
      • G9002.2 – Clinic visit lasting > 45 minutes
      • 98966 – Phone encounter lasting 5-10 minutes
      • 98967 – Phone encounter lasting 11-20 minutes
      • 98968 – Phone encounter lasting 21-30 minutes

• Transitional Care/Chronic Care Management billing:
  • Report: New Codes for Transitional Care Management and Chronic Care Coordination Codes

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.

• Student pharmacists and residents
  • • Journal Article: Further Development of Pharmacy Student-Facilitated Diabetes Management Clinics.
    • Journal Article: School-wide Clinical Intervention System to Document Pharmacy Students’ Impact on Patient Care.
  • Journal Article: Medication Therapy Management Services Provided by Student Pharmacists.
  • Journal Article: An Advanced Pharmacy Practice Experience in a Student-Staffed Medication Therapy Management Call Center.
  • Journal Article: Assessing Student Pharmacists’ Ability to Identify Drug-Related Problems in Patients within a Patient-Centered Medical Home.
  • Journal Article: Preceptors’ perspectives on benefits of precepting student pharmacists to students, preceptors, and the profession.

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 Documentation: See the Documentation section under Clinical Practice Resources below for additional details.
• Consider joining an Ambulatory Care listserv from one of the national pharmacy organizations (ASHP or ACCP) to find templates for EHR documentation.
• Feature Article: ASHP Guidelines on Documenting Pharmaceutical Care in Patient Medical Records

• Quality Improvement: Huddles have become a widely recognized tool across a variety of healthcare settings to quickly communicate and implement a plan and are very popular in ambulatory care.
• Video Resource: How to Huddle
• Feature Article: Pharmacist-led huddles to improve patient care

• Practice Advancement: Sharing successes and patient stories within and outside of the practice site is a powerful tool for the advancement of your practice.
• Feature Article: Example of highlighting innovative practice models
• Book: The Story Factor: Inspiration, Influence, and Persuasion through the Art of Storytelling

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.

• ASHP’s Ambulatory Care Self Assessment Tool

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:

• Book: ACCP Ambulatory Care Survival Guide, 3rd edition
• Book: Building a Successful Ambulatory Care Practice: A Complete Guide for Pharmacists

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.

• Book Chapter: Building a Successful Ambulatory Care Practice
• Tip Sheet for Patient Documentation: Making a Medicine List Makes You “Medicine Smart”
• Website Resource: Documentation of Pharmacy Services

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.

• • Prior Authorization Resources
    • Website Resource: Cover My Meds
    • Website Resource: Decision Resources Group Formulary Lookup
    • Website Resource: Formulary Lookup

• Patient Assistance Programs
  • Website Resource: Needy Meds
  • Website Resource and Smartphone App: Good Rx
  • Website Resource: Medicare Patients Can Qualify for a Low Income Subsidy

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
      • The Morisky Medication Adherence Scale (MAS) is a validated questionnaire used to assess patient medication adherence and comes in both four (MMAS-4) and eight (MMAS-8) question versions. There are copyright limitations to their use.
      • Journal Article: Selection of a Validated Scale for Measuring Medication Adherence

• 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.

• Medication Safety in Older Adults
  • Beers List: Provides a list of potentially inappropriate medications that should be avoided or used cautiously in patients 65 years of age and older
  • Website Resource: Algorithm of medication review in frail older people

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.

• Quality and Performance Measures Compilations: Selected Programs Impacted by Ambulatory/Outpatient Pharmacists
  This document Identifies various outcome measures utilized by governmental and private organizations where pharmacists may be able to have an impact. The tables list the targeted domain (e.g., clinical outcome, financial outcome) and provides an overview of the measure.

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.

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.

• Website Toolkit: AHRQ Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation
• Journal Article: Transitional Care: Moving Patients from One Care Setting to Another
• Resource Guide: CSHP and CPA Transitions of Care Resource Guide
• White Paper: TOC: The Need for a More Effective Approach to Continuing Patient Care
• Model Diagram: Patient Engagement and Care Coordination Model
• Website Resource: Agency for Healthcare Research and Quality (AHRQ) Transitions Between Settings
• Presentation: ACMP Transitions of Care
• Journal Article: Pharmacy-led Medication Reconciliation Programs at Hospital Transitions: A Systematic Review and Meta-analysis
• Website Resource: National Transitions of Care Coalition

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.

• Transitioning from Hospital to Home
  • • Website Toolkit: Project BOOST^(R) (Better Outcomes by Optimizing Safe Transitions)
    • Training Program: The Care Transitions Program
    • Report: ASHP-APhA Medication Management in Care Transitions Best Practices
    • Presentation: Transitions of Care Presentation
    • Agency for Healthcare Research and Quality (AHRQ)
      • Website Toolkit: Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) Toolkit
    • Journal Article: Implementation of Transitions-of-Care Services Through Acute Care and Outpatient Pharmacy Collaboration
• Transitions involving Community Pharmacy
  • • Journal Article: Collaborative Drug Therapy Management: Case Studies of Three Community-Based Models of Care
    •  Journal Article: Pharm2Pharm: Leveraging Medication Expertise Across the Continuum of Care
• Transitions from Emergency Department to post-acute care
  • • Feature Article: Innovation with Care Transitions
    • Report: AHRQ: Improving the Emergency Department Discharge Process
• Transitions involving an Outpatient Clinic
  • • Journal Article: A Practical Guide for Pharmacists to Establish a Transitions of Care Program in an Outpatient Setting
• Transitions involving a Transitional Care Unit (Acute rehab, SNF, etc)
  • Toolkit: STAAR How to Guide: Improving Transitions from Hospital to Skilled Nursing Facilities, Institute for Healthcare Improvement (requires free account registration)
  • Report: Care Coordination Tool or Transitions to Long-Term and Post-Acute Care

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.

• Journal Article: Variations in Pharmacy-Based Transition-of-Care activities in the United States: A National Survey
• White Paper: Improving Care Transitions
• Congressional Testimony: Examining the Medicare Part D Medication Therapy Management (MTM) Program: Improving Medicare MTM for the Future
• Policy Brief: Improving Care Transitions
• Report: Improving Transitions of Care: The Vision of the National Transitions of Care Coalition