Briefing Paper for the ASHP Ambulatory Care Conference and Summit, March 3-4, 2014, Dallas, Texas

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1 Delve into the four domains that will be the focus of the 2014 ASHP Ambulatory Care Conference and Summit on March 3-4 in Dallas, Texas. Experts in advancing ambulatory care pharmacy practice have authored essential background documents on these four domains: Defining Ambulatory Care Pharmacy Practice, Patient Care Delivery and Integration, Sustainable Business Models, and Outcomes Evaluation. Abstracts of each paper are available now. Meeting registrants will have access to the full briefing documents before the meeting. Check back to the website in early 2014 to get the latest information and access to all meeting resources. Defining Ambulatory Care Pharmacy Practice: Time to Lengthen Our Stride Authors: Dennis K. Helling, Pharm.D., D.Sc., FCCP, FASHP, FAPhA Samuel G. Johnson, Pharm.D., FCCP, BCPS (AQ-Cardiology) Patient Care Delivery and Integration: Opportunities for Ambulatory Care Pharmacy Practice in a Dynamic Health Care Environment Kelly T. Epplen, Pharm.D., BCACP Sustainable Business Models: A Systematic Approach toward Successful Ambulatory Care Pharmacy Practice Gloria Sachdev, B.S. Pharm., Pharm.D. Outcomes Evaluation: Striving for Excellence in Ambulatory Care Pharmacy Practice Mary Ann Kliethermes, Pharm.D.

2 Defining Ambulatory Care Pharmacy Practice: Time to Lengthen Our Stride Authors: Dennis K. Helling, Pharm.D., D.Sc., FCCP, FASHP, FAPhA, is Executive Director Emeritus, Pharmacy Operations and Therapeutics, Kaiser Permanente Colorado, and Clinical Professor, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado. Samuel G. Johnson, Pharm.D., FCCP, BCPS (AQ-Cardiology), is Clinical Pharmacy Specialist, Applied Pharmacogenomics, Kaiser Permanente Colorado; Clinical Assistant Professor, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado; and Institute of Medicine Anniversary Fellow in Pharmacy, Purpose. This paper reviews the basic tenets of ambulatory care pharmacy practice, including (1) the need for and value of comprehensive medication management, (2) the education, training, and qualifications of pharmacists, and (3) demonstrated improvement in health and health care outcomes from pharmacists services. Summary. When ambulatory care pharmacists engage in patient care to their full capacity, physician time is saved, access to care is improved, and clinical and economic outcomes are enhanced. There is a need for ambulatory care pharmacists to work toward optimizing safe medication use and optimizing medication therapy for patients with diabetes, asthma, cardiovascular disease, and renal disease. Other opportunities exist in preventive care, precision therapeutics, medication therapy management, mitigation of health care disparities, and in implementing national health care reform. Interprofessional patient care teams should include ambulatory care pharmacists in patient-centered medical homes and accountable care organizations. Ambulatory care pharmacy practice would benefit by enhancing specialty residency training and by creating a third year of residency/fellowship for advanced subspecialty clinical practice and research. Provider status is essential to recognize pharmacists as an integral part of the patient care team. Conclusion. By assertively advancing ambulatory care pharmacy practice, pharmacy will help achieve the national priorities of improving patient care, patient health, and the affordability of care.

3 Patient Care Delivery and Integration: Opportunities for Ambulatory Care Pharmacy Practice in a Dynamic Health Care Environment Kelly T. Epplen, Pharm.D., BCACP, is Assistant Professor of Clinical Pharmacy Practice and Administrative Sciences, James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, Ohio. Purpose. This paper discusses how to plan and implement an ambulatory care pharmacy service, how to integrate a hospital- or health-system-based service with the mission and operations of the institution, and how to help the institution meet its challenges related to quality improvement, continuity of care, and financial sustainability. Summary. The steps in implementing an ambulatory care pharmacy service include (1) conducting a needs assessment, (2) aligning plans for the service with the mission and goals of the parent institution, (3) planning collaboration with patients and physicians, (4) standardizing the patient care process, (5) justifying the service, (6) attaining the necessary resources, (7) identifying stakeholders, (8) identifying applicable quality and competency standards, (9) planning for service payment, and (10) monitoring outcomes. Ambulatory care pharmacists have current opportunities to become engaged with patient-centered medical homes, accountable care organizations, preventive and wellness programs, and continuity of care initiatives. Common barriers to the advancement of ambulatory care pharmacy services include lack of complete access to patient information, inadequate information technology, and lack of payment. Conclusion. Ambulatory care pharmacy practitioners must assertively promote appropriate medication use, provide patient-centered care, pursue integration with the patient care team, and seek appropriate recognition and compensation for the services they provide.

4 Sustainable Business Models: A Systematic Approach toward Successful Ambulatory Care Pharmacy Practice Gloria Sachdev, B.S. Pharm., Pharm.D., is Clinical Assistant Professor of Primary Care, Department of Pharmacy Practice, Purdue University College of Pharmacy, and Adjunct Clinical Assistant Professor, Indiana University School of Medicine, Indianapolis, Indiana. Purpose. This paper discusses how to make pharmacist ambulatory care services at least cost neutral and, ideally, to generate a margin that allows for service expansion. Summary. The four pillars of business sustainability are leadership, staffing, information technology, and compensation. A key facet of leadership in ambulatory care pharmacy practice is creating and expressing a clear vision for pharmacists services. Staffing considerations include training needs, maximizing efficiencies, and minimizing costs. Information technology is essential for efficiency in patient care delivery and outcomes assessment. The three domains of compensation are cost savings, pay for performance, and revenue generation. The following steps toward designing and implementing an ambulatory care pharmacy service are discussed: (1) prepare a needs assessment, (2) analyze existing strengths, weaknesses, opportunities, and threats, (3) analyze service gaps and feasibility, (4) consider financial opportunities, (5) consider stakeholders interests, (6) develop a business plan, (7) implement the service, and (8) measure outcomes. Potential future changes in national health care policy (such as pharmacist provider status and expanded pay-for-performance) could enhance the opportunities for sustainable ambulatory care pharmacy practice. Conclusion. Interrelated challenges facing ambulatory care pharmacy practice are developing sustainable business models, determining which services yield a return on investment, and demanding payment for valuable services.

5 Outcomes Evaluation: Striving for Excellence in Ambulatory Care Pharmacy Practice Mary Ann Kliethermes, Pharm.D., Vice Chair, Ambulatory Care, and Associate Professor, Chicago College of Pharmacy, Midwestern University, Downers Grove, Illinois. Purpose. Key issues in measuring and improving the quality of health care are discussed with an emphasis on applying quality-improvement principles in ambulatory care pharmacy practice. Summary. The various perspectives on health care quality (including those of patients, providers, and payers) are reviewed, and the basic principles of quality measurement and improvement are outlined. Many health care practitioners believe that the most effective way to improve health care is through balanced consideration of the structure, process, and outcomes of health care services. Overall progress in improving the quality of health care has been slow, in part because of lack of patient engagement, use of improvement methods that have not been fully tested, and giving inadequate attention to the systems of providing care. Ongoing efforts of national quality-improvement organizations are reviewed, including those of the government, accreditation bodies, payers, and professional associations. Of special interest in pharmacy is the work of the Pharmacy Quality Alliance, the Patient Safety and Clinical Pharmacy Services Collaborative, and the Center for Pharmacy Practice Accreditation. Ambulatory-care pharmacists have an important opportunity to improve health care quality by reducing adverse drug events, improving medication reconciliation and transitions of care, fostering medication adherence, improving patient medication self-management, providing immunization services, and reducing disparities in access to medications. Conclusion. To be fully effective, national initiatives for improving the quality of health care must penetrate the work of individual health care practitioners, including ambulatory care pharmacists.

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