Impactteam.info

nature publishing group
practice
Integrating Family Medicine and Pharmacy to Advance Primary Care Therapeutics
L Dolovich1,2, K Pottie3–5, J Kaczorowski6–8, B Farrell3,5, Z Austin9, C Rodriguez1,
K Gaebel1 and C Sellors2
The prevalence of suboptimal prescribing of medications a week starting 1 June 2004. They were selected through a struc-
is well documented.1,2 Patients are often undertreated or tured hiring process that emphasized communication and criti-
not offered therapeutic treatments that are likely to confer cal thinking skills and a demonstrated willingness to encourage
benefit.3,4 As a result, drug-related hospital admissions innovation in practice.12 All the pharmacists had previously
are common and often preventable.5 Improvements to the worked within a community setting, and also within a hospital
health-care system are clearly needed in order to maximize or a long-term care setting. The seven family medical practice
the benefits that can be derived from medications. Many sites included inner city, urban, and semirural locations. Six
countries are changing their primary health-care systems were community sites and one was a full academic site. In four
to improve the quality of health-care delivery.6,7 One main of the sites, paper records were used, while the other three used
transformation is the use of multidisciplinary care teams electronic medical records. The number of physicians ranged
to provide care in a coordinated manner often from the from 6 to 15 per location.
same location or by using the common medical record of
the patients. It has been demonstrated that pharmacists IMPACT PrACTICe Model
can improve prescribing, reduce health-care utilization and The project practice model was composed of four components
medication costs, and contribute to clinical improvements that were employed concurrently to foster integration and pro-
in many chronic medical conditions, such as cardiovascular mote optimal prescribing and use of medications (described in
disease, diabetes, and psychiatric illness.8–11 However, the detail Training and support were provided to assist
effect of integrating a pharmacist providing general services the pharmacist and others at the location to manage change. A
into a primary care group has not been extensively studied. 2-day training workshop was held for the pharmacists to assist
The Integrating Family Medicine and Pharmacy to Advance them to transition into the unfamiliar environment of a busy
Primary Care Therapeutics (IMPACT) project was designed family practice. The workshop experience centered on the Family
to provide a real-world demonstration of the feasibility of Practice Simulator, an interprofessional curricular innovation in
integrating the pharmacist into primary care office practice. which physicians, pharmacists, and other health-care profession-
This article provides a description of the IMPACT project als work with standardized patients and carry out activities over
participants; the IMPACT practice model and the concepts the course of a typical day in family practice.13 Ongoing support
incorporated in its development; some initial results from the was provided through a mentorship program. Mentors provided
program evaluation; sustainability of the model; and some emotional support, problem-solving advice, and assistance with
reflections on the implementation of the practice model.
developing clinical knowledge and skills. Each pharmacist had access to a provincial drug information center. The pharmacists IMPACT ProjeCT PArTICIPAnTs
were also provided with profiles of the medical practices at the IMPACT was a demonstration project that placed a pharma- relevant locations and a project implementation guide.
cist into each of seven family medical practice sites across the In order to preserve the relationship and avoid fragmentation province of Ontario, Canada. The pharmacists worked 2–3 days of care, the family physician retained the lead role in diagnosing 1Centre for Evaluation of Medicines, St. Joseph’s Healthcare, Hamilton, Ontario, Canada; 2Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada; 3Élisabeth Bruyère Research Institute, Ottawa, Ontario, Canada; 4Institute of Population Health, University of Ottawa, Ottawa, Ontario, Canada; 5Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada; 6Primary Care and Community Research, Child & Family Research Institute, Vancouver, British Columbia, Canada; 7Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada; 8Department of Health Care and Epidemiology, University of British Columbia, Vancouver, British Columbia, Canada; 9Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada. Correspondence: L Dolovich (Received 17 January 2008; accepted 31 January 2008; advance online publication 19 March 2008. doi: CliniCal pharmaCology & TherapeuTiCs | VOLUME 83 NUMBER 6 | JUNE 2008
practice
Table 1 A description of the IMPACT practice model
intervention component
intervention level Detailed description of intervention component
The provision of comprehensive medication assessments, ongoing on-location collaboration with the health-care team, and collaborative implementation of the pharmacist’s recommendations to resolve drug therapy problems. This involved a review of the medical chart; interview with the patient to gather information on current and past medication history; adherence to medication regimen and patient-reported medication issues; identification of drug-related problems and therapeutic dilemmas; solution-oriented recommendations for optimization of drug therapy being provided to the physician through verbal discussion and written documentation; and working with the physician and other team members to develop and implement medication changes, education, and monitoring of medication use Education and dissemination of new therapeutics evidence to health-care providers (including physicians) System-level activities aimed at improving drug prescribing and use throughout the practice site (e.g., clinical care paths, administrative efficiencies) or through seamless care in other settings, such as Focused activities aimed at enhancing the integration of the pharmacist into the practice IMPACT, Integrating Family Medicine and Pharmacy to Advance Primary Care Therapeutics.
illness, prescribing medications, and consulting with the phar- were an emotional roller coaster for the pharmacists. They fluc- macists. When dealing with individual patients, the physician tuated between feeling underutilized and out of place to feel- was asked to review the advice provided by the pharmacist and ing highly valued and accepted. They recognized the need to determine the management approach, including consultation improve their skills and proactively sought to work with project staff, mentors, and others in managing clinical uncertainties, communicating with their fellow health-care team members, ConCePTs And frAMeworks underlyIng The IMPACT
prioritizing recommendations, implementing recommenda- PrACTICe Model
tions, ensuring proper documentation, and taking on a higher The IMPACT practice model was based on previous research level of responsibility for patient care.
experience in pharmacy practice14–16 and methods of facili- tating change in family practice.17 It also used a knowledge Initial experiences of physicians
translation framework incorporating IMPACT program activi- Physicians recognized many interprofessional benefits by work- ties, with the aim of encouraging the uptake of evidence to ing with a pharmacist directly integrated into their practice.29 improve the prescribing and use of medication. The activities An analysis of qualitative data from semistructured interviews carried out in the IMPACT practice model reflected the use of conducted with 12 participating physicians 12 months after a a multifaceted, multilevel approach (i.e., activities focused at pharmacist began working in the practice identified several per- the levels of patient, provider, and practice) that is well recog- ceived benefits: having a colleague who provided reliable drug nized as being capable of fostering behavior change; in this case, information, getting fresh perspectives, and increased clinical changing the prescribing and use of medication.18–20 Activities security. Benefits for the practice included improved education of the pharmacists were also aligned with the current state of for the group as a whole, a liaison with the community pharmacy, pharmacy practice, which invokes a patient-centered approach and an enhanced sense of being a part of the team. Persistent in optimizing pharmaceutical care.21–24 operational challenges included finding time to learn about the The development of the interdisciplinary IMPACT practice pharmacist’s role and skills, and insufficient space within the model utilized a knowledge translation framework to encourage premises to accommodate the pharmacist. Serial quantitative the integration of the pharmacist into the family practice site and analyses of physicians’ responses showed an increase in their to bring about the intended changes in the prescribing and use perceptions of pharmacists’ contributions to medication-related of medication. The framework drew on theories from education, processes in the practice.30 epidemiology, behavioral sciences, marketing, social learning and innovation, and organizational behavior.18,25–27 Each theory Patient referrals
provided a focus of attention and a rationale for including an The IMPACT intervention led to 1,554 patients being referred additional element in the family practice model to the pharmacist for a comprehensive assessment over the The project received ethical approval from the McMaster course of the 24 months of the project. Of these, 969 (62.4%) University Research Ethics Board, and all the patients provided assessments were completed by the pharmacists for patients who provided informed consent. Further details about the flow of patient referrals are provided in Supplementary Data S1 online.
IMPleMenTATIon of The PrACTICe Model
Of the patients assessed by the pharmacist, 56% (n = 538) of Initial experiences of pharmacists
the referrals were prompted through a chart auditing process. An analysis of qualitative data from monthly narrative reports Further details about the chart auditing process are provided in written by each pharmacist28 showed that the first 4 months Supplementary Data S2 online. The other 44% of the patients
VOLUME 83 NUMBER 6 | JUNE 2008 | www.nature.com/cpt
practice
Table 2 knowledge translation framework for aspects of IMPACT pharmacist integration practice model25–27
Theoretical element that
was a focus in the impaCT
Theories
integration intervention
specific examples in impaCT
Discussion of needs of each practice location Pharmacist–physician one-to-one review of individual patient assessments Training program centered on active situation-based learning Dissemination of evidence through tools such as one-pagers for both health-care provider and patients (cognitive theories) information-seeking Encouraging the justification for pharmacist recommendations with evidence from literature and the Use of profiles of the practice to show overall performance for various indicators of medication The contributions of the pharmacist and the practice to improvements over time in definitions of roles and responsibilities and preparation of an implementation guide Projects aimed at improving the practice, prioritized based on consensus among practice members Presentation and discussion of pharmacist integration intervention with all the members of the Multiple methods of communication used for implementing drug therapy change recommendations Recognition of where physicians and others are along the adoption of innovation continuum Adapting of resources and approaches from one practice location to another Implementation of reminder and monitoring prompts for prescribing issues where possible Providing the practice with financial reimbursement to offset costs associated with participation; holding back part of the reimbursement until project deliverables accomplished Formalizing the role of the key opinion leader within each practice as project liaison Providing role-modeling through a mentorship program Encouraging inter-practice communication through teleconferences and meetings to generate positive Prioritizing areas of change in the organization (improvements) to create some initial Ensuring that key policy makers are well informed and take appropriate steps to minimize Defining roles and responsibilities in the practice for pharmacist, administrators, and physicians organizational conditions Encouraging frequent communication and dialogue between pharmacists and other health-care Recognizing the need for some flexibility in integration across varying practice locations Encouraging regular review of the integration process so as to generate continual improvements Providing strong leadership and support from the central project management Project staff and mentors acting as facilitators of the change management process Providing the tools (e.g., practice profiles and implementation guide) for a framework for the IMPACT, Integrating Family Medicine and Pharmacy to Advance Primary Care Therapeutics.
were referred by their physicians, without prompting and with- Presence of drug therapy issues as identified
out restrictions attached to the reason for referral. The number by the pharmacist
of referrals for the seven practice sites ranged from 133 to 260 At least one drug-related problem (DRP) was identified and per site. Sixty of the sixty-four physicians (94%) across the seven assessed by the pharmacists in 909 (93.8%) patients. A total of practice sites referred at least one patient to the pharmacist 3,974 DRPs were identified, making an average of 4.4 DRPs per patient. The most common DRPs identified included patients in The average age of the patients who were assessed by the phar- whom there were indications requiring a therapy but who were macist was 72 (s.d. 11) years and 62% of them were women. not receiving it (27.0%), patients who were not taking or receiv- Patients had an average of 4.8 (s.d. 2.3) medical conditions and ing the prescribed drugs appropriately (16.5%), and patients who was taking an average of 7.0 (s.d. 3.8) prescription medications and were receiving too low a dose of the drug (16.2%).
3.4 (s.d. 3.2) over-the-counter medications at their first encounter The total number of adverse drug reactions or potential with the pharmacist. On the basis of a 10-item medication-related adverse drug reactions identified was 315 (7.9% of all DRPs risk questionnaire,31 63.1% of the 907 patients who completed the identified). Pharmacists identified adverse drug reactions in 241 questionnaire reported three or more medication-related risks. patients (26.5%). The most frequently reported types of adverse For example, 26.5% of patients were unclear about the need for drug reactions addressed by the pharmacists were those asso- all of their medications and 15.7% found it difficult to fol ow their ciated with over-the-counter medications, nonsteroidal anti- medication regimen or sometimes chose not to.32 inflammatory drugs, and the use of benzodiazepines. Further CliniCal pharmaCology & TherapeuTiCs | VOLUME 83 NUMBER 6 | JUNE 2008
practice
Table 3 Types of adverse drug reactions identified (n = 315)
were at a high level of medication-related risk. The patients’ drug adverse drug reaction
n (%)
therapy problems were addressed, and various improvements emerged within the family medical practice settings in rela- Muscle cramps or myalgias associated with statin use tion to optimization of the prescribing and use of medication. Theoretical concepts and data from earlier research on phar- macy practice and behavioral change in primary care provided a GI effects (including ulcers and bleeding) strong foundation from which to develop the IMPACT practice model, training program, support system, and evaluation of the IMPACT intervention. The explicit approach to optimization of the system of prescription and use of medication recognized that the required change involved people across disciplines, espe- cial y the participating pharmacists and family physicians. It also Side effects of antihypertensive medications recognized that changes in the prescription and use of medica- tion could be achieved when attention was focused on multiple levels: the patient, the provider, and the practice. Successful integration was defined a priori as comprising both a functioning office system and the development of a col abora- tive working relationship between physicians and pharmacists. A functioning office system was characterized by having clear roles Adverse reactions associated with OTC use and levels of responsibility regarding medication use processes for each member of the team; mechanisms to identify, prevent, address, and resolve DRPs; and the capability to innovate, such as by identifying unresolved problems for further action (i.e., contin- uous quality improvement). The program evaluation found that al the IMPACT locations had demonstrated an initial level of success ACE-I, angiotensin-converting enzyme inhibitor; ASA, acetyl salicylic acid; GI, gastrointestinal; NSAIDs, nonsteroidal anti-inflammatory drugs; OTC, over-the-counter.
in integrating the pharmacist into the practice. IMPACT pharma- aIncludes increases in uric acid (due to reduced renal clearance), changes in CrCl, and so cists provided consultation for patients who were on a complex on. bIncludes dry mouth, constipation, fatigue, and so on. cSome examples: serotonin therapeutic regimen, offered timely and tailored drug informa- syndrome; nightmares with use of ranitidine; use of protein pump inhibitors (PPIs) in gal bladder disease; selective serotonin reuptake inhibitor (SSRI) use and sexual tion, and implemented useful medication-focused improvements dysfunction; elevated triglycerides (TGs) and rosiglitazone; and phenytoin toxicity.
in the system. The evaluation of the process of integration al owed for identification of challenges and incorporation of solutions details are provided There were 142 (3.6% of all DRPs during the project. Further analyses are under way to examine identified) actual or potential drug interactions identified in 118 collaborative working relationships over time; patient satisfac- patients (12.1%). The two drugs that were mainly involved in tion; costs; and the effectiveness of such integration of pharmacists drug interactions were warfarin and levothyroxine, identified into primary care practice in improving medication monitoring, prescribing of medications, and clinical outcomes for patients.
system-level improvements in practice methodology
sustainable practice change
The process of effecting changes in the practice involved a com- The efforts of IMPACT, in conjunction with other local initia- plex series of steps for both physicians and pharmacists and tives and policy changes, have helped produce sustained change took time to evolve. Medication-focused practice enhancements in health-care delivery. In Ontario, Canada, the use of multidis- emerged from the practice to facilitate behavior change in related ciplinary care teams comprising various health-care providers practice processes.These processes and tools were intended to providing care in a coordinated manner has manifested as inter- increase the efficiency and effectiveness of both prescription disciplinary practice groups cal ed Family Health Teams (FHTs). and use of medications. Some examples of system-level prac- To date, 150 FHTs have been created in Ontario, Canada. All the tice enhancements developed during IMPACT included: a dia- practice locations involved in IMPACT became FHTs and have betes care monitoring system; a medication switching protocol elected to include a pharmacist position within their FHTs. To (i.e., drug discontinuation or recall); computer system alerts; a date, sixty-seven full-time equivalents for pharmacist services prescription renewal process; drug sampling procedures; and have been approved for FHTs across Ontario, Canada. A toolkit containing guides for pharmacists, lead physicians and loca- tion managers, a physician information pamphlet, and sample dIsCussIon
documents, as well as a Practice Enhancement Guide are avail- IMPACT was a large-scale demonstration project that helped able on the IMPACT website at http://www.impactteam.info. encourage the integration of pharmacists within interdiscipli- IMPACT team members also participate in provincial drug and nary health-care teams as part of primary health-care reform in primary care policy advisory committees. In conjunction with Ontario, Canada. The pharmacists provided care to patients who the Canadian Society of Hospital Pharmacists and the Canadian VOLUME 83 NUMBER 6 | JUNE 2008 | www.nature.com/cpt
practice
Pharmacists’ Association, IMPACT facilitated the founding 10. Machado, M., Bajcar, J., Guzzo, G.C. & Einarson, T.R. Sensitivity of patient outcomes to pharmacist interventions. Part I: systematic review of the Canadian Primary Health Care Pharmacists Network. and meta-analysis in diabetes management. Ann. Pharmacother. IMPACT pharmacists are mentors to newly hired pharmacists 41, 1569–1582 (2007).
to aid their integration into their new roles within FHTs.
11. Machado, M., Bajcar, J., Guzzo, G.C. & Einarson, T.R. Sensitivity to patient outcomes to pharmacist interventions. Part II: systematic review and meta-analysis in hypertension management. Ann. Pharmacother. future opportunities
41, 1770–1781 (2007).
Once integrated, the pharmacists can act as change agents to 12. Babcock, K., Farrell, B., Dolovich, L. & Sellors, C. Hiring a pharmacist to work in primary care: application for ambulatory and hospital pharmacy. promote linkages with community pharmacists, hospital phar- CPJ 139, 46–48 (2006).
macists, or clinical pharmacologists to widen the circle of care, 13. Austin, Z. et al. Teaching and assessing primary care skills in pharmacy: the promote other health-care providers to improve medication Family Practice Simulator model. Am. J. Pharm. Educ. 69, 500–507 (2005).
14. Dolovich, L., Levine, M., Burns, S., Sellors, J. & Marshman, J. A randomized management, and encourage the participation of pharmacists in controlled trial of pharmacotherapy specialist team consultation integrated interdisciplinary initiatives. Pharmacists integrated into primary into primary care practice settings versus specialty service provided in a care practice can foster components of chronic disease manage- hospital outpatient clinic. Canadian Health Services Research Foundation <http://www.chsrf.ca/final_research/ogc/pdf/dolovich_c.pdf> (2001).
ment, health promotion, and il ness prevention, or patient self- 15. Sellors, C., Dalby, D.M., Howard, M., Kaczorowski, J. & Sellors, J. A pharmacist management interventions, so as to optimize prescribing and use consultation service in community-based family practices: a randomized of medication. Aspects of this model are applicable to other set- controlled trial in seniors. J. Pharm. Technol. 17, 264–269 (2001).
16. Sellors, J. et al. A randomized controlled trial of a pharmacist consultation tings that incorporate clinical pharmacologists, hospital pharma- program for family physicians and their elderly patients. CMAJ cists, or community pharmacists into multidisciplinary teams.
169, 17–22 (2003).
17. Lemelin, J., Hogg, W. & Baskerville, N. Evidence to action: a tailored supplementary Material is linked to the online version of the paper
multifaceted approach to changing family physician practice patterns and improving preventive care. CMAJ 164, 757–763 (2001).
18. Grol, R. Beliefs and evidence in changing clinical practice. BMJ ACknowledgMenTs
315, 418–420 (1997).
This article was written on behalf of the IMPACT team members: (Integrating 19. Cook, D.J., Montori, V., McMullin, J.P., Finfer, S.R. & Rocker, G.M. Family Medicine and Pharmacy to Advance Primary Care Therapeutics). Improving patients’ safety locally: changing clinician behaviour. Lancet 363, 1224–1230 (2004).
IMPACT was a large-scale demonstration project funded by the Ontario 20. Wagner, E.H. Chronic disease management: what will it take to improve care Ministry of Health and Long-Term Care (MOHLTC) through the Primary for chronic illness? Eff. Clin. Pract. 1, 2–4 (1998).
Health Care Transition Fund. The views expressed in the article are the views 21. Hepler, C.D. & Strand, L.M. Opportunities and responsibilities in of the authors and do not necessarily reflect those of the Ontario MOHLTC.
pharmaceutical care. Am. J. Hosp. Pharm. 47, 533–543 (1990).
22. Winslade, N.E., Strand, L.M., Pugsley, J.A. & Perrier, D.G. Practice functions ConflICT of InTeresT
necessary for the delivery of pharmaceutical care. Pharmacotherapy The authors declared no conflict of interest.
16, 889–898 (1996).
23. American College of Clinical Pharmacy. A vision of pharmacy’s future roles, 2008 American Society for Clinical Pharmacology and Therapeutics responsibilities, and manpower needs in the United States. Pharmacotherapy 20, 991–1022 (2000).
1. Huang, B., Bachmann, K.A., He X., Chen, R., McAllister, J.S. & Wang, T. 24. Cipolle, R.J., Strand, L.M. & Morley, P.C. Pharmaceutical Care Practice 2nd edn. Inappropriate prescriptions for the aging population of the United States: an analysis of the National Ambulatory Medical Care Survey, 1997. 25. Grol, R. & Grimshaw, J. From best evidence to best practice: effective Pharmacoepidemiol. Drug Saf. 11, 127–134 (2002).
implementation of change in patients’ care. Lancet 362, 1225–1230 (2003).
2. Piecoro, L.T., Browning, S.R., Prince, T.S., Ranz, T.T. & Scutchfield, F.D. 26. Robertson, N., Baker, R. & Hearnshaw, H. Changing the clinical behavior of A database analysis of potentially inappropriate drug use in an elderly doctors: a psychological framework. Qual. Health Care 5, 51–54 (1996).
medicaid population. Pharmacotherapy 20, 221–228 (2000).
27. Kitson, A., Harvey, G. & McCormack, B. Enabling the implementation of 3. Gupta, K. & Gupta, S. Undertreatment of hypertension: a dozen reasons. evidence based practice: a conceptual framework. Qual. Health Care Arch. Intern. Med. 162, 2246–2247 (2002).
7, 149–158 (1998).
4. Rochon, P.A. et al. Use of beta-blocker therapy in older patients after acute 28. Pottie, K., Haydt, S., Farrell, B., Dolovich, L., Sellors, C. & Hogg, W. The use of myocardial infarction in Ontario. CMAJ 161, 1403–1408 (1999).
narrative reports in monitoring and evaluating the integration of pharmacists 5. Winterstein, A.G., Sauer, B.C., Hepler, C.D. & Poole, C. Preventable drug-related into family practice settings. Ann. Fam. Med. (in press).
hospital admissions. Ann. Pharmacother. 36, 1238–1248 (2002).
29. Pottie, K. et al. Physicians’ perspectives on collaborative practice during 6. Schoen, C., Osborn, R., Huynh, P.T., Doty, M., Peugh, J. & Zapert, K. On the front the integration of pharmacists into family practices in Ontario. Can. Fam. lines of care: primary care doctors’ office systems, experiences, and views in seven countries. Health Aff. (Millwood) 25, w555–w571 (2006).
30. Farrell, B. et al. Development and initial validation of a tool to assess 7. Doran, T. et al. Pay-for-performance programs in family practices in the United professional contributions related to medication-related processes in family Kingdom. N. Engl. J. Med. 355, 375–384 (2006).
practice. J. Interprof. Care 22, 17–19 (2008).
8. Sokar-Todd, H.B. & Einarson, T.R. Community pharmacy practice research: a 31. Barenholtz Levy, H. Self-administered medication-risk questionnaire in an systematic review of the past 32 years. CPJ 136, 26–38 (2003).
elderly population. Ann. Pharmacother. 37, 982–987 (2003).
9. Beney, J., Bero, L.A. & Bond, C. Expanding the roles of outpatient pharmacists: 32. McCarthy, L., Dolovich, L., Haq, M., Thabane, L. & Kaczorowski, J. Frequency of effects on health services utilisation, costs, and patient outcomes. Cochrane risk factors that potentially increase harm from medications in older adults Database Syst. Rev. 3, CD000336 (2000).
receiving primary care. Can. J. Clin. Pharmacol. 14, e283–e290 (2007).
CliniCal pharmaCology & TherapeuTiCs | VOLUME 83 NUMBER 6 | JUNE 2008

Source: http://impactteam.info/documents/CPT.pdf