Pharmacists: On the front lines of health care delivery

Their knowledge and expertise as medication experts not only help practitioners provide better health outcomes for patients, but the information they provide is later transformed into research to make health care delivery more efficient and effective as measured by improved patient outcomes, increased patient satisfaction and decreased health care costs.

A pharmacist embedded in a clinical setting is especially important today as it is not uncommon for some patients to be on upwards of 15 medications, in addition to any herbals or other supplements. These complex medication regimens, along with the desire to provide effective continuity of care, further strengthen the need to provide patients with an interdisciplinary health care team, with pharmacy having a central role.

It’s not only pharmacists. Using the team approach, any number of health care professionals such as dieticians and physical therapists can be involved depending on the practice.

“It’s all a very collaborative environment. We educate the patients, review all of their medications, and send recommendations for therapy optimization to the referring provider. Often it is an exchange of ideas with the provider about what can we do for a patient as a team to really improve their care,” said Erin M. Slazak, PharmD ’04, clinical assistant professor in the Department of Pharmacy Practice. She practices at General Physicians, P.C., where she and several other pharmacists receive referrals from primary care providers. The pharmacists then work with these patients to better manage chronic conditions like diabetes, or to better manage complex medication regimens. The team has also implemented a transitions of care program in which the pharmacist completes a comprehensive medication review for patients transitioning from one health care setting to another, such as from the hospital to home.

Introducing pharmacists into physician provider groups has enhanced patient care services. Pharmacists know the latest drug research. They reconcile medications to ensure that dosages are correct or even if the patient should still be on a current regimen. They also provide the necessary follow-up to answer questions and make sure patients stay compliant with their care plans.

“We appreciate the state of health care today where doctors have very little time to accomplish a lot with a very complex patient. We want to be seen as an extender. We help doctors accomplish patient goals,” Slazak adds.

Working for years with Buffalo Medical Group, P.C., Nicole P. Albanese, PharmD, clinical associate professor in the Department of Pharmacy Practice, has helped to solidify pharmacy’s critical role in this physician provider group, but it wasn’t always the case.

“When I first started here and I was sending recommendations to the doctor, they took half of them at best. Now, they take 99 percent,” said Albanese.

However, this evolution to team-based health care delivery is not without its challenges, particularly disabusing patients of the notion that a pharmacist merely dispenses medications at their neighborhood drug store. For many, seeing a pharmacist in a clinical setting takes some getting used to.

“I start all my patient appointments with, ‘I’m a clinical pharmacist. I am not what a normal pharmacist is to you. We don’t dispense medications here.’ Every single person reacts with, ‘Oh, OK. I was wondering who you were and what you are going to do for me,’” Albanese says. “I do a lot of education with every single patient that we see.”

Albanese adds that many patients come into her office angry about why they’re seeing her, but they oftentimes leave the meeting hugging her.

The value that pharmacists bring is especially important as compensation from insurance companies is gradually shifting to patient wellness outcomes. Essentially, when their patients do better, the practices are rewarded. However, primary care groups can’t accomplish all that they need to by doing what they’ve always done.

Buffalo Medical Group is a large multispecialty medical group with approximately 200 hundred providers, including primary care and specialty physicians and advanced practitioners, behavioral health, dietetics and pharmacy. The majority of Albanese’s referrals are for chronic disease state management such as diabetes, hypertension and cardiovascular risk reduction. Additionally, pharmacists can refer as needed to behavioral health or the dietician, further enhancing positive patient outcomes.

Christopher J. Daly, PharmD/MBA ’12, is a clinical assistant professor in the Department of Pharmacy Practice and recently started working at UB Family Medicine on Sheridan Drive. He said primary care groups need to branch out and bring in different levels of expertise but do it cost effectively. This presents an opportunity for pharmacists to enhance improvements in interprofessional patient care as their scope of practice continues to expand and evolve.

“The opportunities for performance or valuebased interventions are going to grow. Practices therefore need to position themselves more strategically to get to that upper echelon to return value to the practice while delivering better patient care. This is contingent on multidisciplinary team approaches and understanding how to best deliver patient care in the future,” Daly said.

While Slazak, Albanese and Daly are on the front lines, there are researchers from the School of Pharmacy and Pharmaceutical Sciences who are looking at the data that’s generated from clinical patient visits more strategically, evaluating the interactions that are most effective.

Crunching the numbers at that higher level is David M. Jacobs PharmD ’11, PhD ’18, assistant professor in the Department of Pharmacy Practice. He works closely with clinical pharmacists in primary care settings to design studies to explore the effectiveness of particular interventions. Together they figure out the objective, the sample, what will be included and excluded, and how the data will be analyzed. After the data is collected, they interpret it to see what worked and what might be improved in the clinical setting.

Jacobs also looks at data at the population level to try to get answers to more general questions.

“We utilize large databases to see, for example, ‘What has been the change in readmissions in a COPD or pneumonia population before and after the advent of this care transition?’ or ‘How does polypharmacy impact health care utilization?’” he said. “These are more general questions that we can look at with some of the large databases, using some big data analytics. It’s a crossover with what we’re doing in the clinic with the patients.”

Jacobs said the ultimate goal from the researcher’s standpoint is to publish in peer-reviewed literature to get feedback from other researchers. From a clinician’s standpoint, it means improving the model, implementing it in the clinic and looking toward the next step to improve patient care. He added that there are an infinite number of primary care research opportunities in the future.

Looking to the future is Collin Clark, PharmD ’17. He’s a freshly minted PharmD, who was recently awarded a prestigious National Research Service Award fellowship, with funding through the National Institutes of Health. Clark will be working out of the UB Department of Family Medicine’s Primary Care Research Institute, which brings together a multidisciplinary team of researchers, clinicians and other health care experts to research ways to solve complex problems in health care.

Clark will be pursuing the practice transformation research track, focusing on changing health care team workflows, practice improvement science and implementing evidence into practice. He will develop scholarship and research techniques to better understand health disparity inequities in primary care related issues and apply these findings to further enhance leadership and care.

The fellowship is being used for postgraduate training that will help him become a better researcher in health services and the primary care arena. It’s a program that allows him to work with mentors across the university to develop his research skill set. Currently, he’s working with a multidisciplinary primary care research team that is focusing on medication safety for the elderly.

“We’re trying to take what we know works and doesn’t work from some of the more classic levels of evidence—things like randomized control trials—and trying to find ways to translate that evidence into practice within the Family Medicine department. We’re working with the university’s physician provider group, UBMD, to try to turn the evidence that we know from more rigorous trials into real-world studies that can hopefully provide better care for our patients,” Clark said.

Specifically, Clark and his group are looking at the practice of “deprescribing” medicine: systematically removing medications that a patient no longer should have as they age because the risks outweigh any potential benefit, or because the medicine is no longer necessary. What they’re trying to figure out is the best way for the health care provider and pharmacist to broker that with the patient.

Clark, Jacobs, Daly, Albanese and Slazak realize the work they are doing now will help further solidify the essential role of the pharmacist in the primary care arena. As the battle plan for a multidisciplinary team approach in primary care is being written, it will be informed by the work done by researchers and clinicians from the UB School of Pharmacy and Pharmaceutical Sciences.