Application of Project ImPACT in the Pharmacy

Time Management: Many community pharmacists are now saying: “Sounds wonderful, but who has the time?” Not surprisingly, two critical, time-saving components in this study of care in the pharmacy were scheduling patient appointments and staffing. The average time spent with patients on their initial visit was 45 minutes (range 30–60 minutes), and that on follow-up visits was 22 minutes (range 10–30 minutes). No doubt pharmacists found ways to streamline these visits as they gained experience. Furthermore, these visits were often arranged by appointment, during mid-afternoons, early evenings and other slow times in the pharmacy. Additionally, pharmacists learned to organize the time they had available and to be creative in integrating the service into the flow of the pharmacy department. Pharmacists can also make optimal use of pharmacy technicians. For example, technicians can be taught to obtain the lipid profile with the desktop analyzer and provide the results to pharmacists for interpretation and counseling.

The Collaborative Care Model: In order for pharmacists to be effective purveyors of health education, disease prevention, and disease management, both they and physicians need to fully understand and embrace a collaborative care model. Collaboration means just that…working together to achieve common goals for the patient. This model deploys pharmacists to help support, encourage, and carry out physician-prescribed care. It does not replace the physician nor supplant his/her care plan. It takes full advantage of the pharmacist’s skill level, service capacity, and extensive know-ledge base. Unfortunately, as the healthcare market becomes more competitive and restrictive, primary care physicians could feel threatened by the pharmacist’s collaborative services. This happened in some cases during the early days of Project ImPACT. But initial suspicion quickly turned to strong professional support once physicians experienced first-hand how the pharmacists’ collaborative services complemented their own. Given the alarming number of hypercholesterolemic patients and their undertreatment, attention given to helping patients persist and comply with therapy is desperately needed to successfully manage this debilitating disease state.

Communication Links: The success of the collaborative care model concept depends upon quick, efficient dissemination of information. During the study, pharmacists recorded their findings and recommendations at the conclusion of each patient’s visit and transmitted this information via phone calls and faxes to the patient’s physician. Ideally, this communication should take place electronically and the feasibility of an electronic health record is being explored. Such a computerized record is envisioned to contain personal, claims transaction, clinical encounter, and quality event data. If a community pharmacy could electronically link itself with healthcare providers, a seamless flow of patient care information between pharmacists and physicians could truly be accomplished.

Opportunities for Reimbursement: An important extrapolation from this study is the issue of reimbursement for services. Even though reimbursement was not a study measure, participating pharmacists were encouraged to place a value for their services and either charge patients directly or seek compensation from third parties. The results were encouraging. An average assigned value per visit was $55; counseling services were $28 and lipid profiles were $27. Of the 232 patients who were asked for payment, 174 (75%) paid an average of $35 per visit. Of the 121 third party payers billed for services, 64 (53%) paid an average of $30 per visit. Compensation was more frequently received for lab services (i.e., the lipid profile) than counseling services, but as third parties learn more about the impact of pharmacists’ consulting services, interest in compensating pharmacists based on successfully maintaining patients at their treatment goal has grown. Interestingly, two project sites executed contracts with managed care organizations to deliver services to their health plan beneficiaries — one a fee-for-service arrangement and the other capitation. Therefore, the collaborative care model presents real opportunities for financial compensation, especially if it is successful in helping patients attain and maintain their treatment goals.

Discussion

Project ImPACT: Hyperlipidemia offers a contemporary view of the importance of pharmacists as providers of health promotion, disease prevention, and disease management. Pharmacists are in a unique position to support and empower patients to achieve therapeutic outcomes in the management of hypercholesterolemia and various other disease states. Pharmacists are ideally positioned to make the collaborative practice model work because of: 1) the growing self-care movement in which patients are taking increasing responsibility for their health, including asking more questions of all healthcare providers; 2) their accessibility to both patients and providers; 3) their ability to provide an advanced level of care; 4) their information management capabilities; 5) their motivation to expand care; 6) their education and training in the area of patient-focused disease management services; and 7) their understanding of how to be a team player.

The results of Project ImPACT should not be underestimated. In spite of effective treatment, which has been proven to reduce coronary artery disease events, most patients with a high CHD risk are not receiving treatment and those who are, are not being treated to goal. This project demonstrates that collaborative care provided by a community pharmacist can have a dramatic impact on treatment success. Project pharmacists produced a two- to four-fold improvement over existing systems in getting hyperlipidemic patients to treatment goals. There is nothing in the literature quite as powerful as these results. Not even interventions aimed at improving the impact of physicians themselves have been as successful. This project unquestionably presents pharmacists with a huge opportunity. The challenge is to take the next step.

Patients are not the only beneficiaries of pharmacists’ collaborative care — so are the pharmacists. Pharmacists involved in Project ImPACT were highly satisfied with their own professional role and 85% rated their relationship with patients very satisfying. The majority of project pharmacists also perceived that their patients and physicians highly valued their services. Perhaps even more telling is that the majority of pharmacists participating in the project (25 of the 26 sites) indicated that they planned to continue to provide these services.

Conclusion

Lipid-lowering goals are difficult to attain for patients with hyperlipidemia. A collaborative care approach that involves pharmacists in community settings working together with primary care providers to support and encourage patients can be instrumental in getting patients to their lipid goals. Project ImPACT offers a sound model for pharmacists. At the end of the day, involvement by pharmacists with hyperlipidemic patients presents a win-win situation: an enhanced quality of life for the patient and improved job satisfaction for the pharmacist.

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