AS THE MEDICATION EXPERTS, pharmacists have an important role to play in the care of patients. By providing patient education, counseling, and medication reviews, they can improve adherence, identify drug-related problems, and make sure treatment is safe and effective. However, some workflows may not allow for the time required for these services.
A new pharmacy model
Enter the "appointment-based model (ABM)," an approach that facilitates scheduling medication refills in an efficient way while creating space for comprehensive clinical pharmacy care for the most complex patients.
According to Saleema Bhaidani, Pharm.D., R.Ph., B.Sc.Phm., "older patients, those receiving a large number of medications and patients visiting a high-volume pharmacy have been disproportionately excluded from receiving clinical services." Dr. Bhaidani is the former director of pharmacy innovation and professional affairs at Wholehealth Pharmacy Partners, headquartered in Markham, Ontario. She currently serves as an international healthcare consultant and pharmacist.
To ensure these patients received the most appropriate pharmacy care, in 2017, Dr. Bhaidani and her colleagues at Wholehealth collaborated with the Leslie Dan Faculty of Pharmacy at the University of Toronto to help several Wholehealth pharmacies shift from a standard pharmacy refill model to an ABM, which allows pharmacists and patients to synchronize medication refills, thereby "shifting the pharmacy workflow to be proactive rather than reactive."
"Using a synchronization calculator, pharmacists can pre-arrange medication refills so that patients can pick up a supply of multiple medications in one trip," explained Dr. Bhaidani. "In addition to making the refill process more convenient for the patient, the visit also provides an opportunity to provide patient counseling, medication reviews, drug use education, and other clinical services. And scheduling ahead of time gives pharmacists the time to prepare for all of this."
The ABM replaces the time pharmacists spend preparing multiple refills for multiple dates with time to review a patient's regimen and a dedicated window to provide clinical services for complex patients. The ABM also helps better control inventory and overall costs, Dr. Bhaidani noted.
ABM data demonstrate success
Results from several Wholehealth pharmacy locations that rolled out the ABM in 2017 demonstrate the value of the model. Those findings, which were presented at the 2020 ASHP Midyear Clinical Meeting, showed that, among 131 patients enrolled in the program at three Wholehealth pharmacies between September 2017 and December 2018, the mean number of distinct refill dates dropped from an average of 6.8 per patient during the six months pre-implementation to 4.9 during the six months after implementation. Over the same period, the mean number of refills per patient increased from an average of 11.9 to 13.3.
Molly Yang, Pharm.D., R.Ph., who is the current manager of pharmacy innovation and professional affairs at Wholehealth Pharmacy Partners, noted that statin adherence increased from roughly 95% before the ABM was rolled out in these pharmacies to 99% afterward.
"I think the improved statin adherence speaks to the core objective of our initiative, which is disease prevention through adherence, control of chronic illnesses, and identification and management of drug therapy problems before they cause undesirable outcomes. ABM can impact all of these outcomes in addition to facilitating comprehensive assessments and utilization of clinical services on the pharmacy side," said Dr. Yang.
The majority of the patients enrolled in the program received one or more medication reviews, with pharmacists identifying issues such as inadequate therapy, therapeutic duplication, and adverse drug reactions, in nearly half of these individuals.
ASHP PAI2030 recommendations
The program is a good example of how following recommendations in ASHP's PAI2030 can lead to better patient outcomes. PAI2030 is an extension of the Practice Advancement Initiative (PAI), which was developed with the goal of "transforming how pharmacists care for patients by empowering the pharmacy team to take responsibility for medication-use outcomes."
Being proactive is at the core of PAI2030, which encourages the utilization of current and upcoming tools and evidence-based strategies to enhance the profession and patient care. The 59 recommendations included in the PAI2030 guide pharmacists, pharmacy leaders, and health systems "in their ongoing pursuit of optimal, safe, and effective use of medications."
In the case of Wholehealth Pharmacy Partners, ABM facilitated a focus on the subdomain of patient-centered care, by developing stronger connections and collaboration with patients and healthcare professionals alike. Within the program, patients engaged in practices such as regular consultations, professional services, and medication synchronization, that have been shown to improve outcomes, noted Dr. Yang. The project also endorsed the subdomain of leadership in medication use and safety by enhancing operational efficiency and facilitating the patient care process. Dr. Yang explained that the proactive nature of the model allows a greater focus on medication assessments, which improved mitigation of drug therapy problems and medication stewardship.
Implementation of an ABM model
Pharmacies thinking of switching to an ABM to improve their own level of care should keep several things in mind to make implementation successful, suggested Dr. Yang.
"Designating personnel to focus on program development and implementation of tools and resources to guide and manage the program at our pharmacies was key for Wholehealth," Dr. Yang said.
They provided pharmacy staff with manuals, video tutorials, marketing tools, a synchronizer calculator to help determine refill dates and amounts, as well as enrolment and prescriber notification forms to help successfully roll out the program, she said.
Dr. Yang also said that while some pharmacies may find the idea of switching workflow models daunting, ABM implementation can be adapted to the unique needs of a given pharmacy.
"ABM does not necessarily mean switching all of your patients over at once," she said. "It can be as simple as delegating one staff member per week, per day, or per shift to start the process. In a busy store, it may take longer, but with some adaptation, you can move toward a more proactive approach."
According to Dr. Bhaidani, getting individual pharmacy owners and staff on board with the new model was easy, "because they understood that the outcome would mean better control of their workflow, a more positive experience for everyone, and better overall patient care."
"One of the most memorable things I heard a pharmacy owner say during implementation was, "How did I not think of this before? ABM is just common sense,'" recalled Dr. Bhaidani. "Once you integrate the proactive approach in your workflow and everyone starts to reap its benefits, the whole process just seems intuitive."
"Ultimately, being able to provide more clinical service opportunities to address patient concerns and needs not only improves patient safety, but helps pharmacists develop stronger relationships with patients," added Dr. Yang. At the end of the day, initiatives such as ABM, which are intuitive from an operational and clinical perspective and are in line with key practice advancement goals, enhance our practice and propel our profession, she explained.