On July 22, 2010, an important policy milestone was achieved as part of the broad and ongoing process of reforming the nation’s health care delivery system—especially with respect to the provision of comprehensive, coordinated, and team-based primary care. At its national “stakeholders’ meeting” in Washington, DC, the Patient-Centered Primary Care Collaborative (PCPCC) (www.pcpcc.net), with which ACCP has been working directly and closely for almost 2 years, released two new “resource documents,” which PCPCC members, stakeholders, policy analysts, and others use in their work to implement and refine the core structures and services of patient-centered medical homes (PCMHs). Of special note and meaning for clinical pharmacists is the publication of the resource titled “The Patient-Centered Medical Home: Integrating Comprehensive Medication Management to Optimize Patient Outcomes” (please see http://www.accp.com/docs/positions/misc/CMM%20Resource%20Guide.pdf).
PCPCC is a 600+ member coalition of health professional societies, clinicians from the principal health care professions, health plans, employer groups, patient care quality organizations, hospitals, and others. This coalition has worked together for more than 3 years, particularly during the health care reform debate in Congress, to define and advocate for comprehensive changes in the way primary care services are structured, coordinated, financed, and delivered. Because of these efforts, the PCMH has emerged as one, if not the key, element of the delivery system and payment policy reform being implemented and evaluated by the U.S. Department of Health and Human Services (HHS), the Centers for Medicare and Medicaid Services (CMS), and the Agency for Healthcare Research and Quality (AHRQ) during the next several years.
The resource guide provides a descriptive framework for the provision of team-based comprehensive medication management services in the PCMH. Also included in the guide are examples of approaches, evidence of effectiveness, and an understanding of the close alignment between the principles of the PCMH and the purposes and outcomes to be achieved through a comprehensive approach to medication management that is team based and that actively engages the patient in the clinical care and goal-setting processes. (See http://www.accp.com/docs/positions/misc/Contribution of Medication Management.pdf.)
Follow-up meetings with key agency personnel at AHRQ and HHS have already been conducted or are being scheduled by the co-leaders of the PCPCC medication management task force. These meetings will introduce the resource guide and its concepts to the agency staff responsible for developing proposed rules, constructing and selecting members of commissions and advisory boards, and developing the grant proposal requests required under the new health care reform law. In each case, our goal is to reinforce and amplify the message—one that PCPCC has now publicly embraced—that a comprehensive, patient-centered, and team-based approach to medication management, usually using the specialized and complementary knowledge and skills of pharmacists as integral team members, is an important practice component of the effective PCMH. This message is also essential to the ability of this comprehensive approach to become the “better way” to provide primary care services to the nation, and it meets the criteria defining the PCMH.
Although the value of this “policy breakthrough” within such an influential, multi-stakeholder organization probably cannot be overstated, it represents little more at this stage than an “opportunity” for substantial forward movement by pharmacists in delivering on the promise of patient-centered and evidence-based pharmacotherapy that underlies the JCPP 2015 Vision for Pharmacy Practice (http://www.accp.com/docs/positions/misc/JCPPVisionStatement.pdf).
Whether pharmacists and their professional organizations—including ACCP—are committed to helping achieve the necessary changes that will support pharmacists in seizing this opportunity is truly at the heart of the answer to what health care reform will mean for us during the next decade.
More questions than answers currently exist regarding how best to incorporate pharmacists into PCMH teams. We know, for example, that there simply are “not enough to go around” to physically staff every PCMH or primary care medical practice with a pharmacist, even if the essential changes in payment policy needed to support an effective, team-structured PCMH practice were in place. (This issue is the focus of the second resource paper released by PCPCC on July 22.) “Virtually constructed” teams and practice relationships, with pharmacists available and committed to serving multiple patient groups and practice settings, will inevitably be required. Design and implementation of these comprehensive medication management practices/structures must be led by pharmacists, working with physicians, nurses, and practice managers who may well embrace the service but who are quite busy themselves trying to reengineer their own practices within the PCMH environment.
Similarly, we know much remains to be done in defining and refining the electronic health information technology infrastructure essential to the provision of patient-centered care across both multiple practice environments and patients’ homes, including their transitions among all of these places. That clinical pharmacy practice developed in the hospital environment, with the patient’s records, data, other providers, and even the patient in one place and available for the pharmacist to draw on, is no coincidence. These resources were essential to building an effective practice in that setting at that time. Electronic health information technology and communication tools provide the “opportunity” (there’s that word again!) to deliver a more patient-centered practice into the world where patients actually live and function—their home, community, and other settings of care.
More importantly, we must fully acknowledge (and behave and practice accordingly) that the consistency, reproducibility, and “24-7 availability” of the comprehensive medication management services that actually meet the real needs and expectations of patients and other team members is an “all-or-nothing” professional and ethical commitment. Our practice activities, business models, and professional behaviors must evolve to unfailingly reflect that commitment if they are to be fully valued by those who receive and pay for the service. The practice cannot “shut down” when a pharmacist goes on vacation or is “off service” for the month to do other things. The practice cannot be, and should not appear to be, vastly different (perhaps even unrecognizable) to the patient or other members of the team if they experience it in different care settings or from different pharmacists. The practice cannot be simply (and perhaps not even with great effort) “worked in” to the existing flow of activity by which medication orders (including those that are appropriate for the patient) are processed, even though each of these activities has an important place in patient care.
The standard of care and practice for comprehensive medication management embodied in the PCPCC resource guide is not yet commonly available to all patients who can benefit from it. But then again, neither is the standard of medical care embodied in the principles of the PCMH commonly available. Both are expressions of a desired and necessary transformation of patient-centered primary care that produces healthier, more involved patients; health care professionals practicing at their highest intellectual and clinical capacity and scope; and higher-quality, more cost-effective care for those who purchase and finance it. This transformation cannot—indeed, must not—wait much longer.
Pharmacy practice transformation that reflects the principles and steps of comprehensive medication management will not occur because of news releases from organizations simply saying how much they like or support the concepts contained in the new resource guide. Transformative action, especially the hard and financially challenging work of practice and business model reengineering, combined with proactive and unrelenting advocacy for payment reform that rewards quality and coordinated, team-based care rather than isolated and episodic treatment and procedures in professional silos, is the essential strategy going forward.
Opportunity doesn’t keep knocking if the door isn’t answered.