Ambulatory Clinical Pharmacy Specialty Services: The Kaiser Permanente Colorado Experience

Abstract

H ealth care in the United States is increasingly being delivered during ambulatory care visits. 1 As new investment in health care shifts from the inpatient to outpatient setting, the role of ambulatory clinical pharmacists (CP) are expanding. While dispensing pharmacists provide clinical screening and patient education for potential drugrelated problems, CPs provide services that complement the care provided by dispensing pharmacists by directly advising and educating other health care providers and patients on appropriate pharmaceutical use and dosing.Initial involvement of CPs in the ambulatory setting occurred primarily in the primary care setting. Early studies examined the impact of CPs and reported improved outcomes with clinical pharmacy management of care on patient compliance, [2][3][4][5][6] diabetes, 7 patient-specific drug information, 8 and treatment of infections.9 Systematic reviews of CP involvement in ambulatory settings note that while the quality of research (e.g., weak methodology, small sample sizes) is limited, the participation of CPs in health care has resulted in positive cost-effective care.10-12 A 2010 Cochrane review summarizing randomized controlled studies of CP involvement noted that most of the studies meeting inclusion took place in a primary care or community pharmacy setting rather than a specialties setting. 12CP involvement in ambulatory specialty areas has expanded into a broader array of disease states. Reports noting CP involvement in psychiatry practices were first published in the 1970s. 13,14 Currently, settings with CP involvement in specialty clinics include primarily health maintenance organizations, teaching institutions, and Veterans Affairs (VA) health systems.15 Other nonfee-for-service settings that may have specialty CP involvement include community clinics and other non-VA government health care systems. Systematic reviews summarizing the roles and/or impact of CP involvement in various specialty areas have been published. These areas include mental health, [16][17] 25 Knapp et al.'s (2005) 2004 survey of 233 ambulatory sites with CP involvement reported that the most common area of specialty CP involvement was oncology (28% of participating sites).15 Less than 10% of participating sites had CP involvement in neurology, heart failure, or psychiatry management, while involvement in other medical specialties was not reported by most participating sites.15 Accordingly, C O M M E N TA R YCP involvement in many specialties in the ambulatory setting has not been described in the literature, and little research on the clinical and economic outcomes of CP involvement has been conducted in specialty settings. [16][17][18]

Clinical Effectiveness of an Outpatient Multidisciplinary Chronic Pain Management Telementoring Service

“…Usual care for noncancer, chronic pain management is provided by clinical pharmacy specialists (CPS) and a patient’s PCC. CPS are residency trained, board-certified pharmacists who complete pain management consults to PCC via the EHR 12. A PCC can self-select for PEP telementoring or provide usual care for any number of her/his patients.…”

“…CPS are residency trained, board-certified pharmacists who complete pain management consults to PCC via the EHR. 12 A PCC can self-select for PEP telementoring or provide usual care for any number of her/his patients. The PEP was promoted widely to PCC at KPCO, and the program's clinicians provided continuing education about the risks of opioid prescribing with several internal continuing education.…”

Impact of a clinical pharmacy research team on pharmacy resident research

“…In addition to clinical pharmacists who provide outpatient dispensing services, KPCO has clinical pharmacy specialist (CPS) staff who provide primary care, anticoagulation, cardiovascular risk reduction, and medical specialty care in centralized and decentralized services. [18][19][20][21][22][23][24] Although CPS staff members' day-to-day practice activities are mainly focused on direct patient care activities, participation in research and scholarship, including precepting pharmacy residents and student pharmacists, is encouraged. Currently, KPCO accepts six trainees into its ASHP-accredited postgraduate year 2 ambulatory care specialty pharmacy residency program each year.…”

Seven key parameters that facilitate clinical pharmacy practice: a comparison between Israel and the United States

“…They see the clinical pharmacist performing roles such as participating in inpatient rounds as part of the team, managing anticoagulation therapy, or accepting referrals for outpatient management of uncontrolled diabetes or hypertension. Therefore, an increasing number of US physicians (and nurses) not only accept clinical pharmacists and their role [ 18 , 19 ], but frankly miss this role if they leave academic settings after residency and go to a community setting that does not have clinical pharmacy. It seems likely that in the future, their demand for clinical pharmacy to work with them will influence these settings as well.…”