Primary Care Provider Use of Embedded Pharmacist Services and Perspectives on Collaborative Practice Agreements

Introduction

The primary care workforce is under pressure from rising demands due to a rapidly aging population with a high volume of chronic diseases. While the need for Primary Care Providers (PCPs) is growing exponentially, the number of PCPs per capita is falling [1,2]. This widening gap creates an opportunity for pharmacists to collaborate with PCPs as members of primary care teams. Integrating pharmacists into primary care practices can help to address all aspects of the Quadruple Aim, which is a vital framework for advancing healthcare. The four aims are:

(1) improving population health, (2) improving patient experience, (3) decreasing healthcare costs, and (4) improving the work-life balance of providers [3,4].

For the purposes of our survey, Embedded Pharmacists (EPs) were defined as pharmacists who have clinical training and experience working as healthcare team members within a primary care practice or clinic. EPs are directly integrated into the primary care team and provide direct patient care responsibilities focused on comprehensive medication management and monitoring. EPs optimize patient outcomes and increase provider satisfactions [5]. In many states, EPs usually have Collaborative Practice Agreements (CPAs) with PCPs to manage patient’s medication regimens. Through integration into the primary care team, EPs are an accessible resource for patients and providers alike.

During a series of appointments with EPs, patients receive individualized care to optimize their health and strive to reach therapeutic goals [6]. Usually, EPs meet with patients who have uncontrolled, chronic conditions (e.g., diabetes [7], hypertension [8], asthma [9], and smoking cessation [10]) that require frequent follow-up between PCP appointments. With the help of an EP and frequent monitoring, patients can achieve therapeutic outcomes to optimize their health and achieve the practice’s outcome measure goals [11]. At each appointment, the EP can work closely with the patient to discuss their medication regimen, adjust dosages or order new medications, and order laboratory tests to make clinical decisions [11,12].

PCPs also benefit from the services of an EP that result in improved workplace satisfaction and decreased clinical workload [13]. Integration of EPs in primary care settings has been shown to address four specific drivers of provider burnout, including workload and job demands, efficiency and resources, meaning in work, and social support and community at work [14]. Also, EPs can help reduce provider workload by managing complex patients and conducting more frequent follow-up appointments. Patients can schedule medication-specific visits directly with the EP, freeing up time in PCPs’ schedules [15].

The objectives of this study are to: (1) characterize the current use of and services provided by EPs in primary care, and (2) describe perceptions of PCPs without EPs regarding CPA utilization by community and embedded pharmacists.

Methods

This study is a secondary analysis from a survey of primary care providers (e.g., physicians, Advanced Practice Registered Nurse (APRN), and Physician Assistants (PA)) in Connecticut. The survey development and methods are described in a previous publication [16]. The survey was distributed electronically using Qualtrics. Online survey responses were collected for 5 weeks between December 2020 and January 2021.

This secondary analysis focuses on the utilization of embedded pharmacists. The study population included PCPs with active licenses who were currently practicing adult primary care in the state of Connecticut. The data source was the state licensure database, which did not include information about PCPs who were retired, part-time, no longer practicing in the state, or no longer working in primary care settings. Therefore, we used responses on returned surveys to determine the study population.

The total number of respondents (N=222) answered core questions as well as branched questions depending on previous work experience with an EP. PCPs who indicated working with an EP (N=64) answered questions to identify the services that EPs provided. PCPs who did not work with an EP (N=158) answered scenario-based questions to gauge perceptions of EPs and questions related to facilitators and barriers of embedded pharmacist CPA utilization.

The UConn Institutional Review Board determined this study to be exempt because responses were completely anonymous.

Results

Survey Response and Demographics

A total of 782 surveys were received, however, 206 were ineligible based on not meeting inclusion criteria listed above and 354 were incomplete for analysis. Therefore, a convenience sample of 222 completed surveys was analyzed.

The demographics for the 222 respondents are shown in Table 1. Most respondents were primary care physicians (41%) and nurse practitioners (46%) who worked in office practice settings (57%). Of the 222 respondents, 64 (29%) indicated they had an EP at their practice site.

Table 1: Respondent Demographics (N=222).

Demographics of Embedded Pharmacists

The employment status of embedded pharmacists was also collected. Of the respondents with EP (N=64), 70.3% had a full-time pharmacist (40 hours per week) and 50% of respondents had a part-time pharmacist (<40 hours per week). These percentages reflect the fact that some respondents had EP who only work full-time, only work part-time, or a combination of the two.

The survey also obtained the distribution of EPs shared among multiple practice sites. Of the 64 respondents, 53% indicated their EP is shared between multiple practice sites. Half of respondents with shared EPs indicated EPs were shared between 2-4 practice locations, and the other half indicated the EPs were shared between more than 4 practice locations. For EPs who were shared in four or more locations, their practice sites were physician office practices (29%), community health clinics (47%), and hospital outpatient clinics (24%).

Services Provided by Embedded Pharmacists in Primary Care

Table 2 highlights the type of PCP who initiates contact with an embedded pharmacist regarding certain pharmacist services.

Table 2: Services Provided by Embedded Pharmacists in Primary Care (N=64)¹.

Patient-Specific Drug Information Questions

The top three patient-specific drug information questions that physicians typically initiate contact with EPs about were most appropriate medication selection (56.0%), patient medication interactions (53.8%), and correct patient dose (54.5%). The top three patient-specific drug information questions that APRNs/PAs typically initiate contact with EPs about were patient medication and device instructions (38.8%), medication affordability assistance (40.0%), and correct patient dose (38.6%). Additionally, no one in the practice discusses the topics of patient medication allergy (14.9%), medication affordability assistance (13.8%), and patient medication or device instructions (10.6%) with an EP. Medication Regimen Optimization Topics

The top three medication regimen optimization topics physicians typically initiate contact with EPs about were comprehensive medication review (55.8%), medication therapy plans (55.1%), and monitoring medications/labs (53.4%). The top three medication regimen optimization topics APRNs/PAs typically initiate contact with EPs about were medication reconciliation (38.7%), monitoring medications/labs (37.5%), and medication therapy plan. Additionally, no one in the practice discusses the medication regimen optimization topics of medication reconciliation (11.1%), comprehensive medication review (9.3%) and monitoring medications/labs (9.1%) with an EP.

Pharmacist Services

The top three patient care services that physicians typically initiate contact with EPs about were chronic disease medication management (54.0%), smoking cessation (39.7%), care transition visits (34.2%). The top three patient care services that APRNs/ PAs typically initiate contact with EPs about were chronic disease medication management (33.3%), smoking cessation (25.6%), and care transition visits (22.4%). Additionally, no one in the practice discusses the patient care service of annual wellness visits (48.1%) with EPs.

Medication-Related Initiatives

The top three medication-related initiatives that physicians typically initiate contact with EPs about were drug treatment protocols and guidelines (52.3%), patient medication safety (50.6%), and P&T/ formulary (44.2%). The top three medication-related initiatives that APRNs/PAs typically initiate contact with EPs about were P&T/formulary (32.5%), drug treatment protocols and guidelines (30.2%), and patient medication safety (30.1%). Additionally, no one in the practice discusses the topics of medication utilization and budget reports (50.0%), quality improvement programs (39.0%), and quality performance measures (38.3%) with an EP (Table 2).

PCP Perceptions of Embedded vs Community Pharmacist CPA Use

PCPs without EPs have significantly different perceptions on the utilization of CPAs with community pharmacists (CPs) versus EPs, as highlighted in Table 3. Only 34% of PCPs without EPs are aware that CPs can utilize CPAs, while 53% are aware that EPs can utilize CPAs (p<0.001). PCPs without EPs are significantly more comfortable signing a CPA with an EP (67%) than CPs (47%) to monitor and manage medications for patients with uncontrolled diabetes and hypertension (p=0.004). PCPs without an EP are more likely to recommend collaboration with an EP utilizing a CPA to a PCP colleague (77%) than a CP utilizing a CPA (59%) (p=0.007). Of the PCPs without an EP, 75% agree that EPs using a CPA would decrease their workload burden, whereas only 54% agree that CPs using a CPA would decrease their workload burden (p<0.001).

Table 3: Perceptions of PCPs without Embedded Pharmacists on the Utilization of Collaborative Practice Agreements (CPAs) with Community and Embedded Pharmacists (N=158)¹.

Facilitators and Barriers of Embedded Pharmacist CPA Utilization

Tables 4 and 5 identify factors that would promote and limit the utilization of CPAs with EPs, specifically to manage medications for uncontrolled diabetes and hypertension. The top three most common facilitators selected were: EP is viewed by patients as a member of primary care practice’s team (78%), EP is available for other medication-related questions from PCPs (73%), and EP monitoring reports provide more timely data between PCP visits (72%). The top three most common barriers selected were: lack of EP’s available time to appropriately monitor and manage the patient’s medications (63%), lack of EP training/experience monitoring patients and managing medications with CPAs (56%), and lack of patient follow-up with EP services (51%).

Table 4: Facilitators of Embedded Pharmacist CPA Utilization.

Table 5: Barriers of Embedded Pharmacist CPA Utilization.