With the increasing availability of advanced pharmaceuticals to treat chronic and rare diseases in the outpatient setting, pharmacists strive to provide specialty medications as well as pharmacy care and drug therapy management. Although these specialty medications offer significant clinical advancements, they are frequently more complex drug regimens with higher incidences of adverse effects, and they are often very costly.
In years past, physicians could expect patients to have prescriptions filled locally, on the same or the next day; now, however, availability of specialty medications is often limited to only a few pharmacies and may require days or weeks to reach the patient. In the past, the physician could also expect to manage the drug therapy and receive support from the hospital outpatient or neighborhood pharmacist with whom he or she talked frequently. With the drug distribution restrictions preventing many pharmacies from purchasing these limited distribution drugs (LDDs), health systems, pharmacists and physicians often feel that they have lost control of the drug therapy component of patient care.
Specialty physician clinics
Hospitals and health systems often have many system-based specialty clinics and are focused on total system-based care, including the drug therapy component. For example, hospital patients receive organ transplants as inpatients and then move to the ambulatory specialty clinics for long-term management. The hospital and the outpatient clinics serve the patient through the continuum of care and are able to provide seamless, total patient care within the same health system. All medical records are available to the different disciplines and interdisciplinary collaboration is convenient and effective. The restrictions on drug access have changed the dynamics of care, though, and hospitals and health systems are now working to restructure their ambulatory care models to regain control of all components of care, including providing specialty drug therapy through their own system-based specialty pharmacies.
Ambulatory pharmacy practice model
As ambulatory pharmacy practice has evolved, the model of embedding pharmacists in outpatient clinics has taken on new value. Whereas many clinical pharmacists have worked in outpatient clinics managing drug therapy with physicians, their role has now evolved to also assisting patients in gaining access to specialty medications. The work that clinic staff do in providing patient information to payers to gain approval for specialty medications is now also being supported by pharmacists and/or other pharmacy staff. The collaboration of in-clinical patient management—focusing on patient education, minimizing adverse drug effects, and managing drug therapy to optimize therapeutic outcomes—has now taken on a new role of facilitating drug access and safe medication therapy. This has deepened the role of the pharmacist or pharmacy liaison in the clinics, as they are greatly simplifying the drug access and dispensing process. Long recognized as a progressive practice model, pharmacists embedded in clinics is now recognized as a key for success and growth for health system–based specialty pharmacies.
Clinical collaborative practice
Pharmacists practicing in specialty clinics have a wide array of opportunities and responsibilities. Having the pharmacist embedded in the clinic gives welcome support to the physician and clinic staff, provides a direct communication conduit to the pharmacy, and increases patients’ satisfaction with their care.
Not only do clinic pharmacists provide direct support to physicians and direct care to patients, they also participate in collateral activities, including clinical research—especially in academic health systems, with their three main focuses of patient services, education, and research. Working with physician specialists in clinical trials also provides the pharmacist with knowledge of pipeline drugs that will possibly become specialty LDDs in the future. Early knowledge of these investigational agents enables the specialty pharmacy to request access to the drug once the drug is approved for marketing.
Physicians are also agreeable to the clinic-based pharmacists and find that they are indispensable once they see the value that pharmacists bring to patient care through collaborative practice and through facilitation of access to drug therapy and improved medication management. Being part of the clinic care team is also beneficial in capturing specialty prescriptions and providing specialty pharmacy care for the system from within the system. Advantages of increased capture rates are better control of care, better coordination of care, and more practitioner collaboration and communication, thus improving clinical outcomes. Better cooperation among practitioners, the clinic, and the pharmacy can also mean improved financial performance for the system.
Quality of care and patient impact
Clinicians are aware of the improved clinical outcomes when there is collaboration between disciplines; patient satisfaction is also better when patients see their caregivers working together through seamless practice models. Patients want to know their providers, and they want their providers to know them, including their individual unique problems and needs. When a patient’s care is provided within a well-coordinated and highly collaborative environment, such as an integrated health system, the patient perceives improved care and patient satisfaction is greater.
Specialty pharmacy services
As hospitals and health systems expand their ambulatory pharmacy models to address the transition to outpatient care, specialty pharmacies have evolved out of necessity to address the needs of hospital patients moving to chronic care management in the outpatient setting. Specialty pharmacies have become commonplace in health systems and their growth has been phenomenal. Although hospitals and health systems make up a small percentage of the total specialty pharmacy market, their impact on critical patient care is pronounced. These health-system–based specialty pharmacies often struggle to gain access to LDDs and to payer networks, but progress is being made to address these challenges. Hospitals and health systems are joining forces through alliances such as Acentrus to address the specialty challenges through collaboration as an integrated delivery network. Working together to recognize best practices, collaborating in clinical practice and benchmarking, and using data analytics to gain access to LDDs and payer networks is proving to be a successful strategy that enables health system specialty pharmacies to fulfill their mission of providing high-quality clinical care.
Discussion
Health systems are complex organizations that provide life-saving and life-changing care to patients. Inpatient care and ongoing ambulatory patient management through primary and specialty clinics are now common, integral components of most health systems. The ambulatory care pharmacy model in which clinical pharmacists are embedded in specialty clinics as caregivers and supporters provide unique benefits, including enhanced clinical outcomes and improved patient satisfaction. Specialty pharmacies within health systems face many challenges, including limited distribution drugs, restricted payer networks, unique drug dispensing and provision issues, and stiff competition from outside entities. However, the synergy produced through collaborative practice and pharmacy integration with clinic operations serves the patient well and is a care model that cannot be achieved with a fragmented system of care providers. Hospitals and health systems are in the unique position to provide unsurpassed value to patients through specialty pharmacy alignment with specialty providers through clinic-embedded pharmacists and pharmacy liaisons serving as the seamless connection among providers, the pharmacy, and the patient.
