Case for a pharmacy-centered medical home

Origin & need for the medical home

One of the commonly and more recently cited solutions to containing healthcare costs and improving access to healthcare is the medical home. The term ‘medical home’ was first used in the 1967 book Standards of Child Health Care[1]. The Council expanded upon the idea in 1974 by writing ‘Fragmentation of Health Care Services for Children,’ a statement saying that care spread out among different practitioners is a serious problem [1]. Indeed, the fragmentation may delay care, lead to a lack of care when it is needed, or even lead to excess care, such as medical test duplications – when it is not needed [1]. Such issues reduce the quality of care for patients, while also facilitating a system that fails to efficiently allocate resources and may even waste some [1]. The solution to fragmented care would be a centralized hub or repository of information, the medical home, or centralized care for a patient by one practitioner or a group. This practitioner would facilitate continuous care for patients and serve at the forefront as the patient’s navigator and advocate [1].

Elements of the medical home

In conjunction with several professional organizations, including the American College of Physicians, American Academy of Family Practice, American Academy of Pediatrics and American Osteopathic Association; the National Committee for Quality Assurance developed a list of various evaluation criteria for the medical home. The nine criteria are: access and communication, patient tracking, care management, patient self-management support, electronic prescribing, test tracking, referral tracking, performance reporting and improvement, and advanced electronic communications [2]. In addition, five elements appear to emerge as a foundation for the medical home: a personal physician, a team-directed practice, whole-person orientation, integrated healthcare and quality and safety. Such elements encompass evidence-based medicine, accountability for continuous quality, active participation of patients, information technology, voluntary recognition of practice and enhanced access to care [3].

Although a relatively new concept, the medical home model has been implemented in various settings, mostly showing incremental improvements in care, access or outcomes. Examples have shown decreases in the use of emergency services [4–6], increases in patient satisfaction [4,6] and even monetary savings in the short-term [7]. Medical homes have decreased the number of hospital admissions [7], but not consistently [4]. While research has provided some data, evidence is relatively scarce and no optimal model has emerged yet. In particular, many studies have focused on physicians, in particular primary care physicians, assuming a central role in the medical home. Martin Sipkoff has explored the idea of pharmacists in the medical home [8], but there is a lack of information specifically regarding the pharmacist as a facilitator of the medical home.

Pharmacist

Chronic disease remains a chief cause of morbidity, mortality and budget concerns across the USA. Given that most chronic conditions can be well managed and controlled with existing therapies, one of the chief causes of poor control has been cited as the fragmentation of care. Such fragmentation remains high for chronic disease. In spite of the various community outreach programs, for example, aimed at improving hypertension awareness, we still have very high levels of undiagnosed, undertreated and uncontrolled hypertension. There is a strong basis to support a central role for the pharmacist in the medical home, which will enhance the correlation between awareness, compliance and outcomes. The direct benefits of pharmacist monitoring, combined with encouragement from peers in social networks, could end fragmentation and improve patient care.

Evidence

Most of the evidence in the literature suggests that the medical home improves the process and, arguably, the outcomes of health care for patients. Centralized care and coordinated teamwork among practitioners offers care that is comprehensive [9]. With knowledge of the patient’s complete medical history, providers would be better equipped to provide patients with holistic care, including preventative, acute, chronic and end-of-life care [10]. With a long-term relationship between a patient and practitioner, patients would receive less fragmented care, more efficient access to care and enhanced opportunities to become actively involved in their own care [3]. This may result in a more positive experience and also better patient satisfaction [11]. The long-term relationship also gives the practitioner increased accountability for safety and quality of care [3]. For providers, the medical home capitalizes on the expertise of those facilitating it, while lifting some of the burden off other providers. For payers, billing may be more efficient with centralized care.

Some of the disadvantages cited for the medical home are that those patients with limited mobility may not be able to readily travel to the same clinic on a regular basis [12]. For providers, some may fear that the medical home would replace their roles, take business away from their practices or steer them away from their patients [13]. There are economic concerns as well. In a position statement about medical homes, the American College of Emergency Physicians warns that the reallocation of resources to medical homes could harm other healthcare divisions, including emergency departments [101]. In addition, the current lack of complete electronic patient medical records and the lacking access of pharmacists to medical records are further barriers to the pharmacist-centered medical home [8].

Case for the pharmacist

Historically, and over the evolution of practice, pharmacists have earned public trust, and have been repeatedly ranked by the public in Gallup Polls, near or at the top in honesty and ethics [102]. They are recognized as culturally competent professionals to whom patients would entrust their care. The infrastructure of pharmacy networks already exist as an intrinsic part of neighborhoods. It is often supported by electronic prescribing, or at the very least, electronic prescription records. Pharmacies are evenly distributed in all neighborhoods and thus very accessible to the community. There are pharmacies even in areas with other limited healthcare access, and pharmacists have successfully worked with patients and other healthcare professionals to improve patient outcomes [16]. Taking into account this information and the central role of prescription drugs in the management of chronic disease, it is appropriate to expect that pharmacists would bring medication management expertise to the coordination of patient care [8].

By signing up in a medical home, the patient commits to visiting the same pharmacy for monitoring and follow-up between physician visits. The pharmacist would be responsible for a variety of management functions, such as measuring blood pressure, administering lipid tests, monitoring glucose levels and titrating medications. These functions are in addition to those that many pharmacists already perform, including distributing prescription drugs, educating patients about their drugs, looking out for drug interactions and encouraging medication adherence. The pharmacist would input all information from patient visits into an interactive live electronic database, available to all providers, and would be able to pull up the information at the next patient visit.

The electronic pharmacy database would be an expansion of a current pharmacy database. Today, many pharmacy databases already contain information about patient identification, prescription drug history, and insurance information. The proposed database would incorporate that information and more, including brand and/or generic drug information, specific prescribing information, patient-reported information and complete medical history. It will be linked to the patient’s electronic health record. Every time a patient receives care, whether from a pharmacist, physician or other healthcare professional, all data would be input into this database. Pharmacists, providers and patients in a separate interface would have access to the database information, thus enhancing communication among these groups.

Although complete electronic medical records do not exist yet, the use of electronic medical records and electronic prescriptions is becoming more widespread [8]. While pharmacists do not yet have access to patient medical records, prescription drug and billing data are already collected in pharmacies, thus reducing the learning curve in the proposed model of the pharmacy-centered medical home. These electronic records could be expanded to full patient records, so as to be readily available for retrieving and inputting information when patients visit pharmacies for monitoring and follow-up. There are economic considerations to take into account, and resources targeting disease maintenance and control are needed.

Different stakeholders may have reservations about the pharmacist-centered medical home. For example, patients with chronic disease will have to step up their responsibilities in the role they play in their own healthcare. They must be willing to visit pharmacies more frequently and on a regular schedule in between physician visits, in order to reach and maintain control of their condition.

Conclusion

The medical home concept for centralized patient care has evolved since the term was introduced in 1967, but little thought has been given to the central role of the pharmacist in this model. Pharmacists are ideally positioned in an existing community infrastructure, to manage medical homes for many reasons, including trust accessibility and medication expertise. In our proposed model, a patient would visit the same pharmacist for monitoring and follow-up between physician visits, and the pharmacist would input the information into an electronic pharmacy database with complete patient records. As facilitators of the medical home, enhanced with electronic health records, pharmacists would help manage and control chronic conditions.

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.