Successfully starting ambulatory clinical pharmacy services

Pharmacists key to continuity of care and medication therapy outcomes

Taking a step-by-step approach to implementing pharmacist-managed ambulatory clinics can lead to success. That's the experience of The Health Alliance of Greater Cincinnati, which opened clinical pharmacist-managed anticoagulation services in a university hospital and community hospital and later expanded the program to another community hospital. The story of the program's success was told in the American Journal of Health-System Pharmacy.

Lead author Kelly Epplen, PharmD, CACP, clinical coordinator for ambulatory care pharmacy services for Health Alliance, tells Drug Formulary Review that persistence is the most important factor in implementing pharmacist-managed ambulatory clinics because too few people are used to pharmacists being in such positions and being able to bill for their services. "If you don't like the answers you are being given, ask again somewhere else," she advises.

Epplen says there are many benefits to adding clinical pharmacy services in an ambulatory care setting in disease areas such as anticoagulation, heart failure, lipids, diabetes, asthma, and vaccination. At the Health Alliance of Greater Cincinnati, she says, there was a recognition of the need to offer these services to distinctly different patient populations served by large health networks, and a commitment was made to improve continuity of care and medication therapy outcomes of patients receiving care in the alliance's ambulatory care clinic systems.

"A methodological approach to implementing ambulatory clinical pharmacy services was developed to facilitate implementation of several disease-management clinics including anticoagulation management, pharmacotherapy, and heart failure clinics across the integrated health care delivery network," she says. "The goal was to ensure seamless transition of patients from inpatient care to the outpatient clinic system."

Epplen and her colleagues used a stepwise approach to developing and implementing ambulatory clinical pharmacy services to help meet the needs of the distinct patient populations in the alliance's university hospital and several community hospitals operating in multiple geographic regions. Using that approach, she says, Health Alliance was able to successfully implement numerous pharmacist clinics. These are the steps that were followed:

1. Needs Assessment. Pharmacy Department administrators and clinicians identified patients at high risk for poor medication-related outcomes and patients in need of improved continuity of care. Patients determined to be most at risk included those with a high frequency of hospitalizations and emergency department visits, high morbidity and mortality related to diagnosis, a need for multiple medications, or a need for complicated drug therapy regimens.

2. Justification of Services. The team estimated the effect of clinical pharmacist interventions on clinical, economic, and humanistic outcomes using existing literature and institution-specific statistics.

3. Determination of Scope of Services to Be Provided. They evaluated state pharmacy practice acts for the states in which the Alliance operates and developed a policy for establishing collaborative practice agreements.

4. Allocation of Resources. A business plan was developed and presented to the corporate director of pharmacy services and hospital administration at each site. Costs related to require full-time equivalents, including pharmacists and supporting personnel, space, and supplies, were estimated. Projected patient volumes and potential revenues were estimated based on existing diagnosis-related groups information. They identified unfilled positions at each of the hospitals that could potentially be used for hiring ambulatory care practitioners.

5. Identification of Key Stakeholders. Financial administration representatives were identified and contacted so that clear mechanisms for billing and revenue generation could be created. Presentations were made to the Office of Medicare Compliance to ensure compliance with federal requirements. Registration and scheduling personnel were contacted to ease patient flow through the outpatient clinic system. Perhaps even more importantly, physicians who were willing to support implementation of clinical pharmacy services in an ambulatory care setting were identified. Four physicians with interest and expertise in the areas of the services being implemented were asked to serve as medical directors for the pharmacist-managed clinics. Key laboratory personnel were contacted and collaboration occurred on point-of-care testing for anticoagulation monitoring.

6. Identification of Quality Standards. Practice standards were identified in the areas of service to be provided. Clinical practice guidelines were researched and used as education tools for involved clinical pharmacists.

7. Protocol Development. Policies and procedures were developed for each clinical pharmacy service being implemented. Criteria for patient referral, collaborative practice documents, clinical evaluation models, methods for documentation, and channels for communication with responsible physicians were created. The alliance purchased point-of-care technology and software for use in the clinics.

8. Development of Competency Programs. Competency modules were developed for several areas of practice. Available board certification programs and continuing education certification programs were completed by pharmacists serving as clinic directors. The alliance developed a model for ongoing evaluation of staff competency to ensure that participating staff members remain current in the selected areas of patient care.

9. Measurement of Outcomes. Outcome measurements that were identified and collected included event rates, hospitalizations, emergency room visits, physician satisfaction, patient satisfaction, census growth, and revenue generation.

10. Development of Mechanisms for Reimbursement. Understanding that a major barrier to developing and implementing ambulatory clinical pharmacy services is a lack of clear-cut billing procedures to ensure reimbursement, the alliance established a successful standardized billing model for all pharmacist-managed clinics across the health system, allowing for justification and further development of ambulatory clinical pharmacy services. Codes specific to clinical pharmacy services within the ambulatory care clinic systems were created and applied to multiple institutions across the health system and a method for tracking charges and actual reimbursement was created.

The University Hospital, Health Alliance, established the pharmacy anticoagulation service in the fall of 1997 as an extension of an outpatient treatment protocol for patients with uncomplicated deep venous thrombosis (DVT). The clinic's objectives were to: 1) prevent thromboembolic events in patients on anticoagulant therapy; 2) prevent hemorrhagic complications in patients on anticoagulant therapy; 3) improve continuity of care for those patients requiring anticoagulation during transition from the inpatient setting to the ambulatory environment; and 4) provide information and education on anticoagulation therapy to patients and healthcare providers.

Safe transition from inpatient to outpatient

The protocol allowed for early discharge, according to strict inclusion and exclusion criteria, for patients with DVT using subcutaneous administration of low-molecular-weight heparin. Such a care model allowed for the early and safe transition of patients from the inpatient to outpatient setting. That innovative approach to managing venous thromboembolic disease rapidly became the care standard at the university hospital, with physicians demanding an organized method for anticoagulation monitoring.

As the volume of referrals to the pharmacy anticoagulation service rapidly increased, additional support and resource allocation became necessary if the intense level of patient care were to be maintained. As a result of the increased demand for clinical pharmacy anticoagulation services, the clinic stopped accepting new patients for acute monitoring on June 24, 1999, until the alliance was able to address issues involving oversight by medical staff with anticoagulation expertise, additional FTE allocation, office space, and reimbursement mechanisms.

A year later, on July 10, 2000, the pharmacy anticoagulation service became fully operational with support from the Department of Internal Medicine and hospital administration. The clinic accepted patients for both acute and chronic monitoring. Collaborative practice agreements specify the desired length of anticoagulation therapy as determined by referring physicians. Point-of-care technology is used to measure the intensity of anticoagulation for improving patient satisfaction.

With the success that had been achieved at University Hospital, the alliance decided to also implement an anticoagulation clinic at one of its community hospitals. They chose St. Luke Hospital, which has separate units serving two distinct geographic regions. The pharmacy anticoagulation clinic was established as an initiative to improve continuity of care by providing comprehensive anticoagulation management in the community hospital environment.

Different types of patients

Available data indicated that patients receiving anticoagulation therapy at community hospital sites differed greatly from those in the university hospital setting with respect to indication for anticoagulation, average age, and demographic statistics. Pharmacy anticoagulation clinics of the St. Luke Hospitals were established in May 2002 in one unit and November 2004 in the second unit. Consultative agreements with primary care physicians in the community setting were established, whereby clinical pharmacists trained in anticoagulation monitored and adjusted anticoagulation therapy. Point-of-care technology was used for shorter turnaround time for laboratory results and to improve patient and provider satisfaction.

Epplen says the concept of clinical pharmacists managing anticoagulation therapy rapidly gained popularity with area office-based cardiologists and primary care physicians. To accommodate the large influx of patients referred to the clinic, the pharmacy anticoagulation clinics of the St. Luke Hospitals implemented the role of a clinical pharmacy technician whose responsibilities included organization and management of patient flow, telephone triage, and patient scheduling. The clinical pharmacy technicians also were trained by clinical pharmacists and laboratory representatives to obtain blood pressure, pulse, and capillary whole blood samples for International Normalized Ratio determination. An examination was administered and competency established before allowing the clinical technician to obtain blood samples.

The study reports the university hospital service was instrumental in facilitating transition of some 1,000 patients (200 per year) requiring acute monitoring to the outpatient setting. The pharmacy anticoagulation service now monitors 300 outpatients.

Revenue stream created

Although establishment of the service was not intended to generate revenue for the institution, increasing patient volume created a revenue stream due to capture of facility charges. Also, cost avoidance secondary to decreased length of stay, demonstration in the literature of minimized adverse events subsequent to comprehensive anticoagulation management, and physician and patient satisfaction have helped to justify the service.

Features of the program that make it unique, according to Epplen, include:

  • creation of a successful care model in a university hospital setting and its adaptation to meet a community hospital's needs;
  • standardization of a billing model using facility charge codes created specifically for pharmacist-managed clinics to facilitate appropriate channeling of revenue to pharmacy cost centers across the health system;
  • support from community physicians in favor of implementing collaborative agreements with clinical pharmacists to improve medication therapy outcomes;
  • creation of a clinical pharmacy technician role to accommodate increasing patient referrals, allowing for increased clinic organization and decreased pharmacist overtime; and
  • establishment of improved continuity of care and patient outcomes, including statistically significant decreases in thromboembolic events and minor hemorrhagic events, increased time within therapeutic range, and increased patient satisfaction.

Epplen tells Drug Formulary Review the corporate billing department initially didn't want to create more cost centers. She says needing to be able to evaluate cost centers became important as demand for services grew and there was a need to justify requests for additional resources. She says the pharmacist team looked into how other non-providers charged for their services, and ended up helping create pharmacy-specific facility codes that were standardized across the alliance.

Pharmacy codes equate to a low-level facility charge, she says. They have stayed with the facility charge rather than going to pharmacist CPT codes because they believe they are receiving a reasonable fee through the facility charge and are being cautious about what the income might be from CPT codes. Epplen says she believes the program will eventually migrate to CPT codes, although that seems to be several years away. She says it will be important that Medicare, Medicaid, and private payers all use the same codes in the same ways.

(Editor's note: Contact Dr. Epplen at (859) 212-5568 or e-mail her at


1. Epplen KK, Dusing-Wiest M, Freedlund J, et al. Stepwise approach to implementing ambulatory clinical pharmacy services. Am J Health-Syst Pharm 2007;64:945-951.