Hospital pharmacy's move to clinical pharmacy serves as best practice model

Decentralization began in the 1980s

Consensus has grown nationwide for national health care reform, and hospitals increasingly are seeing the benefits of including pharmacists in patient care teams. But the question many hospital pharmacy leaders are asking is how they can make a smooth and successful transition to more clinical pharmacy roles or a decentralized pharmacy model.

There is at least one hospital pharmacy that has two decades of experience in making such a transition, and this organization's experience could serve as a best practice model: The Medical Center of Columbus, GA, first began to use a decentralized pharmacy strategy in the 1980s and now has developed many clinical pharmacy roles for hospital pharmacists.

The hospital pharmacy has about 55 full-time employees, including more than 20 pharmacists. Also there are outpatient pharmacies in clinic buildings and a cancer center so the total full-time equivalency (FTEs) is close to 100, says Burnis Breland, MS, PharmD, FASHP, director of pharmacy for The Medical Center, which is part of the Columbus Regional Healthcare System.

The hospital has pharmacists working directly in patient care and on the patient floors. They plan drug therapy and stay close to patients in a patient care team approach from 7 a.m. to 11 p.m., seven days a week, Breland says.

"We have pharmacists in the long-term acute care hospital on the ninth floor, and we provide all pharmacy services to that separate hospital," he adds. "We have pharmacists who cover the emergency department, the intensive care unit, the neonatal intensive care unit, and the medical surgical unit."

One pharmacist might handle two floors of a particular unit, but there at least is pharmacy coverage, he notes.

Also, the hospital has two clinical specialists, including one who works with infectious diseases and microbial stewardship.

"Another specialist is a nutrition pharmacist who does all of the adult IV nutrition," Breland says.

Breland was instrumental in the hospital pharmacy's evolution to a decentralized model over the years. He received a PharmD diploma when the degree still was very new.

"I was the third person in Mississippi to have that degree," he says. "Then I moved to Georgia and started implementing this pharmacy program, and we've worked very hard at it with still more work to do."

The Medical Center's pharmacy residency program was key to the hospital's success with moving to clinical pharmacy care, Breland says.

"It was especially important when there was a shortage of pharmacists," he notes. "You get the cream of the crop students, train them for a year, keep the cream of residency crop, and recruit from within."

This gives the hospital a great recruiting pool of pharmacists.

Now that the pharmacist shortage has eased a little, hospitals should be able to find good clinical practitioners with less investment in training than was necessary in the past, Breland notes.

Another issue pharmacy leaders have to address is the cost of moving pharmacists into clinical roles.

"It's more difficult today than ever to justify new positions," Breland says. "The financial times are so stressful to us now, and hospitals are pressed to provide essential patient care and maintain a positive margin."

Also, hospitals are facing higher-than-ever indigent care loads.

So in this environment, pharmacy has to demonstrate value and return on investment, Breland says.

"Show you can deliver value to the institution through a decentralized clinical pharmacy program," he says. "It's not easy to do that, so start with one to three positions and move up from there, growing the program."

The pharmacy department might even need to carve out pharmacist time from existing positions initially, Breland says.

"Make it happen where you can put one or more pharmacists in patient care areas, and let them build up relationships," he adds.

Once the pharmacists have the support of physicians and nurses, it will be easier to approach the hospital leadership to ask for funding to create full-time pharmacist roles on patient floors.

"Pharmacy managers often think they can't do anything because they don't have positions open, but don't rely on that," Breland advises.

Another selling point for clinical pharmacy positions would be showing how the hospital can save money, at least at first, with increasing antimicrobial involvement and medication management services, he says.

"We have been very successful in reducing drug costs or maintaining costs," Breland says. "We do this by optimizing drug therapy, reducing waste, and eliminating needless drug therapy."

As momentum continues for national health care reform, Breland hopes it will keep the pharmacist's role front and center.

"We need to make sure the pharmacist is an integral part of the patient care team and that we utilize the knowledge, expertise, and skills of clinical pharmacists to improve therapy," Breland says.

"The pharmacist has to stay focused on the patient to optimize medication therapy and maximize medication safety in the delivery of care," he adds. "The closer we can keep the pharmacist to the patient's bedside and involved in drug therapy planning and monitoring to improve the safety and effectiveness of drug therapy, the better off we'll be in providing quality care and more effective care, as well."