Incorporation of clinical pharmacists in the patient-centered medical home model

Methods: Twenty Plan-Do-Study-Act (PDSA) cycles were completed with 5 different patients to further define the role of pharmacists in the health care home model. PDSA cycles focused on the following: patient identification and invitation, workflow development, care plan coordination, clinic education, care plan team meetings, and communication between team members and follow-up.

Medical assistants and providers were responsible for identifying and inviting patients with a patient letter. Social workers, health educators and outreach works were responsible for explaining the “health care home” concept to patients and completing Lifestyle Overview (LSO) and patient perception surveys. Pharmacists were responsible for carrying out their normal duties including medication therapy management, medication reconciliation, disease state management, drug information and medication access services.

Results: A total of 5 patients were seen with over 10 coordinated care visits. Approximately 20 PDSA cycles were completed. Additionally, one combination visit with a provider, diabetes educator and PharmD was completed to develop a care plan. Thus, a total of 1 care plan was created for 1 patient. Inceased coordinated care visits with multiple providers helped improve safety and quality of care for patients. The pharmacist played a crucial role in facilitating involvement of team members and coordination of health care home team meetings.

Components of a care plan included the patient's chart summary, action care plans, emergency care plans, Health care home team contact list, lifestyle overview and patient perception surveys. Incorporation of the care plan into workflow still requires further improvement. Care plan team meetings were found to be useful and rewarding to patients and the team members. In the future, team “huddles” will take place every week to discuss patient cases. With the implementation of electronic health records, team members will be able to flag one another to facilitate increased communication regarding patients. A care coordinator position is necessary on the health care home team to improve progress towards achieving the health care home model.

Conclusion: Medications are a cornerstone of the healthcare system. This provides pharmacists an opportunity to utilize their unique clinical skills to become active participants of the healthcare team. This project has demonstrated that pharmacists play a crucial role in the health care home team. Through motivation and increased involvement, pharmacists will be able to contribute to improving the safety and quality of care.