Academic journal article
By Bray, Bryan
Generations , Vol. 35, No. 4
Collaboration and integration make for a care model that saves money and improves medication management and quality of care.
Medication Management, LLC, is a nontraditional pharmacy practice that integrates clinical pharmacists into physician practices. Its clinical pharmacists provide direct patient care, and there are none of the drug-dispensing functions typical with most pharmacies. The physician refers patients to the clinical pharmacist, who carries out office visits, as would a physician, nurse practitioner, or physician's assistant. This model of care has demonstrated costs savings, improvement in quality of care, and higher patient satisfaction.
A Classic Chronic Disease Patient
To illustrate this model, consider the example of a full-time clinical pharmacist in Greensboro, North Carolina, who has been assigned by Medication Management, LLC, to Greensboro Medical Associates, a large practice including specialists in internal medicine, endocrinology, cardiology, and rheumatology. The practice focus areas for the clinical pharmacist are diabetes, high blood pressure, high cholesterol, anticoagulation therapy, and general drug therapy consultations for patients taking multiple medications.
Doris is an eighty-two-year-old woman who was referred by her physician to see the clinical pharmacist at Greensboro Medical Associates. She has chronic medical conditions requiring multiple medications. Specifically, her atrial fibrillation, which requires anticoagulation with warfarin, is monitored very closely, usually monthly. She arrives at her appointment in a wheelchair (which is highly unusual for her) and appears lethargic and somewhat confused.
In addition to atrial fibrillation, Doris's chronic conditions include hypertension, a history of non-Hodgkin's lymphoma, hyperlipidemia, coronary artery disease, osteoporosis, gastroesophageal reflux disease, and anxiety. Her long-term medication regimen includes warfarin, metoprolol, hydrochlorothiazide, olmesartan, atorvastatin, diazepam, isosorbide mononitrate, digoxin, risedronate, and esomeprazole. She also takes calcium, a multivitamin, and acetaminophen.
Doris recently lost her oldest daughter to breast cancer. Her family says that she has gone downhill since then. She has been eating and sleeping poorly, and falling repeatedly. She cannot ambulate without assistance because she's very unsteady on her feet. In her own attempt to handle the anxiety and insomnia related to her daughter's death, Doris decided to increase the amount of diazepam she was taking from one tablet to three tablets a day. And she sometimes takes two capsules of an over-thecounter (OTC) sleeping medication containing diphenhydramine. She reports that she gets very dizzy when standing up from a sitting or lying down position. The family is concerned that this change in Doris's condition may require them to place her in a nursing facility.
A quick check of her blood pressure (first sitting, then standing) reveals a significant drop, indicating hypotension. Lab results also reveal that she is mildly dehydrated and her International Normalized Ratio (used to monitor the warfarin) is low. The family says Doris has missed several doses of warfarin because she went to sleep and forgot to take it.
It is evident that Doris is suffering from a medication-induced delirium as a result of self-adjusting the diazepam dose and taking the OTC sleep medication. The combination has resulted in a cascade of problems, including dehydration, hypotension, and falls. On her current visit, the clinical pharmacist decreased the diazepam dose to once a day, discontinued the OTC sleep aid, and stopped the olmesartan because of Doris's low blood pressure.
The pharmacist helped her re-establish her drug-taking routine through use of a pill reminder- organizer and a calendar. On a follow-up visit two weeks later, Doris was dramatically improved. Although still grieving, she was now ambulating. …