Obtaining and Using Resources that Support the Objectives
There were two consistent types of resources discussed in the key informant interviews and brainstorming sessions. In both of these data sources, resources were either described as internal or external support. The support received was usually
financial, while other resources were described as physical support for the program itself including, staffing, office space, and administrative engagement. All types of resources and support that the PBDMP and other program sites received are important for
considerations of transferability to other program settings.
Internal Resources
All of the outpatient clinical pharmacy programs received funding from line-item budgets internally from within their respective clinics. More importantly, this financial support was coupled with philosophical support from the clinic’s administrative and clinical leadership. Key informants frequently noted that program finances provided by the clinic were concrete manifestations of the buy-in from clinic leadership. To secure
funding, program directors needed to provide evidence that an outpatient clinical pharmacy program would respond to the patient needs of the clinic, produce positive health outcomes for the patients enrolled in the program, and not serve as a financial burden to the overall clinic.
The Program Director at El Rio noted that the support from the clinic leadership was integral to program development and implementation: “It was all about showing improved outcomes. Solid, improved outcomes. Provider acceptance and provider satisfaction. Convincing our administrators we were a program that mattered.”(98) To garner the support of the key leadership, the PBDMP not only produced a plan for program implementation, but in addition clear outcome data was shared with clinic leadership to encourage continued programmatic support. For example, patient outcome data was shared with El Rio leadership on a weekly and monthly basis. The
administrators also articulated their “full full [sic] support” of the program in the RCA diagram. They went on to discuss their financial support for the program and the importance of providing funding for the PBDMP in the RCA diagram: “mobilizing funding: or helping to get enough for them.” According to the Program Director at El Rio, funding creativity was also important for program sustainability, “We’ve created ways to fund our program.”(98)
In line with the vision of the PBDMP, the “free status” of the program was
identified as a major success in all of the data sources. The Pharmacy and Clinical Group both said that the fact that the program was “free to all patients” enabled clinicians to refer individuals into the program without a financial consideration. As noted in Practice
One, the pharmacists pointed out that the “needs exceed capacity” for the program explicitly since providers tended to refer patients to the program because it was free.
This deluge of patients created a long wait time to see a pharmacist—almost three months—and major challenge for the PBDMP. In the RCA diagrams, there were over eight references describing the types of “free” services offered by the clinic. Notably, the Administrative Group was the only group to not mention the free status of the PBDMP.
It was considered a benefit for the clinic and the patients with diabetes at El Rio that a PBDMP existed. However, the pharmacists saw the program as potentially being
‘over-used’ by providers referring patients that do indeed have diabetes, but who may not need the individualized care that the program offers. Some of the groups argued that this increase in patient volume was beneficial for the patients at El Rio, while others noted that some patients “come to the appointment without the intention of participation” in the program. This lack of program engagement not only wasted pharmacists’ time, it also drained the program’s resources.
Many types of resources were also described in the data in terms of education and knowledge directly received by patients. In multiple RCA maps, “patient education” and knowledge of their current disease state was a positive outcome of the PBDMP. For example, the Clinical Group RCA diagram specifically identified “incorporates other quality services: eye/foot check, medical services” as a resource to patients. And finally, on multiple diagrams, the “ABI” (Ankle-Brachial Index Test) checking for peripheral arterial disease in the legs was mentioned as a service of the PBDMP for patients. The Clinical Group RCA diagram noted the “education in multiple formats” as a resource to
patients enrolled in the program. Many of these resources were explicitly purchased by the PBDMP to use with patients enrolled in the program.
Other educational resources for clinician interactions with PBDMP patients were identified by the brainstorming sessions as priorities of the El Rio leadership. The Pharmacist Group RCA diagram reflected “health education” as a major aspect of direct patient care. Training providers on “patient education” and “motivational interviewing”
were also specifically identified as skills clinicians were taught at El Rio. In addition, the UNC Program Director described patient education as a type of resource: “I think the other thing is that we do an education session every time a new group of medical residents come in and we educate them about any health care programs and what resources we provide to them.”(108) Training the PBDMP staff on how to effectively use program resources to educate and benefit patients within the program, was identified as a success on multiple RCA diagrams.
Physical space, materials, and tools were also described as PBDMP resources in the brainstorming sessions. The Pharmacist Group RCA diagram specified the “eye machine” and “exam rooms to see patients” as resources. The Clinical Group noted the
“help getting supplies/medications” as a success of the program and its potential for providing resources to patients. The Clinical Group also said that the physical setting of the PBDMP within El Rio was a success of the program. The group identified that:
“services delivered in multiple venues” and “co-location on site with PCP” were benefits of the program. Finally, the PBDMP and MHC program both identified as resources a dedicated conference room in the clinic for group education. While the conference rooms
were used for large patient group education settings or clinic staff meetings, there were not seen as necessary for program success.
Staff and personnel working in the program were described as program resources throughout the data. The Program Director of UNC described that the individuals on staff for the program were shared with other departments within the academic setting: “I mean, there’s technically 4 of us, but we are faculty and other responsibilities so if you factor in the amount of time we are funded by the clinic to do clinical work it’s about 2 to 2.25 or something like that.”(108) The number of FTE staff equated financially to the program’s bottom line since the staff services were reimbursed. UNC capitalized on their academic setting to create flexible part-time employees. Similarly, many of the
pharmacists on staff at the PBDMP and MHC program were part time drug dispensing pharmacists as well as employees of the outpatient clinical pharmacy program.
External Resources
In response to the question of buy-in from the clinic’s leadership, the Program Director at the Marana Health Center said: “So, those barriers have been overcome. We have the full support of the health center to do this. Basically, right now, it is just the financial impediment to get reimbursed.”(107) The MHC Program Director continued to describe that the main financial impediment for the program was not internal, but external through medical insurance reimbursements: “So, that’s our stumbling block right now, because to really just to place one or two or three pharmacists into this position, to do what we want to do—develop this program—that costs money. Because you’re pulling someone away from where our real income source is, which is still filling prescriptions,
and counseling.”(107) External insurance reimbursement was a key factor for all of the outpatient clinic pharmacy programs, and a difficult impediment to overcome. All of the programs placed the clinical pharmacists on an annual salary from their respective clinics and filed insurance reimbursements for services rendered.
This external issue of reimbursement was reiterated in multiple data sources. The Director of the UNC program commented, “But, it is frustrating that pharmacists are not providers, but we all know that. And, that it’s hard to figure out the financials of the pharmacists in those particular models. So, yes, we can show that we decreased hospital readmissions with our model, but pharmacists are expensive [and] they can’t technically charge for those visits, so how do we show the financials that are positive feedback to the hospital [or clinic]?”(108) This cycle of care and lack of insurance reimbursement for pharmacists was discussed during the brainstorming sessions as well as in multiple key informant interviews. The cycle of insurance reimbursement represents a barrier to obtaining further resources for the clinics. In some cases, this barrier represents a need to obtain more resources to offset the costs due to the lack of insurance reimbursement for clinical pharmacists.
One major barrier noted in the Pharmacy Group RCA diagram was the fact that patients have “no insurance” and “no money for medication” for medical services. While the PBDMP was free, referrals outside of the program and some medications prescribed from pharmacists within the PBDMP were still too expensive for some patients. The Administrative Group RCA diagram described these issues “social determinants” that highlight the “patient’s complicated patient history” making positive health impacts even
more convoluted and difficult in the long term.
External support also came in the form of community engagement. The Program Director at El Rio noted that “getting buy-in from the community” helped galvanize support in terms of payment reform and pharmacist provider status on a city and state-wide level.(98) The community advocates supported the PBDMP both financially and politically in community forums. The Program Director for El Rio noted: “we had a lot of donors from the community who supported the program because they believed in what we were doing. And they personally had family members who they sent here who had success that hadn’t had success and they tried different programs around the city and different things like that. So, initially it was a lot of that and now we became an
accredited diabetes site and so we can bill for the program...”(98) While many of these supporters provided some financial assistance, their support mostly came in the form of community engagement for the PBDMP.
The PBDMP received a HRSA demonstration grant in the initial stages of the program development and implementation. The Program Director at El Rio noted that the administrators: “sort of had written for the money, but they didn’t know what they were going to implement. Or, what it really meant or how it was going to work.”(98) The process of developing the grant helped clarify the current and future needs of the patients and the program structure. Payment for pharmacists was first discussed during the HRSA demonstration grant: “since clinical pharmacists don’t get paid for their health care services in general they get paid for dispensing product I mean, pharmacists. It is very hard to start a program.”(98) The Program Director went on to note that: “You almost
need like seed money, or you just need somebody who can say, we’re just going to eat the cost of paying the salary.”(98) The grant allowed the leaders of the PBDMP to implement the type of program they thought best addressed the needs of their patient population without directly tackling the issues of pharmacist salary head-on. At MHC and UNC, the outpatient clinical pharmacy programs were created without federal external grants.
Conclusion
The outpatient clinical pharmacy programs obtained resources through multiple sources both internally and externally. The support for the programs from within the clinics was through leadership buy-in and financial line-items. External resources tended to be from of external grants and support from the community. Together, these various resources supported the creation, implementation, and execution of the programs.