Hospital and Ambulatory Care Pharmacy Practices

Hospital Pharmacy Functions

Roles and responsibilities of pharmacy within a hospital setting.

Community Pharmacy Practice

Pharmacy services provided in a community setting.

Hill-Burton Act

Legislation that provided federal funding for hospital construction.

Competition and cost of healthcare now

Payment via Diagnosis Related Groups (DRGs) - capitation (set amount per patient to providers) medicare driven - unbundle services, pre and post surgical billed separately

Horizontal and vertical integration: affiliations and care continuity - containing costs, pre-certification requirements and decreasing lengths of stay

Recession and pandemic impact on elective procedures

reactions to reimbursement methods

capitation payments using DRG
- shift in risk ( fee-for service -> capitation)
- shift in handling of pharmacy
inpatient prospective payment system
- move some surgeries to outpatient
- only coverage for acute phase
Value based purchasing
- measure prescribed process of care
- outcomes measured

Capitated Payments

Payments made to providers based on the number of patients rather than services rendered.

3 ways of classifying hospitals

length of stay: short term <30 days or long term < 30 days
service: general or specialty hospital
hospital ownership: federal, non federal, nonprofit, or for profit

miscellaneous classifications of hospitals

community or non community
teaching hospitals
community hospitals: < 200 beds.
hospital chains: Kaiser, UMMs, Hospital corporation of america

The Joint Commission (TJC) - formerly JCAHO

An organization that accredits health care facilities and sets quality standards.
- improve US healthcare quality
- sets standards
- accredited many types of facilities
- accreditation needed for Medicare and Medicaid reimbursement
TJC focused on health care structure and delivery initially but has evolved to include focus on clinical processes and outcomes
unannounced site visits

In some states like NY accreditation can come from

the department of health can license , credential, and inspect hospitals

Board of Directors

Governing body for for-profit hospitals.

Board of Trustees

Governing body for not-for-profit hospitals.

pharmacy responsibilities

safe and effective use of drug therapy
- product selection
- product procurement
- distribution
- appropriately prescribed
- follow guidelines
- manage $$

Director of Pharmacy

staff and clinical pharmacists
technical and support staff

Floor-Stock Distribution

Nurses dispense medications
predetermined number of dosage forms
reorder from pharmacy as needed.

Unit-Dose Distribution

-pharmacist reviews all physician orders
-medications are dispensed in unit doses

Centralized Pharmacy Services

Single location
fewer professional and technical resources required

Decentralized Pharmacy Services

-multiple locations
-specialized or satellite locations

Intravenous Admixture Services

Preparation of sterile medication dosage forms
adherence to additional standards by USP
testing standard for entry level pharmacists

Drug Therapy Monitoring

Clinical pharmacy practice
verify drug dose and route of admin
monitor med related problems
conduct admission and discharge drug histories
resolve discrepancies
participate in patient care rounds
address fiscal implications and clinical effectiveness of drug treatment
adverse reaction monitoring

Adverse Reactions Monitoring

Reduces preventable adverse drug reactions.
review suspected adverse drug reactions
alert medical staff of potenital adverse drug reactions associated with certain drugs

Medication-Utilization Evaluation

-Quality assurance program
-Quality improvement focus
-Evaluate use of drugs (compare to specific criteria: justification for use, monitoring parameters, outcome measures to evaluate efficacy

Hospital Formulary System

formulary management
ensure appropriate drug therapy and control drug costs
list of approved medications
process of evaluating and selecting medications to be included in the formulary
advisory group: pharmacy and therapeutics committee ( P&T)
formulary vs non formulary drugs

Purchasing and Inventory Control

Manages drug procurement and inventory levels.
brand of product determined by pharmacy :
- quality of manufacturer
- cost
- dosage form
group purchasing agreements
handle investigational drugs

Residency Program for Pharmacists

Postgraduate training
develop pharmacy competencies in a specific area
PGY1 - postgraduate year 1 : develop skills beyond requirements for licensure
PGY2 - advanced / specialized training
follows PGY1

Ambulatory Care

Health care services provided on an outpatient basis.
healthcare not requiring overnight hospitalization
payer incentives to decrease inpatient stays
impact of common disease states on medication use: majority diagnosis and prescribed drugs come from few common diseases

types of medical practices

Fee for service

Managed Care Organizations
Large impact on ambulatory - HMO or PPO
reduce costs
PMPM - prepayment

Medicare prospective payment system (PPS) for inpatient hospitalizations
- 1983
- shorter inpatient stays - sooner and sicker
0 augmented ambulatory care programs

Types of ambulatory care

private medical office practice
non physician practitioners : NP, PA could perform 75% of primary services for adults and 90% for children
Hospital related : clinics, ER
free standing services
- primary care
- urgent care
- retail clinics
- ambulatory surgery
- community health centers and public health departments

Managed care orgs

identity of practice independent of physicians in it
Health Maintenance Org (HMO): health plan prepays providers (capitation) and patients provide copay at time of service
Preferred provider org (PPO): contracted by a health plan to provide service , negotiated discount for services

Transition from Solo to Group Practices

Shift towards economically efficient group medical practices.
promoted insurance to improve access
AMA - encouraged denying hospital privileges for GHI salaried MDs, found guilty of monopoly conspiracy
Advantages to group practice:
- after hours and vacation coverage
- shared office overhead
- peer consultation
- medicare and other insurance encourage group practice

Patient-Centered Medical Homes (PCMHs)

Team-based care model led by a personal physician providing coordinated patient care across a patient lifetime .
includes collaboration with other healthcare professionals for preventative, acute, chronic and end of life care
Transition to PCMH
- payment reforms
- increased use of health info tech
- pharmacists active in PCMH - cost saving

Accountable Care Organization (ACO)

Legal entity including providers and suppliers to coordinate care for Medicare beneficiaries.
meet medicare quality measures:
- combine fee for service with shared savings and bonuses linked with quality standards
- Goals : timely, appropriate care, avoid duplicates, medical emergencies and hospitalizations

Teaching Hospital Clinics

Clinics providing supervised training for medical students
clinics function as group practices: medical , surgical, specialty
usually for:
- low income (changing)
- follow up visits

Ambulatory Surgery Centers

Facilities for outpatient surgeries without hospital admission.
hospital related or free standing
anesthesia advances drive this
patients go home same day
less time, lower cost, high satisfaction
preferred by 3rd party payers
accreditation: Medicare, joint commission

Emergency Department (ED)

Staffed for life-threatening illness and injury care.
- physician and nurse specialists
- injury, poison, adverse drug events = 1/3 of visits
function as community safety nets
- visit rate of uninsured higher than insured
- physician referrals
- high level of inappropriate use for non urgent care
three types of care: emergent, urgent, non urgent

Emergent Cases

Immediate medical care required.

Urgent Cases

Medical care needed within hours.

Non-Urgent Cases

Minor medical issues , non acute in severity
often used by patients with no regular physician or ability to pay
medical issues could be managed at more cost effective venues
Preventable - some visits are labeled based on diagnosis

Freestanding Facilities

Non-hospital based health care facilities.
owned and operated by hospitals, physician groups, corporate chains
ex) urgent care, retail clinics, ambulatory surgery, federally qualified health centers, public health ambulatory services, not for profits

Urgent Care Centers

Walk-in facilities for acute illness and injury.
for profit, physician groups, MCO
episodic care after hours, non emergency
staffL primary care physician, nurses, lab
self pat, insured ( insurer reimbursed)

Retail Clinics

Operate in pharmacies, provide limited health services.
triage software manage diagnosis
staffed by NP, PA and physicians on call
strong patient, insurer acceptance
academy of family physicians recognizes need , physician opportunities - urges referrals and quality guidelines

Federally Qualified Health Centers (FQHCs)

established in 1960s by US office of Economic oppertunity
Community health centers Act of 1974
urban and rural : called Neighborhood Health Centers
ACA funded expansion

Community Health Centers (CHCs)

FQHCs = Community Health Centers that meet additional federal standards
serve 20 million anually
2/3 uninsured and Medicaid patients.- high povery levels , high infant mortality
sliding fee payments for paying patients
Mandated services:
- diagnosis and treatment consultation
- lab and imaging services
- medical and dental services
- pharmaceutical services

Indian Health Service (IHS)

treaties signed with Native american tribes stipulated provision for medical and hospital services
managed by the department of health and human services public health service (PHS)
IHS - 27 hospitals, 98 health centers
covers american indians and alaskan natives residing near or on reservations
IHS pharmacies are PHS commissioned Corps
pharmacy innovations :
- fill prescriptions directly from patients chart
- primary care to ambulatory patients with acute and chronic diseases
- private counseling rooms

Local Public Health Services

colonial era charitable tradition by cities and states
Tax-supported departments addressing public health needs.
services that private practices has little interest in:
- immunizations
- infectious disease case finding and control
Filled service gaps for needy and medicaid patients
- family planning
- high risk pediatric care
- prenatal care and well baby care
- immunizations

Health Department Services

Four categories:
communicable diseases: contagious, STD

maternal health: low income families, prenatal care, well baby care

chronic diseases: preventative care, screening

general ambulatory care: low income patients in underserved areas

Prison Health Services

Federal bureau of prisons
hospitals with clinics for Ambulatory care
full time pharmacies in larger prisons : distribute drugs from formulary, chronic care clinics including HIV/AIDS

Not-for-Profit Agencies

Cause - related, grass root missions
- community values and charity
- fill gaps for special need populations and advocacy
- governed by volunteer board of directors
- education, medical care, advocacy
ex) American Red Cross, Salvation Army, church missions

Funding : government and private foundation grants, private donations, medicare and medicaid, private insurance, sliding fee scale

School Health Clinics

Provide health education
limited care for students.
maintain safe and healthy school environment
personal health services

Free Clinics

5 requirements:
- physical facility
- trained health personnel ( volunteers) : medical, dental and psychological services
- available to all
- specified hours of operation
- no set payment required

financing and staffing by voluntary health professionals are obstacles - some evolved into CHC

Ambulatory Pharmacy Services

hospital outpatient counseling
primary care and family practice clinics
community pharmacy
- dispensing
- diversified services

community pharmacy studies

document and access pharmaceutical care
medication therapy management
access clinical, humanistic, economic impact of pharmaceutical care