Pharmacy Practice Settings

diagnosis related groups (DRGs)

• payment is capitation Medicare driven

• complete shift in risk from fee-for-service to capitation

• pharmacy is now a cost center instead of a revenue center

hospitals: classification

• length of stay:

  • short-term (< 30 days)

  • long-term (> 30 days)

• service:

  • general hospital

  • specialty hospital

• hospital ownership:

  • federal

  • non-federal

  • non-profit

  • for-profit

teaching hospitals

serve as clinical training sites for physicians

horizontal integration

• flagship hospital

  • affiliated hospital

  • affiliated hospital

vertical integration

• flagship hospital

  • health plan

  • affiliated physician practices

  • owned physician practices

  • ambulatory care center

  • post-acute facilities/services

hospital management

• Board of Directors (for-profit) or Board of Trustees (not for-profit)

• hospital administration

• medical staff

• pharmacy department varies in where it reports

The Joint Commission (TJC)

• functions to:

  • improve U.S. health care quality

  • responsible for setting standards

  • accredits many types of health care facilities

    • accreditation needed for Medicare and Medicaid reimbursement

• focused on health care structure and delivery initially

• has evolved to include focus on clinical processes and outcomes

• unannounced site visits

Department of Health

in some states (such as NY), they can license, credential, and inspect hospitals

hospital pharmacy responsibilites

• structure:

  1. Director of Pharmacy

  2. staff and clinical pharmacists

  3. technical and support staff

• safe and effective use of drug therapy

  • product selection

  • product procurement

  • product distribution

  • appropriate prescribing

  • follow guidelines

  • manage costs

floor-stock distribution

• predetermined number of dosage forms

• nurses dispense medications

• 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 dosage forms of medications

• adhere to additional standards by U.S. Pharmacopeia

• testing standards for entry-level pharmacists

drug therapy monitoring

• clinical pharmacy practice

• verify drug, dose, and route of administration

• monitor medication-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 reactions monitoring

medication-utilization evaluation

• quality assurance program

• quality improvement focus

• evaluate use of drugs

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 on formulary

  • Pharmacy and Therapeutics (P&T) Committee

residency programs

• post-graduate training programs

• develop competencies in a specific area of pharmacy practice

• PGY1 → develop skills beyond requirements for licensure

• PGY2 → advanced or specialized training following a PGY1 residency

ambulatory care

• “care for an individual presenting for personal health services, who is neither bedridden, nor currently admitted to any healthcare institution”

• health care not requiring an overnight stay

fee-for-service (FFS) practice

patient pays rate of charges for services

managed care programs

• large impact on ambulatory care

• HMO or PPO

• reduce costs

• per member per month (PMPM) → pre-payment

Medicare Prospective Payment System (PPS)

• instituted in 1983

• shorter lengths of inpatient stays

• augmented ambulatory care programs

types of ambulatory care

• private medical officer practice

• non-physician practitioners

• hospital-related (clinics, emergency departments)

• freestanding services

  • primary care

  • urgent care

  • retail clinics

  • ambulatory surgery

  • community health centers and public health departments

group practice: advantages

• after hours and vacation coverage

• shared office overhead

• peer consultation

• Medicare and other insurance providers encourage group practice

patient-centered medical homes (PCMHs)

• team-based care led by a personal physician providing coordinated care across patient’s lifetime

• includes collaboration with other health care professionals for preventative, acute, chronic, and end-of-life care

accountable care organization (ACO)

• legal entity including providers and suppliers to coordinate care for Medicare beneficiares

• meet Medicare quality measures

teaching hospital clinics

• types:

  • medical

  • surgical

  • specialty

• supervised teaching opportunity for students and residents

• usually for:

  • low-income patients

  • follow-up visits

ambulatory surgery centers

• hospital-related or freestanding

• anesthesia advances are primary driver

• surgeries and procedures not requiring admission

• patient goes home same day as procedure

• less time, lower cost, high level of patient satisfaction

• preferred by third party payers

• accreditation → Medicare, TJC

hospital emergency department

• staffed and equipped for life-threatening illness and injury

• “safety net” → high levels of inappropriate use for non-urgent care

• levels of cases:

  • emergent: immediate medical needed

  • urgent: medical care needed within hours

  • non-urgent: minor or non-acute in severity

    • 50% of cases

freestanding facilities

• non-hospital based facilities

• owned and operated by hospitals, physician groups, or corporate chains

urgent care centers

• ownership → for-profit, physician groups, managed care organizations

• episodic care, after hours, non-emergency

• self-pay or insured

retail clinics

• operate in pharmacies (ex: CVS, Walgreens)

• smaller scope than urgent care centers

• strong insurer acceptance

• Academy of Family Physicians recognizes need for retail clinics

  • urges referrrals and quality guidelines

federally qualified health centers (FQHCs)

• renamed community health centers (CHCs)

• 2 out of 3 patients are uninsured or eligible for or receive Medicaid

  • high poverty levels

• sliding fee payments for paying patients

Indian Health Service (IHS)

• treaties signed with Native American tribes stipulated the provision of certain medical and hospital services

• directly operates 27 hospitals and 98 health centers

• covers American Indians and Alaskan Natives residing on or near reservations

• majority of IHS pharmacists are PHS Commissioned Corps

local public health services

• colonial era charitable tradition by cities and states

• services that private practice medicine had little interest in

health department services

• communicable disease control

  • contagious diseases

  • STDs

• maternal and child health

  • low-income families

  • prenatal care

  • well-baby care

• chronic diseases

  • preventative care

  • screening

• general ambulatory care

  • low-income patients in underserved areas

not for-profit agencies

• cause-related, often grassroots missions

• repositories of community values and charity

• fill gaps for special needs populations and advocacy

• governed by volunteer boards of directors

• ex: American Red Cross, Salvation Army, church missions

school health clinics

• provide health education for students

• maintain a safe and healthy school environment

• personal health services

• limited care provided on site