Developing Clinical Practice

Developing a Clinical Practice
Mary Ann Kliethermes, Pharm.D.

Midwestern University
Downers Grove, Illinois

Mary Ann Kliethermes, Pharm.D.
Midwestern University
Downers Grove, Illinois
ACCP Updates in Therapeutics® 2016: Ambulatory Care Pharmacy Preparatory Review and Recertification Course
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Learning Objectives 1. Which is the most important initial step to perform?

A. Meet with the cardiology and pulmonary
1. Develop, conduct, and analyze an internal and exter- services to let them know you are on board and
nal environmental scan for planning an ambulatory able to provide clinical pharmacy services to
clinical patient care service. assist in managing their high-risk patients and
2. Create a formal service proposal or business plan the medications for these patients.
with the key elements you have identified as impor- B. Develop a mission statement that describes
tant to your organization. the services you will provide to high-risk
3. Analyze the feasibility of your service and develop patients and the vision that your services will
a pro forma statement that financially supports the improve patients’ health through reduced
sustainability of your service within a business plan. hospitalizations.
4. Describe three key characteristics that differentiate C. Spend time collecting data from patients
marketing and providing a service from marketing who have been rehospitalized during the
and providing a product. past 6 months to determine reasons for the
5. Incorporate the seven “P’s” of successful marketing rehospitalization.
into a marketing plan for an ambulatory clinical service. D. Research the literature for pharmacist-run
6. Identify three clinic operational activities to ambulatory clinics that provide services for
perform before opening a clinic. patients with heart failure and COPD.
7. Develop an optimal workf low process for an
ambulatory clinic. 2. You suggest to the director of pharmacy that putting
8. Develop and evaluate an effective set of clinic together a team of stakeholders would enhance your
policies and procedures for an ambulatory clinic. success of establishing clinical pharmacy services at
your institution. You have a cardiologist, a primary
Self-Assessment Questions care physician, the heart failure nurse practitioner,
Answers and explanations to these questions may be and the clinic office manager on the team. Which
found at the end of the chapter. additional key stakeholder is most important to add
to the team?
Questions 1–4 pertain to the following case.
A. A staff pharmacist.
You recently completed a residency with an ambulatory
B. The chief operations officer.
care focus, and now, you have been hired by a health-
C. The compliance officer.
system pharmacy department to start ambulatory
D. A medical assistant.
services. The health system has an outpatient clinic with
primary care and medical specialty services; however,
3. When doing a SWOT analysis (analyzing the
to this point, the pharmacy department has provided
strengths, weaknesses, opportunities, and threats)
only inpatient services to the organization. The director
of your proposed ambulatory clinic model, which
of pharmacy has secured your position as a viable
is potentially the greatest weakness you may en-
solution to the health system’s need to reduce its 30-day
counter and need to plan for?
readmissions. In the proposal accepted by the health-
system administration, the new Medicare transition-of- A. A poorly defined payment model for
care codes for billing will be used to support your service. your services.
The top readmission diagnosis is heart failure, closely B. Providers’ lack of a good understanding
followed by chronic obstructive pulmonary disease of pharmacist services.
(COPD), which is resulting in a significant revenue loss C. Lack of access to patient medical records.
for your organization. You are tasked with developing D. Nurse practitioner competition for role.
an ambulatory service in the hospital-based outpatient
clinic that will address this organization’s unacceptably
high readmission rate for heart failure and COPD.
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4. To ensure patient volume for your clinic, which is 6. Which is the best example of an important compo-
the optimal referral method? nent of your service or business proposal?
A. Mandatory referral for all patients with A. Explaining how you expect to integrate
heart failure and/or COPD who have been with the hospital pharmacy services.
hospitalized in the past 6 months. B. Ensuring that the service proposed meets
B. Provider referral based on their analysis of the patient services you were trained to do
patients who need pharmacy services for heart during residency.
failure and COPD. C. Including whether you will be using pharmacy
C. Patients with COPD or heart failure given the technician services in your plan.
option to receive pharmacist clinical services. D. Ensuring that the mission and vision of the
D. Referral made for patients with polypharmacy, proposed pharmacist patient care services
defined as eight or morhe medications for aligns with that of the organization.
chronic conditions.
Questions 7 and 8 pertain to the following case.
Questions 5 and 6 pertain to the following case. You have been hired as an assistant professor focused
The hospital, a large physician group, and a payer in your in ambulatory care at a new college of pharmacy. The
community are forming an accountable care organization college has secured a new practice site in a family
(ACO). You are the clinical services coordinator for a small practice office that is in the process of reengineering its
chain of community pharmacies with five pharmacies practice to a patient-centered medical home (PCMH).
strategically located near the hospital or the primary Although the group members have heard of pharmacists
care offices of the physician group. You have some basic providing clinical services in physician offices, they
medication therapy management (MTM) programs through have had no experience with pharmacists working in
Medicare Part D and you provide immunization services. You this capacity. They agreed to a 1-year evaluation to see
believe this is a great opportunity to develop an integrated whether this arrangement would be of value to their
service program, which you have been learning about at practice. You are passionate about providing ambulatory
national meetings. Your cold call to the administrators of the services and want to make a positive impression in your
hospital and large physician group was timely. They are in new practice site. You decide to create a marketing plan
negotiations with several payers and have been concerned from a training module provided in your residency.
about management of the prescription benefit because they
have little control over medication use in the outpatient 7. Which is the most appropriate first step in develop-
setting. They have discussed medication management as ing your marketing plan?
an area of concern because they do not currently have a A. Identify your customers.
provider with that skill set in the ambulatory setting. They B. Define your patient care services.
have discussed this with the hospital’s director of pharmacy. C. Create a brochure for patients.
The recommendation was to seek out that skill set and hire D. Give an in-service to providers in the PCMH.
someone to fit the need. They are interested in your alternative
proposal of using your community pharmacy. They would 8. You do some research on marketing and find that
like to see a service proposal from you to describe how this promoting a service has some marketing challenges.
will fit their needs. Which is the best example of one of the challenges?
A. It is difficult to put a price on service.
5. In the Financial Summary section of your service
B. There may be significant intervariability
proposal, which is most important for you to do?
and intravariability in services.
A. Write the summary primarily in narrative format. C. Patients have difficulty determining whether
B. Exclude any start-up costs; just include ongoing they have received quality services.
resource costs. D. Your only marketing option is written brochures.
C. Include a projected payer mix and the costs
avoided by implementation.
D. Include only a pro forma statement.
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Summary of Case Examples
1. You have recently completed a residency with an ambulatory care focus, and you have now been hired by a
health-system pharmacy department to start ambulatory services. The health system has an outpatient clinic with
primary care and medical specialty services; however, up to this point, the pharmacy department has provided
only inpatient services to the organization. The director of pharmacy has secured your position because of the
health system’s need to reduce its 30-day readmissions.
2. The local hospital system, a large physician group, and a payer in your community are in the process of
forming an ACO. You are the clinical services coordinator for a small chain of community pharmacies with five
pharmacies strategically located near the hospital and near the primary care offices of the physician group. Your
responsibilities so far have been developing the MTM programs through Medicare Part D and the pharmacy’s
immunization services. You believe this is a wonderful opportunity to develop an integrated service program,
which you have been learning about at national meetings.
3. You have been hired as an assistant professor focused in ambulatory care at a new college of pharmacy. The
college has secured a new practice site in a family practice office that is in the process of reengineering its
practice to a PCMH. Although the group members have heard of pharmacists providing clinical services in
physician offices, they have had no experience with pharmacists working in this capacity. They have agreed to
a 1-year evaluation to see whether this arrangement is of value to their practice.
I. IDENTIFYING THE NEED FOR AMBULATORY CLINICAL PHARMACY PROGRAM

AND ASSOCIATED PATIENT CARE SERVICES
Note: Although the information in “Developing a Clinical Practice” is presented in a certain order, the work in
each section should occur simultaneously. Please review a suggested timeline at the end of the chapter as a guide to
integrating each of these steps as you develop plans for your clinic. In addition, in this document, the terminology
program and services are differentiated in that a pharmacy program is used to describe the complete set of clinical
pharmacy services you plan to offer. In some instances, this may just be one service, such as anticoagulation; in other
cases, it may be a variety of services from medication management to transition of care, wellness, and others.
Domain 4: Practice Models and Policy, Task 1, item 4
A. Perform an internal environmental scan. In developing a successful clinical pharmacy program, the initial
step is doing the necessary background, planning, and thorough evaluation of your practice setting. It is
essential to understand your particular setting well as you embark on planning your ambulatory patient
care services.
1. Become organized by evaluating and prioritizing your opportunities. As you move forward, keep in
mind the following important factors.
a. Potential services that may be offered by your program: Which approach or model may provide
the most value in your setting?
b. Resources: What are your available resources and what are resource limitations?
c. Culture of the organization: Do any political issues exist? Are patient care pharmacy services
usual and customary in your setting?
d. Practical considerations such as your and/or your team’s time and ability to pursue this endeavor
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2. Collect data. You will need data to show the need for the services you are proposing. (Examples may
include rehospitalization rates and reasons for hospitalization, adverse drug event data, and elevated
surrogate markers such as blood pressure and hemoglobin A1C.) The data should support the need for,
and financial viability of, your pharmacy program and the services you propose to offer. In today’s
health care environment, your services have to improve quality of patient care in both clinical disease
state outcome measures and humanistic measures (e.g., patient satisfaction and engagement) as well
as attain positive economic outcomes of reducing costs.
3. Define clearly and exactly what your program will entail. This includes defining exactly what the
pharmacist will be providing (i.e., the pharmacist’s specific roles) to each customer: patients, other
providers, the organization, and payers for each service proposed.
4. Develop a proposed mission and vision statement for your program for the service(s) you are
planning to offer.
a. A mission statement describes in a clear, concise, and informative manner the purpose of your
program and explains why the program should exist.
b. A vision statement defines what the program desires to accomplish in the future, usually at
5–10 years. The value of the service is articulated in the vision statement.
5. Mission and vision statements are best when there is input from the entire team. Your responsibility
is to generate the ideas for these statements so that your team may then discuss, edit, and finalize them.
a. Develop suggested goals and objectives for your overall program and each proposed service.
b. Goals are indicators for success.
c. Objectives describe how you are going to measure the goals.
d. Goals and objectives should be finalized by your team.
B. To be successful, you must assume the role of leader for your initiative and pull together a supportive and
functional team. It will be very difficult if you try to do this by yourself. As with a good research project,
greater success will be achieved if you approach the project as a team. You will want to start this process
early in your planning stage. To identify and recruit your team members, take the following steps:
1. From your work with the internal environmental scan
a. Identify the needs and priorities of key stakeholders for your initiative.
b. Determine how well their needs and priorities are being met.
c. Identify opportunities, risks, and practice or health care service trends.
d. Know best practices.
e. Know the organizational structure and understand how your program and proposed services will
optimally integrate into the organization’s structure.
2. Identify your stakeholders. Depending on your clinic and practice site, key stakeholders may include
the following:
a. Physicians and other providers who will refer patients
b. Billing or the compliance officer who is responsible for adherence to billing practices and legal
ramifications surrounding billing and contracts
c. Administrators who are concerned with revenue and costs
d. Practice managers who will facilitate the planning and procurement of space, equipment, and supplies
e. Pharmacy colleagues
i. Pharmacy managers or directors who may need to make the initial presentation for your
program and services
ii. Pharmacy staff who will participate in the program and provide the services
f. Opinion leaders or well-known individuals within an organization who have the ability to
influence opinions of others
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g. Patients and/or caregivers (or your customers) within the organization whose health care stories
describe a need for your proposed service(s). Their stories may sway decisions.
h. Payers who may have high costs in a certain area, or quality measures for which they
are accountable, and where they may be underperforming
i. Quality improvement managers or those responsible for the quality measures within
your organization that are tied to payment
j. Board of directors, particularly at least one who may need to support you at
board-level discussions
k. Laboratory services, particularly if you plan to do point-of-care testing
l. Other providers (e.g., nursing staff, dietitians, social workers). You will want these groups
to support your program and services and not view your proposal as conflicting or competing
with their work.
m. Risk managers who are responsible for minimizing adverse patient events in the organization.
They may be your allies if drug problems are a significant issue that leads to patient
dissatisfaction, morbidity, mortality, and legal actions.
3. Mobilize key participants or stakeholders to create your team. Create a team that has sufficient
stakeholders to move your project forward but not so large as to be ineffectual.
a. Secure a commitment from the key stakeholders and members of your team.
b. Unite the team members by having them contribute to and finalize the mission, vision, and goals.
c. Secure a commitment upfront for anticipated resource needs from the appropriate stakeholders
involved with financial approvals.
4. Engage the stakeholders.
a. Establish a relationship by identifying their goals for participating on your team.
i. Identify their roles and contributions to your proposal.
ii. When establishing a relationship, remember the most important variables of collaboration:
relationship initiation, trustworthiness, and role specification.
b. Nothing grabs attention like hard data; therefore, share and professionally present the data from
the internal and external scans.
c. Share your plans for outcome measurements and gather their input.
d. Address all concerns raised by the stakeholders.
5. Team members should begin to articulate your program and services to others in the organization,
particularly the consensus mission, vision, and goals.
a. Show how your statements align with the organization’s mission, vision, goals, and strategic plan.
b. Identify the critical challenges and risks in achieving the proposed program’s mission and goals.
c. Articulate the results you expect from your program, and explain how these results will meet the
organization’s needs.
6. Inspiring and maintaining enthusiasm with the team requires a commitment to the following:
a. Transparency and honesty in all communication, with no hidden agendas
b. Openness to feedback and ideas from your stakeholders. Listen carefully to their concerns and
recommendations, and adjust your proposed service as needed.
c. Clear communication and clear expectations
d. Integrity in all interactions, such that trust, support, and confidence exist among the team
and stakeholders. Trust in your knowledge and skills cannot be overstated in this process.
e. Creativity, innovation, and an entrepreneurial spirit in solving the challenges that will
present themselves
f. Expertise on the proposed service(s) and its(their) specifics
Domain 4: Practice Models and Policy, Task 1, item 6 and Task 3 item 4
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C. Perform an External Environmental Scan.

1. Identify literature that supports the pharmacy program and proposed services you are considering.
Whenever possible, be sure to use literature from the professional journals important to your
stakeholders (e.g., medicine, family practice, health administration journals). See Box 1.
2. Learn from the work of others.
a. Understand what helped others succeed.
b. Understand the barriers they encountered, and learn how they may have overcome them.
3. Review and incorporate into your plans any standards of practice or the best practices for the type
of service(s) you plan to provide.
4. Know what your organization’s competitors are doing. Does your organization need to consider
your proposal to stay competitive? Will your proposal regard your organization as innovative
and/or cutting edge in your community?
Box 1. Key General Literature Resources
American College of Clinical Pharmacy. Standards of Practice for Clinical Pharmacists. Available at www.
accp.com/docs/positions/guidelines/standardsofpractice.pdf. March 2014. Accessed September 15, 2014.
American Pharmacists Association and National Association of Chain Drug Stores Foundation. Medication
Therapy Management in Pharmacy Practice: Core Elements of an MTM Service Model, Version 2.0. APhA
and NACDS, 2008.
Berdine HJ, Skomo ML. Development and integration of pharmacist clinical services into the patient-centered
medical home. J Am Pharm Assoc 2012;52:661-7.
Brush JE, Handberg EM, Biga C, et al. 2015 ACC health policy statement on cardiovascular team-based care
and the role of advanced practice providers. J Am Coll Cardiol 2015;65:2118-36.
Centers for Disease Control and Prevention (CDC). Collaborative Practice Agreement and Pharmacist Patient
Care Services: A Resource for Decision Makers. Atlanta: U.S. Department of Health and Human Services,
Centers for Disease Control and Prevention, 2013.
Chisholm-Burns MA, Lee JK, Spivey CA, et al. U.S. pharmacists’ effect as team members on patient care:
systematic review and meta-analysis. Med Care 2010;48:923-33.
Choe HM, Ferris KB, Stevenson JG, et al. Patient-centered medical home: developing, expanding, and
sustaining a role for pharmacists. Am J Health Syst Pharm 2012;69:1063-71.
Doherty RB, Crowley RA. Principles supporting dynamic care teams: an American College of Physicians
opinion paper. Ann Intern Med 2013;159:620-6.
Exploring Pharmacists Roles in the Changing Health Environment. Avalere Health LCC. Available at
www.avalere.com/expertise/life-sciences/insights/exploring-pharmacists-role-in-a-changing-healthcare-
environment. May 2014. Accessed September 2014.
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Box 1. Key General Literature Resources (continued)
Isasi F, Krofah E. The Expanding Role of Pharmacists in a Transformed Health Care System. Washington,
DC: National Governors Association Center for Best Practices, January 13, 2015. Available at www.nga.org/
files/live/sites/NGA/files/pdf/2015/1501TheExpandingRoleOfPharmacists.pdf. Accessed March 5, 2015.
Isetts BJ, Brummel AR, Ramalho de Oliveira D, et al. Managing drug-related morbidity and mortality in the
patient-centered medical home. Med Care 2012;50:997-1001.
Joint Commission of Pharmacy Practitioners. Pharmacists Patient Care Process. Available at www.pharmacist.
com/sites/default/files/JCPP_Pharmacists_Patient_Care_Process.pdf. May 2014. Accessed September 15, 2014.
Kliethermes MA, Brown TR, eds. Building a Successful Ambulatory Care Practice: A Complete Guide for
Pharmacists. Bethesda, MD: American Society of Health-System Pharmacists, 2012.
Kozminski M, Busby R, McGivney MS, et al. Pharmacist integration into the medical home: qualitative
analysis. J Am Pharm Assoc 2011;51:173-83.
Marrufo G, Dixit A, Perlroth D, et al. Medication Therapy Management in a Chronically Ill Population:
Interim Report (prepared by Acumen LLC under Contract No. HHSM-500-2011-00012I/TO0001). Atlanta:
Centers for Medicare & Medicaid Services (CMS) Center for Medicare & Medicaid Innovation, 2013.
McInnis T, Strand LM, Webb CE. The Patient-Centered Medical Home: Integrating Comprehensive
Medication Management to Optimize Patient Outcomes: A Resource Guide. Washington, DC: Patient
Centered Primary Care Collaborative, 2010.
Nigro SC, Garwood CL, Berlie H, et al. Clinical pharmacists as key members of the patient centered medical
home: an opinion statement of the Ambulatory Practice and Research Network of the American College of
Pharmacy. Pharmacotherapy 2014;34:96-108.
Perez A, Doloresco F, Hoffman JM, et al. Economic evaluations of clinical pharmacy services: 2001-2005.
Pharmacotherapy 2009;29:128-66.
Rodriguez de Bittner M, Adams AJ, Burns AL, et al. Report of the 2010-2011 Professional Affairs Committee:
effective partnerships to implement pharmacists’ services in team-based patient-centered healthcare. Am J
Pharm Educ 2011;75:1-22.
Roth MT, Ivey JL, Esserman DA, et al. Individualized medication assessment and planning: optimizing
medication use in older adults in the primary care setting. Pharmacotherapy 2013;33:787-97.
Santschi V, Chiolero A, Bernand B, et al. Impact of pharmacist care in the management of cardiovascular risk
factors: a systematic review and meta-analysis of randomized trials. Arch Intern Med 2011;171:1441-53.
Schuh MJ, Crumb DJ, Dubois J. Building a pharmacist-managed pharmacotherapy medication therapy
management practice. Consult Pharm 2011;26:404-13.
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Box 1. Key General Literature Resources (continued)
Smith M, Bates DW, Bodenheimer T, et al. Why pharmacists belong in the medical home. Health Aff
(Millwood) 2010;29:906-13.
Smith M, Bates DW, Bodenheimer TS. Pharmacists belong in accountable care organizations and integrated
care teams. Health Aff (Millwood) 2013;32:1963-70.
Taylor EF, Lake T, Nysenbaum J, et al. Coordinating Care in the Medical Neighborhood: Critical Components
and Available Mechanisms: White Paper (prepared by Mathematica Policy Research under Contract No.
HHSA2902009000191 TO2). AHRQ Publication 11-0064. Rockville, MD: Agency for Healthcare Research
and Quality, June 2011.
Touchette DR, Doloresco F, Suda KJ, et al. Economic evaluations of clinical pharmacy services: 2006-2010.
Pharmacotherapy 2014;34:771-93.
II. THE SPECIFICS IN PREPARING YOUR PHARMACY PROGRAM PROPOSAL
A. Required Attributes of Your Program: Remember the four key attributes your service must possess to
be approved and successful: valuable, scalable, reproducible, and sustainable.
1. “Value” is the quality divided by the cost. Will your service improve quality, decrease cost, or both?
2. “Scalable” denotes the ability of your program and services to be easily expanded or upgraded.
Growth is generally inevitable, and this should be planned for in your proposal.
3. “Reproducible” denotes the ability to re-create your practice at another site. Larger organizations may
look at scalability by piloting your proposal at a single site and then reproducing the service at other sites.
4. “Sustainable” denotes the ability to maintain a positive value/cost ratio as needs shift and
resources fluctuate.
Domain 4: Practice Models and Policy, Task 1 item 3 and Task 3 items 2 and 3
B. Determine Your Scope of Practice.

1. Review your state pharmacy practice act and the Board of Pharmacy rules. Terminology, definitions,
and sections vary between states. The following are sections or definitions you may want to pay
particular attention to:
a. Practice of pharmacy
b. Scope of practice
c. Collaborative practice
d. MTM
2. Be mindful of nuances in the details of state and federal laws and regulations when incorporating
processes for pharmacist-provided clinical services.
a. Requirements for physician oversight and orders
b. Allowable pharmacy services (e.g., medication administration, physical examination)
c. Any differences related to the practice site (e.g., community pharmacy, hospital, long-term care)
3. Develop your proposal in compliance with the specific allowances for managing patients’ drug
therapy and related care in your state.
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4. In 2014, the Centers for Medicare & Medicaid Services (CMS) added to the requirements for
“incident-to” billing (an option many pharmacists use for billing their services) that the service
provided must be within the state scope of practice for the personnel providing the incident-to
service (Fed Regist 2013;78:74826-5200).
C. Analyze Your Proposed Patient Care Services.
1. SWOT analysis. Using your review of the literature and your particular circumstances, your next
goal is to understand the strengths, weaknesses, opportunities, and threats (a SWOT analysis) to your
program and to any of your proposed patient care services.
a. Strengths. Evaluate the strengths that you, your proposed program and services, and/or your
organization currently possess. Identify those that will increase your chances of successfully
initiating and performing the proposed service(s). For example, strengths may be that you have
highly trained individuals (PGY2 ambulatory trained resident) for the proposed service(s) or that a
strong physician-pharmacist relationship exists.
b. Weaknesses. Identify the weaknesses that exist within your core team, your service, and/or the
organization, which may create barriers and make it difficult to provide the proposed service(s).
For example, if your current ambulatory billing is 100% fee for service, you will likely generate
insufficient revenue to cover costs of the proposed service using solely that revenue source.
c. Opportunities. Identify opportunities that exist in your setting, which will support the establishment
of your proposed program and service(s) as well as their growth at a desired pace. For example,
your institution may have a high hospital readmission rate and face significant financial penalties.
The cost of your proposed program and service(s), if successful at reducing hospitalization, may
more than offset the total program costs by reducing or eliminating the losses from the associated
financial penalty.
d. Threats. Understand the threat(s) that put your proposal or service at risk and that may result in
its insolvency. For example, there are currently discussions of potential mergers of your physician
group with another health system that historically has not supported the type of pharmacist model
you are proposing. Another example may be that the Part D plan used by most of your population,
which already has an established MTM program, may compete with the services you are proposing.
2. The models of care where pharmacists participate in direct patient care are listed below, with a
suggested general SWOT analysis provided in Table 1.
a. Office-based practice model
i. Physician office or independent clinic
ii. Community health centers/federally qualified health centers
iii. Medical residency programs
b. Pharmacy department–based practice model
i. Community pharmacy
ii. Health-system ambulatory outpatient pharmacy or clinic
c. New integrated models of care. These may occur through physical or virtual integration.
i. PCMHs/ACOs
ii. Home-based primary care
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Table 1. SWOT Analysis of Care Delivery Models

Delivery
Strengths Weaknesses Opportunities Threats
Model
• Physician • Health care • High level of • Reimbursement may
collaboration provider may not practice be poor, limited
• Fewer fully use available • Pay-for-performance to “incident-to”
Physician communication pharmacist services support service at first level
office based barriers or understand scope • Grants as source in certain parts of
• Access to patient of practice of funding the country; may be
medical record • Limited population unable to cover cost
• Often limited space of services
Delivery
Strengths Weaknesses Opportunities Threats
Model
• Health system has • Space challenges in • Added services • Billing and
several clinic sites in community setting may improve collection challenges
community • Staffing challenges other business for expanded
• Serves diverse or and ability to pull • Opportunity for services
entire population out of existing niche or specialty • Outside
Pharmacy
• Health system has pharmacy services practices organizations
department
billing option of • Lack administrative • Ability to affect and (community
practice
facility fee billing support; provide care to many pharmacy) may
model
model communication with diverse patients be able to provide
other providers more the services
challenging • Considered
competition to
primary care
• Core function • Not well-developed • Improved quality of • Other team members
through a payment models care (i.e., advanced
multidisciplinary • Pharmacist not • Potential for reduced practice nurses) may
team always part of teams costs have better quality/
New models
• Strong IT • IT not fully • Prime setting for cost ratios
of care
cornerstone, developed to support research and grants • Ability to
allowing the teams secure contracts
sharing of patient • Political pressures
information abound
IT = information technology; SWOT = strengths, weaknesses, opportunities, threats. Domain 4: Practice Models and Policy, Task 1 item 2,4
and 5 and Task 2
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D. Evaluating Your Resource Needs – The key resource needs for any business are personnel, space, equipment,
and supplies. Each of these resources will be a cost to your program, which you will need to consider and
control as you determine the financial cost/value equation for your program and proposed services.
1. Personnel – The pharmacists and other support personnel anticipated to staff your clinic are the
primary resources needed for most models. Their salary and benefits will compose most of the
costs of your program. The expected patient volume for your proposed service will determine your
staffing needs. Although personnel are the greatest driver of resources, specific data to guide the
number of clinical pharmacists needed to service patients in many of the above models are scant. For
assistance in determining needed staff, network and speak with colleagues as well as with financial or
accounting departments in your organization. It is advisable to use maximums and minimums in your
proposal for best- and worst-case scenarios.
a. Determine or estimate patient volume to estimate staffing needs.
i. Providers may be able to tell you the types and number of patients they would recommend
for pharmacists’ patient care services.
ii. Billing data may provide the number of patients in your setting who have certain
conditions or characteristics to help identify potential patient referrals to your clinic
(e.g., high medication costs or high total costs).
iii. A particular payer’s population may be an initial focus of your program (e.g., high-cost
patients in a Medicare Part C or Medicare Advantage Plan). The payer may be able to provide
an estimated number of such patients who are routinely serviced by your organization.
iv. Practice managers or other administrators may already be routinely collecting data to
determine your clinic patient volumes, using characteristics such as diagnoses or surrogate
clinical outcome markers.
v. Use data from your internal environmental scan for population estimates (e.g., how many
patients with diabetes in your organization have an A1C value greater than 9%, or what
percentage of patients are being readmitted to your hospital with heart failure).
b. Determine the capture rate of the estimated patient volume. How patients are directed to your
services will influence your capture rate.
i. Mandatory referral will likely have the highest yield: For example, all patients with an A1C
value greater than 9% will be seen by the pharmacist.
ii. Provider referral will depend on the providers’ comfort with referral as well as their recognition
of the need to refer. This may be slow initially but will grow as you begin to develop your
clinic, provide examples of your skills, and have an impact on patient care and costs.
iii. Patient discretion may produce the lowest capture rate because patients are often unfamiliar
with this type of pharmacist service or reluctant to carve out yet another health care visit
from their schedules.
c. Prepare for changes in health care outside your organization that may affect your services.
Today’s environment is incredibly dynamic, and it is imperative that you and your team devise
an efficient method to stay abreast of changes that will affect your program. This may include
having industry-related e-mail lists or subscribing to various CMS notifications and newsletters
such as MLN Connects – the Medicare Learning Network newsletter for providers.
i. Health care market – Entry and exit of other providers and mergers of providers may provide
opportunities or threats for your services.
ii. Government policy – Many changes to legislation that affect pharmacy and pharmacy
practice are being proposed at both the state and federal levels: Provider status, changes in
coverage, or changes in rules. For example, each year around March, CMS releases a Call
Letter for the changes it will be implementing in the Part D program.
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iii. Insurance coverage changes – As more and more payers report success with the new
integrated models of care and global payment billing models, the major insurer in your area
may consider participating in the development of similar models. Justifying pharmacist
services is easier in these models because it is based on who can do the desired job within
their scope of practice at a standard the organization sets, for the lowest cost. This is unlike
fee for service, where revenue is dependent on the fee received for each provider seeing a
patient and providing a specific service. In fee for service revenue is generated by numbers
seen and favors the services that have the highest reimbursement.
d. Determine the duration and frequency of visits. Anticoagulation services are generally 30 to 45
minutes initially, with 15- to 20-minute follow-up visits. High-risk patients with complex medical
conditions may require 60-minute initial visits and 30-minute follow-up visits. Patients may be
seen as often as weekly (not uncommon for patients at high risk or with cognitive or psychiatric
conditions) to quarterly (patients with more stable conditions) to yearly (wellness visit or patients
with stable conditions). Data to guide time needed for pharmacist-provided patient services are
limited. The following factors will influence length and frequency of visits:
i. Medical complexity of patients’ conditions as well as age, geographic location (urban,
suburban, rural), and social situation (underserved population, middle class, upper class)
ii. Type of services you will provide and specifically what will be provided with each service
iii. Other team members and their roles and how these may influence your specific role and
services. For example, will the medical assistant perform vital signs and obtain a current
medication list before your patient visits?
iv. Special patient appointment requirements (i.e., need for evening-hour appointments)
v. Double-booking guidelines within your organization
vi. Need for patients requiring immediate availability or same-day appointments
e. Other factors to consider
i. Anticipate patients not showing up for appointments or the “no-show” rate – This can vary
by up to 50% depending on the setting, services, and model (Ann Intern Med 2013;159:1-8;
BMC Health Serv Res 2012;12:304).
ii. Nonproductive time – Need for breaks, lunch, etc.
iii. Patient and provider telephone calls – For example, if part of your service includes
responding to visiting home nurses in the community with medication management, or
responsibility for medication refill requests from dispensing pharmacies, you will need to
carve that non−face-to-face patient visit time into your daily scheduling.
iv. Need for overbooking – This may be a particularly important consideration if your service
plan includes transitions of care or discharges to home after hospitalization (transition-of-
care Medicare payment codes require optimal face-to-face visits within 7 days of discharge).
The ideal follow-up to ensure appropriate medication use is considered within a 72-hour
to 7-day interval for at-risk patients. To accomplish this goal in a busy clinic, patients may
require overbooking.
v. Preclinic visit chart review, documentation, and follow-up visit work. This may require
another 30–40 minutes above patient visit time, depending on the service provided,
workflow, and system support for scheduling, patient data access, documentation, etc.
f. Non-direct patient care duties need to be factored into time considerations for staffing.
i. Teaching and assuming the role of preceptor to students and residents
ii. Quality measurement and outcomes data collection and analysis
iii. Research participation and dissemination of your model and lessons learned
iv. Meeting attendance within the organization and outside (e.g., continuing education)
v. Leadership service to professional activities
vi. Committee work
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g. Support staff. To be efficient, it is important to use support staff for duties that can be delegated and
that do not require the skills of a pharmacist. This may require adding duties to existing clerical and
other staff in the organization. It may also be accomplished using pharmacy technicians and employed
students in new and innovative ways. Examples of duties that may be delegated include the following:
i. Patient scheduling
ii. Patient reception, rooming, and potentially performing vital signs
iii. Point-of-care testing (e.g., performing international normalized ratio [INR] testing)
iv. Data collection for measuring your goals or quality indicators
v. Clerical duties such as filing and mailing
vi. Maintaining and ordering supplies and educational materials
vii. Managing medication assistance programs (i.e., pharmaceutical manufacturer assistance programs)
viii. Submitting the billing for your services
ix. Following up on no-shows
x. Calling for appointment reminders, if needed
h. Calculate your personnel/labor needs in the following way:
i. Estimate the hours needed to provide patient care services and other duties using the
variables mentioned earlier.
ii. Add the hours needed either daily or weekly.
iii. Increase your number by 10%–20% to account for sick days and vacation time.
iv. Determine the full-time equivalent (FTE, or 40-hour-week person) personnel needed.
Planning Pearl: Plan for your pharmacists to practice at “the top of their license” for efficient use of your most costly
resource. They should be doing activities that only pharmacists are qualified to do for most of their working time. For
example, do not have your pharmacists scheduling patients or managing social issues such as meals on wheels.
2. Space, equipment, supplies, and other provisions. Usually, you do not start with a blank slate but operate
within an organization that may already have in place many of the necessary non-personnel resources. Even
if you do not need to include many of the following items in your particular plan, knowledge about these
costs will help you understand and value the view your administrator may have in reviewing your proposal.
Non-personnel resources are as important as people because you may need to alter your plans to balance the
availability of certain resources with the ideal needs to run your service. Just like clinical decision-making,
you will need to do a risk-benefit analysis for most of these steps as it pertains to your practice model setting.
a. Space may already exist, or a build-out will be needed. Often, a dollar amount per square foot is
used to determine space costs. You may need to consider this in your cost determinations, both
for a build-out and for a monthly “rent” or use-of-space. This amount will vary depending on
your geographic location, your community, and the current market for office space. Speak with
the financial or accounting personnel in your organization to obtain that information (see Box 2
for an example of calculating an estimated cost for your clinic space). In designing your clinic
space, elements to consider are as follows:
i. Visit rooms that can accommodate a large wheelchair, as well as caregivers and others
who may need to be in the room during a visit (i.e., students), and any needed equipment
(scale, educational material)
ii. Workspace or office outside the visit room, as needed
iii. Space for support personnel, students, residents
iv. Reception or check-in and check-out area for patients, if needed
v. Utility needs (e.g., hand-washing)
vi. Trash and biomedical waste
vii. Storage areas for supplies, which may include items such as office supplies, educational
material, pillboxes, medications, textbooks, and research or quality improvement material
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b. Equipment and supplies. Your focus should be on large-ticket items in the planning stage
(see Table 2 for details).
i. Furniture
ii. Office supplies – Including account and/or contracts needed to acquire office supplies
iii. Medical supplies – Including account and/or contracts needed to acquire medical supplies
iv. Marketing material
v. Recruitment and training expenses
c. Information technology (IT) systems – You may anticipate using your organization’s established
electronic medical record (EMR), or you may already have a pharmacist documentation system
in your organization. However, you may need to purchase a separate system, or need specific
software code written for your services and billing. Consider the following items when assessing
your IT needs:
i. Patient information retrieval
ii. Documentation of your services
iii. Patient information exchange among you and other providers
iv. Ability to collect quality measurement data
v. Additional pharmacist billing needs (i.e., Part D billing)
Box 2. Estimating the Yearly Rental Cost of Your Allocated Space
1. Determine the size of your space – Example: You have two visit rooms that are each 10 ft wide x 12 ft long
and adjacent office space that is 8 ft x 11 ft
2 Calculate your square footage by multiplying the width or your space by the length of your space
Example: 10 x 12 = 120 sq ft x 2 = 240 sq ft for the visit rooms; 8 x 11 = 88 sq ft for the office space;
240 + 88 = 382 sq ft of space
3. Determine the current average rental cost per square foot for office space in your community
Example: $20.00 per sq ft per year
4. Calculate the cost of your space: $20 x 382 = $7640 per year
Table 2. Large-Ticket Clinic Equipment and Supplies to Consider

Furniture Office supplies Medical supplies
Chairs Computers Blood pressure cuffs
Desks Fax machine/copier Point-of-care devices
File cabinets Knowledge needs (INR, blood glucose, lipids)
Refrigerator - Medical information resources Sharps and biomedical
Storage cabinets - Subscriptions waste containers
(including secure storage) - Textbooks Stethoscopes
Tables Patient educational material Thermometer
Any other special furniture needs Printers Weight scale
Software
- Electronic medical record
- Scheduling
- Billing
- Communication and office
software
Telephones
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E. Financial Assessment: Evaluating Expenses Versus Revenue

1. Calculating your costs. Costs are usually split into implementation costs and operating expenses.
a. Implementation costs – Capital expenditures
i. Equipment and supplies
ii. IT needs
iii. Space build-out costs
b. Operating costs
i. Personnel cost or what you have calculated for staffing needs (e.g., number of FTEs)
ii. Determine total cost of your needed staff according to the current salary in your community.
iii. Add the benefit adjustment, which may be as high as 30%. Information on this number is
available from your organization’s human resources, financial, or accounting personnel.
iv. Overhead – Rent and utilities
v. Supplies
c. Direct and indirect costs. Your administrator may use and request cost information, using this
common accounting terminology. Below are items that generally fit into each of the categories:
i. Direct costs are costs that can be easily identified or assigned to your program, essential
personnel costs, and items that only you use.
(a) Salaries and wages
(b) Materials and supplies
(c) Equipment
ii. Indirect costs are costs incurred by the group that cannot be easily separated out or assigned
to your service.
(a) Salaries of shared office and billing personnel
(b) Utilities, telephone, fax, etc.
(c) Shared office supplies
2. Determining the financial potential of your program. Return on investment or ROI is often used
as a measure of what financial benefit the organization may expect from your services.
The equation is as follows:
ROI = gain from investment − cost of investment
cost of investment
a. Consider using the literature (Box 1) to determine the financial potential if no other resources
are available to you. ROI = 4.81/1 (Pharmacotherapy 2009;29:128-66)
b. Review your payer mix in the context of your practice model.
i. Medicare
ii. Medicare managed care
iii. Medicaid
iv. Commercial payer
v. Commercial managed care
vi. Self-pay
vii. Charity care
c. Review your billing opportunities according to your payer mix.
i. Fee for service – Health system versus office based
ii. Capitated contracts tied to pay for performance and other newer payment models or
contracts such as value-based purchasing
iii. States where payment is available for pharmacists and patient care services
iv. Direct contracts with payers or insurers who will reimburse for pharmacist services
v. Pay-for-performance revenue
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d. Evaluate visit types that have billing opportunities based on your service or practice model and
payer mix. (For further clarification and understanding, please see the Reimbursement section
of the Maintaining Your Practice chapter.)
i. Fee-for-service or cash payment
ii. Incident-to visits
iii. CMS Part D MTM visits
iv. Transition-of-care visits
v. Immunization visits
vi. Diabetes education
vii. Wellness visits
viii. Chronic care management
ix. Specific contracts for payment of clinical pharmacist services with commercial payers
x. State-based programs, where available
e. Understand how your organization generates revenue overall. How are other providers paid and
incentivized. Often, physicians do not refer to clinical pharmacy services because they have their own
relative value units (see Maintaining Your Practice chapter) goals to meet, and pharmacists may detract
from these goals. This may affect a clinic’s bottom line and often the physicians’ paycheck as well.
f. Estimate the number of visits per visit type over a period and the potential revenue for each visit from
your payer mix.
g. Recognize that the amount billed is not always the amount collected. To determine this, review
your plan with the financial personnel of your service or organization. They will have an idea of
the general percentage collected for the organization. Some reimbursement levels are as low as
50% of billed amounts.
h. Soft dollar contributions: Areas where your service can affect cost but not by collection of direct
revenue. Although the impact of your services may be significant (i.e., reduction in rehospitalizations),
it is more difficult to garner support for this financial proposal from administrators whose focus is
largely on generating revenue.
i. Cost avoidance
(a) Relieving services provided by another provider, usually physicians, who may then generate
greater revenue by seeing more patients at their higher reimbursement rate. Examples
include patient education, dose titration of certain medications (e.g., angiotensin-converting
enzyme inhibitors, insulin), and disease or high-risk medication management.
(b) Medication cost reduction such as trade to generic conversions
(c) Improved patient safety, efficiency, and effectiveness in management
(e.g., anticoagulation clinics)
(d) Improved efficiency
ii. Grant money
i. Create a pro forma statement, which is an estimated profit and loss statement, for the next 3–5 years.
Use assumptions to predict a point at which your cost value will benefit your organization (see Table 3).
i. Estimate growth.
ii. Estimate expenses.
iii. Estimate revenues.
Planning Pearl: If you are concerned that support to approve your proposed service is not strong, it may be wise to
consider proposing a pilot with specific outcome measurements as an option.
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Table 3. AWV Clinic: Example Health System

3-Year Pro Forma Statementa Year 1 Year 2 Year 3
Clinic visits:
Total 1000 2000 2500
Initial 1000 1000 500
Follow-up 0 1000 2000
Clinic visit charges:
Initial AWV G0438 $ 184.54 $ 186.00 $ 190.00
Follow-up G0439 $ 124.62 $ 126.00 $ 130.00
Expenses
Personnel expense
Pharmacist one FTE $ 120,000 $ 125,000 $ 195,000(+0.5 FTE)
Benefits $ 30,000 $ 32,000 $ 49,500
Office medical assistants 10% of time one FTE $ 2800 $ 3900 $ 5500
10% of benefits $ 3000 $ 3200 $ 3300
Medical supplies $ 600 $ 636 $ 655
Office supplies $ 400 $ 416 $ 425
Telephone $ 600 $ 636 $ 655
Rent @ $24/sq ft $ 4800 $ 4800 $ 4800
Total expenses 162,200 170,588 259,835
Revenue
Initial AWV G0438 $ 184,540 $ 186,000 $ 95,000
Follow-up G0439 $0 $ 126,000 $ 260,000
Total Revenue $ 184,540 $ 318,000 $ 355,000
Net Income $ 22,340 $ 170,270 $ 95,165

a
Based on 2015 Illinois Chicago region rates, visit estimates are as follows: Initial AWV 5/day; year 2 initial AWV 2/day and WV 5/day; year 3
initial AWV 1/day and WV 8/day.
AWV = annual wellness visit; FTE = full-time equivalent; WV = wellness visit.
F. Determine measures that will evaluate the outcomes of your program and the services you provide.
This will be discussed in greater detail in the next chapter.
1. Short-term measures
a. Growth measures such as referral numbers
b. Type of referrals
c. Reimbursement numbers
2. Long-term measures
a. Effect on patient outcomes for services provided
b. Patient and provider satisfaction
3. Determine how, and to whom, you will be reporting your results.
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Case Scenario 1
During your planning phase, you have determined that heart failure and COPD are the top reasons for readmission
to your hospital. You have collected internal data identifying medication-related problems as the source of more
than 70% of the readmissions. You have pulled evidence from the literature showing that pharmacy services
have provided a benefit to the outcomes of patients with these conditions. You have gathered stakeholders: a
key cardiologist, an internal medicine physician, a compliance officer, the practice manager for the clinic, and
the director of pharmacy. Your agreed-on service will be to see all patients with heart failure within 7 days of
discharge for transition-of-care services together with a cardiology fellow. You will provide comprehensive
medication management services as defined by the PCPCC Resource Guide for Medication Management (Patient-
Centered Primary Care Collaborative, January 2014) to all patients admitted to the hospital two or more times
for heart failure and to any patients for whom these services are deemed appropriate and who are referred by
medical staff. Your plan is to place your services in the internal medicine department, where there is some newly
vacated space. Reviewing patient medical records in the system, together with their key diagnosis, you anticipate
that 150 patients will be seen each month and that you will need one FTE pharmacist to support the service.
You will use many of the resources already available in the internal medicine clinic. The compliance officer is
assisting you in identifying the billing codes that may be available to you and your supervising providers for
reimbursement of your services. You continue to work on the specifics of your service proposal.
III. DEVELOPING YOUR SERVICE PROPOSAL OR BUSINESS PLAN
A. Purpose of Writing the Service Proposal or Business Plan. You will need a formal document that explains
the specifics, or the what, why, who, when, and how of your proposal. This document is key to gaining the
support you will need to justify and approve your program throughout the organization. It will be the main
vehicle for communicating and selling your idea. Often, “proposal” and “plan” are used interchangeably;
however, there are some subtle differences. A proposal in business usually consists of a new business
proposition and an accompanying document that may or may not be invited by leadership. A business plan
details how an already proposed business idea will be set up and function. There are six basic steps in
preparing and presenting your proposal.
1. Conceptualizing the initiative. These steps were addressed in the first two sections of this chapter.
The next step is to put the work you have done on paper in a logical format for others to read.
2. Researching the feasibility and details. This step has also been addressed and entails the internal and
external scan that you have performed. Most important to relay in your plan are the data you have
collected that support the need for your program.
3. Evaluating and refining the concept. This was done in the previous section when you considered many
of the variables that may affect your program and services.
4. Outlining the business plan
a. You may not need every section in your specific proposal or plan, and some sections may not need
as in-depth discussions as other sections. This depends on what you have determined to be the
expectations of the decision-makers in your organization for approving your program proposal.
b. Therefore, before completing your business plan, it may be wise to meet with the decision-makers to
identify which sections they consider essential to approval and which sections they want you to address.
c. Depending on these factors, your plan may range from 4 to 20 pages.
5. Preparing the service proposal or business plan (the focus of this section)
6. Presenting your plan formally
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B. Preparing the Service or Business Plan. The document should be written at a professional level and be
packaged as professionally as possible. Your goal is for your proposal to have the highest professional
appearance, suggesting that the contents are important to the reader and the writer. The presentation of
your plan will speak volumes and is a powerful advertising tool for your service.
1. Cover page. The cover page should indicate the title of the program that is proposed, the date of
preparation, and the author’s name, credentials, and job title. You may also include the organization’s
logo, if available.
2. Table of contents page. This page should list the sections of the plan and the page on which they are
found. This will aid in organizing your plan and allow the reader to find the key components of their
interest for reading or reviewing.
3. Executive summary. This is the most important section of your plan because it gives the overview of
the program you are proposing and the services you plan to provide. Although the executive summary
appears at the beginning of the document, it should be the last section written in your business plan.
The goal is to summarize all the key specifics of the following sections. Attributes of the executive
summary are as follows:
a. Length is usually 1–3 pages.
b. Written in narrative style, and written clearly and succinctly
c. Written to persuade the reader to review the remainder of the document
d. Proposal should demonstrate the following:
i. Logical thought process
ii. Thorough planning
iii. Ability to be accomplished in the proposed time interval
iv. Ability to meet the needs of the organization
v. Financial viability
e. Summarize each section of the plan. In particular, the following sections should be addressed:
i. Mission statement
ii. Market analysis
iii. Market plan
iv. Facility and equipment
v. Management and organization
vi. Financial summary
4. Description of program and services. Use this section to describe your program and clearly define the
services that will be provided. Include the following:
a. Scope of services provided to each customer you identify (i.e., patient, providers, administrators, payers)
b. Competitive benefits of services (how they fill a need)
c. Location and staff involved
d. Time frame for establishment
e. Financial and volume trends
f. Previous program or service history, if applicable
5. Consistency with mission. Explains how the proposed program serves to support the mission, vision,
philosophy, and strategic objectives of the organization
a. Start with your mission and vision.
b. Explain how your program aligns with your organization’s mission and goals.
c. Include the ROI your program may expect. Use an ROI found in the literature, if necessary (Box 1).
d. Explain how your program and proposed services will positively affect organizational performance.
e. Explain how the program and services will address the identified needs of the organization and
its patients.
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6. Market analysis – Discuss the market analysis or external environmental scan you performed in the
earlier sections.
a. Identify and describe the market for the services you plan to provide.
b. Define your customers (all of them): Who they are and their characteristics. Depending on your
program, they will include, at a minimum, patients, other providers, and administrators and may
also include your organization’s contracted payers.
c. Include your SWOT analysis in this section.
d. Describe barriers to providing the services and plans to minimize the barriers.
e. Describe key characteristics of the services and their relationship to quality within the organization,
quality measures with a focus on outcome measures, and standards of care in the market.
f. Include the economics of the market—in particular, trends, reimbursement, and revenue. For
example, the average wellness visits used in the pro forma statement have seen a $20 increase in
reimbursement during the past 2 years.
g. Predict your success in the future.
7. Marketing plan. Marketing will be discussed further in the next section. The essentials revolve around
the seven “P’s.” Remember to address marketing strategies for each of your customers.
a. Describe how you will introduce the services to your customers.
b. Describe how you have engaged the key stakeholders for support.
c. Address the seven “P’s” (see section below, Marketing your Service, for further definitions).
i. Product – How you plan to describe your program and services to your customers
ii. Price – How you will communicate your value to your customers
iii. Place – Describe how your location meets customers’ needs.
iv. Promotion – How you will promote your program and services to each of your customers
v. People – Describe the credentials, competencies, and skill of your staff.
vi. Packaging – Describe the experience your customers will have in receiving your service(s).
This includes location, space, and patient flow.
vii. Process – Describe the process for receiving the service for each customer.
8. Facility, technology, and equipment: This section of your plan describes the space and equipment
requirements you evaluated and have determined are needed from the previous section.
a. Space
i. Include required square footage and desired layout.
ii. Relay the work needed for construction and renovation.
iii. Estimate the time interval for any build-out.
b. Equipment and other resources needed
i. Limit equipment to high-ticket items or fixed costs that are one-time expenses.
ii. Technology and software needs should be in this section.
9. Management and organization: In this section, you describe the team for your proposed program and
explain how you anticipate that the reporting structure for your team will fit within the organization.
a. Describe the organizational or reporting structure of your program, and explain how it will
integrate into the organization’s structure.
b. Describe the capabilities and expertise of your team.
c. Describe management within your team.
d. Outline your staffing plan; if new staff must be hired, describe their qualifications and the time
needed for recruitment. Include job descriptions as an appendix, if warranted.
e. Address any contractual relationships (e.g., split positions with a college of pharmacy, union
requirements, if applicable).
f. Include the timeline for implementing new services, with particular attention to key milestones.
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10. Financial summary: This section is self-explanatory, yet it may be the most difficult section to
complete because of the uncertainty of financial projections. It includes your expenses, anticipated
revenues, and the pro forma statement you worked on earlier.
a. Use tables, spreadsheets, and graphs.
b. Be conservative and honest, and use standard business formats.
c. Include the following:
i. Start-up budget
ii. Staffing budget
iii. Fixed-cost expenses
iv. Projected payer mix
v. Expected revenues
vi. Costs avoided by implementing the program
vii. Pro forma statement
11. Evaluation: This section should explain how you will evaluate your program and its ability to meet the
mission, vision, goals, and objectives articulated in the proposal.
a. Describe how you will monitor the performance of the program.
b. Include performance indicators that will define success.
c. Describe the frequency of monitoring and reporting.
d. Name the stakeholders who will receive the reports.
Planning Pearl: Your success will be based on your ability to build and describe a high-quality pharmacy patient care
program providing a specific set of services, and one that is based on sound business principles.
C. Presenting the Plan. Preparing and presenting the program at a high professional level will be essential for
success. Nothing trumps the personal touch. Plan for face-to-face meetings with the decision-makers to present
your proposal. You need to sell your proposal. A strong belief in, and passion for, your program is vital.
1. Develop a high-level overview of the program that you can quickly communicate.
2. Develop an “elevator pitch” that will enable you to quickly introduce your program concept and the
services to be provided and that will capture the interest of the stakeholders you need to convince.
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Case Scenario 2
Your cold call to the administrators of the hospital and the large physician group was timely. They are currently negotiating
with several payers as they plan the formation of their ACO. They are concerned about management of the prescription
benefit because they currently have little control over medication use in the outpatient setting. They have identified
that medication management is an area of need because the performance of medication management measures is not
optimal in the ambulatory practice setting. They have discussed this need with the hospital’s director of pharmacy, who
stated they currently do not have that skill set and will need to hire personnel to fit the need. You present an alternative
for services, for which there is interest. They would like for you to provide them a service proposal. You request a
meeting with the key stakeholders: the physicians who may refer patients to you; the hospitalists who may recommend
services on discharge; the administrative personnel negotiating with the payer; and the hospital and the physician group’s
compliance officers. You survey your patients who use the hospital and the physician group because these individuals
are likely to participate in the ACO. You have analyzed the data you have collected, evaluated qualifications of your
staff, and determined you will provide an 8-hour/day, 5-day/week MTM service at two of your pharmacies that are
strategically located for the anticipated patient population. You will need a build-out for private patient visit space in each
of these settings. You complete each of the requested sections in your proposal. Using the ROI of $4:1 for these services,
transition-of-care and chronic care as potential add-on revenue, and anticipated pay-for-performance ACO incentives,
you believe this endeavor will be financially viable for you and the organization. The ACO has provided you a cost-per-
patient range for your services, which you believe you can meet. You are scheduled to present your plan to the board of
directors for the hospital and the physician group as well as to the administrative teams working to establish the ACO.
IV. MARKETING YOUR SERVICES
Marketing knowledge and skill generally fall under business training; consequently, many pharmacists may feel
inadequately skilled or trained in this area. Marketing, however, is an extremely important function for the initial and
continued success of your program. Much of marketing will make perfect sense once you understand your customers
and their behaviors, as well as the key components of marketing. If you are still uncomfortable, collaborate with those
in your organization who have marketing training or skill.
A. Understanding Your Customers’ Behavior

1. Identifying your customers. Pharmacists providing patient care services in the current health care
system have many customers, which is a main reason marketing may be challenging.
a. Patients. Patients are the ultimate beneficiaries and direct recipients of your services because the
universal goal is to improve their health and well-being; from the perspective of pharmacists, this is
through appropriate medication use.
b. Other health care providers, primarily physicians. Pharmacists are mid-level providers and therefore
require collaboration with a supervising provider. To delegate services for which the supervising
providers are responsible, physicians need to be comfortable with the skill and ability of the mid-
level provider (pharmacists) and be willing to delegate and receive an expected outcome from the
delegated service.
c. Administrators. Administrators are responsible for keeping the organization viable while providing
quality health care services. Pharmacists must meet their needs of cost-effectiveness, efficiency,
revenue generation, and quality patient care.
d. Payers. In some situations, the payer or insurer is also a customer. Your program will need to meet
their needs of cost containment and quality, or contribute to their quality measure goals.
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2. Understanding the behavior of your customers

a. Prepurchase phase. Consider what stimuli exist that would have your customers seek out or
want your program and services. Do your customers have a need that is unmet, and how do your
proposed program and services alleviate that need? Consumers are stimulated in three ways.
i. Commercial stimuli: When the consumer sees an advertisement, a brochure, or an industry article
ii. Social stimuli: When the consumer hears good words about this type of service from peers
or other users
iii. Physical stimuli: When consumers need to have a personal issue solved because they are
not feeling well or when an organizational issue occurs that must be solved (e.g., high
rehospitalization rates because of poor medication use the month after discharge in patients
with heart failure)
b. Consumption phase: When your customer actually uses or experiences the services
c. Postpurchase evaluation. Customers will evaluate the service they received and decide whether it
adequately met their need. At that time, they will decide whether the service was valuable enough
to seek it out again.
B. The Four “I’s” of Service. Promoting services is more challenging than promoting a product.
Understanding these challenges is important because these factors or characteristics also create challenges
to assigning value to services.
1. Intangible. Services are intangible, unlike a product such as a car; they cannot be seen, touched,
weighed, or physically measured. Services do not exist before they are delivered. Unlike a product
that may be held, handled, and visualized, service quality cannot be determined before it is delivered.
2. Inseparability. Services are variable. Services provided can vary not only between different providers
but also from the same provider. Variation in personality, attitude, work ethic, or how a provider
feels on any particular day may affect the level of service from one day to the next and from one
provider to the next. Your customers play a role in determining the success of the services. You can be
providing top-notch service, but it will be unsuccessful if your customers are unwilling partners and
choose not to accept it.
3. Inconsistency. Services can be different from one provider to the next. There may be differences in
experience, training, and knowledge among providers supplying the same service. This may lead to
variability in quality measures and customer experiences.
4. Inventory. This is interpreted in a more abstract way because services are perishable. Perishable
means services are produced and consumed simultaneously. They cannot be stored; therefore, after
they are consumed, they are essentially lost. Similarly, your fixed costs are there (personnel, space,
etc.) whether a consumer is there or not, making it difficult to adjust staffing. You cannot pre-produce
the service to provide later when the customer may be available.
C. Specific Challenges for Ambulatory Pharmacist Patient Care Services

1. A novel service and therefore not well understood
2. Not a service traditionally expected to be provided by pharmacists
3. Most customers may not know your service exists.
4. Fear and concern from other health professionals of job competition
D. Conducting Market Research. Marketing research is the process of gathering and analyzing information
for use in the marketing planning process. It is a method for you to understand your customers’ needs.
1. Primary goal is determine what customers want.
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2. Qualitative research is conducted to gather in-depth information on customer behaviors. Your goal is
to learn their opinions, perceptions, and reasoning. This may be accomplished in the following way:
a. In-depth interviews with customers
b. Focus groups
3. Quantitative research is conducted to determine whether there is a need for your service. (Note: This
is the same as what you performed in your internal environmental scan.)
a. Primary sources of data – Your organization’s data
b. Secondary sources of data – Community, state public health, or census data
c. Does not stop once your program is under way; you always need to be aware of your market and
the changes occurring in it
E. Creating the Marketing Plan

1. Start with what should be at this point a well-defined practice model with well-defined services to be
provided. Solidify your practice model to meet the needs identified.
2. Analyze the situation. Know the environment or climate in which you will roll out your marketing
plan. You will note you have already done this step in the preparation for your clinic and service plan.
a. Federal health care legislation and rules
b. State pharmacy practice and legislation
c. Pharmacy profession initiatives and standards
d. Changes in technology
e. Cultural and societal changes
3. Lay the groundwork for your marketing strategy: Connect your marketing plan with your service plan.
a. Ensure that the mission and vision support the needs of your customers.
b. Determine the resources needed for marketing.
c. Evaluate the ways in which the current business environment will affect the plan.
4. Create and implement your marketing plan. The plan should include strategies and tactics based on
the marketing research and other preparations that are incorporated into a plan you can reasonably
execute. Marketers of health care service products use a framework of seven elements known as the
seven “P’s.”
a. Product. Your product is the services you will be providing, not only to your patients but also to
each of your customers.
i. Define the services you will provide to each of your customers.
ii. Connect the services to each customer’s needs.
iii. Discuss how you will distinguish your services from those of your competitors.
iv. Your goal is to provide a persuasive discussion such that your services are deemed the best
value for meeting each of your customer’s needs.
b. Price. Price is the amount paid to you for your services and should reflect the value each of your
customers places on your service.
i. Difficult because of third-party payer influence that will dictate direct revenue
ii. Apply a cost-benefit story for each of your customers.
iii. Consider the demand for your services and the current and potential market size.
iv. High-quality valued service deserves corresponding compensation, so do not sell your
services short.
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c. Place. Place is the where and how your services are provided. Services need to be in the right
place at the right time and in the right quantity.
i. Consider your access and availability to your customers, including during non-clinic hours.
ii. Ease of interaction. The ease with which your customers can interact with you is important.
Are you visible, available, and easily found? If your interaction is other than face-to-face,
what is the telephonic process or web-based interaction like? Is the process easy, technology
sufficient for a positive interaction?
d. Promotion. Promotion is a diverse set of activities used to communicate, educate, and persuade
your customers regarding the merits of your services so that they choose to purchase and use
them. Any of the promotion options can be used for any customer of your program and services.
Knowing and understanding their individual needs and characteristics will assist you in choosing
the optimal promotion method. Promotion is what many think of when considering marketing.
As this section denotes, marketing has many components other than promotion. Options for
promotion include the following:
i. Direct interaction or personal face-to-face selling (i.e., direct meeting with your customers
and promoting your service)
(a) Small financial cost
(b) Word of mouth is a powerful promotion tool.
ii. Media promotion. What you may choose to do depends on the resources available to you.
(a) Brochures
(b) Billboards or information boards around the institution
(c) Web pages both public and internal
(d) Radio, television, etc.
(e) Social media
iii. Promotional events
(a) Open house
(b) Special services day (e.g., brown bag)
iv. Public relations: Participating in community events
e. People. People may be the most important marketing tool for a service industry. Customers
usually cannot separate the service from the person who provides it. As your strongest marketing
tool, your employees should have the following qualities:
i. “People skills” such as caring, empathy, honesty
ii. Strong communication skills with the ability to communicate with all customers and with
people at all levels of health literacy
iii. Positive attitudes
iv. Calm demeanor
v. Excellent problem-solving skills
vi. Strong knowledge base for the services they will provide
f. Packaging: The experience your customers receive from the environment and atmosphere during
the provision of your service. Customers seek out tangible and intangible clues to help them
understand the nature and quality of the services they are receiving. Consider the following:
i. Tangible packaging
(a) Adequate space to feel comfortable
(b) Adequate privacy to feel comfortable
(c) Professional appearance of staff and space
(d) Neatness and cleanliness
(e) Pleasant surroundings, such as comfortable chairs, wall color, and artwork
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ii. Intangible packaging

(a) How your customers are welcomed (e.g., how patients or other providers are welcomed
into the clinic; how patients and providers are greeted when they phone in to the clinic)
(b) How at ease the customers are in your clinic; keeping chaos and any disorganization
away from patients
(c) How responsive you and your clinic are to their needs and requests
g. Process: The quality and efficiency of how your service is delivered. Process and procedures
should be understandable to your customers. Your do not have to provide patients with details of
your procedures, but they should easily understand how to enter, move through, and exit your
clinic. They want it to be easy and to have no points of confusion regarding what they are so
supposed to do or where they are supposed to go next. Providers and administrators also want a
process that is easy and efficient in their interactions with you and your service. Avoid negative
processes that will sabotage your marketing, such as the following:
i. Long wait times
ii. Poor response to inquiries
iii. Unprofessional treatment
h. Relationship marketing is a key marketing process in health care. It involves building and
developing relationships with your customers. Your focus is to retain your customers by building
trust and collaboration for a long-term relationship.
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Case Scenario 3
You are passionate about providing ambulatory services and want to make a positive impression in your new
practice site. You decide to create a marketing plan from a training module provided in your residency. You identify
your customers as the patients who will be referred to you, the providers and staff in the office, and the practice
administrators, who will be judging the value of the college’s relationship to the organization. Using the seven “P’s”
of service marketing, you construct the following plan:
Product: You clearly define your services to your three customers. Patients: You resolve patients’ drug-related
problems and ease their minds in managing their health by assisting them in the self-management of their
medications and conditions. You will help patients feel better. Providers and administrators: By focusing on
medication adherence, drug-related problems, and patient education, you assist providers and administrators in
reducing hospitalizations and in meeting surrogate outcomes measures that are tied to the reimbursement received
by the clinic.
Price: You provide the literature cost/value of 4:1 and produce your estimate of the cost/value of your services. You
plan to review the cost/value on a yearly basis and provide the information to both administrators and providers.
Place: You are able to secure a patient visit room next to the physician visit rooms and the triage nurses. The room is
altered to accommodate your services. The examination table is removed and replaced with a table and comfortable
chairs, which will facilitate patient education.
Promotion: Brochures are created for patients and a separate brochure for providers. Posters will be placed around
the organization, promoting the new service. A web page outlining the services will be created for both external
and internal pages. The external pages will promote the direct patient services, and the internal pages will promote
your services and credentials to the providers.
People: The internal and external web pages will outline the credentials of the pharmacy practitioner(s), place of
graduation, residency and board certification, and accomplishments or awards.
Packaging: Your room will be painted with a soothing color, and in addition to a few educational posters, some
calming artwork will be placed in the room. Privacy will be ensured.
Process: You will use the same process as the physicians in the intaking, rooming, and exiting of your patients
because patients are familiar with that process. You set up 60-minute first-visit appointments and 30-minute follow-
up visits, with a 30-minute break between every three visits for unanticipated longer visits, unscheduled visits, and
catch-up for documentation and telephone calls.
Domain 4: Practice Models and Policy, Task 4
V. CREATING YOUR SERVICE MODEL
It is advisable to start considering the details of your model as you plan your proposal. Most of the work, however,
you will do once your proposal is approved. Your thoughtful planning so far should minimize any barriers as you set
up your clinic.
A. Clinic Operations
1. Space and considerations – Space in most organizations is a premium commodity because
administrators look at the revenue generation associated with space. The higher the revenue
generation, the greater the space that will be allocated to that service. Certain basic space
requirements for your service include the following:
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a. Reception space for check-in and check-out as well as a patient waiting area, which may be
shared with other providers
b. Visit room entry that can accommodate a large wheelchair
c. If a teaching site, space and computer access for students
d. In the visit space, avoid any barriers such as tables and computer screens between provider
and patients. Not only will such barriers imply “a barrier” to your customers, but they will also
impede your efficiency for activities such as physical assessment or medication administration
(e.g., vital signs, immunization).
2. Essential equipment to consider (Box 3)
Box 3. Essential Equipment to Consider
Chairs for patients that are extra-wide patient with arms and non-cloth seats
Chairs for caregivers
Clock with a second hand
Computer with a large screen so that patients are able to view it as needed and a printer
Desk, chair, and countertop for provider
Equipment
- physical assessment items as needed, depending on services provided (thermometer, scale, measuring tapes,
microfilament probes)
- sphygmomanometer and assorted cuff sizes that is wall-mounted or portable, stethoscope
Space for sharps container, point-of-care testing, and latex-free examination gloves
Sink and hand soap or hand sanitizer dispenser
Storage space in the room for educational material
Telephone, fax, copier, scanner
3. Miscellaneous items to consider and plan for

a. Identification badge
b. Office keys or access and who should be in possession of these items
c. Laboratory coat
d. Pager, if desired
e. Business cards, appointment cards
f. Codes for fax, copiers, etc., and voice mail, etc.
g. On-call service
h. After-hours access
4. Billing requirements. Billing requirements may affect the setup in your clinic and therefore should be
considered. In the setting of physician offices or hospital-based clinics, pharmacists function as mid-
level providers and must work under a supervising health care provider (usually a supervising physician)
in order to bill. In servicing Medicare beneficiaries, CMS has rules regarding the proximity of the
supervising provider when using incident-to or facility fee billing (covered in the Managing a Clinical
Practice chapter). Medicare rules stipulate that the supervising provider be within the same office space
(physician office billing) or within the same building attached to the hospital for hospital-based facility
fee billing. They have relaxed this ruling to general supervision for transition-of-care and chronic care
codes. (See Managing a Clinical Practice chapter.)
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5. Clinic workflow processes. Important considerations as you put together your workflows. The process
must be seamless and easy to maneuver for a patient, should be efficient for you and your staff, and
should mesh well with other activities or providers in your workspace.
a. Patient scheduling
i. Integrate scheduling into the processes used by other providers at your location as much
as possible. This will save you time and cause much less confusion for patients referred
to your services.
ii. Determine the specifics of your patient schedule.
(a) Times during the day available for patient scheduling and number of slots for each
visit time length. For example, new patient visits may be 60 minutes only at certain
times of the day.
(b) Build in time for telephone, previsit and postvisit activity, precepting, documentation,
and non-patient visit duties.
(c) Days you will see patients. Depending on your role, you may need administrative time
for quality activities, meetings, etc.
(d) Time slots for walk-ins. This may be important if you are providing transition-of-care
visits that may need scheduling in a shorter time interval.
(e) Flexibility in scheduling is key, especially for the new models of care.
b. Referral process
i. Integrate whenever possible with other providers’ systems for referrals, and follow similar
processes used by other providers in the organization.
ii. Determine who may refer patients (physicians, nurses, self-referrals).
iii. Will approval be needed to see patients? This may depend on who may refer patients; for
example, can a registered nurse refer patients, or are there specific criteria for referrals based
on payer contract? Consider a courtesy notification to the primary provider if others may refer
(i.e., specialty provider or payer).
iv. Once the referral is made, determine who will schedule the patients.
v. Format of the referral: As stated earlier, try to use what other providers use.
(a) Paper
(b) Fax
(c) EMR
(d) Telephone
vi. Content of the referral. There are two important considerations in determining the content of
your referral. First, it should not be burdensome to the person making the referral or it will
not occur. Second, it must contain reasons for the referral, which is required by many payers
for mid-level practitioners. CMS refers to this as a statement of medical necessity and usually
requires that it come from a Part B provider. Using quick checkboxes will aid in this process.
(a) Whom the referral is from
(b) Whom it is going to
(c) Reason for referral
(d) Expectations of referral
c. Access to necessary patient information
i. If your services are within the health system or organization
(a) Access to patient information is usually not a barrier if your services are part of or within
the health system or organization. For access and EMR use, you will need to obtain
provider sign-ons and create passwords, as well as schedule training for optimal and
correct use of the EMR.
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(b) If you assume the role of preceptor to students or residents, establish a process for
training and obtaining sign-ons and passwords for them as well.
(c) Gaining remote access to the EMR and permission to link in from another computer is
advisable because patient care services often extend beyond a typical 40-hour workweek.
(d) If you are not connected to a hospital, it is advisable to obtain password access to view
hospital EMRs and records for the institutions where the providers you work with have
admitting privileges.
ii. If your program and services are outside the system i.e. as a contracted services with virtual
components: you will need to consider several communication issues.
(a) Are you able to obtain access to the EMR? What will the expectation be for relaying
information in a bidirectional manner (i.e., EMR, fax, letter, state secure coordination of
care systems, and telephone)?
(b) If done with paper, how will that “paper” information be communicated to other
providers? Many sent paper forms of communications are placed in large stacks to be
read or scanned.
(c) Be sure you have a process that allows efficient communication for critical and
noncritical information (e.g., routine information may be scanned for the provider to
review at the next patient visit). Urgent information must be called to the provider’s
attention in a different way.
d. Patient check-in for face-to-face visits
i. Identify who will check in patients.
ii. Determine the required paperwork and the items you may need, or consider the following:
(a) New-patient information history form
(b) Billing information or copays
(c) Health Insurance Portability and Accountability Act (HIPAA) form for authorization on
sharing patient information and privacy policies
(d) Consent for services – Or agree to participate in the collaborative practice agreement
(required by some states)
(e) Patient rights and responsibilities
iii. Determine where patients will wait until they are directed to the visit room.
e. Vital signs and point-of-care testing
i. Determine what you will routinely do at each visit and who will perform the testing.
(a) Consider medical assistants to perform this function if already providing such services
to other providers.
(b) Consider this a role for a pharmacy technician.
ii. Determine the flow of where this may be done, if not by you, and how the information
will be communicated and documented.
f. Non−face-to-face visits. Your service may use other methods for patient visits, such as phone
or webcam. Your process may need to adapt to the different means of contact.
i. Identify who will contact patients. Is there a schedule to contact patients?
ii. Determine the required paperwork and how it will be obtained (some items may require
mailing; others will be done verbally during visit).
g. Visit process – Consider the role of students/residents and standardizations to your visit process.
i. Consistency in patient information allows easier expansion and scalability.
ii. Incorporate quality measurement into your daily process by establishing and standardizing
processes for data you may need to collect for each patient (e.g., adherence). This will save
you significant time in trying to collect this information retrospectively.
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iii. Standard roles for students (e.g., doing the comprehensive medication review). Integrating
students into your workflow with standard roles improves their learning experience, provides
additional no-cost staffing support, and lessens the workload you may experience with the
preceptor role.
iv. Deliverables for patients such as medication list and patient-specific action plans.
Who will be involved, and how will these important aspects of care be generated,
maintained, and distributed?
v. Patient educational materials
(a) Determine the key patient educational materials, patient handouts, etc., you will use. How
will they be maintained so that they are always current and readily available?
(b) Where will they be stored for easy access during a visit?
(c) Consider the health literacy and cultural competency of your population and its needs.
h. Follow-up scheduling and management of no-shows: For the best use of your skills, these are
activities to delegate.
i. Coordination of care processes to other providers and institutions should be standard and done
within an appropriate time interval.
j. Clinic visit documentation points to consider (covered in Communication Strategies chapter)
i. Get the most from your EMR system. Choose a system that helps you document your work
efficiently. Develop templates for consistency among providers and for efficiency.
ii. Many organizations require documentation to be completed by the end of the workday.
Consider time/schedule management for completing documentation.
iii. Dictation options are available but often are expensive.
iv. Billing documentation requirements (covered in more detail in Managing a
Clinical Practice chapter)
v. Legal issues – Some state laws and boards of pharmacy have requirements regarding clinical
documentation, including the following:
(a) Requirements for certain documents such as referrals
(b) Storage requirements: Hard copy versus electronic and duration of storage
(c) Requirement for billing and auditing components
(d) Procedures for EMR downtime
(e) Time requirement for visit notes
B. Policies and Procedures. For both small and large organizations, you will want to develop policies and
procedures to ensure consistency and help define standards and quality in your service. As discussed in the
Marketing section, there is variability in services; policies and procedures assist in minimizing that effect.
Depending on your practice setting, various accreditation and certification organizations may dictate content.
Consider the following content and structure for your policies and procedures:
1. General title stating the document’s policy and procedures for your clinic
2. Mission and vision statement
3. List of specific services provided
4. Address, telephone, and other contact numbers
5. Hours of operation and off-hour coverage process
6. Personnel
a. Credentials and preferred experience for each pharmacy staff member
b. Job descriptions, including duties and responsibilities
c. Continuing education requirements
d. Continuing credentialing and/or privileging processes
e. Student and resident roles and requirements
f. Pharmacy staff assessment and promotion
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7. Scope of practice and clinic privileges

a. Collaborative practice agreements
b. Description of supervision process
8. Referral process
a. Routine referrals
b. Urgent referrals
9. Patient scheduling process
a. New visits (length of visits)
b. Follow-up visits (length of visits)
10. Patient clinic entry paperwork
a. Health, medication history
b. Service consent
c. Privacy policy and HIPAA agreed-on medical information sharing
d. Patient rights and responsibilities
11. Clinic workflow process
a. Standards of care you follow (e.g., CHEST guidelines, American Diabetes Association)
b. Team care planning process
c. Patient deliverables
i. Medication list standards and formats
ii. Patient self-management plans of care formats
d. Standard patient educational material
e. Follow-up process for patients and recommended intervals
f. Coordination of care procedures
g. Discharge or transfer from service
h. No-show policy
12. Documentation standards
a. Location of documentation
b. Time allotted for completion
c. Standard formats and templates
13. Clinic billing process
a. Billing codes used
b. Claim process and procedures
14. Emergency management
a. Patient emergency or need for acute care procedures
b. Patient code procedures
c. Environmental emergencies
15. Quality improvement program and processes
16. Point-of-care testing
a. Clinical Laboratory Improvement Amendments (CLIA) waiver – Certain waivers are deemed by
the FDA (U.S. Food and Drug Administration) and the CDC (Centers for Disease Control and
Prevention) to have minimal risk. To perform these tests in a clinic, the following should be done:
i. Be sure the point-of-care test you plan to use qualifies for CLIA waiver at www.cms.gov/clia.
ii. Complete an online application.
iii. Pay the required fees.
(a) Testing procedures: A CLIA waiver requires you to follow manufacturer testing instructions.
(b) Waste disposal: Follow OSHA (Occupational Safety and Health Administration)
guidelines and check state rules and regulations because these may vary by state.
b. Procurement, maintenance, storage of point-of-care machine and supplies
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VI. SUGGESTED TIMELINE FOR ESTABLISHING A PRACTICE
Month 1
• Perform internal and external environmental scan.
• Draft mission and vision statement and goals for your service.
• Identify important stakeholders and potential members for you implementation team.
• Review state and federal rules on scope of practice and payment that may affect your proposed service.
• Perform a SWOT analysis.
Month 2
• Convene your planning team.
• Finalize mission, vision, and goals with team.
• Determine resource needs together with start-up costs.
• Estimate the operational costs and potential revenue for your clinic.
• Develop a plan for measuring the work of the clinic (proposed measures) and timeline for presenting results
to your organization.
• Begin developing and writing your service proposal or business plan.
• Meet with stakeholders and decision-makers to informally discuss your anticipated services and identify areas
and concerns they would like you to address.
Months 3−4
• Complete your service proposal or business plan.
• Schedule formal meetings and presentations to stakeholders and decision-makers within your organization.
Months 5−6
(You can begin this work while awaiting approval so you are ready to go once approval of your service is obtained.)
• Develop you marketing plan.
• Plan setup of your clinic.
• Order necessary equipment and supplies.
• Develop policies and procedures.
• Obtain CLIA waivers as needed.
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REFERENCES
General 13. Helling DK, Johnson SG. Defining and advanc-
1. ACCP Clinical Practice Affairs Committee. Prac- ing ambulatory care pharmacy practice: it is time
tice guidelines for pharmacotherapy specialists: a to lengthen our stride. Am J Health Syst Pharm
position statement of the American College of Clini- 2014;71:1348-56.
cal Pharmacy. Pharmacotherapy 2000;20:487-90. 14. Isasi F, Krofah E. The Expanding Role of Pharma-
2. American College of Clinical Pharmacy. Establish- cists in a Transformed Health Care System. Wash-
ing and evaluating clinical pharmacy services in ington, DC: National Governors Association Center
primary care. Pharmacotherapy 1994;4:743-58. for Best Practices, January 13, 2015. Available at
3. Bates DW. Role of pharmacists in the medical home. www.nga.org/files/live/sites/NGA/files/pdf/2015/15
Am J Health Syst Pharm 2009;66:1116-8. 01TheExpandingRoleOfPharmacists.pdf. Accessed
March 5, 2015.
4. Bleser WK, Miller-Day M, Naughton D, et al. Strat-
egies for achieving whole-practice engagement and 15. Kliethermes MA, Brown TR, eds. Building a Suc-
buy in to the Patient Centered Medical Home. Ann cessful Ambulatory Care Practice: A Complete
Fam Med 2014;27-45. Guide for Pharmacists. Bethesda, MD: American
Society of Health-System Pharmacists, 2012.
5. Brummel A, Lustig A, Westrich K, et al. Best prac-
tices: improving patient outcomes and costs in an 16. Luder HR, Frede SM, Kirby JA, et al. Transition
ACO through comprehensive medication therapy RX: impact of community pharmacy postdischarge
management. J Manag Care Pharm 2014;20:1152-8. medication therapy management on hospital read-
mission rate. J Am Pharm Assoc 2015;55:246-54.
6. Brush JE, Handberg EM, Biga C, et al. 2015 ACC
health policy statement on cardiovascular team- 17. Maine LL, Knapp KK, Scheckelhof DJ. Pharmacists
based care and the role of advanced practice provid- and technicians can enhance patient care even more
ers. J Am Coll Cardiol 2015;65:2118-36. once national policies, practices and priorities are
aligned. Health Aff 2013;32:1956-62.
7. Chamberlain M. The vertically integrated pharmacy
department. Am J Health Syst Pharm 1998;55:669-75. 18. Nau DP, Ried D, Lipowski E. What makes patients
think that their pharmacists’ services are of value? J
8. Ellen K, Dusing-Wiest M, Feedlund J, et al. Stepwise
Am Pharm Assoc (Wash) 1997;NS37:91-8.
Approach to Implementing Ambulatory Clinical
Pharmacy Services. Available at www.medscape. 19. Nigro SC, Garwood CL, Berlie H, et al. Clinical
com/viewarticle/557517_print. Accessed November pharmacists as key members of the patient cen-
12, 2009. tered medical home: an opinion statement of the
Ambulatory Practice and Research Network of the
9. Epplen K, Dusing-Wiest M, Freedlund J, et al. Step-
American College of Pharmacy. Pharmacotherapy
wise approach to implementing ambulatory clini-
2014;34:96-108.
cal pharmacy services. Am J Health Syst Pharm
2007;64:945-51. 20.
Patient-Centered Primary Care Collaborative
(PCPCC). Integrating Comprehensive Medication
10. Epplen KT. Patient care delivery and integration:
Management to Optimize Patient Outcomes, 2nd
stimulating advancement of ambulatory care phar-
ed. Resource Guide. Washington, DC: PCPCC, June
macy practice in an era of health care reform. Am J
2012. Available at www.pcpcc.org/sites/default/files/
Health Syst Pharm 2014;71:1357-65.
media/medmanagement.pdf. Accessed January 2014.
11. Farrell B, Ward N, Dore N, et al. Working in interpro-
21. Sachdev G. Sustainable business models: sys-
fessional primary health care teams: what do phar-
tematic approach toward successful ambulatory
macists do? Res Social Adm Pharm 2013;9:208-301.
care pharmacy practice. Am J Health Syst Pharm
12. Hamond RW, Schwartz AH, Campbell MJ. Col- 2014;71:1366-74.
laborative drug therapy management by pharma-
cists-2003. Pharmacotherapy 2003;23:1210-25.
1-159
22. Scuderi CB, Lee KY, Bilello LA, et al. Team-based 6. Ho PM, Lambert-Kerzner A, Carey EP, et al. Mul-
care – the “who” of the patient-centered medical tifaceted intervention to improve medication adher-
home. Osteopath Fam Physician 2014;6:14-9. ence and secondary prevention measures after acute
23. Smith M, Bates DW, Bodenheimer T, et al. Why coronary syndrome hospital discharge. JAMA In-
pharmacists belong in the medical home. Health Aff tern Med 2014;174:186-93.
(Millwood) 2010;29:906-13. 7. Kripalani S, Roumie CL, Dalal AK, et al. Effect of
24. Smith MA. Pharmacists and the primary care work- a pharmacist intervention on clinically important
force. Ann Pharmacother 2012;46:1568-71. medication errors after hospital discharge. Ann In-
tern Med 2012;157:1-10.
25. Snella KA, Sachdev GP. A primer for developing
pharmacist-managed clinics in the outpatient set- 8. Lauffenburger JC, Vu MG, Burkhart JL, et al. De-
ting. Pharmacotherapy 2003;23:1153-66. sign of a medication therapy management program
for Medicare beneficiaries: qualitative findings from
26. Tan ECK, Stewart K, Elliot RA, et al. Pharmacist
patients and physicians. Am J Geriatr Pharmacother
services provided in general practice clinics: a sys-
2012;10:129-38.
tematic review and meta-analysis. Res Social Adm
Pharm 2014;10:608-22. 9. Lifer SM, Musser MR, Kier K. Evaluation of a phar-
macist-run antiarrythmic clinic in an ambulatory
27. Touchette DR, Doloresco F, Suda KJ, et al. Econom-
practice. J Am Pharm Assoc 2015;55:e381-e386.
ic evaluations of clinical pharmacy services: 2006-
2010. Pharmacotherapy 2014;34:771-93. 10. McConaha JL, Tedesco GW, Civitarese L, et al. A
pharmacist’s contribution within a patient-centered
28. Weber AZ, Skelley J, Sachdev G, et al. Integration of
medical home. J Am Pharm Assoc 2015;55:302-6.
pharmacists into team-based ambulatory care prac-
tice models. Am J Health Syst Pharm 2015;72:745-51. 11. Pringle JL, Boyer A, Conklin MH, et al. The Penn-
sylvania project: pharmacist intervention improved
29. White S. Leading from a staff or clinical position.
medication adherence and reduced health care costs.
Am J Health Syst Pharm 2009;66:2092-3.
Health Aff 2014;33:1444-52.
Clinical Service Descriptive Reports/Research

Clinical Services for Different Patient Populations
1. Andrus MR, Clark DB. Provision of pharmacother-
Cardiology
apy services in a rural nurse practitioner clinic. Am
1. Ripley TL, Adamson PB, Hennebry TA, et al. Col-
J Health Syst Pharm 2007;64:294-7.
laborative practice model between cardiologists
2. Carmichael JM, Alvarez A, Chaput R, et al. Es- and pharmacists for management of patients with
tablishment and outcomes of a model primary care cardiovascular disease in an outpatient clinic. Ann
pharmacy service system. Am J Health Syst Pharm Pharmacother 2014;48:412-9.
2004;61:472-82.
2. Singh LG, Accursi M, Korch Black K. Implementa-
3. Cioffi ST, Caron MF, Kalus JS, et al. Glycosylated tion and outcomes of a pharmacist-managed clini-
hemoglobin, cardiovascular, and renal outcomes in cal video tele-health anticoagulation clinic. Am J
a pharmacist-managed clinic. Ann Pharmacother Health Syst Pharm 2015;72:70-3.
2004;38:771-5.
4. Cone SM, Brown MC, Stambaugh RL. Character- Diabetes
istics of ambulatory care clinics and pharmacists in 1. Anaya JP, Rivera JO, Lawson K, et al. Evaluation
veterans’ affairs medical centers: an update. Am J of pharmacist-managed diabetes mellitus under a
Health Syst Pharm 2008;65:631-5. collaborative drug therapy agreement. Am J Health
5. Heilmann RM, Campbell SM, Kroner BA, et al. Syst Pharm 2008;65:1841-5.
Evolution, current structure, and role of a primary 2. Bluml BL, Watson LL, Skelton JB, et al. Improving
care clinical pharmacy service in an integrated outcomes for diverse populations disproportionally
managed care organization. Ann Pharmacother affected by diabetes: final results of Project IM-
2013;47:124-31. PACT: Diabetes. J Am Pharm Assoc 2014;54:474-55.
1-160
3. Franklin BE, Farland MZ, Thomas J, et al. Phar- 2. Milfred-LaForest SK, Chow SL, DiDomenico RJ,
macoeconomic analysis of the diabetes initiative et al. Clinical pharmacy services in heart failure:
program: a pharmacist-physician collaborative care an opinion paper from the Heart Failure Society of
model. Ann Pharmacother 2013;47:1627-34. America and American College of Clinical Phar-
4. Jacobs M, Sherry PS, Taylor LM, et al. Pharmacist- macy Cardiology Practice and Research Network. J
Assisted Medication Program Enhancing the Regu- Card Fail 2003;19:354-69.
lation of Diabetes (PAMPERED) study. J Am Pharm 3. Murray M, Young J, Hoke S, et al. Pharmacist in-
Assoc 2012;52:613-21. tervention to improve medication adherence in
5. Morello CM, Zadvorny EB, Cording MA, et al. heart failure – a randomized trial. Ann Intern Med
Development and clinical outcomes of pharmacist- 2007;146:714-25.
managed diabetes care clinics. Am J Health Syst
Pharm 2006;63:1325-31. Hepatitis C
6. Wallgren S, Berry-Cabán CS, Bowers L. Impact of 1. Smith JP, Dong MH, Kaunitz JD. Evaluation of a
clinical pharmacist intervention on diabetes-related pharmacist-managed hepatitis C care clinic. Am J
outcomes in a military treatment facility. Ann Phar- Health Syst Pharm 2007;64:632-6.
macother 2012;46:353-7.
7. Wubben DP, Vivian EM. Effects of pharmacist Hypertension
outpatient interventions on adults with diabetes 1. Carter BL, Ardery G, Dawson JD, et al. Physician
mellitus: a systematic review. Pharmacotherapy and pharmacist collaboration to improve blood pres-
2008;28:421-36. sure control. Arch Intern Med 2009;169:1996-2002.
8. Yu JY, Shah BM, Ip EJ, et al. A Markov model of 2. Carter BL, Coffey CS, Ardery G, et al. Cluster-ran-
the cost-effectiveness of pharmacist care for dia- domized trial of a physician/pharmacist collabora-
betes in prevention of cardiovascular diseases: evi- tive model to improve blood pressure control. Circu-
dence from Kaiser Permanente Northern California. lation 2015;132:93-100.
J Manag Care Pharm 2013;19:102-14. 3. Carter BL, Rogers M, Daly J, et al. The potency of
team-based care interventions for hypertension: a
Geriatrics meta-analysis. Arch Intern Med 2009;169:1748-55.
1. Davis RG, Hepfinger CA, Sauer KA, et al. Retro- 4. Margolis KL, Asche SE, Bergdall AR, et al. Effect
spective evaluation of medication appropriateness of home blood pressure tele-monitoring and pharma-
and clinical pharmacist drug therapy recommenda- cist management on blood pressure control: a cluster
tions for home-based primary care veterans. Am J randomized clinical trial. JAMA 2013;310:46-56.
Geriatr Pharmacother 2007;5:40-7. 5. O’Neill JL, Cunningham TL, Wiitala WL, et al.
2. George J, Elliott RA, Stewart DC. A systematic re- Collaborative hypertension case management by
view of interventions to improve medication taking registered nurses and clinical pharmacy special-
in elderly patients prescribed multiple medications. ists within the Patient Aligned Care Teams (PACT)
Drugs Aging 2008;25:307-24. model. J Gen Intern Med 2014;29(suppl 2):S675-81.
3. Rojas-Fernandez CH, Patel T, Lee L. An interdisci- 6. Ripley TL, Hennebry TA, Sanders TN, et al. Impact
plinary memory clinic: a novel practice setting for of a clinical pharmacist on a cardiovascular surrogate
pharmacists in primary care. Ann Pharmacother endpoint: a pilot study. Pharm Pract 2012;10:173-9.
2014;48:785-95.
Hyperlipidemia
Heart Failure 1. Miller AE, Hansen LB, Saseen JJ. Switching statin
1. Koshman SL, Charrois TL, Simpson SH, et al. Phar- therapy using a pharmacist-managed therapeu-
macist care of patients with heart failure: a system- tic conversion program versus usual care conver-
atic review of randomized trials. Arch Intern Med sion among indigent patients. Pharmacotherapy
2008;168:687-94. 2008;28:553-6.
1-161
2. Olson KL, Potts LA. Role of the pharmacist in Underserved

the management of dyslipidemia. J Pharm Pract 1. Brahm NC, Palmer T, Williams T, et al. Bedlam
2006;19:94-102. Community Health Clinic: a collaborative interdis-
ciplinary health care service for the medically indi-
Oncology gent. J Am Pharm Assoc 2007;47:398-403.
1. Shah S, Dowell J, Greene S. Evaluation of clinical
pharmacy services in a hematology/oncology outpa- Developing a Service or Business Plan
tient setting. Ann Pharmacother 2006;40:1527-33. 1. Harris IM, Baker E, Berry TM, et al. Developing a
2. Tuffaha HW, Abdelhadi O, Omar SA. Clinical phar- business-practice model for pharmacy services in am-
macy services in the outpatient pediatric oncology bulatory settings. Pharmacotherapy 2008;28:7e-34e.
clinics at a comprehensive cancer center. Int J Clin
Pharm 2012;34:27-31. Marketing
3. Watkins JL, Landgraf A, Barnett CM, et al. Evalu- 1. Chartered Institute of Marketing. Marketing and the
ation of pharmacist-provided medication therapy 7 Ps: A Brief Summary of Marketing and How It
management services in an oncology ambulatory Works. 2009. Available at www.cim.co.ui/marketin-
setting. J Am Pharm Assoc 2012;52:170-4. gresources. Accessed September 2011.
2. Doucette WR, McDonough RP. Beyond the 4 Ps:
using relationship marketing to build value and de-
Palliative Care
mand for pharmacy services. J Am Pharm Assoc
1. Atayee RS, Best BM, Daniels CE. Development of
2002;42:183-94.
an ambulatory palliative care pharmacist practice. J
Palliat Med 2008;11:1077-82. 3. Garcia CM, Snyder ME, Harriman McGrath S, et
al. Generating demand for pharmacist-provided
medication therapy management: identifying patient
Psychiatry preferred marketing strategies. J Am Pharm Assoc
1. Caballero J, Souffrant C, Heffernan E. Develop- 2009;49:337-40.
ment and outcomes of a psychiatric pharmacy clin-
4. McDonough RP, Doucette WR. Using personal sell-
ic for indigent patients. Am J Health Syst Pharm
ing skills to promote pharmacy services. J Am Pharm
2008;65:229-33.
Assoc 2003;43:363-74.
5. Patterson BJ, Solimeo SL, Steward KR, et al. Per-
Smoking Cessation
ceptions of pharmacists’ integration into patient-cen-
1. Bock BC, Hudmon KS, Christian J, et al. A tai-
tered medical home teams. Res Social Adm Pharm
lored intervention to support pharmacy-based coun-
2015;11:85-95.
seling for smoking cessation. Nicotine Tob Res
2010;12:217-25. 6. Smith MC. Marketing pharmaceutical services.
Chapter 39. In: Brown TR, ed. Handbook of Insti-
tutional Pharmacy Practice, 4th ed. Bethesda, MD:
Transplantation
American Society of Health-System Pharmacists,
1. Chisholm-Burns MA, Spivey CA, Garrett C, et al.
2006:543-55.
Impact of clinical pharmacy services on renal trans-
plant recipients’ adherence and outcomes. Patient
Prefer Adherence 2008;2:287-92. Operations and Workflow
1. Centers for Disease Control and Prevention (CDC).
2. Wang HY, Chan AL, Chen MT, et al. Effects of
Current CLIA Regulations. Available at www.cdc.
pharmaceutical care intervention by clinical phar-
gov/clia/rgs/toc.aspx. Accessed November 2013.
macists in renal transplant clinics. Transplant Proc
2008;40:2319-23. 2. Health Insurance Portability and Accountability Act.
Summary of the HIPAA Security Rule. HIPAA PHI
Regulations. Available at www.hhs.gov/ocr/privacy/hip-
pa/understanding/srsummary.html. Accessed July 2011.
1-162
3. Hirsch JD, Metz KR, Hosokawa PW, et al. Valida-

tion of a patient-level medication regimen complex-
ity index as a possible tool to identify patients for
medication therapy management intervention. Phar-
macotherapy 2014;34:826-35.
4. Moore CG, Wilson-Witherspoon P, Probst JC. Time
and money: effects of no-shows at a family practice
residency clinic. Fam Med 2001;33:522-7.
5. Nguyen TT, Mehta BH, Rodis JL, et al. Evaluation
of provider documentation of medication manage-
ment in a patient-centered medical home. Innov
Pharm 2014;5:1-7.
6. Nuti LA, Lawley M, Turkcan A, et al. No-show to
primary care appointments: subsequent acute care
utilization among diabetic patients. BMC Health
Serv Res 2012;12:304.
7. Snella K, Trewn R, Hansen L, et al. Pharmacist
compensation for cognitive services: focus on the
physician office and community pharmacy. Pharma-
cotherapy 2004;24:372-8.
8. Trong HA, Groves CN, Congdon HB, et al. Po-
tential cost savings of medication therapy man-
agement in safety-net clinics. J Am Pharm Assoc
2015;55:269-72.
9. Unertl K, Weinger MB, Johnson KB, et al. Describ-
ing and modeling workflow and information flow in
chronic care. J Med Inform Assoc 2009;16:826-36.
10. U.S. Food and Drug Administration (FDA). Clini-
cal Laboratory Improvement Amendments. Avail-
able at www.fda.gov/MedicalDevices/DeviceRegu-
lationandGuidance/IVDRegulatoryAssisstance/
umc124105.htm. Accessed November 2013.
11. VandeGriend JP, Saseen JJ, Bislip D, et al. Priori-
tization of patients for comprehensive medication
review by a clinical pharmacist in family medicine.
J Am Board Fam Med 2015:28:418-24.
12. Vazquez S, Campbell J, et al. Anticoagulation
clinic workflow analysis. J Am Pharm Assoc
2003;49:78-85.
13. Xakellis GC, Bennett A. Improving clinic efficien-
cy of a family medicine teaching clinic. Fam Med
2001;33:533-8.
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ANSWERS AND EXPLANATIONS TO SELF-ASSESSMENT QUESTIONS

1. Answer: C teach the other providers how best to use their services
The most important first step is to do the research to un- and how the services you are providing will improve pa-
derstand the needs of your organization. This is called an tient outcomes. Although a poorly defined payment model
internal environmental scan. This background work will for your services is certainly a weakness there are many
help you develop your service so that it effectively meets current pharmacist practice models using available billing
the needs of your setting. It will also help you get the atten- codes, P4P, and quality measure attainment to overcome
tion of the stakeholders, whose support you will need for this weakness and therefore create a viable service. The
approval of your service. Your stakeholders will most like- ability to access patient medical records continues to be-
ly have some idea of the important issues you need to ad- come less of a barrier. Many organization now have pro-
dress. Your ability to know this information well will help cesses to allow various levels of EMR access based on an
establish your credibility and ensure that the stakeholders outside providers need to know patient information. Ex-
seriously consider your services as a solution. Knowing change of information is a requirement of the American
what the specific needs are of your organization will help Recovery and reinvestment Act of 2009 and the “mean-
you narrow your research of the literature to citations that ingful use” requirements for all Medicare providers. Turf
will help you support the services and should be a second battles with other providers who may “compete” with a
step. When you have the data from the internal and exter- pharmacists also is becoming less of a barrier with the for-
nal scans to support initial discussions of your proposal, mation of team based models. Team members do need to
you will likely have a more successful meeting with the have defined specific roles, however in every case there is
groups who will utilize your services. Although you may likely more work than there are providers.
begin to draft a mission and vision statement, it is best if
the entire team of stakeholders participate in development 4. Answer: A
of the final version of these statements. The best way to ensure patient volume when you get start-
ed in your clinic is to determine a set of patients who will
2. Answer: C automatically be referred to your clinic. As stated in ques-
Although each person listed could be considered a stake- tion 3, providers are initially unfamiliar with your services
holder team member, depending on the service you are and often do not even consider a referral to pharmacy dur-
proposing and the construct of your organization, the or- ing a patient visit, or they are already used to managing
ganization’s compliance officer is a key person to have on these issues (optimal or not) in their day-to-day work. It
your team. The compliance officer is responsible for the will take time to teach referring providers which patients
billing process for all payers. This person understands the you can assist in treating. Patients, too, are generally un-
reimbursement contracts and rules that are applicable to familiar with the type of pharmacist services you plan to
your setting. Therefore, the compliance officer is impor- provide. Patients often feel overloaded with health care
tant in helping you determine the billing and revenue for provider visits and therefore are reluctant to add another
your service. Making sure you have a viable and sustain- visit unless they can clearly see a benefit. Clinical pharma-
able service will always be a first step. cy services are not tangible and are consumed only once
they are provided. It is often difficult for patients to under-
3. Answer: B stand why they need the pharmacist visit until they have
Probably the most difficult aspect of starting a new clinic received the services. Therefore, giving patients options
is providers’ unfamiliarity with pharmacist clinical ser- will also take significant time before you can build your
vices, particularly physicians and nurses who have never service. Seeing all patients with eight or more medications
worked with pharmacists in a clinical capacity. In many for chronic conditions is a viable option, but may be less
cases, the services you are proposing may have already efficient in showing value than option A. This is because
been accommodated for in some way by other providers there certainly may be patients in that group that are do-
in their daily practices. Although the outcome in how the ing fine and seeing them may not be as valuable to your
problem is being addressed may not be optimal, many pro- organization as those potentially costing the system such
viders are used to addressing these problems in their usual as recently hospitalized patients.
way. It is up to clinical pharmacists to be proactive and
1-164
5. Answer: C 8. Answer: B
Because administrators usually have significant influ- Services are intangible and are evaluated only once re-
ence in approving your proposal, the financial section ceived. Consequently, evaluations highly depend on
of your proposal must meet their needs and contain the each person providing the service and how that person
information they want to review. Financial charts and approaches his or her work day to day. If there is large
graphs should be used in this section. Start-up costs variability in pharmacist skills and competency and how
need to be included, as do resources and the routine a group of pharmacists provides service or large variabil-
or ongoing costs of providing the service. This section ity day to day for individual pharmacists (i.e., depending
should include a pro forma statement that projects the on how his or her day is going), it will be difficult to suc-
financial viability of your service for the next 3–5 years. cessfully market the service. Standardization and clear
The remainder of the answers are not sufficient to meet definitions of the services to be provided will be impor-
the scrutiny of an administrator who must weigh in on tant. Although setting a price is challenging, problems
whether the cost of your services provide sufficient rev- with pricing lie more with what the market will bear than
enue and value. with the ability to determine a price for the service. Ac-
cording to their own priorities, patients will determine
6. Answer: D the quality of the services they receive. Finally, there are
Mission and vision statements are extremely important. many aspects to marketing; using brochures is just one
They set the purpose of your clinic and directly identify small part of the process.
goals and expected outcomes. Aligning the clinic mis-
sion and vision statements with those of the organization
ensures that what you are proposing will help the overall
organization meet its objectives and goals. This also will
help garner interest in your proposal and provide support
for approval. Although each of the answers are important,
mission and vision statements drive the decisions of the C
suite and you will overcome a first pass hurdle if you have
synergy with the organization with these statements.
7. Answer: A
A common mistake when considering marketing is to
assume that marketing involves only promotion or ad-
vertisement such as creating a brochure. The first step
in marketing is to identify your customers. What makes
clinical pharmacy services difficult is that there are often
four simultaneous customers. The patient is always the
primary customer of services, but in many situations, so
are other providers, administrators, and payers. Provid-
ers, especially supervising providers, must be satisfied
with the services you deliver to their patients; adminis-
trators are concerned about whether you are working ef-
ficiently; and payers may want certain outcomes for pay-
ment of your services. Your marketing plan must address
and meet the needs of all of your customers. In follow up
to identifying your customers is defining the patient care
services to meet the needs of all your customers. Promo-
tion is a later step.
1-165

Developing Clinical Practice

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Developing Clinical Practice

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Developing a Clinical Practice

Mary Ann Kliethermes, Pharm.D.

Developing a Clinical Practice

Learning Objectives 1. Which is the most important initial step to perform?

Summary of Case Examples

I. IDENTIFYING THE NEED FOR AMBULATORY CLINICAL PHARMACY PROGRAM

Domain 4: Practice Models and Policy, Task 1, item 4

C. Perform an External Environmental Scan.

Box 1. Key General Literature Resources

Box 1. Key General Literature Resources (continued)

Box 1. Key General Literature Resources (continued)

II. THE SPECIFICS IN PREPARING YOUR PHARMACY PROGRAM PROPOSAL

B. Determine Your Scope of Practice.

Table 1. SWOT Analysis of Care Delivery Models

Box 2. Estimating the Yearly Rental Cost of Your Allocated Space

Table 2. Large-Ticket Clinic Equipment and Supplies to Consider

E. Financial Assessment: Evaluating Expenses Versus Revenue

Table 3. AWV Clinic: Example Health System

Net Income $ 22,340 $ 170,270 $ 95,165

Domain 4: Practice Models and Policy, Task 1, item 4

III. DEVELOPING YOUR SERVICE PROPOSAL OR BUSINESS PLAN

Domain 4: Practice Models and Policy, Task 1, item 1

IV. MARKETING YOUR SERVICES

A. Understanding Your Customers’ Behavior

2. Understanding the behavior of your customers

C. Specific Challenges for Ambulatory Pharmacist Patient Care Services

E. Creating the Marketing Plan

ii. Intangible packaging

Domain 4: Practice Models and Policy, Task 4

V. CREATING YOUR SERVICE MODEL

Box 3. Essential Equipment to Consider

3. Miscellaneous items to consider and plan for

7. Scope of practice and clinic privileges

VI. SUGGESTED TIMELINE FOR ESTABLISHING A PRACTICE

Clinical Service Descriptive Reports/Research

2. Olson KL, Potts LA. Role of the pharmacist in Underserved

3. Hirsch JD, Metz KR, Hosokawa PW, et al. Valida-

ANSWERS AND EXPLANATIONS TO SELF-ASSESSMENT QUESTIONS

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