Ascension Saint Thomas/Saint Louise Family Medicine Center

Practice Setting

The Saint Louise Family Medicine Center is a patient-centered medical home that is part of Saint Thomas Medical Partners and has affiliations with Ascension Saint Thomas Rutherford and the University of Tennessee. The clinic was founded in 2010 in an effort to provide care to indigent patients. The clinic is staffed by medical residents, in addition to seven attending physicians, two full-time nurse practitioners, and two part-time nurse practitioners. Saint Louise is fortunate to have substantial support staff and services including licensed practice nurses, medical assistant, a licensed clinical social worker, a dietician, a patient navigator, and others. In 2015, Saint Thomas Rutherford began offering clinical pharmacy support one half-day per week, and expanded to full-time support in 2017.

Clinical pharmacy services include comprehensive medication management to established patients with chronic conditions under a broad collaborative practice agreement that spans 14 areas of practice, including diabetes, hypertension, heart failure, asthma, COPD, and hepatitis C. Services are provided by both in-person and via telehealth modalities.  Addtionally, the clinic serves as a rotation site for PGY1 and PGY2 Ambulatory care residents.  

Why was the pharmacy service developed? (Describe any compelling data collected prior to implementation)

The pharmacy service was developed by the Director of Pharmacy in conjunction with one of the clinic attending physicians. The initial goal was to establish a transitions of care clinic for patients with heart failure one half day per week but services were later expanded to providing collaborative support to medical residents for patients with diabetes and anticoagulation needs. When the Community Benefits department heard of the great value pharmacy was providing to patients, the department was encourged to apply for funding for a full-time position.

What training, certification, credentialing, and practice agreement is utilized by the practice setting pharmacist(s)?

The clinic pharmacists is residency trained (PGY1 and PGY2) and is also double board certified in pharmacotherapy and ambulatory care.  Clinical pharmacy services are provided under a collaborative practice agreement.

What outcomes are being measured to evaluate the model's success? (Clinical metrics, revenue, cost-savings, patient satisfaction, etc.)

Quarterly quality assurance metrics include pre and post-PharmD hemoglobin A1c, blood pressures, heart failure, and COPD admissions/readmissions.  For example, monitoring hemoglobin A1c greater than 9% have shown a reduction from 29% of patients in 2017 - 2018 to 23% of patients in 2019 – 2020.

How have you made this service sustainable? (Include billing, reimbursement, etc.) 

Clinical pharmacy services have remained sustainable by  pursuing reimbursement as providers.  Clinic pharmacists have successfully enrolled with two major commercial health insurers and are hopeful to begin billing E/M visits. Additionally, services are enrolled in the TennCare MTM program which helps add to reimbursement while also reduce administrative burden.

How did you gain support of administrators, providers, and other key stakeholders to implement your practice model?

When you have a clinically significant impact on your patients, especially the tough ones, your providers will notice. Be mindful of their pain points and accessible to offer help, even if it is not your passion area. For example, medication access and drug information are two “soft skills” pharmacists have that other providers may not consciously think about—however, when you begin providing those services and fill in that gap for them you soon become indispensable.

For administrators, realize that most full time clinicians do not track their outcomes. It can be burdensome to incorporate into your busy schedule, but when you are able to prove what your providers are seeing with data, that carries a lot of weight with administrators. You don’t have to get IRB approval to do this—just a simple spreadsheet tracking your before and after outcomes is usually enough. It also helps to be a good storyteller—before meeting with an administrator, reflect on some of the impactful patient visits you’ve had over the past month, so you can share those concrete stories rather than speaking in abstract generalities.

What are some lessons learned while implementing your practice model that you would like to share

Whether formal or informal, do a needs assessment at baseline and periodically to ask what are the needs of your practice site. Sometimes this may reveal that a service you were planning on offering duplicates another resource available in the community. Continuing with that service anyway may end up causing confusion and tension.

On the flip side, there may be a need that is not being met that you are ideal to fill. Even if that need would require some learning and stretching on your part! For example, one of our physicians wanted to start a hepatitis C clinic. This required pharmacists committing to learning a new disease state and new patient assistance program workflows, but now that expertise has increased our value to the clinic and administrators.