Non-dispensing pharmacists integrated into general practices as a new interprofessional model:A qualitative evaluation of general practitioners’ experiences and views

Background: A new interprofessional model incorporating non-dispensing pharmacists in general practice teams can improve the quality of pharmaceutical care. However, results of the model are dependent on the context. Understanding when, why and how the model works may increase chances of successful broader implementation in other general practices. Earlier theories suggested that the results of the model are achieved by bringing pharmacotherapeutic knowledge into general practices. This mechanism may not be enough for successful implementation of the model. We wanted to understand better how establishing new interprofessional models in existing healthcare organisations takes place. Methods: An interview study, with a realist informed evaluation was conducted. This qualitative study was part of the Pharmacotherapy Optimisation through Integration of a Non-dispensing pharmacist in primary care Teams (POINT) project. We invited the general practitioners of the 9 general practices who (had) worked closely with a non-dispensing pharmacist for an interview. Interview data were analysed through discussions about the coding with the research team where themes were developed over time. Results: We interviewed 2 general practitioners in each general practice (18 interviews in total). In a context where general practitioners acknowledge the need for improvement and are willing to work with a non-dispensing pharmacist as a new team member, the following mechanisms are triggered. Non-dispensing pharmacists add new knowledge to current general practice. Through everyday talk (discursive actions) both general practitioners and non-dispensing pharmacists evolve in what they consider appropriate, legitimate and imaginable in their work situations. They align their professional identities. Conclusions: Not only the addition of new knowledge of non-dispensing pharmacist to the general practice team is crucial for the success of this interprofessional healthcare model, but also alignment of the general practitioners’ and non-dispensing pharmacists’ professional identities. This is essentially different from traditional pharmaceutical care models, in which pharmacists and GPs work in separate organisations. To induce the process of identity alignment, general practitioners need to acknowledge the need to improve the quality of pharmaceutical care interprofessionally. By acknowledging the aspect of interprofessionality, both general practitioners and non-dispensing pharmacists will explore and reflect on what they consider appropriate, legitimate and imaginable in carrying out their professional roles. Trial registration: The POINT project was pre-registered in The Netherlands National Trial Register, with Trial registration number NTR-4389.</p

The degree of integration of non-dispensing pharmacists in primary care practice and the impact on health outcomes: A systematic review

Background: A non-dispensing pharmacist conducts clinical pharmacy services aimed at optimizing patients individual pharmacotherapy. Embedding a non-dispensing pharmacist in primary care practice enables collaboration, probably enhancing patient care. The degree of integration of non-dispensing pharmacists into multidisciplinary health care teams varies strongly between settings. The degree of integration may be a determinant for its success. Objectives: This study investigates how the degree of integration of a non-dispensing pharmacist impacts medication related health outcomes in primary care. Methods: In this literature review we searched two electronic databases and the reference list of published literature reviews for studies about clinical pharmacy services performed by non-dispensing pharmacists physically co-located in primary care practice. We assessed the degree of integration via key dimensions of integration based on the conceptual framework of Walshe and Smith. We included English language studies of any design that had a control group or baseline comparison published from 1966 to June 2016. Descriptive statistics were used to correlate the degree of integration to health outcomes. The analysis was stratified for disease-specific and patient-centered clinical pharmacy services. Results: Eighty-nine health outcomes in 60 comparative studies contributed to the analysis. The accumulated evidence from these studies shows no impact of the degree of integration of non-dispensing pharmacists on health outcomes. For disease specific clinical pharmacy services the percentage of improved health outcomes for none, partial and fully integrated NDPs is respectively 75%, 63% and 59%. For patient-centered clinical pharmacy services the percentage of improved health outcomes for none, partial and fully integrated NDPs is respectively 55%, 57% and 70%. Conclusions: Full integration adds value to patient-centered clinical pharmacy services, but not to disease-specific clinical pharmacy services. To obtain maximum benefits of clinical pharmacy services for patients with multiple medications and comorbidities, full integration of non-dispensing pharmacists should be promoted

Design of the POINT study: Pharmacotherapy Optimisation through Integration of a Non-dispensing pharmacist in a primary care Team (POINT)

__Background:__ In the Netherlands, 5.6 % of acute hospital admissions are medication-related. Almost half of these admissions are potentially preventable. Reviewing medication in patients at risk in primary care might prevent these hospital admissions. At present, implementation of medication reviews in primary care is suboptimal: pharmacists lack access to patient information, pharmacists are short of clinical knowledge and skills, and working processes of pharmacists (focus on dispensing) and general practitioners (focus on clinical practice) match poorly. Integration of the pharmacist in the primary health care team might improve pharmaceutical care outcomes. The aim of this study is to evaluate the effect of integration of a non-dispensing pharmacist in general practice on the safety of pharmacotherapy in the Netherlands. __Methods:__ The POINT study is a non-randomised controlled intervention study with pre-post comparison in an integrated primary care setting. We compare three different models of pharmaceutical care provision in primary care: 1) a non-dispensing pharmacist as an integral member of a primary care team, 2) a pharmacist in a community pharmacy with a predefined training in performing medication reviews and 3) a pharmacist in a community pharmacy (care as usual). In all models, GPs remain accountable for individual medication prescription. In the first model, ten non-dispensing clinical pharmacists are posted in ten primary care practices (including 5 – 10 000 patients each) for a period of 15 months. These non-dispensing pharmacists perform patient consultations, including medication reviews, and share responsibility for the pharmaceutical care provided in the practice. The two other groups consist of ten primary care practices with collaborating pharmacists. The main outcome measurement is the number of medication-related hospital admissions during follow-up. Secondary outcome measurements are potential medication errors, drug burden index and costs. Parallel to this study, a qualitative study is conducted to evaluate the feasibility of introducing a NDP in general practice. __Discussion:__ As the POINT study is a large-scale intervention study, it should provide evidence as to whether integration of a non-dispensing clinical pharmacist in primary care will result in safer pharmacotherapy. The qualitative study also generates knowledge on the optimal implementation of this model in primary care. Results are expected in 2016

Controversy and consensus on a clinical pharmacist in primary care in the Netherlands

Background Controversy about the introduction of a non-dispensing pharmacist in primary care practice hampers implementation. Objective The aim of this study is to systematically map the debate on this new role for pharmacists amongst all stakeholders to uncover and understand the controversy and consensus. Setting: Primary health care in the Netherlands. Method Q methodology. 163 participants rank-ordered statements on issues concerning the integration of a non-dispensing pharmacist in primary care practice. Main outcome measure: Stakeholder perspectives on the role of the non-dispensing pharmacist and pharmaceutical care in primary care. Results This study identified the consensus on various features of the non-dispensing pharmacist role as well as the financial, organisational and collaborative aspects of integrating a non-dispensing pharmacist in primary care practice. Q factor analysis revealed four perspectives: “the independent community pharmacist”, “the independent clinical pharmacist”, “the dependent clinical pharmacist” and “the medication therapy management specialist”. These four perspectives show controversies to do with the level of professional independency of the non-dispensing pharmacist and the level of innovation of task performance. Conclusion Despite the fact that introducing new professional roles in healthcare can lead to controversy, the results of this Q study show the potential of a non-dispensing pharmacist as a pharmaceutical care provider and the willingness for interprofessional collaboration. The results from the POINT intervention study in the Netherlands will be an important next step in resolving current controversies

Controversy and consensus on a clinical pharmacist in primary care in the Netherlands

Background Controversy about the introduction of a non-dispensing pharmacist in primary care practice hampers implementation. Objective The aim of this study is to systematically map the debate on this new role for pharmacists amongst all stakeholders to uncover and understand the controversy and consensus. Setting: Primary health care in the Netherlands. Method Q methodology. 163 participants rank-ordered statements on issues concerning the integration of a non-dispensing pharmacist in primary care practice. Main outcome measure: Stakeholder perspectives on the role of the non-dispensing pharmacist and pharmaceutical care in primary care. Results This study identified the consensus on various features of the non-dispensing pharmacist role as well as the financial, organisational and collaborative aspects of integrating a non-dispensing pharmacist in primary care practice. Q factor analysis revealed four perspectives: "the independent community pharmacist", "the independent clinical pharmacist", "the dependent clinical pharmacist" and "the medication therapy management specialist". These four perspectives show controversies to do with the level of professional independency of the non-dispensing pharmacist and the level of innovation of task performance. Conclusion Despite the fact that introducing new professional roles in healthcare can lead to controversy, the results of this Q study show the potential of a non-dispensing pharmacist as a pharmaceutical care provider and the willingness for interprofessional collaboration. The results from the POINT intervention study in the Netherlands will be an important next step in resolving current controversies

Non-dispensing clinical pharmacists in general practice : training, implementation and clinical effects

Avoidable medication-related morbidity and mortality is a broadly acknowledged health care problem and is currently inadequately addressed. With the aging population, this problem is expected to increase. Elderly patients often have multimorbidity and use multiple medications, adding to the complexity of pharmacotherapy. As most of pharmacotherapy is initiated or continued in general practice, safety and effectiveness of pharmacotherapy needs to be improved in primary care. Research evidence indicates that community pharmacists can contribute to safe and effective pharmacotherapy, but are hampered to take up their role as pharmaceutical care provider. To make optimal use of their pharmaceutical knowledge, we propose that pharmacists minimize involvement in the dispensing process and focus on pharmaceutical care. These so-called non-dispensing pharmacists (NDPs) can then take integral responsibility for pharmaceutical care, without being distracted by logistics and pharmacy management. Once integrated in the primary care team, they will have full access to patients’ medical records. This integration will result in better collaboration with general practitioners (GPs), and consequently, the quality of pharmacotherapy will improve. Additional clinical training is required for pharmacists to develop as patient-centered care providers. Therefore, we developed the POINT practice model (Pharmacotherapy Optimization through Integration of a Non-dispensing pharmacist in a primary care Team). The NDPs who worked within the POINT practice model provided pharmaceutical care completely separated from the dispensing process. NDPs performed clinical medication reviews for patients with polypharmacy, medication reconciliation for patients discharged from the hospital and provided individual patient consultations to solve specific drug therapy problems. NDPs organised quality improvement projects to systematically identify and treat patients at risk of medication errors, and educated team members on optimal pharmacotherapy. With a series of both qualitative, quantitative and mixed-method studies, we evaluated the training, implementation and clinical effects of NDPs in general practice. The results from our study demonstrate that the risk on medication-related hospitalisations in practices with NDPs is lower compared to usual care. Non-dispensing pharmacists do effectively identify and solve drug therapy problems. Providing follow-up to patients is considered to be essential for optimal pharmaceutical care delivery. Additional post-graduate training, including peer provided reflective learning at the workplace, did help the NDP to develop skills and clinical expertise to add value as pharmaceutical care provider in general practice. Pharmacists in a general practice can develop a professional identity of patient-focused, clinical pharmaceutical care provider able to take responsibility for the patient’s pharmacotherapy. In short, high-risk patients will benefit most from integrated pharmaceutical care. Full integration of an NDP in clinical practice, adequate training and integral responsibility are key conditions of success for this new concept of pharmaceutical care provision

Non-dispensing clinical pharmacists in general practice : training, implementation and clinical effects

Avoidable medication-related morbidity and mortality is a broadly acknowledged health care problem and is currently inadequately addressed. With the aging population, this problem is expected to increase. Elderly patients often have multimorbidity and use multiple medications, adding to the complexity of pharmacotherapy. As most of pharmacotherapy is initiated or continued in general practice, safety and effectiveness of pharmacotherapy needs to be improved in primary care. Research evidence indicates that community pharmacists can contribute to safe and effective pharmacotherapy, but are hampered to take up their role as pharmaceutical care provider. To make optimal use of their pharmaceutical knowledge, we propose that pharmacists minimize involvement in the dispensing process and focus on pharmaceutical care. These so-called non-dispensing pharmacists (NDPs) can then take integral responsibility for pharmaceutical care, without being distracted by logistics and pharmacy management. Once integrated in the primary care team, they will have full access to patients’ medical records. This integration will result in better collaboration with general practitioners (GPs), and consequently, the quality of pharmacotherapy will improve. Additional clinical training is required for pharmacists to develop as patient-centered care providers. Therefore, we developed the POINT practice model (Pharmacotherapy Optimization through Integration of a Non-dispensing pharmacist in a primary care Team). The NDPs who worked within the POINT practice model provided pharmaceutical care completely separated from the dispensing process. NDPs performed clinical medication reviews for patients with polypharmacy, medication reconciliation for patients discharged from the hospital and provided individual patient consultations to solve specific drug therapy problems. NDPs organised quality improvement projects to systematically identify and treat patients at risk of medication errors, and educated team members on optimal pharmacotherapy. With a series of both qualitative, quantitative and mixed-method studies, we evaluated the training, implementation and clinical effects of NDPs in general practice. The results from our study demonstrate that the risk on medication-related hospitalisations in practices with NDPs is lower compared to usual care. Non-dispensing pharmacists do effectively identify and solve drug therapy problems. Providing follow-up to patients is considered to be essential for optimal pharmaceutical care delivery. Additional post-graduate training, including peer provided reflective learning at the workplace, did help the NDP to develop skills and clinical expertise to add value as pharmaceutical care provider in general practice. Pharmacists in a general practice can develop a professional identity of patient-focused, clinical pharmaceutical care provider able to take responsibility for the patient’s pharmacotherapy. In short, high-risk patients will benefit most from integrated pharmaceutical care. Full integration of an NDP in clinical practice, adequate training and integral responsibility are key conditions of success for this new concept of pharmaceutical care provision

The degree of integration of pharmacists in primary care and the impact on health outcomes

Background: A non-dispensing pharmacist conducts clinical pharmacy services aimed at optimizing patients individual pharmacotherapy. Embedding a non-dispensing pharmacist in primary care practice enables collaboration, probably enhancing patient care. The degree of integration of non-dispensing pharmacists into multidisciplinary health care teams varies strongly between settings. The degree of integration may be a determinant for its success. Objectives: This study investigates how the degree of integration of a non-dispensing pharmacist impacts medication related health outcomes in primary care. Methods: In this literature review we searched two electronic databases and the reference list of published literature reviews for studies about clinical pharmacy services performed by non-dispensing pharmacists physically co-located in primary care practice. We assessed the degree o integration via key dimensions of integration based on the conceptual framework of Walshe and Smith. We included English language studies of any design that had a control group or baseline comparison published from 1966 to June 2016. Descriptive statistics were used to correlate the degree of integration to health outcomes. The analysis was stratified for disease-specific and patient-centered clinical pharmacy services. Results: Eighty-nine health outcomes in 60 comparative studies contributed to the analysis. The accumulated evidence from these studies shows no impact of the degree of integration of non-dispensing pharmacists on health outcomes. For disease specific clinical pharmacy services the percentage of improved health outcomes for none, partial and fully integrated NDPs is respectively 75%, 63% and 59%. For patient-centered clinical pharmacy services the percentage of improved health outcomes for none, partial and fully integrated NDPs is respectively 55%, 57% and 70%. Conclusions: Full integration adds value to patient-centered clinical pharmacy services, but not to disease-specific clinical pharmacy services. To obtain maximum benefits of clinical pharmacy services for patients with multiple medications and comorbidities, full integration of non-dispensing pharmacists should be promoted

The degree of integration of pharmacists in primary care and the impact on health outcomes

__Background:__ A non-dispensing pharmacist conducts clinical pharmacy services aimed at optimizing patients individual pharmacotherapy. Embedding a non-dispensing pharmacist in primary care practice enables collaboration, probably enhancing patient care. The degree of integration of non-dispensing pharmacists into multidisciplinary health care teams varies strongly between settings. The degree of integration may be a determinant for its success. __Objectives:__ This study investigates how the degree of integration of a non-dispensing pharmacist impacts medication related health outcomes in primary care. __Methods:__ In this literature review we searched two electronic databases and the reference list of published literature reviews for studies about clinical pharmacy services performed by non-dispensing pharmacists physically co-located in primary care practice. We assessed the degree of integration via key dimensions of integration based on the conceptual framework of Walshe and Smith. We included English language studies of any design that had a control group or baseline comparison published from 1966 to June 2016. Descriptive statistics were used to correlate the degree of integration to health outcomes. The analysis was stratified for disease-specific and patient-centred clinical pharmacy services. __Results:__ Eighty-nine health outcomes in 60 comparative studies contributed to the analysis. The accumulated evidence from these studies shows no impact of the degree of integration of non-dispensing pharmacists on health outcomes. For disease specific clinical pharmacy services the percentage of improved health outcomes for none, partial and fully integrated NDPs is respectively 75%, 63% and 59%. For patient-centred clinical pharmacy services the percentage of improved health outcomes for none, partial and fully integrated NDPs is respectively 55%, 57% and 70%. __Conclusions:__ Full integration adds value to patient-centred clinical pharmacy services, but not to disease-specific clinical pharmacy services. To obtain maximum benefits of clinical pharmacy services for patients with multiple medications and comorbidities, full integration of non-dispensing pharmacists should be promoted

Additional file 1 of Non-dispensing pharmacists integrated into general practices as a new interprofessional model: a qualitative evaluation of general practitioners’ experiences and views

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