When Brian Cross, PharmD, first went to work for the Indian Health Service (IHS) on the San Carlos Apache Reservation in eastern Arizona in 1991, he believed that the physician–pharmacist collaboration that he encountered there—a model pioneered by the IHS and a handful of other federal agencies and private health care systems—was common across the country.
“As you can imagine,” Cross told Pharmacy Today, “I was alarmed to find out that this was not the way it was done almost anywhere else in the United States, other than closed-loop systems such as Kaiser Permanente, Intermountain Health, and the Veterans Health Administration.”
Three years later, his next career stop was at a small VA ambulatory care facility in north-central Florida, where he oversaw the cardiovascular risk reduction clinics and had full prescribing privileges in collaboration with cardiologists and an internist.
It was around that time that Cross vowed to himself that whatever professional changes came later, “I wouldn’t do anything that didn’t allow me to practice like this.”
He kept his word. Today Cross is a pharmacotherapy specialist with East Tennessee State University (ETSU) Family Physicians of Kingsport, TN, and Associate Professor in the Departments of Pharmacy Practice and Family Medicine at ETSU’s Bill Gatton College of Pharmacy and James H. Quillen College of Medicine in Johnson City, TN. The ETSU Family Physicians run three separate comprehensive primary care clinics that provide community-focused medical education as well as patient-centered care for the medically underserved population of rural southern Appalachia. Besides the Kingsport clinic, where Cross practices, the others are in Johnson City and Bristol, TN.
Working with American Academy of Family Physicians President Reid Blackwelder, MD, Professor of Family Medicine and Director of Medical Student Education at ETSU’s James H. Quillen College of Medicine in Johnson City, as well as other medical team members, Cross has not only been able to practice his vision of collaborative primary care but also to help pass on that vision to scores of young pharmacists, physicians, and nurses at ETSU. Blackwelder told Pharmacy Today that the clinics have worked hard to foster a collaborative culture “where everybody has a voice. We’re all there to make sure our patients get the best outcomes,” he said. The Family Physicians clinic at Kingsport has approximately 12,000 to 13,000 patient visits a year, Blackwelder said. They include individuals of all ages—“from cradle to grave” is the way he put it. Many of them have multiple chronic conditions, including diabetes, heart failure, and chronic obstructive pulmonary disease (COPD). And most are on complex medication regimens.
On a typical weekday, an average of about 55 patients arrive for appointments at the Kingsport clinic. Each is triaged by a nurse to a team that occupies one of the clinic’s five suites, each with three to four examination rooms. The team typically includes a faculty physician, family medicine resident and medical students, as well as a faculty clinical pharmacist, student pharmacists, and a postgraduate year (PGY)2 ambulatory pharmacy resident rotating through the service. Patients with mental health or other personal or family issues have access to a psychologist and licensed clinical social worker. The clinic also performs routine laboratory tests and performs minor procedures including excisions, casting of fractures, and nasolaryngoscopies.
When Blackwelder sees patients, he said he often includes student pharmacists in the discussions. “They are there learning about clinic flow,” he said, “but the expectation is that they are not just shadowing. They are part of the team. We encourage them to make suggestions about medication adherence and about specific medications.”
Cross said the comments that the ambulatory care residents and student pharmacists make after rotating through the clinic show that they “are struck by the true integration that we have been able to accomplish.”
“On any given day,” he said, “we’ll have three or four medical residents in clinic, and at least a couple of those will have their own pharmacy student or pharmacy resident. I act as a sort of pharmacy attending, if you will. We take them into the room as a team. Sometimes the pharmacy student or resident will go in for a preliminary patient interview and medication review. They come out and briefly discuss their findings with the medical resident, identifying the medication problems they’ve uncovered. That allows the resident to have a much more efficient and effective visit with the patient. Often the pharmacy resident or student will join the resident during the visit.”
“I think it’s an area of mutual respect,” Cross said. “If there is one thing I would say is that if this is going to work, it is all about relationships, and egos being off the table.”
One of the biggest obstacles to establishing more universal pharmacist–physician collaborative practices, Cross said, is the inadequate reimbursement system currently in place in the United States. Without the financial support that institutions like ETSU provide, he said it would be difficult to sustain this type of team-based care. He believes strongly that the reimbursement focus should not be on achieving individual provider payments but on creating a system in which payments are based on the care that teams provide, with payments within the team commensurate with the contributions of individual members.
“If where we’re going as a model is a team-based approach,” he said, “then as a profession we need to be aligning much more with models that will reimburse teams, not individuals.”
As for research demonstrating the benefits of pharmacist–physician team care, Cross said that a proposal had been submitted to the ETSU Institutional Review Board (IRB) to study outcomes at ETSU Family Physicians’ Interprofessional Transitions of Care (IPTC) clinic in Kingsport. This service works to improve care during the difficult time of transition from the acute care setting back to the ambulatory setting after discharge from the hospital. The clinic, established some 8 months ago, is staffed by third-year family medicine residents, a clinical pharmacy faculty, a social worker, an attending physician, and sometimes a PGY2 pharmacy resident in ambulatory care. It provides a unique educational setting wherein the family medicine residents-in-training can be part of a clinical care team that will hopefully change their thought of what ambulatory medical practice should look like in the future.
Cross said, “We’re going to be measuring patient and provider satisfaction, readmission rates and outcomes such as worsening heart failure, numbers of medications, costs of care—those kinds of things.” “Hopefully, I’ll have more to tell you about that in a couple of years,” he added.
Despite the advances that collaborative practice has made since Cross began his career more than 2 decades ago, he believes there is still a long way to go. “What we have done is craft these little niches where we have been able to make some significant impact. The problem is it needs to be scalable,” he said.
“Quite some time ago I said I did not want to get to the end of my career and look back as if the whole thing was a demonstration project.” His hope, he added, is that 10 years from now practice will have evolved to the point that if the students he teaches want to pursue a career in collaborative care in the ambulatory setting, “the opportunity will be there for them.”
At East Tennessee State University, Reid Blackwelder, MD, and Brian Cross, PharmD, have developed an effective way to counter the silo mentality and egos that so often hamper interdisciplinary collaboration: start at the grassroots. Put medical students and student pharmacists together in the same lecture room, and challenge them to jointly tackle a medical treatment puzzle.
For the past 3 years or so, Blackwelder and Cross have taught a series of 2- to 3-hour educational lessons to small groups of third-year ETSU medical students during their family medicine rotations. Often they are joined by fourth-year student pharmacists on their ambulatory or acute care rotations with family medicine.
The students are broken into small groups, each with two to three medical students at a table with a single student pharmacist. They are presented with a case involving a patient with multiple cardiovascular risk factors, and each group is asked to use evidence-based analyses to create and defend a course of action intended to lower at least one of the patient’s risks.
The “fun part,” said Cross, is watching the lively dynamic that develops within the individual groups and among the different groups. Blackwelder and Cross use that debate, Cross said, “to show that in medicine it is much more about the ability to answer the ‘why’ question than the ‘what’ question.”
He said the lectures have proven to be a valuable way to demonstrate the effectiveness of blending the medical students’ diagnostic training with student pharmacists’ knowledge about “crafting unique therapies for specific patients.”
Blackwelder said that the third-year students routinely see this as one of their favorite lectures in medical school.
“The question,” said Cross, “is how can we ramp this up so that more people do this consistently in the medical and pharmacy schools’ curricula.”
Reid Blackwelder, MD, and Brian Cross, PharmD, first crossed paths years ago when they were both giving presentations at educational meetings. “We developed a mutual respect for one another’s approach to teaching,” Blackwelder said, “and I kept trying to find ways to recruit him to the ETSU Family Physicians practice.” In the mid-2000s, when the discussions about the ETSU College of Pharmacy started, Cross decided to make a career change and join the faculty. (The college would welcome its first class in January 2007.)
At the same time, Blackwelder said he “was pushing hard to ensure that family medicine as a clinical department within the ETSU College of Medicine connected with the new College of Pharmacy.
“Happily,” he said,” as things moved forward we were able to forge a relationship between the College of Pharmacy and our Family Medicine Department that allowed us to put a clinical pharmacist in each of our three medical residencies, so Dr. Cross is not unique. He has fellow faculty members at the Bristol and Johnson City clinic programs. And they’ve been a big part of our education process for our residents and students since then.”
Brian Cross, PharmD, told Pharmacy Today that the collaborative spirit at Kingsport extends not just to physicians and pharmacists but throughout the entire clinical team. He described, as an example, a recent team visit to the home of a woman whose blood glucose levels were swinging wildly from highs to lows because of inconsistent eating habits—a couple of days without meals often followed by a binge. “As you can imagine, she was feeling horrible,” said Cross, who is also a certified diabetes educator. “The most important person on the team that day wasn’t me, and it wasn’t the physician,” he said. “It was the social worker who got Meals on Wheels set up.” The patient’s blood glucose levels significantly improved, he added.