Once the foundations for telehealth services have been established in your institution, successful implementation of telehealth pharmacy practice will require an effective and efficient workflow. Your team must be prepared to utilize telehealth technologies, train medical staff and patients, conduct the visit, perform administrative functions (e.g., electronically rooming patients, setting up appointments), implement quality assessments, and establish billing procedures. Furthermore, these new practices need to be incorporated into the clinics’ existing workflow if a hybrid of telehealth and in-person patient care visits is developed.

Many of the activities associated with telehealth and in-person clinical encounters will be similar, but the delivery of telehealth pharmacy practice services will present unique opportunities and challenges. These changes will require the development of new workflows. This chapter explores necessary considerations when developing workflows for telehealth pharmacy practice services. Moreover, we will address specific barriers to successful implementation and recommend strategies to overcome these barriers.

PREPARING FOR TELEHEALTH PHARMACY PRACTICE APPOINTMENTS

Workflow Mapping

The implementation of telehealth may present many changes to your existing workflow. Prior to implementing telehealth, it is important to have a good understanding of the current clinic workflow. This will help identify necessary modifications to existing workflow to accommodate and integrate telehealth pharmacy practice visits. A visual representation of your clinic workflow is helpful to identify the entire work process before, during, and after the appointment. Tasks such as patient registration, scheduling, rooming, performing vitals, patient education, and follow-up scheduling need to be adapted to accommodate a remote environment. Workflow varies widely among institutions and must be customized to each individual institution and organization. Basic steps to creating a workflow diagram are listed in Table 4.1.

Table 4.1.

Basic Steps to Creating Workflow1

1. Clarify the purpose or outcome of the process.

2. Identify a clear start and end point for the process.

3. List or draw out the tasks and decision points within the process and put them in order.

4. Define and note which role completes each step.

5. Identify and name the process.

Important elements of workflow include the consideration of physical and/or mental tasks, role delineation, work processes, and communication with other members of the team or external organizations. Developing a workflow map that shows a picture of these steps can be helpful in standardizing processes and identifying where gaps may exist (Figure 4.1). Workflow tasks can be sequential or simultaneous and should be customized to your clinic. Sequential tasks occur in a stepwise fashion, whereas simultaneous tasks rely on coordination of staff to perform tasks at the same time.

Figure 4.1.
Figure 4.1.

Example for visual workflow for telehealth pharmacy practice: care flow for multidisciplinary intersection points

Source: DeRemer CE, Reiter J, Olson JL. Transitioning ambulatory care pharmacy services to telemedicine while maintaining multidisciplinary collaborations. Am J Health-Syst Pharm. 2021;78(5):371-375. Permission from Oxford University Press.

In addition to mapping the process for patient encounters, it is important to clearly identify who performs each task. Most ambulatory care clinics rely on multiple disciplines for a variety of tasks. Telehealth pharmacy services may bring additional challenges when team members are working remotely. Additional methods for communication between team members may be needed to ensure that these tasks are completed. Synchronization of these tasks in a remote environment will require careful coordination. Table 4.2 lists key questions to consider with workflow mapping, and Table 4.3 lists examples of clinic-level workflows.

Table 4.2.

Key Questions to Consider in Workflow Mapping for Telehealth2,3

  • How will patients be informed of the availability of telehealth services?

  • What technology requirements will be needed for providers and patients?

  • What staff will be involved in scheduling telehealth appointments and coordinating with remote specialists?

  • How will staff manage referrals?

  • On the day of the telehealth encounter, who will educate/train the patient?

  • Who is responsible for coordinating patient follow-up?

  • For remote patient monitoring, how will staff receive data?

  • How will you handle billing?

Table 4.3.

Example of Clinic Workflows for Telehealth

  • Answering phones

  • Reporting diagnostic test results

  • Appointment system

  • Ordering medications

  • Messaging

  • Referrals

  • Scheduling procedures

  • Follow-up

  • Ordering diagnostics/labs

Clinic-level workflows are important for ensuring smooth operations between clinic staff, provider, pharmacist, and patients. In addition to clinic-level workflows, interorganizational workflows must also be considered. For example, workflow between the pharmacist, the patient's primary care provider, specialty providers, and community pharmacy also needs to be considered. The process for communication with external organizations may not differ from traditional visits, but considerations may need to be made if clinic personnel are working remotely. One strategy to create your workflows is to visualize the process into three separate phases: pre-visit, telehealth visit, and post-visit. Throughout each of these steps, care should be taken to consider the flow of communication.

Pre-visit Workflow

In the pre-visit phase, your process should include delegation of personnel that will contact the patient and ensure the patient is prepared for and has consented to the telehealth visit. Institutions may designate clinical or nonclinical staff for this task. In some instances, call centers may be utilized to perform initial patient contact. Where call centers or nonclinical staff are utilized, clear instructions must be provided on what to communicate to patients (e.g., purpose of visit, information requirements, and expectations for technology). A designated person should also evaluate what clinical data (e.g., vitals, laboratory measurements) are needed for the encounter and determine how this information will be provided by the patient and made available to the provider. Designated staff will need to perform a technology assessment to determine if the patient is able to provide the necessary clinical data prior to or during the remote patient encounter.

Patients should be told what to expect from the encounter and what services will be provided. Confirmation of these assessments then needs to be documented, with communication back to the responsible party conducting the telehealth pharmacy practice visit. Daily staff huddles with providers and pharmacist can be useful to communicate this information. In remote settings, teleconferencing can be utilized to ensure appropriate information is communicated to all responsible and participating parties.

Telehealth Visit

Policies and procedures should be developed to guide the telehealth pharmacy practice visit. All parties, including the patient, need to be trained on the platform being used. Accommodations may be needed for certain patient populations during the encounter. Workflows should consider the need for medical interpreter and/or other means of communication for those with disabilities (e.g., visual, hearing, or cognitive). Integrating these needs during the telehealth visit may require careful coordination with external organizations and interface capabilities with your clinics’ telehealth technologies.

As part of the telehealth visit, patients may need to perform self-monitoring clinical assessments (e.g., blood glucose, blood pressure, pulse, weight). These measurements may be self-reported or transmitted electronically if technology permits. If self-reported, the pharmacist conducting telehealth pharmacy visits should ensure measurements are accurately recorded into the medical record in the proper locations. Permission to access documentation may be needed from the institution, so evaluation of this access point has to be considered prior to conducting patient encounters. Where clinical data can be transmitted electronically (e.g., connected to smart devices), the data should be summarized and documented in the patient's medical record prior to the telehealth visit so that the information is readily available during the encounter.

Post-visit Workflow

The post-visit phase includes everything that occurs once the pharmacist has evaluated the patient. This includes assessment of the patient's problems and development of a plan for the patient, as well as communication and education of the plan to the patient and provider. Once the plan is communicated, the encounter must be documented and any changes to the patient care plan need to be transmitted. For example, new prescriptions will need to be transmitted to the patient's pharmacy electronically. Referrals will need to be entered into the system. The type of follow-up should be determined (e.g., face-to-face or telehealth) and should be scheduled. Workflow mapping can help determine who is responsible for these tasks and how they will get done.

In collaborative practice models where pharmacists are working with other healthcare providers, additional considerations should ensure that recommendations are communicated and that the plan of care is executed. Most electronic health records should have provisions for pharmacists to enter orders that are then cosigned by physicians. Appropriate alerts and flags need to be in place to ensure timely execution of these clinical orders. Staff huddles or teleconferencing to review patient encounters are useful to ensure appropriate follow-up of patient care plans.

CONDUCTING A TELEHEALTH PHARMACY PRACTICE APPOINTMENT

While telehealth might be new to the reader's practice, the skills needed to be successful in telehealth mirror the skills needed for successful clinical pharmacist care while face-to-face. Patient connections and relationship building through use of motivational interviewing, patient and medication assessment with optimization of therapies with evidence, and enhancement of patient education remain central to the telehealth patient care experience. Let's take a look at some of the essential components of the telehealth pharmacy practice appointments utilizing the considerations we have discussed.

Pre-visit Assessment

Prior to the start of a telehealth pharmacy practice appointment, an assessment should be completed to see if the patient is a good candidate for telehealth. During the scheduling or identification process, the patient's expectation for the appointment can be defined, assessment of the patient's understanding of health technology can be completed, and a decision can be made on a delivery method for the telehealth pharmacy practice experience. Another approach is to predefine patient visit types that would benefit from the telehealth pharmacy practice model prior to scheduling. For example, the reader could define that all insulin titration appointments could be offered as a telehealth pharmacy practice appointment. If possible, you can collaborate with clinic administration to identify resources within your network to allow for this administrative work to be completed by clinic support staff. If a medical assistant, pharmacy technician, or scheduling support individual is not available, consider using students and other learners to support workflow processes, keeping in consideration time when they will not be available (e.g., holidays, school breaks).

An important organizational step is to set the expectation for reminder calls or electronic reminder processes to contact the patient as to when and how to access the appointment platform. This step is especially important if the patient is used to seeing their pharmacist face-to-face in their provider's office. If the patient is remaining at home, they should be reminded to remain home. If the patient is going to a satellite medical office, they should be informed of the address, as well as, if it is their first visit, information specific to the location that may be different from their home clinic experience. If not previously decided upon, this would be the time to decide if the visit will be a telephonic appointment or a tele-video, including which platform will be used if your practice allows for multiple options. Patients should also be educated on how to join in the experience, who to expect to interact with, and what they should have near them during the appointment. Prepping patients to have medication vials, medication lists, blood glucose monitor or logs, blood pressure monitor or logs, and any other logs or assessment tools nearby avoids delays during the appointment. If reminder processes are being completed in the days prior to the appointment, the patient can also be instructed to complete necessary lab work to help with assessment during the appointment.

On the day of the visit, it may be important to have the patient checked in per normal processes. This check-in experience may vary based on expectations from the practice site. When a patient comes onsite to meet with a pharmacist, the front desk may verify changes in personal information and insurance, and check the patient in to meet the requirements in your electronic medical record (EMR). When this physical front desk is removed, what processes will be put in place to ensure that these activities are completed with the use of support staff, as available? If the telehealth pharmacy practice experience has the patient coming into a satellite location, that staff needs to be aware of the need to check in pharmacy clinic patients. Increased communication and planning around the check-in experience is an important workflow step to consider.

Conducting the Telehealth Pharmacy Practice Encounter

When it is time to start the telehealth pharmacy practice encounter, as with a face-to-face visit, the rooming of a patient begins the experience. Rooming of a patient may vary based on the setting, but traditional activities include bringing the patient back into a patient care space, obtaining vitals and other physical assessments, completing screenings, and updating the patient's medical record. In current workflow, this may be done by support individuals, pharmacy student or pharmacy resident, or the pharmacist completing that appointment. A workflow plan for these activities in telehealth is needed with higher attention paid to the regulatory requirements for these experiences, while providing the care via telehealth. For example, which vitals can be entered as patient self-reported?

If the patient is going into another medical facility to meet with the pharmacist through facility-based telehealth, the clinic support staff at the site can aid in this rooming. Deciding on workflow for vitals, EMR updates, and medication reviews is important. Establishing what point-of-care testing or lab facilities are onsite can help in the flow of the patient experience.

The telehealth pharmacy practice experience where the patient is at home leads to increased complexity. Patients may or may not have supplies at home to obtain vitals such as blood pressure, weight, or oxygen saturation. Adding to the complexity is how you are able to add vitals to the patient's medical record. It is key that you understand what can be added to a patient's medical record via self-reporting home vitals and what needs to be facility obtained. For example, during the COVID-19 pandemic, patient's blood pressure results for controlling high blood pressure or comprehensive diabetes care measure for Healthcare Effectiveness Data and Information Set (HEDIS) have not been allowed to be self-reported.4 Another consideration for patient-reported vitals is recording the date and time of when the vital was obtained. If the patient provided a weight, was that obtained at the start of the appointment or the last time they checked, which may have been weeks ago? Including this date with the reporting may aid in finding patterns and allow for proper assessment. As telehealth rapidly expands, there is opportunity for more EMRs to have a designation between patient-provided and facility-obtained vitals. With the addition of this option, the complexity of reporting vitals should diminish. Another growth opportunity for consideration in this space is the use of remote patient monitoring as addressed in previous chapters.

Patient Assessment during Encounter

Providing patient and medication use assessment during telehealth pharmacy practice may vary based on the experience selected. If the appointment is provided via a tele-video experience, you should ensure that you are able to see the patient clearly to be able to assess nonverbal cues. With telephone-based telehealth, the added complexity of not viewing the patient needs to be considered. If the lack of nonverbal cues may impact the assessment, the choice may be made to limit the types of experiences that occur over the phone, such as selecting quick check-in-type discussions versus complete appointments. It may also be decided that complex new information discussions, such as starting insulin therapy for the first time, occur over tele-video or face-to-face if patient safety might be at risk without an expanded assessment of understanding.

Patient Education Delivery

Patient education comes in many forms, all of which need to be considered in telehealth workflows. In face-to-face encounters, disease state and general medication-related education may have been provided via patient-facing handouts or booklets. The reader may have also relied on sharing video or websites with patients while face-to-face together. Now that the patient and the pharmacist are in a different location, it is still feasible to provide this same level of education, but workflow adjustments will be needed. Ideally, developing a process to share materials with patients in real time should be optimized. Some EMRs allow for sharing PDF documents directly with patients through their patient portal. If PDFs are not available, patient education items may need to be mailed to the patient's house, which involves preplanning, post-appointment reliable execution, and time to allow for delivery. A secure email may also be a possible route to explore. Working with the information technology (IT) department to discover options is recommended. For videos or other online options, it may be possible to send them to the patient for them to watch, with you listening in. A better option may be to enable the patient to share your screen, which is available on some tele-video platforms. With this option, it is vital that you clear your screen of all other items not related to the care of the current patient.

Verbal patient education can continue similarly to verbal education in a face-to-face environment. Assessment of a patient's understanding of patient education, changes in therapy plans and medications, and other provided information may need to be expanded in telehealth. With a tele-video visit, you may find that your normal assessment of nonverbal cues and your normal practice of motivation interviewing fit the patient care experience. However, even with a video visit, a different approach to education may be needed inasmuch as you are in a different location than the patient. As above, with a telephone visit, you might find that the lack of nonverbal cues is a barrier that may lead you to select which activities to provide via telephone assessment and which activities to shift to tele-video or face-to-face visit. For example, when starting a new inhaler for a patient with a history of previously poor inhaler technique, you could decide that a visit should occur in person or at least in a two-way tele-video visit.

After completion of an appointment, patients may have an expectation of a physical updated medication list or written instructions for medication or care plan changes. Encouraging the use of patient portals should be a priority if they are available in your EMR. For patients without access to a patient portal, or for those who prefer paper copies of information, a copy of select informational items can be mailed. It is important that mailing occurs quickly after the appointment so as not to delay patient changes. Mailing the patient information may also add a level of complexity if the pharmacist is providing care out of their home. It may be best to consider pulling resources and having a contact physically onsite in the clinic that can print and mail materials.

Post-visit Planning

While patient assessment should be done prior to the appointment for appropriateness of telehealth pharmacy practice delivery of care, it should continue throughout the patient's care. The reader should assess if the current appointment was successful in meeting the patient's and the healthcare team's goals. If it was not, assessment should be made as to how to best deliver the next appointment.

Telehealth pharmacy practice models may also cause you to assess how you provide patient follow-up with the addition of tools or online applications for education, processes for written information, and even considerations for billing requirements with telehealth. You may currently see a patient every three months when they make a quarterly visit to the physician's office, but now you have the availability to see them more often. It is vital, however, that the pharmacist continue to have an eye toward the best experience for the patient's needs. While you could provide a full pharmacist appointment every week, that may not be the best use of the patient's time, the pharmacist's time, or finances. However, now is the time to ensure that patients are getting the level of care they need as barriers (i.e., transportation, time off work) are removed. As with face-to-face care, the type of follow-up needed for the patient should be assessed based on the disease state, medication profile, clinical guidelines, and specific patient factors.

  • You may find that patients are able to meet the follow-up expectation when the barriers of travel, excess time off work, and so on are removed.

  • You may find that your appointment cadence remains the same, but you add touches utilizing remote monitoring, patient portals, or telephone check-ins as you grow your telehealth pharmacy practice offerings.

  • You may find that you change the duration of your appointments to larger intervals than before as you have other ways to check in with patients.

  • You may find that you change the duration of your appointments to smaller intervals than before for high-risk patients as you have better tools to support appointments outside of the office.

Tools for Telehealth Pharmacy Practice Visit Flow Model: Develop a Streamlined Approach by Planning Steps for Pre-visit, Concurrent/during Visit, and Post-visit Steps

Before the remote visit

  • Determine which platform and technology will be used for remote visit.

  • Ensure the patient has consented to telehealth visit and has necessary technologies.

  • Determine appropriate space to conduct the visit.

  • Ensure technology is working.

  • Confirm patient appointment.

  • Communicate with clinic staff for a consistent and streamlined care approach.

During the remote visit

  • Maintain visual eye contact if completing a tele-video appointment.

  • Ensure patient readiness and minimize distractions if present.

  • Conduct the interview and provide clear instructions for any physical assessments needed.

  • Provide education to patient on assessment and plan using teach-back method.

After the remote visit

  • Document in the electronic health record; indicate that visit was performed remotely via telehealth pharmacy practice services.

  • Provide patient with electronic instructions for follow-up care, medication changes.

  • Streamline process for access to information post-visit if materials are to be mailed or sent alternatively to electronic follow-up.

SPECIFIC TELEHEALTH PHARMACY PRACTICE EXAMPLES

Heart Failure Telehealth

Heart failure is associated with high morbidity and mortality.5 Telehealth services in heart failure can reduce hospitalizations and improve overall heart failure symptoms.6 Successful implementation of these services is contingent on the provider having access to relevant health information and the ability to perform virtual visits for patient assessments. Collection of this information requires utilization of remote technologies that patients can use to transmit data and traditional technologies (e.g., cellphones) to connect patients with providers. Furthermore, heart failure care requires multidisciplinary and interorganizational support. The complexity of care makes clear workflow processes critical to its success. In this section, we outline an example workflow process for heart failure telehealth.

Patient Selection

Remote telehealth for patients with heart failure can be used to triage patients who require urgent care or routine follow-up care.7 Workflow processes should be developed to triage appropriate care for heart failure patients. For example, patients with Stage D or end-stage heart failure may not be good candidates for virtual visits. These patients may require more physical assessment and multidisciplinary services, given the complex care required. Telehealth can be reserved for patients who require routine heart failure follow-up care (e.g., medication titration, laboratory check, weight and blood pressure assessment). Clear guidance should be provided to identify appropriate patients for telehealth, and whether telehealth is used to help triage patients should be decided.

Clinic Workflow

The heart failure telehealth pharmacy practice visit can flow similarly to a traditional heart failure visit. History taking, medication reconciliation, review of patient vitals, and laboratory measurements can be completed through remote technologies. Ideally, clinical data gathered from remote technologies are prepared in advance for the pharmacist, but they can also be collected during the encounter. Video technology can be used for medication reconciliation and physical examination (e.g., neck veins, peripheral edema, exercise tolerance). At the end of the encounter, the provider–pharmacist team should ensure that the patient receives proper education and communication of the plan. Care should be taken to ensure that referrals are made through proper channels and clearly communicated to the patient. Furthermore, follow-up laboratory and/or diagnostic tests (e.g., echocardiograms, electrocardiograms) need to be coordinated with outside organizations.

Anticoagulation Telehealth Clinic

Telehealth pharmacy practice services for anticoagulation management are well established. A meta-analysis including 15 randomized controlled trials demonstrated that technology-based interventions significantly improved the effectiveness of anticoagulation management.8 Evaluating time in therapeutic range (TTR), the authors found that patients in the technology-based intervention group had significantly better management compared to that of the control group. Furthermore, major and minor bleeding events were not different between the groups. Home INR testing has been associated with significant improvements in thromboembolic and bleeding events.9

Patient Selection

Most patients on anticoagulation can be candidates for remote telehealth pharmacy practice services. Traditionally, these services have been offered to patients on warfarin due to the frequent monitoring warfarin requires, but patients on direct oral anticoagulants can also benefit. Patients on direct oral anticoagulants may benefit from periodic laboratory measurements to check renal function, liver function, adherence monitoring, and safety assessments for signs and symptoms of bleeding.

Clinic Workflow

Workflow for anticoagulation management will depend on the availability of remote monitoring services available to the patient and clinic. Patients on warfarin can obtain INRs from a local laboratory or they can complete home INR testing if available. These data can be gathered prior to the visit to improve workflow efficiency. During the visit, the interview can be conducted to gather remaining patient information. Time should be spent carefully reviewing patient adherence, signs and symptoms of bleeding or thromboembolic complications, and educating the patient on the care plan. Following the encounter, documentation and patient follow-up should be coordinated. The plan should be electronically transmitted to the patient in a secure environment or mailed if that is more appropriate, but with careful consideration regarding what the potential time delay may impose.

Diabetes Telehealth Clinic

Telehealth services in diabetes are also well established. A meta-analysis that included data from 42 randomized controlled trials found that the use of telemedicine led to significant reductions in hemoglobin A1c compared to patients in the usual care group. Older patients (> 50 years) also tended to benefit more when compared to younger patients, dispelling concerns of age-related technological literacy concerns.10 An abundance of remote monitoring technologies is available to help guide telehealth services in diabetes, including connected glucometers, blood pressure cuffs, and weight scales. These readily available remote monitoring technologies enable the provision of effective telehealth pharmacy practice services.

Patient Selection

The majority of patients living with diabetes are required to perform periodic self-monitoring including blood glucose, blood pressure, weights, and lifestyle assessments. Many remote technologies exist that allow the transfer of data from the patient to the pharmacist. These data can be used to adjust the patient's antihyperglycemic medications to achieve goal HbA1c. Given the wide availability of remote monitoring technologies available, patient selection will be determined primarily by patient willingness to participate and by clinic readiness. Additional consideration may need to be given for new patients versus established patients. Some clinics may prefer in-person visits for new patients since trust as well as confidence for technology literacy need to be developed.

Clinic Work Flow

Collection of data, including self-monitoring blood glucose, blood pressure, and weight, prior to the appointment will improve the efficiency of the telehealth visit. During the visit, patients will need to be instructed on any physical assessment that may be performed (e.g., foot check, retinal exams). Provisions may also need to be made for incorporating specialty providers into the visits. These include dietitians, diabetes educators, or other specialty providers. Careful coordination may be needed if specialty providers are working remotely and not in the same facility.

GROUP TELEHEALTH VISIT TYPES

Some clinics may also decide to incorporate group visits into the telehealth workflow. The use of group visits can improve outcomes by increasing patient engagement and motivation. Group visits typically include 3–20 patients and involve a multidisciplinary team. Group visits are often focused on patient education, shared problem solving, and care coordination.11 Given the multidisciplinary nature of group visits, coordination of telehealth pharmacy practice services needs to include several different members of the care team (e.g., clinical nurse educator, social worker, physician, medical assistant, and pharmacist). Group visits will require patient consent and utilization of compatible telehealth platforms for all patients involved.

ADDITIONAL SERVICES PROVIDED VIA TELEHEALTH PHARMACY PRACTICE

Medicare Annual Wellness Visits12

During the COVID-19 global pandemic, the Centers for Medicare and Medicaid Services (CMS) allowed for Medicare Annual Wellness Visits (AWV) to be adapted to telehealth. While this was likely a temporary measure, it does have benefits for seniors who may not be able to travel to healthcare facilities. It also may allow for providing Medicare AWV services to patients in clinics without access to a pharmacist. As with other appointments, obtaining and documenting vitals or screening tools, as well as providing patient education and written materials, are needed.

For AWV, changes to workflow may be largest within the screening sections. If screening tools are currently completed by support staff in the office, how will they still get completed if the patient and/or the pharmacist is not in the office? In addition, the type of screening tools and your response to the patient's answers may have to be adjusted.

Screening tool examples are as follows:

Cognitive Impairment Assessment:

  • If you normally complete a Mini-Cog or other screening tool that requires visual assessment, are you still able to do so via a tele-video visit?

  • What assessment tool will you use on a telephone Medicare AWV?

    • The Telephone Intervention for Cognitive Status (TICS) has been recommended for a telehealth visit.

Fall Risk Assessment:

  • Is it safe for the patient to complete a physical screening assessment such as a Timed Up and Go (TUG) test while at home without the support of the healthcare team?

    • It has been recommended to consider changing to a question-based fall risk screening for the patient’s safety.

Screening for Depression:

  • How will you handle a patient screening positive for depression or suicidal risk?

    • How will you handle this if the patient is home with or without additional support?

    • How will you involve your other care team members for support?

      • If during a face-to-face visit you are able to incorporate a physician or a behavioral health team member into the care visit to discuss or provide a quick assessment, how will you provide this service if you are not onsite with those care team members?

Transitions of Care Telehealth Example

The Community Health Network is a large integrated health system in central Indiana serving over 300,000 patients in primary care settings. All pharmacists in the ambulatory care space focus on transitional care management (TCM) for the patients they serve. At the Community Health Network, the goal was always to have a patient complete a postdischarge medication review with a pharmacist as part of value-based care contracts, as well as its known impact on reducing readmission rates.13 The largest barrier has been coordinating schedules for the pharmacist to see the patient face-to-face prior to the physician or advanced practice provider appointment. The pharmacy team also felt that a telephone review with the loss of assessment for nonverbal cues was not as impactful and noted that the highest risk patients were being prioritized for this pharmacist review.

During the COVID-19 global pandemic, the Community Health Network ambulatory care pharmacy team adjusted to telehealth over the course of 72 hours. With the ability to provide tele-video postdischarge medication reviews, the team felt more confident in transitioning the pharmacist portion of a TCM appointment to a telehealth pharmacy practice encounter. An option remained for a telephone visit if a video visit was not feasible for the patient. During a tele-video visit, the pharmacist was not only able to evaluate a patient's nonverbal cues, but was also able to view pill bottles, assess inhaler and insulin techniques, as well as make other visual assessments that are routine during a face-to-face postdischarge review.

The Community Health Network ambulatory care pharmacy team was able to greatly expand their involvement with postdischarge medication reviews following transitions to tele-video visits. In addition to reaching more of their clinic patients during the postdischarge period, the team expanded to provide postdischarge telehealth pharmacy practice appointments to patients of clinics without a pharmacist and also was able to provide the service to patients following up with a cardiologist in place of or in addition to their primary care provider. In 2019, the team provided 383 postdischarge medication reviews. In 2020, with the addition of a telehealth pharmacy practice focused TCM service, the team completed 1,905 postdischarge medication reviews. This increase represented an almost 400% increase over the previous year.

ADDITIONAL CONSIDERATIONS FOR TELEHEALTH WORKFLOWS

Regardless of whether your workflow for telehealth pharmacy practice appointments looks similar to, or completely different from face-to-face offerings, there are a number of factors to consider when developing your telehealth service. It is important to assess these considerations, as well as any others that may arise in the planning prior to developing the service and at multiple intervals throughout the delivery of the telehealth pharmacy practice service.

Patient-Related Factors

Like any workflow or service, telehealth pharmacy practice services are not one size fits all. As previously mentioned, assessing a patient to ensure telehealth pharmacy practice can meet their needs is an important first step. However, there are additional considerations beyond just deciding if they can receive their pharmacist services via telehealth. Social determinants of health are an important aspect of all of the care provided in an ambulatory care environment. With the addition of telehealth, the gap between patients may widen as those patients with more personal resources may have more access to tools to make telehealth care successful. Here are some considerations for your workflow and planning.

  • Patient resources for telehealth

    • How will you manage patients without access to a device to allow for video visits?

      • While you may find a need for telephone-based telehealth at times, does telephone alone work for your service?

      • How do you ensure patients receive the same level of care despite their resource differences?

    • If your appointment has a need to screen share, how will this work for patients completing their tele-video visit on their smaller smartphone device?

    • If your patient has a smartphone with limited data, how much data will your tele-video visit consume?

    • If your appointment is sensitive in nature, does the patient have a private space to speak with you?

      • For patients in abusive relationships, how will providing care while they are in their home allow for confidential conversations even if your appointment is not sensitive in nature?

  • Social determinants of health14

    • Economic stability:

      • How does your workflow support all patients regardless of resources at home?

      • How does requesting a patient use their cellphone data plan impact their finances?

    • Healthcare access and quality:

      • How do you provide the same level of service to patients regardless of their resources?

      • If you determine that tele-video visits are the preferred method for your workflow, do you provide an additional hardship to patients without the access to resources?

        • If you determine that patients without access to video visits need to complete face-to-face visits more often, you may be requiring the patients with the least ability to manage transportation barriers to continue to manage those barriers.

      • How can you check a patient's understanding of their healthcare instructions utilizing telehealth?

      • Do you have a process for patients to report poor communication with their pharmacist utilizing telehealth?

      • Do you have access to high-quality interpretive services, and how will you incorporate that in with your telehealth workflow?

    • Social and community context:

      • How is health literacy addressed during telehealth?

Closing Care Gaps in Telehealth

Pharmacists have become integral team members in ambulatory care in part because of their ability to help patients achieve goals. Often, these patient-specific goals are part of a value-based care contract. As billing opportunities continue to lag behind the value pharmacists can provide in ambulatory care, attention to these value-based care contracts measures will be needed to continue to justify the service. Examples of care gaps include a hemoglobin A1c and attention to nephropathy for patients with diabetes, mammograms and colonoscopies for cancer screening, and recommended vaccinations. As patients have less in-person contact with the healthcare team, it is important to develop ways to continue to stress the importance of items that may require face-to-face engagement. Here are some considerations for workflow and planning.

  • Laboratory data

    • How are you ensuring that labs to help drive the patient care plan and/or needed to close a care gap are still completed?

    • Do you know what labs are important to your value-based care contracts so you can ensure your plans continue to meet these needs?

    • If you are providing point-of-care labs during patient appointments, how will you fill that gap?

      • Could you consider a point-of-care lab day each month where patients can still come to their home physician office for this convenient lab?

        • Could you offer this point-of-care testing in a drive-thru fashion?

      • Could you utilize the support staff still in clinic, for example, a nurse visit for a point-of-care test?

      • Can you partner with lab services to fill this gap?

      • Could you consider the use of at-home point-of-care testing?

      • Do any local retail or independent pharmacies offer point-of-care testing?

    • If the patient cannot travel to a physical site for lab draws, can you collaborate with home health services?

  • Vitals

    • Do you know what vitals are important to your value-based care contracts to ensure your plans continue to meet these needs?

    • Do you understand what vitals are allowed to be self-reported and how to enter those in your specific EMR?

    • If vitals need to be obtained within the healthcare system, do you have a plan to complete them?

      • Could you consider a “vitals” day each month where patients can still come to their home physician office for this purpose?

        • If so, can you offer this in a drive-thru fashion?

      • Could you utilize the support staff still in clinic, for example, a nurse visit for a vitals check?

      • If the patient cannot travel to a physical site for vitals, can you partner with home health services or utilize remote patient monitoring?

  • Health maintenance

    • What health maintenance items are important to your value-based care contracts to ensure your plans continue to meet these needs?

    • If face-to-face workflow involves closing health maintenance items, such as during Medicare Annual Wellness Visits, what are the plans to continue to focus on this while utilizing telehealth?

  • Vaccinations

    • If vaccinations are normally completed during face-to-face visits, what will be the plan for completing vaccinations along with telehealth?

      • Could you consider hosting monthly drive-thru vaccination clinics?

      • Could you partner with a local retail or independent pharmacy?

      • Could you utilize the support staff still in clinic, for example, a nurse visit for a vaccination?

MANAGING CARE TEAM RELATIONSHIPS

Successful ambulatory care pharmacists do not provide care in a silo; rather, they are productive members of a care team. Just as important as the relationship the pharmacist has with their patient, the relationship that the pharmacist has with the rest of the care team is vital to the quality of care they provide. How the pharmacist interacts with the physicians and advanced practice providers in the clinic, as well as nursing and support staff, should be considerations when developing telehealth pharmacy practice workflows.

A benefit to pharmacist-provided telehealth is the ability to expand the reach of pharmacy services. Without telehealth, a pharmacist may be located in one clinic or rotate through a few clinics, but now they could provide a pharmacy service to a much larger patient base. If the current state has a pharmacist rotate between two clinics but the network has eight additional clinics not covered, there are now more tools to expand and provide telehealth pharmacy practice services to the patients of all 10 clinics.

In adjusting a current pharmacy practice experience to include more telehealth services, adjusting the expectations of others in the clinic is another factor to consider. How will providers and staff members be educated regarding the change in delivery method? Another consideration is how will feedback be collected on this offering? If the addition of telehealth pharmacy services leads to covering additional clinic sites or moving the pharmacist offsite, establishing an understanding that pharmacist time will be split between locations can help define expectations. An example of expectations to define may be the availability for helping providers and patients between appointments, as impromptu needs arise for medication education. For example, during face-to-face office encounters, a pharmacist could stop in rooms for new inhaler use education, but if transitioned to remote models, how would these unscheduled needs be managed to maintain optimal care to patients?

If the service is first being offered as a pharmacist telehealth service, establishing care team relationships should be considered essential during the planning discussions, especially if the service is not performed physically onsite with other team members. Planning to meet new team members in person and ensuring involvement with both formal and informal team-building activities could be part of the assessment and planning steps for how to build strong working relationships.

Establishing Expectations

When establishing a telehealth service, there is a need to discuss and clearly outline the patient's expectation for how they are receiving their pharmacist care. Equally vital is establishing expectations with the clinic staff, medical collaborators, and you, individually, as the pharmacist. This first adjustment may be a lot to orient to, but it is important to identify and plan for the fact that it will not be the last adjustment you make to establish an effective and coordinated telehealth pharmacy practice.

When working to adjust patients’ expectations for pharmacist care, consider how you define expectations as they pertain to real-time care assessments, flow for appointment, and the overall success of the service for the patient. As patients begin to enjoy the telehealth pharmacy services, how will patient-specific factors be addressed if outlier concerns are raised? Another consideration is how will patients be addressed if they expect all services to be offered remotely if the mixed model is preferred by the clinic?

Regardless of your role on the pharmacy team, there will be a need to look at this new or changing service from a leadership perspective in regard to pharmacy team members providing this remote service. Providing telehealth pharmacy services may not be something that all involved are trained to do. What training will be available to pharmacists and support staff, and how will their ability to work within this new delivery model be assessed? When hiring new staff, will assessments change to address telehealth pharmacy practice skills? A plan for pharmacy learners in this space will also need to be assessed and will be addressed in future chapters.

Clinic workflows need to be redesigned for the provision of telehealth services. In addition to ensuring that the clinic is equipped with telehealth-enabling technology, the clinic must also create workflows that consider staff, provider, and pharmacist responsibilities and physical space. Coordination between organizations must also be considered. Workflow mapping for telehealth services can help identify and anticipate potential barriers and areas where additional support will be needed. Potential barriers for telehealth implementation can be mitigated through clear communication of expectations to both patients and medical staff. With the appropriate resources, telehealth should increase access to care and improve patient satisfaction. Similar to in-person clinic workflows, telehealth pharmacy practice workflows must prioritize patient care and patient safety.

REFERENCES