CommunityPharmacistIntegrationintoTeam-BasedCareProvidedbyanAccountableCareOrganization:A

ToolkitforFuturePartnerships

CreatedbyAshleyAbode,PharmD,ShannonRiggins,PharmD,RyanWheeler,PharmDandChristyHolland,PharmD

SupportProvidedbytheCommunityPharmacyFoundationandRealoDiscountDrugs

CommunityPharmacistIntegrationintoTeam-BasedCareProvidedbyanAccountableCareOrganization:AToolkitforFuturePartnerships

ObjectivesThisprojectsetouttodothefollowing:

• CreateamodelfortheintegrationofacommunitypharmacistintotheAccountableCareOrganizationcareteam

• ApproachanAccountableCareOrganizationaboutapotentialpartnership• Obtainaccesstotheelectronichealthrecordonandoffsite• Educateprovidersandofficestaffaboutpharmacyservices• Delivercomprehensivemedicationreviewsandtargeteddiseasestateeducation

sessionstopatientsbyreferral• Explorebillableopportunitiestosustainpartnership• Createanimplementationguidetoassistcommunitypharmacistinbuildingfuture

partnershipwithanAccountableCareOrganizationModelBackgroundWithknowledgeinmanagingdiseasestatesandunderstandingmedicationregimens,communitypharmacistsareinakeypositiontoincreasemedicationunderstandingandadherence,improvediseasestatecontrol,andreducereadmissionrates.AstudyconductedbyKhdourMR,KidneyJC,SmythBM,etal.focusedonpharmacy-leddiseaseandmedicineeducationatanoutpatientclinic.Onehundredseventy-threepatientswereincludedwithaconfirmeddiagnosisofchronicobstructivepulmonarydisease(COPD).Eighty-sixpatientswereassignedtoreceivetheintervention,and87patientsreceivedusualcare.Theinterventionincludedacombinationofeducationonthediseasestate,medications,andbreathingtechniquesprovidedbyacommunitypharmacist.Follow-upwasprovidedat6and12monthsduringascheduledvisitwiththepharmacist.Theinterventionsweredoneateachoutpatientclinicvisit,withfollowupphonecallstoreinforcetheeducationthatwasprovided.Thestudyresultedinstatisticallysignificantdecreasesinemergencydepartmentvisitsandhospitalizationrates,decreasesinsymptoms,anddifferencesinknowledgeandadherencecomparedtothecontrolgroup.1Communitypharmacistswerealsoabletoshowanimpactinchronicheartfailure(CHF)patientsinastudybyBouvy,MarcelLetal.Intheinterventiongroup,74patientsreceivedamonthlyconsultationfromtheircommunitypharmacistduringa6-monthperiodand78patientsreceivedusualcare.Patientsintheinterventiongrouphad140outof7656dayswithoutuseofloopdiureticscomparedwith337outof6196intheusualcaregroup(relativerisk0.33[confidenceinterval(CI)95%0.24-0.38]).Patientsintheinterventiongroupalsohadtwoconsecutivedaysofnondosingon18outof7656dayscomparedto46outof6196daysintheusualcaregroup(relativerisk0.32[CI95%0.19-0.55).2

InaninitialpilottoachieveapartnershipwithanAccountableCareOrganization(ACO),communitypharmacistsfromRealoDiscountDrugsutilizedevidence-basedpatientfriendlyhandouts,currentguidelinesforpossibleinterventions,andinterdisciplinaryrelationshipsbetweenthepharmacistandtheproviderinanattempttoshowapositiveimpactonreadmissionrates.Thepharmacistsincludedinthisprojectweretrainedinmotivationalinterviewingskillsforthepurposeofachievingpositivepatientoutcomes.WithsupportfromtheCommunityPharmacyFoundation,RealoDiscountDrugs(Realo)setouttoshowtheimpactacommunitypharmacistcanhavewithinanACObyprovidingservicesinthreeambulatoryclinics,buildingasustainablefinancialrelationship,anddevelopingatoolkittoassistothercommunitypharmacistsestablishpartnershipswithACOs.Toolkit:IntegratingaCommunityPharmacistintoTeam-BasedCareThisguidewilloutlinethestepsRealotooktobuildarelationshipwithandbecomeembeddedinanACOtoprovidepharmacyservices.Thistoolkitwillalsoprovideinsightintothestrugglesofembeddingapharmacistwithinaninfrastructurewherepharmacywaspreviouslyabsent;thisinformationisincludedunderthesub-headingof“WhatWeLearned”belowsomesections.Thetoolkitincludesthefollowingsections:

• Makingconnections• Developingaserviceset• ObtainingaccesstotheElectronicHealthcareRecord(EHR)• Marketingservices• Providingpharmacyservices• Addressingsetbacks• Obtainingfeedback• Presentingresults• Implementingfeedback• Creatingapaymentmodel

MakingConnectionsFindingaLocalACORealo’sflagshipstoreislocatedinNewBern,NorthCarolina.NewBernisfortunateenoughtohavealocalACO.AnestimatedfiftypercentofthepatientsatRealoinNewBernareunderthecareofaproviderwithinthisACO.Thepartnerforthisprojectisamulti-specialtygrouppracticeconsistingofanetworkof44physicians,11physicianassistants,8nursepractitionersandanumberofnursesandcaremanagers.Priortothisprojecttherewasnotapharmacistonstaff.

ProvidingEnhancedServicesRealoispassionateaboutpatientcareandimprovingoutcomes.Inordertoimprovepatients’overallhealthandprovidethemwiththesupporttheyneed,Realooffersmanyclinicalservices.Providingenhancedservicesisalsoessentialtobuildingrelationshipswithhealthcarepartners.Theseservicesinclude:

• Transitionofcareclinicalservices• Chroniccaremanagement• Homehealthconsulting• Specialtypharmacyservicesstate-wideandsurroundingstates• Compounding• Veterinarymedicine• DiabetesSelf-ManagementEducation(DSME)• Kids’vitaminsprogram• Homevisits• MedicationTherapyManagement• PartneredwithCarolinaHomeMedicalforDurableMedicalEquipment• Medicareenrollmentassistance• Medicationsynchronization• 24-houron-callemergencypharmacistservice• Adherencepackaging• LocalDelivery• Refillrequestonline,phone/tabletApp• Smokingcessationsupport• Naloxonedispensingandeducation• Pointofcaretestingandvitalsignscollection• Medicationreconciliation

Priortotheformalcollaboration,RealoworkedwithmanyACOpatientsandcaremanagersthroughtheadherencepackagingprograms,andmanypatientsreceivedenhancedservicesunderthecareofRealo.BuildingRelationshipswithACOLeadershipThroughtheseenhancedservices,Realowasinteractingwithcaremanagersregularly.Tofurtherexpandthispartnership,RealoinitiallymetwiththeDirectorofCareCoordinationattheACOtoassesswhichserviceswouldprovidethemostbenefit.FuturediscussionledtomeetingswiththeChiefExecutiveOfficer(CEO)whowasakeydrivingforceingettingthepharmacistembeddedintheclinicsforthepilot.Whendiscussionsexpandedthemodeltoincludepayment,thePresidentandChiefMedicalOfficer,whoalsoservesastheQualityAssurance/ImprovementChair,wasavailabletobringintheproviders’perspectives.

LearningWhatMattersMosttotheACOReadmissionshaveaheavyimpactonACOsanddecreasereimbursement.Theinitialpilotsetouttoimprovereadmissionratesthrougheducation.AnotherareatoconsideristhequalitymeasurebenchmarksbywhichtheACOisgradedandwherecommunitypharmacistscanhaveanimpact.Seehttps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/2018-and-2019-quality-benchmarks-guidance.pdfforalistofACOQualityMeasureBenchmarks.DevelopingaServiceSetTheinitialpilotforthisprogramfollowedtheflowchartinFigure1.ThetargetpopulationincludedpatientswhorecentlyexperiencedatransitionofcareandeitherhadCOPDand/orCHF.Patientsreferredtothisprogramwouldreceivethreein-person,in-clinicpharmacistconsultationsandthreefollow-upphonecallsaftereachin-personconsultation.

Whatwelearned:Limitingthepartnershiptotwodiseasestatesandestablishingstrictcriteria(i.e.recenttransitionofcare)drasticallydecreasedthenumberofpatientseligibleforpharmacyservices.Itispossiblethatsettingthesecriteriacouldhaveledtoconfusionorinhibitedreferralsbycaremanagersbecausetheywereunsurewhetherpatientsmetthepropercriteriaforinclusion.ObtainingAccesstotheElectronicHealthcareRecordandTrainingToobtainandbeginworkingwithintheElectronicHealthcareRecord(EHR),trainingwasrequired.ThistrainingincludedtrainingontheEHRsystem(Allscripts),HIPAAtraining,andOSHAtraining.PharmacistobtainedlogininformationtoaccesstheEHRaswellasaccesstothevirtualprivatenetwork(VPN)whichensuredasecureconnection.ApharmacyconsultnotetemplatewascreatedbytheACO’sITdepartment,andthisnotewasusedtoprovidetheserviceanddocumentfindings.Oncethepharmacistcompletedthenote,itwouldforceatasktotheproviderforco-signature.Thisco-signaturewouldensuretheproviderviewedthenoteandrecommendationsmadebythepharmacist.Whentrainingconcluded,thepharmacistvisitedtheofficelocationinordertomeetpertinentstaff(officemanagers,caremanagersandproviders),receivebadgesforofficeaccess,andsecurealaptoptoaccessEHRoff-site.Whatwelearned:UnderthearrangementtheACOrequiredthatthey“own”thelaptopbeingused.LimitingaccesstotheEHRononecomputerpreventedwide-spreaduse.AccesstotheEHRallowedfortasknotestobesenttoaproviderforanyRealopatient.Theabilitytotaskforclarificationssimplifiedthemedicationreconciliationprocess;however,onlythreepharmacistshadaccesstothesystem,andeightpharmacistsworkatthepharmacy.SomesuggestionswouldbetoobtainremoteaccesstotheEHRondispensingcomputersatthepharmacyinordertoprovideeasieraccess.Itwouldalsoberecommendedtoobtainuseraccessforalldispensingpharmaciststoensuretheseadditionalresourcesarealwaysavailableregardlessofwhoisstaffing.MarketingServicesMeetandGreetwithProvidersRealopharmacists,accompaniedbyaNursePractitionerwhoalsoservesastheApplicationsTrainer,visitedeachclinictomeettheprovidersanddetailtheservicesthatwouldbeprovided.TheCEOalsomarketedtheserviceateachprovidermeeting.

BrochureContent:Priortoprovidingtheserviceanelectronicbrochurewasdistributedtoproviderswiththefollowingcontent:

WhoWillBeIncluded:

COPDandCHFpatientsinitially

HowItWillWork:

• AttheTransitionofCarecallthatisprovidedwithin48hoursofhospitalization,

patientswillbescheduledwiththeirproviderandthenthepharmacist.

• Patientswillcomeinforanappointment(30-60minutes)withthepharmacist.

• Attheconclusionoftheappointmentthepatientwillbescheduledforafollow-

upsession.

• Patientswillreceivethreeinclinicface-to-faceencounterswiththepharmacist.

Pharmacistwillcontactthepatienttwoweeksaftertheencountertoreinforce

lifestylemodificationsthatwerereviewedatthepreviousencounter.

• Appointmentopeningsmaybeusedforpatientswithoutarecenttransitionof

carevisitifstillvacant5daysinadvance.

AftertheTransitionofCareofvisitwiththeproviderandatthenextsessionthe

pharmacistwill:

•Reviewtheentiremedicationregimenwiththepatient.

•Provideone-on-onediseasestateeducationtoincludemedicationregimen,

lifestylemodifications,self-careandmonitoring.

•Addressanyinteractions,costconcerns,adherencebarriers.

WhyMakeThisReferral:

•Disease-stateeducationprovidedbyapharmacisthasbeenproventodecrease

hospitalizations,improveadherenceandincreasedisease-stateunderstanding.

•Apharmacist’sperspectiveaddstothesuccessofthemulti-disciplinary

healthcareteam.

•Enhancepatientengagement.ProvidingPharmacyServicesUnderthispilot,severalmethodswereattemptedtoincreasepatientreferralratesoveran18-monthperiod.

InitialProcess:Thepharmacistmetwithcliniccaremanagersandnursestodetailtheserviceprovided.NursesandcaremanagersidentifiedpatientswithanactivediagnosisintheEHRofCHForCOPDafterreceivingatransitionofcare(TOC)officevisit.ThisTOCvisitoccurredwithin7daysofdischargefromthehospital.Caremanagersornursesmadethereferraltothepharmacistandscheduledthepatientwithin30daysofthisvisit;appointmenttimeswerereservedforeachcliniclocation.Patientswerealsoidentifiedthroughroutineofficevisitsandcaremanagementinteractions;however,priorityforappointmenttimeswasgiventotransitionofcarepatients.PatientsthatoptedintotheprogramreceivedaHIPAAAuthorizationandAdultConsentFormtosignattheinitialpharmacistencounter.Patientsthatoptednottoparticipatereceivedtheirusualmedicalcareandwerenotprovidedtheservicesofferedbythepharmacistspecifictothisstudy.Ifpatientsattheinitialencounterdidnotwishtosignconsentforms,theywerenotenrolledinthestudybutreceivedacomprehensivemedicationreview.Theinterventionwasinitiallyprovidedatthreeclinics,andschedulingwaslateradjustedtooptimizepatientinteractionsandincreaserecruitment.Patientswerescheduledattheconclusionofeachsessionforafollow-upvisitwithpharmacistthenextmonth.Thisinitialdesignengagedpatientsinthreeclinicconsultationsoverafour-monthtimeframeandaminimumofthreephonefollow-upcalls.Atotaltimeframeoffourmonthswasselectedtoaccountforamissedappointment.Underthismodelonlyfourpatientscompletedtheprocessattheconclusionofyearone.AttemptedAdjustments:Withpoorattendancethemodelrequiredsomeadjustments.Theinitialadjustmentwasaddinganadditionalclinicintothepatientrecruitmentprocess.Littleprogresswasmadefromthischange,soadjustmentsweremadetodecreasetotwoclinics.Wetriedtoofferschedulingjustonedayeachweek,andthensplittotwohalf-daysinclinicbeforedecreasingtojustoneclinic.Ultimatelyadecisionwasmadetoofferamedicationreviewthatcouldoccuratthepharmacy,intheclinicorbyphoneanddocumentingtheencounterintheEHR.Whatwelearned:Fromourcollaborationwelearnedthathavingthreein-clinicsessionswastoointense.Manypatientsstruggledwithtransportationorkeepingtheirfirstappointment.Welearnedthatwithlimitedscheduleavailability,wewerenotabletocapturepatientsafterthetransitionofcarevisit.Identifyingapatientatthetransitionofcarevisitpresentedachallengehoweverwewereunabletoobtainfeedbackaroundthisissue.Possiblesolutionswereincreasingdaysinclinicorschedulingpatientsoffsiteatthepharmacy,asmostpatientscometothepharmacytopickupneworrefilledmedications.Schedulingpatientstobeseenatthepharmacyprovidesthemostflexibilityintheeventapatientdoesnotshow.Thisallowsforthepharmacisttomoveontotheirnextavailableclinicaltask.Whileonsiteattheclinicthepharmacistdidnotalwayshaveaccesstoaphoneandcouldnotviewthedispensingsoftwareorexternalwebsites.

ObtainingFeedbackProvidersweresurveyedtogaugetheirthoughtsandperspectivesabouttheinvolvementofthecommunitypharmacistwithintheACO.SurveyResultsThesurveywasdistributedto44membersofthehealthcareteam,ofwhich16responded.Sixphysicians,onenursepractitioner,threephysician’sassistants,twonurses,twocaremanagers,oneofficemanagerandonepracticemanagercompletedthesurvey.Whenasked“Whatisyourvisionfortheroleofthecommunitypharmacistwithinthehealthcareteam?”providersrespondedwiththefollowing:“Tobeabletoeducateandassistmorepatientswithmedication”“Helpavoidmedicationerrorandduplicationofmeds.Educationofpatientsabouttheirmeds.”“Tobereadilyavailableforquestionsaboutmedicationsandtohelpreviewmedicationsforpatientswithspecificissueslikepolypharmacy”“Recommendations,medinteractions,betterchoicesbasedonuptodatepharmacydata”“Educationonhealthylifestylesincludingnon-pharmaceuticalproducts.Affordablemedical/medicationliving.”“Withpatientsseeingmultipleprovidersthesedaysthecommunitypharmacistisabigassettohelppatientswiththeirpolypharmacytoavoidinteractionandduplication.”“Workinconjunctionwithphysicianstocoordinatetheoptimummedicationdecisionmakingforpatients,especiallythosewithmultiplemedications.”“Tocoordinatecare”“Toassistinhavingpatientsgetmedicationsthatwillbeaffordablewithlessinteractionswiththeirothermeds”“Betterpatientcare”“Shareinthecoordinationforthepatientseducationregardingmedicationregimeandadherence”“Reviewandcostreductionsuggestions”“Ithinkacommunitypharmacistshouldbearegularpartofthepatientcareteam.”

Thebarriersidentifiedincluded:“Onlyinoneoffice”“Tryingtofindtimeinmyscheduletogivefeedbackandcommunicatewithpharmacist”“Iseenobarriers.Myonlyproblemispatients(don’t)showfortheirscheduledappts”“Lackoffundingforsuchaposition”“Patientnoncompliance,time,financialcoverage,location”“Addedcosttothehealthcareburden”“Patientswhohavelimitedlevelofunderstanding,money,transportation”“Lackofpersonnel”“Parttime”Whenaskediftheproviderhadeverreferredapatientforamedicationconsultationwithapharmacistwithintheirclinic,7respondedyesand2responded“other”,citingtheydidnothaveanopportunityyetorthattheyhadonlyrequestedthattheirstaffrefertothepharmacist.Whenaskediftheproviderhadeverreferredtoapharmacist’sconsultnoteortasknotewithintheEHR,eightprovidersresponded“yes.”Suggestionsgivenweretoincreaseschedulingavailabilityandtoattendtheprovider’smeetingtosharemoreaboutservices.Whatwelearned:Itwouldhavebeenbeneficialtosurveyprovidersearlierintheprocess.Thesurveywasdistributed16monthsafterfirstembeddingthepharmacistinclinic.PresentingResultsInordertoshowACOleadershiptheimpactcommunitypharmacistshavehadonanACOpatient,wepresentedabriefhandoutsynopsiswhichincludedthesurveyresults.Inthishandout,Realoincludedasampleofinterventionsinclinicandduringoff-sitemedicationreviewsperformedbyphoneorinperson,aswellasafewexamplesofclinicalimpact.Realoalsopresentedasummaryofproviderresponses.

ClinicSchedulefrom10/12/17-presentDate ClinicalHighlights10/12/17 Suggesteddiscontinuationofcorticosteroidbeyond

recommendedduration;identifiedinappropriateuseofVoltarengelinpatienthavingbleedingepisodes

10/24/17 Medreviewprovided10/24/17 Medreviewprovided11/14/17 Statinintoleranceandthereforenon-adherenceidentified12/21/17 Medreviewprovided1/18/18 COPDeducation/incorrectinhalerusage,sleephygiene/

timingofsertralineadmin.,helpedobtaincompressionstockings,premarincream&CVrisk

2/8/18 Blisterpacks,multiplemedsnon-adherence,medsmissingfromACOmedlist;abletoidentifythroughmail-orderpharmacy

3/8/18 SleepHygiene,medicationadministrationcorrections3/13/18 Medreviewprovided3/22/18 Medreviewprovided3/29/18 COPDevaluation,uncontrolled,recommendedadditional

therapy4/5/18 Fallriskmitigation,dementiaassessmentand

anticholinergicinteraction/discussionwithcaregiverregardingriskvs.benefitandQOL

12-dayImpactofMedicationReconciliationperformedbyRealoPharmacistTotalACOPatientsReceivingMedReviews 27 %OfTotal

#ofpatientstakingmedicationsnotreportedonmedlist(andsomestillreceivingrefills)

10 37%

#ofpatientswithmedicationsonmedlistpatientwasnottaking(andwassupposedtobe)

15 56%

#ofpatientswithmedicationdosing/freqchangedbyphysicianbutnotreflectedinmedlist(required

newscript)

7 26%

#ofpatientsreportingaccuratediscontinuationthatwerestillonactivemedlist

12 44%

Total#ofmedicationdiscrepancies 44 1.6meddiscrepanciesperpatient

*ThissnapshotwascompiledfromtheCMRsprovidedbyoneofourthreeclinicalpharmacists.UsualcombinedtotalCMRspermonthaverage>100.

RealoMedReviewClinicalImpactSnapshots1. Patientwithheartfailureunabletodiuresefluiddespitebeingonmetolazoneand

furosemide2TPOQD.Hemisunderstoodtreatmentinstructionsandwastakingfurosemide40mgBIDinsteadandwasnottakingmetolazone30minutesbeforehand

2. PatientwasreceivingFosamaxtreatmentdoseforosteoporosisandshouldhavebeenonpreventativedose.(Reviewedpatient’st-scoretodetermineappropriatedose)

3. Patientnon-adherenttoSymbicortwhichrequiredclarificationtoassessifpatientshouldstillbetaking.Patientwasalsoinneedofarescueinhalerforemergencies

4. Patientwasnon-adherenttoPradaxa.DuplicationoftherapywithGabapentinscripts5. 85yearoldmanstillreceivingdualanti-platelettherapy4yearsafterMI

ProviderSurveySynopsis

ImplementingFeedbackAftermeetingwithACOleadershipanddiscussingthesurveyresults,itwasdecidedthattheapproachforprovidingthisserviceneededtochange.Ratherthanjustmakingtheserviceavailable,aRealopharmacistwouldpartnerwithoneortwoprovidersthatwasreadytoworkwithpharmacy.Prioreffortsmadethepharmacistavailablebyhavingscheduledtimeinseveralclinics,butthemodeldidnotreceivemuchbuy-infromproviders.Havingaprovidervoluntarilypartnerwithpharmacyseemstobeamoresuccessfulapproachandisournextstepforthisproject.

63%0%

37%

ProviderSatisfaction

Satisfied

Unsatisfied

Other

Ofthe16(6physicians,1NP,1PA)respondents,noproviderswereunsatisfiedwithRealo’sparticipation.Thirty-sevenpercent(6)selected“other”asanoptionstatingthefollowing: -Theywereunawareoftheserviceprovided -Didnotbelievetheserviceappliedtotheirclinic

-Statedtheyhadnothadtheopportunity-Requestedmoreavailability-Requestedmaterialsandpresenceatprovidermeetings

Ninety-fourpercentofrespondentsselectedthatthey’dliketohavemoreinvolvementfromcommunitypharmacistsorthatthey’dlikelearnmoreabouthowthecommunitypharmacistcouldassistinmanagingchronicdiseasestatesandimproveoutcomes.

CreatingaPaymentModelTherearefewmodelsbywhichcommunitypharmacistscanbereimbursedfortheclinicalservicestheyprovideoutsideofthegeneralbillingplatformssuchasOutcomesandMirixa.Therefore,RealopresentedtoACOleadershiptwomodelsbywhichtheycouldgetreimbursedforprovidingservicesunderchroniccaremanagementcodesfromMedicare:1.Pharmacistseeingpatientsinclinicprovidingmedicationreviews2.PharmacistseeingpatientsinthepharmacyorbyphoneprovidingmedicationreviewsBothservicesincludediseasestateeducationandadherencesupport.TheACOpartnerhascaremanagersregularlybillingforandprovidingchroniccaremanagement.Realopharmacistswouldsimplycontributetotheminutesofservice.InJune2018,theACOagreedtopartnerwithRealotoprovideChronicCareManagementservices.Underthisnewprotocol,thepharmacistmeetswithpatientsinclinic,offsiteatthepharmacy,andbyphone,contributingtotheminutesbilledtoMedicareundertheChronicCareManagementcode.TheACOhasagreedtopayRealoforallthetimecontributedbyitspharmacistsreflectedintheamountcollectedfromchroniccaremanagementservices.ThereferralprocessisledbythepharmacistatRealobutcanalsooccurbycaremanagerrecommendation.Thepharmacistisabletotaskthecaremanagerregardingpatientstheythinkwouldbenefitfromamedicationreviewormedicationeducation.Thecaremanagerwillthensubmitarequesttotheproviderforapproval.Duringthefirsttwoweeksunderthisnewprocess,Realohasseenfourpatientsandhasdocumentednotesandminutesthatcontributetochroniccaremanagement.Thepharmacistnotecreatedfortheinitialprojectwasadjustedtoallowforthedocumentationofminutesbutmaintainstherequirementforco-signaturebytheprovider.Itwilltakeapproximately60daystoreceivereimbursementfortheservicewiththefirstpaymentexpectedinSeptember.References

1. KhdourMR,KidneyJC,SmythBM,McelnayJC.Clinicalpharmacy-leddiseaseandmedicinemanagementprogrammeforpatientswithCOPD.BrJClinPharmacol.2009;68(4):588-98.

2. BouvyML,HeerdinkER,UrquhartJ,GrobbeeDE,HoeAW,LeufkensHGM.EffectofaPharmacist-LedInterventiononDiureticComplianceinHeartFailurePatients:ARandomizedControlledStudy.JCardFail.2003;9(5).doi:10.1054/S1071-9164(03)00130-1.

3. HollandR,BrooksbyI,LenaghanE,AshtonK,HayL,SmithR,ShepstoneL,LippA,DalyC,HoweA,HallR,HarveyI.Effectivenessofvisitsfromcommunitypharmacistsforpatientswithheartfailure:HeartMedrandomisedcontrolledtrialBMJ2007;334:1098/