A new role for pharmacists in regional integrated care: “There’s a lot of potential”

The traditional division of labour between pharmacy and medicine is becoming increasingly blurred, and interprofessional partnerships are on the rise. There is a lot of potential, especially in the field of integrated care. We spoke with OptiMedis Board Member Dr h. c. Helmut Hildebrandt and Stefan Göbel, a pharmacist from Hesse, about what roles pharmacists could play, and what first steps have already been taken.

Dr Hildebrandt, you want pharmacists to be even more involved in integrated care in the future. What opportunities do you see?

HildebrandtDr h. c. Helmut Hildebrandt, a pharmacist and health scientist, has been working in the development of health systems for many years, and has established several regional population-oriented care models. Photo: OptiMedisPharmacists can play an important role, not only in medication management, but also in health coaching. For one thing, they have the necessary pharmaceutical health expertise, they know about the interplay between body, mind, behaviour and genetics in the development of diseases and health, but they also have a good understanding of the needs of their customers. In addition, there is a particularly low barrier to patient access.

There is great potential, both in terms of patients’ quality of life, and in economic terms. For example, it is estimated that as much as 3 to 6 percent of all hospital admissions worldwide can be attributed to the incorrect use of medicines. Projecting the latter figure to the European Union, this would suggest 1.25 million unplanned admissions due to drug-related side effects, half of which could be prevented. There is also a lot that could be achieved through well-coordinated behavioural medical support in the area of chronic illnesses and their prevention.There are already several successful approaches on the international stage. Experience from the USA and Scotland, for example, shows significant improvements in health in projects that involve pharmacists.

Can you give some specific examples?

One very successful example in the USA is the Community Pharmacy Enhanced Services Network (CPESN), an integrated network of over 2000 participating pharmacies which has been running since 2019. Examples of the services they offer include medication reviews, prescription synchronisation and medication record management, providing support for opioid users and HIV patients, performing vaccinations and participating in disease-management programmes. The effects of the interventions are recorded, and income-related remuneration is determined on the basis of these records.

Also, since 2013, pharmacists in Scotland have been given training as independent prescribers in addition to their clinical skills, meaning that they are able to prescribe and change medications for their patient population. Some of them work in medical practices, but they are also a first point of contact in the pharmacy itself for chronically ill and multimorbid patients requiring polypharmacy. This particular type of pharmaceutical care is currently being developed further, starting with the management of simple urinary tract infections, support for COPD self-management programmes, and impetigo treatments.

Mr Göbel, from your practical experience, what possibilities do you see for involving pharmacists in integrated care, and what advantages could this bring?

göbelStefan Göbel manages the Brücken-Apotheke in Heringen, is involved in interdisciplinary medication manage-ment and is a lecturer in clinical pharma-cy at the University of Jena. Photo: privateOne big advantage of public pharmacy is that many customers have a very close and trusting relationship with us. This is true for many pharmacists, but especially in rural areas. Patients tell us things they would rarely discuss with their doctor, such as not taking medication properly. As an example, ASS 100, for the prevention of strokes, is usually meant to be taken at noon. Many patients, however, often only take their medication in the morning or evening, and either simply forget to take the lunchtime tablet, or they skip it completely. In these cases, we might talk to the GP and delay the dose until the morning. This is just a minimal intervention, but it can have a big effect. Patients often do not understand how to take their medication. As pharmacists, we can explain this clearly and provide peace of mind, thus increasing adherence. In addition to the medical aspects for patients, there is also a huge health economics potential here. The ABDA (Federal Union of German Associations of Pharmacists) and health-economic publications estimate that non-adherence costs the German healthcare system around 10 billion euros per year. Some estimates put this figure as high as 15 to 20 billion euros.

Dr Hildebrandt, “network” is the key word here. How does the partnerships with pharmacists work in the regional health networks in which OptiMedis is involved?

With the Gesundes Kinzigtal (Healthy Kinzig Valley) company, there have already been several innovative approaches to involve pharmacists more in integrated care, for example through the continuous participation of representatives from local pharmacies and the local specialist hospital in a medications committee and discussions on the evaluation of data on the provision of medication to the population concerned.

Pharmacies have been involved as partners in the Gesunder Werra-Meißner-Kreis (Healthy Werra-Meissner District) project since its launch in 2019. In addition to a joint medications council involving doctors and pharmacists, as well as targeted drug reviews by ATHINA (Pharmaceutical Safety in Pharmacies)-qualified pharmacists, pharmacists and pharmaceutical assistants are trained as “health advisors”. They give patients advice on health promotion, work with them to develop goals and support them in their self-management and health literacy. Improved training in the area of digital applications is planned for the future. Here I can see many more opportunities for pharmacies to develop into “local health hubs” in the future.

At the same time, we are working on the further development on the “FORTA = Fit for the Aged” polypharmacy classification instrument, using algorithmic approaches and artificial intelligence. In the future, this will help doctors and pharmacists to use the most suitable drugs for patients with multiple diseases.

How are pharmacists remunerated?

Gesunder Werra-Meißner-Kreis GmbH sees the additional work of pharmacists and pharmaceutical assistants as an investment in the health of the local population. Since any success in improving the health of the insured population benefits the company itself through contracts with health insurance companies, the company pays the pharmacies, for example, for advice by the health advisors, participation in training courses, and so on. The pharmacies also later share in the profit of the GmbH. With regard to pharmaceutical consultation in the narrower sense, we are currently looking forward to the implementation of the Local Pharmacy Act and the additional remuneration it provides for. We would like to offer ourselves as a pilot model for this.

Mr Göbel, what plans are you pursuing together for the Werra-Kali district in the North Hesse/Thuringia region?

Our aim is to build an integrated health network similar to Gesunder Werra-Meißner-Kreis in the Werra-Kali district, involving medical and social players, and which offers interventions tailored to our region and is remunerated based on success. We also want to involve larger companies, because many of them have an interest in sustainably improving health care for a region in which many of their employees live.

A recent article on this topic: Lyles L.F., Hildebrandt, H., Mair, A. (2020). Population Health Management Approach: Integration of Community-Based Pharmacists into Integrated Care Systems: Reflections from the U.S., Achievements in Scotland and Discussions in Germany. International Journal of Integrated Care, 2020; 20(2): 13, 1-9. Link