Critical Pathways of Care Delivery Are Key

Pharmacy TimesNovember 2019
Volume 85
Issue 11

Without them, we are doomed to become irrelevant and are at risk of a complete mechanical takeover of pharmacy practice.

Critical pathway modeling was developed in the middle part of the past century to identify what processes, if slowed or stopped, would cause a delay in an overall deliverable, such as the building of a skyscraper. These types of analyses allow a manager to identify processes and resources that must be monitored closely to ensure they are functioning well, because if they are not, the entire system will begin to fail. They have frequently been applied to prescription dispensing to help make the process safer and more efficient.


There are some obvious basic resources that a pharmacy relies on every day: electricity, inventory, a licensed pharmacist, etc. All of us who have worked in a pharmacy know the dread of losing power, lacking vaccines, or the partner pharmacist calling in sick. One could probably start a support group of horror stories of critical paths disrupted, such as when your pharmacy switch goes down and cannot adjudicate claims. It is a character-building experience, for sure.


In 2 words: care delivery. We all aspire to provide care in the pharmacy when we can. It feels good to resolve medication-related problems. It is fulfilling to counsel a patient about taking an antihypertensive and have them actually listen and respond favorably. It is meaningful to work with a prescriber to titrate the dose of a medication. It is professional to investigate whether a new patient is having an adverse effect. It is rewarding to review a blood pressure (BP) reading and act on a dangerous result.

We get a sense of achievement if a patient hits a clinical goal, like a glycated hemoglobin A1C measure less than 7%. Having a patient say, “Thank you for caring. It means something to me,” can bring life and energy to an overworked health care provider. The pharmacy does not stop when care delivery does not happen. None of the care pathways required to produce those results are critical or present at most pharmacies.


Sure, we have safety checks. Among other activities, “counsel the patient” and “utilization review” pathways are common, but those are deployed and designed mostly as defensive maneuvers to avoid medical and legal risk, with the best and most recent example being the ensuring of judicious use of opioids. Currently, we leverage our information technology systems and patient interactions to avoid making mistakes rather than to deliver care and optimize medication use.


The near complete absence of care delivery on pharmacy critical paths is not surprising, if we are honest with ourselves. Why would they be? Most pharmacy businesses rely almost entirely on selling medications and avoiding medication-related mistakes created by or left unresolved by the pharmacy to continue operating. If drug reimbursement claims systems go down, it is a crisis. If the BP cuff gets broken, “Well, we’ll have to wait until the next time you pick up a prescription.” It is not on a critical pathway, so no urgency needed, no transformative change required.

Professional responsibility is paramount to most of us, but participating in above-and-beyond care delivery activities tends to end at the shores of financial sustainability and regulatory requirement. But what if taking a patient’s BP on a regular basis were not on an optional care pathway but a required care pathway? What if that prescription cannot go out the door without the BP being taken and an outlier result being acted on?

To put this in a starker perspective, imagine that direct and indirect renumeration fees were dependent on taking BP. Thousands, or tens of thousands, of dollars could be at risk if patients taking antihypertensives do not have regular BP measures documented in the pharmacy management system. That would put care delivery on your critical pathway, and you would be sure to get it done.


Without care delivery processes added to critical pharmacy pathways, community-based pharmacy practice is doomed. The only antidote to a complete mechanical takeover of pharmacy practice is a type of medication-centric care delivery that cannot be more effectively and efficiently provided anywhere outside the community-based pharmacy. The health care system and its reform advocates are screaming, “We need cheaper drugs and better care delivery!” Unfortunately, the “cheaper” part is unfairly targeting pharmacists, and the “better care delivery” part has been voluntary.


What if every community pharmacy in the country took 10 BP readings a day? This is not a crazy notion, right? Thirty seconds to screen at the drop-off window for taking antihypertensives, 2 minutes to take the reading, and 90 seconds for the pharmacist to review for outliers and determine whether action is needed. Only 10. If all of us did this every day, community pharmacy would record 237 million readings every year and have the opportunity to provide care delivery for tens of millions of patients not at their BP goal. That cannot be ignored by payers and policy makers. And unlike prescription fulfillment alone, care delivery alongside fulfillment is not just sustainable; it is a game changer.

Troy Trygstad, PharmD, PhD, MBA, is vice president of pharmacy programs for Community Care of North Carolina. He also serves on the board of the American Pharmacists Association Foundation and the Pharamcy Quality Alliance.

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