Clinical Specialist will serve an integral role on the CCM multidisciplinary care team. The CCM team will be embedded in local primary care practices and will partner closely with PCPs, Integrated Behavioral Health Professionals, Nurses, and other local resources in the Primary Care Practice to develop multi-disciplinary care plans. Clinical Specialists will be paired with Pharmacy Technician Liaisons to support the medication-related needs of the CCM team and patients enrolled in the program.
Clinical specialist ensures optimum patient-related outcomes for general internal medicine disorders by preventing or resolving drug-related issues, optimizing the drug therapy of patients and supporting medication adherence. Provides drug information to patients, physicians, nurses, and other healthcare professionals. Additionally, the Clinical Specialist coordinates clinical projects, ensures billing compliance and helps to lead other projects as needed. Serves as a resource and drug expert for all general internal medicine-related medications and strives to increase knowledge through research and writing activities.
ESSENTIAL RESPONSIBILITIES / DUTIES:
Work in collaborative fashion with all specialty area nurses, fellows, and attendings toward optimizing patient outcomes, with added focus on reducing total cost utilization and improving population health activities important to institutional goals and mission.
The ambulatory clinical pharmacy specialist will be responsible for providing primary care-focused pharmacotherapy services within the clinic, and evaluate and manage patients with chronic conditions (e.g., DM, Hyperlipidemia, Hypertension, COPD/Asthma, Heart Failure, Smoking Cessation, Hepatitis C) through direct patient care as outlined in the individual's Scope of Practice. The specialist will work closely within a multi-disciplinary team of primary care physicians, medical residents, nurses, and pharmacy liaisons to optimize and promote rational, safe, evidence-based and cost-effective therapy. The ambulatory clinical pharmacy specialist is responsible for working with patients to identify strengths and barriers and to develop an individualized, patient-centered pharmacotherapy care plan. Excellent interpersonal skills, clinical expertise in conditions prevalent in the Medicaid population (e.g., Substance Use Disorder, Serious Mental Illness, CHF, DM), patient engagement skills and the ability to work independently and collaboratively are key requirements of the job.
The primary responsibilities specific to the hospital and the department of pharmacy:
- Takes an active role in the development and implementation of quality improvement projects
- Maintains own professional and specialized competency through continued education.
- In all activities comply with accreditation, legal and regulatory requirements.
- Maintains HIPAA standards and confidentiality of protected health information.
- Adheres to departmental/organizational policies and procedures.
- Meets hospital-wide standards in the following areas:
- Conforms to standards of performance and conduct, including those pertaining to patient rights, so that the best possible customer service and patient care may be provided.
- Utilizes hospital's Values as the basis for decision-making and to facilitate the division's hospital mission.
- Follows established hospital infection control and safety procedures
- Develops goals for each fiscal year based on the institutional scorecard and under the guidance of Clinical Coordinator
- Identifies opportunities for the development of new care management approaches
- Performs other duties as needed.
The primary responsibilities specific to the clinic site:
- Monitor patients for appropriateness and response to therapy
- Document pertinent findings in the electronic medical record
- Develop, document, and execute a patient-centered plan of care utilizing national guidelines or established local protocol
- Provide ongoing care for chronic problems as delineated in protocol
- Order laboratory studies
- Analyze laboratory and diagnostic test data so as to modify drug therapy and dosing as necessary
- Identify and take specific corrective action for drug-induced problems
- Notify primary provider regarding atypical findings
- Provides effective transition of care needs including, but not limited to, medication reconciliation and completing post-discharge phone calls
- Provides drug education and counseling to patients as outlined in department policies and procedures
- Provides in-service education to nurses, physicians and other healthcare practitioners, as needed.
- Provides pharmaceutical care in alignment with complex care management objectives
- Demonstrates a whole-person orientation to the provision of patient care
- Utilizes a patient-centered approach to care, and develops and implements patient-centered pharmaceutical care plans
- Utilizes motivational interviewing to promote behavior change
- Educates patient on their medication regimen with the goal of building their self-management skills
- Collaborates with patient and care team to develop patient-centered care plan, with particular focus on medication adherence
- Collaborates with community partners, such as VNA agencies
The primary responsibilities specific to the ACO CCM program:
- Meets regularly with leaders at the local clinical site(s), care management supervisor and pharmacy supervisor to triage program issues appropriately.
- Participates in local site operations, including team meetings, curbsides with care team members, etc.
- Actively participates in planning and growth of program with relevant stakeholders as needed, to respond to evolving needs of MassHealth ACO.
- Facilitates interdisciplinary consultation on patient's behalf through participation in rounds, team meetings and clinical reviews
- Complies with established metrics for performance and adheres to documentation and work flow standards
- ED and inpatient visits
- Total medical expense
- Patient satisfaction
- Clinical outcomes
- Provider satisfaction
- Avoidable admissions
EDUCATION: Work requires a Degree in Pharmacy from an accredited college of pharmacy.
CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:
- Work requires a Massachusetts pharmacist license in good standing
- Current Board Certification in Pharmacotherapy (BCPS), Ambulatory Care Pharmacy (BCACP) or Geriatric Pharmacy (BCGP), or must obtain certification within one year of eligibility
- Current Basic Life Support (BLS) certification, or must obtain certification prior to performing home visits where applicable
Requires a minimum of 2 years' experience functioning as a clinical pharmacist in an ambulatory care practice or completion of a post-graduate pharmacy residency program focused in ambulatory care
- Direct patient care
- Care management
KNOWLEDGE AND SKILLS:
- Comprehensive understanding of the procedures, systems, and equipment used by pharmacists and technicians in the pharmacy as well as a high level of proficiency in performing pharmacist's duties and responsibilities.
- High level of analytical ability, organizational and personal management skill and focus to ensure the concerted approach to operations.
- Professional in conduct and appearance
- Excellent interpersonal skills and ability to work collaboratively
- Excellent written and verbal communication
- Able to maintain professional boundaries
- Ability to work with diverse, safety-net population
- Skilled at motivational interviewing, patient engagement and setting patient-centered goals
- Creative problem solver
- Ability to adapt to changes in healthcare delivery at local and systems level
- Extensive knowledge of healthcare systems and community resources
- Ability to leverage systems and resources for improved patient outcomes
- Strong organizational and time management skills
- Proficient with standard software used in healthcare office setting (i.e. MS Word, Excel, web browser, etc)
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