ASHP guidelines: Minimum standard for ambulatory care pharmacy practice.

In recent years, there has been an increasing emphasis in health systems on the provision of ambulatory care services. Payers have created incentives to decrease hospitalization rates and length of stay, making way for a new shift toward pay-for-performance, outcomes-based reimbursement, and accountable care. There is also an increasing focus in medicine on preventive health, patient education, and care transitions. Yet, the number of patients with multiple chronic medical conditions that require longitudinal and integrated care management across a continuum of care settings is growing. Appropriate medication therapy in the ambulatory care setting is often the most common and most cost-effective form of treatment, yet the consequences of adverse drug events (ADEs) and the inappropriate use of medications in this setting can be catastrophic. Ambulatory care pharmacy services are therefore an essential component of any comprehensive healthcare delivery system. Pharmacists have become integral members of healthcare teams in a variety of settings, such as patient-centered medical homes, community health centers, long-term care facilities, hospital outpatient departments, and freestanding pharmacies, among others; the care they provide has enabled patients, other providers, and payers to achieve their clinical, humanistic, and economic goals. There is growing recognition and understanding that ambulatory care pharmacy services extend far beyond the dispensing of medications and include direct patient care and the design and management of complex medication regimens and care delivery systems. Current evidence demonstrates that the inclusion of pharmacists practicing in ambulatory care settings on the healthcare team improves quality of care, enhances patient outcomes, and contributes to cost avoidance. Most states now allow pharmacists to provide direct patient care services under a physician–pharmacist collaborative agreement, further supporting the expansion of ambulatory care pharmacy services. The primary purpose of these guidelines is to outline the minimum requirements for the operation and management of services for patients in this rapidly evolving ambulatory care setting. The elements of service that are critical to optimal, safe, and effective medication use in the ambulatory setting include (1) leadership and practice management, (2) patient care, (3) drug distribution and control, and (4) facilities, equipment, and other resources. Although the scope of pharmacy services will vary from site to site, depending on the needs of the patients served and the resources available, these elements are directly linked to improved patient, population, and health-system outcomes. Specific attention to each element is essential to delivering patient care of the highest quality. As providers of care to patients in ambulatory care settings, pharmacists should be concerned with and take responsibility for the outcomes of their services in addition to the provision of these services. Care should also extend into and be coordinated with care providers in other settings; therefore, these guidelines should be used, as applicable, in conjunction with minimum standards for other practice settings. Rather than including detailed advice in this document, readers should refer to other referenced documents that address many of the outlined topics for additional information and guidance. Aspects of these guidelines may not be applicable in some settings due to differences in settings and organizational arrangements and complexity. Pharmacists practicing in ambulatory care settings should use their professional judgment in assessing and adapting these guidelines to meet the needs of their own practice settings. These guidelines are intended to be a comprehensive overview of current minimum requirements for the operation and management of services for patients in the ambulatory care setting. These guidelines are complemented by the ASHP/ASHP Foundation Ambulatory Conference and Summit consensus recommendations, which provide a long-term vision for aspirational and forward-thinking pharmacy practice models that will ensure that pharmacists participate as members of the ambulatory healthcare team who are responsible and accountable for patient and population outcomes.