Are We Preparing the Integrators?
A colleague challenged me recently to consider the relationship between the aims of pharmacy education and the concepts articulated by Donald Berwick and colleagues in the 2007 Health Affairs article entitled “The Triple Aim: Care, Health, and Cost.” Dr. Berwick has recently assumed the role of Administrator of the Centers for Medicare and Medicaid Services (CMS) in the Department of Health and Human Services. CMS currently covers as many as 100 million lives and the agency's policies often influence coverage decisions in other public and private insurance programs. CMS has substantial jurisdiction for implementation of key provisions of the March 2010 health care reform legislation. 
 
The perspectives of Dr. Berwick on health safety and quality are well known to pharmacists and other clinicians working to improve health care. The Institute for Healthcare Improvement (www.ihi.org) has led numerous efforts to improve the safety and quality of care of patients, especially in the institutional environment, for over 30 years. IHI hosts the Open School, affording educators and students significant resources for teaching and learning the tools and strategies for quality improvement in health care. Rapid cycle improvement, learning collaboratives, and benchmarking against meaningful measures of quality are hallmarks of IHI's work under its founding president, Dr. Berwick. 
 
The triple aim outlined in Berwick's writing includes: improving the individual experience of care; improving the health of populations; and reducing health care per capita costs. Consider the match between these aims and the competencies outlined by AACP's Center for the Advancement of Pharmaceutical Education (CAPE), now embedded in current accreditation standards, to educate student pharmacists: to deliver pharmaceutical care to individuals, contribute to public health at the population level, and design and manage effective systems of care. These same constructs are part of the vision for pharmacy practice in 2015 as articulated by the Joint Commission of Pharmacy Practitioners. Pharmacists' full engagement in activities that ensure the most optimal outcomes from the use of medications is a requirement for achievement of “the triple aim.” The alignment of goals is quite remarkable. 
 
Berwick and colleagues define the role of an “integrator” as key to achieving the triple aim for health care. While their intent was that the integrator was a health delivery organization that would “produce or contract for individual care and population-based interventions that are evidence-based and highly reliable,” reading their article, I could not help but think of our graduates in the role of an integrator in the delivery system. An integrator: creates partnerships with individuals and families, redesigns primary care, provides population health management, aligns financial incentives for quality care, and offers macro-system integration of health services. 
 
As outlined by Smith and coauthors in their May 2010 Health Affairs article,1 “Why Pharmacists Belong in the Medical Home,” individual and population health for those suffering 1 or more chronic illness can be vastly improved with care coordination enhanced by pharmacists' involvement. Improved patient engagement and pharmacists' monitoring and triage for evidence-based primary and specialty care leads to better clinical and economic outcomes in community and ambulatory care settings, specialty clinics, and institutional care delivery. A systematic review by Dr. Chisholm-Burns and colleagues provides a new examination of this evidence.2 The Commonwealth Fund recently profiled a number of projects involving pharmacists' integration in new models of primary care in its newsletter Quality Matters.3 
 
Over the next several years, 30 million newly insured patients will enter the health care system. Many of them will not only be sicker as a result of not having insurance, they also will need to learn how to access the health system to use their new insurance. Our primary care delivery systems will be totally overwhelmed and leaders must identify strategies that ensure that patients are integrated into the most appropriate care systems delivering evidence-based treatments efficiently and effectively. Given the centrality of medication use for prevention and acute and chronic health management, pharmacists must contribute significantly to expanded access to primary care service delivery. Indeed, I believe we are educating an integrator for future care delivery systems.