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KELLY EPPLEN, PHARM.D., CACP, is Clinical Coordinator, Ambulatory Care Pharmacy Services, Health Alliance, Florence, KY. MICHELLE DUSING-WIEST, PHARM.D., BCPS, is Director of Clinical Programs, Health Alliance, Cincinnati, OH. JOANNA FREEDLUND, PHARM.D., CACP, is Clinical Pharmacy Practitioner; and NICOLE HARGER, PHARM.D., is Drug Policy and Development Specialist, Clinical Coordinator, The University Hospital, Health Alliance, Cincinnati. SUSAN KATHMAN, PHARM.D., is Director of Pharmacy, St. Luke Hospitals, Florence, KY. MARIANNE F. IVEY, PHARM.D., M.PH., FASHP, is Corporate Director of Pharmacy Services, Health Alliance, Cincinnati.

Address correspondence to Dr. Epplen at Ambulatory Care Pharmacy Services, Health Alliance, 7380 Turfway Road, Florence, KY 41042.

Purpose. A methodological approach was developed to facilitate expansion of clinical pharmacist-managed anticoagulation services across an integrated health care delivery network. Methods. A stepwise approach to the development and implementation of ambulatory care clinical pharmacy services was used to facilitate expansion of pharmacistmanaged anticoagulation clinics in a university hospital setting and a community hospital within the same health network. Results. The Health Alliance of Greater Cincinnati successfully created a care delivery model using clinical pharmacists to provide comprehensive anticoagulation management services at a university hospital and a community hospital. The incidence of thromboembolic events was significantly lower in the pharmacy anticoagulation service patients versus the patients in the usual care setting (p = 0.005). A statistically significant decrease in minor bleeding events was observed in the pharmacist-managed group (p = 0.038). Although a decrease in major bleeding events was observed, it was not statistically significant (p = 0.075). International Normalized Ratio values of the patients managed by the pharmacy anticoagulation clinics were within the therapeutic range approximately 75% of the time. Conclusion. A stepwise approach to the development and implementation of ambulatory care clinical pharmacy services has facilitated the expansion of pharmacistmanaged anticoagulation clinics across an integrated health system. This may serve as a valuable template for other systems as they strive to develop medication therapy management services. Index terms: Ambulatory care; Anticoagulants; Clinical pharmacists; Clinical pharmacy; International Normalized Ratio; Interventions; Methodology; Models; Pharmaceutical services; Thromboembolism; Toxicity