WASHINGTON, DC—What does a pharmacist working in a VA hospital look like? Twenty years ago, that person would likely have been male, have entered the VA system with a baccalaureate degree, and spent much of their time behind a counter doing the grunt work of filling prescriptions. Or, as Louis Cobuzzi, VA’s associate pharmacy chief consultant explained in a recent interview with U.S. Medicine, they would have spent their time “peeling, licking, and sticking.”
VA, along with pharmacy systems everywhere, have seen an evolution in the role of the pharmacist—sometimes driving the change, sometimes reacting to it—where the prescription filling and tracking once done by pharmacists is automated, and pharmacists are no-longer behind a counter but beside hospital beds.
“Due to different challenges over the past 15 or 20 years, I think that the pharmacist role has changed a great deal and is in evolution towards a greater degree of clinical practice in a setting of direct patient care,” Cobuzzi said. “Pharmacists are becoming providers. They make sure the patients understand their medications, make sure the patients know why they’re taking them and how to take them, understand their disease state, and how the medication will affect their particular disease state.”
Part of the reason for this evolution is what Cobuzzi described as “degree-creep.” Fifteen years ago, pharmacists were being graduated by pharmacy schools with a baccalaureate degree—the entry-level degree for being hired into the VA system. Now, the PharmD is the entry-level degree.
“We’ve gone over to an all-PharmD professional education process,” Cobuzzi explained. “So the earlier baccalaureate levels—those registered pharmacists—are still around, but they’re not graduating that level of practitioner anymore. We’ve moved on to a more clinically-based program. That program includes an extra year where students are actually practicing in pharmacy and clinical settings. That’s moved everything forward as a profession, both in and outside of VA.”
Many times, after that first year of post-graduate clinical work, pharmacy students will take on a second year of residency, where they focus on more specific areas, such as cardiology, oncology, geriatrics, or mental health. Pharmacists who used to enter the VA system with four years of education are now coming in with eight to 10 years, including at least one year of clinical exposure under their belt.
Within 10 years, as people retire and are replaced with newer graduates, people with PharmD after their name will make up 70% of VA pharmacists, Cobuzzi estimated. Also, their number will become increasingly female, as schools are graduating twice as many women as men. Currently, VA employs more than 6,500 licensed pharmacists, not including contracted pharmacists employed at VA’s consolidated mail-order pharmacies.
The moving of VA pharmacists into the clinical setting has also been the result of a system-wide effort by VA to redefine the clinical experience for patients. The providers a patient sees while in a VA facility are being coordinated as part of patient-aligned care teams that provide better communication, both to each other and to the patient, and are designed to provide more patient-specific care. Pharmacists are now being given access to these teams and being given an opportunity to provide care.
“We’ve moved from being core-based pharmacists, primarily communicating some information to patients and filling prescriptions to this new care model,” Cobuzzi said. “They’re on the front lines and doing more direct patient care, are involved on the care team, working with the clinicians and nurse practitioners and dieticians.”
Our goal is eventually for every patient to have an identified pharmacist assigned to them, just like they would any other clinician.”
Currently, VA officials are working on systemwide standards for how pharmacists interact with patients and what exactly their role should be in care teams. A recently established coordinator position at VA will allow for someone to coordinate the development of national standards, with input coming in from pharmacy leaders across the country.
Attracting Pharmacists to VA
There has been a pharmacist deficit in the country, starting around 2000 and projected to continue until at least 2020. This is a result of a number of
factors, including the aging population and the baby boomer generation moving into an older age group, and the expanded number of prescriptions being written under Medicare. At VA, this deficit is exacerbated by the push to include pharmacists more and more in the clinical setting. The goal of every patient having a dedicated pharmacist puts an increased burden on VA’s pharmacist recruitment efforts.
As recently as six years ago, VA was not considered a choice destination for pharmacists,” Cobuzzi noted. “We started to take this very seriously, because we had problems recruiting, as did private sector and everywhere else.”
Because VA dealt with inpatients and outpatients and were responsible for patients under a total care model, the agency believed it could offer pharmacists a far wider range of opportunities than other systems. However, pharmacists were graduating from schools without ever having been exposed to VA.
VA’s Healthcare Retention and Recruitment Office conducted a wide-ranging survey targeting every type of pharmacist they could reach, from clinicians to administrators to retail pharmacists. The survey asked what their impressions were of VA and what they would be looking for from a potential employer. VA used the information gathered from that survey to put together flyers and brochures targeting each kind of pharmacist, explaining what the agency does, and why VA feels they can provide what that particular pharmacist was looking for.
The agency also began establishing a presence at conference and clinical venues. Previously, separate VA facilities were mostly responsible for their own recruitment, but now VA was recruiting for the agency as a whole and developing brand-name recognition as a choice destination for graduating pharmacists.
The changes in pharmacists’ training have been an asset to VA recruitment, Cobuzzi declared. “Schools are pushing the clinical aspects of care. Pharmacists are coming out of college looking for clinical models and looking for clinical practice. They’re looking to be a health care provider. We feel our model is advantageous to people coming out with these skills.”
Now every pharmacy school is partnered with at least one VA facility, and many times more than one, and VA has expanded the number of externships to accommodate those schools.
The Search for Administrative Pharmacists
Still, recruitment remains a challenge. Last year, VA was given funding to start a pharmacy recruitment and retention office. The two-person office was given the charge of carrying recruitment efforts forward, establishing a pharmacy field representatives’ network, and targeting hard-to-recruit areas. There is no one type of region where recruitment is a problem, however rural areas remain difficult for attracting all medical specialties.
“It can always be difficult in some of the smaller areas, the more rural spots,” Cobuzzi noted. “They just don’t have a school in the area, so people don’t tend to go there unless they’re from there. And with the expansion of our programs, we need a significant number of these people.”
VA also established the VA Learning Opportunities Residency, where VA is looking to recruit 100 of the top 2% of pharmacy students and bring them to VA for a year to work alongside clinical pharmacists in a topic of clinical expertise. That program, Cobuzzi said, has been very successful. “Once they get exposed to VA, they want to stay there. And in some instances, they’re willing to go to these areas where we’re having difficulties recruiting because they want to get in the VA system.”
The biggest pharmacy recruitment issue for VA today, one that will likely remain at the top of the agency’s priority list for some time to come, is the lack of administrative pharmacists. These are national pharmacist executives—directors or chiefs of pharmacy at the facility or VISN level. “Pharmacy as a profession has a real deficit in this category,” Cobuzzi explained. “And it’s a real problem in VA.”
In the 1980s there was an effort in VA to “flatten out the agency,” simplifying hierarchies and cutting many middle-management positions. However, that included positions like deputy chiefs of pharmacy—a person who would have been groomed to eventually move up to the pharmacy chief position.
Pharmacy schools are little help in this area, Cobuzzi said. “Their curriculum doesn’t really contain many administrative pharmacy courses. People come out with this focus, they want be a clinical pharmacist. They don’t want management headaches.”
The American Society of Health-System Pharmacists has conducted yearly surveys confirming this, showing that while the need for pharmacists in general is starting to even out, the need for administrative positions has remained at an 80%-90% level.
But as a whole, Cobuzzi feels that VA is in a far better position in terms of recruiting pharmacists than it once was. “We have a multipronged approach for recruitment,” he said. “And we have a development plan and goals for advancing the clinical pharmacist in VA and for the agency to be a leader in the profession.”
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