By Anthony P. Morreale, PharmD, MBA, BCPS; Heather Ourth, PharmD, BCPS, CGP; and Julie A. Groppi, PharmD, CDE VA Pharmacy Benefits Management Services for Clinical Pharmacy Services and Healthcare
Clinical Pharmacy Specialists have an irreplaceable role within VA’s team-based care model due to their extensive experience in managing complex medication regimens used in the treatment of the most common disease states. In 2013, we will continue our effort to fully incorporate these highly skilled professionals into our team-based approach to healthcare.
Reducing the Burden on Physicians
Today, multiple medications are used to treat a chronic disease and a variety of patient factors to evaluate when selecting a medication. The extensive knowledge demonstrated by the Clinical Pharmacy Specialist (CPS) in pharmacology, pharmacokinetics, pharmacodynamics, pharmacogenomics and therapeutics is leading VA healthcare to a new paradigm that fully utilizes the advanced practice skills of our CPS workforce in improving care and reducing the burden on both primary- and specialty-care providers.
The CPS is authorized, under an advanced scope of practice, to prescribe medications in all healthcare settings in VA.
VA recognizes that clinical pharmacy specialists have a wealth of knowledge, training and experience to assume this responsibility. Since 2004, all graduating pharmacists in the United States possess a doctor of pharmacy degree. Many pharmacists undertake further professional development in the form of post-graduate pharmacy residency or fellowship training, professional experience and obtaining advanced board certifications as pharmacotherapy specialists (Board of Pharmaceutical Specialties).
VA has approximately 6,100 pharmacist full-time equivalent employees, and approximately 2,640 (43%) have an advanced scope of practice with prescriptive privileges.
This highly skilled workforce has the qualifications and training to address multiple medication management needs across multiple disease states for VA patients during a single patient visit.
Background on Clinical Pharmacy Programs in VA
Beginning in 2010, we launched an effort to begin measuring and describing the activities of our CPS professionals. We also wanted to organize, standardize, energize and expand our clinical pharmacy base by developing a national program office with oversight for clinical pharmacy services.
Consequently, we instituted our Clinical Pharmacy Program Office in April 2010 and rapidly set about developing a robust infrastructure to assess and measure clinical pharmacy activities in VA.
At the very time the program office was created, VA was realigning ambulatory care practices to follow the team-based approach, otherwise known as Patient Aligned Care Teams (PACT). We viewed this as a perfect opportunity to further define the progressive role of CPS within PACT. Specifically, we focused on how the highly evolved skills of the CPS in disease and complex medication management could be standardized throughout VA in the nonphysician provider role serving to bridge patient care needs between primary care and specialty care.
To this end, we pursued an aggressive agenda to transform our practices to fully utilize the skills of these highly trained individuals. A large component of this effort involved educating providers and VA leaders on how to properly integrate the CPS into team based settings in a transformed healthcare delivery system.The Clinical Pharmacy Specialist’s Role in Specialty Care
As the integration of PACT in VA has progressed, recognition has increased that, in order to complete the medical home concept, strong links to specialty care were needed. Recognition that the CPS has a long history of being imbedded in specialty care granted pharmacy a unique opportunity to assist in bridging the known gaps between the two.
Surveys of our CPS personnel demonstrated that they already had scopes of practices and served as nonphysician providers embedded in nearly 40 different medical subspecialty settings, including common referral areas such as endocrinology, cardiology, infectious disease, mental health, hepatology and pain management. When a primary-care provider refers a patient to a specialty clinic in VA, it is often the CPS who collaboratively manages that patient with the specialists to achieve therapeutic goals.
With a national shortage of both primary care and specialty providers in areas that are pharmacotherapy intensive, the CPS can play a critical role in bridging the gap and transitioning the patient back and forth as necessary.
This role improves access to both provider groups and has been shown to improve patient outcomes. This ability has been greatly enhanced by the placement of the CPS in PACT, as the CPS can facilitate medication management on behalf of the team and its patients.
We’ve been successful during the last two years in standardizing practices and enhancing refresher training for our highly skilled CPS workforce. This has resulted in widespread adoption of this collaborative-care model, a trend we hope to continue in 2013 and well beyond.
Pharmacists in VA are well-positioned to address many roles in a healthcare system that has broad needs for comprehensive medication management. As the medication experts on drug information, medication selection for specific diseases and medication safety, they represent a strong resource for our primary- and specialty-care teams.
The CPS in the nonphysician-provider role is a valuable member of VA’s transformation to team-based care that is improving both access and outcomes. These individuals will continue to play an irreplaceable role in caring for our nation’s veterans today and for years to come.Clinical Pharmacy Boot Camps
We assessed the services provided by our pharmacists by conducting a field survey of pharmacists assigned to PACT in 2010. We identified a high demand to provide clinical pharmacy practice refresher courses. In response to that demand, we developed knowledge and case-based Clinical Pharmacy Services Boot Camp Training Programs to assist pharmacists as they become integral members of our Patient Aligned Care Teams.
The goals for the boot camps are to provide evidence-based educational training in seven specific clinical practice areas which are integral to primary care in support of the PACT initiative; establish an educational network infrastructure to provide ongoing training and education for VA clinical pharmacy specialists; share best practices and standardized guidance in clinical pharmacy practice areas; and teach integrated models of care that maximize the skills of the CPS. The program’s interactive, case-based presentations create a uniform framework for disease state management training in osteoporosis, diabetes, hypertension, hyperlipidemia, pain management, hepatitis C and smoking cessation.
This training provides local facilities with the ability to have additional experienced personnel available to provide comprehensive medication management services to veterans. This improves access to care, decreases the burden for physicians and achieves optimal patient outcomes and lower overall healthcare costs.
The PhARMD Project
Clinical pharmacy clinic workload data provides a basis for determining the number of clinical pharmacy visits that occur in VA. It is unable, however, to describe the types of patients and impact of the interventions made by the CPS on a day-to-day basis. A need existed to develop a nationwide, standardized system for documenting and tracking clinical pharmacy interventions made by our CPS workforce during direct patient-care visits that demonstrates the impact of clinical-pharmacy care on the healthcare system.
We began the PhARMD project (Pharmacists Achieve Results with Medications Demonstration) as a grassroots project at two separate VA medical centers — Kansas City and West Palm Beach VA Medical Centers. Working together, they developed a tool for tracking CPS interventions using the computerized patient record system and a clinical-reminder template with embedded health factors. This new “reminder” tool assists our CPS professionals in documenting their progress notes during direct patient-care activities and tracking their key interventions.
This tool documents clinical pharmacy interventions made by the CPS in key disease states in PACT (diabetes, hyperlipidemia, hypertension, heart failure, smoking cessation, bone health, hepatitis C and anticoagulation) as well as additional pharmacotherapy interventions that have demonstrated the potential to reduce harm to patients and avoid costs to the healthcare system.
The reminder tool has point-and-click functionality and can be used easily by the CPS to document therapeutic interventions made, goals achieved due to medication management by the CPS and specific pharmacotherapy interventions, such as prevention or management of an adverse drug reaction or allergy, management of a drug-drug interaction or treatment of a previously untreated existing diagnosis.
We’ve also developed the ability to retrieve the clinical-pharmacy interventions logged by the CPS at the local medical center through database extracts, therefore demonstrating the impact of the CPS at a national level. During six months — from April to September 2012 — more than 35,000 clinical pharmacy interventions were made by CPS personnel at the nine expansion pilot sites. Once the expansion pilot has been completed, the reminder tool will be available for other VA medical centers to utilize.
National rollout of this tool is anticipated for fall of 2012 and throughout 2013. Use of this tool by our CPS workforce in the outpatient setting will provide VA with clinical-pharmacy interventions that can be used for benchmarking clinical outcomes for the profession of pharmacy as a whole.
A facility-specific survey found that 138 of 140 VA facilities reported shortages of medical officers, with psychiatry and primary care positions being the most frequently listed.
When Terrence O’Neil, MD, retired as chief of nephrology at the James H. Quillen VAMC in Johnson City in December 2016, he left in his wake decades of work treating kidney disease—nearly 35 years in the Air Force and DoD, plus 11 more at VA.