By Annette M. Boyle
WEST PALM BEACH, FL – How much of a role are clinical pharmacists playing in patient care at VA?
Since December 2011, the Pharmacists Achieve Results with Medications Demonstration (PhARMD) program has sought to answer that question by documenting frequency and impact of clinical pharmacy interventions in selected VA Medical Centers. Now used by 356 pharmacists in 28 sites, the program opened to interested sites nationwide in April and might soon lead to new models of care.
As of March 1, PhARMD had already documented more than 81,000 clinical pharmacy interventions during direct patient care visits.
“The results demonstrate the significant impact pharmacists can make in patient outcomes in veterans,” said Julie A. Groppi, PharmD, CDE, national director, Clinical Pharmacy Benefits Management Service for the VA. “They also show how pharmacists’ pharmacotherapy management helps with cost avoidance and reduces potential harm to patients.”
PhARMD “shows the benefit of clinical pharmacists acting as nonphysician providers and the specific areas where they contribute to care. As experts in comprehensive medication management services, they are skilled at medication management across chronic disease states,” Groppi told U.S. Medicine.
“The tool has provided medical centers a way to quickly highlight the work of CPS across the system and see that pharmacists are key professionals filling current gaps in care,” she noted.
Among the specific interventions documented for various disease states, one particularly stands out.
“Pharmacists most commonly make interventions in diabetes management, and help patients achieve their individual goals. We’ve documented 12,000 medication changes in 5,800 diabetic patients and helped 28% of them reach their goals in a short period of time,” Groppi pointed out. “Pharmacists are able to see patients at shorter intervals, as they’re not limited by a panel of patients. Consequently, they help patients achieve their goals more quickly.”
New Patient Care Models
The tool is a way to document continuing changes in pharmacy practice and obtain data on which to form new models for effective practice and patient care, according to Groppi, who added, “pharmacists are moving away from the traditional dispensing role to team care. There’s a need for medication management in chronic disease and the provider work force is already burdened.”
“We’re looking at the development of metrics and reports to identify new areas to expand, such as to inpatient and specialty care, to see how pharmacists can meet care gaps in other settings,” she noted. “We’re fortunate at the VA to have been functioning in advanced practice roles for close to 40 years and have had a scope of practice as pharmacists since the 1990s. Of the 7,100 pharmacists in the VA healthcare system, 2,700 have a scope of practice.”
The PhARMD program originated independently in the Kansas City and West Palm Beach VA Medical Centers.
The Kansas City VAMC first piloted an inpatient proprietary tool that it used for about three months in 2010. During that time, the participating pharmacists documented more than 4,000 interventions.
The West Palm Beach VAMC wanted to use similar technology in a primary care setting and rolled out its version in February 2011 to document clinical pharmacist’s interventions in the areas of hypertension, hyperlipidemia, heart failure and diabetes. The West Palm Beach program documented more than 6,000 interventions associated with those four conditions in less than a year.
By the end of 2011, the two programs had jointly created a reminder tool with embedded health factors that prompts clinical pharmacy specialists to document their interventions and make progress notes in the computerized patient record system.
As of the end of September 2012, the program had expanded to nine sites, adding the VAMCs in Atlanta, Baltimore, Charleston, Reno, San Diego, Tahoma and Washington, DC. In addition, the team incorporated changes to clarify the types of interventions being made and began tracking interventions associated with smoking cessation, hepatitis C, anticoagulation, and bone health — all conditions commonly encountered by pharmacists acting as part of Patient Aligned Care Teams (PACTs).
The expansion to nine sites enabled them “to identify key parameters that would lead to success of later expansions and best practices for implementation of the tool. The team involved in the rollout also developed new educational materials, quality assurance parameters and documentation for the program,” Groppi said. This foundation helped the program rollout seamlessly to Veteran Integrated Service Networks 12, 17, 21 and 22 from December 2012 to March 2013.
“Now we are educating sites across the nation to prepare them for the rollout,” she explained. “We’re starting with sites that express interest and using the approach that worked at the regional level — training trainers who will work with site coordinators who will train others to use the tool.” As of this month, the program is open to any location in the VA system.
The PhARMD tool itself is fairly straight forward, with “point-and-click” functionality that pharmacists use to document each therapeutic intervention made and note goals achieved due to medication management by clinical pharmacists. In addition, pharmacists record other specific pharmacotherapy interventions, such as those that prevent, reverse or reduce the risk of an adverse drug reaction or allergy or manage drug-drug interaction. They can also note treatment for previously untreated existing diagnoses.
Data entered by local pharmacists can be extracted centrally to identify national trends in care, numbers of interventions and impact on patients.
“We’re in the process of validating data, analyzing the intervention logs, developing a cost/benefit model and creating new metrics and reports that may drive changes to practice models,” Groppi said.
In addition, the team is looking at modifications that will allow pharmacists to document interventions that take place during shared medical appointments, which are particularly common in diabetes treatment.
Ultimately, the PhARMD tool will provide the VA with information about clinical-pharmacy interventions in outpatient settings that can be used to benchmark clinical outcomes for the pharmacy profession. At the same time, it could provide the data needed to guide the expansion of pharmacy practice into new areas in the coming decades.
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.