Veterans have fewer options for physician visits in rural areas, and the MISSION Act, allowing them to access community care, doesn’t help that much when the doctor-patient ratio is 53.3 per 100,000 in rural areas. The VA has turned to clinical pharmacists to help, initially in managing diabetes, mental health and pain management but now also involved in care and medication management for alcohol use disorder, heart failure and chronic obstructive pulmonary disease.
Structure of the Clinical Pharmacy Specialist Rural Veteran Access Initiative.
WASHINGTON — By making space for clinical pharmacy specialist (CPS) providers on care teams dedicated to primary care, mental health and pain management, VA has provided better health outcomes, improved the patient experience and increased the likelihood that the team will provide the best medication possible for patients, especially rural ones who frequently bear a greater burden in terms of access and healthcare needs.
The growing physician shortage has resulted in a doctor-to-patient ratio of 53.3 per 100,000 in rural areas. In addition, the aging patient population, a trend seen more acutely at VA, has 30% of patients taking five or more medications, with four billion prescriptions dispensed annually. When these two challenges in providing care are combined, they result in unoptimized medication therapies that cost the U.S. healthcare system more than $500 billion and result in an estimated 250,000 deaths per year.
In October 2016, VA’s Pharmacy Benefits Management (PBM) Clinical Pharmacy Practice Office (CPPO) partnered with VA’s Office of Rural Health to create the CPS Rural Veteran Access (CRVA) Initiative. The initiative focused on providing greater access to comprehensive medication management (CMM) and chronic disease management for those rural veterans facing the greatest health disparities.
The five-year program led to the integration of 180 CPS providers at 63 VA facilities across the country. At least 75% of the CPS provider’s time was dedicated to CMM services, including a minimum number of direct patient care interactions, which could be in-person or telehealth. When they weren’t interacting with patients, the providers gave support to the care team through chart consultation and e-consults.
Individual facilities were given great flexibility as to where to station the CPS provider, since virtual care accounted for about 69% of provider interactions with patients and telehealth appointments could be accomplished anywhere. Because of the focus on rural veterans, this meant the best place for a provider was as likely to be a community-based outpatient clinic as the main hospital.
The initiative also had a training and education component that resulted in the CPS providers attending face-to-face boot camps. The short-term objective of the training was to ensure each clinical pharmacist had in-depth knowledge on how to advance clinical pharmacy practices at a facility so that it improved patient outcomes. The long-term objective was to ensure these advances stayed in place beyond the five-year project period.
The education component also included a mentor program. Between October 2017 and September 2018, the project team matched 54 CPS mentors and mentees across the country. The pairs met virtually over the course of that year to help find ways they could promote CPS integration at their facilities.
A report summarizing the results of the initiative was published recently in the American Journal of Health-System Pharmacy. PBM officials found that the project successfully integrated CPS practices into VA care and in doing so improved overall care for rural veterans.1
A total of 180 CPS providers, including 111 in primary care, 40 in mental health and 35 in pain management, were hired during the initiative. From October 1 to March 30, CRVA clinical pharmacists served 213,477 veterans during 606,987 visits.
Clinical pharmacists were found to be especially helpful when it came to managing diabetes, mental health and pain management; however, during the initiative, growth especially was seen in interactions involving alcohol use disorder, heart failure and chronic obstructive pulmonary disease. These types of conditions frequently require patients to try different medications, as well as regularly monitor their effects. In the veteran population, they also are commonly found in conjunction with other comorbidities, raising the likelihood the patient is prescribed multiple medications.
Monitoring Medication
The most common intervention by a CRVA clinical pharmacy specialist on a mental health team was medication monitoring, followed by adjusting medication and providing comprehensive health education to patients. For those on pain management teams, the most common intervention was nonopioid pain management.
As of March 2020, there were 4,566 clinical pharmacy specialists working for VA—49.2% of the total number of VA pharmacists. Of those, 2,992 were providing direct patient care—2,171 in primary care, 517 in mental health, 304 in pain management. According to the researchers, those numbers have been increasing steadily over the last three years, with the highest growth (110%) seen in pain management.
According to the PBM report, facility leadership has readily embraced using clinical pharmacy specialists in more patient-centric roles. During the initiative, the project team visited 27 VA facilities to provide on-site consultation on how CPS providers could be better used. A survey conducted following the visits found that following the consultation, 82% of respondents increased their pace to promote optimization of CPS providers and that most facilities reported their practice change being well accepted by senior leadership.
“Nonoptimized medication therapy could mean that a patient does not receive the medications that are most effective for their disease state conditions, that they are not individualized based on the patient’s needs, or they may not receive a medication at all leading to adverse events and missed patient care opportunities,” the report’s authors concluded. “This project provides a blueprint for other health systems to follow to address the medication optimization problem, namely the integration of a CPS provider into all ambulatory settings to ensure patients have access to essential CMM services. All team members must work together to ensure success, and this project demonstrates that with the addition of a CPS provider, access is increased and the path toward medication optimization can be achieved.”
- Groppi JA, Ourth H, Tran M, Morreale AP, McFarland MS, Moore TD, Jorgenson T, Torrise V. Increasing rural patient access using clinical pharmacy specialist providers: Successful practice integration within the Department of Veterans Affairs. Am J Health Syst Pharm. 2021 Mar 31;78(8):712-719. doi: 10.1093/ajhp/zxab011. PMID: 33580241.