VASDHS Proposal for Integrating Pharmacists into Existing ...


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  • VASDHS Proposal for Integrating Pharmacists into Existing ...

    1. 1. Practice Models for Clinical Pharmacy Specialists (CPS) in the Patient Centered Medical Home<br />
    2. 2. Objectives<br />Explain how clinical pharmacy contributes in providing direct patient care<br />Incorporate intensive clinical pharmacy services into Medical Home Model<br />Present pharmacy outcomes data from VA Medical Home Models<br />Reviewresources & restructuring required to meet the Medical Home Model initiative <br />
    3. 3. Patient Centered Medical Home<br />The Patient Centered Medical Home Model is a patient-driven, team-based approach that delivers efficient, comprehensive and continuous care through active communication and coordination of resources.  <br />Medical Home model puts the relationship with the provider and team at the center of a patient’s care, and has expectations for timely, continuous, patient-centered, and coordinated care. <br />
    4. 4. Patient Centered Medical Home<br />Replaces episodic care based on illness and patient complaints with coordinated care and a long term healing relationship    <br />The Primary Care Team <br />Takes collective responsibility for patient care<br />Responsible for providing all the patient’s health care needs<br />Arranges for appropriate care with other specialties as needed <br />Enhanced Access<br />Enhanced communication between <br />Patients<br />Providers<br />Staff<br />
    5. 5. Medical Home Model<br />“Patient Centered Medical Home”<br />Presentation by David Macpherson, MD<br />Chief Medical Officer, VISN 4<br />
    6. 6. Key Principles of the Medical Home<br />Each member of the team works at their highest training level<br />Medication management goals can be delegated to Clinical Pharmacy Specialists, who are key members of PCMH<br />When possible care of the patient will be delivered by their team <br />Same day appointments will be available to care for acutely ill panel members decreasing ED visits<br />Improve provider throughput to improve time spent with direct patient care<br />
    7. 7. The Clinical Pharmacy Specialist Role<br />Identify patients who do not achieve a variety of performance goals and assist in chronic disease management to achieve therapeutic outcomes <br />Enhance drug information by functioning as a therapeutic consultant to providers and other health care workers<br />Relieve providers by assisting them with patient follow-up after medication changes, therapeutic drug monitoring, and patient medication counseling. <br />Increase patient satisfaction by decreasing overall appointment wait times while providing the highest quality of care for our veterans <br />
    8. 8. The Clinical Pharmacy Role<br />Increase effectiveness of medication reconciliation by decreasing medication discrepancies through prospective pharmacist review <br />Improved inventory/formulary managementresulting in more effective budget management<br />Enhance medication safety by having the pharmacist assure that patients on certain medications get timely and appropriate laboratory assessments for both efficacy and adverse event prevention <br />
    9. 9. Clinical Pharmacy Specialists can increase the efficiency of physician-patient interactions and allow for greater patient access to clinics<br />Improved Quality & Efficiency of Care<br />TIER II <br />TIER I<br />
    10. 10. “Patient Centered Medical Home”<br />Presentation by David Macpherson, MD<br />Chief Medical Officer, VISN 4<br />
    11. 11. Clinical Pharmacy Specialist<br />Direct Patient Care<br /><ul><li>Scheduled Clinic Visits
    12. 12. Telephone Visits
    13. 13. Walk in / Urgent /Group Visits
    14. 14. Pertinent Clinical Reminders</li></ul>Care Management<br /><ul><li>Manage/prescribe medications for identified disease states in accordance with published guidelines and generally recognized standards of care to include orderings and reviewing lab and diagnostic studies. Care management is not limited to hypertension, diabetes, hyperlipidemia, anticoagulation, heart failure, kidney disease, tobacco cessation, COPD, and asthma.
    15. 15. Documents clinical drug therapy interventions and plan of care
    16. 16. Preventive care needs
    17. 17. Non VA records / Dual care / Traveling veterans
    18. 18. Medication Reconciliation
    19. 19. Evaluate Non-Formulary or Criteria-Based medication requests to ensure compliance with VA National Formulary and established Criteria for Use
    20. 20. Complete Medication Use Evaluations to assess appropriateness of use, appropriate monitoring parameters, and compliance with national guidelines</li></li></ul><li>Clinical Pharmacist<br />Direct Patient Care<br /><ul><li>Walk in or Urgent Visits
    21. 21. Telephone Visits/Telephone triage
    22. 22. Assessment of Medication Management/Patient education
    23. 23. Medication order processing/medication clinic interventions
    24. 24. Pertinent Clinical Reminders</li></ul>Care Management<br /><ul><li>Medication Counseling
    25. 25. Medication Reconciliation
    26. 26. Identify/monitor high risk medications and evaluates appropriate monitoring parameters
    27. 27. Preventive care needs
    28. 28. Non VA record review as appropriate
    29. 29. Evaluate Non-Formulary or Criteria-Based medication requests for the team to ensure compliance with VA National Formulary and established Criteria for Use</li></li></ul><li>Clinical Pharmacy Specialist (CPS)<br />Primary Care can utilize the Clinical Pharmacy Specialist in direct patient care roles. They are mid-level providers with a VA scope of practice and able to perform to the highest level of their profession.<br /> * Managing patient’s drug therapy to goal <br /> for chronic disease states and other specialty care <br />These positions are highly respected provider members with advance professional skills<br />
    30. 30. Clinical Pharmacy Specialist (CPS)<br />The CPS has an advanced degree <br />(today - Doctor of Pharmacy)<br />Four years in medication management<br />Residency trained <br />ASHP accredited residency program (PGY-1)<br />May have completed advance practice residency (PGY-2)<br />Board Certification<br />The CPS functions under an expanded Scope of Practice<br />
    31. 31. VHA Directive 2009-014: <br />Pharmacist as an Individual Practitioner <br />CPSs are granted medication prescribing & monitoring privileges based on a locally-defined scope of practice.<br />Scope of practice is approved by:<br />Clinical/Medical Executive Committee <br />Chief of Staff or Associate Director for Patient Care Services<br />Chief of Pharmacy<br />
    32. 32. CPS Scope of Practice<br />Scope of Practice allows CPS to:<br />Work in concert with an attending physician<br />Evaluate medication therapy through direct patient care involvement<br />Prescribe medications, devices and supplies to include: initiation, continuation, discontinuation, monitoring and altering therapy without co-signature <br />Perform physical measurements necessary to ensure appropriate patient clinical responses to drug therapy <br />Order consults, as appropriate, to maximize positive drug therapy outcomes and disease state management.<br />
    33. 33. Scope of Practice versus Use of Protocols<br />Protocols are flow based algorithms<br />Protocols are not intended to address complex medication related problems <br />Today, chronic disease medication management utilizes a variety of drug classes.<br />Protocols require vigilant maintenance to reflect the standards of care, safety bulletins, and VA National Formulary changes.<br />
    34. 34. Chronic Disease Medication Management<br />Chronic diseases have multiple drug therapy options to achieve therapeutic goals.<br />VA’s National Formulary and PBM/MAP Criteria for Use documents provide patient specific criteria<br />CPS and Clinical Pharmacists are well versed with the VA National Formulary and are VA experts on drug information, medication selection for specific diseases and medication safety (alerts and bulletins). <br />CPS have the advance skills necessary to provide Medication Management Services in Primary Care and Specialty Care<br />The Clinical Pharmacist plays a vital role in dual-care management, therapeutic interchange, and medication reconciliation<br />
    35. 35. VA Experience with CPS Integrated in Primary Care Settings<br />San Diego VAMC<br />West Palm Beach VAMC<br />Jesse Brown Chicago VAMC<br />
    36. 36. San Diego VA Medical Center<br />
    37. 37. VASDHS Primary Care Clinics<br />Anticoagulation<br />Hyperlipidemia<br />Intensive Diabetes Care<br />FIRM-HTN/Lipid/DM<br />Dermatology<br />Pain<br /><ul><li>Mental Health
    38. 38. Smoking Cessation
    39. 39. Medication Management
    40. 40. Pulmonary
    41. 41. Anemia of CKD</li></li></ul><li>VASDHS Secondary Care Clinics<br />Neurology<br />Heart Failure<br />Urology<br />SPID<br />Rheumatology<br />Urology<br />Oncology<br />Nephrology<br />Diabetes<br />General Medicine<br />
    42. 42. A Routine Day: Utilizing CPS Within the Home Model<br />Patient Clinic Visits (via appointment package)<br />Managing Pharmacotherapy<br />Patient Education<br />Clinical Reminders<br />Physical Assessment<br />Medication Renewals<br />PreceptingPharm.D. Residents/Students<br />TeleHealth Follow-Up & Interventions<br />Administrative Role/Quality Assurance<br />
    43. 43. Clinical Pharmacy Specialists Can Address:<br /><ul><li>Identification of absent therapies, sub-optimal doses, significant drug interactions
    44. 44. Medication adherence assessment
    45. 45. Provision and monitoring of cost effective and safe regimens
    46. 46. Dietary/Lifestyle recommendations
    47. 47. Participation in quality improvement initiatives
    48. 48. Provider education
    49. 49. Patient education</li></li></ul><li>Chronic Disease Management Outcomes<br />VASDHS DIABETES INTENSE MEDICAL MANAGEMENT CLINIC<br />
    50. 50. TeleHealth Therapeutic Outcomes<br />
    51. 51. West Palm Beach VA Medical Center<br />
    52. 52. West Palm Beach VAMC Opened in June 1995<br />Guiding philosophies/principles (that endured)<br />Interdisciplinary team based care<br />Patient centered<br />Staff function at highest level of ability/licensure<br />Efficient and Effective Use of Resources<br />                                                   <br />Not all original principals opening principles/approaches endured<br />                         <br />Pharmacy Service CPS pharmacist managing chronic medication patients as part of the PC teams (and on other teams) from opening day.<br /> <br />The CPS pharmacy model at WPB continues today with significant expansion of CPSs<br />
    53. 53. West Palm Beach: A Historical Perspective<br />Medical Center Opened June 26, 1995:<br />1,100 employees<br />25,384 vets served<br />229,237 outpatient visits<br />CPS Pharmacists <br />3 FTEE Primary Care Medication Management Clinics<br />1 FTEE Mental Health Clinic<br />1 FTEE Infectious Disease Clinic<br />1 FTEE Acute Medicine<br />1 FTEE Long Term Care<br />
    54. 54. West Palm Beach CPS Program 2010Ambulatory Care<br />Infectious Diseases (1 FTEE)<br />Cardiology (1 FTEE)<br />Mental Health (1 FTEE)<br />Substance Abuse (1 FTEE)<br />Smoking Cessation<br />Hem-Onc (1 FTEE)<br />Pain Clinic (1 FTEE)<br />Anticoagulation (3 FTEE)<br />Medication Management- Primary Care (4.5 FTEE)<br />Community Based Clinics-Telemedicine (1 FTEE)<br />Home Based Primary Care (1 FTEE)<br />Endocrine Clinic (1.5 FTEE)<br />
    55. 55. West Palm Beach CPS Program 2010Inpatient Services<br />Pulmonary-Critical Care (1 FTEE)<br />Acute Medicine (4 FTEE)<br />Long-Term Care (1 FTEE)<br />Hospice (1 FTEE)<br />Inpatient Psychiatry (1 FTEE)<br />
    56. 56. West Palm Beach VA Home Model<br />Primary Care Clinical Pharmacist Responsibilities Distribution of the Work Week<br />80% Direct Patient Care<br />60% Med Management Clinic (3 days/week)<br />HTN, DM, HL, COPD, CHF, Thyroid, Polypharmacy Management<br />30 minute appointments from 8:00am-2:30pm<br />20% Walk-in Pharmacy Clinic (1 day/week)<br />Based on need: 2-10 face-to-face, 30 non face-to-face interviews<br />20-30 Non-Formulary Consults<br />20 PC Pharmacy Clinic Consults<br />PCP requests for patient medication counseling<br /> 20% Indirect Patient Care (1day/week)<br />Administration/Unscheduled Clinic Coverage<br />Med Reconciliation/Allergy Assessment for Newly Enrolled Veterans<br />Lab Monitoring and Telephone f/u<br />
    57. 57. West Palm Beach VA Team Approach<br />PC Provider sees patient for normal scheduled visit<br />Patient’s lipid values not at goal levels<br />PC Provider makes medication adjustment at that visit<br />PC Provider refers patient to Clinical Pharmacist for follow-up lipids and goal attainment<br />Patient is scheduled to see Clinical Pharmacist until they reach goal LDL-c levels<br />
    58. 58. Patient Scheduling with and without the use of CPS<br />without PharmD<br /> with PharmD<br />Courtesy of Dr. Rubin, D.O.<br />Chief of Primary Care Service<br />West Palm Beach VA Medical Center<br />
    59. 59. Evidence for Improved Outcomes within the Home Model<br />Retrospective chart review of 150 patients treated for CAD in PC Clinics at WPB VAMC: CPS referral vs. PCP alone<br />Despite the relatively high percentage of patients reaching goal LDL in the PCP group, referral to CPSs resulted in statistically significant increases in the number of patients appropriately treated for hypercholesterolemia and achieving goal LDL<br />Geber J, Parra D, Beckey NP, Korman L. Optimizing drug therapy in patients with cardiovascular disease: the impact of pharmacist-managed pharmacotherapy clinics in a primary care setting. Pharmacotherapy. 2002 Jun;22(6):738-47<br />
    60. 60. Evidence for Improved Outcomes<br />Geber J, Parra D, Beckey NP, Korman L. Optimizing drug therapy in patients with cardiovascular disease: the impact of pharmacist-managed pharmacotherapy clinics in a primary care setting. Pharmacotherapy. 2002 Jun;22(6):738-47<br />
    61. 61. Jesse Brown Chicago VA Medical Center<br />
    62. 62. Jesse Brown VAMC Primary Care Home Model<br />Primary Care Team Staffing<br />Each team:<br /><ul><li> 3 Primary Care Physicians
    63. 63. 1 Nurse Case Manager
    64. 64. 1 LPN
    65. 65. 0.5 Health Tech
    66. 66. 1 Clinical Pharmacy Specialist</li></ul>Chronic Disease Management Role of CPS<br /><ul><li> Anticoagulation
    67. 67. Diabetes
    68. 68. COPD/Asthma
    69. 69. BPH
    70. 70. Hypertension
    71. 71. Hyperlipidemia
    72. 72. Medication Management
    73. 73. Therapeutic Drug Monitoring</li></li></ul><li>Jesse Brown VAMC Home Model<br />Standard Pharmacy Clinic Structure<br /><ul><li> 4.5 clinic days per week
    74. 74. 20 minute appointments
    75. 75. 16-18 appointment slots per day </li></ul> (except Thursdays: ½ day clinic)<br />Referral Process<br /><ul><li>providers schedule directly into CPS clinic
    76. 76. review of patients who do not meet performance/therapeutic goals are scheduled
    77. 77. Referrals based on national formulary changes and national medication efficiency programs</li></li></ul><li>Jesse Brown VAMC Home Model<br />Four Primary Care Teams<br />Data from 3/09 – 3/10; <br />source – VSSC cube and VISTA<br />
    78. 78. Jesse Brown VAMC Home Model<br />Other Clinical Pharmacy Specialist Responsibilities<br /><ul><li> Medication Use Evaluations – QA program
    79. 79. Non-Formulary Consult Review
    80. 80. Assist with Formulary Conversions and Annual </li></ul> Cost Savings Initiatives<br /><ul><li>Assist with facility performance measures/initiatives
    81. 81. Membership in various Local, VISN, and/or National </li></ul>Groups/Committees<br /><ul><li> Research
    82. 82. Precept 4th Year Pharmacy Students (min 5 students/year)
    83. 83. Precept PGY-1 Pharmacy Practice Residents</li></li></ul><li>Jesse Brown VAMC Home Model<br />CPS integrated in primary care at main station and four community based outpatient clinics (CBOC)<br />CPS reports to pharmacy service<br />Success of this integrated role has led to CPS expansion in specialty clinics throughout the medical center<br />Pharmacy continues to receive requests from medical staff to expand CPS services<br />
    84. 84. Jesse Brown VA Medical Center Home Model<br />Specialty Clinical Pharmacy Clinics<br /><ul><li>Intense Diabetes Management
    85. 85. Emergency Department
    86. 86. Geriatrics
    87. 87. Gastroenterology
    88. 88. Home Based Primary Care
    89. 89. Home Infusion Program
    90. 90. Infectious Diseases
    91. 91. Co-Infection – Hepatitis C
    92. 92. Mental Health
    93. 93. Nephrology
    94. 94. Pain
    95. 95. Pulmonary
    96. 96. Smoking Cessation
    97. 97. Urology
    98. 98. Women’s Health</li></li></ul><li>Jesse Brown VA Medical Center Home Model<br />Pharmacy Clinic Outcomes – Diabetes Management<br />Percentages given as a mean<br />2009<br />
    99. 99. Jesse Brown VA Medical Center Home Model<br />Pharmacy Clinic Outcomes – Women’s Health<br /> Multidisciplinary clinic model<br /> Mean number of visits: 2.4 over 6 months<br />Values given as a mean<br />2009<br />
    100. 100. Case: Izzy<br />Isabella Vicenza is a moderately obese 66 year old female veteran with diabetes, coronary artery disease, and COPD<br />She is a current smoker and doesn’t want to quit<br />Hemoglobin A1c is 10.2, and has never been below 9.0 for the past 10 years<br />LDL is146<br /> She has never consented to a mammogram, a colonoscopy, or a regular pap smear<br />
    101. 101. Case: Izzy<br />Her medications are <br />Glypizide 5mg daily <br />(which she takes when she feels like her blood sugar is high. She won’t take her blood sugar because she doesn’t like to poke herself)<br />Fish oil 1000mg twice a day<br />(she will take this because its ‘natural’)<br />Aspirin 81mg daily <br />(as long as she doesn’t notice any bruising – she’s willing to take this because her father had a stroke and refused to take aspirin)<br />She has been prescribed an atrovent/albuterol inhaler which she only uses when she feels short winded. She has been instructed to use it four times a day, but doesn’t because she’s annoyed that she’s expected to do something for the doctor four times a day<br />“I’m already taking enough medicines. They’re all poisons as far as I’m concerned.” <br />
    102. 102. Population of Women Veterans<br />Source: VHA ADUSH for Policy and Planning<br />
    103. 103. Women: An Underserved Population<br />
    104. 104. VISN 21 Male Gender Dashboard<br />
    105. 105. VISN 21 Female Gender Dashboard<br />
    106. 106. Performance by Gender<br />
    107. 107. Staffing Guidance<br />
    108. 108. Achieving PCMH Goals<br />Many medical centers have been staffing Clinical Pharmacy Specialist to work in Primary Care for less than 40 hours per week. <br />Primary Care has identified goals to require that the staffing be dedicated to work in the Patient Centered Medical Home, as Clinical Pharmacy Specialists for management of chronic diseases and patients on anticoagulation therapy. <br />Primary Care instructions for funding allow:<br />Clinical pharmacy specialists to be added to the PCMH team<br />
    109. 109. Achieving PCMH Goals<br />Facilities may recruit or staff existing VA clinical pharmacy specialists into these new roles as full time employees and then backfilling their vacated positions<br />Don’t Miss This Opportunity to Recruit <br />VA has 400 pharmacy practice residents who complete their training each June. <br />At current turn-over rates, VA is only able to hire about 50% of these highly skilled clinical pharmacists, leaving an annual pool of up to 200 potential Clinical Pharmacy Specialists who could be hired to support the PCMH for management of chronic disease medication therapy. <br />
    110. 110. PCMH Staffing Recommendations: <br /> Staffing for Clinical Pharmacy Specialists working in Primary Care for chronic disease management: <br />0.3 CPS per 1200 PC panel of patients<br />Or said differently: <br />Approximately 1 FTEE CPS for every 3 primary care providers<br />
    111. 111. PCMH Staffing Recommendations: <br /> Staffing for Clinical Pharmacy Specialists working in Anticoagulation: <br />0.2 CPS per 1200 PC panel of patients<br />Or said differently: <br />Approximately 1 FTEE CPS for every 5 primary care providers<br />Note: this provides a 1:300 ratio which may be higher that current requirements. Many sites reported a 1:400 ratio. <br />Anticoagulation programs should <br />remain centralized <br />
    112. 112. VA is a nationally recognized leader in Clinical Pharmacy Services.<br />The team based approach of the Patient Centered Medical Home provides the opportunity for this role and that of the other team members to become the standard of care.<br />
    113. 113. Questions ?<br />