Complexity of patients with mental healthcare needs cared for by mental health clinical pharmacist practitioners in Veterans Affairs.

PURPOSE: The complexity of patients with mental healthcare needs cared for by clinical pharmacists is not well delineated. We evaluated the complexity of patients with schizophrenia, bipolar disorder, and major depressive disorder (MDD) in Veterans Affairs (VA) cared for by mental health clinical pharmacist practitioners (MH CPPs). METHODS: Patients at 42 VA sites with schizophrenia, bipolar disorder, or MDD in 2016 through 2019 were classified by MH CPP visits into those with 2 or more visits ("ongoing MH CPP care"), those with 1 visit ("consultative MH CPP care"), and those with no visits ("no MH CPP care"). Patient complexity for each condition was defined by medication regimen and service utilization. RESULTS: For schizophrenia, more patients in ongoing MH CPP care were complex than those with no MH CPP care, based on all measures examined: the number of primary medications (15.3% vs 8.1%), inpatient (13.7% vs 9.1%) and outpatient (42.6% vs 29.7%) utilization, and receipt of long-acting injectable antipsychotics (36.7% vs 25.8%) and clozapine (20.5% vs 9.5%). For bipolar disorder, more patients receiving ongoing or consultative MH CPP care were complex than those with no MH CPP care based on the number of primary medications (27.9% vs 30.5% vs 17.7%) and overlapping mood stabilizers (10.1% vs 11.6% vs 6.2%). For MDD, more patients receiving ongoing or consultative MH CPP care were complex based on the number of primary medications (36.8% vs 35.5% vs 29.2%) and augmentation of antidepressants (56.1% vs 54.4% vs 47.0%) than patients without MH CPP care. All comparisons were significant (P < 0.01). CONCLUSION: MH CPPs provide care for complex patients with schizophrenia, bipolar disorder, and MDD in VA.

Assessment of burnout and pandemic fatigue among pharmacy leadership in the Veterans Health Administration healthcare system.

PURPOSE: Factors associated with burnout in Veterans Health Administration (VHA) pharmacy leadership positions were examined during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: A questionnaire was distributed to all pharmacy executives of the VHA healthcare system. It collected demographic and employment characteristics, career satisfaction and work-related variables, indicators of burnout using validated single-item measures adapted from the Maslach Burnout Inventory, and the impact of the COVID-19 pandemic on psychosocial and work-related variables. A χ2 test with Bonferroni correction was used to evaluate the data. Burnout was defined as a score of 4 or greater on either of the 2 single-item validated statements adapted from the Maslach Burnout Inventory to assess emotional exhaustion and depersonalization. RESULTS: In total, 407 (of 1,027; 39.6%) VHA pharmacy leaders representing Veterans Integrated Service Network pharmacy executives, chiefs of pharmacy, associate chiefs of pharmacy, and inpatient and outpatient supervisors completed the survey. The overall prevalence of burnout was 68.6% using the aggregate measure of emotional exhaustion or depersonalization. Pharmacy leaders who worked more than 60 hours a week reported significantly greater rates of burnout than those who worked 40 to 60 hours a week (86.7% vs 66.9%, χ2 = 7.34, degrees of freedom = 1, P < 0.05). Those experiencing increased workload related to COVID-19 also reported high burnout rates (72.1%, χ2 = 16.40, degrees of freedom = 1, P < 0.001). Burnout scores were similar across groups when respondents were stratified by leadership position, gender, age, or years in position. CONCLUSION: As of March 2021, two-thirds of pharmacy leaders were experiencing burnout. It is important for healthcare system leadership to identify patterns of burnout among their pharmacy leaders to ensure a productive and sustainable workforce.

Evaluation of Patient Experience with Veterans Affairs Clinical Pharmacist Practitioners Providing Comprehensive Medication Management.

Patient experience is considered an important dimension of health care quality and thus is included as part of the quadruple aim of health care. The VHA Clinical Pharmacist Practitioner (CPP) operates as an advanced practice provider (APP) providing comprehensive medication management (CMM) with authority to initiate, discontinue or modify medication under a scope of practice (SOP). The VHA CPP practices in many different outpatient clinical areas to include but not limited to primary care, mental health, pain management, cardiology, substance use disorder and anticoagulation. While literature regarding the ability of the VHA CPP to increase access and quality of care is well published, very little information exist regarding patient experience with the VHA CPP. We sought to report the patient experience with VHA CPP as measured electronically over 1 year by Veterans. Patient experience surveys were electronically sent to randomly selected Veterans via email to evaluate a recent outpatient healthcare encounter at a VA medical center or outpatient clinic with a CPP with scoring on a Likert scale of 1-5 with 5 being optimal. A total of 743 Veteran surveys were completed for a response rate of 20%. For individual domains of patient experience based on respondent scores of 4 or 5, ease and simplicity were rated at 94.4%, quality 91.9%, employee helpfulness 94.9%, satisfaction 95.0% and confidence/trust 91.9%. Results demonstrate that Veterans' experience with the CPP in every patient care experience domain was positive with scores ranging from the low to high 90th percentile.

Assessing the Impact of Comprehensive Medication Management on Achievement of the Quadruple Aim.

Nonoptimized medication regimens cost patients and payors in the United States more than $528 billion in additional health care expenses each year. Comprehensive medication management is a patient-centered approach to medication optimization delivered by a clinical pharmacist working with the patient, physicians, and other members of the health care team. Comprehensive medication management ensures medications are assessed for appropriateness, effectiveness, and safety given the patient's clinical status, comorbidities, and other medications, as well as the patient's ability to take the medications as intended and adhere to the regimen. This article reviews the growing body of literature demonstrating the value of comprehensive medication management in achieving the quadruple aim of health care: better care, reduced health care costs, an improved patient experience, and provider well-being.

Assessment of pharmacist gender bias: Egalitarianism of the Department of Veterans Affairs.

For the past 2 decades, the earnings gap between genders has narrowed for pharmacists, making it 1 of the smallest for a high-wage profession. Gender bias is reflected in 2 main areas, pay and opportunity. The Department of Veterans Affairs (VA) is the largest integrated health care system in the country, and the authors performed an analysis to see if there was any evidence of gender bias within its pharmacist workforce. The distribution of pharmacists by gender, age, and years of service was examined and whether part-time employment had any impact was also studied. Overall, there is a high degree of gender egalitarianism in terms of pay and opportunity for pharmacists at the VA. The level of step achievement, and thus, pay for men and women, was not associated with gender but rather years of service.

Increasing access to care using clinical pharmacy specialist providers in outpatient mental health: Successful practice integration within the Department of Veterans Affairs.

BACKGROUND: To highlight the role and impact of the mental health (MH) clinical pharmacist provider in outpatient MH through successful practice integration into team-based care. OBJECTIVE: The MH clinical pharmacy specialist (CPS) provider serves in many key roles to improve patient-centered care and medication outcomes by supporting the needs of the MH team, patients, and caregivers in areas of comprehensive medication management. MH CPS providers are integrated as MH providers in general and specialty MH clinics, behavioral health clinics embedded in primary care, residential rehabilitation facilities, specialty MH programs, and in inpatient MH units to improve access, quality, and safety. PRACTICE DESCRIPTION: There is a shortage of psychiatrists across the United States, which affects the ability to provide MH care to patients. PRACTICE INNOVATION: There is a need to transform the MH team to include clinicians focused on providing services to the growing population with MH conditions; hence, the expertise of the MH CPS is an asset to increase access to comprehensive medication management services. EVALUATION: The MH CPS provider serves patients with a variety of MH conditions, managing medication-related adverse events, performing ongoing and acute medication monitoring, and collaborating with other health care providers for management of new diagnoses. RESULTS: The MH CPS provider improves access to care, clinical outcomes, and safety when deployed as direct patient care providers on Veterans Affairs (VA) interprofessional care teams. VA MH clinical pharmacy practice continues to demonstrate what the MH CPS provider, practicing at the top of their license, can achieve as a core member in MH team-based care. CONCLUSION: These foundational concepts can be applied to further expand MH clinical pharmacy practice into non-VA settings through the use collaborative practice agreements and integration into interprofessional care teams, providing access to patients in need of MH care.

Comparison of clinical pharmacy specialists and usual care in outpatient management of hyperglycemia in Veterans Affairs medical centers.

PURPOSE: The results of a study to assess the effectiveness and safety of hyperglycemia management provided by clinical pharmacy specialists (CPSs) versus usual care in outpatients with diabetes from 53 Veterans Affairs (VA) medical centers are reported. METHODS: An historical cohort study of outpatients with baseline glycosylated hemoglobin (HbA1c) values of >9% who were referred to a CPS for management of hyperglycemia and primary care patients who were not referred to a CPS was conducted. The primary outcomes were change in HbA1c over time and time to reach an HbA1c value of <8%. Secondary outcomes included the number of visits to achieve an HbA1c value of <8%, proportion of patients with an HbA1c value of <6% who were receiving secretagogues, and proportion of patients with serious hypoglycemia. RESULTS: After propensity score matching by baseline characteristics, there were 12,327 patients in each group. The mean ± S.D. number of visits to reach an HbA1c value of <8% was 2.46 ± 1.58 in the pharmacist-managed group and 1.82 ± 1.27 with usual care (p < 0.001). The proportion of patients with an HbA1c value of <6% who were receiving secretagogues was 39.9% with pharmacist-managed care and 38.6% with usual care (p = 0.73). Serious hypoglycemia was noted in 4.3% of pharmacist-managed patients and 3.1% of usual care patients (p < 0.001). CONCLUSION: Data from 53 VA medical centers revealed that CPSs managed the care of ambulatory care patients with hyperglycemia as well as primary care providers.

Increasing access for veterans with hepatitis C by enhancing use of clinical pharmacy specialists.

OBJECTIVES: To increase access to hepatitis C virus (HCV) care and cure by deploying clinical pharmacy specialist (CPS) providers across the largest integrated health care system in the United States. SETTING: National integrated health care system. PRACTICE DESCRIPTION: In late 2016, the Department of Veterans Affairs (VA) Pharmacy Benefits Management Clinical Pharmacy Practice Office (CPPO) partnered with the VA HIV, Hepatitis, and Related Conditions Program with the central priority of expanding veteran access to novel HCV treatments and timely cure to ultimately prevent morbidity and mortality associated with HCV disease progression. This successful collaboration resulted in clinical resource funding to bolster access to HCV treatment through the deployment of CPS providers. This enterprise-wide initiative to expand clinical pharmacy services for unmet health care needs in HCV treatment resulted in 52 VA facilities submitting full-time employment equivalent (FTEE) funding requests totaling more than $10 million dollars. Facilities may have requested funding for 1 or more FTEEs. RESULTS: Facilities hired 47 CPS providers and 5 clinical pharmacy technicians. CPS providers in this project recorded 24,888 patient care encounters providing care for 9593 unique patients and initiated new HCV treatment for 1191 treatment-naïve patients. For an additional 8402 patients, the CPS provided HCV care activities such as evaluation and monitoring before, during, and after treatment. CPPO estimates that the same care delivered by nonpharmacist provider specialists (e.g., specialty physicians) cost an additional $936,535, or 48% more. CONCLUSION: The deployment of HCV CPS resulted in a significant number of new HCV patients being screened and treated within the VA system.

Development of a Pharmacoeconomic Model to Demonstrate the Effect of Clinical Pharmacist Involvement in Diabetes Management.

BACKGROUND: A data collection tool was developed and nationally deployed to clinical pharmacists (CPs) working in advanced practice provider roles within the Department of Veterans Affairs to document interventions and associated clinical outcomes. Intervention and short-term clinical outcome data derived from the tool were used to populate a validated clinical outcomes modeling program to predict long-term clinical and economic effects. OBJECTIVE: To predict the long-term effect of CP-provided pharmacotherapy management on outcomes and costs for patients with type 2 diabetes. METHODS: Baseline patient demographics and biomarkers were extracted for type 2 diabetic patients having > 1 encounter with a CP using the tool between January 5, 2013, and November 20, 2014. Treatment biomarker values were extracted 12 months after the patient's initial visit with the CP. The number of visits with the CP was extracted from the electronic medical record, and duration of visit time was quantified by Current Procedural Terminology codes. Simulation modeling was performed on 3 patient cohorts-those with a baseline hemoglobin A1c of 8% to < 9%, 9% to < 10%, and ≥ 10%-to estimate long-term cost and clinical outcomes using modeling based on pivotal trial data (the Archimedes Model). A sensitivity analysis was conducted to assess the extent to which our results were dependent on assumptions related to program effectiveness and costs. RESULTS: A total of 7,310 patients were included in the analysis. Analysis of costs and events on 2-, 3-, 5-, and 10-year time horizons demonstrated significant reductions in major adverse cardiovascular events (MACEs), myocardial infarctions (MIs), episodes of acute heart failure, foot ulcers, and foot amputations in comparison with a control group receiving usual guideline-directed medical care. In the cohort with a baseline A1c of ≥ 10%, the absolute risk reduction was 1.82% for MACE, 1.73% for MI, 2.43% for acute heart failure, 5.38% for foot ulcers, and 2.03% for foot amputations. The incremental cost-effectiveness ratios for cost per quality-adjusted life-year during the 2-, 3-, 5-, and 10-year time horizons were cost-effective for the cohorts of patients with a baseline A1c of 9% to < 10% and ≥ 10%. CONCLUSIONS: CPs acting as advanced practice providers reduced A1c from baseline for veterans with type 2 diabetes compared with modeled usual care. Archimedes modeling of the A1c reductions projects a decreased incidence of diabetes complications and overall health care spending when compared with modeled usual care. DISCLOSURES: There was no outside funding source or sponsor for this project. None of the authors report any conflicts of interest. The views expressed in this article are those of the authors and do not necessarily reflect the views or policies of the U.S. Department of Veterans Affairs. Preliminary data from this project were previously presented in abstract form at the Academy of Managed Care Pharmacy 27th Annual Meeting and Expo; April 8-10, 2015; in San Diego, California.

Results of a Regional Effort to Improve Warfarin Management.

BACKGROUND: Improved anticoagulation control with warfarin reduces adverse events and represents a target for quality improvement. No previous study has described an effort to improve anticoagulation control across a health system. OBJECTIVE: To describe the results of an effort to improve anticoagulation control in the New England region of the Veterans Health Administration (VA). METHODS: Our intervention encompassed 8 VA sites managing warfarin for more than 5000 patients in New England (Veterans Integrated Service Network 1 [VISN 1]). We provided sites with a system to measure processes of care, along with targeted audit and feedback. We focused on processes of care associated with site-level anticoagulation control, including prompt follow-up after out-of-range international normalized ratio (INR) values, minimizing loss to follow-up, and use of guideline-concordant INR target ranges. We used a difference-in-differences (DID) model to examine changes in anticoagulation control, measured as percentage time in therapeutic range (TTR), as well as process measures and compared VISN 1 sites with 116 VA sites located outside VISN 1. RESULTS: VISN 1 sites improved on TTR, our main indicator of quality, from 66.4% to 69.2%, whereas sites outside VISN 1 improved from 65.9% to 66.4% (DID 2.3%, P < 0.001). Improvement in TTR correlated strongly with the extent of improvement on process-of-care measures, which varied widely across VISN 1 sites. CONCLUSIONS: A regional quality improvement initiative, using performance measurement with audit and feedback, improved TTR by 2.3% more than control sites, which is a clinically important difference. Improving relevant processes of care can improve outcomes for patients receiving warfarin.

Estimated Cost-Effectiveness, Cost Benefit, and Risk Reduction Associated with an Endocrinologist-Pharmacist Diabetes Intense Medical Management "Tune-Up" Clinic.

BACKGROUND: In 2012 U.S. diabetes costs were estimated to be $245 billion, with $176 billion related to direct diabetes treatment and associated complications. Although a few studies have reported positive glycemic and economic benefits for diabetes patients treated under primary care physician (PCP)-pharmacist collaborative practice models, no studies have evaluated the cost-effectiveness of an endocrinologist-pharmacist collaborative practice model treating complex diabetes patients versus usual PCP care for similar patients. OBJECTIVE: To estimate the cost-effectiveness and cost benefit of a collaborative endocrinologist-pharmacist Diabetes Intense Medical Management (DIMM) "Tune-Up" clinic for complex diabetes patients versus usual PCP care from 3 perspectives (clinic, health system, payer) and time frames. METHODS: Data from a retrospective cohort study of adult patients with type 2 diabetes mellitus (T2DM) and glycosylated hemoglobin A1c (A1c) ≥ 8% who were referred to the DIMM clinic at the Veterans Affairs San Diego Health System were used for cost analyses against a comparator group of PCP patients meeting the same criteria. The DIMM clinic took more time with patients, compared with usual PCP visits. It provided personalized care in three 60-minute visits over 6 months, combining medication therapy management with patient-specific diabetes education, to achieve A1c treatment goals before discharge back to the PCP. Data for DIMM versus PCP patients were used to evaluate cost-effectiveness and cost benefit. Analyses included incremental cost-effectiveness ratios (ICERs) at 6 months, 3-year estimated total medical costs avoided and return on investment (ROI), absolute risk reduction of complications, resultant medical costs, and quality-adjusted life-years (QALYs) over 10 years. RESULTS: Base case ICER results indicated that from the clinic perspective, the DIMM clinic costs $21 per additional percentage point of A1c improvement and $115-$164 per additional patient at target A1c goal level compared with the PCP group. From the health system perspective, medical cost avoidance due to improved A1c was $8,793 per DIMM patient versus $3,506 per PCP patient (P = 0.009), resulting in an ROI of $9.01 per dollar spent. From the payer perspective, DIMM patients had estimated lower total medical costs, a greater number of QALYs gained, and appreciable risk reductions for diabetes-related complications over 2-, 5- and 10-year time frames, indicating that the DIMM clinic was dominant. Sensitivity analyses indicated results were robust, and overall conclusions did not change appreciably when key parameters (including DIMM clinic effectiveness and cost) were varied within plausible ranges. CONCLUSIONS: The DIMM clinic endocrinologist-pharmacist collaborative practice model, in which the pharmacist spent more time providing personalized care, improved glycemic control at a minimal cost per additional A1c benefit gained and produced greater cost avoidance, appreciable ROI, reduction in long-term complication risk, and lower cost for a greater gain in QALYs. Overall, the DIMM clinic represents an advanced pharmacy practice model with proven clinical and economic benefits from multiple perspectives for patients with T2DM and high medication and comorbidity complexity. DISCLOSURES: No outside funding supported this study. The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Preliminary versions of the study data were presented in abstract form at the American Pharmacists Association Annual Meeting & Exposition; March 27, 2015; San Diego, California, and the Academy of Managed Care Pharmacy Annual Meeting; April 21, 2016; San Francisco, California. Study concept and design were contributed by Hirsch, Bounthavong, and Edelman, along with Morello and Morreale. Arjmand, Ourth, Ha, Cadiz, and Zimmerman collected the data. Data interpretation was performed by Ha, Morreale, and Morello, along with Cadiz, Ourth, and Hirsch. The manuscript was written primarily by Hirsch and Zimmerman, along with Arjamand, Ourth, and Morello, and was revised by Hirsch and Cadiz, along with Bounthavong, Ha, Morreale, and Morello.

Pharmacy Benefits Management in the Veterans Health Administration Revisited: A Decade of Advancements, 2004-2014.

Over the past decade, the Department of Veterans Affairs (VA) Pharmacy Benefits Management Services (PBM) has enhanced its formulary management activities and added programs to ensure that the national drug plan continues to meet the pharmacy needs of veterans and to promote safe and appropriate drug therapy in the face of rising medication expenditures. This article describes the broad range of services provided by the VA PBM that work in partnership to deliver a high-quality and sustainable pharmacy benefit for veterans. In support of formulary management, VA PBM pharmacists prepare extensive clinical guidance documents (e.g., drug monographs and criteria for use) that are used by physicians and pharmacists with operational and clinical oversight of the VA national formulary. The VA PBM has utilized various contracting techniques and continually evaluates drug utilization data to identify opportunities for potential savings. Remarkably, since before 2004, the average acquisition cost for a 1-month supply of medication has remained fairly stable at approximately $13-$15. Two new VA PBM programs are the VA Center for Medication Safety (VA MedSAFE) and the Clinical Pharmacy Practice Office (CPPO). VA MedSAFE is a comprehensive pharmacovigilance program focused on the detection, assessment, and prevention of adverse drug events, and CPPO is dedicated to improving safe and appropriate medication use by supporting and expanding clinical pharmacy practice. Moving forward, the VA PBM will consider new initiatives to stay at the forefront of providing quality care while maintaining economic viability. DISCLOSURES: No outside funding supported this research. This work was supported by VA Pharmacy Benefits Management Services (VA PBM), Hines, Illinois, and VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania. Glassman is co-director of the VA Center for Medication Safety, which is part of the VA PBM. He is also part of the Medical Advisory Panel for the VA PMB. All other authors are employed by the VA PBM. The views expressed in this article are those of the authors, and no official endorsement by the U.S. Department of Veteran Affairs or the U.S. government is intended or should be inferred. Study concept and design were contributed by Valentino, Cunningham, Good, Aspinall, and Sales. Calabrese and Ourth took the lead in data collection, along with Good, Cunningham, Aspinall, Sales, Burk, Moore, Neuhauser, and Golterman. Data interpretation was performed by Burk, Newhauser, and Golterman, along with Glassman, Calabrese, Moore, and Ourth. The manuscript was written by Aspinall and Sales, along with Burk, Newhauser, Golterman, Ourth, and Cunningham. Good, Glassman, and Moore revised the manuscript, along with Calabrese, Valentino, and Aspinall.

Clinical pharmacist prescribing activities in the Veterans Health Administration.

PURPOSE: A comprehensive overview of clinical pharmacist prescribing authority and collaborative drug therapy management activities within the Veterans Health Administration (VHA) is presented. SUMMARY: In VHA terminology, "scope of practice" (SOP) denotes authorization to perform as an advanced practice provider, autonomously or collaboratively managing all facets of a patient's disease or condition; VHA clinical pharmacists with an SOP have prescribing authority. National policies outline the broad requirements for conferral of an SOP to VHA clinical pharmacists and processes for SOP development and oversight, as well as the responsibilities of facility and clinical pharmacy leaders to support the role of the clinical pharmacist within the VHA healthcare system. The limits of each pharmacist's SOP are determined at the facility level, with prescribing and other patient care authorities granted according to demonstrated competence. There are approximately 7700 VHA clinical pharmacists, of whom about 3200 (41%) have an active SOP. During fiscal year 2015, VHA clinical pharmacists accounted for more than 5 million patient encounters and 1.9 million prescriptions for chronic disease-targeted medications, generating at least 20% of prescriptions for hepatitis C therapies, hypoglycemic agents, and erythropoiesis-stimulating agents and 69% of prescriptions for anticoagulants systemwide. CONCLUSION: Clinical pharmacists with an SOP constitute a rapidly expanding workforce within the VHA system, as illustrated by tremendous growth in their numbers since 2010. These individuals play a key role as advanced practice providers, helping to improve access to high-quality chronic disease and medication management for the nation's veterans.

Knowing the patient: A qualitative study on care-taking and the clinical pharmacist-patient relationship.

BACKGROUND: Previous studies have found clinical pharmacists (CPs) and clinical pharmacy specialists (CPSs) in direct patient care have positive effects across various patient outcomes. However, there are also other kinds of care-taking occurring in pharmacy-run clinic appointments that produce value for patients. OBJECTIVE: To identify and characterize how CPs/CPSs in direct care clinics develop and practice care-taking behaviors which advance the pharmacist-patient relationship. METHODS: Semi-structured CP/CPS interviews were conducted once per year for two years (46 year 1, 50 year 2) along with direct observations of clinical pharmacy work as part of an anticoagulation improvement intervention. Participants were from Veterans Health Administration (VHA) medical centers and VHA community-based outpatient clinics in the Northeastern U.S. Interviews were transcribed verbatim and thematically analyzed using NVIVO 10 software. RESULTS: It was found that CPs/CPSs practice "knowing the patient" in ways related to, but distinct from this practice in the nursing literature. For CPs/CPSs, knowing the patient occurred over time, and it produced familiarity and trust between CPs/CPs and patients. A reciprocal relationship developed in which patients came to rely on CP/CPSs for other types of assistance. Patterns of knowing the patient and being known by the patient manifested in three distinct ways: 1) identifying the patient's unmet needs, 2) explaining other medications, and 3) helping the patient navigate the system. CONCLUSION: This research identifies an action, knowing the patient, whereby CPs use their knowledge of the patient to deliver individualized care. This study contributes to the developing literature on pharmacist-patient relationships and pharmacist-patient communication.