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.

Increasing rural patient access using clinical pharmacy specialist providers: Successful practice integration within the Department of Veterans Affairs.

PURPOSE: Access to care is a critical issue facing healthcare and affects patients living in rural and underserved areas more significantly. This led the Department of Veterans Affairs (VA) to launch a project that leveraged the expertise of the clinical pharmacy specialist (CPS) provider, embedding 180 CPS providers into primary care, mental health, and pain management across the nation. METHODS: This multidimensional project resulted in hiring 111 CPS providers in primary care, 40 CPS providers in mental health, and 35 CPS providers in pain management to serve rural veterans' needs. From October 2017 to March 2020, CPS providers provided direct patient care to 213,477 veterans within 606,987 visits. This was an average of 43,000 additional visits each quarter to support comprehensive medication management services, demonstrating an additional 219,823 visits in fiscal year 2018 and 232,030 visits in fiscal year 2019. Over the course of the project, the team provided mentorship to 164 CPS providers, performed consultative visits at 27 VA facilities, and trained 180 CPS providers in educational boot camps. CONCLUSION: VA funding of rural health initiatives adding CPS providers to primary care, mental health, and pain teams has resulted in positive measures of comprehensive medication management, interdisciplinary team satisfaction, facility leadership acceptance, and multiple positive outcomes.

Specialty services offered by pharmacists in the community.

In a recent IJHPR article, Schwartzberg and colleagues report on clinical and other specialty services offered by pharmacists in the community in Israel and in the international arena. The article covers examples of activities recently introduced due to legislative changes which expanded the pharmacist's scope of practice, along with obstacles that are serving to slow broader expansion and availability of these services. This commentary details the success of clinical pharmacy services being provided by the United States Veterans Health Administration, and offers a framework of elements that support clinical pharmacy practice expansion.

Advancement of clinical pharmacy practice through intervention capture.

PURPOSE: The methods and processes utilized to deploy the Pharmacists Achieve Results with Medications Documentation (PhARMD) Project intervention template across the largest integrated healthcare system in the United States are described. SUMMARY: The PhARMD Project team at the Department of Veterans Affairs (VA) designed, developed, and deployed a standardized template within VA's electronic health record (EHR) that allows the clinical pharmacy specialist (CPS) to efficiently document select interventions made during patient care encounters that specifically contribute to the overall care provided and patient outcomes. The template is completed by the CPSs as part of progress note documentation within the EHR. Using point-and-click functionality, a CPS selects the check boxes corresponding to specific interventions made during that patient care encounter. This improves workflow and negates the need to document interventions in a separate software system, streamlining documentation. The implementation and use of the PhARMD template at each VA facility are voluntary. From October 1, 2016, to September 30, 2017, 4,728 CPSs documented 3,805,323 interventions during 2,384,771 patient care encounters. These interventions were documented across 592,126 unique patients, with a mean of 6.4 interventions per patient during this period. Most interventions (95%) were performed by CPSs functioning as advanced practice providers and with autonomous prescriptive authority authorized under their scope of practice. CONCLUSION: The PhARMD template demonstrated that the capture of clinical pharmacy interventions and outcomes can be achieved across a large integrated healthcare system by thousands of CPSs in numerous practice settings.

Workforce Assessment of VA Home-Based Primary Care Pharmacists.

The majority of clinical pharmacy specialists are using global scopes of practice, which allow more autonomy to provide direct patient care and comprehensive medication management services to home-based primary care veterans.

Evaluation of clinical pharmacy interventions in a Veterans Affairs medical center primary care clinic.

PURPOSE: The development of an electronic tool to quantify and characterize the interventions made by clinical pharmacy specialists (CPSs) in a primary care setting is described. SUMMARY: An electronic clinical tool was developed to document the clinical pharmacy interventions made by CPSs at the Veterans Affairs Medical Center in West Palm Beach, Florida. The tool, embedded into the electronic medical record, utilizes a novel reminder dialogue to complete pharmacotherapy visit encounters and allows CPSs to document interventions made during patient care visits. Interventions are documented using specific electronic health factors so that the type and number of interventions made for both disease-specific and other pharmacotherapy interventions can be tracked. These interventions were assessed and analyzed to evaluate the impact of CPSs in the primary care setting. From February 2011 through January 2012, a total of 16,494 pharmacotherapy interventions (therapeutic changes and goals attained) were recorded. The average numbers of interventions documented per patient encounter were 0.96 for the management of diabetes mellitus, hypertension, dyslipidemia, and heart failure and 1.36 for non-disease-specific interventions, independent of those interventions being made by the primary physician or other members of the primary care team. CONCLUSION: A clinical reminder tool developed to quantify and characterize the interventions provided by CPSs found that for every visit with a CPS, approximately one disease-specific intervention and one additional pharmacotherapy intervention were made, independent of those interventions being made by the primary physician or other members of the primary care team.

Protected professional practice evaluation: A continuous quality-improvement process.

PURPOSE: The development, implementation, and evaluation of a protected peer-review process for clinical pharmacists with advanced scopes of practice are described. SUMMARY: A protected practice evaluation committee (PPEC) was created at a Veterans Affairs medical center to formulate policies and procedures for conducting peer reviews. The committee comprises six clinical pharmacists, none of whom hold a supervisory position, and assigns appropriate peers to review and rate clinical pharmacists' cases based on PPEC-developed performance measures. Peers rate the level of pharmacist-provided care by deciding whether most experienced, competent practitioners would have handled the case similarly in all aspects (level 1), might have handled the case differently (level 2), or would have handled the case differently (level 3). Each practitioner receives a report summarizing the findings and recommendations for improvement. The data are protected from legal discovery and shared with management only in aggregate. Of the 250 cases reviewed between January and October 2009, 236 (94.4%) received level 1 care and 14 cases (5.6%) received level 2 care; none received level 3 care. The number of cases judged as receiving level 2 care decreased to 1 by September 2009. Improvements in process indicators, including documentation of medication reconciliation and patient adherence, were noted. A survey of the clinical pharmacists indicated strong support for the review process. CONCLUSION: Protected practice evaluation engaged clinical pharmacists in a continuous quality-improvement effort, generated data regarding practicewide as well as individual practitioner performance, and encouraged self-reflection. Frontline practitioners agreed that peer review is important for quality-improvement purposes.