Transcript VA Transformational Initiatives Patient Aligned Care Team

Transformation of Clinical Pharmacy
Practice in the VA: Implications for
Profession
Anthony P. Morreale, Pharm.D., MBA, BCPS
National Director, Clinical Pharmacy Services and Healthcare Services
Research. Department of Veterans Affairs Pharmacy Benefits Management
Objectives
• Understanding the global goals of the VA Transformation
of Ambulatory Care Practice including both primary care
and Specialty Care
• Become knowledgeable about the strategies that VA PBM
has taken to realign current operational and clinical
practices to meet these challenges
• Create Awareness of the Challenges that exist in meeting
these changes
• Understand the implications of the VA’s transformation on
the practice of Pharmacy and on Healthcare reform
VA Transformational Initiatives
VA embarked upon an aggressive, transformational reorganization of its entire
ambulatory care practice model to make the primary care medical home a standard of
practice in April 2010
This year that transformation has broadened into New Models of Care and a linkage
with the Medical Home to Specialty Care
Since the VA is not under the shackles of individual state laws dramatic changes in the
roles of various professions could result
VACO Pharmacy Benefits Management embarked on creating new infrastructure to
lead clinical pharmacy's critical role in that reorganization. The goal is an organized,
national initiative, to create a set of minimum, uniform standards of practice to assure
that pharmacists talents are appreciated, recognized and incorporated into the new
systems
Patient Aligned Care Team
• The Patient Aligned Care Team
Model is a patient-driven, teambased approach that delivers
efficient, comprehensive and
continuous care through active
communication and coordination
of resources.
• PACT 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.
Key Principles of Medical Home That Teams
are Tasked to Meet
Each member
of the team
works at their
highest
training level
Agreements
in the team as
to what the
role of each
member will
be including
the clinical
pharmacist
When possible
all care of the
patient will be
delivered in
the team
without need
for referral.
This can be
accomplished
remotely.
Same day
appointments
will be
available to
care for
acutely ill
panel
members
decreasing ED
visits
Improve
provider
throughput to
improve time
spent with
direct patient
care
VA CPS Scope of Practice
Scope of Practice allows CPS to:
• Work in concert with an attending physician
• Evaluate medication therapy through direct patient care
involvement
• Prescribe medications, devices and supplies to include: initiation,
continuation, discontinuation, monitoring and altering therapy
without co-signature
• Perform physical measurements necessary to ensure appropriate
patient clinical responses to drug therapy
• Order consults, as appropriate, to maximize positive drug therapy
outcomes and disease state management.
• By working with a Scope of practice and not a protocol CPS can
adopt practice changes quickly to reflect changes in literature,
medication formulary and safety changes as well as new practice
guidelines.
Why the CPS is Important to the PACT Team
PACT Pillars:
Access –
yellow
Care
Coordination
– blue
Practice
Redesign - red
Midlevel Model with CPS : Chronic Disease Manager Model
Mid-level Providers provide MTM services to complex patients
Provider
Physician
Nurse Practitioner/
Physician
Assistant
Patient
Complex
Medication
Therapy
Management
Patient
Patient
Clinical
Pharmacy
Specialist
Patient
Pros:
• Offload management of chronic
disease
• Expertise in optimizing drug
therapy for complex high risk
patients
• Extensive knowledge of
resources available
Patient
Patient
Clinical
Pharmacy
Specialist
Chronic Disease Medication Management
• Chronic diseases have multiple drug therapy
options to achieve therapeutic goals.
• VA’s National Formulary and PBM/MAP
Criteria for Use documents provide patient
specific criteria
– 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).
• CPS have the advanced skills necessary to
provide Medication Management Services in
Primary Care and Specialty Care
• The Clinical Pharmacist plays a vital role in
dual-care management, therapeutic
interchange, and medication reconciliation
Patient Complexity, Health Status, Needs
Medical Home Team
Specialty Care
Clinical Nurse
Leader,
Case Managers,
Clinical
Pharmacist
Specialist
Coordination of
Care
Disease/Cohort Management
Management of Care
Great Concepts But
How Do You Make it
Happen Nationally?
Pharmacy Business Rules for PACT
Overall Principles
CPS should be aligned under Pharmacy Service to manage duties,
competency, and cross coverage
Teams should have one CPS for every 3 provider panels not including
anticoagulation
Clear referral processes will be established with the team including
when patients are identified via database or complex diseases
referred by providers to CPS and back again
Standardized note templates should be used for communication
regarding referral patients
Pharmacy Business Rules for PACT
Overall Principles
To facilitate use
of the CPS at
the top of their
license, the
following
should be
implemented:
• CPS should be provided the
same clerical and vital sign
support given to other
providers on the team
• CPS needs support from the
Pharmacy Service to handle
routine outpatient
pharmacy duties
• CPS should have
established a Scope of
Practice document that
includes prescriptive,
laboratory, and other test
ordering privileges in the
most common disease
states
Pharmacy Business Rules for PACT
Clinic Schedules
CPS in PACT should have established core schedules that have been discussed
with the team and are adhered to consistently
Clinic schedules are built on appointment slots of:
• 20-30 minutes for face to face visits
• 10-15 minutes for telephone calls
Establish open appointment slots to accommodate same day patient care
Establish standardized priorities for walk-in appointments during blocked time
for telephone intervention
Templates for new and established appointments for panel-building providers
may be customized at the discretion of physician and nurse team leaders
Pharmacy Business Rules for PACT
Trainees
Resident and student pharmacists on ambulatory care rotations will
be assigned to PACT teams
Specific assignments and oversight for trainees assigned will be
conducted under the oversight and guidance of the PACT CPS
PACT pharmacists are ultimately responsible for medication therapy
management services provided by the pharmacy trainees, including
supervision and co-signature on documentation
Pharmacy Business Rules for PACT
Clinic Leave
Pharmacy Service to manage leave requests
Pharmacy Service will assure cross coverage and communicate methods of
coverage to the PACT teams
PACT pharmacists are encouraged to block planned leave in appointment
schedule
Pharmacy Service leaders:
• Ensure this policy is followed
• Maintain master leave schedule and surrogate assignments
• Select alternative CPS coverage
• Assure all alternates have competency in required areas
• Notify teamlets immediately of unplanned leave and coverage strategies
Educating Leadership How to Evolve
• Technicians
• Workload Assessment
• Outpatient Staff
• Innovation
• Clinical Staff
• Technology
• Experts
• “Buy vs. Make”
• Contractors
• Service Line Budgets
IV Preparation
Acquisitions
Patient
Medication
History
Fully Utilizing
Pharmacy
Technicians
and
Automation
Screening
NFs/PAs
Controlled
Substances
Checking
Unit Doses
Ward
Inspections
Quality
Assurance &
MUE
NonFormulary
Medication
Recalls
Medication
Reconciliation
Other Ways
Pharmacy Service
Can Support PACT
& SCAN
Business Rules
Patient
Counseling
New Patient
Enrollment
Drug
Shortages
Refill
Extensions
Quality
Assurance &
MUE
Educational Initiatives
Both Leadership and Staff Educational programs are being launched nationwide
Clinical Pharmacist “Clinical Boot Camps” programs started in May to teach consistent
competencies in DM, HTN, Lipids, Smoking, HepC, Osteoporosis, and Pain Management.
Expert panel designed curriculum.
Future endeavors will focus on diseases such as , Heart failure, renal disease,
pharmacogenomics, Antimicrobial Stewardship management.
National SharePoint site with comprehensive position management tools has been
established.
Monthly Clinical Pharmacy “Live Meeting” educational programs have been launched in
January 2011
Clinical Pharmacy Newsletter to share successes started in April 2011
Research Initiatives
Numerous opportunities exist in the VA for Health Services Research regarding the
contributions that CPS can make to the care of patients in the VA Medical Home.
We are creating databases that will try to pull in data points nationally through the use of
standardized note templates and data warehouse extracts.
This will allow us to measure outcomes achieved across the country and establish
benchmarks on what is expected. Pharmacists Achieve Results with Medications
Demonstration (Ph.A.R.M.D) Project
Measuring the effectiveness of educational endeavors
Grants, collaboratives, and other funded projects are actively being implemented and
sought.
National Implementation Challenges
Consistent use of CPS Justification Documents including
business plans, position papers, literature and slide sets
Updated Functional Statements and Performance Standards
Standardized Ongoing Professional Evaluation Assessment
Methodologies
Creation of Competency & Training Assessment Tools
Documents
National Implementation Challenges (cont)
Local, Regional or national Data Warehouse Support
Standardized Methods to rollup Outcomes Assessments from
all sites to further measure the success of the CPS
Pharmacy Resident and Student Integration
Methods to reorganize Pharmacy Services to incorporate the
Medical Home & Specialty Models and increase employee
satisfaction
Identifying the Role of the Pharmacy Technician in the model
Implications to the Pharmacy
Profession
VA success or failure implementing the Medical Home
Model and Specialty Care Integration and its
assessment of the outcomes of the model could have
a significant impact on the healthcare debate in the
United States
Successfully integrating the Clinical Pharmacists
Specialist into the VA Medical Home and Specialty
Care as a provider, and accurately assessing the
successes and impacts of that role is likely to have a
profound effect on the future of clinical pharmacy
practice and the arguments of prescriptive privileges
or independent MTM activities
An Eye Toward the Future: Vision
Every patient and team will have access to a well trained, highly
competent clinical pharmacists to help them manage their
medications and diseases both in primary care and in specialty
areas.
To accomplish this Pharmacy and VHA leadership will need to act
boldly and creatively about structure to take advantage of a big
unmet need in our patient population
Pharmacists role as the medication expert will extend way beyond
the Medical Home as new models of care and specialty care
integration takes on greater importance .
Every Pharmacy employee will need to be an active advocate for
meeting the many unmet needs of our patient population by fully
utilizing the unique and powerful skill sets of the CPS.