2013 Midyear Clinical Meeting Federal Forum: Challenges and Best Practice Solutions from Federal Pharmacy Objectives . Describe VA Advanced Pharmacy Services Shining a Spotlight on VA Clinical Pharmacy Practice: Advanced Services, Strong Communication, Quality Outcomes . Describe Communication Process: Education and Committee Structure Scott E. Mambourg, PharmD, BCPS, AAHIVP Representing: . Define Quality Outcomes VA Clinical Pharmacy Advisory Board (CPAB); VA Clinical Pharmacy Program Office (CPPO) Scope of Practice (SOP) . VHA Policy System‐wide since 1995 . Each VHA pharmacist with direct patient care responsibility which includes prescriptive authority must have a Scope of Advanced Practice Practice . Medication prescribing privileges for non‐controlled substances can be granted to Clinical Pharmacy Specialists (CPS) based on a locally‐defined Scope of Practice . The Scope of Practice delineates any prescriptive authority and the ability to order laboratory tests, screenings, referrals, and other items pertinent to monitoring and assessing the patient’s drug therapy. Direct Patient Care Activities Pharmacist Scope of Practice . Allows for autonomous practice and prescribing of the pharmacist to address the medication management needs of the Veterans . Prescriptive authority and responsibility will include practice areas for which the pharmacist has experience and expertise, including but not limited to: • Addressing medication management needs of patients with defined diagnoses, • Management of medication‐related adverse events, • Ongoing and acute medication monitoring, and • Collaboration with other healthcare providers for management of new diagnoses 6 © 2013 American Society of Health-System Pharmacists 1 2013 Midyear Clinical Meeting Federal Forum: Challenges and Best Practice Solutions from Federal Pharmacy Scope of Practice Core Elements of a Pharmacist Scope of Practice . Part 1. General area of responsibility for activities to be performed under the scope of practice (must choose at least one): . Developing, documenting, and executing therapeutic plans [ ] Medical center . Ordering and interpretation of diagnostic studies [ ] Community Based Outpatient Clinic [ ] Contracted locations . Prescribing medications, devices and supplies [ ] Telemedicine, specify location: • Note: Medical center policy may be developed to allow the ordering of [ ] Other location (specify below): non‐medication supplies _______________________________________________________ . Ordering and administering vaccines . Taking independent corrective action for identified drug‐induced . Part 2. The pharmacist scope of practice includes the following practice problems areas or diseases/conditions (must choose at least one) . Ordering consults (e.g., dietician, social work, specialty provider), as [ ] Comprehensive Medication Management, inpatient appropriate, to maximize positive drug therapy outcomes [ ] Internal Medicine [ ] Specialty Care such as surgery, infectious disease, critical care, community . Serving to provide clinical pharmacy expertise for practice‐based living centers, psychiatry, hematology/oncology, etc. (define specialty below): areas to include clinics and wards in conjunction with the attending _______________________________________________________ physician or team (e.g., Home Based Primary Care, Internal [ ] Comprehensive Medication Management, outpatient medicine, critical care, Community living centers) [ ] Primary Care [ ] Specialty Care (define specialty below): Pharmacist FTE and % CPS w/SOP VA VISN MAP 700 70.0% 600 60.0% 500 50.0% 400 40.0% FTE w/SOP 660 CPS 300 30.0% % 200 20.0% 100 10.0% 0 0.0% VISN VISN VISN VISN VISN VISN VISN VISN VISN VISN VISN VISN VISN VISN VISN VISN VISN VISN VISN VISN VISN 1 2 3 4 5 6 7 8 9 10 11 12 15 16 17 18 19 20 21 22 23 VISN Data Sources: HR Employee ProClarity Cube, CPPO SharePoint SOP Database Pharmacists with a Scope of Practice Pharmacists with a Scope of Practice by VISN 350 300 250 200 150 100 50 0 VISN VISN VISN VISN VISN VISN VISN VISN VISN VISN VISN VISN VISN VISN VISN VISN VISN VISN VISN VISN VISN 1 2 3 4 5 6 7 8 9 10 11 12 15 16 17 18 19 20 21 22 23 Pharmacist w/SOP VISN Avg © 2013 American Society of Health-System Pharmacists 2 2013 Midyear Clinical Meeting Federal Forum: Challenges and Best Practice Solutions from Federal Pharmacy VHA has approximately 7,050 Pharmacists Pharmacist SOP by Disease State 1125 Pharmacists with Scope of Practice exceeds 2,800 (41%) 917 543 508 458 435 370 296 294 296 Of These 2,800 210 219 182 175 177 158 139 103 94 74 55 51 BPS Other Residency & Residency Certification Certification Certification = 62% = 34% = 10% = 72% Pharmacists With a Scope of Practice –Growth Scope of Practice Trends Over Time 1,375 3,100 2,900 2,853 1,175 2,700 2,716 975 2,654 Anticoag 2,500 2,473 775 Lipids Diabetes 2,300 2,284 Hypertension 46% 575 Global 2,100 2,087 375 1,945 1,900 175 11 11 11 12 12 12 12 12 12 12 12 12 11 11 11 13 13 13 13 13 13 13 13 13 1,700 12 12 12 ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Jul Jul Jul 13 13 12 12 12 11 11 13 13 13 13 13 13 12 13 12 12 12 12 12 12 12 11 12 11 11 11 Jan Jan Jun Jun Oct Oct ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Feb Apr ‐ ‐ ‐ ‐ Feb Apr Sep Sep Sep Dec Dec Aug Aug Aug Nov Nov Mar Mar May May Jul Jul Jul Jan Jan Jun Jun Oct Oct Apr Feb Apr Feb Sep Sep Sep Dec Dec Aug Aug Aug Nov Nov Mar Mar May May Data Source: CPPO Scope of Practice SharePoint Database Data Source: CPPO Scope of Practice SharePoint Database Pharmacists Achieve Results with Medications Nationwide Workload Trends Documentation (PhARMD) Project Parameter FY11 FY12 FY13 % Change . Clinical reminder with embedded health factors • Assigned to the pharmacists at your facility location # Pharmacists 2,132 2,616 2,853 34% . Health factors represent tracking items of interest with SOP • Clinical interventions and therapeutic goals • DM, lipids, HTN, HF, Smoking Cessation, Bone Health, Hepatitis C Encounters/FTE 403 615 586 45% specific • Additional pharmacotherapy interventions % Pharmacists 30.9% 38.6% 41% 33% • General interventions on other disease states w/SOP • Used interventions which other authors have assigned cost avoidance Total 160 2,454,419 3,677,269 3,751,001 53% . Project started in 2010 at 2 separate medical centers Encounters and has expanded to 62 sites in 2013 18 Am J Health‐Syst Pharm 2002;59:2070‐7 © 2013 American Society of Health-System Pharmacists 3 2013 Midyear Clinical Meeting Federal Forum: Challenges and Best Practice Solutions from Federal Pharmacy PhARMD Tool Design PBM PhARMD Pharmacotherapy Reminder Tool Tool Design and Use . The PBM PhARMD Pharmacotherapy Reminder was developed in a way to allow quick and easy documentation of clinical pharmacy interventions Document any interventions made for the disease states or additional pharmacotherapy interventions listed . The disease state interventions have been standardized across the various diseases so they look similar . Pharmacists have found that the tool takes on the average of 1‐3 minutes of additional time in documenting the interventions • Completes the visit encounter at the same time . Created in a way that by logging the interventions using the tool it will add text into the progress note under the title of “Assessment and Plan”. • This is a useful option to help the CPS quickly document their interventions and complete their progress note in a timely manner. 19 20 Example Disease State Documentation PBM PhARMD Pharmacotherapy Reminder – Additional Pharmacotherapy Interventions 22 PBM PhARMD Pharmacotherapy Reminder Tool Example of Progress Note Text Education and Communication 23 © 2013 American Society of Health-System Pharmacists 4 2013 Midyear Clinical Meeting Federal Forum: Challenges and Best Practice Solutions from Federal Pharmacy Clinical Pharmacy Boot Camp Concept Bootcamps . Subject Matter Experts (SME) providing evidence‐based, . Purpose: Pharmacy Chronic Disease Management intense, and current training on standards of care Movement (Phase I) . Sharing Strong Practices . Providing Education Platform for training Clinical Pharmacy . Pain Management Specialists (CPS) working in Primary Care and Specialty Areas . Diabetes . Train the Trainer and Self‐Directed Learning . Hepatitis C • Talent Management System (TMS) part of VA Learning University (VALU) . Hyperlipidemia . Creating a Minimum Competency Standard for Pharmacists . Hypertension . Starting a movement on disease state management in Patient Aligned Care Teams (PACT) in primary care . Osteoporosis • diabetes, hypertension, hyperlipidemia, anticoagulation, smoking . Tobacco Dependence cessation, pain management, hepatitis C, osteoporosis How to Start a Movement… Specialty Clinical Pharmacy Boot Camps . Clinical Pharmacy Boot Camp Material . These programs (Phase II) were presented Summer . The faculty provided the training to equip others with what 2013 they needed to get started when they returned to their facility . Six disease states/clinical practice areas covered (train the trainer) . Some techniques to consider: • Cardiology –Heart Failure • Shadowing • Mental Health • Lunch time series to review the materials • Hematology/Oncology • Self study materials • Respiratory • Staff study groups/Journal Clubs incorporating the materials from this week • Nephrology • TMS training for all PACT and Specialty CPS (minimum • Women’s Health competency expectations) PACT Clinical Pharmacy Boot Camp II How to Access Training . These programs (Phase III) were presented during . All training