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Enhancing Equitable Healthcare Among U.S. Veterans through Patient Aligned Care Teams

Donnie R. Johnson, Jr., Pharm.DTallahassee VA Healthcare Center

02/24/17

Disclosure Statement

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� I, Donnie Johnson, Jr., do not have a vested interest in or affiliation with any corporate organization offering financial support or grant money for this continuing education program, or any affiliation with an organization whose philosophy could potentially bias my presentation.

ObjectivesPharmacist� Provide basic information pertaining to the Department of

Veterans Affairs structure and operation.� Summarize the major components of the Patient Aligned

Care Team (PACT) model of care.� Explain how the components of the PACT team facilitate

holistic care and life-long health and wellness to veterans.� Understand the role and impact clinical pharmacist

specialist (CPS) have on the PACT team.

Technician� List the major components of the PACT team.� Understand the key components of the clinical

pharmacist specialist role on the PACT team.3

Veterans Affairs (VA) MissionTo fulfill President’s Lincoln’s promise “ To care forhim who shall have borne the battle, and for hiswidow, and his orphan” by serving and honoring themen and women who are America’s Veterans.

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VA Core Values

INTEGRITYCOMMITMENTADVOCACYRESPECTEXCELLENCE

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General Structure of the VA

� VA comprises a Central Office (VACO) – Washington, DC.� Veterans Health

Administration

� Veterans Integrated Service Networks (VISNs) � VHA is divided into 21 areas

called VISNs.

� VA Medical Centers (VAMCs) � Outpatient Clinic� Community Based Outpatient

clinic

• VA Sunshine Healthcare Network (VISN 08)

• The nations largest system of hospitals and clinics serving a population of more than 1.6 million Veterans.

• Ranges 64,153 square miles

• Spreads across 79 counties

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General Structure of VA

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A quick glance at North Florida/South Georgia Veterans Health System….8

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North Florida/South Georgia Veterans Health System

� Completed appointments as of December 2016 -81,289

� Pending appointments as of January 15th 2017 –259,667

� Visits in 2016 – 1,689,6279

North Florida/South Georgia – Sites of Care

� VA Medical Centers� Gainesville VAMC (Malcom

Randall)� Lake City VAMC

� Outpatient Clinics� Jacksonville� Tallahassee� Villages

� Additional Gainesville Locations� Compensation and Pension

Clinic� Optometry and PC Dermatology � Pain Clinic

• Community Based Outpatient Clinics– Lecanto– Marianna– Ocala– Palatka– Perry– St. Augustine– St. Mary's, GA– Valdosta, GA– Waycross, GA

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• Largest VA System in the Nation - 19 Counties in Georgia and 31 Counties in Florida (In 1998, the Lake City and Gainesville VAMCs along with the CBOCs and OPCs became the “North Florida/South Georgia Veterans Health System)

• FY 2016: 135,395 Veterans enrolled; over 1.68 million outpatient visits; average approximately 6,000+ visits daily system wide

• FY 2016: Women Veterans 10,989; Returning Combat Veterans: 10k+

• FY 2016: Largest patient population from the Vietnam Era (36.3%) and Persian Gulf War Era (27.2%)

• Current FTEE: over 5,800+ (33% Veterans) with an annual budget of $1,069,726,361

One billion sixty-nine million seven hundred twenty-six thousand three hundred sixty-one.”

• During FY 2016 Performed over:- 685,719 Specialty Consults - 222,952 Radiology Studies- 12,856 GI procedures - 1268 Cath Lab Procedures- 8,298 Surgeries (GV – 6,192 & LC – 2,106)

The State of NF/SGVHS

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Infrastructure Investment and Expansionsion

§ Tallahassee Clinic Grand Opening (Serving 16K+ Veterans)

§ $56 Million budgeted Infrastructure Investment

§ Submitted requests for expansion clinical space in Jacksonville area, Gainesville and Ocala, and replacement clinic for Ocala

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§ Fast Growing Population

§ Influx of younger Veterans: 58% of Women OEF/OIF Veterans Use VA

§ 14K Enrolled in NF/SGVHS –largest population in VISN 8

§ Expansion of Women’s Health Programs in Gainesville & JAX include gynecological and in house mammography programs

Women Veterans

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VA Clinical FACTS� 1958 Invented the implantable cardiac pacemaker, helping

many patients prevent potentially life-threatening complications from irregular heartbeats.

� 1968 Performed the first successful liver transplants and developed techniques for suppressing the body’s natural attempt to reject transplanted tissue.

� 1984 Developed the nicotine patch and other therapies to help smokers give up the habit.

� 1991 Developed Functional Electrical Stimulation (FES) systems that allow patients to move paralyzed limbs.

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What are the core values of the VA?

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1) ICAN

2) ICARE

3) IWILL

4) IWON

Answer: B

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Birth of the PACT model of care…….Development of PACT is a part of the VA’s health careinitiative, Defining Excellence in the 21st Century which aims to:� Align all components of VA health care into a unified

integrated delivery system� Reduce variations within the VA health care system� Build a standardized system throughout the VA health care

system� Use evidence as agent of change

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What is PACT?

A Patient Aligned Care Team (PACT) is each Veteran working together with health care professionals to plan for whole-person care and life-long health and wellness. They focus on:� Partnerships with Veterans� Access to care using diverse methods� Coordinated care among team members� Team-based care with Veterans as the center of their PACT

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Old Primary

Care Model

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PACT is…..

Patient Centered

Collaborative Partnership

Whole Person Orientation

Effective Communication

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“…you ought not to attempt to cure the eyes without the head or the head without the body, so neither ought you to attempt to cure the body without the soul…for the part can never be well unless the whole is well.” Plato

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VA Health CarePatient Centered

PastVA

PresentVA

Future VA

“What can I fix?” “How can we help what is wrong with you?”

“How can we help you live the life you want to

live?”Physician Clinical Team Veteran, Family and

Health Care TeamCase-Based Paper

Medical RecordDisease-Based

Electronic Medical Record

Whole-Person Electronic Health

Record“We’ll address your immediate concern.”

“You have a riskyproblem, please follow this plan to improve by

your next visit.”

“We can design your personalized health plan

to meet your goals.”

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The Patient’s PACT Team� Team: Per panel of patientsØ Veteran (Center of the team

and may include family or caregiver)

Ø Primary Care providerØ Registered NurseØ Clinical AssociateØ LPNØ Medical AssistantØ Health Tech

Ø Clerk

� Expanded Team MembersØ Clinical Pharmacy SpecialistØ Social WorkØ NutritionØMental Health IntegrationØ Case Managers

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The Roles in the PACT Team� Veteran� Is the focus of the PACT model� Accesses the assigned PACT team for coordination of all

aspects of care� Learns the skills and treatments necessary to optimize

own health

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The Roles in the PACT Team� Primary Care Provider� The teams point person-leads the care team� Coordinates the identification and management of at-

risk and special needs Veterans� Assures development of a clinical care plan for each

patient compatible with the Veteran’s personal health goal in order to assist the Veteran attain the maximum health potential� Coordinates chronic disease tracking� Responsible for Panel outcomes assuring that teams

goals and metrics are accomplished

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The Roles in the PACT Team

� Clinical Pharmacist Specialist-PACT� Provides same day access for medication issues and

medication management� Performs medication reconciliation prior to 1st PC visit

for newly enrolled Veterans and as needed thereafter� Reviews Chronic Disease Registry and databases for

medication optimization� Participates as requested in post discharge follow-up� Utilizes scheduled face to face visits, work-in visits,

group visits, secure messaging, and telephone appointments

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The Roles in the PACT Team� Clinical Pharmacist Specialist-PACT� Completes pertinent clinical reminders� Assists with management of treatment resistant

patients or patients with adherence issues� Manages/ prescribes medications and documents plan

for identified disease states in accord with published guidelines and generally recognized standards of care� Manages traveling veterans� Evaluates non-formulary or criteria-based medication

requests to ensure compliance with VA National formulary and established Criteria for Use guidelines� Participates in Team meetings

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Pillars of PACT

Patient Aligned Care Teams

Access

CareManagement

& Coordination

Practice Redesign

Patient CenteredPerformance Improvement

VA and Community Resources30

Pillars of PACT: AccessOffer every patient an appointment with their own

provider “today” for any problem, urgent or non-urgent. Alternatives to single Face-to-Face with physician:

Group educationSecure messagingVisits with RNVisits with Clinical PharmacistTelephone appointmentsTele-healthHBPC (Home Based Primary Care)Shared Medical AppointmentsDrop in Group Medical Appointments

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Old World

Veterans ride in a van for hours to the nearest VA

medical center to keep an appointment—just to find out

their blood count.

New World

Patient gets blood drawn at a hometown clinic. A short time

later, a healthcare provider calls to discuss the results.

Dr. Robert Petzel said, “We will need to give up the idea of solving all health issues by seeing

patients at appointments.”

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Pillars of PACT: Care Management & CoordinationPACT team proactively manages each patient’s healthcare

to achieve their maximum state of health.

� Utilize PC Almanac and Compass to initiate the process of patient management by identifying at risk patients including those with chronic/special disease:§ DM with HgbA1C>9§ Poorly controlled hypertension§ Hyperlipidemia§ Obesity/metabolic syndrome§ COPD

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Pillars of PACT: Care Management & Coordination� PACT team identifies special needs patients:� Frequent CAU visits� Numerous ER visits� Recurrent hospital admissions� Refractive behavior/non-compliance� Opiate dependence� Homeless� Mobility disabilities� Impaired intellect

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Pillars of PACT: Care Management & CoordinationUsing the databases (PC Almanac and Compass) theteam stratifies risk for all patients on the panel.

High Risk

Moderate Risk

Lower Risk

Unknown Risk (no-shows, no recent visit)35

Pillars of PACT: Practice RedesignPractice redesign is the approach that teams use

working together with clinic leadership toenhance the teams clinical care processes to assure

that the right person does the right work at the right time in support of the patient. How do we work and

why?

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What are the three pillars of the PACT model of care?

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a. Access

b. Care Management and Organization

c. Practice Redesign

d. Care Management and Coordination

e. A, B,C

f. A,C, D

Answer: A, C, D

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� Access, Practice Redesign, Care Management and Coordination

Not only do we anticipate what our patients need, we offer multiple options

for meeting those needs.

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PACT Clinical Pharmacy Specialist Improve Access to Care

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Source: VHA Support Service Center (VSSC): New Outpatient Visits & Uniques Trend, 10/7/15

19%

81%

81% of Teams lack sufficient core team members

Source: Network Structure and Effectiveness of Veterans Affairs Patient Aligned Care Teams Eean R. Crawford, PhD, Cody J. Reeves, BS, Greg L. Stewart, PhD and Stacy L. Astrove

VHA Patient

Care Needs

are Increasi

ng

VHA’s Primary Care Core Team (i.e. the Team)Primary Care Providers have enough appointments to see a patient 2.5 times per year; not near enough for our aging Veteran patients on complex medication regimens who may be at risk for adverse events.

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Perceptions of pharmacists' integration into PACT teams

� “Role clarity and work activities were influenced by team member attitudes toward and previous experiences with pharmacists”

� “Non-pharmacist members of PACT teams reported some reluctance in pharmacists’ integration.”� “They attributed this reluctance to

knowledge deficits, limited participation in PACT training by pharmacists, an imbalance in effort expended for pharmacists’ integration, and coordination or communication challenges.”

Patterson BJ, Solimeo, SL, Stewart, KR, et al. http://www.sciencedirect.com/science/article/pii/S1551741114000709

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� Many were unclear when or how to involve pharmacists and there was a general lack of knowledge of how pharmacists’ clinical skills could be incorporated into the PACT model.� Teams with less integration of pharmacists often

perceived pharmacists’ main role as approvers and dispensers of medications. � Those aware of role in chronic disease management

were often unable to take full advantage� Some desire for pharmacists to take a greater role in

addressing incoming patient calls regarding medications

Results: Role NegotiationPerceptions of pharmacists' integration into PACT teams

Patterson BJ, Solimeo, SL, Stewart, KR, et al. http://www.sciencedirect.com/science/article/pii/S1551741114000709

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� Pharmacist Integration varied by team and facility� “Across facilities, pharmacy integration was

evidenced by participants describing instances where they considered the pharmacist to be a member of the core team, involving the pharmacist in formulary issue resolution, medication management for chronic diseases, or shared medical appointments”� Teams with limited integration reported pharmacist

participation in new patient orientations

Results: Variation in Pharmacist IntegrationPerceptions of pharmacists' integration into PCMH teams

Patterson BJ, Solimeo, SL, Stewart, KR, et al. http://www.sciencedirect.com/science/article/pii/S155174111400070944

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Barriers to Successful Integration Lessons Learned and Opportunities

PACT CPS

Space

Ancillary Support

FTE Resources

Role Clarity

50% of facilities lack adequate space

43% of PACT CPS are not co-located with

team

70% of PACT CPS lack ancillary support for

items like appointment management, vitals,

education and training

46% shortfall in facilities meeting PACT CPS ratios

Lack of Pharmacist resources Impact PACT

CPS role

Many facilities lack optimized processes to

support Veterans Medication Needs, e.g.,

traveling Vets, dual care

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To truly gain momentum and start a movement, you have to tell your story with a clear message……

The CPS is an Advanced Practice Provider that improves access to care….46

Know Your PACT Clinical Pharmacy Specialist (CPS)

• Independent Prescriptive Authority• Practice-Area (Global) Scope of Practice to manage

multiple chronic disease states of PACT patients• Panel and Population Management

PACT CPS=PHARMACIST PROVIDER

• Comprehensive Medication Management services to allows other PACT providers to see more urgent/acute patients

• Bridging the gap to specialty care• Same Day Medication management services

IMPROVING ACCESS

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CPS Providers Impact Access� For a typical panel of 1200

patients, PACT Providers only have appointment slots to see a patient 2.5 times per year

� Typical patient visits to Target*� Diabetes =6 visits� Hypertension =3 visits� HepC = 9-12 visits

� Using CPS Providers avoids shifts to Specialty Care

*based on FY15 computer extracted data

PACT Provider

Initial Visit

6 mo. visit

12 mo. visit

18 mo. visit

PACT CPS

Disease Management visit (virtual or F2F)

Disease Management visit (virtual or F2F)

Disease Management visit (virtual or F2F)

Optimizing PACT CPS to see patients between PACT Provider visits increases patient access

for medication management services48

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Pharmacist Providers Bridging the Gap Between Primary Care and Specialty Care

Coordination of Care

Disease/Cohort Management

Reference: A. Morreale June 2011

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The PACT CPS Provider’s Impact on Access Comprehensive

Medication Management

(Diabetes, HTN, Lipids, etc.)

Pain Management

Hepatitis C Clinics

Same Day PACT Access

Transitions of Care and Discharge

Follow-up

Anticoagulation Clinics

Pharmacy Med Intake Clinics

Heart Failure Clinics

Proven Performancein Primary

Care

Proven Performancein Primary

Care

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Advanced Practice Providers

High Level of Training

Best to Recruit

Highest Retention Rate

• Over 3,400 Clinical Pharmacists with a SOP to prescribe

• VA CPS workforce has Advanced Clinical Practice Training

• VA trains 600 CPS per year available for hiring in July of each year

• Patient’s know their CPS Provider

The CPS Provider Workforce

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Established PACT Staffing Ratios and Evaluation Gaps In Clinical Pharmacy Coverage

• FTE allotments must take into account for Primary Care Direct Patient Care (PCDPC) Time

• Defined by VHA Handbook 1101.02 as “the time required to prepare for, provide, and follow-up on the clinical needs of Primary Care patients”

• Can be delivered by traditional or non-traditional modalities

If additional medication management services are included in the role, the facility must consider additional FTE

needs

The PACT CPS is a core team member that

improves access

At least 1 CPS for every 3

PACT team panels

Approx. 1 CPS for

every 3600 patients

PACT CPS functions as an Advanced

Practice Provider

providing med

management services the majority of

the time

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PACT CPS Staffing Opportunities

� In FY15, there were over 5 Million Clinical Pharmacy Encounters� 1.7M in Anticoagulation� 857,000 in Primary Care� Only 35% were Face to Face

� Handbook recommended PACT CPS Staffing Ratio (1 CPS per 3 PACT Providers)� No VISN currently meets.� Wide variation exists (24-85%)� National avg is 54% of needed

� 675 Pharmacists would be needed across the system to meet PACT CPS ratios and optimize services

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

V01

V02

V03

V04

V05

V06

V07

V08

V09

V10

V11

V12

V15

V16

V17

V18

V19

V20

V21

V22

V23

Percentage of PACT Pharmacist FTE Based on Recommended Staffing Ratios

Oct '15

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Recommended PACT CPS Staffing Ratio

As Described in VHA Handbook 1100.10 PACT and VHA Handbook 1108.11 Clinical Pharmacy Services54

The Reality: PACT CPS Staffing RatioMadison VA - 2015

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Past Reality:Madison VA - 2015� Strong centralized Anticoagulation service� Long-standing excellence in residency training � First ever Ambulatory Care residency in 1983

� Primary and Specialty Care was primarily resident driven with preceptor oversight� Only 1.0 CPS FTE dedicated truly to PACT

� Residents and preceptors were in a different location than PACTs� No team based care� Very few teams meeting on a regular basis

� Limited population management� Alignment with PACT Business Rules needed

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Path to a New Reality …Step 1 for PACT CPS Integration

� Gap Analysis� Calculated how many FTE we were short based on 1:3 ratio� Short 6.0 FTE

� Educational campaign � Got on the agenda for every discipline’s staff meeting� Explained PACT CPS role – created handout “Overview of PACT CPS services”� Performed PACT Provider Needs Assessment � Gained support from PACT Providers

� Integrated Pharmacy Leadership into Primary Care Leadership� Submitted Business Proposal� PACT Providers were loud in asking for more PACT CPS � 4.0 FTE approved

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Path to a New Reality …Step 2 for PACT CPS Integration

� Assigned PACT CPS to teams � As close to 1:3 ratio as possible� Created extended PACTs, including SW, IC, Nutrition

� Secured space (co-location) and ancillary support� Off-loaded non-PACT workload e.g., anticoagulation, non-

formulary reviews� Created PACT CPS grids, stopped using consults� Included front-line PACT CPS in decisions � Considered individual site needs e.g., walk-ins, telephone vs face to face

� PACT CPS were drivers of starting weekly team meetings� Population management – put RNCMs in charge� Another provider on the team

� On-going assessment of PACT CPS services� Completed self-assessment, surveyed PACTs

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Path to the New Reality….Step 3 for PACT CPS Integration

� New Patient Medication Intake Calls� Other sites have implemented face to face, CVT, new patient orientation, etc.

Team scheduler prints PACT Provider appointments one week in advance, hands to PACT CPS

PACT CPS reviews appointments, identifies any patients coming for first ever VA Primary Care appointment

PACT CPS calls patient, performs medication reconciliation, converts to formulary alternatives, places consults (including for PACT CPS services), orients to VA pharmacy, clinical reminders, orders labs, performs disease

management, obtains HPI, additionally signs PACT Provider59

Path to the New Reality…. Step 4 for PACT CPS Integration

� PCP to CPS Appointment Conversions� Identified low-utilizer of PACT CPS services� Obtained PACT Provider buy-in� PACT CPS reviewed PACT Provider RTC orders, cancelled any that

PACT CPS could do� PACT CPS alerted scheduler to schedule with PACT CPS instead� Short-time frame, helped PACT Provider understand which patients

could go to PACT CPS� After 3 months, transitioned to PACT Provider and other team

members identifying appropriate patients and sending to PACT CPS proactively

� Tracked the number of appointments converted

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Improving PACT Access with Pharmacists Gold Status-William S. Middleton Memorial VA

Clinical Pharmacy Specialists (CPS) Increased Access to Primary Care� PACT CPS Chronic Disease Clinics: 13.8% ñ in clinic utilization� New patient calls: saved primary care provider 20 minutes on average for

every new patient� Converting PCP visits to PACT CPS Resulted in: 27% PCP appointments

converted= 16.5 hours s newly opened access = 66 new telephone appts or 33 new face-to-face appointments Per Primary Care Provider

� Improved Provider Satisfaction = PCPs unanimously requested more pharmacists!

Applied nationally this would translate into 272,000 new appointments annually.

Pharmacy Clinic Education

Conversion of PCP to PACT CPS

AppointmentsCPS Assigned to

PACT TeamsNew Patient Medication

Intake Clinic

Gold Status Project-Improving Access to Primary Care Utilizing CPS61

Utilizing your PACT CPS to the Top of their Licensure and Scope

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PACT CPS Roles to Improve Access

Ensure PACT Teams understand roles of the PACT CPS

Assure roles that can be performed by other team members have been carefully assessed and distributed where

appropriate

Assure that the PACT CPS has space, technology and ancillary support to maximize efficiency

Assure that the CPS has a broad, practice area based scope of practice

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“Mapping out” a Typical Day� Focuses on Optimization of Direct Patient Care � Primary Care Direct Patient Care (PCDPC) Time for the PACT CPS� 75-85% of the time should be spent in direct patient care� 30 hours of time per week spent in direct patient care activities,

or a target of 12 to 15 medication management encounters per day

� Provides appropriate cross-coverage of duties� Allows PACT CPS and leadership to talk about

opportunities that exist� Allows the team to optimize the medication

management services needed� Allows for discussion of expansion of PACT CPS role

with team

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Optimized Direct Patient Care for the PACT CPSExample Clinic Schedules

Telephone visits incorporated

Time to Discuss clinical pharm issues

Admin Time added Thanks to the Sierra Nevada VA Medical Center65

Key TakeawaysPACT CPS� Advanced Practice Providers with

Independent Medication Prescriptive Authority

� Highly trained Clinical Workforce that is poised to assume more direct patient care duties.

� Graduating nearly 600 highly trained clinical residents annually. Most of which want to stay in VA.

Optimize roles of CPS to provide Essential Chronic Disease and

Medication Management Services

Clinical Pharmacy Specialists (CPS) are the Team’s Medication

Experts

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PBM CPPO Clinical Pharmacy Practice Resources/Reference

� PBM Access Fact Sheet-Optimizing the Role of the CPS to Improve Access

� VHA Handbook 1108.11, Clinical Pharmacy Services� Outlines Clinical Pharmacist Scope of Practice� Describes clinical pharmacy roles and responsibilities for

pharmacists� VHA Directive 1033, Anticoagulation Therapy

Management� Defines policy elements and strong practice recommendations

for anticoagulation programs� Gold Status Project-Improving Access to Primary Care

Utilizing CPS� PBM CPPO Clinical Pharmacy Practice SharePoint

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