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Practice Models for Clinical Pharmacy
Specialists (CPS) in the Patient Centered Medical
Home
Practice Models for Clinical Pharmacy
Specialists (CPS) in the Patient Centered Medical
Home
ObjectivesObjectives• Explain how clinical pharmacy contributes
in providing direct patient care• Incorporate intensive clinical pharmacy
services into Medical Home Model• Present pharmacy outcomes data from VA
Medical Home Models• Review resources & restructuring required
to meet the Medical Home Model initiative
• The Patient Centered Medical Home Model is a patient-driven, team-based approach that delivers efficient, comprehensive and continuous care through active communication and coordination of resources.
• Medical Home 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.
Patient Centered Medical Home
Patient Centered Medical Home
Patient Centered Medical Home
Replaces episodic care based on illness and patient complaints with coordinated care and a long term
healing relationship • The Primary Care Team
– Takes collective responsibility for patient care– Responsible for providing all the patient’s health care
needs– Arranges for appropriate care with other specialties as
needed • Enhanced Access• Enhanced communication between
– Patients– Providers– Staff
Team members• Clinical Pharmacy
Specialist: ± 3 panels• Clinical Pharmacy
anticoagulation: ± 5 panels
• Social Work: ± 2 panels• Nutrition: ± 5 panels• Case Managers• Trainees• Integrated Behavioral
Health• Psychologist ± 3 panels• Social Worker ± 5 panels• Care Manager ± 5
panels• Psychiatrist ± 10 panelsTeamlet: assigned to
±1200 patients (1 panel)• Provider• RN Care Manager• Clinical Associate
(LPN, Medical Assistant, or Health Tech)
• Clerk Patient
MEDICAL HOME MODEL
MEDICAL HOME MODEL
“Patient Centered Medical Home”Presentation by David Macpherson, MDChief Medical Officer, VISN 4
Key Principles of the Medical Home
Key Principles of the Medical Home
• Each member of the team works at their highest training level– Medication management goals can be delegated
to Clinical Pharmacy Specialists, who are key members of PCMH
• When possible care of the patient will be delivered by their team
• 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
The Clinical Pharmacy Specialist Role
The Clinical Pharmacy Specialist Role
• Identify patients who do not achieve a variety of performance goals and assist in chronic disease management to achieve therapeutic outcomes
• Enhance drug information by functioning as a therapeutic consultant to providers and other health care workers
• Relieve providers by assisting them with patient follow-up after medication changes, therapeutic drug monitoring, and patient medication counseling.
• Increase patient satisfaction by decreasing overall appointment wait times while providing the highest quality of care for our veterans
The Clinical Pharmacy RoleThe Clinical Pharmacy Role• Increase effectiveness of medication
reconciliation by decreasing medication discrepancies through prospective pharmacist review
• Improved inventory/formulary management resulting in more effective budget management
• Enhance medication safety by having the pharmacist assure that patients on certain medications get timely and appropriate laboratory assessments for both efficacy and adverse event prevention
Pharmacy
WorkloadProvider Burden
Dose
Titra
tions
&
Diseas
e
Manag
emen
t
Labor
ator
y
Monito
ring
Form
ular
y
Manag
emen
tMedica
tion
Recon
cilia
tion
Impro
ved Pa
tient
Inte
ract
ions
Clinical Pharmacy Specialists can increase the efficiency of physician-patient interactions and allow
for greater patient access to clinics
Clinical Pharmacy Specialists can increase the efficiency of physician-patient interactions and allow
for greater patient access to clinics
Improved
Quality &
Efficiency of Care
TIER
I
TIER
II
Tier II:• Med Reconciliation• Formulary Regulation• Refill/Walk-In Clinic• Medication Counseling • Medication Adherence• Drug Information Consultant
for Providers
Tier I:• PC Anticoagulation Clinic• PC Pharm Clinic
• Disease State Management• Medication Initiation & Dose
Titration• Therapeutic Drug Monitoring• Decision Support
Performance Data• Medication Counseling• Medication Adherence
Pharmacy
“Patient Centered Medical Home”Presentation by David Macpherson, MDChief Medical Officer, VISN 4
Clinical Pharmacy SpecialistClinical Pharmacy Specialist• Direct Patient Care• Scheduled Clinic Visits• Telephone Visits• Walk in / Urgent /Group Visits• Pertinent Clinical Reminders• Care Management• Manage/prescribe medications for identified disease states in accordance with
published guidelines and generally recognized standards of care to include orderings and reviewing lab and diagnostic studies. Care management is not limited to hypertension, diabetes, hyperlipidemia, anticoagulation, heart failure, kidney disease, tobacco cessation, COPD, and asthma.
• Documents clinical drug therapy interventions and plan of care• Preventive care needs• Non VA records / Dual care / Traveling veterans• Medication Reconciliation• Evaluate Non-Formulary or Criteria-Based medication requests to ensure
compliance with VA National Formulary and established Criteria for Use• Complete Medication Use Evaluations to assess appropriateness of use,
appropriate monitoring parameters, and compliance with national guidelines
Clinical PharmacistClinical Pharmacist• Direct Patient Care• Walk in or Urgent Visits• Telephone Visits/Telephone triage• Assessment of Medication Management/Patient education• Medication order processing/medication clinic interventions• Pertinent Clinical Reminders• Care Management• Medication Counseling• Medication Reconciliation• Identify/monitor high risk medications and evaluates appropriate
monitoring parameters • Preventive care needs• Non VA record review as appropriate• Evaluate Non-Formulary or Criteria-Based medication requests for the
team to ensure compliance with VA National Formulary and established Criteria for Use
Clinical Pharmacy Specialist (CPS)
Clinical Pharmacy Specialist (CPS)
• Primary Care can utilize the Clinical Pharmacy Specialist in direct patient care roles. They are mid-level providers with a VA scope of practice and able to perform to the highest level of their profession.
* Managing patient’s drug therapy to goal for chronic disease states and other specialty
care
• These positions are highly respected provider members with advance professional skills
Clinical Pharmacy Specialist (CPS)
Clinical Pharmacy Specialist (CPS)
• The CPS has an advanced degree – (today - Doctor of Pharmacy)
• Four years in medication management• Residency trained
– ASHP accredited residency program (PGY-1)– May have completed advance practice
residency (PGY-2)• Board Certification• The CPS functions under an expanded
Scope of Practice
VHA Directive 2009-014: VHA Directive 2009-014:
• CPSs are granted medication prescribing & monitoring privileges based on a locally-defined scope of practice.
• Scope of practice is approved by:– Clinical/Medical Executive Committee – Chief of Staff or Associate Director for
Patient Care Services– Chief of Pharmacy
Pharmacist as an Individual Practitioner
CPS Scope of PracticeCPS Scope of PracticeScope 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.
Scope of Practice versus Use of Protocols
Scope of Practice versus Use of Protocols
• Protocols are flow based algorithms• Protocols are not intended to address
complex medication related problems – Today, chronic disease medication management
utilizes a variety of drug classes.• Protocols require vigilant maintenance to
reflect the standards of care, safety bulletins, and VA National Formulary changes.
Chronic Disease Medication Management
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 advance 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
• San Diego VAMC
• West Palm Beach VAMC
• Jesse Brown Chicago VAMC
VA Experience with CPS Integrated in Primary Care Settings
San Diego VA Medical Center
San Diego VA Medical Center
VASDHS Primary Care ClinicsVASDHS Primary Care Clinics
• Anticoagulation• Hyperlipidemia• Intensive Diabetes
Care• FIRM-HTN/Lipid/DM• Dermatology• Pain
• Mental Health• Smoking Cessation• Medication Management
• Pulmonary• Anemia of CKD
VASDHS Secondary Care ClinicsVASDHS Secondary Care Clinics
• Neurology• Heart Failure• Urology• SPID• Rheumatology
• Urology• Oncology• Nephrology• Diabetes• General Medicine
A Routine Day: Utilizing CPS Within the Home Model
A Routine Day: Utilizing CPS Within the Home Model
• Patient Clinic Visits (via appointment package)– Managing Pharmacotherapy– Patient Education– Clinical Reminders– Physical Assessment
• Medication Renewals• Precepting Pharm.D.
Residents/Students• TeleHealth Follow-Up & Interventions• Administrative Role/Quality Assurance
Patients Not Meeting Goals
Referrals From Primary Care
Bi-Weekly Outliers From
Vista Lab Package
Decision Support
Performance Data
Clinical Pharmacy Specialists Can Address:
•Identification of absent therapies, sub-optimal doses, significant drug interactions
•Medication adherence assessment•Provision and monitoring of cost effective and safe regimens•Dietary/Lifestyle recommendations •Participation in quality improvement initiatives•Provider education•Patient education
Chronic Disease Management Outcomes
Chronic Disease Management Outcomes
Baseline
Mean±SD
3 Months
Mean±SD
Change
Age, yrs 62.1±1.3 NA NAHbA1C, % 10.8±1.3 8.4±2.0 - 2.4FPG, mg/dL 215±82 150±76 -65Weight, lbs 230.2±53.
3228.8±58.
1- 1.4
BMI, kg/m2 32.5±6.7 32.7±8.1 0.2LDL, mg/dL 92±39 80±28 -12TG, mg/dL 361±381 257±178 -104HDL, mg/dL 38±10 36±7 -2SBP, mmHg
130±16 128±14 -2
DBP, mmHg
71±11 69±12 -2
VASDHS DIABETES INTENSE MEDICAL MANAGEMENT CLINIC
TeleHealth Therapeutic Outcomes
TeleHealth Therapeutic Outcomes
West Palm Beach VA Medical Center
West Palm Beach VA Medical Center
West Palm Beach VAMC Opened in June 1995
West Palm Beach VAMC Opened in June 1995
• Guiding philosophies/principles (that endured)– Interdisciplinary team based care– Patient centered– Staff function at highest level of ability/licensure– Efficient and Effective Use of Resources
• Not all original principals opening principles/approaches
endured • Pharmacy Service CPS pharmacist managing chronic
medication patients as part of the PC teams (and on other teams) from opening day.
• The CPS pharmacy model at WPB continues today with
significant expansion of CPSs
West Palm Beach: A Historical Perspective
West Palm Beach: A Historical Perspective
• Medical Center Opened June 26, 1995:– 1,100 employees– 25,384 vets served– 229,237 outpatient visits
• CPS Pharmacists – 3 FTEE Primary Care Medication Management
Clinics– 1 FTEE Mental Health Clinic– 1 FTEE Infectious Disease Clinic– 1 FTEE Acute Medicine– 1 FTEE Long Term Care
West Palm Beach CPS Program 2010
Ambulatory Care
West Palm Beach CPS Program 2010
Ambulatory Care• Infectious Diseases (1
FTEE)• Cardiology (1 FTEE)• Mental Health (1 FTEE)• Substance Abuse (1 FTEE)• Smoking Cessation• Hem-Onc (1 FTEE)• Pain Clinic (1 FTEE)• Anticoagulation (3 FTEE)
• Medication Management- Primary Care (4.5 FTEE)
• Community Based Clinics-Telemedicine (1 FTEE)
• Home Based Primary Care (1 FTEE)
• Endocrine Clinic (1.5 FTEE)
West Palm Beach CPS Program 2010
Inpatient Services
West Palm Beach CPS Program 2010
Inpatient Services• Pulmonary-Critical Care (1 FTEE)• Acute Medicine (4 FTEE)• Long-Term Care (1 FTEE)• Hospice (1 FTEE)• Inpatient Psychiatry (1 FTEE)
West Palm Beach VA Home ModelWest Palm Beach VA Home Model
• Primary Care Clinical Pharmacist Responsibilities Distribution of the Work Week– 80% Direct Patient Care
• 60% Med Management Clinic (3 days/week)– HTN, DM, HL, COPD, CHF, Thyroid, Polypharmacy Management– 30 minute appointments from 8:00am-2:30pm
• 20% Walk-in Pharmacy Clinic (1 day/week)– Based on need: 2-10 face-to-face, 30 non face-to-face interviews– 20-30 Non-Formulary Consults– 20 PC Pharmacy Clinic Consults– PCP requests for patient medication counseling
– 20% Indirect Patient Care (1day/week)• Administration/Unscheduled Clinic Coverage
– Med Reconciliation/Allergy Assessment for Newly Enrolled Veterans– Lab Monitoring and Telephone f/u
West Palm Beach VA Team ApproachWest Palm Beach VA Team Approach
• PC Provider sees patient for normal scheduled visit
• Patient’s lipid values not at goal levels
• PC Provider makes medication adjustment at that visit
• PC Provider refers patient to Clinical Pharmacist for follow-up lipids and goal attainment
• Patient is scheduled to see Clinical Pharmacist until they reach goal LDL-c levels
Patient Scheduling with and without the use of CPS
Patient Scheduling with and without the use of CPS
Initial VisitPC Visit
LDL not at goal
6 Months PC Visit
12 Months PC Visit
18 Months PC Visit
4-6 weeks Pharm D
6 Month PC Visit
4-6 weeks Pharm D
12 months
4-6 weeks Pharm D Visit
18 months
Patients generally get to goal quicker with the use of Pharm D’s because there are more aggressive medication changes done in a shorter period of time.
with PharmD
without PharmD
Courtesy of Dr. Rubin, D.O.Chief of Primary Care ServiceWest Palm Beach VA Medical Center
Evidence for Improved Outcomes within the Home Model
Evidence for Improved Outcomes within the Home Model
• Retrospective chart review of 150 patients treated for CAD in PC Clinics at WPB VAMC: CPS referral vs. PCP alone
• Despite the relatively high percentage of patients reaching goal LDL in the PCP group, referral to CPSs resulted in statistically significant increases in the number of patients appropriately treated for hypercholesterolemia and achieving goal LDLGeber J, Parra D, Beckey NP, Korman L. Optimizing drug therapy in patients with cardiovascular disease: the impact
of pharmacist-managed pharmacotherapy clinics in a primary care setting. Pharmacotherapy. 2002 Jun;22(6):738-47
Evidence for Improved Outcomes
Evidence for Improved Outcomes
Geber J, Parra D, Beckey NP, Korman L. Optimizing drug therapy in patients with cardiovascular disease: the impact of pharmacist-managed pharmacotherapy clinics in a primary care setting. Pharmacotherapy. 2002 Jun;22(6):738-47
CPS Referral
PCP Alone P-value
Appropriate Treatment of Hypercholesterolemia 96% 68% p < 0.0001
Goal LDL values achieved below 105mg/dL 85% 50% p < 0.0001
Appropriate antiplatelet/anticoagulation
therapy prescribed97% 92% p = 0.146
Appropriate Therapy with ACE-I or Alternative in those with EF <40%
89% 69% p < 0.05
Cardiac Events 27 22 p = 0.475
Jesse Brown Chicago VA Medical Center
Jesse Brown Chicago VA Medical Center
Jesse Brown VAMC Primary Care Home Model
Jesse Brown VAMC Primary Care Home Model
Primary Care Team StaffingEach team:
• 3 Primary Care Physicians• 1 Nurse Case Manager• 1 LPN• 0.5 Health Tech• 1 Clinical Pharmacy Specialist
Chronic Disease Management Role of CPS• Anticoagulation
• Diabetes• COPD/Asthma• BPH
• Hypertension• Hyperlipidemia• Medication Management• Therapeutic Drug
Monitoring
Jesse Brown VAMC Home ModelJesse Brown VAMC Home Model
Standard Pharmacy Clinic Structure• 4.5 clinic days per week• 20 minute appointments• 16-18 appointment slots per day
(except Thursdays: ½ day clinic)
Referral Process• providers schedule directly into CPS clinic• review of patients who do not meet
performance/therapeutic goals are scheduled• Referrals based on national formulary changes and
national medication efficiency programs
FTEE Unique patients
Encounters Unique patients per provider
Primary Care Physicians
10.6 13,134 40,468 1,239
Clinical Pharmacy Specialists
3.5 2,779 11,769 794
Jesse Brown VAMC Home ModelJesse Brown VAMC Home Model
Data from 3/09 – 3/10; source – VSSC cube and VISTA
Four Primary Care Teams
Jesse Brown VAMC Home ModelJesse Brown VAMC Home Model
Other Clinical Pharmacy Specialist Responsibilities
• Medication Use Evaluations – QA program• Non-Formulary Consult Review• Assist with Formulary Conversions and Annual Cost Savings Initiatives• Assist with facility performance measures/initiatives• Membership in various Local, VISN, and/or National Groups/Committees• Research• Precept 4th Year Pharmacy Students (min 5 students/year)• Precept PGY-1 Pharmacy Practice Residents
Jesse Brown VAMC Home Model
Jesse Brown VAMC Home Model
• CPS integrated in primary care at main station and four community based outpatient clinics (CBOC)
• CPS reports to pharmacy service• Success of this integrated role has led to
CPS expansion in specialty clinics throughout the medical center
• Pharmacy continues to receive requests from medical staff to expand CPS services
Jesse Brown VA Medical Center Home Model
Jesse Brown VA Medical Center Home Model
Specialty Clinical Pharmacy Clinics
• Intense Diabetes Management
• Emergency Department • Geriatrics• Gastroenterology• Home Based Primary Care• Home Infusion Program• Infectious Diseases• Co-Infection – Hepatitis C
• Mental Health
• Nephrology
• Pain
• Pulmonary
• Smoking Cessation
• Urology
• Women’s Health
Jesse Brown VA Medical Center Home Model
Jesse Brown VA Medical Center Home Model
N = 142 Baseline Follow Up (6 mos)
HgbA1c 11.1% 8.3%
HgbA1c < 9% 0% 63%
HgbA1c < 7% 0% 29%
LDL (<100 mg/dL) 55% 82%
Statin Use 71% 86%
BP (<130/80 mm Hg)
43% 71%
ACE Inhibitor Use 87% 90%
Anti-Platelet Therapy
78% 89%
Pharmacy Clinic Outcomes – Diabetes Management
Percentages given as a mean2009
Jesse Brown VA Medical Center Home Model
Jesse Brown VA Medical Center Home Model
N = 48 Baseline Follow Up Mean Change
HgbA1c 10.3% 7.3% - 3.0%
LDL (mg/dL) 161.6 104.9 - 56.7
BP (mm Hg) 148/89 130/80 -18/9
Pharmacy Clinic Outcomes – Women’s Health
Multidisciplinary clinic modelMean number of visits: 2.4 over 6
months
Values given as a mean2009
Case: IzzyCase: Izzy
• Isabella Vicenza is a moderately obese 66 year old female veteran with diabetes, coronary artery disease, and COPD
• She is a current smoker and doesn’t want to quit– Hemoglobin A1c is 10.2, and has never been
below 9.0 for the past 10 years– LDL is146
• She has never consented to a mammogram, a colonoscopy, or a regular pap smear
Case: IzzyCase: Izzy
• Her medications are – Glypizide 5mg daily
• (which she takes when she feels like her blood sugar is high. She won’t take her blood sugar because she doesn’t like to poke herself)
– Fish oil 1000mg twice a day • (she will take this because its ‘natural’)
– Aspirin 81mg daily • (as long as she doesn’t notice any bruising – she’s willing to take this
because her father had a stroke and refused to take aspirin)
– She has been prescribed an atrovent/albuterol inhaler which she only uses when she feels short winded. She has been instructed to use it four times a day, but doesn’t because she’s annoyed that she’s expected to do something for the doctor four times a day
– “I’m already taking enough medicines. They’re all poisons as far as I’m concerned.”
Population of Women VeteransPopulation of Women Veterans
Source: VHA ADUSH for Policy and Planning
Women: An Underserved Population
Women: An Underserved Population
All VISNS
VISN 21
All living male veterans 22,245,866
Unique male users 4,806,760
Market penetration (male) 22%
All living Women Veterans 1,743,091 86,400
Unique women users 261,831 11,073
Market penetration (female) 15% 12.82%
VISN 21 Male Gender Dashboard
VISN 21 Male Gender Dashboard
VISN 21 Female Gender DashboardVISN 21 Female Gender Dashboard
Performance by GenderPerformance by Gender
MeasuresMale
% #MalesFemale %
# Female
s p valueDM A1C annually 96.5 31,599 95.2 1,204
p=0.0072
DM A1C >9 16.1 31,599 17.8 1,204 p=.0546
DM LDL < 100 68.2 31,599 55.8 1,204p<0.000
1DM and BP < 140/90 78.6 31,599 74.8 1,204 p=.0007DM retinal Exam in past 2 yrs 86.9 31,778 80.8 1,207
p<0.0001
DM LDL annually 94.6 31,599 93.7 1,204 p=0.008IHD LDL annually 90.4 3,414 87.5 80
p=0.1928
IHD LDL < 100 67.2 3,414 55 80p=0.010
9HTN BP < 140/90 76.3 66,028 73.1 2,985
p<0.0001
Staffing GuidanceStaffing Guidance
Achieving PCMH GoalsAchieving PCMH Goals• Many medical centers have been staffing Clinical
Pharmacy Specialist to work in Primary Care for less than 40 hours per week.
• Primary Care has identified goals to require that the staffing be dedicated to work in the Patient Centered Medical Home, as Clinical Pharmacy Specialists for management of chronic diseases and patients on anticoagulation therapy.
• Primary Care instructions for funding allow:• Clinical pharmacy specialists to be added to the
PCMH team
Achieving PCMH GoalsAchieving PCMH Goals• Facilities may recruit or staff existing VA clinical
pharmacy specialists into these new roles as full time employees and then backfilling their vacated positions
• Don’t Miss This Opportunity to Recruit • VA has 400 pharmacy practice residents who
complete their training each June. • At current turn-over rates, VA is only able to hire
about 50% of these highly skilled clinical pharmacists, leaving an annual pool of up to 200 potential Clinical Pharmacy Specialists who could be hired to support the PCMH for management of chronic disease medication therapy.
PCMH Staffing Recommendations: PCMH Staffing Recommendations:
Staffing for Clinical Pharmacy Specialists working in Primary Care for chronic disease management:
• 0.3 CPS per 1200 PC panel of patients
– Or said differently: • Approximately 1 FTEE CPS for every 3 primary care providers
Staffing for Clinical Pharmacy Specialists working in Anticoagulation:
• 0.2 CPS per 1200 PC panel of patientsOr said differently:
• Approximately 1 FTEE CPS for every 5 primary care providers
Note: this provides a 1:300 ratio which may be higher that current requirements. Many sites reported a 1:400 ratio.
Anticoagulation programs should remain centralized
PCMH Staffing Recommendations: PCMH Staffing Recommendations:
VA is a nationally recognized leader in Clinical Pharmacy
Services.
The team based approach of the Patient Centered Medical Home provides the opportunity for this role and that of the other team
members to become the standard of care.
Questions ?Questions ?