Practice Models for Clinical Pharmacy

Specialists (CPS) in the Patient Centered Medical

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Practice Models for Clinical Pharmacy

Specialists (CPS) in the Patient Centered Medical

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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

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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 ?