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Expanding and Advancing Clinical Pharmacy Practice

Heather Ourth, PharmD, Julie Groppi, PharmD, Kim Quicci-Roberts MS Department of Veterans Affairs

CPE Information and Disclosures

The American Pharmacist Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

Heather Ourth, PharmD, Julie Groppi, PharmD, Kim Quicci-Roberts MS : “declare no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria.”

CPE Information

• Target Audience: Pharmacists & Technicians

• ACPE#: 0202-0000-15-189-L04-P/T

• Activity Type: Knowledge-based

Pharmacist Learning Objectives

• Describe the many tools, policies, and guidance developed by Department of Veterans Affairs (VA) Clinical Pharmacy Practice Office (CPPO) that are available to help facilities manage the expansion of clinical practice for pharmacists.

• State how some facilities have been successful in using the tools created to expand practices.

• Discuss challenges and obstacles that are faced by field facilities in using these tools and possible future tools that might be used to overcome these barriers.

Technician Learning Objectives

• Describe the tools, policies and guidance developed by the VA Clinical Pharmacy Practice Office (CPPO) which have transformed many tasks now performed by pharmacists to technicians.

• State how some facilities have been successful in using the tools to involve technicians in expanding operational and clinical roles.

• Discuss challenges and obstacles that are faced by field facilities in using these tools and possible future tools that might be used to overcome these barriers.

Self-Assessment Question 1

Which of the following are tools developed by the VA Clinical Pharmacy Practice Office (CPPO) to promote practice expansion?

A: Acute Care Staffing ToolB: PhARMD Project ToolC: Competency Assessment Tools for Pharmacists and Pharmacy TechniciansD: All of the Above

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Self-Assessment Question 2

How have facilities have been successful in using the tools created to expand practices?

A: Expanding FTE in Acute CareB: Movement to Practice Area Based Scope of PracticeC: Shifting Workload to TechniciansD: All of the Above

Self-Assessment Question 3

Which of the following are future tools that might be used by facilities to overcome barriers in practice?

A: PhARMD Project ToolB: Workload Pivot ToolC: Both A & BD: Nothing can help overcome barriers

• For over 40 years, clinical pharmacists have practiced comprehensive medication management and provided cognitive clinical pharmacy services.

• The Clinical Pharmacy Practice Office (CPPO) was created by PBM in 2010 to streamline VHA’s clinical pharmacy program while developing standardized pharmacy practice models, educational initiatives, developing projects that assess the impact of clinical pharmacy interventions and penetration, as well as providing guidance on issues related to clinical pharmacy practice.

• The CPPO continues to develop advanced roles of the clinical pharmacist and clinical pharmacy specialist that helps the VA and Veterans medication related problems and better manage disease states

VA Clinical Pharmacy Practice Office (CPPO)

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Effective Change Management

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1. Motivating Change

2. Creating a Vision for Change

3. Developing Support

4. Managing the Transition of Change

5. Sustaining Momentum

MOTIVATING CHANGE

Identification of needsGlimpse of our Pharmacy WorkforceShifting Workload Training and Clinical Pharmacy Boot Camps

Identification of Needs Through Systems Redesign Survey

• Purpose: Obtain an accurate characterization of VHA Pharmacy Services nationwide.

• Method: Assessment Tool (Questionnaire)

Pharmacy Practice Model

Characteristics

Application of Information

Technology in the Medication-Use

Process

Successful Implementation of

New Pharmacy Practice Models

Advancing the Use of Pharmacy Technicians

Survey Tool

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Survey Question: Does a lack of pharmacy technician staff impede development of an optimal pharmacy practice model at your institution?

0%10%20%30%40%50%60%70%

Yes1A 67%1B 46%1C 64%2 54%3 33%

Are there Clinical Pharmacy Specialists (CPS) with a scope of practice (that includes prescriptive authority and the ability to order laboratory tests and other diagnostic studies necessary to monitor and support the patient's drug therapy)?

0%10%20%30%40%50%60%70%

There are in allareas/situations

(100%)

There are in mostareas/situations (50-

99%)

There are in someareas/situations (1-

49%)1A 19% 62% 19%1B 23% 62% 15%1C 22% 64% 14%2 8% 50% 42%3 33% 39% 28%

Are pharmacists doing any of the following that could be assigned to technicians? (Select all that apply)

0%10%20%30%40%50%60%70%80%90%

Checking unitdoses

InventoryManagement

Medication UseEvaluation data

collection

Ward Inspections MedicationProcurement

1A 38% 24% 90% 33% 5%1B 39% 8% 85% 54% 0%1C 36% 14% 86% 29% 7%2 31% 4% 88% 4% 0%3 50% 0% 72% 11% 0%

Have you added new services staffed by CPS?

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Yes No1A 71% 29%1B 85% 15%1C 86% 14%2 77% 23%3 67% 33%

Optimization of Pharmacy Technician Workforce

Use Pharmacy Technicians to do all

tasks that don’t require Pharmacists

Allow sites to exchange 1

Pharmacist vacancy for 3 Techs where

needed (same cost)

Enhance Pharmacy Technician training

to support new tasks and

competencies

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Pharmacy Technicians: Shifting Responsibilities

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TECHNICIANS

IV Preparation

Screening NFs/PAs

Acquisitions

Ward Inspections

Checking Unit Doses

Quality Assurance

Patient Medication

History

Controlled Substances

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Systems Redesign Toolkit

• Ward Inspections• Inpatient Tech check Tech• Compounding Sterile Preparations• Customer Service• ADR Documentation• Inventory Management• Prepackaging

Core Technician Functions

• Window Fill ReductionTask Elimination

System Redesign Return on Investment Tool (SPIRIT) Core Competency Assessment Tools

System Redesign Return On Investment Tool (SPIRIT)

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InteractiveCustomizableExcel WorkbookEasy to understand: Stop Lights- Red, yellow, Green (Go)

System Redesign Return On Investment Tool (SPIRIT)

Total Number of Pharmacists (Onboard Employee) by Fiscal Year

6,634

6,8596,997

7,251

7,5817,736

6,000

6,200

6,400

6,600

6,800

7,000

7,200

7,400

7,600

7,800

8,000

2010 2011 2012 2013 2014 2015Total Number of Pharmacists GS11-15

PACT Implementation

mid-2010

Of These 3,180

Residency = 68%

BPS Certification

= 44%

Other Certification =

18%

Residency &/or

Certification = 76%

Pharmacists with Scope of Practice exceeds 3,180 (41%)

VHA has approximately 7,700 Pharmacists Number of Pharmacists With a Scope of Practice – Growth Over Time

Data Source: CPPO Scope of Practice SharePoint Database

1,945

2,087

2,284

2,473

2,6542,716

2,8532,965

3,0593,185

1,700

1,900

2,100

2,300

2,500

2,700

2,900

3,100

3,300

63%

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Scope of Practice Trends

Data Source: CPPO Scope of Practice SharePoint Database

175

375

575

775

975

1,175

1,375

Jul-1

1Se

p-11

Nov

-11

Jan-

12M

ar-1

2M

ay-1

2Ju

l-12

Sep-

12N

ov-1

2Ja

n-13

Mar

-13

May

-13

Jul-1

3Se

p-13

Nov

-13

Jan-

14M

ar-1

4M

ay-1

4Ju

l-14

Sep-

14N

ov-1

4Ja

n-15

Mar

-15

May

-15

Jul-1

5Se

p-15

Anticoagulation Lipids Diabetes Hypertension Global

Training and Clinical Pharmacy Boot Camps

• Educated all levels of leadership on our transformational plans at National Meeting in Denver

• Over 400 participants focused heavily on implementation, maintenance, and growth of clinical pharmacy programs

2010

• Launched face to face Regional Clinical Pharmacy “Boot Camps” that trained over 300 Clinical Pharmacists on 7 core chronic primary care diseases

2011 • Virtual Training• Specialty Boot

Camps which have been used by over 1,000

• Training for board certification resulting in over 90% pass rate

• Launched national certification support in Antimicrobial Stewardship for two pharmacists at every facility

2013-14

Boot Camps

Pharmacy Chronic Disease Management (Phase I)

Pain ManagementDiabetesHepatitis CHyperlipidemiaHypertensionOsteoporosisTobacco Dependence

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Specialty Boot camps (Phase II)

Cardiology – Heart FailureMental HealthHematology/OncologyRespiratoryNephrologyWomen’s Health

CREATING A VISION

Key Messages and Initiatives to Promote Practice Advancement

Creating a Vision for Change

• All teams have access to a Clinical Pharmacists who perform medication management under a scope of practice which includes all core elements

• Clinical Pharmacy Specialists (CPS) provide direct care the majority of the time

– Assigned to specific teams based on the practice area• Credentialing of Pharmacist with a Scope of Practice is

similar to other prescribers– Scope of Practice Oversight (the PPE process) is performed in

accordance with medical staff bylaws• Recognition as a advanced practice practitioner in all practice

areas

• And the list goes on and on…..

Defining the Vision

Professional Policy

Workload Capture

Pharmacist Scope of Practice

Staffing Standards

Pharmacist Outcomes (PhARMD

tool)

• All elements work together to Promote Practice Advancement

• Professional Policy is one piece of how we can define practice to promote advancement

• Describing New Practice Areas

• Promoting Practice Standardization

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Balancing Collaborative and Independent Practice Roles in Clinical Pharmacy: A Qualitative Research Study

Summary Conclusion• Interruptions are a manifestation of the health care

system’s and other health are providers’ under recognition of the dual roles of CPs.

• Interruptions affect the work flow and possibly the effectiveness of CPs, especially when they are delivering direct care.

Our study at least raises the issue of whether the current system is functioning optimally to support pharmacy practice in direct care delivery.

McCullough, MB et.al., Annals of Pharmacotherapy 1-7

HOW CAN WE ENCOURAGE FULL TIME CPS POSITIONS IN HIGH DEMAND SETTINGS?

DEVELOPING SUPPORT

Policy and Guidance DevelopmentCreation of Staffing Tools

Developing Support through Policy

• In July 2015, VHA published its first Handbook that encompasses all key elements surrounding clinical pharmacy services

• Over time numerous guidance documents have been created to describe practice elements

• FACT Sheets are developed to further describe roles of pharmacists practice settings

• Partnering with Key Stakeholders to Identify Areas of Opportunity

Clinical Pharmacy Services Policy to Define the Vision

Defining the Plan• Staffing Ratios• Workload Capture• Collaborative

Care/Service Agreements

• Shared Practices

Patient Care Activities• FACT Sheets• Improving Access• PhARMD Interventions• Included as key

member of the team

Support and Infrastructure• Clinical Pharmacy

Services Handbook• Key VHA Policies:

PACT, HBPC, ED, Pain, ASP

• Guidance to Clarify Elements

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Developing an Infrastructure with Clinical Pharmacy Staffing Standards

• Clinical pharmacy staffing models are evaluated at regular intervals – Include the needs of the facility, complexity, size, and

clinical programs available

• Staffing Models Exist– Outpatient Clinical Pharmacy Workload Mapping Tool– Acute Care Clinical Pharmacy Staffing Model– Hep C Clinical Pharmacy Staffing Model– Antimicrobial Stewardship Staffing Tool and Guidance

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Staffing ToolsWhat can they do and what they cannot

• Staffing tools assist with staffing standardization, but do not set standards

– Don’t determine what services must be offered • Require supervisor interpretation

– How much administrative time should an individual have?– What activities should be performed by which individuals?

• Precision of the output depends on precision of input– Bad data in = bad data out

Clinical Pharmacy Outpatient Workload Mapping Tool

• Base tool to estimate workload in the Ambulatory Care setting– May be used in a variety of practice areas

• Assists with needs assessment• Standardized definitions for the input values

Clinical Pharmacy Specialist Workload Mapping Tool

Output Weekly Encounter rates: Maximum encounter rates are purely based upon clinic structure and clinic operation time. Clinic cancelations, no-shows and unscheduled appoints are not addressed. The adjusted possible encounters are the estimated encounters per week considering the cancelation rates and no show rates.Output Extrapolated estimated encounters per day, week and year based upon the adjusted weekly encounters above. If total clinic operation is <9 hours, estimated encounters per day will not be calculated.

Calculated Encounter Information Value UnitsMaximum possible encounters per week Disease state / Clinic 1 0 Encounters/WkAdjusted number of potential encounters per week Disease state / Clinic 1 0 Encounters/WkMaximum possible encounters per week Disease state / Clinic 2 0 Encounters/WkAdjusted number of potential encounters per week Disease state / Clinic 2 0 Encounters/WkMaximum possible encounters per week Disease state / Clinic 3 0 Encounters/WkAdjusted number of potential encounters per week Disease state / Clinic 3 0 Encounters/WkMaximum possible encounters per week Disease state / Clinic 4 0 Encounters/WkAdjusted number of potential encounters per week Disease state / Clinic 4 0 Encounters/WkMaximum possible encounters per week Disease state / Clinic 5 0 Encounters/WkAdjusted number of potential encounters per week Disease state / Clinic 5 0 Encounters/Wk

Estimated Encounter Information DAY WEEK YEARDisease State / Clinic 1 0 0 0

Disease State / Clinic 2 0 0 0

Disease State / Clinic 3 0 0 0

Disease State / Clinic 4 0 0 0

Disease State / Clinic 5 0 0 0

TOTAL PROJECTION OF AVAILABLE ENCOUNTERS : 0 0 0

Determining Gaps in Primary Care

• Staffing Ratios Established– 1 CPS per 3 PACT

teamlets (1:3,600 patients)• Identification of gaps in care

related to clinical pharmacy services– Teamlets without clinical

pharmacists– Facilities with ratios below

recommended levels• Ability for Management staff

to provide gap assessments to Senior Leadership

Teams with

PACT CPS

Improved Performance

Measures

Improved Outcomes

High Performing

Teams

Improved Access

Primary Care Staffing Ratios and Evaluation Gaps In Clinical Pharmacy Coverage

Acute Care Clinical Pharmacy Staffing Tool allows for evaluation of staffing needs based on activities performed by CPS• Average Daily Census Numbers from Workload Reports• Estimated Avg. Daily Number of patients (or % of the daily census)

the service is provided for• Estimated number of days per week services are provided

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CPS Support for the Acute Care Setting

Anticoagulation ASP activities PK Monitoring Nutrition Support

NF/ Restricted Drug Consults

Patient Care Rounds

Clinical Chart Reviews Other

Utilizing Staffing Tools to Support ChangeEastern Colorado VA HealthCare System

Clinical Pharmacists

• 10 FTE• Traditional

pharmacy roles

• Rotation on days, weekend, evenings

• Coverage of infusion clinic, LCL

CPS

• 5 FTE• Assigned to

ICU, Medicine teams, psychiatry

• No evening and limited weekend coverage

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Applying a Productivity Assessment to the Acute Care Setting

• Staffing calculator tool used to estimate FTEE for current clinical services

– Facility average daily census used, excluding MH and CLC #70– Discharge Med Recon 7-days/week– Anticoagulation Management (M-F)– Pharmacokinetic monitoring (M-F)– Team rounds 20% in ICU only (M-F)

• Developed a Business Proposal to Optimize Clinical Services and Collaborative Care Agreement to Define Services

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Collaborative Care Agreements to Define Services

• Identified a physician champion (hospitalist)• Met with all service chiefs of admitting services• Defined needs of population (AC, PK, other)• Determined clinical services that can be provided

– Opt-out vs. Opt-in– Minimum staffing and schedule

• Defined CPS and CP activities • Defined scope of practice vs non-scope activities• Included responsibilities for all providers

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Support Change in Clinical Pharmacy Roles

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PGY1 Precepting• Clinical

rotations• Research

Utilize Scope of Practice

• MTM follow-up• Clinical recs.

• Order verification

• D/C Med. Rec. and

counseling

Medicine/ICUs• MTM (All patients)

• Team rounds• 7-day/week clinical

services & ICU rounds

Recommendations to provider

PGY1 Precepting• Operations

Day, night, weekend operations centralized

order entry

PI/QI; Committees

CPS Clinical Pharmacists

Non-ICU Surg/PM&R • PM&R rounds 2/week

• Clinical Recs• MTM follow-up MANAGING TRANSITION

Movement to SOP Practice areaCompetency Tools for Pharmacists and Pharmacy Technicians

Changing Landscape in VA Scope of Practice

• VHA established system-wide scope of practice (SOP) authority, including prescriptive authority, for pharmacists in 1995

• Expanded Role of CPS to address the comprehensive medication management needs of the patients– Movement to Practice Area Based SOP

• Changes in State Practice Act Collaborative Practice Authority – Currently 48 states with some sort of CPA authority

• Practice-Area Based SOP

– Consistent with other practitioners

– Allows focus on the medication management needs of the Veteran more fully

Executing Therapeutic

Plans

Ordering Labs and Diagnostic

Tests

Prescribing Medications

Ordering and Administering

VaccinesOrdering Consults

Obtaining Informed Consent

Independent Corrective

Action

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Re-Defining “Core” Elements in a Scope of Practice (SOP)

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Ensuring Competency for Practice Expansion

• Rapid expansion of CP/CPS into clinical roles – Primary Care (PACT) Competencies for Clinical

Pharmacists• Need for Pharmacy Technicians to take on

traditional Pharmacist roles in addition to supportive roles

• Need for standardized assessment of minimum competencies

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PACT Competency Assessment Form

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Practical Application of the GuidanceCentral Alabama Veterans Health Care System (CAVHCS)

32,000 primary care uniques1,500 FTEETwo Main CampusesNew HCC—State of Art PACT Space4 CBOCs in Alabama and Georgia45.5 Pharmacist25.5 CPS with a Scope of Practice

– 1.5 Anticoagulation CPS– 9 PACT CPS

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CAVHCS Utilization of Competency Tools

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• Expansion from PACT Pharmacist limited to Practice Area Based SOP

• Assigned the trainee to a mentor – Face to face training – Remote mentoring– Mentor co-signed notes and ordered med/labs

• Completed Tool attached to SOP Request along with Management Review

Practical Application--Tennessee Valley (TVHS) Inpatient Restructure

• Move to a structure where Clinical Pharmacist are working at the top of their license and Clinical Pharmacy services are provided 7 days a week 7am-7pm

• Movement of GS-12 Clinical Pharmacist to coverage of inpatient medicine teams

• Need to evaluate competency of Clinical Pharmacist – Inpatient training documents developed for self study for clinical

pharmacist– Competency document created using PACT competency as an

outline– Week orientation performed with current rounding clinical

pharmacist– Competency documents completed

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Pharmacy Technician Competencies

• Standardized Toolkits– Background– Relevant definitions– Suggested Education and Training

• Links to Training (TMS, PPTs, Other)– Core Competency Objectives– Validation Tool (linked)

• Competency Assessment Check List– Quality Assurance– Resources and Relevant VHA

Directives/Handbooks

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SUSTAINING MOMENTUM

National Clinical Pharmacy Practice CouncilsReports to Describe Clinical Pharmacy Services

It Takes A Village

National Clinical Practice Council

• Bi-directional Communication CONDUIT locally, regionally and nationally

• Share strong practices related to clinical pharmacy practice;• Assess clinical pharmacy outcomes and workload, clinical

pharmacy interventions and return on investment (ROI) for clinical pharmacy practice;

• Evaluate clinical performance metrics and population management for opportunities;

• Identify gaps in patient care that exist with emphasis on expansion of clinical pharmacy services; and

• Ensure a platform for discussion of clinical pharmacy professional practice elements for consistency with national guidance and policy

PRACTICE ADVANCEMENT FORUM | JUNE 11, 2015

Measuring Impact of Clinical Pharmacy Care

• Clinical Pharmacy Interventions• Improvements in Performance Measures• Improvement in Access to Primary Care

and Specialty Care Providers• Clinical Pharmacy Dashboards• Clinical Pharmacy Workload

PRACTICE ADVANCEMENT FORUM | JUNE 11, 2015

Nationwide Clinical Pharmacy Workload Trends

Parameter FY11 FY12 FY13 FY14 FY15 % Change

# Pharmacistswith SOP

2,132 2,616 2,870 3,059 3,185 49%

% PharmacistUnder SOP

NA 32% 35% 41% 41% 28 %

Encounters/FTE 403 615 629 664 692 72%

Total 160 Encounters

2,454,419 3,677,269 4,067,110 4,450,815 5,051,831 106%

*FY15 estimated based on Q1-3 data

Addressing Challenges in Workload Capture

• Workload pivot– Allows classification of encounters by practice

area and modality• Stop Code guidance

– Ensures pharmacist workload is appropriately reported and measured

• Active Pharmacy Clinic report– Allows sites an easy way to review clinic set-up

for appropriateness and alignment with guidance

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PhARMD Project Tool Capturing Interventions System-Wide

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• One tool for all Pharmacist Users• Use of Reminder Health Factors to retrieve pharmacist

specific data elements• Reporting Infrastructure created and available to all

participating sites

Pharmacists Impacting CareReason for Referral

0 50,000 100,000 150,000 200,000 250,000 300,000

GOAL OF <7%

GOAL OF <8%

GOAL OF <9%

GOAL OTHER

GOAL OF <140/90

GOAL OF <140/80

GOAL OF <150/90

GOAL OF <130/80

GOAL OTHER

DM

TYP

E 2

HTN

Number of Goal Interventions

Pharmacists Impacting Care Reaching Disease State Therapeutic Targets

0 50,000 100,000 150,000 200,000

All Disease States

HTN

LIPIDS

DM TYPE 2

178,829

63,028

43,542

33,281

At Goal or End of Active Tx Selected

PhARMD Tool Expansion

• Prior tools tracked only interventions in the ambulatory care setting

• New version release will allow VA to quantify types and volume of interventions made in acute care

Anticoagulation Nutrition Support

Antimicrobial Stewardship

Pain Management

Mental Health

Key Points

• VA CPPO has been successful in the creation of policy and tools to promote practice expansion across the system

• Application of these tools into practice requires strong facility support and leadership

• It Truly Takes A Village!• CPPO is continually looking for ways to address

gaps in care and opportunities that remain

Self-Assessment Question 1

Which of the following are tools developed by the VA Clinical Pharmacy Practice Office (CPPO) to promote practice expansion?

A: Acute Care Staffing ToolB: PhARMD Project ToolC: Competency Assessment Tools for Pharmacists and Pharmacy TechniciansD: All of the Above

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Self-Assessment Question 2

How have facilities have been successful in using the tools created to expand practices?

A: Expanding FTE in Acute CareB: Movement to Practice Area Based Scope of PracticeC: Shifting Workload to TechniciansD: All of the Above

Self-Assessment Question 3

Which of the following are future tools that might be used by facilities to overcome barriers in practice?

A: PhARMD Project ToolB: Workload Pivot ToolC: Both A & BD: Nothing can help overcome barriers

Together We Can Make A Difference

Heather Ourth, PharmD, Julie Groppi, PharmD,

Kim Quicci-Roberts MS ClinicalPharmacyPracticeOfficeCPPO@va.gov