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May/June 2018 - Best Practice Spotlight: Pharmacist Providers in Primary Care

23 May 2018 12:51 PM | MSHP Office (Administrator)

Kansas City VA Medical Center Diffusion of Excellence Project
Author: Sarah Cook, PharmD: Clinical Pharmacist at SSM Health St. Joseph’s Hospital – St. Charles

The Kansas City VA (KCVA) has implemented a practice model that allows pharmacists to practice at the top of their scope in the primary care setting, resulting in increased utilization of pharmacists, offloading of primary care provider appointments, and improved patient outcomes.  Kyleigh Gould, PharmD, BCPS is the Associate Chief of Clinical Pharmacy Services at KCVA Medical Center and was instrumental in the implementation of this practice at her site.  She has graciously participated in an interview to share the work she is doing at the KCVA with MSHP members.  If you have any questions regarding the topic, please sent them to Sarah.Cook@ssmhealth.com and they will be forwarded on to Dr. Gould. 


Please describe the program you started at your institution.

In 2015, the Under Secretary for Veteran Affairs, Dr. David Shulkin, recognized that individual Veteran Affairs (VA) institutions had successful and innovative practices, but they weren’t being effectively implemented throughout the system nationwide. As a result, the Diffusion of Excellence (DOE) program was created to improve standardization across the VA system by identifying best practices and finding frontline champions to adopt and replicate them at other VA sites. Dr. Ellina Seckel, on behalf of the William S. Middleton Memorial Veterans Hospital in Madison, WI, submitted a project titled: “Increasing Access to Primary Care with Pharmacist Providers,” which was selected as one of 13 Gold Status practices. The results of the project showed when Patient Aligned Care Team (PACT) Clinical Pharmacy Specialists (CPS) were fully optimized in their roles, PACT CPS can offload 27% of primary care provider (PCP) appointments. In addition, implementation of pharmacist driven new patient medication intake appointments prior to the initial primary care provider appointment saved primary care providers 20 minutes on average for every new patient. Team satisfaction and communication improved, and 4 additional pharmacist resources were approved locally. Since 2016, Dr. Seckel and the Pharmacy Benefits Management (PBM) Clinical Pharmacy Practice Office (CPPO) have continued to implement this Gold Status practice at VA medical centers across the country.

 

In October of 2016, The Kansas City VA (KCVA) pharmacy leadership team requested a visit from the DOE consultative visit team to review the CPS role at the time and potential opportunities for implementation of the DOE Gold Status practice. KCVA proceeded with implementation of the DOE model in the recommended phased approach; beginning with one pharmacist and then implementing to the broader pharmacist team over several months.  Based on the clinic location I was practicing at, I was the phase one pharmacist that led the DOE roll-out at KCVA. However, all PACT CPS’s were involved with the successful roll-out at KCVA.  Implementation occurred in a multimodal approach:

  • Aligning each CPS to designated PAC-Teams in the appropriate ratio of 1 CPS to 3 PAC-Teams. The PAC-Team consists of a medical support assistance (MSA), licensed practical nurse (LPN), registered nurse and primary care provider.
  • An educational campaign to outline disease states CPS can help manage. Education was provided to Veterans and team members.
  • CPS participating in weekly PAC-Team meetings/huddles to focus on team-based population management initiatives and day-to-day needs.
  • CPS performing new patient medication intake visits to help streamline initial PCP visits.

How do you (pharmacists) in your program provide care to patients and ensure safe and effective medication therapy?  

Within the VA system, a PACT CPS is an advanced practice provider who has a practice -area based scope of practice to independently evaluate patients, prescribe medications and order labs, imaging and consults as necessary for Veteran care post-diagnostically. CPS’s provide comprehensive medication management to improve medication use and clinical outcomes.  CPS’s have scheduled appointments of multiple modalities such as face-to-face, telephone, and virtual telemedicine. CPS’s improve access in multiple practice areas by providing comprehensive medication management to improve medication use and clinical outcomes, which creates opportunity for other providers to see more urgent/acute patients.

What services have you determined to be essential to support your programs?

Prior to the DOE roll-out, the KCVA PACT CPS’s did not have support for ancillary functions such as scheduling appointments and performing vital sign checks. As the role of the CPS evolved to be an additional provider on the team and the number of Veterans cared for by the CPS increased, it was necessary to establish the same ancillary support for the CPS as the primary care provider. Through leadership and frontline staff collaboration, the KVCA PACT CPS’s have successfully gained ancillary support for scheduling, patient check-in’s, and care coordination with the RN care manager.

How did you gain support of hospital administrators, physicians, and nursing to implement your program?

Gaining support was a widespread approach. While the DOE consultative visit team was on-site much of their time was spent meeting with hospital leadership, front-line supervisors and front-line team members explaining the benefits of the Gold status practice and how rolling out at KCVA could benefit our facility. Additionally, the DOE team discussed the individual needs of KCVA and how to put our touch on the project which resulted in tracking pharmacists’ involvement on the PAC-Team and specific Healthcare Effectiveness Data and Information Set (HEDIS) measures: A1C >9 %, diabetics with blood pressure above goal and patients with atherosclerotic cardiovascular disease not on statins. 

After the consultative team visit, pharmacy leadership scheduled weekly internal calls with primary care leadership, front-line supervisors and PACT CPS to review progress, overcome barriers and ensure continued momentum for the project. I met with the front-line MSAs and LPNs several times to ensure consistent support. In addition, weekly team meetings helped to improve communications and relationships with the team and focused on population management initiatives to proactively engage high-risk patients into care.

 

What are key barriers that needed to be overcome to start your program?

The main barrier was the need for consistent ancillary support and clinic space to allow the CPS to spend 75-85% of time in direct patient care performing comprehensive medication management services. Scheduling support and patient-check-in support helps to streamline CPS patient visits and improve CPS efficiency. We worked with the clinic managers to gain dedicated space within the clinic to perform patient care visits.

Pharmacy leadership also worked hard to off-load operational pharmacy tasks to the appropriate member within the pharmacy department to ensure the PACT CPS is consistently working at the top of their scope. Through consistent education, redirection and strong leadership support we have been able to work through these barriers. 

What are some key considerations to gain employee acceptance and buy-in for your program?

Consistent and positive communication regarding the program and showing the benefits are important. Tracking outcomes helped to show each member that their support has helped to prove the programs benefits.

What benefits have you been able to show with your program?

For the three PACTs involved with the phase one roll out, we tracked outcomes on the following HEDIS measures: A1C >9 %, diabetics with blood pressure above goal and patients with atherosclerotic cardiovascular disease not on statins. For all three teams, all three HEDIS measures improved! This was a true testament of each team member working together. This project successfully helped define and optimize the role of the CPS on the team and show the positive impact of embedding the CPS into the team. During the roll-out, Dr. Geetha Kamath, a primary care providers involved in the initial phase reported to pharmacy leadership, “I would like to update you and provide feedback on the significant positive impact made by this project in improving quality of care to our patients. Patients on our panel have closer follow-up and med reconciliation and chronic disease management with our pharmacist Kyleigh Gould’s active participation and involvement in medication management. I would definitely recommend this be continued on an ongoing basis/permanently as part of PACT team”. We have successfully spread this model throughout all the KCVA primary care clinics and are excited to continue to be a key member of the PACT.

What are lessons learned while implementing your program that you would like to share with other pharmacists?

Culture change is hard and takes time, but through positive interactions, collaboration, transparency and teamwork, it is doable and well worth the effort!

The MSHP Newsletter Committee would like to thank Dr. Gould for being willing to share the pharmacy practice at KCVA that is allowing pharmacists to practice at the top of their scope!  Finally, if you have a best practice which you feel others in the state would benefit from reading about, please contact me – Sarah Cook, Vice Chair of the MSHP Newsletter Committee – at Sarah.Cook@ssmhealth.com. 


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