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Purpose Access to care is a critical issue facing healthcare and affects patients living in rural and underserved areas more significantly. This led the Department of Veterans Affairs (VA) to launch a project that leveraged the expertise of the clinical pharmacy specialist (CPS) provider, embedding 180 CPS providers into primary care, mental health, and pain management across the nation. Methods This multidimensional project resulted in hiring 111 CPS providers in primary care, 40 CPS providers in mental health, and 35 CPS providers in pain management to serve rural veterans’ needs. From October 2017 to March 2020, CPS providers provided direct patient care to 213,477 veterans within 606,987 visits. This was an average of 43,000 additional visits each quarter to support comprehensive medication management services, demonstrating an additional 219,823 visits in fiscal year 2018 and 232,030 visits in fiscal year 2019. Over the course of the project, the team provided mentorship to 164 CPS providers, performed consultative visits at 27 VA facilities, and trained 180 CPS providers in educational boot camps. Conclusion VA funding of rural health initiatives adding CPS providers to primary care, mental health, and pain teams has resulted in positive measures of comprehensive medication management, interdisciplinary team satisfaction, facility leadership acceptance, and multiple positive outcomes.

Objectives To increase access to hepatitis C virus (HCV) care and cure by deploying clinical pharmacy specialist (CPS) providers across the largest integrated health care system in the United States. Setting National integrated health care system. Practice description In late 2016, the Department of Veterans Affairs (VA) Pharmacy Benefits Management Clinical Pharmacy Practice Office (CPPO) partnered with the VA HIV, Hepatitis, and Related Conditions Program with the central priority of expanding veteran access to novel HCV treatments and timely cure to ultimately prevent morbidity and mortality associated with HCV disease progression. This successful collaboration resulted in clinical resource funding to bolster access to HCV treatment through the deployment of CPS providers. This enterprise-wide initiative to expand clinical pharmacy services for unmet health care needs in HCV treatment resulted in 52 VA facilities submitting full-time employment equivalent (FTEE) funding requests totaling more than $10 million dollars. Facilities may have requested funding for 1 or more FTEEs. Results Facilities hired 47 CPS providers and 5 clinical pharmacy technicians. CPS providers in this project recorded 24,888 patient care encounters providing care for 9593 unique patients and initiated new HCV treatment for 1191 treatment-naive patients. For an additional 8402 patients, the CPS provided HCV care activities such as evaluation and monitoring before, during, and after treatment. CPPO estimates that the same care delivered by nonpharmacist provider specialists (e.g., specialty physicians) cost an additional $936,535, or 48% more. Conclusion The deployment of HCV CPS resulted in a significant number of new HCV patients being screened and treated within the VA system.

Purpose The development and validation of a staffing calculator and its use in creating staffing guidance for antimicrobial stewardship programs (ASPs) in Veterans Health Administration (VHA) facilities are described. Methods The Tools and Resources Work Group of the Antimicrobial Stewardship Task Force and PBM Clinical Pharmacy Practice Office of the Department of Veterans Affairs developed, tested, and validated a staffing calculator to track patient care and ASP management activities needed to maintain a comprehensive ASP. Time spent on activities was based on time-in-motion tracking studies and input from experienced antimicrobial stewards. The staffing calculator was validated across VHA facilities of varying sizes and complexities to determine the number of needed clinical pharmacist full-time equivalents (FTEs) to implement and maintain ASPs per 100 occupied beds. Results A total of 12 facilities completed the staffing calculator for 1 calendar week. The median number of occupied beds was 226. Most facilities had at least 100 occupied beds, and 6 of the 12 were considered high complexity facilities. The median calculated FTE personnel requirement was 2.62, or 1.01 per 100 occupied beds. The majority of FTE time (70%) was spent on patient care activities and 30% on program management activities, including infectious diseases or ASP rounds. The final recommendations indicated that in order to implement and manage a robust ASP, a pharmacist FTE investment of 1.0 per 100 occupied beds would be needed. Conclusion A staffing calculator to account for the time needed to implement ASP activities and provide staffing guidance across a large health-care system was validated.

Background To highlight the role and impact of the mental health (MH) clinical pharmacist provider in outpatient MH through successful practice integration into team-based care. Objective The MH clinical pharmacy specialist (CPS) provider serves in many key roles to improve patient-centered care and medication outcomes by supporting the needs of the MH team, patients, and caregivers in areas of comprehensive medication management. MH CPS providers are integrated as MH providers in general and specialty MH clinics, behavioral health clinics embedded in primary care, residential rehabilitation facilities, specialty MH programs, and in inpatient MH units to improve access, quality, and safety. Practice description There is a shortage of psychiatrists across the United States, which affects the ability to provide MH care to patients. Practice innovation There is a need to transform the MH team to include clinicians focused on providing services to the growing population with MH conditions; hence, the expertise of the MH CPS is an asset to increase access to comprehensive medication management services. Evaluation The MH CPS provider serves patients with a variety of MH conditions, managing medication-related adverse events, performing ongoing and acute medication monitoring, and collaborating with other health care providers for management of new diagnoses. Results The MH CPS provider improves access to care, clinical outcomes, and safety when deployed as direct patient care providers on Veterans Affairs (VA) interprofessional care teams. VA MH clinical pharmacy practice continues to demonstrate what the MH CPS provider, practicing at the top of their license, can achieve as a core member in MH team-based care. Conclusion These foundational concepts can be applied to further expand MH clinical pharmacy practice into non-VA settings through the use collaborative practice agreements and integration into interprofessional care teams, providing access to patients in need of MH care.

Purpose A comprehensive overview of clinical pharmacist prescribing authority and collaborative drug therapy management activities within the Veterans Health Administration (VHA) is presented. Summary In VHA terminology, “scope of practice” (SOP) denotes authorization to perform as an advanced practice provider, autonomously or collaboratively managing all facets of a patient’s disease or condition; VHA clinical pharmacists with an SOP have prescribing authority. National policies outline the broad requirements for conferral of an SOP to VHA clinical pharmacists and processes for SOP development and oversight, as well as the responsibilities of facility and clinical pharmacy leaders to support the role of the clinical pharmacist within the VHA healthcare system. The limits of each pharmacist’s SOP are determined at the facility level, with prescribing and other patient care authorities granted according to demonstrated competence. There are approximately 7700 VHA clinical pharmacists, of whom about 3200 (41%) have an active SOP. During fiscal year 2015, VHA clinical pharmacists accounted for more than 5 million patient encounters and 1.9 million prescriptions for chronic disease–targeted medications, generating at least 20% of prescriptions for hepatitis C therapies, hypoglycemic agents, and erythropoiesis-stimulating agents and 69% of prescriptions for anticoagulants systemwide. Conclusion Clinical pharmacists with an SOP constitute a rapidly expanding workforce within the VHA system, as illustrated by tremendous growth in their numbers since 2010. These individuals play a key role as advanced practice providers, helping to improve access to high-quality chronic disease and medication management for the nation’s veterans.

The majority of clinical pharmacy specialists are using global scopes of practice, which allow more autonomy to provide direct patient care and comprehensive medication management services to home-based primary care veterans.

Purpose The methods and processes utilized to deploy the Pharmacists Achieve Results with Medications Documentation (PhARMD) Project intervention template across the largest integrated healthcare system in the United States are described. Summary The PhARMD Project team at the Department of Veterans Affairs (VA) designed, developed, and deployed a standardized template within VA’s electronic health record (EHR) that allows the clinical pharmacy specialist (CPS) to efficiently document select interventions made during patient care encounters that specifically contribute to the overall care provided and patient outcomes. The template is completed by the CPSs as part of progress note documentation within the EHR. Using point-and-click functionality, a CPS selects the check boxes corresponding to specific interventions made during that patient care encounter. This improves workflow and negates the need to document interventions in a separate software system, streamlining documentation. The implementation and use of the PhARMD template at each VA facility are voluntary. From October 1, 2016, to September 30, 2017, 4,728 CPSs documented 3,805,323 interventions during 2,384,771 patient care encounters. These interventions were documented across 592,126 unique patients, with a mean of 6.4 interventions per patient during this period. Most interventions (95%) were performed by CPSs functioning as advanced practice providers and with autonomous prescriptive authority authorized under their scope of practice. Conclusion The PhARMD template demonstrated that the capture of clinical pharmacy interventions and outcomes can be achieved across a large integrated healthcare system by thousands of CPSs in numerous practice settings.

Purpose The development of an electronic tool to quantify and characterize the interventions made by clinical pharmacy specialists (CPSs) in a primary care setting is described. Summary An electronic clinical tool was developed to document the clinical pharmacy interventions made by CPSs at the Veterans Affairs Medical Center in West Palm Beach, Florida. The tool, embedded into the electronic medical record, utilizes a novel reminder dialogue to complete pharmacotherapy visit encounters and allows CPSs to document interventions made during patient care visits. Interventions are documented using specific electronic health factors so that the type and number of interventions made for both disease-specific and other pharmacotherapy interventions can be tracked. These interventions were assessed and analyzed to evaluate the impact of CPSs in the primary care setting. From February 2011 through January 2012, a total of 16,494 pharmacotherapy interventions (therapeutic changes and goals attained) were recorded. The average numbers of interventions documented per patient encounter were 0.96 for the management of diabetes mellitus, hypertension, dyslipidemia, and heart failure and 1.36 for non-disease-specific interventions, independent of those interventions being made by the primary physician or other members of the primary care team. Conclusion A clinical reminder tool developed to quantify and characterize the interventions provided by CPSs found that for every visit with a CPS, approximately one disease-specific intervention and one additional pharmacotherapy intervention were made, independent of those interventions being made by the primary physician or other members of the primary care team.

Purpose The development, implementation, and evaluation of a protected peer-review process for clinical pharmacists with advanced scopes of practice are described. Summary A protected practice evaluation committee (PPEC) was created at a Veterans Affairs medical center to formulate policies and procedures for conducting peer reviews. The committee comprises six clinical pharmacists, none of whom hold a supervisory position, and assigns appropriate peers to review and rate clinical pharmacists’ cases based on PPEC-developed performance measures. Peers rate the level of pharmacist-provided care by deciding whether most experienced, competent practitioners would have handled the case similarly in all aspects (level 1), might have handled the case differently (level 2), or would have handled the case differently (level 3). Each practitioner receives a report summarizing the findings and recommendations for improvement. The data are protected from legal discovery and shared with management only in aggregate. Of the 250 cases reviewed between January and October 2009, 236 (94.4%) received level 1 care and 14 cases (5.6%) received level 2 care; none received level 3 care. The number of cases judged as receiving level 2 care decreased to 1 by September 2009. Improvements in process indicators, including documentation of medication reconciliation and patient adherence, were noted. A survey of the clinical pharmacists indicated strong support for the review process. Conclusion Protected practice evaluation engaged clinical pharmacists in a continuous quality-improvement effort, generated data regarding practicewide as well as individual practitioner performance, and encouraged self-reflection. Frontline practitioners agreed that peer review is important for quality-improvement purposes.