11/2/2016. CPE Information and Disclosures. Learning Objectives. CPE Information. Changes in the Healthcare Marketplace. Self-Assessment Questions

Transcription

1 CPE Information and Disclosures VA Service Breakout - Advancing Clinical Pharmacy Practice into the Future Michael H Tran, PharmD., BCPS VA Great Lakes Network (VISN 12) PBM Clinical Pharmacy Practice Office (CPPO) Michael Tran declares 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. The American Pharmacist Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. CPE Information Target Audience: Pharmacists & Technicians ACPE#: L04-P/T Activity Type: Knowledge-based Learning Objectives Describe several key initiatives for transformation of clinical pharmacy services in the Veterans Health Administration (VHA). State the changes in the health care marketplace that are impacting opportunities for the clinical pharmacy specialist (CPS) to become more involved in several practice areas (e.g., primary care, pain management, and mental health). Identify several VA-developed tools that promote practice initiatives and expansion across the system to provide patient-centered care with a focus on medication reconciliation. Self-Assessment Questions 1) Clinical Pharmacy Specialists (CPS) within VA: a) prescribe medications b) order labs/diagnostic studies c) place consults d) all of the above 2) PACT CPSs may assist with basic pain assessment, nonopioid pain management recommendations, and ADR assessment and management. (True or False) 3) VA has defined medication information as having the following components: a) refill request management b) medication reconciliation c) patient education of new prescriptions d) all of the above Changes in the Healthcare Marketplace Focus on access All disciplines working at the top of their licensure Interdisciplinary team-based care Patient centric Outcome based Efficiency and cost 1

2 Provider Time Workload Demand Impact on Care A primary care physician with a panel size of 2500 patients will spend 7.4 hours per day doing recommended preventative care A primary care physician with a panel size of 2500 patients will spend 10.6 hours per day doing recommended chronic care Demand Access Patient Shortage of support Medication Issues Yarnall et al. Am J Public Health 2003;93:635 Ostbye et al. Annals of Fam Med 2005;3:209 Healthcare transformation Midlevel Model with CPS In 2010, VHA began implementation of the Patient Centered Medical Home (PCMH) model Now known as the Patient Aligned Care Team (PACT) Delivery of healthcare is transformed to be interdisciplinary and patient-centric Practice at the top of the license Pharmacists provide comprehensive medication management, including population health VA PCP Physician Nurse Practitioner/ Physician Assistant Pros: Reduce teamlet burden by managing chronic diseases Expertise in optimizing drug therapy for complex high risk patients Extensive knowledge of drug information Patient Patient Patient Patient Patient Patient CPS Provider Clinical Pharmacy Specialist Clinical Pharmacy Specialist Adapted from slides by Gordon Schectman, MD Pharmacist Providers Impact Access Typical patient visits to Target* Diabetes = 6 visits Hypertension =3 visits HepC = 9-12 visits Effective Use of CPS Providers Avoids Shifts to Specialty Care Improves Access To Essential Medication Management Services *based on VA computer extracted data VA Provider Initial Visit 6 mo. visit 12 mo. visit 18 mo. visit CPS Provider Disease Management visit (virtual or F2F) Disease Management visit (virtual or F2F) Disease Management visit (virtual or F2F) Optimizing PACT CPS to see patients between PACT Provider visits increases patient access for medication management services Pharmacist Providers Bridge the Gap Optimization of clinical pharmacy services avoids specialty care visits The Clinical Pharmacy Specialist (CPS) can coordinate and manage care during: Transitions of Care Between Primary and Specialty Care Working under a scope of practice, they increase access 2

3 Scope of Practice In VA, a SOP allows a pharmacist to prescribe and deliver care autonomously in an all-inclusive manner Includes ordering laboratory tests/diagnostic studies, performing physical measurements, and making referrals for additional care or services Since 2010, the number of clinical pharmacists working under a SOP has increased 63% In FY 15, CPSs working under a SOP provided over 5 million patient care encounters and 1.9 million prescriptions VHA has approximately 7,700 Pharmacists Pharmacists with Scope of Practice exceeds 3,427 (45%) Residency = 68% Of These 3,427 BPS Certification = 44% Other Certification = 14% Residency &/or Certification = 76% *based on VA computer extracted data Nationwide Workload Trends Parameter FY 11 FY 15 % Change # Pharmacists with SOP 2,132 3,185 49% n/a 41% 28% % Pharmacist Under SOP Encounters/FTE % Total 160 Encounters 2,454,419 5,092, % * 4,000 3,500 3,000 2,500 2,000 1,500 1, Number of Pharmacists With a Scope of Practice and PACT Pharmacist FTE Growth Over Time 2,965 3,059 2,853 2,473 2,6542,716 2,284 2,087 1, Jul-11 Sep-11 Nov-11 Jan-12 Mar-12 May-12 Jul-12 Sep-12 Nov-12 Jan-13 Mar-13 May-13 Jul-13 Sep-13 Nov-13 Jan-14 Mar-14 May-14 Jul-14 Sep-14 Nov-14 Jan-15 Mar-15 May-15 Jul-15 Sep-15 Nov-15 Jan-16 3,427 3,185 Pharmacist with SOP PACT Pharmacist FTE Percentage of Time Spent Working Under Scope of Practice < 25% 25-49% 50-74% > 75% Encounters with a Pharmacist Provider by Modality FY 2015 Home Telehealth, 1,709 Home Care, 40,977 Telephone, 1,724,499 Group, 72,502 Face-to- Face, 1,801,864 Call Center, 157,021 Chart Consult, 1,100,491 CVT, 69,554 econsult, 122,118 * based on VA computer extracted data 3

4 Encounters with a Pharmacist Provider by Practice Area FY 2015 ID Hem/Onc Pharmacokinetics Hepatology Pain Endocrinology Geriatric Med Rec General Medicine SUD Home Based Care Uncategorized Mental Health NF/PA Primary Care Clinical Pharmacy Services Anticoagulation *based on VA computer extracted data Proposed Future State Vision for VA Healthcare Deliver personalized, proactive, and Use innovative technologies and care models to optimize health outcomes Invest and grow VA s core competencies patient-driven health care How do Pharmacists Contribute? Focus on research and education aligned with VA s core competencies Use metrics and data analytics to drive improvement Maintain a highperforming network to deliver community care Using Data to Advance Pharmacy Practice 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 CPPO recognized the importance of data and focused early on the development of a data infrastructure to advance clinical pharmacy practice Data Tools to Overcome Practice Barriers Clinical Pharmacy Interventions Improvements in Performance Measures Improvement in Access to Primary Care and Specialty Care Providers Clinical Pharmacy Dashboards Clinical Pharmacy Workload Data Tools to Overcome Practice Barriers Continued Clinical Pharmacy Interventions Improvements in Performance Measures Improvement in Access to Primary Care and Specialty Care Providers Clinical Pharmacy Dashboards Clinical Pharmacy Workload Clinical Pharmacy Interventions Pharmacists Achieve Results with Medications Documentation (PhARMD) Tool Document and track pharmacist interventions throughout VA Data used to create clinical pharmacy staffing tools and models Ability to characterize the roles of pharmacists in a variety of practices 4

5 PhARMD Tool Capturing Interventions System Wide PhARMD Tool Anemia 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 Addresses a wide variety of medical conditions that a PACT pharmacist may encounter in their practice including Anemia COPD Hypertension Pain Anticoagulation Diabetes Thyroid Tobacco Antimicrobial Stewardship Gout Lipids Transplant Asthma Heart Failure Mental Health Women s Health Bone Health Hep C Nutrition CKD HIV PhARMD Tool Health Factors over Time FY16 Type 2 DM Health Factors 1,100, ,000 Number of Health Factors 1,000, , , , , , , , ,000 PhARMD Tool Report s FY14Q1 FY14Q2 FY14Q3 FY14Q4 FY15Q1 FY15Q2 FY15Q3 FY15Q4 FY16Q1 FY16Q2 FY16Q3 Number of Health Factors 250, , , ,000 50,000 0 PhARMD Tool Report s FY16Q1 FY16Q2 FY16Q3 DM Type 2 Interventions by Facility PhARMD Tool Number of Health Factors 3,000 2,500 2,000 1,500 1, NONPHARM INTERV NO CHANGE INITIATE MED GOAL OTHER GOAL OF <9% GOAL OF <8% GOAL OF <7% END OF ACTIVE TX CHANGED OR DC MED ADJ MED LOW BS Allows comparison of data across sites Reports developed and available for all to use Infrastructure has been developed to maintain and update the tool and efficiently disseminate to sites Includes inpatient and outpatient pharmacist interventions Constantly adding more specialty areas 0 FY16Q1 FY16Q2 FY16Q3 ADJ DOSE FREQ MED PhARMD Tool Report s 5

6 Data Tools to Overcome Practice Barriers Clinical Pharmacy Interventions Improvements in Performance Measures Improvement in Access to Primary Care and Specialty Care Providers Clinical Pharmacy Dashboards Clinical Pharmacy Workload Clinical Pharmacy Workload Clinical Pharmacists Professional Activity Summary (CPPAS) Report Need to summarize pharmacist activities at a facility level Used for Ongoing Professional Practice Evaluation (OPPEs) with many sites already collecting similar data CPPAS Report CPPAS Report Scope of Practice CPPO CPPAS Report s CPPO CPPAS Report s CPPAS Report - Activities CPPAS Report Select individual pharmacists to compare activities side by side Includes pharmacists with and without a scope of practice Exportable for easier viewing and manipulation CPPO CPPAS Report s 6

7 Data Tools to Overcome Practice Barriers Clinical Pharmacy Interventions Improvements in Performance Measures Improvement in Access to Primary Care and Specialty Care Providers Clinical Pharmacy Dashboards Clinical Pharmacy Workload Clinical Pharmacy Reports - TTR National Time in Therapeutic Range (TTR) Reports TTR: Measure of quality of anticoagulation control for patients on warfarin therapy Difficult to calculate without tools Majority of anticoagulation within VA is done by pharmacists Developed individually by many groups Separate reports could not be compared TTR Reports Need for accurate measure of quality of anticoagulation control Identify and share best practices Track the impact of changes to anticoagulation practices Subject Matter Expert (SME) Workgroup Reports currently being validated 72.0% 70.0% 68.0% 66.0% 64.0% 62.0% 60.0% TTR by VISN Data currently undergoing validation 58.0% A B C D E F G H I J K L M N O P QCPPO RTTR Report S TTR Facility Level Follow Up TTR Patient Level Actionability CPPO TTR Report CPPO TTR Report 7

8 TTR Reports Using infrastructure to pursue Opportunities to Expand Clinical Pharmacy Practice Provide data tools to Measure performance (TTR) Provide individual patient actionability Allow all pharmacists to actively use data tools and be aware of what is being measured Office of Rural Health requested proposals from program offices to increase access for rural health veterans Clinical Pharmacy Practice Office (CPPO) submitted a proposal to leverage Clinical Pharmacy Specialists Office of Rural Health Proposal Goal: increase access to rural veterans Include comprehensive resources to support CPS to allow them to work at the top of their license Ancillary support (e.g. MSA, tech, etc.) Travel/training Equipment Office of Rural Health Proposal Sites must use PhARMD tool and other data collection tools developed by CPPO Complete assessments developed by CPPO to see their current state of clinical pharmacy practice Ensure a minimum number of encounters to demonstrate increased access for rural veterans Office of Rural Health Proposal 223 submissions from the field 60+ FTEE requests for Pain and Mental Health Clinical Pharmacy Specialist 160+ FTEE requests for PACT Clinical Pharmacy Specialist Key Points Clinical Pharmacy Specialists working under a scope of practice can increase access by providing comprehensive medication management to patients. Clinical Pharmacy encounters have increased 107% since fiscal year VA CPPO has been successful in creating tools to promote expansion across the system CPPO reviewed submissions and recommended approval of 115 FTEE, awaiting review by ORH and VA leadership 8

9 CPE Information and Disclosures Role of Pharmacy in Mental Health Cynthia A. Gutierrez declares 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. Cynthia A. Gutierrez, PharmD, MS, BCPP Clinical Pharmacy Program Manager The American Pharmacist Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. Focus of Presentation Section Mental Health (MH) Clinical Pharmacy Specialist (CPS) integration into the MH team VHA trends for MH CPS Integrating MH CPS into MH practice Perceived Barriers Scalability and Additional Opportunities Psychiatrist Diagnostic evaluation/ clarification Prescribing of controlled substances Inpatient psychiatry admissions and discharges Medication management (prescriber) for new/established patients Mental Health Treatment Coordinators and team leader MH e-consults Ongoing patient assessment MH CPS Polypharmacy review and consultation Intensive medication education Ongoing medication monitoring MUE and QI projects MH CPS Trends in VA Evolving Role of MH CPS Parameter FY13 FY14 FY15 FY16 (thru March) % Change # Pharmacists with MH SOP % Pharmacist Prescribing of MH medications % Not available 1.1% 1.3% 1.5% 19 % Consultant Provide recommendations Extender Implement treatment plans Provider Manage patient panel MH Encounters with CPS Provider 48,277 53, ,094 81, % VHA PBM Clinical Pharmacy Program Office, Data on file. 9

10 Current Roles and Opportunities Primary Care Mental Health Integration Substance Use Disorders MH CPS BHIP/Specialty Mental Health Inpatient Psychiatry Improving Access and Performance for Mental Health Performance Measures Directly Impacted by the MH CPS SAIL (Discharge followup, depression measure Mdd43h - Behavioral Health) PDSI High risk patients Improved Access Same day access Telemental health Independent patient panel 57 Pharmacy Clinic Set-Up and Stop Code Guidance Updated SAIL Metrics Some are based on stop code and others based on diagnosis with CPT Code As part of the MyVA Access Initiative, VA is working to improve access to care in clinics deemed critical or priority. All mental health appointments in the 502, 540, or 562 stop codes meet this definition. The Healthcare Operations Dashboard lists in real time the number of these MH appointments that are scheduled more than 30 days from the preferred date. CPS practicing in MH should review SAIL data/definitions and work closely with their MH service to ensure appropriate clinic set-up. OMHO Collaboration Office of MH Operations Reviewed all MH Performance Measures to insure the CPS is included as applicable effective Q3FY16 Alcbac, deprisk, depeval, depmhevl, ptsdrisk, ptsdeval, ptsdmhevl Presentation to VISN MH Leads 4/25/16 Facilities have a significant opportunity to re-deploy or add additional trained CPS to these roles as a key member of the IDT or as a MH team leader. Appropriate allocation of resources to MH CPS provides an additional avenue for addressing MH prescriber needs at facilities. Same Day Access FAQ from OMHO CPS and MH Initial Evaluation Screening As outlined in current policy, the initial screening evaluation must be completed by a licensed independent provider (LIP), which may include primary care, other referring licensed independent providers, or a licensed independent mental health provider. An LIP is defined as any provider licensed or otherwise authorized by the state to practice. These would include medical professionals - MD, DO, NP, PA, CNS, as well as Clinical Pharmacy Specialists (CPS) and mental health professionals psychologists, social workers, licensed marriage and family therapists, and licensed professional counselors. Residents and interns are authorized providers functioning under the supervisory licensed professional. FAQ doc online: Perceived Barriers Diagnostic Evaluations REALITY: Most come to MH with prior diagnoses Work with second team prescriber for patients without diagnosis, or if diagnosis is unclear (second opinion) Controlled Substances REALITY: Prescriptive authority dependent on state of licensure (ex: VISN 12) Team huddle to discuss with second team prescriber if needed 10

11 Perceived Barriers Perceived Barriers to MH CPS Utilization Admitting Privileges REALITY: Most patients admitted through ED rather than direct admission from clinic, regardless of prescribing provider Complicated Patients Assistance with Call Coverage REALITY: MH CPS can round and write daily notes on inpatients for weekend and holiday coverage of inpatient psychiatry units REALITY: MH CPS specifically trained to manage complicated medication regimens, minimize polypharmacy, perform therapeutic and side effect monitoring Scalability in Support of MH CPS Integration at VA The VA CPS workforce has advanced clinical practice training and is primed and ready to take on these roles system-wide. Over 90% of VA pharmacist trainees with advance practice post-graduate residencies report a high desire to work for the VA. Many VA facilities report difficulty in recruitment of psychiatrists. VA graduates 75 PGY2 Mental Health Pharmacy Residents in June of each year and many would like to seek employment within the VA. It has been VA Pharmacy experience that recruiting clinical pharmacist and CPS can be successful when coupled with VA recruitment tools. Additional Opportunities Dashboard development/academic detailing Champion for tool development to identify at risk patients Lithium and mood stabilizer monitoring High dose/polypharmacy Suicide risk and prevention Specialty population clinics Pain/mental health (in primary care) Metabolic monitoring and weight management) Substance use disorders in Primary Care Women s mental health Pregnancy and lactation Substance use disorders Key Points MH CPS numbers and roles expanding across VA to meet increasing need for MH providers MH CPS contribute to improved veteran access to care and performance measures Real and perceived barriers to CPS have been and continue to be successfully addressed Large qualified applicant pool available because of increased VA commitment to PGY2 Psychiatric Pharmacy Residency programs Clinical Pharmacy Specialists and Pain Management: Roles, Responsibilities & Training Mitchell Nazario, PharmD, CPE VISN 8 PBM Program Manager, Pain Management West Palm Beach VAMC 7305 N. Military Trail West Palm Beach, FL Mitchell.nazario@va.gov

12 CPE Information and Disclosures Overview Mitchell Nazario, Pharm.D.: declares 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. The American Pharmacist Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. Describe the Opioid Epidemic and the opportunities it creates for enhanced involvement of the Clinical Pharmacy Specialist (CPS) in Pain Management. Describe the VA s Clinical Pharmacy Practice Office (CPPO) Initiative, through a Pain Management SME Workgroup, to define the role, responsibilities and training needs of the PACT CPS in Pain Management List pain management training opportunities for the CPS and describe the current state of Residency Training in Pain Management. Atkinson T, Gulum Ah, Forkum WG. The future of Pain Pharmacy: Driven by Need Integrated Pharmacy Research and Practice 2016: Chronic Disease Prevalence Integrated Pharmacy Research and Practice 2016: Pharmacy pain specialists are uncommon even among other clinical pharmacy specialists, with few training programs available, creating an incredible disparity between disease prevalence and lack of trained specialists. Drug overdose deaths in the United States hit record numbers in 2014 More people died from drug overdoses in 2014 than in any year on record. The majority of drug overdose deaths (more than six out of ten) involve an opioid. Since 1999, the number of overdose deaths involving opioids (including prescription opioid pain relievers and heroin) nearly quadrupled. From 2000 to 2014, nearly half a million people died from drug overdoses. 1 Centers for Disease Control and Prevention. MMWR 2015;64(1):32 2 Centers for Disease Control and Prevention. January from Li-Hui Chen. 3 Centers for Disease Control and Prevention Opioid Overdose Data In 2012, 259 million prescriptions for opioid pain medication were written. That is equivalent to every adult having their own bottle of pills (such as oxycodone, hydrocodone or methadone. Since 1999, the number of sales and the number of deaths related to prescription opioids quadrupled. One in 4 people receiving prescription opioids for long term, non-cancer pain struggles with addiction. The 2013 and 2014 National Survey on Drug Use and Health (NSDUH), reported that 50.5% of people who misused prescription painkillers got them from a friend or relative for free, and 22.1% got them from a doctor

13 Opioid Overdose Data More than 1,000 people are treated every day in emergency departments for the misuse of prescription opioids. About 78 people die each day from opioid overdose. The average age for first-time use of a prescription painkiller is 21.2 years. The overdose rate of an opioid is highest among adults aged years. People addicted to prescription opioids are 40 times more likely to be addicted to heroin. High-Dose Opioid Analgesics A 9-fold increase in opioid OD has been reported in patients receiving high dose opioids (> 100mg MEDD) compared to low dose (< 20mg MEDD) Patients on > 120mg MEDD were more likely to have alcohol or drug related encounters (intoxication, withdrawal, OD) A reduction in the proportion of patients receiving > 120mg MEDD resulted in a 50% reduction in opioid related deaths. Opioid Use in the VA Population Veterans are twice as likely to die from accidental OD compared to non-veteran population Veterans with PTSD are more likely to: Be prescribed opioids at higher doses Receive opioids and sedative hypnotics (including benzodiazepines) concurrently Opioid use in Mental Health populations is associated with: Opioid-related, alcohol, and non-opioid drug related accidents and overdoses Self-inflicted injuries and violence related injuries Higher incidence of wounds or injuries CPPO Pain Management SME Workgroup Pain SME Workgroup initiatives and goals FY16 Subgroup 1: Describing CPS Pain Mgmt Roles/Responsibilities and Strong Practices Subgroup 2: Pain CPS Staffing Model Review time in motion study and the staffing tool Subgroup 3: Residency Training Review barriers and challenges Discuss future needs, what do we need to accomplish our goals? Workgroup Members Workgroup Charter and Charges Team Leaders: Julie Groppi (CPPO), Terri Hahn, Jeremy McKelvey, Gordana Milosevic, Mitch Nazario Team Members: Shawn McFarland (CPAB) Kellie Rose (Pain CPS) Jeff Fudin (Pain CPS) Diana Higgins (Pain CPS) Michael Chandler (Pain CPS) Paul Rozzero (Pain CPS) Timothy Atkinson (Pain CPS) Robert Sproul (Pain CPS) Friedhelm Sandbrink, MD Ilene Robeck, MD Ron Williams Jr., DO Nancy Millner, MD Paul Harden (Pain CPS) Elzie Jones (Pain CPS) Sarah Popish (PBM AD) Michael Harvey (PBM AD) Carson Bechtold (PGY2) CPPO Members: Heather Ourth, Kim Quicci-Roberts, Michael Tran 78 Multiple charges to focus on Key Areas: FY16 Initiatives Review the current state and describe practice of CPS involvement in pain management to identify the roles, responsibilities and strong practices Evaluation of Education and Training Needed to Support the Role of the CPS Development of a Staffing Model for the Pain CPS Additional Goals Development of a Business Plan to Support FTE Requests Presentations and Education to Key Stakeholders Assessment of Patient Care Tools 79 13

14 Subgroup 1: Describing CPS Pain Mgmt Roles/Responsibilities and Strong Practices Goals and Objectives: 1. Review the current state and describe practice of CPS involvement in pain management to identify the roles and responsibilities. Propose opportunities and strategies to expand practice to improve access for patients in primary and specialty care. 2. Evaluate various methods and metrics which can enhance the documentation of pain management activities including PhARMD tool, encounters, and pharmacist prescribing functions and identify if (and what) additional documentation is necessary to identify CPS pain management services. 3. Identify strategies to expand the use of the PhARMD tool to capture CPS activities in pain management. 80 PACT CPS PACT CPS. A PACT CPS is a CPS with a scope of practice which includes medication prescriptive authority that has training and expertise to provide comprehensive medication management services to primary care (PACT) patients. Training and experience includes, but is not limited to, Post Graduate Year 1 (PGY1) residency training, Post Graduate Year 2 (PGY2) residency training in am care, board certification, direct patient care experience working in a primary care setting. The PACT CPS will be located in the primary care setting and be assigned to PACT teams caring for a variety of chronic primary care conditions to include, but not limited to, diabetes, hypertension, hyperlipidemia, pain management, osteoporosis, etc. Stepped Pain Model of Care CPS Providers Role Across the Continuum Stepped Pain Model of Care CPS Providers Role Across the Continuum Step 1 - PACT Teams Routine Screening & Pain Assessment Management of Common Pain Syndromes Support for MH-PC, OEF-OIF, Post Deployment Pharmacy Pain Management Clinics PACT CPS Provider Step 2 - Specialty Consultation/Care Collaboration Pain Medicine Specialty Teams Behavioral Health Teams SUD and MH Teams Multidisciplinary Pain Teams Step 3 Tertiary, Interdisciplinary Pain Centers Advanced Pain Care CARF Facilities PAIN CPS Provider Optimizing the role of the PACT CPS requires facility Pain CPS FTE PAIN CPS Provider Step 1, Level 1 Primary Care PACT: Role of the PACT CPS Conducts basic pain assessment Assists patient in formulating personalized pain management goals Assesses, recommends, and provides management assistance with nonopioid pharmacotherapy (e.g., APAP, NSAIDs, topicals, adjuvants for neuropathic pain) Assesses patient for ADRs to therapy and prescribes appropriate treatment as clinically indicated, e.g., constipation management Step 1, Level 1 Primary Care PACT: Role of the PACT CPS Assists with interpreting and review of urine drug testing (UDT) Assists with reviewing the State Prescription Drug Monitoring Program (SPDMP) when appropriate Provides Opioid Education and Naloxone Distribution (OEND) Serves as a resource for opioid renewal clinics/programs (managed by other disciplines) 14

15 Step 1, Level 2 Primary Care PACT Expanded Role of the PACT CPS In Facilities with Pain CPS FTE, the PACT CPS may assume additional responsibilities Comprehensive Medication Therapy Management which may include: assessment and provision of recommendations for opioid pharmacotherapy; orders and/or interprets UDS, reviews the SPDMP, and provides OEND services Provides education related to pain management either to individual patients and/or patient groups as well as the PACT team Provides formulary management recommendations related to pain management Precepts trainees with a pain management experience within an Ambulatory Care (PGY1 and/or PGY2) rotation Pain CPS Pain CPS. A Pain CPS is a CPS with a scope of practice which includes medication prescriptive authority that has specialized training and expertise to provide comprehensive medication management services to patients with chronic pain. Training and experience includes, but is not limited to, PGY2 training in pain management, specialized certification in pain, direct patient care experience working in a pain interdisciplinary team (IDT) or similar model. The Pain CPS may function in a variety of practice settings to include a specialty care or primary care (Patient Aligned Care Team (PACT)) setting. Step 2, Secondary Consultation/ Collaborative Care: Role of the Pain CPS Supports Clinical Pharmacists and PACT CPS relating to pain management, and serves as a liaison between pharmacy, PACT, and specialty care. Serves as a pain Point of Contact (POC) for the facility and pharmacy in conjunction with the interdisciplinary team (IDT), including involvement with pain committees, quality management initiatives, and provides pain management education on a facility, VISN, and national level. Collaborates with the IDT and other specialty teams to formulate plan of care for high-risk/complex patients Population management to include dashboard review and identification of high risk patients Step 2, Secondary Consultation/ Collaborative Care: Role of the Pain CPS Comprehensive Medication Therapy Management which includes but is not limited to the following activities: evaluates effectiveness of treatment, manages high risk/complex patients, refers to other services as appropriate (e.g., Pain, Neuro, PM&R, PT, RT/pool therapy, prosthetics, primary care behavioral health, behavioral medicine, etc.) and triages and refers to mental health and/or addiction treatment services for mood disorders including suicidality and substance abuse /opioid use disorder. Precepts trainees on a Pain Management rotation Residency director for a PGY2 Pain and Palliative Care Residency Step 3, Tertiary Interdisciplinary Pain Centers: Role of the Pain CPS The Role of the Pain CPS will be similar to the roles outlined in Steps 1 and 2. Involvement in Step 3, will be dependent on the facility's development of advanced pain medicine rehabilitation programs. Subgroup 3: Assessment of Training and Education 15

16 Subgroup 3: Assessment of Training and Education Goals and Objectives: 1. Identify areas where additional CPS educational programs are needed to supplement the existing clinical pharmacy boot comp programs previously developed on this topic. 2. Propose additional training opportunities to include promotion of CPS role for non-pharmacy specific audiences (e.g., PACT Pain COP teleconferences, VeHU, etc.) 3. Evaluate and Update the existing pain pharmacy FACT sheet describing the role of the CPS in Pain Management 92 Recommended Pain Management Training and Education Step 1, PACT CPS Levels 1 and 2 1. Understand universal precautions, identify high risk patients, drug monitoring and educated on naloxone distribution 2. Understand site specific availability of resources (acupuncture, PT, procedures, aquatic therapy, etc.) 3. Training in the following areas of pain management General Skills Pain related conditions Non-pharmacologic Management Non-opioid Management Opioid Management Specialty Management Recommended Pain Management Training and Education Step 2, Secondary Consultation/Collaborative Care AND Step 3, Tertiary Interdisciplinary Pain Centers: Role of the Pain CPS 1. Recommend one of the following: a. Complete a PGY-2 in pain b. Complete a PGY-2 in psych with longitudinal pain management experience c. Complete a PGY-2 in ambulatory care with longitudinal pain management experience d. 3 years practical experience in pain management with competency in the following areas: Recommended Pain Management Training and Education Step 2, Secondary Consultation/Collaborative Care AND Step 3, Tertiary Interdisciplinary Pain Centers: Role of the Pain CPS 2. Training in the following areas of pain management (in addition to those recommended for Step 1 CPS): a. Non-pharmacologic Management b. Other (relaxation techniques, acupuncture, physical therapy, chiropractor, massage, aquatic therapy, hot/cold compresses, OT, spiritual considerations, etc.) c. Substance Use Disorder / Substance Abuse d. Specialty Management Fact Sheet: Table 2 Recommended CPS Training Resources Recommends available training resources for the pain mgmt topics outline under the recommended training and education for each level within the Stepped Model Resources include VA Boot Camps, SCAN- ECHOs, TMS (i.e. OEND), other (i.e. Whole Health, Spine Health Videos) and additional resources PCSS-O, JPEP, Pain PACT COP Site, VA PACT Pain Roadmap Example: General skills Pain and Risk Assessment Strategies VA Boot Camp Aberrant Behaviors SCAN ECHO: Review of Opioid Side Effects SCAN ECHO: PDMP SCAN ECHO: Difficult Conversations with Patients UDS I SCAN ECHO: Difficult Conversations with Patients UDS II SCAN ECHO: Difficult Conversations with Patients UDS III SCAN ECHO: High Dose Opioid Therapy SCAN ECHO: Pain Assessment Tools SCAN ECHO: STORM Stratification Tool for Opioid Risk Mitigation 16

17 Example: General skills- cont. Motivational Interviewing SCAN ECHO: Difficult Conversations with Patients Whole Health [Login and Password: service] Acute Pain Management SCAN ECHO: Acute Pain Management Residency Training Chronic Disease Prevalence Integrated Pharmacy Research and Practice 2016: PGY2 Residency Programs Integrated Pharmacy Research and Practice 2016: PGY2 Specialty Residencies VA vs Non-VA Integrated Pharmacy Research and Practice 2016: (PGY2) Palliative Care/Pain Management Pharmacy Residency Programs Am Care MH P&PC VA ALL Name of Site Central Arkansas Veterans Healthcare System Dana-Farber Cancer Institute Lakeland Regional Health NF/SG Veterans Health System Stratton VA Medical Center Summa Health System - Akron City Hospital The Johns Hopkins Hospital The OSU COP/HospiScript Services, LLC UF Health Jacksonville University of California, Davis Medical Center University of Maryland School of Pharmacy UW Medicine West Palm Beach VA Medical Center State AR MA FL FL NY OH MD OH FL CA MD WA FL 17

18 PGY2 P&PC Residency Program Distribution Questions Moving Forward Should we require our PGY2 Residency programs in Am Care and MH to incorporate a longitudinal Chronic Pain rotation (or simple rotation) in their programs? Should it be mandatory? Should we expand our PGY2 P&PC residency offerings within the VA? How much is enough? One program per VISN? Funding? Transfer funds from other positions? Is there another solution we should consider? Questions Moving Forward Do PACT CPS have the capacity to take on the additional role/responsibility? I can t take this on with current workload? Concerns with provider dumping? How do we address the PACT CPS fear of taking on this new role, and fear of provider dumping? How do move forward with operationalizing the PACT CPS role? Medication Information Management Eric Spahn, Pharm D VHA Pharmacy Benefits Management CPE Information and Disclosures Overview Eric Spahn declares 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. The American Pharmacist Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. VA Medication Information and Reconciliation The Role of Standards in Medication Management Change Management Strategies in Medication Information and Reconciliation VA has Employed 18

19 Statistics What is medication information? If the CDC were to include preventable medical errors as a category, they would be the third leading cause of death in America. 1 All information regarding the Veteran s medications. An estimated 70%-95% of clinic record medication lists are not accurate 2-4 Medications the Veteran s healthcare team(s) have ordered or recommended. Multiple medication Lists at discharge are discrepenat in approximately 1/3 of VA charts. 9 Veteran s medication history, including effectiveness, allergies and adverse effects & events. In VA, only 59% of inpatients strongly agree that they understand the purpose of taking each of their meds when they are discharged Education materials and resources the Veteran/Caregiver uses to understand his/her medications At the kitchen table The anatomy of a patient s home medication list Drug Name, Strength How the Veteran takes the med Who prescribed it Where they got it What s important to the Veteran Medication Instructions Prescriber * Pharmacy Notes/Indications Lisinopril 10mg 1 tab daily Jones (VA) VA Heart Simvastatin 80mg ½ tab daily Jones (VA) VA Cholesterol Lasix 80mg ½ tab Daily Carlton (VA heart VA Water pill Doc) Tylenol 200mg 2 caps bed time Walmart Back Pain Celexa 20mg 1 tab daily Hernandez (St. Marks Psych Doc) Samples Happy Pill Zestril 10mg 1 tab daily Smith (St Marks heart Doc) Walmart Kidney/BP Image used with permission 11 2 **Prescriber names are fictitious 11 3 Medication information management is important Alignment VA Medication Reconciliation Directive and The Joint Commission Requirements Understand what the Veteran is taking and why. The Joint Commission 2016 Patient Safety Goals VA Medication Reconciliation Directive Optimize therapy and achieve best outcomes from medications. Avoid harm and medication misadventure, especially at transitions. Customize medication treatment planning. Empower the Veteran to play a central role in their medication treatment planning Element of Performance (EP): 1. Obtain information on the medications the patient is currently taking 2. Define the types of medication info to be collected in non 24-hour settings and different patient circumstances. 3. Compare the medication info 4. Provide the patient (or family as needed) with written info 5. Explain the importance of managing medication info to the patient Associated Provision of Care Standards (PCS): PCS : Info about treatment is provided to other service providers PCS : Coordinating info during transitions in care both within and outside of the organization PCS : Patient education on safe medication use (OIG FQ MedRecon Review) 1. Obtaining medication info from patient, caregiver, and/family 2. This documentation includes active medications, recently expired medications, non-va medications, and medications given at other VA facilities 3. Comparing Veteran s info to the medication info available in the electronic medical record 4. Communicating with and providing education to patient, caregiver, and/or family regarding this info. 5. Communicating this with the healthcare team(s)

20 Medication Reconciliation: A part of how we manage 1. NPSG EP1: Obtain information on the medications the patient is currently taking 2. NPSG : Define the types of medication information to be collected in non 24-hour settings and different patient circumstances. 3. NPSG EP3: Compare the medication information 4. NPSG EP4: Provide the patient (or family as needed) with written information 5. NPSG EP5: Explain the importance of managing medication information to the patient 6. PC : Information about treatment is provided to other service providers 7. PC : Coordinating information during transitions in care both within and outside of the organization 8. PC : Patient education on safe medication use What is the purpose of each med? How do we refill? Do they understand their meds? Medication Information Who Who helps prescrib them with es their their meds? meds? What system do they use? ie pill boxes, reminders Do their healthcare teams coordinat? What makes it hard to take meds? Track Med Experience Get Ready At the Kitchen Table Organize Med Use System Review Request Refills Decide Manage Med List Order Share Med Experience Get Questions Answered Share Support Caregiver(s) Get Ready 11 6 Unmet Needs: Medication Reconciliation and Information Management Requires standardization in data, process, and tools Best when pharmacy is involved and entire team contributes* Loses relevancy when uncoupled from workflow ADE prevention strategies Effective transitions in care Optimization of medication treatment plan Patient experience: Customization of medication treatment plan Preference Barriers to Adherence VA s medication information barriers No agreed-upon medication information standards. Rapidly expanding development of tools. Information derived from Pharmacy Dispensing System: No medication treatment plan or goals of care. Unclear pharmacy terminologies displaying to staff and patients. Many sources of medications and medication information. Existing processes support modular development rather than an integrated approach to seamless care. Prescriptions (Rx) Rx s 20

21 Essential Med Info Standards Directive (VHA 1164) 3 components Evaluation of Variation: Environmental Scan Defines essential medication information necessary for : review and communication of medications with patients. sharing information with other healthcare teams and systems. patient self-management of medication information. Defines the authoritative sources of medication information in order to promote standardization and reduce the likelihood that incomplete and/or incompatible data is displayed in different patient and provider facing venues; underscores the importance of Pharmacy as Subject Matter Experts. Provides style guidance about how medication information should be displayed to patients and providers in these form factors; Print, Web, Point of Service, and Mobile. 21

22 Environmental scan Compliance with Standards Incomplete data Veterans see Medication Name, Strength, Form, Dose and Instructions and Rx # on prescription labels. This application shows Medication Name and Form, but not Strength or Rx #. It shows instructions in Latin. This application does not include the Dose or Instructions. Different sets of data Different terminology Are Current medications the same as Active, Fillable, and Refillable medications? The use of certain terms and data sets may make sense in the context of a single application, but those variations have a negative impact on usability because they make it very difficult to manage medications across applications. This medication list includes Local and Non VA medications, but not Remote. This application includes Local, Self entered and Remote medications, but not Non VA. Solution Increase consistency of medication information => improve Veteran, Caregiver, Clinician and Pharmacist experience with VHA applications. Actions: Essential Medication Information Standards (EMIS) compliance checklists. Design Patterns. VA Medical Center Support (Integrated System Design (ISD)). Partnering with Veterans and their Medications Task Force. Medication design patterns Good LISINOPRIL 40MG TAB Use generic medication names as per VA pharmacy standards. Group medication name, strength and form as per FDA draft guidance, National Center for Patient Safety (NCPS) /VA prescription labels and VA Health Information Exchange data standards (CCDA). Medication name, strength, and dosage form is available to patient, clinician, and pharmacy facing systems. Better Lisinopril 40mg Tab Mixed case increases readability via increased shape contrast. Emphasize the medication name information when it is displayed with other information to increase scan-ability. Best Lisinopril 40mg Tab (Zestril) Include brand name equivalent to help patients who receive medications from multiple sources. 22

23 EMIS Compliance Review Checklist Medication Information Management Supporting Enterprise Change Integrated System Deployment (ISD) Veteran Engineering and Resource Center (VERC), on behalf of a VHA program office, implements nationally standardized products and processes designed in accordance with internal/external directives, mandates, imperatives, etc. across VHA. Medication Reconciliation ISD 2016 Medication Reconciliation Integrated Systems Deployment (ISD) Integrated System Deployment Short Term Essential Medication Information Standards Directive Long Term Partnering with Veterans and their Medications Task Force Short Term Plan 4 Phases 3 Products- 1. Introductory Site Visits 2. CPRS Health Summary Component Essential Medication List for Review (EMLR) 3. After Visit Summary (AVS) 4. Medication Review Allergy Review (MRAR) Overall Summary- MedRecon ISD Phase I 9 Pilot sites were conducted between November 2015 and January VERC Partners supported MedRecon ISD Phase I 139 total site visits were completed by VERC Partners 15 site visits were combined for cost savings 514 questions came into the MedRecon Resource Center from the field >500 Artifacts collected Artifact Analysis 617 artifacts collected from the 136 sites Policies Process observations PDO information CPRS templates Inpatient Outpatient Primary Care Admission Discharge Skilled Nursing 23

24 What s coming up Partnering with Veterans and their Meds Task Force Long Term Plan: TIU Object Search Tool Supporting documents have been submitted Testing expected to start soon in Region 1 Exemplars from the field Site collected artifacts Phase II- EMLR expected late fall Phases III and IV- AVS and MRAR expected next fiscal year Assemble Task Force to establish governance for VHA Medication Information Management Review of environmental scan, gaps, and overlaps analysis of current medication reconciliation and medication information management IT projects and Initiatives Address key medication information/reconciliation related mandates like OIG Reports collaboratively Publish Patient Medication Information policy that outlines overarching strategy for VHA elements of ISD Evaluate Engage all aspects Subject of Matter ISD Experts including to identify Develop (but the not standardize education limited to) d products/ materials baseline processes/ Develop readiness, for VERC a solutions deployment marketing Partner to and training, training plan be to disseminate effectivenes presentatio deployed information s, as product/ n part to the of intervention to field, the field ISD etc. enculturatio before, during, n and and t i bilit VERC collaborates with the ISD Business Owner to: Strategize the most Determine effective the deployme selection nt plan criteria of Identify ideal Subject VERC Partners Matter Experts to support VERC Partners during 14 deployme 2 Results of MedRecon ISD Visited 130+ VA medical facilities. Captured 600+ artifacts. Answered 500+ questions incorporated into an FAQ. Developed a toolkit for ongoing support. Created sustainment plan for ISD business owner. Proposed long term partnership with Veterans Medication Management Office Evaluation Veterans require accurate medication information, especially vulnerable populations This process will inform best practices for future ISD deployment plans: Determine the essential components and critical elements that lead to a successful implementation. Evaluate the efficiency, effectiveness, ease of use, success rate of implementation, and quality of use of deployed products. Determine patient or system outcomes that result from the implementation of the MedRecon ISD occurs. Veterans at risk for opiate overdoses Veterans with chronic pain, mental illness, TBI Veterans discharged from hospitalizations Transitioning Servicemembers, our new Veterans And more

25 Goals Moving Forward: Next Steps Empowering the Veteran Help all the members of their healthcare team stay connected Maintain, update and take ownership of their medication information Create a medication use system that works for the Veteran Pill reminders, calendars, and med lists Foster a safe place for the Veteran to raise concerns Employ shared and informed decision making including consideration of the Veteran s Goals of care Personal medication use Barriers or preferences that affect medication adherence Reports of any problems with medications Our responsibilities Deploy an Enterprise Strategy for Seamless Experience with Medication Information Standardize Data, Tools, and Processes Synchronize Through every platform and form factor Synergize our communities Measure to ensure value, usability, safety, and ongoing improvement Make Med Info Seamless 14 6 Problem: We have a problem with medication information management now Solution: Convene the Partnering with Veterans and their Medications Task Force Review Medication Information Gaps and Overlaps Analysis Construct overarching strategy for Medication Information Management Establish the mission statement for the Medication Management Program Office Obtain funding to support Medication Management Program Office in FY2018 (VHA Call for Initiatives) 14 7 Self-Assessment Questions 1) Clinical Pharmacy Specialists (CPS) within VA: a) prescribe medications b) order labs/diagnostic studies c) place consults d) all of the above 2) PACT CPSs may assist with basic pain assessment, nonopioid pain management recommendations, and ADR assessment and management. (True or False) 3) VA has defined medication information as having the following components: a) refill request management b) medication reconciliation c) patient education of new prescriptions d) all of the above Thank you Michael Tran, PharmD, BPCS Michael.Tran5@va.gov Cynthia A. Gutierrez, PharmD, MS, BCPP Cynthia.Mascarenas@va.gov Mitchell Nazario, PharmD, CPE Mitchell.nazario@va.gov Eric Spahn, PharmD Eric.Spahn@va.gov 25