Disclosure Statement. Objectives. Veterans Affairs (VA) Mission 2/23/2017

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1 Disclosure Statement I, Donnie Johnson, Jr., do not have a vested interest in or affiliation with any corporate organization offering financial support or grant money for this continuing education program, or any affiliation with an organization whose philosophy could potentially bias my presentation. Enhancing Equitable Healthcare Among U.S. Veterans through Patient Aligned Care Teams Donnie R. Johnson, Jr., Pharm.D Tallahassee VA Healthcare Center 02/24/17 2 Pharmacist Objectives Provide basic information pertaining to the Department of Veterans Affairs structure and operation. Summarize the major components of the Patient Aligned Care Team (PACT) model of care. Explain how the components of the PACT team facilitate holistic care and life-long health and wellness to veterans. Understand the role and impact clinical pharmacist specialist (CPS) have on the PACT team. Veterans Affairs (VA) Mission To fulfill President s Lincoln s promise To care for him who shall have borne the battle, and for his widow, and his orphan by serving and honoring the men and women who are America s Veterans. 3 Technician List the major components of the PACT team. Understand the key components of the clinical pharmacist specialist role on the PACT team. 4 1

2 INTEGRITY COMMITMENT ADVOCACY RESPECT EXCELLENCE VA Core Values General Structure of the VA VA comprises a Central Office (VACO) Washington, DC. Veterans Health Administration Veterans Integrated Service Networks (VISNs) VHA is divided into 21 areas called VISNs. VA Medical Centers (VAMCs) Outpatient Clinic Community Based Outpatient clinic VA Sunshine Healthcare Network (VISN 08) The nations largest system of hospitals and clinics serving a population of more than 1.6 million Veterans. Ranges 64,153 square miles Spreads across 79 counties 5 6 General Structure of VA 7 8 A quick glance at North Florida/South Georgia Veterans Health System. 2

3 North Florida/South Georgia Veterans Health System Completed appointments as of December ,289 Pending appointments as of January 15 th ,667 Visits in ,689,627 9 North Florida/South Georgia Sites of Care VA Medical Centers Gainesville VAMC (Malcom Randall) Lake City VAMC Outpatient Clinics Jacksonville Tallahassee Villages Additional Gainesville Locations Compensation and Pension Clinic Optometry and PC Dermatology Pain Clinic 10 Community Based Outpatient Clinics Lecanto Marianna Ocala Palatka Perry St. Augustine St. Mary's, GA Valdosta, GA Waycross, GA The State of NF/SGVHS Largest VA System in the Nation - 19 Counties in Georgia and 31 Counties in Florida (In 1998, the Lake City and Gainesville VAMCs along with the CBOCs and OPCs became the North Florida/South Georgia Veterans Health System) FY 2016: 135,395 Veterans enrolled; over 1.68 million outpatient visits; average approximately 6,000+ visits daily system wide Infrastructure Investment and Expansionsion Tallahassee Clinic Grand Opening (Serving 16K+ Veterans) FY 2016: Women Veterans 10,989; Returning Combat Veterans: 10k+ FY 2016: Largest patient population from the Vietnam Era (36.3%) and Persian Gulf War Era (27.2%) Current FTEE: over 5,800+ (33% Veterans) with an annual budget of $1,069,726,361 One billion sixty-nine million seven hundred twenty-six thousand three hundred sixty-one. During FY 2016 Performed over: - 685,719 Specialty Consults - 222,952 Radiology Studies - 12,856 GI procedures Cath Lab Procedures 11-8,298 Surgeries (GV 6,192 & LC 2,106) 12 $56 Million budgeted Infrastructure Investment Submitted requests for expansion clinical space in Jacksonville area, Gainesville and Ocala, and replacement clinic for Ocala 3

4 Women Veterans Fast Growing Population Influx of younger Veterans: 58% of Women OEF/OIF Veterans Use VA 14K Enrolled in NF/SGVHS largest population in VISN 8 Expansion of Women s Health Programs in Gainesville & JAX include gynecological and in house mammography programs VA Clinical FACTS 1958 Invented the implantable cardiac pacemaker, helping many patients prevent potentially life-threatening complications from irregular heartbeats Performed the first successful liver transplants and developed techniques for suppressing the body s natural attempt to reject transplanted tissue Developed the nicotine patch and other therapies to help smokers give up the habit Developed Functional Electrical Stimulation (FES) systems that allow patients to move paralyzed limbs What are the core values of the VA? Answer: B 1) ICAN 2) ICARE 3) IWILL 4) IWON

5 Birth of the PACT model of care. Development of PACT is a part of the VA s health care initiative, Defining Excellence in the 21 st Century which aims to: Align all components of VA health care into a unified integrated delivery system Reduce variations within the VA health care system Build a standardized system throughout the VA health care system Use evidence as agent of change What is PACT? A Patient Aligned Care Team (PACT) is each Veteran working together with health care professionals to plan for whole-person care and life-long health and wellness. They focus on: Partnerships with Veterans Access to care using diverse methods Coordinated care among team members Team-based care with Veterans as the center of their PACT Old Primary Care Model

6 PACT is.. Whole Person Orientation Collaborative Partnership Effective Communication Patient Centered you ought not to attempt to cure the eyes without the head or the head without the body, so neither ought you to attempt to cure the body without the soul for the part can never be well unless the whole is well. Plato Past VA What can I fix? VA Health Care Patient Centered Present VA How can we help what is wrong with you? Future VA How can we help you live the life you want to live? Physician Clinical Team Veteran, Family and Health Care Team Case-Based Paper Medical Record We ll address your immediate concern. Disease-Based Electronic Medical Record You have a risky problem, please follow this plan to improve by your next visit. Whole-Person Electronic Health Record We can design your personalized health plan to meet your goals

7 The Patient s PACT Team Team: Per panel of patients Veteran (Center of the team and may include family or caregiver) Primary Care provider Registered Nurse Clinical Associate LPN Medical Assistant Health Tech Clerk Expanded Team Members Clinical Pharmacy Specialist Social Work Nutrition Mental Health Integration Case Managers The Roles in the PACT Team Veteran Is the focus of the PACT model Accesses the assigned PACT team for coordination of all aspects of care Learns the skills and treatments necessary to optimize own health The Roles in the PACT Team Primary Care Provider The teams point person-leads the care team Coordinates the identification and management of atrisk and special needs Veterans Assures development of a clinical care plan for each patient compatible with the Veteran s personal health goal in order to assist the Veteran attain the maximum health potential Coordinates chronic disease tracking Responsible for Panel outcomes assuring that teams goals and metrics are accomplished The Roles in the PACT Team Clinical Pharmacist Specialist-PACT Provides same day access for medication issues and medication management Performs medication reconciliation prior to 1 st PC visit for newly enrolled Veterans and as needed thereafter Reviews Chronic Disease Registry and databases for medication optimization Participates as requested in post discharge follow-up Utilizes scheduled face to face visits, work-in visits, group visits, secure messaging, and telephone appointments

8 29 The Roles in the PACT Team Clinical Pharmacist Specialist-PACT Completes pertinent clinical reminders Assists with management of treatment resistant patients or patients with adherence issues Manages/ prescribes medications and documents plan for identified disease states in accord with published guidelines and generally recognized standards of care Manages traveling veterans Evaluates non-formulary or criteria-based medication requests to ensure compliance with VA National formulary and established Criteria for Use guidelines Participates in Team meetings 30 Access Pillars of PACT Patient Aligned Care Teams Care Management & Coordination Patient Centered Performance Improvement VA and Community Resources Practice Redesign Pillars of PACT: Access Offer every patient an appointment with their own provider today for any problem, urgent or non-urgent. Alternatives to single Face-to-Face with physician: Group education Secure messaging Visits with RN Old World Veterans ride in a van for hours to the nearest VA medical center to keep an appointment just to find out their blood count. New World Patient gets blood drawn at a hometown clinic. A short time later, a healthcare provider calls to discuss the results. Visits with Clinical Pharmacist Telephone appointments 31 Tele-health HBPC (Home Based Primary Care) Shared Medical Appointments Drop in Group Medical Appointments 32 Dr. Robert Petzel said, We will need to give up the idea of solving all health issues by seeing patients at appointments. 8

9 Pillars of PACT: Care Management & Coordination PACT team proactively manages each patient s healthcare to achieve their maximum state of health. Utilize PC Almanac and Compass to initiate the process of patient management by identifying at risk patients including those with chronic/special disease: DM with HgbA1C>9 Poorly controlled hypertension Hyperlipidemia Obesity/metabolic syndrome COPD Pillars of PACT: Care Management & Coordination PACT team identifies special needs patients: Frequent CAU visits Numerous ER visits Recurrent hospital admissions Refractive behavior/non-compliance Opiate dependence Homeless Mobility disabilities Impaired intellect Pillars of PACT: Care Management & Coordination Using the databases (PC Almanac and Compass) the team stratifies risk for all patients on the panel. High Risk Pillars of PACT: Practice Redesign Practice redesign is the approach that teams use working together with clinic leadership to enhance the teams clinical care processes to assure that the right person does the right work at the right time in support of the patient. How do we work and why? Moderate Risk 35 Lower Risk Unknown Risk (no-shows, no recent visit) 36 9

10 What are the three pillars of the PACT model of care? a. Access b. Care Management and Organization Answer: A, C, D Access, Practice Redesign, Care Management and Coordination c. Practice Redesign d. Care Management and Coordination e. A, B,C 37 f. A,C, D 38 Not only do we anticipate what our patients need, we offer multiple options for meeting those needs. PACT Clinical Pharmacy Specialist Improve Access to Care

11 VHA Patient Care Needs are Increasi ng VHA s Primary Care Core Team (i.e. the Team) 81% of Teams lack sufficient core team members 81% 19% 41 Source: Network Structure and Effectiveness of Veterans Affairs Patient Aligned Care Teams Eean R. Crawford, PhD, Cody J. Reeves, BS, Greg L. Stewart, PhD and Stacy L. Astrove Source: VHA Support Service Center (VSSC): New Outpatient Visits & Uniques Trend, 10/7/15 Primary Care Providers have enough appointments to see a patient 2.5 times per year; not near enough for our aging Veteran patients on complex medication regimens who may be at risk for adverse events. Perceptions of pharmacists' integration into PACT teams Role clarity and work activities were influenced by team member attitudes toward and previous experiences with pharmacists Non-pharmacist members of PACT teams reported some reluctance in pharmacists integration. They attributed this reluctance to knowledge deficits, limited participation in PACT training by pharmacists, an imbalance in effort expended for pharmacists integration, and coordination or communication challenges. Patterson BJ, Solimeo, SL, Stewart, KR, et al Results: Role Negotiation Perceptions of pharmacists' integration into PACT teams Many were unclear when or how to involve pharmacists and there was a general lack of knowledge of how pharmacists clinical skills could be incorporated into the PACT model. Teams with less integration of pharmacists often perceived pharmacists main role as approvers and dispensers of medications. Those aware of role in chronic disease management were often unable to take full advantage Some desire for pharmacists to take a greater role in addressing incoming patient calls regarding medications Results: Variation in Pharmacist Integration Perceptions of pharmacists' integration into PCMH teams Pharmacist Integration varied by team and facility Across facilities, pharmacy integration was evidenced by participants describing instances where they considered the pharmacist to be a member of the core team, involving the pharmacist in formulary issue resolution, medication management for chronic diseases, or shared medical appointments Teams with limited integration reported pharmacist participation in new patient orientations 43 Patterson BJ, Solimeo, SL, Stewart, KR, et al Patterson BJ, Solimeo, SL, Stewart, KR, et al

12 Barriers to Successful Integration Lessons Learned and Opportunities Many facilities lack optimized processes to support Veterans Medication Needs, e.g., traveling Vets, dual care Role Clarity Space PACT CPS Ancillary Support 50% of facilities lack adequate space 43% of PACT CPS are not co-located with team To truly gain momentum and start a movement, you have to tell your story with a clear message 46% shortfall in facilities meeting PACT CPS ratios Lack of Pharmacist resources Impact PACT CPS role 45 FTE Resources 70% of PACT CPS lack ancillary support for items like appointment management, vitals, education and training 46 The CPS is an Advanced Practice Provider that improves access to care. 47 Know Your PACT Clinical Pharmacy Specialist (CPS) PACT CPS=PHARMACIST PROVIDER Independent Prescriptive Authority Practice-Area (Global) Scope of Practice to manage multiple chronic disease states of PACT patients Panel and Population Management IMPROVING ACCESS Comprehensive Medication Management services to allows other PACT providers to see more urgent/acute patients Bridging the gap to specialty care Same Day Medication management services CPS Providers Impact Access For a typical panel of 1200 patients, PACT Providers only have appointment slots to see a patient 2.5 times per year Typical patient visits to Target* Diabetes =6 visits Hypertension =3 visits HepC = 9-12 visits Using CPS Providers avoids shifts to Specialty Care *based on FY15 computer extracted data 48 PACT Provider Initial Visit 6 mo. visit 12 mo. visit 18 mo. visit PACT CPS 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 12

13 Pharmacist Providers Bridging the Gap Between Primary Care and Specialty Care The PACT CPS Provider s Impact on Access Comprehensive Medication Management (Diabetes, HTN, Lipids, etc.) Heart Failure Clinics Pain Management Pharmacy Med Intake Clinics Proven Performance in Primary Care Hepatitis C Clinics Coordination of Care Anticoagulation Clinics Same Day PACT Access Reference: A. Morreale June 2011 Disease/Cohort Management Transitions of Care and Discharge Follow-up 51 The CPS Provider Workforce Advanced Practice Providers High Level of Training Best to Recruit Highest Retention Rate Over 3,400 Clinical Pharmacists with a SOP to prescribe VA CPS workforce has Advanced Clinical Practice Training VA trains 600 CPS per year available for hiring in July of each year Patient s know their CPS Provider Established PACT Staffing Ratios and Evaluation Gaps In Clinical Pharmacy Coverage The PACT CPS is a core team member that improves access At least 1 CPS for every 3 PACT team panels 52 Approx. 1 CPS for every 3600 patients PACT CPS functions as an Advanced Practice Provider providing med management services the majority of the time FTE allotments must take into account for Primary Care Direct Patient Care (PCDPC) Time Defined by VHA Handbook as the time required to prepare for, provide, and followup on the clinical needs of Primary Care patients Can be delivered by traditional or non-traditional modalities If additional medication management services are included in the role, the facility must consider additional FTE needs 13

14 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 53 PACT CPS Staffing Opportunities Percentage of PACT Pharmacist FTE Based on Recommended Staffing Ratios V01 V02 V03 V04 V05 V06 V07 V08 V09 V10 V11 V12 V15 V16 V17 V18 V19 V20 V21 V22 V23 Oct '15 In FY15, there were over 5 Million Clinical Pharmacy Encounters 1.7M in Anticoagulation 857,000 in Primary Care Only 35% were Face to Face Handbook recommended PACT CPS Staffing Ratio (1 CPS per 3 PACT Providers) No VISN currently meets. Wide variation exists (24-85%) National avg is 54% of needed 675 Pharmacists would be needed across the system to meet PACT CPS ratios and optimize services 54 Recommended PACT CPS Staffing Ratio As Described in VHA Handbook PACT and VHA Handbook Clinical Pharmacy Services The Reality: PACT CPS Staffing Ratio Madison VA Past Reality: Madison VA Strong centralized Anticoagulation service Long-standing excellence in residency training First ever Ambulatory Care residency in 1983 Primary and Specialty Care was primarily resident driven with preceptor oversight Only 1.0 CPS FTE dedicated truly to PACT Residents and preceptors were in a different location than PACTs No team based care Very few teams meeting on a regular basis Limited population management Alignment with PACT Business Rules needed

15 57 Path to a New Reality Step 1 for PACT CPS Integration Gap Analysis Calculated how many FTE we were short based on 1:3 ratio Short 6.0 FTE Educational campaign Got on the agenda for every discipline s staff meeting Explained PACT CPS role created handout Overview of PACT CPS services Performed PACT Provider Needs Assessment Gained support from PACT Providers Integrated Pharmacy Leadership into Primary Care Leadership Submitted Business Proposal PACT Providers were loud in asking for more PACT CPS 4.0 FTE approved Path to a New Reality Step 2 for PACT CPS Integration Assigned PACT CPS to teams As close to 1:3 ratio as possible Created extended PACTs, including SW, IC, Nutrition Secured space (co-location) and ancillary support Off-loaded non-pact workload e.g., anticoagulation, nonformulary reviews Created PACT CPS grids, stopped using consults Included front-line PACT CPS in decisions Considered individual site needs e.g., walk-ins, telephone vs face to face PACT CPS were drivers of starting weekly team meetings Population management put RNCMs in charge Another provider on the team On-going assessment of PACT CPS services Completed self-assessment, surveyed PACTs Path to the New Reality. Step 3 for PACT CPS Integration New Patient Medication Intake Calls Other sites have implemented face to face, CVT, new patient orientation, etc. Team scheduler prints PACT Provider appointments one week in advance, hands to PACT CPS PACT CPS reviews appointments, identifies any patients coming for first ever VA Primary Care appointment PACT CPS calls patient, performs medication reconciliation, converts to formulary alternatives, places consults (including for PACT CPS services), orients to VA pharmacy, clinical reminders, orders labs, performs disease management, obtains HPI, additionally signs PACT Provider 60 Path to the New Reality. Step 4 for PACT CPS Integration PCP to CPS Appointment Conversions Identified low-utilizer of PACT CPS services Obtained PACT Provider buy-in PACT CPS reviewed PACT Provider RTC orders, cancelled any that PACT CPS could do PACT CPS alerted scheduler to schedule with PACT CPS instead Short-time frame, helped PACT Provider understand which patients could go to PACT CPS After 3 months, transitioned to PACT Provider and other team members identifying appropriate patients and sending to PACT CPS proactively Tracked the number of appointments converted 15

16 Improving PACT Access with Pharmacists Gold Status-William S. Middleton Memorial VA Pharmacy Clinic Education CPS Assigned to PACT Teams New Patient Medication Intake Clinic Conversion of PCP to PACT CPS Appointments Utilizing your PACT CPS to the Top of their Licensure and Scope Clinical Pharmacy Specialists (CPS) Increased Access to Primary Care PACT CPS Chronic Disease Clinics: 13.8% in clinic utilization New patient calls: saved primary care provider 20 minutes on average for every new patient Converting PCP visits to PACT CPS Resulted in: 27% PCP appointments converted = 16.5 hours s newly opened access = 66 new telephone appts or 33 new face-to-face appointments Per Primary Care Provider Improved Provider Satisfaction = PCPs unanimously requested more pharmacists! Applied nationally this would translate into 272,000 new appointments annually. 61 Gold Status Project-Improving Access to Primary Care Utilizing CPS 62 PACT CPS Roles to Improve Access Assure that the CPS has a broad, practice area based scope of practice Assure that the PACT CPS has space, technology and ancillary support to maximize efficiency Assure roles that can be performed by other team members have been carefully assessed and distributed where appropriate Ensure PACT Teams understand roles of the PACT CPS Mapping out a Typical Day Focuses on Optimization of Direct Patient Care Primary Care Direct Patient Care (PCDPC) Time for the PACT CPS 75-85% of the time should be spent in direct patient care 30 hours of time per week spent in direct patient care activities, or a target of 12 to 15 medication management encounters per day Provides appropriate cross-coverage of duties Allows PACT CPS and leadership to talk about opportunities that exist Allows the team to optimize the medication management services needed Allows for discussion of expansion of PACT CPS role with team

17 Optimized Direct Patient Care for the PACT CPS Example Clinic Schedules Telephone visits incorporated Time to Discuss clinical pharm issues PACT CPS Key Takeaways Advanced Practice Providers with Independent Medication Prescriptive Authority Highly trained Clinical Workforce that is poised to assume more direct patient care duties. Graduating nearly 600 highly trained clinical residents annually. Most of which want to stay in VA. Clinical Pharmacy Specialists (CPS) are the Team s Medication Experts 65 Admin Time added Thanks to the Sierra Nevada VA Medical Center 66 Optimize roles of CPS to provide Essential Chronic Disease and Medication Management Services PBM CPPO Clinical Pharmacy Practice Resources/Reference PBM Access Fact Sheet-Optimizing the Role of the CPS to Improve Access VHA Handbook , Clinical Pharmacy Services Outlines Clinical Pharmacist Scope of Practice Describes clinical pharmacy roles and responsibilities for pharmacists VHA Directive 1033, Anticoagulation Therapy Management Defines policy elements and strong practice recommendations for anticoagulation programs Gold Status Project-Improving Access to Primary Care Utilizing CPS PBM CPPO Clinical Pharmacy Practice SharePoint