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VA Project Expands Clinical Pharmacy Services to Rural Veterans

[March 1, 2017, AJHP News]

Kate Traynor

BETHESDA, MD 13 Feb 2017—A major project at the Department of Veterans Affairs (VA) to position pharmacists as healthcare providers in rural settings is poised to generate new data on how pharmacists improve patient care.

The 5-year, $70-million project—a collaboration between VA's Clinical Pharmacy Practice Office (CPPO) and its Office of Rural Health (ORH)—funds 115 new clinical pharmacy specialist (CPS) positions in rural outpatient clinics managed by 60 VA healthcare facilities. About half of the pharmacists will specialize in primary care, and the rest will focus on mental health or pain management.

"We really wanted to focus on those 3 key areas and develop an enterprisewide initiative that would integrate our clinical pharmacy specialists into rural area care teams," said Julie Groppi, national pharmacy benefits management program manager for CPPO.

Groppi said funding was awarded to the sites in October 2016, and the sites have been working with local human resources offices to hire staff for the CPS positions. She estimated that about half of the positions had been advertised or filled by the start of this year.

Nearly 3 million veterans living in rural areas are enrolled in VA healthcare programs, according to ORH. For many of these veterans, Groppi said, VA is the sole source of healthcare. But access can be a challenge.

"Rural patients often have more difficulty in coming to their main VA medical center for their care, and they have many care needs," Groppi said.

The collaboration with ORH supports face-to-face and remotely managed CPS services. In addition to funding the CPS positions, each participating facility was allotted funding for ancillary staff to support CPS staff and to purchase equipment to manage patients' needs remotely.

"We've tried to give sites a lot of flexibility," Groppi said. "They might decide that they want to place a clinical pharmacy specialist at their rural clinic. Or they may decide that they want to use telepharmacy to have virtual meetings, and use telephone visits, and use clinical video telehealth . . . to support patient care."

CPPO has developed guidelines and policies for the successful deployment of CPS staff. This year, the office will hold "boot camps" for facility leadership and CPS staff to provide training and ensure consistency in how pharmacists are integrated into healthcare teams.

Anthony Morreale, assistant chief consultant for clinical pharmacy services and healthcare research at CPPO, said the project exemplifies a change in the way ORH disseminates successful patient care practices.

Until recently, Morreale said, ORH has solicited proposals from rural sites to fund small projects suggested by the sites. He said these projects may incrementally improve care, but benefits are mostly limited to the site undertaking the project.

In an effort to improve the spread of successful patient care strategies, ORH's strategic plan for 2015–19 established a system-directed approach to identifying and funding projects. The plan also requires ORH to engage with all of VA's program offices to develop projects for implementation across the VA system.

So when ORH reached out to CPPO about developing a large project to increase the role of pharmacists in rural healthcare, Morreale and his colleagues seized the opportunity.

"Our program office is set up to look for gaps in patient care and to identify opportunities for clinical pharmacy practitioners to apply their skills to help resolve those gaps," Morreale said. "We know where we can do well—if we have resources."

Groppi said VA's clinical pharmacists have improved quality of care, access to care, and clinical outcomes for veterans.

She said one standout project, developed at the William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin, found that having a CPS as part of the primary care team greatly increased the site's patient care capacity [see December 15, 2016, AJHP News].

CPPO also has data to support a role for clinical pharmacy specialists in pain management and mental health, the other 2 priority areas for the collaboration with ORH.

"Especially in mental health, we have had success in having the clinical pharmacy specialist actually serve as a mental health provider. So they have a panel of patients that they care for and continuously follow as a part of the mental health team," Groppi said.

VA provided mental health services to more than 1.6 million veterans during fiscal year 2015 and expects the need for such care to increase in the coming years, according to the agency.

Morreale said the CPPO–ORH project's robust informatics infrastructure will generate important data that build on the findings of earlier pilot projects.

"As the initiative moves forward, it creates a research platform to document all of the roles and outcomes of clinical pharmacists in those rural health settings," Morreale said. "In the areas of mental health and in pain management, we're interested in additional data to support the roles that the clinical pharmacy specialists are taking on."

Groppi said VA closed out fiscal year 2016 with more than 3,500 CPSs, an 84% increase over 5 years. During fiscal year 2016, those pharmacists documented more than 5 million patient encounters, she said.

"We've had a lot of growth, but we still have lots of areas of opportunity," Groppi said.

Morreale said the clinical pharmacy practice leaders whose sites applied to participate in the CPPO–OHR project know how pharmacists can improve care. But sites often lack the funding to fully meet their CPS needs, he said.

"This project allowed the sites to get dedicated money to hire a pharmacist. And so a lot of them saw that as an opportunity to get additional resources that were paid by the central office," Morreale said.

He expects that the sites will eventually be able to use data from the project and the infrastructure of the care models to justify the hiring of additional CPS staff.

"Once you establish a good practice in a good setting—whether it's primary care or mental health or whatever—all of the sudden everybody wants pharmacists," he said. "So it's really exciting for us in our office, because we've been working so hard on this for so long, to see this come to fruition with resources."

 

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