Vanderbilt University Medical Center - Transplant Pharmacy

Practice Setting 

 The Renal Transplant Clinic at Vanderbilt University Medical Center (VUMC) transplanted 265 renal transplant recipients in 2020 and currently services thousands of patients to manage their long-term post-transplant care. Currently, the Vanderbilt Transplant Pharmacy services around 1,300 renal transplant patients monthly providing about 6,500 outpatient prescriptions and additional medication related pharmacy services. Transplant Pharmacy Services have had a pharmacist embedded in the outpatient renal transplant clinic since 2015. The pharmacists serve as a liaison between the clinic and pharmacy to improve communication and streamline care. A pharmacist is available in clinic for in person communication when needed for medication reconciliation, referral for financial assistance, or patient counseling. Pharmacists are also available offsite and can communicate with the clinic staff via phone or messaging through the patient's electronic health records.

Why was the pharmacy service developed? (Describe any compelling data collected prior to implementation)

 In 2015, VUMC pharmacy services implemented a Transplant Pharmacy after assessing the needs of all outpatient transplant clinics. The renal transplant clinic specifically identified a need for a pharmacist to assist with medication refill requests and other medication related services. The first clinical pharmacist was embedded in the renal transplant clinic in July 2015 and a second clinical pharmacist was dedicated to the clinic in December 2016. Pharmacists began assisting with prescription refills, patient/caregiver medication counseling, drug information and recommendations to clinical staff, insurance prior authorizations, financial assistance coordination, and resolving barriers to obtaining medications.

Our clinical pharmacists work under a collaborative pharmacy practice agreement (CPPA), which allows the pharmacists to refill non-controlled medications without a physician’s involvement. Ours was the first such agreement at VUMC after the Tennessee Pharmacist Association and the Tennessee Medical Association enacted rules allowing CPPAs in July 2014. Two years after the launch of the agreement, physicians were authorizing only 9% of immunosuppressant refill requests, compared to 72% prior to the agreement. This has allowed our physicians to focus on taking care of their patients and given our pharmacist autonomy to better manage the medication needs of our patients.

What training, certification, credentialing, and practice agreement is utilized by the practice setting pharmacist(s)?

 Our clinical pharmacists participating in the CPPA have +5 years of experience in the outpatient pharmacy setting. Some of our pharmacists are certified specialty pharmacists (CSPs), while others are working towards specialization and certifications within the clinical/transplant field. Our current CPPA includes providing patient care and drug therapy management for patients with chronic kidney disease, end stage renal disease, or those who have undergone a kidney transplant. Medications included consist of immunosuppressant, cardiovascular, endocrine, respiratory, gastrointestinal, antimicrobial, hematologic, analgesic, central nervous system, and supportive care medications.

What outcomes are being measured to evaluate the model's success? (Clinical metrics, revenue, cost-savings, patient satisfaction, etc.)

 While revenue is not a primary driver of our success within our clinical practice, the Transplant Pharmacy continues to see growth in this area, along with an increase in patient and prescription volumes since the inception of our CPPA. We measure clinical interventions within our pharmacy systems along with other metrics such as the number of prescriptions signed under CPPA guidelines. We also survey our providers each year to measure not only their satisfaction with our clinical pharmacists, but also with the entire transplant pharmacy department. Patient satisfaction surveys sent to our patient population consistently show that our patients are highly satisfied with the care we can provide through the Vanderbilt Transplant Pharmacy. All measurements taken together are excellent indicators of our value to our patients and our institution.

How have you made this service sustainable? (Include billing, reimbursement, etc.)

 Our revenue stream comes through the generation of prescriptions filled and billed through our own in-house outpatient transplant pharmacy. From the start of our CPPA until now, we have tripled the number of patients we are servicing monthly. We are in continuous communication with clinic leadership about the expected growth of the outpatient transplant clinics to anticipate future needs and maintain our expected level of care for years to come. We continue to look for more ways to increase revenue through reimbursement and actively look for ways to expand our clinical services for our pharmacists, but our primary focus remains on the high level of care our patients and providers have come to expect from our department.

How did you gain support of administrators, providers, and other key stakeholders to implement your practice model?

 We gained provider trust and support by helping with various medication needs from generating prescription orders through the CPPA, medical record assessments, medication counseling, financial and insurance questions, and prior authorization assistance. We kept pharmacy administrators on board by increasing the number of patients that used the Transplant Pharmacy and increasing the number of scripts processed and dispensed by our pharmacy.

What are some lessons learned while implementing your practice model that you would like to share?

Physician buy-in was essential for successful implementation of our practice model. Our providers are supportive of pharmacists' expansion of clinical services and transplant pharmacy services. Renal transplant physicians at VUMC aided in the implementation of our initial CPPA and at present support the process of helping us expand our current roles. Although implementing a CPPA was a lengthy process, it has been beneficial for the pharmacists, clinic, and patients.