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February 25, 2013

Pharmacists Integral to Continuity of Care at Scott and White Memorial Hospital

DISCHARGE FROM HOSPITAL TO HOME or a long-term care facility is a busy time for both patients and care providers. When administrators at Scott and White Memorial Hospital, a 600-bed academic medical center in Temple, Tex., found that the computer-assisted discharge medication reconciliation process wasn’t robust enough, they tapped pharmacy staff for a solution.

Seizing the opportunity to demonstrate leadership, the pharmacy staff devised a plan, and with the hospital administration’s approval, the High-Risk Medication Team (HRMT) was born. Their endeavor successfully implements ASHP’s Pharmacy Practice Model Initiative recommendation for pharmacist involvement in establishing processes to ensure medication-related continuity of care.

Getting Off to a Good Start

Seeking to expand pharmacist duties often requires making a case to management, but at Scott and White, the administration had full faith in pharmacy staff from the start.

From left, Kurt Bradley Anderson, Pharm.D., staff pharmacist, consults with patient care pharmacists Lori Jackson-Khalil, Pharm.D., and Qing Xu, Pharm.D.

“We were fortunate that our leadership was in tune to this vulnerable period for patients,” said Tricia A. Meyer, M.S., Pharm.D., FASHP, of the HRMT. “They saw this as an opportunity for pharmacists based on our understanding of patient medication profiles and discharge medications.”

Tasked with providing options to the administration, the pharmacy staff set about devising several plans from which to choose. They met with the hospitalist, nursing staff, and leaders from different units to get their input and learn about their discharge processes.

Team members also called other institutions where they knew pharmacists had responsibilities similar to those they were seeking to obtain.

“We decided it would be a great opportunity for a new group of pharmacists to focus strictly on discharge,” said Meyer. “We already have pharmacists who focus on patient care, but they don’t have the time to dedicate to discharge.”

The team came up with three potential plans: One would cover medication review for every discharge; one would focus on high-risk patients and medications; and one would focus solely on anticoagulation. Administration opted for the second program, which focuses on high-risk.

From there, Meyer searched for a pharmacist who had expertise in patient interaction and counseling, and two additional team members who were ambulatory care specialists comfortable with counseling patients and reviewing medication profiles.

Working Past the Challenges

Although the pharmacy team did not have to worry about administrative buy-in, implementing the HRMT program was not without its challenges.

Patient care pharmacist Qing Xu, Pharm.D., consults with a physician about a patient’s medications.

“One of the initial barriers we had was easily knowing when patients were to be discharged,” Meyer said. “Sometimes even the attending physician doesn’t know when the patient will be discharged. Test results or a change in the patient’s condition can extend or shorten a stay, and the physician might not know until rounds.”

The team tapped into several resources around the hospital, consulted with inpatient pharmacists, and accessed data from outpatient clinics, according to Lori Jackson-Khalil, Pharm.D., patient care specialist. “For example, the anticoagulation clinic has a list of patients, and we review that list each day. The cath lab would send us a list of patients on their schedule every day, as well.”

At first, software presented a challenge, said Jackson-Khalil. “We started with a spreadsheet in Excel, and we would manually input patient data. The trick was to set up the spreadsheet to give us the information we needed.”

The team decided to err on the side of caution and create detailed records.

“We kept data on everything—every visit to a patient’s room, every call to a physician, all categorized by drug and service. The team spent a lot of time documenting,” said Meyer. “But it was worth it. In the first six months or year of a new program, you are vulnerable. You have to show that you are accomplishing the goals the administration has given you. You can never keep too much data when trying to justify a program and its growth.”

Laborious data entry may soon be a thing of the past, however. The hospital is currently switching over to a new system that the staff believes will make it easier to identify which patients are about to be discharged.

Expanding Responsibilities

Once patients on high-risk medications are identified as transitioning to discharge, their orders are scanned to the pharmacy. Initially, the HRMT would review the orders and consult with prescribers as necessary regarding additions, possible errors in omissions, and unsafe prescribing conditions.

But as of November 2012, pharmacists are able to add medications or modify discharge orders. Their new responsibilities came about in part because they were able to demonstrate their impact on patient care through the data in their spreadsheets. For example, between January and June 2011, the team identified and successfully intervened in 42 unintentional omissions of high-risk medications such as phenytoin, warfarin, clopidogrel, and prasugrel.

“Now the administration sees us as a very effective team, and physicians call us and request that we add drugs to our oversight list,” said Meyer.

Pharmacy leadership in medication-related continuity of care is currently expanding. The team has begun counseling and oversight for patients with congestive heart failure in the hope that pharmacist-provided medication management at discharge will decrease readmissions.


Expansion into Prescribing at the VA

Lauren Rass, Pharm.D., a PGY1 pharmacy resident, (center left) and Lynsey Neighbors, Pharm.D., BPCS, RPD, counsel a patient.

A KEY ELEMENT of advancing pharmacy practice—and a recommendation of ASHP’s Pharmacy Practice Model Initiative—is the expansion of pharmacists’ duties to include writing medication orders.

At the Central Alabama Veterans Health Care System (CAVHCS), which serves more than 134,000 veterans in a 43-county area of Georgia and Alabama, the clinical pharmacy team has achieved this goal through a 10-year evolution.

What began with protocol-driven care in anticoagulation management has expanded into broad scopes of practice across a range of diseases and conditions. Pharmacy practice at CAVHCS now includes not only medication management, but prescribing privileges, in person and on the telephone.

Finding a Physician Champion

Expanding pharmacy practice in a health system requires strategy. When a system-wide evaluation revealed that CAVHCS wasn’t meeting its goals for lipid management, pharmacists saw an opportunity to showcase both their training and their clinical competency.

“We thought lipid management would be fairly easy to sell to management because it’s less risky than other practice areas,” said Addison Ragan, Pharm.D., BCPS, GCP, clinical pharmacy program manager. In 2002, the system opened a lipid management clinic where pharmacists had prescribing privileges under a protocol, and it wasn’t long before physicians throughout the system took notice.

“The primary care providers loved it, and they referred patients to us across the hospital setting,” said Ragan.

The following year, pharmacists moved into managing dyslipidemia in diabetes, again, under protocols. After the VA’s national clinical pharmacy leadership released guidance on dyslipidemia and diabetes and field guidance advocating broad scopes of practice, CAVHCS pharmacists worked closely with endocrinologist Neil E. Schaffner, M.D., meeting with him weekly for a roundtable discussion. The rapport that the team developed with Schaffner would later prompt him to become a physician champion for pharmacist-provided care.

Lynsey J. Neighbors, Pharm.D., BCPS, trained with Dr. Schaffner.

“He was somewhat skeptical of pharmacists stepping into this role at first, but after working with other pharmacists and later myself, he realized what pharmacists could do,” she said.

Accountability Counts

Ragan knew that if CAVHCS pharmacists wanted to work under broad scopes of practice, they would have to demonstrate their competency in quantifiable ways. The team developed competency checklists and professional practice evaluations to determine pharmacists’ knowledge and ability. She also implemented a mentoring process to improve performance as necessary. Under this system, pharmacists evaluate their peers every quarter.

“Having an accountability system in place shows leadership that you are monitoring the clinical competency of your staff,” said Ragan. “Even if there are cases where there need to be improvements, leadership can see that you are doing your due diligence.”

Such accountability helps pharmacists be their own best advocates, she added. “We become more conscientious in our documentation because we know it will be reviewed.”

When the time came to ask for expanded scopes of practice for several pharmacists, Ragan presented the evaluations to the administration, and Schaffner wrote a letter attesting to the pharmacists’ clinical competency.

With such evidence before them, the administration saw fit to grant Ragan’s request. Now, pharmacists have expanded scopes of care that allow them to prescribe and manage medications for anticoagulation, diabetes, dyslipidemia, hypertension, pain, hypothyroidism, osteoporosis, and gout, with more opportunities on the way as Neighbors dives into the world of hepatitis C management.

Saving Time and Money

Expanded scopes of care and increased pharmacist involvement in direct patient care have been time-savers for physicians and patients alike.

“Pharmacists now titrate insulin, do follow-up, work with insulin pump patients, and handle the day-to-day management of diabetes that doesn’t always fit into a physician’s schedule,” Neighbors said. She is currently training other pharmacists to take on these new roles in diabetes care.

Other pharmacists are currently handling aftercare for heart failure patients. The pharmacists meet the patients in shared appointments with cardiologists. From there, the pharmacists follow up via telephone to discuss medications, blood pressure, and post-discharge care.

Pharmacists with this expanded scope of practice have prescribing privileges that allow them to adjust medications based on the cardiologists’ goals for treatment, particularly with respect to diuretics.

“We’re hoping that, by having pharmacists engaged in diuretic management, we will be able to prevent readmissions,” Ragan said.

Pharmacist follow-up via telephone has been a boon to patients, many of whom live in rural areas and must travel as far as 80 miles to come to one of the system’s facilities. Patients aren’t charged for the pharmacists’ telephone calls, so the saved time translates into saved money, as well—enough so that the team is now testing a video telehealth program.

But beyond that, it’s just plain easier on the patients, said Ragan. “Often they’re not feeling well,  so it’s taxing for them to travel long distances for simple changes in their medications.”

Pharmacy practice continues to expand at CAVHCS, Ragan added.

“Current scopes of practice are written to be very general and broad, and we can jump into managing disease states that we wouldn’t have been able to before without completely rewriting their scopes.”


February 11, 2013

ASHP Headquarters Named to Honor Dr. Joseph A. Oddis

Filed under: From the CEO,Home — Tags: , , , — jmilford @ 10:30 am

Paul W. Abramowitz, Pharm.D., Sc.D. (Hon.), FASHP

TODAY, I AM PLEASED TO MAKE a very special announcement to the members of ASHP.

At its January meeting, the Board of Directors voted unanimously to name the ASHP headquarters building, here at 7272 Wisconsin Avenue in Bethesda, Md., after the man who led our organization for 37 years: Dr. Joseph A. Oddis.

As of now, the headquarters of ASHP will be known as the Joseph A. Oddis Building. The building will be dedicated at a ceremony to be held this spring.

There could not be a more fitting person to receive this honor. Dr. Oddis’ leadership over nearly four decades helped make ASHP the strong, vibrant, growing, and influential organization it is today. Joe’s vision for what ASHP could be and the important role we could play in shaping pharmacy practice, improving patient care, and influencing public policy to improve public health set this organization on the path it still follows today.

Here are just a few significant achievements from Dr. Oddis’ career and his legacy to ASHP:

  • Joined ASHP in 1960 as Executive Secretary, later to be renamed Chief Executive Officer.
  • Leading ASHP’s growth from 3300 members and a staff of 1 (himself!) to 31,000 members and a staff of 180.
  • Developing a staff culture that focuses on serving our members in a respectful, team-based approach, with a commitment to excellence.
  • Growing ASHP’s education services, launching the national meetings that would become the ASHP Summer Meeting and the ASHP Midyear Clinical Meeting, now the largest meeting of pharmacists in the world.
  • Building upon ASHP’s early support of international efforts to improve pharmacy practice, including serving as president of FIP from 1986 – 1990.
  • Improving pharmacy practice and raising the visibility and status of ASHP by recognizing the importance of practice standards. Under Dr. Oddis’ stewardship, ASHP worked with practitioners to develop and publish nearly 100 practice standards, guidelines, technical assistance bulletins, and position papers.
  • Helping promote the concept of formularies and the acceptance of pharmacy and therapeutics (P&T) committees in the early 1960s by building consensus among key stakeholders, including the American Hospital Association, the American Medical Association, the American Pharmacists Association, and ASHP.  In 1965, Medicare based its standards on ASHP’s statements and standards and The Joint Commission deemed an active P&T committee essential for hospital accreditation.
  • Establishing ASHP’s pharmacy residency accreditation program, now celebrating its 50th anniversary. Today, ASHP has 1,582 pharmacy residency programs and 246 pharmacy technician training programs in the accreditation process. In 2012, there were more than 2,500 residents in a PGY1 or PGY2 residency program.
  • Creating the ASHP Research and Education Foundation, which today offers extensive research grant, educational, and awards programs that assist and recognize pharmacists providing care to patients in our nation’s hospitals and health systems, leading to optimal medication outcomes.
  •  Expanding ASHP’s publishing efforts:
    • Introducing the American Hospital Formulary Service (AHFS), which has gained national recognition as the most comprehensive resource of unbiased drug information, and recognized by the U.S. Congress as an official compendium.
    • Introducing International Pharmaceutical Abstracts (IPA), which was published by ASHP from 1964 to 2004.
    • 1964 publication of Mirror to Hospital Pharmacy, which has developed into the ASHP National Survey of Hospital and Health-System Practice.
  • Building ASHP’s leadership and influence by collaborating with other pharmacy and health care organizations and government regulatory agencies on the important issues of the time, including the American Hospital Association, the American Nurses Association, the American Society of Internal Medicine, The Joint Commission, the Food and Drug Administration, and the agency that administered Medicare, among others.

Please join me in thanking Dr. Oddis for his dedication to ASHP and the profession of pharmacy.


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