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VA Clinical Pharmacy Practice Office and Pharmacy Residency Program Office Win ASHP Board of Directors’ Award of Excellence

Anthony Morreale, Pharm.D., M.B.A., BCPS, FASHP

WHEN ANTHONY MORREALE, PHARM.D., M.B.A., BCPS, FASHP, started working for the Veterans Health Administration (VA) in 1985, only a few pharmacists had advanced practice prescriptive authority in the ambulatory care setting, and the majority of their clinical practices were in hospital-based acute care. As the VA evolved into more of an ambulatory care-based system, the role of clinical pharmacists continued to expand.

Prescriptive Privileges

Now, a decade after the VA and Dr. Morreale launched a dedicated Clinical Pharmacy Practice Office (CPPO), the health system has a highly interactive, supportive infrastructure to engage pharmacy leadership, share best practices, and promote the role of clinical pharmacy specialists (CPSs) system-wide. Over 4,500 CPSs, about half of all pharmacists in the VA. have prescriptive privileges as part of their advanced practice roles managing patients in primary care, pain management, mental health, acute care, and antimicrobial stewardship.

It’s a primary reason why the VA Pharmacy Benefits Management CPPO and Pharmacy Residency Program Office (PRPO) were among two recipients of the 2020 ASHP Board of Directors’ Award of Excellence.

“The VA CPPO and PRPO developed and implemented comprehensive strategies to expand advanced clinical practice excellence and post-graduate pharmacy residency training,” ASHP said in a formal announcement. “These innovative efforts resulted in greater patient access to care, improved patient safety, identification and treatment of substance use disorders, and enhanced care coordination.”

According to Dr. Morreale, the CPPO work started in primary care with the VA’s system-wide adoption of the team-based care medical home model, which embraced pharmacists with prescriptive privileges playing key roles in those teams.

“That just happened to be a natural marriage that really helped expand the role of clinical pharmacy specialists in ambulatory care,” he said. “Having pharmacists embedded in all of those teams really launched a number of initiatives.”

Boot Camps for Pharmacists

The pharmacists initially helped manage patients with core diseases like diabetes and hypertension, said Dr. Morreale. Then the CPPO created clinical boot camps in different geographic regions to train primary care pharmacists on additional conditions they would encounter in ambulatory care, including osteoporosis and pain management, utilizing a train-the-trainer model where they would go back and teach their colleagues. In 2015-2016, with the approval of better drugs for hepatitis C, CPPO held national boot camps to train hundreds of pharmacists, who eventually managed over 30% of all hepatitis C patients, resulting in nearly 100% of those patients having a clinical cure from the disease.

More recently, CPPO, in conjunction with the Office of Rural Health, has held boot camps focused on expanded primary care, mental health, and pain management efforts to fill an identified gap in comprehensive medication management in the veteran population. In this project, over 180 CPSs were hired across 63 VA medical facilities focused on improving veterans’ access to comprehensive medication management in rural settings.

“The physicians really appreciate the comprehensive medication management support, because many of those disease states have either complex pharmacotherapy or require a lot of hand-holding of the patients, and they may not have the time or bandwidth to do it,” Dr. Morreale said.

Additionally, CPPO holds leadership trainings for pharmacy champions, conducts site visits with VA center leadership to promote the role of clinical pharmacists, and operates a coaching and mentoring program through which new clinicians and pharmacy leaders are paired with seasoned pharmacists. It’s been a multi-pronged approach to expanding roles for CPSs that was built one step at a time, said Dr. Morreale.

“We obviously don’t do all of this work to win an award—we’re doing it to do the right thing and take care of the Veterans,” he said. “But it’s always nice, after 10 years of hard work with some major successes, to have the recognition of ASHP and national attention to the program. Maybe as a result, there will be more programs that will start to implement the same type of strategies.”

Innovation in Residency Training

Lori Golterman, Pharm.D.

The VA also was recognized for its work in post-graduate pharmacy residency training. The VA operates the largest pharmacy residency program in the country, said Lori Golterman, Pharm.D., National Director of Residency Programs and Education for the PRPO, with some 272 residency program directors, and 628 residents and fellows. About 60% of residents are recruited into full-time positions with the VA when they complete training.

“We’re extremely innovative with our programs,” Dr. Golterman said. Residents have trained in a variety of areas including mental health, rural health, pain, neurology, and oncology. “We are the leaders in psychiatric training, with approximately 77 residents trained annually, as well as pain, neurology and other specialties such as ambulatory care. We were recognized with this award for our latest expansion of pain residencies. We are training 15 residents a year, and it continues to grow as former residents are eligible to become residency program directors.”

Besides monthly calls with residency program directors and residents, PRPO supports teaching and preparing for accreditation visits, responses to surveys, preceptor development, resilience, and much more, Dr. Golterman said. “PRPO supports its trainees throughout the year, with a variety of learning opportunities. The residency year starts with a project design and statistics course, a learning program for presenting articles and evaluating literature, quarterly leadership presentations, monthly conference calls, resilience training, and periodic surveys to check on well -being,” she explained.

The Federal Resident’s Council —a group of 25 residents that include VA and Indian Health Service residents (next year it will include the Department of Defense)—provides information to residents nationally through several committees such as a professional development committee; research committee; networking committee; and an IT committee. The Council works with the Residency Advisory Board to support issues like virtual interviewing and mentoring.

Promoting Resilience

The program also dedicates a lot of time to resilience. “We were among the first to identify stress, anxiety, and depression among

Virginia Torrise, Pharm.D.

residents and report it to ASHP,” Dr. Golterman said. PRPO brought in a psychologist to help with these issues and promoted using mental health resources offered through the VA’s employee assistance program. And, with the start of the COVID-19 pandemic, the residency program quickly adopted virtual training methods for situations where residents could not be on-site.

Dr. Golterman noted that receiving the ASHP Board of Directors’ Award of Excellence is a reflection on the entire team. Her residency advisory board has a combined 240 years’ experience in pharmacy. “They are the heartbeat of the program, and they spend a lot of their own time to support the residency program directors and preceptors and strive toward excellence,” she said.

Virginia Torrise, Pharm.D., deputy chief consultant of Pharmacy Benefits Management professional practice for the VA, added, “Drs. Morreale and Golterman have ensured that the VA has highly qualified, advanced pharmacist-practitioners serving our veteran patients on interdisciplinary teams to meet VA priority needs in primary care, mental health, and pain specialty.  Their work has ensured VA expanded clinical pharmacy telemedicine services to our Veterans who reside in rural health settings and addressed difficulties commuting to a VA clinic. I couldn’t be prouder of their leadership, foresight, and dedication to advancing residency training and clinical pharmacy practice in the VA.”

By Karen Blum

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