ASHP InterSections ASHP InterSections

April 30, 2019

ASHP Joins the National Academy of Medicine Action Collaborative on Countering the U.S. Opioid Epidemic as a Sponsoring Member

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

I AM PLEASED TO SHARE WITH YOU THAT ASHP has become a sponsoring member of the National Academy of Medicine Action Collaborative on Countering the U.S. Opioid Epidemic. The other Collaborative Sponsors are:

  • Accreditation Council for Graduate Medical Education
  • Aetna
  • American Hospital Association
  • American Medical Association
  • Arnold Ventures
  • Association of American Medical Colleges
  • Centers for Disease Control and Prevention
  • CDC Foundation
  • Centers for Medicare and Medicaid Services
  • Council of Medical Specialty Societies
  • Federation of State Medical Boards
  • HCA Healthcare
  • National Institute on Drug Abuse
  • Robert Wood Johnson Foundation
  • Substance Abuse and Mental Health Services Administration

The mission of the Action Collaborative is to “convene and catalyze public, private, and non-profit stakeholders to develop, curate, and disseminate multi-sector solutions designed to reduce opioid misuse and improve outcomes for individuals, families, and communities affected by the opioid crisis.”

ASHP and our 50,000 members who serve as direct patient care providers in hospitals, health systems, rehabilitation centers and ambulatory clinics will bring a great deal of expertise to the Collaborative and play a major role to mitigate and end the opioid epidemic on behalf of our patients and communities, while ensuring that our patients receive appropriate pain management.

ASHP will serve on the Action Collaborative’s Opioid Prescribing Guidelines and Evidence Standards Working Group, and will also be providing insights and expertise to the Collaborative’s Health Professional Education and Training Working Group; Prevention, Treatment, and Recovery Services Working Group; and Research, Data, and Metrics Needs Working Group.  As part of our initial work with the Collaborative, we have made several commitments that include but are not limited to:

  • Creation and dissemination of patient and prescriber education on pain management and opioid abuse mitigation best practices.
  • Enhanced patient access to evidence-based treatment for opioid use disorder through increased utilization of pharmacists on the healthcare team.
  • Standardization of a framework for pain stewardship to coordinate pain management, opioid prescribing, and use of non-opioid therapies.
  • Coordination of care among patients, caregivers, and healthcare professionals through the use of standardized patient-specific pain management and substance use disorder treatment plans.
  • Improvement of interoperability, artificial intelligence, and clinical decision support in healthcare information systems.
  • Identification of performance and quality metrics to assess impact.
  • Stimulating research on pain and opioid use disorders and their respective pharmacologic and non-pharmacologic treatments.
  • Advancing efforts to prepare the pharmacy workforce through pharmacy education and professional development programs.

ASHP has also been actively involved in numerous public and private sector efforts to address the opioid crisis through the leadership of pharmacists and has worked diligently across a number of fronts to identify enduring solutions, including advocating for better access to medication-assisted treatment. We had the pleasure of working with the White House Office of National Drug Control Policy and attending the ceremony to commemorate the signing of H.R. 6, the “SUPPORT for Patients and Communities Act,” bipartisan legislation to combat the opioid crisis in October. ASHP will also continue to pursue policies that further support the vital roles pharmacists play as patient care providers in the treatment of acute and chronic conditions, including opioid and substance-use disorders.

You can find additional ASHP resources on our website, including:

We look forward to sharing more about our work with the National Academy of Medicine Action Collaborative on Countering the U.S. Opioid Epidemic and on ASHP’s ongoing efforts surrounding the opioid crisis, including creating various tools, education, and resources to support you in your practice.

Thank you for being a member of ASHP, and for everything that you do for your patients.

Sincerely,

Paul

August 18, 2015

New Mexico Clinic Pharmacists Wield Extensive Prescribing Privileges

From left, PMG Pediatric Pharmacy Specialist Kari Bishop, Pharm.D., discusses improvements in the electronic health record system related to adult and pediatric heparin infusions with Pharmacy Anticoagulation Specialist Linda R. Kelly, Pharm.D., Ph.C., CACP.

From left, PMG Pediatric Pharmacy Specialist Kari Bishop, Pharm.D., discusses improvements in the EHR system related to adult and pediatric heparin infusions with Pharmacy Anticoagulation Specialist Linda R. Kelly, Pharm.D., PhC, CACP.

IF THEY TAKE A MOMENT to look, patients who fill prescriptions after visiting one of the ambulatory care clinics in Albuquerque’s Presbyterian Medical Group (PMG) will see that the name on the medication bottle belongs to a pharmacist.

“When I write a prescription, it’s not checked or approved by a physician because I’m recognized as a healthcare provider by my state and my health system,” said Robert Rangel, Pharm.D., BCPS, PhC, director of pharmacist clinicians and anticoagulation services with PMG, noting that state laws dictate the limits of collaborative practice.

“That changes the perception among patients and colleagues about pharmacists’ abilities to care for patients, and it means that we’re recognized as advanced practitioners.”

Independent Prescribing

Collaborative practice agreements (CPAs) under which pharmacists write prescriptions are no longer isolated experiments. But most require a physician or nurse practitioner to review and sign off on every order. That’s where PMG breaks new ground: Any of the 14 clinical pharmacists practicing in ambulatory care can independently prescribe any medication used in the scope of a primary care visit as well as manage a spectrum of common chronic disease states. Right now, that list includes diabetes, elevated lipid levels and cardiovascular disease, hypertension, asthma and COPD, and even psychiatric and thyroid conditions.

Robert Rangel, Pharm.D., BCPS, Ph.C.

Robert Rangel, Pharm.D., BCPS, Ph.C.

The current CPA emerged from an earlier version at PMG’s anti-coagulation clinic, where pharmacists had wide latitude to adjust warfarin regimens and counsel patients. Improved clinical outcomes, such as a reduction in thromboembolic events, opened the door to the current, far more expansive CPA. This new practice agreement covers 15 primary care clinics, two cardiology clinics in greater Albuquerque, and one rural clinic with plans to expand to other parts of New Mexico. All of the more than 100 PMG physicians participate in the agreement.

“We’ve seen again and again that when you put a pharmacist in a clinic, even if they’re doing something small to begin with, sooner or later they’ll be asked to do more,” said Dr. Rangel.

The effectiveness of PMG’s ambulatory care practice reveals what pharmacists could do for patients if they were granted healthcare provider status under Medicare Part B, according to Joseph M. Hill, ASHP director of federal legislative affairs.

“This story is so great because it reinforces our message that pharmacist-provided care expands patient access and is cost effective,” Hill said, noting that the collaborative nature of PMG’s CPA mirrors the evolution of new care delivery models.

Charting Improvements in Fundamental Quality Measures

Three years ago, PMG restructured its budget so that the medical group, not the pharmacy department, paid the salaries of the ambulatory care pharmacists. A year later, the chain of command shifted; now, PMG ambulatory care pharmacists report to the director of the medical group rather the pharmacy director. The impact was huge, recalled Dr. Rangel.

“We’d been working and living in the medical group’s clinic but following a different management hierarchy. We didn’t feel like we were really a part of the medical group, and they felt the same way about us. We were still outsiders,” said Dr. Rangel.

The administrative shake-up solidified the unit and led to a collegial, supportive environment. “It really sealed the deal,” said Dr. Rangel.

Pharmacists at PMG clinics help patients manage a variety of chronic conditions, including diabetes.

The CPA’s success resulted from a lot more than just managerial and financial reshuffling. Once clinical pharmacists entered the scene, across-the-board improvements in fundamental quality measures followed, such as tighter A1c control for diabetic patients and improved blood pressure and lipid levels for cardiovascular patients. “We see better numbers for all three of them when pharmacist clinicians work in ambulatory care,” said Dr. Rangel.

Though their colleagues are accustomed to the presence of pharmacists in the outpatient clinics, patients are still getting used to the idea. Many express surprise when a pharmacist walks into the exam room to chat. “The majority of patients still see pharmacists as just drug dispensers,” said Dr. Rangel. “We still have a long way to go to change that perception. However, we are getting the word out, and it is making a difference.”

Expanding Scopes of Practice for Hospital Pharmacists

Linda Kelly, Pharm.D., CACP, PhC, a pharmacy anticoagulation specialist, anticipates that a CPA will emerge on the inpatient side at PMG. “I practice to the limit of my professional license in the outpatient clinics because of the CPA, but we haven’t yet defined a comparable role for clinician pharmacists on the inpatient side,” she said.

Setting comparable scopes of practice for clinical pharmacists throughout the organization will blur the lines between inpatient and outpatient care and create a more patient-centered care model, Dr. Kelly asserts. It just makes sense, she explained, that patients receive the same level of care from pharmacists wherever they practice in the organization.

“I already conduct medication management and offer prescribing recommendations for inpatients, but I can’t write orders independently,” she said. “Expanding our role to include prescribing is a logical next step.”

Dr. Rangel cautions that pharmacists tread carefully – but confidently – when seeking to expand their roles within a health system. “We were fortunate because we had already established relationships and a solid track record in the anti-coagulation clinic,” he said. “If we had walked into a clinic and said, ‘We’re here to manage your patients with chronic diseases and write prescriptions,’ we’d have hit forceful push back.”

“It was a slow process. We used our experience in the anticoagulation clinic as our introduction, and that made the transition much easier.”

Dr. Rangel suggests starting small, finding a niche, and letting the momentum build naturally.

“If I were starting from scratch, I’d ask the medical group what they need and how we can help… maybe managing diabetic or hypertensive patients,” he said. “Often members of the care team welcome that kind of offer. And as trust builds, demand for your services will almost certainly grow.”

–By Steve Frandzel

March 28, 2011

Reforms in the Middle East, Changes in Pharmacy

Diane Ginsburg, M.S., FASHP

AS I WRITE THIS, the world is witnessing amazing changes in the Middle East. Citizens from Tunisia to Egypt–and now in Libya–are rising up, demanding an end to totalitarian regimes that have long suppressed their human rights. What has struck me as I’ve watched the news reports is just how organic the changes have been, how they started with ordinary citizens, and how no one seems to have been able to fully predict the swiftness or totality of changes that are happening.

This relates to pharmacy in a very real way, I believe. We are on the cusp of huge changes in our country’s health care system. Health care reform is pushing many of us to look with new eyes at the ways in which we ensure patient safety and quality of care. This issue of InterSections offers a peek into the future of our profession in several different, and fascinating, stories.

The cover story, “Gazing Into the Crystal Ball” features conversations with top pharmacy leaders about the ways in which ASHP’s Pharmacy Practice Model Initiative might potentially change the way we work. From a better use of properly educated, well-trained technicians; to improved work flow and collaboration with other health-care providers; to the introduction and deployment of new technologies, the world of pharmacy will look much different in the coming years from what many of us know.

Another story, “ACOs in the Age of Health Care Reform,” reveals how the Patient Protection and Affordable Care Act of 2010 provides a plethora of opportunities for pharmacists to optimize their patient-care services. As health systems and physicians, groups create ACOs (Accountable Care Organizations) to reach the performance measures laid out in the Medicare Shared Savings Program, they are turning to pharmacists to fine-tune the management of chronic diseases, reduce hospital readmissions, and improve medication safety.

Sometimes in looking at where we’re going, it helps to look backward and see where we’ve been. The pace of change in pharmacy is readily apparent when you look at the innovations revealed by ASHP’s National Survey of Health-System Pharmacy Practice in the story titled “Use of Technology Growing, Pharmacists’ Roles Changing.” Each year, half of the survey focuses on two of six aspects of the medication-use system: prescribing, transcribing, dispensing, administration, monitoring, and patient education. The other half focuses on staffing or current hot topics and evolving issues. This story is a fascinating overview of just how far we’ve come in terms of pharmacists’ roles.

I hope you enjoy this issue of InterSections. It offers a real glimpse into the ways in which our profession is changing for the better!

September 28, 2010

Frontlines at Home

Illustrated by Matt Sweitzer ©2010 ASHP

SINCE 2002, more than 425,000 veterans of the U.S. wars in Afghanistan and Iraq have been treated by the Department of Veterans Affairs (VA). That is an average of 258 new patients each day. As the system struggles to cope with the demand for services, pharmacy clinicians are coming face to face with a veteran population whose needs are strikingly different than those of veterans of previous wars and conflicts. Today’s veterans are young, many of them present with co-morbidities that include a psychological component, and 12 percent of them are women—the highest percentage of females in the system to date.

If ever there was a time for pharmacists to use their training as care providers and coordinators in tending to the nation’s wounded, that time is now. Fortunately, they are prepared: Pharmacists have been playing an integral role in care at the VA—and

in the Department of Defense (DoD), treating active-duty military personnel—since long before the U.S. launched military operations in the two current wars.

“We’ve been at the forefront of clinical pharmacy practice and have had quite a sophisticated level of practice for many years, with pharmacist-managed clinics and pharmacists embedded in primary-care teams,” said Michael Valentino, R.Ph., MHSA, chief consultant, Pharmacy Benefits Management Services, VA, Washington, D.C. “Now we are moving into some areas that require additional staffing to enhance services, such as mental health. We’re also involved with specialty clinics and centers, such as the five polytrauma centers in the system.”

The day-to-day activities of a pharmacist at the VA or DoD depend on the size of the facility, whether the pharmacist is working

with inpatients or outpatients, and the pharmacist’s own specialty, he added.

In general, however, pharmacists are rising to meet challenges in several key areas: patient transition from active duty (treatment by the DoD) to veteran (treatment by the VA); mental health, particularly where there are co-morbidities; and women’s care.

Transitioning Patients

According to Valentino, whenever there are handoffs during a patient’s transition from active duty to veteran, there is potential for a glitch, mainly because the computerized systems at the DoD and the VA are not linked. Although both agencies are working on ways to rectify the disconnect, for now the transition requires pharmacists and other clinicians to do some legwork.

“The VA and DoD try to look at handoffs at the micro level, and the VA has in fact put some staff at DoD centers to help smooth transitions,” Valentino said. “Before patients are discharged [from active duty], they are advised about VA services and hooked up with providers.”

“Good patient handoff is critical,” said Lieutenant Colonel Eric M. Maroyka, Pharm.D., BCPS, pharmacy director, Fort Belvoir Community Hospital, Fort Belvoir, Va., and former U.S. Army officer in residence at ASHP. “We want to make sure that nothing gets dropped and that people don’t get lost to follow-up, with no one checking up on them for appointments and so on. We’re doing better at handing off information and plans to the VA and civilian sector.”

Mental Health and Co-Morbidities

Pharmacists who treat military personnel and veterans are seeing more patients who need behavioral health care than ever before. Part of the increase has to do with the nature of the current wars, said Maroyka.

“This is a tired military force with many of the combat troops getting deployed three or four times,” he said. “Over time, that can increase the risk of conditions like depression and post-traumatic stress disorder.”

Traumatic injuries such as loss of limbs and disfiguring burns complicate a patient’s needs, he added. “Initially, the person may seem okay with it and appear to be progressing,” said Maroyka, “but down the road, behavioral issues will trump all.”

Perhaps the greatest challenge comes from traumatic brain injuries, including concussions from blast injuries. Treatment then becomes a test of a clinical pharmacist’s skill and training.

“If there is a traumatic brain injury, then all bets are off, and you’re flying by the seat of your pants,” said Matthew A. Fuller, Pharm.D., BCPS, BCPP, FASHP, clinical pharmacy specialist in psychiatry, Louis Stokes Cleveland VA Medical Center. “You have to use what you know to treat the symptoms, especially if it is organic depression caused by head injury.”

He added that there is a dearth of published studies about patients in this particular population. “It’s frustrating,” said Fuller. “Trying to do research in that setting is next to impossible, and it is difficult to find supporting literature. We just don’t have it.”

“Co-morbidities are one of the biggest problems,” said Jennifer L. Mauldin, Pharm.D., clinical pharmacist at the James A. Haley Veterans’ Hospital in Tampa. “There are so many different specialists to refer patients to—the traumatic brain injury team, the psych team, the primary physician. I do a lot of medication reconciliation, making sure patients are on the same meds as outpatients that they were as inpatients.”

Mauldin noted the clinical challenges of co-morbidities. “For example, you might be inclined to give a patient a benzodiazepine for anxiety, but not if there’s a brain injury, because these drugs slow cognitive function,” she said. “On the other hand, a prescriber might order stimulants for a patient with a brain injury, but those can cause insomnia, which is not what someone with sleep disorders from post-traumatic stress needs.”

Patricia Oh, Pharm.D., clinical pharmacist at the Warrior Clinic of the Walter Reed Army Medical Center, Washington, D.C., said that co-morbidities present a clinical challenge to pharmacists in terms of coordinating care.

“One of the things we have to be proactive about is recognizing the signs and symptoms of co-morbidities and indicators of risk,” she said. “We’re part of a multidisciplinary team, and we need to be able to refer patients to their doctors or specialists appropriately.”

Oh noted the important role that pharmacists play in ensuring that patients and their caregivers understand how to manage patient medications.

“A lot of our work has been education,” she said, “whether it’s with the patients themselves or with their non-medical attendants,” such as family members, friends, or others.

Coordinating Care in Smaller Facilities

The James A. Haley Veterans’ Hospital has one of the five polytrauma centers in the VA system, which gives it a leg up on managing care for patients with co-morbidities. However, coordinating care can be more challenging in smaller VA facilities, such as the VA Sierra Nevada Health Care System in Reno, Nev., where Scott E. Mambourg, Pharm.D., BCPS, is clinical pharmacy coordinator and residency director.

“Here we have to coordinate that care with bigger medical centers,” Mambourg said, which results in interfacility VA referrals or fee-basis to private care, depending on patient need. “It requires a lot of communication, and important functions such as medication reconciliation and monitoring for outcomes and adverse events become that much more critical.”

Virginia Torrise, Pharm.D.

He added that it can be tough for patients in rural areas to travel to the medical center. Younger veterans in rural areas often turn to private, civilian care, which can create complications for co-managed care. In response, the VA is funding rural health solutions such as telephone care and community-based outpatient clinics.

“Some veterans come to us for the prescription benefits. They will present prescriptions written by private-care providers for expensive drugs, but prescriptions have to be written by a VA provider for us to fill them,” Mambourg said. “For the VA to take that responsibility, we would need the patient’s private records, and the patient would have to be enrolled in the care of a VA primary care or specialty provider for the prescribing and monitoring of those medications.”

Women’s Health Challenges

Every VA facility has a women’s health coordinator and women’s health clinic separate from the general clinic, and female veterans may choose which clinic to go to for care. However, the main challenge in meeting women’s needs is facilities-based.

“The VA just wasn’t set up for women’s health,” said Lt. Col. Maroyka. “VAs never really handled obstetrics and gynecology or delivered babies before. The facilities weren’t designed for it.”

Now, VA and DoD pharmacists are finding themselves having discussions with patients about genetic testing and counseling pregnant patients on the relative risks of pharmacologic treatment of depression.

“As the medication experts, we have to consider what is best for both mother and child, because the drugs can affect the fetus,” said Fuller, of the Louis Stokes VA Medical Center. “If the depression isn’t severe, we can point to cognitive behavioral therapy, without drugs, especially during the first trimester. Likewise, pregnancy pushes us away from certain anticonvulsants that can normally be used for traumatic brain injury.”

Roughly 10 percent of VA facilities have clinics geared specifically toward women’s mental health issues, he added. These programs employ specialists who focus on treating female veterans who have post-traumatic stress disorder, sexual trauma (which encompasses a broad range of issues from sexual harassment to sexual assault), and other mental health issues.

A Growing Need for Pharmacists

The wars in Afghanistan and Iraq have resulted in an increased need for clinical pharmacists and clinical pharmacy specialists who can support case managers and care coordinators, said Virginia Torrise, Pharm.D., deputy chief consultant for professional practice and clinical informatics, Department of Veterans Affairs, Washington, D.C.

“VA is embracing the principles of the patient- centered medical home, and we are recommending that there be a higher number of clinical pharmacy specialists available,” she said. “It’s a great opportunity for pharmacy managers to provide guidance for what staffing is required to adequately support the medication management needs of our veterans.”

Clinical pharmacy specialists in the VA can prescribe medications and order tests within the practice setting, an expansion of scope of practice that can benefit patients, according to Torrise.

“Our specialists are highly trained professionals working at the top of their skills,” she noted, adding that VA pharmacists often treat multiple chronic diseases in primary care. “Our physicians are recognizing the excellent care that clinical pharmacists provide and seeing how these referrals free up their time for more urgent clinical needs. Our veterans are entitled to the best care, and pharmacists are key members of the clinical teams to provide this care.”

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