Leadership Through Service in Federal...

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Leadership Through ServiceIn Federal Pharmacy

Dr. George E. Jones, Jr., Defense Health AgencyCOL John Spain, MS, US ArmyCAPT Thinh Ha, MSC, US Navy

Col Melissa Howard, BSC, US Air ForceCDR Aaron Middlekauff, US Coast Guard

Mr. Ron Nosek, Department of Veterans AffairsRADM Pamela Schweitzer, US Public Health Service

October 31, 2016

CPE Information and Disclosures

The American Pharmacist Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

Dr. George Jones, COL John Spain, CAPT Thinh Ha, Col Melissa Howard, CDR Aaron Middlekauff, Mr. Ron Nosek and RADM Pamela Schweitzer declare no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria.

Learning Objectives

• Pharmacist Learning Objectives:• State joint federal and service/agency-specific key initiatives and their impact on local pharmacy operations and

patient care services.

• Discuss strategic goals and the impact that their implementation will have on the delivery of care at the local level.

• List examples of federal pharmacy programs that improve access and quality of care for our military, veteran, and public health service patient populations.

• Pharmacy Technician Learning Objectives:• State joint federal and service/agency-specific key initiatives and future goals and their impact on local pharmacy

operations and patient care services.•

Discuss strategic goals and the impact that their implementation will have on the delivery of care at the local level.•

List examples of programs that improve access and quality of care for our military, veteran, and public health service patient populations.

Self-Assessment Questions

The DoD Pharmacy Enterprise, enabled by the Defense Health Agency, achieved:A. Capability for MTF pharmacies to receive downtown ePrescriptions.B. MTF goal based reports / analysisC. More savings than were expected.D. All of the Above


Sustaining DoD Pharmacy Value includes ensuring readiness and improving health.

True or False


Pharmacist support to the Air Force Medical Home model includes:A. 11 Medical Treatment Facilities (MTFs).B. Criteria includes ACG Score, Beneficiary population.C. Execution-year funding for FY 15-16.D. All of the Above

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Key Components of academic detailing in the VA related to opioid overdose education and Naloxone distribution includes: A. Education and training regarding opioid overdose prevention and recognition B. Opioid overdose rescue response C. Issuing naloxone kits D. All of the above


As pertains to Health Care Delivery Reform, it is important for pharmacists to be at the table as decisions are being made.

True or False

“Integrated for Excellence”DoD Pharmacy Enterprise /

Defense Health Agency Dr. George E. Jones, Jr.

Chief, Pharmacy Operations DivisionDefense Health Agency

DoD Pharmacy Enterprise –Defense Health Agency

• Mission The DHA Pharmacy OperationsDivision has responsibility for corporate management and compliance oversight of enterprise-wide pharmacy projects enabling DoD pharmacy benefit delivery in support of the MHS.

Integrated for Excellence

• DoD Pharmacy – Caring as an Enterprise– Enabled by Defense Health Agency Pharmacy

Operations Division – Oct 2016 - its “3rd Birthday”

• Success Story! - DoD Pharmacy EnterpriseDelivered Savings/Process Improvements/Efficiencies

• The Key – Pharmacy Work Group

Army, Navy, Air Force, Coast Guard, DHACol John Spain / CAPT Thinh Ha / Col Melissa Howard /

CDR Aaron Middlekauff / Dr. George Jones

Pharmacy Work Group –Your Team

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Pharmacy Operations Scope

• 9.4M beneficiaries • ~$8 Billion Spend

(FY16 estimated)

– 708 military worldwide pharmacies

– ~59,000 retail pharmacies

– Mail order– ~80% of all eligibles used

a pharmacy in FY16

14 Pharmacy Costs – FY16Mean cost per Beneficiary per Year

Data source: M2 & PDTS Data, FY16 (extrapolated from data through 9/10/16)

*Notes: MTF costs include estimated MTF dispensing costs; retail costs are net of

refund/rebates from manufacturers, copays, dispensing fee, tax and other payer costs; but do not include other contract costs; mail order costs are net of copays and per Rx admin fees, but do

not include other contract costs

* Including estimated retail refunds & estimated MTF dispensing cost

**2015 Commercial and Medicare Part D costs from ESI Drug Trend Report

76%7.2M

24%2.2M

Eligible Beneficiaries65+

< 65

65+

< 65

53%~66M

47%~59M

Rxs

DoD$544*

<65

$1060**

65+

$1745*

MedicarePart D

$2914**

All Ages

$829*

FY16 (estimated) PMPY Cost Comparison

< 65

Cost

65+

50%~$3.9B

50%~$3.9B

Commercial

DoD

DoD

15

16

Pharmacy Savings Index (PSI) FY16 Overall Target –$230M

1Target ( $M

) $ 19 $ 38 $ 57 $ 77 $ 96 $ 115 $ 134 $ 153 $ 172 $ 192 $ 211 $ 230

Cost Savings $ 34 $ 69 $ 105 $ 140 $ 174 $ 210 $ 245 $ 281 $ 317 $ 353 $ 389 $ 417

Goo

dG

ood

$230M = $133 MERHCF and $97M DHP

Pending final data for initiatives #3

Contract Compliance: Intermittent shortages of various drugs may decrease contract compliance.

B2G: Brand to Generic Cost Avoidance calculated by DHA

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Initiative #3 - Generic & Contracting Compliance, Estimated Cost Savings

1

Goo

dG

ood

New B2G Target List from DLA; updated starting in January to reflect new targets

Source data for September is currently unavailable; Sep-16 estimate is based

on historical averages.

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• Drug Take Back Capability– 100% Available to DoD Patients

• DoD / VA Collaborative Drug List– Psychologically Active Drugs Transition

• 100% MTF capability to receive eRxs– Over 40% of civilian-written Rxs are eRxs– Increased Efficiency Convenience Safety

Managing the Pharmacy Benefit –Leading Forward

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• Reports / Analysis supporting MTF goals

• Patient Centered Medical Home (PCMH)– Promote expanded inclusion of Pharmacists as either

embedded or supporting PCMH teams– Medication therapy management/adherence– Tri-Service workflow Clinical Pharmacy AIM page

• Specialty Pharmacy Services Project– Uniform benefit access driving patient results

Managing the Pharmacy Benefit –Leading Forward

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• Essential – Sustain On-going Projects• Projects Under Development for 2017 –

Founded on the goal of optimal patient care!– Uniform Controlled Substance framework– Specialty Pharmaceuticals– Uniform Automation requirements / Integrated execution– Drug Database Standardization– Antibiotic Stewardship– Medication Therapy Management pilot– Expand Clinical focus

• Facilitate successful transition to MHS GENESIS

DoD Team Pharmacy – On to 2017!Collaborative / Integrated / Consistent Excellence

Sustaining Value: A Bright Future For

Army PharmacyCOL John Spain

Pharmacy Consultant to the Army Surgeon General U.S. Army Medical Command Pharmacy Program Manager

31 October 2016

Point of reference for reflection…

“Enthusiasm…the sustaining power of all great action”

Samuel Smiles

Inaugural Clinical Pharmacy Course, February 2016, Ft Sam Houston

Agenda

• Sustaining pharmacy value– Ensuring readiness– Improving health

• Advancing organizational high reliability aspirations• To What End?• Questions/Comments

Sustaining Value

• Clinical measures: • Impacting outcomes via predictive

modeling Diabetes index• Impacting access & adherence

• Financial measures: • Clinical care time• Coding compliance/RVU generation• Medication decision cost savings

• Readiness measures:• Percent high risk Polypharmacy engaged*

by clinical team • Percent non deployable due to medication

use engaged* by clinical team• Tobacco cessation? / Weight Loss?

Clinical

Financial

Readiness

* Engaged = screened at minimum and encounter appointment per pharmacist decision

Ensuring Readiness

• Non deployable Medication Use• Polypharmacy Review• Medical profile access• ~Tobacco Cessation?• ~Weight loss?

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Improving Health RADaR Measures Pharmacy Value...

• Access: • Goal: DSM increases provider access• Measure: DSM encounters documented in TSWF (target Diabetes)

• Quality:• Goal: MTM/DSM improves outcomes & adherence• Measure: Diabetes index, proportion of days covered (>80%/>95%)

• Safety: • Goal: Standardized interaction at dispensing improves safety• Measure: Change in Pharmacy ADR, Allergy, and D/C rates

• Satisfaction• Goal: Manage wait time expectations; transaction to service transition

Measure: JOES, > 87.5% in > 25% of MTFs• Network

• Goal: Reduce retail medication expenditures (Chronic>acute) • Measure: network expenditures by POS, < 25%

• Productivity• Goal: Clinical pharmacist/technician care time • Measure: > 65% of available time

High Reliability Aspirations Aspiration to Reality

For Those I Love, I Will Sacrifice

Laura Rauch / © Stars and Stripes

For Those Who Sacrifice, I Will Always Remember

http://www.enduringpride.org/Memorial-Day-Event-2009.html

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Comments / Questions

“I know the price of success: dedication, hard work, and an unremitting devotion to the things you want to see happen.

Frank Lloyd WrightNavy Pharmacy

Thinh V. Ha, PharmD MBA MSCAPT MSC USN

FY16 InitiativesNavy Pharmacy is leading multiple initiatives that center around providing world class care for its patients and implementing innovative, data-driven solutions that better enable pharmacy operations.

PATIENT EXPERIENCE

RxMAP

SUPPLY OPTIMIZATION

COMPREHENSIVE PAIN MANAGEMENT

Identifies Chronic Pain, long-term opioid therapy (LOT) patients and validates that the necessary funding and resource are available for clinical pharmacists to serve these patients.

Advances Navy Pharmacy towards patient demand-driven inventory practices leading to optimized inventory, visibility into customer service levels, standardizing supply chain best practices, and opportunities for cost avoidance.

Focuses on improving patient experience, maintaining patient safety, and recapturing retail leakage by increasing convenience, medication availability, and service quality through scalable, customizable metrics and recommendations.

Provides analytical solutions to increase operational efficiency and improve patient experience, such as predicting wait time, by integrating core pharmacy automation with workflow queuing systems to improve real-time decision-making and long-term strategic planning.

Patient Experience OverviewIn order to develop and implement a sustainable patient experience improvement strategy, Navy Pharmacy needed a comprehensive understanding of patient priorities, expectations, and perceived performance gaps.

Measured

Convenience

Medication Availability

Patient Safety

Service Quality

Identified gaps between patients’ expectations and perceptions of pharmacy services, enabling prioritization of high-impact areas.

DefinedUsing a combination of primary and secondary research, developed a comprehensive, measurable definition of patient experience, comprised of four key dimensions.

Developed RecommendationsIntegrated quantitative data with client- and customer-driven perspectives, via Human-Centered Design, to develop a suite of patient-centered improvement recommendations.

Customer Service Training

Patient Education Materials

Staffing Calculator

Patient Experience Scorecard

Tabl

eSt

akes

Site

-Spe

cific

NIS Process Improvement

Integration of Care

Front- and Back-End Refill Isolation

Staff Scheduling

Patient Experience Outcomes and Implementation Plan

Completed PlannedNH Camp LejeuneNHC Cherry PointNH Guantanamo BayNH JacksonvilleNH Oak HarborNH PensacolaNH Twenty-Nine Palms

NH BremertonNH BeaufortNH Camp PendletonNH LemooreNMC PortsmouthNMC San Diego

Enterprise Implementation PlanImplement Table Stake recommendations at all Naval Hospitals (NHs) and Naval Medical Centers (NMCs) in the continental U.S. (CONUS) by spring 2017

Facilitate performance management and goal-setting discussions at each implementation site

Provide BUMED leadership with an Enterprise Scorecard view on a quarterly basis

As of September 2016, Navy Pharmacy has implemented the Patient Experience Table Stakes at 7 CONUS sites, enabling sites to identify performance gaps, act on patient feedback, and improve patient experience.

Sample of Patient Experience Outcomes To-Date

Calling patients with NIS medications led to a 22% increase in patient service quality at NH Jacksonville

Increased service quality

Training more staff to work the window led to a 46% increase in patients served in 30 minutes at NHC Cherry Point

Improved medication availability

25%

22%An 11x increase in average

monthly customer satisfaction survey responses has given sites a

more robust and actionable understanding of patient needs, facilitating targeted improvement

Increased Patient Feedback

11x

Improved patient wait-times

46%

Refill process adjustments led to a 25% increase in patient-reported medication availability at NHC Cherry Point

Navy Pharmacy Management Analytics Program (RxMAP)

PERFORMANCE MANAGEMENT DASHBOARD

PATIENT INFORMATION CENTER RESTROSPECTIVE ANALYTICS REPORTING

APPROACH

Increase insight into operations and enables improved workflow management.

Provides patients information such as wait time predictions and track the status of their tickets.

Monitor site performance through KPIs and provide standardized, consolidated metrics.

Design and Gather SME Input Develop Analytical SolutionStandardize Data Capture,

Usage, and Supporting Processes

GOALS

EFFECTIVELY USEDATA

IMPROVE WORKFLOW AND WAIT TIMES

IMPROVE PATIENT EXPERIENCE

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Performance Management Dashboard Patient Information Center

Navy Pharmacy Dashboards –Pharmacy Performance Mgmt

Before After

Wait times are difficult to see and understand

There are no predictive elements to wait time

Wait times in the last half hour and expected wait times for patients entering the pharmacy are clearly visible.

Navy Pharmacy Dashboards -Patient Information Center

Before After

Tickets have a clear location and recently called tickets are highlighted.

ImpactsStandard

Data Capture

Improved Patient

Experience

Enhanced Reporting1. 3.2.

1

Design prevents intuitive understanding of pharmacy workflow and bottlenecks

1

Pharmacy Supply Optimization

1 2 3 4OPTIMIZE INVENTORY LEVELS

MONITOR MEDICATION AVAILABILITY

INFORM SUPPLY DECISIONS

STANDARDIZE DATA CAPTURE

OVERVIEW AND GOALS

INVENTORY OPTIMIZATION PLATFORM

Recommends critical inventory level updates to meet patient demand

Allows leadership to track supply performance through an actionable scorecard

Provides access to live feed reports to monitor medication shortages and help manage the DMLSS catalog

Enables data driven research by providing detailed medication information

Identifies lower risk medications to purchase during periods of mandated spend

The Inventory Optimization Platform pulls patient dispensing demand and compares that with purchasing history to recommend stocking levels that account for seasonal changes in demand.

*Images from the Inventory Optimization Platform

Inventory Optimization Platform –Demand Discrepancy Report

WHAT IS IT? The report provides insight into the largest volume and cost inconsistencies between purchasing and dispensing demand, where purchases exceed dispenses as a result of uncaptured demand.

WHERE IS IT FOUND? The report can be found within the Inventory Optimization Platform.

VALUE ADD? The report provides insight into hidden demand sources, helps identify drugs that may be at risk for potential diversion, and facilitates fiscally-sound decision making with year-end purchases.

*Images from the Inventory Optimization Platform

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Pharmacy Supply Optimization Impact

`PATIENT DEMAND ALIGNMENT COST AVOIDANCE

OPPORTUNITIES ($M)MEDICATION AVAILABILITY

97.0%97.5%98.0%98.5%99.0%99.5%

100.0%

Jan-

16

Feb-

16

Mar

-16

Apr-1

6

May

-16

Jun-

16

Target 98%

Below are a sample of metrics that have been realized from the implementation of the Supply Optimization solution.

Navy Pharmacy sites implemented to date10Navy Pharmacy sites

will get the Inventory Optimization Platform70

Aligning stocking levels to meet patient need.

Identifying areas of excess spend not associated with patient need.

Tracking and monitoring stockoutsfor outpatient dispensing.

$2.72

$3.30

$4.97

Optimal Outpatient Spend

Potential Cost Avoidance

Inpatient & Additional Demand

Polypharmacy Pharmacist Initiative

1. Provide a multi-disciplinary effort to improve the coordination, consistency, and access to the Navy’s pain management resources

2. Support a Stepped Care Model for beneficiaries suffering from complex acute, high-risk acute, and chronic pain with an emphasis on restoration of function for active duty service members

Collaboration: Inter-Service & Intra-Service

• DHA – Polypharmacy Report & PDMP dialog

• Army Pharmacy – PCMH ECHO training

• Navy and Marines Corp Public Health Center – “CHUP-plus” Report

• Navy Comprehensive Pain Management Program – Long Term Opioid (LOT)

Collaboration: Multi-disciplinary

• Acupuncturist• Clinical Pharmacist• Clinical Psychologist• LPNs• Medical Assistants• Pain Management MDs• Physical Therapists• Psychiatrist• Psychiatrist w/ Addiction

Specialty• RN• RN Care Coordinator

23 pharmacists approved (17 currently on-board)

The Navy Pharmacy community conducts monthly teleECHOclinics that include education

regarding best practices and new developments relating to chronic

pain patients and case presentation in which

management recommendations are obtained from the group.

OVERVIEW AND GOALS

Key Points

• Navy Pharmacy is implementing innovative, data-driven tools to improve patient experience and better support operational decisions

• Analytical solutions like RxMAP and the Inventory Optimization Platform are providing pharmacy staff actionable insight into data never before utilized or in places where data gaps exist

Air Force PharmacyColonel Melissa R. Howard

Pharmacy Consultant to AF/SG

Overview

• Air Force Pharmacy Technology• Pharmacist Direct Support to

Air Force Medical Home

Technology: Automation Refresh

• Phase I: 17 MTFs• Phase II: 31 add’l sites • ECAT: 25 smaller sites • 4 large refill centers• Synchronize automation

contracting

SrA Smith works with new equipment at D-M

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Capt Murphy and SrA Jaime dealing with the aftermath of installation at Davis-Monthan

Technology: MHS Genesis

• IOC sites: Oak Harbor (Navy), Fairchild (AF), Bremerton (Navy), Madigan (Army)

• Issues: – Clinical Decision Support– Pharmacy Data Standardization– Formulary Management– Inventory Management– Controlled Substance Tracking

Technology: e-Prescribing & Patient Queuing

• e-Prescribing– Fully deployed DoD-wide– e-Rx scripts now 30-40% of new civilian Rx – Macro to automate e-Rx processing

• Queuing Systems– Metrics: E.g., wait-time definition– Integration with current / future automation

Pharmacist Direct Support to Air Force Medical Home (AFMH)

• 11 MTFs: Wright-Patterson, MacDill, Fairchild, Patrick, Eglin, Randolph, Scott, Luke, Lackland, Keesler, USAF Academy

• Criteria: ACG score, beneficiary population • Execution-year funding for FY15-16• In the future-year program for FY17 and

beyond

Encounters

0

200

400

600

800

1,000

1,200

SEP OCT NOV DEC JAN FEB MAR APR MAY2015 2016

Enco

unte

rs

Group Class

Polypharmacy Review

Medication TherapyManagementDisease State Management

AFMH Metrics

• Metrics (Best Value / Better Care):– Maximize utilization/productivity – Maximize value– Optimize medication use – Prevent medication-related errors – Improve outcomes – Improve AFMH performance– Enhance patient experience– Improve AFMH staff satisfaction

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Interventions & Cost AvoidanceEstimated ROI = 2.5 : 1

Expansion of Support to AFMH

• 15 additional sites beginning in FY18:

– ACG >1.17 and enrolled population over 6,500 and/or IM

– Execution-year funding for FY17– In the program for FY18 and beyond

Andrews Elmendorf HollomanLangley MacDill-Brandon MaxwellMcConnell Mt. Home NellisOffutt Sheppard TinkerTravis Tyndall Vandenberg

Summary

• Air Force Pharmacy Technology• Pharmacist Direct Support to

Air Force Medical HomeUS Coast Guard

PharmacyCDR Aaron P. Middlekauff, USPHS,

U.S. Coast Guard Pharmacy Program Coordinator/Consultant

Learning Objectives

• Challenges/Opportunities

• Fellow Federal Partnerships

• Make a difference

JFPS Family

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Challenges and Opportunities

• Electronic Health Record

• Privileging

• Vaccine management and oversight

Fellow Federal Partnerships

• Public Health Service

• DoD

• SNS Resources

Make a Difference

• Leave your legacy

• All thrust…no vector?

• Come Monday

Key Points

• Challenges/Opportunities

• Fellow Federal Partnerships

• Make a difference

Before I go…Happy Halloween!!! Closing Thought

“The pessimist sees the difficulty in every opportunity; the optimistic sees the opportunity in every difficulty.”

-Sir Winston Churchill

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Leadership Through Service in Federal Pharmacy

Ronald A. Nosek, Jr. R.Ph., MS, FASHP Department of Veterans Affairs

Overview and Key Initiatives in VA

• VHA and PBM• CMOP Overview• Virtual Pharmacy Services• Clinical Pharmacy Programs

– Hepatics C Treatment– VA Pharmacy Residencies

• Opioid Education and Naloxone Distribution

Veterans Health Administration

• Over 1,600 sites of care including: – 168 Medical Centers– Over 1,000 Outpatient Points of Service (e.g., Community-Based Outpatient Clinics (CBOCs)– 300 Vet Centers (Readjustment Counseling), 70 Mobile Vet Centers – Outreach and mobile medical clinics serve the most remote rural Veterans—all tethered to one of

our 168 medical centers

• Provides health care services to 8.9 million Veterans each year– 92.4 M OP appointments annually– 16,801 Average Operating Beds– 707.4 K Admissions– 312 K surgeries annually

• Pharmacy Services– Approximately 8,500 Pharmacists; 600 Residents/Fellows; 4,500 Technicians– 223 outpatient pharmacies; 7 mail order pharmacies– 146 M Rx’s (271 M 30-day Eqv) annually (80% filled by mail)– $3.7 billion in drug cost

Pharmacy Benefits Management

• VA operates a world-class pharmacy benefits management program with demonstrated excellence in several key areas including:

– Clinical pharmacy practice (profession benchmark)– Top Pharmacy Residency Training Programs – Pharmacy automation (innovator)– Medication safety (national and international reputation)– Formulary management (sustained superior performance in access,

cost and quality over the past decade)

CMOP Overview

• Workload– 120 million Rx’s (80% of all OP Rx’s filled in VA)– 325,000 packages mailed/day– $3.18 billion ($12.7 million/day)

• Low Volume Products– Goal to increase # of line items carried by CMOP (>1,700 added)– Products >10 Rx’s/month across VA

• Specialty Pharmacy (GL-CMOP)– Centralized approach through CMOP; reduce burden on VAMCs– Focus on products with wholesale restrictions– Dispensing ~50 line items and 45,800 Rx’s

CMOP Overview

• Non VA Partnerships– Continue to maintain our partnership with Indian Health processing prescriptions for

more than half of all IHS sites. – Annual workload: 480,000 Rx’s/year

• Veterans Tracking the delivery of their medication using MyHealtheVet– An average of 5,700 Veterans track the delivery of their medication every work day– 363,400 Veterans have signed up for email notification that their medication package

has been mailed– 4.6 million emails have been sent to Veterans

• JD Power Pharmacy Survey– VA received an “Among the Best” ranking, one of only two organizations.– This is the 8th consecutive year for this recognition– For six of the last eight years, VA received the highest customer satisfaction score for

all mail order pharmacy organizations surveyed.– Score improved by 29 points in 2016 to 905. Highest score was 906

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PBM Virtual Pharmacy Service (VPS)

• The Issue… “VAMC OP Pharmacies report significant backlog of pending prescriptions waiting pharmacist verification:

– Delay in fulfillment of prescriptions – Possible disruption in medication therapy – Increase phone call volume to pharmacy – Decreased satisfaction among pharmacy staff and patients – Resources diverted away from direct patient care and clinical functions– Potential increase in medication errors – Significant use in overtime pay, comp time, contracts

• VPS Process:– Sites (e.g., Washington DC VAMC) enter into an agreement with PBM VPS program– Guidelines for each site are developed prior to implementation– PBM Pharmacists access the local VAMC pharmacy system and verifies the

prescription virtually– No additional software/hardware needed

PBM Virtual Pharmacy Service

• Results– Partnerships with 19 VAMCs (e.g., DC, Portland, Baltimore Phoenix, Minneapolis)– Turn around time at participating institutions decreased to an average of 1.52 days– Significantly decreased or eliminated use of OT, comp time, and contracts at sites– Partner sites are able to allocate resources to clinical/direct patient care functions– FY 2014: 1.78 Million Rx’s– FY 2015: 2.07 Million Rx’s – FY 2016 3 Million Rx’s

• Recognized by VHA as one the top 15 initiatives (Best Practice Category) to improve Veteran Health Care

Clinical Pharmacy Practice in VA

• Clinical Pharmacists are Essential Providers of Comprehensive Medication Management Services

– Over 3,180 (41%) Clinical Pharmacists with a Scope of Practice (SOP)– 76% are Residency Trained and/or Board Certified– Nearly 50% of pharmacists serve as clinical providers

• Credentialing of Clinical Pharmacists similar to all other LIPs in VA• Significant growth of Clinical Pharmacy Services:

– Hepatitis C Care: Up 79%– Mental Health: Up 179%– ID/AS Up 90%

• Medication Prescribing Across VA, Pharmacists Prescribe:– 69% of all Anticoagulants– 30% of all Hepatitis C medications– 28% of all Anemia medications

Hepatitis C Treatment in VA

• VA has had a comprehensive National Viral Hepatitis Program since 2001 and is a leader in the U.S. in HCV screening, care and treatment.

• Initial estimates were ~140,000 Veterans in VA care with chronic Hepatitis C infection making it the largest single HCV provider in the U.S.

• VA has screened 73% of Veterans born within the 1945-1965 cohort, a group which the CDC and USPSTF recommend one-time screening. (This is substantially higher than the 50% screening rate nationally in this cohort)

• VA has treated over 67,000 Veterans with the new interferon free direct acting antivirals since January 2014.

• Averaging 850 new starts per week currently.• 72,000 Veterans awaiting treatment (as of October 1st)• Overall Sustained Virologic Response (VSR) rate (i.e., cure rate) is 93%• Hep C drug treatment was over $1.16 billion in FY2016

Hepatitis C Treatment in VA Expanding Clinical Pharmacy Services in VA

• VHA has made significant efforts to expand clinical pharmacy services to meet access demands (i.e., Mental Health, Pain, HCV screening and treatment , PACT) however many facilities struggle for resources.

• Clinical Pharmacy Practice Office Joint Initiatives with VA Public Health Program Office and Office or Rural Health

– Improve access by utilizing Clinical Pharmacy Specialists (CPS)– Target sites with access challenges– 243 proposals were submitted between the two programs– 104 facilities were selected to receive funding for 181.5 new FTEEs

• HCV: 44 CPS/22.5 technician FTEE• Pain: 22.5 CPS FTEE• MH: 23.5 CPS FTEE• PACT: 69 CPS FTEE

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VA Residency Program Overview

• Total number of programs: 236PGY1 – 141 programsPGY2 – 95 programs

• Total Allocations 608– 600 Residency Positions– 8 Fellowships

• Medication Safety ACCP Accreditation Pending• Infectious Disease ACCP Accredited• Pain/Palliative Care OAA Fellowship• Cardiology

Growth of VA Pharmacy Residencies

318

359 347368 375 376

435 434 426 424

39 46 5266

89 98

142157

171 176

357

405 399

434464 474

577591 597 600

0

100

200

300

400

500

600

700

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

PGY1

PGY2

Total

Filled Pharmacy Trainee

VHA Priorities and Meeting Gaps in Access to Care

Goal to Train More Pharmacists in Key Areas of:• Mental Health

– Psych Trained Pharmacist– Ambulatory Care Trained Pharmacist

• Ambulatory Care (PACT)– Trained to managed a variety of VHA priorities which include MH,

Pain, etc.• Pain/Palliative Care

– Key area for management of opioids, chronic pain• Hepatitis C

– Pharmacists prescribe 30% of all Hepatitis C drugs and growing

Academic Detailing: Opioid Overdose Education and Naloxone Distribution

• In-person educational outreach– Information is provided interactively so the academic detailer can:

• Understand where the provider is coming from in terms of knowledge, attitudes, and behavior personal motivations for practice

• Modify the interaction to meet the needs of the provider• Engage the provider by acknowledging their expertise and learning

together rather than teaching • Uses balanced evidence-based information and tools• Delivered by a healthcare professional specially skilled in empathic persuasive

communication• Over time, the educator and provider develop a trusted and useful relationship

• As of March 2015, VHA mandated implementation of Academic Detailing in every Veteran Integrated Service Network to be provided by Clinical Pharmacy Specialists


• A harm reduction and risk mitigation initiative that aims to decrease opioid-related overdose deaths

• Key Components – Education and training regarding opioid overdose prevention and

recognition – Opioid overdose rescue response – Issuing naloxone kits


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• Pharmacists making an impact (9/6/2016):– 44,949 naloxone kits prescribed– 41,769 naloxone kits filled– 16.3% (7,340) were prescribed by Clinical Pharmacy Specialists


14

5

MA: 48

1

91

CT: 11

RI: 1

6

404

12

10

1

2

1

DE: 2

2

4

9

MD: 2

NJ: 2

1 2

Reported Reversals by State Pilot Collection (Dec 2014 to Feb 2016)

Total: 172 reversals reported

U.S. Public Health Service

One Step at a TimeRADM Pamela Schweitzer, USPHS

Chief Professional Officer For Pharmacy

@USPHSPharmacy #USPHSPharmacy

PHS Pharmacists by Agency(1,292 Commissioned Corps September 2016)

IHS 557 CMS 38FDA 410 CDC 21BOP 158 NIH 11SAMHSA 5 HRSA 14AHRQ 1 OS 14Coast Guard 16 DOD TMA 10ICE 20

Indian Health Service (IHS)Chief Principal Pharmacy ConsultantCAPT Kevin Brooks

• IHS Great Plains Area Mission

• Opioids– Responsible

prescribing– Naloxone– Medication Assisted

Treatment (MAT)• Moving to more

comprehensive/integrated clinics; Improving Patient Care (IPC)

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Indian Health ServicePGY1 Pharmacy Residency

Bureau of Prisons (BOP)Chief PharmacistCAPT Martin Johnston

BOP Pharmacy Update

• Collaborative Practice Agreements (CPA’s)– 160 CPA’s, 94 pharmacists, 48 sites– Board Certified Pharmacists – 34

• Ambulatory Care, Nuclear, Nutrition, Psych, Pharmacotherapy

– National Clinical Pharmacist Specialist (NCPS)-37

• Anticoagulation, Diabetes, HIV, Hepatitis C, Dyslipidemia, Hypertension, Pain Management, Pain Palliative

• CAPT Jeff Haug, IHSC Chief Pharmacist• The IHSC provides direct patient care to ICE

13,500 detainees at 21 facilities– Services include: medical, dental, pharmacy, mental

health care, and public health services.

• Pharmacy focus this past year:– Collaborative practice agreements (initiated in 2016)– Anticoagulation, HIV, diabetes, Gender Dysphoria – Pharmacists assisting in testing and implementation of

new eMAR.

U.S. Immigration and Customs Enforcement (ICE) Health Service Corps (IHSC)

U.S. Surgeon General: Call to end the Opioid Crisis

“We, as clinicians, are uniquely positioned to TURN THE TIDE on the opioid epidemic.”

U.S. Surgeon General Vivek Murthy

#TurnTheTide - Take the Pledge

10/30/2016

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Launch of Tobacco Cessation Training Web Site

• Rx for Change Program

• Free CE for clinicians• Ask-Advise-Refer

program for busy clinicians or non-clinicians

• Skills demonstration• Train-the-Trainer

program• Certificate

Social Media – Twitter@USPHSPharmacy

New care delivery models – new measures

• As new care delivery models evolve to focus on value, accountability, and team-based care, new measure development opportunities exist to address care gaps and to support team-based care delivery systems and care transitions.

http://www.ajmc.com/journals/ajpb/2015/ajpb_januaryfebruary2015/medication-management-measuring-what-matters/P-2#sthash.gvjkknwq.dpuf

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Patient Segmentation Analysis

• Crucial to understand differences across patients and their needs.

• Uses big data to help divide the population into distinct groups, which can then be targeted with care models and intervention programs tailored to their needs.Whole populations Sub populations High-risk populations

Mt Kilimanjaro – 19,341 ft Sunrise from the top of Mt Kilimanjaro

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10/30/2016

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Key Points

• Turn the Tide – Sign the Pledge• Momentum – expanding pharmacist clinicians• Health care delivery reform - Important for pharmacists to be

at the table as decisions are being made

“Take the first step in faith. You don't have to see the whole staircase, just take the first step.”

Dr. Martin Luther King Jr.

Answers To Self-Assessment Questions

The DoD Pharmacy Enterprise, enabled by the Defense Health Agency, achieved:A. Capability for MTF pharmacies to receive downtown ePrescriptions.B. MTF goal based reports / analysisC. more savings than were expected.D. All of the Above


Sustaining DoD Pharmacy Value includes ensuring readiness and improving health.True


Pharmacist support to the Air Force Medical Home model includes:A. 11 Medical Treatment Facilities (MTFs).B. Criteria includes: ACG Score, Beneficiary population.C. Execution-year funding for FY 15-16.D. All of the Above


Key Components of academic detailing in the VA related to opioid overdose education and Naloxone distribution includes: A. Education and training regarding opioid overdose prevention and recognition B. Opioid overdose rescue response C. Issuing naloxone kits D. All of the above


As pertains to Health Care Delivery Reform, it is important for pharmacists to be at the table as decisions are being made.True

10/30/2016

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Closing RemarksDr. George E. Jones, Jr.

[email protected]

COL John [email protected]

Col Melissa [email protected]

Closing RemarksCAPT Thinh Ha

[email protected]

CDR Aaron [email protected]

Mr. Ron [email protected]

RADM Pamela [email protected]

Leadership Through Service in Federal...

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