key: cord-0927527-5jtz28e4
authors: Thomas, Ashley M.; Baker, Jennifer W.; Hoffmann, Terry J.; Lamb, Kristen
title: Clinical pharmacy specialists providing consistent comprehensive medication management with increased efficiency through telemedicine during the COVID19 pandemic
date: 2021-07-11
journal: J Am Coll Clin Pharm
DOI: 10.1002/jac5.1494
sha: ede4d88e4e1754aac3558ce6b6ddbd0ebbd961e8
doc_id: 927527
cord_uid: 5jtz28e4

INTRODUCTION: The Veterans Affairs (VA) has been at the forefront of harnessing the skills of clinical pharmacy specialists (CPS) in patient‐aligned care teams (PACT) to improve patient care outcomes and create access for veterans. With the unfortunate arrival of Coronavirus disease 2019 (COVID19), PACT CPS were duty‐bound to expand telehealth services at an accelerated rate. The purpose of this quality improvement analysis is to compare CPS efficiency as well as some objective patient metrics to assess for a change in the quality of care. This is the first study to compare the efficiency and quality of care by CPS in the VA pre‐COVID19 and during the COVID19 pandemic. METHODS: This is a retrospective review of PACT CPS comprehensive medication management from 3/10/19 to 11/30/19 and 3/10/20 to 11/30/20. Data points focused on clinic encounters, patient accountability to appointments, disease state expansion, and markers of disease‐state management. Given diabetes and hypertension are the main disease states managed by most PACT CPS', the study evaluated changes in hemoglobin A1c (HbA1c) and blood pressure (BP) between the two cohorts as well. Data were analyzed using GraphPad Software or Microsoft Excel. A student T‐test was used for continuous data and Chi‐squared or Fishers Exact for nominal data. RESULTS: The total number of PACT CPS encounters increased 32% in 2020, and the number of unique patients increased by 12%. There were a statistically significant increase in telephone and direct‐to‐consumer (DCT) video visits. The rates of no shows and cancellations significantly decreased between 2019 and 2020. There was no difference in the average change in HbA1c or average blood pressure between the two study groups. CONCLUSIONS: When PACT CPS services transitioned from primarily face‐to‐face visits to all virtual care, the consistency of care improved, and the quality of care was not compromised.

The Veterans Affairs (VA) has been at the forefront of harnessing the skills of clinical pharmacy services to improve patient care outcomes and create access for veterans. Since the integration of clinical pharmacy specialists (CPS) into the patient-centered medical home model (PCMH) known within the VA as patient-aligned care team (PACT), literature has continued to show the impact CPS have in primary care when involved in comprehensive medication management (CMM). [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] The integration of PACT CPS into primary care in the VA has served to enhance the PCMH. 11, 12 While CPS services expanded and showed benefit in patient care metrics, it became evident there remained a veteran population that was underserved. Clinical pharmacy services were often unavailable in smaller, rural clinics. In recognition of this, CPS services through telemedicine in the VA emerged through adopting both direct-toconsumer (DTC) and facilitated telemedicine modalities to assist in reaching underserved populations. While telephonic care in between face-to-face appointments was already a key component for standard CMM, video telemedicine was an innovative method of delivering healthcare services. The VA is a pioneer in telehealth advancement to reach and improve access for rural veterans. 13, 14 The 2018 "Maintaining Internal Systems and Strengthening Integrated Outside Networks" (MISSION) Act was signed in law prior to the COVID19 pandemic and had a goal of all VA providers in mental health and primary care service lines capable and experienced with providing video visits. 14 To address the impending doubt that the quality of care could be maintained through telemedicine modalities with no in-person visits, two observational analyses were conducted at a Tennessee VA medical center. Results illustrated that DTC and facilitated telemedicine visits were just as effective at achieving patient healthcare goals as in-person visits. 15, 16 Evidence continued to surface as outlined by Niznik and colleagues in a meta-analysis of practices with pharmacists providing telemedicine services. Out of the 34 initiatives reviewed, 26 showed a net positive impact and seven showed an overall neutral impact. 17 As telemedicine utilization diffused across healthcare systems, many benefits were widely recognized. One patient satisfaction survey indicated that the majority of patients treated through DTC telemedicine were more or just as satisfied compared to traditional inperson visits. Themes included convenience, quicker appointment times, and an overall positive experience. Only 1.5% of survey participants were less satisfied with telemedicine citing difficulties with technology or personal preference. 18 While the patient population of this survey differs from that of the typical veteran population, the benefits remain applicable. Despite the progressively changing perception and initiatives to catalyze utilization, DTC telemedicine accounted for less than 30% of overall PACT CPS encounters at the Tennessee Valley VA in 2019.

With the unfortunate arrival of the Coronavirus disease 2019 (COVID19) pandemic, PACT CPS were duty-bound to expand telehealth services at an accelerated rate. During the initial surge of the pandemic, many PACT CPS provided full time telemedicine in the remote setting of home. Because of the infrastructure in place after enactment of the MISSION act, VA providers were able to quickly adapt to telehealth modalities of care to ensure continuity for every veteran. 19 The purpose of this quality improvement analysis is to compare PACT CPS efficiency via patient encounter data as well as to review some objective patient metrics to evaluate if quality in regards to outcomes were compromised during the COVID19 pandemic. This is the first study to our knowledge to compare the efficiency and quality of care by clinical pharmacists in PACT in the VA pre-COVID19 and during the COVID19 pandemic. Table 1 for demographic characteristics. increased from 3% to 7% of overall CPS encounters (P = .0001) (see Figure 1) . The rates of no shows and cancellations significantly decreased between 2019 and 2020 (see Table 2 ).

Diabetes was still the primary diagnosis encountered by the CPS show that these specific outcomes were not affected negatively. Data collected was all comers as opposed to newly initiated with CPS services and the final average A1c was less than 8% both years with final blood pressure <140/90. 20 This study showed that through optimal utilization of telemedicine, more veterans were able to be reached without compromising outcomes including A1c and BP during a national pandemic. Although a devastating time in healthcare, this is a positive discovery regarding the potential future direction of CPS provided direct patient care in telemedicine while preserving exceptional quality of care.

When pharmacist-led outpatient CMM clinics transitioned from primarily face-to-face patient care to all virtual care, the consistency and quality of care was not compromised, and actually improved in regard to number of patients seen and number of encounters documented, with a decrease in no show rates. Clinical outcomes of A1c and BP were unchanged between the two time periods.

VHA PCMH Model Concept Paper, unpublished data

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A pharmacist visit improves diabetes standards in a patient-centered medical home

Adding pharmacists to primary care teams reduces predicted long-term risk of cardiovascular events in Type 2 diabetic patients without established cardiovascular disease: Results from a randomized trial

Impact of clinical pharmacist intervention on diabetes-related outcomes in a military treatment facility

A pharmacist care program: Positive impact on cardiac risk in patients with type 2 diabetes

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Pharmacists' impact on improving outcomes in patients with type 2 diabetes mellitus

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Impact of pharmacy services on initial clinical outcomes and medication adherence among veterans with uncontrolled diabetes

Optimizing the primary care clinical pharmacy specialist: Increasing patient access and quality of care within the Veterans Health Administration

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The growth of telehealth services in the Veterans Health Administration between 1994 and 2014: A study in the diffusion of innovation

VA exceeds 1 million video telehealth visits in FY2018: One-year achievement represents a 19%

Evaluation of the impact of a pharmacist-led telehealth clinic on diabetes-related goals of therapy in a Veteran population

Utilizing clinical video telehealth to improve access and optimize pharmacists' role in diabetes management

Impact of clinical pharmacist services delivered via telemedicine in the outpatient or ambulatory care setting: A systematic review

Administering a Telemedicine Program

Flattening the curve by getting ahead of it: How the VA healthcare system is leveraging telehealth to provide continued access to care for rural veterans

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Standards of practice for clinical pharmacists

Implementation and evaluation of comprehensive medication management in telehealth practices

Use of home telehealth monitoring with active medication therapy management by clinical pharmacists in veterans with poorly controlled type 2 diabetes mellitus

Impact of the clinical pharmacy specialist in telehealth primary care

Evaluation of the clinical and safety outcomes of face-to-face vs a telephonic model of a pharmacist-led outpatient anticoagulation service

The authors declare no conflicts of interest.

https://orcid.org/0000-0002-4358-2827