For years, pharmacists working at the VA, as well as the DoD, have had broader scope of practice than those in the community. The COVID-19 pandemic expanded it even more, with VA pharmacists playing essential roles in identifying, treating and prevention SARS-C0V-2.
WASHINGTON, DC — For years, clinical pharmacy specialists (CPS) at VA have been on a path of increased responsibility and integration into patient care. The COVID-19 pandemic drastically accelerated this, changing how VA pharmacists interact with patients both inside and outside the hospital—changes that are unlikely to go away anytime soon.
Some of this increased role of CPS is due to VA being at the forefront of using pharmacists in patient care. By making them part of the patient-aligned care team (PACT), the department ensured that pharmacists had a voice in the day-to-day treatment of patients. VA’s existing investments in telehealth technology were also key, allowing pharmacists to communicate with veterans regularly, even when the veteran, and sometimes the pharmacists, were unable to come to the hospital.
Ivan Cephas, PharmD, Chief of Pharmacy at the DCVAMC
“The VA had started pushing telehealth a lot more before the pandemic. Sometime right before [the pandemic began] a special assignment was sent out asking all of our providers to test their apparatus—their capabilities for telehealth. Then, low and behold, here comes the pandemic,” explained Ivan Cephas, PharmD, Chief of Pharmacy at the DCVAMC.
Soon, VA physicians were having a large portion of their patient interactions over the phone and online, and clinical pharmacists were a part of this.
“We did see our PACT pharmacist get to increase their panels. And we had pharmacists that did a lot of [telemedicine appointments],” Cephas explained. “We also had to come up with strategies of having some pharmacists to work from home more often, just in case we had an outbreak at our service, and we’d have to rotate people. So we didn’t have a total service failure. But, yes, the pharmacists were definitely there in support of everything the hospital needed.”
According to a study published last year in the Journal of the American College of Clinical Pharmacy that looked at CPS encounters before and during the pandemic, not only did PACT CPS encounters increase 32% in 2020 and the number of unique patient encounters increase by 12%, but there was a simultaneous decrease in patient cancellations and no-shows. At the same time, several key metrics tracking medication adherence remained stable even during the height of COVID-19.1
During the pandemic, as before, diabetes and hypertension remained the two most-common conditions pharmacists helped veterans manage. Diabetes encounters went from 14,279 in 2019 to 19,588 in 2020—a 37% increase. Average reductions in A1c were .57% in 2019 and .58% in 2020.
Hypertension management visits decreased slightly, from 9,299 in 2019 to 8,669 in 2020. However, average reductions in systolic blood pressure remained unchanged and the average decrease in diastolic blood pressure improved from 1.1 mmHg in 2019 to 2mmHg in 2020.
“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,” the researchers concluded.
The decrease in cancellation was likely due to the reliance on telemedicine. With patients no longer needing to go to a facility to see the CPS, there were fewer reasons to miss the appointment. Face-to-face visits decreased from 56% in 2019 to just 5% in 2020, while the amount of telephone visits increased from 32% to 87% of all encounters. Video visits into patients’ homes increased from 3% to 7%.
“This is a significant advancement, as it potentially indicates that this primarily elderly veteran population is capable of becoming increasingly comfortable with virtual modalities of care,” the study noted. “Furthermore, even with a significant increase in the number of unique patients treated and an increase in number of patient encounters, the quality of care was not decreased. In fact, expansion was seen in disease state management, with a greater than 400% rise in encounters for tobacco cessation. … The efficiency of telemedicine undoubtedly abetted the PACT CPS to expand beyond traditional management.”
Vaccine Distribution
It’s not just the PACT team pharmacists who saw an increased role during the pandemic. The importance placed on testing and the distribution of vaccines meant a much greater weight on VA pharmacists’ shoulders in general, as well as a brighter spotlight.
“As a pharmacy service, of course the vaccine has changed our lives,” Cephas said. “We basically had to set up the whole [vaccine distribution] operation at our facility. … Pharmacists would prepare the vaccine. We also had pharmacists who would be where the vaccine was being distributed to the nurses. Then there was a lot of running back and forth to get the vaccine to the clinic. One of our clinics was in the hospital; at another, we had a satellite tent site set up outside the hospital.”
At the pandemic’s peak, pharmacists at the DCVAMC were distributing up to 1,000 vaccinations a day. When President Joe Biden visited the facility in March 2021, it was a pharmacist who showed him the operation, demonstrating vaccine preparation and administration.
There also was the role of pharmacists in the management of monoclonal antibody treatment–one of the few approved treatments for COVID-19.
“That involved a national process with very stringent rules,” Cephas explained. “So we had a team of pharmacists—our antimicrobial stewardship pharmacists were very involved with that.”
And while the pandemic continues, VA hospitals have reopened and are accepting most patient visits again. Which means pharmacists in every area of the hospital will be pressed to keep up with new responsibilities while adding in previous ones.
“Our staff has really stepped up in these trying times, not just to maintain services but to increase and enhance our services,” Cephas declared. “There have been a lot of growing pains in doing new things, but we’ve thrived.”
- Thomas AM, Baker JW, Hoffmann TJ, Lamb K. Clinical pharmacy specialists providing consistent comprehensive medication management with increased efficiency through telemedicine during the COVID19 pandemic. J Am Coll Clin Pharm. 2021 Aug;4(8):934-938. doi: 10.1002/jac5.1494. Epub 2021 Jul 11. PMID: 34518814; PMCID: PMC8426730.
