VIP Treatment for Vets

By Jane E. Rooney

As someone who treats patients in a pulmonary clinic, Dr. Edward Portillo, assistant professor, University of WisconsinMadison School of Pharmacy, Pharmacy Practice and Translational Research Division, has seen firsthand the damaging effects of Chronic Obstructive Pulmonary Disease (COPD). He has had patients whose breathing is so labored that they cannot go up a flight of stairs in their own home. For others, the condition interferes with social connections and their ability to work. While the statistics are sobering for the general population—COPD is the sixth-leading cause of death in the United States—the disease takes an even greater toll on the veteran population. Veterans are three times more likely to experience COPD, and it is the second leading cause of hospitalization for VA healthcare users. For his residency project in 2016, Portillo wanted to develop a primary care service to deliver high-quality COPD management to veterans. The result was COPD CARE (Coordinated Access to Reduce Exacerbations), which began at one VA clinic in Madison and has since expanded to more than 30 medical centers and 100 clinics across the country.

“My goal has been to develop a team-based program that positions pharmacists to benefit our veterans,” Portillo explained. “There are treatments and best practices that we know will improve the lives of those with COPD. The difficulty is delivering these best practices routinely to patients. Every healthcare setting is different. Providing optimal care for a high number of patients is difficult. Half of patients with COPD do not receive recommended treatment, and 85 percent of patients with inhalers do not use them as prescribed. There have been examples of programs that integrate COPD best practices at one clinic or medical center, but to scale these programs becomes incredibly difficult. As you scale you often lose the ability to deliver the program with high fidelity, so the effectiveness drops.”

After COPD CARE was selected as a National Gold Status Practice by the Veterans Health Administration in 2018, which provided support to train hundreds of clinicians, the service expanded to more than 20 facilities and 500 practitioners nationwide. In 2021, the program received a Best Practice Award from the American Society of Health-System Pharmacists thanks to impressive results such as reducing hospital/emergency department readmissions from 18 percent to 8 percent.

COPD CARE received yet another boost last year with a five-year, $16.7 million grant from the U.S. Department of Veterans Affairs Office of Rural Health, which will fund new positions within the program and support an additional 22 full-time pharmacists in advanced primary care settings across the country. “COPD CARE has taken the VA’s team-based model and positioned our pharmacists to use their expertise managing chronic diseases,” Portillo noted. “We’ve leveraged our skillset to support our veterans. We as pharmacists are well positioned to not only serve on these teams but be the ones managing the medications and prescribing the right treatments.”

An Action Plan to Empower Veterans

COPD CARE began with Portillo brainstorming ways to optimize team-based care delivery. Patients in the program visit VA clinics and have a primary care provider as well as a clinical pharmacist, termed a Clinical Pharmacist Practitioner (CPP), to prescribe medications, optimize therapy, place critical referrals and prescribe tobacco cessation treatment. Other team members often include nurses and respiratory therapists who are essential to the program’s success. “It’s a collaborative service,” Portillo emphasized. “The pharmacist is practicing at the top of his or her license. COPD is a progressive disease so if we can administer treatment early, we can slow the progression of this disease and help patients feel better. The pharmacist, nurse, primary care provider and members of the team deliver all of these best practices.”

After patients have been admitted to a hospital or ER following a flare, a nurse from the program calls them 48 hours after discharge to evaluate symptoms, and then the patient is seen at a COPD wellness visit. “We want to empower our veterans to know what to do when they are having symptoms,” he continued. “We developed a COPD action plan. It gives a lot of the power to the patient so they have a plan. We do a follow-up a month later to make sure interventions have been carried out. That leads to an annual visit with a primary care provider. Then there are clear next steps in place so we are optimizing every member of the team.”

In addition to improved access to care and reduced readmission rates, the service identifies more patients for referral services such as pulmonary rehabilitation, tobacco treatment services and telehealth. A significant portion of veterans (92 percent) complete follow-up with a clinician within 30 days after a hospital visit compared to standard of care (49 percent). The service also leads to much greater delivery of COPD best practices, including inhaler technique and adherence review, tobacco use screening and management of COPD comorbidities such as hypertension and diabetes.

CPPs are key to the VA’s team-based model because “they are so incredibly highly trained as healthcare leaders and clinicians,” he said. “We know these medications, we know how to treat patients and we are so good at tailoring treatment regimens to the needs of our patients. Within the VA, CPPs are accustomed to serving on clinical teams and collaborating with team members.”

Portillo initially applied for support through the VA Diffusion of Excellence Office in 2018 with an eye toward broadening the service to communities throughout the United States. His proposal was one of 11 selected from 622 submissions. He worked on creating the COPD CARE Academy, a five-week training program to teach other VA medical centers how to implement COPD CARE and scale it to meet their specific needs. Through his collaboration with the VA Clinical Pharmacy Practice Office, funds were allocated to hire pharmacy student interns, and he noted that those student pharmacists were instrumental in engaging with VA leaders to engineer and build out the Academy.

Dr. Molly Lehmann, a clinical pharmacist practitioner and Primary Care/Patient Aligned Care Team (PACT) clinical pharmacy supervisor at the William S. Middleton Memorial Veterans Hospital in Madison, got involved with COPD CARE during her first-year residency project as the team was considering how to expand the service beyond the original clinic in Madison. She worked closely with the students as they analyzed data and revamped educational materials to help CPPs learn the program’s infrastructure.

“Students developed videos to help with education and resources, patient cases, quick guides and other materials. They were huge in the education piece and helped lead and organize meetings as we spread nationwide,” Lehmann said. “What an incredible opportunity for a student to be able to be involved in a project directly supporting veterans on such a large scale, learning from our clinicians and seeing them practice at the top of their license. It was amazing for students to gain that exposure and have the leadership support to elevate them to the next level and support as many patients as possible. [They saw] the steps that are needed to create a new service, how to get key stakeholders involved and how to finetune that service over time. This experience is applicable to any setting as long as you’re looking at quality improvement to take care of patients and manage chronic disease states.”

She pointed out that data show that many patients do not take medications as prescribed or need reinforcement about how to optimize use, and that’s where pharmacists come in: adjusting and monitoring therapy based on guidelines. “We serve as another resource for that patient to reach out to us with questions. There are a lot of other comorbidities that factor into this disease, things that increase the complexity of the clinical picture, so pharmacists are providing that additional support and meeting patients’ changing needs over time.”

Positive feedback from students indicated that they appreciated the hands-on learning opportunity and the chance to polish their skills. Lehmann praised Portillo for providing a unique opportunity that allowed students to take on responsibilities that played to their strengths. “One student really loved writing and was interested in manuscript development and the research component, and we had another student who really got into making the videos and being creative,” she noted. “Ed has been able to see those strengths and empower them to make that area of COPD CARE their own and make the program shine.”

Providing Essential Medication Management

Efforts to expand COPD CARE began with a few clinics in Illinois and Wisconsin, as well as the healthcare system in Fayetteville, Arkansas. Timothy Hagen, VHSO Systems Redesign and Improvement Coordinator, Veterans Health Care System of the Ozarks, worked with his facility’s medical center director to scale Madison’s program to fit their size and needs. “Thinking about how to implement the process from a large into a small facility was a learning curve. Our resources weren’t the same so we had to look outside the box,” Hagen said. “First I went through all the departments and collaborated with the chief stakeholders: primary care, pharmacy, respiratory—and we added telehealth. That was new to the process. I reached out to them because our telehealth folks communicate with all of our outgoing patients. That allowed us to identify the COPD patients. Having the ability to catch them as they were being discharged, we were able to develop a tool that would enable our telehealth folks to focus on that diagnosis.”

Dr. Michelle Balli, associate professor, pharmacy practice, University of Arkansas for Medical Sciences College of Pharmacy Northwest Campus, and a clinical pharmacist practitioner with the Veterans Health Care System of the Ozarks, participated in brainstorming sessions about how to facilitate the program’s rollout at the telehealth ambulatory care clinic she runs in Branson, Missouri. “I shared information on the program with my clinic site director and communicated with my team nurses to provide information on how this program can be beneficial for our patients,” Balli said. “I receive COPD CARE referrals for patient enrollment directly from care coordination nurses at our facility and am able to order appropriate diagnostic tests or proceed with medication management dependent on the patient scenario.”

Because COPD is prevalent in the veteran population, she said, “direct, focused attention to this disease state improves patient outcomes. The unique collaboration between team nurses and pharmacists allows for open communication and quick referral for veterans recently admitted for COPD exacerbations.”

“Optimal medication selection is of utmost importance based on a patient’s past medical history, history of COPD exacerbations and current COPD-related symptoms,” she continued. “There are many different types of inhalers used for COPD management. Pharmacists can directly assist with appropriate inhaler selection and thorough patient education to ensure proper technique for administration.

We can also identify additional care referrals and preventative care strategies including tobacco cessation interventions as appropriate. Assistance with medication selection and education can improve efficacy for COPD symptom relief and improvements in lung function and quality of life.”

Hagen agreed that pharmacists are integral to the program’s success thanks to their medication management expertise. “Teaching the veterans the proper use of inhalers, and then being available to do the follow up…that was missing in the picture. [It was typical for a patient] to have a 30-day readmission after an acute exacerbation,” he continued. “How do we limit that? The pharmacists’ knowledge of the medication was the key component to providing clear understanding to the veterans. During the pilot we went down to zero readmissions.”

One of the crucial things the program does, he added, is impress upon veterans the need to stay on top of treatment and pay attention to symptoms. “The connection 48 hours after discharge was the big component that was the winner. With the telehealth people contacting them and setting up appointments for them with primary care, it created awareness that the condition requires urgency,” Hagen said. “If we did not make that contact and get them in within two weeks to see the pharmacist, we would have continued to have readmission rates within 30 days. The constant communication built into the process is key to its sustainment.”

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A Multidisciplinary Model

Dr. Amanda Stahnke, clinical associate professor at the University of Missouri-Kansas City School of Pharmacy, was one of several PACT clinical pharmacist practitioners who piloted COPD CARE at the Kansas City Veteran Affairs clinics. She provided training sessions that began a few months before rollout and coached stakeholders in implementation to help expand the program across all of PACT.

“Our knowledge of chronic disease states and evidence-based medication management allow us to assist in providing the highest-quality care to our veterans,” she noted. “An important aspect of the COPD CARE service is how it utilizes the multidisciplinary model of care extremely well with inclusion of all members of the PACT (primary care providers, registered nurse care managers, advanced medical support assistants, telehealth clinical technicians and CPPs), along with a clinical pharmacy technician and pharmacy trainees (residents and students).”

Student pharmacists were involved in identifying more than half of the veterans during the initial phases of the COPD CARE expansion using population management databases, Stahnke said. “These students also assisted in increasing utilization of VA Video Connect (virtual video care visits) and assisted the CPP with care management visits with veterans. Depending on when they were involved, they could have seen the expansion process, implementation, the impact of the service or may have been directly involved with care. All levels of the project provided a significant learning opportunity about the importance of interprofessional care, clinical service development and expansion, utilization of population health management tools, comprehensive medication management and the impact pharmacists can make on patient care.”

Portillo said that the program fosters collaboration and patient empowerment, which is important for students to witness. “What I hope our students are seeing is that when we empower each other as healthcare teams, really good things can happen for patient care,” he said. “You can drive forward this initiative and support the relationship building. It’s all been trainees who have done this. Empowering the learners has allowed this to happen.”

A key outcome has been better access to care for veterans, particularly those in rural communities. “Seeing the improvement in veterans’ daily function, comfort with their inhalers and how appreciative they are of this and our other services demonstrate the success of the CPP clinics,” Stahnke added.

For Molly Lehmann, being involved with COPD CARE transformed the direction of her clinical career. “It absolutely ignited my interested in innovation and administrative leadership within health systems pharmacy. As a resident being able to work with students in that capacity gave me an introduction into project management as a primary preceptor,” she said.

Portillo is now focused on the next steps that are needed to sustain the service. “We want to understand what type of clinical settings are able to most effectively deliver the program. We hope to continue to deliver COPD CARE across the country,” he said. “And of course, learning from our veterans. Their voice is the most important so we can further enhance our work.” P

Jane E. Rooney is managing editor of Academic Pharmacy Now.