Zellmer Lecturer Spotlights VA Pharmacy Advancement Initiatives

By specifically designating pharmacists as essential members of primary care teams, the Department of Veterans Affairs (VA) has successfully expanded its clinical pharmacy practitioner (CPP) workforce to better serve veterans and the department, says Virginia S. Torrise, recipient of this year’s William A. Zellmer Lecture Award.

Torrise presented her lecture Sept. 12 in Bethesda, Maryland, as part of ASHP’s annual Policy Week activities.

“We have many highly trained pharmacists with in-depth knowledge and skills to provide comprehensive medication management across America,” Torrise told the audience. “Our challenge is recognizing and influencing changes that will place pharmacists’ talent where it can best serve patient care needs.”

Torrise is deputy chief consultant for professional practice in the Veterans Health Administration Pharmacy Benefits Management (PBM) Services. As one of VA’s many strong advocates for advancing clinical pharmacy programs, she said it’s been gratifying to witness departmental initiatives, such as mail-order medication delivery and virtual pharmacy operational programs, that give CPPs more time “to meet with veterans and deliver comprehensive medication management [CMM] services.”

Torrise said VA’s PBM group has a solid history of setting national policy and clarifying expectations for pharmacy services at VA facilities nationwide. The group’s early focus was primarily on pharmacy’s involvement in medication delivery, managing the VA national formulary, and establishing emergency pharmacy services for disaster relief.

“PBM had provided national education to support clinical pharmacy programs, showcasing a variety of models [using] VA pharmacist practitioners,” Torrise explained. “But we hadn’t yet established our national office dedicated to clinical pharmacy.”

It was in 2009, Torrise said, that VA goals for supporting integrated, team-based primary care in the medical home setting converged with PBM’s professional goals to expand the roles of what came to be known as CPPs. Pharmacists who earned the CPP designation could practice in patient-centered, team-based primary care settings to provide CMM services — a VA priority.

“The institutional impact would be that patients are more likely to receive the right care and at the right place and at the right time,” Torrise said. CPP deployment was also viewed as an opportunity to supplement primary care and mental health service teams and lessen the effects of healthcare occupational shortages.

VA’s Patient Aligned Care Team (PACT) initiative, implemented in 2010, was used to embed CPPs in primary care practice settings. VA describes CPPs as members of a multidisciplinary care team who practice autonomously, under a defined scope of practice, to provide CMM services for patients with chronic conditions.

Torrise said the vision for CPP deployment within PACT was that the pharmacists’ services would be based on compelling principles that support integrated care delivery and information sharing among team members.

“The team members would ... ensure a comprehensive treatment plan that would serve the needs of the patient. These clinicians would monitor quality improvement and use data to track populations, improving quality and outcomes,” Torrise said.

To promote wellness and better outcomes in primary care, VA recommended that CPPs be key team members, with each pharmacist serving three primary care providers, for a total patient panel of about 3,600. Torrise said the establishment of the primary care staffing standard became a national model, supported by VA leadership, that redefined the role of CPPs and broadened their responsibilities in primary care.

Another VA project that has supported CPP expansion is the annual “shark tank” competition, a problem-solving initiative established by the Veterans Health Administration. Torrise called out a winning shark tank project from 2014 at the William S. Middleton Memorial Veterans' Hospital in Madison, Wisconsin. The VA facility demonstrated that 27% of primary care return appointments could be shifted over to the team’s CPP.

“This increased the ability for providers to see new patients, versus return patients requiring chronic disease management,” Torrise explained. Under this model, clinical outcomes continued to improve, and patient and provider satisfaction increased.

Torrise said that to document the value of CPPs, VA pharmacy programs monitor and track progress on predetermined quality outcomes, taking a data-driven approach that helps VA rapidly disseminate innovations and practices that improve veterans’ health and meet departmental objectives.

One such objective is caring for veterans who need mental health services. Torrise said that in 2015, VA had fewer than 90 CPPs with a scope of practice in mental health.

To increase this pool of clinicians, the department strategically expanded its postgraduate year 2 pharmacy residency positions in mental health, complementing VA’s investment in pharmacy residencies.

“Today, VA offers 77 mental health pharmacy residencies annually,” Torrise said. “We have now over 500 mental health CPPs. ... This has been an incredible change at a time of great need.”

In 2020, VA’s Clinical Pharmacy Practice Office partnered with the department’s Office of Rural Health and Office of Mental Health and Suicide Prevention to develop a training program for more than 250 CPPs on the care of patients with alcohol and opioid use disorders.

“This helped provide foundational services across all VA practice settings,” Torrise said. “Today, CPPs are providing [substance use disorder] services to over 91,000 veterans across our system.”

She said further training and expansion of CPP practice areas within mental health, including substance use disorder, remains a top priority.

Torrise emphasized that it’s important for pharmacy leaders to identify opportunities to educate healthcare executives about how CPPs can fill needs and solve problems that align with healthcare system needs.

“When we started this journey, we maybe had sufficient staffing to support 15% of primary care provider panels,” Torrise noted. “Today, with incremental annual support for expanding clinical pharmacy services — especially to rural health care patients — VA has nearly 75% of provider teams served by CPPs.”

Torrise said VA relies heavily on all pharmacy professional organizations to support initiatives that define national policy and best practices.

“We depend on you!” Torrise told the audience. “As everyone helps prepare ASHP policy and guidance, my hope is that VA is serving your needs to demonstrate the benefits of implementing integrated team-based care models and continues to demonstrate the benefit of expanding roles for CPP serving patients in direct care.”

The William A. Zellmer Lecture Award, established in 2009 by ASHP and the ASHP Foundation, recognizes exceptional leadership in healthcare-related policy that enables pharmacists to improve the safety and effectiveness of medication use.