Expanded Role of Primary Care Pharmacists in the Management of Heart Failure

理由。心衰（HF）是VA的常见病，具有很高的发病率和死亡率。

Justification. Heart failure (HF) is a common condition in the VA, with high morbidity and mortality. Accordingly, HF hospitalization and mortality are a focus of VA Safety Analytics for Improvement and Learning (SAIL). Furthermore, HF medical treatment is complex as there are now four classes of medications known to independently prolong survival and are recommended to be used together (five for African Americans). Several medications require titration to recommended doses while monitoring for uncommon but dangerous side effects. Given the complexity of treatment and the insufficient number of cardiologists to manage this large patient population, standardized medication initiation and titration of medications by non-physicians has been tested as an adjunct to current primary care practice of patient aligned care teams (PACT). Pharmacist medication initiation and titration of medications has been found to improve recommended care in multiple randomized trials. However, few VA sites have implemented medication initiation and titration of medications for HF by PACT pharmacists. Hypothesis: Pharmacy medication initiation and titration of HF medications can be implemented successfully at two sites in VA Palo Alto HCS and will increase recommended use of three medication classes for Veterans with HF. Gaps Addressed (Knowledge and Practices). A National HF Dashboard is available to track guideline recommended therapy and shows many patients are not receiving optimal HF car e. Innovation. The use of PACT pharmacists to provide protocolized care for HF will free up primary care providers from this work allowing them to increase access to primary care. Given that patients are often referred to VA Cardiology for this task, pharmacist management can also improve access to VA Cardiology. Specific Aims 1) Implement pharmacist led protocolized care in PACTs for the initiation and titration of HF medications at two types of primary care sites. 2) Determine facilitators, barriers, fidelity and cost of implementation. 3) Demonstrate an impact on recommended HF care and increased access to VA Primary Care and VA Cardiology as a result of PACT pharmacist management. Project Methods We have partnered with pharmacy and PACT leadership at VA Palo Alto HCS in their use of PACT pharmacist HF medication management at one CBOC (Monterey, CA). In this project we will spread this practice to two types of sites: VA Palo Alto Medical Center based Primary Care Clinic (large) and the VA San Jose CBOC, CA (small). Implementation Strategies As part of the proposed project we (partnership of the VISN CMO Dr. Godbout and the QUERI Team) will 1) organize local champions, 2) facilitate spread to the two sites and 3) provide audit and feedback to PACT pharmacy and primary care leadership. We will bring together local champions (VA Pharmacy, VA Primary Care and VA Cardiology leadership) who will be shown results over time and will provide advice on how to modify the implementation for their site. To facilitate implementation, we will develop and provide an operation manual and toolkit that includes pharmacy medication management protocols. Evaluation Our evaluation will examine implementation (e.g. fidelity, barriers, facilitators, cost, provider satisfaction, employee engagement) and outcomes (fraction of patients meeting guideline recommended care, access). Description of primary outcomes/endpoints. The implementation outcomes will include the number of HF patients managed by pharmacists per month per PACT team, and number of medication changes made by PACT pharmacists per month per PACT team. Pharmacist and primary provider satisfaction and perceived burden with the expanded pharmacist role will be determined. Cost of implementation will be determined and compared with benefits (increased access, increased quality of care metrics) to provide both a business case analysis and return on investment. The care outcomes will be use of five VA recommended HF medication classes from the National VA HF Dashboard, access/wait times for PACT and VA Cardiology appointments, admission, readmission, mortality, emergency department visits and adverse drug reactions.