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2019 HSR&D/QUERI National Conference Abstract

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1051 — Challenges of clinical pharmacy specialists' role expansion to improve access to PACT and pain management: A mixed methods formative evaluation

Lead/Presenter: Megan McCullough,  COIN - Bedford/Boston
All Authors: McCullough MB (Center for Healthcare Organization and Implementation Research, Boston University School of Public Health ), Gillespie, CK (Center for Healthcare Organization and Implementation Research), Kleinberg, F(Center for Healthcare Organization and Implementation Research) Reisman, JL (Center for Healthcare Organization and Implementation Research) Tran, M (Pharmacy Benefits Management, Clinical Pharmacy Practice Office) Ourth, H (Pharmacy Benefits Management, Clinical Pharmacy Practice Office) Morreale, A (Pharmacy Benefits Management, Clinical Pharmacy Practice Office) Miller DR (Center for Healthcare Organization and Implementation Research, Boston University School of Public Health)

Objectives:
The Office of Rural Health and PBM's Clinical Pharmacy Practice Office has implemented the addition of clinical pharmacy specialist (CPS) to clinical teams in rural areas. VA CPS are advanced practitioners with prescribing privileges and the ability to independently, but collaboratively, manage patient disease states. As part of the larger mixed methods CPS intervention evaluation, this paper characterizes the complex challenges of role expansion from the perspective of CPS' and clinical teams.

Methods:
Semi-structured interviews were conducted with 10 CPS and 20 clinical team members (physicians, nurse practitioners, physician assistants, nurse care mangers, etc.). Qualitative analysis drew deductively on our Donabedian-informed structures/processes model combined with inductive data-led thematic analysis. 133 CPS and 1,015 clinical team members completed an online survey to assess perceptions of pharmacist's skills, roles, team integration, and organizational context.

Results:
While overall survey results indicate acceptance of CPS role expansion, qualitative data point to gaps of understanding about abilities, integration and communication between CPS and their clinical teams in primary care and pain management. Primary care CPS felt their full clinical abilities were not understood by clinical team members. By contrast, pain management CPS perceived that their skill set (especially opioid tapering) was embraced quickly. Clinical team members reported CPS were improving access, patient care and taking on needed clinical tasks but some clinicians offered qualifiers. Data indicated the nature of pain management (opioid tapering/discontinuation) creates communication barriers and exacerbates teamwork issues in more pronounced ways than barriers in primary care. There are nuances to CPS role expansion indicating different levels of integration and the need to improve team communication and consensus building.

Implications:
This work identifies the complexities of team integration and how role perceptions impact organizational issues such as communication and decision-making. Identifying and addressing these challenges can improve team productivity and quality of care.

Impacts:
In VA, CPS are increasingly identified as the solution to access to care, improved pain management and other critical areas. Understanding team integration dynamics will help scale up and adapt the use of CPS across other areas of care, thereby providing lessons on improving team-based care for providers and Veterans.