Pharmacy - Care of Patients - Veterans Affairs



CARE OF PATIENTSVA PUGET SOUNDMEMORANDUM TX-08HEALTH CARE SYSTEMJULY 2013SUBJECT: AMBULATORY CARE PHARMACY SERVICESEXECUTIVE SUMMARY: Prescription drug services are a major component of ambulatory care services provided to eligible Veterans. These services include direct and indirect patient medication counseling, drug and supply dispensing services, and clinical pharmacist activities as a component of the interdisciplinary health care team. This revision includes new information regarding controlled substance exceptions to 30 day supply limit, medication management requirements for Home Care, availability of Plan B, and Community (non-VA) pharmacy prescription blank requirements. The revision also incorporates information from the Pharmacist General Scope of Practice.POLICY: Outpatient Pharmacy Hours of OperationSeattle Divisiona)Monday through Friday 8:00 am – 8:00 pmb)Saturday and Minor Holidays 8:00 am – 3:00 pmc)Closed Sundays, Thanksgiving and ChristmasAmerican Lake Divisiona)Monday through Friday 8:00 am – 5:30 pmb)Minor Holidays 8:00 am – 3:00 pmc)Closed Weekends, Thanksgiving and Christmas PrescriptionsPrescriptions are to be ordered electronically using the Computerized Patient Records Systems (CPRS) with electronic signature except as noted below:a)Outpatient chemotherapyb)Medications administered in designated clinicsc)Isotretinoind)Lenalidomidee)Fee Basis prescriptionsf)Contracted Nursing Home (CNH) prescriptions VA prescribers may use computer generated VA Form 10-1158 Doctor’s Order Sheet when handwritten prescriptions are requiredPrescriptions for Schedule II controlled substances must be wet-signed (original ink signature) on VA Form 10-1158 Doctor’s Order Sheet. After entering the Schedule II medication order into CPRS, prescribers may go to the orders tab and print a hard copy VA form 10-1158 to wet-sign. Pharmacy will not fill prescriptions for Schedule II controlled substances until hard copy, wet-signed VA Form 10-1158 is received.Prescription forms (VA Form 10-1158) will be for internal use only and primarily for Schedule II prescriptions and for times when computers are not operational. The Director, Pharmacy & Nutritional Care must approve any changes or alterations to any prescription form.Pre-signed blank prescription forms are not acceptable. Prescribers must not use unapproved abbreviations and symbols for handwritten prescriptions. Prescribers may access the VA Puget Sound Pharmacy web page for a list of unapproved abbreviations and symbols: Unapproved Abbreviations and Symbols Pharmacists will contact the prescriber for clarification when any confusing abbreviation, symbol or acronym is used.Prescriptions written by physicians, physician assistants, nurse practitioners and pharmacists will be honored only if the prescriber is authorized as indicated in the VistA new person file. Electronic signatures will be accepted for medication orders entered in CPRS. In addition, prescribers will need to wet-sign a hard copy prescription for Schedule II controlled substances. VA healthcare prescribers may use their personal VA Puget Sound DEA registration number or their own unique internally assigned DEA number (VistA DUZ number) when ordering controlled substances. Providers authorized to prescribe will be given access to the CPRS to enter medication orders. The provider’s full name and DUZ number will be maintained in the VistA electronic new person file and prescription record.To decrease chance for error, Pharmacy will not routinely accept verbal medication orders for outpatients. In the event of an emergency and when an order cannot be entered into CPRS, only a licensed pharmacist may accept a verbal order (exception, see # (9)). To verify accuracy in the event of an emergency verbal order, the pharmacist must immediately transcribe the verbal order and read back the verbal order to the prescriber. The pharmacist will enter the prescription into the VistA prescription file before processing.Home Based Primary Care (HBPC) nurses may accept telephone orders during home visits when medication changes are required to prevent adverse events, emergency room visits, or hospitalization. HBPC nurses will confirm that an order has been placed in CPRS within one business day of accepting the verbal order.Pharmacy is not responsible for dispensing non-expendable medical equipment.A registered pharmacist must check all outpatient prescriptions for legend drugs filled by a non-pharmacist.The average Outpatient Pharmacy prescription processing time for window pick-up is 30 minutes or less. All refills and renewals are routinely processed for mail. Pharmacy will strive to meet telephone service performance measure for call abandonment rate of less than 5% and an average speed to answer of less than or equal to 30 seconds. Prescription orders for non-formulary drugs follow MCM TX-01 Medication and Formulary Use.Prescriptions orders for investigational drugs follow MCM TX-15 Use of Investigational Drugs in Human Subjects in Research.Eligibility and Pharmacy Benefits Determining patient eligibility for pharmacy services is a function of Health Plan Management. Patient eligibility is available in CPRS. Incarcerated patients are not eligible for VA prescription benefits.Prescription co-payments will be charged to all non-service connected Veterans and Veterans who are rated less than 50% service-connected who receive a medication for a non-service connected condition as determined by the prescriber during CPRS order entry. Veterans who have been determined to be income exempt will not be charged a co-payment. Co-payments include an $8.00 charge for a 30-day supply of medication and a $24.00 charge for a 90-day supply of medication. Employee (non-Veteran) prescriptions must be limited to emergency treatment and minor ailments which interfere with the immediate ability to perform duties. Medications cannot exceed a 72-hour supply except for items listed in #5. Larger supplies may be authorized for employees treated in conjunction with workman’s compensation. Employees participating in a smoking cessation program may obtain this free benefit by requesting VA National Formulary NRT prescriptions (patches, gum, lozenges) from the Occupational Health Office Provider or designee.Emergency Pharmacy ServicesUrgently needed outpatient medications may be obtained 24 hours daily. Urgently needed outpatient medications are medications that, in the clinical judgment of the VA prescriber, if not taken within 24 hours of determining the need of those medications have the potential to result in serious patient harm. Every effort must be made to utilize VA pharmacies for prescription services. When appropriate, arrangements can be made for emergency prescription services through a community pharmacy for certain programs (e.g. Fee Basis, CBOC). Veterans utilizing Fee Basis emergency first-fill program will need to initially pay for medications but will be reimbursed based on acquisition cost of an acceptable generic drug, dispensing fee and formulary status. Veterans utilizing the CBOC first-fill contract will not need to pay up front for medications. Pharmacy can also ship emergency prescriptions from the VA pharmacy via overnight mail, Monday through Thursday. Prescriptions to be filled at a community (non-VA) pharmacy are to be printed on tamper-resistant paper. The paper requires a special seal and other security features and must be approved by the Washington State Board of Pharmacy. Faxed or phoned prescriptions are exempt from the requirement.Plan B will be available to patients at both divisions, American Lake and Seattle as well as from the Community Based Outpatient Clinic (CBOC) associated retail pharmacies during clinic business hours of operation. Plan B is available during off hours at the Seattle Division in the Emergency Department and at American Lake in the Acu-Dose cabinets. Urgent prescription fills needed after hours can negatively impact the service that is given to inpatients. The inpatient pharmacist’s first priority is to fill inpatient orders (Seattle, American Lake, Spokane and Walla Walla) before filling urgent outpatient prescriptions. For security reasons, patients will not be sent to Inpatient Pharmacy between the hours of midnight and 7am. Emergency Department staff will ask the patient to wait in the Emergency Department waiting area for the pharmacist to deliver the medication. The Emergency Department prescriber must contact the Inpatient Pharmacy anytime an outpatient medication is needed after hours to ensure the order is processed as soon as possible. Traveling Veterans are instructed to request prescription refills from their home VA Medical Center; however for urgent, unexpected needs VA Puget Sound pharmacists who hold an advanced scope of practice may provide refill extensions during regular business hours of operation when appropriate. Every effort is made to ensure that a Veteran requiring a prescription refill while on travel receives medication without any disruption to therapy. Some Veterans may be referred to the Emergency Department outside of normal business hours if no pharmacist with an advanced scope of practice is on duty or if the medication needs falls outside the pharmacists scope of practice. Ambulatory Care Clinical Pharmacy ServicesIt is the goal of Pharmacy to enhance medication-related therapeutic outcomes in an effort to improve the patient’s quality of life. In order to realize this goal, pharmacist with advanced scopes of practice will be assigned to work in clinics and on the wards as an interdisciplinary member of the healthcare teams. All patients, including those discharged from inpatient wards, are to be educated about their medications prior to, or at the time of dispensing. Such counseling needs to be tailored to the patient by focusing on their individualized drug regiment. Medication teaching, counseling, and education are a multidisciplinary responsibility involving prescribers, pharmacists, nurses, dietitians, and other disciplines within their scope of practice. Pharmacists will review the patient medication profile to discuss necessary drug information with the patient, identify potential drug-drug and drug-food interactions, evaluate laboratory tests deemed necessary for monitoring the outcomes of medication therapy, and make recommendations to healthcare providers as appropriate,All healthcare providers are to review the patient medical record for the presence of allergy information and the potential for adverse drug events prior to medication ordering and dispensing.A pharmacist will perform initial and periodic assessments of medication therapy for Home Based Primary Care (HBPC) patients. HBPC staff will not deliver medications to the patient’s home, except vaccinations to be administered in the home by the nurse. HBPC staff will educate patients on proper medication disposal. PROCEDURES:PrescriptionsAll prescriptions using VA Form 10-1158 for dispensing must be completed in a legible manner by an authorized provider. These prescriptions must contain the following:a)Patient’s full nameb)Social security number (last 4)c)Patient’s current addressd)Allergy informatione)Name of medication (generic)f)Dosage form (a range in the number of tablets/capsules is permitted in outpatient orders when patient needs to adjust dosage to their symptoms)g)Frequency (a range in time is not permitted on outpatient orders)h)Strength (metric)i)Quantityj)Directions for use. Non-specific directions such as “as directed” and “as needed” without a frequency of administration are not acceptable. Dose limitations must be included.k)Indications for use (see # (2) below)l)Number of refills (mark “no refills if applicable)m)DEA number or Hospital DEA number and assigned suffix for controlled substancesn)Patient’s service status (e.g. SC, NSC) for the condition being treatedo)Provider’s printed (or stamped) namep) Signature of providerq)Date prescription writtenPrescribers will specify the indication for as needed (PRN) medication orders and are highly encouraged to include the indication for other medication orders, especially when the drug may be prescribed for the treatment of multiple disease states. In CPRS, the indication can be entered in the comments field during CPRS order entry. For handwritten prescriptions the indication can be listed under the directions to the patient. Prescription indications enhance the patient’s understanding of medication use and compliance. The pharmacist will add the indication when it is absent from the “as needed” orders or contact the prescriber if the indication is not clear from the medical record.Each non-controlled prescription order with a 30-day supply may have a maximum of eleven refills or 12 months of therapy. Each controlled substance prescription order (Schedule III, IV and V) prescribed for a 30-day supply may have a maximum of five refills or 6 months of therapy. Refills are not authorized for Schedule II controlled substances.The quantity dispensed for non-controlled substances should be based on individual patient needs, expectations and safety. Non-controlled substance prescriptions may be renewed for a 90-day supply with three refills. Suggested criteria to use for a 90-day fill would be for patients who have been on a medication for at least three months, are stabilized on the medication, have been compliant and who are expected to continue on the same medication for at least the next 3 months. Chemotherapy prescriptions will be limited to a 30-day supply. Pharmacists working in direct patient care areas are authorized to dispense a 90-day supply when appropriate.Controlled substances will be limited to a 30-day supply. Pharmacy will review controlled substance prescription fills once per quarter to ensure compliance with this policy. Exceptions to the 30-day limit for controlled substances include the following:a)Phenobarbital, pregabalin, and lacosamide may be dispensed in 90 day supplies only when uses for seizure prevention/control; the indication for use must be included in the prescriber’s instructions for us (sig)b)Testosterone patches may be dispensed up to a 60-day supplyc)Testosterone injection may be dispensed up to a 90-day supplyPrescriptions which include a taper or titration schedule should be ordered with no refills to ensure that patients are not given a refill with incorrect directions for use.To minimize patient waiting time for patients receiving new prescriptions, all refills will normally be processed for mail. Pharmacy instructs patients to request refills at least 14 days before running out of medication to assure adequate time to process and mail medication before the patient runs out of medication. Prescribers and other healthcare providers who use CPRS to order refills must limit the number of requests for window pick-up (instead of mail) to emergency circumstances only (routine refill requests will be mailed). Patients are advised that they may request refills by using any of the following methods:a)Toll-free automated telephone refills system. The number is 1-800-329-8387. This number can be used anywhere within the State of Washington.b)Mail in computerized refill request form.c)Drop off their computerized refill request form at the Outpatient Pharmacyd)Order using My Health-E-Vet8)Prescription Renewal Requestsa)Upon a patient’s telephone request for a prescription renewal, a pharmacist, pharmacy technician, nurse or program support assistant that has received adequate training, may sign into CPRS and send an Unsigned Renewal Order to the Primary Care Provider, Mental Health Provider, or designated prescriber. Renewals generated by this method will not include Schedule II-V controlled substances, medications that have been discontinued, and prescriptions that have expired for greater than 180 days, have not been filled for more than 180days, or have active refills remaining. b)Authorized employees may electronically flag orders for types of requests that do not allow for an unsigned renewal request. In flagging the order, the employee will enter a brief reason for the flag and select the Primary Care Provider, Mental Health Provider, or designated provider as the alert recipient. The employee will look in the Primary Care Team/Primary Care Provider box in the CPRS header for the patient’s primary care provider. If the patient does not have a primary care provider, the employee will send the flag to the designated prescriber. The employee will send Mental Health originated prescriptions to the last prescriber.c)When the unsigned renewal order or view alert is received, the provider will evaluate the renewal request for appropriateness, electronically sign the order and release it to Pharmacy for processing. If the renewal request is not appropriate, the provider will ensure the patient or original prescriber is contacted to discuss the action plan. Primary Care providers need to designate a surrogate provider to receive unsigned renewals/alerts.Drug and Drug Dosage Changes:a)Prescribers and pharmacists need to ensure the medication profile is accurate and current (e.g. medication reconciliation). b)Prescriber responsibilities for drug/dose changes:Document “dose change” or “replaces drug (name)” along with the date of the change in the prescriber’s CPRS Medication Order in the Comments boxAdd “send when due” or “Send (date)” in the provider comments if the prescription should be sent at a future dateEducate the patient on the changes to the medication directionsc)Pharmacist responsibilities for drug/dose changes:Identify pending prescriptions with the provider comments “Dosage change (or replaces drug) change – (date) and “send when due” or Send/ (date)”Add the comment “Note increase/decreased dose (date)” and/or “note new tablet/capsule strength” or change in drug (“replaces drug name and strength(s)…”) to prescription direction, as appropriate.If new supply of the medication should not be sent until a future date, suspend the new prescription for 14 days prior to the future fill date.d)Practitioners in the anticoagulation clinics are exempt from updating the prescription records when the updates have the potential to compromise patient safety (e.g. periods of frequent dose titration or temporary holds). Prescriptions for other frequently titrated drugs (e. g. immunosuppressants, insulin, and loop diuretics) are also exempt from these prescription updating requirements, when the updates have the potential to compromise patient safety.e)Anticoagulation clinic providers or prescribers of other frequently titrated drugs will update the prescription each time an order is renewed or a new order is placed. It will include the current dose in the prescription instructions and the statement “or as directed by the anticoagulation provider/other prescriber”. The anticoagulation clinic provider will record the most current dosing information in the Anticoagulation note. Prescribers of other frequently titrated drugs will record the most current dosing information in the clinic progress note. f)Drug substitutions due to manufacturer drug shortages, contract changes or medication recalls will be handled under specific procedures identified and approved by the VA Puget Sound Pharmacy, Nutrition and Therapeutics Committee.10)In the HBPC setting, prefilled insulin syringes must be placed in clearly marked containers or plastic bags, labeled with patient name, type of insulin, doses, directions for use, applicable cautionary instructions, name of preparer and expiration date.Emergency Pharmacy ServicesFor urgent, CBOC first-fill prescriptions to be filled at a community retail pharmacy (or anytime a Veteran wants to obtain an prescription from at retail pharmacy at his or her own expense), the following options allow VA providers to comply with Washington State Law:a)Providers may fax or phone in the prescription directly to the outside pharmacy.b)Upon request from a provider, Pharmacy will issue serially numbered tamper-resistant prescription pads. The provider must sign for receipt and secure the prescription pads in their clinic work area.c)Upon request from a clinic manager, Pharmacy will issue serially numbered tamper-resistant prescription printer paper. Paper must be secured and signed for by the clinic manager. To be able to use the printer paper, the clinic needs to establish a designated printer and/or designated printer tray. To prevent inappropriate use of the paper, the number of designated printers will be limited, the printers must be secured and a new printer name for the printer and/or tray must be established in accordance with Information Technology.d)To maintain a complete medication profile, all prescriptions issued for filling outside the VA must be documented in CPRS as non-VA medications.e)Tamper resistant prescription pads and paper will be available for distribution from the Seattle and American Lake Outpatient Pharmacies. For urgent prescriptions needed at the Seattle Division after hours, the Emergency Department prescriber must contact the Inpatient Pharmacy at any time an urgent outpatient medication is needed to ensure order is processed as soon as possible according to the following procedures:a)After 8pm (weekdays), 3:00 pm (Saturdays and minor holidays), and all day (Sundays, Thanksgiving, and Christmas), the Emergency Department will contact the Inpatient Pharmacy (ext. 66726) to alert the pharmacist of a need for an urgent outpatient prescription. After midnight, the Emergency Department staff will notify the pharmacy via pager (206-416-4103).b)Emergency Department staff will inform the patient that night shift prescriptions may take up to two hours to process. Emergency Department staff may elect to offer patients the alternative of receiving a one-time medication (to be administered by the nurse) and returning the following day to pick up their prescription from the Outpatient Pharmacy (except if the next day is Sunday or a major holiday). The one-time dose may be taken from the AcuDose cabinet or sent from Pharmacy via the pneumatic tube system. This option requires a one-time order and an outpatient prescription entered in CPRS. The night pharmacist will process the CPRS pending order to be filled by Outpatient Pharmacy staff during regular business hours. One-time doses of drugs which can cause drowsiness, such as narcotic pain medications should not be given to someone who will be driving. c)Emergency Department prescribers will use the CPRS “ED PREFERRED MEDICATIONS” menu to order urgent outpatient medications whenever possible. This enhances efficiency and turn-around time by using pre-packs and inventory readily available in the Inpatient Pharmacy.d)The prescriber does not have to initiate a new order for medications with active refillable prescriptions listed on the computerized medication profile. The pharmacist will be able to fill an emergency refill for these prescriptions if absolutely necessary. e)Schedule II controlled substances will be processed for pick up during regular hours unless the need is urgent and a one-time dose in the Emergency Department is adequate to sustain the patient until Outpatient Pharmacy opens. For Schedule III-V controlled substances, non-refillable and/or expired prescription orders, a minimum supply of critical medications can be ordered for the patient and will be dispensed by the inpatient pharmacist. Prescribers need to review the patient’s chart to determine if the patient is on a Narcotic Medication Plan. Prescribers should encourage patients to follow up with their primary care provider. The number of days supplied should not exceed the time until the next scheduled clinic appointment or amounts indicated in a Narcotic Medication Plan.f)For non-controlled substances the Inpatient Pharmacist may dispense a 14-day supply to the patient and mail the remainder of the order to the patient during regular business hours.At the American Lake Division, Outpatients treated outside regular Ambulatory Care Pharmacy window hours may receive a prescription to be filled at a local non-VA retail pharmacy using the Heritage First Fill certification (CBOC first fill contract).Pharmacists that hold a Scope of Practice may assist with urgent medication needs for traveling Veterans during administrative hours. At other times, the Veteran may need to be referred to the Emergency Department for an urgent medication need. Pharmacists may extend an emergency supply (1-14 days) of a non-controlled substance prescribed for chronic use when the prescription has no remaining refills, and has passed the expiration date. The patient must have a future clinic appointment or an open appointment with a primary care provider. Chemotherapeutic drugs, antibiotics, controlled substances, and investigational drugs are excluded. The Pharmacist will also send an unsigned prescription renewal request to the Primary Care Provider for additional refills. When a CBOC provider needs to order Plan B the same procedures used for emergency first-fills are followed:a)Provider writes urgent first-fill prescription via CPRS Non-VA prescription orders and prints on tamper-resistant paper.b)Provider gives prescription and Heritage Health, “VA initial fill Rx Certificate” to the Veteranc)Veteran takes the prescription and the “VA initial fill Rx Certificate” to a contracted retail pharmacyd)Contracted retail pharmacy fills and dispenses the prescription and counsels the Veteran.e)Bill for the prescription is completed via the VISN 20 urgent first-fill program.Clinical Pharmacy ServicesPharmacists will work directly in Ambulatory Care whenever possible to be as close to the patient and provider as possible. This allows the pharmacist to resolve drug related problems at the front end of the prescription order process, decrease waiting times, increase patient satisfaction, and improve clinical outcomes. Pharmacists will assist in medication reconciliation and drug selection to insure the most appropriate and economically available therapy. Pharmacists will contact prescribers if any medication orders are incomplete, illegible (hand-written orders), or unclear.Pharmacists will review the patient medical record for the present of allergy information.Pharmacists will screen profiles and prescription orders for drug-drug, drug-food, or any drug-related problems and monitor drug therapy for safety, efficacy and desired clinical outcomes. Pharmacist will evaluate the medication order for appropriate dosing, taking into account the renal and liver function of the patient.Pharmacists will evaluate laboratory tests deemed necessary for monitoring the outcomes of medication therapy.Pharmacists will instruct patients on appropriate medication use whenever a patient is receiving a new medication or whenever the patient needs additional assistance with any medications. Pharmacists will verify the patient understands of medication indication/use, what the patient should expect from the medication, information on medication use and storage and how to obtain more medication.Pharmacists will ask patients to verify historical and allergy information and enter information into CPRS. Pharmacists will provide drug information to other Medical Center staff by providing in-services and answering drug-related questions. Pharmacists with a Scope of Practice will work in collaboration with physicians and non-physician practitioners in performing a variety of services to facilitate optimal medication therapy as outlined in MCM TC-36: Pharmacy Collaborative Practice Clinics. Pharmacy collaborates with HBPC staff to provide education to patient and caregivers on the proper use of medications to include administration, safe storage, indications for use, side effects, adverse effects, and precautions on high alert and look-alike sound alike medications. Pharmacists will perform medication reviews for HBPC patients within 30 days of admission and every 90 days thereafter.RESPONSIBILITY:Prescriber: Responsible for medication reconciliation prior to prescribing medication and supplies for patients, knowing the limits of their prescribing authority and ensuring that the information listed in the VistA provider file is accurate and up to date, obtaining proper authorization to order non-formulary or restricted medication, recording patient allergy information, and determining prescription co-payments. Pharmacist: Responsible for providing the highest quality of pharmaceutical care to improve the patient's quality of life by recommending optimal drug selection and therapy, screening for drug related problems, monitoring for desired clinical outcomes, educating and verifying patient's understanding of medication information, maintaining the CPRS patient medication profile, and providing drug information to professional staff. Home Based Primary Care (HBPC) pharmacists: for completing medication therapy reviews including monitoring, recommendations, and education as needed for HBPC patients in collaboration with HBPC staff and participating in HBPC patient care conferences. Pharmacy Program Managers: Responsible for overall Ambulatory Care Pharmacy activities.MCCF: Responsible for collecting prescription co-payments.REFERENCES: Veterans Health Administration (VHA) Handbook 1108.05, Outpatient Pharmacy Services, May 30, 2006.VHA Handbook 1108.01, Controlled Substances (Pharmacy Stock), November 16, 2010.VHA Directive 2008-028, Access to Urgently Needed Outpatient Prescription Medications, May 16, 2008. VHA Directive 2007-033, Telephone Service for Clinical Care, October 11, 2007.The Joint Commission Comprehensive Accreditation for Hospitals, E-dition, January 1, 2013 (updated July 1, 2013).MCM TX-15, Use of Investigational Drugs in Human Subject in Research, February 2012.VHA Directive 2010-041, Smoking Cessation Benefit for VHA Employees: No-Cost Provision of Nicotine Replacement Therapy, September 16, 2010. VHA Handbook 1141.01 Home-Based Primary Care Program, January 31, 2007.MCM TX-01 Medication and Formulary Use, April 2013.RESCISSION: TX-08 Ambulatory Care Pharmacy Services, October 2010.FOLLOW-UP RESPONSIBILITY: Director, Pharmacy and Nutritional CareEXPIRATION DATE: Last work day of July 2016.MICHAEL J. MURPHY, FACHEDirector ................
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