Centralized Specialty Medication Management
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Share PrintSpecialty medications taken at home are expensive, complex to administer, and have unique side effect profiles. Centralized Specialty Medication Management (CSMM) connects specialty pharmacists with Veterans initiating select specialty medications for detailed education and close monitoring. This innovation contains costs (with a positive ROI) and improves medication safety while achieving high satisfaction from both Veterans and providers.
Origin:
January 2020, William S. Middleton Memorial Veterans' Hospital (Madison)
Adoptions:
2 successful, 1 in-progress
Awards and Recognition:
Clinical Pharmacy Practice Office Best Practice
Partners:
Academic Affiliations, Clinical Pharmacy Practice Office, Dermatology, Gastroenterology and Hepatology, Neurology, Rheumatology
Recent Updates
Overview
The problem
Specialty medication can drastically improve patient health and quality of life but are very expensive. Prior to the approval of currently available specialty medications, work disability impacted 22-44% of patients with rheumatoid arthritis. Biologic agents, a subset of specialty medications, can allow Veterans to return to normalcy and improve the associat
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Specialty medication can drastically improve patient health and quality of life but are very expensive. Prior to the approval of currently available specialty medications, work disability impacted 22-44% of patients with rheumatoid arthritis. Biologic agents, a subset of specialty medications, can allow Veterans to return to normalcy and improve the associated pain, fatigue, and anxiety. Biologics are expensive and even a few Veterans starting specialty medications can have a significant impact on pharmacy budgets. These biologic agents account for only 2% of US prescriptions but cost $120 billion annually or 37% of net drug spending. As biologics are subcutaneous and require self-injection at home, they can be difficult for patients to administer. Up to 40% of patients require administration technique re-education. Biologic agents have complex adverse effects, including increased risk of infection and injection site reactions.
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Images
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Problems associated with specialty medications include cost, complex side effects, and are difficult to use
The solution
The Centralized Specialty Medication Management (CSMM) clinic presents an opportunity for VHA to embed ambulatory care specialty pharmacists to closely monitor Veterans on specialty medications and coordinate care with specialty providers. CSMM improves quality of care and adherence while containing costs. To support Veterans initiating specialty medications
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The Centralized Specialty Medication Management (CSMM) clinic presents an opportunity for VHA to embed ambulatory care specialty pharmacists to closely monitor Veterans on specialty medications and coordinate care with specialty providers. CSMM improves quality of care and adherence while containing costs. To support Veterans initiating specialty medications, the CSMM clinic was started in January 2020 at the William S. Middleton Memorial Veteran’s Hospital in Madison, WI. This pharmacist-led clinic performs detailed new medication education with close monitoring for Veterans staring select specialty medications throughout the first year of use. The clinical pharmacist practitioners (CPPs) use the VHA advanced pharmacy practice model and leverages telehealth to increase Veteran access.
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Images
Above:
Poster presentation by PharmD Albright, White, Simonet and Margolis given at ASHP Midyear
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Pharmacist completing education for a biologic specialty medication
Links
- Article published in 2022 in the Journal of the American Pharmacists Association describing the CSMM clinic and initial implementation results Feasibility of a centralized specialty biologic medication management clinic at a VA hospital
The results
The CSMM clinic has established feasibility at two VA systems (Madison, WI and Milwaukee, WI). During the first year of the Madison VA CSMM clinic, pharmacists conducted 28 new medication educations, 133 follow-ups, made 11 medication changes, and 5 medication storage corrections. Today, the Madison VA CSMM clinic manages about 175 patients annually, totalin
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The CSMM clinic has established feasibility at two VA systems (Madison, WI and Milwaukee, WI). During the first year of the Madison VA CSMM clinic, pharmacists conducted 28 new medication educations, 133 follow-ups, made 11 medication changes, and 5 medication storage corrections. Today, the Madison VA CSMM clinic manages about 175 patients annually, totaling 2 million dollars of medication use with 0.3 pharmacist FTE. On average, 12% of interventions have cost savings implications and the clinic conservatively saves $787 per patient. The cost savings the CSMM pharmacists generate is about 50% greater than the cost of the clinic.
When compared to standard of care, CSMM pharmacists improve the quality of Veteran medication use. The CSMM clinic supports Veteran staying on their specialty medication, minimizes injections site reactions, and corrects medication doses and administration technique. The CSMM pharmacists have high Veteran and specialty provider satisfaction. As stated by a dermatology physician colleague, “The Centralized Specialty Medication Management clinic provides high value to my partners and Veteran patients in improving patient safety and adherence. I believe this program should be scaled to other VAs to broaden impact. Injectable biologics are relatively safe and highly effective treatments, but can lead to expensive medication waste or adverse events when incorrectly used.” A rheumatology physician added “It has been my experience that the CSMM service has significantly improved the consistent use of newly prescribed medications and has decreased the number of times medications have been discontinued for reasons that could be remedied before the next scheduled clinic visit.” See more
When compared to standard of care, CSMM pharmacists improve the quality of Veteran medication use. The CSMM clinic supports Veteran staying on their specialty medication, minimizes injections site reactions, and corrects medication doses and administration technique. The CSMM pharmacists have high Veteran and specialty provider satisfaction. As stated by a dermatology physician colleague, “The Centralized Specialty Medication Management clinic provides high value to my partners and Veteran patients in improving patient safety and adherence. I believe this program should be scaled to other VAs to broaden impact. Injectable biologics are relatively safe and highly effective treatments, but can lead to expensive medication waste or adverse events when incorrectly used.” A rheumatology physician added “It has been my experience that the CSMM service has significantly improved the consistent use of newly prescribed medications and has decreased the number of times medications have been discontinued for reasons that could be remedied before the next scheduled clinic visit.” See more
Images
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Veteran testimonial about CSMM clinic
Metrics
- Veterans were 25% less likely to discontinue their new biologic at one year due to adverse effects. This was attributed to management of injection site reactions (60% CSMM, 13% control; p=0.009). Figure 1
- CSMM pharmacists make or recommended medication changes for 1 in 5 Veterans and corrected storage requirements in 1 in 10 Veterans. Table 1
- CSMM clinic conservatively save $787 per patient seen. The cost avoidance related to CPP interventions was 149% compared to the cost of the pharmacist to run the clinic. Cost savings was primarily due to medication adjustments and replacement of defective devices.
- CSMM service has high Veteran satisfaction with a mean overall satisfaction of 4.92 out of 5 (excellent). All patients said they would choose to use CSMM again if prescribed a new specialty medication.
- In January 2024, the Milwaukee VA implemented CSMM and corrected injection technique in 40.5% of patients. Figure 2
Diffusion tracker
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Multimedia
Images
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Table 1: CSMM outcomes following Biologic Medication initiation.
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Figure 1. Kaplan Meier survival plots agents comparing CSMM and usual care for medication discontinuation due to safefy.
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Figure 2. Poster presentation by PharmD Furley, Margolis, Uildriks, Jablonski, McGill and Koch given at Pharmacy Society of Wisconsin 2024 Educational Conference
Implementation
Timeline
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Month 0
- Review the Clinical Pharmacy Practice Office CSMM toolkit- Identify medications for CSMM and subsequent patient volume of new medication starts (Suggested initial medications: adalimumab, etanercept, ixekizumab, risankizumab, secukinumab, ustekinumab)- Identify current process for new biologic medication education and ongoing monitoring/maintenance-Meet with pharmacy leadership -
Month 1
- Establish workgroup of CSMM pharmacists, pharmacy leadership, and key specialty providers for service development and collaboration- Ensure all CSMM pharmacists have allocated time for program development and management -
Month 2-3
- Dedicate necessary time and staff to CSMM clinic (for initial clinic implementation, recommend ratio of 0.1 pharmacist FTE per 50 annual new formulary approvals)- Develop necessary clinic materials, including templates, disease state questionnaires, patient education materials, and scope of practice- Submit new clinic grid request through local process -
Month 4-5
- Marketing of service in collaboration with specialty clinics and specialty providers- Self-education of the Clinical Pharmacy Practitioner (CPP) if needed- Consider new CSMM pharmacists shadowing established CSMM pharmacists at other VAs (can be virtual) -
Month 5-6
- Patient identification and scheduling- Begin seeing patients- Take note of inefficiencies or pressure points during initial implementation- Reach out to other VAs with established CSMM clinics for collaboration and suggestions -
Ongoing
- Track clinic utilization and productivity- Consider expanding list of biologic medication, disease states and specialty clinics- Consider conducting patient satisfaction interviews and/or tracking CPP interventions
Departments
- Dermatology
- Gastroenterology
- Pharmacy
- Allergy, asthma and immunology
- Rheumatology
- Neurology
Core Resources
| Resource type | Resource description |
|---|---|
PEOPLE |
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PROCESSES |
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TOOLS |
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Links
- A step-by-step guide for implementing CSMM at a local VA created after winning CPPO Strong Practice Competition CSMM implementation toolkit
Support Resources
| Resource type | Resource description |
|---|---|
PROCESSES |
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TOOLS |
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Risks and mitigations
| Risk | Mitigation |
|---|---|
| Pharmacist FTE |
CSMM supports pharmacy budget stewardship and saves more money than it costs to run the clinic. VAs interested in implementing a CSMM clinic can consider re-allocation from among ambulatory care and/or formulary pharmacists. |
About
Origin story
The Madison VA has a progressive pharmacy practice with a strong history of innovation. In recent years, there was an increase in specialty medication use and associated cost. Many specialty clinics had an increase in specialty medication prescribing specialty medications without an embedded pharmacist. In 2019 discussions began to pilot a pharmacist-managed
...
The Madison VA has a progressive pharmacy practice with a strong history of innovation. In recent years, there was an increase in specialty medication use and associated cost. Many specialty clinics had an increase in specialty medication prescribing specialty medications without an embedded pharmacist. In 2019 discussions began to pilot a pharmacist-managed centralized specialty medication management program to improve Veteran education on specialty medications with close monitoring. This allowed for improved Veteran care and pharmacy budget stewardship.
Original team
Tyler Albright
Clinical Pharmacy Practitioner
Amanda Margolis
Clinical Pharmacy Practitioner; Associate Professor
Anna White
Clinical Pharmacy Practitioner
Ryan Simonet
Clinical Pharmacy Practitioner
Ellina Seckel
Associate Chief of Pharmacy
Andrew Wilcox
Chief of Pharmacy
Comment
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