CAPT Tami Rodriguez 0:00 Providers to do it, particularly in a correctional setting. Our goal as medication experts is to be integrated into the healthcare team, to work alongside our physicians, our APPs, our nurses and co-workers to support one another, ultimately, to improve the health of our patients. Next slide. Okay, so the part of my presentation is really going to talk about what the avenues are for pharmacists to be engaged in clinical care. So the first thing I want to talk about of scope is scope of practice, or the boundary in which a healthcare provider may practice. So for pharmacists, it's defined by state regulations and Boards of Pharmacy. It's increasingly shifting to clinical, patient-centered, team-based care, and every state has adopted different strategies to facilitate that. And there's a couple different ways this may look within the states that I'll go into. Next slide, please. So the first is Collaborative Practice Agreements. I imagine many of you on this call are familiar with this. And this is a formal agreement between a licensed provider, most often a physician who makes the diagnosis, who supervises the patient care, and the pharmacist who works under that agreement to perform specific functions. This can be population- specific or patient-specific. So patient-specific is the most restrictive, and that is a specific agreement between the provider and the pharmacist for one specific patient. And then the population-specific, which is what we see much more often is... focuses on a group of patients with shared characteristics or needs. These patients may have inclusion criteria. So this population specific CPAs allow pharmacists to add patients to their caseload as needed. For example, I was an HIV clinical pharmacist when I was in an institution, I had a Collaborative Practice Agreement to manage patients with HIV. So anytime we had a new patient enter our care with HIV, I could pick up and see them. I'd get their labs ordered, I'd start their immunizations, I'd renew their medications, talk to them how they were doing, adjust the medications as needed, and that's was all lined out in the CPA with what I was allowed to do. Next slide, please. So Collaborative Practice Agreements include a couple components that are listed here and Commander Valgardson will provide examples and details of what a specific collaborative practice may look like, but in general, it is an overarching authorization of everything the pharmacist can consider so can they order meds? Can they order labs? Can they discontinue? How do they monitor? How do they document? How do they refer the patient back to the collaborating providers needed? Requirements for training and demonstrations of competence, like peer reviews, are all outlined in a successful CPA. Next slide, please. So a couple other ways pharmacists can be engaged in clinical care are through autonomous prescribing or independent prescribing. And what that is, is the authority given to pharmacists that allows them to solely prescribe for any medical condition where permission for other healthcare providers, such as the physician, is not required, so through that autonomous prescribing, they don't need a CPA. There are a couple different ways that can look and the first is through a statewide protocol where every licensed pharmacist in the state who meet the requirements are authorized to prescribe certain medications, and this is authority granted through a state statute or regulation. So this could, for example, be that all pharmacists in a state may test for HIV and prescribe pre-exposure prophylaxis when the patient is at high risk for contracting HIV. Next slide, please. So the second type of autonomous prescribing is standing orders. This is somewhat similar to the statewide protocol. However, in standing orders, a physician or a person within a state agency or public health department signs the authorization to allow pharmacists to provide care. So for example, the physician from the State Health Authority would authorize pharmacists to test patients for HIV and provide pre-exposure prophylaxis. The difference is, is that if this position, or that granting authority were to leave the position, a new standing order under the new person that comes in would have to be signed, whereas a stand a statewide protocol is written into statute. Next slide please. The final type of autonomous prescribing is category-specific. So this is, in a statute, pharmacists are given authority by the state to prescribe certain categories of medications based on clinical guidance and professional judgment and. A great example of this is hormonal contraception. Some states, pharmacists are authorized in their pharmacies to prescribe an entire category of hormonal contraception, choosing the best medication for that patient based on clinical guidance and in consultation with the patient. Next slide please. So you're probably wondering, why are we talking about all these details? This is very confusing. There's lots going on, lots of different ways pharmacists can practice. And yes, it is. And there are. There are 50 states and 50 ways of doing things right now. So every state, the biggest thing I want to make sure that we take away from this presentation, every single state in the United States authorizes CPAs between pharmacists and prescribers. How that looks varies between state and I'll show some examples of that. But many states also have varying types and levels of autonomous prescribing as well. So for our local and state corrections folks that are on this call, this presentation's for you, there are ways your pharmacist can be involved clinically in your correctional institutions, and there are ways to find out, you know, what does my state allow? The first is ask your pharmacist. Pharmacists want to be involved clinically. This is what we were trained to do. We see a need, and we want to be there to help and support our coworkers and improve our patients' outcomes. So ask them, is there something you could be doing that we're not currently that the state would allow you to do? State Boards of Pharmacy will always on their website have those things that the pharmacists are are not able to do. And then finally, the NASTAD Pharmacy Database is a great database that summarizes everything allowed in each state. It was last updated, I believe, in 2022, so you want to make sure that everything's still accurate. If anything, states have allowed pharmacists to do more since then, but it is a great place to start to get an idea of what your state allows. So some examples, Idaho, for instance, is probably the most forward-thinking state when it comes to pharmacists as clinical providers. In 2019 they passed about bill that allows pharmacists to independently prescribe more than 20 classes of medications, to include conditions that do not require new diagnosis, conditions that are minor and self-limiting, conditions that can be diagnosed with a CLIA-w aved test, and for situations where the pharmacist, using their professional judgment, determines it to to be an emergency. In Idaho, pharmacists are also able to bill and be paid as a provider in their state, which is a big deal. Many states allow pharmacists to do clinical work, but do not pay them to do so. So that's a big deal in Idaho. In relation, West Virginia, my home state, is a little more restrictive, so they do have a statewide standing order for naloxone. This was prior to it becoming over the counter, but pharmacists could provide naloxone without needing a separate prescription from a provider. And they do also allow CPAs. Every CPA must be filed with the state and a fee must be paid. So that's where things are a little different between states, even if allowing a CPA, things could look differently on this slide here, you see a picture of California. This is taken directly from the NASTAD database. California is another very forward thinking state where pharmacists have statewide protocols for things like hormonal contraception, HIV, pre- and post-exposure prophylaxis, all approved vaccinations. They also allow collaborative practice agreements. They don't have to be filed. There is no fee. And they also have a category of pharmacists as licensed Advanced Practice Pharmacists. They have independent authority to initiate, adjust and modify drug therapy without requiring a Collaborative Practice Agreement, and they have some opportunities for payment for those services as well. Next slide, please. Want to talk a little bit about a hot topic, because it's corrections, and I can't get away without talking about OUD every day. So I wanted to talk a little bit about some of the specific and unique, unique regulatory implications for prescribing medications for Opioid Use Disorder, because there have been some very significant changes in the past couple years that I want to make sure this audience is aware of. So prior to 2021 we had the X-Waiver, data waiver, you had to have a special number on your DEA license to be able to prescribe buprenorphine or suboxone. That X-Waiver was only authorized for physicians and nurse practitioners and PAs. So even though the DEA authorizes pharmacists to register and have an independent DEA number in more than 10 states at this point, we couldn't get an X-Waiver, so we couldn't help if we wanted to legally by prescribing Suboxone. In 2021, the Consolidated Appropriations Act eliminated the requirement for the X-Waiver, so pharmacists under a CPA may be able to prescribe buprenorphine, and they certainly do in the bureau. An additional update was the OTP regulations, or 42 CFR Part 8. That's the next bullet. Maybe. There we go. So prior to updates that were implemented last year, the practitioner was defined as a physician who was appropriately licensed in the state and possesses an X-Waiver effective April 2nd, 2024 - thats the spring of last year, that definition of "practitioner" was updated and states that, for the purpose of this part, "practitioner" means a healthcare professional appropriately licensed by a state to prescribe or dispense medications for opioid use disorder, and they're authorized to practice within an OTP. So that change again, further allowed pharmacists to be engaged in Opioid Use Disorder care. And then finally, the Centers for, I never remember what this is called, Substance Abuse and Mental Health Services Administration, I'll get it eventually - Federal guidelines for OTPs also recognizes the importance of pharmacists as part of the collaborative practice, or the collaboration in treating patients with opioid use disorder, and state that here that pharmacist that services may be provided by many people, including a pharmacist. Next slide, please. So I'm sure Opioid Use Disorder is a hot topic for all of us in corrections, we will be having a specific presentation on how our pharmacists engage with OUD treatment on October 17. So stay tuned. That will be the Clinical Pearls series: #6. Next slide, please. So I want to show a little bit of evidence, because that's the question, right, is, does this? Does this improve outcomes? Do pharmacists engaged in care benefit our institution? Is this something we need to pursue. So as I mentioned earlier, pharmacists love research. We love evidence, and we're also not great at providing it ourselves. So these studies are are what we have so far. There's a lot more work being done, even in our own agency, to demonstrate the importance of pharmacists. Logic will tell us it's helpful, but we want to have the numbers because we are pharmacists. But in the studies that have been done this first one in 2019 by Funk et.al. did show that incorporating pharmacists into comprehensive medication management helped to decrease workloads patients receive... felt they were receiving better care. It enhanced professional learning and increased access to providers. Quality measures were approved, and providers reported that they felt reassurance that these patients medications were being managed safely. Next slide, please. There was also a literature review done that showed that incorporating pharmacists into clinical care had many different benefits, including economic and financial. We know what drugs cost. We wouldn't expect that one of our physicians or APPS to necessarily know that because they're not ordering, they're not seeing the actual cause day-to-day. So pharmacists were able to identify opportunities for cost savings. There was an improved quality of prescribing and a reduced number of medications. Believe it or not, pharmacists generally don't like a lot of pills. We really don't like polypharmacy, and we're really good at de-prescribing when it's appropriate, we can help resolve drug-related problems, help get therapeutic goal attainment for specific considerations and also the humanistic approach, pharmacists showed that they were able to educate their patients on what their medications do, how to take them and encourage them to do a better job taking them. Some other studies, there was a study done at the VA in Tuscaloosa in 21 that showed a 60% decrease in the number of patients, 60% increase and the number of patients who achieved therapeutic goals for their mental health treatment and a 32% decrease in the number of patients who were discharged and referred to a specialty mental health clinic when pharmacists were involved in their medication management for their mental health. The National Drug Abuse Treatment Clinical Trials Network also found a study in 2021 that showed when pharmacists were integrated into Opioid Use Disorder management and buprenorphine management, the patient was treated by the physician initially, then transitioned to a community pharmacy for six months. After six months, it resulted in over 90% of patients endorsing that they were very satisfied with their experience and the quality oftreatment offered, and that holding buprenorphine visits at the same place the medication was dispensed was very or extremely useful. We hear that for many patients, especially in the communities, that if we can combine services and do things in one place that increases engagement and care, and with that, I will turn it over to Commander Valgardson to talk a little bit about whatclinical pharmacy has looked like in our setting. Cmdr. Josh Valgardson 15:50 Thank you, Captain Rodriguez. I'll just start with one clarification: Episode 6 on Opioid Use Disorder. I do hope you all attend. It is not in October, though, as much as I'm sure you'd all like to hang around until then. It is in April. April 17, I believe is the date for that. So look forward to that. I think that it'll be a well attended, hopefully one, and we've got some great things to show that we've done with our clinical pharmacists. So I think we're at our last poll for today. We just kind of wanted to get a sense of those out in the field. What is your current sort of use of pharmacists? Using them, kind of in the traditional role, primarily for filling, maybe in a more clinical and traditional space they may fill, but also provide clinical services. Are you using pharmacists through teleservice, remote, not on site, no pharmacist integration whatsoever or something else? CAPT. Chad Garrett 16:46 Okay, that poll is open and we have 24 seconds left. Cmdr. Josh Valgardson 16:56 It's like the shot clock. CAPT. Chad Garrett 16:58 Exactly. Cmdr. Josh Valgardson 16:59 Missing good basketball right now. So I appreciate you for skipping out on basketball with me today. CAPT. Chad Garrett 17:05 We have about 20 folks who haven't answered yet, and you've got six seconds to do so. Okay, let me share those results with you. Cmdr. Josh Valgardson 17:24 It looks like a pretty even split from what I can see on my screen, maybe. CAPT. Chad Garrett 17:29 Yep, looks like "Traditional" and "Clinical" are tied, and then "Remote" has 4, "No pharmacist integration" is 3, and "Something else completely" is 3. "No pharmacist integration" is 6. "Something else" is 3. Cmdr. Josh Valgardson 17:47 Okay, great, very good. Well, hopefully today, I'll just briefly kind of introduce you to some things that we're doing within the Federal Bureau of Prisons that we have the capacity to do, and also, hopefully, again, what your appetite for some specific presentations in our series. So before we do that, let me just kind of those of you, especially if you're not a pharmacist, to kind of walk you through, I think the way most pharmacists tend to think so, we see a prescription, we use Mounjaro®, 10 milligrams subcutaneous once a week. So what's the kind of what's going through our minds? First thought, obviously, is, you know, where's the donuts and and the coffee, because, you know who's who's not thinking about that when they see the prescription for Mounjaro®. But of course, you know, then the flood of thoughts start to hit our minds. Is this a clinically appropriate prescription? Are there drug interactions, you know, is this a good formulary option so our liver, kidney function, adherence, concerns, precautions, indications, adverse effects, procurement issues. How are we going to provide this medication? Who's going to train on it, a device, if it needs training. You know, again, polypharmacy, as CAPT Rodriguez mentioned earlier, actually tend to be more focused on taking medicines away often than adding medications. Is there cost saving opportunities, drug allergies, patient education? Again, kind of all these things you can and, you know, I think obviously all of us as healthcare professionals on the call, these are things that definitely go through our minds. But I think the pharmacist is really trained towards focusing in on a lot of these things and maybe a more definitive or acute way. And so I think having that mindset really kind of leads us to that team-centered or person-centered care in a team-based approach. So I'm generalizing this, so I don't want to make it feel like that. This is always, you know, works out in these perfect spaces, and this is the only way to provide this care model. But I think in general, in a lot of situations we tend to see this happen. So on the left hand side, you have your practitioners, or those that may be focusing on that history and physical, the diagnosing, obviously, they're also heavily concerned about social determinants when they're evaluating their patients, screening, prevention, all these things are are kind of forefront of their minds. Pharmacists kind of can sit in the middle, on the right side, you know, you have kind of those that are more focused in on the delivery mechanism, so administering medications or other tools or services, patient engagement and education is kind of a big part, I think, on the right side, adherence and triage and again, all these I would I'm going to make sure it's very clear this is intermixed, right? Not, no, not one person does any of these things better than another, or fully versus another. But I think, as CAPT Rodriguez mentioned earlier, there's more work out there than usually people to provide it. And so really, kind of finding a way to to bridge that, to make sure the patient is still the focus of everything that we do, and a lot of places, you know, both within our system, really kind of also this is also true, but in out in our community settings, you know, our pharmacists tend to be kind of that middle man that has that easy access for the patient. Can really be, sort of be that bridge across the spectrum to make sure the patients have access to all spectrums of care and are receiving that - that focus that they need. So kind of, let me just introduce you to the Federal Bureau of Prisons, if you're not familiar with kind of, you know who we are, what we do. So we have 121 institutions located throughout the country. All the red dots on your screen there, we do have seven medical referral centers. These centers are those places where we tend to send our our sickest patients, those that need maybe more high acuity care, more nursing, especially focused care, maybe providing inpatient type services as well. We have around 200 pharmacists in general. I think our numbers around 210 currently. And we also provide a central pharmacy service, which I'll talk about here on this slide in the next a little bit. But we have, there's eight pharmacists assigned to 22 institutions that don't have a pharmacist on site. So they actually provide remote service, pharmacy services for those institutions. So they'll do order processing, you know, contact the physician, in some cases, also doing tele Clinical Pharmacy work as well, which I'll kind of get into here in more detail in a little bit. But they actually have all their medications filled through a central fill and distribution center. So we have one site that actually will process, and all those medications that get processed actually fill for those 22 remote sites. They also have a 23rd site they fill for that's a contract site, and so they'll actually send the medications to those patients for those centrally filled institutions. So there's about 30,000 of our patient population of about 150 total. So about 15 to 18% of our total patient population is actually filled through this central fill. Central fill itself, I think, is slated for six pharmacists. They had a few deserved promotions, and other things have happened. So I think they're a little short right now, and they manage about a 300 a little over 300,000 prescriptions on average per year, at about $30 million. There's a couple of pictures of the automation that they're using. We also do use, sorry, an automated dispensing cabinet Pixus is actually what we primarily use for administration medications within the institution. So all of our facilities have this structure set up to ensure that, you know, patients have access to the medications at administration, especially for emergent situations. So kind of delving into our clinical pharmacy program. So out of those 200- roughly, 200 pharmacists, 126 I just looked at the numbers this week, currently have a Collateral Practice Agreement. So as Captain Rodriguez mentioned earlier, we use CPAs as our structure for pharmacists have the ability to follow these patients and help manage the different chronic diseases that they're focused on. 82 of our pharmacists have some level of a board certification. I know Captain Rodriguez mentioned that kind of early in the presentation. So if you were asleep, then I'll hopefully wake you back up with this. Actually, I should say it the other way. I'm sure I'm putting you to sleep. She had you riveting in your chair, especially at the start. But we also have 27 pharmacists that have a National Clinical Pharmacy Specialist credential. So this is actually kind of unique to the federal system currently, and this is a separate credential that's given or certificate that's given to our pharmacist recognizing the quality of care that they're providing in their clinic. So this is in order to receive this credential, pharmacist has to submit a packet with outcomes for patients that they're following, as well as interventions that they're making. And then 23 of our pharmacists have actually completed some type of post graduate pharmacy residency, and we're definitely excited to have them, and would love to see that continue to grow. We also, in the future, would love to restart we had a pharmacy residency itself that we offered within the agency had some issues maintaining the position a few years ago, and we're working hard to try to get that back. And we'd love to see that program grow within the agency as well. The Cloud of Practice Agreement itself is just kind of a snapshot or snapshot of the first page of the document. And there's, there's a lot to this. I'm not going to go through this in major detail, but just kind of give you a little global overview of how we manage how we manage this or handle it, the document itself is designed and structurally set up to be... help our pharmacist focused on comprehensive medication management, especially the we have them set up on a two-year cycle, so they do require assessment/renewal every two years with the collaborating physician. Or if a new physician comes in and they need a new new oversee, a new clinical director comes in, I should say they need to have a new signature, they'll recreate the CPA at that time. We also do require, as part of the CPA, annual reporting outcome. So every year we do have our pharmacist report outcomes for the patients that they're following. Actually, just within the last year or two, we enhanced and improved, or actually really kind of established a peer review process for our clinical pharmacist. So that's now kind of a new feature. With our cloud of practice agreement with each renewal, it does require the pharmacist to have a peer review completed by another pharmacist, kind of familiar with their situation or the disease states that they manage, and their structure built into the CPA for referrals to outside of maybe the practice area, the pharmacist expertise, so that if they need to refer a patient to a higher-level of care or more specialty care, they can do that as well. There's an area, so for the physicians who are reviewing these really try to build this so that it's would give the physician a good sense of A.) What is the pharmacist going to do? And then B.) We wanted to make sure that the physician felt comfortable with the training of the pharmacist. Now, again, as Captain Rodriguez mentioned earlier, the innate training within the Pharm.D. program curriculum now is really geared towards clinical pharmacy and managing chronic disease. But in addition to that, most of our pharmacists will have some additional training, and we encourage them to continue to receive that as well. So we have a space so the pharmacist can document all of their credentials, extra certificate programs and other things that they've completed, as well as their continuing education. That way, it really kind of helps the physician or provider who's signing this the CPA to be comfortable and aware of the different training that the pharmacist might have for as part of their CPA. And then finally, we do designate prescriptive authority by drug class. So we do have the pharmacist have access to different prescriptions that they can order without co-signature based off what's in the CPA. So a pharmacy visit itself, this is just kind of a, I'm not going to go through each of these really in detail. This kind of gives you an idea, not outside the scope of really kind of any other discipline. You know, I think every discipline, when they do clinic visits and they see patients, they tend to follow somewhat similar models, from patient to patient. Pharmacists will do the same thing, generally speaking, you know, we're definitely focusing on history, especially most recent history for the chronic disease that we might be following, but our focus then really kind of hones in on the medications themselves. I'm going to actually share a case here in a minute that'll kind of look at that in a little bit more detail, but, but it's not just limited to medications. I want to make sure that's kind of clear our pharmacists are doing sort of comprehensive sort of comprehensive patient evaluations. So we will look at vital signs, do limited physical assessments. We can order labs, look at the labs, interpret those. You know, we often will need to contact a provider to maybe add a diagnosis for a patient-based off a lab result, or to adjust a diagnosis as things improve or change as well. And so there's a lot of communication that goes back and forth with that as well, the everything that we do, we document, you know, in our electronic health record, and so our physicians or other prescribers who are overseeing the pharmacy clinics will have an opportunity to really, kind of see all the things that we might discuss with the patient during our clinic visit. So I think, really, what I'm hoping you'll see is that, obviously, as was has been mentioned several times now, is just how busy we are. You know, you've got your prescribers on one side that are diagnosing patients with all these chronic diseases, which are very time intensive to do education on, especially for a lot of these men - A lot of these chronic diseases require intensive medication follow up and so, you know, making sure that patients have, you know, access to these I think the pharmacist really is a great mechanism to bring in to really kind of help assist with this flow, so they can kind of take away some of that workload from, you know, our prescribers, who often are just overworked and overburdened, and the pharmacist can really step in and help with those follow-ups provide that but easier access, as was mentioned earlier, to the patients, help with, you know, lab ordering and follow-up, screening, prevention and immunizations, all those kinds of things. So let me give you an example, maybe, of a quick patient case. So here we have a 55 year old Hispanic female. She's referred to our pharmacy clinic for anticoagulation service. She's on warfarin for amechanical heart valve. So that's what she's being seen for today. And pharmacist sitting down in the clinic, and you know, they looked at, look at the patient list or problem list, and see the patient's got that mechanical heart valve, but also has a diagnosis of hypertension, two prior MI's (2011, 2018) hyperlipidemia, GERD, and Osteoarthritis. So looking at kind of some pertinent, maybe vitals and labs, blood pressures, you can see are a bit elevated for the most part. And then labs, so A1C (5.9%), LDL (110), kidney function, serum creatinine (0.85), H/H, which would be, obviously the one of the primary focuses in the clinic to see if the patient might have bleeding. Platelets look okay. Hemoglobin looks fine. And then the INR, which is kind of the focus of the visit today, is 2.75 which was in this patient's goal range. Looking at the full medication list for this patient, though, we see, you know, she's on quite a few other medications, obviously. So couple medicines for the blood pressure, amlodipine, lisinopril, she's on aspirin with prior MI, atorvastatin, also for the MI and the hyperlipidemia, famotidine for the GERD, clopidogrel presumably for the MI post-surgery, ibuprofen for the Osteoarthritis likely, and then the warfarin for the mechanical heart valve. So what are kind of things that are major of concern today, right? So in the visit, obviously, this is an anti coagulation visit, so really, we would want to focus on those things first. And bleeding risk is would be top of mind for this patient. You know, 55 year old, Hispanic female. She's getting older, she's obviously going to be at a higher risk for bleeding. Really, kind of looking at this, she's really on a quadruple whammy for medications that can cause bleeding. So why is this patient still on clopidogrel, might be the question. So at this point, I would probably want to stop the clopidogrel. I think in a lot of cases, we would, you know, discuss with the physician, maybe some alternative reasons why the patient could be on the clopidogrel. But if it was just strictly for those MIs you know, you're talking, you know, 2018 was the last one, you know, unless you had other high risk factors, probably not really needed anymore at this point. In addition for that bleeding risk, we would think probably GI protection would be a little better with the omeprazole in general. But something that, you know, I think, I wanted to point out is that through the interview, I didn't tell you this, but I'm telling you now, the pharmacist found out that the omeprazole wasn't really working for the GERD symptoms anyway, and so famotidine probably wasn't the best choice just for that management. Or so considering a dose increase might be good, but maybe actually changing to a better medication for GI protection in this patient at high risk for bleeding. Ibuprofen to acetaminophen seems like a pretty easy recommendation at this point, our adjustments to the pharmacist can make that change. You know, Osteoarthritis, first line treatment really should be acetaminophen anyway, and just being at that high risk for bleeding, that would be something that I think the pharmacist would likely key in on. But I just wanted to kind of again emphasize that the pharmacist really has the opportunity to do comprehensive management of medication for this patient. So while the focus is on the anticoagulation for the day, you know, if all we did was look at the INR and say, yep, she's good, clinic done, you know, we could send her on her way. There's a lot of other opportunity that could be missed here. So, you know, we noted the hypertension really not well-controlled lisinopril. So it could, pharmacist could increase the dose of that medication, LDL, at 110 it's probably a little elevated for somebody with prior MI you know, again, there's a lot of other factors to consider, but may not be unreasonable to bump that stat to a higher intensity, and then that 5.9 A1C that patient's in the pre-diabetes range, and so, you know, if they haven't already received counseling education on diabetes prevention, I would definitely say that's a top of line important thing to review in this visit. And if the patient, you know, maybe even even offering that for them today, maybe this is a situation where this is a known thing, and this is kind of number two, you know, I think the pharmacist might be more aggressive towards recommending that medication in that situation. And then, of course, I don't want to leave out our screening and prevention. So, influenza vaccine probably recommended today, if it's not been received already. There's probably other some other vaccinations. This patient might be a candidate for that the pharmacist could review the CDC chart and recommend. So hopefully that gives you a little better picture of pretty typical visit for a lot of our clinical pharmacists. This will give you an idea of kind of where our pharmacists focus their their caring currently. So this is based off our Collaborative Practice Agreement for practice agreement focus areas that we had, as you recall the earlier, anticoagulation is still our number one. I think this is a lot of places, a lot of pharmacists tend to get their foot in the door clinically in anticoagulation, and then just see it grow. This actually has decreased, to be honest with you, over the last few years, just because we don't have as many patients on warfarin anymore. But diabetes has progressively gone grown over the years. Hepatitis has been especially focusing on hepatitis C elimination has been key, and then Opioid Use Disorder. I'll talk a little bit more about that. What we've seen with that, but that one's been our big grow over the last couple of years. Here you can see the encounter numbers for fiscal year 2024 so last year, we had almost 25,000 encounters. So I felt bad in myself. I should have just done five more clinic visits last year. I could have pushed us up over that 25,000, but you can see, opioid use disorder is by far and away, our largest currently, but we really have pretty robust management. And this is actually not every one of them. This was obviously just the top grouping of the areas that our pharmacists have done clinics for over the last fiscal year. And then outcomes I mentioned earlier every year the pharmacists are expected to submit outcomes. So I just picked kind of some top line ones from last fiscal year, viral hepatitis followed over 550 patients, 246 cures, pain management: 182, patients followed, improving their spasm scores. 91 new patients with HIV followed. And this has been a pretty typical thing. I'm going to talk about our consultants here, real quick, here in a minute. You can see they improved viral load suppression from 69% on intake to 97% and they maintain that for basically all patients once they're integrated into our care. And then lastly, diabetes and my passion. So 674, patients followed by our agency last year. And you can see a pretty dramatic decrease in A1C amongst patients followed within our clinic. This is just a kind of a maybe a little bit of a teaser. So episode 9, the very last one. I hope you'll stick it out through the the end of them all while I will be joining you again. Hopefully I've done a good job today. We have a really great pharmacist that's going to be joining me, and I look forward to having him and share some of his experience. But I think this might be something new to a lot of corrections facilities. I'll just say, from my experience, when I got started down the path of trying to figure out how to bring diabetes technology into our system. I asked the different companies who made these products, you know, what the experiences they had in correctional environments? And there was nothing. So, you know, I really felt like I was a little bit out on an island by myself, but we were able to integrate continuous glucose monitoring. So this is actually one institution, about a year and a half worth of data. So October, sorry, January 1st, 2023, is when we officially started using this, and we've really found it to be quite effective, and the patients love it, and it's really been kind of a life changing thing for a lot of them. And so we're looking forward to continuing to see this grow. You can kind of see a little bit of a snapshot over that time period we provided, provided it to over 150 patients, and you can see the A1C lowering amongst patients who had used it. This actually is pretty impressive to me. One pharmacist, had reported for this is Opioid Use Disorder management, over 1000 patients screened for treatment. They met themselves, started treatment for 486 patients. They regularly follow about 180 to 200 patients, and then 350 patients had released from custody on Opioid Use Disorder treatment under their care. And you know, no patients had had reported any overdose deaths associated with patients enrolled in the in treatment in this clinical pharmacist space. So even one pharmacist, you can see the impact that they have. You know, obviously this, this pharmacist is as a site that has good support, lots of actually a good team to allow them the time to do this. But even we have great pharmacists at small sites that are by themselves, that are doing a lot of impressive work and really kind of making sure our patients have access to the medications as well as treatments that they need. Kind of finishing off here, I just wanted to introduce this our clinical pharmacy consultants. A lot of the presenters you'll see in our series are actually members of our consulting groups or leads in 20... 2004, excuse me, the agency really kind of saw a need to help, maybe direct things a little bit with regards to high cost or high complex disease states. And so HIV was the initial group started, followed by hepatitis C. These are collateral duties and remote work that our pharmacists will provide. They receive advanced training, and they really kind of considered the subject matter experts for the agency. So they provide consultative services to, you know, other pharmacists, but as well as many other different disciplines, and they've actually become key and relied on a lot. So they get a lot of focused questions for really complex cases that can help guide provider teams and managing our patients. And they do often review non-formula requests to make sure that, you know, we're using medications appropriately based off of our formulary and what's best for our patients. They help with education program development, and then kind of new to their table, we added on that peer review. So they really help us with making sure that we get expert peer reviews done, so that our pharmacists really get good feedback on ways to improve their clinical care and services. So this will give you a little bit of a maybe a picture, back to that slide of the BOP as a whole. So you might have an HIV consultant that's, you know, stationed in Minnesota. This is a backwards, wrong direction, the simplified version. So they may have three institutions that they're assigned to that have questions, and so they'll be able to reach out and assist these facilities to really kind of help them in areas where, otherwise, you know, they might have to send outside to a specialist or something. So it's really kind of a method to help provide more timely follow-up and feedback and suggestions, as well as to save on on cost. So the HIV, Hepatitis C is one of the others you can see, kind of that same touch point. And again, this is a simplification. Most of our consultants oversee or have assigned regions to them. So they might have 10 or 15 or 20 institutions that they have a sign that that can reach out if they need something specific to that disease state. And the other there's five totals. We have antimicrobial stewardship, mental health, and substance use disorder. So you can really see the power just having one or two individuals to have these touch points to really assist at a larger scale, having these consultants, consultants in place. This slide, just in lieu of time. I'll probably not go through many of the details here, but you can see on average, we have anywhere between 10 to 20 pharmacist consultants within each of our groups, and I mentioned earlier, a majority of what they do is you can see some of the numbers of non-formularies that they reviewed. You can see some of the outcomes. Again, I mentioned earlier that, you know, HIV consultants improving the suppression from 32 to 96% maintaining that routinely. But we also have our viral hepatitis who are working on eliminating hepatitis C from the agency. Our mental health consultants are heavily involved with a lot of education and review of of our really complicated mental health patients. Antimicrobial Stewardship. You can see some of the improvements that they have found in some of their initiatives and and campaigns to help improve antimicrobial prescribing. And then our newest on the block is a Substance Use Disorder Consultant Pharmacists and there really have been key in helping drive the increase in the number of OUD treatments that we provided throughout the agency. So just in conclusion, again, I hope that you've got a better feel, if you weren't familiar already, of what a role that a pharmacist can be, and you know what access they can provide from comprehensive medication management, looking at different state regulations. Obviously, every state's gonna have different scopes, but as Captain Rodriguez mentioned earlier, it's growing, and I think it will continue to grow. I think that a lot of individuals, I think a lot of payer systems, and I think a lot of states, boards of pharmacies as well, just advocating for the power of what a pharmacist can do in the access of what a pharmacist provides, is really kind of expanding that scope of what of an integrating care and into primary care of our pharmacists. And then finally, us, you know, we, we definitely use those collaborative practice agreements, and I'm more than happy to kind of share if anybody has any questions or needs any assistance, or, you know, would like some information about how we've integrated. You know, please reach out to myself or Captain Rodriguez. We'd be happy to share some of our experiences, as well as some of our documents and procedures. So I think at that point I will stop. It's hard to tell in presenter mode even what time it is, so hopefully I didn't go too far over. CAPT. Chad Garrett 42:07 No, my friend, I think it was just about perfect. Cmdr. Josh Valgardson 42:14 Well, thank you. CAPT. Chad Garrett 42:16 So... and just like that, believe it or not, that went by really, really quick. So on behalf of the National Institute of Corrections, I wanted to extend a sincere, thank you for your time, attention and engagement. We know & understand that your time is valuable, so we appreciate you spending some time with us, which is just awesome. Speaking of things coming up, don't forget our next session, where we'll be diving into eliminating hepatitis C with Commander Katrina Klang and Lieutenant Commander Alex Brorby, trust me, not, a session you want to miss. It's going to be amazing, but if perhaps you do miss it, remember these sessions will be recorded and will be posted on the Clinical Pearls Website, and we have in the chat posted how to get to that website. So until then, keep pushing boundaries, keep questioning the status quo, keep striving for the kind of patient care that makes a real impact. And thanks again. Stay curious. We'll see you next time. Um, actually, we'll see we've got time maybe for one or two questions. Chris, do we have any questions? Christopher Smith, NPA 43:29 Yeah, Chad, we haven't had any questions. So if anybody has a question, if you want to type it in real quick and give us a chance to look at it, and I can read it out, but while we're giving you a moment just to look at it, we did get a comment chat from Cassandra Obi, and I just want to let you know, if you're interested in further discussing your comment, Cassandra, you're welcome to reach out to Captain Rodriguez, and she can get with you, one-on-one, on your information that you put in the chat. So I appreciate it. Thank you for the statement. Looks like we just got one question. How does someone find a clinical pharmacist to help manage? CAPT Tami Rodriguez 44:11 Yeah, so I can, I can answer that really most pharmacists, particularly any pharmacist that's graduated or recently wants to be clinically involved. So advertising your positions in a way that indicates either you are already including clinical services or you want to expand those will attract those pharmacists that want to be engaged in clinical work. As I mentioned, we're, this is what we're trained to do in school. We spend four years talking about clinical pharmacy. We have you actors that we have to talk to about STI treatment. And, you know, I mean, we're, we're actively trained to do this. And for me, I worked retail. When I first got out of school, I was kind of a shock that I. Wasn't able to use my clinical training at the extent I had expected to. So you're going to find that pharmacists want to do this work and really just giving them the opportunities to do so most will run with it. I saw there was a question about seeing institutions or site tours. Dr. Tapley, I did get your email, and absolutely love information sharing. The California Department of Corrections, I don't know if anybody is on from there, they were wonderful about letting us come visit them and see how they do things, and we certainly love to provide the same opportunities. So Dr. Tapley, I will follow up with you after the call. And for anybody else, please feel free to reach out to Commander Valgardson and I, and we can certainly share as much information as we're able to. Christopher Smith, NPA 45:52 Thank you very much. Deborah Rodriguez, it looks like we have one more question I got put in by Michelle Guard says, "Because BOP pharmacists work within a health system, does this change the number of provider, pharmacist relationships needed?" Cmdr. Josh Valgardson 46:09 I might be able to just speak to that really quick. I mean, it's, I don't know that that's, that's, that is definitely a loaded question. I think by institution that can be a challenge, right? So I think every institution has different needs, and so we don't necessarily have a set number of like pharmacists per to provider kind of settings. And so I think that what we've found is that in most instances, regardless of even if a provider kind of team that's designated for the site is is fully staffed, a lot of times, there's still space that they the pharmacist is needed or could be used. Other instances where maybe they have a hard time filling the positions at all, and so that really, the pharmacist can step in. And the challenge is, obviously, you still the pharmacists don't have prescriptive authority, or, sorry, diagnostic authority, so they're not diagnosed. We're not diagnosticians. We're not trained to do that. So we would need somebody who obviously can legally do that and or is trained to do that, to get the diagnosis in place. But really, you know, freeing up the time for that has really been critical in most of our situations, to, you know, allow, you know, our patients to receive as the care that they need. CAPT. Chad Garrett 47:13 Well, thank you, and that puts us just at time. So thank you again. To my speakers. You guys are wonderful. I always enjoy listening to you, and for all the people who are still on and still out there, I want to challenge you to keep pushing those boundaries, keep questioning the status quo, and keep striving for the kind of patient care that makes a real impact. Thanks again. Stay curious, and hopefully we'll see you next week. Thank you very much. Christopher Smith, NPA 47:46 Take care, everybody.