Advancing ambulatory pharmacy practice through a crisis: Objectives and strategies used in an ambulatory care action team's response to the ...
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Advancing ambulatory pharmacy practice through a
crisis: Objectives and strategies used in an ambulatory
care action team’s response to the COVID-19 pandemic
Tina Do, PharmD, MS, BCPS,
Department of Pharmacy, Yale New Purpose. The objectives and strategies used by an ambulatory care
Haven Hospital, New Haven, CT, USA
action team operating within a large health system’s pharmacy incident
Steph Luon, PharmD, BCACP, BCPS, command structure during the initial response to the coronavirus disease
Department of Pharmacy, Yale New
Haven Hospital, New Haven, CT, USA 2019 (COVID-19) pandemic are discussed.
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Kimberly Boothe, PharmD, MHA, The
Kimber Boothe Group, LLC, Cincinnati, Summary. In a time of crisis, a pharmacy ambulatory action team was
OH, USA formed to provide ambulatory clinical pharmacy expertise and meet an im-
Martha Stutsky, PharmD, BCPS, mediate and ongoing need to limit nonemergent care during the COVID-19
Department of Pharmacy, Yale New pandemic. By building a strong communication infrastructure and part-
Haven Hospital, New Haven, CT, USA
nership with ambulatory care providers, clinic medical and operational
Marie Renauer, PharmD, MBA, leaderships, clinical laboratory staff, and infusion centers, the team was
BCACP, Corporate Pharmacy Services,
Yale New Haven Health, West Haven, able to swiftly execute solutions and respond to new issues and requests.
CT, USA Ambulatory care pharmacy practice continued to advance through provi-
sion of services to vulnerable patient populations with chronic conditions
that were anticipated to experience gaps in care management during the
COVID-19 pandemic. These efforts resulted in expansion of pharmacists’
involvement in collaborative drug therapy management, support of pa-
tients’ transition from in-clinic injection to home self-administration, pro-
vision of medication assistance support, and management of 1,300 pa-
tients via protocol-based warfarin management. Additionally, ambulatory
pharmacy services in 15 primary care, anticoagulation, and specialty clinic
sites were transitioned to telehealth. The ambulatory action team also im-
plemented several strategies to manage medication therapy associated
with COVID-19–related shortages and implemented electronic decision
support to guide prescribing of hydroxychloroquine and azithromycin.
Conclusion. Building a strong communication infrastructure and a phar-
macy ambulatory action team were essential to respond to a crisis and
continue ambulatory clinical pharmacy services expansion.
Keywords. ambulatory care, coronavirus, COVID-19, pharmacy practice
advancement, pharmacy service
Am J Health-Syst Pharm. 2021;78:720-725
T he coronavirus disease 2019
(COVID-19) pandemic has tested the
emergency preparedness of healthcare
had 2.4 million outpatient encounters
in fiscal year 2018. The largest hospital
in the system, Yale New Haven Hospital,
facilities and created new challenges and houses its own retail pharmacy, and all
opportunities for the delivery of ambula- YNHHS hospitals are networked to an
tory care, including pharmacy services. integrated specialty pharmacy.
Address correspondence to Dr. Do Yale New Haven Health System (YNHHS) Prior to the COVID-19 pandemic,
(tina.do@ynhh.org).
is a large academic health system con- the YNHHS pharmacy department
sisting of 5 hospitals (with a total of 2,563 was implementing strategic expan-
© American Society of Health-System licensed beds in fiscal year 2018) and a sion plans that aligned with American
Pharmacists 2021. All rights reserved.
For permissions, please e-mail: journals. physician foundation of more than 130 Society of Health-System Pharmacists
permissions@oup.com. community practices in Connecticut, (ASHP) Practice Advancement Ini
DOI 10.1093/ajhp/zxab063 Rhode Island, and New York. YNHHS tiative 2030 goals to ensure patients
720 AM J HEALTH-SYST PHARM | VOLUME 78 | NUMBER 8 | April 15, 2021AMBULATORY CARE ADVANCES DURING COVID-19 Note
have access to a pharmacist in all care Communication
settings.1 One of these strategies was KEY POINTS One of the first objectives assigned
to integrate and advance ambulatory • The formation of a pharmacy to all the YNHHS pharmacy action
clinical pharmacy services across the incident command structure teams was to establish clear and ef-
health system. At the onset of the pan- and ambulatory care ac- fective channels for communica-
demic, the pharmacy department’s tion team facilitated a strong tion with key stakeholders across the
strategic plan projects were tempor- communication infrastructure health ecosystem. The key strategies
arily halted to respond to the imme- and connection with all key were to (1) identify key partners, (2)
diate need to limit nonemergent care stakeholders. confirm methods of communication,
and create surge capacity for patients and (3) facilitate sharing of informa-
• Ambulatory pharmacy practice
with COVID-19. In response, YNHHS tion. The key partners for the ambu-
can advance during a time
initiated a hospital incident command latory action team were identified as
of crisis through identifica-
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structure (HICS) for system oversight the ambulatory care providers, clinic
tion and closure of gaps in
of system incident management (SIM). medical and operational leaderships,
care management for vulner-
A pharmacy incident command struc- clinical laboratory staff, and infusion
able populations with chronic
ture (PICS) was deployed to integrate centers. The main methods of com-
conditions.
with the HICS and create an infrastruc- munication were reporting at SIM am-
ture to manage long-term emergency • Focusing on patient access to
bulatory action team meetings and
response demanded by the pandemic. clinical and laboratory services,
electronic communication via an SBAR
The PICS included a commander, do- medication access, and drug
(situation-background-assessment-
main chiefs, and action teams. Action use policy management is im-
recommendation) format.
teams were diverse and functional portant in maintaining patient-
workgroups formed to execute iden- centered care during a pan- Patient access
tified objectives and strategies during demic.
Another objective of the ambula-
the pharmacy department and health- tory action team was to ensure ambu-
system emergency response. latory pharmacy services supported
An ambulatory action team was outpatient care as providers and nurses
formed. The team comprised a team were redeployed to inpatient care areas
lead, alternate lead, and membership patient care or medication concerns in response to increased surge capacity.
across the system pharmacy enterprise, conveyed from the SIM structure or Prioritization was given to supporting
including adult, pediatric, and on- front-line pharmacy practitioners were areas with established ambulatory
cology ambulatory clinical pharmacy discussed at daily PICS meetings in pharmacy services, where existing rela-
services, specialty pharmacy services, order to develop collaborative strat- tionships and infrastructure facilitated
and retail pharmacy services. The lead egies and response timelines and as- operationalizing new virtual workflows.
and alternate lead of the pharmacy am- sign an action team to execute them. Thus, support was provided within 1 to
bulatory action team also participated A timeline for the COVID-19 response 2 weeks for requests that aligned with
in the SIM ambulatory action team. To can be seen in Figure 2. current ambulatory pharmacy services
plan for our response, each PICS action Though the pandemic initially offered, such as diabetes, hypertension,
team, including the ambulatory action stopped ambulatory pharmacy strategic anticoagulation, and outpatient paren-
team, completed comprehensive plan- expansion plans, the integration of phar- teral antibiotic therapy management.
ning facilitated by the ASHP COVID-19 macy practice with the SIM structure However, new patient population or
Pandemic Assessment Tool for Health- highlighted the pivotal role pharmacy service additions, such as postpartum
System Pharmacy Departments2 and has in emergency response and ambu- hypertension management, were only
scenario planning exercises with inci- latory patient care. This approach al- planned during the initial acceler-
dent action plans. The main scenario lowed for ambulatory pharmacy practice ation phase of the pandemic, but pro-
for ambulatory care was that vulner- at YNHHS to continue to advance and gram implementation did not occur
able populations with chronic condi- for expansion of services to vulnerable until a recovery phase, when sufficient
tions would experience gaps in care populations. In response to the COVID- pharmacist resources were available.
management.3 Objectives and strat- 19 pandemic, the ambulatory action Strategies implemented by the am-
egies developed from the action team team was able to execute the key object- bulatory action team to maintain pa-
planning were added to a standardized ives of establishing clear and effective tient access included expansion of
project plan template (Figure 1), which communication with key stakeholders, chronic disease state management and
facilitated execution of strategies and ensuring patient access to clinical and anticoagulation services through use of
reporting to the PICS on progress and laboratory services, and managing drug telehealth. As a result, the total number
barriers. Newly identified ambulatory shortages related to COVID-19. of pharmacist visits increased from
AM J HEALTH-SYST PHARM | VOLUME 78 | NUMBER 8 | April 15, 2021 721Note AMBULATORY CARE ADVANCES DURING COVID-19
Figure 1. Action plan implemented by ambulatory action team in response to coronavirus disease 2019 (COVID-19)
pandemic. REMS indicates medications subject to risk evaluation and mitigation strategy requirements.
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approximately 1,000 visits per month safe patient transitions and medication Anticoagulation management.
to more than double that figure by July assistance program copayment support As ambulatory nurses were redeployed
2020 (Figure 3). from external, manufacturer-sponsored to meet inpatient care needs, ambu-
Telehealth transition. Transi programs or grants from disease state– latory clinical pharmacists assumed
tioning patient appointments to focused organizations for patients with responsibility for protocol-based war-
telehealth (telephone or video visits) financial need. For medications not farin management for approximately
became a priority during the initial available through our pharmacy, use of 1,300 patients. Seven ambulatory clin-
pandemic response to ensure com- 340B Drug Pricing Program–contracted ical pharmacists, 2 ambulatory care
pliance with the Centers for Disease pharmacies was advised. In collabor- postgraduate year 2 pharmacy resi-
Control and Prevention’s guidance for ation with the pharmacy and medical dents, and 5 pharmacy technicians
social distancing, quarantine, and iso- leaderships, consensus guidance was were trained. Three to 5 pharmacists
lation.4,5 With the need for rapid video developed to provide for consideration and 3 to 4 technicians were assigned
visit training, one of the ambulatory of patient self-administration of medi- each day to support this patient popu-
clinical pharmacists with experience cations that did not have labeled indi- lation. Assigned pharmacy staff and re-
conducting video visits trained clinic cations for home self-administration maining nursing staff participated in a
staff and led a virtual training for 17 am- (eg, omalizumab). daily huddle to assign roles and ensure
bulatory clinical pharmacists. Within The ambulatory clinical pharma- effective communication.
a week all patients were converted to cists also used the telehealth visits as The ambulatory action team created
telehealth visits. a way to facilitate triage of patients for a guidance document to clearly out-
Pharmacist telehealth visits were further care and assessment. If there line what action should be taken when
used to provide injection training and were any concerns for COVID-19–re- patients reported urgent concerns,
patient counseling for self-admin lated symptoms, patients were triaged including potential COVID-19 symp-
istration of biologic therapies for 27 to the responsible provider and/or call toms. To decrease the risk of potential
patients in the pulmonary clinic. center. This workflow aligned with the COVID-19 transmission, opportunities
Partnering with our health system spe- SIM ambulatory action team’s COVID- to extend the International Normalized
cialty pharmacy ensured efficiency in 19 symptoms triage pathway. Ratio (INR) monitoring interval to up to
722 AM J HEALTH-SYST PHARM | VOLUME 78 | NUMBER 8 | April 15, 2021AMBULATORY CARE ADVANCES DURING COVID-19 Note
Figure 2. Timeline of ambulatory action team (AAT) strategic planning and transformation plan implementation during
early months of response to coronavirus disease 2019 (COVID-19) pandemic. PICS indicates pharmacy incident com-
mand structure; HVC, heart and vascular.
Week of March 8, 2020
PICS forma on April 1–May 8, 2020
• AAT twice-weekly mee ngs
• Review, reporting, and execu on
of project plan
March 12
Ambulatory care staff huddle started
March 12–June 9, 2020 May 13–Present
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AAT lead and alternate a end system April 6, 2020 • Review, reporting, and execu on of
incident management AAT mee ngs Started support of HVC transforma on plan
an coagula on services • AAT once-weekly mee ng
March | April | May
March 16–20, 2020
All adult ambulatory pharmacists May 6, 2020
converted to work from home April 21, 2020 Transforma on plan created
Peak of COVID-19
cases at Yale New
March 24, 2020
Haven Hospital
AAT chiefs, leads, and
alternates perform COVID-19
scenario planning
March 30, 2020
AAT kick-off mee ng and finaliza on of
project plan
12 weeks in patients with stable doses of guidance to enhance care of patients of medications. Guidelines outlining
warfarin and consistently therapeutic across the health system. essential laboratory monitoring param-
INRs were identified.6-8 Pharmacists Through this collaboration, op- eters and those for which testing could
also identified opportunities to transi- portunities to optimize and stand- be delayed for patients with diabetes,
tion patients to direct oral anticoagu- ardize workflows between departments hypertension, heart failure, and/or other
lant (DOAC) therapies to decrease the managing warfarin therapy were identi- chronic diseases were created.
required monitoring frequency. fied. Standardization improved efficiency
An ambulatory anticoagulation and consistency through creation of 21 Medication access and drug
management workflow document was documentation templates and a central- use policy
prepared and disseminated across the ized workflow resource, which were con- A final objective of the ambulatory
health system through the SIM ambu- tinually updated as new processes were action team was to ensure that pa-
latory action team to provide multidis- implemented. This standardization jled tients retained access to critical chronic
ciplinary providers with strategies for to important protocol clarifications and medications during the pandemic and
management of the target population. more streamlined and consistent work- that prescribers received clear guid-
It included considerations for DOAC flows across the health system. ance on drug prescribing and moni-
conversion in eligible patients, INR Essential laboratory moni- toring during this period. Disruptions
monitoring interval extension, options toring. To ensure effectiveness of medi- in the drug supply chain, as well as
for home INR monitoring, and avail- cation therapy while minimizing risks emerging evidence supporting use of
ability of laboratory testing locations of staff exposure to COVID-19, the am- approved drugs for the treatment of
exclusively for patients with confirmed bulatory action team completed an as- COVID-19, led to drug shortages that
or suspected COVID-19. Through this sessment of current ambulatory clinical would potentially impact patients re-
communication, the ambulatory ac- pharmacy services and essential labora- ceiving chronic therapy with affected
tion team had the opportunity to share tory tests for initiation and monitoring drugs. The team worked to develop
AM J HEALTH-SYST PHARM | VOLUME 78 | NUMBER 8 | April 15, 2021 723Note AMBULATORY CARE ADVANCES DURING COVID-19
Figure 3. Ambulatory care pharmacist visits by type (10,895 visits in total) during early months of pandemic response.
2500
2000
1500
1000
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500
0
2020 2020 2020 2020 2020 2020 2020
January February March April May June July
Office Visits Telehealth Visits Total Visits
prescribing guidance, information guidance from the drug manufacturer medications be reserved for patients
technology restrictions within the provided for 7 medications and a change with medical conditions for which their
computerized order entry system, and from the usual REMS process for 6. use had been established and there
inventory management strategies to re- Drug shortages management. were no alternatives. Dermatology and
tain drug supply for the health system’s During the early weeks of the COVID- rheumatology prescribers identified
patients who were receiving these 19 pandemic, several readily avail- patients whose hydroxychloroquine
medications chronically. Risk manage- able medications were demonstrated therapy could be decreased via once-
ment programs for frequent monitoring to have possible activity against the daily dosing to conserve supply and
of some medications were modified in virus in hospitalized patients, including also recommended avoiding new-start
response to the COVID-19 pandemic to hydroxychloroquine, azithromycin, and hydroxychloroquine therapy.
reduce the need for patient laboratory HIV-1 protease inhibitors. The increased Implementation of electronic deci-
visits, and it was essential to communi- demand and utilization of these medica- sion support for hydroxychloroquine
cate these changes to prescribers. tions for the acute treatment of COVID- and azithromycin prescribing resulted
Risk evaluation and mitigation 19 in hospitalized patients resulted in in generation of an advisory warning
strategies (REMS) management. supply shortages in the community for upon medication prescribing that out-
The US Food and Drug Administration’s outpatients receiving the medications lined restrictions on prescribing of
release of the guidance document chronically. Several strategies were these medications in the outpatient
“Policy for Certain REMS Requirements implemented to manage medication setting. These prescriptions also re-
During the COVID-19 Public Health therapy associated with COVID-19–re- quired an associated diagnosis code
Emergency” provided temporary relief lated shortages, including outpatient and contained a hard-stop limit on
from selected laboratory testing require- prescribing guidance, prescriber deci- days’ supply per fill (ie, a maximum
ments or days’ supply limitations for sion support within the electronic med- of 30 days). Upon receipt of any new
drugs subject to REMS requirements.9,10 ical record, internal pharmacy validation hydroxychloroquine prescriptions,
To provide awareness of REMS program of prescriptions, and dispensed quantity clinical pharmacists within the health-
requirement changes, the team compiled limitations. Guidelines for outpatient system specialty pharmacy reviewed
a list of medications subject to REMS re- prescribing of hydroxychloroquine, electronic medical record documenta-
quirements prescribed within the health HIV-1 protease inhibitors, and azith tion to validate indications for use and
system, the updated requirements, and romycin were developed in collabor- escalated cases to the rheumatology
the manufacturers’ letters about the up- ation with members of the pharmacy leadership if compliance with the out-
dates. During a 13 month period prior and medical leaderships with expertise lined guidelines was unclear.
to the start of the COVID-19 pandemic, in infectious diseases, pulmonary medi- The strategies implemented to
14 such medications were prescribed cine, rheumatology, and dermatology; manage COVID-19–related drug
within the health system, with formal the guidelines recommended that these supply shortages in the outpatient
724 AM J HEALTH-SYST PHARM | VOLUME 78 | NUMBER 8 | April 15, 2021AMBULATORY CARE ADVANCES DURING COVID-19 Note
setting allowed YNHHS pharmacies Successful execution of the ac- References
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6. Witt DM, Delate T, Clark NP, et al.
the ambulatory action team, they were Ambulatory care pharmacy plays an Twelve-month outcomes and predictors
introduced to the pharmacy staff at essential role by providing support to of very stable INR control in prevalent
town halls and huddles. The ambula- the community, patients, department, warfarin users. J Thromb Haemost.
tory action team and pharmacy leader- 2010;8(4):744-749.
and multidisciplinary team. The for-
7. Barnes GD, Kong X, Cole D, et al.
ship also reminded staff of the correct mation and work of the ambulatory ac- Extended international normalized
method of escalation if there was a de- tion team was critical for the continued ratio testing intervals for warfarin-
viation in the process. The ambulatory advancement of YNHHS’ ambulatory treated patients. J Thromb Haemost.
action team became the hub of all am- pharmacy practice during the early 2018;16(7):1307-1312.
bulatory care–related issues, improve- 8. Schulman S, Parpia S, Stewart C, et al.
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Warfarin dose assessment every 4 weeks
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munication framework. flicts of interest. Bosentan_REMS_IPU_for_COVID-19.pdf
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