"[MUSIC]" "Sothisweekwe'restudyingcareer pathways in pharmacy, and we're talking about the roles of pharmacists in the healthcare system." "And you've been meeting some different practitioners throughout the course, and we're going to be meeting some more interesting ones this week." "And we have one with us today, her name is Angela" "Zielinski, she works for the VA Ambulatory Center in Columbus, Ohio." "And Angie, I thank you for being with us." "Thankforhavingme." "[CROSSTALK] anxious to hear about the interesting practice you have and we'll kind of get into that, but before we do so, can you just tell me, tell us a little bit about your background and how you got to where you are today." "Okay." "I completed my PharmD here at Ohio State, I completed that in 2003." "And then I applied for residency and I was fortunate enough, fortunate enough to match with the VA, the Veteran Affairs clinic here in Columbus, Ohio," "where I've been for the last 10 years." "And then during my time there I've gone on to become board certified in pharmacotherapy, and also I got my CDE or certified diabetes educator." "Good,greattraining." "and you know you've hit on several things that we have or will talk about in this course." "So, you know, board certification and residency programs and, and you've hit several things that have, have led you down a pathway to being the practitioner you are today." "Mm-hm." "So,thanksforsharingthat with us." "So, got a good background, and we're anxious to hear about this practice you have, so can you describe your, your clinic, your, your ambulatory care center, and kind of what your role is in it?" "Okay." "the, the Veteran Affairs, the ambulatory care clinic itself is quite large, there's lots of different specialties available there." "So, pa, patients can go for dermatology, endocrinology, rheumatology, same day surgery we have a nephrologist, so basically anything, any kind of specialty, almost any kind of specialty we have available there." "the pharmacists and, I'll talk about my practice in particular, I like to think of it more as what I do in a week rather than what I do in a day." "Mm-hm." "because" "I do something different every day." "Yeah." "Sodependingon whatday oftheweek it is, like today I had my MTM clinic, which is the medication therapy management clinic, so I saw patients with diabetes, high blood pressure high cholesterol." "I saw a patient that was new to the VA who needed to get some of his medications switched over because we work within a formulary system." "Mm-hm." "SoI hadto helpmakesome  conversions for what he was on currently to things that we have on our formulary, and then also make recommendations for his physician for follow up after we made those changes." "I might see a patient who's getting started on an, like a Procrit or an Epogen to help build up their blood if they're anemic from having chronic kidney disease." "So it's a wide variety in my MTM clinic," "I never know, I mean I have a general idea what" "I'm going to get that day, but it's usually pretty good variety." "if, if it's a Tuesday, I'm working in the anti-coagulation clinic, monitoring patients on Warfarin or Pradaxa." "if it is, then in the afternoon, since we do have a formulary system, anything that is non-formulary has to be requested and it goes through a review, and the pharmacist, the clinical pharmacy specialists, review those requests." "So I'll review non-formulary requests and either approve or deny." "And then if we deny we have to make a recommendation for what, like, formulary alternative would be a therapeutic equivalent for what the, what the patient needs." "on a Wednesday I might be working in the heart disease group, which is a group appointment, where I may have anywhere from eight to ten patients all at the same time." "And I work with a nutritionist, and we make adjustments on their cholesterol and blood pressure medications, and talk about lifestyle changes to help decrease their risk of heart disease and stroke." "I also on Wednesdays may work in renal clinic, and that I work in con, I don't have prescriptive authority in renal clinic, but I work re, with the renal physician making recommendations for medication changes." "I think that's, I think that's a pretty good summary." "[LAUGH]" "Youdoalot ." "OfwhatIdoduringtheweek." "Andyou'reactually,you 'resortof a walking dictionary from our, we have a thing called pharmacy fundamentals we're talking about in the course Angie, and you've hit about every one of them as you walk through here." "Ohreally," "[CROSSTALK]." "SoMTMandall the kindofthings you're doing, so that we start to see that this is real, I mean, you're practicing in this way." "Yeah." "Sooneof thethingsthat Iam interested in is we know that VA pharmacists and, and actually kind of federal pharmacists in the United States sometimes are able to practice differently, and" "VA pharmacists have pretty innovative practices." "And in some cases as I understand it VA pharmacists have prescriptive authority." "Mm-hm." "Soandthis,thisisof interestto us, so can you tell us what that means and, you know how does, how does it work, and how does a pharmacist get that author, authority to do it in the VA?" "Okay." "so every, every clinical pharmacy specialist within the" "VA may, can operate underneath a scope of practice." "And the scope of practice has to be signed off by the, like the, the head of the whole, the clinic as well as the Chief of Pharmacy." "in order to get a scope of practice you need to have a PharmD or a Masters degree." "You need to have a residency or equivalent experience." "They encourage you to become board certified as well." "Mm-hm." "andthenyouwillbegranted prescriptive authority underneath your scope of practice." "So, for example we have a pain clinic at the VA, and I don't work in the pain clinic." "we can't write, no pharmacist as far as I know within the VA system can write for narcotics, as far as I know." "it has to be, that, that particular thing has to be allowable under state law, since we're a federal facility we operate under federal law, but the narcotic part it has to be a state law that pharmacist can prescribe that." "Right." "Butthepharmacistatpain clinic can write for non-controlled substances, so, it might be like a" "Gabapentin, you know, to help with neuropathy." "Mm-hm." "Oritmightbea stoolsoftener to help combat the side effect of the narcotic." "but I don't work in that clinic, so I can't prescribe those medications." "So, you have to have the training and the skill for the disease states that you're able to write for." "So if a doctor would put in a consult for me for whatever disease state usually it's going to be diabetes or high blood pressure, high cholesterol, and then within my scope, I'm able to write for, initiate," "adjust, stop diabetes medications, blood pressure medications, cholesterol medications." "If a patient would come to me complaining, you know, that they're, they're having neuropathy from their diabetes, I cannot, even though I'm seeing them for diabetes," "I can't write for their Gabapentin." "I would have to go and talk with the physician and have them evaluate the, the patient to see if that would be appropriate for them." "Yeah." "Soat,on thesametokenlet's sayI have a patient that's anemic, and I see them for diabetes, in order for me to, you know, if they would need to start Procrit the doctor would have to put" "in a separate consult and then I could take over at that as well." "Okay." "So you have to have certain qualifications?" "Mm-hm." "Youhaveto be approvedbythe directors in your," "Yep,inyourfacility." "Inyou'reclinic." "youhave,we alsodopeer review." "Mm-hm." "Ona monthlybasis,somychartsare reviewed." "I, it's anywhere from five to ten charts per month are reviewed from when I see a patient to make sure that I'm making good, therapeutic decisions." "Interesting." "Andthenthat'sreviewed." "That's,that'sthat'sout there isn't it?" "Yeah." "Yeah." "Yeah." "Sothat's,that'sgood." "Iknowno different,Ithinkit's wonderful." "That's, that's, that's wonderful." "let me, and I'm sure you probably have a quick answer to this but, how important is collaborative practice in your work, you know, how does, how does that work around this prescriptive authority but even around all these daily things you do in the clinics?" "Okay." "I think one of the newer buzz words is primary care medical home." "Mm-hm." "wehaveourown termforitwithin  the" "VA system, we call it the PACT model, or the" "Patient Aligned Care Team." "And within the team I always tell my patients I belong to team four, which is two physicians and a nurse practitioner along with three RNs, three LPNs." "We have a social worker who is an expanded team member, so she's just, not just a member of team four but she serves like three other teams as well." "We have a nutritionist within our team." "we have monthly meetings where we will, one wonderful thing about working within the VA is that it's very easy to pull data from the computer system." "So if we notice that, you know what, we're not performing as well in a certain measure, we can sit down and say okay, we're going to focus on getting our A1C's down." "And we can see the patients, and we can kind of focus on them, and say okay, what does Mr so-and-so need." "You know, social work can you help with getting him, you know, he has to go to the food pantry, can you help him get set up with food stamps?" "So it's, it's vitally important." "Mm-hm." "Andthenwithinthat,that PACT team  too, one of the things I, I like so much is that I have pharmacy students with me, the physicians have medical students and residents, the nurses have nursing students." "So then they can see kind of how it works and what a great model it is and then hopefully when they graduate and start their own practices, they can, you know." "Carryitwiththem." "Carryitwiththem,exactly." "Yeah." "So we've talked about collabor, collaborative practice a lot in this course, but this is really formalized where you're working." "Yeah." "Andit's,it 'steambasedandit's kind of established models, so that's that's, that's very interesting." "I have one more question for you." "Yes." "AndI 'm,I 'mguessingthat, you know, a large number of the patients you see are, are elderly in, in the VA system." "and you know caring for seniors is important and, you know, we're, our population is aging, and so maybe, could you give us some, your thoughts on, you know, special skills that are needed to work with elderly people." "And, you know, how, how will our health system have to shift to accommodate these needs?" "Oneofthefirstthingsthatcomes to mind is when I first started working at the VA I would come home and my husband would say, why are you yelling." "[LAUGH]" "And its just because one of the things that we have is you know they're hard of hearing." "Not only are they elderly but they were in the military, they didn't wear ear protection." "Yeah." "Whentheywere,you know,ontheir  airplanes or directing air traffic or had their, you know, military training, so, one is just" "being able to communicate with them." "we also not, not only have that, but some of our patients don't read very well." "So when you have a combination of I can't hear very well and I can't read very well, you really have to be innovative with how you are providing your instructions." "Mm-hm." "So like when I'm going through their medications I, if, you know, I'll, I'll, I'll ask them to read it to me, and if they can't I'll be like, can you" "match up the letters, and then I'll use like a sun for the morning and a moon for the night for when they need to take it." "So just being innovative on the ways you need to prac, the, you know, just on how you communicate with them." "And then the other thing I would say is that a lot of the times with the, the older generation, the wives like to take over for their husbands for their medications, which is understandable, and very helpful especially with patients" "that have cognitive impairment." "but when their wives pass away, it, it's hard for them to take care of themselves." "Yeah,I bet." "Whentheyhavehad someonethereto do it for them for so long." "Yeah." "So,that'sanotherchallengethat we have." "And another challenge where like, the social workers are incredibly helpful there at the" "VA, because they can help us tap community resources to get nursing to come into their home for maybe a month or two until they get their medication regimen under control and regulated." "So they can just have a better understanding of what they're, what they're going to do." "Yeah." "Well, we talked about the importance of communication in our course, or, or we will be but that, this kind of takes, takes that to the next level in terms of how do I, how can, can they hear, can they read?" "Yeah." "Cantheycommun, how can we translate this in a way that makes sense?" "Andthenthemildcog, like the cognitive impairment that comes along sometimes with aging, too." "Yeah." "So,it'sjust,Icantellyou15 different times of, kinds of pillboxes and alarmed pillboxes, and locked with alarms." "And you know, sometimes even with that I have patients that'll say, yeah, I heard a beeping, but I couldn't remember what I was supposed to do, so it's." "Mm-hm." "So we got tools, and we have resources in the community needed to pull those in." "Yeah,right." "Well,Angieyourpracticeisreally interesting." "I hope that our viewers have learned, you know, kind of a different aspect of pharmacy where, where this might be more of what the future may look like and it's." "Ihopeso ." "Andwe'll,andwe'llseethat." "Yeah." "So,thanksfordoingthis ." "Yeah." "Sharingyourpracticewithus." "Anytime." "Goodluckto youinthefuture." "Thankyou." "[MUSIC]"