Video visit allows Navy pharmacist to show patient how to use insulin

Naval Hospital Jacksonville begins telehealth pilot program

Virtual visits with patients are well suited to the roles of pharmacists on primary care teams at Naval Hospital (NH) Jacksonville in Florida.

That’s because these clinical pharmacists tend to see their patients more frequently and for longer duration than primary care providers, explained CDR Janel B. Rossetto, PharmD, MS, BCNSP, MSC, USN, head of the pharmacy department at NH Jacksonville. Also, they mostly aren’t involved in hands-on assessments of patients, although they perform limited physical exams, and they often manage chronic conditions.

NH Jacksonville launched the Navy Care virtual visit pilot program for Navy Medicine in January 2018, as an extension of value-based care. The first phase of the pilot included a wide range of primary and specialty services. The second phase began in July 2018, focusing on the medical readiness of active-duty patients as well as specialty services for all types of patients. Clinical pharmacists are one of the top specialists utilizing virtual visits, along with neurology, allergy, dietitians, and Navy Independent Duty Corpsmen.

Using the Navy Care app, pharmacists perform the same workflow, except they see the patient through a screen instead of on the seat in front of them, Rossetto said. They continue to document in the current electronic medical record (EMR), setting up the tablet to both see the patient and type in the EMR.

 

“Virtual visits are part of the greater vision of the future care model, ensuring active-duty readiness is at the forefront of our medical care today and in the future,” she said.

 

NH Jacksonville pharmacists work on teams in family medicine and internal medicine both in the hospital and at branch clinic locations. One clinical pharmacist works in the pain clinic and covers the inpatient hospital for adult medicine daily rounds. 

 

Their patients range from younger to older, and across active-duty, families, and retirees. They live close to the clinics or in remote locations hours away. With virtual visits, patients are able to meet at their location, on their schedule, with no traffic or parking concerns.

“While this is not ideal for every patient, there is a significant benefit for many of the patients we see,” Rossetto said. Patients still need to come in or go to a local pharmacy for acute prescriptions, and patients who present for pharmacists’ performance of finger sticks are not candidates. But the telehealth program works for patients such as those on anticoagulants who do home monitoring of INR levels, or who need a follow-up virtual visit after scheduling lab tests at their convenience. 

 

As Rossetto tells the story, one patient with extremely uncontrolled diabetes was part of NH Jacksonville’s diabetes integrated practice unit (IPU) but didn’t show for appointments because he lived almost 2 hours away. But thanks to the pilot program, he called in from his living room. Taking his video call was Adriane Lyles, PharmD, BCPS, CDE, a clinical pharmacist on the diabetes IPU. 

 

Lyles started at a very basic level because the patient’s regimen seemed to be more complicated than what the patient could handle, Rossetto noted. During this visit, the pharmacist realized the patient was using his long-acting insulin glargine after testing his blood glucose before meals. “He was confused about the function of his glargine and was using it as if it were short- or rapid-acting,” Rossetto said. The pharmacist showed the patient on video which insulin to use, how much, and how often. Then she scheduled another virtual visit for him in 1 week.

 

“It’s very likely this patient would have gone 6 to 12 months before scheduling another in-person visit and could have ended up in the hospital for hypoglycemia or worse,” Rossetto said.

 

Given the success of virtual visits provided by clinical pharmacists, opportunities to expand utilization currently are being considered. While patients are admitted to the hospital, the inpatient adult medicine clinical pharmacist will begin scheduling virtual follow-up visits for discharging patients to allow face-to-face consultation for medication reviews. This should contribute significantly to preventing hospital readmissions and for overall better care, according to Alexandra Vance, PharmD, BCPS, pharmacy clinical coordinator at NH Jacksonville.