D.6 - NMVAHCS - MCP 119-60 - Multidisciplinary Anticoagulation Services.pdf

MULTIDISCIPLINARY ANTICOAGULATION SERVICES

New Mexico VA Health Care System

Albuquerque, NM

MCP 119-60

Signatory Authority

Director NMVAHCS

Rescinded Document

MCP 119-19, Multidisciplinary Outpatient

Anticoagulation Clinics July 23, 2020, MCP 119-47, Multidisciplinary Inpatient

Anticoagulation Service May 23, 2019, MCP 119-55 Home-Based primary Care

Anticoagulation Management

Service Line

Pharmacy

Effective Date

October 2022

Responsible for Updates

Anticoagulation Program Manager

Recertification Date

October 31, 2027

1. POLICY

This medical center policy (MCP) establishes New Mexico VA Health Care System

(NMVAHCS) policy regarding Anticoagulation Services.

2. JUSTIFICATION

This MCP exists to ensure compliance with VHA Directive 1108.16(1), Anticoagulation Therapy Management, and Joint Commission standards.

3. SUMMARY OF CHANGES

Combined MCP 119-19, Multidisciplinary Outpatient Anticoagulation Clinics, MCP

119-47, Multidisciplinary Inpatient Anticoagulation Service, MCP 119-55 Home-Based

Primary Care Anticoagulation Management.

4. DEFINITIONS

a. C/CBOC. Contract/Community-Based Outpatient Clinic.

b. CPP. Clinical Pharmacy Practitioner.

c. DOAC. Direct Oral Anticoagulant.

d. HBPC. Home-Based Primary Care.

e. INR. International Normalized Ratio.

f. PCP. Primary Care Provider.

https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=9173 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=9173

October 2022 MCP 119-60

g. POC. Point-of-Care.

5. RESPONSIBILITIES

a. Anticoagulation Program Manager. The Anticoagulation Program Manager is responsible for:

Co-chairing the facility Anticoagulation Stewardship Subcommittee to coordinate quality monitoring program activities for anticoagulation services, as outlined in 6. c. Ongoing Anticoagulation Quality

Monitoring Program.

b. Hospitalist or Inpatient Provider. The hospitalist or inpatient provider is responsible for:

(1) Following applicable procedures and protocols for anticoagulation as outlined in 6.a. Parenteral Anticoagulation Protocols.

(2) Placing laboratory orders for monitoring of anticoagulation, except for International Normalized Ratio (INRs).

(3) Evaluating the patient for appropriateness of therapeutic anticoagulation and discussing the benefits, risks and alternatives with the patient and caregiver before initiating therapy.

(4) Ordering the anticoagulant, with assistance from the Inpatient

Clinical Pharmacy Practitioner (CPP) if desired.

(5) Opting out of CPP management of anticoagulation, if desired; the provider includes a comment in the anticoagulant medication order to specify the anticoagulation will be managed by the provider and not the CPP.

(6) Collaborating with the Inpatient CPP if a change in anticoagulant, dose, or holding status is indicated based on the CPP review of the patient.

(7) Collaborating with the Inpatient CPP if anticoagulation reversal is indicated, including entering a non-formulary request or before authorization request if necessary and informing the Inpatient CPP responsible for completing the consult.

(8) Notifying the Inpatient CPP regarding any urgent invasive procedures.

(9) Entering an Outpatient Anticoagulation Clinic consult for outpatient follow-up if the patient is on long-term anticoagulation and discharged home. Providers must review and ensure patient meets the eligibility criteria for clinic enrollment as described in 6.d.

Outpatient Pharmacy Anticoagulation Management Requirements and Policy.

c. Inpatient Nursing Staff. The inpatient nurse is responsible for:

Following applicable procedures and protocols for anticoagulation as listed in 6.a. Parenteral Anticoagulation Protocols.

d. Inpatient Clinical Pharmacy Practitioner. The Inpatient CPP is responsible for:

(1) Completing training specific for anticoagulation therapy management before engaging in the management of anticoagulation.

Competencies specific to anticoagulation management are completed upon hire and repeated as needed. Updated guidelines or new anticoagulants require updated competencies to include knowledge of the standard terminology, pharmacology of anticoagulants, monitoring requirements, dose calculations, common side effects, nutrient interactions, dietary considerations, and drug-to-drug interactions.

(2) Monitoring and managing inpatient anticoagulation as described in Pharmacy SOP PHA-CL-17, Inpatient Pharmacy

Anticoagulation Services.

e. Primary Clinical Pharmacist or Referring Provider to

Anticoagulation Clinic or to Home-Based Primary Care Clinical

Pharmacy Practitioner. The PCP or referring provider is responsible for:

(1) Providing preliminary anticoagulation patient education or requesting assistance for education from Nursing or Pharmacy Service before

Anticoagulation Clinic referral. Perform education within a reasonable timeframe of starting anticoagulation, preferably before the first dose.

Education must include benefits, risks, and alternatives to oral https://dvagov.sharepoint.com/:w:/r/sites/VHAABQDCS/SOP%20Library/IP-17%20Inpatients%20with%20Prescribed%20SpecialtyHome%20Medications.docx?d=w0eeae7ffaa294fd5b64204096d473b99&csf=1&web=1&e=uonSk4 https://dvagov.sharepoint.com/:w:/r/sites/VHAABQDCS/SOP%20Library/IP-17%20Inpatients%20with%20Prescribed%20SpecialtyHome%20Medications.docx?d=w0eeae7ffaa294fd5b64204096d473b99&csf=1&web=1&e=uonSk4 anticoagulant therapy.

(2) Assessing the potential for unintended pregnancy, including effective anticoagulants and obtaining a baseline pregnancy test before initiating warfarin or a Direct Oral Anticoagulant (DOAC). The provider must complete any required pregnancy/lactation and teratogenic medication clinical reminder(s) accordingly upon prescribing the anticoagulant.

(3) Ordering required baseline labs within a reasonable timeframe before initiating oral anticoagulation.

(4) Ordering the initial anticoagulant prescription for the patient with at least 14 days' supply of medication. The Anticoagulation Clinic or f. Home-Based

Primary Care (HBPC) CPP may change the anticoagulant or dose as clinically indicated. See the list of resources in 6. b. Other Paragraphs -

Anticoagulation Clinical Guidance Documents.

(5) Before starting treatment, perform an anticoagulation risk vs. benefit assessment and again at least annually. Document the decision and rationale for continuing or discontinuing the anticoagulation therapy in the electronic health record.

(6) Contacting the Anticoagulation Clinic or HBPC CPP and educate the patient to contact the Anticoagulation Clinic or HBPC CPP with any new interacting medications added to their medication regimen.

(7) Alerting the Anticoagulation Clinic or HBPC CPP and educating the patient to contact the Anticoagulation Clinic or HBPC CPP about upcoming procedures at least 2 weeks in advance.

(8) Being available or designating a surrogate to be available by phone or pager for further consultation from the Anticoagulation Clinic or HBPC CPP and responding to outstanding lab values during weekends and holidays as clinically indicated.

(9) Entering the Anticoagulation Clinic Consult or HBPC Anticoagulation

Consult including the indication(s), International Normalized Ratio (INR) goal range if using warfarin, and duration of anticoagulation. NOTE:

Patient eligibility criteria as defined in 6.d. Other Paragraphs - Outpatient

Pharmacy Anticoagulation Management Requirements and Policy.

(10) Outpatient Pharmacy Anticoagulation Management Requirements and

Policy.

(a) Consults may be canceled and anticoagulation management deferred to the referring provider if the indication for anticoagulation is not within standard practice or supported by robust clinical evidence;

address these consults on a case-by-case basis and additional information may be required.

(11) Ensuring compliance with VHA Directive 1310 (1), Medical Management of

Enrolled Veterans Receiving Self-Directed Care From External Health Care

Providers. VA providers must not simply re-write prescriptions from an external health care provider without first making a professional assessment that the prescribed medication is medically appropriate. The

VA providers actively monitor and manage the care associated with the medication.

(12) Entering a new consult if the patient is transitioning from the

Anticoagulation Clinic to HBPC CPP anticoagulation management or vice-versa.

(13) Home-Based Primary Care Provider must enter new Anticoagulation

Consult if/when changing therapy from warfarin to DOAC or vice-versa.

(14) Providing the Anticoagulation Clinic or HBPC CPP with current clinical data to support any INR goal range outside of national guidelines.

f. Home-Based Primary Care Nursing Staff. The HBPC nursing staff are responsible for:

(1) Implementing the anticoagulation therapy plan of care as prescribed by the

HBPC CPP. Twice-weekly visits for lab draws may be required for some patients, with home health agency assistance when indicated.

(2) INRs may be checked by point-of-Care (POC) finger stick at the patient's home in accordance with MCP 113-14 Ancillary Testing Policy. The nurse is responsible for obtaining POC INRs and communicating the results to the

HBPC CPP by text pager, with a standard format to include the patient's first and last initials followed by the POC INR result. Verify POC INR values ≥4.1 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=9461 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=9461 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=9461 https://dvagov.sharepoint.com/:w:/r/sites/VHAABQDCS/ABQ%20Active%20Library/Ancillary%20Testing%20Policy.docx?d=w2fc69bdf51fa402b9f5a17896c290373&csf=1&web=1&e=SMyRq0 with a venipuncture sample submitted to the lab; in these cases, treatment decisions will be based upon the venipuncture result.

(3) By the end of the business day, document POC INR results in the Electronic

Health Record laboratory package using the “Fast Bypass" system.

(4) Drawing venipuncture labs and returning collected lab vials to the VA location out of which the HBPC nurse is based (e.g., Albuquerque or C/CBOC).

Samples delivered to a C/CBOC before 2pm will be transferred to NMVAHCS for processing the same day.

(5) Communicating anticoagulant dose changes to patients or caregivers and adjusting medication organizers for patients as indicated.

(6) Ask patients and/or caregivers regarding medication compliance; new, modified or discontinued medications, supplements or vitamins; adverse events; changes in diet; and changes in overall health. This information is reported directly to the HBPC CPP.

g. Anticoagulation Clinic Staff and Home-Based Primary Care Clinical

Pharmacy Practitioner. Anticoagulation Clinic staff and HBPC Clinical

Pharmacy Practitioner are responsible for:

(1) Adhering to Pharmacy SOP PHA-CL-13, Pharmacy

Anticoagulation Clinic and Pharmacy SOP PHA-CL-16, HBPC

Pharmacy Anticoagulation Services.

(2) Directly providing management of the anticoagulant therapy without PCP co-signature (e.g., clinically evaluating and acting on test results, adjusting doses, or prescribing anticoagulation or "bridging" medications), as allowed per functional statements and scope of practice.

(3) Completing training specific for anticoagulation therapy management before engaging in the management of anticoagulation.

(4) Competencies specific to anticoagulation management are completed upon hire and repeated as needed based on updated guidelines or new anticoagulants and may include knowledge of the standard terminology, pharmacology of anticoagulants, monitoring requirements, dose calculations, common side effects, nutrient interactions, dietary considerations, and drug to drug interactions. Providing services for enrolled https://dvagov.sharepoint.com/:w:/r/sites/VHAABQDCS/SOP%20Library/CL-13%20Pharmacy%20Outpatient%20Anticoagulation%20Clinics1.docx?d=w2ebb318880a64cb0a35cc4f2166e862a&csf=1&web=1&e=Xxde77 https://dvagov.sharepoint.com/:w:/r/sites/VHAABQDCS/SOP%20Library/CL-13%20Pharmacy%20Outpatient%20Anticoagulation%20Clinics1.docx?d=w2ebb318880a64cb0a35cc4f2166e862a&csf=1&web=1&e=Xxde77 https://dvagov.sharepoint.com/:w:/r/sites/VHAABQDCS/SOP%20Library/Home%20Based%20Primary%20Care%20Pharmacy%20Anticoagulation%20Services.docx?d=wcc41c8e6906540948dc63581e31cb5e5&csf=1&web=1&e=Pjhxvy https://dvagov.sharepoint.com/:w:/r/sites/VHAABQDCS/SOP%20Library/Home%20Based%20Primary%20Care%20Pharmacy%20Anticoagulation%20Services.docx?d=wcc41c8e6906540948dc63581e31cb5e5&csf=1&web=1&e=Pjhxvy

Veterans, including anticoagulation education to patients or family and outpatient follow-up for long-term oral and injectable anticoagulant use

(more than 6 weeks duration).

(5) Providing comprehensive peri-procedural anticoagulant management to enrolled Veterans.

(6) Utilizing standardized note titles in the electronic medical record and monitoring tools as outlined in Pharmacy SOP PHA-CL-13, Pharmacy

Anticoagulation Clinic, and Pharmacy SOP PHA-CL-16, HBPC

Pharmacy Anticoagulation Services,

(7) Ensuring the Veteran understands the requirements for Anticoagulation

Clinic enrollment and continued monitoring.

(8) Contacting the Anticoagulation Clinic Medical Director and PCP if it is medically dangerous to continue anticoagulant therapy or if unusually problematic situations occur where the Anticoagulation Clinic can't treat or follow up appropriately.

(9) Alerting non-VA care staff of STAT non-VA lab consults if outside-of-VA venipuncture INRs are needed.

(10) Review new consults within 2 business days upon receipt of the consult and arrange the first phone or video visit with the patient (or first telephone contact attempt made).

(11) Providing anticoagulation education per Pharmacy SOP PHA-CL-13, Pharmacy Anticoagulation Clinic, and Pharmacy SOP PHA-CL-16, HBPC Pharmacy Anticoagulation Services, as soon as possible.

(12) Canceling consults and notifying the provider per Pharmacy SOP

PHA-CL-13, Pharmacy Anticoagulation Clinic, and Pharmacy SOP

PHA-CL-16, HBPC Pharmacy Anticoagulation Services, if:

(a) The consult does not contain all the required information.

(b) The Veteran does not meet the criteria for CPP anticoagulation management, is unavailable for the initial appointment, or is unable to be contacted by phone

(13) Managing oral anticoagulant therapy for enrolled patients, including prescribing, ordering lab tests, adjusting doses, and any associated follow-https://dvagov.sharepoint.com/:w:/r/sites/VHAABQDCS/SOP%20Library/CL-13%20Pharmacy%20Outpatient%20Anticoagulation%20Clinics1.docx?d=w2ebb318880a64cb0a35cc4f2166e862a&csf=1&web=1&e=Itk3Eu https://dvagov.sharepoint.com/:w:/r/sites/VHAABQDCS/SOP%20Library/CL-13%20Pharmacy%20Outpatient%20Anticoagulation%20Clinics1.docx?d=w2ebb318880a64cb0a35cc4f2166e862a&csf=1&web=1&e=Itk3Eu https://dvagov.sharepoint.com/:w:/r/sites/VHAABQDCS/SOP%20Library/Home%20Based%20Primary%20Care%20Pharmacy%20Anticoagulation%20Services.docx?d=wcc41c8e6906540948dc63581e31cb5e5&csf=1&web=1&e=Pjhxvy https://dvagov.sharepoint.com/:w:/r/sites/VHAABQDCS/SOP%20Library/Home%20Based%20Primary%20Care%20Pharmacy%20Anticoagulation%20Services.docx?d=wcc41c8e6906540948dc63581e31cb5e5&csf=1&web=1&e=Pjhxvy https://dvagov.sharepoint.com/:w:/r/sites/VHAABQDCS/SOP%20Library/CL-13%20Pharmacy%20Outpatient%20Anticoagulation%20Clinics1.docx?d=w2ebb318880a64cb0a35cc4f2166e862a&csf=1&web=1&e=Itk3Eu https://dvagov.sharepoint.com/:w:/r/sites/VHAABQDCS/SOP%20Library/CL-13%20Pharmacy%20Outpatient%20Anticoagulation%20Clinics1.docx?d=w2ebb318880a64cb0a35cc4f2166e862a&csf=1&web=1&e=Itk3Eu https://dvagov.sharepoint.com/:w:/r/sites/VHAABQDCS/SOP%20Library/CL-13%20Pharmacy%20Outpatient%20Anticoagulation%20Clinics1.docx?d=w2ebb318880a64cb0a35cc4f2166e862a&csf=1&web=1&e=lqTwwb https://dvagov.sharepoint.com/:w:/r/sites/VHAABQDCS/SOP%20Library/CL-13%20Pharmacy%20Outpatient%20Anticoagulation%20Clinics1.docx?d=w2ebb318880a64cb0a35cc4f2166e862a&csf=1&web=1&e=lqTwwb https://dvagov.sharepoint.com/:w:/r/sites/VHAABQDCS/SOP%20Library/Home%20Based%20Primary%20Care%20Pharmacy%20Anticoagulation%20Services.docx?d=wcc41c8e6906540948dc63581e31cb5e5&csf=1&web=1&e=ldbN50 https://dvagov.sharepoint.com/:w:/r/sites/VHAABQDCS/SOP%20Library/Home%20Based%20Primary%20Care%20Pharmacy%20Anticoagulation%20Services.docx?d=wcc41c8e6906540948dc63581e31cb5e5&csf=1&web=1&e=ldbN50 up with the patient per Pharmacy SOP PHA-CL-13, Pharmacy

Anticoagulation Clinic, and Pharmacy SOP PHA-CL-16, HBPC Pharmacy

Anticoagulation Services, .

h. Anticoagulation Clinic Medical Director. The Anticoagulation Clinic

Medical Director is provided by Ambulatory Care Service and is responsible for:

(1) Supervising the clinical services for the Anticoagulation Clinic.

(2) Being available for contact in circumstances where the PCP is unavailable or unresponsive and the patient requires more than basic triage from the

CPP.

i. Contract/Community-Based Outpatient Clinic (C/CBOC) Staff. C/CBOC staff are responsible for:

(1) Following up on Return to Clinic orders submitted by the CPP for lab draws and contacting patients to schedule them for lab appointments accordingly. If a Return to Clinic order cannot be scheduled as requested due to limited appointment availability, consult with the clinic Nurse

Manager and Anticoagulation Clinic for the best solution.

(2) Contact the C/CBOC Nurse Manager if they cannot access or have issues with the Fast Bypass system. If someone needs troubleshooting for FastBypass, they can access it via

ABQLABANCILLARYTESTING@va.gov.

(3) Verifying which type of anticoagulant, the patient is prescribed and ensuring there is an active lab order before drawing labs. If there are no lab orders, contact the Anticoagulation Clinic.

(4) Entering POC-PT/INR results into Fast Bypass the same day it is obtained, before the close of business under the CPP's name. If Fast Bypass is unavailable, document in the electronic medical record with a note titled

"Point of Care CBOC/CCBOC" and view-alerting Anticoagulation Clinic staff to the note.

(5) Immediately contact the Anticoagulation Clinic if the POC-PT/INR is 4.1 or greater via instant messaging or phone. Contact the Anticoagulation Clinic for further instructions and strongly discourage the patient from leaving.

https://dvagov.sharepoint.com/:w:/r/sites/VHAABQDCS/SOP%20Library/CL-13%20Pharmacy%20Outpatient%20Anticoagulation%20Clinics1.docx?d=w2ebb318880a64cb0a35cc4f2166e862a&csf=1&web=1&e=lqTwwb https://dvagov.sharepoint.com/:w:/r/sites/VHAABQDCS/SOP%20Library/CL-13%20Pharmacy%20Outpatient%20Anticoagulation%20Clinics1.docx?d=w2ebb318880a64cb0a35cc4f2166e862a&csf=1&web=1&e=lqTwwb https://dvagov.sharepoint.com/:w:/r/sites/VHAABQDCS/SOP%20Library/Home%20Based%20Primary%20Care%20Pharmacy%20Anticoagulation%20Services.docx?d=wcc41c8e6906540948dc63581e31cb5e5&csf=1&web=1&e=swj3T7 https://dvagov.sharepoint.com/:w:/r/sites/VHAABQDCS/SOP%20Library/Home%20Based%20Primary%20Care%20Pharmacy%20Anticoagulation%20Services.docx?d=wcc41c8e6906540948dc63581e31cb5e5&csf=1&web=1&e=swj3T7

(6) Entering STAT non-VA lab consults if required by the Anticoagulation Clinic.

j. C/CBOC Nurse Managers. C/CBOC Nurse Managers are responsible for:

(1) Ensuring that all clinic staff can perform Point of Care Prothrombin

Time/International Normalized Ratio and have Fast Bypass access promptly.

(2) Ensuring that warfarin patients have access to timely INR checks as indicated by Anticoagulation Clinic.

(3) Referring new staff members expected to have access to Fast Bypass to NMVAHCS Laboratory for lab training and orientation, if necessary, ideally during New Employee Orientation.

(4) Contacting the C/CBOC Automated Data Processing Application

Coordinator and NMVAHCS Laboratory if issues with Fast Bypass occur.

k. Pharmacists Verifying Anticoagulant Orders. Pharmacists verifying anticoagulant orders and prescriptions are responsible for:

(1) Notifying the inpatient CPP managing the patient's care, and the

Anticoagulation Clinic or HBPC CPP for further assessment

(2) Management of critical drug-drug interactions via phone call or instant messaging,

(3) Viewing alerts to a medical record addendum.

(a) Such interactions for warfarin include but are not necessarily limited to:

1. Amiodarone,

2. Carbamazepine,

3. Doxycycline,

4. Fluconazole,

5. Fluoroquinolones,

6. Metronidazole,

7. Minocycline,

8. Prednisone,

9. Rifampin,

10. Sulfamethoxazole-Trimethoprim.

(b) Such interactions for DOACs include but are not necessarily limited to:

1. Carbamazepine,

2. Dronedarone,

3. Enzalutamide,

4. Itraconazole,

5. Ketoconazole,

6. Phenobarbital,

7. Phenytoin,

8. Rifampin,

9. Ritonavir,

10. St. John's Wort.

l. Traveling Veteran Coordinator. The Traveling Veteran Coordinator is responsible for:

(1) Coordinating care for traveling veterans per VHA Handbook

1101.11(3), Coordinated Care for Traveling Veterans.

(2) Coordinating labs for Veterans not enrolled in the NMVAHCS

Anticoagulation Clinic, ensuring that if the Veteran is enrolled with another

VA ("preferred facility") or another federal facility, arrangements have been made for lab result follow-up and dose adjustments with the primary anticoagulation care provider.

6. OTHER PARAGRAPHS

a. Parenteral Anticoagulation Protocols. Find the following protocols on the

NMVAHCS Pharmacy web page.

(1) High-Intensity Weight-Based Heparin Protocol (Pulmonary Embolus, Deep

Venous Thrombosis, Venous Thromboembolism)

(2) Low-Intensity Weight-Based Heparin Protocol (Cardiac, Atrial fibrillation, Coronary Artery Disease, Acute Coronary Syndrome)

(3) No Bolus Weight-Based Heparin Protocol

(4) Standard Argatroban Infusion Protocol (no hepatic impairment and non-critically ill)

(5) Modified Argatroban Infusion Protocol (hepatic impairment or critically ill)

b. Anticoagulation Clinical Guidance Documents. The following evidence-based resources are available for provider use in daily practice; they do not https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=3099 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=3099 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=3099 https://dvagov.sharepoint.com/sites/VHAABQIntranet/Org/AsocDir/Pages/Pharmacy.aspx replace clinical judgment in unique or unusual circumstances. Access the resources via the NMVAHCS Pharmacy web page.

(1) VA PBM Warfarin Initiation Management Algorithm.

(2) VA PBM Warfarin Maintenance Management Algorithm.

(3) DOAC Management Guide.

(4) Enoxaparin Dose-Rounding and Syringe Size Guidance.

(5) Peri-Procedure Anticoagulation Management Guide.

(6) Reversal of Anticoagulation and Management of Bleeding Events.

c. Ongoing Anticoagulation Quality Monitoring Program. The

Anticoagulation Stewardship Subcommittee of the Pharmacy &

Therapeutics Committee meets every quarter to evaluate the anticoagulation management program across inpatient and outpatient care settings; this multidisciplinary team reviews performance and safety data and identifies the following: practice improvements, ensures appropriate action is taken and evaluates the effectiveness of improvement initiatives.

d. Outpatient Pharmacy Anticoagulation Management Requirements and

Policy. Anticoagulation therapy poses risks to patients and often leads to adverse drug events due to complex dosing, requisite follow-up monitoring, and inconsistent patient compliance. Using standardized practices for anticoagulation therapy that includes patient involvement can reduce the risk of adverse drug events associated with the use of oral anticoagulant medications.

(1) The Anticoagulation Clinic is an outpatient consult service comprised of

CPPs and clinical pharmacy technicians and is available to Veterans who receive their primary care at the NMVAHCS: either at the main

Albuquerque facility or the associated NMVAHCS C/CBOCs.

(2) HBPC CPP anticoagulation management is available to Veterans enrolled in the NMVAHCS HBPC program, as outlined in Pharmacy SOP PHA-CL-

16, HBPC Pharmacy Anticoagulation Services.

(3) Assign an NMVAHCS PCP to the Veteran before consulting the

Anticoagulation Clinic. The Anticoagulation Clinic and HBPC CPP only manage Veterans assigned to a PCP associated with the NMVAHCS and https://dvagov.sharepoint.com/sites/VHAABQIntranet/Org/AsocDir/Pages/Pharmacy.aspx https://dvagov.sharepoint.com/:w:/r/sites/VHAABQDCS/SOP%20Library/Home%20Based%20Primary%20Care%20Pharmacy%20Anticoagulation%20Services.docx?d=wcc41c8e6906540948dc63581e31cb5e5&csf=1&web=1&e=swj3T7 https://dvagov.sharepoint.com/:w:/r/sites/VHAABQDCS/SOP%20Library/Home%20Based%20Primary%20Care%20Pharmacy%20Anticoagulation%20Services.docx?d=wcc41c8e6906540948dc63581e31cb5e5&csf=1&web=1&e=swj3T7 who have seen their NMVAHCS PCP within the previous 13 months or are newly discharged from the NMVAHCS with a scheduled PCP appointment.

Evaluate requests for exemptions on a case-by-case basis and will be approved temporarily only.

(4) Co-management of anticoagulation therapy is prohibited to ensure patient safety and program consistency. The Anticoagulation Clinic is not required to follow recommendations of external health care providers and may not enroll patients for whom a VA provider has re-written an external provider anticoagulant prescription. Veterans may be discharged from the

Anticoagulation Clinic to the PCP if they abuse alcohol or illegal substances, do not adhere to the prescribed medication regimen or required labs, do not follow up with the PCP at least annually, decline pharmacy anticoagulation management follow-up modalities, or fail to maintain communication with the

Anticoagulation Clinic or HBPC CPP.

(5) In addition to the above requirements, to be considered eligible for pharmacy anticoagulation monitoring, the Veteran must:

(a) Be able to self-administer medications or have a supervising caregiver able to administer medications to the patient.

(b) Provide verbal consent to participate in follow-up via phone, voicemail, and letter.

(c) Agree to routine lab monitoring and, if not enrolled in HBPC, have transportation to the lab or clinic, which may include INR checks up to twice weekly for warfarin.

(d) Require long-term anticoagulation (more than 6 weeks duration).

(e) Maintain reliable telephone contact with the Anticoagulation Clinic or

HBPC CPP.

(f) Notify the Anticoagulation Clinic, or HBPC PCP, promptly of hospitalizations and emergency department visits to ensure appropriate follow-up.

(g) Notify the Anticoagulation Clinic or HBPC CPP at least 2 weeks before any planned procedures or surgeries.

(h) Notify the Anticoagulation Clinic or HBPC CPP regarding any changes in medication therapy given the potential for drug-drug interactions.

(i) Verbally agree and acknowledge understanding of the requirements for enrollment in the Anticoagulation Clinic outlined in Pharmacy

SOP PHA-CL-13, Pharmacy Anticoagulation Clinic, and Pharmacy

SOP PHA-CL-16, HBPC Pharmacy Anticoagulation Services.

(6) Veterans are encouraged to present to C/CBOCs before 2:00 P.M. or as directed due to lab courier transit cut-off times.

(7) The clinic may make recommendations regarding peri-procedure planning for

Veterans not enrolled with the clinic upon provider request if adequate advance notice and information is provided; in this situation, the consulting provider is responsible for providing patient education and managing the anticoagulation surrounding the procedure.

(8) Report critical INR results after-hours and on holidays, in accordance with MCP 11-64, Critical Test Results.

7. REFERENCES

a. VHA Directive 1108.16(1), Anticoagulation Therapy Management, dated January

29, 2021

b. VHA Directive 1310 (1), Medical Management of Enrolled Veterans Receiving

Self-Directed Care From External Health Care Providers October 4, 2021.

c. VHA Handbook 1101.11(3), Coordinated Care for Traveling Veterans, dated

April 22, 2015

d. MCP 11-64, Critical Test Results, dated May 26, 2022.

e. MCP 113-14, Ancillary Testing Policy, dated June 4, 2022.

f. VHA Consult Business Rules

8. REVIEW

This MCP will be reviewed 120 days before recertification or sooner if when there are changes to governing documents cited in references above.

9. RECERTIFICATION

This MCP is scheduled for recertification on the last working day of October 2027.

https://dvagov.sharepoint.com/:w:/r/sites/VHAABQDCS/SOP%20Library/CL-13%20Pharmacy%20Outpatient%20Anticoagulation%20Clinics1.docx?d=w2ebb318880a64cb0a35cc4f2166e862a&csf=1&web=1&e=lqTwwb https://dvagov.sharepoint.com/:w:/r/sites/VHAABQDCS/SOP%20Library/CL-13%20Pharmacy%20Outpatient%20Anticoagulation%20Clinics1.docx?d=w2ebb318880a64cb0a35cc4f2166e862a&csf=1&web=1&e=lqTwwb https://dvagov.sharepoint.com/:w:/r/sites/VHAABQDCS/SOP%20Library/Home%20Based%20Primary%20Care%20Pharmacy%20Anticoagulation%20Services.docx?d=wcc41c8e6906540948dc63581e31cb5e5&csf=1&web=1&e=swj3T7 https://dvagov.sharepoint.com/:w:/r/sites/VHAABQDCS/SOP%20Library/Home%20Based%20Primary%20Care%20Pharmacy%20Anticoagulation%20Services.docx?d=wcc41c8e6906540948dc63581e31cb5e5&csf=1&web=1&e=swj3T7 https://dvagov.sharepoint.com/:w:/r/sites/VHAABQDCS/ABQ%20Active%20Library/Critical%20Test%20Results.docx?d=w2dfac8c724e34faa840265be6e2cc6b4&csf=1&web=1&e=Zpf7dd https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=9173 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=9173 https://vaww.va.gov/vhapublications/publications.cfm?pub=1&order=asc&orderby=pub_Number https://vaww.va.gov/vhapublications/publications.cfm?pub=1&order=asc&orderby=pub_Number https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=3099 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=3099 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=3099 https://dvagov.sharepoint.com/:w:/r/sites/VHAABQDCS/ABQ%20Active%20Library/Critical%20Test%20Results.docx?d=w2dfac8c724e34faa840265be6e2cc6b4&csf=1&web=1&e=Zpf7dd https://dvagov.sharepoint.com/:w:/r/sites/VHAABQDCS/ABQ%20Active%20Library/Ancillary%20Testing%20Policy.docx?d=w2fc69bdf51fa402b9f5a17896c290373&csf=1&web=1&e=SMyRq0

This MCP will continue to serve as local policy until it is recertified or rescinded. In the event of contradiction with national policy, the national policy supersedes and controls.

SIGNATORY AUTHORITY

/S/ Robert McKenrick Executive Director

NOTE: The signature remains valid until rescinded by appropriate administrative action