Impact diabetes

IMPACT DIABETES

PARTNERSHIP TO IMPLEMENT TEAM-

BASED PHARMACIST-

INTEGRATED DIABETES CARE IN THE

SAFETY-NET SETTING

SALLIE MAYER, PHARMD, MBA, BCPS, CDE

SALLY GRAHAM, MSN, RN-C,ANP

MICHAEL DAIL, PHARMD

Insert Your Logo(s) Here

OBJECTIVES

P R O J E C T I M P A C T : D I A B E T E S 2

Describe the benefits of team-based, pharmacist-

integrated diabetes care models

Learn about the IMPACT: Diabetes Program and outcomes

Understand the resources and steps needed to develop

and implement an enhanced diabetes program

Take away key tools and resources that can be modified

for various safety-net settings

Discuss sources of funding, methods of pharmacist

engagement, and sustainability for diabetes programs in

the safety-net

DIABETES IN THE SAFETY NET


Disease Burden

Complication Burden

Complexity of Patient Needs

Access Barriers

Resources

Specialty Care

DIABETES CARE MODELS - SAFETY-NET


Traditional Model

Group Education

Group Visits

“Diabetes Day”

Chronic Care Model

Individual Wellness-Based

Team-Based

Pharmacist-Integrated o Community

o Primary-Care Team Member

DIABETES CARE MODELS – PHARMACIST


Core Pharmacist Role o Educator

o Clinician • Part of Primary Care Team • At the bedside

o Consultant

Core Pharmacist Expertise o Self-management education o Pharmacotherapy management o Treatment tailoring and intensification o Complication avoidance through treatment goal attainment


CrossOver Heatlhcare Ministry ten years ago o Volunteer Pharmacist / Community Resident Training

Clinical Pharmacy Faculty Practice Site

Diabetes Intensive Care Program

Patient-Centered Medical Home Initiative

IMPACT: Diabetes Grant

Expansion to other CrossOver sites

Expansion to Goochland Free Clinic and Family Services

Other Engaged Free Clinics

VCU SCHOOL OF PHARMACY - SAFETY NET

PARTNERSHIP

IMPACT: DIABETES PROJECT


IMPACT DIABETES – PARTNERS


VCU School of Pharmacy

CrossOver Healthcare Ministry

Goochland Free Clinic and Family Services

FanFree Clinic (Initial Partner)

Rx Partnership

Richmond Memorial Healthcare Foundation (Greater

Richmond PCMH Initiative)

Local Pharmacies

Local Hospitals (In-kind services)

IMPACT: DIABETES MODEL


Infrastructure Needed

Collaborative Practice Agreement / Model

Agreed Definition of Pharmacist Scope of Practice

Patient Referrals o A1c (Lab review), Comorbidities, Insulin, New diagnosis, New

patients, Pre-Diabetes, Review of patient database

Pharmacist as “Primary-Care Provider”

Scheduling

Core and Support Team

Pharmacist as Diabetes Team Leader


“XXXX” CLINIC COLLABORATVE PRACTICE AGREEMENT

A. AUTHORITY

As the Cross-Over Health Center Medical Director and a physician who holds an active license to practice from

the Virginia Board of Medicine, I, __________________M.D. authorize the clinical pharmacists named herein,

who hold an active license to practice from the Virginia Board of Pharmacy, to manage and/or treat patients of

the _____________Clinic pursuant to written, patient-specific orders from me or my designees. This authority

follows the laws § 54.1-2400 and Chapters 33 and 34 of Title 54.1 of the Code of Virginia and regulations § 18

VAC 110-40-10 et seq. of the Commonwealth of Virginia.

B. SCOPE OF PRACTICE

Upon receipt of a patient-specific referral from the Medical Director or designee, and written consent from the

patient, the clinical pharmacists will have the authority to manage and/or treat patients in accordance with this

section. In managing and/or treating patients, the clinical pharmacists may:

Access medical records

Document pertinent findings and recommendations in the medical record

Order laboratory tests and other noninvasive tests to facilitate therapeutic monitoring

Perform point-of-care testing to monitor the efficacy or toxicity of drug therapy

Request consultations from other health care providers

Interview patients and perform minor physical assessment to determine patient response to therapy

Evaluate patient response to pharmacological interventions and:

o Adjust dosages or discontinue therapy as clinically indicated

o Authorize prescription refills on current drug therapies

o Initiate new prescriptions after conferring with a clinic physician or referring provider

Administer immunizations and medications within established clinic protocols or approved guidelines

Provide patient education

Initiate, coordinate, and participate in research projects and/or quality assurance assessments

Precept pharmacy, medicine, or other health care profession residents and/or students

B.1. Diabetes

The clinical pharmacists will have authority to define therapeutic goals and manage diabetes therapy as

outlined in the American Diabetes Association (ADA) Standards of Medical Care in Diabetes 20131 and

American Association of Clinical Endocrinologists (AACE) Diabetes Guidelines2. In doing so, they will

have authority to manage the use of drugs for the treatment of diabetes which may include, but are not

limited to the following classes: sulfonylureas, biguanides, alpha-glucosidase inhibitors,

thiazolidinediones, insulin, meglitinides, amylin analogs, incretin mimetics, and dipeptidyl-peptidase 4

inhibitors.

B.2. Dyslipidemia

The clinical pharmacists will have authority to define therapeutic goals and manage dyslipidemia as

outlined by National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III)3,4,5

. In

doing so, they will have authority to manage the use of drugs for the treatment of lipids which may

include, but are not limited to the following classes: HMG-CoA reductase inhibitors (statins), bile-acid

sequestrants, cholesterol absorption inhibitors, fibrates, omega-3 fatty acids and niacin.

IMPACT: DIABETES PROJECT – PHARMACIST

ENGAGEMENT


School of Pharmacy Faculty o Student involvement

Co-Funded Pharmacy Resident

Volunteer Pharmacists o CrossOver

o Diabetes-Certificate Training Program

o Pharmacy Residents

o Community Pharmacists

IMPACT: DIABETES MODEL - TEAM


Team Members o Front Desk Staff / Schedulers

o Nurses (floor, lab review)

o Physicians / Nurse Practitioners

o Interpreters

o Nurse Manager

o Clinic Manager

o Clinic Directors

o Dental

o Ophthalmology

o Podiatry

o Others!

IMPACT DIABETES: IMPLEMENTATION


o Referrals

o Pharmacist primary care visits during “PharmD” Clinic Days

• Varied from ½ to 1 full day per week

• Number of patient visits varied from 4 to 10 per half day

o Patient Visits

• Initial

• Follow-up

• Visit Length

o Patient “Discharge”

• Continued co-management is the norm


PharmD

Diabetes

Schedule

IMPACT DIABETES – PHARMACIST VISITS


o Pre-round calls, chart review, and preparation

o Assessment of diabetes knowledge

o Medication review, reconciliation with focus on access

o Assessment of refill status – current medication supply / source

o Interview and review of systems

o Individualized education

o Foot Exams

o Vaccines

o Intensification of therapy to meet chronic disease goals • Diabetes, Hypertension, Lipids, ASA, ACEI – ARB use

o Provision of diabetes testing supplies and A1C goal incentives

o Individualized laboratory monitoring with POCT A1C when available

o Coordination with PCP and referrals (eye, social work, dental, counseling)

o Impact Diabetes Note: Assessment and plans for chart documentation

o Prescription refills

o Follow-up phone calls

o Relationships with patients

o Communication with providers


PharmD

Diabetes

Note

IMPACT DIABETES: OVERALL INTERIM RESULTS


IMPACT DIABETES - LOCAL RESULTS

DEMOGRAPHICS


90 patients met eligibility criteria for project

Average Age: 49.9

Gender: o Female 55.6% (n=50)

o Male 40% (n=40)

Baseline Knowledge Assessment: o Beginner (34.4%)

o Proficient (51.1%)

o Advanced (14.4%)



Demographics

African American

Caucasian

Hispanic

Asian

Other

41.1 %

33.3 %

18.9%

5.6%

IMPACT DIABETES: LOCAL RESULTS

VISIT INFORMATION


Number of visits o Average 5 visits per patient during year

Average Visit Length o First Visit: 48 minutes

o Follow-up Visits: 38 minutes

Visit Interventions o Medication Review and Reconciliation:

93% of visits

o Medication Pharmacotherapy Plan:

93% of visits

o Referral or Some Intervention Made:

87% of visits

o Documentation and Follow-up:

100% of visits

Blood Sugar Log

Date Before Breakfast

Before Lunch

Before Dinner

Bedtime


CLINICAL MEASURES


N = Baseline

Most

Recent

Change

to Date

P

Value

Days

Experience

A1C 89 10.0 8.2 -1.8 0.000 293.2

BMI 89 34.3 34.5 0.3 0.212 267.9

Systolic BP 89 130.2 128.4 -1.7 0.213 288.7

Diastolic BP 89 78.6 77.4 -1.2 0.188 288.7

LDL-C 69 118.1 79.0 -39.1 0.001 250.2

HDL-C 74 41.4 43.5 2.1 0.024 254.3

Triglycerides 73 279.5 167.0 -112.5 0.000 251.3

Total Cholesterol 74 191.7 154.0 -37.7 0.000 254.3

IMPACT DIABETES – LOCAL RESULTS

PROCESS MEASURES


Eye Exam o 100% who did not have an eye exam had been referred by study

end

Foot Exam o 83.3% who did not have a foot exam at study start did so by study

end

o Most performed by pharmacist

Smoking o 25.9 % quit smoking during study period

Vaccines o 66.7% who did not have influenza vaccine at study start did so by

study end

IMPACT DIABETES – PATIENT / PROVIDER

SATISFACTION


Establishing Pharmacist-Integrated Diabetes Care in a Rural Clinic

Tonya M. Mawyer, PharmD; Spencer E. Harpe, PharmD, PhD, MPH; Sallie D. Mayer, PharmD, MBA, CDEVirginia Commonwealth University School of Pharmacy, Department of Pharmacotherapy and Outcomes Science, Richmond, Virginia

RESULTS RESULTS DISCUSSION

REFERENCES

BACKGROUND INFORMATION

• The ADA standards of care regarding diabetes management

state that patients should receive care from a physician-

coordinated team that includes physicians, nurses,

pharmacists, dieticians, and mental health professionals.1

• The Asheville Project and the Diabetes Ten City Challenge have

demonstrated the positive impact of community pharmacists on

diabetes care.2,3

• Currently there is a lack of evidence describing pharmacist

integration into a multi-disciplinary team in a rural, free clinic

setting.

• Prior to this study, Goochland Free Clinic and Family Services

diabetes care team consisted of a chronic disease physician

and a diabetes nurse educator, with mental health professionals

available by referral.

• The IMPACT: Diabetes grant allowed for an inner city free clinic

pharmacist-integrated diabetes care model to be expanded

and adapted in a rural free clinic

OBJECTIVES

1. Describe the integration of pharmacists into a rural, free clinic

2. Identify the types of interventions being made by the

pharmacist

3. Evaluate patient and provider satisfaction with pharmacy

services

METHODS

1. American Diabetes Association. Standards of Medical Care in

Diabetes-2012. Diabetes Care 2012; 35(Suppl 1):S11-63

2. Cranor CW, Bunting BA, Christensen DB. The Asheville

Project: Long-Term Clinical and Economic Outcomes of a

Community Pharmacy Diabetes Care Program. J Am Pharm

Assoc. 2003; 43:173-84.

3. Fera T, Blumi BM, Ellis WM. Diabetes Ten City Challenge:

Final economic and clinical results. J Am Pharm Assoc. 2009;

49:383-391.

Table 3: Education

Education provided at each patient visit

• Therapeutic goals • Foot care

• Hypoglycemia signs,

symptoms and treatment

• Hyperglycemia signs,

symptoms and treatment

Targeted Education Provided as Appropriate

• Self monitoring of blood

glucose values

• Evidence supporting

pharmacotherapy

recommendations

• Medication mechanism of

action and side effects

• Insulin or other injectable

administration

• Risk reduction • Disease process

• Vaccinations • Eye care

• Smoking cessation • Nutrition

• Integration of a pharmacist into the diabetes care team has

been well received by both the providers and patients.

• Providers recognized that pharmacists bring a necessary

set of unique qualities and expertise to the patient care

team.

• The majority of the patients referred were complex with

difficult to control diabetes, despite being on insulin therapy,

• The pharmacist inevitably served as a physician extender

with more frequent, longer appointments than typical

chronic disease visits.

• This increased amount of time and number of visits allowed

the pharmacist to fully explore the unique barriers that each

patient is facing thereby catering to their specific needs.

• The collaborative practice agreement allowed for frequent

changes in medications as appropriate, especially with

regard to insulin titrations.

• An extensive amount of education was provided at every

visit allowing patients to be more involved in the

management of their diabetes.

• Pharmacist-integrated diabetes services and clinical

outcomes will continue to be collected and evaluated as

part of the IMPACT: Diabetes project.

• Collaboration for resources and funding are underway to

sustain the pharmacist-integrated model.

Table 4: Core Themes Noted on Satisfaction Surveys

PR

OV

IDE

RS

n=

8

• Pharmacist is a key resource for managing

patients on insulin.

• Changed view of the role of pharmacist - direct

patient care provider with clinical expertise.

• More time is spent with patients and overall

diabetes care has improved.

• Areas of Improvement: sustainability, scheduled

team meetings every 2 to 4 weeks.

PA

TIE

NT

S

n=

7

• Thought pharmacist only worked at a store to

answer questions and give you medications.

• Pharmacist works on nutrition, diet, weight loss,

changing insulin, explaining more about

medications, adherence, and disease process.

• 100% of patients

• felt their diabetes was better controlled

• would recommend this service

• were satisfied with pharmacist care

• When asked for areas of improvement via survey,

none were listed .

Table 1: Baseline Characteristics, n=24

Mean Age (range) 54 (41-64)

% Male 54

Ethnicity

% Caucasian

% African American

% Hispanic

50

42

2

Type of Diabetes

% Type 1

% Type 1.5

% Type 2

4.2

29.1

66.7

% New Diagnosis 8.3

Mean years with diabetes (range) 10.6 (0.08-42)

Mean number of disease states 7 (2-12)

Mean number of medications 7 (2-18)

Mean A1c (range) 9.2 (6.1- >12)

% Patients on insulin therapy 71

CONCLUSIONSTable 2: Interventions over 6 month period

Total number of visits 74

Mean visits with patients (range) 3 (1-9)

Mean time spent with patients (range) 41 min (20-90)

Mean time spent on preparation (range) 12 min(5-30)

Number of medications

Initiated

Discontinued

Titrated dose

Tapered dose

12

8

26

8

Insulin adjustments 24

Medication refills 29

Diabetic supplies provided 27

Referrals (Eye, M.D., Labs) 14

Flu Voucher Provided 16

Pneumococcal Immunization Provided 9

IMPACT DIABETES: RESULTS


Patient Successes

CrossOver Patient Story

Goochland Patient Story

Video Highlights Richmond area projects o http://www.youtube.com/watch?feature=player_embedded&v=gZ1T

63qJrS4

http://www.youtube.com/watch?feature=player_embedded&v=gZ1T63qJrS4



IMPLEMENTATION: GOOCHLAND PERSPECTIVE


Consensus on need for diabetes counseling/support

Project approach consistent with existing model

Staff open to working with faculty and students

Able to identify and track high risk patients

Communication- pre-visit referral

and post-visit review

Manageable number of patients

Consistent provider

Existing resources needed for success- meds and testing supplies

GFCFS offers transportation

IMPLEMENTATION: CROSSOVER PERSPECTIVE


Ability to address Language Needs o Interpreters

o Education

Patient volume – physician and leadership support of program

Large percentage of volunteer providers

Integration of pharmacist on “team” – primary care visit

Complex Patients o “Insulin Experts” and New Diagnosis

Continuity of care

Provider and pharmacy leadership team participation

Pharmacy resident integration in other clinic activities

IMPACT DIABETES: OVERCOMING BARRIERS


Staff Engagement and Education

More Structured Role Definitions o Adaptability in non-physician-based settings

Flexibility and Awareness of Pharmacist Provider

Enhanced Communication (Staff and Leadership!) o Outcomes

o Success Stories

Data Collection

Clinic Administrative / Clinical Support o Patient No-shows

o Interpreters

o Prescription Assistance Programs

o Clinic Support / Space

IMPACT DIABETES: SUCCESSES


Patient Referrals

Patient Acceptance

Flexible Visit Length

Physician-Patient-Pharmacist

Collaborative Practice Model

Scheduling

Outcomes

Sustainability

Resource-Sharing

Pharmacist Engagement

IMPACT DIABETES – COST CONSIDERATIONS


Pharmacist Time

Pharmacist Volunteer Training o Current Safety-Net Pharmacist Providers

o Diabetes Certificate Programs

Diabetes Testing Supplies

Support Staff

Medications / Insulin and Supply Usage

IMPACT DIABETES: SUSTAINABILITY


Continued Grant Funding

Partnership Synergies

Co-Funded Resident

Expanded Projects / Roles

Student Opportunities

Innovative Practice

IMPACT DIABETES: FUNDING


Collaborative Academic o Community Engagement

o Residency Programs

Pharmacy Organizations

Retail Pharmacy

Foundations

Health Disparities

Accredited Education Programs (Medicare)

ADDITIONAL PHARMACIST COLLABORATIONS


Interprofessional Evening Student Teaching Clinic

Vaccine Clinic

Polypharmacy Medication Reviews

Chronic Disease Clinic

Chart Review

Community Outreach Events

Continuing Education

Consultation o Patient cases

o Medication formulary / costs

IMPACT DIABETES: IMPLEMENTATION TOOLS


Case Studies: o http://www.projectimpactdiabetes.org/case-studies

Documentation: o Impact: Diabetes Note

Collaboration o Sample Collaborative Practice Agreement

Education o Knowledge Self-Assessment

o Self Monitoring Blood Glucose Logs

o “Living With Diabetes”

OPPORTUNITIES FOR REPLICATION /

MODIFICATION


Engagement with local pharmacies / pharmacists

Pharmacist-sharing

Nurse – Social Work – Health Educator Models

Rural / Remote settings

Other IMPACT: Diabetes Models o http://www.aphafoundation.org/project-impact-diabetes/communities

http://www.aphafoundation.org/project-impact-diabetes/communities





SUMMARY AND CONTACT INFORMATION


Sallie Mayer: [email protected]

Sally Graham: [email protected]

Michael Dail: [email protected]

IMPACT: Diabetes Link: http://aphafoundation.org/project-

impact-diabetes

mailto:[email protected]



http://aphafoundation.org/project-impact-diabetes





Impact diabetes

Health & Medicine

Transcript of Impact diabetes