Impact diabetes

IMPACT DIABETES
PARTNERSHIP TO IMPLEMENT TEAMBASED PHARMACISTINTEGRATED DIABETES CARE IN THE
SAFETY-NET SETTING
S ALLIE M AYER , P HARM D, MBA, BCPS, CDE
S ALLY G RAHAM , MSN, RN-C,ANP
M ICHAEL DAIL , P HARMD

Insert Your Logo(s) Here

OBJECTIVES
 Describe the benefits of team-based, pharmacistintegrated 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

PROJECT IMPACT: DIABETES

2

DIABETES IN THE SAFETY NET
 Disease Burden
 Complication Burden
 Complexity of Patient Needs
 Access Barriers
 Resources
 Specialty Care


3

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


4

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
o
o
o

Self-management education
Pharmacotherapy management
Treatment tailoring and intensification
Complication avoidance through
treatment goal attainment


5

VCU SCHOOL OF PHARMACY - SAFETY NET
PARTNERSHIP
 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


6

IMPACT: DIABETES PROJECT


7

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)


8

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


9

“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.


10

IMPACT: DIABETES PROJECT – PHARMACIST
ENGAGEMENT
 School of Pharmacy Faculty
o Student involvement

 Co-Funded Pharmacy Resident
 Volunteer Pharmacists
o
o
o
o

CrossOver
Diabetes-Certificate Training Program
Pharmacy Residents
Community Pharmacists


11

IMPACT: DIABETES MODEL - TEAM
 Team Members
o
o
o
o
o
o
o
o
o
o
o

Front Desk Staff / Schedulers
Nurses (floor, lab review)
Physicians / Nurse Practitioners
Interpreters
Nurse Manager
Clinic Manager
Clinic Directors
Dental
Ophthalmology
Podiatry
Others!


12

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


13

PharmD
Diabetes
Schedule


14

IMPACT DIABETES – PHARMACIST VISITS
o
o
o
o
o
o
o
o
o

Pre-round calls, chart review, and preparation
Assessment of diabetes knowledge
Medication review, reconciliation with focus on access
Assessment of refill status – current medication supply / source
Interview and review of systems
Individualized education
Foot Exams
Vaccines
Intensification of therapy to meet chronic disease goals
•

o
o
o
o
o
o
o
o

Diabetes, Hypertension, Lipids, ASA, ACEI – ARB use

Provision of diabetes testing supplies and A1C goal incentives
Individualized laboratory monitoring with POCT A1C when available
Coordination with PCP and referrals (eye, social work, dental, counseling)
Impact Diabetes Note: Assessment and plans for chart documentation
Prescription refills
Follow-up phone calls
Relationships with patients
Communication with providers


15

PharmD
Diabetes
Note


16

PharmD
Diabetes
Note


17

IMPACT DIABETES: OVERALL INTERIM RESULTS


18

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%)


19

Demographics
5.6%

18.9%

41.1 %

African American
Caucasian
Hispanic
Asian
Other

33.3 %


20

IMPACT DIABETES: LOCAL RESULTS
VISIT INFORMATION

 Number of visits

o Average 5 visits per patient during year

Blood Sugar Log
Date

Before
Breakfast

Before
Lunch

Before
Dinner

Bedtime

 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


21

CLINICAL MEASURES
A1C
BMI
Systolic BP
Diastolic BP
LDL-C
HDL-C
Triglycerides
Total Cholesterol

N = Baseline
89
10.0
89
34.3
89
130.2
89
78.6
69
118.1
74
41.4
73
279.5
74
191.7

Most
Change
P
Days
Recent
to Date Value Experience
8.2
-1.8 0.000
293.2
34.5
0.3 0.212
267.9
128.4
-1.7 0.213
288.7
77.4
-1.2 0.188
288.7
79.0
-39.1 0.001
250.2
43.5
2.1 0.024
254.3
167.0
-112.5 0.000
251.3
154.0
-37.7 0.000
254.3


22

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


23

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, CDE
Virginia Commonwealth University School of Pharmacy, Department of Pharmacotherapy and Outcomes Science, Richmond, Virginia

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

Mean number of disease states
Mean number of medications
Mean A1c (range)
% Patients on insulin therapy

7 (2-12)
7 (2-18)
9.2 (6.1- >12)
71

Table 2: Interventions over 6 month period
Total number of visits
Mean visits with patients (range)
Mean time spent with patients (range)

METHODS

RESULTS

Mean time spent on preparation (range)

74
3 (1-9)
41 min (20-90)
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

Table 3: Education
Education provided at each patient visit
• Therapeutic goals
• Hypoglycemia signs,
symptoms and treatment

• Hyperglycemia signs,
symptoms and treatment

DISCUSSION
•
•

• Foot care

Targeted Education Provided as Appropriate
• Self monitoring of blood
glucose values

• Evidence supporting
pharmacotherapy
recommendations

• Medication mechanism of
action and side effects
• Risk reduction

• Disease process

• Vaccinations

• Nutrition

•

• Eye care

• Smoking cessation

•

• Insulin or other injectable
administration

Table 4: Core Themes Noted on Satisfaction Surveys
• 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.
• 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 .

PROVIDERS
n=8

OBJECTIVES

RESULTS
Table 1: Baseline Characteristics, n=24
Mean Age (range)
54 (41-64)
% Male
54
Ethnicity
% Caucasian
50
% African American
42
% Hispanic
2
Type of Diabetes
% Type 1
4.2
% Type 1.5
29.1
% Type 2
66.7
% New Diagnosis
8.3
Mean years with diabetes (range)
10.6 (0.08-42)

PATIENTS
n=7

BACKGROUND INFORMATION
• The ADA standards of care regarding diabetes management
state that patients should receive care from a physiciancoordinated 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

•
•
•

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.

CONCLUSIONS
•
•

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.

REFERENCES
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.


24

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


25

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


26

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

27

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
o
o
o

Patient No-shows
Interpreters
Prescription Assistance Programs
Clinic Support / Space


28

IMPACT DIABETES: SUCCESSES
 Patient Referrals
 Patient Acceptance
 Flexible Visit Length
 Physician-Patient-Pharmacist
Collaborative Practice Model
 Scheduling
 Outcomes

 Sustainability
 Resource-Sharing
 Pharmacist Engagement

29

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


30

IMPACT DIABETES: SUSTAINABILITY
 Continued Grant Funding
 Partnership Synergies
 Co-Funded Resident
 Expanded Projects / Roles

 Student Opportunities
 Innovative Practice


31

IMPACT DIABETES: FUNDING
 Collaborative Academic
o Community Engagement
o Residency Programs

 Pharmacy Organizations
 Retail Pharmacy

 Foundations
 Health Disparities
 Accredited Education Programs (Medicare)


32

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


33

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”


34

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


35

SUMMARY AND CONTACT INFORMATION
 Sallie Mayer: sdmayer@vcu.edu
 Sally Graham: sgraham@co.goochland.va.us
 Michael Dail: dailm@vcu.edu
 IMPACT: Diabetes Link: http://aphafoundation.org/projectimpact-diabetes


36

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