DIABETES MANAGEMENT can be tricky, especially for patients who have been diagnosed and prescribed oral agents or insulin to help them control their blood glucose. Those with type 2 diabetes often also grapple with hypertension and dislipidemia and must take additional medications.
The juggling act these patients face inspired Zachary A. Weber, Pharm.D., BCPS, BCACP, CDE, clinical assistant professor of pharmacy practice at Purdue University College of Pharmacy and clinical pharmacy specialist in primary care at Wishard Hospital in Indianapolis, to approach the hospital’s endocrinologists with a working model that focused on multidisciplinary teamwork.
The resulting collaborative practice agreement between Weber and physicians in the endocrinology clinic serves as a great example of how pharmacists can be granted enhanced patient-care privileges as part of integrated care teams, one of the recommendations of ASHP’s Pharmacy Practice Model Initiative.
New patient-care privileges can include starting new medications, adjusting medication doses, and ordering relevant laboratory monitoring.
A Basis for Teamwork
The collaborative practice agreement Weber has with the endocrinology department is modeled after agreements among other pharmacists and primary care physicians in clinics throughout the Wishard system. These agreements allow pharmacists to serve as physician extenders and work side-by-side with ambulatory care physicians to optimize patients’ medication regimens.
“The evidence from the initial collaborative practice site demonstrated improved patient care, and we felt it would be beneficial to extend it,” Weber said. “We changed the primary care agreement to fit the endocrine clinic, but the agreements are basically the same throughout the system. We have one for primary care and one for specialty care.”
Rattan Juneja, M.D., associate professor of clinical medicine, who reviewed Weber’s proposal, said the agreement came at an opportune time.
“We were swamped. Our waiting lists were six to eight months long. We spoke with Zach about how to deal with patients who [were having trouble managing their blood glucose], and he came up with the idea to work directly with patients in managing their medications.”
Under the collaborative practice agreement, physicians such as Dr. Juneja and his colleague Dr. Kieren Mather, M.D., associate professor of medicine, draw up diabetes management plans and oversee patient care.
Select patients are then referred to Weber, a certified diabetes educator, for the nitty-gritty of explaining how medications work and demonstrating how to take insulin.
Weber also helps to make ongoing adjustments to the medications within the written scope of the collaborative practice agreement to help patients achieve their goals. This agreement allows him to make certain adjustments without needing to seek physician approval.
“People tend to think that you send a patient to an endocrinologist, and the endocrinologist fixes the diabetes,” said Dr. Juneja. “But it’s really the patient who treats the diabetes, and physicians can’t oversee the details of diabetes management to the extent patients need because of our patient volume.”
The results thus far have been positive: Over two years in clinic, patients who received care from Dr. Weber experienced a reduction in their average A1C levels around 1.5 – 2 percent. In addition, patients’ average LDL dropped around 20-25 mg/dl, with many more achieving American Diabetes Association (ADA) goals of less than 100 mg/dl.
Similarly, the average blood pressure for Dr. Weber’s patients fell within the recommended ADA treatment goal.
Ironing out the Details
Although the collaborative practice agreement has been successful, initially, there were a few wrinkles. To further a continuity of process, the clinic staff had to get used to having a pharmacist around and scheduling appointments for Weber.
“We wanted patients to experience checking into the clinic, going to the exam room, leaving the clinic, and scheduling appointments as a simple process, and we didn’t want the support staff to have to learn something new,” said Weber.
“But the reality is that we were adding a whole new provider. It took some time for the clinic staff to understand who I am, what I do, and how my patients should be treated as they move through the clinic as compared to the physicians’ patients.”
The team also needed to strike a balance in terms of when patients saw whom, said Dr. Mather.
“The intent is not to refer patients to Zach as an alternate approach to long-term diabetes management. Instead, the intent is to help patients overcome hurdles to get their disease on track with better control, starting early in their care through our clinic.”
Ramping up took some time, as well. In the beginning there weren’t many referrals, Weber said. “There were only a few patients. You have to show what you can do in the clinic and how you can help patients before physicians send patients your way. You have to build that trust.”
ROI Can Take Time
The hospital administration had already seen successful collaborative practice agreements among pharmacists and physicians in primary care clinics, so there were no raised eyebrows when it took over a year for Weber to have a steady stream of patients. It also didn’t hurt that he was already salaried as a professor at Purdue.
“I didn’t face too much pressure because I have a faculty appointment, but pharmacists at other health systems or hospitals might want to stress to their administrations that it could be 12 to 24 months before there’s a return on investment,” he noted. “They might have to do some convincing at first.”
Finally, there was the issue of compensation. Because Weber is salaried, his work in the clinic does not cost Wishard any extra money. Other institutions might not have the same situation, said Mather.
“Because we are an academic institution, we’re able to have it that way, but other hospitals or physicians in private practice may face a few financial challenges with that, depending on how pharmacists are licensed in their states.”
Because Wishard physicians are not compensated per patient, neither Mather nor the other physicians in the clinic are paid for supervising and signing off on Weber’s care. “But that’s fine because the collaboration is such a help to us.”