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VA Pharmacist-Led Diabetes Clinic Dramatically Improves Patient Outcomes

Candis M. Morello, Pharm.D., CDE, FCSHP, FASHP

BACK IN 2009, when the VA San Diego Healthcare System wanted to help its primary care physicians meet performance measures for diabetes as well as help its patients with diabetes improve their metabolic goals, Candis M. Morello, Pharm.D., CDE, FCSHP, FASHP, saw an opportunity to apply her knowledge as both a pharmacist and diabetes educator.

Working together with the departments of endocrinology, internal medicine, and pharmacy, she devised the Diabetes Intense Medical Management Clinic, a pharmacist-led clinic that delivers individualized diabetes care.

“The new model provides integrated care that covers not only diabetes, but hypertension, lipids, food choices, activity, mood, adherence, and motivation. We then put it all together to create a unique treatment plan for each patient,” said Dr. Morello, who is professor of clinical pharmacy and associate dean for student affairs at the Skaggs School of Pharmacy and Pharmaceutical Sciences at the University of California, San Diego (UCSD).

Achieving Multiple Goals

At its inception, the clinic sought to answer two questions. First, would 60-minute visits with a pharmacist who provided medication therapy management and tailored diabetes education help patients manage their diabetes better? Second, would the patients come away from the clinic with skills they could use for the rest of their lives in primary care settings?

“I was hoping that if we spent more time with each patient in a less rushed visit, it would meet two goals: Help patients to achieve and sustain diabetes control while lowering costs for the medical center,” said Morello.

Melissa Christopher, Pharm.D.

Those were lofty goals considering that patients would only have three or four visits in a span of six months and Morello could be in clinic just one half-day per week. Seeing the challenge her limited hours would present with scheduling, the clinic got approval to train another pharmacist, Melissa D. Christopher, Pharm.D. After six years with the clinic, Dr. Christopher became national director for academic detailing with the VA last year.

The patient population itself presented challenges. Nearly 75 percent of the patients have at least three physical comorbidities in addition to their diabetes, and 45 percent have mental health comorbidities.

“Many patients have limited ability to do physical activity because they’re in a wheelchair or have a pain syndrome that limits their amount of walking. But activity is a component of controlling weight and blood glucose, so we had to look at different strategies, including modifying medications to compensate for what they can’t do with exercise,” said Christopher.

During her visits, Morello adjusts and prescribes medication as well as orders and interprets lab tests for diabetes, hypertension, lipids, hypothyroidism, and diabetic peripheral neuropathy. She also educates patients on what their medications do and how to take them, and on lifestyle changes that may help them achieve their goals. If necessary, patients are welcome to schedule phone calls of 10-15 minutes as well.

Care That Gets Results

In the early days of the clinic, patients had to have an A1c of at least nine percent to be referred, and the mean A1c of the first 116 patients to come to the clinic was 10.5 percent. As the clinic’s impact became apparent, physicians began referring patients with A1cs higher than 8 percent. Patients do not leave the clinic and return to primary care until they achieve their metabolic goals. Usually, they visit the clinic for six to nine months, although some have visited for a year.

At the six-month mark, the mean A1c had dropped 2.4 percent, compared to .02 percent in patients who stayed in primary care, and 79 percent of the patients in the clinic had achieved their diabetes goals. The lower A1c values for clinic patients translate into a three-year cost avoidance of $9,104 per patient compared to an estimated cost avoidance of $1,803.

The overwhelming feedback is that patients are happier.

Evidence like this is crucial when making a case for expanding the clinic or for introducing the clinic to other medical centers in the VA system, said Dr. Morello.

“You have to justify what you’re doing, and demonstrate that it will work,” she said. “We had a three-fold cost improvement while also improving patient care and diabetes control in a complex patient population. Any system should embrace those types of outcomes.”

Patients and physicians alike have been more than satisfied with the clinic, Dr. Morello added. “The overwhelming feedback is that patients are happier, and that the clinic ultimately allows for a better primary care visit because the physicians can focus on other issues patients may have that are non-metabolic.”

The Importance of Institutional Support

Steven V. Edelman, M.D., professor of medicine at UCSD, said that although he has had a positive experience with the clinic, he’s not surprised at the outcomes.

“I was always on board with this approach,” he noted. “It only reinforces the fact that you do not have to be an endocrinologist to be a great diabetes doctor.”

Medication management, lifestyle changes like exercise and diet, and working closely with a clinical pharmacist help patients with diabetes to achieve better outcomes.

Pharmacists already have an excellent background for an expanded role in diabetes care, Dr. Morello said. “We have the medication knowledge, the people skills, the self-care management education, and the training to integrate all of that to provide personalized care.”

Although Dr. Morello is a certified diabetes educator, she doesn’t feel that such certification is necessary.

“I’m putting together a program to train pharmacists to use our same model. As long as you get some specific training, especially about empowering patients, as well as about nutrition, dietary education, and activity so you know what works, that’s what’s important.”

Dr. Morello invites ASHP members to contact her directly at VA San Diego Healthcare if they would like assistance or advice about developing similar programs and clinics.

“We’ve already ironed the kinks out and have shown that the model works,” she said. “If we can achieve such successful outcomes in patients with high comorbidity complexity and high medication regimen complexity, it’s possible to achieve the same for any kind of patient.”

–By Terri D’Arrigo