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Pharmacist-managed Diabetes Clinic Improves Care for Native Americans

Pharmacists at the Winslow Indian Health Care Center care for patients with elevated A1c levels who haven’t been able to meet treatment goals with primary care visits.

THE NAVAJO NATION stretches across more than 27,000 square miles of Arizona, Utah, and New Mexico. Many of its 300,000 residents have no physical address, no electricity, or no running water.

Some tribe members must drive for hours across dirt tracks and road-less open range to buy groceries, use a pay phone, or see a doctor. The difficulties residents face are compounded by the fact that more than 22 percent age 20 and older have diabetes–four times the rate of the same age group in the general U.S. population.

To help patients manage this often-devastating disease, pharmacists at the Winslow Indian Health Care Center (WIHCC) in Arizona are stepping into the gap. A pharmacist-managed insulin-titration clinic now serves patients with elevated A1c levels who haven’t been able to meet treatment goals through visits with their primary care providers.

“Some of our diabetic patients travel as far as 90 miles to get to our facility,” said LCDR Kelly Pak, Pharm.D., NCPS, CDE, clinical pharmacist/medication safety officer at the Winslow Indian Health Care Center. “And because the volume of patients is so high, it’s difficult for providers to find the time to consult with them regularly about insulin titration. Many patients only see their providers occasionally—perhaps every one to three months. That’s far from ideal.”

At that rate, it would take years to correctly titrate insulin dosing, and there’s no way to know how well patients are following their prescribed therapy regimen, added CDR Peter Laluk, Pharm.D., BCACP, NCPS, a clinical pharmacist and the WIHCC’s director of quality management.

Pharmacists at Winslow educate and monitor patients, mostly by telephone. Their common goal? To bring their patients’ A1c levels in line with the American Diabetes Association recommendation of less than 7 percent (based on age, A1c goal might be higher) and reduce the number of emergency room visits and hospitalizations caused by hypoglycemic episodes.

Helping Patients Become Self-Sufficient

Since its founding in 2013, the clinic’s impact has been nothing short of dramatic: Among 80 clinic patients, A1c levels have decreased by a mean of 3.0 percent, compared with a 1.1 percent decrease among control group members who were followed by their primary care providers but received no pharmacist intervention. In satisfaction surveys, clinic patients report that they feel more in control of their diabetes and feel more comfortable with home diabetes management.

CDR Peter Laluk, Pharm.D., (left) and LCDR Kelly Pak, Pharm.D.

The clinic, noted Dr. Pak, embodies key elements of ASHP’s Practice Advancement Initiative (PAI) recommendations (formerly known as the Pharmacy Practice Model Initiative, or PPMI), which call for every pharmacy department to “identify drug-therapy management services that should be provided consistently by its pharmacists.”

Clinic treatment begins with an initial educational session (conducted in person if possible). This is followed by weekly pharmacist follow-up phone calls to review progress, discuss hypoglycemic episodes, and adjust insulin dosages. Periodic visits to the clinic are encouraged but not mandatory.

“We want patients to reach the point where they can mostly take care of themselves,” said LT Kenya Destin, Pharm.D., a clinical pharmacist and Dr. Pak’s clinic partner.

Unique Challenges for a Special Patient Population

Although a reliance on working by phone allowed clinicians to reach more patients more frequently, it also has limitations. In such a large rural area, phone service can be spotty, and some patients can’t afford cellphone plans. In fact, some patients only have access to pay phones that are miles from home.

Another unique challenge with this patient population is that a significant number of elderly residents speak only Navajo and practice traditional medicine.

Since its founding in 2013, the clinic’s success has been nothing short of dramatic.

“Some patients told me their medicine man said to stop taking insulin for a couple of weeks before an important ceremony, and they ended up having hyperglycemia episodes,” said Dr. Pak. “Obviously, I can’t force my patients to always do what I’ve guided them to do. It’s important to be sensitive to cultural standards.”

The clinic, which began as a pilot program, has become a fixture at the WIHCC, in large part because the study results quantified its success and suggested even greater potential. “Dr. Pak’s presentation of the data to medical staff showed how well the program really works, and their support is what caused it to really take off,” said Dr. Laluk.

Equally important to the clinic’s acceptance and growth has been the rapport among pharmacists and physicians, which was carefully cultivated well before the clinic opened.

“That took some time to build,” recalled Dr. Laluk. “We were able to effectively show how we can provide a greater service beyond just filling prescriptions and counseling. Building that level of trust with our fellow healthcare professionals really helped to make the clinic happen.”

–By Steve Frandzel