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February 13, 2019

A3 Collaborative Elevates Diabetes Care in Rural Appalachia

Amy Westmoreland, Pharm.D., BCGP, counsels a patient about her medications.

Amy Westmoreland, Pharm.D., BCGP, Pharmacy Manager and Clinical Pharmacist at Carilion Giles Community Hospital, has a frontline view of the challenges of diabetes management. For years she wondered if there was a way for her and the other pharmacists at the hospital to provide services to patients beyond filling lifesaving prescriptions. Many of the patients admitted to the 25-bed facility in rural Appalachia were there due to lack of adherence to a diabetes medication regimen.

“Many of my patients didn’t understand all of the complexities involved in taking care of their diabetes, and that could spell disaster once they were discharged from the hospital,” explained Dr. Westmoreland. She noticed that some patients weren’t entirely sure how to monitor their blood sugar, and others had only a vague idea of what they should and should not eat. Many were resistant to any sort of dietary education, or those interventions proved to be ineffective.

A3 Collaborative
About a year ago, Dr. Westmoreland heard about a unique program known as the A3 Collaborative. The collaborative is made up of three organizations – ASHP, Apexus, and AIMM (Alliance for Integrated Medication Management). Its purpose is to help healthcare providers and organizations step in to and succeed in the new era of value-based payment models. The A3 Collaborative provides funding to hospitals that would like to bolster the role pharmacists play in value-based patient care.

Dr. Westmoreland (right), collaborates with case manager Jody Janney, R.N., medical social worker Drema Gautier, Mariana Gomez De La Espriella, M.D., and hospitalist Stephanie Boggs, Pharm.D.

Through Dr. Westmoreland’s efforts, Carilion became a member of the A3 Collaborative and was the recipient of 12 months of guidance and leadership from ASHP, Apexus, and AIMM. The comprehensive medication management program she and her colleagues created with help from the collaborative is simple, but it’s already delivering significant results. Carilion’s new value-based patient care model allows diabetes patients more access to their pharmacist in the days, weeks, and months after discharge.

“Our patients are really happy that they have someone they can turn to, someone they can call and help them understand their illness better,” said Dr. Westmoreland. There have been times when she met patients who were on 30 different medications and they needed someone who could help them understand their diabetes management plan.

Postdischarge Counseling
Dr. Westmoreland and her colleagues started the program in July 2018, and they are currently following 22 patients after discharge. Before the patient is discharged, Dr. Westmoreland and her colleagues meet with the patient. They review their medication list and determine what information and help they may need after they’re discharged from the hospital and moved to ambulatory care.

Before discharge from the hospital, the attending pharmacist will ask the patient if they’d like a follow up phone call from a pharmacist to answer any lingering questions. The pharmacist also provides their information and phone number so the patient can contact them during business hours.

If a patient opts into the medication management program, then the pharmacist coach will call to follow up at 10 days, 20 days, a month, and two months after discharge. After that, calls are made once a month. During each call, a pharmacist ask a specific list of questions:

  • Are you able to afford your medication?
  • Are you taking your meds as prescribed?
  • How often do you check your blood sugar?
  • What is the range of your blood sugar ratings? Are you keeping a log?
  • Are you having any side effects such as low blood sugar occurrences?

Although the program is still relatively new, Dr. Westmoreland and her colleagues have already identified a number of medication-related problems such as duplication errors. They found, for example, that one patient was unnecessarily taking two different forms of thyroid replacement therapy. She’s observed other concerning trends as well: Many patients don’t understand the difference between long-acting insulin and short-acting insulin. Some patients are unclear how — and when — to test their blood sugar, or why it is important that a patient log this information for their doctor to review at follow-up appointments.

“Taking the time that is required to effectively review a medication list is time-consuming,” said Dr. Westmoreland. “That’s where a pharmacist has the skill set to come in and effectively look at the medications and provide recommendations for eliminating some drugs that may not be necessary, or optimize doses to make things better for the patient.”

Amy Westmoreland, Pharm.D., BCGP

Closing the Care Gap
Dr. Westmoreland said the program also addresses the disconnect that often exists between specialists and a primary care physician, especially when a patient’s doctors are not all contained in one facility — meaning there may be more than one electronic medical system where the patient’s records are kept.

“There’s a huge gap in care, in my opinion, without having the pharmacist on the care team for every patient,” said Dr. Westmoreland. “I think we’re at a crossroads in healthcare with having the pharmacist on the care team. Pharmacists have a unique knowledge of the medications, and they understand what a normal dose would be and what an exorbitant dose would be. They could look at a prescription and realize something is off or not correct, whereas nurses and doctors may not be looking at the medication lists in the way that pharmacists do.”

A3 Adds Value
Melanie Smith, Pharm.D., BCACP, DPLA, Director of ASHP’s Section of Ambulatory Care Practitioners, serves as a staff liaison for the A3 Collaborative. She noted that the collaborative allows ASHP members to test out great ideas that could help keep patients out of the hospital. “Many of our members are being tasked with setting up a clinic or setting up a service in an ambulatory care setting,” said Dr. Smith. “Participating in a program like the A3 Collaborative provides them with essential coaching and mentoring, and helps provide a foundation and the bridge they need to transition the clinical practice from inpatient to outpatient.”

Dr. Westmoreland, for her part, hopes the success of the program will demonstrate the value of adding pharmacists to patient-care teams. “We’re trying to be very proactive before the point of discharge.” It’s important, she said, for patients to have someone they can turn to when their diabetes management becomes overwhelming, or they can’t afford their prescriptions, or their doctor is not readily available to answer questions. “I would like others to see there’s enough value in this program for it to be expanded across the system and across the nation.”


By Jessica Firger


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February 9, 2016

Pharmacist-managed Diabetes Clinic Improves Care for Native Americans

The Winslow Indian Health Care Clinic serves patients with elevated A1c levels who haven’t been able to meet treatment goals through primary care visits.

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.

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

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

March 31, 2015

VA Pharmacist-Led Diabetes Clinic Dramatically Improves Patient Outcomes

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

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.

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.

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

March 28, 2011

ACOs in the Age of Health Care Reform

Multidisciplinary teamwork is a key feature of Accountable Care Organizations.

THE PATIENT PROTECTION AND AFFORDABLE CARE ACT OF 2010 provides a plethora of opportunities for pharmacists to optimize their patient-care services. As health systems and physicians, groups create accountable care organizations (Acos) to reach the performance measures laid out in the medicare Shared Savings Program, they are turning to pharmacists to fine-tune the management of chronic diseases, reduce hospital readmissions, and improve medication safety.

Med Management and the Medical Home

The medical home model can provide a foundation for an ACO. In this model, pharmacists, working as members of the interdisciplinary care team, concentrate on medication management as a way of not only improving patient care but also curtailing costs.

For example, Baylor Health Care System in Dallas is creating an ACO in which chronic disease management is a core competency. Pharmacists will be involved in several key areas: medication compliance, polypharmacy management, and reduction of unnecessary medication. Baylor is integrating hospital electronic health records with outpatient electronic health records to facilitate medication reconciliation, as well.

Baylor also operates a medication assistance program for indigent patients at high risk for hospital readmission. Pharmacists help patients in the program apply for free medications from pharmaceutical manufacturers.

“We started that many years ago, and originally focused on the transplant patient population to help them get medications to prevent organ rejection, but the program has been so successful in realizing savings that we plan to use it heavily in our ACO,” said Michael D. Sanborn, vice president, cardiovascular services. “If we are able to get high-risk patients free or reduced medications, we can reduce hospital admissions and reduce overall cost.”

At four clinics, Fairview Health Services, an eight-hospital health system in Minnesota, is also incorporating the medical home model into its ACO. Fairview is establishing medical homes in which the goals are to reduce costs, increase patient satisfaction, place 50 percent more patients under a clinic physician’s care, and improve quality-of-care measures.

Efficient work flow is a cornerstone of Fairview’s efforts, said Scott Knoer, Pharm.D., M.S., director of pharmacy at the University of Minnesota Medical Center. “We want to have the right people doing the right thing. Anything with medication should involve the pharmacy, either pharmacists or pharmacy technicians, as appropriate.”

For example, pharmacy technicians interview patients and enter patient histories into the electronic health record. Standardizing medical histories enhances medication reconciliation and can help smooth the transition from inpatient to ambulatory care. Meanwhile, pharmacists have more time for direct patient care and education, such as helping patients manage their blood pressure and control their diabetes. These efforts will combine to improve patient care and rein in costs, Knoer said.

Above, Kevin J. Colgan, M.A., FASHP

Waiting for Guidelines

The Department of Health and Human Services hasn’t yet laid out guidelines or rules governing ACOs. But there are several things to keep in mind as health systems forge ahead to provide higher quality while lowering costs, said former ASHP President Kevin J. Colgan, M.A., FASHP, corporate director of pharmacy at Rush University Medical Center in Chicago.

“It’s important to set parameters to determine risk for readmission or problems with adherence and incorporate pharmacy services as appropriate,” Colgan said, pointing to a study of 58 readmitted patients at the medical center that revealed each patient was taking, on average, 11 different medications.

“It’s obvious what the role of the pharmacist is there,” Colgan said. “Pharmacists should be providing medication education and assistance with managing therapy so that you get good outcomes.”

Health systems in the process of creating ACOs will also have to determine which patients should be enrolled, he added, noting that the opportunity to reduce overall cost shrinks for those at low risk who require fewer services.

Finally, ACOs will need to determine where to concentrate resources to provide the best care. “Theoretically, the idea would be to transition patients to prevent unnecessary hospital readmissions and lower costs that way,” said Colgan. “It may mean that you move some resources to an ambulatory setting to help patients avoid hospitalization.”

He added that overall, there is room for variation in ACO development. “There will be different forms and structures, with room to shape what the pharmacist’s role will be,” he said.

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