Impact diabetes


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Impact diabetes

  2. 2. 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
  3. 3. DIABETES IN THE SAFETY NET  Disease Burden  Complication Burden  Complexity of Patient Needs  Access Barriers  Resources  Specialty Care PROJECT IMPACT: DIABETES 3
  4. 4. 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 PROJECT IMPACT: DIABETES 4
  5. 5. 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 PROJECT IMPACT: DIABETES 5
  6. 6. 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 PROJECT IMPACT: DIABETES 6
  8. 8. 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) PROJECT IMPACT: DIABETES 8
  9. 9. 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 PROJECT IMPACT: DIABETES 9
  10. 10. “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. PROJECT IMPACT: DIABETES 10
  11. 11. 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 PROJECT IMPACT: DIABETES 11
  12. 12. 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! PROJECT IMPACT: DIABETES 12
  13. 13. 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 PROJECT IMPACT: DIABETES 13
  14. 14. PharmD Diabetes Schedule PROJECT IMPACT: DIABETES 14
  15. 15. 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 PROJECT IMPACT: DIABETES 15
  16. 16. PharmD Diabetes Note PROJECT IMPACT: DIABETES 16
  17. 17. PharmD Diabetes Note PROJECT IMPACT: DIABETES 17
  19. 19. 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%) PROJECT IMPACT: DIABETES 19
  20. 20. IMPACT DIABETES - LOCAL RESULTS Demographics 5.6% 18.9% 41.1 % African American Caucasian Hispanic Asian Other 33.3 % PROJECT IMPACT: DIABETES 20
  21. 21. 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 PROJECT IMPACT: DIABETES 21
  22. 22. IMPACT DIABETES - LOCAL RESULTS 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 PROJECT IMPACT: DIABETES 22
  23. 23. 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 PROJECT IMPACT: DIABETES 23
  24. 24. 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. PROJECT IMPACT: DIABETES 24
  25. 25. IMPACT DIABETES: RESULTS  Patient Successes  CrossOver Patient Story  Goochland Patient Story  Video Highlights Richmond area projects o 63qJrS4 PROJECT IMPACT: DIABETES 25
  26. 26. 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 PROJECT IMPACT: DIABETES 26
  27. 27. 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 PROJECT IMPACT: DIABETES 27
  28. 28. 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 PROJECT IMPACT: DIABETES 28
  29. 29. IMPACT DIABETES: SUCCESSES  Patient Referrals  Patient Acceptance  Flexible Visit Length  Physician-Patient-Pharmacist Collaborative Practice Model  Scheduling  Outcomes  Sustainability  Resource-Sharing  Pharmacist Engagement PROJECT IMPACT: DIABETES 29
  30. 30. 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 PROJECT IMPACT: DIABETES 30
  31. 31. IMPACT DIABETES: SUSTAINABILITY  Continued Grant Funding  Partnership Synergies  Co-Funded Resident  Expanded Projects / Roles  Student Opportunities  Innovative Practice PROJECT IMPACT: DIABETES 31
  32. 32. IMPACT DIABETES: FUNDING  Collaborative Academic o Community Engagement o Residency Programs  Pharmacy Organizations  Retail Pharmacy  Foundations  Health Disparities  Accredited Education Programs (Medicare) PROJECT IMPACT: DIABETES 32
  33. 33. 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 PROJECT IMPACT: DIABETES 33
  34. 34. IMPACT DIABETES: IMPLEMENTATION TOOLS  Case Studies: o  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” PROJECT IMPACT: DIABETES 34
  35. 35. 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 PROJECT IMPACT: DIABETES 35
  36. 36. SUMMARY AND CONTACT INFORMATION  Sallie Mayer:  Sally Graham:  Michael Dail:  IMPACT: Diabetes Link: PROJECT IMPACT: DIABETES 36