BETHESDA, MD 15 October 2013—Collaborative drug therapy management (CDTM) officially arrived in New York in 2011 as a three-year experiment, and pharmacists in the state have been working since then to ensure that their legal authority for practice remains in place.
"Our sunset is next year," said New York State Council of Health-System Pharmacists (NYSCHP) Executive Director Debra Feinberg, referring to the provision in the 2011 law that causes it to expire next September unless the state legislature acts to extend or expand CDTM.
NYSCHP has long been a proponent for CDTM, and the organization played the lead role in getting the CDTM legislation passed.
Feinberg said NYSCHP is collecting data now in preparation for a report to the legislature on how CDTM affects patient care. The legislature will consider that data as it determines whether to continue CDTM.
Although the report isn't due until May 2014, Feinberg said NYSCHP is being proactive by ensuring that the legislature has positive data on CDTM well in advance of the deadline.
"I think that the data is going to show that [CDTM] reduced hospitalizations, it reduced length of stay, it kept people out of the hospital, it reduced health care costs, it improved patient care, it reduced the number of medications people are on and improved patients' lives," she predicted.
Most states allow pharmacists to perform CDTM.
New York's CDTM law allows pharmacists who meet specific education and training requirements to adjust and manage drug therapy in accordance with a protocol or medication order developed in collaboration with a patient's physician.
Under such a protocol, the law states, pharmacists may order laboratory tests directly related to the drug therapy for specified disease states and evaluate the results of the tests. Pharmacists may also be authorized under protocol to perform "routine patient monitoring functions" such as assessing vital signs and collecting and reviewing patients' medical histories.
For now, CDTM in New York is limited to pharmacists in teaching hospitals and their affiliated outpatient patient care centers—except for residential facilities and nursing homes, which are specifically excluded under the law.
Feinberg estimated that fewer than 100 hospitals in the state qualify for CDTM as it is described in the law. She said just a handful of hospitals are providing data for the report.
Mark Sinnett, director of clinical and educational pharmacy services at Montefiore Medical Center in the Bronx, said Montefiore will provide data about CDTM services at the hospital's pharmacist-run heart failure clinic.
He said the pharmacists reconcile patients' medication lists, adjust medication dosages, and ensure that patients are taking all medications necessary to control their condition.
Sinnett said that initially, about 15–20% of patients at the heart failure clinic weren't taking an angiotensin-converting enzyme (ACE) inhibitor, and about a third of patients needed a higher dosage of an ACE inhibitor or Β-blocker.
"We maxed the doses of these medications," Sinnett said. "So, spending upwards of one to two hours per patient, adjusting their medications, we saw a significant drop in our readmission rate in a pharmacist-run clinic, compared to prior to the pharmacist-run clinic."
"We're definitely showing a benefit, there's no question about it. So it does validate what other states have shown, what the literature has shown over the last 40 years," Sinnett said.
He said pharmacists in New York have been able for years to perform dosage adjustments and otherwise manage medications for inpatients under protocols developed by hospitals' pharmacy and therapeutics committees.
"CDTM adds another thing in terms of writing [drug orders] for outpatients. That's a whole new area," Sinnett said. "It's been a big thing, for me, as far as credibility and really working at the top of our licenses. So instead of verbal orders, the way we've been doing them for years, asking physicians for permission, we just do it independently" under the CDTM protocol.
Mary Jo Lakomski, ambulatory care pharmacist at the State University of New York's Upstate University Hospital in Syracuse, said the CDTM law has resulted in more efficient, timely, and meaningful care for her patients.
Lakomski and Lisa Phillips, associate professor of pharmacy practice at St. John Fisher College's Wegmans School of Pharmacy in Rochester, will be submitting data for the upcoming report on CDTM.
"Our site is predominantly going to be focusing on our diabetes management," Phillips said. Among other things, she said the preliminary data show a decrease in glycosylated hemoglobin (HbA1c) levels among patients receiving care from a pharmacist.
Lakomski said she hopes the pharmacists' care will result in a sustained reduction in HbA1c levels.
In addition to using the diabetes care data to gain legislative support for CDTM, Lakonski wants to show private insurers the value of paying for pharmacists' services.
"We want to take what we have, hopefully, and [use] that in our fight for recognition as providers as well. That's really the be-all and end-all. We need to be recognized as providers," Lakomski said.
Sinnett said hospitals have had to spend a lot of time working through the credentialing process for pharmacists who want to perform CDTM and also educating physicians about the practice.
He said physicians "weren't really familiar with what collaborative practice was and what was writing under a protocol."
"Which was kind of interesting, since about 45 other states had done this already," Sinnett added.
He emphasized that the process of working with the physicians at Montefiore has been positive, and physicians say they plan to write letters supporting CDTM for the legislature.
Feinberg predicted that the legislature will accept the report's findings and CDTM will continue in the state.
"I don't know if we'll get as much expansion as we want. But we will do away with the sunset. I think we will see it at least expanded to all hospitals and long-term-care facilities. I'm not sure if we'll get it into the community setting right away, but down the road, yes," she said.