BETHESDA, MD 14 Jul 2014—San Diego veterans with a long history of type 2 diabetes are learning to take charge of their condition and make lasting improvements, thanks to coaching from a clinical pharmacist.
Candis M. Morello, director of the Diabetes Intense Medical Management (DIMM) clinic at the Department of Veterans Affairs (VA) San Diego Healthcare System, said in a phone interview that many veterans who are referred to the clinic have had diabetes for a decade or longer. Clinic patients have a glycosylated hemoglobin (HbA1c) level that exceeds 8% and suffer from other health problems in addition to their diabetes.
Morello called her work a personalized "tune-up" for these medically complex veterans.
During the initial 60-minute visit, Morello and the patient identify treatment and lifestyle goals and motivational strategies.
Morello said what motivates patients the most is "how many times they get up at night to go to the bathroom."
"We're talking five, six, eight times a night. I say, 'How would you like to fix that? I can help you. And how would you like to fix that even within a few weeks, and start getting more energy? I can help you do that,'" she explained.
"It's not your typical 20-minute primary care provider visit," she said.
The DIMM clinic operates just four hours per week, and most patients need about three to five sessions with Morello before returning to their primary care provider for routine diabetes management.
According to data Morello presented in June at the American Diabetes Association scientific meeting in San Francisco, average HbA1c values over a six-month period fell by 2.4 percentage points among 85 DIMM clinic patients, compared with a 0.2-percentage-point decline among 51 primary care patients who were not referred to the DIMM clinic.
That translates to a three-year medical cost avoidance of $6412 per DIMM clinic patient and a return on investment of $7.81 per dollar spent on Morello's services, she said.
Morello said she's provided information about the clinic to VA staff and outside groups, and she would like to see the care model replicated elsewhere.
"There are so many [advantages] to this clinic that not only benefit the patient and the medical center but also benefit expanding the scope of other clinical pharmacists," she said.
Morello, associate professor of clinical pharmacy and associate dean for student affairs at the University of California, San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, said she operates the DIMM clinic through a collaborative practice agreement with endocrinologist Robert R. Henry, chief of the VA San Diego Center for Metabolic Research and its section of endocrinology, metabolism, and diabetes.
Morello said the clinic was created to help the VA facility meet performance measures related to the care of more than 3000 patients with uncontrolled type 2 diabetes and to improve patients' HbA1c values while avoiding hypoglycemia and weight gain.
To accomplish these goals, Morello uses the medication therapy management "spider web," a teaching tool she developed and described in a publication last fall.1 The tool allows clinicians to assess medical, socioeconomic, and behavioral issues unique to each patient and incorporate these factors into a patient-centered care plan.
Among other things, Morello said, the spider web allows her to identify daily triggers in a patient's routine, such as walking the dog or listening to a radio program, that the patient can associate with medication use and thereby improve adherence.
Morello emphasized that patients are in charge of their own daily care, and they learn skills to make good decisions about their medications and the habits that affect their glucose control.
"I tell them: I can't be with you at the refrigerator. I can't be with you when taking your medicine, I can't be with you to say go take your dog for a walk. I can give you tools, I can help guide you, I can help direct you, but you're the big decision-maker. And that totally resonates with them," she said.
Morello said her veterans are spreading the word about their successes, and primary care physicians are also noticing the clinic's work.
"I'm starting to see a shift as the primary care providers figure out how well their patients are tuned up by the time they get back," she said. "They're starting to send me patients who are just diagnosed or have only been diagnosed in [the past] three years or so."
A primary care clinic that is part of the BHS Physicians Network, a private multispecialty group in San Antonio, Texas, has also reaped benefits from having a pharmacist onsite to help care for patients with type 2 diabetes.
Data from 118 patients showed an average drop of nearly four percentage points in HbA1c values for those whose care team included a pharmacist, compared with blood glucose values before the pharmacist was added to the practice, said clinical pharmacist Jodie Gee, who presented the findings at the American Diabetes Association meeting.
The addition of the pharmacist to the healthcare team also led to increases in the use of statins, low-dose aspirin, and angiotensin-converting enzyme inhibitors, said Gee, who spends half of her work hours at the BHS primary care clinic and the rest at the University of Texas at Austin College of Pharmacy, where she is a clinical assistant professor.
Gee initially sees her patients monthly in 45-minute sessions. She conducts a thorough medication review that includes medications for diabetes and the patient's other conditions.
"We even have a lot of patients on inhalers, and we always check that inhaler technique," she said.
The sessions also include a review of the patient's blood glucose log and diet. For newly diagnosed patients, she reviews the pathophysiology of diabetes and helps them understand how their medications work and the importance of adherence.
Gee now works under a collaborative practice agreement with the three physicians in the primary care clinic, and she can initiate and adjust medications independently for patients with diabetes. But that wasn't the case several years ago, when she came to the site to establish an experiential program for pharmacy students and residents.
"The physicians in the clinic, when I arrived, did not know what a Pharm.D. can do," Gee said.
She said she started off teaching patients how to use their glucometer and inject their insulin. Then she gradually demonstrated to the physicians the value of performing medication reconciliations while gaining the practice members' confidence in her ability to actively manage patients.
"Once they realized how much of a help it was, they started actually referring to me more patients," she said. "Eventually, we got the collaborative practice set up, so now they say, 'Go see Dr. Gee.'"
When Gee started managing her patients, she saw them monthly until their HbA1c level was controlled and then released them to their physician's care.
"But . . . once they'd been discharged from my service, they would always be re-referred because their A1c's would go up again," Gee said.
Now, she said, after patients get their blood glucose under control, they return periodically to see her and maintain their progress.
"And actually, that's worked," Gee said.
Gee said the biggest lesson she has learned in her work at the clinic is the importance of being personable and persistent and engaging with the other members of the ambulatory care team.
She encouraged other pharmacists who have an interest in ambulatory care practice to "go for it."
"You can definitely show a benefit of having a Pharm.D. as part of a primary care team," Gee said.
1. Morello CM, Hirsch JD, Lee KC. Navigating complex patients using an innovative tool: the MTM spider web. J Am Pharm Assoc. 2013; 53:530-8.