Direct Engagement As Part of Collaborative Practice Improves Diabetes Care
Pharmacists’ direct engagement with patients whose diabetes mellitus had not been under control has helped a health care organization better serve this population and save money, metrics suggest.
The direct engagement is part of the collaborative practice protocol between the medical group and pharmacists at Desert Oasis Healthcare for the management of patients with diabetes, said Lindsey Valenzuela and Teresa L. Hodgkins.
Valenzuela is the director of medication management services at the health care organization, based in Palm Springs, California.
Hodgkins until recently was the services’ administrator. She is now the health care organization’s associate vice president for clinical performance and outcomes.
Better outcomes, lower costs. The year before the health care organization created the protocol-based program, Hodgkins said, 24% of seniors with diabetes in the Medicare Advantage plan had a glycosylated hemoglobin (HbA1c) level greater than 9%.
But then, with the program in operation, the prevalence of poorly controlled disease dropped by at least half. Hodgkins said less than 12% of those seniors had an HbA1c level greater than 9% in 2012 and 2013.
"That’s in the five-star cut point," she said, referring to the top grouping in the Centers for Medicare and Medicaid Services’ quality-rating system for Medicare Advantage, or Part C, plans.
Hospitalizations also decreased.
In 2010, before implementation of the protocol-based program, patients with diabetes accounted for 40% of the bed days in acute care hospitals for the Medicare Advantage plan, Hodgkins said.
That percentage has dropped as well, she said.
Through the program, which starts with a physician’s referral, Hodgkins said, the pharmacists at any particular time manage 120–150 of the health care organization’s 5000-some patients with diabetes. These 120–150 collaboratively managed patients primarily are enrollees in the organization’s capitated health care plans: the Medicare Advantage plan and the commercial health maintenance organization.
"How we can improve the outcomes and ultimately reduce costs is how they justify having the program," Hodgkins said of her health care organization.
The organization has reported a return on investment for the program of approximately 5:1.
Reasons for success. Valenzuela said the requirement for a physician’s referral works in the pharmacists’ favor.
By virtue of the referral, she said, "the physician has vetted that the program is positive." The result is that even patients who were initially reluctant to be treated by a pharmacist are likely to follow the pharmacist’s instructions.
Hodgkins said her health care organization embarked on the diabetes care program hoping to decrease hospital utilization, prevent preventable admissions, and perform better on the diabetes-related Medicare Part C and Healthcare Effectiveness Data and Information Set quality measures.
In 2013, the California Association of Physician Groups recognized Desert Oasis Healthcare’s "Pharmacist-Enabled Diabetes Care Management" program as a case study in excellence.
Hodgkins and Valenzuela ascribed the success of their program to some features the two considered unusual. Under the protocol-based program, they said, the pharmacists
- Can make the changes described in the collaborative practice agreement rather than recommend changes to the primary care physician and await a decision and action,
- Conduct face-to-face visits with patients between their appointments with the primary care physician, in addition to telephoning patients,
- Do not charge for visits, and
- Target patients with poorly controlled disease.
"Because we don’t have a copayment for our visits," Valenzuela said, "we can have contact and ‘touches’ with a patient on a very regular basis."
And providing those visits at no cost to patients was important to the medical director, Hodgkins said.
Valenzuela said the medication management services’ office contacts each patient at least once a week to ask, How are you doing? Did you have any side effects? Did you pick up your medication?
"I think patients feel somewhat connected to their pharmacist" as a result of that frequent contact, Valenzuela said. "They’re much more likely to call with problems [that arise] or to inform us when maybe they’re not following the program exactly as we prescribed."
Each day about two pharmacist full-time equivalents, aided by support staff, manage patients’ diabetes, she said.
Hodgkins acknowledged that the face-to-face visits consume time, "but that’s what helps bond the patient to the process" and produce the good outcomes.
Direct engagement. Valenzuela said many of the program’s patients arrive at the first face-to-face visit with an HbA1c level well above 10%, perhaps as high as 18%.
"They really don’t feel well," she said.
The first visit with a patient who needs to start insulin therapy takes about 60 minutes, Valenzuela said. The second visit, a week later, may take 30–45 minutes. She said that throughout the initial startup of insulin therapy, the pharmacist provides "intense coaching" to ensure the patient progresses well.
At every visit, the pharmacist downloads the data from a patient’s blood glucose meter, she said. "It’s a nice visual for the patient because, of course . . . to see any difference [in an HbA1c level] you’re talking months, but you can really see a difference and a change in their blood glucose profile in a week or two."
That improvement in the blood glucose profile gratifies the patient, Valenzuela said, and provides motivation to continue following the pharmacist’s plan.
Hodgkins said all the pharmacists in the program completed an ASHP-accredited, hospital-based pharmacy residency program and, during the ambulatory care rotation, displayed "a calling" for that type of practice.
"To be successful in ambulatory care," Valenzuela said, "you really have to be able to change your message or change the approach of your message to the patient that’s with you at the moment. Some people have referred to it as the emotional quotient, or EQ. . . . That’s what we try and look for when we’re looking for a pharmacist to fill roles within our department."
The department added a coronary artery disease program in March 2013, she said. It focuses on patients who have just had coronary artery bypass grafting or stent placement.
Preliminary data suggest this program, which starts with an intensive medication reconciliation over the telephone with patients in the first 48 hours after hospital discharge, decreases the 30-day readmission rate, Valenzuela said.