Medication therapy management is a key component of ensuring good outcomes in diabetes care. The clinical pharmacist can play a key role in ensuring good transitions of care, avoiding problems of polypharmacy, addressing financial issues, and providing patient education.
Published Online: March 18, 2016
Joseph Manganelli, PharmD, MPA
When clinical pharmacists are part of the interdisciplinary team that manages chronic conditions, such as diabetes, their interventions contribute to positive patient outcomes. As the trend toward value-based contracting with both private and government healthcare payers accelerates, clinical pharmacists can play a vital role in achieving cost and quality benchmarks.
At Montefiore Health System, which has such arrangements covering more than 350,000 lives, including over 50,000 in a Pioneer Model accountable care organization (ACO), clinical pharmacists at the Care Management Organizaton (CMO), Montefiore Care Management, are integral participants in the interdisciplinary care teams that provide healthcare and care coordination services.
All of the CMO’s pharmacists are licensed doctors of pharmacy; most have completed postgraduate residencies, and several have additional credentialing in ambulatory care or other specialties. As part of orientation and training, each must complete a course in motivational interviewing.
Diabetes is a condition that affects approximately 29.1 million individuals in the United States1 and is prevalent in the population served by Montefiore Care Management. The organization has dedicated resources, including robust case management programs for beneficiaries with type 2 diabetes (T2D), as well as chronic conditions, such as heart failure and respiratory conditions.
The clinical pharmacists have various roles in diabetes management. Some are centrally based and interact with patients telephonically and with providers via the electronic health record (EHR). Other pharmacists are embedded in community-based primary care sites, where they meet face-to-face with patients by appointment or by physician referral. The pharmacists who practice at the primary care sites are trained as Certified Diabetic Educators.
Medication therapy management (MTM) ensures that Part D-covered drugs are used to optimize therapeutic outcomes through improved medication use. MTM programs are developed in cooperation with licensed and practicing pharmacists and physicians, and are intended to reduce the risk of adverse events.2 Diabetes remains among the top targeted diseases for MTM initiatives.
When reviewing pharmacotherapy, a form of MTM is performed by all pharmacists regardless of practice location. Montefiore Care Management pharmacists provide cognitive services and are referred to patients by providers throughout the integrated delivery network. After a review of lab results and prescription and nonprescription therapies, the pharmacist offers recommendations intended to optimize medication treatment for diabetes and other conditions.
Providers are encouraged to document the reason when they refer cases for pharmacist review. In general, the reasons for referral include at least one of the following:
• Transitions of Care. When a patient transitions across care settings such as from hospital to home, discrepancies in medications prescribed or taken may occur. In these cases, the pharmacist must access several databases to reconcile medication lists from the prehospital admission, the hospital stay, and the postdischarge setting.
• Polypharmacy. Frequently, patients presenting with diabetes are taking several medications to treat the condition, as well as medications that treat comorbid conditions. Patients who are struggling with complex medication regimens are contacted by a pharmacist to discuss strategies that address adherence. Some of our recommendations include keeping medication lists and using pillboxes or blister-packaging prescription drugs. If a combination agent is available that would decrease daily pill burden, this agent will be recommended.
• Financial Issues. Montefiore serves an area where poverty affects a large portion of the population. Patients who take multiple medications for diabetes and other conditions often have challenges with medication costs and co-payments. ACO pharmacists are often called upon to connect these patients with resources, such as pharmaceutical manufacturer programs, to help cover the costs of therapy.
• Patient Education. Educated patients are empowered to self-manage their medications and their health conditions. The Montefiore Care Management pharmacists provide telephonic and face-to-face education to make sure patients understand their medications’ indications and proper utilization. During the education process, pharmacists use “teach-back” methods to ensure that patients are using their medications and devices correctly. Motivational interviewing strategies are employed during these interactions.
The next level of pharmacist intervention involves joint ventures with providers, known as collaborative drug therapy management (CDTM). A CDTM arrangement allows pharmacists to initiate, adjust, and monitor pharmacotherapy. The pharmacists must have specialized training in the condition being managed and patients must consent to this co-management. Upon successful completion of the credentialing process, the pharmacists are granted limited prescribing privileges in the EHR of the integrated delivery system. There is always physician oversight, and a defined escalation protocol is written into the collaborative agreement. CDTM agreements are currently in place for the co-management of anticoagulation, heart failure, and respiratory conditions. A CDTM is being developed for the co-management of T2D and is expected to be implemented in early 2016.
Organizations that participate in ACOs and other value-based contracts are responsible for meeting quality and financial benchmarks to earn shared savings. Pharmacist intervention can positively impact several of these measures. For example, in the domain of “care coordination/patient safety,” medication reconciliation after discharge is a service Montefiore Care Management pharmacists are performing. Talks with patients about preventive health, such as influenza immunization and pneumococcal vaccination, have been woven into the pharmacist’s script. Vaccination status is then documented in the EMR.
While conducting comprehensive medication reviews, the pharmacist also has a key role in meeting the measures that address “at-risk populations-diabetes,” such as control of glycated hemoglobin (A1C), low-density lipoprotein (LDL) cholesterol, and blood pressure. Pharmacists also inquire about tobacco use, and connect patients who are still smoking with tobacco- cessation programs.
Another important component of the comprehensive medication review is making sure that all therapy recommendations are aligned with the patient’s formulary. Some medications or pen devices may not be on a preferred drug list. There are also many coverage edits associated with diabetes treatments, such as quantity limitations and prior authorizations. Coverage of diabetic supplies may default to a medical benefit versus a pharmacy benefit. The coverage process may be confusing and frustrating for both providers and patients. If this results in nonadherence, poor outcomes can be expected. Having a pharmacist who is a member of the interdisciplinary care team intervene and resolve these problems has reduced barriers to diabetic medications and supplies, and has had a positive effect on outcomes.
As the drug experts, pharmacists also conduct or arrange periodic continuing staff education for case managers, as well as medical and pharmacy residents in the ACO’s integrated delivery network. There have been several new treatments and devices approved for diabetes. It is important to keep all members of a patient’s interdisciplinary care team informed and up-to-date.
In conclusion, when an interdisciplinary team that includes clinical pharmacists is charged with managing diabetes in a population, the results are positive, with significant clinical and quality outcomes. Internal data analysis reveals an overall lowering of A1C, LDL cholesterol, and blood pressure. It has also been noted that there has been a decrease in inpatient admissions and the 30-day readmission rate. Most of all, at Montefiore, we have observed reduced morbidity and mortality in our population, and therefore, an improvement in patient quality of life.
1. National diabetes statistics report: estimates of diabetes and its burden in the United States. CDC website. http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf. Published 2014. Accessed February 12, 2016.
2. Medication therapy management. CMS website. https://www.cms.gov/medicare/ prescription-drug-coverage/prescriptiondrugcovcontra/mtm.html. Updated February 3, 2016. Accessed February 12, 2016.