Expanding Pharmacist Provider Status Can Improve Diabetes Management
As a physician and CEO of a digital health company, I work with leading health systems that are working to provide cost-effective, quality healthcare to their members. Over the past year, I have had the privilege of working with the Medication Management Department at Desert Oasis Health Care (DOHC) in Palm Springs, California, an integrated managed healthcare organization. DOHC is a Pioneer Accountable Care Organization and an affiliated medical group of Heritage Provider Network, which provides care to its members through innovative programs and services designed specifically for the managed care environment.
Working with the department's director, Lindsey Valenzuela, PharmD, I have seen first-hand the successful implementation of a collaborative practice protocol model in which pharmacists provide care under guidelines established by a physician. It allows the pharmacist to play a greater role in a patient’s care. DOHC has implemented this model for diabetes, coronary artery disease, hepatitis C, and coagulation management with tremendous success.
According to the American College of Clinical Pharmacy’s position statement, published in 2003, a collaborative practice agreement is “between one or more physicians and pharmacists wherein qualified pharmacists working within the context of a defined protocol are permitted to assume professional responsibility for performing patient assessments; ordering drug therapy-related tests; administering drugs; and selecting, initiating, monitoring, continuing, and administering drug regimens.”
As a group, physicians have resisted expanding provider status to other healthcare professionals. But in this changing world of providing more access to care at reduced costs, they’re being encouraged to become more collaborative. The new healthcare rules are demanding it; new payment models are encouraging it; and new technologies are facilitating it.
At DOHC, pharmacists play a significant role in diabetes management, working with physicians. They spend an initial 1-hour consultation with patients, followed by 45-minute follow-up visits. During these visits pharmacists focus on evaluation of medications and barriers to adherence. This includes interpretation of lab data, vitals and glucose meter downloads to inform initiation, deletion and titration of medications for diabetes, dyslipidemia and hypertension. This model of care has been very effective to improve glycemic control in patients referred to the medication management program from primary care. To qualify for the program, all patients have an initial hemoglobin A1C >9% with an average of 10.54%. After 90 days in the program, 49% of all patients had an A1C < 9%. Equally important, DOHC has seen a reduction in acute care utilization and 100% patient satisfaction with the program.
There are several challenges as the organization looks to build on this success: increasing patient engagement, scalability (this model is limited due to the time-intensive nature of the interaction), and sustainability of results post-discharge from the program. We are working with DOHC to address each of these concerns using digital health tools. The clinical pharmacists have proven the impact they can have on patient outcomes, cost of care and patient satisfaction. Now we need to extend the reach of these physician extenders.
As part of a pilot program and clinical study, pharmacists are using an online diabetes management program to interact with their patients. They are able to receive and review self-monitored blood glucose data as well as exercise, diet and journal entries from patients both during and between clinic visits. Based on this data set, and leveraging clinical decision support algorithms built into the platform, pharmacists can model treatment changes to individual patient's medications and care plans. The pharmacists have found that they are able to titrate medications more aggressivley and more frequently using the program and initial clinical results show a dramatic improvement in hemoglobin A1C in a shorter period of time.
The program allows the pharmacists to demonstrate the anticipated effect of new medications to patients. Their patients have indicated that they feel more engaged in their care and they perceive a better relationship with the pharmacist, even thought much of this interaction may be taking place remotely online. The ability to manage patients both in the clinic and between clinic visits is important as health systems face growing populations of patients with poorly managed diabetes but do not necessarily have increasing staff to bring all of these patients through the clinic in a traditional care delivery model.
As more pharmacists gain provider status, I see an opportunity for them to play a major role in advancing digital tools in patient care, especially in diabetes management. Multiple studies have shown improved outcomes when pharmacists are placed in diabetes management roles. And with retail pharmacies such as CVS, Walgreens and Walmart jumping into primary care and chronic disease management, they’ll have access to more opportunities.
Diabetes is a a chronic condition that impacts 29 million Americans, As the numbers continue to escalate, we are faced with not only a physician shortage, but a provider shortage. We need to embrace the role of healthcare professionals like pharmacists and certified diabetes educators and then further expand their impact through the use of digital health technologies.
Yes, it’s new and different, and change can be hard. But I see it as a positive. The increasing role of pharmacists in collaborating with physicians and reaching more people with diabetes and other chronic conditions can only improve patient care and save lives. My hope is that my physician colleagues will jump on the bandwagon and join me in embracing this new trend.