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.
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.