The Asheville Project: factors associated with outcomes of a community pharmacy diabetes care program

OBJECTIVE: To assess the importance of environment, patient characteristics, and health behavior in explaining differences in clinical, economic, and humanistic outcomes of pharmaceutical care services (PCS) for patients with diabetes. DESIGN: Quasi-experimental, pre-post cohort-with-comparison group study using multivariate logistic regression. SETTING: Twelve community pharmacies in Asheville, N.C. PATIENTS AND OTHER PARTICIPANTS: Eighty-five patients with diabetes who were employees, dependents, or retirees from two self-insured employers; community pharmacists who completed a diabetes certificate program and received reimbursement for PCS. INTERVENTIONS: Scheduled consultations with pharmacists involving education and training, assessment, monitoring, follow-up, and referral. MAIN OUTCOME MEASURES: Change in glycosylated hemoglobin (A1c) value, diabetes diagnosis and all-diagnosis utilization and cost of medical care, quality of life, and satisfaction with pharmacy services. RESULTS: The strongest predictors of improvement in A1c following PCS were the patient characteristics baseline glycemic control and type 1 diabetes. All patients with type 1 diabetes had reduced their A1c concentrations at follow-up. Patients in one employer group (an environmental characteristic) were significantly more likely to have a 10% reduction in diabetes diagnosis costs, compared with employees in the other group. They were also more likely to report improved satisfaction with pharmacy services. No other statistically significant relationships were found. CONCLUSION: The greatest improvement in A1c occurred among patients with type 1 diabetes and/or higher baseline A1c concentrations. When controlling for other factors, PCS did not emerge as a significant factor in lowering A1c, but it was imprecisely measured, and our proxy measure did not capture the full complement of PCS provided to patients. Success in terms of cost savings and patient satisfaction differed by employer group.     

The Asheville Project: participants' perceptions of factors contributing to the success of a patient self-management diabetes program

OBJECTIVE: To ascertain patients', providers', and managers' perceptions of the factors that contributed to the success of the Asheville Project. DESIGN: One-time focus groups of patients and diabetes care providers and individual interviews with managers involved in the project. SETTING: The City of Asheville and Mission-St. Joseph's Health System (MSJ), Asheville, N.C. PATIENTS AND OTHER PARTICIPANTS: Twenty-one patients with diabetes who were employees of the two self-insured employers participating in the Asheville Project; four specially trained pharmacists who provided diabetes-related pharmaceutical care and one diabetes educator, all of whom received reimbursement for their services; six managers employed by the City of Asheville or MSJ who were involved in the project. INTERVENTION: A trained facilitator conducted four focus groups and six manager interviews in September 2001. Each session lasted 60 to 90 minutes, and the facilitator used a standard list of open-ended questions. The focus group sessions were recorded for subsequent analysis. MAIN OUTCOME MEASURES: Perceptions of focus group participants and managers of how the Asheville Project enabled patients with diabetes to become more responsible and successful in self-managing their condition. RESULTS: Focus group participants and managers were enthusiastic about their experiences with the project. Patients valued the relationships they established with their pharmacist or diabetes educator; as a result of these providers' support, patients felt more in control of their lives and were healthier. The waived co-payments for diabetes medications and related supplies was the decisive incentive for getting many patients to enroll in the project. For the providers, the project was a source of professional growth and satisfaction. Managers felt the project helped them fulfill their health care responsibilities to their employees, reduced overall costs, enhanced their organizations' reputations in health care delivery, and resulted in less absenteeism. CONCLUSION: Patients, providers, and managers in the Asheville Project believed that aligned incentives and community-based resources that provide health care services to patients with diabetes offer a practical, patient-empowering, and cost-effective solution to escalating health care costs.     

The Asheville Project: long-term clinical, humanistic, and economic outcomes of a community-based medication therapy management program for asthma.

OBJECTIVE: To assess clinical, humanistic, and economic outcomes of a community-based medication therapy management (MTM) program for 207 adult patients with asthma over 5 years. DESIGN: Quasi-experimental, longitudinal pre-post study. SETTING: 12 pharmacy locations in Asheville, N.C. PATIENTS/OTHER PARTICIPANTS: Patients with asthma covered by two self-insured health plans; professional educator at Mission Hospitals; 18 certificate-trained community and hospital pharmacists. INTERVENTIONS: Education by a certified asthma educator; regular long-term follow-up by pharmacists (reimbursed for MTM by health plans) using scheduled consultations, monitoring, and recommendations to physicians. MAIN OUTCOME MEASURES: Changes in forced expiratory volume in 1 second (FEV1), asthma severity, symptom frequency, the degree to which asthma affected people's lives, presence of an asthma action plan, asthma-related emergency department/hospital events, and changes in asthma-related costs over time. RESULTS: All objective and subjective measures of asthma control improved and were sustained for as long as 5 years. FEV1 and severity classification improved significantly. The proportion of patients with asthma action plans increased from 63% to 99%. Patients with emergency department visits decreased from 9.9% to 1.3%, and hospitalizations from 4.0% to 1.9%. Spending on asthma medications increased; however, asthma-related medical claims decreased and total asthma-related costs were significantly lower than the projections based on the study population's historical trends. Direct cost savings averaged 725 dollars/patient/year, and indirect cost savings were estimated to be 1230 dollars/patient/year. Indirect costs due to missed/nonproductive workdays decreased from 10.8 days/year to 2.6 days/year. Patients were six times less likely to have an emergency department/hospitalization event after program interventions. CONCLUSION: Patients with asthma who received education and long-term medication therapy management services achieved and maintained significant improvements and had significantly decreased overall asthma-related costs despite increased medication costs that resulted from increased use.     

A satellite pharmacy program in a community hospital

A satellite (decentralized) pharmacy program in a medium-size community hospital is described. The hospital is a private institution consisting of three divisions: an acute-care division, a psychiatric division, and a long-term care division. Pharmacy services are provided on an around-the-clock basis, and the satellites are operational 16 hours daily. Pharmacy services include unit dose distribution, I.V. admixture services, and clinical pharmacy programs. Structurally, the department is divided into four satellite units and a central pharmacy unit to provide care to all areas of the health center. The professional staff is divided into several categories as a means to overcome the difficulties and take full advantage of all of the benefits of the satellite system. The Associate Director and the Assistant Director perform primarily administrative functions in order to maintain overall control, coordination, and quality assurance of the department. The Education Coordinator helps maintain the level of basic competence of the staff and coordinates the development and implementation of new departmental programs. Staff Pharmacists II provide both administrative and professional functions in their roles as team leaders of individual satellite units. Staff Pharmacists I serve the traditional staff functions in a satellite unit or in the central pharmacy.     

Primary care provider perceptions of an integrated community pharmacy hypertension management program

BackgroundTrained community pharmacists provided hypertension (HTN) management services in collaboration with a patient-centered medical home (PCMH).ObjectiveTo explore primary care provider (PCP) perceptions of a HTN management program in which patients at the PCMH with elevated blood pressure could choose to receive follow-up care with a trained community pharmacist at a chain community pharmacy.MethodsWe conducted informal interviews with 8 PCPs with a range of level of involvement with the collaborative HTN management program to inform the development of a 13-question online survey that was distributed to PCPs at 10 participating Michigan Medicine PCMH clinics. The primary outcome was the percent of PCPs who reported that the program improved their patient’s blood pressure. Secondary outcomes included awareness of the program, alternative follow-up strategies, PCP satisfaction, and barriers to using the program.ResultsA total of 39 PCPs (30.0%) responded to the survey. More than one-half (n = 21 of 39, 53.9%) of respondents reported that at least 1 of their patients had seen a trained community pharmacist for HTN management services. Almost all of these PCPs (n = 19 of 21, 90.5%) reported being satisfied with the program, and 80.9% (n = 17 of 21) agreed that it helped patients improve their blood pressure control. The most common barriers identified were patients preferring to follow up directly with their PCP (n = 18 of 39, 46.2%), PCPs being more comfortable with patients having a visit with an embedded ambulatory care pharmacist (n = 16 of 39, 41.0%), and a lack of written materials to share with patients about the program (n = 15 of 39, 38.5%).ConclusionPCPs who used the integrated community pharmacy HTN management program were satisfied with the program and thought that it resulted in improved blood pressure control. PCPs may benefit from written information to share with their patients as well as education to increase their awareness of the program and its beneficial effect on patient blood pressure.     

Incorporating a diabetes certificate program in a pharmacy curriculum

Objective. To determine student competency and confidence in the provision of diabetes care and satisfaction with incorporation of the American Pharmacist Association/American Association of Diabetes Educators (APhA/AADE) diabetes certificate program into the required doctor of pharmacy (PharmD) curriculum.Design. Material from the diabetes certificate program was incorporated longitudinally into the third-year curriculum skills laboratory courses. Educational techniques used included self-study modules with case questions, lectures using the program’s slides and live seminar materials, and active-learning techniques including instructor-led modeling and role-playing exercises, small group activities, objective structured learning exercises (OSLE) using standardized patients, and a week-long diabetes simulation.Evaluation. Students achieved a 100% pass rate on a diabetes certificate program examination and earned a mean score of 71.8 out of 100 points on a medication therapy management (MTM) objective structured clinical examination (OSCE). A student survey demonstrated high student confidence in their ability to provide diabetes care (mean scores 4.2 to 4.8) and satisfaction with the program (mean scores 4.5 to 4.8).Conclusion. Longitudinal integration of a nationally recognized diabetes certificate program into the required PharmD curriculum produced satisfied students competent in providing diabetes pharmaceutical care.     

A retrospective analysis of patient care activities in a community pharmacy mental illness and addictions program

BackgroundThe Bloom Program, a community pharmacy-based mental health and addictions care program, was developed and implemented to optimize pharmacists' care of eligible patients. Characterizing pharmacists' activities in the Bloom Program can facilitate program quality improvement and contribute more broadly to the knowledge base regarding pharmacists’ roles and contributions to patient care.ObjectivesTo characterize the patient care activities of the pharmacists in the Bloom Program.MethodsA retrospective analysis of patient charts for participants enrolled in the program for three months or longer was conducted. Using all available documentation, pharmacists’ activities were coded into eight non-mutually exclusive categories: navigation/resource support, urgent triage, medication management, collaboration/communication, education, social support, self-care, and other.Results2055 activities from 1144 patient care encounters were identified for 126 participants (48 ± 16 years of age, 61% female, 5 regular medications). Medication management was coded most often per encounter (73%). Each of social support, collaboration/communication, and education were coded in 20–25% of encounters. Frequency of navigation/resources, self-care, and urgent triage were 16.6%, 13.5%, and 2.8%, respectively. Non-medication management activities represented 59.4% of all pharmacist patient care services.ConclusionsMedication management activities were coded in over 70% of patient encounters for pharmacists delivering a community pharmacy-based mental illness and addictions program. However, this accounted for 40.6% of activities with an average of 1.8 activities per encounter. Other activities were identified frequently (e.g., education, collaboration, social support, navigation and resource support) and help to characterize the nature of pharmacist-patient encounters and facilitates a better understanding of the role of the pharmacist in mental illness and addictions patient care.     

Integration of community pharmacy in primary health care: The challenge

Community pharmacies and pharmacists predominantly operate in a retail environment independently of other health care providers, and they are not often viewed as an integral member of the healthcare team. Thus, they remain overlooked or excluded during integration processes of health care systems. At the same time, there are calls by the profession at national and international levels for community pharmacy to be integrated within primary care systems. The COVID-19 pandemic appears to have further stimulated this desire. When pressing for integration, various terms, such as integration, integrated care, or interprofessional collaboration, are used in an interchangeable manner leading to lack of clarity, ambiguity and confusion for health care policy makers, planners, and other healthcare professionals. The literature was reviewed to identify critical components for community pharmacy to consider for integration. From the five selected articles describing integration of community pharmacies, four different constructs were identified: consensus, connectivity, communication and trust. The integration of community pharmacy into the health system may translate into better access for patients to primary care services, contribute to cost effectiveness, and promulgate the sustainability of the system. However significant political, economic, social, and practice change would be required by all stakeholders. Further research is needed to underpin a consensus for a definition, the type of integration, and the model optimally suited to integrate community pharmacy into primary care. These models, specific and adaptable to each national health care system and political environment, would need to be consensus-based by principal stakeholders to overcome a variety of barriers, including government resistance. Mere calls or demands by the pharmaceutical profession, although laudable, will not be sufficient to overcome the historical, cultural, and economic challenges.