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Tuesday, October 14, 2014

Pharmacist-led diabetes disease management: We get to cruise control

This is Part 2 of the story of Sandra Leal, PharmD. Part 1 described her care for an older woman, Maria, at the El Rio Community Health Center, a Federally Qualified Health Center.  Sandra’s program received the Pinnacle Award in September 2014 from the American Pharmacists Association.

     We’re in medical suites, like the other medical providers.  We have appointments for patients who are referred to us for trouble with the control of their diabetes, or who’re struggling to get control, or starting insulin, and have issues with that, e.g., insulin resistance, being afraid of that, etc., so we try to spend a lot of time on the best medication regimen.  With Maria, I spent about 25 minutes yesterday to do an a1C, review her immunizations, and have her vital signs done by a Medical Assistant.  We’re a Diabetes Self-Management Training Site, and a Federally Qualified Health Center, so we have double accreditation, and get paid by Medicare for people like Maria, though here in Arizona, not by Medicaid.

     We’ll handle issues like affordability, complexity of the regimen, and how to fit it into their life.  That’s a big challenge when they’re taking multiple medications for diabetes, usually coupled with cholesterol, nerve pain, depression, etc.  So they take six to twelve medications. That’s a usual amount.  Yesterday 1 had a woman who was taking 18 meds.  Even WITH health insurance, $15 times six to twelve medications is amazingly expensive and unaffordable.  I really try to customize the regimen for their lifestyle.  I really listen to their needs, and work with them. 

     For providers, our automatic trigger is to increase and add another medication.  But it’s better to see why they’re not taking it.  My role as a pharmacist is to focus on that, and really delve into the barriers.  That’s my specialty, which is often overlooked by other medical providers.   Often they’ll send people to the pharmacy just to dispense medication. 

     The most common barriers are not understanding the importance of taking the medication and what it could do for her.  I really spend a lot of time with each medication and what it’d do, connecting it to the lab values.    They might complain about having to go to the bathroom a lot, fatigue, etc.  So I’ll emphasize that they’ll have more energy, and won’t have to get up three times in the night to go to the bathroom.  A lot of times it clicks with people, so they don’t say any longer, I don’t want to take them at all.  We connect the dots for them.  We’ll compromise.  Once we have one success, they come back, asking what else can we do? 

     We have a Collaborative Practice Agreement, so I can initiate insulin, order labs, and generate a referral to other providers.  That makes it more efficient.  We document what we do in the electronic medical record.  We’re med reconciling, adding the mammogram, recoding about the colonoscopy, etc.  That frees up time for the doctor to focus with the patient.  Providers in this model really work well:  it’s more efficient and effective for the patient, because their needs are addressed.

     For a patient like Maria with Type 2 diabetes, her next a1C test is due in three months, so she should come back then.  After that, when we get to “cruise control,” I’ll see her every six months.  When she comes back, we’ll take care of a lot of other issues too, e.g., an eye exam, foot exam, and immunizations.  I’ll make sure we’re doing those on a yearly basis.  We do eye screening here. That used to be a barrier to find transportation, so we worked with a local ophthalmologist to have screening on site. 

     If a patient has another chronic condition, like pain management or depression, we’re basically triaging things for which they should see another provider.  We’d send the patient and we tell the doctor and patient: Focus specifically on depression.  We write it down for the patient:  Your next visit is for depression specifically, because this is impacting your ability to do other things.

Thanks to Sandra Leal, PharmD, MPH, FAPhA, CDE for sharing her story.  Sandra is the Medical Director of Clinical Pharmacists.  Maria is a pseudonym.

Read another story about diabetes care.

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