Role of the Pharmacist in Diabetes Care: A Community Pharmacy Experience

1. Role of the Pharmacist in Diabetes Care: A Community Pharmacy Experience Magaly Rodriguez de Bittner, Pharm.D., BCPS, CDE Associate Professor University of Maryland School of Pharmacy and Program Coordinator, Giant Pharmacy Diabetes Care Outpatient Education Program

2. Objectives • Provide an overview of the need for pharmacist involvement in diabetes management and education. • Describe the Diabetes Care Program at Giant Pharmacy • Describe the challenges facing pharmacies and pharmacists in diabetes management and education • Describe the role of the pharmacist in DSME programs

3. Background • Incidence of Diabetes is increasing at an alarming rate- Epidemic Proportions • 18 million Americans • 6-8 million have diabetes but have not been diagnosed • Complications of Diabetes • Treatment Complexity • Diabetes education is instrumental in reducing complications and decreasing overall health care costs • Prevention

4. Background • Pharmacists are knowledgeable about the treatment and management of many chronic illnesses • Pharmacists are accessible • Pharmacist managed diabetes programs have increased dramatically over the last five years • Payment for these services have been a challenge

5. Pharmacists’ RoleDiabetes Care • Variety of settings • Variety of roles • Direct providers of care • Members of the Interdisciplinary Team • Providers of education (400 CDE RPh/12, 390 CDE’s) • Providers of Pharmaceutical care • Providers of Products • Consultants

6. Diabetes Self-Management Education • What is it? • A structured and comprehensive educational process • Assess instructional needs • Develop educational plan • Use a variety of instructional methods • Teach self-management skills • Evaluate outcomes

7. A Diabetes Care Program in a Food-Drug Chain Pharmacy

8. Background • Joint venture between the University of Maryland School of Pharmacy and Giant Pharmacy • Offers the convenience of the community pharmacy and the expertise of an academic center

9. Setting • Giant Food Inc. • Food-drug chain store • 137 pharmacies in 4 states and D.C. • Employs ~600 pharmacists • Strong interest in health and wellness- Healthy Ideas Program • Excellent reputation and client base

10. Patient Care Centers • Counseling rooms • Located at Two stores –Annandale, Virginia and Baltimore, Maryland • Large Prescription Volume • Mixed socioeconomic population

11. Patient Care Centers • One-on-one counseling with pharmacist • By Appointment only • Physician participation • To date: out-of-pocket payment • Pharmacist with additional training • Equipment to performed a variety of tests • Patient Education Materials

12. Diabetes Care Program • An ADA Recognized Program: The first chain pharmacy diabetes education program to be recognized in the nation • Provides diabetes education with a personal touch • Comprehensive education tailored to the patients’ needs • Conveniently located in the pharmacy • Work in collaboration with the patient’s doctor and family members • Provides patients with free glucose monitors and monofilaments

13. Diabetes Care Program • Obtain patient information • Confidentiality/Informed consent • Measurement of the Patients’ • knowledge • quality of life • satisfaction • short/long term goals

14. Diabetes Care Program • Teaching Sessions- Four or Eight • Based on ADA standards for diabetes self-management education programs-Life with Diabetes • Pharmaceutical care + Education + Nutrition • Multidisciplinary program/ Dietitian • Advisory Board that oversees the Program

15. Educational Sessions • Overview of Diabetes • Monitoring • Complications • Medications • Foot, Skin, and Dental Care • Coping with Diabetes • Nutrition and Exercise • Conclusion/ Wrap-up

16. Marketing and Recruitment • Marketing of program: • Brochure distributed at store level • All patients receiving prescription for diabetes medication speak with pharmacist • Recruitment: • Free 15 minute consultation • Program overview

17. Program Evaluation • Throughout, 3, and 6 months after completion of program

18. Outcomes • Improvement in Clinical Markers • Blood glucose, HbA1c, BP, weight, etc. • Improvement in patient’s quality of life • Improvement in patient’s knowledge of the disease • Patient’s satisfaction with the services • Decrease in overall health care cost, hospitalizations, ER visits and complications of diabetes

19. Challenges • Breaking new grounds • Slow Process • Recognition Process • Reimbursement • Pharmacist Training • Marketing • Medicare Provider Number

20. Patient Testimonials • Giant’s Diabetes Program • “Where have you been?” • “ I have been to group programs before that were covered by my insurance and they just went too fast and didn’t give me a chance to ask questions.” • “Having my prescription filled at this Giant was the best thing I could have done.” • “No one has ever taken the time to explain my condition to me and I have had diabetes for 11 years.”

21. In the Future... • Expansion of the Diabetes Care Program to other sites • Giant employees program • Secure Reimbursement from Insurance Companies • Medicare Billing • Expanding to other diseases like Asthma, Cholesterol, Weight Management and Osteoporosis

22. Medicare • Balanced Budget Act of 1997 • Expanded coverage (effective 7/1/98) • Outpatient diabetes self-management training by “certified” providers • Blood glucose monitors, test strips, and other monitoring supplies • Interim program rules published 2/99 • Final program rules 12/29/00 • Effective date February 27, 2001

23. Medicare • Eligibility (Conditions of Coverage) • Physician’s (practitioner’s) order • Comprehensive educational plan • Content, number, frequency, and duration • Individual training permitted under special circumstances • Reasonable and necessary • Signed by the physician

24. ADA Recognition Process • Required by Medicare for provider eligibility • Recently changed in May 2000 • New process for application and review • New personnel requirements

25. Application for ADA Recognition • 6th edition will only be accepted online via the ADA’s web site. Form must be filled electronically • There is not a Meeting the Standards manual with this application • http://www.diabetes.org/recognition/Education/application.asp • Fee: $850.00 includes one site, additional sites $50.00/site • Data period: 6 months, must be submitted with the application to the ADA within 3 months of the end of the data period • Do not need to send documentation, just fill the application. Documents will be review on the site visit • If the program is re-applying it can submit the application two months before the current recognition expires • Score is Pass or Fail • Certificate of recognition good for 3 years • Annual Status Report must be completed and returned to the ADA

26. State / Local Issues • State Mandated Coverage • Majority of states mandate coverage for diabetes education and supplies • Eligibility and provider requirements vary significantly • Some states have developed own credentialing process (i.e. NJ, RI)

27. Conclusions • Community-based pharmaceutical care is feasible even in large volume chains • Pharmacists have a significant role in diabetes care • Patients find value in these services • Must find creative ways to secure reimbursement for these services and capture their economic, humanistic and clinical impact in patients outcomes • There is a need to have more pharmacists involved!