El Rio Community Health Center Clinical Pharmacy Services Arthur N. Martinez, M.D., MSHA

1. El Rio Community Health Center Clinical Pharmacy Services Arthur N. Martinez, M.D., MSHA Chief Medical Officer

2. El Rio Community Health Center 2009 Snapshot • 73,651 patients were served • 280,808 patient encounters • 15% patients uninsured • 22% patients on Medicaid • 62% patients at or below Federal poverty level

3. Clinical Pharmacy Services • Clinical Pharmacy Demonstration Grant from the Office of Pharmacy Affairs • Arizona Revised Statute 32-1970 • First Clinical Pharmacist in Arizona

4. Services:Physician Concerns I don’t want: • to be forced to share patients • someone to take over “my” patients • someone to provide medical care I do not agree with

5. Success:Physician Support • Volunteer referral system • Great formal and informal communication and follow-up with physicians • Comprehensive evaluation and treatment plan • You knew and agreed with the clinical guidelines/ADA Guidelines

6. Standards: • Productivity • Quality

7. HEDISDiabetes • Process • A1C Testing • Retinal Exam • LDL-C Screening • Monitoring for Nephropathy • Outcome • Poor A1C Control • LDL-C Level < 130mg/dL

8. Clinical Pharmacy HEDIS Comparison

9. Typical Visit • Day before appointment-thorough review of chart for baseline • Foot exam/monofilament test • Review of diabetes, blood pressure, lipids including goals and previous lab work • Initiate self-testing • Ophthalmology referral • Smoking cessation counseling • Aspirin • Depression Screening • Update vaccinations

10. Results Changes in Recommended Annual Follow-up Screenings

11. Results Changes in Metabolic and BP Measures: Baseline to Follow-Up

12. 19 Diabetic retinopathy 17 Nephropathy 15 Severe nonproliferative or proliferative retinopathy 13 Neuropathy 11 Microalbuminuria Relative Risk 9 7 5 3 1 6 7 8 9 10 11 12 A1C Why do we try so hard? Relative Risk of Progression of Diabetic Complications as a Function of Mean A1C* *Based on DCCT data Reprinted with permission from Skyler J. Endocrinol Metab Clin North Am. 1996;25:243-254.

13. Reduction in Risk of Diabetic Complications with 1% Decline in Updated A1C (UKPDS) Diabetes- Related Mortality All-Cause Mortality Myocardial Infarction Peripheral Vascular Disease Microvascular Disease 0 –10 –20 –30 –40 –50 –14% –14% –21% –37% All P<.0001 –43% A1C = glycosylated hemoglobin; UKPDS = United Kingdom Prospective Diabetes Study. Adapted from Stratton IM et al. BMJ. 2000;321:405-412.

14. The Patient Safety & Clinical Pharmacy Services Collaborative (PSPC) Change Package is organized into five color-coded strategies to achieve accountability for results: • Leadership Commitment• Measurable Improvement• Integrated Care Delivery• Safe Medication Use Systems• Patient Centered Care http://www.hrsa.gov/patientsafety/changepackage.htm

16. Publications

17. Results Changes from Baseline to Follow-Up for Patients on ASA and ACEIs/ARBs • 102 patients with ASA contraindication • 91patients had contraindication to ACEI/ARB • 8 patients had a contraindication to statins

18. Studies • Conversation Maps • Self Management • Dental • ROI

28. http://www.hrsa.gov/patientsafety/changepackage.htm