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Pharmacists improving outcomes in patients with Diabetes

Pharmacists improving outcomes in patients with Diabetes. An argument for expansion of scope of practice. Outline. Theory Diabetes Pharmacists Legislation The Asheville project Recommendations Acknowledgements. Theory. The Health Belief Model

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Pharmacists improving outcomes in patients with Diabetes

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  1. Pharmacists improving outcomes in patients with Diabetes An argument for expansion of scope of practice

  2. Outline • Theory • Diabetes • Pharmacists • Legislation • The Asheville project • Recommendations • Acknowledgements

  3. Theory • The Health Belief Model • Developed by Irwin Rosenstock in 1966 to explain why people used health services. • The first version only had the first 3 points • Subsequent versions have added 4 ,5 and 6

  4. Health Belief Model • 1. Perceived Susceptibility • 2.Perceived Seriousness • 3.Perceived benefits of taking action and perceived barriers to such • 4.Perception that benefits outweigh risks • 5.Cues to action • 6.Perceived self efficacy

  5. Health Belief Model • This theory is especially apt for diabetes • The prognosis depends on the patients ability to do the following things: • Take their medication • Change their behavior ( checking blood sugar regularily) • Change their diet and lifestyle • Before they can make these changes they have to believe in their susceptibility, the seriousness of the disease and have they must have self efficacy

  6. Diabetes • 346 million people worldwide have diabetes • 25.8 million people (8.3%) in the United States have diabetes • The American Diabetes Association has established goals for treatment • Hemoglobin A1C <7%, blood pressure <130/80 , total cholesterol <200mg/dL

  7. Diabetes • By 2030 the estimate is that 1 in 3 people will have diabetes. • People do not die from diabetes they die from the complications of diabetes • Cardiovascular Disease, kidney disease, blindness ,nerve damage and amputations are complications of diabetes • It is the number one cause of adult onset blindness and end stage renal disease

  8. Diabetes • Total costs for diabetes care were $124 billion nationally (ADA 2012) • Individual employers can spend up to $4410 more per year for each employee with diabetes (Cranor and Christensen 2003) • Costs for patients with diabetes are due to sick days, emergency department visits and hospitalizations for exacerbations and complications.

  9. Diabetes • Only 57% of people with diabetes have met the A1c goal of less than 7% • Only 45% have met the goal of blood pressure less than130/80 • Only 46.5% have a total cholesterol of less than 200mg/dL • Only 12.2% are meeting all 3 goals

  10. Pharmacists • Pharmacists are among the most trusted and accessible professionals ( Survey 2012) • They are less expensive than physicians • They are well versed in medication requirements for diabetes

  11. Pharmacists • Pharmacists have been managing patients with diabetes for years in Ambulatory care, Federal facilities and hospitals ( Giberson et al 2011) • Community pharmacists can do it too if given the tools ( Asheville Project 2012) • Currently in California community pharmacists can manage patients with diabetes if they have a Collaborative Practice agreement with a physician.

  12. Legislation • Collaborative Practice Agreement between pharmacist and a physician. • This allows the pharmacist to perform routine drug therapy related assessment • It allows the pharmacists to order related laboratory tests, • It allows the pharmacist to administer drugs and biologicals by injection and initiate or adjust the drug regimen pursuant to physician order or following an established protocol. ( CA Board of Pharmacy 2012)

  13. Legislation • SB1481 went into effect January 2013 • Allows the pharmacists to perform heretofore restricted clinical duties without a physicians oversight • Pharmacists are now allowed to conduct certain lab tests as provided by the Clinical Laboratories Improvement Amendment (CLIA) of 1988

  14. Legislation • As long as the pharmacy obtains the certificate of waiver. • The ability to check A1C, blood glucose and cholesterol in the pharmacy would allow the pharmacist to better manage the patients with diabetes • One could check to see if patients are at goal at their first visit and then periodically thereafter.

  15. Legislation • Clinical Pharmacist Practitioner ( CPP) • Established legislation in North Carolina • July 1st 2000 • Allows for established pharmacists with Collaborative Practice Agreements to order, change , substitute therapies or order tests according to an established protocol ( Dennis 2012)

  16. Legislation • Pending legislation • SB 493 introduced by Senator Ed Hernadez • Advocates for provider status for pharmacists in California • The bill is intended to allow these highly trained practitioners to practice to the full extent of their abilities and expand access to healthcare in light of the shortage of primary care physicians. ( Hernandez 2013)

  17. Asheville project • A joint project in the city of Asheville, North Carolina • Between the City of Asheville ( the City), University of North Carolina ( UNC), Mission St John Healthcare (MSJ) and the North Carolina Pharmacists Association ( NCPhA) • The project has been running since 1997 and uses Pharmacists as health coaches.

  18. Asheville Project • The patients meet with the pharmacists regularly • Pharmacists in the program have the ability to adjust/change medications as needed. • They also have the ability to order necessary laboratory tests to track patient progress. • The project has yielded marked improvements in A1C, cholesterol and blood pressure ( Mattson 2013)

  19. Asheville Project Cranor et al 2003

  20. Medical claims/patient costs Innovations in Quality patient care: The Asheville experience Webb, Michael2013

  21. Compared to US Averages • U.S. Average $7,808 prior to start of program • U.S. Average $7,239 1997 • U.S. Average $7,485 1998 • U.S. Average $7.762 1999 • U.S. Average $8,088 2000 • U.S. Average $8,468 2001

  22. Percentage of lab values in optimal range • C Cranor et al 2003

  23. Recomendations • Passage of SB 493 and introduction and passage of a similar federal bill. • Enhanced use of Collaborative Practice Agreements to allow pharmacists to start to help more patients with diabetes pending passage of this bill. • Recognition of Pharmacists as Non Physician Practitioners ( NPPs) by the Centers For Medicare and Medicaid Services (CMS).

  24. Recommendations • Implementation of the Asheville Project Model ( Healthmaprx) for Diabetes management in all employer and non-employer healthcare plans • Healthmaprx program can be bought and implemented by any organization it is a good value for money and well worth the investment • Funding should be allocated for community and state organizations that cannot afford the implementation fee. • It should be implemented on a federal level by CMS, VA services Indian Health Services and US Public Health Services.

  25. Acknowledgements • Sally Geisse • Ramon Castelblanch • Mickey Eliason • Nina Wallerstein • Jessica Wolin • Judith Ottoson • SukdipPurewal • The faculty and Staff of the MPH program • Cohorts 2012, 2013 and 2014

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