We are frequently asked what training pharmacists are required to have in order to provide disease management services in the Asheville Project and how the training program was developed.

In 1996, an agreement was reached with the City of Asheville to pilot a demonstration project that would use pharmacists as “health coaches” for individuals with diabetes. The primary focus would be on appropriate medication use; however, pharmacists would also be expected to help educate patients, coach them to improve their overall health, and work closely with physicians.

Program planners believed that pharmacists already possess skills that would allow them to be successful in improving medication therapy. They also recognized, however, that interested pharmacists would need some further training in order to provide these services. At this early stage, they faced 3 important questions: (1) what will be taught, (2) who would teach it, and (3) who would be taught.

A Need for Consistent Standards

Because the first disease management program was to address the needs of patients with diabetes, pharmacists would obviously need to be up-to-date on diabetes care. Even 10 years ago, well-established, authoritative, national guidelines for diabetes were in place. Most prominent among those were the standards established by the American Diabetes Association (ADA) and the American Association of Diabetes Educators. The ADA core curriculum became the “training manual” for the program pharmacists.

The goal was not for pharmacists to become certified diabetes educators (CDEs). It was decided to use some of the same reference material that was used to educate CDEs and physicians, however, so that pharmacists would be on the same page as other providers. The obvious role for pharmacists in this program was a focus on improving medication management of diabetes; because of the opportunity to interact with patients on a very regular basis, planners recognized that there also would be significant opportunities for pharmacists to assist patients in long-term self-management and overall health issues. Therefore, they would need specific training to allow them to do this well.

Once it was decided what material would be taught, the next step was to look at who would provide the training. Recall that this discussion was taking place more than 10 years ago, at a time when pharmacist certificate programs were practically non-existent. In fact, the first pharmacists training program conducted in Asheville was not even referred to as a certificate program. It was simply a training program with a significant number of Accreditation Council for Pharmacy Education (ACPE) credit hours.

In our case, the decision on who would provide the training was relatively easy. In North Carolina, we are privileged to have a system of Area Health Education Centers (AHECs) that are funded by the state. These AHECs, among other functions, provide continuing education for allied health, including pharmacy. The program planners worked with the staff of the Mountain Area Health Education Center Department of Pharmacotherapy in Asheville to set up the initial training program. They in turn worked with pharmaceutical manufacturers to obtain grant funding to offset the costs of the training program.

Keeping It Local

Although it would have been possible to bring in experts in diabetes from other parts of the country, there was a conscious decision to use local physicians and diabetes educators, as well as individuals from the University of North Carolina School of Pharmacy and Campbell University School of Pharmacy, as the training faculty. This accomplished 2 objectives. It helped establish buy-in from key stakeholders on the state level. Even more importantly, it fostered relationships with local physician experts and the local diabetes educator community.

These relationships and the support garnered through the involvement of local experts have been invaluable. We continue to hear stories from our physician faculty, who have become our unofficial “champions,” regarding discussions with their physician colleagues about this “pharmacist program.” These physicians are in an excellent position to say, “Yes, I know about the program, I helped train the pharmacists.”

In retrospect, this was one of the more important decisions made in the early days of the program. Although there are now a number of national certificate programs available to pharmacists, we would highly recommend involvement of local experts in some level of the pharmacist training if at all possible, even if just for a skills lab, a presentation on diabetes care by a locally respected endocrinologist, or a presentation by diabetes educators on what they teach during diabetes education classes.

Casting a Wide Net

The roll-out of the training program began with a letter to all pharmacists in the region inviting them to attend a training program in diabetes. They were told that it would involve a significant amount of home study, 2 weekends of didactic training, and hands-on training in meter devices, blood pressure monitoring, and foot exams. They were also told that there would be an opportunity to use this knowledge in direct patient care. We decided to open the program up to any interested pharmacist who was willing to receive the training and not restrict it only to pharmacists with a PharmD, residency-trained pharmacists, or those who were board-certified pharmacotherapy specialists.

Pharmacists would be expected to review all medications and assess them for patient adherence, appropriateness, and dosage. Pharmacists also would download meters, check blood pressures, conduct foot exams, provide patient education, help patients set goals, and communicate findings and recommendations to physicians. In the opinion of the planners, the most important factors for success would be the motivation of the pharmacist, his or her willingness to be trained in diabetes guidelines, and availability. None of the above requirements would preclude Bachelor of Science (BS)-trained pharmacists. Knowledge level would, of course, be important, but equally important would be the ability of the pharmacist to communicate effectively with patients and physicians. A majority of the first group of patients followed in the Asheville Project were, in fact, served by BS pharmacists.

The program qualified for 36 hours of ACPE credit and was attended by 24 pharmacists. The pharmacists were informed during the training session of the opportunity to use this training to follow individuals with diabetes that worked for the City of Asheville; 20 agreed to participate and allow their names to be put on a list of providers in the project. This list of pharmacist providers was subsequently given to patients as they enrolled, so they had a choice of locations.

Patients agreed to meet with their program pharmacist as frequently as once a month for 20 to 30 minutes. Pharmacist providers agreed to meet with their patients in one-on-one sessions away from the dispensing counter in at least a semi-private counseling area. These were appointment-based encounters, and the frequency of visits was ultimately determined by the pharmacists, based on the patient’s needs.

This training program has been repeated several times over the years. Many in the original group were independent pharmacy owners; however, a significant number of patients are now also being followed by pharmacists who work for a progressive regional chain, Kerr Drug, and by Mission Hospitals pharmacists in clinic settings.

Conclusion

In our experience, the key factors related to training pharmacists to provide disease management services are the use of national guidelines as the training material and the motivation of the pharmacist to receive some additional training. We believe, however, that this program has been successful primarily because of the basic skill-set that pharmacists bring to the table—-their comprehensive knowledge of medications and ability to make an assessment of all the patient’s medications, not just those for the condition that brought them to the program. No one is in a better position than the pharmacist to assess if a patient is actually taking his or her medications as directed.

Is special training necessary? Yes. Pharmacists need to be up-to-date in their knowledge of the medical condition that brings the patient to them. Employers, whose health plans are paying for the services, should reasonably expect assurance that pharmacist providers are qualified and trained to provide patient care services. Who should train the pharmacists? The logical choice is professionals who are already experts in the field. Is training a barrier? No. In our experience, any competent, motivated pharmacist with the interest and the time can succeed in this program.