Reinforcing Patient-Specific Diabetes Care Plans

JANUARY 16, 2018


Troy Trygstad, PharmD, MBA, PhD; Richard Wynn, MD; Steven Peskin, MD, MBA; and Tripp Logan, PharmD, explore the importance of pharmacy involvement and good communication among health care team members in helping patients with type 2 diabetes mellitus adhere to their care plan.

Troy Trygstad, PharmD, MBA, PhD: This sounds like a difficult task. Somebody walks in and they get diagnosed. You want to make sure that you give the optimized treatment, the classic medical model: diagnose and treat. But we’re bringing an element into this that sounds difficult. It requires a “it takes a village” kind of philosophy. In your mind, who makes up the diabetes care team? Who are all of the moving people, and what are all of the moving parts that are needed to accomplish this very difficult task, as we all describe it?

Richard Wynn, MD: The care team starts with a MD, or a provider, and a PA, nurse practitioner, whose field is diabetes management. They can speak to the patient about clinical goals. “What are your goals? What’s important to you about this?” And then, the pharmacist is extremely important. They recognize that the patient’s not taking anything. They’re not taking it correctly. They’re running out early when they shouldn’t. They didn’t pick the drug up because of cost. They can suggest therapeutic substitutions for medications that an insurance plan has changed, where they now can’t get the drug. They don’t necessarily share everything with the doctor, but they’re more casual with the pharmacist who they see fairly regularly. A lot of information comes forward that way. A nutritionist, and I’m talking about a nutritionist coach for them, I’m just saying to the patient, “Well, it was Thanksgiving. What did you have?” That kind of conversation is familiar to a nutritionist. They understand someone who is living a life and has to negotiate diabetes through that.

Troy Trygstad, PharmD, MBA, PhD: It’s interesting. If I take what Dhiren and you said, we’re sort of setting a care plan for this patient.

Richard Wynn, MD: And prioritizing their goals, first.

Troy Trygstad, PharmD, MBA, PhD: Prioritizing their goals.

Richard Wynn, MD: So, is this really someone who is going to change everything. They are going to start exercising today. “Eat this, not that” and “Take this.” Maybe that’s a small subset of patients. The care plan has to include the patient’s goals and, “What’s important to you about this?”

Troy Trygstad, PharmD, MBA, PhD: So, diagnose, regimen, treatment, care plan, which is patient-specific, right? So, personalized medicine isn’t just about biotechnology. Personalized medicine is about behaviors and motivations, and patient goals, etc, etc.

Steven Peskin, MD, MBA: Yes, I would emphasize understanding what the patient’s goals are. That’s an important part of the conversation.

Troy Trygstad, PharmD, MBA, PhD: So, we’re setting some kind of care plan up. I’m looking at somebody like Tripp who’s out in the field, right? You’ve got this care plan. It seems to me that what you’re saying is that one of Tripp’s roles–and the role of the folks that are around him, and his support folks in the community pharmacy–is diagnosing when we’re off our care plan. Right? You’re sort of setting this holistic care plan. You’ve got some team members around you. And then, they’re off into the field. Right?

What happens when you’re not in that 16-minute, or 6- to 13-minute meeting with the patient? We could set a perfect care plan, but it may not be a perfect care plan next week when they’re diagnosed with something else. Or it might not be a perfect care plan if they can’t afford it, don’t have transportation, or don’t believe in it. Maybe the neighbor says, “You shouldn’t. I saw this. I had a bad side effect,” etc. In diagnosing somebody, how do you figure out, in the pharmacy, this, “I bet this person’s off their care plan?” How do you engage that patient and go through that Sherlock Holmes exercise?

Tripp Logan, PharmD: The Sherlock Holmes piece is typically, “What is the care plan?” Nine times out of 10, or even more than that, probably 99% of the time, we don’t have access to whatever that particular patient’s care plan is. We have to deduce what the most likely care plan is for the patient. And then, what are we seeing? We’ve got some advantages, in the community space, because we see a lot of blood glucose meter readings. We check blood pressures, so we can kind of tell. If the blood glucose is high, obviously something is going on and it’s time for us to intervene.

I’m real envious of this relationship, here, because we don’t always have it with all of the providers that we work with. It makes life so much easier when we can pick up the phone and say, “Hey, you know, we just took Miss Jones’ blood glucose and it was high. We’ve noticed that she’s not filling her insulin as often as she probably should. What’s the care plan? Would you like for us to intervene? Would you like for us to refer, at this point?” That’s the ideal world. We’ve got that relationship with many prescribers, but not all of them. So, that’s where we want to be, because we can do our job a lot better that way.

Troy Trygstad, PharmD, MBA, PhD: It’s interesting. We’re starting to go through a renaissance in medical practice, a different type of relationship with the patient. What does that relationship look like between the provider and patient? How do we involve them in shared decision making and motivational intervening? How do we foster relationships between care team members? And, if it takes a village to take care of diabetes, what are we doing to foster those types of communications and interpersonal, interprofessional relationships? Most of the interactions might be to put a fact tag over preauthorization. Or eligible handwriting. And whatever else. How do we communicate those care plans and say, “Here’s a care plan that we set for a patient, please let us know”?

Tripp Logan, PharmD: To me, it’s even bigger because we have to get over this event-based medicine. Right now, all the time, when we’ve got a patient discharged from a health system or a hospital, we see that this was an event. They’re out. All of a sudden, it’s somebody else’s problem. Then it goes to the family practice physician. Maybe they haven’t seen the patient yet. So, we’re stuck in between, in the pharmacy, 2 events: One that hasn’t occurred yet, which is that family practice visit, the follow-up, and one is a discharge. Nobody’s taken ownership for what’s going on right now. A lot of times, this is a gap or an issue. And so, getting there, I think, starts with good handoffs.
 


Troy Trygstad, PharmD, MBA, PhD; Richard Wynn, MD; Steven Peskin, MD, MBA; and Tripp Logan, PharmD, explore the importance of pharmacy involvement and good communication among health care team members in helping patients with type 2 diabetes mellitus adhere to their care plan.

Troy Trygstad, PharmD, MBA, PhD: This sounds like a difficult task. Somebody walks in and they get diagnosed. You want to make sure that you give the optimized treatment, the classic medical model: diagnose and treat. But we’re bringing an element into this that sounds difficult. It requires a “it takes a village” kind of philosophy. In your mind, who makes up the diabetes care team? Who are all of the moving people, and what are all of the moving parts that are needed to accomplish this very difficult task, as we all describe it?

Richard Wynn, MD: The care team starts with a MD, or a provider, and a PA, nurse practitioner, whose field is diabetes management. They can speak to the patient about clinical goals. “What are your goals? What’s important to you about this?” And then, the pharmacist is extremely important. They recognize that the patient’s not taking anything. They’re not taking it correctly. They’re running out early when they shouldn’t. They didn’t pick the drug up because of cost. They can suggest therapeutic substitutions for medications that an insurance plan has changed, where they now can’t get the drug. They don’t necessarily share everything with the doctor, but they’re more casual with the pharmacist who they see fairly regularly. A lot of information comes forward that way. A nutritionist, and I’m talking about a nutritionist coach for them, I’m just saying to the patient, “Well, it was Thanksgiving. What did you have?” That kind of conversation is familiar to a nutritionist. They understand someone who is living a life and has to negotiate diabetes through that.

Troy Trygstad, PharmD, MBA, PhD: It’s interesting. If I take what Dhiren and you said, we’re sort of setting a care plan for this patient.

Richard Wynn, MD: And prioritizing their goals, first.

Troy Trygstad, PharmD, MBA, PhD: Prioritizing their goals.

Richard Wynn, MD: So, is this really someone who is going to change everything. They are going to start exercising today. “Eat this, not that” and “Take this.” Maybe that’s a small subset of patients. The care plan has to include the patient’s goals and, “What’s important to you about this?”

Troy Trygstad, PharmD, MBA, PhD: So, diagnose, regimen, treatment, care plan, which is patient-specific, right? So, personalized medicine isn’t just about biotechnology. Personalized medicine is about behaviors and motivations, and patient goals, etc, etc.

Steven Peskin, MD, MBA: Yes, I would emphasize understanding what the patient’s goals are. That’s an important part of the conversation.

Troy Trygstad, PharmD, MBA, PhD: So, we’re setting some kind of care plan up. I’m looking at somebody like Tripp who’s out in the field, right? You’ve got this care plan. It seems to me that what you’re saying is that one of Tripp’s roles–and the role of the folks that are around him, and his support folks in the community pharmacy–is diagnosing when we’re off our care plan. Right? You’re sort of setting this holistic care plan. You’ve got some team members around you. And then, they’re off into the field. Right?

What happens when you’re not in that 16-minute, or 6- to 13-minute meeting with the patient? We could set a perfect care plan, but it may not be a perfect care plan next week when they’re diagnosed with something else. Or it might not be a perfect care plan if they can’t afford it, don’t have transportation, or don’t believe in it. Maybe the neighbor says, “You shouldn’t. I saw this. I had a bad side effect,” etc. In diagnosing somebody, how do you figure out, in the pharmacy, this, “I bet this person’s off their care plan?” How do you engage that patient and go through that Sherlock Holmes exercise?

Tripp Logan, PharmD: The Sherlock Holmes piece is typically, “What is the care plan?” Nine times out of 10, or even more than that, probably 99% of the time, we don’t have access to whatever that particular patient’s care plan is. We have to deduce what the most likely care plan is for the patient. And then, what are we seeing? We’ve got some advantages, in the community space, because we see a lot of blood glucose meter readings. We check blood pressures, so we can kind of tell. If the blood glucose is high, obviously something is going on and it’s time for us to intervene.

I’m real envious of this relationship, here, because we don’t always have it with all of the providers that we work with. It makes life so much easier when we can pick up the phone and say, “Hey, you know, we just took Miss Jones’ blood glucose and it was high. We’ve noticed that she’s not filling her insulin as often as she probably should. What’s the care plan? Would you like for us to intervene? Would you like for us to refer, at this point?” That’s the ideal world. We’ve got that relationship with many prescribers, but not all of them. So, that’s where we want to be, because we can do our job a lot better that way.

Troy Trygstad, PharmD, MBA, PhD: It’s interesting. We’re starting to go through a renaissance in medical practice, a different type of relationship with the patient. What does that relationship look like between the provider and patient? How do we involve them in shared decision making and motivational intervening? How do we foster relationships between care team members? And, if it takes a village to take care of diabetes, what are we doing to foster those types of communications and interpersonal, interprofessional relationships? Most of the interactions might be to put a fact tag over preauthorization. Or eligible handwriting. And whatever else. How do we communicate those care plans and say, “Here’s a care plan that we set for a patient, please let us know”?

Tripp Logan, PharmD: To me, it’s even bigger because we have to get over this event-based medicine. Right now, all the time, when we’ve got a patient discharged from a health system or a hospital, we see that this was an event. They’re out. All of a sudden, it’s somebody else’s problem. Then it goes to the family practice physician. Maybe they haven’t seen the patient yet. So, we’re stuck in between, in the pharmacy, 2 events: One that hasn’t occurred yet, which is that family practice visit, the follow-up, and one is a discharge. Nobody’s taken ownership for what’s going on right now. A lot of times, this is a gap or an issue. And so, getting there, I think, starts with good handoffs.
 
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