Back in the mid-nineties, health care professionals in North Carolina collaborated to implement the Asheville Project, a proactive approach to health care. Instead of fixing patients when they break, as Barry A. Bunting, PharmD, likes to say, the goal is to prevent patients from breaking and manage their conditions in such a way that they eventually improve. Bunting, one of the project?s founders, is clinical manager of pharmacy and Asheville Project coordinator at the Diabetes and Health Education Center at Mission Hospitals in Asheville. The intended result was 3-fold: not only would patients? health improve, employer health care costs would be reduced, and overall employee productivity would increase.
That idea came to fruition in 1997, when the first Asheville Project was launched with just a small group of diabetes patients employed by the City of Asheville. Now, a decade later, the initiative has moved beyond diabetes to other chronic conditions, and it is being replicated across the country.
One of the main factors behind the attractiveness of the Asheville model is its flexibility; the concept can be adapted to coincide with the resources that exist in any given community. For example, some Asheville sites boast pharmacists? networks that are coordinated through the state pharmacy associations; others have more informal arrangements that are handled by the pharmacists themselves. At one Asheville site, a pharmacy benefits manager acts as administrator of the pharmacists? network. Many patients visit their health care coaches/pharmacists at the local pharmacy; however, an increasing number of pharmacists visit their patients? workplaces to conduct regular monitoring sessions.
At its core, the Asheville model is extremely simple. In order to work, what is required is a willing employer, a willing health care coach (most often a pharmacist), and willing patients. Physicians and health care educators?- those conducting the seminars that patients are required to attend?-must also be on board.
Dr. Bunting suggests that the best condition to start with is diabetes. ?It is just in so much need of improvement, and the return on investment appears to be very quick and significant,? he says. ?We got into asthma, high blood pressure, and depression as a result of the success of the diabetes program.? No matter what condition pharmacists are monitoring, they must attend training in order to update their knowledge of the disease.
The Asheville model is designed for self-insured employers, and pharmacists interested in launching their own Asheville Project should start there. ?If there are several employers geographically close to your location whose employees are coming into your store, then it?s those employers you should be thinking about contacting,? Dr. Bunting advises.
In Asheville, the pharmacy department at Mission Hospitals was the catalyst for recruiting and training interested pharmacists and matching them with an employer. ?I tell a new employer who has expressed an interest to look at their numbers,? Dr. Bunting relays. ?Every time we have done that, they have come back with sticker shock: a realization that they are spending, in many cases, more than $10,000 per person per year in health care costs?- especially on people with diabetes.?
Although the pharmacist?s role is to offer coaching, monitoring, ongoing education, and accountability, the patient is at the center of the Asheville model. ?They are the most critical?-more so than their physician or their pharmacist?-because they deal with this 24 hours a day,? Dr. Bunting notes. ?What the health care community can provide is help, and they are going to do well or not so well largely depending on the help they get from the health care system.? Pharmacists, in turn, can use this as an opportunity to return to the roots of the profession: helping patients improve their health while being compensated in return.
Providing patient care services takes time, and in order for this to work, pharmacists need to manage it properly. ?Time is money, and if they are being paid to do this, and they are being compensated comparably to what they would earn if they were dispensing, that gives the pharmacist an option,? Dr. Bunting says. ?However, with the shortage of pharmacists, the biggest challenge to this model working beyond Asheville is the ability of pharmacists to create the time to see patients. Ultimately, that is going to mean using technicians more and using automated technology more. That needs to be embraced rather than feared.?
He adds that pharmacists also should be wary of biting off more than they can chew: start with a handful of patients rather than a loaded roster. ?It?s best for them to start out with a manageable number that seems to match up with the time they have been able to free up.?
The success of the Asheville model relies upon collaboration among all parties involved: employers, patients, pharmacists, health care educators, and physicians. One of the most significant barriers to the program?s effectiveness is if physicians are not on board well before the model is launched. ?A common mistake is not gaining the support of the physician community up front,? Dr. Bunting points out. In Asheville, organizers solved this by engaging the physicians in the pharmacist training. ?They gained knowledge about what we were trying to do, and they became unofficial champions.?
Ultimately, a successful launch is dependent upon the desire by everyone involved to make it happen. Not only must pharmacists have the motivation to make some changes in their practice, employers, too, must be open to the potential benefits if the model is implemented properly. ?They need to be committed to the idea that prevention is possible,? Dr. Bunting says. ?This model is a reasonable strategy that can help them reduce their health care costs and improve their employees? health and productivity.?
Ms. Koutnik-Fotopoulos is a staff writer for Pharmacy Times.
Sen Richard Burr (R, NC) knows the state?s health care system needs serious improvement. He supports legislation in Congress that will make health care more accessible and affordable for all Americans through private insurance companies.
?Emergency rooms across North Carolina are filled with patients who aren?t getting preventive care and who don?t have health insurance. Unfortunately, not only are these people more likely to get sick because they aren?t getting good preventive care, but the cost to treat them affects all of us who ultimately foot the bill through higher health costs,? he said. ?We need to find a way to increase the number of those who have health care insurance and put a greater emphasis on keeping people healthy in the first place.?
In January 2007, Burr addressed the Senate floor regarding the state of health care. He proposed 2 strategies to get a handle on the incredible cost of health care: (1) provide coverage and (2) promote prevention and wellness. ?If we can teach people how to control disease, then the number of times they access health care is going to be less,? he said.
While his statement is common sense, there is a problem. ?If we can?t create a relationship between an individual and a health care professional, how in the world are we ever going to complete the educational process of what disease management is??
He cited the Asheville Project that began 10 years ago in his home state as the prime example of patients working with a pharmacist to control their diabetes. The project was, ?clearly out of the box because the community decided, with a grant, they were going to reimburse pharmacists to counsel diabetes patients,? Burr told the Senate.
The Asheville Project, which is being replicated across the country, allows patients with certain conditions like diabetes, hypertension, and asthma to form a relationship with pharmacists through patient counseling. The pharmacist will evaluate a patient?s medication to make sure it is correct and there are no interactions with other medications they may be taking. The pharmacist will provide education on exercise and diet and monitor their progress. In a nutshell, patients will learn how to manage their disease state.
In his address, Burr said the proof is the data, noting the significant cost savings?approaching $3000 per diabetes patient/year, according to the most recent data??because we now provide for every diabetic this intense relationship with a health care professional.?
?Now what you have to understand is that in Asheville?s case, and these other areas around the country, this is not the traditional entry point where we would choose to educate. This is quite creative. As a matter of fact, we have talked about it, and it has been rejected in this institution before, that we actually pay pharmacists to do part of the health care education. I hope it is something we will reexamine because I think there is tremendous merit to it.?
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