Barry A. Bunting, PharmD

We are frequently asked what training pharmacistsare required to have in order to providedisease management services in the AshevilleProject and how the training program wasdeveloped.

In 1996, an agreement was reached with the City ofAsheville to pilot a demonstration project that would usepharmacists as ?health coaches? for individuals with diabetes.The primary focus would be on appropriate medicationuse; however, pharmacists would also be expected tohelp educate patients, coach them to improve their overallhealth, and work closely with physicians.

Program planners believed that pharmacists alreadypossess skills that wouldallow them to be successfulin improving medicationtherapy. They also recognized,however, that interestedpharmacists wouldneed some further trainingin order to provide theseservices. At this early stage,they faced 3 importantquestions: (1) what will be taught, (2) who would teach it,and (3) who would be taught.

Because the first disease management program was toaddress the needs of patients with diabetes, pharmacistswould obviously need to be up-to-date on diabetes care.Even 10 years ago, well-established, authoritative, nationalguidelines for diabetes were in place. Most prominentamong those were the standards established by theAmerican Diabetes Association (ADA) and the AmericanAssociation of Diabetes Educators. The ADA core curriculumbecame the ?training manual? for the programpharmacists.

The goal was not for pharmacists to become certifieddiabetes educators (CDEs). It was decided to use some ofthe same reference material that was used to educateCDEs and physicians, however, so that pharmacists wouldbe on the same page as other providers. The obvious rolefor pharmacists in this program was a focus on improvingmedication management of diabetes; because of theopportunity to interact with patients on a very regularbasis, planners recognized that there also would be significantopportunities for pharmacists to assist patients inlong-term self-management and overall health issues.Therefore, they would need specific training to allow themto do this well.

Once it was decided what material would be taught, thenext step was to look at whowould provide the training.Recall that this discussion wastaking place more than 10years ago, at a time whenpharmacist certificate programswere practically non-existent.In fact, the first pharmaciststraining program conductedin Asheville was not evenreferred to as a certificate program. It was simply a trainingprogram with a significant number of Accreditation Councilfor Pharmacy Education (ACPE) credit hours.

In our case, the decision on who would provide thetraining was relatively easy. In North Carolina, we areprivileged to have a system of Area Health EducationCenters (AHECs) that are funded by the state. TheseAHECs, among other functions, provide continuing educationfor allied health, including pharmacy. The programplanners worked with the staff of the Mountain AreaHealth Education Center Department of Pharmacotherapyin Asheville to set up the initial training program.They in turn worked with pharmaceutical manufacturersto obtain grant funding to offset the costs of thetraining program.

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

These relationships and the support garnered throughthe involvement of local experts have been invaluable. Wecontinue to hear stories from our physician faculty, whohave become our unofficial ?champions,? regarding discussionswith their physician colleagues about this ?pharmacistprogram.? These physicians are in an excellentposition to say, ?Yes, I know about the program, I helpedtrain the pharmacists.?

In retrospect, this was one of the more important decisionsmade in the early days of the program. Althoughthere are now a number of national certificate programsavailable to pharmacists, we would highly recommendinvolvement of local experts in some level of the pharmacisttraining if at all possible, even if just for a skills lab, apresentation on diabetes care by a locally respectedendocrinologist, or a presentation by diabetes educatorson what they teach during diabetes education classes.

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

Pharmacists would be expected to review all medicationsand assess them for patient adherence, appropriateness,and dosage. Pharmacists also would downloadmeters, check blood pressures, conduct foot exams, providepatient education, help patients set goals, and communicatefindings and recommendations to physicians. Inthe opinion of the planners, the most important factors forsuccess would be the motivation of the pharmacist, his orher willingness to be trained in diabetes guidelines, andavailability. None of the above requirements would precludeBachelor of Science (BS)-trained pharmacists.Knowledge level would, of course, be important, butequally important would be the ability of the pharmacistto communicate effectively with patients and physicians.A majority of the first group of patients followed in theAsheville Project were, in fact, served by BS pharmacists.

Overview of diabetes and its complications

Assessment and education of the patient withdiabetes

Development of a pharmacist consultation serviceand reimbursement

Self-monitoring and blood glucose devices

The program qualified for 36 hours of ACPE credit andwas attended by 24 pharmacists. The pharmacists wereinformed during the training session of the opportunity touse this training to follow individuals with diabetes thatworked for the City of Asheville; 20 agreed to participateand allow their names to be put on a list of providers inthe project. This list of pharmacist providers was subsequentlygiven to patients as they enrolled, so they had achoice of locations.

Patients agreed to meet with their program pharmacistas frequently as once a month for 20 to 30 minutes.Pharmacist providers agreed to meet with their patients inone-on-one sessions away from the dispensing counter inat least a semi-private counseling area. These wereappointment-based encounters, and the frequency of visitswas ultimately determined by the pharmacists, basedon the patient?s needs.

This training program has been repeated several timesover the years. Many in the original group were independentpharmacy owners; however, a significant number ofpatients are now also being followed by pharmacists whowork for a progressive regional chain, Kerr Drug, and byMission Hospitals pharmacists in clinic settings.

In our experience, the key factors related to trainingpharmacists to provide disease management services arethe use of national guidelines as the training material andthe motivation of the pharmacist to receive some additionaltraining. We believe, however, that this program hasbeen successful primarily because of the basic skill-set thatpharmacists bring to the table?-their comprehensiveknowledge of medications and ability to make an assessmentof all the patient?s medications, not just those for thecondition that brought them to the program. No one is ina better position than the pharmacist to assess if a patientis actually taking his or her medications as directed.

Is special training necessary? Yes. Pharmacists need tobe up-to-date in their knowledge of the medical conditionthat brings the patient to them. Employers, whose healthplans are paying for the services, should reasonably expectassurance that pharmacist providers are qualified andtrained to provide patient care services. Who should trainthe pharmacists? The logical choice is professionals who arealready experts in the field. Is training a barrier? No. In ourexperience, any competent, motivated pharmacist with theinterest and the time can succeed in this program.

Articles

Dr. Bunting is clinical manager of pharmacy and Asheville Project
coordinator, Diabetes and Health Education Center, Mission
Hospitals, Asheville, NC.

Training Pharmacists for Disease
Management Roles

The Pharmacy Department of Mission Hospitals,a 700-bed, community hospital located inAsheville, NC, was instrumental in the development,implementation, and administration of theAsheville Project. Communities tend to look to their hospital(s) as resources for health care expertise, and this wasthe case with the development of the Asheville Project.Hospital pharmacy departments throughout the countrymight consider their own potential to be a catalyst forpharmacist-coordinated disease management programs intheir communities, as Mission Hospitals was in ours.

When I reflect on why the Asheville Project flourishedin our community, a major reason was that the hospitalfunctioned as the hub of the program. It contributeddevelopmental brainpower, arranged for pharmacist training,and brought the program to community pharmacists.This could, and should, be happening in other communities.Who better to do this than a hospital pharmacydepartment that has talented, motivated pharmacists witha reputation for clinical expertise within its walls?

Mission Hospitals? pharmacy department functions at avery high clinical level, but until the Asheville Project, thedepartment had primarily focused on inpatient clinicalservices. Asheville offered pharmacists the opportunity touse those same talents to help patients in ambulatoryareas. Hospital pharmacy departments have the potentialto improve care outside the hospital, and there is a tremendousneed to do so.

The original Asheville demonstration project began asthe brainstorm of key thought leaders in the state.Prominent among them were state pharmacy associationand school of pharmacy leaders, as well as representativesfrom state government and industry. The idea was todetermine if patients with medical conditions requiringchronic medications could benefit from regular face-to-facecounseling with pharmacists, based on the premisethat if pharmacists were given the opportunity to applytheir clinical skills, patients would do better clinically, outcomeswould improve, and possibly even result in lowertotal health care costs.

The group realized that it would be necessary to conducta demonstration project to study the value of suchservices. The burden of proof was on the pharmacy professionto prove convincingly to purchasers of health careservices, employers, government, insurance companies,and patients that pharmacists have knowledge and skillsworth purchasing.

To test the idea, someone needed to ?give us a chance.?A purchaser of health care services, an employer, wouldneed to be approached and agree to allow pharmacists todemonstrate whether, in fact, these services improved careand if improved care would lead to lower health carecosts.

Daniel G. Garrett, RPh, MS, FASHP, then director ofpharmacy at Mission Hospitals, took to heart the chargeto find a payer to ?give us a chance? and approached theRisk Benefits Manager of the City of Asheville, JohnMiall, to see if the city would be willing to partner in ademonstration project where the city would offer a diseasemanagement program to their employees with diabetes,and the pharmacy department at Mission Hospitals woulddevelop, implement, and administer the program in thecommunity. In addition, the pharmacy department wouldprovide expertise to determine program outcomes andpublish results.

Even after the agreement in principle was reached,many decisions still had to be made, involving a widerange of issues and stakeholders. In the area of pharmacistsalone, we had to look at training, curriculum, recruitment,and development of a pharmacist network. We neededincentives to recruit patients and match them to pharmacists.Roles and relationships with the employer benefitsstaff had to be defined, as well as outreach to physiciansand community diabetes educators. We also needed a planfor marketing, replication, and measuring outcomes.Pharmacy leadership at the hospital was responsible forfleshing out the demonstration project idea in these areas.

Although all of this sounds daunting, it was notimpossible, and the administrative and clinical expertisethat allowed this to happen in Asheville is available inmany other communities with progressive hospital pharmacydepartments. We have seen other communitiesimplement similar programs without the direct involvementof their local hospitals; however, in our experience,it is much easier when they are involved.

One of the biggest challenges for a community thatwould like to initiate a project like this is figuring out howto get started. Once begun, it is much easier to sustain, buthaving a point person or a point organization is critical.

Yet why would a hospital, whose focus is primarily onacute care, be interested in a program that focuses onambulatory care?

Hospitals need to realize there is actually something init for them. In our case, Mission Hospitals? pharmacydepartment not only helped an employer in our communityimprove its employees? health, we also provided theservices for our own hospital employees, improving theirhealth and decreasing our hospital?s health plan costs. Infact, even if a hospital pharmacy department were only toprovide disease management services for its own employees,this would make a lot of sense for the hospital.Furthermore, once they have put the pieces together fortheir own employees, they could easily market these servicesin the community, which is exactly what we havedone. Mission Hospitals currently coordinates diseasemanagement programs for 7 employers in the region fordiabetes, asthma, hypertension, hyperlipidemia, anddepression and has helped other communities start similarprograms in more than a dozen different states.

Another plus for our department is that we havegained inestimable value in the eyes of our hospital?sadministration as a result of this program. We have beenable to document that our efforts are helping the hospitalsave millions of dollars on health plan costs. While manyemployers, including hospitals, have experienced double-digitaverage annual increases in total health care costs overthe last few years, Mission Hospitals has had a net decreasein total health care costs over the last 4 years.

Also a plus for hospital pharmacies is that this programprovides another venue for them to use their staff ?sclinical skills, and they are actually getting paid for theservices. We have been able to hire pharmacist staff basedon our ability to fund their positions with disease managementservices. A disease management service also fits wellwith the overall national trend for more hospital servicesbeing offered in the outpatient setting. Here is anotheropportunity for pharmacists to work in outpatient clinicsettings, and this fits very well with evolving medicationtherapy management programs.

Hospitals also need to look at this as an opportunityto become ?the good guy? in the community. Hospitals arecontinually hammered by payers for being the cause ofrising health care costs. Yet when we?-together with ourAsheville Project employers?-looked at the true drivers ofrising health care costs, we found that most of the increasesare due to people simply using more hospital services,rather than actual increases in the costs of the services.

When we were asked to help a local employer determinewhy it had a 30% increase ($7 million) in health carecosts in 1 year, we discovered that 5% was indeed due toan increase in hospital charges. But the other 25% wasstrictly due to a significant increase in the number of tripsto the hospital by employees.

When people come to the hospital, they get treated,and it will be expensive. Should US health care strategiesfor controlling costs include interventions that help keeppeople from needing expensive hospital services in the firstplace? Of course. It is exactly what this pharmacist-drivendisease management approach does.

Because of this program, our hospital administration isable to point to its key role in the Asheville Project as a tangibleinvestment to improve the community?s health. Thehospital is doing more than simply fixing people when theybreak; we are helping people keep from breaking and fromneeding our services. This is a great public relationsmove?a hospital driving programs that, when successful,actually keep people out of the hospital. We are not the badguy anymore or at least viewed as less of a bad guy.

It may come as a surprise to many that there has beensignificant interest in the Asheville Project outside of pharmacycircles. We receive more calls from employers acrossthe country than we do from the pharmacy community.Why? Because the Asheville Project illustrates that there isa better strategy for controllinghealth care cost than tocontinue to focus primarilyon lowering payments todoctors and hospitals, aswell as dispensing fees. It isa failed strategy. No matterhow much services are discounted or fees cut, if peopleincreasingly need hospital services, costs are going to go up.

The better strategy is to focus on prevention. In ourcase, a focus on using medications more effectively bothimproves health and decreases expensive hospitaladmissions.

In our community, there has been a significant collaborationbetween hospital pharmacy and community pharmacypractice. Many hospital pharmacies have alreadyexpanded clinical services into hospital ambulatory clinics,and with the recent experimentation with communitypharmacy-based minute clinics, it appears that communitypharmacy may be moving in a similar direction?bothhaving realized that the future of pharmacy is in applyingour clinical expertise to meet the growing need to improveambulatory patient care.

The need is overwhelming, and there is room for everyone.Hospital pharmacy and community pharmacy mustwork together to pool our assets and resources aroundimproving patient care. In our experience, when this happens,everyone wins.