Clinical improvements for patients with diabetes seen in a collaboration between the University of North Carolina and Blue Cross and Blue Shield of North Carolina.
“If you look at where we were in 2021 versus where we are this year 2024, you'll see a common theme. Of course, in '21 we were coming out of the pandemic; we were still in the pandemic, so public health was a huge health policy priority,” Jon Easter, BSPharm, professor of the practice and vice chair of practice advancement at the University of North Carolina Eshelman School of Pharmacy, said in a session at the 2024 National Association of Chain Drug Stores Total Store Expo. “This is a huge sort of opportunity, if you will, not only for health care in the US and for patients, but for pharmacy.”1
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He stated that more than 30% of spending for health care goes into hospital care, noting that acute exacerbations from diseases that are not well treated are driving hospitalizations. Further, approximately 50% of Americans have 1 chronic condition and 90% of what is spent in health care in the US can be attributed to chronic conditions, Easter said. He added that 70 of 100 counties in North Carolina are rural, indicating that access is a prominent issue in these counties—particularly when it comes to diabetes and economic conditions.1
“Diabetes is obviously something that we all need to be paying attention to, and better treatment and prevention. So, we launched a telehealth project a couple of years ago that was very successful in rural and underserved areas. And then the latest project, the Community-Based Value Initiative (CBVI), has been really with a focus on diabetes, and taught us a lot about the role of the pharmacist there,” Easter said in an interview.2
The CBVI, funded by the NACDS Foundation, is made up of 3 parts: patient identification, screening and pharmacist consultation, and provider communication. The intervention by pharmacists included diabetes education, nutrition education, blood sugar education, heart disease, cholesterol, self-care, and a review of diabetes medication management, according to Easter. As part of the program, there were 21 different sites across 5 states, including large independent chains, small independent chains, and large grocers.1
“We wanted to make sure that core intervention was there, but that it would the toolkit itself, or the implementation process could be flexible based on which environment we were in,” Easter said. “That's why we took such a broad approach to implementing the project. We talk a lot about the therapeutic area, we talk about diabetes, we talk about the education. What we don't talk enough about, I think, is the implementation process.”1
To implement the program, the team focused on 3 core areas of implementation, including replication, sustainability, and success, according to Easter. He added that for implementation to be successful, the intervention has to be defined with strategies and steps that the sites and investigators can follow to ensure coaching, training, quality, and feedback can be accurately captured. Another aspect of success is the implementation of metrics as well as the effectiveness of the metrics.1
“What we're doing on the innovation front right now is trying to figure out how best to implement these diabetes interventions within the pharmacy setting. We've been guilty in pharmacy of 'one in a row' for a long time; so we can implement an intervention and it works well, but how do we scale it up? How do we replicate that? The interventions that we're really working on now is through implementation science and applying frameworks to be able to scale up these great interventions,” Easter said in an interview.2
For the metrics, Easter said they were trying to tie HbA1c, blood pressure control, and PHQ-9 directly to the role of the pharmacists and show how pharmacist intervention could impact the clinical metrics. Over a 6-month period, they found reductions in HbA1c of a half point—from 9.5% to 9%. Further, Easter said that 100% of patients engaged were satisfied with the program.1
For pharmacists, there were improvements in acceptability, but it was flat on appropriateness. There were also declines in feasibility and intent to sustain. He stated that the feasibility aspect was affected because pharmacists were in the midst of coming out of the COVID-19 pandemic and were reworking their workflow. He said that pharmacists said they were getting paid for vaccinations, but not for this program.1
1. Pharmacists can play a key role in managing chronic conditions through interventions and education.
2. The Community-Based Value Initiative (CBVI) demonstrated the effectiveness of pharmacist-led interventions in improving diabetes outcomes (HbA1c reduction).
3. Collaboration between pharmacists, health plans, and other stakeholders to improve chronic disease management.
Jasmine Perry, PharmD, CPHQ, a senior clinical pharmacist at Blue Cross and Blue Shield of North Carolina, said the Blue Cross and Blue Shield NC team developed a program called “More Than a Script.” The program, according to Perry, connects “our members or our patients with community pharmacies across the state to have impact on their diabetes care.”1,3
“In North Carolina we have a diabetes epidemic, which is something that we truly want to have impact on. So, our internal Blue Cross NC Drivers of Health team does a ton of research on marginalized communities and underserved communities and how they're impacted by this condition,” Perry said in an interview. “Internally, we have been able to identify communities across our state that have wider diabetes care gaps or who are not at goal, and through that research, we have developed specific partnerships with communities in those areas to make sure that those members, those patients, have access to a community pharmacist that can help close some of those care gaps in diabetes.”3
The program was launched in June 2024, using the real-world data of Easter’s research. Perry added that Medicare populations have historically been the focus of clinical programs, so they wanted to include those with commercial insurance.1
“With this program, we're closing a couple gaps. The first is we're closing the gap of pharmacist reimbursement, so we're now incentivizing pharmacies to do the clinical work that they have been doing previously for no cost,” Perry said. “Beyond that, we're closing clinical gaps, so improvement in A1c, improvement in blood pressure, as Jon mentioned, and alignment with [Pharmacy Quality Alliance] quality metrics.”1
One of the goals of the program is overall health status, Perry said, stating, “As pharmacists, we truly understand that medications are an important component of improvement in clinical outcomes, but lifestyle factors are also vitally important.” That’s why the program has a focus on holistic care, not just medication. She added that the program also focuses on health equity. In the future, Perry hopes to add other disease states and health care, such as contraceptive access, pre- and post-exposure for HIV, and smoking cessation. She also wants the program to expand to other pharmacy organizations since it currently works with independent pharmacies.1
“Through partnerships, through the work that's been done in research and literature, we've been able to develop this innovative, value-based care program in a space where we hadn't seen a program done like this before,” Perry said. “We're reimbursing community pharmacists for this work as an incentive, but we know that pharmacists provide clinical education for free now, currently across the nation, so we know that pharmacists can do the work now. We are implementing ways to standardize this work and make it an approach that can be utilized by other states and redeveloped and tweaked and changed for your own populations.”1
