Cole Daniels, PharmD, BCPS, discusses a quality improvement initiative for glycemic outcomes with pharmacist management of insulin.
Pharmacy Times interviewed Cole Daniels, PharmD, BCPS, clinical coordinator of an inpatient Behavioral Health Hospital in Montana, on the role of managing diabetes and improving glycemic outcomes in behavioral health. Daniels discussed how behavioral health populations are at very high risk for many metabolic syndromes. Daniels emphasized that the study provided positive results, that could aid medical practitioners and ensure benefits among patients. Additionally, Daniels discussed the importance of enabling other pharmacists and behavioral health sites to see that it can be done.
Can you introduce yourself?
My name is Cole Daniels. I'm actually the clinical coordinator of a 270-bed inpatient Behavioral Health Hospital in Montana. [A] very rural setting, so access to care can be challenging as far as neighboring hospitals and such. I graduated pharmacy school in 2018 from The University of Montana Skaggs School of Pharmacy. I have been at this site for the past five and a half years. My fourth year in experiential pharmacy school, I was able to do a rotation at a behavioral health hospital. [I] never had a whole lot of interest in basic behavioral health until I went through that rotation. [I] just how at risk and vulnerable that patient population was, and it really sparked a big interest in me to have a career in that arena — so very fortunate for that to happen. I love working with the behavioral health population. I have a passion to help those in need, and those who are vulnerable, and it's a great platform to do that.
Can you tell me about managing diabetes and improving glycemic outcomes in behavioral health? Why is it important?
The behavioral health populations are at very high risk for any metabolic syndrome, whether it be dyslipidemia, obesity, diabetes, all of those are risks factors for any Cardioembolic... As we know that patient population has decreased life expectancy, upwards of 15 to 20 years. With that, they get all the potential sequela of stroke, not limited to death, as far as any type of neurological sequala. Their diagnosis is challenging enough, we don't want to exacerbate those risk factors at all. And so, there's a major emphasis on treating those risk factors, [like] diabetes.
From a pharmacy perspective, there's a lot that we can do in that arena, and also take the load off of the medical practitioners as well. That patient population specifically has a lot of risk factors from the medications they take. So, atypical antipsychotics, high risk lifestyle, typically have a lot of medical comorbidities, as well, and so managing diabetes is paramount for them as well. In my perspective, it's a low hanging fruit from a pharmacy perspective. We know these medications inside and out; we have excellent rapport with the patient population to where we can have our influence and see some major impact and outcomes.
Another issue that we see, especially in rural Montana is lack of access to care. These patients, conceivably, we are more or less their primary care providers. A lot of them have frequent hospital readmissions, and that's just a part of their underlying disease state to where when they come in, we obviously have to do a very thorough assessment and manage their chronic disease states as well.
Another issue that we see too is underinsured patients. From the pharmacy standpoint, we're very in tune with how expensive some of these medications can cost and what programs we can get them into. We can actually modify their treatment regimen to increase their chance of actually having access to these medications. It can be challenging. As we know, behavioral health medication adherence is an issue at times. And so that's from pharmacy — the education component, frequent meeting with the patient, even if there's a little hesitancy at first from the patient to get buy in to take these meds. Or to manage lifestyle or anything like that. I find that the more we meet with them, the more we educate them, become involved in their treatment team. Their hesitancy to follow such treatment plans is a lot less. Then we get a lot more of their buy in and understanding as well. Their health literacy tends to be quite low. And so, we really have to help them along the process and getting them to understand 'okay, what's the risk?' If we don't treat this what could happen? What we need to do to get to order what our goals are and how long that might take. It's up to them and they're adhering to our plan as well.
Can you give a brief overview on why the study was conducted, what was learned and why it is impactful?
Initially, we never really intended to do a formal study. Last fall we had a conversation with our company— I actually work for CPS solutions, [and] we decided to kind of take a closer look at what the hospital's glycemic control looked like. From a pharmacy perspective, we knew that there were likely some issues there, but didn't have any concrete information. Part of a quality improvement initiative with our QI departments, we started tracking hypoglycemic events, [and] overall glycemic control, and actually came up with some fairly surprising numbers. For December of 2022, we found that 37% of all blood sugars were over 200 milligrams per deciliter, which to me was a relatively staggering number. And so those numbers enabled the pharmacy to approach the hospital and essentially say, 'hey, we've got the skill set.' Let us manage patients that are insulin dependent, and then we can expand from there throughout the hospital for potentially all diabetic patients — which we can get into a little bit.
So that's what we did. January of 2023, we formally started our insulin management protocol. We had weekly rounds on all insulin dependent patients, and we made modifications to their drug therapy— starting basal insulin, basal bolus type regimens, adjunctive therapies with orals, in addition of STLC2, GOP1. We also worked with our dietary department to modify their dietary regimens as much as we could and saw some pretty excellent results. After initiation, for the purpose of the study, we had a five-month captured window from January to May and we saw a 50% reduction in those blood sugar's, over 200. That went from proximately 37% to right around 17%, for those numbers. We have some graphs [that] we actually presented a poster here at Midyear this year. You can see there was an association between our monthly pharmacist interventions, and decreases in our blood sugars throughout the month, these hypoglycemic events, and we had a total of 113 intervention. Most of those related to basal insulin titration. Several patients, we actually discontinued insulin because it was not appropriate for them. But we saw just excellent, excellent results, The other side of it too that was part of our work and value discussion with the hospital was safety. We did not notice a significant increase in any hypoglycemic events. Slight uptake, I think it was a 0 to 0.6% increase between 40 and 70 milligrams per deciliter. So slightly decreased hypoglycemia, none of them were symptomatic, all treated accordingly with our protocol, which is to be expected. When you treat accordingly, there will be just a bump up, and those seeming of that. [It was] very well received from the hospital. It took a big load off of our medical practitioners to where they know those patients are in good hands.
To me, my whole hope and intent for having a poster — maybe publishing in the future potentially on different platforms, is to incentivize or enable other pharmacists to see that it can be done. I've talked with several other behavioral health sites in the Pharmacy Departments, and there's a little hesitancy there. Logistically speaking, within maybe the hospital administration provider by in, what have you. And to me, I hope that the study can be used more as a tool to where they can show pharmacy can manage this safely. There can be a lot of effective results that you would see from this. It also gets us into the arena of more progressive clinical management, especially in behavioral health. So that was my intent, just to aid and assist other pharmacies in and proposing a program of such.
How do the results allow pharmacists to improve patient outcomes? What do the findings mean for the future?
Well, what I hope it means is that — like you said, I touched on a little bit, is we can see a lot more pharmacy involvement. Not just in diabetes, but metabolic syndrome, all characteristics. obviously, ambulatory care. This is old news. A lot of different venues, but not necessarily in the behavioral health domain. And that's what I'm hoping to see in the future is a lot more pharmacist involvement to where we manage these things. In my experience, we see things a lot different than the medical practitioners. Just from access perspective, very subtle medications specifics that we can pick up on more often than a lot of our counterparts. And so, these are all things that I think will contribute in a very, very good way from pharmacy.
Is there anything you would like to add?
I am actually a pharmacist from CPS solutions. If I were to encourage anybody, anything it would be to use whatever resources that are at your disposal for these programs. I leaned on them. Our CPS corporate clinical team was awesome through this whole process, so a shout out to them. Yeah, otherwise, that's all I got.