Improving Collaborative Care in Diabetes - Episode 5

Physician-Pharmacist Collaboration in Diabetes

Troy Trygstad, PharmD, MBA, PhD; Steven Peskin, MD, MBA; Richard Wynn, MD; and Dhiren Patel, PharmD, provide examples of what good collaboration among physicians and pharmacists looks like and discuss the importance of joint ownership for meeting clinical goals in diabetes care.

Troy Trygstad, PharmD, MBA, PhD: You’re in clinic. A diabetes patient walks in. A really high proportion of the time, it’s really a larger metabolic syndrome construct or challenge. And so, you’re having a patient visit. Who are the various folks for a typical patient, even within a closed system, that you’re going to have to coordinate with to optimize therapy for that patient?

Dhiren Patel, PharmD: There are a lot. Again, I’m fortunate. I work in a system where I have access to that. But in many situations, they probably know what that ideal care team looks like but they can’t refer a patient to a nutritionist or dietician. So, again, those are some of the things that we have that luxury of. We have a pool consult. We can send them to our own pool. Those types of things don’t exist everywhere. But it goes back to that team. A lot of folks have to touch that patient, from the person at the front desk who is booking that patient’s appointments for the referrals that you make—just because you documented the referral doesn’t mean that patient is going to have that eye exam or foot exam—all the way down to the pharmacist level. And then again, taking it beyond and outside of the hospital. And the office, I think, is where a lot of the focus needs to be.

Troy Trygstad, PharmD, MBA, PhD: It’s interesting that you say that. I keep imagining when my kindergartner went to school. We watched them closely. We rear them. We get them to the age of 5, and then we pat them on the head and get them on the bus. Then they’re out in the wild, so to speak. Right? So, a system of care would mean that we’re sort of monitoring and watching and coaching wherever we’re at throughout the system. We’re trusting that whoever we’re handing off to knows how to take care of this child, right? I go back to an interesting model that you have, doctor, within your practice. You’re in a more open system in your environment. You’ve chosen to have a really close relationship with the community pharmacy. Some of their staff actually comes to your practice. You’ve got this interesting dynamic. You have some folks from the outside world in your practice, and you extend some expectations into the outside world from your practice. Can you describe what that looks and feels like, and why it’s so important for diabetes, in particular?

Richard Wynn, MD: Oh, yes. We have a model. We have a fairly normal primary care practice with some specialists who are actively involved in HIV, etc. We have an in-house pharmacy and a relationship with a pharmacy that actually expands to have access to our charts. We send prescriptions there for prior authorizations for consults on the best choice for this patient. Sometimes it’s based on insurance issues. Sometimes it’s drug interactions and determining what’s safest for patients who have questions or concerns. There are so many reasons why patients are noncompliant with diabetic care. They become afraid of this medication because they saw an ad from a lawyer which looked for patients on it. Or they had a hypoglycemic episode and they were very afraid of seeing that happen again. So, they were afraid to take their insulin regularly. They don’t understand how this one works versus the other one. Having that many people who are knowledgeable about the process involved, and having the patient recognize it, as well as the relationship, is invaluable.

Troy Trygstad, PharmD, MBA, PhD: You have an appreciation for adherence. Solving the problem of adherence is not just reminding the patient to take their medication, right?

Richard Wynn, MD: Not at all.

Troy Trygstad, PharmD, MBA, PhD: That’s a dramatically oversimplified intervention, right? There’s 1000 patients. You’ve got 1000 different reasons why they’re adherent. They’re very patient-centric. You might have 400 different interventions that are required in some way, shape, or form, to solve the issues for those 1000 nonadherent events. What I hear you saying is that you’ve got a different level of expectation of the pharmacist and pharmacies that you work with?

Richard Wynn, MD: I expect interaction with the patient directly, but also with me, and feedback as to, “Have you thought about trying this?” Or, “This happened with this. Would you mind if we tried this?”

Troy Trygstad, PharmD, MBA, PhD: Yesteryear, this was my responsibility or your responsibility. And what I hear you migrating toward is that this is our responsibility.

Richard Wynn, MD: Because we have the same goals, hopefully.

Troy Trygstad, PharmD, MBA, PhD: Which means you have expectations of that care team member. “Hey, I expect this of you. I need this for my measures, my professional fulfilment, and my patients that need to get to goal.” Tripp, what does that look like on the outside?

Tripp Logan, PharmD: This sounds like the recognition of shared goals, which is the barrier we run into a lot when trying to work more closely with a lot of the providers in our area. Sometimes there’s this disconnect. We’ve got the same goal that they have. We get this stamp, a lot of times, of being a dispensary. We actually share the goals. It’s sometimes hard to get over that hump. We spend a lot of time there. And once you do, it’s very rewarding for both sides. But unfortunately, there is that siloed piece of “This is my event. This is your event. We’re going to stay in our lanes.” Unfortunately, that’s the reality right now in most situations.

He’s got ownership, right? It all comes back to ownership. What we’re hearing is that there is a joint ownership of this patient, “This is our patient.” What we see is that there really is not a very efficient handoff from event to event, to event to event. If we can invest cardiovascular—let’s say, in diabetes— we’ve got patients that come in regularly for medication optimization. Or, “Are you at goal? What’s going on? What can we do better?” New guidelines come out. It makes us rethink what we’re going to do at this point. Maybe it’s more expensive in the short term.

Well, in our current insurance mix, we kind of bought a 12-month budget. We’re not really looking. So, it may be expensive for 12 months, but we may save hospitalizations, amputations. We may save all kinds of things 10 years down the road. Who’s accountable for that? Obviously, the patient is. But we need to make sure that we’re all focused on that. I know that all pharmacies aren’t where we are, but more and more are. I tell our staff, all the time, when we go in to talk to provider groups about doing services, that the bar is so low right now for pharmacy expectations. It’s dispensing, dispensing, dispensing.

So, we go in to talk to a payer. We talk to a health system. We talk to a provider group. I always have this conversation with them when we walk in: “Do we need to tell them about this?” “No. They’re used to nothing. They’re used to no communication. Anything we offer is a plus.” We can only build from there. And that’s where we, as a community pharmacy profession, need to be better about going in and building those relationships from the base, from the low expectations.

Troy Trygstad, PharmD, MBA, PhD: Expect more from me.

Tripp Logan, PharmD: Exactly.

Troy Trygstad, PharmD, MBA, PhD: Right? Expect more from me. One of my goals is to help you get home on time, meet your metrics and deliverable on your performance, and ultimately improve patients’ lives. That seems logical to me, right?

Dhiren Patel, PharmD: I think it might be happening. In the news, right now, you see what’s going on with someone like an Aetna and CVS Caremark. That’s exactly what you described. If you can get everyone aligned, in terms of the metrics, and the financials make sense, then, all of a sudden, I think they’re going to start caring. Up until now, there just wasn’t that reimbursement. If you look at it from a community pharmacy level, for those cognitive services—and you guys run a remarkable pharmacy down there—I could have other colleagues who would argue that, “Well, I’m being looked at and benchmarked for how many MPNs or immunizations I do.”

Tripp Logan, PharmD: Well we say the same thing.

Dhiren Patel, PharmD: “I just don’t have this time.” You ask many of the pharmacists, and all of them want more time to counsel. But they don’t necessarily have it because that’s not tied to any type of reimbursement or recognition of their cognitive services.