Integrated pharmacist-led care models help to improve diabetes outcomes, expand CGM use, and reduce costs through proactive, multidisciplinary patient management.
In an interview with Pharmacy Times, Elizabeth Senior, PharmD, clinical pharmacy specialist with UPMC Health Plan, and Esra Karslioglu-French, MD, MBA, clinical chief of the Division of Endocrinology at UPMC, discussed how integrated health plan–provider collaboration enhances diabetes management through proactive, multidisciplinary care models and pharmacist-led interventions.
Pharmacy Times: Can you please introduce yourselves?
Elizabeth Senior: Hello. My name is Elizabeth Senior, and I’m a clinical pharmacy specialist with UPMC Health Plan.
Esra Karslioglu-French: Hi, I’m Esra Karslioglu-French. I’m an endocrinologist at the University of Pittsburgh, Division of Endocrinology. I’m the clinical chief of the Division of Endocrinology, and I collaborate with UPMC Health Plan to develop diabetes population health strategies.
Pharmacy Times: From a clinician’s perspective, how does collaboration with UPMC Health Plan enhance diabetes management beyond what you can do in the clinic alone?
Karslioglu-French: Diabetes is a common, complex, and costly chronic disease. While we typically see patients in our clinics every three months, countless factors between visits impact disease control. By collaborating with the health plan, we create multidisciplinary teams necessary to improve patient outcomes. Pharmacists, certified diabetes care and education specialists, health coaches, and registered dietitians work directly with patients to implement treatment plans initiated during office visits with PCPs.
Remember that 90% of people with diabetes are managed by primary care doctors rather than specialists, and our collaboration helps extend specialized support to the primary care setting. As an integrated delivery and finance system, we create programs that identify high-risk patients. We reach out to patients proactively with resources to keep them healthy and prevent unplanned, costly care.
Finally, we collaborate with the health plan’s research arm, the Center for High-Value Health Care, to evaluate the impact of these programs on patient and cost outcomes. This data enables us to refine our strategies and ensure we’re delivering effective and high-value care.
Pharmacy Times: From the health plan side, how do pharmacists help identify and engage members who would benefit from enhanced diabetes management or CGM use?
Senior: The health plan uses predictive analytics to identify members who may not be adherent with their medications, those with possible therapeutic duplications on their medication lists, contraindications to some therapies, and those at risk for adverse effects of medications. Others may be contacted if they might benefit from therapies that can prevent the complications of diabetes, if they’ve sought unplanned care through urgent care, the emergency department, or an inpatient admission, or if they may be prescribed a CGM for the first time.
Our care management pharmacists conduct telephonic outreach to engage these members, meet them where they are in their individual experience of living with diabetes, and provide comprehensive medication management.
Pharmacy Times: For patients using CGMs, what are the biggest day-to-day management challenges you see, and how does this model help address them?
Karslioglu-French: We often encounter patients who fill their CGM prescriptions but never open the box, highlighting a need for better guidance on initiation and long-term management. While CGMs empower users with real-time data for lifestyle adjustments, they can also cause data overload and overwhelm patients. Furthermore, while data is easily accessible to patients by smartphones or readers, integration into electronic medical records remains limited, making it difficult for PCPs to access the information needed to make treatment changes.
Pharmacy Times: What does medication management look like in practice—how are pharmacists addressing adherence, therapy optimization, or access barriers?
Senior: Pharmacists use motivational interviewing techniques to address issues with medication adherence. We encourage strategies to help members take their medications as prescribed, such as using weekly pillboxes, setting alarms, or marking on a calendar when a dose was taken. We also refer members to internal and external resources to help them obtain prepackaged medications that promote adherence. In addition, health plan pharmacists often address strategies to minimize side effects and issues with medication administration.
If we identify an opportunity to optimize therapy, we will coordinate with the member’s provider directly through the electronic health record when possible. Of course, determining barriers to accessing medications is a part of every conversation with our members. Our pharmacists screen for social determinants of health with every interaction and communicate with providers as appropriate. Our team can also refer members to other health plan resources, such as case managers and social workers, for assistance with coordination of care, transportation, or other issues discovered during the interaction.
Pharmacy Times: How are lifestyle interventions, like nutrition counseling or diabetes education, effectively integrated into your treatment plans?
Karslioglu-French: Providers across the system need and want easy access to lifestyle programs for their patients. In collaboration with the health plan, we have an order set called “Prescription for Wellness” within our electronic medical record. PCPs can initiate this during office visits, prompting a health coach, dietitian, or CDCES to reach out to the patient within 72 hours to engage in a treatment plan. These programs include group classes and individual coaching by video or phone. Since most programs are remote, they are easily accessible to patients regardless of location.
Pharmacy Times: Can you walk through what this collaboration looks like for a patient—from identification through ongoing management?
Senior: Once the health plan identifies members who could benefit from working with a pharmacist, we attempt to engage them and determine their individual needs based on our interactions. After that initial outreach, pharmacists contact providers if needed to help address medication therapy problems. We may also collaborate with pharmacists in retail or clinic settings to support our patients. In addition, members are offered referrals to other health plan resources, including our diabetes disease management program or lifestyle coaching programs to support nutrition, physical activity, and weight loss, along with stress management and smoking cessation programs.
We can also refer patients to work with certified diabetes educators. Finally, a follow-up call from the health plan pharmacist may also be part of the process.
Karslioglu-French: I’ll give an example from our diabetes-targeted automatic e-consult program, the TACOs program. We use clinical analytics to identify patients with uncontrolled diabetes and high hemoglobin A1c. An endocrinologist sends an e-consult with a treatment plan to the PCP on the day of the patient’s scheduled appointment. The patient and PCP discuss the recommendations and implement agreed-upon strategies. For instance, if a CGM is recommended by the e-consult, the PCP prescribes it, after which a pharmacist contacts the patient to initiate the CGM, monitor blood sugars remotely, and adjust medications based on established protocols.1
Pharmacy Times: What outcomes have improved the most with this coordinated approach—whether clinical, engagement, or utilization?
Karslioglu-French: These programs improve diabetes management, resulting in lower A1c levels and increased adoption of guideline-based treatment plans, such as higher utilization of SGLT2 inhibitors, GLP-1 receptor agonists, and CGMs in high-risk patients. By optimizing disease control, we reduce unplanned health care events and lower the total cost of care.
Senior: From a health plan perspective, we look at outcomes associated with pharmacy and medical costs, along with total cost of care. Based on these results, we continually refine our clinical programs to ensure that we’re seeing optimal outcomes for our members. Because we use multifaceted approaches to engage our members, we also examine which modalities are most successful so that we can tailor our program approaches and continue to refine them based on members’ needs.
For example, we have an “Ask a Pharmacist” telehealth platform that allows members to schedule an appointment with a pharmacist when they have a question or need support. This way, they don’t need to wait for a pharmacist to call them. This telehealth platform resulted from conversations about wanting to meet members where they are and offering more solutions to increase engagement.
Pharmacy Times: For pharmacists watching, what are the most actionable steps they can take to better support patients using CGMs or managing diabetes more broadly?
Senior: Since managing diabetes requires a long-term commitment, the approach I try to take with members is to check in with them, follow up, and build a network of resources for their support. If you can engage with a patient more than once, ask how things are going. If we don’t ask, we may not know if there’s a problem using a CGM, difficulties administering medications, or fluctuating blood sugars. If you’re helping a patient with their diabetes management, follow up if possible to ensure the issue is resolved. Sometimes our first recommendation doesn’t fully address the problem, or an additional issue can arise.
Finally, we all have limits within our scope of practice, so try to develop a list of additional resources for your patients. Helping patients manage diabetes takes collaboration, so work with endocrinologists, local health systems, and insurers to help patients access diabetes education programs or connect with a certified diabetes educator.
Karslioglu-French: Pharmacists play a critical role in the implementation of this life-changing technology. Both patients and PCPs need pharmacy support to identify candidates, initiate CGM use, and review data to guide treatment. Pharmacists can act as a guiding light for organizations and practices to decrease clinical inertia, reduce friction, and get patients on diabetes treatments like CGM, helping them improve their diabetes control.
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