Dr. Bunting is clinical manager of pharmacy and Asheville Project coordinator, Diabetes and Health Education Center, Mission Hospitals, Asheville, NC.
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.A Meeting of the Minds
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.Hospital Pharmacists Take the Lead
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?What?s in It for Us?
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.A Tangible Investment
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.