Dr. Bunting is clinical manager of pharmacy and Asheville Project coordinator, Diabetes and Health Education Center, Mission Hospitals, Asheville, NC.
We are frequently asked what training pharmacistsare required to have in order to providedisease management services in the AshevilleProject and how the training program wasdeveloped.
In 1996, an agreement was reached with the City ofAsheville to pilot a demonstration project that would usepharmacists as ?health coaches? for individuals with diabetes.The primary focus would be on appropriate medicationuse; however, pharmacists would also be expected tohelp educate patients, coach them to improve their overallhealth, and work closely with physicians.
Program planners believed that pharmacists alreadypossess skills that wouldallow them to be successfulin improving medicationtherapy. They also recognized,however, that interestedpharmacists wouldneed some further trainingin order to provide theseservices. At this early stage,they faced 3 importantquestions: (1) what will be taught, (2) who would teach it,and (3) who would be taught.A Need for Consistent Standards
Because the first disease management program was toaddress the needs of patients with diabetes, pharmacistswould obviously need to be up-to-date on diabetes care.Even 10 years ago, well-established, authoritative, nationalguidelines for diabetes were in place. Most prominentamong those were the standards established by theAmerican Diabetes Association (ADA) and the AmericanAssociation of Diabetes Educators. The ADA core curriculumbecame the ?training manual? for the programpharmacists.
The goal was not for pharmacists to become certifieddiabetes educators (CDEs). It was decided to use some ofthe same reference material that was used to educateCDEs and physicians, however, so that pharmacists wouldbe on the same page as other providers. The obvious rolefor pharmacists in this program was a focus on improvingmedication management of diabetes; because of theopportunity to interact with patients on a very regularbasis, planners recognized that there also would be significantopportunities for pharmacists to assist patients inlong-term self-management and overall health issues.Therefore, they would need specific training to allow themto do this well.
Once it was decided what material would be taught, thenext step was to look at whowould provide the training.Recall that this discussion wastaking place more than 10years ago, at a time whenpharmacist certificate programswere practically non-existent.In fact, the first pharmaciststraining program conductedin Asheville was not evenreferred to as a certificate program. It was simply a trainingprogram with a significant number of Accreditation Councilfor Pharmacy Education (ACPE) credit hours.
In our case, the decision on who would provide thetraining was relatively easy. In North Carolina, we areprivileged to have a system of Area Health EducationCenters (AHECs) that are funded by the state. TheseAHECs, among other functions, provide continuing educationfor allied health, including pharmacy. The programplanners worked with the staff of the Mountain AreaHealth Education Center Department of Pharmacotherapyin Asheville to set up the initial training program.They in turn worked with pharmaceutical manufacturersto obtain grant funding to offset the costs of thetraining program.Keeping It Local
Although it would have been possible to bring inexperts in diabetes from other parts of the country, therewas a conscious decision to use local physicians and diabeteseducators, as well as individuals from the Universityof North Carolina School of Pharmacy and CampbellUniversity School of Pharmacy, as the training faculty.This accomplished 2 objectives. It helped establish buy-infrom key stakeholders on the state level. Even more importantly,it fostered relationships with local physician expertsand the local diabetes educator community.
These relationships and the support garnered throughthe involvement of local experts have been invaluable. Wecontinue to hear stories from our physician faculty, whohave become our unofficial ?champions,? regarding discussionswith their physician colleagues about this ?pharmacistprogram.? These physicians are in an excellentposition to say, ?Yes, I know about the program, I helpedtrain the pharmacists.?
In retrospect, this was one of the more important decisionsmade in the early days of the program. Althoughthere are now a number of national certificate programsavailable to pharmacists, we would highly recommendinvolvement of local experts in some level of the pharmacisttraining if at all possible, even if just for a skills lab, apresentation on diabetes care by a locally respectedendocrinologist, or a presentation by diabetes educatorson what they teach during diabetes education classes.Casting a Wide Net
The roll-out of the training program began with a letterto all pharmacists in the region inviting them to attend atraining program in diabetes. They were told that it wouldinvolve a significant amount of home study, 2 weekends ofdidactic training, and hands-on training in meter devices,blood pressure monitoring, and foot exams. They were alsotold that there would be an opportunity to use this knowledgein direct patient care. We decided to open the programup to any interested pharmacist who was willing toreceive the training and not restrict it only to pharmacistswith a PharmD, residency-trained pharmacists, or thosewho were board-certified pharmacotherapy specialists.
Pharmacists would be expected to review all medicationsand assess them for patient adherence, appropriateness,and dosage. Pharmacists also would downloadmeters, check blood pressures, conduct foot exams, providepatient education, help patients set goals, and communicatefindings and recommendations to physicians. Inthe opinion of the planners, the most important factors forsuccess would be the motivation of the pharmacist, his orher willingness to be trained in diabetes guidelines, andavailability. None of the above requirements would precludeBachelor of Science (BS)-trained pharmacists.Knowledge level would, of course, be important, butequally important would be the ability of the pharmacistto communicate effectively with patients and physicians.A majority of the first group of patients followed in theAsheville Project were, in fact, served by BS pharmacists.
The program qualified for 36 hours of ACPE credit andwas attended by 24 pharmacists. The pharmacists wereinformed during the training session of the opportunity touse this training to follow individuals with diabetes thatworked for the City of Asheville; 20 agreed to participateand allow their names to be put on a list of providers inthe project. This list of pharmacist providers was subsequentlygiven to patients as they enrolled, so they had achoice of locations.
Patients agreed to meet with their program pharmacistas frequently as once a month for 20 to 30 minutes.Pharmacist providers agreed to meet with their patients inone-on-one sessions away from the dispensing counter inat least a semi-private counseling area. These wereappointment-based encounters, and the frequency of visitswas ultimately determined by the pharmacists, basedon the patient?s needs.
This training program has been repeated several timesover the years. Many in the original group were independentpharmacy owners; however, a significant number ofpatients are now also being followed by pharmacists whowork for a progressive regional chain, Kerr Drug, and byMission Hospitals pharmacists in clinic settings.Conclusion
In our experience, the key factors related to trainingpharmacists to provide disease management services arethe use of national guidelines as the training material andthe motivation of the pharmacist to receive some additionaltraining. We believe, however, that this program hasbeen successful primarily because of the basic skill-set thatpharmacists bring to the table?-their comprehensiveknowledge of medications and ability to make an assessmentof all the patient?s medications, not just those for thecondition that brought them to the program. No one is ina better position than the pharmacist to assess if a patientis actually taking his or her medications as directed.
Is special training necessary? Yes. Pharmacists need tobe up-to-date in their knowledge of the medical conditionthat brings the patient to them. Employers, whose healthplans are paying for the services, should reasonably expectassurance that pharmacist providers are qualified andtrained to provide patient care services. Who should trainthe pharmacists? The logical choice is professionals who arealready experts in the field. Is training a barrier? No. In ourexperience, any competent, motivated pharmacist with theinterest and the time can succeed in this program.