Disease State Management The Pharmacist’s Role The profession of pharmacy has been shifting from a practice that is product-focused to a practice that is patient-focused by ensuring that patients receive appropriate drug therapy and by communicating appropriate drug information to improve and promote patient health. One aspect of delivering care that has become increasingly of interest to pharmacists is disease management (DM). J Manag Care Pharm. 2005;11(6):505-12

Why the Interest ?? Chronic diseases account for billions of dollars in annual medical expenditures Loss of work time and decreased worker productivity contribute to indirect costs Health care services for chronic conditions are often not coordinated among providers, creating opportunities for overuse or underuse of medical care People with chronic conditions generally use more health care services, including physician visits, hospital care, and prescription drugs. Increases in the number of people living longer with chronic conditions coupled with rising health care expenditures have spurred health plans, employers, and the government to look for ways to reduce health care use and costs. Disease management is one approach that aims to provide better care while reducing the costs of caring for the chronically ill. Disease management programs are designed to improve the health of persons with specific chronic conditions and to reduce health care service use and costs associated with avoidable complications, such as emergency room visits and hospitalizations. Center on an Aging Society, GEORGE TOWN UNIVERSITY BMJ.2002;325:925

Disease State Management Definition A system of coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts can be implemented Circulation. 2006;114:1432-1445

Disease State Management Definition Disease management (DM) Supports practitioner/patient relationship and plan of care Emphasizes prevention of exacerbations & complications through the use of evidence-based practice guidelines and patient empowerment strategies Evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health Circulation. 2006;114:1432-1445

Disease State Management Benefits Improve the safety and quality of care Improve access to care Improve patient self-management Improve financial cost containment without sacrificing quality or patient satisfaction Improve patient quality of life

Disease Management Program Components Population identification processes Evidence-based practice guidelines Collaborative practice models (multidisciplinary teams that may include physicians, pharmacists, nurses…)

Disease Management Program Components Patient self-management education (may include primary prevention, behavior modification programs, and compliance/surveillance) Process and outcomes measurement & evaluation Monitoring system/feedback loop that include patients and providers

Collaborative Drug Therapy Management (CDTM)

Collaborative Drug Therapy Management (CDTM) “A collaborative practice agreement between one or more physicians and pharmacists wherein qualified pharmacists working within the context of a defined protocol are permitted to assume professional responsibility” for certain tasks Pharmacotherapy 2003;23:1210-1225.

Collaborative Drug Therapy Management (CDTM) Tasks include: Performing patient assessments Ordering and evaluating drug therapy-related tests Selecting, initiating, monitoring, continuing and adjusting drug regimens Assessing patient response to therapy Counseling and educating a patient on medications Administering medications Pharmacotherapy 2003;23:1210-1225.

How Does it Work ? As a first step, a disease management program must identify the population group Programs target individuals with a specific disease that is chronic in nature and costly Individuals with multiple conditions may also benefit

DM Program Characteristics The diseases typically targeted by DM programs have the following characteristics: Prevalent chronic condition High resource utilization Potential for lifestyle modification to improve outcomes A variety of treatment options A high risk of negative outcomes

DM Programs Examples Ann Acad Med Singapore 2010;39:861-7 Depression Management Asthma/COPD Diabetes Congestive Heart Failure Management Coronary Heart Disease Management Osteoporosis Arthritis Hypertension Ann Acad Med Singapore 2010;39:861-7

How Does it Work ? Multidisciplinary team of providers are recruited (e.g. physicians, pharmacists, nurses, dieticians psychologists) to assist individuals in managing their condition(s) Practice guidelines based on clinical evidence ensure consistency in treatment across target population

How Does it Work ? The goal of disease management is to encourage patients to: Use medications properly Understand and monitor their symptoms more effectively Change their behavior Clinical, economic and quality of life outcomes are evaluated to assess success of interventions

The Pharmacist Role Assist in the identification of individuals Conduct monitoring for specific diseases (e.g. DM, HTN) Provide patient education (e.g. glucose monitoring) Provide advice on disease management Assist with medication adherence Identify & manage drug-related problems Evaluate outcomes of programs (clinical, economic, QOL)

The Pharmacist Role Conduct outcomes research to form the basis for treatment guidelines Ensure the ongoing involvement of the pharmacy and therapeutics (P&T) committee in the disease management process Educate other pharmacists and physicians about treatment guidelines Use health system databases to track drug expenditure patterns and health care professionals' adherence to health care management regimens

The Pharmacist Role - Examples Asthma Management Provide educational programs about the disease Conduct periodic review of the patient's inhaler technique Perform ongoing monitoring of peak-flow function tests Manage chronic medication use, including compliance assistance

The Pharmacist Role - Examples Diabetes Management Provide educational programs about the disease Regularly monitor both self-tested and lab tested glucose levels Educate patients on how to use glucose monitoring equipment Monitor patient compliance with prescribed therapies and appointments Screen for drug interactions and adverse drug reactions Provide medication management and review

The Pharmacist Role - Examples Hypertension & Cholesterol Management Educate patients about these silent diseases Monitor compliance with medications, diet and exercise Screen for drug interactions and adverse drug reactions Perform periodic blood pressure checks Perform periodic cholesterol level checks

Organizations Offering DM Programs Hospitals Inpatient setting Ambulatory setting Pharmaceutical companies Community pharmacies

Organizations Offering DM Programs Community Pharmacies Desirable setting for providing DM for several reasons: People visit pharmacies more often than any other health care facility Community pharmacies account for dispensing the majority of prescriptions Accessibility of pharmacists creates the opportunity for patients and pharmacists to develop rapport Prescription databases allow pharmacists to readily retrieve patient-specific information to screen for high-risk patients and identify potential drug-related problems J Manag Care Pharm. 2005;11(6):505-12

Perceived Barriers to DM Programs Limited time Limited staff Limited space Reimbursement issues High cost Limited patient acceptance Lack of knowledge about disease management J Manag Care Pharm. 2005;11(6):505-12

Pharmacist Qualifications To provide DM services, a pharmacist must be a registered pharmacist & complete a disease specific certification program National Institute for Standards in Pharmacist Credentialing (NISPC) adopted the designation of Certified Disease Manager (CDM) for those pharmacists successfully completing one of the disease management exams