Pharmacist Collaborative Practice Privileges in Diabetes Management Nisha Patel, PharmD PGY1 Pharmacy Resident El Rio Community Health Center, Tucson, AZ 5/20/11

El Rio Community Health Center A private, non-profit community health center since 1969 The largest provider of medical and dental services to the uninsured and Medicaid populations of Pima County, Arizona. 75% live below Federal Poverty Level 78% are Hispanic and American Indian Member of the Patient Safety and Clinical Pharmacy Services Collaborative sponsored by the Health Resources and Services Administration (HRSA)

El Rio Community Health Center The first sight in state of Arizona to receive collaborative practice agreement Collaborative practice started in 2001 diabetes, hypertension, and cholesterol management A total of four clinical pharmacists working in collaboration with approximately 50 providers Includes the management of diabetes, hypertension and cholesterol

El Rio Community Health Center A total of 2200 are managed by the clinical pharmacists Patient-Centered Medical Home Pt centered medical home: this concept promotes primary care providers working collaboratively to coordinate patient-centered care. Pharmacists utilize their clinical expertise in monitoring and managing diabetes medication plans to positively impact health outcomes and empower patients to actively manage their health

Collaborative Drug Therapy Management (CDTM) Collaborative Drug Therapy Management (CDTM) is a type of collaborative practice where a provider and one or more pharmacists have jointly agreed, on a voluntary basis, to work together under protocol where the pharmacist may perform certain patient care functions authorized by provider subject to specific conditions and/or limitations.

Collaborative Drug Therapy Management (CDTM) The duties of the pharmacists involved in CDTM may include Patient assessment Ordering drug therapy-related lab tests Administering drugs Selecting, initiating, monitoring, and adjusting drug regimens

Collaborative Drug Therapy Management (CDTM) 45 out of 50 states now have provisions for CDTM However, authorized abilities allowed under CDTM vary from state to state Involves written protocols between prescribers and pharmacists These protocols may be required to be specific for disease, for patient, or for both. In Arizona the protocols are specific for disease. Except for Alabama, Delaware, District of Columbia, Illinois, and New York. For Arizona, it is specific for disease state

Collaborative Drug Therapy Management (CDTM) State laws or boards of pharmacy usually spell out what needs to be included in the protocol Depending on practice setting, there can be different requirements for pharmacists engaging in CDTM For example, community phamacists in some states might be required to get approval of protocols by their board of pharmacy. On the other hand, protocols in the hospital setting might only need approval by the Pharmacy and Therapeutics committee or they might be exempted from certain requirements

Collaborative Drug Therapy Management (CDTM) States might also require pharmacists to have special training or approval/certification by the state board of pharmacy Typically focuses on managing complex medication regimens or chronic disease medication therapies for diabetes, hypertension, dyslipidemia, anticoagulation, or asthma Pharmacists need to have requisite clinical training and practice experience

Protocol Agreements Regardless of Practice Site CDTM agreements between a pharmacist and a provider, or group of providers, are voluntary agreements CDTM agreements provide delegated authority by the provider and increase the opportunity for pharmacists to contribute their specialized expertise to a patient’s drug therapy CDTM agreements should be between the provider and the pharmacist NOT the provider and the practice sites.

CDTM in State of Arizona CDTM is guided by board-approved drug therapy management agreement No location restrictions Allows CDTM agreements with physicians and nurse practitioners The CDTM agreement in AZ was limited to only four practice sites An acute care hospital; A nursing care institute; A staff model HMO; A community health center However, the lagistlation has recently changed and it removed the location restrictions for pharmacists to enter into drug therapy agreement with physicians and also allowed such agreements to be entered into with nurse practitioners that are primary care practitiioners.—This law will go into effect on July 20 of this year

CDTM in State of Arizona Authorized abilities per practice agreement for pharmacists Implement, monitor, and modify drug therapy The protocol has to be renewed annually Pharmacists have to complete 6 hours of CE per disease state annually Adapted from Arizona Administrative Code. Available at: http://www.azsos.gov/public_services/Title_04/04-23.htm Pharmacists can modify or implement drug, dosage, or dosage form Order and interpret laboratory tests -Some states may allow pharmacists additional authorities: such as to administer drugs by injection (California), allow therapeutic interchange (changing from diovan to lisinopril, mariland, missori etc. but it has to be specified in the protocol agreement.

El Rio Community Health center The CDTM includes diabetes, blood pressure and cholesterol management Patients have to have diagnosis Patients are referred to clinical pharmacist by primary care providers Pharmacist processes the referral patients have to give consent before clinical pharmacists can see them. Also the consent form is scanned in to patient’s medical record.

El Rio Community Health Center Yearly monofilament test Yearly eye screening Depression screening On board Nutritionist Referrals Depression screening- as we all know depression has major impact on patient’s ability to manage their disease states

El Rio Community Health Center Several project involvement to improve outcomes and expand program Cardinal Foundation Grant EDGE Grant Project IMPACT Diabetes Cardinal foundation grant – EDGE grant – group classes for diabetes using conversation maps.

Considerations before Entering a CDTM Agreement Agreements are voluntary and entered into on an individual basis Provider and pharmacist should identify specific communication responsibilities for sharing information and improving patient’s continuity of care Provider and pharmacist should discuss how often and in what form (electronic, phone etc.) they should communicate regarding patient monitoring and CDTM activities 1, these agreements are voluntary 3. Furthermore, --Effective communication is essential to avoid confusion and fragmented care

Conclusion CDTM arrangements can be a powerful and positive way to improve patient care and build inter-professional relationships Allow providers and pharmacists to make the most of their respective education and training for patients’ best interests

Conclusion A comprehensive approach to healthcare, encouraging the collaboration of health care providers, improves the quality, efficiency and cost-effectiveness of medical care The growing body of literature supporting the role of pharmacists in diabetes care Provide “continuity of care” There is a growing body of … Pharmacists can provide “continuity of care” by following patient care progress between provider visits, utilizing their clinical expertise to monitor and manage diabetes medication plans, and educating patients on disease, lifestyle, and adherence issues.

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