Role of the Pharmacist in Diabetes Care: A Community Pharmacy Experience Magaly Rodriguez de Bittner, Pharm.D., BCPS, CDE Associate Professor University of Maryland School of Pharmacy and Program Coordinator, Giant Pharmacy Diabetes Care Outpatient Education Program

Objectives Provide an overview of the need for pharmacist involvement in diabetes management and education. Describe the Diabetes Care Program at Giant Pharmacy Describe the challenges facing pharmacies and pharmacists in diabetes management and education Describe the role of the pharmacist in DSME programs

Background Incidence of Diabetes is increasing at an alarming rate- Epidemic Proportions 18 million Americans 6-8 million have diabetes but have not been diagnosed Complications of Diabetes Treatment Complexity Diabetes education is instrumental in reducing complications and decreasing overall health care costs Prevention

Background Pharmacists are knowledgeable about the treatment and management of many chronic illnesses Pharmacists are accessible Pharmacist managed diabetes programs have increased dramatically over the last five years Payment for these services have been a challenge

Pharmacists’ Role Diabetes Care Variety of settings Variety of roles Direct providers of care Members of the Interdisciplinary Team Providers of education (400 CDE RPh/12, 390 CDE’s) Providers of Pharmaceutical care Providers of Products Consultants

Diabetes Self-Management Education What is it? A structured and comprehensive educational process Assess instructional needs Develop educational plan Use a variety of instructional methods Teach self-management skills Evaluate outcomes

A Diabetes Care Program in a Food-Drug Chain Pharmacy

Background Joint venture between the University of Maryland School of Pharmacy and Giant Pharmacy Offers the convenience of the community pharmacy and the expertise of an academic center

Setting Giant Food Inc. Food-drug chain store 137 pharmacies in 4 states and D.C. Employs ~600 pharmacists Strong interest in health and wellness- Healthy Ideas Program Excellent reputation and client base

Patient Care Centers Counseling rooms Located at Two stores –Annandale, Virginia and Baltimore, Maryland Large Prescription Volume Mixed socioeconomic population

Patient Care Centers One-on-one counseling with pharmacist By Appointment only Physician participation To date: out-of-pocket payment Pharmacist with additional training Equipment to performed a variety of tests Patient Education Materials

Diabetes Care Program An ADA Recognized Program: The first chain pharmacy diabetes education program to be recognized in the nation Provides diabetes education with a personal touch Comprehensive education tailored to the patients’ needs Conveniently located in the pharmacy Work in collaboration with the patient’s doctor and family members Provides patients with free glucose monitors and monofilaments

Diabetes Care Program Obtain patient information Confidentiality/Informed consent Measurement of the Patients’ knowledge quality of life satisfaction short/long term goals

Diabetes Care Program Teaching Sessions- Four or Eight Based on ADA standards for diabetes self-management education programs-Life with Diabetes Pharmaceutical care + Education + Nutrition Multidisciplinary program/ Dietitian Advisory Board that oversees the Program

Educational Sessions Overview of Diabetes Monitoring Complications Medications Foot, Skin, and Dental Care Coping with Diabetes Nutrition and Exercise Conclusion/ Wrap-up

Marketing and Recruitment Marketing of program: Brochure distributed at store level All patients receiving prescription for diabetes medication speak with pharmacist Recruitment: Free 15 minute consultation Program overview

Program Evaluation Throughout, 3, and 6 months after completion of program

Outcomes Improvement in Clinical Markers Blood glucose, HbA1c, BP, weight, etc. Improvement in patient’s quality of life Improvement in patient’s knowledge of the disease Patient’s satisfaction with the services Decrease in overall health care cost, hospitalizations, ER visits and complications of diabetes

Challenges Breaking new grounds Slow Process Recognition Process Reimbursement Pharmacist Training Marketing Medicare Provider Number

Patient Testimonials Giant’s Diabetes Program “Where have you been?” “ I have been to group programs before that were covered by my insurance and they just went too fast and didn’t give me a chance to ask questions.” “Having my prescription filled at this Giant was the best thing I could have done.” “No one has ever taken the time to explain my condition to me and I have had diabetes for 11 years.” Educate consumers (and your pharmacists and other staff ) -- Survey after survey shows one of the key things that consumers want relative to healthcare is information. A recent Readers Digest Survey (telephone interviews of 1200 adults >18 years old) showed the growth of managed care, aging of the population, increased volume of healthcare advertising and widespread availability of alternative remedies and treatments are dramatically changing consumers needs and interests in healthcare information and their desire to take more control of their health, their interaction with doctors, and pharmacists, and their purchase decisions. 91% of consumers surveyed in the Readers Digest Survey said they are interested in learning more about health and 60% say the need will increase in the next few years. Most want to learn more about health conditions like high blood pressure, stress/anxiety, arthritis and high cholesterol. The retailer who acts as an information source will give the shopper a reason to make a repeat visit and build loyalty. Fulfill this need via the pharmacist and your HABA personnel to help build loyal customers.

In the Future... Expansion of the Diabetes Care Program to other sites Giant employees program Secure Reimbursement from Insurance Companies Medicare Billing Expanding to other diseases like Asthma, Cholesterol, Weight Management and Osteoporosis

Medicare Balanced Budget Act of 1997 Expanded coverage (effective 7/1/98) Outpatient diabetes self-management training by “certified” providers Blood glucose monitors, test strips, and other monitoring supplies Interim program rules published 2/99 Final program rules 12/29/00 Effective date February 27, 2001

Medicare Eligibility (Conditions of Coverage) Physician’s (practitioner’s) order Comprehensive educational plan Content, number, frequency, and duration Individual training permitted under special circumstances Reasonable and necessary Signed by the physician

ADA Recognition Process Required by Medicare for provider eligibility Recently changed in May 2000 New process for application and review New personnel requirements

Application for ADA Recognition 6th edition will only be accepted online via the ADA’s web site. Form must be filled electronically There is not a Meeting the Standards manual with this application http://www.diabetes.org/recognition/Education/application.asp Fee: $850.00 includes one site, additional sites $50.00/site Data period: 6 months, must be submitted with the application to the ADA within 3 months of the end of the data period Do not need to send documentation, just fill the application. Documents will be review on the site visit If the program is re-applying it can submit the application two months before the current recognition expires Score is Pass or Fail Certificate of recognition good for 3 years Annual Status Report must be completed and returned to the ADA

State / Local Issues State Mandated Coverage Majority of states mandate coverage for diabetes education and supplies Eligibility and provider requirements vary significantly Some states have developed own credentialing process (i.e. NJ, RI)

Conclusions Community-based pharmaceutical care is feasible even in large volume chains Pharmacists have a significant role in diabetes care Patients find value in these services Must find creative ways to secure reimbursement for these services and capture their economic, humanistic and clinical impact in patients outcomes There is a need to have more pharmacists involved!