1. Pharmacists’ role in a family medicine clinic: a focus on patients with diabetes Benjamin Chavez, PharmD, BCPP, BCACP Associate Professor Pacific University Oregon School of Pharmacy Previously: Clinical Associate Professor University of Hawaii John A Burns School of Medicine Department of Family Medicine and Community Health

2. Disclosures No conflicts of interest to disclose

3. Objective To describe the role of clinical pharmacist embedded in a family medicine clinic serving an underserved population

4. Practice Site – Physician Center at Mililani Outpatient primary care, family-medicine, clinic Main outpatient clinic for residency program for Department of Family Medicine and Community Health at University of Hawaii 18 residents (6 each year) 7 attending physicians 6-8 medical assistants Front desk staff 10 patient rooms

6. Patient Population Serves mostly under-served lower socio-economic patient population –Mostly on Hawaii’s Medicaid or uninsured “Rural” area Large Pacific Islander patient population –Marshal Islands –Federated States of Micronesia (Yap, Chuuk, Pohnpei, Kosrae) –Guam –Samoa –Palau Asian descent As well as Hawaii locals

7. LET’S TALK GEOGRAPHY...

11. BACK TO OUR SERVICE

12. Pharmacy Services Started in July 2010 From electronic patient records, high-risk patients would be identified for intervention –Started with HgA1C > 10% –Telephone calls asking people to come in for appt with pharmacist –Success was moderate Eventually, physicians and residents started referring more and more patients with different disease states Specific protocols written for diabetes, hypertension, and hyperlipidemia Other disease states seen as well Pharmacy students were integrated in October 2010

13. Office Visits Patient appointments were scheduled for 30 minutes We did not bill for these services Seen as an added benefit for our patients ~2-3 days per week of scheduled appointments –Also there to precept/support residents and students ~1-2 days per week of serving as preceptor for residents

14. Other Responsibilities Communication with retail pharmacies Phone calls from patients re: medication questions Insurance companies prior authorizations Provider education –Journal club –Topic discussions Curbside consults

15. Data Collected (Sept 2010 – July 2013) Number of patients referred = 168 –Number of patients who never showed = 41 Number of appointments scheduled = 602 Number of appointments completed = 380 No show rate = 36.9% (Clinic average was 10%-15%) Numbers of patients with > 1 appointment = 73 Average number of visit/patient = 2.3

16. Reasons for Office Visits - Reason for visit only accounts what physician put down as reason for referral or patient’s chief complaint -It may not account for other disease states/conditions treated during appointment * Other = constipation, pain, fatigue, migraines

17. Types of Interventions

18. Types of intervention - Limitations Retrospectively collected from chart Medication change included increase, decrease, d/c, or adding a new medication Lab order not accurately captured initially Device education –Many were tacked on to end of visit with PCP and not documented

19. Office visits – With Diabetes Number of patients with DM = 102 (61%) –Only 3 patients did not come in for at least 1 visit Total number of scheduled visits = 469 Number of visits completed = 322 No show rate = 29.8% Average number of visits per patient = 3.2

20. Laboratory Values – 3 years - DM DM patients and labs were the only ones we had sufficient numbers for meaningful data 70 patients had pre- and post- A1C –Pre-A1C had to be no > 3 months prior to referral –Post-A1C no > 6 months after last visit Average Pre-A1C = 10.2% (5.9-16.4%) Average Post-A1C = 8.8% (5.8-14.4%) Average Change = -1.23% (p<0.001) –95% CI (-1.68, -.061)

22. Other DM Results Range of A1C improvement = -6.3% to +4.2% Only 19 out of 70 patients had an increase in A1C –Only 8 of those were > 1% 34 out of 70 patients had a decrease of > 1% –21 were > 2% –14 were > 3% –8 were > 4% –5 were > 5% 25 patients were < 8% A1C at end 11 patients were < 7% A1C at end Examined for correlation with medications –No clear relationship found

23. Challenges / Limitations Recruitment of patients High no-show rate Retrospective collection method Multiple factors involved in improvement Not everything pharmacy did was documented

24. QUESTIONS? COMMENTS?