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

2. 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)

3. 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

4. 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

5. 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.

6. 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

7. 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

8. 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

9. 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

10. 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.

11. 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

12. 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:
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.

13. 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.

14. 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

15. 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.

16. 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

17. 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

18. 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.

19. QUESTIONS!!