1. Pharmacists improving outcomes in patients with Diabetes An argument for expansion of scope of practice

2. Outline Theory Theory Diabetes Diabetes Pharmacists Pharmacists Legislation Legislation The Asheville project The Asheville project Recommendations Recommendations Acknowledgements Acknowledgements

3. Theory The Health Belief Model The Health Belief Model Developed by Irwin Rosenstock in 1966 to explain why people used health services. Developed by Irwin Rosenstock in 1966 to explain why people used health services. The first version only had the first 3 points The first version only had the first 3 points Subsequent versions have added 4,5 and 6 Subsequent versions have added 4,5 and 6

4. Health Belief Model 1. Perceived Susceptibility 1. Perceived Susceptibility 2.Perceived Seriousness 2.Perceived Seriousness 3.Perceived benefits of taking action and perceived barriers to such 3.Perceived benefits of taking action and perceived barriers to such 4.Perception that benefits outweigh risks 4.Perception that benefits outweigh risks 5.Cues to action 5.Cues to action 6.Perceived self efficacy 6.Perceived self efficacy

5. Health Belief Model This theory is especially apt for diabetes This theory is especially apt for diabetes The prognosis depends on the patients ability to do the following things: The prognosis depends on the patients ability to do the following things: Take their medication Take their medication Change their behavior ( checking blood sugar regularily) Change their behavior ( checking blood sugar regularily) Change their diet and lifestyle Change their diet and lifestyle Before they can make these changes they have to believe in their susceptibility, the seriousness of the disease and have they must have self efficacy Before they can make these changes they have to believe in their susceptibility, the seriousness of the disease and have they must have self efficacy

6. Diabetes 346 million people worldwide have diabetes 346 million people worldwide have diabetes 25.8 million people (8.3%) in the United States have diabetes 25.8 million people (8.3%) in the United States have diabetes The American Diabetes Association has established goals for treatment The American Diabetes Association has established goals for treatment Hemoglobin A1C <7%, blood pressure <130/80, total cholesterol <200mg/dL Hemoglobin A1C <7%, blood pressure <130/80, total cholesterol <200mg/dL

7. Diabetes By 2030 the estimate is that 1 in 3 people will have diabetes. By 2030 the estimate is that 1 in 3 people will have diabetes. People do not die from diabetes they die from the complications of diabetes People do not die from diabetes they die from the complications of diabetes Cardiovascular Disease, kidney disease, blindness,nerve damage and amputations are complications of diabetes Cardiovascular Disease, kidney disease, blindness,nerve damage and amputations are complications of diabetes It is the number one cause of adult onset blindness and end stage renal disease It is the number one cause of adult onset blindness and end stage renal disease

8. Diabetes Total costs for diabetes care were $124 billion nationally (ADA 2012) Total costs for diabetes care were $124 billion nationally (ADA 2012) Individual employers can spend up to $4410 more per year for each employee with diabetes (Cranor and Christensen 2003) Individual employers can spend up to $4410 more per year for each employee with diabetes (Cranor and Christensen 2003) Costs for patients with diabetes are due to sick days, emergency department visits and hospitalizations for exacerbations and complications. Costs for patients with diabetes are due to sick days, emergency department visits and hospitalizations for exacerbations and complications.

9. Diabetes Only 57% of people with diabetes have met the A1c goal of less than 7% Only 57% of people with diabetes have met the A1c goal of less than 7% Only 45% have met the goal of blood pressure less than130/80 Only 45% have met the goal of blood pressure less than130/80 Only 46.5% have a total cholesterol of less than 200mg/dL Only 46.5% have a total cholesterol of less than 200mg/dL Only 12.2% are meeting all 3 goals Only 12.2% are meeting all 3 goals

10. Pharmacists Pharmacists are among the most trusted and accessible professionals ( Survey 2012) Pharmacists are among the most trusted and accessible professionals ( Survey 2012) They are less expensive than physicians They are less expensive than physicians They are well versed in medication requirements for diabetes They are well versed in medication requirements for diabetes

11. Pharmacists Pharmacists have been managing patients with diabetes for years in Ambulatory care, Federal facilities and hospitals ( Giberson et al 2011) Pharmacists have been managing patients with diabetes for years in Ambulatory care, Federal facilities and hospitals ( Giberson et al 2011) Community pharmacists can do it too if given the tools ( Asheville Project 2012) Community pharmacists can do it too if given the tools ( Asheville Project 2012) Currently in California community pharmacists can manage patients with diabetes if they have a Collaborative Practice agreement with a physician. Currently in California community pharmacists can manage patients with diabetes if they have a Collaborative Practice agreement with a physician.

12. Legislation Collaborative Practice Agreement between pharmacist and a physician. Collaborative Practice Agreement between pharmacist and a physician. This allows the pharmacist to perform routine drug therapy related assessment This allows the pharmacist to perform routine drug therapy related assessment It allows the pharmacists to order related laboratory tests, It allows the pharmacists to order related laboratory tests, It allows the pharmacist to administer drugs and biologicals by injection and initiate or adjust the drug regimen pursuant to physician order or following an established protocol. ( CA Board of Pharmacy 2012) It allows the pharmacist to administer drugs and biologicals by injection and initiate or adjust the drug regimen pursuant to physician order or following an established protocol. ( CA Board of Pharmacy 2012)

13. Legislation SB1481 went into effect January 2013 SB1481 went into effect January 2013 Allows the pharmacists to perform heretofore restricted clinical duties without a physicians oversight Allows the pharmacists to perform heretofore restricted clinical duties without a physicians oversight Pharmacists are now allowed to conduct certain lab tests as provided by the Clinical Laboratories Improvement Amendment (CLIA) of 1988 Pharmacists are now allowed to conduct certain lab tests as provided by the Clinical Laboratories Improvement Amendment (CLIA) of 1988

14. Legislation As long as the pharmacy obtains the certificate of waiver. As long as the pharmacy obtains the certificate of waiver. The ability to check A1C, blood glucose and cholesterol in the pharmacy would allow the pharmacist to better manage the patients with diabetes The ability to check A1C, blood glucose and cholesterol in the pharmacy would allow the pharmacist to better manage the patients with diabetes One could check to see if patients are at goal at their first visit and then periodically thereafter. One could check to see if patients are at goal at their first visit and then periodically thereafter.

15. Legislation Clinical Pharmacist Practitioner ( CPP) Clinical Pharmacist Practitioner ( CPP) Established legislation in North Carolina Established legislation in North Carolina July 1 st 2000 July 1 st 2000 Allows for established pharmacists with Collaborative Practice Agreements to order, change, substitute therapies or order tests according to an established protocol ( Dennis 2012) Allows for established pharmacists with Collaborative Practice Agreements to order, change, substitute therapies or order tests according to an established protocol ( Dennis 2012)

16. Legislation Pending legislation Pending legislation SB 493 introduced by Senator Ed Hernadez SB 493 introduced by Senator Ed Hernadez Advocates for provider status for pharmacists in California Advocates for provider status for pharmacists in California The bill is intended to allow these highly trained practitioners to practice to the full extent of their abilities and expand access to healthcare in light of the shortage of primary care physicians. ( Hernandez 2013) The bill is intended to allow these highly trained practitioners to practice to the full extent of their abilities and expand access to healthcare in light of the shortage of primary care physicians. ( Hernandez 2013)

17. Asheville project A joint project in the city of Asheville, North Carolina A joint project in the city of Asheville, North Carolina Between the City of Asheville ( the City), University of North Carolina ( UNC), Mission St John Healthcare (MSJ) and the North Carolina Pharmacists Association ( NCPhA) Between the City of Asheville ( the City), University of North Carolina ( UNC), Mission St John Healthcare (MSJ) and the North Carolina Pharmacists Association ( NCPhA) The project has been running since 1997 and uses Pharmacists as health coaches. The project has been running since 1997 and uses Pharmacists as health coaches.

18. Asheville Project The patients meet with the pharmacists regularly The patients meet with the pharmacists regularly Pharmacists in the program have the ability to adjust/change medications as needed. Pharmacists in the program have the ability to adjust/change medications as needed. They also have the ability to order necessary laboratory tests to track patient progress. They also have the ability to order necessary laboratory tests to track patient progress. The project has yielded marked improvements in A1C, cholesterol and blood pressure ( Mattson 2013) The project has yielded marked improvements in A1C, cholesterol and blood pressure ( Mattson 2013)

19. Asheville Project Cranor et al 2003

20. Medical claims/patient costs Innovations in Quality patient care: The Asheville experience Webb, Michael2013

21. Compared to US Averages U.S. Average $7,808 prior to start of program U.S. Average $7,808 prior to start of program U.S. Average $7,2391997 U.S. Average $7,2391997 U.S. Average $7,4851998 U.S. Average $7,4851998 U.S. Average $7.7621999 U.S. Average $7.7621999 U.S. Average $8,0882000 U.S. Average $8,0882000 U.S. Average $8,4682001 U.S. Average $8,4682001

22. Percentage of lab values in optimal range C Cranor et al 2003

23. Recomendations Passage of SB 493 and introduction and passage of a similar federal bill. Passage of SB 493 and introduction and passage of a similar federal bill. Enhanced use of Collaborative Practice Agreements to allow pharmacists to start to help more patients with diabetes pending passage of this bill. Enhanced use of Collaborative Practice Agreements to allow pharmacists to start to help more patients with diabetes pending passage of this bill. Recognition of Pharmacists as Non Physician Practitioners ( NPPs) by the Centers For Medicare and Medicaid Services (CMS). Recognition of Pharmacists as Non Physician Practitioners ( NPPs) by the Centers For Medicare and Medicaid Services (CMS).

24. Recommendations Implementation of the Asheville Project Model ( Healthmaprx) for Diabetes management in all employer and non-employer healthcare plans Implementation of the Asheville Project Model ( Healthmaprx) for Diabetes management in all employer and non-employer healthcare plans Healthmaprx program can be bought and implemented by any organization it is a good value for money and well worth the investment Healthmaprx program can be bought and implemented by any organization it is a good value for money and well worth the investment Funding should be allocated for community and state organizations that cannot afford the implementation fee. Funding should be allocated for community and state organizations that cannot afford the implementation fee. It should be implemented on a federal level by CMS, VA services Indian Health Services and US Public Health Services. It should be implemented on a federal level by CMS, VA services Indian Health Services and US Public Health Services.

25. Acknowledgements Sally Geisse Sally Geisse Ramon Castelblanch Ramon Castelblanch Mickey Eliason Mickey Eliason Nina Wallerstein Nina Wallerstein Jessica Wolin Jessica Wolin Judith Ottoson Judith Ottoson Sukdip Purewal Sukdip Purewal The faculty and Staff of the MPH program The faculty and Staff of the MPH program Cohorts 2012, 2013 and 2014 Cohorts 2012, 2013 and 2014