By Melinda Young
A care coordination team pilot project improved clinical outcomes by adding a pharmacist to the team to counsel patients with diabetes, according to the results of an unpublished pilot program.
“We looked at outcomes at six months and 12 months for patients with diabetes. Sixty-three percent of the patient population’s A1C levels improved,” says Liz Morash, PharmD, clinical pharmacy specialist at Piedmont Health Partners, an affiliate of AnMed in Anderson, SC.
Morash says internal results revealed that the pilot program’s 160 diabetes patients recorded a 158-point total drop in A1C levels — an average of about 1 point per patient. Anything above 6.5 A1C is considered diabetic.
Using another study’s research on the financial effect of a 1-point reduction in A1C, Morash calculated that the program produced $360,000 to $1.2 million in medical cost savings over three years.1
The care coordination team-led program also works with patients with diabetes and/or cardiovascular disease and taking statin medication. The goal is to show improved adherence to medication and better outcomes as determined by the medication adherence measures of the Centers for Medicare & Medicaid Services (CMS) Star Measures, which rate a health system’s quality of care.
The program addresses three medication adherence measures. Each of these measures is triple rated, meaning they are crucial to the Star Measures’ scores. They include adherence to angiotensin-converting enzyme inhibitors and angiotensin 2 receptor blockers, adherence to statin medications, and adherence to diabetes medication, Morash explains. Assigning a pharmacist to address these specific issues can be an efficient and effective way to improve outcomes.
“My position started in 2021 as a pilot project,” Morash says. “We wanted to involve pharmacists in diabetes management, and so we took our employee health plan population as our pilot population.”
All employees, spouses, and dependents who had been diagnosed with diabetes were included in the project. Morash called them and provided phone counseling about their medication, symptoms and side effects, and any barriers they faced to taking their medication regimen as prescribed.
When the pilot period ended, the results showed a drop in A1C points and projected cost savings. The healthcare organization decided to make the pharmacist position full-time.
“That’s when I dug in and started making outreach to all of our patients and not just those on the employee plan,” Morash explains. “I focus on diabetes management and closing gaps like statin medication adherence and consults from our providers.”
The pharmacist role became a part of the care coordination team at Piedmont Health Partners. Other care coordination team members include nurses, certified nursing assistants, social workers, and inpatient navigators.
“Before this position, I was a transitions of care pharmacist and helped patients with whatever they needed in medication to get out of the hospital and to try to prevent them from coming back to the hospital,” Morash says. “I picked up the skills there, but also learned while working with the care coordination team. AnMed has good cross-communication and translating, and adding a pharmacist to the care coordination team is a piece to the puzzle.”
The team helps the pharmacist make the most of the disease management role. For example, if a patient reports a need that Morash cannot help with, such as applying for Medicaid or another insurance, then she can ask the social worker to step in.
“If someone needs extra education, I bring the nurse on board, and the nurse can do home visits,” Morash says.
Morash’s job entails calling about 15 patients per day. Using health record data, she identifies the people with poor outcomes who need additional support and education. The people Morash helps often have social needs, such as housing insecurity, transportation issues, and challenges in affording their medication.
“We have had patients living with friends or who are essentially homeless — maybe living in a hotel,” Morash says. “That’s when I send a referral for a social worker to get involved because they’re the experts in that area.”
When patients skip their daily medication, Morash counsels them by phone about taking their medication each day to stay healthy. If they fail to take their medication because they cannot afford it, she will help them enroll in a pharmaceutical company’s patient assistance program, which will cover the costs.
“If someone has transportation problems, I get them transferred to a mail-order pharmacy so their medication is delivered right to their door,” Morash notes.
To build trust, the key is to listen to patients. “When I get a patient on the phone, I make it known that I’ll do whatever is needed to help them,” she adds.
For example, some patients are reticent to tell their physician about symptoms or side effects, but they will share that information with Morash when she counsels them. Because of the pharmacist’s close relationship with physicians, Morash can call them about a medication problem and quickly get a response — such as a physician changing the prescription to a drug that does not produce the same side effects.
“If they’re having any adverse effects and it’s an immediate threat, I advise the patient and reach out to their doctor to tell them what’s happening and maybe recommend a switch to a different medication,” Morash explains. “If a medication like metformin is causing stomach side effects, then I may recommend they take it with food or get the medication switched to an extended-release formulation.”
Achieving positive outcomes for patients requires excellent communication and team effort. “Teamwork makes this all possible and successful,” Morash says. “We all work together.”
REFERENCE
- Gilmer TP, O’Connor PJ, Manning WG, Rush WA. The cost to health plans of poor glycemic control. Diabetes Care 1997;20:1847-1853.
A care coordination team pilot project improved clinical outcomes by adding a pharmacist to the team to counsel patients with diabetes, according to the results of an unpublished pilot program.
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