In his session at ENDO 2019, Jeffrey Boord, MD, MPH, proposed the use of clinical pharmacists in primary care practices to help manage patients as well as overcome clinical inertia.
Clinical inertia is one of the issues that can be a deterrence to optimal care for diabetes patients in a primary care setting, which, according to Jeffrey Boord, MD, MPH, Chief Quality and Safety Officer at Parkview Health, a community not-for-profit health system in Fort Wayne, Ind., can be defined as a “failure to advance or de-intensify therapy when it is appropriate to do so.”
A very high proportion of diabetes patients fail to reach their glycemic targets for a considerable length of time after diagnosis, Boord explains. “They may also initially achieve a good level of control, but then as the illness progresses over time, have clinical deterioration and have a very long period of poor control before therapy is appropriately escalated,” he says.
It’s Complicated
Boord says that while current diabetes treatment guidelines provide a framework for glycemic management and diabetes treatment, this process competes against a variety of priorities in the primary care clinic. Everything from common ailments ranging from back pain or a rash, to an inability to sleep, to patients simply needing prescriptions refilled are what primary care physicians have to juggle along with a patient’s glycemic control.
“So, if the primary care provider can actually get time to set an individualized glycemic goal for the patient,” he explains, “they’re then confronted with myriad drug therapy options, each with advantages and drawbacks depending upon the patient’s co-morbidities, ease of use, risk of side effects, and costs. In other words, it’s complicated.”
Adding a Clinical Pharmacist to the Team
So how can endocrinologists help their primary care provider colleagues and patients overcome clinical inertia?
A solution that Boord and his colleagues implemented at Parkview Health in primary care is the addition of clinical pharmacists to co-manage diabetes. “A clinical pharmacist is a provider with a PharmD degree, who is residency trained with clinical experience in primary ambulatory care, has an advanced certification and a specialized skillset ideal for implementing diabetes pharmacotherapy,” Boord explains.
“Instead of the patient getting a referral and having to wait to see one of [the endocrinologists], the patient is immediately able to engage with a pharmacist, identify barriers to care, and develop an individualized care plan, often the same day that they are seeing their primary care physician.”- Jeffrey Boord, MD, MPH, Chief Quality and Safety Officer at Parkview Health in Fort Wayne, Ind.
According to Boord, the program works by embedding a clinical pharmacist in primary care practice sites that have a large concentration of patients with uncontrolled diabetes on their provider panel. Each pharmacist has a written collaborative practice agreement. “Each physician in the practice knows the pharmacist personally, and there is a collaborative agreement with every provider within the clinic,” he explains. “The document outlines guideline-based algorithms for medication therapy, initiation and titration, lab monitoring, gap closure on screenings and immunizations, as well as cardiovascular risk factor management such as hypertension, statins, and smoking cessation.”
The patient can be identified either through a patient panel report from the electronic health record (EHR) or directly referred by a primary care provider for a variety of reasons, Boord says, adding “each patient has individualized glycemic goals which are set collaboratively with the patient and primary care provider.”
According to Boord, the process with the pharmacist is fairly straightforward: At the initiation of care, the pharmacist has an hourlong, face-to-face visit with the patient that includes medication history; risk factor assessment; care needs; determine the patient’s level of baseline diabetes education and their readiness for change; assess any barriers to care; and determine current medication adherence. Once the patient begins an appropriate medication therapy regimen, which is titrated per protocol, there is regular follow up with monthly visits and virtual follow up with the pharmacist by telephone and through the EHR patient-messaging app.
Results Don’t Lie
So far, Boord and his fellow endocrinologists at Parkview Health have been very pleased with the clinical pharmacist program. “For patients who have completed at least three months of therapy, we have seen an average 1.77% reduction in A1C, as well as meaningful increases in statin treatment and completion of microvascular screening,” he says. “Patients really like having another provider on their primary care team focused on helping them manage their diabetes.”
Boord says that the primary care physicians love it because they are able to identify a patient who has uncontrolled diabetes, “hand that off to the clinical pharmacist right on the spot, and get the patient immediately started on an effective care plan.”
“I have yet to meet a clinical colleague who’s told me that they can’t get enough referrals for diabetes. So, access is really a big help and our clinical pharmacy program is really helping empower our primary care providers to provide timely, excellent, and equitable care for diabetes.” – Jeffrey Boord, MD, MPH, Chief Quality and Safety Officer at Parkview Health in Fort Wayne, Ind.
So why does Boord think the addition of a clinical pharmacist to the primary care team has been successful?
“The clinical pharmacist focuses on diabetes and they have time,” Boord says. “They can just work the diabetes care plan and that provides the primary care provider more time to focus on other issues. The pharmacist can also provide the necessary education and tailor the therapy to the patient. They can help initiate and titrate the medication successfully.”
Boord adds that the clinical pharmacists have proven to be masters at removing barriers. “They can identify patients that need low-cost regimens. They can help overcome reluctance to new treatments such as injectables,” he says. “They can also navigate the myriad of different formularies and prior authorization requests that often can frustrate busy primary care providers. The pharmacist also provides active titration and feedback, assuring that the care plan is advancing, the patient is reaching their glycemic goal, and that they’re being appropriately monitored for any side effects.”
Boord adds that the physicians in Parkview Health’s endocrinology clinic are big fans of the program because it helps the endocrinologists with patient access. “Instead of the patient getting a referral and having to wait to see one of us, the patient is immediately able to engage with a pharmacist, identify barriers to care, and develop an individualized care plan, often the same day that they are seeing their primary care physician,” he explains. “I have yet to meet a clinical colleague who’s told me that they can’t get enough referrals for diabetes. So, access is really a big help and our clinical pharmacy program is really helping empower our primary care providers to provide timely, excellent, and equitable care for diabetes.”
— Newman is the editor of Endocrine News. He wrote about the Endocrine Society’s first LGBTQ+ reception at ENDO 2019 in the June issue.
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