There is no question that caring for diabetic patients puts a strain on the time and resources available to most PCPs, and it is also clear that more than half of all diabetics in this country have yet to get their disease under the kind of control that evidence-based guidelines suggest is needed to prevent or delay costly complications. To find solutions to these problems, healthcare organizations are experimenting with new models that could bolster the kind of care that is provided to diabetics while at the same time activating these patients to do a better job of managing their own health. One such approach now being implemented and tested nationwide is the American Pharmacists Association (APhA) Foundation's Diabetes Ten City Challenge (DTCC), an approach that leverages the skills of community pharmacists to work one on one with diabetic patients to help them get better control of their disease. The approach is modeled in part after the much heralded Asheville Project, a pharmacist-driven diabetes program, first implemented in 1996 for the City of Asheville, NC (a self-insured employer), that continues to deliver clinical and financial dividends.
With support from GlaxoSmithKline, more than 30 employer-payers in 10 regions (see the box on p. 72) are participating in the DTCC with the hope that results from the Asheville Project can be duplicated on a larger scale.
Project attempts to repeat success
The idea behind the DTCC is to prove that the Asheville model can be implemented successfully in diverse geographic regions. In fact, many of the people who implemented the Asheville Project are now involved with this effort, according to William Ellis, CEO of the APhA Foundation. "We know we have a process that works. We have shown that through multiple projects," he says. "So the next question is, how do you make that more widely available to people and do it on a scale that lets people know that we believe this can work anywhere."
To gear up for the DTCC, community pharmacists undergo training offered through the APhA to provide them with additional background on diabetes, including basic clinical information, as well as strategies for supporting patients in their own care. Key employer representatives also undergo training in benefit design because some elements of the APhA model, specifically related to the waiving of copays for diabetes-related medicines or supplies, are left up to employers to decide. "Some of the original learnings from the Asheville Project showed that by waiving copays you provide a real economic incentive for people to keep their meetings with the pharmacist to learn about their disease," says Ellis.
Just one year into its involvement with the DTCC, Dalton, GA-based Hamilton Health Care System has seen its pharmacy costs increase by as much as 60%, and medical claims have increased by 20%. However, the increases are in line with what other participating employers have experienced at this stage of the program, explains Jason Hopkins, the director of human resources at Hamilton Health Care. "We know if we waive copays and pay for supplies and medicines on the front end that we are going to see utilization and costs increase," he says, but Hopkins points out that he expects to see positive trends with respect to HbA1c results, weight loss, and other clinical indicators when early data from the effort are tabulated in the next few weeks. And he points out that those improvements should eventually have an effect on the financial side. "We have seen results from other communities that have been in this longer than we have, and [overall medical] costs have decreased over time."
Diabetes was an "easy target" for the company, says Hopkins, because the disease accounts for as much as 20% of the firm's overall medical expenditures. However, to implement APhA's program, the company had to invest time and effort in making sure that community physicians and associates at the company's wellness facility understood the concept of the program and what their role in the process would be.
Pharmacists work one on one with patients
The way that the approach typically works is employer-payers will identify all covered individuals who are diabetics and invite them to participate in the program. Those who voluntarily agree to participate will then be assigned to a community pharmacist who has undergone program training. In many cases, the pharmacist is already familiar with the patient, according to Charles Maret, RPh, a Dalton, GA, pharmacist who already had established relationships with some of the patients he now works with as part of the DTCC. The pharmacist will begin the process by calling the individual and setting up an appointment to meet with him or her. Hamilton Health Care brings the pharmacists on site to meet with the participants, although other employers may handle this aspect of the model differently. During the initial encounters, the pharmacist gathers information about patient history, medications, and PCPs. He or she then ascertains how much the patient understands about his or her disease. This process is facilitated by computer-based assessments and prompts that have been woven into the program.
The patient is then asked to sign a consent form so the PCP can keep the pharmacist apprised of all diabetes-related lab results. In addition, following each encounter with the patient, the pharmacist sends the physician reports about what was accomplished during the encounter, as well as any comments or recommendations that he or she may have regarding patient care.
Of the five people he works with as part of the DTCC, Maret says that some patients have more knowledge about their disease than others, but he adds that they all have the desire to learn more. "All people suffer a little bit of white coat syndrome, and I think we [offer an atmosphere] that is a little bit more relaxed, and we talk with them more one-on-one. This gives them the opportunity to ask questions in kind of a low-key way," he says. "I think that is a big thing-being relaxed and able to talk about it."
Early results show promise
Patients meet with their assigned pharmacist about once every six weeks during the first year of the program, according to Ellis. In addition, patients who have HbA1c readings over 9 are encouraged to attend diabetes education sessions at a diabetes education center. Preliminary results from the first year of the DTCC will be released later this year, although enrollment in the program at many participating employers has just begun this year.
"You are going to see positive improvements on some of the key indicators like HbA1c levels-I think you will see that for sure," says Ellis, noting that the indicators are tracking in a positive direction.
Although final results from the effort will not be available until late 2008, APhA is already working separately with companies that want to implement the model as part of a voluntary health benefit. This program, called HealthMapRx, offers DTCC-style programs focused on both diabetes and cardiovascular health, and APhA plans to further enhance its capabilities in the coming years.