In 2011, Utah Navajo Health System, Inc. began a new program that involved primary care providers, working with clinical pharmacists, to help educate patients more thoroughly about medications and how to treat diabetes more effectively.
For the first 18 months of the program, clinical pharmacists (PhamD's) worked with the primary care providers, but could only make recommendations, regarding patient medications and treatment. Eventually, clinical pharmacists demonstrated to the UNHS Medical Director and staff that not only was the program working, but also that they were competent and knowledgeable enough to be trusted with prescribing medications, ordering lab tests and performing the duties they had only been allowed to recommend earlier.
UNHS Clinical Pharmacist Director, Albert Noyes, said there was some natural skepticism about the new program at first. But in October 2012, the UNHS Medical Director and staff demonstrated their trust in the program by signing a formal Collaborative Practice Agreement, extending prescriptive authority to the clinical pharmacists. And that's when the battle to fight diabetes and lower A1C levels in diabetes patients took a major step forward.
Clinical Pharmacist Andrew Bayless explained recently that since October 2012, clinical pharmacists have worked with 1026 diabetes patients, whose A1C level has dropped by an average of 3.13%. From May of this year, through November, 294 diabetes patients have been seen, with an average A1C decrease of 1%, Bayless added.
"A1C is measured between 4% to 14%. Anything above 6.5% is considered diabetes," Bayless explained. "For every 1 step down on the percentage scale, you reduce the risk of heart disease, blindness and kidney failure by about 40%. So for those patients who have taken multiple steps down that scale, they've dramatically reduced their risk. Our most effective oral medication for diabetes, which is Metformin, lowers the A1C by about 2%. So participating in the program does more than our strongest pill, alone."
According to Bayless, one major factor in the success with lowering A1C is that clinical pharmacists are able to spend more time with patients than primary care physicians. He said most primary care patient visits are blocked in 15-minute increments. Clinical Pharmacists' visits are 30 to 40-minute sessions.
"When we started, we said if we're going to review all of their medicines and all of their disease states and all their interactions, we're never going to commit to a 15-minute window. We schedule ourselves in 30-minute blocks but on average we take about 40 minutes with a patient. So it's a longer encounter and it allows for better relationships," Bayless continued. "We get to know people and over time they either ask, 'is the drug doctor here?' or some of them will ask for us by name. That's how they understand the differences. We're the drug person, where they're other physician is a whole practitioner. We're the drug guy. It allows the patient to identify us pretty quickly."
"Quite often the providers that we work with will say, hey, I know this is what the patient needs to talk about. I don't have time to spend on it. We can be that extension to address those things," Noyes added. "It's been a real nice team effort. We've had a really supportive group of providers here, even with the providers changing over."
Clinical Pharmacist Emily Hunter works exclusively in the UNHS Montezuma Creek Community Health Center. She said the teamwork with primary care providers has been even better with some of the new providers.
"Because I'm already established when they come in and it's not like some bizarre thing and I'm trying to take patients away from them. It's more, 'hey you're here to help me. I love help," she said.
Hunter said she believes the new PA's and doctors are becoming more familiar with the clinical pharmacist program while in school. "At least their behavior is more like they're excited. Even when we have the medical students here, they ask 'where's the pharmacist?'"
Bayless said that while the program is working, there is still a major education process for most new patients clinical pharmacists see.
"One of first concerns is med misinformation," Bayless said. "Whatever the medication might be they either have a misunderstanding, or someone has told them something very specific and untrue about why they shouldn't take their medication. And so that's one of our first goals, find out if there is a reason why they are not using their medication and is that why their disease is uncontrolled? After that, if there are no specific concerns, we'll just move into general concerns. But the big one is who's told you what and why don't you take your medicine?"
Bayless said he believes the number one reason for the dramatic drop in A1C levels among UNHS patients is medication adherence. Those patients who were taking their medication sporadically, or not at all, after learning how they work, why they are used, and what they're effects will be, they increase their adherence and start to feel the benefit.
"We always tell patients, medications don't work if they're sitting on your shelf," he said.
Hunter said she thinks the program is becoming more successful because patients are more familiar with how it works, and with the clinical pharmacists. She said since she first started she's become more confident, is more visible with an office in the clinic, and patients have gotten to know and trust her.
"I have a lot success stories, including a lot of older people who say they never knew what diabetes was," Hunter said. "No one ever explained it to them. I feel like I get that less and less now because I'm seeing so many more people. There are less people to give my spiel to. I have a lot of people who say they know all about diabetes because people in their family have it. I tell them, 'just bear with me and look at my terrible drawings,' and I make them sit through the presentation. A lot of times they say, 'wow, well that makes sense.'
"I feel like a lot of people have had a bad experience, where someone has said, okay you have diabetes and you're going to take these medications, and the pharmacist hands them a bag of meds and they're told to take them and they go home," Hunter continued. "I don't know if it's true or not, but their perception is that no one took the time to explain anything to them."
Bayless, Hunter and Noyes all agree that the clinical pharmacist program has been successful in educating patients, and their families, about the need to take medication properly, make aggressive lifestyle changes, exercise and eat properly in order to control diabetes. Bayless said many patients have come to trust their clinical pharmacists, and bonds have been forged between the PharmD's and their patients that have helped with diabetes control and treatment. Noyes said this success, and the numbers that verify the success, are just what the doctor ordered when advocating for legislative changes that recognize and fund the clinical pharmacy program.
"Now when you're looking at the ability for us to advocate for change in health policy, and things like that, to recognize this kind of a program you have to have those kinds of numbers behind you," Noyes said. "Talking about 'we have this many fewer patients progressing toward end stage kidney disease and getting on dialysis. We have this many percent fewer emergency room visits for heart attack and stroke for our diabetic patients. Fewer cases of blindness and things like that.' Those are the things that get us a lot of traction. So this is a step toward painting that full picture. I guess that's what we're looking for."
"Nationwide, clinical pharmacist programs are successful," Bayless added. "We bring a different perspective, and a different background, different training, and it helps things. Being part of the team helps. And here at UNHS we've had, since day 1 in 2011, amazing support from the administrative staff and the executive team, and that's made a huge difference. Because in the very beginning, when we didn't have any data to present here, they just said do it. And now we can turn in these great reports that show the success. For the first couple of years it was just very supportive administrators who said, 'by word of mouth I get reports that you guys are doing good things. So keep it up.' Finally, now, we have the data to say, here's the numbers."
Bayless also offered advice for those concerned about diabetes.
"The best advice for someone struggling with control, or worried about diabetes, is that diabetes is most easily managed early in the course of the disease. Aggressive therapy, big lifestyle changes and early treatment will result in the best outcomes," he said. "But even someone who has known they have diabetes for a long time and hasn't treated it, any change, any treatment will always improve your health when it comes to diabetes. So, Don't Wait!