Disease management program relies heavily on pharmacist care, education

Clinic focuses on diabetes and anticoagulation therapy

When hospitals expand to outpatient clinics that focus on chronic disease management, it is an ideal opportunity for pharmacists to fulfill a major role.

Pharmacists and pharmacy residents and students who work at the Outpatient Clinic and Ambulatory Care Pharmacy, which is part of Columbus Regional Healthcare System in Columbus, GA, provide medication management and disease management care to indigent patients, ultimately saving the health care system money.

Here are some of the areas of focus and how it works:

Diabetes management: "The large component of diabetes management is education, making sure patients have the ability to handle self-management issues," says Lori Hornsby, PharmD, BCPS, an assistant clinical professor with the Harrison School of Pharmacy at Auburn University in Auburn, AL. Hornsby also is an ambulatory clinical pharmacist with the Columbus Regional Healthcare System.

The pharmacist ensures that diabetic patients receive blood glucose monitors and education on proper use.

"We also provide extensive education to include diabetes-related complications, the goals of therapy, dietary information, and medication counseling," Hornsby says. "We work collaboratively with patient's physicians to ensure they are on appropriate therapy, adjust medications if needed, and track success through A1c values."

Follow-up varies. Patients who are beginning insulin therapy may be seen the next week, and those who are using monitors for the first time may be seen in two weeks. Better controlled patients might be seen every four weeks, she adds.

For better controlled patients, they might be seen every 2-4 weeks.

"This is one of the benefits of having pharmacists involved in diabetes management," Hornsby notes. "Follow-up with physicians is often extended."

Also, the pharmacists' visits supplement physician visits, providing more oversight.

Anticoagulation therapy: Like many hospital systems, Columbus Regional Healthcare System has many patients who are admitted to the hospital or emergency room with problems from their anticoagulation medications, Hornsby says.

A small change in their medications can have a big impact, so it's important to have pharmacists involved in anticoagulation treatment management.

"All patients who come in on anticoagulation therapy are referred to us," Hornsby says. "We've been following the recent Joint Commission [of Oakbrook Terrace, IL] guidelines for 10-plus years."

As patients bring anticoagulation prescriptions into the dispensing pharmacy, the staff ensures that these patients are scheduled an appointment for follow-up with the ambulatory clinical pharmacist in the Outpatient Clinic, she adds.

Pharmacists ensure anticoagulation patients are aware of drug-drug and drug-food interactions.

Patients are encouraged to be consistent in their dietary choices and to discuss all changes in prescription and over-the-counter medications with their pharmacist, Hornsby says.

"We make sure patients are educated and that they understand the risks and benefits of therapy," Hornsby says. "We teach them about the risks of bleeding, how to monitor for signs and symptoms of bleeding, and when to seek medical attention."

Initial visits average 30-60 minutes, depending on the patient's understanding of their therapy and whether or not they're experiencing confusion, she says.

The clinic has a point-of-care monitoring machine that is utilized by the pharmacists. When the patient's blood is entered into the machine there is an automatic reading in 10-15 seconds, so pharmacists have instant information necessary for making therapeutic decisions, explains Sherry Martin, PharmD, the outpatient pharmacy operations coordinator at The Medical Center Inc., which is part of the Columbus Regional Healthcare System in Columbus, GA.

The immediate results allow for real-time assessment and management, which avoids the need for follow-up calls and to track down patients when utilizing other methods, Hornsby notes.

The clinic follows patients closely, calling them if they haven't returned for follow-up, she adds.

"For patients who haven't been coming to have their lab work done, the dispensing pharmacy can flag their prescriptions so that patients can be directed to consult with a pharmacist to order follow-up labs before prescriptions are refilled," she says.

"Patients who are new to anticoagulation therapy are seen once a week for several weeks," Hornsby says. "Then the goal is to get them where they come in once a month because even patients who are very stable usually need monthly follow-up care."

It is a challenge in today's environment to provide cost-effective primary care to low-income patients, Hornsby says.

"Physicians and pharmacists working together in a collaborative practice, utilizing 340B drug pricing, and accessing patient assistance programs allow Columbus Regional Healthcare System to provide excellent patient care for their low-income patients," she adds.