Clinical Pharmacists Provide Outpatient Medication Management to Patients With Severe Diabetes and Those on Anticoagulants, Leading to Improved Outcomes and Lower Costs

Service Delivery Innovation Profile

Clinical Pharmacists Provide Outpatient Medication Management to Patients With Severe Diabetes and Those on Anticoagulants, Leading to Improved Outcomes and Lower Costs

Snapshot

Summary

Clinical pharmacists working in 13 community health centers, 1 specialty clinic, and 2 clinics within Quentin Mease and Lyndon B. Johnson Hospitals in the Harris Health System provide direct care to high-risk patients, including those with severe diabetes, those on anticoagulants, and others. Most patients are indigent or elderly, and many are Hispanic. The pharmacists perform medication reconciliation, monitor patients according to key indicators, adjust medication doses as necessary, and educate patients and providers about managing these conditions. The program has led to significant improvements in health outcomes, including improvements in blood glucose levels among patients with diabetes and international normalized ratio levels among those on anticoagulants, prevention of many adverse drug events, and meaningful cost savings due to reductions in emergency department visits and inpatient admissions.

Evidence Rating

Moderate: The evidence consists of before-and-after comparisons of key outcomes measures, including the percentage of anticoagulation patients achieving their international normalized ratio goal and average hemoglobin A1c, cholesterol, and blood pressure levels.

Developing Organizations

Harris Health System

Houston, TX

Date First Implemented

2001

The program began on a small scale in 2001 and was expanded to all Harris Health System clinics beginning in 2006.

Problem Addressed

Due to time constraints and the need to focus on the care of acute conditions, primary care physicians often do not have adequate time to focus on the complex medication management needs of those with severe diabetes and those on anticoagulants. Although clinical pharmacists can help manage dosing, few are employed in outpatient care settings.

  • Need for ongoing care management: Medication management can be complex for patients with diabetes and for those taking anticoagulants, and few primary care physicians have adequate time to provide these services during the typical office visit. Diabetes patients' hemoglobin A1c (or blood glucose) levels often fluctuate significantly, creating the need for ongoing review of medications and dosages.1 Successful anticoagulant care involves frequent, numerous adjustments to dosing and administration schedules, which may need to vary from day to day and month to month to keep the patient's international normalized ratio at the appropriate level, thus minimizing the risk of bleeding or clotting.2
  • Few clinical pharmacists available: Evidence suggests that having clinical pharmacists manage medications can improve patient care and, in some cases, lower costs.3 However, few community health centers, primary care practices, or other outpatient care sites have a clinical pharmacist on staff.

Description of the Innovative Activity

Clinical pharmacists working in 13 community health centers, 1 specialty clinic, and 2 clinics within Quentin Mease and Lyndon B. Johnson Hospitals provide direct care to high-risk patients, including those with severe diabetes, chronic hypertension, and high cholesterol, as well as those on anticoagulants. Most patients are indigent or elderly, and many are Hispanic. The pharmacists perform medication reconciliation, monitor patients according to key indicators, adjust medication doses as necessary, and educate patients and providers about how to better manage these conditions. One clinical pharmacist is located in each of the 13 centers. Key elements of the program include the following:

  • Patient referral: Physicians refer patients to clinical pharmacists according to criteria designed to identify high-risk cases. Examples of patients who are referred include those taking anticoagulants or more than five medications, those with a hemoglobin A1c level above 9 percent, and those with hypertension that remains uncontrolled after three physician visits. The vast majority have severe diabetes or are taking anticoagulants. Physicians refer patients using a form that can be found on the Harris Health System's electronic medical record (EMR); referred patients are entered into the pharmacist's daily scheduling template.
  • Clinical pharmacist services: The clinical pharmacist meets in person with the patients, typically 3 to 4 weeks after the patient's visit with the physician; pharmacists also take same-day, drop-in appointments. A description of the services provided by the pharmacist appears below:
    • Services for anticoagulation patients: The pharmacist checks the patient's international normalized ratio via a finger-stick test, makes dosage adjustments if necessary, educates the patient, and schedules followup appointments as needed (typically every 3 to 6 weeks to ensure that the international normalized ratio remains in range).
    • Services for those with diabetes: The pharmacist checks the patient's laboratory values, adjusts diabetes medications if necessary, reorders hemoglobin A1c tests, and writes prescriptions for any needed refills of existing medications. The pharmacist also performs a physical assessment (e.g., conducts foot examinations, examines bruises from insulin shots, and looks for signs and symptoms of bleeding/bruising), if required, to ensure appropriate medication monitoring. Appointments are scheduled according to individual patient needs. For example, patients who begin taking insulin typically require frequent followup visits until the dosage is stabilized. Patients may be discharged from the clinical pharmacist's care if hemoglobin A1c levels remain at 7 percent or less for at least three consecutive testing cycles. In addition, one of the clinical pharmacists conducts a weekly diabetes clinic focusing on patient education and monitoring.
    • Services for other patients: Other patients treated by the pharmacist include those with uncontrolled hypertension, hyperlipidemia, or polypharmacy.
    • Medication reconciliation for all patients: In addition to careful monitoring, clinical pharmacists perform medication reconciliation for all patients to ensure that their full medication list is accurate and appropriate and that records remain up to date. This process can help to reduce the risk of adverse drug events (ADEs).
    • Education for physicians and nurses: Clinical pharmacists provide education to physicians and nurses through live quarterly drug therapy updates that include a review of new guidelines and answers to specific questions.
  • Communication with referring physician: Clinical pharmacists enter visit notes and document the care provided in the EMR; referring physicians can view the notes when accessing the patient's record.

Context of the Innovation

The Harris Health System is a health system with three hospitals (totaling approximately 1,000 beds) and 13 community health centers located in the Houston metropolitan area. The Harris Health System, which is designated by the Centers for Medicare & Medicaid Services as a Disproportionate Share Hospital, serves many indigent patients, with approximately 88 percent to 90 percent of indigent patients being uninsured and another 10 percent to 12 percent being covered by Medicare. In addition, a small percentage of patients have Medicaid coverage. The average age of Harris Health System's patient population is 59 years old, and many patients are Hispanic. The community health center physicians are employees of the Baylor College of Medicine or the University of Texas College of Medicine, which contract with the Harris Health System to provide medical care. In 2001, two pioneering pharmacists asked physicians at two of the community health centers if they would be interested in having a clinical pharmacist serve in a nontraditional (nondispensing) role, assisting in the care of their diabetes and anticoagulation patients. The physicians agreed to test the idea.

Results

The program has led to significant improvements in a number of health outcomes, prevented many ADEs, and generated meaningful cost savings due to reductions in emergency department (ED) visits and inpatient admissions.

  • Improved outcomes: The program has improved outcomes for many participants.
    • Better outcomes for anticoagulation patients: Between fiscal year 2006 and 2007, the percentage of patients achieving their international normalized ratio goal rose from 24.6 percent to 64.7 percent. In fiscal year 2007, anticoagulation patients in the Harris Health System had no major bleeds or clots due to warfarin administration.
    • Better management of diabetes: Between fiscal year 2006 and 2007, the number of diabetes patients with a hemoglobin A1c level of under 7.5 percent increased by 50 percent. The average hemoglobin A1c level fell by 2.54 percent in fiscal year 2007 and by 0.94 percent in fiscal year 2008.
    • Lower cholesterol: Average low-density lipoprotein (commonly known as LDL) cholesterol levels fell by 10.13 mg/dL between fiscal year 2007 and fiscal year 2008.
    • Lower blood pressure: Between fiscal year 2007 and fiscal year 2008, average systolic blood pressure declined by 3.23 mm Hg, while average diastolic blood pressure fell by 1.24 mm Hg.
  • Fewer ADEs: Clinical pharmacists identify and prevent approximately one ADE every 2 days.
  • Cost savings: An analysis by the Harris Health System estimated that the weekly half-day diabetes clinic alone resulted in a cost savings of roughly $1 million due to reduced ED visits and hospitalizations. Actual savings are likely much higher, given that the scope of program services goes well beyond this clinic.

Evidence Rating

Moderate: The evidence consists of before-and-after comparisons of key outcomes measures, including the percentage of anticoagulation patients achieving their international normalized ratio goal and average hemoglobin A1c, cholesterol, and blood pressure levels.

Planning and Development Process

Key elements of the planning and development process included the following:

  • Slowly building referrals: After agreeing to let clinical pharmacists play a nontraditional role, physicians in two of the health centers slowly began referring patients to the pharmacists for patient education; referrals for ongoing care management began soon thereafter. Improvements in patient outcomes encouraged additional referrals.
  • Creating a business plan for expansion: In 2006, the pharmacists created a business plan that demonstrated the value of the program with regard to revenue and cost savings. Based on this business plan, the Harris Health System administrator and chief operating officer approved expansion to other sites.
  • Marketing and expansion to other health centers: The pharmacists held meetings at the other 10 community health centers, presenting information on program services, the potential improvement in outcomes that could be achieved, and expansion plans. In 2006 and 2007, the Harris Health System added 10 more pharmacists, allowing the placement of one clinical pharmacist in each community health center. In 2009, another community center opened its doors and a clinical pharmacist was added to this site as well.

Resources Used and Skills Needed

  • Staffing: One full-time clinical pharmacist is employed at each of 13 community health centers. All pharmacists have a PharmD degree and have completed 1 to 2 years of clinical pharmacy residency training. Each pharmacist has a caseload of approximately 250 patients and handles roughly 16 visits per day.
  • Costs: The cost of the program consists primarily of salary and benefits for the clinical pharmacists.

Funding Sources

A portion of program costs are reimbursed by Medicare through the general facility fee that the system receives. Clinical pharmacy services are generally not reimbursed separately on a fee-for-service basis.

Getting Started with This Innovation

  • Establish services slowly: Not all physicians are familiar or comfortable with clinical pharmacists providing direct patient care. To overcome physician reluctance, pharmacists should start with a small number of patients, demonstrate their skills and ability to enhance outcomes, and build relationships with the physicians to cultivate trust.
  • Leverage existing physician organization and systems: For example, Harris Health System physicians are organized into two large medical groups that share an EMR system, thus making it easy for them to refer patients to clinical pharmacists.
  • Develop a business plan: The business plan should consider the program's impact on hospital finances and on quality of care, highlighting the potential to reduce costs and improve outcomes.

Sustaining This Innovation

  • Encourage referrals: Continually remind physicians about the program and its benefits, because achieving sufficient volume is critical to maximizing the program's impact and ensuring that cost savings exceed program expenses.
  • Monitor and report outcomes: Continually track the program's impact and report results to physicians and administrators. These steps help to demonstrate the value of the service and ensure continued support.

Contact the Innovator

Note: Innovator contact information is no longer being updated and may not be current.

Santhi Masilamani, PharmD, CDE, MBA
Director, Ambulatory APPE
Office of Experiential Programs
University of Houston College of Pharmacy
RPD- PGY1 Community Pharmacy Residency Program
1441 Morsund St
Houston, TX 77030
(832) 842-8359
 

Monica Robinson Green, PharmD, BCPS, BCACP
Clinical Pharmacy Manager, Ambulatory Pharmacy Services
Harris Health System
Kirby Administrative Offices
9240 Kirby Drive, Suite 600
Houston, TX 77054
Phone: (713) 634-1517
monica.green@harrishealth.org



Innovator Disclosures

Dr. Green has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

Footnotes

  1. Interview with Santhi Masilamani, October 17, 2008.

  2. Machtinger E, Wang F, Chen L, et al. A visual medication schedule to improve anticoagulation control: a randomized, controlled trial. Jt Comm J Qual Patient Saf. 2007;33(10):625-35. [PubMed]

  3. Bond CA, Raehl CL, Franke T. Clinical pharmacy services, pharmacist staffing, and drug costs in United States hospitals. Pharmacotherapy. 1999;19(12):1354-62. [PubMed]

Comments

Original Publication: 11/24/08

Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last Updated: 12/09/15

Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: 08/24/16

Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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