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Outcomes and Factors Contributing to the Success of a Community Based Patient Self-Management Diabetes Program: The Asheville Project . Daniel G. Garrett, MS Senior Director, Medication Adherence APhA Foundation dgarrett@aphanet.org. Objectives.

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Outcomes and Factors Contributing to the Success of a Community Based Patient Self-Management Diabetes Program:The Asheville Project

Daniel G. Garrett, MS

Senior Director, Medication Adherence

APhA Foundation

dgarrett@aphanet.org

objectives
Objectives
  • Describe the Asheville Project and the Outcomes being achieved
  • Share the perceptions of patients, providers and managers on the factors contributing to success of the Asheville Project Care Model
our mission

Our Mission

“The mission of the American Pharmacists Association Foundation is to improve the quality of consumer health outcomes that are affected by pharmacy.”

http://www.APhAFoundation.org/

patient centric drug therapy
Patient Centric Drug Therapy
  • Patient is the:
    • Applier
    • Utilizer
    • Determiner

...of the outcomes associated with

medication “technology”

Patients on drug therapy ultimately “manage their own care”.

original intent of the north carolina pharmaceutical care project 1993
Original Intent of the North Carolina Pharmaceutical Care Project- 1993
  • To demonstrate that community pharmacists could provide pharmaceutical care that results in positive patient outcomes
  • To demonstrate the value of pharmaceutical care to employers so they would pay pharmacists for “clinical” services
original design of the nc pharmaceutical care project
Original Design of the NC Pharmaceutical Care Project
  • Committee with representatives from all state pharmacy organizations, schools of pharmacy, industry and a PBM
  • Met for 3 years to come up with protocol for 3 projects (asthma, diabetes and HTN) in 3 communities, with control groups and computer software supported care ($150,000 price tag)
  • ECHO model for outcomes tracking
the answer to how is when
*“The Answer to How? Is When.”
  • Decided in 1996 to try one project in one disease state using pencil and paper
  • The City of Asheville agreed to try for one year and see if it worked before they paid the pharmacists
  • Diabetes was selected by the City’s Medical Consultant as the place to start
  • The pharmacists training program was created in conjunction with the MSJ DEC with a grant of $10,000
  • The City decided to waive patient co-pays and the PBM issued special rx cards
  • The original patients were identified from a PBM report with a yellow highlighter

*Peter Block, Stewardship, 1993; 234-237

you cannot control the system you can only disturb it

“You cannot control the system…you can only disturb it”

Bennett Sims,

Servanthood,

Leadership for the 3rd Millennium

patient incentives and care model how we disturbed the system
Patient Incentives and Care Model (how we “disturbed the system”)
  • Patient selection / recruitment
  • Patient education — Mission + St. Joseph’s Diabetes Center
  • Matching patients to pharmacists
  • Incentives
    • Glucose meters
    • PBM co-pay waivers
    • Labs without co-pays
  • The operative word in pharmaceutical care is “care” (Madge Testimonial)
how they do it
How They Do It

“Patient making better food choice. Blood glucosemuch improved. 2 x 1.5c cm wound RLE. Referredto physician for evaluation and therapy.”

asheville clinical outcomes avg glycosylated hemoglobin
Asheville Clinical Outcomes:Avg. Glycosylated Hemoglobin

HbA1c

n=136 136 81 55 39 26 16 11

Cranor et. al. JAPhA 2003; 43(2): 175-176.

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70

70

n=50

Cranor et. al. JAPhA 2003; 43(2): 184.

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$8468

$8088

$7762

Total Healthcare Costs, Combined Missions St Josephs and City of Asheville for all enrollees (unpublished data)COA & MSJ Total Healthcare Costs (avg/patient/year) prior to programfor diabetes and each year of the program for 1st 5 years

$7485

20%

Medical

CPI

Increase

$2,195,228

Cumulative

savings

$7239

city of asheville diabetes sick leave usage n 37
City of Asheville Diabetes Sick-Leave Usage (n=37)

Cranor et. al. JAPhA; 43 (2): 180.

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The Asheville Project: Participant’s Perceptions of Factors Contributing to the Success of a Patient Self-Management Diabetes Program
  • Focus groups of patients and diabetes care providers and individual interviews with managers involved in the project
  • 21 patients, 4 pharmacists, 1 CDE, 6 managers from employer groups

Garrett DG, Martin, LA. J Am Pharm Assoc. 2003;43:185-90

patient perspective
Patient Perspective
  • “The program saved my life”
  • Patients were positive about experience and enjoyed relationship with pharmacist
  • Reasons for joining the program:
    • Financial incentive
    • Fear of diagnosis

Garrett DG and Martin LA. JAPhA March/April ;43(2):187.

employers perspective
Employers’ Perspective
  • Significant resources were required to run the program; however, the benefits derived far outweighed the costs of the program
  • Employees appreciated reductions in medical costs
  • Enhanced patient well-being and decreased absenteeism
  • Patients sense of hope for controlling their diabetes was increased

Garrett DG and Martin LA. JAPhA March/April 2003; 43(2): 187.

pharmacist perspective
Pharmacist Perspective
  • Participated in program because
    • Professional responsibility (make a difference)
    • Increased marketability in career
  • Pharmacists identified two primary factors that affected patients’ success in the program:
    • Whether the individual viewed his or her health as a priority
    • The willingness of the health care professional to take time with patients

Garrett DG and Martin LA. JAPhA,

March/April, 2003 43:(2) 188

wagner et al chronic care model
Wagner et.al. Chronic Care Model
  • The health system is part of the larger community and there are appropriate links to health care resources in the community.
  • Effective self-management support and links to patient-oriented community resources help to inform patients and families and motivate them to cope with the challenges of living with and treating chronic diseases.

Wagner EH, Austin BT, Davis C et al. Improving chronic illness care: translating evidence into action. Health Aff 2001; 20(6):64-78.

wagner et al chronic care model23
Wagneret.al. Chronic Care Model
  • Teams of physicians and other health care providers need to have the clinical and behavioral expertise required for productive patient interactions. Guidelines and protocols have a minimal impact unless they are implemented as part of an ongoing system of care that includes education, reminders, specialist involvement, and decision support interventions.
  • An organized and standardized approach to collecting, summarizing, and reviewing individual and aggregate patient data is needed.

Wagner EH, Austin BT, Davis C, et al. Improving chronic illness care: translating evidence into action. Health Aff 2001;20(5):64-78.

results from focus groups consistent with wagner colleagues chronic care model
Results from Focus Groups consistent with Wagner & colleagues Chronic Care Model
  • Employer interest was in improving and coordinating healthcare and investing resources in a community-based system
  • Patients reported that the incentives and community-based self-management support they received on an ongoing basis was essential in helping them cope with their diabetes
  • Pharmacists and diabetes educators reported it took more than knowledge to care for patients. Key to success was the opportunity pharmacists had to work with individual patients on an ongoing basis to answer their questions and support their self-motivated behavior changes
  • On-going Outcomes Data collected and reported

Garrett DG and Martin LA. JAPhA 2003;43(2):189.

the asheville program today
The “Asheville Program” Today
  • Now over 800 patients from 3 employers are enrolled for diabetes, asthma, hypertension and lipid therapy management
  • Patients continue to have improved outcomes & increased medication adherence
  • 50% reduction in sick days
  • Zero workers comp claims in the City diabetes group over 6 years
  • Average net savings of over $1,600 per person with diabetes each year from year 2 on
lessons learned that can applied anywhere
Lessons Learned that can Applied Anywhere
  • “Plans are nothing, planning is everything”
    • the foresight and comprehensive planning of “the committee” resulted in a sound process of care and collection of valuable outcomes data
  • CAREing makes the difference
    • the City paid the pharmacists before the data was in
  • The best way to reduce risk is to share risk
    • every stakeholder had an incentive to succeed
jerry mcguire

Jerry McGuire

“Show me the money!”

“It’s all about relationships”

question asked in asheville in 1996
Question Asked in Asheville in 1996

What are you going to do

if “it” works?

(Will pharmacists be willing/able

to meet the demand for patient care services?)

“It” works…as reported on the

front page of the Washington Post,

August 20, 2002.

what are you going to do if it works
“What Are You Going to Do if It Works?”
  • Process vs. demonstration research
    • How do we scale this up for large employers in diverse markets?
    • How do we ensure consistency of care and outcomes?
    • How can we make this efficient?
    • What are the components of care required for positive outcomes?
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Patient Self-Management: Diabetes ProgramImproving the Healthof America’s Workforce andReducing Health Care Costs

Empower the Patient. Improve the Outcomes. Control the Costs.SM

it s a wonderful thing to have a beautiful mind but more wonderful to have a beautiful heart
“Integral” or “Holistic” approaches are required for “transformation” (vs. “translation”) See Ken Wilber, Marriage of Sense and Soul

At least four quadrants…biological(technical), psychological, social and cultural are needed for chronic health management

John Nash manages his health through growth and support in all quadrants, if the state of NJ had forced him to leave his home to build a bridge would this have adversely affected his health?

“It’s a wonderful thing to have a Beautiful Mind, but more wonderful to have a Beautiful Heart”
slide33

Can a Ripple in a Mountain Stream

Start a Wave Across the Ocean?