Pharmacists Disease State Management Through a Collaborative Practice Model

Increased rates of type II diabetes has reached alarming proportions in the United States in recent years. Often thought of as a disease of adults and minorities, it is now entering the lives of children as well as adults of all races and ethnic groups. In the United States, it is estimated that there are currently 18.2 million people with either type I or type II diabetes (about 6.3% of the total U.S. population). Hispanic/Latino Americans, American Indians, Alaska Natives, as well as non-Hispanic blacks face the greatest risk of developing this potentially deadly disease.¹

In 2002, it was estimated that $132 billion was spent on diabetes. Of this, $92 billion can be attributed to direct medical costs. The remaining $40 billion accounts for indirect medical costs due to things such as disability, work loss, or premature mortality.²

In the United States, a physician or midlevel provider may be providing care to anywhere from 10–25 patients per half day. Health care providers, support personnel, and ancillary staff are pushed to the limits every day to care for patients with very limited resources and little available time. Matters of productivity and reimbursement dominate the health care system and determine the quality of care patients receive. This system is based on the assumption that the patient has an identified payer source and the means to obtain necessary health care.³ In addition, the dominant model for care assumes that the patient's literacy level allows him or her to navigate through the system's voluminous red tape and to act as his or her own advocate. Health care organizations, hospitals, and community health centers have made a virtue of necessity as they creatively design programs that fit the needs of not only the organization but, most importantly, the patients.⁴

Clinical Pharmacists

By increasingly focusing on disease state management, clinical pharmacists can make recommendations and changes in patient regimens and, in this way, help to alleviate problems that the current health care system engenders. Such involvement on the part of pharmacists will improve patient's quality of life, improve medication adherence, and avoid medication-related complications.^5–13 These interventions are likely to save health care dollars; the most recent estimate is that the cost of drug-related morbidity and mortality exceeds $177.4 billion per year.¹⁴ Changes in the pharmacist's role will also facilitate the new Medicare drug program that will promote the involvement of clinical pharmacists in chronic disease state management. Having the assistance of pharmacists will help the overworked and overburdened practitioners provide a better quality of care to their patients.

Arizona Legislation

In Arizona, new legislation (Arizona Revised Statute 32-1970) allows qualified pharmacists in specified health care settings (such as a community health center) to implement, monitor, and modify drug therapy as described by written protocols in collaboration with physicians. This practice model is referred to as Collaborative Drug Therapy Management (CDTM). Health care programs administered by U.S. Public Health Services (such as the Indian Health Service [his], the armed services, and the Veterans Health Administration [VA]), as well as independent practice settings in 40 states across the United States, now support pharmacist participation in CDTM. Most of these require drug- or disease-specific collaborative practice agreements or drug therapy management plans approved by physicians participating in and supervising these programs.^15,16 This format, modeled after the original IHS programs, limits the pharmacist's clinical activities to those found in the physician-approved guidelines. The program at El Rio Health Center, described below, falls into this category. There are also programs, mainly in the community pharmacy setting, where the pharmacist provides education and compliance support services, but has no prescriptive authority and must make recommendations to the patient's provider regarding changes in pharmacotherapy and disease monitoring parameters.

El Rio Clinical Pharmacy Demonstration Project

Originally funded as a Clinical Pharmacy Demonstration Project by the Office of Pharmacy Affairs (part of the Health Resources and Services Administration's Healthcare Systems Bureau), the El Rio...