Diabetes Management: A Novel Approach to Caring for Underserved Patients

Established in 1991 as a nonprofit healthcare corporation, Escambia Community Clinics, Inc (ECC), Pensacola, FL, has provided access to care for the medically needy, underinsured, and underserved citizens of Escambia and Santa Rosa counties.¹ ECC has been staffed by primary care physicians, advanced nurse practitioners, physician assis­tants, nurses, medical technologists, and medical assistants who all play a pivotal role in the healthcare management of the underserved population.¹ However, as new healthcare laws are enforced and individuals consistently experience economic challenges, providing healthcare has become more difficult because of the limited amount of providers and time available to spend with patients. Healthcare professionals, such as pharmacists, have become essential in assisting practitioners to help patients holistically and achieve necessary outcomes.

Promoting Outreach to Underserved Populations

The College of Pharmacy and Pharmaceutical Sciences (COPPS) at Florida Agricultural and Mechanical University (FAMU) has a rich history of producing high-caliber graduates capable of providing exceptional pharmaceutical care.² The program focuses on academic excellence, research superiority, and community service, which better prepares the students for leading roles in pharmacy, research, and public health practices. In 2004, FAMU COPPS developed a program, Community Outreach and Service Learning (COSL), as a way to meet the American Association of Colleges of Pharmacy’s charge to explore ways to instill the value of action-oriented care for disadvantaged and underserved populations in students.^3,4 COSL is an initiative for graduates of professional degree programs, generating commitment to, and interest in, providing care to underserved populations.

After opening the Crestview Instructional Center, a pharmacy-based satellite campus, in 2012, FAMU and ECC formed a collaborative practice agreement in which a faculty member could run and provide an advanced pharmacy practice experience to meet COSL requirements for student pharmacists rotating throughout the Florida panhandle area.⁵ The opportunity to perform rounds with practitioners in fields of primary care, psychiatry, and women’s health are available for students, as are interactions with behavioral therapy professionals and social workers. These interactions allow student pharmacists to experience interprofessional communication, and understand the value of an interdisciplinary team.

Diabetes: Meeting A_1C Level Goals

During the first 3 months of the collaborative practice agreement, a primary goal of ECC was to lower their patient population’s A_1C levels and improve overall outcomes. Decreasing A_1C levels by ≥1% decreases the risk for end-organ damage by 41% and improves quality of life by reducing the risk of death by 21%.⁶ In 2013, the FAMU diabetes clinic was established as part of the COSL initiative to help ECC address this need. The program was designed to help patients and their primary care providers design, implement, and monitor therapeutic goals to achieving successful management of their disease, specifically diabetes. In student pharmacists, the program also instills the importance of providing care to underserved populations.

Medication Therapy Management

The pharmacist and student pharmacists at the FAMU diabetes clinic perform medication therapy management (MTM) services for all patients enrolled at the clinic. See the Figure for the 5 important components of MTM.⁷ MTM services aim to enhance drug therapy and improve therapeutic outcomes for patients. Within the diabetes clinic, MTM services are the foundation upon which the pharmacist and student pharmacists are able to effectively help patients reach their therapeutic goals.

Per established protocols, a patient enrolled in the clinic must complete an initial face-to-face consultation to assess the patient and educate him or her about diabetes. The educational component encompasses information on diet, exercise, MTM, treatment of hypoglycemic and hyperglycemic episodes, and performing a risk factor analysis to prevent complications from other major disease states (eg, hypertension and hyperlipidemia). In addition to MTM services, patients are assessed for potential complications such as retinopathy and neuropathy. Recommendations are also made for all patients to receive the influenza vaccine annually, and patients aged ≥65 years are encouraged to receive the pneumococcal vaccine.⁸ All tobacco users enrolled are encouraged to quit smoking during each visit, and, if interested, offered information about available smoking cessation programs. The initial face-to-face consultation qualifies the patient for phone call follow-ups to alleviate any transportation burdens. The FAMU diabetes clinic has adopted goals for glycemic control from the American Diabetes Association, including A_1C levels of <7%, preprandial glucose levels between 80 and 130 mg/dL, and 2-hour postprandial glucose levels of <180 mg/dL.⁸

Patient Follow-Ups

Patients are contacted weekly by phone or a face-to-face visit to have their progress toward achieving their specific target goals assessed. In addition, patients are strongly advised to record their daily glucose readings to determine where potential problems may arise, and where regimen adjustments need to be made. Pharmacists review daily glucose readings recorded by patients, and make recommendations on medication therapy or diet to help the patient reach his or her desired therapeutic outcomes. Because many patients have comorbid conditions (eg, hypertension and hyperlipidemia), they are also counseled to maintain a blood pressure <140/90 mm Hg, hyperlipidemia goals involving low-density lipoprotein levels <100 mg/dL, and triglyceride levels <150 mg/dL.⁹ After consultation, the patient’s primary care provider is informed via electronic medication record about any diabetes and/or chronic disease complications, and how they were addressed. Phone calls or face-to-face follow-ups continue until therapeutic goals are met, or until the patient is dismissed for missing 4 scheduled follow-up visits, after which their primary care provider, at their next routine appointment, follows up with the patient.

Enforcing Patient Trust and Accountability

The clinic has approximately 40 patients enrolled, and sees 6 patients for in-office appointment s for about 1 hour per week. A majority of the patients prefer phone call follow-ups to face-to-face visits because of the convenience and lack of transportation needed. Because the clinic only has 1 pharmacist, a limited amount of patients can be seen. Therefore, most referrals include patients who have microvascular or macrovascular complications and consistent out-of-range A_1C levels for more than 6 months. Although the clinic has only been established for 2 years, many patients have responded positively to the program.

Initially, many patients are unsure what to expect, especially when they learn that a pharmacist will be providing their care. After the initial in-depth, face-to-face interview, many patients realize that they have to be accountable for their own health. The accountability is enforced because of the required blood glucose monitoring and the weekly follow-ups. The trust and rapport that develops is an aspect many patients enjoy and it can help them achieve the interventions they truly need at times, such as starting insulin therapy. Patients who achieve their goals and are successfully discharged will sometimes continue to keep in touch with the clinic, ask questions, and stop by to greet the pharmacist and student pharmacists.

We currently have an ongoing study examining the outcomes of the clinic since its originality. Therefore, we do not have any data to release at this time; however, there have been numerous success stories further solidifying the importance of the clinic. One example is of a patient who was referred to the diabetes clinic with an A_1C level of 11%. The patient was properly educated on the many important components of managing diabetes, such as, medication compliance, diet, and exercise. The largest obstacle the patient overcame was her reluctance to start insulin therapy, which was needed because her oral medications were not effective. After approximately 3 months, the clinic was able to effectively lower the patient’s A_1C to within therapeutic levels of <7%. This type of success story is the most rewarding experience the pharmacist and student pharmacists can have, because it is a moment when they realize the impact they had on another person’s health and well-being, which can, by extension, assist the patient in various areas of his or her life.

Overcoming Barriers to Success

When the clinic was starting out, there were numerous challenges to overcome, including logistics, finding space to run the clinic, establishing protocol, incorporating the clinic into ECC’s servers, integrating FAMU’s technology with various ECC departments, determining which patients would be eligible for referral to the clinic through their primary care providers, and when patients would be eligible for discharge. There were many more challenges, but overcoming these particular barriers was essential to starting the clinic. Although some of these barriers are ongoing, protocols and technology are consistently revamped to ensure success and maintenance of the program. The most important challenge is maintaining the provision of free diabetes clinic services to the patient.

The clinic has also proved to be a great environment for fourth-year student pharmacists to enhance their patient interaction skills and ability to implement clinical knowledge in the development of effective pharmaceutical care plans, while acknowledging real-world financial issues that many patients face. Student pharmacists can assist pharmacists with tasks such as performing initial patient consultations and follow-up visits, setting up appointments, developing pharmaceutical care plans, and recording proper documentation. They make clinical recommendations and collaborate with the pharmacist and primary care physician in developing nonpharmacologic and pharmacologic diabetic interventions. ECC also provides community outreach opportunities to residents of Escambia County, FL, by hosting a monthly class targeting relevant issues regarding diabetes. This class is open to the general public, and promotes an environment where individuals can share success stories, as well as concerns, about the complications and management of diabetes.

Conclusion

The FAMU diabetes clinic within ECC has played a pivotal role in assisting the underserved population to reach his or her desired diabetic therapeutic outcomes. The clinic’s goals of assisting the community through outreach efforts are being fulfilled, and an effective learning environment for fourth-year student pharmacists is created through the service learning model. Although the diabetes clinic is still in its infancy, it has proved to be a great model of collaboration between primary care providers and pharmacists, and has helped display the breadth and depth of healthcare a pharmacist can provide.

References

1. Escambia Community Clinics, Inc. About. www.ecc-clinic.org/about. Accessed May 14, 2015.
2. Florida Agricultural and Mechanical University. Pharmacy mission, vision and goals. http://pharmacy.famu.edu/bluepill.php?sect=includes/mission. Accessed May 14, 2015.
3. Community Outreach and Service Learning (COSL). Florida Agricultural and Mechanical University College of Pharmacy and Pharmaceutical Sciences website. http://pharmacy.famu.edu/bluepill.php?sect=includes/student-services/cosl. Accessed May 11, 2015.
4. Brandt BF. Chair report for the Professional Affairs Committee. Am J Pharm Educ. 2001;65:19S-25S.
5. Florida Agricultural and Mechanical University. Crestview Instructional Center. www.pharmacy.famu.edu/bluepill.php?sect=includes/departments/crestview. Accessed May 14, 2015.
6. Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: US Department of Health and Human Services.
7. American Pharmacists Association; National Association of Chain Drug Stores Foundation. Medication therapy management in pharmacy practice: core elements of an MTM service model (version 2.0). J Am Pharm Assoc (2003). 2008;48:341-353.
8. American Diabetes Association. Standards of medical care in diabetes—2015. Diabetes Care. 2015;38 (Suppl 1):S17-S19.
9. American Diabetes Association. Standards of medical care in diabetes— 2014. Diabetes Care. 2014;37(Suppl 1):S14-S80.