Diabetes Management: Concerns in the Community

Troy Trygstad, PharmD, MBA, PhD: In your practice, do you feel like you’re out on an island, or do you solicit help?

Javier Morales, MD, FACP, FACE: Actually, I am.

Troy Trygstad, PharmD, MBA, PhD: Presumably, there are some bridges, and boats, and ways to interact, off that island…

Javier Morales, MD, FACP, FACE: That’s actually a great play, because I think all of the team members are those bridges, and those boats that could get the patients to the destination that they need to get to. What’s very nice is that you have this interdisciplinary team, which is very, very helpful. But, not every place in the United States has that luxury—especially in rural America where we’re really relying on the small town pharmacists to help with ensuring adherence, and answering any questions. As you had mentioned before, it’s about initiating a titration algorithm in patients who may be on an insulin. Or, maybe it’s about helping with some of the financial burdens that the patients may experience, because some of these agents could be a little bit more expensive.

Troy Trygstad, PharmD, MBA, PhD: Tripp, might I say that you’re a small town pharmacist?

Tripp Logan, PharmD: That’s an accurate statement.

Troy Trygstad, PharmD, MBA, PhD: How might you work with some small town physicians with updates on guidelines, updates on therapy, or even with some ways of working together that aren’t traditional practice but may speak to community events or education? You’re in a small, tight-knit community. Have you tested out any other models of collaborating that we may not have heard of?

Tripp Logan, PharmD: It’s funny because in talking about collaborative practice agreements or collaborating in a small rural area, it’s all just people. It’s me working with Dr. Robbins, and working with the other nurse practitioners in the area. We see each other at the grocery store, or at church, and it just is what it is. The collaboration is daily. There’s nothing formal. Everybody wants to put it in a box. 'Check these boxes. These are the things that you can or can’t do.' If we’ve got a patient who just started on insulin, they know that we’re a really good place to send them because we’ve got somebody who can sit down, and help them with titration, and check on them. We will call back and say, 'Hey, it wouldn’t work. We’re going to bump it up a little bit, adjust your notes, and your chart,' and so on. Also, we are going to check in on these patients, and then refer them to folks in our community, that we know, or who specialize in certain areas. So, in behavioral health, we work very closely. We have a son who plays basketball with the director of the clinic. We’ve got a personal relationship. It’s easy referral, right? What gets trickier is when we’ve got something that we specifically want to do. We’re helping each other out, and we say, 'Hey, I’ve got something I really want to talk to you about.' It’s pharmacogenomics, or something that we’re really excited about. It’s not always a good idea on the other side. That’s fine. The relationship still continues. We still greet each other in the grocery store, and we still share information back and forth. One of the challenges, in the community, is thinking, 'Well, I may burn my bridge here by throwing something out there that we think’s really important. What if they don’t like it?' Well, that’s OK. It’s something, and we need to go down that path. And eventually, over time, we have found that these things that we may have brought up 2 or 3 years ago have come around. All of a sudden, we’re collaborating on a project with the local prescriber on something that we thought was a good idea then, but it became a really good idea now.