Improving Diabetes Management: Coordinated Care

Troy Trygstad, PharmD, MBA, PhD: What’s your assessment of the effect on the patient—out there in the frontlines, in the community—where you’re seeing that patient many, many times a year, when you have that relationship with the prescriber in the community, and there’s an interaction, and a dialogue, and professional trust, and you communicate with each other fluidly, versus a scenario where you may not have that relationship, or they’re coming from a medical center that is 2 hours away, or something like that? What’s the difference in the patient who you see, not only in the relationship that you have with them, but also maybe even in some outcomes that you can observe over time?

Tripp Logan, PharmD: It’s huge. I even see it in our staff. The patient is already seeing somebody that we work very well with. We’ve got a lot of local prescribers who know we do things differently, and we know that they do things differently. So, we work well, collaboratively. I can see us engaging patients, and recommending things more often than for those who we know we’re not going to get a positive response, or even a picking up of the phone, or an answer of the fax from. And so, unfortunately, it’s to the detriment of that patient we’re taking care of. That’s a legit problem. It really is. The unfortunate thing is, a lot of prescribers see every pharmacy as exactly the same. They’re not. And every prescription doesn’t have to just fall off into the dispensing abyss, which is sometimes how it seems. We went to a clinic, and we were doing an in-service for their staff. We had some of their prescribers, social workers, and community health workers. We talked to them about challenges, things that we could do to help, and things that we did. One of the things they said was, 'We just want to know if our patients fill their prescriptions. We have no idea if they even fill them.' To me, that was an aha moment—thinking, 'Here we are. We’re trying really hard, but we need to open up this communication on our end, and back to the prescriber, too.' That’s a gap that I hadn’t considered.

Troy Trygstad, PharmD, MBA, PhD: At the VA, you would want to know?

Dhiren Patel, PharmD: Yes.

Troy Trygstad, PharmD, MBA, PhD: You’re a pharmacist at the VA. You’re working closely with folks like Dr. Morales. If that prescription goes out into the abyss, as Tripp put it, which I think is wonderfully put, what should it look like? How should it be different? What kind of relationship would you need, as a pharmacist with pharmacies in the community, for patients who had special support needs?

Dhiren Patel, PharmD: That’s definitely a big question. When that prescription is initiated, you might not be seeing that patient back again for 3 months. You’re going to be able to know if they came back for their second fill. So, I think that care coordination is important. Or, at least a, 'Hey, heads up—this patient’s not taking it, and had this adverse reaction.' There’s obviously that attractive feature of being a closed system. And so, we try to keep whatever we can in-house. That way, when I look into our computerized records, I can see their refill records. When I’m in clinic, the first thing that we have our students, and residents do, even before the patient comes in, is go through their medication list, and look at refill records. They can see a 90-day fill that lasted for 180 days. Then, you don’t need to intensify treatment. You just need to talk to them about medication adherence, and the importance of taking it on a regular basis. I understand that not everyone has it that easy. That’s why I think what you’re saying is so important. We need to have this bidirectional communication. It’s not just on the pharmacist because you didn’t write up the prescription correctly. I think we’ve evolved from that. I think both ends see this relationship maturing, and see that there are different levels of work. We recognize what one can bring to the table. So, I think the relationship has definitely improved. I know it has in our institution.

Troy Trygstad, PharmD, MBA, PhD: It sounds to me like something that would be very helpful is if that the expectations of community pharmacies were different for you? So, if there was an expectation that there was that follow up, I think it would be great if all of our diabetic patients followed up in 3 months. I don’t know what your return rate is in 3 months, but we all need help out there. It takes a village to take care of these patients. But when you’re in clinic, how are you helping a practitioner like Dr. Morales? What are some specific services that might be there for the patient, where you’re working as a team?

Dhiren Patel, PharmD: The way our clinic is set up, we have a team. I sit within an endocrine clinic. We have 3 endocrinologists, myself, and a nurse practitioner who make up our core team. And then, we obviously have the ability to refer to nutrition dieticians, social workers, and all of our other care team members. But, that consists of our core unit. We take referrals, and consults from all of our primary care colleagues. In a typical day, we carry our own panel of patients in a way very similar to what a nurse practitioner or a physician’s assistant would. But then, we’re also available for any warm transfers. Dr. Morales could see a prescription and decide, 'I’m starting this patient on insulin. He needs to know a little bit about hypoglycemia, how to inject it, and how to use a meter.' Well, his time probably could be used a little bit more effectively by seeing another patient, and by making another diagnosis. And for those, we’ll take the warm transfers. We’ll make sure that we show them the first injection in the clinic. We’ll do a demonstration for them. We’ll even have the students go downstairs, and pick up their supplies, and practice on their own supplies, if it’s the first time. But, it’s that additional time that’s needed, where they can’t fit it into a 15- or 30-minute meeting. Or, in many cases, for us it’s a follow-up, right? So, if he were to start insulin today, the patient needs to get titrated sooner than during the next 3-month appointment. On that 2-week follow-up, I can say, 'Hey, I wanted to see how your blood sugars are. What are the averages?' And if I need to, I can talk to the provider. 'In the morning, it’s still high. We’re going to go up.' So, in between the visits, we kind of close that gap, as well.

Troy Trygstad, PharmD, MBA, PhD: If you’re in an endocrinology clinic, it speaks to the intersections as well. If you need to titrate on the antidiabetic medications with a cohort where there’s high comorbidity rates with depression, it’s the same story, right?

Dhiren Patel, PharmD: We see it all.

Troy Trygstad, PharmD, MBA, PhD: There’s a need for titration. There’s a need for determining how we get to a stabilized result. That first prescription, out the door, is not necessarily where you’re going to land at 3, 9, or 12 months down the road.