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The Asheville Project A special supplement on how pharmaceutical care produced successful outcomes in diabetes patients in one North Carolina city Brought to you through a co-sponsorship from Pfizer Inc. and Glaxo Wellcome. A Romaine Pierson Publication/An MWC Company A Romaine Pierson Publication/An MWC Company Supplement to The Asheville Project A special supplement on how pharmaceutical care produced successful outcomes in diabetes patients in one North Carolina city Brought to you through a co-sponsorship from Pfizer Inc. and Glaxo Wellcome.

The Asheville Project The Asheville Project

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Page 1: The Asheville Project The Asheville Project

The Asheville ProjectA special supplement on how pharmaceutical care

produced successful outcomes in diabetespatients in one North Carolina city

Brought to you through a co-sponsorshipfrom Pfizer Inc. and Glaxo Wellcome.

A Romaine Pierson Publication/An MWC CompanyA Romaine Pierson Publication/An MWC Company

Supplement to

The Asheville ProjectA special supplement on how pharmaceutical care

produced successful outcomes in diabetespatients in one North Carolina city

Brought to you through a co-sponsorshipfrom Pfizer Inc. and Glaxo Wellcome.

Page 2: The Asheville Project The Asheville Project

Pharmacy Times 2 October 1998

Dear Pharmacist,

We would like to thank you for taking the time to learn about the Asheville

Project. Practical application of pharmaceutical care is the goal of the North

Carolina Center for Pharmaceutical Care.

We believe the pharmacists described in this special supplement of

Pharmacy Times demonstrate that patients’ health can be improved by connect-

ing the resources available in a community. We cannot say enough about their

commitment in Asheville and the courage they had to try something new.

These pharmacists participated in an intensive training program, rearranged

their workplaces, and found the time to counsel patients in their busy practices.

These men and women agreed to participate in the study for one year without

any guarantee of payment. Good things happen when people do the right thing,

and we appreciate their efforts in advancing the practice of pharmacy.

We are grateful to Glaxo Wellcome and Pfizer Pharmaceuticals Corporation

for co-sponsoring the publication of the Asheville Project as a supplement in

Pharmacy Times.

We would also like to thank the City of Asheville and Mission St. Joseph’s

Health System for their commitment to innovation.

In closing, we ask pharmacists nationwide to help us achieve the ultimate

goal of replicating the Asheville Project nationally by making the connections in

your community that will lead to the implementation of pharmaceutical care in

your practice.

Best professional regards,

Dan Garrett Fred Eckel

President Executive Director

Page 3: The Asheville Project The Asheville Project

October 1998 3 Pharmacy Times

An MWC Publication

Senior Vice PresidentJeffrey Hennessy

PublisherJames R. Granato

Associate PublisherJack Sadlon, RPh

Editor-in-ChiefBruce Buckley

Managing EditorAnn W. Latner, JD

Assistant EditorKristen Leahy

Special Features EditorEileen M. McCormick

Continuing Education EditorTom O’Connor, PharmD, MBA

Pharmacy Law EditorLarry M. Simonsmeier, JD, RPh

Hospital Pharmacy Times EditorFred M. Eckel, MS

Technology EditorMark A. Underwood

Copy EditorsKathryn Pinto, Barbara Marino

Jane Kolodziej

• • • • • • • • •

Administrative AssistantTricia McCormick

Production ManagerAlaina Pede

Graphic ArtistSusan Stewart

Special Projects CoordinatorEileen R. Lewis

• • • • • • • • •

Advertising Representatives

James R. Granato(East/Midwest)

732-656-1140 Ext. 144

Lara M. J. Fichera (East)516-997-0377 Ext. 133

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732-656-1140 Ext. 107

Peter Schulz (West)626-403-1300

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Classified AdvertisingRepresentative

Roberta Neutuch732-656-1140 Ext. 189• • • • • • • • •

Medical World Communications Corporate Officers

Chairman, CEO, PresidentJohn J. Hennessy

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Chief Financial OfficerSteven J. Resnick

COPYRIGHT © 1998 Romaine Pierson Publishers, Inc. Contents may not be reproduced without permission of the publisher. Reprints avail-able in quantity (min. 200). Write: Reprint Dept., Romaine Pierson Publishers, Inc., 1065 Old Country Road, Ste. 213, Westbury, NY 11590.Microfilm copies of articles are available through University Microfilms International, 300 N. Zeeb Road, Ann Arbor, MI 48106. Postmaster: Sendchange of address to PHARMACY TIMES, c/o Computer Fulfillment, 120 Cross Street, Winchester, MA 01890.

The Asheville Project: A Special Report

Essential Information for Today’s Pharmacist

Supplement to

Page 4: The Answer to How Is When:The Genesis of the Asheville ProjectDaniel G. Garrett, MS, FASHP

Page 6: The Asheville Project—One Year LaterFred Eckel, MS

Page 9: Walking the Tightrope to Better HealthScotti Kent

Page 11: Taking a Fresh Look at the Pharmacy Practice ModelBarry Bunting, PharmD, and Bill Horton, RPh

Page 19: Outcomes of the Asheville Diabetes Care ProjectCarole W. Cranor, RPh, MS Pharm

Page 26: Working Together to Improve Patient CarePaul Martin, MD

Page 28: An Investment in Health Offers a High Return for AllJohn Miall, Jr., ARM

Page 30: Using Existing Resources to Prepare Pharmacistsfor an Expanded RoleCindy Spillers, MS, RD, CDE

Cover photo of Ashville: Tim Barnell — All other photos: Blake Madden

Page 4: The Asheville Project The Asheville Project

Pharmacy Times 4 October 1998

H“How are we going to get community andhospital pharmacists to stop fighting over dis-criminatory pricing?” This was a question posedto me in February 1994 by Joe Edwards, thenpresident of the North Carolina PharmaceuticalAssociation. At the time, I was president of theNorth Carolina Society of Hospital Pharmacists.My response to Joe was, “When we get pharma-cists to understand that we are in a knowledgebusiness and not in a commodities market.”

Out of this discussion grew a commitment

from pharmacy leaders in North Carolina todemonstrate the benefit of pharmaceutical careprovided by pharmacists in a community-basedinitiative with a self-insured employer. It wastime to prove pharmacists’ value.

How were we going to develop a plan foran outcomes-based demonstration project? Thisquestion was answered when we invitedtogether pharmacists from NCSHP, NCPhA,Campbell University, University of NorthCarolina, the pharmaceutical industry, andPharmacy Network National Corporation (apharmacy benefits management companyowned by North Carolina pharmacists.) Thisdiverse group worked for 2 years to identifypotential self-insured employers, develop out-comes parameters, and define an educationand training program for pharmacists and aproposal for the demonstration project.

How were we going to fund the project?This was answered when the above-mentionedgroups came together to form the NorthCarolina Center for Pharmaceutical Care.

How were we going to find the communi-ty pharmacists to volunteer to provide diseasestate management for free? We had the answerwhen pharmacists in Asheville decided theywould complete the training program andagreed to begin caring for patients.

How were we going to find a payer andgain support of physicians? This happenedwhen we contacted the risk/benefit manager

The Answer to HowIs When: The Genesis of

the Asheville ProjectBy Daniel G. Garrett, MS, FASHP

Daniel G. Garrett, MS, FASHP, is president ofthe North Carolina Center for PharmaceuticalCare and Executive Director of the NorthCarolina Pharmaceutical Association.

Dan Garrett, MS, RPh, president of the North Carolina Center forPharmaceutical Care, shares outcomes with Asheville Project participants.Improvements were shown in the areas of quality of life, lab values, satis-faction with pharmacy, and costs to payer.

Page 5: The Asheville Project The Asheville Project

October 1998 5 Pharmacy Times

for the City of Asheville and asked physiciansin Asheville to review our proposal and giveus input.

How were we going to get a project ofsuch complex magnitude under way and makesure we had taken care of all the details? Whenwe decided to start! We knew we were makingthis up as went along, so we simply began tocare for patients.

How are we going to follow up on the suc-cess of the Asheville Project? We took action onthis when we started openly sharing ourprocesses and results. Now we have pharma-cists across our state who are interested, wehave payers who are interested, and we havepharmacy educators who are interested in try-ing this in their communities.

Have we done anything that others haven’tthought about, written about, or even done?No. We just did what we knew was right. Westarted with a few pharmacists and built upon

the relationships that existed within a localcommunity. I was recently asked what webased the Asheville project on. I couldn’tanswer this question. Sometimes you just actintuitively.

Joe Edwards and I talked again in July ofthis year. Joe and I discussed how were wegoing to form a pharmacist network for pro-viding and contracting for reimbursement forpharmaceutical care. Pharmacists have beentalking about this in our state for over a year.Joe and I concluded that this would happenwhen we decided to form the network. Thenetwork will be formed in October 1998.

We have come a long way since the initialcontroversy over discriminatory pricing. Pharma-cists are now getting paid for what they know.

How will you make this transformation inyour community? When you begin.

We hope the story of the how the Ashevilleproject began will help you decide when.

Genesis of Asheville Project — Continued from page 4

“I have had diabetes for 10 years, and the education I received at the Diabetes Center taught me things Inever knew.The pharmacist helps me and encourages me on diet and exercise. I have lost weight and feelbetter.”

–Doug Ingle, retired Sanitation Supervisor

“This is the best thing that has ever happened to me and my son.The pharmacist has pushed me, and I'vecontrolled my diet, started walking, and am quitting smoking (down to four cigarettes a day from threepacks a day). I was diagnosed with diabetes 5 years ago, probably had diabetes longer…and haven't feltbetter in years.”

–Madge Beheler, Fire and Police Dispatcher and mother of diabetic who is in the Program

“I think of the pharmacist as my coach. I have a much stronger sense of well-being because I know I have agood support system now. I am thrilled with the program, and with Bill’s (pharmacist) help, I’ve formedbetter habits, like monitoring my blood sugar every day. And I’ve set goals to enable me to feel even morein control of my health.”

–Pat Leckey, City Accountant

“I have had diabetes for 19 years and have never really been under control. Before the program, my bloodsugar would average 180…now it is 143. I check my blood sugar four times a day now, and I used to checkit maybe once or twice a day. The pharmacist cares about me.”

–K. K.Waddell, retired Captain of Fire Department

Comments from City of Asheville Participants

Page 6: The Asheville Project The Asheville Project

Pharmacy Times 6 October 1998

The Asheville Project—One Year Later

By Fred Eckel, MS

CCan all these opportunities really be relat-ed to the Asheville Project? How can we getdone all that needs doing as a result of thisproject? These are the questions I seem to beasking myself frequently. So many things havehappened since the Asheville Project gotunder way that it is hard to accept that theyare not related to this Project. Maybe theywould have happened anyway but it seemslike the Asheville Project has stimulated a lotof activities.

One conclusion that became apparent asthe Asheville Project got under way was thatfor the project to continue there would need tobe some organization that could negotiate onbehalf of the pharmacist. Such an organizationcould facilitate the billing process, assure thequality of care provided, as well as determine

what new pharmacists would be eligible to par-ticipate in the process. Pharmacists from otherregions of the state, perhaps stimulated bywhat was happening in Asheville, also begantalking about the need to establish a network.North Carolina pharmacy is in the process ofestablishing a statewide PPO as a membershiporganization controlled by pharmacists tonegotiate with employers to provide pharma-ceutical care services to their employees. Weanticipate that the statewide network will workwith local pharmacist networks that are also inthe process of formation. Based on ourAsheville experience, it is apparent to us thatdisease management or health managementprograms, as I prefer to call them, will best beaccomplished through local initiatives.Eventually, regional or national employers orpayers may get into the act, but our greatestsuccess will come through local projects. Thatis why we are encouraging the formation oflocal IPAs even as we develop a statewidepharmacist network.

The Asheville Project seemed to providealmost instant credibility to the skeptical phar-macist that cognitive services was not some-body’s pipe dream. It did represent an oppor-tunity for pharmacists who wanted to practiceinto the 21st century. We collected datathroughout the project and shared the prelimi-

Fred Eckel is professor and director, Office ofPractice Development and Education at theUniversity of North Carolina at Chapel Hilland executive director of NCCPC. He is alsoeditor of Pharmacy Times’ Hospital/HealthSystems edition.

“Our goal is to help individuals manage their disease through lifestylechanges that only they can make,” says Bill Horton, RPh, shown here at the12-month follow-up meeting for the Asheville Project.

Page 7: The Asheville Project The Asheville Project

October 1998 7 Pharmacy Times

nary results at pharmacy meetings across thestate. What we told pharmacists was that reim-bursement for diabetes management occurred3 months into the project and that pharmacistswere receiving upwards of $300 per patient,per year for this service. This got a lot of atten-tion. We are in various stages of communica-tion with at least five areas of North Carolinawhere we think a diabetes management pro-gram can be initiated. The interest in duplicat-ing the Asheville Project in other communitiesmay lead to the recruitment of a staff person tofacilitate community development efforts topromote diabetes management initiatives bypharmacists.

It was exciting to see pharmacists actuallyget involved in the training program to do dia-betes education and management. It was evenmore exciting to hear those pharmacists talkabout how they have changed their practice toaccommodate this new role. When an olderpharmacist with many years of practice realizesthat he or she can make a difference in thatpatient’s life, both the pharmacist and thepatient get excited. When this pharmacist tellsthe story of this successful encounter, otherpharmacists quickly gain the needed confi-dence to participate. Once pharmacists start towork with patients and realize that they can doit, once patients experience the benefits andbegin to appreciate the pharmacists’ contribu-tions, and once other health care professionalsreceive communications from pharmacistsabout their patients and see how pharmacistscan contribute to patient care as team mem-bers, changes in the care of diabetic patientsoccur. The resulting outcomes are very benefi-cial for everyone, especially patients. When apharmacist says to me, “I really have becomeexcited about this new role. I really feel appre-ciated by the patient in ways that I haven’t feltappreciated for a long time,” it makes all of thehard work worthwhile. When other pharma-cists hear about this new practice, they toobegin to realize that they can do it. As morepharmacists believe they can do it, the entiremovement begins to snowball.

Pharmacists recognize that there will be aneed for new skills to do what is being request-

ed. This places an increased demand on thepostgraduate education system in NorthCarolina to meet these needs. Yes, there hasbeen an explosion of interest in certificate pro-grams, but there are not enough programsavailable to train all the pharmacists necessaryto meet the growing demand for pharmaceuti-cal care services. To focus attention on gettingthe right kinds of programs available, the stateassociation and the two schools of pharmacythat are the primary providers of continuingeducation in North Carolina have agreed towork together to develop a postgraduate edu-cation strategic planning initiative. A meeting ofinterested individuals will be held this fall todevelop the plan. Although all of the elementsare not defined, we are considering how wecan tie the statewide meetings being conduct-ed by various professional organizations andthe evening programs conducted by local asso-ciations into a plan to facilitate certificate pro-gram development. Perhaps the didactic com-ponent that makes up a portion of certificateprograms could be developed through localassociation programming. Maybe the work-shops that are offered at statewide meetingscould focus on the skills development, whichare a part of certificate programming. Althoughit will not be easy to accomplish, it makessense that working together is necessary tohave an adequate number of pharmacists pre-pared to deliver the pharmaceutical care ser-vices that will be demanded. A strategic planseems essential to make this happen.

Another issue the Asheville Project hasraised is how to assure that pharmacists remaincompetent to provide services. Just becauseone has successfully completed a certificateprogram and is even providing pharmaceuticalcare services to specific patients does not meanthat he/she is keeping up with new develop-ments in the field. Part of our strategic plan forpostgraduate education will include ways bywhich we can facilitate the continuing growthof pharmacists engaged in health managementefforts. The issue of how to renew certificates,however, will require a clear understanding ofthe problem and wisdom in selecting an appro-priate mechanism to assure continued compe-

Page 8: The Asheville Project The Asheville Project

tency without creating hurdles that will be toodifficult to manage or too cumbersome forpharmacists to fulfill.

The success of the Asheville Project gaveincreased visibility to the North Carolina Centerfor Pharmaceutical Care (NCCPC), the sponsorof this project. This organization continues toreceive inquiries from across the country onhow others might duplicate the AshevilleProject, and we gladly share what informationwe have. As North Carolina pharmacists andothers within the health care community beganto recognize the potential the NCCPC organiza-tion represents, several important developmentshave occurred. There is a growing sense ofcooperation occurring within the whole phar-macy community. This sense of cooperation hasagain stimulated a number of initiatives. As thepharmacist has become recognized as an essen-tial component for an effective disease manage-ment program, we have been asked to sendrepresentatives to various health care initiativesthat state agencies and private organizationshave started. These developments occurred atleast in part because we did an excellent job ofcommunicating the results of the AshevilleProject within the Asheville community as wellas to the health care community in NorthCarolina. A special issue of The CarolinaJournal of Pharmacy was devoted to theAsheville Project and was distributed, with sup-port of NCCPC, to pharmacist managers in com-munity pharmacies across North Carolina.

The success of the Asheville Project result-ed from the cooperation of pharmacists in thecommunity and hospital setting. Although themovement to achieve a one voice/one visionorganization in North Carolina did not occurspecifically because of the Asheville Project, Ibelieve the Project has contributed to themomentum and support for the single pharma-cy organization structure in North Carolina. Aunification program is in full swing, and per-haps NCCPC might be subsumed into the neworganizational structure as the research anddevelopment arm of the “North CarolinaPharmacist Association.”

When the Asheville Project started, it be-came apparent that for pharmacists to function

effectively in these new roles they would needto obtain and practice a new skill set in orderto become comfortable providing health man-agement services. To prevent a proliferation ofeducational programs unable to adequatelyprepare pharmacists for these new roles, theNCCPC established the Certificate ProgramReview Committee (CPRC). It was suggestedthat all certificate programs conducted in NorthCarolina be submitted to this organization forreview and approval. The CPRC would assurethat the programs comply with the agreed stan-dards for certificate programming developedby a task force convened by the deans of thetwo North Carolina schools of pharmacy. Thisfall, the CPRC will be evaluating those stan-dards to see if they are adequate or should bechanged and will also be addressing the needto reissue certificates for graduates of certificateprograms.

The Asheville Project gave North Carolinapharmacy visibility on the national level.Because of it, people associated with the pro-ject have been invited to discuss their experi-ences and the results achieved to national andother state audiences. It has even attracted theattention of members of the pharmaceuticalindustry who have approached us about devel-oping special projects with them to improvedrugs therapy outcomes. These new relation-ships solidify the value of the pharmacist as anessential contributor to the team care ofpatients. We are beginning to identify howthese cooperative efforts can lead to win/winoutcomes for everyone. In the words ofColonel John “Hannibal” Smith (GeorgePeppard), the leader of the A-Team, “I love itwhen a plan comes together!”

Pharmacy Times 8 October 1998

NOTE: The following organizations cametogether to create NCCPC, and we appreciatetheir willingness to invest in pharmacy’s future:NCPhA, NCSHP, NCASCP, Campbell UniversitySchool of Pharmacy, UNC School of Pharmacy,Eli Lilly, Novo Nordisk, Bayer, Pfizer Inc., GlaxoWellcome, CVS, Pharmacy Network NationalCorporation, Mutual Drug Patient Care, Merck,Roche, and Kerr Drug.

W

Page 9: The Asheville Project The Asheville Project

The Asheville Project:Walking the Tightrope to

Better Healthby Scotti Kent

October 1998 9 Pharmacy Times

WWhat is it like to live with diabetes? In thewords of one woman, diagnosed with diabetesin 1968 at the age of 18: “Living with the dailystress of trying to keep blood glucose levels incontrol is a balancing act more death-defyingthan that of the tightrope walker.”

Indeed, the challenges that confront peo-ple with diabetes would intimidate many ahigh-wire acrobat. Giving oneself insulin injec-tions; monitoring blood glucose levels; plan-ning food intake to make sure insulin is cov-ered, at the same time trying not to take in toomany calories; trying to time meals and snacksto cover the absorption rates of the insulin;dealing with insulin reactions when theyoccur; and making sure energy output andexercise is also balanced with insulin and foodintake—all are part of daily life for thoseafflicted with diabetes. No wonder they areeager, even desperate, to comprehend what isgoing on in their bodies, to find ways to copewith the craziness, to talk to someone whounderstands and will support their efforts tomanage this devastating disease.

The nature of diabetes and the difficultiesfacing its victims made it an ideal choice forthe first disease management pilot projectundertaken by the North Carolina Center forPharmaceutical Care (NCCPC), a coalition ofstate pharmacy organizations. Members ofthe NCCPC have long believed that pharma-cists need to become much more than dis-pensers of medications. Several key factssupport their belief:

• Pharmacists already have a basic under-standing of medication therapy.

• Resources exist—often locally—to helppharmacists expand their role for specificdiseases to that of counselor, clinical edu-cator, and patient advocate.

• People with chronic illnesses like dia-betes see their local pharmacist five timesmore often than any other health careprofessional. With these factors in mind, in early 1997,

the NCCPC teamed with Mission St. Joseph’sHealth System in Asheville, North Carolina,local pharmacies, and the City of Asheville toconduct a year-long study on the impact phar-macists can have on the ability of people withchronic illnesses to manage their disease. Thegoals of the project were to enhance physi-cians’ efforts, improve the health of patients,and save money for payers.

Accenting Community InvolvementNCCPC was aware that a number of com-

mercial companies were marketing diseasemanagement programs to employers to helpthem keep down costs. NCCPC’s goal was notonly to emphasize this expanded “pharmaceu-

Scotti Kent is a freelance health care writerand editor based in Asheville, North Carolina.

“A chronic illness like diabetes

requires a lot of self-management,”

says Jeff Russell, MD, endocrinolo-

gist and medical director for

Mission St. Joseph’s Diabetes

Center. “Pharmacists educated and

trained to assist in the management

of that specific health problem can

make a difference.”

Page 10: The Asheville Project The Asheville Project

Pharmacy Times 10 October 1998

tical care” role for community pharmacists, butalso to design a program that was truly a com-munity-wide effort. To test their idea, theyneeded an employer who was willing to par-ticipate. The City of Asheville was identified tothem as a progressive payer.

With a handshake, the Asheville Project waslaunched in March 1997. To prepare for theirexpanded role, 24 community pharmacistsattended intensive training sessions conductedby local physicians, dietitians, nurses, and otherpharmacists. The classes were coordinated byThe Diabetes Center of Mission St. Joseph’s andfunded in part by a grant from Eli Lilly.

The project was configured to include notonly the employer/payer and the communitypharmacists, but a university—in this case theUniversity of North Carolina at Chapel Hill—tohandle the research component. The schools ofpharmacy at UNC-Chapel Hill and at CampbellUniversity in Buies Creek have both beeninvolved in the study—in the training programfor the pharmacists and overseeing the out-comes measurement and analysis.

Following training and education of thepharmacists, the next step in the study was tonotify each patient’s physician about his or herparticipation, and invite input from the physi-cian. Each participant was then matched with apharmacist.

Moving ForwardThe Asheville Project has been so successful

for people with diabetes, a second study isalready under way involving asthma patients whowork for the City of Asheville. Also, considerableinterest has been shown at the state and nationallevel. The NCCPC has been invited to share itsfindings with HCFA (Health Care FinancingAdministration), representatives from Medicaid,and the City of Raleigh, North Carolina.

Employers are taking note as well. The Cityof Asheville has decided to continue the projectfor employees with diabetes and add a pro-gram to address asthma. Mission St. Joseph’s,the largest employer in Buncombe County,North Carolina, has decided to offer similar dis-ease management services to employees begin-ning in 1999.

View from the TightropeIn Webster’s Collegiate Dictionary, the sec-

ond definition of “tightrope” is “a dangerouslyprecarious situation.” As might be expected,people walking a tightrope need support fromothers, whether it be support through educa-tion and counseling, or just the knowledge thatsomeone cares. It is especially helpful if sup-port is available from a person you can contactat almost any time, almost any day of the week.

The positive responses from participantsspeak volumes about the value of the servicepharmacists have provided through TheAsheville Project. These comments are rein-forced by the data, which reveal improvementsin health, health care costs, and the way peo-ple with diabetes look at their lives. For manyparticipants, this is the first time they have feltconfident enough to look up and see a futurefor themselves, instead of focusing only on thethin wire beneath their feet, wondering whenthey will lose their balance and fall. Thanks toThe Asheville Project, they are no longer work-ing without a net.

Key participants in the Asheville Project include:

• Patients

• Community Pharmacists

• Employer/Payer : City of Asheville

• Coordination/Funding:–NCCPC, Chapel Hill–Mission St. Joseph’s, Asheville

• Outcomes Measurement/Analysis:–University of North Carolina at Chapel Hill–Mission St. Joseph’s Outcomes Department, Asheville–Mission St. Joseph’s Laboratory, Asheville

• Grants for Education/Training:–Eli Lilly–Pharmacy Network National Corporation (PNNC)

• Pharmacists’Training:–Mission St. Joseph’s Diabetes Center, Asheville–Local Physicians, Asheville–Campbell University, Buies Creek

A Team Effort

Page 11: The Asheville Project The Asheville Project

October 1998 11 Pharmacy Times

The Asheville Project:Taking a Fresh Look at thePharmacy Practice Model

by Barry Bunting, PharmD, and Bill Horton, RPh

TThe pharmacy practice model that has

served pharmacy for decades is at risk. Thismodel has served us well, at least financially.However, this financial base has been erodingfor years due to decreasing fees and, morerecently, due to the added threats of mail-orderand automated dispensing technologies.

Roles change for a variety of reasons.Basically, we change when we are motivated todo so. Sometimes this is self-motivated change,but more often than not the stimulus comesfrom outside forces. For at least the past 25years, schools of pharmacy have been attempt-ing to motivate and prepare pharmacy studentsto change their roles. There have always been,and continue to be, significant barriers to estab-lishing real-world pharmaceutical care practicemodels, but now there is a growing sense thatthese barriers need to be overcome very soon.As a result, a number of initiatives across thecountry are attempting to establish new rev-enue streams based on the provision of phar-maceutical care. One such initiative that hasexperienced some success in probing thesebarriers is The Asheville Project.

Breaking Down the BarriersWe ourselves—the pharmacists—are one of

the most significant barriers standing in theway of a new pharmacy practice model. We

have a professional inferiority complex. Toovercome this, pharmacists need to be awarethat many important medication-related patientneeds are not being adequately met. There isample literature documenting that our societysuffers from significant medication-relatedproblems. Second, as pharmacists, we need tobe convinced that we can solve the problem.There is also a growing body of literatureshowing that pharmacists can indeed help.Third, we need to be convinced that peoplewho are made aware of these needs will pay—or demand that someone pay—to have theseneeds met. “If we build it, they will come” hasbeen our experience in Asheville.

The most obvious barrier can be describedby the expression “show me the money.” Ourprofession must demonstrate that our servicessave more health care dollars than they cost.

Barry Bunting, PharmD, is clinical managerof Community Pharmacy Services for MissionSt. Joseph’s Health System in Asheville; BillHorton, RPh, is owner of Beverly Hills PSAPharmacy in Asheville.

Weaverville Drug Co. has the look and feel of “the old days,” but the phar-maceutical care offered there by Pharmacist Chuck Sprinkle is leading theway to better outcomes for people with chronic illness, such as diabetes.

Page 12: The Asheville Project The Asheville Project

Pharmacy Times 12 October 1998

Then we must use our successes to convinceincreasing numbers of payers (patients andthird parties) that these services are worth pur-chasing. This is the area that needs our greatestattention. Fortunately, we have begun to seethe financial results of some pharmaceuticalcare outcomes from studies like The AshevilleProject. We need to build upon and skillfullymarket these small successes, or we will havepockets of excellence instead of a new phar-macy practice model.

The involvement of chain pharmacies willbe critical to the success of any new model.Chain pharmacy management will need to beconvinced that pharmaceutical care “pays.” Ifnot convinced, they will settle for high-volumeprescription filling via automation and fillingcenters that distribute prescriptions to theirstores for patients to pick up. Chain stores needto maintain store traffic. If offering pharmaceu-tical care in their stores generates new revenueand also brings people into stores where theywill then purchase other items, chains can beexpected to support pharmaceutical care. Ofcourse, pharmaceutical care will also have to

“pay” for independents.A less obvious barrier is the lack of an

integrated health system. Whenever a patientis in “the system,” the body of informationabout that patient needs to be available to allhealth care providers interacting with thepatient at the time. Providers might include ahome health nurse, a community pharmacist,an emergency room physician, a hospitalpharmacist, or a physician who is covering fora partner who is out of town. Like most com-munities, Asheville, North Carolina, does nothave a fully integrated health information net-work. This is perhaps the single biggest barri-er to providing exceptional health care in acommunity.

In the meantime, we have to work withwhat we have. We must establish relationshipswith other health care professionals so therecan be a free flow of information aboutpatients. As pharmacists, we need to use fax,phone, and mail to communicate informationthat we have to other health care providerswho have a stake in the care of the patient, andvice versa. We must “connect the dots” inhealth care. To do this, pharmacy must teachthe other “dots” that they can benefit frombeing connected to us.

In Asheville, we have been successful inconnecting community pharmacists with anemployer and their employees with diabetesand asthma. We have also established connec-

Weaverville Drug Co. in Weaverville, NC.

Lord’s Drug Store in Asheville, NC, offers “one-stop shop-ping” within the convenient location inside a supermarket.

Page 13: The Asheville Project The Asheville Project

October 1998 13 Pharmacy Times

tions between community pharmacists and theDiabetes Center nurses, dietitians, endocrinolo-gists, and, more recently, with asthma special-ists. These pharmacists also obtain patientrecords from primary care physicians and com-municate information to physicians on thesepatients. Permission to receive and send patientinformation is not a big barrier in our experi-ence. We simply have patients who enroll inthe program sign a request for release of med-ical information, which allows the pharmacistto obtain and communicate medical informa-tion about the patient. Even though we havebeen successful in connecting several “dots” inour community, we have a long way to go tohave a truly integrated system. Pharmacy canact as a force in a community to stimulate thisinformation integration.

The physician community can also be abarrier. Physicians are under tremendous pres-sure from every direction. Breaking down thisbarrier involves educating physicians aboutwhat pharmaceutical care is and is not. Mostphysicians we have talked to one on one verycandidly admit that they do not always havetime to do their best. They actually do atremendous job given the constraints underwhich they work. They really do care. They justdo not have the time or resources to do every-thing that needs to be done, especially withregard to monitoring medication therapy.Physicians have come to the realization thatthey need to spend their time concentrating onwhat only they can do, which is why we areseeing more physician assistants and familynurse practitioners. If we pharmacists offer our-selves as another type of physician extenderand we do it in a service-oriented way and limitit to our area of expertise (medication use), ourexperience has been that physician resistanceis minimal. We need to look for opportunitiesto make these points with physicians.

At the beginning of our project, we usedevery means we could think of to communicatewith physicians about the project, includingindividual letters to physicians informing themthat their patient had enrolled in an employer-sponsored wellness program, pharmacy andtherapeutics committee presentations, pharma-

cy newsletters, and a letter from the City ofAsheville medical director. Despite all theseefforts, a number of physicians did not “get themessage.”

Physicians feel that they manage theirpatients’ chronic illnesses, and pharmacistswould be wise to avoid the term “pharmacistdisease management program.” In reality,patients manage their own chronic disease,with assistance from others. And they eithermanage it well or they don’t. Pharmacy’s rolein disease management is to help patients,physicians, and other health care professionalsmanage chronic illnesses better than they cur-rently do without pharmaceutical care.

Another concern expressed by one physi-cian was: “Isn’t this further fragmenting analready fragmented system?” If pharmacy weretrying to create another “dot” this could be thecase. But we aren’t. We already exist and are,in fact, the most accessible health care profes-sionals. (For more insight in physician issues,

At Kerr, Pharmacist Phil Crouch is a perfect example of howeven large chain drugstores can offer personalized, “user-friendly” services that help people improve their health.

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Pharmacy Times 14 October 1998

see the article by Paul Martin, MD, in this spe-cial edition of Pharmacy Times.)

Our message needs to be: “It is broken.Pharmacy can help fix it.” We need to teachphysicians that we have information they needand convince them we can and will help themmanage their patient’s illness. Communitypharmacists in particular have information thatprimary care physicians need. Physicians needto know if their patient filled the prescriptionthey wrote (nearly 15% of patients don’t); theyneed to know if they are taking it (about 13%of patients don’t, even if they get the prescrip-tion filled); they need to know if the medica-tion is working; and they need to know if themedication is causing their patient any prob-lems that need to be resolved, especially ifthose problems have caused the patient tostop taking the medication. Most important,the physician needs to know these thingsbefore the patient’s next appointment, whichis months away.

An additional barrier is that pharmacists

need to develop some skills that we have nottraditionally been taught. How many pharma-cists know the nuances of downloading a glu-cose meter? How many pharmacists candemonstrate how to use a peak flow meter?How many pharmacists would know how toassess a patient who is on phenytoin for nys-tagmus or ataxia? How many pharmacistswould know how to assess the adequacy ofdiuretic therapy by listening for rales, or thesignificance of the “yellow zone” for an asthmapatient? At first glance, learning these mayseem daunting, but another lesson we havelearned in The Asheville Project is that this isnot rocket science. It does not take hundreds ofhours and an advanced degree to learn sup-plemental skills that make a difference. We canlearn these things without a huge investment oftime or money. What a project like this doestake, however, is motivated pharmacists whoare willing to make commitments to learn newthings and to venture outside their comfortzones. Initially, our pharmacists were definitelyremoved from their comfort zones. There wasconsiderable anxiety on the part of the com-munity pharmacists that we trained. “Can I real-ly do this?” was the question in the minds ofmany. But not only did they do it, they did itvery well. One illustration of their success isthe objective data we obtained that shows sta-tistically significant reductions of the hemoglo-bin A1c in our study group.

To expand pharmaceutical care successesinto a new model, we will need a critical massof pharmacists who are willing to developnew comfort zones. Without that, even if theopportunities are created, this new pharma-ceutical care model will not happen. If we areinterpreting the current forces correctly, wewill have a new model whether or not wedesign one. The problem is, if we do notbecome involved, it will not be one we arecomfortable with.

Program ParticularsAs participants in the diabetes segment of

The Asheville Project, pharmacists are expect-ed to spend in-depth “quality” time with peo-ple who have diabetes, to monitor and help

At Lord’s, Kim Ferguson, RPh, provides “food for thought” topeople with diabetes seeking to better manage their health.

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October 1998 15 Pharmacy Times

them manage their own health. We also pro-vide information to that person’s physicianabout drug interaction or make suggestions if aparticular form of drug therapy fails. We alertthe physician if someone is not taking his orher medication as prescribed. Our goal is tohelp individuals manage their disease throughlifestyle changes that only they can make.

Before we could begin doing any of thesethings, however, several important steps had tobe completed. To pharmacists who are interest-ed in following in the footsteps of The AshevilleProject, we offer the following advice.

Training and EducationIt is absolutely essential that you obtain

education and training from experts. Yourknowledge base needs to be expanded toinclude those topics which are currentlyacknowledged as the national standard:Standards of Knowledge, Standards of DiabetesEducation, and Standards of Medical Care.

For The Asheville Project, we were fortu-nate to be able to tap into a communityresource that has been available to people withdiabetes in our community for many years: TheDiabetes Center of Mission St. Joseph’s. (Seethe article on “Training” by Cindy Spillers inthis issue of Pharmacy Times.)

Behind the ScenesNo program with the scope of The

Asheville Project can be successful without a“point person,” a coordinator who acts as aconduit and overseer. This person is responsi-ble for assembling all the pieces—the talent,

knowledge, and enthusiasm of participants—into an efficient, effective program.

Among the project coordinator’s duties are:• Matching participating patients with

pharmacists• Communicating with all participants• Development of necessary forms• Scheduling of laboratory determination for

study patients• Collecting data• Tracking the flow of information and the

progress of each individual in the program. • Acting as a mentor to participating pharma-

cists, making time to answer questions anddiscuss the various elements of the project.

In order to decide which pharmacist a per-son would consult, the coordinator for TheAsheville Project provided a list of trained phar-macists and asked patients who were enrollingto indicate a first, second, and third choice ofpharmacy location. Using that information,

Barry Bunting, PharmD, explains to patient Charles Saggus ofAsheville how managing diabetes contributes to overall health.

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Pharmacy Times 16 October 1998

each person was matched with a pharmacist.We tried to make sure that every pharmacisthad about the same number of patients. As itturned out, most people were assigned to theirfirst choice.

Getting participating pharmacists togetherregularly to talk about the program and toshare experiences is a key factor in communi-cation. Meeting individually with the pharma-cists is also important. We found it helpful totry to schedule a group meeting about 3months into the project, then again at 6 and 12months. Logistically, this is very difficult, givencommunity pharmacists’ schedules, and it issomething we need to figure out how to dobetter in the future. It is important to encour-age the pharmacists to discuss their success sto-ries as well as what could be improved. Thefirst year of a program like The AshevilleProject is the most critical, especially when itcomes to measuring outcomes.

The clinical coordinator for the diabetes seg-ment of The Asheville Project also worked full-time as a pharmacist for Mission St. Joseph’s.Administrative coordination for the project tookabout 20 hours a week during the first 2 weeks.Much of this time involved identifying patientsfrom the employer-provided PBM prescriptionrecords and arranging for group patient meet-ings to fill out forms and draw blood. A fairamount of this time falls into the clerical catego-ry, and anyone considering coordinating such aprogram would do well to plan for several hoursof secretarial time per week (on average). Thetime commitment peaked again at the 6-monthand 12-month follow-up points.

Taking StockIn addition to receiving special education

and training, you will need to take an invento-ry of the diabetes-related products alreadyavailable in your store. You will want to have awell-stocked diabetes department. Even moreimportant, familiarize yourself with these prod-ucts so you can teach others how to use themwith confidence.

Ideally, you should designate a separatearea for counseling. Design your work sched-ule to allow uninterrupted time to meet withparticipants. Set up a filing system for docu-mentation and a method for billing your ser-vices. Make sure you have plenty of copies ofany handouts or forms you plan to use.

The Initial ConsultationOnce a patient has been matched up with

a pharmacist, the pharmacist calls the patient toarrange for a counseling session time that isconvenient for both. The initial sessions takeabout 60 minutes on average.

If the client is not familiar with the servicebeing provided, help him or her understandwhat you hope to accomplish together. Take adetailed history using standard forms providedfor that purpose.

Learn as much as you can about what com-munication style will work best with a particu-lar individual. Pharmacists participating in TheAsheville Project have been testing “PatientCommunication Insights,” a computer softwareprogram that offers “a quick and inexpensivemethod to assess behavioral characteristics thatinfluence patients’ actions in a medical setting.”Patients complete a one-page personality pref-erence questionnaire, and the information isentered into the computer by the pharmacist.Based on these personality characteristics, theprogram provides “tips” to the caregiver onhow to increase that individual’s level of trustand compliance. “Patient CommunicationInsights” is being comarketed by the NorthCarolina Pharmaceutical Association andHealth Care Insights.

Help the person set goals regardinglifestyle changes he or she would like to make.To many people, just knowing that they are

Medicap Pharmacy in Black Mountain, NC.

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October 1998 17 Pharmacy Times

going to be monitored is an incentive. Let themknow that this is a team approach and that theyare the most important members of the team.

Provide any necessary training, such as howto use a glucose meter or how to mix insulin.

Record and document everything in a stan-dard format such as FARM (finding, assessment,recommendation, monitoring) or SOAP (sub-jective and objective findings, assessment, andtreatment plan).

Plan follow-up visits. These should takeplace at least once a month, and in our experi-ence they average 20 to 30 minutes per patientper month.

Physician CommunicationA team approach is central to the success

of pharmaceutical care. Let each referringphysician know that you have met with his orher patient. Explain what you hope to accom-plish. Ask physicians to tell you if they haveany special orders, instructions, or goals for theperson. It may be helpful to actually list themost likely areas with respect to the particulardisease being managed. For diabetes, this listmight include how often to monitor blood glu-cose, diet, exercise, blood sugar goals, weight,lipids, blood pressure, and smoking and alco-hol use. Assure physicians that you will followup regularly with them.

Follow-up MeetingsDuring follow-up meetings, you can build

on what has already been learned and provideadditional training or review past education.Monitor the person’s blood sugar levels overthe past month. Ask about problems or ques-tions the person may have. Document themeeting.

Rules for the WiseIn our experience, the following should be

considered “commandments” for any pharma-ceutical care program.

Pharmacists should participate in diseasemanagement by reinforcing the physician’splan of care. The physician in turn should befollowing national guidelines with individualcustomization as appropriate. These guidelines

are available and should be a reference pointfor the pharmacist.

It is essential for pharmacists to receiveappropriate training and education on diseasesthey expect to help manage and to maintaintheir expertise. Objective certification lendscredibility and an assurance that adequatetraining has taken place.

Written policies and procedures must beused consistently for all specialized services,such as drug monitoring, disease monitoring,and disease management.

Why the New Model Works“Structured accountability with financial

incentives.” We believe this phrase summarizeswhy the new model has worked for us. Thefinancial incentive for patients is that their co-pay will be waived if they go to a particulartrained pharmacist (who is at a location that thepatient has selected from a list of trained phar-macists). For the pharmacists, the financialincentive is that they will be paid for this cog-nitive activity. The financial incentive to theemployer, in this case a self-insured employer,is that healthier employees with diabetes willhave lower overall health care costs. There isbuilt-in accountability due to the fact thatpatients need to get their medications and sup-plies somewhere on a regular basis and theywill go to this particular pharmacist because, ifthey do, it will cost them less. While they are

A popular feature of the Medicap Pharmacy is its time-savingdrive-up window. Inside, Ruth Higgins, RPh, spends as muchtime as needed to counsel and educate participants in theAsheville Project.

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Pharmacy Times 18 October 1998

there, the pharmacist will praise them if theyare doing well and “pester” them if they arenot. They know the pharmacist will ask them ifthey brought in their meter and will check theirweight. Therefore, they are motivated to do thefinger sticks and follow their diet instruction.They know someone is watching. We all dobetter if we have an accountability partner,whether the goal is smoking cessation, weightloss, or blood sugar control. This model struc-tures such a relationship, initially almost pure-ly based on financial motivation.

Some would say the new model is really areturn to the old model. In days gone by, phar-macists had time to have a one-on-one rela-

tionship with a patient. We knew what wasgoing on, what was working and what wasn’t,and could intervene when a problem was iden-tified. The commodity part of our professionhas pulled us further and further away fromthis relationship. Presumably, the commoditywill always be a part of our profession. But thebalance once again seems to be shifting fromcommodity to counseling. This shift from retailto relationship can invigorate our professionand make it a vital part of health care’s future.The need exists, and the opportunity must bepursued, or, in many cases, created. Our expe-rience indicates that this is possible. Theopportunity was created by “selling” the ideainitially to an innovative payer. Enlisting phar-macists, developing the program, and enrollingthe patients actually came later. This is perhapsthe most unique difference between what wasdone in Asheville and what has been done inother places.

After working with this new model for overa year now, we believe that the long-term ben-efits of the model are an inherent byproduct ofestablishing a close relationship between apatient with a chronic illness and a caring,motivated pharmacist. This relationship is thekey, not the intellectual prowess or credentialsof the pharmacist.

ConclusionWe pharmacists like to say we are commit-

ted to helping people. Indeed, that is the pub-lic’s perception of our profession. By network-ing with each other, we can establish standardsfor pharmaceutical care programs. We can thennegotiate with payers in a consistent mannerwith respect to charges, reimbursement, andpotential savings to the payer. We have anopportunity to put our education and experi-ence to a higher use by becoming an integralpart of a team dedicated to improving healthcare and improving disease outcomes. Everytechnique and approach we have used towarddiabetes in The Asheville Project can be usedeffectively for management of asthma, hyper-tension, hyperlipidemia, and many otherchronic conditions.

Pharmacists Pharmacies (all in North Carolina)

Hashim Badr Asheville Discount Pharmacy, Asheville

Lisa Barnett St. Joseph’s Hospital, Asheville

Larry Brookshire B&B Pharmacy, Asheville

Sam Burris Martin’s Drug Store, Canton

Gloria Cobb Biltmore Center Pharmacy, Asheville

Russ Coble Memorial Mission Hospital, Asheville

Phil Crouch Kerr Drug (formerly Ideal), Asheville

Kim Ferguson Lord’s Drug Store, Asheville

Charles Gillespie Pollards Drug Store, Burnsville

Ruth Higgins Medicap Pharmacy, Black Mountain

Carol Hilley PSA Swannanoa, Swannanoa

Bill Horton PSA Beverly Hills, Asheville

Bill Kaufman B&B Pharmacy, Asheville

Caroline Lewis Smith Drugs,Waynesville

J.C. McGee PSA Beverly Hills, Asheville

Bill Morris Smith Drugs,Waynesville

Stephanie Norris Biltmore Center Pharmacy, Asheville

Mike Overman Lord’s Drug Store, Asheville

Steve Roberts Black Mountain Drug Co., Black Mountain

Jennifer Robertson Memorial Mission Hospital, Asheville

Roger Spittle Kerr Drug (formerly Ideal), Asheville

Chuck Sprinkle Weaverville Drug,Weaverville

Mike Tolley PSA Swannanoa, Swannanoa

Jim West Kerr Drug (formerly Ideal), Asheville

Diabetes Program Pharmacist Participants

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October 1998 19 Pharmacy Times

Outcomes of the AshevilleDiabetes Care Project

Carole W. Cranor, RPh, MS Pharm

TThe parameters studied in The Asheville

Project are those that have become standard inthe outcomes measurement field: clinical, eco-nomic, quality of life, and patient satisfaction.Each member of the team played a role in gath-ering the information needed to evaluate thesuccess of the project. Staff at Mission St.Joseph’s Health System (MSJHS) analyzed thequality of life (QOL) surveys and collected andanalyzed blood samples. The City of Ashevilleand the University of North Carolina School ofPharmacy were responsible for summarizingthe insurance and prescription claims results.Community physicians shared clinical data withthe pharmacists, and the pharmacists provideddetailed progress notes documenting eachpatient encounter. Finally, and most important,the patients participated by monitoring theirblood glucose, meeting regularly with theirpharmacists to download glucose data, andcompleting surveys and questionnaires.

Outcomes MeasuredThe demonstration project was designed as

a before-and-after pharmacist interventionstudy. Patients agreed to enter the program inMarch 1997, and the baseline, or preinterven-tion, date was set as March 1, 1997. The fol-lowing patient-specific data were collected atbaseline and at 8 and 14 months after the startof the program: clinical lab values (serumhemoglobin A1C and lipids), functional sta-

tus/quality of life (MOS SF36), and patient sat-isfaction with pharmacist survey. Insuranceclaims and prescription drug claims were eval-uated for the 12 months before and after thebaseline date.

Pharmacist’s RoleEach patient chose a community pharma-

cist to serve as a pharmaceutical careprovider during the project. The pharmacistsagreed to provide a minimum level of care toeach patient and to document that care in astandardized format. (Samples of the formsused in the program can be obtained bysending a stamped, self-addressed envelopeto Ashville Forms, Pharmacy Times, 1065 OldCountry Road, Westbury, NY 11590.)

Pharmacists and patients met on anappointment basis at the pharmacy of choice.The pharmacist met with each patient for aninitial history, needs assessment, and goal-setting meeting. Subsequent monthly follow-up appointments were used to monitorprogress, provide further training, and setadditional goals.

The employer provided all patients withblood glucose monitors free of charge, and thepharmacists provided training in the use of themonitors. The results of the patients’ daily glu-cose monitoring were downloaded monthlyonto the pharmacist’s computer, and the result-ing printouts were reviewed with the patient ateach appointment. Pharmacists were encour-aged to share the results of their meetings withthe patient’s physician and with the MSJHSDiabetes Education Center (DEC) as needed. Atthe beginning of the project, physicians and the

Carole Cranor is a doctoral candidate at theSchools of Pharmacy and Public Health,University of North Carolina, Chapel Hill.

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Pharmacy Times 20 October 1998

DEC provided guidelines to the pharmacistscovering situations in which patients shoulddefinitely be referred for consultation.

Pharmacist Documentation The pharmacists kept a separate folder for

each patient in which all information wasrecorded. Documentation of findings, assess-ments, recommendations, and follow-up planswere entered on a standard progress note formafter each appointment. Requests for andresponses from referrals to physicians and theDEC were also documented in the progressnotes. Copies of all laboratory work were sup-plied to the pharmacists by MSJHS. Some phar-macists requested additional patient recordsfrom the patient’s physician. For billing pur-poses, each pharmacist noted the amount oftime for each appointment on the progressnote and used a modified NCPA claims form tosubmit charges to the insurer.

Patient PopulationAt the beginning of the project, there were

46 patients. Of these, 67% were male, 87%were white, 50% had at least some college edu-cation, and 46% earned between $20,000 and$39,000 a year (Table 1). Twelve patients (26%)were retirees, 5 (11%) were spouses, and 2(4%) were children of City of Asheville employ-ees. The mean age was 49.

Sixteen patients were on insulin only, 21took oral agents only, six took both oralagents and insulin, and three relied on dietonly. Of comorbidities typically associated

% of Patients

Characteristic (N = 46)

Gender:

Male 67

Female 33

Race:

White 87

Black 13

Marital Status:

Married 67

Separated/Divorced 14

Widowed 2

Never Married 17

Education:

Less Than 8th Grade 11

Some High School 17

High School Graduate 22

Some College 39

College Graduate 4

Any Postgraduate Work 7

Income:

Less Than $20,000 13

$20,000 - $39,999 46

$40,000 - $59,999 26

$60,000 - $79,999 4

$80,000 or More 4

Prefer Not to Answer 7

Top 5 Comorbidities*:

Hypertension 61

Arthritis 38

Trouble Seeing 22

Back Problems 17

Trouble Hearing 17

* Some patients have multiple comorbidities.

Table 1. Patient Characteristics

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October 1998 21 Pharmacy Times

with diabetes, hypertension was present in46%, vision problems in 22%, cardiovasculardisease in 20%, and renal disease in 11% ofpatients in the program.

ResultsClinical Outcomes

The percent of patients with normal hemo-globin A1C and serum lipids improved consis-tently over the treatment period (Figure 1). Atbaseline, 33% of patients had hemoglobin A1Cwithin the normal range of 4.4% to 6.4%. After14 months in the program, this figure improvedto 67%. While two of three patients were with-in the normal A1C range, the total proportionof patients whose A1C showed at least someimprovement after 14 months was 85%. Themean lab values showed similar improvement

(Table 2). At the end of 14 months, the group’smean hemoglobin A1C had improved by 1.4percentage points. A change of this magnitude

Reference Baseline 8 Months 14 Months(units) (n) (n) (n)

Hemoglobin A1c 4.4-6.4 7.6 7.0* 6.2*

(%) (40) (41) (39)

Total cholesterol 130-200 210 208 198

(mg/dl) (32) (38) (37)

HDLa 27-67 45 42* 48*

(mg/dl) (30) (40) (37)

LDLb 70-165 118 113* 98*

(mg/dl) (25) (30) (30)

LDL/HDL ratio 1.0-3.55 2.7 2.8 2.05

(ratio) (25) (30) (30)

Triglycerides 10-190 277 290 301

(mg/dl) (32) (38) (37)

* paired t-test, significant p<0.05aHDL - high density lipoproteinbLDL - low density lipoprotein

Table 2. Mean Laboratory Values

Total Cholesterol

High Density Lipoprotein (HDL)

Low Density Lipoprotein (LDL)

LDL/HDL Ratio

0 10 20 30 40 50 60 70 80 90 100

53%45%

68%

90%93%

97%

80%90%

100%

68%80%

100%

Baseline

8 months

14 months

Figure 1. Percent of Patients with Normal Laboratory Values at Baseline and Follow-up

Figure 2. Patient Satisfaction with Pharmacy Survey Scores

Explanation

Consideration

Technical Competence

General Satisfaction

0 10 20 30 40 50 60 70 80 90

72%86%

84%79%

63%85%

83%78%

59%86%

84%79%

71%86%

82%78%

Baseline

8 months

14 months

IowaComparison

Hemoglobin A1C33%

37%67%

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Pharmacy Times 22 October 1998

has been associated with significant long-termimprovements in diabetes complications,including a decreased risk of retinopathy, pro-teinuria, heart disease, and amputation.1 TheDiabetes Control and Complications Trialfound that a decrease in a group mean hemo-globin A1C resulted in a decreased risk of upto 63% for retinopathy, 60% for neuropathy,and 54% for albuminuria.2

Patient SatisfactionSatisfaction with pharmacy services was

assessed at three group meetings attended bythe patients. Satisfaction was measured using amodified version of a questionnaire developedand validated by MacKeigan and Larson.3 In thequestionnaire, patients rated their overall satis-faction with the pharmacists, as well as theirsatisfaction with the pharmacists’ explanationof drug therapy (explanation), technical com-petence, and the courteousness of staff (con-sideration). At the baseline measurement, theCity of Asheville pharmacists were rated lowerin all categories compared with ratings given agroup of independent community pharmacistsfrom Iowa.4 After implementation of pharma-ceutical care, however, not only did patient sat-isfaction improve over baseline, but both sub-sequent assessments rated the Ashevillepharmacists higher than the Iowa pharmacistsin all categories (Figure 2).

Economic OutcomesInsurance claims for the patients were

assessed for the 12 months before and afterbaseline (Table 3). The total cost of inpatientand outpatient services declined $20,246 duringthe 12-month treatment period. Of interest is

12-Month Baseline 12-Month Treatment Difference a

(3-1-96 to 2-28-97) (3-1-97 to 2-28-98)

Inpatient Claims $ 103,541 (142)b $ 64,571 ( 113) -c $ 38,970 (- 29)

Outpatient Claims $ 117,515 (782) $ 120,503 ( 992) +d $ 2,988 (+210)

Pharmacists fee 0 $ 5,320 (196) + $ 5,320 (+196)

Glucose Monitors 0 $ 2,465 + $ 2,465

MSJHS DECe 0 $ 8,000 + $ 8,000

Total $ 221,105 (924) $ 200,859 (1301) - $20,246 (+377)

a Treatment minus baselineb Number of claimsc "-" = decrease over baselined "+" = increase over baselinee Mission St Joseph’s Health System Diabetes Education Center

Table 3. Diabetes Program Costs

0

10

20

30

40

50

60

Decrease/No change

59%

41%

Increase

Figure 3. Percent of Patients with Changes in Amount of Claims Paid

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October 1998 23 Pharmacy Times

the observation that while the overall numberof patient-provider interactions increased dur-ing the treatment period, the apparent shiftfrom costly inpatient services to outpatient carewas accompanied by an overall decrease incosts to the payer. The payer also incurred totalone-time treatment start-up costs of $262 perdiabetic patient for blood glucose monitors anddiabetes education provided by MSJHS-DEC.

The changes in treatment costs for individ-ual patients were also analyzed (Figure 3).When the treatment period was compared withbaseline, 59% of patients experienced adecrease or no change in the dollar value ofclaims paid.

During both time periods, a small propor-tion of patients accounted for a large propor-tion of the total claims paid. The analysis isincomplete at this time, but it is clear that threeof these patients incurred costs due to kidneyfailure. Further study is required to determine ifthese and several other patients were sufferingfrom complications of diabetes. One of thegoals of The Asheville Project is to reducepatients’ risk of developing such disablingcomplications as renal and cardiovascular dis-ease by providing early and continuous inter-vention in the disease process.

Functional Status and Quality of LifeThe mean quality of life data showed

improvement over baseline in all domains at 8months and in 5 of 8 domains at 14 months(Figure 4). These data were statistically signifi-cant in 6 of the 8 categories at 8 months and in2 categories at 14 months. Statistical compari-son for the entire group was limited, becausedata were available for all three data points inonly 34 patients. More study of the QOL isunder way, including a comparative analysisfor each individual patient. These individualpatient QOL results will be shared with thepharmacists and incorporated into eachpatient’s chart so that pharmacists and patientsmay work together to identify opportunities forimprovement.

Pharmacist Encounters and ReimbursementThe pharmacists documented a total of

Figure 4. Patient Quality of Life/Functional Status

* Significant (p<0.05) at 8 months compared to Baseline ^ Significant (p<0.05) at 14 months compared to Baseline

Worst Best

Physical Function*

Role Physical*

Pain*

Mental

Role Emotional*

Social Function

Energy*^

General Health Perception*^

0 10 20 30 4040 50 60 70 10080

Baseline

8 months

14 months

50%54%

47%

56%53%

48%

83%82%

80%

66%77%

66%

69%71%

70%

65%71%

67%

65%72%

60%

72%73%

67%

Time Period 3-1-97 through2-28-98

Total Number of Patient Visits 196

Mean Number of Visits per Patient 5.8(Range per Patient) (1-10)

Mean Time per Visit 28 minutes(Range) (10 - 70 minutes)

Mean Reimbursement per Visit $ 27.14(Range) ($20-100)

Total Reimbursement $ 5320

Table 4. Pharmacist Cognitive Encounters

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Pharmacy Times 24 October 1998

196 patient visits from March 1997 throughFebruary 1998 (Table 4). The initial visit typical-ly lasted about 60 minutes, with follow-up visitsusually ranging from 15 to 30 minutes. The aver-age length of a visit was 28 minutes, and themean amount reimbursed per visit was $27.14.

ConclusionOne of the most innovative aspects of The

Asheville Project was that the insurer reimbursedthe community pharmacists for their cognitiveservices. To receive this payment, the pharma-cists were required not only to submit a claims

form to the payer, but also to document manyaspects of each patient encounter. As we phar-macists continue to expand our role as providersof pharmaceutical care, it is imperative that webecome proficient at documenting the care wegive, especially if our goal is to develop long-term relationships with our patients and to bereimbursed for our services. We cannot provideadequate clinical care without complete andaccurate records of both the process and the out-comes of that care. And we certainly will not bereimbursed if we cannot prove to the payers thatwe have provided the services we are billing for.

Patient identified by

payer.

Patient agrees to participate

in study.

Group meeting of patients

who are participating.

MD receives form and forwards H&P

Form signed to request H&P from MD. Sent to MD with initial visit

information from pharmacist.

MD forwards copy of H&P.

Form signed by patient to request H&P from MD and sent to MD along

with initial visit information for pharmacy.

Letter of participation sent to MD.

(Information forwarded)

Patients choose pharmacy; MD identified; patient

education level identified; hemoglobin A1C drawn.

Patient calls pharmacy to plan

initial visit.

Has patient been educated at Diabetes

Center?

Patient participates in education at

Diabetes Center.

Patient calls pharmacy to plan

initial visit.

NO

YES

Diabetes Project Flow Chart for Patient Enrollment and Initial Visits

Begin:

MD = Primary Care Physician H&P = History and Physical

Page 25: The Asheville Project The Asheville Project

October 1998 25 Pharmacy Times

The Asheville Project demonstrates the successthat can be achieved when a community workstogether to improve the health of its citizens. Notonly were all four types of outcomes improved afterthe project began, but the clinical indicators showedcontinued improvement throughout the study peri-od. Pharmacists were essential to this success.

References1. Klein R. Hyperglycemia and microvascular

and macrovascular disease in diabetes. DiabetesCare 1995;18(2):258-268.

2. Diabetes Control and Complications Trial

Research Group. The effect of intensive treatment ofdiabetes on the development and progression oflong-term complications in insulin-dependent dia-betes mellitus. New England Journal of Medicine1993;329:977-986.

3. MacKeigan LD, Larson LN. Development andvalidation of an instrument to measure patient satis-faction with pharmacy services. Medical Care1989;27:522-536.

4. Larson LN, MacKeigan LD. Further validationof an instrument to measure patient satisfaction withpharmacy services. Journal of PharmaceuticalMarketing and Management 1994;8(1):125-139.

Pharmacist assists and schedules appropriate

follow-up time.

Is problem a referral situation?

Should pharmacist notify MD or Diabetes Center?

Pharmacist calls MD office. Gives summary of problem;

either schedules appointment for patient or asks for MD

advice.

Based on MD consult, pharmacist assists patient and documents actions.

Patient returns to pharmacy for evaluation.

Problem is identified.

Diabetes Center

(Information forwarded)

(Information forwarded)

(Visit information forwarded) (Information forwarded)

Visit information referred to pharmacist.

Patient goes to MD office for visit.

MD

Information to MD.

Patient seen at Diabetes Center.

Pharmacist calls Diabetes Center contact and asks for assistance.

Pharmacist assists patient based on

Diabetes Center consult and schedules

appropriate follow-up.

NO

YES

MD

Diabetes Project Flow Chart for Follow-up Visit

Begin:

Page 26: The Asheville Project The Asheville Project

Pharmacy Times 26 October 1998

Working Together toImprove Patient Care:

Asking the Right Questions Is KeyBy Paul Martin, MD

WWhen physicians are approached about

someone else’s unsolicited involvement withour patients, we tend to ask more than a fewpointed questions. Like good journalists, wewant to know who, what, where, when, how,and why? We take our responsibility for anindividual’s health care seriously. As the sayinggoes, “Too many cooks spoil the broth,” andnothing spoils a person’s well-being like a frag-mented health care delivery system.

In today’s world of managed care, physi-cians are also asking questions like:

“Exactly who is managing this patient’s care?”“Who should be managing it?” “Is The Asheville Project just an attempt by

a pharmacy benefits management company totell me how to practice medicine?”

I’ve had my share of concerns. Even so,after hearing the facts about medication com-pliance problems in this country and afterworking closely for over a year with pharma-cists participating in The Asheville Project, Ihave a very specific question of my own: Whyaren’t we involving pharmacists more?

Consider the following: Nearly 50% ofmedications fail to produce the desired resultsbecause they are not taken as directed. Tenpercent of hospital admissions among theelderly are due to failure to comply with pre-scribed medications. Poor medication compli-ance is estimated to add $100 billion to U.S.health care costs annually.

The truth is, many people with chronichealth conditions need encouragement toactively participate in their own care—withhelp from their physician, as well as physicianextenders like family nurse practitioners andphysician assistants. We physicians are findingthat we need additional resources to properlymonitor patients with chronic illness. The goodnews is, when it comes to medication therapy,we have access to “extenders” who are unique-ly qualified to help us and our patients in thisarea: pharmacists educated and trained to assistin the monitoring of specific health problems.

Physicians do not and cannot interact withpatients as often as pharmacists, who seepatients five times more often than any otherhealth care provider. Every time an individualenters the drugstore to purchase medicine orsupplies, the pharmacist has a chance to ask

Dr. Martin is the medical director of the City ofAsheville, North Carolina.

Paul Martin, MD, physician for the City of Asheville's Employee HealthServices, takes a closer look at the eyes of Ed Lennon, a participant in theAsheville Project. Untreated, diabetes can lead to blindness.

Page 27: The Asheville Project The Asheville Project

October 1998 27 Pharmacy Times

how things are going and to answer questionsabout medication and its proper use. Whenlines of communication between pharmacistsand physicians are open, physicians, pharma-cists, and patients learn. Constrict or blockthose lines of communication, and everyone isleft sitting in silence, wondering why a patient’scondition has not improved.

From my perspective, the most importantquestion we physicians can ask is, “What isbest for our patients?” The Asheville Project’smost significant achievement—and, in fact, thedriving force behind the project—is improvedpatient care. Data that were gathered duringthe project clearly show that strides have beenmade in blood glucose control, participants’understanding of their disease, and compliancewith medications.

At the same time, economic benefits havebeen realized by the City of Asheville, a self-insured organization trying to balance a firmcommitment to the well-being of its employeeswith harsh financial realities. In addition,thanks to The Asheville Project, physicianshave had the benefit of a second set of eyesand ears monitoring their chronically illpatients—without hiring extra staff and without

working extra hours. Individuals with diabetesare feeling better about themselves and takingbetter care of themselves. They don’t get sickas often and are much more likely to avoid theserious health consequences that can resultwhen self-care is neglected.

Pharmacists are valuable partners. Withspecific training and education, pharmacistscan provide many complementary services toassist in compliance with disease management.Physicians involved in The Asheville Projecthave benefited from the pharmacists’ compli-ance/adherence monitoring, efficacy monitor-ing, side effect/adverse effect monitoring,patient education, and monitoring of over-the-counter medication use. Patients who were sig-nificantly out of compliance were referred totheir primary care physicians for reevaluation.

The comments from Asheville-area physi-cians printed on this page reflect what I ampleased to report is the overwhelmingly posi-tive view our medical community has takenwith respect to The Asheville Project. I believeit is time for physicians, pharmacists, and pay-ers across the nation to ask one final, criticalquestion about involving pharmacists in patientcare, and that question is: Why not?

“A chronic illness like diabetes requires a lot of self-management. Pharmacists educated and trained toassist in the management of that specific health problem can make a difference by monitoring peoplewith diabetes and encouraging them to follow through on self-care and with other providers.The factthat supplies were provided free of charge to the participants in The Asheville Project was extremelyimportant.This type of program works best as a team effort, with primary care physicians, endocrinolo-gists, pharmacists, educators, case managers, data managers, and hospital administrators working togeth-er.” — Jeff Russell, MD, endocrinologist and medical director for The Diabetes Center of Mission St.Joseph’s

“In my clinical experience, the insulin-resistance syndrome is the major risk factor for African Americanswho develop coronary, carotid, renal, and peripheral vascular disease.The City of Asheville-NCCPCDiabetes Project offers the consistent, compulsive detection, treatment, and preventive medicine pro-gram necessary to address this problem.” — John Russell, MD, Asheville Cardiology Associates

“I feel the program is of great benefit, as the one city employee I have as a patient has shown better com-pliance and blood sugar control. I think it may be something private companies may wish to adopt aswell, to lower absenteeism due to complications related to uncontrolled diabetes.” — Robert J. Uhren,MD, family practice physician

COMMENTS FROM PHYSICIANS

Page 28: The Asheville Project The Asheville Project

AAn Investment in Health

Offers a High Return for AllBy John Miall, Jr.,ARM

As director of risk management for the Cityof Asheville, North Carolina, I have beeninvolved with the city’s benefit programs formore than 18 years. The City of Asheville isself-insured, providing benefits for 830 full-timeemployees and their dependents, as well as for200 retired workers. Over the years, we havedesigned cost-effective benefits programs usingunique and creative approaches. As an employ-er with a record of taking cutting-edgeapproaches to health care, we were a naturalchoice when the North Carolina Center forPharmaceutical Care (NCCPC) and Mission St.Joseph’s looked for a company to take part ina pilot disease management program.

I have had plenty of opportunities to seehow a chronic condition like diabetes orhypertension can lead to much more serious,even fatal, health problems. Professionally, Iam focused on the cost associated with theseconditions. That’s why I was more than will-

ing to listen when Iwas approached bythe NCCPC to consid-er participating inThe Asheville Project.As the NCCPC ex-plained it, the pur-pose of the year-longstudy was to observethe impact pharma-cists can have on dis-ease management.

According toHospitals and HealthNetworks, the fiveconditions most often

targeted for disease management are diabetes,hypertension, asthma, arthritis, and gastro-esophageal disease/ulcer. With the help of ourthird party administrator, we collected data thatenabled us to determine that our employeeswith diabetes should be the focus of the pilotdisease management program.

Our TPA identified 60 city employees anddependents who have diabetes, which is statis-tically consistent with figures for the generalpopulation. The group consisted of 31 men and15 women, including 12 retirees.

We initially committed to an expenditure ofabout $2,000 for at-home glucose monitoringequipment. We already had a drug card pro-gram in place with a $5 co-pay for genericdrugs and a $15 co-pay for brand name med-ications. Our plan had always covered insulin,syringes, and test strips, so these were notadded expenses, but we decided to waive theemployees’ co-pays on insulin and supplies asan incentive for them to enroll in the program.

In addition, if the pilot proved successful,we agreed that the city would compensate thepharmacists for their time. NCCPC and MissionSt. Joseph’s Health System in Asheville wouldpick up all other expenses, including thepharmacists’ training, lab tests, and outcomestracking.

The response from our employees wasfavorable from the outset. Living with a chron-ic disease like diabetes can be stressful and attimes overwhelming. At the initial meeting toannounce the program, one employee cameup to me crying and grabbed my hand. Shesaid, “I can never tell you how much thismeans to me.”

“For anyone in risk manage-ment, this is a no-brainer,”says John Miall Jr., ARM, Cityof Asheville.

Pharmacy Times 28 October 1998

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October 1998 29 Pharmacy Times

After 3 months, our nurse was noticing thatthe individuals involved in the study were takingbetter care of themselves than they had in yearsin terms of diet, sleep, exercise—in every regard.I’m convinced that simply having someoneknowledgeable to talk with about their healthconcerns benefits these patients a great deal.They think of the pharmacist as their “coach.”

Feedback from all the employees participat-ing in the project was so positive that I arrangedto compensate the pharmacists ahead of time,instead of waiting until the end of the pilot asplanned. Six months into the project, savingshad already been realized, in spite of the factthat one participant diagnosed with leukemiaincurred costs over $9,000 above those of thecontrol period. We were also seeing improvedemotional, physical, and mental health for theparticipants, and improvements in cholesterol,triglyceride, and hemoglobin levels.

Cost-Benefit AnalysisI arranged to pay the pharmacists $75 for

their initial assessments, $45 to $65 for inter-mediate assessments that lasted 30 to 45 min-utes, and $20 for routine visits. That brought

our initial investment to $8,000. Payment forformal diabetes education for participantsthrough The Diabetes Center of Mission St.Joseph’s Health System in Asheville added a lit-tle over $6,000.

All told, our start-up expenses for the pro-ject did not exceed $14,000—even after com-pensating the pharmacists and The DiabetesCenter for their services retroactive to thebeginning of the program.

Compared to our $4 million-per-year bene-fit program, $14,000 is a drop in the bucket. Ifyou’re preventing one diabetic patient fromfacing an amputation in the future by improv-ing his/her care now, you’re saving between$30,000 and $50,000.

Now that I have seen an analysis of our 12-month data, I am more convinced than everthat we need to continue this project for theforeseeable future. As Asheville Mayor LeniSitnick has observed: “The Asheville Project isa true partnership between the City, local phar-macists, and a segment of employees with cer-tain health problems. It is another opportunityfor us to provide a positive health benefit forour employees.”

The City of Asheville, with its record of cutting-edge health initiatives, was a natural for this pilot programin diabetes management.

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Pharmacy Times 30 October 1998

Using Existing Resourcesto Prepare Pharmacists for

an Expanded Roleby Cindy Spillers, MS, RD, CDE

DDiabetes is a complex syndrome of disor-ders, and successful management of the diseaserelies on day-to-day choices made by the per-son with diabetes. People with diabetes requireknowledge about the various factors that raiseand lower blood glucose levels. They must bal-ance food, activity, and possibly medication,even as they continuously monitor and learnabout the disease. The person with diabetes isthe key member of the diabetes care team. Therole of health professionals on the team is toprovide support and to assist that individual in

his or her effort to achieve optimal self-care.From the beginning, the NCCPC realized

that a key factor in the success of TheAsheville Project was preparing the pharma-cists for an expanded role on the diabetes careteam. The pharmacists needed to update theirknowledge of diabetes and managementissues, including disease monitoring, diabetes-related products, and prescription and nonpre-scription medications taken by people withdiabetes. Perhaps even more important, theyneeded practical, hands-on training to rein-force the basic education and to enable themto be supportive of the patients.

The staff of The Diabetes Center of MissionSt. Joseph’s consists of a team of dietitians,nurses, a clinical social worker, and an exercisespecialist. The majority of the staff are cross-trained in all areas of diabetes care and arenationally credentialed as Certified DiabetesEducators. The Center offers an ongoing pro-gram of education and support for individualswith diabetes. Endocrinologist Jeffrey K.Russell, MD, is our medical director. Dr. Russellis a supporter of the idea that pharmacists edu-cated and trained about the management of aspecific health problem are in a key position tomonitor and encourage people to followthrough on optimal self-care. The DiabetesCenter was identified as a major resource forthe Asheville Project, along with pharmacistsand physicians who are experts in diabetesmanagement.

Faculty members from the schools of phar-

Cindy Spillers is the director of the TheDiabetes Center of Mission St. Joseph’s.

Mission St. Joseph’s Diabetes Center provided pharmacists in The AshevilleProject with training and education similar to what the Center offers inclasses for people with diabetes. Here diabetes educator Mary Beth Horrell,MS, RD, CDE, asks one of her “students” about her self-care routine.

Page 31: The Asheville Project The Asheville Project

October 1998 31 Pharmacy Times

macy at the University of North Carolina atChapel Hill and from Campbell University inBuies Creek were enlisted to assist with thetraining, as well as Diabetes Center staff mem-bers and Asheville physicians. Intensive train-ing sessions were provided for the pharmacistsover two weekends in January 1997, just a fewmonths before The Asheville Project began.

The Training ProgramThe format for the training program includ-

ed lectures, group discussions, and hands-onexperience.

During the training, the pharmacists per-formed many of the tasks that people with dia-betes must perform on a daily basis to discov-er what it’s like to be “in their shoes” and tolearn how much dexterity and visual acuity arenecessary to carry out these tasks. Theypricked their fingers and used blood glucosemonitors to test their own blood sugar levelsand learned to inject themselves—using salinerather than insulin.

In addition, throughout the two weekends,they ate snacks and meals that would be rec-ommended for people with diabetes. We want-ed them to see that meal planning is no longerrestrictive and that the foods aren’t tasteless. Inthe past, many people diagnosed with diabeteswere simply handed a diet sheet and told tofollow it. Today, meal planning involves muchmore interactive education. At both weekendsessions, the pharmacists saw that people withdiabetes should have a variety of flavorfulfoods which are also good for them, and weprovided copies of the recipes.

The FacultySix physicians from the Asheville commu-

nity who work with people with diabetes wereinvited to present lectures and share informa-tion with the pharmacists. These six physiciansincluded a cardiologist, an endocrinologist, anephrologist, a pediatric endocrinologist, a reti-nal specialist, and an orthopedist, who sees anumber of patients with diabetes-related footproblems.

Six members of The Diabetes Center madesignificant contributions to the training pro-

gram. For example, the center’s certified clini-cal social worker explained how stress canaffect patients with diabetes and their families;other educators lectured on topics such asexercise, nutrition and meal planning, and howto teach patients. They also conducted thehands-on classes on insulin administration(devices and techniques) and blood glucosemonitoring supplies and techniques.

The remaining faculty and presenters werepharmacists from NCCPC and from the twouniversities. Their tasks were to review currentpharmacotherapy treatment strategies for dia-betes, contraindications, how other medica-tions may impact blood sugar, etc.

Measuring SuccessThe pharmacists were given a “pre-test”

and a “post-test.” We wanted to see how muchthey knew before the two weekend intensives,and then how much they knew at the end. Thetests showed dramatic improvement.

Feedback in the form of comments fromthe participants themselves was also encourag-ing. One of the pharmacists had worked withpeople with diabetes for several years but stillfelt she had learned a great deal from thehands-on work. Another participant appreciat-ed the chance to learn how to use a variety ofblood glucose monitors as well as the specificsabout diet and exercise. He commented that hecould now go into detail with patients abouthow much exercise and what kind of exerciseis important, and why it helps improve theirphysical condition.

Perhaps the best measure of the training’seffectiveness has been the response from thecity employees and their dependents who areparticipating in The Asheville Project. Theirenthusiasm and improved health are powerfultestimonials to the value of the pharmacists’expanded role and the importance of thepreparation and training those pharmacistsreceived.

Funding for the pharmacists’ training wasprovided by the North Carolina Center forPharmaceutical Care, Mission St. Joseph’s HealthSystem, and grants from Lilly and PharmacyNetwork National Corporation–PNNC.

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