Programs aimed at diabetic patients are hardly new to retail pharmacy. In the past, they often amounted to little more than a rack of educational materials next to the prescription counter, plus some shelves featuring sugar-free nutritional products, hypoglycemic remedies, glucose monitor supplies, and perhaps a small selection of foot care and skin care items.
Here and there, a few pioneering independents set up practices offering more complete pharmacy care for individuals with diabetes.
But in the past few years, an upsurge in disease management programs-most with a strong emphasis on diabetes-has begun to hit retail pharmacies. The pharmacies range from networks of independents and small chains to some of the biggest chains in the land, such as Eckerd, CVS, and Rite Aid. Supermarket operators, including Giant Food, Dominick's, Cub Foods, and Ukrop's, have also launched pilot programs.
One of the biggest obstacles for retailers is cost. Pharmacies need to be redesigned, pharmacists trained, and equipment purchased. Even if done on a shoestring, such programs still face the burden of pharmacists' salaries.
So far, the return on investment has been spotty, and managed care hasn't been quick to pick up the tab. Larger chains keep pilot programs afloat because they see a time when pharmaceutical care might provide a new revenue stream. Independents often resign themselves to the fact that they're not going to get rich in disease management. They do it for other reasons, both competitive and professional.
David Nau, R.Ph., Ph.D., assistant professor at West Virginia University's School of Pharmacy, has been working with a group of independents called the Ohio Valley Pharmaceutical Care Network. He explained what it takes to get geared up for patient care.
'The pharmacists in our network invested between $5,000 and $7,000 to buy equipment and go through training,' he said. 'Some had to do some minor remodeling to make space to meet with the patients privately. The amount we are getting right now is not enough to make this a lucrative business.'
But, he added, 'mainly the pharmacists want to have a greater role in patient care, to do good by their patients. It's a lot more fulfilling professionally.'
For some pharmacies, diabetes care has been the catalyst for thirdparty payment, as a few forward-- looking payers have accepted the idea that tight blood glucose control fostered by regular visits with trained pharmacists can prevent or reduce life-threatening complications.
Often, the impetus for a retail diabetes program comes from a pharmacy school interested in developing student residency sites. Pharmaceutical manufacturers also have a strong self-interest in supporting community pharmacy programs because they promote utilization of their products. So they provide patient and pharmacist educational resources, free blood glucose meters for indigent patients, and starter packages with testing materials such as strips and lancets.
Wholesalers like McKesson, Bergen Brunswig, and AmeriSource have also weighed in with programs to help their customers establish practices more oriented to patient care.
It's the diabetes programs in retail settings that involve patient contact most directly, however. Following are overviews of three very different types of programs.
Ohio Valley Network
David Nau has been working for two years with this group of 13 pharmacists in seven practice sites in the upper Ohio Valley covering parts of West Virginia and Ohio. Most of the pharmacists are independents; two are from a small local grocery chain called Riesbecks.
In a series of strategic planning sessions, the pharmacists decided to focus on quality assurance and disease management. The area they felt had the greatest potential was diabetes. They signed a contract with the largest health maintenance organization in the area, the Health Plan of the Upper Ohio Valley, which agreed to foot the bill for their covered patients.
A little over a year after they began planning, the network had designed a pilot project to help improve diabetes outcomes for the managed care organization. It includes measuring and monitoring HbA^sub 1c^ values, glucose screening, lipid profiles, medication compliance, diet and exercise, and training in glucose monitor use.
The HMO helped recruit patients by telling physicians, and the pharmacists promoted it in their stores with brochures. Most of the 54 patients enrolled in the program came from existing patient bases at the pharmacies, Nau said.
'We sent letters to every person who took a diabetes medication, but they didn't come knocking down the doors,' said Roger Cole, R.Ph., owner of Moundsville Pharmacy, Moundsville, W Va. 'We had to basically recruit each person. Most of them have come in because it's a covered benefit at a health plan. We don't have anybody who has paid for the entire program.'
Pharmacists receive $125 from the HMO in payment for an initial assessment, which Nau said was 'not a lot for the amount of work the pharmacist puts into it.' Follow-up visits are $35.
The pharmacy network had a one-year contract with the HMO, which it has now agreed to continue because it has had such good response. 'Bottom line is that the pharmacists have had a positive impact,' said Nau. To gain official American Diabetes Association (ADA) recognition, the network has started to build a multidisciplinary program with dietitians, podiatrists, ophthalmologists, physical trainers, and social workers. ADA recognition is essential for getting paid by Medicare.
Eckerd's Patient Care Program
Tina Lampeizaguerre, Pharm.D., was recruited by Eckerd two years ago to help launch a clinical pharmacy program in a physician out-- patient building near chain headquarters in Largo, Fla.
'Things went so well that Eckerd decided to expand the program,' she said; now nine other pharmacists rotate through stores located in the Tampa Bay area. 'The program primarily takes a generalist approach,' she said, but it has a strong diabetes component. As part of their clinical assessments, pharmacists do blood pressure and weight checks and evaluate drug therapy. They also test for cholesterol levels and perform monofilament tests for signs of peripheral neuropathy.
In addition, they keep track of HbA^sub 1c^ levels over time and use a questionnaire to evaluate patient quality of life. The evaluation, she said, 'breaks down into different domains, from emotional impairment to physical impairment to social functioning impairment.'
Laura Hungiville, R.Ph., is one of the rotating pharmacists in the program. She has worked for Eckerd Drug for 15 years in roles ranging from staff pharmacist to district manager as well as in managed care. She now provides pharmaceutical care to some 400 patients, about half of whom have diabetes.
A rewarding part of the job is being able to draw in patients who were unaware how much they could be helped. 'I was amazed,' she said, 'at how many of them aren't monitoring and testing their blood sugars because nobody really stressed to them that it's important or showed them how, especially if they're on oral meds.'
'As a pharmacist, you hand people pills, they go home, and you just assume that they get better,' Hungiville concluded. 'When you get this involved, you do know what happens.'
Giant's Diabetes Care Program
The Giant program developed as a partnership between the University of Maryland School of Pharmacy and Giant Pharmacy. 'It really came out of the school wanting to get involved with community pharmacists, in developing pilot projects to incorporate pharmaceutical care into community pharmacy and to develop sites where our students can go to learn,' said Magaly Rodriguez de Bittner, Pharm.D., BCPS, CDE (Certified Diabetes Educator), an associate professor at the university. Just this August, the Giant initiative became the first community chain pharmacy-based program in the country to gain ADA recognition.
Rodriguez de Bittner received a grant from Giant in 1996 to train pharmacists in pharmaceutical care and other disease states. Together, the school and the retailer designed a pilot patient care program for the busiest store in Baltimore. Because she's a CDE, the program began with diabetes. 'We chose the store because if you could work there, you could work anywhere,' she said. A second reason was that the large customer base made it easier to recruit patients.
The organizers turned an unused counseling room into a patient care center and identified potential patients by flagging diabetic individuals. Patients were asked if they wanted a free 15-minute consultation with a pharmacist. So far, 70 patients have had this helpful interaction, and 30 have signed up for the full eight-- part program of clinical assessments and diabetes education. Six have opted for only one or two sessions. The full program costs $300, while individual sessions are $45.
The first session is simply an overview. On subsequent visits, patients decide the order of the educational topics, which include nutrition, coping, monitoring, complications, foot care, and medications. Most choose foot care for starters, but nutrition is a close second.
The pharmacists test patients' knowledge before and after the educational sessions and then follow up in the areas of quality of life and clinical status.
One problem: 'It's a great service, but it's very difficult to make money from it,' she revealed, 'because pharmacists' time is very expensive.' So far, managed care hasn't come through. Partial salvation may come from the program's ADA recognition, which she indicated would allow Medicare to pay for services.
Six months ago, the program added a second site in Annandale, Va.
[Author Affiliation]
By Bruce Buckley, New York-based pharmacy journalist and frequent contributor to Drug Topics
