Outcomes and Factors Contributing to the Success of a Community Based Patient Self-Management Diabetes Program: The Asheville Project Daniel G. Garrett,

Outcomes and Factors Outcomes and Factors Contributing to the Contributing to the

Success Success of a Community Based of a Community Based

Patient Self-Management Patient Self-Management Diabetes Program:Diabetes Program:

The Asheville Project The Asheville Project

Daniel G. Garrett, MSDaniel G. Garrett, MS

Senior Director, Medication AdherenceSenior Director, Medication Adherence

APhA FoundationAPhA Foundation

[email protected]@aphanet.org

ObjectivesObjectives

- Describe the Asheville Project and the Describe the Asheville Project and the Outcomes being achievedOutcomes being achieved

- Share the perceptions of patients, Share the perceptions of patients, providers and managers on the factors providers and managers on the factors contributing to success of the Asheville contributing to success of the Asheville Project Care ModelProject Care Model

Our MissionOur Mission

““The mission of the American The mission of the American Pharmacists Association Pharmacists Association

Foundation is to improve the Foundation is to improve the quality of consumer health quality of consumer health

outcomes that are affected by outcomes that are affected by pharmacy.”pharmacy.”

http://www.APhAFoundation.org/

Patient Centric Drug TherapyPatient Centric Drug Therapy

• Patient is the:Patient is the:– ApplierApplier– UtilizerUtilizer– DeterminerDeterminer

...of the outcomes associated with...of the outcomes associated with

medication “technology”medication “technology”

Patients on drug therapy ultimately Patients on drug therapy ultimately ““managemanage their own their own carecare”.”.

Original Intent of the North Original Intent of the North Carolina Pharmaceutical Care Carolina Pharmaceutical Care Project- 1993Project- 1993• To demonstrate that community To demonstrate that community

pharmacists could provide pharmacists could provide pharmaceutical care that results in pharmaceutical care that results in positive patient outcomespositive patient outcomes

• To demonstrate the value of To demonstrate the value of pharmaceutical care to employers so pharmaceutical care to employers so they would pay pharmacists for they would pay pharmacists for “clinical” services“clinical” services

Original Design of the NC Original Design of the NC Pharmaceutical Care ProjectPharmaceutical Care Project

• Committee with representatives from Committee with representatives from all state pharmacy organizations, all state pharmacy organizations, schools of pharmacy, industry and a PBMschools of pharmacy, industry and a PBM

• Met for 3 years to come up with protocol Met for 3 years to come up with protocol for 3 projects (asthma, diabetes and for 3 projects (asthma, diabetes and HTN) in 3 communities, with control HTN) in 3 communities, with control groups and computer software groups and computer software supported care ($150,000 price tag)supported care ($150,000 price tag)

• ECHO model for outcomes trackingECHO model for outcomes tracking

*“*“The Answer to How? Is The Answer to How? Is When.”When.”• Decided in 1996 to try one project in one disease Decided in 1996 to try one project in one disease

state using pencil and paperstate using pencil and paper• The City of Asheville agreed to try for one year and The City of Asheville agreed to try for one year and

see if it worked before they paid the pharmacistssee if it worked before they paid the pharmacists• Diabetes was selected by the City’s Medical Diabetes was selected by the City’s Medical

Consultant as the place to startConsultant as the place to start• The pharmacists training program was created in The pharmacists training program was created in

conjunction with the MSJ DEC with a grant of $10,000conjunction with the MSJ DEC with a grant of $10,000• The City decided to waive patient co-pays and the The City decided to waive patient co-pays and the

PBM issued special rx cardsPBM issued special rx cards• The original patients were identified from a PBM The original patients were identified from a PBM

report with a yellow highlighterreport with a yellow highlighter

*Peter Block, Stewardship, 1993; 234-237

The Asheville ProjectThe Asheville Project

““You cannot control the You cannot control the system…system…

you can only disturb it”you can only disturb it”

Bennett Sims, Bennett Sims,

Servanthood,Servanthood,

Leadership for the 3rd Leadership for the 3rd MillenniumMillennium

Patient Incentives and Patient Incentives and Care Model Care Model (how we “disturbed (how we “disturbed the system”)the system”)• Patient selection / recruitmentPatient selection / recruitment

• Patient education — Mission + St. Patient education — Mission + St. Joseph’s Diabetes CenterJoseph’s Diabetes Center

• Matching patients to pharmacistsMatching patients to pharmacists• IncentivesIncentives

– Glucose metersGlucose meters– PBM co-pay waiversPBM co-pay waivers– Labs without co-paysLabs without co-pays

• The operative word in pharmaceutical The operative word in pharmaceutical care is care is ““carecare”” (Madge Testimonial) (Madge Testimonial)

How They Do ItHow They Do It

““Patient making better food choice. Blood glucosePatient making better food choice. Blood glucosemuch improved. 2 x 1.5c cm wound RLE. Referredmuch improved. 2 x 1.5c cm wound RLE. Referredto physician for evaluation and therapy.”to physician for evaluation and therapy.”

HbA1c

Asheville Clinical Outcomes:Asheville Clinical Outcomes:Avg. Glycosylated Avg. Glycosylated HemoglobinHemoglobin

7.606.60 6.506.8 6.8 6.9 6.7

6.8

0.001.002.003.004.005.006.007.008.009.00

Basel

ine

6 M

onths

12 M

onths

18 M

onths

24 M

onths

30 M

onths

36 m

onths

42 m

onths

Cranor et. al. JAPhA 2003; 43(2): 175-176.

n=136 136 81 55 39 26 16 11

n=50

70 70

Cranor et. al. JAPhA 2003; 43(2): 184.

Asheville Enrollee Average Asheville Enrollee Average Total Healthcare CostsTotal Healthcare Costs Cranor, et.al. JAPhA 2003:43(2); 183.Cranor, et.al. JAPhA 2003:43(2); 183.

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

Baseline 1 2 3 4 5

Follow-up Year

Mea

n C

ost

/ Pat

ien

t / Y

ear

Other RxDiabetes RxMedical Claim

N=164 N=155 N=116 N=74 N=43 N=28

Total Healthcare Costs, Combined Missions St Total Healthcare Costs, Combined Missions St Josephs and City of Asheville for all enrollees Josephs and City of Asheville for all enrollees

(unpublished data)(unpublished data)COA & MSJ Total Healthcare Costs (avg/patient/year) prior to COA & MSJ Total Healthcare Costs (avg/patient/year) prior to

programprogramfor diabetes and each year of the program for 1for diabetes and each year of the program for 1stst 5 years 5 years

$4371$4291

$7042

$4025$3795

$3932

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

Prior to Programn = 164

1997n = 47

1998n = 72

1999n = 131

2000n = 147

n =

2001n = 174

$7239$7485

$7762$8088

$8468

20%Medical

CPI Increase

$2,195,228Cumulative

savings

City of Asheville Diabetes City of Asheville Diabetes Sick-Leave Usage Sick-Leave Usage (n=37)(n=37)

6.00 5.68 5.81 5.67

8.46

12.60

0

2

4

6

8

10

12

14

Cranor et. al. JAPhA; 43 (2): 180.

The Asheville Project: The Asheville Project: Participant’s Perceptions of Participant’s Perceptions of Factors Contributing to the Factors Contributing to the Success of a Patient Self-Success of a Patient Self-Management Diabetes Management Diabetes ProgramProgram• Focus groups of patients and diabetes Focus groups of patients and diabetes

care providers and individual care providers and individual interviews with managers involved in interviews with managers involved in the projectthe project

• 21 patients, 4 pharmacists, 1 CDE, 6 21 patients, 4 pharmacists, 1 CDE, 6 managers from employer groupsmanagers from employer groupsGarrett DG, Martin, LA. J Am Pharm Assoc. 2003;43:185-90

Garrett DG and Martin LA. JAPhGarrett DG and Martin LA. JAPhA March/April ;43(2):187.A March/April ;43(2):187.

Patient PerspectivePatient Perspective

• ““The program saved my life”The program saved my life”• Patients were positive about experience Patients were positive about experience

and enjoyed relationship with and enjoyed relationship with pharmacist pharmacist

• Reasons for joining the program:Reasons for joining the program:– Financial incentiveFinancial incentive– Fear of diagnosisFear of diagnosis

Garrett DG and Martin LA. JAPhGarrett DG and Martin LA. JAPhA March/April 2003; 43(2): 187.A March/April 2003; 43(2): 187.

Employers’ PerspectiveEmployers’ Perspective• Significant resources were required to run Significant resources were required to run

the program; however, the benefits the program; however, the benefits derived far outweighed the costs of the derived far outweighed the costs of the programprogram

• Employees appreciated reductions in Employees appreciated reductions in medical costs medical costs

• Enhanced patient well-being and Enhanced patient well-being and decreased absenteeismdecreased absenteeism

• Patients sense of hope for controlling their Patients sense of hope for controlling their diabetes was increaseddiabetes was increased

Pharmacist PerspectivePharmacist Perspective• Participated in program becauseParticipated in program because

– Professional responsibility (make a Professional responsibility (make a difference)difference)

– Increased marketability in careerIncreased marketability in career

• Pharmacists identified two primary Pharmacists identified two primary factors that affected patients’ success factors that affected patients’ success in the program:in the program:– Whether the individual viewed his or her Whether the individual viewed his or her

health as a priorityhealth as a priority– The willingness of the health care The willingness of the health care

professional to take time with patientsprofessional to take time with patients

Garrett DG and Martin LA. JAPhA,March/April, 2003 43:(2) 188

Wagner EH, Austin BT, Davis C etWagner EH, Austin BT, Davis C et al. Improving chronic illness care al. Improving chronic illness care: translating evidence into action. : translating evidence into action. Health Aff 2001; 20(6):64-78. Health Aff 2001; 20(6):64-78.

WagnerWagner et.al. et.al. Chronic Care Chronic Care ModelModel• The health system is part of the larger The health system is part of the larger

community and there are appropriate links community and there are appropriate links to health care resources in the community.to health care resources in the community.

• Effective self-management support and Effective self-management support and links to patient-oriented community links to patient-oriented community resources help to inform patients and resources help to inform patients and families and motivate them to cope with families and motivate them to cope with the challenges of living with and treating the challenges of living with and treating chronic diseases.chronic diseases.

Wagner EH, Austin BT, Davis C, eWagner EH, Austin BT, Davis C, et al. Improving chronic illness cart al. Improving chronic illness care: translating evidence into action.e: translating evidence into action. Health Aff 2001;20(5):64-78. Health Aff 2001;20(5):64-78.

WagnerWagner et.al.et.al. Chronic Care Chronic Care ModelModel• Teams of physicians and other health care Teams of physicians and other health care

providers need to have the clinical and behavioral providers need to have the clinical and behavioral expertise required for productive patient expertise required for productive patient interactions. Guidelines and protocols have a interactions. Guidelines and protocols have a minimal impact unless they are implemented as minimal impact unless they are implemented as part of an ongoing system of care that includes part of an ongoing system of care that includes education, reminders, specialist involvement, and education, reminders, specialist involvement, and decision support interventions.decision support interventions.

• An organized and standardized approach to An organized and standardized approach to collecting, summarizing, and reviewing individual collecting, summarizing, and reviewing individual and aggregate patient data is needed.and aggregate patient data is needed.

Garrett DG and Martin LA. JAPhAGarrett DG and Martin LA. JAPhA 2003;43(2):189. 2003;43(2):189.

Results from Focus Groups consistent with Results from Focus Groups consistent with Wagner & colleagues Chronic Care ModelWagner & colleagues Chronic Care Model

• Employer interest was in improving and Employer interest was in improving and coordinating healthcare and investing resources coordinating healthcare and investing resources in a community-based systemin a community-based system

• Patients reported that the incentives and Patients reported that the incentives and community-based self-management support community-based self-management support they received on an ongoing basis was essential they received on an ongoing basis was essential in helping them cope with their diabetesin helping them cope with their diabetes

• Pharmacists and diabetes educators reported it Pharmacists and diabetes educators reported it took more than knowledge to care for patients. took more than knowledge to care for patients. Key to success was the opportunity pharmacists Key to success was the opportunity pharmacists had to work with individual patients on an had to work with individual patients on an ongoing basis to answer their questions and ongoing basis to answer their questions and support their self-motivated behavior changessupport their self-motivated behavior changes

• On-going Outcomes Data collected and reportedOn-going Outcomes Data collected and reported

The “Asheville Program” The “Asheville Program” TodayToday• Now over 800 patients from 3 employers are Now over 800 patients from 3 employers are

enrolled for diabetes, asthma, hypertension enrolled for diabetes, asthma, hypertension and lipid therapy managementand lipid therapy management

• Patients continue to have improved Patients continue to have improved outcomes & increased medication adherenceoutcomes & increased medication adherence

• 50% reduction in sick days 50% reduction in sick days • Zero workers comp claims in the City Zero workers comp claims in the City

diabetes group over 6 yearsdiabetes group over 6 years• Average net savings of over $1,600 per Average net savings of over $1,600 per

person with diabetes each year from year 2 person with diabetes each year from year 2 onon

Lessons Learned Lessons Learned that can Applied Anywherethat can Applied Anywhere

• ““Plans are nothing, planning is everything”Plans are nothing, planning is everything” – the foresight and comprehensive planning of “the the foresight and comprehensive planning of “the

committee” resulted in a sound process of care and committee” resulted in a sound process of care and collection of valuable outcomes datacollection of valuable outcomes data

• CAREing makes the differenceCAREing makes the difference – the City paid the pharmacists before the data was in the City paid the pharmacists before the data was in

• The best way to reduce risk is to share risk The best way to reduce risk is to share risk – every stakeholder had an incentive to succeed every stakeholder had an incentive to succeed

Jerry McGuireJerry McGuire

““Show me the money!”Show me the money!”

““It’s all about It’s all about relationships”relationships”

Question Asked in Asheville in Question Asked in Asheville in 19961996

What are you going to do if “it” works?

(Will pharmacists be willing/able to meet the demand for patient care services?)

“It” works…as reported on the front page of the Washington Post,

August 20, 2002.

““What Are You Going to DoWhat Are You Going to Do if It Works?” if It Works?”

• Process Process vs. demonstration researchvs. demonstration research– How do we scale this up for large How do we scale this up for large

employers in diverse markets?employers in diverse markets?– How do we ensure consistency of care How do we ensure consistency of care

and outcomes?and outcomes?– How can we make this efficient?How can we make this efficient?– What are the components of care What are the components of care

required for positive outcomes?required for positive outcomes?

Patient Self-Management: Patient Self-Management: Diabetes ProgramDiabetes Program

Improving the HealthImproving the Healthof America’s Workforce andof America’s Workforce andReducing Health Care CostsReducing Health Care Costs

Empower the Patient. Improve the Outcomes. Control the Costs.SM

PSM: DiabetesPSM: Diabetes Pilot Sites Pilot Sites

EmployerEmployer RPh NetworkRPh Network Starting DateStarting Date

VF Corporation VF Corporation

4 North Carolina Sites4 North Carolina SitesPiedmont Piedmont Pharmaceutical Care Pharmaceutical Care NetworkNetwork

January 03January 03

Mohawk CarpetMohawk Carpet

Dublin, GeorgiaDublin, GeorgiaGeorgia Pharmacy Georgia Pharmacy AssociationAssociation January 03January 03

Healthcare CoalitionHealthcare Coalition

Manitowoc, WisconsinManitowoc, WisconsinPharmacist Society of Pharmacist Society of WisconsinWisconsin March 03March 03

The Ohio State The Ohio State UniversityUniversity

OSU Managed CareOSU Managed Care March 03March 03

The Kroger CompanyThe Kroger Company

Columbus, OhioColumbus, OhioKroger PharmaciesKroger Pharmacies March 03March 03

““It’s a wonderful thing to have aIt’s a wonderful thing to have a Beautiful MindBeautiful Mind, but more , but more wonderful to have a wonderful to have a Beautiful Beautiful Heart”Heart”

• ““Integral” or “Holistic” approaches are required for Integral” or “Holistic” approaches are required for “transformation” (vs. “translation”) See “transformation” (vs. “translation”) See Ken Wilber, Ken Wilber, Marriage of Sense and SoulMarriage of Sense and Soul

• At least four quadrants…biological(technical), At least four quadrants…biological(technical), psychological, social and cultural are needed for psychological, social and cultural are needed for chronic health managementchronic health management

• John Nash manages his health through growth and John Nash manages his health through growth and support in all quadrants, if the state of NJ had forced support in all quadrants, if the state of NJ had forced him to leave his home to build a bridge would this him to leave his home to build a bridge would this have adversely affected his health?have adversely affected his health?

Can a Ripple in a Mountain Stream Start a Wave Across the Ocean?