Disease State ManagementThe Pharmacist’s Role

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Why the Interest ??

•Chronic diseases account for billions of dollars in annual medical expenditures

• Loss of work time and decreased worker productivity contribute to indirect costs

•Health care services for chronic conditions are often not coordinated among providers, creating opportunities for overuse or underuse of medical care

BMJ.2002;325:925

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Disease State Management Definition

A system of coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts can be implemented

Circulation. 2006;114:1432-1445

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Disease State Management Definition•Disease management (DM)

▫Supports practitioner/patient relationship and plan of care

▫Emphasizes prevention of exacerbations & complications through the use of evidence-based practice guidelines and patient empowerment strategies

▫Evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health

Circulation. 2006;114:1432-1445

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Disease State Management Benefits• Improve the safety and quality of care• Improve access to care• Improve patient self-management• Improve financial cost containment without sacrificing

quality or patient satisfaction• Improve patient quality of life

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Disease Management Program Components

1. Population identification processes

2. Evidence-based practice guidelines

3. Collaborative practice models (multidisciplinary teams that may include physicians, pharmacists, nurses…)

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Disease Management Program Components

4. Patient self-management education (may include primary prevention, behavior modification programs, and compliance/surveillance)

5. Process and outcomes measurement & evaluation

6. Monitoring system/feedback loop that include patients and providers

Collaborative Drug Therapy Management (CDTM)

Collaborative Drug Therapy Management (CDTM)

“A collaborative practice agreement between one or more physicians and pharmacists wherein qualified pharmacists working within the context of a defined protocol are permitted to assume professional responsibility” for certain tasks

Pharmacotherapy 2003;23:1210-1225.

Collaborative Drug Therapy Management (CDTM)

•Tasks include:▫Performing patient assessments▫Ordering and evaluating drug therapy-related

tests▫Selecting, initiating, monitoring, continuing

and adjusting drug regimens▫Assessing patient response to therapy ▫Counseling and educating a patient on

medications ▫Administering medications

Pharmacotherapy 2003;23:1210-1225.

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How Does it Work ?

•As a first step, a disease management program must identify the population group

▫Programs target individuals with a specific disease that is chronic in nature and costly

▫Individuals with multiple conditions may also benefit

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DM Program Characteristics

•The diseases typically targeted by DM programs have the following characteristics: ▫Prevalent chronic condition▫High resource utilization▫Potential for lifestyle modification to improve outcomes ▫A variety of treatment options▫A high risk of negative outcomes

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Ann Acad Med Singapore 2010;39:861-7

DM Programs Examples

Depression Management

Asthma/COPD Management

Diabetes Management

Congestive Heart Failure Management

Coronary Heart Disease Management

Osteoporosis Management

Arthritis Management

Hypertension Management

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How Does it Work ?

•Multidisciplinary team of providers are recruited (e.g. physicians, pharmacists, nurses, dieticians psychologists) to assist individuals in managing their condition(s)

•Practice guidelines based on clinical evidence ensure consistency in treatment across target population

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How Does it Work ?

•The goal of disease management is to encourage patients to: ▫Use medications properly▫Understand and monitor their symptoms more effectively▫Change their behavior

•Clinical, economic and quality of life outcomes are evaluated to assess success of interventions

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The Pharmacist Role

• Assist in the identification of individuals

• Conduct monitoring for specific diseases (e.g. DM, HTN)

• Provide patient education (e.g. glucose monitoring)

• Provide advice on disease management

• Assist with medication adherence

• Identify & manage drug-related problems

• Evaluate outcomes of programs (clinical, economic, QOL)

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The Pharmacist Role

• Conduct outcomes research to form the basis for treatment guidelines

• Ensure the ongoing involvement of the pharmacy and therapeutics (P&T) committee in the disease management process

• Educate other pharmacists and physicians about treatment guidelines

• Use health system databases to track drug expenditure patterns and health care professionals' adherence to health care management regimens

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The Pharmacist Role - Examples

•Asthma Management▫Provide educational programs about the disease▫Conduct periodic review of the patient's inhaler technique▫Perform ongoing monitoring of peak-flow function tests▫Manage chronic medication use, including compliance

assistance

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The Pharmacist Role - Examples

•Diabetes Management▫Provide educational programs about the disease▫Regularly monitor both self-tested and lab tested glucose levels▫Educate patients on how to use glucose monitoring equipment▫Monitor patient compliance with prescribed therapies and

appointments▫Screen for drug interactions and adverse drug reactions▫Provide medication management and review

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The Pharmacist Role - Examples

•Hypertension & Cholesterol Management▫Educate patients about these silent diseases▫Monitor compliance with medications, diet and exercise▫Screen for drug interactions and adverse drug reactions ▫Perform periodic blood pressure checks▫Perform periodic cholesterol level checks

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Organizations Offering DM Programs•Hospitals

▫Inpatient setting▫Ambulatory setting

•Pharmaceutical companies

•Community pharmacies

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Organizations Offering DM ProgramsCommunity Pharmacies

• Desirable setting for providing DM for several reasons:

▫ People visit pharmacies more often than any other health care facility

▫ Community pharmacies account for dispensing the majority of prescriptions

▫ Accessibility of pharmacists creates the opportunity for patients and pharmacists to develop rapport

▫ Prescription databases allow pharmacists to readily retrieve patient-specific information to screen for high-risk patients and identify potential drug-related problems

J Manag Care Pharm. 2005;11(6):505-12

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Perceived Barriers to DM Programs• Limited time• Limited staff• Limited space•Reimbursement issues•High cost• Limited patient acceptance• Lack of knowledge about disease management

J Manag Care Pharm. 2005;11(6):505-12

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Pharmacist Qualifications

•To provide DM services, a pharmacist must be a registered pharmacist & complete a disease specific certification program

•National Institute for Standards in Pharmacist Credentialing (NISPC) adopted the designation of Certified Disease Manager (CDM) for those pharmacists successfully completing one of the disease management exams