Pharmacists in Federally Qualified Health Centers: Models of Care to Improve Chronic Disease.

INTRODUCTION: Pharmacists are underused in the care of chronic disease. The primary objectives of this project were to 1) describe the factors that influence initiation of and sustainability for pharmacist-provided medication therapy management (MTM) in federally qualified health centers (FQHCs), with secondary objectives to report the number of patients receiving MTM by a pharmacist who achieve 2) hemoglobin A1c (HbA1c) control (≤9%) and 3) blood pressure control (<140/90 mm Hg). METHODS: We evaluated MTM provided by pharmacists in 10 FQHCs in Ohio through qualitative thematic analysis of semi-structured interviews with pharmacists and FQHC leadership and aggregate reporting of clinical markers. RESULTS: Facilitators of MTM included relationship building with clinicians, staff, and patients; regular verbal or electronic communication with care team members; and alignment with quality goals. Common MTM model elements included MTM provided distinct from dispensing medications, clinician referrals, and electronic health record access. Financial compensation strategies were inadequate and varied; they included 340B revenue, incident-to billing, grants, and shared positions with academic institutions. Of 1,692 enrolled patients, 60% (n = 693 of 1,153) achieved HbA1c ≤9%, and 79% (n = 758 of 959) achieved blood pressure <140/90 mm Hg. CONCLUSION: Through this statewide collaborative, access for patients in FQHCs to MTM by pharmacists increased. The factors we identified that facilitate MTM practice models can be used to enhance the models to achieve clinical goals. Collaboration among clinic staff and community partners can improve models of care and improve chronic disease outcomes.

The effect of an interprofessional pain service on nonmalignant pain control.

PURPOSE: The primary objective of this project was to evaluate an existing interprofessional, nonmalignant pain service by measuring the difference in patient pain scores (numeric rating scale-11) before and after a pharmacist-led pain education class and medication therapy management (MTM) visit. Secondary objectives included determining the percentage of pharmacist recommendations approved, patient satisfaction, and difference in immediate release (IR) and extended release (ER) opioid use before and after enrollment. METHODS: Baseline data were obtained from a retrospective chart review. Enrolled patients attended an educational pain class with the pharmacist. At the MTM visit with the pharmacist 3-14 days after the initial education class, the patient's pain score was assessed along with his/her medication use, and a care plan was developed and forwarded to the referring provider for implementation. Three months after the pain class and participation in the MTM visit, patients were contacted via telephone to complete a survey. The survey questions assessed patient satisfaction with the pain education program, their current pain score, and their knowledge of information covered during the pain class. RESULTS: Patients reported an average preenrollment pain score of 8.3/10 (n = 39) and a post-survey pain score of 5.6/10 (n = 39). The IR opioid use averaged 19.7 morphine equivalent daily dose (MEDD) at enrollment and decreased by 40% to 11.8 MEDD. The provider approval rate of the pharmacist-recommended interventions ranged from 80% to 92%, depending on the predesignated disease state category. CONCLUSION: An interprofessional, nonmalignant-pain service including a pharmacist-led class resulted in a decrease in average pain scores and MEDD in an underserved population.

The Effect of Pharmacy-Led, Small-Group Academic Detailing on Prescribing Patterns in an Ambulatory Care Clinic.

Background: While academic detailing seems to be the most promising intervention to improve prescribing patterns, implementation could be challenging for small community practices. Objective: A pharmacy-led, interactive, and tailored small-group academic detailing in a federally qualified health center is described. The primary objective of the study was to determine if the small-group academic detailing improved the prescribing patterns of the medical providers for select disease states: type 2 diabetes mellitus (T2DM), hyperlipidemia (HLD), and essential hypertension (HTN). Methods: Prescribing patterns in a federally qualified health center were examined in relation to small-group academic detailing sessions from April 2010 to March 2015. The markers for improvement were the increase in utilizing metformin and statins in patients diagnosed with T2DM and HLD, respectively, and the reduction of ß-blocker use in patients diagnosed with essential HTN. Changes in prescribing patterns were evaluated using Pearson's χ2 and Fisher's exact tests. Results: The average number of active, adult patients with T2DM, HLD, and essential HTN was 839, 1768, and 2547, respectively. Utilization of metformin in T2DM increased from 5.5% at baseline to 37.7%, statin utilization in HLD increased from 77.1% to 86.9%, and ß-blocker use in HTN decreased from 17.9% to 13.8% (P < .005). Conclusions: A pharmacy-led, small-group academic detailing program improved and maintained appropriate prescribing patterns in an underserved community practice. This study serves as a successful pilot emphasizing the pharmacist's role as an educator and a resource to medical providers regarding appropriate medication use.

Improving Chronic Disease Outcomes Through Medication Therapy Management in Federally Qualified Health Centers.

INTRODUCTION: Appropriate management of chronic diseases, including proper use of medications, can lead to better disease control, decrease disease-related complications, and improve overall health. Pharmacists have been shown to positively affect chronic disease outcomes through medication therapy management (MTM). The primary objectives of this project are to increase the number of patients with (1) A1c in control and (2) blood pressure in control; secondary objectives are to (3) describe number and type of medication-related problems identified and resolved by pharmacists providing MTM in Federally Qualified Health Centers (FQHCs), (4) identify potential (pADEs) and actual adverse drug events (ADEs), and refer patients to diabetes self-management education classes, as needed. METHODS: This multisite, prospective, descriptive pilot study engaged three FQHC sites with distinct models of established pharmacist MTM services to care for patients with uncontrolled diabetes and/or hypertension. Data were reported in aggregate regarding primary and secondary outcomes. RESULTS: As of December 2015, 706 patients were enrolled in the project. Of the 422 with uncontrolled diabetes, 52.84% (n = 223) had an A1c <9%; 72 patients (17.06%) achieved an A1c between 8% and 9%, 19.19% (n = 81) of patients achieved an A1c <8% and ≥7%, and 16.59% (n = 70) of patients achieved an A1c <7%. The percentage of patients with blood pressure <140/90 mm Hg improved to 65.21%. CONCLUSION: Pharmacist-provided MTM can improve chronic disease intermediate outcomes for medically underserved patients in FQHCs.

Over diagnosis of chronic obstructive pulmonary disease in an underserved patient population.

INTRODUCTION: While cross-national studies have documented rates of chronic obstructive pulmonary disease (COPD) misdiagnosis among patients in primary care, US studies are scarce. Studies investigating diagnosis among uninsured patients are lacking. OBJECTIVE: The purpose of this study is to identify patients who are over diagnosed and thus, mistreated, for COPD in a federally qualified health center. METHODS: A descriptive study was conducted for a retrospective cohort from February 2011 to June 2012. Spirometry was performed by trained personnel following American Thoracic Society recommendations. Patients were referred for spirometry to confirm previous COPD diagnosis or to assess uncontrolled COPD symptoms. Airway obstruction was defined as a forced expiratory volume in the first second of expiration (FEV1) to forced vital capacity ratio less than 0.7. Reversibility was defined as a postbronchodilator increase in FEV1 greater than 200 mL and greater than 12%. RESULTS: Eighty patients treated for a previous diagnosis of COPD (n = 72) or on anticholinergic inhalers (n = 8) with no COPD diagnosis were evaluated. The average age was 52.9 years; 71% were uninsured. Only 17.5% (14/80) of patients reported previous spirometry. Spirometry revealed that 42.5% had no obstruction, 22.5% had reversible obstruction, and 35% had non-reversible obstruction. CONCLUSION: Symptoms and smoking history are insufficient to diagnose COPD. Prevalence of COPD over diagnosis among uninsured patient populations may be higher than previously reported. Confirming previous COPD diagnosis with spirometry is essential to avoid unnecessary and potentially harmful treatment.