The Asheville Project
Overview | Asthma Initiative | Update 2000 | Success | Observations
The Diabetes Ten City Challenge: Interim clinical and humanistic outcomes of a multisite community pharmacy diabetes care program
Toni Fera, Benjamin M. Bluml, William M. Ellis, Cynthia W. Schaller, and Daniel G. Garrett
The Asheville Project: Clinical and economic outcomes of a community-based long-term medication therapy management program for hypertension and dyslipidemia
Barry A. Bunting, Benjamin H. Smith, and Susan E. Sutherland
Some Employers are Offering Free Drugs
New York Times, February 21, 2007
The Asheville Project: Long-term Clinical, Humanistic and Economic Outcomes of a Community-based Medication Therapy Management Program for Asthma
Journal of the American Pharmacists Association, March/April 2006
Pharmacy Times Supplement, June 2005
An Opportunity for Our Profession
What pharmacists should know about disease management
Patient Self-Management Program for Diabetes: First -Year Clinical, Humanistic, and Economic Outcomes
Copyright 2005 American Pharmaceutical Association. Used by permission of APhA.
All articles Copyright 2003 American Pharmaceutical Association. Used by permission of APhA.
Proving That Pharmaceutical Care Makes a Difference in Community Pharmacy
The Asheville Project:
Participants' Perceptions of Factors Contributing to the Success of a Patient Self-Managment Diabetes Program
The Asheville Project:
Short-Term Outcomes of a Community Pharmacy Diabetes Care Program
The Asheville Project:
Factors Associated With Outcomes of a Community Pharmacy Diabetes Care Program
The Asheville Project:
Long-term Clinical and Economic Outcomes of a Community Pharmacy Diabetes Care Program
Asheville Project Overview
The October 1998 Supplement to Pharmacy Times gives a comprehensive overview of the Asheville Project. The Table of Contents is listed below. To obtain a copy contact NCAP.
Supplement to Pharmacy Times, October 1998
The Asheville Project: A Special Report
The Answer to How is When: The Genesis of the Asheville Project
Daniel G. Garrett, MS, FASHP
The Asheville Project — One Year Later
Fred Eckel, MS
Walking the Tightrope to Better Health
Taking a Fresh Look at the Pharmacy Practice Model
Barry Bunting, PharmD, and Bill Horton, RPh
Outcomes of the Asheville Diabetes Care Project
Carole W. Cranor, RPh, MS Pharm
Working Together to Improve Patient Care
Paul Martin, MD
An Investment in Health Offers a High Return for All
John Miall, Jr., ARM
Using Existing Resources to Prepare Pharmacists for an Expanded Role
Cindy Spillers, MS, RD, CDE
The Asthma Initiative
The Asheville Project has been expanded to include the Asthma Initiative, a program designed to treat patients with asthma. The enclosed March 2000 Pharmacy Times supplement highlights three pharmacist-managed asthma programs throughout the state.
The Table of Contents is listed below. To obtain a copy, please contact NCCPC.
Supplement to Pharmacy Times, March 2000
The Asthma Initiative: Connecting National, State, and Community Efforts
Pharmacist Participation is Key
Daniel G. Garrett, MS, FASHP and Fred Eckel, MS, FASHP
Improved Outcomes in Asthma: Looking at Personal, Clinical, and Quantitative Results
Carole W. Cranor, RPh, MS Pharm; Susan Maultsby, RN, BSN; and J. Spencer Atwater, MD
Providing Pharmaceutical Care: Issues, Initiatives, and Insights
Barry A. Bunting, PharmD; John P. Miall Jr., ARM; Daniel G. Garrett, MS, FASHP; Roy A Pleasants, PharmD; Sharon Kast, Nurse Practitioner; Steve Wilcox, MS; J. Spencer Atwater, MD; Peter Gal, Pharm D, BCPS, FASHP, FCCP; Teresa Devora, BA, CMM; Peter Koval, PharmD, BCPS; and Chris Rubino, PharmD, BCPS
Asheville Project Update: Results Continue to Exceed ADA Goals
Barry Bunting, PharmDThe following article appeared in the January/February, 2000 issue of North Carolina Pharmacist.
The Asheville Project continues to grow and make a difference in the lives of patients.
Most readers of the North Carolina Pharmacist are probably familiar with the Asheville Project, but a little background may be helpful.
A strategic planning meeting of state pharmacy leaders in 1995 resulted in a decision to sponsor pharmaceutical care demonstration projects in North Carolina. At the time a lot was being said about "Pharmaceutical Care" in pharmacy circles but practical models, especially in community settings, were lacking. The purposes of these projects were to be at least twofold. First, to develop practical working pharmaceutical care models. And secondly, to demonstrate the value of utilizing community pharmacists to provide pharmaceutical care services in improving patient care. If these projects could successfully develop practice models that measurably improved patient outcomes, the model could then be expanded and the data used to lobby for payment from a variety of payers.
The first project was begun in Asheville early in 1997. The City of Asheville agreed to partner with the North Carolina Center for Pharmaceutical Care (NCCPC), which had been formed to plan and implement these projects.
NCCPC offered to train community pharmacists in diabetes management and to offer pharmaceutical care services for city employees with diabetes. They offered to arrange that this be done for the first six months at no charge to the city. Then if measurable clinical and financial improvements could be demonstrated, NCCPC would negotiate with the city for payment for the services.
The city agreed to offer incentives for employees with diabetes to participate in this "wellness program." These included waiving employee co-payments on all diabetes-related medications and supplies. They also agreed to pay 100% of the cost of a formal diabetes education program offered by the Education Center of Mission St. Joseph’s Health System (MSJ).
Employees who enrolled in the program agreed to go through this formal diabetes education program if they had not previously had formal education, or if it had been more than two years prior. They also agreed to meet on a regular basis, usually every month, with one of the specially trained pharmacists, who they selected from a list of those who had gone through the training.
Pharmacists who were interested in participating in the project agreed to receive training in the management and monitoring of diabetes. They also agreed to the arrangement of providing pharmaceutical care services at no charge for six months. Initially all pharmacists in the greater Asheville area were sent a letter informing them of the program and availability of training. The original training program attracted twenty-four pharmacist participants who went through a two weekend, thirty-two hour, program in diabetes. This was arranged by NCCPC with the assistance of The University of North Carolina, Campbell University, six area physicians and The Diabetes Center of MSJ.
In May of 1997, 21 pharmacists participated in a certificate program in asthma, and in November, enrollment began for city employees with asthma.
In October 1998, Pharmacy Times published a supplement on "The Asheville Project" which reported significant improvement in clinical, financial, and humanistic outcomes for the diabetes project patients.
In November of 1998, 19 pharmacists participated in another asthma certificate program and in January of 1999, 20 pharmacists participated in a diabetes certificate program.
Early in 1999 a second employer was added to the program. Mission St. Joseph’s Health System, the largest employer in Western North Carolina, with approximately 10,000 covered lives, agreed to offer the pharmacy sponsored wellness programs in diabetes and asthma.
As of January 1, 2000 there are 165 patients being followed by program pharmacists, 121 with diabetes and 44 with asthma. Twenty-two pharmacy locations in the greater Asheville area currently provide these services and 65 individual pharmacists have been trained. Many pharmacists have participated in both diabetes and asthma training, and a number of trainees have been from outside of the Asheville area and even from other states.
For pharmacists a significant early outcome came within a few months of beginning the project when the city, having received a great deal of positive feedback from their employees, voluntarily began paying the pharmacists, even before objective patient data was available.
We were understandably anxious for comprehensive outcomes data which came after a full year of the program. Fortunately this data confirmed the subjective observations. Average hemoglobin A1c results for the 40 City of Asheville employees decreased from 7.6% to 6.2%. Total cholesterol averages dropped from 210mg/dl to 198 mg/dl. The LDL average decreased from 118 mg/dl to 98 mg/dl. All of these averages exceeded the American Diabetes Association goals of <7% for hemoglobin A1c, <200 mg/dl for total cholesterol, and <100 mg/dl for LDL. Health status and satisfaction with pharmacy also improved significantly. In addition, the city spent nearly $20,000 less on total healthcare costs for these 40 employees during the first year of the program compared to the previous baseline year. Equally impressive was the finding that the average participant worked 6.5 more days during the project year compared to the prior year. The city quantified the monetary value of this at approximately $18,000.
Second year data for this original group of 40 diabetes patients is just now becoming available. Although analysis is still being conducted we are pleased to publish, for the first time, some of these results. After two full years in the program ADA goals continue to be surpassed. The group’s hemoglobin A1c average continues to be below 7%, at 6.8%. The total cholesterol and LDL averages have decreased even below one year levels. The total cholesterol average is 190 mg/dl and the LDL is 94 mg/dl.
The significance of sustained two-year improvement cannot be overemphasized. It is extremely important for pharmacists to not just demonstrate their ability to improve clinical parameters, education alone can do that, but to demonstrate that a pharmacist-patient relationship can sustain this
improvement. We are, after all, attempting to prove that pharmaceutical care is a cost-effective intervention that will reduce long-term complications of diabetes. Risk reduction is something that is not attainable without prolonged improvement in blood glucose control. Unfortunately this level of control is often associated with high resource, high expense programs. Notably, the 1,400 patient, 10 year, landmark Diabetes Control & Complication Trial (DCCT) stated in their concluding paragraph, "Intensive therapy was successfully carried out in the present trial by an expert team of diabetologists, nurses, dietitians, and behavioral specialists, and the time, effort, and cost required were considerable. Because the resources needed are not widely available, new strategies are needed to adapt methods of intensive treatment for use in the general community at less cost and effort." If someone were searching for a simple description of community based pharmaceutical care it could easily be referred to as a "new strategy," "widely available," "in the general community," "at less cost and effort." And at two years the Asheville Project results continue to exceeded ADA goals by using "widely available resources" with relatively little "time, effort, and cost."
Also, for the first time, we have asthma outcomes to report. Of the 44 asthma patients currently enrolled in the City of Asheville and MSJ programs 25 have been in the program at least six months. The most significant improvement has been in the MSJ group, which interestingly had significantly poorer baseline respiratory function than the city employees. This is an especially interesting finding in light of the fact that health system employees would be expected to be more knowledgeable about their asthma, and perhaps even have better access to care. The MSJ group’s baseline FEV1 (Forced Expiratory Volume in 1 second) average was 64%, compared to a baseline of 84% for the city group. Both groups improved significantly, the MSJ average improving from 64% to 88%, and the city average from 84% to 98%. There were also significant improvements in the "Role Physical" health status indicator, which is a measure of the impact of their disease on their physical ability to function normally on a day to day basis. At baseline the MSJ patients reported that asthma limited their daily activity an average of 4.5 days in the previous month. After being in the program this number decreased significantly to 1.5 days per month. Additionally, at baseline, only 10% of enrollees had a National Asthma Education Program (NAEP) recommended "asthma action plan." As a result of the program 100% of enrollees now have individualized asthma action plans.
Further analysis is being conducted on both the diabetes and asthma groups. A supplement to Pharmacy Times in March, 2000 will include data on not only the Asheville Project, but on other pharmacy asthma initiatives in the state. And now that two-year data are available on the diabetes group, our plan is to publish comprehensive results in a peer reviewed journal this year.
In The Works
The City of Asheville has been so pleased with the program’s results, they are asking us to provide a similar service for their employees who have hypertension and/or hyperlipidemia. They would like for pharmacists to start seeing patients in April and have identified over 200 employees whom they believe will qualify for the program. We currently are very busy with program planning and are preparing training programs for pharmacists.
Each disease is different. People with diabetes seem to be highly motivated to participate in wellness programs. We had almost 100% enrollment of patients who were offered the diabetes program. However, with asthma the enrollment was closer to 25%. Approximately 75% of asthmatics have infrequent symptoms and presumably it is harder to interest them in wellness programs than someone with diabetes who has constant daily reminders of their disease. And we suspect that enrollment for programs in hypertension and hyperlipdemia, which are virtually asymptomatic, may be even lower. Our current thought is that we may need to modify our enrollment approach to include risk awareness education prior to enrollment. And perhaps the incentives will need to be different.
Follow the money. This sounds a little mercenary but the genius of the Asheville Project was the foresight of North Carolina pharmacy leaders to realize the need to begin by partnering with a self-insured payer. Whether it was consciously spoken, or intuitive, the question they asked was, "Who stands to benefit the most financially if employees live healthier lives?" The answer was "employers." So this is where they started. Under the traditional U.S. model employers basically pay 80% of an employee’s health care costs and, therefore, have a huge stake in reducing overall health care costs. So approaching a self-insured employer rather than, for example, an insurance company, avoided a middle man who would have very likely said "no."
Inform and connect. Although there are pros and cons to this method, our general approach with physicians has been to inform them of the program, but not necessarily ask them to give their blessing to every step of the process. If individuals, and their employer, choose to participate in a wellness program it is their choice. After all it is their money. And even the 20% share that U.S. employees pay out of their pockets every year for health care amounts to approximately $265 billion. So they also have a vested interest in lowering health care costs. The first step in informing physicians about the program was a letter sent by the city’s medical director, who was involved in the planning of the program, to all the physicians in the community who cared for patients with diabetes. This letter informed them of the intention of the city to offer their employees a wellness program that included incentives for patients to comply with the physician’s treatment plan. The letter also explained that the program would include the use of specially trained community pharmacists to monitor these patients and assist them with self-management aspects of their disease. Physicians receive a copy of all program related laboratory information, and spirometry results, as well as summary letters and individual patient recommendations from the pharmacists. There has been amazingly little negative feedback to this approach and what did occur was handled by the city’s medical director or the coordinator of the project. The primary fear of physicians has been that this was just another group "trying to tell them how to practice medicine," and that it would further "fragment care." It has been helpful to be able to emphasize that these were local pharmacists, who had received special training by local physician experts, and who were simply acting as an extra set of eyes and ears for the physician. Also we point out that patients already see pharmacists five times more often than any other health care provider and that in this program the participating pharmacists were committing to take time to make that interaction more useful to both the patient and physician.
No lone rangers. We can do many things well but we should not attempt to do everything. A good example of this is our partnership with the Certified Diabetes Educators in the Asheville area to offer a comprehensive education program for patients. Pharmacists in the project do not do extensive diet instruction. Pharmacists are in an excellent position to assess whether patients have comprehended and are applying diet instruction that they receive from CDEs. However, we have not attempted to train pharmacists to be experts in diabetic diet instruction. That is not to say that some pharmacists may have the interest to become experts or of necessity need to be this type of resource in areas that lack CDEs. But our philosophy has been to connect-the-dots, not duplicate them. We each need to do what we do best. Physicians need to continue to diagnose and prescribe good treatment plans. Professional educators need to continue to assist patients in learning self-management skills. Pharmacists need to monitor adherence, efficacy, side effects, and assess/supplement patient knowledge. And we all need to communicate with each other. Due to pharmacy’s tremendous edge in accessibility and medication knowledge, pharmacists have an opportunity to position themselves as unique and valuable health care providers.
Novelty vs. practice. We are rapidly approaching a critical phase in pharmaceutical care in Asheville and perhaps in the state. We have demonstrated that payers are willing to buy what we have to sell. It is time, as the saying goes, to "fish or cut bait." We have proven the boat will float but we still have one foot in the boat and one on dry land. It is not clear at this point how many pharmacists are in a position to step into the boat or even know how to do it. But a couple of models appear to be evolving that offer hope that this step can actually be taken by a critical mass of pharmacists.
"Hired gun chain model." "Dual-hat independent model." The ideal model we envisioned several years ago now seems a bit naïve. Some of us had hoped that a large enough number of pharmacists could be trained in a region that virtually every pharmacy would have a pharmaceutical care provider with expertise in a variety of disease states. However, with the shortage of pharmacists, the need for multiple expensive certificate programs, and a finite number of highly motivated pharmacists, this "ideal" model has some problems. As the reality of this has set in we have had to look at different ways of making this work. We may achieve the ideal model some day but in the interim we need different models. Two of these seem to be evolving in our area.
The "hired-gun chain model" may be an answer for busy chain stores who are having difficulty staffing their stores, let alone providing pharmaceutical care. We currently have a pharmacist experimenting with an approach that provides pharmaceutical care at several locations for a chain. They have contracted with the chain to provide the service. This pharmacist makes appointments to meet with program patients at a time that is convenient for the patient and themselves. This allows the pharmacist to group appointments at particular locations on particular days. This model provides the prospect of highly motivated pharmacists earning a living providing pharmaceutical care on a contract basis. For the patient this has the advantage of offering a greater number of pharmacy locations to choose from. For the chain it provides store traffic, builds customer loyalty, and they do not have to worry about staffing, scheduling, training expense, or finding enough motivated pharmacists. A similar scenario that is also being explored in Asheville is a pharmacist who has been hired by a chain who will be given blocks of time at specific stores on specific days to provide pharmaceutical care services.
The "dual-hat independent model" is probably best described in the words of one of our program pharmacists, Bill Horton, owner of the PSA Beverly Hills Pharmacy in Asheville. Bill’s response to being asked if he was too busy to accept any more project patients was, "You can’t send me too many patients! I would love to have enough pharmaceutical care patients that I have to hire someone to run the store. Then I can spend most of my time providing pharmaceutical care, which is what I want to do anyway." This attitude, if shared by enough pharmacists, may offer a partial answer to the critical question, "How does pharmacy make the transition from the current commodity based practice to a patient care practice?" Bill’s comment illustrates how it is possible to transition a practice as the income from the pharmaceutical care side grows to the point where one is able to support hiring extra help. Independents in particular have the advantage of flexibility in being able to make this decision without having to deal with corporate red tape. From a program coordinator’s perspective, it will take relatively few such independent pharmacists, and/or individuals contracting with chains, to provide a good geographic distribution of pharmacies. This will allow aggressive marketing of a network of such providers to employers or other payers in a region. This is currently our strategic plan.
It is not rocket science. Yes, there is considerable expertise in providing pharmaceutical care, but pharmacists already possess most of that expertise. A motivated pharmacist can supplement his/her knowledge and skills with a reasonable investment of time and effort. As for compliance monitoring, counseling, and education, most pharmacists are already capable of functioning at high levels of competence. It is noteworthy that of the core group of pharmacists who have been responsible for a majority of the great outcomes in the Asheville Project none had the Doctor of Pharmacy Degree. And most had been out of school long before pharmaceutical care became a buzzword. But what they did have was interest, motivation, and experience. We believe good outcomes are as much a result of the relationship as they are pharmaceutical care expertise.
There are literally millions of Americans who need help which pharmacists are capable of giving. We can make a difference. But this takes time, time which pharmacists cannot afford to take unless they are paid to provide the services. The Asheville Project has demonstrated that there are payers who are willing to pay pharmacists to provide these services. This is because it has also demonstrated that pharmaceutical care services do make measurable clinical and financial differences. However, if this is to become more than just a regional phenomena, others will need to pursue opportunities in their own communities. Opportunities will differ from community to community, and one approach will not work for everyone, but there should be some common elements. It is our hope that sharing some of our experiences will help others float their boat.
About the Author...
Barry Bunting, PharmD, is Clinical Manager of Community Pharmacy Services for Mission St. Joseph’s Health System in Asheville. He has been coordinating the Asheville Project for two and one-half years. He can be reached via e-mail at email@example.com
Physicians tend to be increasingly wary of projects promoted in the name of "Managed Care." Although Asheville is in a region that has not been "highly penetrated" by managed care organizations, physicians still assume that care management frequently is driven by cost management. Physicians are further distanced in cooperating with a caremanagement plan if they do not see the immediate benefit to the patient.
So what factors allowed the Asheville Project to succeed? In a word, relationships. The City Employee Health Services have enjoyed a long-term relationship with the medical community of Asheville. The Occupational Health Nurse has served as a tremendous resource for information and surveillance of ongoing treatment. Although episodic care is rendered at the Employee Health Service, the community physicians are well aware that long-term chronic health care will be referred to the primary care offices.
The City physician has also served in a number of well-recognized positions in themedical community. A former member of the Family Practice residency teaching faculty, past President of the county Medical Society, and a leader in a number of indigent care initiatives, the City physician has worked closely with the majority of physicians in the community.
When the diabetes project was in a planning phase, the recognized community diabetes experts were brought on board to assist with project development and community education initiatives. By lending their names to the project, the diabetes consultants essentially endorsed the concept to the physician community.
This project was launched at a time of significant controversy about pharmacists seeking "prescribing privileges." Attention had to be given to separating these two issues and assuring local physicians that they would be in charge of the care management and that the pharmacists were functioning as an extension of the physician team.
In summary, the caveats that promoted the success of the Asheville Project among the physician community were:
- Prior relationship with the industry.
- Prior relationship with the industry health services.
- Active solicitation of input from community physicians during the project development.
- Identification of a key physician sponsor who was well known and respected in the community.
- Association with the identified "diabetes experts" in the community.
- Careful attention to political concerns regarding the goals of the project
- Feed-back to the medical community regarding progress and outcome of the study.
- This progress and outcome demonstrated the value of the project to improved patient care as well as improved and increased follow-up through physician offices.
The Asheville Project is a truly collaborative model that enjoyed a good bit of success secondary to effective cultivation of multiple relationships.
The Asheville Project
Observation form the City of Asheville Occupational Health Nurse
LYNN HOLLIFIELD, BSN, RN, COHN-S
Having been the primary nurse for City employees since 1984, I have had the opportunity and privilege of knowing the employees by name, meeting their family members, and learning about their lives outside work. I found that once we established a relationship of trust and respect, our employees were more receptive to our teaching efforts (and to anyone the teaching efforts of anyone to whom we gave a good reference!) Speaking to that, there is the example of the newly diagnosed diabetic who brought her glucometer to us and requested instruction in its use. Yes, she had received prior instruction but preferred that I go over it with her as well.
Over the years, our in-house nursing services have detected numerous undiagnosed diabetics with the classic symptoms, as well as those cases with subtle symptoms of blurred vision or an admission of overindulging in Cadbury Easter Egg candies coupled with increased thirst!
Due to financial strains, employees tend to postpone medical treatment. Our nurses have been fortunate enough to find and intervene with diabetics before a medical crisis occurred.
A large number of our employees are laborers with low income who may have semi-literacy problems. In working with each individual, it is important to remember that OUR GOALS MAY NOT BE THEIR GOALS. For them, providing food and shelter may very well supercede other needs. Poor personal money management combined with poor understanding of the disease are often factors in cases of noncompliance or uncontrolled diabetes.
It is my feeling that most diabetic employees tried to be compliant, but financial restraints made it hard for them to do so. Prior to the Asheville Project, some employees had to be creative to meet their diabetic needs. For example, the City employees have confessed to:
- cutting test strips in half
- reusing insulin syringes
- using previous left-over diabetic meds when current prescription ran out
- doing without meds & supplies until payday
- limiting glucose checks to once a day (or less) to stretch the supply of test strips
- sharing supplies and medications with parent
- following their diabetic diet until the money runs out, then eating whatever is available
I was ecstatic that the Asheville Project provided free medications and supplies to participating employees. Those folks who really wanted to take better care of themselves now had more means to do so.
The benefits of the Asheville project were a Godsend. Our full-time employees were not eligible for financial assistance on doctor visits and medication purchases because they had health insurance and a pharmacy card. The hard truth is that an hourly wage of $7.25 only goes so far when supporting a family. Meeting the basic medical needs of these "working poor" has been one of the biggest challenges of my job. Someone once commented to me, " A poor man can’t afford to be sick." If you don’t work with those challenges everyday, you take your standard of living for granted and forget what it’s like to walk in another man’s shoes.
The comments I have heard most often from the participating diabetics are that they just feel better overall. I have heard them ask more intense questions related to their disease management. I have seen them take pride in being part of the project, and I have seen their confidence grow in their self-management.