With over 29 million Americans living with diabetes, there is significant pressure on health systems to improve patients’ glycemic control in order to prevent or slow the progression of costly microvascular and macrovascular complications associated with type 2 diabetes mellitus (T2DM). Like most health systems, the Veterans Affairs San Diego Healthcare System (VA San Diego) treats thousands of patients with uncontrolled T2DM. When left uncontrolled, the complications associated with chronic hyperglycemia lead to costly treatments for the medical center, not to mention the personal costs to the patient.
Diabetes care typically consists of clinical visits that may be supplemented with patient education programs. For most health care systems, standard clinical care (ie, 20 to 30 minute visits) for patients with T2DM results in decreases of HbA1c by less than 1% over a 12-month period.1,2 The effects of stand-alone general diabetes education courses vary widely; some have been shown to reduce HbA1c less than 0.5%, but patients are required to attend additional sessions that may not be well integrated with their clinical care.3-5
VA San Diego is charged with meeting diabetes-related performance measures as well as helping patients with diabetes achieve their metabolic goals. Our medical centers are compared regionally and nationally based on specific performance measures such as achieving HbA1c, LDL, and blood pressure goals. With continuous increases in the number of patients with T2DM, it became clear our primary care physicians (PCPs) needed additional support to meet these goals. In 2009, the endocrinology, pharmacy, and internal medicine departments proposed implementing a pharmacist-driven clinic called the Diabetes Intense Medical Management (DIMM) clinic. We posited that the innovative design of the clinic could facilitate the following outcome improvements:
Essentially, the purpose of the DIMM clinic is to dedicate more time to medication management per patient on the front end with the goal of improving clinical outcomes and ultimately saving money for the medical center on the back end. The clinic was designed to assist the PCPs in achieving performance measures, help mitigate the costs of treating future diabetes complications, and save patients from the devastating long-term complications of T2DM. Specifically, the clinic is charged with:
Based on the collaborative efforts of planning and design, DIMM clinic services were implemented in a deliberate manner. A pharmacist (who also is a certified diabetes educator, as well as a clinical provider in this setting) manages the clinic’s patients with oversight from an endocrinologist. As a clinical provider, she has prescribing privileges, performs lab test ordering, and interprets lab values to adjust medication therapy for diabetes and all related conditions (eg, hypertension, lipids, hypothyroidism, diabetic peripheral neuropathy). Patients are purposely treated in the clinic for a limited time (target of three visits over 6 months), and then return to the care of their PCP once metabolic goals are achieved.
The clinic is comprehensive in selecting the best combination of diabetes medications for each patient; treatment is guided by an integrated MTM Spider Web we developed and published in 2013 (see FIGURE 1). A strong emphasis is placed on medication regimen adherence, as well as empowering patients to take control of their diabetes and avoid hypoglycemic events. To enable this, medication regimens are simplified and assessments are performed to mitigate therapeutic duplications and drug-drug/drug-disease interactions. Likewise, educating patients on the reasons for, and effects of, medications (see FIGURE 2), as well as how lifestyle changes and proper blood glucose control can safeguard against the damaging effects of diabetes, will empower the patient and encourage adherence.
Visits are scheduled for 60 minutes approximately every 2 to 3 months, and the clinic accommodates these visits during a half-day session each Thursday of the week. During each visit, HbA1c, blood glucose concentrations, electrolytes, and lipid panel values are assessed, and blood pressure and weight are measured and recorded. Additional patient-specific interventions provided by the DIMM clinic pharmacist include initiating or modifying an individualized treatment plan and conducting a comprehensive foot exam. If needed, patient-initiated, 10 to 15 minute follow-up phone calls are scheduled to review treatment strategies, pattern management, glycemic management, and goals.
Gain Administration Support
Prior to implementation, the DIMM clinic model was reviewed, approved, and supported by key decision makers at the medical center: the chief of pharmacy, the chief of endocrinology, and the chief of internal medicine representing the PCPs. The 9-month planning and implementation process was a team effort and involved the participation of several pharmacists, pharmacy students, physicians, nurses, and administration personnel. The clinic’s scope of practice was defined and a collaborative care protocol was created (with an endocrinologist) outlining the clinic pharmacist’s role and responsibilities. These program measures were approved by the medical executive committee, as well as the medical center’s chief of staff.
The implementation process involved creation of clinic educational materials for patients, documentation templates in the EMR, clinic set-up in an existing exam room, and a scheduling and referral mechanism within the central medical center’s system. With support and an introduction by the chief and director of internal medicine, the clinical pharmacist attended all PCP group meetings to describe the purpose of the DIMM clinic, detail its unique model, and explain the patient referral process. Initially, to qualify for a referral, patients had to have an HbA1c of greater than 9%; however, due to the clinic’s success, patients now can be referred with an HbA1c of greater than 8%.
Measuring Program Effectiveness
The DIMM clinic’s success is largely due to the efforts of pharmacists who take the time to personalize patient education while providing specific medication and lifestyle management skills, which ideally will remain with the patient long after they have left the clinic. Through these efforts, we have proven that glycemic control can be achieved within 6 months for most patients, while simultaneously avoiding weight gain and hypoglycemia. In our case, mean A1c reduction at 6 months was 2.4% with about three-quarters of patients achieving their A1c goals.6
Furthermore, patients are highly satisfied with the clinic experience, medical center costs are avoided, and preliminary results show glycemic control has been sustained through both the 6- and 12-month time periods following clinic discharge. In addition, the improvements delivered by the clinic are linked directly to improved quality performance measures for the medical center.
Candis M. Morello, PharmD, CDE, is professor of clinical pharmacy at Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, as well as a clinical pharmacy specialist at Veterans Affairs of San Diego Healthcare System.
Jan D. Hirsch, BS Pharm, PhD, is associate professor of clinical pharmacy at Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, as well as a clinical pharmacy specialist at Veterans Affairs of San Diego Healthcare System.