SummaryAs part of the Maryland P3 (Patients, Pharmacists, Partnerships) Program™, a pharmacist coach meets regularly with employees who have diabetes to assess their health, monitor their medications, and strengthen their self-management skills. Self-insured employers participating in the program waive participants' copayments for diabetes-related drugs and supplies. The program improved blood glucose and blood pressure control, increased the provision of recommended services, and reduced overall health care costs.Suggestive: The evidence consists of comparisons of key outcomes measures in 176 diabetes patients who participated in the program to national and (in some cases) state averages for similar patients enrolled in commercial plans (comparisons with state averages for national commercial, and Maryland commercial payers).
Developing OrganizationsAmerican Pharmacists Association Foundation; Maryland Department of Health and Mental Hygiene, Office of Chronic Diseases; Maryland Pharmacists Association; University of Maryland School of Pharmacy Department of Pharmacy Practice & Science
The Maryland P3 (Patients, Pharmacists, Partnerships) Program™ was developed by the Department of Pharmacy Practice and Science at the University of Maryland School of Pharmacy in partnership with the Maryland Pharmacists Association, the American Pharmacists Association Foundation, and the Maryland Department of Health and Mental Hygiene.
Use By Other OrganizationsAs noted, sites participating in the Ten City Challenge Program used a very similar approach; more information on these initiatives can be found at:
Problem AddressedDiabetes is a common, costly disease that can lead to serious complications and death. Although proactive patient self-management that includes monitoring of blood glucose, regular eye and foot examinations, proper diet and exercise, and medication adherence can prevent many common comorbidities, few individuals with diabetes follow these guidelines. Pharmacists represent an underutilized but potentially effective resource to assist patients in improving self-management.
- A common, costly condition: Diabetes affects approximately 23.6 million people, representing 7.8 percent of the U.S. population;1 approximately 373,000 Marylanders (8.7 percent of the state's population) have the disease.2 While incidence increases with age, 10.8 percent of working individuals between the age of 40 and 59 have diabetes. The seventh leading cause of death in the United States in 2006, diabetes increases the risk of heart disease, stroke, high blood pressure, blindness, kidney disease, nervous system disease, amputations, dental disease, and pregnancy-related complications.1 The total costs of diabetes are estimated to be $174 billion, consisting of $116 billion in direct medical costs and $58 billion in indirect costs, including disability, missed work (roughly 15 million days are lost each year due to diabetes-related absenteeism3), and premature mortality. This latter figure does not include the costs of "presenteeism" (when workers are at work but not fully productive), which likely exceed the costs of absenteeism.4
- Unrealized benefits of patient self-management: Patients with diabetes who successfully manage their glucose, blood pressure, and lipid levels can significantly reduce the risk of complications and comorbidities; regular eye and foot examinations and proactive screening and treatment of kidney disease can also significantly reduce diabetes-related problems.1 Yet, less than 2 percent of adults with diabetes follow American Diabetes Association recommendations for self-management, including blood glucose monitoring, diet and physical activity, and medication adherence.5 Adhering to prescribed medication regimens can be particularly difficult, due in part to the taking of multiple medications. A recent Maryland study found that patients with metabolic syndrome (a cluster of risk factors that often lead to diabetes) had been prescribed an average of 5.4 medications.2
- Largely untapped potential of pharmacists: Studies have shown that pharmacists can help those with diabetes better manage the condition by improving medication adherence and ensuring the provision of appropriate services (e.g., eye and foot examinations).6 Relatively few individuals with diabetes, however, have access to pharmacists' chronic disease services in the community.
Description of the Innovative ActivityAs part of the Maryland P3 (Patients, Pharmacists, Partnerships) Program™, a pharmacist coach meets regularly with employees who have diabetes (and potentially other chronic conditions as well) to assess their health, monitor their medications, and strengthen their self-management skills. Self-insured employers participating in the program waive participants' copayments for diabetes-related drugs and supplies. Key elements of the program are described below:
- Marketing and enrollment: Participating self-insured employers market the program to employees with diabetes as part of the company's health benefits, typically during open enrollment periods. In addition, University of Maryland School of Pharmacy personnel regularly participate in employer health benefit fairs, handing out brochures and discussing the program with employees. Interested employees sign up through their employer's health benefits department. Information provided in December 2011 indicates that six employers and 500 patients participate in the program.
- Pharmacist-led, employer-funded disease assessment and coaching: Enrolled employees receive assessment and coaching services from one of approximately 30 pharmacists. (The program has trained more than 150 pharmacists.) The pharmacist contacts the employee to schedule an initial meeting, with subsequent meetings occurring at least quarterly. These consultations take place in locations convenient to participants, such as a worksite clinic or retail pharmacy. More details on the assessment and coaching process appear below:
- Initial meeting to assess self-management skills: At the initial 1-hour session, the pharmacist takes a medical history, conducts a brief physical assessment (e.g., height, weight, blood pressure); inquires about current conditions, providers, and medications (including any problems with these medications); and asks about diabetes-related goals that have been set with providers. Using motivational interviewing, the pharmacist begins to assess the individual's baseline knowledge with respect to diabetes, ability to self-manage the condition, and medication adherence. Although diabetes represents the main "entry point" to the program, the pharmacist will, as needed, address participants' other chronic conditions in this initial and/or in subsequent visits. For example, he or she may also coach the patient regarding hypertension, high cholesterol, coronary artery disease, and depression as needed.
- Subsequent meetings to develop skills and assess clinical progress: Subsequent face-to-face meetings occur as deemed necessary by the pharmacist, usually five to seven times a year. During these 30-minute sessions, the coach provides education and works with the employee to reduce barriers to medication-related problems, improve adherence, and build self-management skills and knowledge related to lifestyle and medication use, with choice and sequencing of topics based on the patient's needs. The pharmacist also evaluates the patient's clinical progress (e.g., changes in blood glucose levels) since the previous visit, reviews the patient's medications, and determines the need for recommended preventive care (e.g., foot and eye examinations, flu vaccination).
- Communication and coordination with regular providers: The pharmacist provides written notes after each visit and contacts the participant's regular provider(s) on an as-needed basis—typically after each meeting—to update them on the patient's progress. The pharmacist also asks the physician about any therapeutic goals that have been set or that the physician wants the pharmacists to emphasize and asks about recent laboratory test results. As needed, the pharmacist will work with the provider to arrange any needed referrals, such as to a dietitian or other specialist.
- Documentation: The pharmacist documents all visits and interactions with the patient in a Web-based system.
- Waived copayments: In addition to paying pharmacists for the consultations, participating employers waive copayments for diabetes-related drugs and supplies for program participants. Some participating employers also reduce or waive copayments for other chronic disease medications taken by participating employees, such as angiotensin-converting enzyme inhibitors, lipid-lowering agents, and blood pressure medications.
- Quality assurance: The school of pharmacy performs quality assurance by reviewing pharmacist notes on participant interactions and confirming adherence to the program's standards of care (which are based on standards set by national organizations such as the American Diabetes Association).
- Data collection and feedback to employers: The School of Pharmacy regularly collects data on cost and health measures and produces aggregate reports for employers on the clinical outcomes and costs of the program for their employees. (Note: The program does not disclose individual employee data.)
Context of the InnovationThe University of Maryland School of Pharmacy, founded in 1841, is ranked ninth among all pharmacy schools in the United States by U.S. News and World Report. Their mission is to lead pharmacy education, scientific discovery, patient care, and community engagement in the state of Maryland and beyond. The school is a national leader in promoting pharmacists' expanded role as medication experts who can play a key role in chronic disease management. In 1994, the school of pharmacy initiated a project in a local supermarket chain in which pharmacists helped patients manage their chronic diseases; however, due to lack of reimbursement from third-party insurers, the program had limited business viability and eventually ended. Nevertheless, the department chairperson continued to discuss the program at various events, including one where he met a Maryland state delegate also interested in expanding the pharmacist role in chronic disease management. School of pharmacy leaders also became aware of the success of the American Pharmacists Association Foundation's Diabetes Ten City Challenge program, in which employers provided pharmacist coaches to patients with diabetes and reduced or eliminated copayments for diabetes medications (see the Innovations profile at http://www.innovations.ahrq.gov/content.aspx?id=2602). The P3 Program site in Cumberland, MD, was one of the 10 cities in the Ten City Challenge program.
ResultsThe program demonstrated high rates of blood glucose and blood pressure control, provision of recommended services, and reduced overall health care costs.
Suggestive: The evidence consists of comparisons of key outcomes measures in 176 diabetes patients who participated in the program to national and (in some cases) state averages for similar patients enrolled in commercial plans (comparisons with state averages for national commercial, and Maryland commercial payers).
- Better blood glucose control: Information provided in December 2011 indicates that after 12 months in the program, 55.6 percent of participants had good blood glucose control (with a hemoglobin A1c level of 7 percent or below), significantly above the level of control reported by commercial insurance plans about their patients. Moreover, 42 percent of participants achieved the best possible therapeutic goal (with hemoglobin A1c level of 6.5 percent or less). Moderately good blood glucose control (with a hemoglobin A1c level between 7.1 and 8 percent) was achieved by 83 percent of the participants, again significantly above the rates of 62 percent reported by commercial plans in 2011. Finally, only 7.3 percent of participants had poor blood glucose control (with hemoglobin A1c levels over 9 percent), well below the 27.3-percent rate for commercially insured diabetes patients nationally.
- Better blood pressure control: Information provided in December 2011 indicates that after 12 months, 82 percent of participants had good blood pressure control (less than 140/90 mm Hg), compared with only 65.1 percent of national commercial plan enrollees with diabetes. In addition, 53 percent of participants reached the therapeutic goal for blood pressure (less than 130/80 mm Hg), compared with just 33.9 percent of commercial plan enrollees with diabetes nationally.
- More likely to get recommended services: The majority of program participants received recommended services, including influenza vaccinations (67 percent), eye examinations (73 percent), and foot examinations (67 percent). These adherence rates exceed those in most populations of commercial enrollees with diabetes.
- Lower overall costs: Total actual cost savings averaged $3,281 per patient for one employer and $495 for a second employer after 1 year of participation in the program.2 The cost savings compared with projected health care costs averaged $5,343 and $1,508, respectively. Cost savings reported are net of Maryland P3 program costs.
Planning and Development ProcessKey elements of the planning and development process included the following:
- Identifying partners: The department chairperson and the state delegate reached out to other organizations to identify potential partners for the program, including the Maryland Department of Health and Mental Hygiene, the Maryland Pharmacists Association, and several large, self-insured employers.
- Introducing legislative action: The delegate introduced a bill to the Maryland State legislature in an effort to secure funding from the State department of health and mental hygiene.
- Recruiting employers: The School of pharmacy recruited self-insured employers through a variety of means, including conducting information sessions at Mid-Atlantic Business Coalition n Health and Virginia Business Coalition on Health meetings, working with health care benefit management companies, and making presentations to large companies.
- Recruiting and training community pharmacists: P3 Program staff conduct ongoing outreach among the school's alumni and other pharmacy organization meetings to invite participation of motivated pharmacists interested in chronic disease management activities. Training is often free and is an avenue for highly trained pharmacists to network. The school of pharmacy training involves both a home study course and an onsite 5- to 6-hour session in which pharmacists demonstrate their coaching and clinical skills (e.g., blood pressure monitoring, blood glucose testing, and insulin injection). Training also focuses on adapting recommendations and goal setting to the patient's health literacy level and cultural background. Pharmacists receive 18 hours of continuing education credit for participating in this training. To date, approximately 300 pharmacists have been trained.
Resources Used and Skills Needed
- Staffing: P3 staff includes a director, a full-time assistant director pharmacist who manages program operations, and program operations staff. Each pharmacist works part-time on the program, handling a caseload of approximately 3 to 30 patients depending on how much time he or she wants to dedicate to it.
- Costs: Data on total program costs related to development, implementation, and ongoing operations (including the pharmacist fees and the value of reduced copayments) are generally not available. See the Funding Sources section below for information on the level of support provided by the state of Maryland.
Funding SourcesUniversity of Maryland School of Pharmacy; Maryland Department of Health and Mental Hygiene, Office of Chronic Diseases
In addition to fees for services, funding is provided by the Maryland Department of Health and Mental Hygiene (as mandated by the Maryland legislature); an initial grant of $50,000 covered development and implementation, while annual funding of roughly $100,000 partially supports ongoing operations. As noted, self-insured employers pay for the pharmacist consultations on a fee-for-service basis; they also pay the University of Maryland School of Pharmacy for program coordination and data management/reporting activities.
Getting Started with This Innovation
- Identify important stakeholders: Soliciting the support and involvement of key stakeholders helps to generate enthusiasm for the program, identify potential resources to support it, and anticipate and address potential roadblocks. Reaching out at an early stage to the physician community can be especially important to avoiding misunderstandings about the expanded pharmacist role. The University of Maryland did not include physicians during the planning stages, and program leaders now believe that their support and feedback would have been helpful as implementation moved forward.
- Target employers with sufficient patient volume: Participating employers must have a sufficient number of employees and employee family members with diabetes or a targeted chronic disease to make startup cost-effective.
Sustaining This Innovation
- Secure ongoing funding: Potential sources of funding include government agencies (e.g., the local or State health department) and large local or regional health systems.
- Be flexible in adapting program to employer needs: Some employers have requested that the pharmacists focus on care of other chronic diseases, such as depression, asthma, and chronic obstructive pulmonary disease. Meeting these requests requires flexibility in areas such as training and benefit design.
- Monitor environment and adapt to new initiatives: Continue to adapt the program to the changing health care environment. For example, the pharmacist coaching program (particularly its payment mechanisms) could be incorporated into medical home and accountable care organization initiatives being led by insurance carriers, health plans, and provider organizations. By moving beyond self-insured employers to these other potential partners, the program can remain viable as the environment changes in response to health care reform initiatives.
Use By Other OrganizationsAs noted, sites participating in the Ten City Challenge Program used a very similar approach; more information on these initiatives can be found at:
Contact the InnovatorMagaly Rodriguez de Bittner, PharmD, BCPS, CDE
Professor & Chairperson, Department of Pharmacy Practice and Science
Director, Maryland P3 Program
University of Maryland School of Pharmacy
Pharmacy Hall, Room N431
20 North Pine Street
Baltimore, Maryland 21201
Innovator DisclosuresMs. Rodriguez de Bittner has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.
References/Related ArticlesRodriguez de Bittner M. Maryland P3 Program™: Evaluation Report 2008. Baltimore, MD: Commissioned by the Maryland Department of Health & Mental Hygiene, 2009.
1 Centers for Disease Control and Prevention. National Diabetes Fact Sheet, 2007. Available at: http://www.prnewswire.com/mnr/dtccfinaldata/37319/docs/37319-NEW_CDC_National_Diabetes_Fact_Sheet.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software.)
2 Rodriguez de Bittner M. Maryland P3 Program: Evaluation Report 2008. Baltimore, MD: Commissioned by the Maryland Department of Health & Mental Hygiene, 2009.
Fera T, Blumi BM, Ellis WM. Diabetes Ten City Challenge: final economic and clinical results. J Am Pharm Assoc. 2009 May-Jun;49(3):383-91. [PubMed]
Beckles GL, Engelgau MM, Narayan KM, et al. Population-based assessment of the level of care among adults with diabetes in the U.S. Diabetes Care. 1998 Sep;21(9):1432-8. [PubMed]
Choe HM, Mitrovich S, Dubay D, et al. Proactive case management of high-risk patients with type 2 diabetes mellitus by a clinical pharmacist: a randomized controlled trial. Am J Manag Care. 2005 Apr;11(4):253-60. [PubMed]
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Original publication: December 22, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: February 26, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: February 17, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.