Ken Krizner

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The leading problems that endocrinologists and educators see from their daily interactions with diabetes patients.

Top Challenges in Managing Diabetes

Hospital pharmacists are not unlike pharmacists in other practice settings. Their primary objective is to ensure that patients experience safe medication use.

Beyond that purpose, however, the role of hospital pharmacists (also known as health-system or clinical pharmacists) encompasses a broad range of duties with the ultimate goal of providing quality care during an inpatient stay, ensuring a seamless transition of care, and reducing the number of medication errors.

Hospital pharmacists consult on diagnosis, examine patient charts, conduct patient evaluations to recommend a course of treatment, and choose the appropriate dosing of medications and evaluate their effectiveness.

“In health systems, pharmacists are more involved with direct patient care than ever before,” says Norman Tomaka, CRPh, a clinical consultant pharmacist in Melbourne, Florida. “There’s an incredible opportunity for pharmacists to improve patient outcomes. I see that happening more and more.”

With the continued trend toward value-based payment models, hospital pharmacists are taking an active part in efforts to reduce readmission rates.

“The role of pharmacists in the hospital is shifting from a distribution-centric model to more of a service delivery focus,” says Eric Maroyka, PharmD, BCPS, director of the Center on Pharmacy Practice Advancement section for the 

American Society of Health-System Pharmacists

 (ASHP). “They’re part of an interprofessional team that may cut across different settings of care. Some of this is driven by a move to value-based care, such as CMS’ quality measures and readmission targets.”

The suggested pharmacist-to-patient ratio for optimal care is about 1-to-30 (1-to-20 in the intensive care unit), notes Kimberly A. Boothe, PharmD, MHA, system director, pharmacy services for 

 in Fort Thomas, Kentucky. (The traditional pharmacist-to-patient ratio is in the 1-to-50 to 1-to-100 range).

With fewer patients to treat, hospital pharmacists can examine patients more holistically for both acute and chronic conditions.

Acutely, a patient is admitted with signs and symptoms of emerging sepsis, although the lab work initially seems fine. Hospital pharmacists are knowledgeable about those signs and symptoms. They can identify a drug that may be harmful if not adjusted to compensate for acute changes in kidney function because of emerging sepsis.

“A hospital pharmacist can take steps to communicate with the nursing and physician team about a dose adjustment or preemptively recommend discontinuing a medication,” Maroyka stresses. “They can make proactive changes based on evidence instead of reactive changes later that will unnecessarily extend a patient’s hospital stay.”

How Health Systems Use Pharmacists to Reduce Readmissions

For patients with chronic conditions, hospital pharmacists can collaborate with physicians to manage disease states such as hypertension and chronic obstructive pulmonary disease, mainly through patient education and counselling, drug safety management, medication review, monitoring and reconciliation, detection and control of specific risk factors, and outcomes.

These examples of interactions show the value of the hospital pharmacist participating in rounds as part of the care team.

“Many times, the body stresses when someone is in the hospital,” says Brook DesRivieres, PharmD, MS, a member-spokeswoman for the 

 (APhA). “What works at home may not work in the hospital. Hospital pharmacists can make sure prescriptions and doses are clinically appropriate.”

DesRivieres describes the hospital pharmacist as a watchdog. “We’re the safety net,” she points out. “A provider may order a drug therapy, but it may not be administered until the pharmacist does a safety check. That’s the biggest contribution pharmacists make in the inpatient setting.”

Medication management has many gaps that, if not closed, could result in an adverse event for patients. Those gaps become more noticeable-and potentially more life threatening-during a transition of care from the hospital to home, a rehab or skilled nursing facility, or other care setting. Hospital pharmacists coordinate post-discharge care to prevent adverse events.

At discharge, pharmacists ensure there is an accurate and updated medication list communicated with patients and their providers. In certain cases, pharmacists will check to see whether patients have access to the pharmacy and a way to pay for the medications. Care coordination may be done with the servicing outpatient pharmacy.

“The pharmacist can determine whether there is a reason that a medication is no longer indicated and be discontinued,” notes Erika Thomas, MBA, BS Pharm, director of the Inpatient Care Practitioners section for ASHP. “If the patient is elderly and at risk for falls, the risk and benefits of certain medications must be evaluated.”

Transition of care is important for the health of the patient and because of the changeover from fee for service to value-based payments. More than 2,500 hospitals nationwide will receive reduced reimbursement because of high patient readmission rates during fiscal year 2019 (ending September 30), according to the CMS.

“Readmissions will impact the bottom line,” Tomaka maintains. “Reimbursements are lower due to readmissions. Hospital pharmacists can collaborate with community practitioners, including primary care physicians, nursing home agency, and home healthcare, so there is a medication management plan carried out when patients leave the hospital to prevent readmissions.”

Numerous studies show hospital pharmacists substantially contribute to safer medication use by collaborating with other providers, and they improve the quality (reduced medication discrepancies) of admission and discharge reconciliation by exercising oversight.

Further studies document that pharmacists identify a significantly higher number of medications taken per patient, including more over-the-counter and herbal medications, compared with nurses, and they contact patients’ outpatient pharmacies significantly more often than nurses.

Fewer errors are found when a pharmacist, rather than a physician, completes a patient’s medication reconciliation during a hospital stay, 

“There has been lots of research that documents the important role of hospital pharmacists,” Boothe stresses.

Data at St. Elizabeth Healthcare show a reduction of errors from 2.8 discrepancies per patient to 0.5 discrepancies per patient with a pharmacy-assisted medication reconciliation process with the addition of medication history technicians and a pharmacist reconciliation review.

Hospital care is complex, and there are multiple opportunities for miscommunication-both in the hospital and post discharge. Hospital pharmacists are trained to circumvent miscommunication. By doing so, they help ensure a quality patient experience.

“Hospital pharmacists must move beyond dispensing and into more clinical areas,” says Melanie R. Smith, PharmD, BCACP, DPLA, director of the Ambulatory Care Practitioners section for ASHP. “This increases patient access to care, while also expanding the role of the pharmacist on a healthcare team. All of which helps to improve the patient care experience.”

Ken Krizner is a freelance writer based in Cleveland, Ohio. 

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Why hospital pharmacists are playing an increasingly-large role in patient care and why their involvement can boost medication outcomes and reduce errors.

Hospital Pharmacist Role Expands in Patient Care

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The life of a patient diagnosed with diabetes is complicated.

“Treating diabetes is not simple,” says Gregory J. Deines, DO, division chief, Diabetes & Endocrinology of 

 in Grand Rapids, Michigan. “It involves a complex medication regimen.”

, according to the National Institute of Diabetes and Digestive and Kidney Diseases. Published studies estimate between 38% and 93% of those patients are noncompliant with their treatment regimen. “It is a significant number, no matter which end of the range,” says Patricia L. Bononi, MD, medical director for the Center for Diabetes at 

Often, patients see their treatment as too difficult, too expensive or interfering with their daily activities. “There is a lot of work associated with having diabetes,” Bononi stresses.

One of the biggest issues with diabetes is that patients usually don’t feel any symptoms until they experience a medical event, such as a heart attack or stroke, says Jason Bhan, MD, co-founder and chief medical officer of 

“Until then, there is little or no consequence for their behavior,” he notes. “As long as patients don’t feel like they need to take something, there is a whole list of reasons for them to not take their medications.”

But compliance is a medical necessity. The key is to create a setting where patients understand complying with their treatment plan is necessary to their health, but providers understand the variables that stop patients from being in compliance. To create such a setting, providers have developed team-based care solutions that examine medical and nonmedical conditions that prevent compliance.

A complex disease such as diabetes requires a team-based approach to help patients comply with their regimen, providers say. The team can be comprised of endocrinologists, pharmacists, dieticians, social workers, educators, and behavioral health specialists. Each specialist uses their skills to discover the motivations of a patient. By fostering a one-on-one relationship with patients, and not just telling them what they should do, the chances of compliance increase.

“It’s important to think in terms of a team approach, even for physicians who may not be blessed with a complex [healthcare] system,” says Edward Dick, MD, senior vice president of Integrated Health Services at 

 in San Antonio, Texas. “They need to develop a team within the community and with payers.”

Survey: Patients Reveal Biggest Negative Effects of Diabetes

Methodist Healthcare Ministries sees patients at two San Antonio clinics, many of whom are at 200% of the federal poverty level and lack insurance. Often, a diagnosis of diabetes is incidental to why a patient originally sought treatment.

Patients at this income level face a number of self-determinant challenges, Dick says. For example, getting to an appointment might be difficult because of issues related to a job, transportation or childcare.

“That’s why we have the [different] specialists offer as many services as possible during one visit,” Dick says. “We try to find alternative means of education to make sure patients can actually achieve their goals. The team has to recognize that patients have their own priorities, and those priorities are not always the same as physicians.”

Allegheny Health Network’s team evaluates patients during a 12-week period at a diabetes specialty center. Not only are there medical tests, but the team addresses obstacles that might prevent an improvement in treatment compliance, Bononi says. Moreover, the team provides quality metrics and education and serves as a resource to primary care practices.

“Since primary care is where the vast majority of patients receive their diabetes care, it’s important that they can access education there,” Bononi says. “And it’s important that the staff has the knowledge to help coach patients.” In Grand Rapids, Deines says one issue is that patients simply can’t take their medications every day-whether the reason is cost, quality of life issues, or other variables. So, the team tries to get to know and understand the personal circumstance of patients, as well as their desired outcomes and goals.

“Once you understand what motivates and drives your patients’ decisions, you can better partner with them,” Deines notes. “We can employ resources to help with issues like income, beliefs, or ideas about certain treatments.”

While it’s a medical fact that hitting certain blood pressure and blood glucose numbers are critical for long-term health, sometimes patients are simply concerned with enjoying their favorite hobby unimpeded by possible side effects, Deines says. “The healthcare team must understand the patient’s complete situation,” he maintains.

The multidisciplinary approach has had a positive impact on many patients. “They come to our clinic, and they tell us it’s the first time anyone asked about their goals and what’s important to them,” Deines says. “The outcomes are much improved.”

Some patients come to a Methodist Healthcare Ministries clinic and tests reveal an A1c level of 13% (The target A1c level for individuals with diabetes is usually less than 7%). Normally, these patients would immediately start on a regimen that includes several medications and intensive lifestyle changes, Dick says. But working with patients individually, some choose to start on only 

 In some instances, lifestyle changes and metformin can reduce A1c levels significantly.

“Thanks to the hard work of our patients and care team, our diabetes outcome measures are trending favorably,” Dick says. “But we know there is much more work to be done.”

Allegheny Health Network’s initiatives have paid dividends, especially in the area of education. Bononi says she was surprised by a statistic that indicated 31% of prescriptions written for diabetes are never filled. Expense is one reason; another is patients don’t like to take more medications than they feel are necessary. They’re also skeptical about the medication’s efficacy or have concerns about side effects.

“That’s where our pharmacists have helped us,” she says. “They do a great job of explaining how the medications work, and why they are beneficial.”

In 2018, Prognos conducted extensive research on a subset of its patient population diagnosed with diabetes, examining patients prescribed first-line medication therapy-either or both metformin and sulfonylureas-during the first half of 2017 and were on no prior medications during the previous year.

Five Diabetes Factors Health Execs Should Care About

While not examining compliance and noncompliance, Bhan says care managers can use the research to motivate noncompliant patients into taking their medications and maintaining a healthier lifestyle more regularly.

“If just 20% to 25% of patients can be moved from non-adherence to adherence by educating and engaging them, that’s a huge number in savings and morbidity,” Bhan stresses. “It’s much easier to engage patients around hard facts versus hypotheticals.”

The patient population with better control of their diabetes utilizes less resources, including emergency department visits and hospitalizations, and have fewer rates of complications, such as end-stage renal and cardiovascular disease.

“Patients want to live their lives as close to normal without their treatment getting in the way,” Deines says. “We have to partner with patients so they can achieve that goal. But we have to help patients understand they can better achieve that goal if they adhere to their treatment plan.”

A complex disease such as diabetes requires a team-based approach to help patients comply with their regimen.

Ken Krizner

Articles

Top Challenges in Managing Diabetes

Hospital Pharmacist Role Expands in Patient Care

5 Metrics that Will Define Healthcare

Team Approach Offers Hope of Increasing Diabetes Treatment Compliance