Fighting Back Against Chronic Disease

Dr. Lourdes Planas, associate professor, department of pharmacy: clinical and administrative sciences, University of Oklahoma College of Pharmacy, and current chair of AACP’s Social and Administrative Sciences Section, conducts research around the pharmacist’s role in medication therapy management services in community pharmacy settings and ambulatory care clinics. “When pharmacists have been involved with patients with chronic conditions, particularly hypertension and diabetes, when pharmacists educate patients on their disease states and how to take their medication and how to self-monitor, such as checking blood pressure and blood glucose, we found that patients improve in several different clinical outcomes for their conditions,” Planas noted.

“We were able to show more of an improvement for patients who were seeing pharmacists,” she continued. “It’s not just about educating the patient; a big part of it is looking for medication-related problems such as sub-optimal therapy—doses that are too low and a pharmacist recommending to a physician that those doses be increased. First it’s about making sure the patient is taking the prescribed dose. Sometimes the education component helps patients to understand. If adherence is not an issue, pharmacists can work with a physician to recommend a different dose or additional medication.” In some cases, patients’ drug regimens are not optimal according to clinical standards for their condition (for example, some patients with diabetes need to be on an ACE inhibitor for renal protection).

“Many community pharmacies offer convenient and accessible opportunities for patients to check their blood pressure,” Planas said. “Hypertension is one of those diseases that if patients aren’t regularly going to a doctor’s office, they might not be getting their blood pressure checked, or maybe they get it checked at the pharmacy in between doctor’s visits. Hypertension is a silent disease so people often don’t even feel any different.” Helping patients manage chronic conditions enables pharmacists to prevent medication-related harm and minimize complications.

Curricular Changes Address Chronic Conditions

With the ACPE standards calling for a bigger focus on public health over the past decade, Planas said schools are increasingly training student pharmacists in chronic disease prevention. Several students at Oklahoma’s College of Pharmacy who take classes in entrepreneurship and must develop a business plan as part of their coursework have proposed wellness pharmacies. “A lot of our students have proposed weight clinics to work with patients to lower their weight because that has been linked to so many chronic conditions,” she said. “Many of our graduates have started to work with protein-rich diets. Students on rotation are getting exposure to these things, primarily in independent pharmacies.”

The college offers integrated modules where the students receive instruction on a combination of pharmacotherapy, medicinal chemistry, pharmacology and pathophysiology. “In the general health module they learn a lot about the influence of obesity on chronic conditions,” Planas noted. “Through their co-curricular plan, our students participate in a lot of health fairs and have opportunities to interact with members of the public. Often students will check BMI and talk with patients about lowering their risk for chronic diseases. The overwhelming majority of patients our students interact with are overweight or obese. Those experiences interacting with patients are very rewarding for our students because they get a chance to practice what they’ve learned.”

Haines pointed out that the revised ACPE standards elevate the need for interprofessional education and that curricular reform is occurring. “Some schools are structuring selective school experiences,” she said. “Students can deepen their didactic knowledge and experiential learning through courses in specialty areas such as infectious diseases, cardiovascular disease, diabetes and community pharmacy. We are also seeing curricular emphasis related to rural health/telehealth, health disparities and underserved populations as well as more interprofessional coursework across the entire curriculum.”

She added that pharmacy schools are trying to prepare learners to perform and leverage themselves for positions that don’t exist yet. “Specialty pharmacy is on the rise. Student pharmacists need to take every opportunity to further their education after graduation and through these individualized learning tracks we’re seeing. I think certificate programs play an important role in providing focused training. [It’s crucial to] continue with professional development and maintaining credentials; to provide a high level of clinical care and expertise is really essential. We continue to expand our practice roles in direct patient care and furthering our engagement in population and public health initiatives.”

AACP’s Ragucci agrees that signs point to pharmacy schools making changes to the curricula. “Schools and colleges are incorporating more team-based learning, simulations and interprofessional experiences for students,” she noted. “Diabetes and immunization certifications are also offered in addition to unique electives such as MTM. Preparing students for the current workforce and understanding the importance of practice transformation is particularly important.”

Ragucci sees telehealth as a new frontier for pharmacists reaching out to patients. “Telehealth is a huge opportunity for pharmacists to get more involved with chronic disease state management and prevention,” she said. “Patients who tend to get admitted to the hospital over and over often don’t have access to primary care services. You can reduce those ER visits and costs if you can improve access to healthcare, and telehealth is one of those ways. It also allows faculty to have more access to both students and residents on rotation and use that technology to communicate.”

Team-Based Care Is the Future

The next step is getting a payment structure in place and trying to get pharmacists reimbursed, Ragucci said. “We know we can improve patient health, but convincing [physician offices] and other employers to pay for medication therapy management is another thing.”

Said Haines, “We have an opportunity ahead of us to change the paradigm in community practice and change the scope in direct patient care activities across settings. We have an opportunity to expand our role and have a seat at the table. The provision of provider status is important. Equally important is what happens at the state level. The provision of provider status and compensation recognizing pharmacists for clinical services is critical to move us forward.”

Planas said she hopes to see a greater focus on weight and nutrition since obesity and poor eating habits are big contributors to chronic disease. “The more that pharmacists are in positions where they are able to assess how patients are doing in those areas, the better they will be equipped to make recommendations. And having the ability to do screenings [is crucial]. Because of their accessibility, a pharmacy could be the first place a patient finds out his or her blood pressure is high. In pharmacy schools we develop those skills in our students of recognizing the importance of those types of screenings and following through with offering programs or knowing referral sources in the community.”

She added that if a patient is obese and has high blood pressure and high blood glucose, ideally the pharmacist should know a local nutritionist who can help. “We know it’s not going to be just one healthcare provider. It’s a team effort: a physician, a nutritionist, a pharmacist. For some patients there might even be a physical therapist involved. It’s about interprofessional education—that emphasis is going to benefit not only our profession but all professions.”

Jane E. Rooney is managing editor of Academic Pharmacy Now.