If listed in mortality statistics, medication adverse events would be the fourth leading cause of death in the United States, according to the Institute of Medicine.
Thomas Buckley, an associate clinical professor of pharmacy practice at UConn, is working to prevent medication misuse and to optimize patient treatment in Connecticut by training and certifying community pharmacists in the state’s urban centers to manage medications and counsel their patients on the safest and most effective use of all of their medications.
Buckley, who also is a Principal Investigator at UConn’s Center for Health, Intervention, and Prevention (CHIP), is doing this as part of a larger $8 million grant from the U.S. Centers for Disease Control (CDC) to the Connecticut Department of Public Health (CTPDH) focused on chronic disease management. His portion of the grant is empowering pharmacists to help urban patients with diabetes and hypertension.
Possible barriers to the target patient populations receiving optimal care include poor access to medical care and language barriers, said Buckley, whose research and community outreach addresses health disparities.
In addition to certifying participating community pharmacists and tracking improvements in their patients’ medical outcomes, Buckley is simultaneously advocating for public policy changes in Connecticut that would help pharmacists continue providing their patients with these new medication therapy management (MTM) services after his five-year grant ends.
“Upside-Down” Medication Management
“Often healthcare professionals focus their attention on their patients’ medication non-adherence first, but this approach may blame the patient and is upside down,” Buckley said.
He and his grant co-investigator, Marissa Salvo, an assistant clinical professor of pharmacy practice at UConn, are training community pharmacists to look first at the appropriateness of their patients’ medications for their conditions, then to assess the effectiveness of the medications, and to weigh the seriousness of the drugs’ side effects against potential benefits, all before addressing patients’ adherence to their medication regimens.
“If you don’t address the first three issues, you don’t really get at the problem,” Buckley said. “You also might be forcing patients to adhere to medications that might not be right for them.”
As part of the project, the community pharmacists complete a 24-credit certification course that involves reviewing and analyzing numerous sample patient cases online and in person with Buckley, Salvo and other UConn faculty working with them. Once the pharmacists are certified, they begin consulting with patients at their pharmacies. Their first patient consultations may take up to an hour, with at least three follow-up appointments with each patient within the year.
Buckley and Salvo encourage the pharmacists to tackle some of their most complex cases first – with patients who may be taking a dozen or more daily medications – because those patients are at greatest risk for medication complications and because helping them has the greatest potential to significantly drive down health care costs, Buckley said.
A Proven Approach
Buckley and Marie Smith, assistant dean for practice and public policy partnerships and the Dr. Henry A. Palmer endowed professor of community pharmacy practice, previously took a similar approach training community pharmacists to provide medication therapy management services to Connecticut Medicaid patients in federally qualified health centers.
“We found cost savings of $2.50 for every $1 spent, because the intensive medication therapy management optimized patients’ medication regimens and reduced health resource utilization, such as hospitalizations, emergency department visits and additional physician office visits,” Buckley said.
For his new grant, Buckley started with the same Arrow Pharmacies in Hartford where he previously had conducted another CDC grant to CTDPH that aimed to increase vaccinations in populations with health disparities. Changes to state law allowing pharmacists to administer vaccines allowed Buckley to focus on urban pharmacies and their relationships in the community to improve vaccination rates for pneumococcal vaccine for African Americans and Latinos, two populations that had historically low immunization rates and higher than normal hospitalization rates for pneumonia.
Buckley has since expanded his current project to more community pharmacies in Bridgeport, New Haven, Stamford, Norwalk and Ansonia.
Buckley and Salvo currently are working with 10 pharmacies, reaching about 500 patients. They plan to work with at least 40 community pharmacies.
“Our goal is to reach underserved populations statewide,” Buckley said.
Buckley, who coordinates the public health and health policy course for the School of Pharmacy and who has served as legislative chair for the Connecticut Society of Health System Pharmacists for 20 years, recently assisted in drafting proposed wording for a state bill that would allow credentialed pharmacists to be reimbursed through Medicaid for providing MTM services.
According to the National Conference of State Legislators, 18 states already have similar legislation mandating Medicaid reimbursement. The wording for the Connecticut bill is similar to Minnesota’s law, which mandates that pharmacists be reimbursed and is considered “the gold standard,” Buckley said.
In a Minnesota Medicaid published report, estimated savings as a result of pharmacists providing MTM services were $12 for every $1 spent, he said.
The proposed state legislation also mirrors currently pending federal legislation that would allow pharmacists to be reimbursed for providing MTM services through Medicare.
Buckley previously played a key role in the passage and implementation of Connecticut’s collaborative practice bill, which passed in 2010 giving pharmacists the authority to prescribe medications under protocols developed with physicians.
He said the current bill is “the next big push” to have pharmacists recognized as healthcare’s medication experts, to allow them to use their expertise and provide their patients with expanded services, and to have them reimbursed appropriately. Progressive laws in this regard are key to recruiting excellent pharmacy faculty members and students to UConn and keeping the pharmacists UConn trains working in the state after graduation, he said.
The CDC/ CTDPH grant requires Buckley and Salvo to measure their diabetes and hypertension patients’ clinical outcomes, including blood sugar levels, blood pressure levels, and their medication adherence values, but the researchers also are collecting fresh data on cost savings tied to pharmacists delivering MTM services to bolster their legislative push in Connecticut.
“Through this grant, we’re training community pharmacists to provide this valuable new service in urban areas. How will we sustain the program?” Buckley asked. “How will pharmacists be reimbursed for these services once the grant runs out?”
Early Success Stories
The five-year project is just in its second year, but already the community pharmacists have made noticeable strides, especially with some of their Spanish-speaking patients, who are being reached by community health workers working with the community pharmacists.
Initially, a number of the Spanish-speaking patients participating in the project were not comfortable discussing their medication questions with their physicians, or even with their own families, but that is changing, Buckley said.
“First, we need to engage these patients and then we can empower them,” Buckley said. “The more engaged they are in their therapy, the more adherent and successful they will ultimately be.”