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Morani said Gable received a 5—the highest score possible—during the state’s most recent annual review of the team’s fidelity to the model of assertive community treatment. Collaboration as the start. In April, the Missouri Board of Pharmacy reported that, as of March 21, 17% of pharmacists with an active state license had received a “certificate of medication therapeutic plan authority.”

The board’s rules regarding the certificate went into effect in August 2012. Soon thereafter, Gable said, she received her certificate, which allowed her to engage in collaborative drug therapy management, and Places for People petitioned the mental health department to approve her to function as a psychiatric care provider and prescriber at the agency. “I was qualified and capable,” she said. Places for People formed its IMPACT Team in November 2012.

Pharmacists improve diabetes care


an Diego veterans with a long history of type 2 diabetes are learning to take charge of their condition and make lasting improvements, thanks to coaching from a clinical pharmacist. Candis M. Morello, director of the Diabetes Intense Medical Management (DIMM) clinic at the Department of Veterans Affairs (VA) San Diego Healthcare System, said Candis M. Morello in a phone interview that many veterans who are referred to the clinic have had diabetes for a decade or longer. Clinic patients have a glycosylated hemoglobin (HbA1c) level that exceeds 8% and suffer from other health problems in addition to their diabetes.

Appointment Starlin Haydon-Greatting, M.S., B.S.Pharm., FAPhA, FASCP, clinical pharmacist consultant at SHG Clinical Consulting in Springfield, Illinois, has been appointed to the National Quality Forum’s Endocrine Steering Committee. The committee is identifying and endorsing performance measures concerning diabetes mellitus, thyroid disease, osteoporosis, metabolic syndrome, and other endocrine conditions.


Morello called her work a personalized “tune-up” for these medically complex veterans. During the initial 60-minute visit, Morello and the patient identify treatment and lifestyle goals and motivational strategies. Morello said what motivates patients the most is “how many times they get up at night to go to the bathroom.” “We’re talking five, six, eight times a night. I say, ‘How would you like to fix that? I can help you. And how would you like to fix that even within a few weeks, and start getting more energy? I can help you do that,’” she explained. “It’s not your typical 20-minute primary care provider visit,” she said. The DIMM clinic operates just four hours per week, and most patients need about three to five sessions with Morello before returning to their primary care provider for routine diabetes management. According to data Morello presented in June at the American Diabetes Association scientific meeting in San Francisco, average HbA1c values over a six-month period fell by 2.4 percentage points among 85 DIMM clinic patients, compared with a 0.2-percentage-point decline among 51 primary care patients

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In announcing the new team, the state’s Assertive Community Treatment Newsletter listed Gable as “Clinical Pharmacist/Psychiatric care provider.” The newsletter stated that the mental health department was approving clinical pharmacists on a case-by-case basis “to fulfill the role of psychiatric care provider.” —Cheryl A. Thompson DOI 10.2146/news140053

who were not referred to the DIMM clinic. That translates to a three-year medical cost avoidance of $6412 per DIMM clinic patient and a return on investment of $7.81 per dollar spent on Morello’s services, she said. Morello said she’s provided information about the clinic to VA staff and outside groups, and she would like to see the care model replicated elsewhere. “There are so many [advantages] to this clinic that not only benefit the patient and the medical center but also benefit expanding the scope of other clinical pharmacists,” she said. Morello, associate professor of clinical pharmacy and associate dean for student affairs at the University of California, San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, said she operates the DIMM clinic through a collaborative practice agreement with endocrinologist Robert R. Henry, chief of the VA San Diego Center for Metabolic Research and its section of endocrinology, metabolism, and diabetes. Morello said the clinic was created to help the VA facility meet performance measures related to the care of more than 3000 patients with uncontrolled type 2 diabetes and to improve patients’ HbA1c values while avoiding hypoglycemia and weight gain.


To accomplish these goals, Morello uses the medication therapy management “spider web,” a teaching tool she developed and described in a publication last fall.1 The tool allows clinicians to assess medical, socioeconomic, and behavioral issues unique to each patient and incorporate these factors into a patientcentered care plan. Among other things, Morello said, the spider web allows her to identify daily triggers in a patient’s routine, such as walking the dog or listening to a radio program, that the patient can associate with medication use and thereby improve adherence. Morello emphasized that patients are in charge of their own daily care, and they learn skills to make good decisions about their medications and the habits that affect their glucose control.

“I tell them: I can’t be with you at the refrigerator. I can’t be with you when taking your medicine, I can’t be with you to say go take your dog for a walk. I can give you tools, I can help guide you, I can help direct you, but you’re the big decisionmaker. And that totally resonates with them,” she said. Morello said her veterans are spreading the word about their successes, and primary care physicians are also noticing the clinic’s work. “I’m starting to see a shift as the primary care providers figure out how well their patients are tuned up by the time they get back,” she said. “They’re starting to send me patients who are just diagnosed or have only been diagnosed in [the past] three years or so.” A primary care clinic that is part of the BHS Physicians Network, a private multispecialty group in San Antonio,

Texas, has also reaped benefits from having a pharmacist onsite to help care for patients with type 2 diabetes. Data from 118 patients showed an average drop of nearly four percentage points in HbA1c values for those whose care team included a pharmacist, compared with blood glucose values before the pharmacist was added to the practice, said clinical pharmacist Jodie Gee, who presented the findings at the American Diabetes Association meeting. The addition of the pharmacist to the healthcare Jodie Gee team also led to increases in the use of statins, low-dose aspirin, and angiotensin-converting enzyme inhibitors, said Gee, who spends half of her work hours at the BHS primary care clinContinued on page 1242

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ic and the rest at the University of Texas at Austin College of Pharmacy, where she is a clinical assistant professor. Gee initially sees her patients monthly in 45-minute sessions. She conducts a thorough medication review that includes medications for diabetes and the patient’s other conditions. “We even have a lot of patients on inhalers, and we always check that inhaler technique,” she said. The sessions also include a review of the patient’s blood glucose log and diet. For newly diagnosed patients, she reviews the pathophysiology of diabetes and helps them understand how their medications work and the importance of adherence. Gee now works under a collaborative practice agreement with the three physicians in the primary care clinic, and she can initiate and adjust medications independently for patients with diabetes. But that wasn’t the case several years ago, when she came to the site to establish an experiential program for pharmacy students and residents. “The physicians in the clinic, when I arrived, did not know what a Pharm.D. can do,” Gee said. She said she started off teaching patients how to use their glucometer and inject their insulin. Then she gradually demonstrated to the physicians the value of performing medication reconciliations while gaining the practice members’ confidence in her ability to actively manage patients. “Once they realized how much of a help it was, they started actually referring to me more patients,” she said. “Eventually, we got the collaborative practice set up, so now they say, ‘Go see Dr. Gee.’” When Gee started managing her patients, she saw them monthly until their HbA1c level was controlled and then released them to their physician’s care. “But . . . once they’d been discharged from my service, they would always be re-referred because their A1c’s would go up again,” Gee said. Now, she said, after patients get their blood glucose under control, they return


periodically to see her and maintain their progress. “And actually, that’s worked,” Gee said. Gee said the biggest lesson she has learned in her work at the clinic is the importance of being personable and persistent and engaging with the other members of the ambulatory care team. She encouraged other pharmacists who have an interest in ambulatory care practice to “go for it.”

“You can definitely show a benefit of having a Pharm.D. as part of a primary care team,” Gee said. 1. Morello CM, Hirsch JD, Lee KC. Navigating complex patients using an innovative tool: the MTM spider web. J Am Pharm Assoc. 2013; 53:530-8.

—Kate Traynor DOI 10.2146/news140054

White House summit tackles opioid abuse


wo public health problems in the United States—prescription drug abuse and heroin use—are inextricably linked, and solutions will require comprehensive efforts, said participants in a June 19 White House policy summit. “It is impossible to understand our nation’s heroin challenge without also understanding our prescription drug abuse challenge,” said Michael Boticelli, acting director of the Office of National Drug Control Policy. The half-day summit was closed to the public but broadcast live via a webcast. Participants included U.S. Attorney General Eric Holder, state and local officials, and professionals in fields related to addiction treatment, education, and prevention. About 110 Americans died of a drug overdose every day during 2011—more than died from traffic accidents, according to federal data. Boticelli said that prescription opioids were a factor in nearly 17,000 overdose deaths in 2011, and heroin use contributed to more than 4,000 deaths. Some recent research suggests that people who became addicted to heroin were first hooked on prescription opioids. And policymakers and others have speculated that efforts to restrict the illicit use of prescription opioids may be

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prompting those who are addicted to switch to heroin. Among the believers is Vermont Governor Peter Shumlin, who told summit attendees that the oxycodone-abuse problem of a decade ago has been supplanted by a deadly epidemic of heroin use in his state. “You can buy Oxycontin on the streets of Vermont for 80 bucks a pill. You can buy a bag of heroin on the streets of Vermont for $30 a bag,” Shumlin said, adding that heroin is even cheaper in nearby states. “There’s a huge economic incentive to get this drug into my state, and it’s happening,” he said. Shumlin in January devoted virtually all of his state-of-the-state address to the problem of opioid addiction and drugrelated crime in Vermont. He said the number of heroin-related deaths more than doubled in the state since 2000, as did the number of Vermonters treated for heroin addiction, with 40% of that increase occurring last year. Shumlin said a “full-blown heroin crisis” exists in the state. Vermont’s response to the problem involves a combination of law enforcement activities and public health initiatives, including increased funding for substance abuse and needle exchange programs.

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