Pharmacy Times

Introduction

Summary

References

PART 1
Marketing Pharmaceutical Care

The Marketing Strategy

The Importance of Synergy

Which Comes First: Education or Marketing?

Establishing a Patient Target Market

PART 2
Improving Asthma Outcomes Through National, State & Local Efforts

National Level Initiatives

State and Local Initiatives

Reimbursement

PART 3
Education of Pharmacists for Collaborative Practice

Ensuring Quality Programs

CHARTS
Current State of Compliance

Need for Interventions to Assure Safety & Efficacy

Providing Pharmaceutical Care: 
Issues, Initiatives, 
and Insights

Barry A. Bunting, PharmD; John P. Miall Jr., ARM; Daniel G. Garrett, MS, FASHP; Roy A. Pleasants, PharmD; Sharon Kast, Nurse Practitioner; Steve Willcox, MS; J. Spencer Atwater, MD; Peter Gal, PharmD, BCPS, FASHP, FCCP; Teresa Devora, BA, CMM; Peter Koval, PharmD, BCPS; and Chris Rubino, PharmD, BCPS

Affiliations Barry A. Bunting, PharmD, Clinical Manager of Community Pharmacy Services for Mission St. Joseph’s Health System in Asheville, NC; John P. Miall Jr., ARM, Director of Risk Management and President of the Asheville Claims Corporation, City of Asheville, NC; and Daniel G. Garrett, MS, FASHP, Executive Director of the North Carolina Association of Pharmacists and the North Carolina Center for Pharmaceutical Care in Chapel Hill, NC.

Introduction

Over the past several years, prescription drug sales have risen steadily. The National Association of Chain Drug Stores (NACDS) reported that the number of prescriptions dispensed in the retail pharmacy marketplace in 1998 increased by 6% over 1997. Based on data collected in August, prescription volume for 1999 was expected to be 8% above 1998 levels.¹ Thomas M. Ryan, president and CEO of CVS Corporation, predicts this pattern will continue, with prescription volume increasing from an average of 1,000 per week in 1997 to as many as 2,000 per week in 2005.² 

Although dispensing medications has always been a primary responsibility for pharmacists, many have become frustrated with the constant race to fill prescriptions and performing only this role. Fortunately, community pharmacy practice today offers opportunities for change. More pharmacists are directing their energy toward pharmaceutical care (PC), particularly in the area of chronic disease management. Currently, most chronic diseases are only successfully managed in 25% to 50% of cases,³ indicating an opportunity to improve health care in this area. Because pharmacists are in a position to monitor drug compliance, inappropriate drug selection, and adverse drug reactions—factors that play an important part in the management of chronic diseases—they are the most appropriate health professionals to include in treatment and monitoring efforts. 

There are millions of patients who need the care PC pharmacists can offer. In order to provide this care, pharmacists must obtain adequate training as PC providers and market their skills to appropriate audiences. Their goal must be to mold environments that allow them to use their professional knowledge to earn a living, while making a measurable difference in peoples’ lives. 

PC is more than a concept. It is being applied in several communities and is resulting in successful outcomes. In North Carolina, for example, pharmacists are working proactively as partners with other health care providers to help patients with chronic illnesses, such as diabetes and asthma, manage and improve their condition. 

This article provides information to help pharmacists understand how PC can improve outcomes. It identifies payers who would benefit from the implementation of PC, describes how pharmacists can join forces with each other through national, state, and local associations to affect change in this area, and presents an example of one method for training pharmacists in PC to the satisfaction of payers and physicians.

Part I

Marketing Pharmaceutical Care

With the availability of mail order pharmacy, Internet pharmacies, and automated filling technology, many pharmacists wonder where they fit in. Some are comfortable with primary dispensing roles and there will continue to be a need for these. However, many would like to have more patient-oriented roles such as those found in the provision of PC.

Because of the prevalence of inappropriate medication use in the United States, pharmacists have a tremendous opportunity to help decrease health care costs by assuming a more responsible role for appropriate medication use. A major advantage that pharmacists have over other health care providers is access. Patients see pharmacists five times more often than any other health care provider. This offers a chance to act as an accountability partner for patients. Whether someone is trying to lose weight, quit smoking, or comply with a medication regimen, a professional partner can help.  Fortunately, pharmacists already have most of the tools they need to make a difference. Thus, PC is about creating the opportunity to use these tools more often. It is also about relationships and the pharmacists who build them—one patient, one intervention, one organization, and one physician at a time.

The Marketing Strategy

Pharmacists who market the effectiveness of PC in managing chronic diseases are not simply selling PC services. They are offering a chance for people with chronic illnesses to live healthier lives through the appropriate use of effective medications. It is necessary when marketing PC to a prospective payer to point out that pharmacists are in a unique position to provide important services in the areas of compliance (adherence), efficacy, and side-effect monitoring, and patient education. Marketing PC to a prospective PC client includes describing why chronic disease management is important, explaining that failure to manage chronic disease is a national health concern, and showing how pharmacists can help alleviate the problem.

Several reports and studies on poor compliance and lack of interventions support the need for PC—the monitoring and the more frequent one-on-one—in managing all chronic diseases and asthma in particular. 

Further, reports on the benefits of patient education on managing disease appropriately and the negative results of the lack of it prove that additional care is needed. For example, education has been noted by many experts to play a key role in helping patients understand their asthma and acquire and use the skills needed to manage their disease.^24-27 Poor understanding of the disease process and of appropriate medication use have been identified as possible causes of increasing death and illness rates as a result of asthma.^7,28-30 In addition, numerous studies have found that patients with asthma are not able to demonstrate correct administration of their medications, especially proper inhaler use.^9,13,14

And finally, studies have shown that PC from a pharmacist can make a positive difference in patients’ health and use of health care services. The simple act of the pharmacist handing the prescription to the patient improves compliance by 25%.³¹

The pharmacist is not only in a position to monitor a patient’s compliance with medications and reinforce the physician’s treatment plan but also to help hold the patient accountable.^32,33 Pharmacists are in an ideal position to act as an early warning system for patients who are getting into trouble but fail to consult their physician.^18,34

A study of systematic pharmacist review of medications in the general population found that 35% of patients were not taking medication properly, 24% of medications could be discontinued, 11% were causing adverse effects, 9% of patients could use a less expensive alternative, and 5% were on two different medications for the same condition.³⁵ A financial analysis of the value of this medication review program indicates that because of the pharmacist intervention, there was a return on investment of $3.20 for every dollar spent on the program.

A pharmacist-managed emergency room asthma intervention program resulted in a decrease in emergency room visits from 47 to 6, during the same months of the study in the prior year, in a study population of 25 high-risk patients. This resulted in cost savings in excess of $30,000.³⁴ Five additional studies involving pharmacists in asthma management programs reported dramatic improvements in asthma control.^36-40

In diseases where medication compliance is critical, pharmacists have demonstrated an ability to improve compliance over traditional care. A Veterans Administration study found that a pharmacist/nurse-operated clinic resulted in a compliance rate of 75% in a group of hypertensive patients compared to 20% in the control group, and blood pressure control in 91% of patients compared to 29% in the control group.⁴¹

Community pharmacists are highly accessible health care providers because of their broad distribution and extended hours of operation, 

often averaging 60 to 70 hours per week. In areas of the country where there are shortages of physicians (for example, 4.2 physicians per 100,000 people), there are 37 pharmacists per 100,000.^34,42

A Yale-New Haven Hospital study titled “Improving Asthma Care in an Inner-City Primary Care Center” used a multidisciplinary approach that included a pharmacist. The study found a 64% decrease in emergency room visits, 63% decrease in hospital admissions, and a calculated cost-avoidance for 50 high-risk patients of $172,397 per year. A pharmacist-managed asthma education clinic found a 40% reduction in hospitalizations and a 67% reduction in emergency room visits.⁴³ The same study also found an improvement in proper inhaler use from 25% at baseline to 90% after pharmacist education. At least two other studies have shown that pharmacist-generated teaching programs have led to improved inhaler technique.^44,45

The Importance of Synergy

The concept of PC will “sell” if pharmacists can find significant synergies with other health care players. In addition, PC pharmacists must invest time and money to supplement their skills and become recognized PC providers. However, at the top of the pharmacist’s agenda is receiving reimbursement for providing cognitive services. The good news is pharmacists are being paid for cognitive services. The foundation has been laid, now the construction must begin. 

The concept of reimbursing pharmacists for disease management services must be embraced by prospective payers, including employers, physicians, pharmacy benefits management companies (PBMs), health maintenance organizations (HMOs), pharmaceutical manufacturers, disease management companies, and preferred provider organizations (PPOs). Disease management programs like The Asheville Project for diabetes and the asthma community initiatives in North Carolina prove that PC can make a difference in the lives of patients, bringing new life to the pharmacy profession in the process. To be most effective, disease management has to be a team effort. Pharmacists need to work hard to involve other health care providers and resources as appropriate. The first challenge to implementing such projects is not the payers, but convincing pharmacists that PC services add value, and therefore they should be compensated for the added responsibilities. Even after that challenge is met, pharmacists will still have questions such as: I am just one person, how can I market my pharmaceutical care skills? Where do I start? Exactly what am I selling? Assuming I had the time and ability, to whom would I market? What would I say? Why would they pay?

Which Comes First: Education or Marketing?

PC cannot be provided by a technician or an automated filling device, which means a payer who wants to provide PC services will need competent, motivated pharmacist providers. The question then arises: Should pharmacists be educated to provide PC first, or should they first be looking for market opportunities? It can work either way. In one pilot program in North Carolina, pharmacists who had been educated in PC formed an organization of independent 

pharmacist providers that initially focused on relationships with physicians. Agreements are now being pursued with employers and other payers. In another community, pharmacists approached an employer with the idea of providing the service, partnered with the employer to develop the program, and then the pharmacists were educated to provide the service. 

If pharmacists are interested and educational programs are available, training pharmacists first may be the best plan. The educated pharmacists can then market their services to physicians, employers, or other payers. If educational programs are not available in a given area, pharmacists can ask pharmacy associations or schools of pharmacy to sponsor such programs.
If a chain pharmacy offers or is developing a PC program, it is important to make sure the chain is committed to providing pharmacists with time to perform the service once the training is complete. Pharmacists should be asking: Who will form the patient base? How will the services be marketed? Are contracts with area employers and managed care organizations being pursued? How can a pharmacist enroll in a training program?

With chain pharmacy training programs, the participating pharmacists may come from different areas of the country. However, when they return to their communities, it is readily apparent that one provider cannot meet the needs of even one large employer. A network of providers is necessary within a chain pharmacy region to cover a geographic area and to share processes, ideas, and resources. 

Educational programs offer perfect opportunities to begin forming networks of providers with identifiable, marketable skills because program participants are generally individuals with similar interests and motivations, usually from the same geographic area, who have come together for a common purpose: to supplement their skills and become recognized providers of PC.

Establishing a Patient Target Market 

Some chains are working on PC programs that they plan to market to payers, arranging contracts that will result in patients coming to see the chain’s pharmacist providers. 

Independent pharmacists in particular may be able to use the services of groups who specialize in marketing health care services to payers. In some parts of the country there is a movement to form associations of independent PC providers—not unions but true associations of independent providers who will develop marketing strategies. 

PC brings patients into retail stores for extended periods of time, builds customer loyalty, and offers a new revenue stream. Thus, having an agreement with an employer or some other payer, such as an HMO or PPO, is important because these groups can identify large numbers of patients who may benefit from PC services and direct such patients to a PC program.

Employers  For independent pharmacists, the first step may be to identify the large employers in the area and find out if they are self-insured or if their health benefit is provided by a managed care organization or large insurer. Self-insured employers are often very receptive to what PC offers and may be easier to sell to because they tend to be more locally controlled, and decision makers can be readily identified. Business is most likely to come from employees who happen to live or work in an area convenient to the pharmacists offering the service. Therefore, the approach should be made by a loose network of trained providers rather than by any one individual or store.

Some employers have provided opportunities for their employees to learn about PC by arranging meetings at which the service is explained (marketed) and employees can enroll, fill out forms, and receive baseline testing (eg, spirometry in the case of asthma). Also, employers can describe PC to new employees during orientation, at which time they can enroll, or employers may provide incentives to encourage participation. For example, they may waive copays on medications and supplies related to the covered disease. In the case of the initiatives undertaken in North Carolina, this included asthma-related medications and supplies such as spacers and peak flow meters.

Employers are responsible for a substantial part of the health care bill. Under the traditional model, they generally pay 80% of an employee’s health care costs and are highly motivated to decrease those costs. They want to spend less on health care and at the same time have healthier, more productive employees. The ability to improve compliance, increase efficacy, and decrease adverse medication events represents tremendous potential for a return on investment. Employers are discovering that even increasing a benefit to pay 100% of medication costs for chronic medications can result in significantly greater savings as a result of improved outcomes. Although in pilot programs, employers have been paying more for medications, laboratory testing, physician office visits, and PC, these increases in cost are more than offset by lower inpatient costs and an increase in days worked.

Pharmacists can often identify progressive self-insured employers by seeking those who have a reputation in the community for providing comprehensive health benefits for their employees.^46,47 Benefits like addiction recovery programs and mental health benefits can be strong indicators. Pharmacists can look for opportunities to speak with health care alliances that have formed in some communities to leverage their buying power in the health care market. Examples of these would be local trade or business groups.

In the long run, however, direct-to-employer marketing alone may not be sufficient to move the profession of pharmacy where it needs to go.

Health Maintenance Organizations  HMOs should currently be very motivated to look for ways to reduce their losses by investing their prepaid premiums in preventive services. PC offers a low-cost, high-return service that targets the heart of health care costs: preventable complications. HMOs are also looking for unique ways to differentiate their product from the pack. PC can be part of such a product. 

Pharmaceutical Manufacturers Pharmaceutical manufacturers are in the business of developing and selling medications, and more recently, instituting disease management programs. They spend millions of dollars every year proving that these medications are safe and effective, yet nearly a third of patients fail to take even one dose of a prescription. And of those who do take their medications, at least half do not take them appropriately. The synergies between PC and pharmaceutical manufacturers are that PC providers promote compliance and enhance the safe and effective use of medications.

Physicians  Physicians need concise, relevant information on their patients, including when patients are not taking prescribed medications, when the treatment plan is not working, and if the patient is experiencing adverse effects from the medication. Most importantly, they need to know these things before their patients’ health deteriorates and they present at the emergency room. Thus, PC virtually markets itself to physicians. When a pharmacist spends quality time with a patient, the result is the identification of problems the physician needs to know about. PC also allows physicians to treat more patients and manage larger capitated groups.

Pharmacy Benefits Management Companies PBMs’ customers can include employees or other third-party payers needing prescription claims filed and prescription costs controlled. PBMs often have relationships with manufacturers and managed care organizations and offer disease management services, such as sending a letter to a physician suggesting that a change in some aspect of the patient’s therapy be considered. Because they process millions of prescriptions each month, they have a tremendous amount of data on what is prescribed for patients. For example, they are able to analyze the percentage of asthmatics who are on beta-agonist inhalers but not on inhaled steroids. They also have the ability to identify overusers of beta-agonists.

Potential synergies between PC providers and PBMs are great. First, PBMs provide services that PC providers need. They have the ability to assign provider codes to PC provider pharmacists for the purpose of cognitive billing. This allows online billing within a system that already exists.

PBMs may also be willing to help PC providers track adherence. Their software allows their mail order businesses to notify patients who have failed to refill a chronic medication within an appropriate time frame. If adherence information were to flow freely between the PBM and the PC provider, they could analyze centrally, PC providers could intervene locally, and outcomes could be reported together. In addition, progressive PBMs are motivated to learn more effective ways to monitor and influence patient medication adherence and physician guideline compliance. A strong case can be made that linking PBM resources with PC providers on a regional and local level creates opportunities to do this more effectively and therefore improve patient care.

Another potential area of synergy is that a network of PC providers could more effectively influence physician prescribing patterns with regard to PBM formularies than the current system does. Finally, providers of PC and PBMs could benefit from joining forces because they will eventually be working for the same customers. Together they need to explore what each does best, so that the primary customer, the employer, and the ultimate customer, the patient, receive maximum benefit. 

Disease Management Companies Because disease management companies are accepting some financial risk when they contract to improve care of a particular population, PC services that target specific areas, such as improving compliance and medication-related outcomes, could be a valuable, low-cost supplement to current programs. Also, because patients already see pharmacists, a new entity does not need to be created. Emphasis on strengths in pharmacologic knowledge, access, and public trust may be the best approach to use with these groups. 

Preferred Provider Organizations  PPOs can connect health care providers who need patients with patients who need the services. Organizations in this line of work are very interested in marketing services that offer opportunities to reduce health care costs.
These PPOs need to be sold on the concept of PC, and they need pharmacist providers to market it. Pharmacists in western North Carolina are working with a regional PPO that has already arranged contractual agreements between other health care providers and more than 200 employers in the region. Because they are aware of the success of The Asheville Project for diabetes, they are anxious to market PC to these payers.

Even physician PPOs may offer some opportunities for marketing PC. These groups are interested in services that improve patient outcomes and make physician members look good in areas such as compliance with national guidelines. Helping physicians meet these national standards, some of which are medication-related, may be viewed as helpful to the physician organization. 

The goal of marketing PC to patients, employers, health care organizations, and other health care providers is ultimately to improve patients’ health. There are millions of patients who need the type of help PC can provide. No matter how beneficial a service is, if people do not know it exists or that it has value for them, they are not going to buy it. Thus, pharmacists must market their skills to those who stand to benefit, and PC must be marketed beyond the local level if it is to be more than an isolated regional phenomenon. Therefore, the importance of combining pharmacy resources through national, state, and regional associations cannot be stressed enough.

Part II

Improving Asthma Outcomes
Through National, State & Local Efforts

Roy A. Pleasants, PharmD, Clinical Associate Professor, UNC School of Pharmacy and Specialist in Pulmonary Medicine, Duke University Health Systems; Sharon Kast, Nurse Practitioner with Mountain Allergy and Asthma Associates in Asheville, NC, and member of the Board of Directors of the Association of Asthma Educators; Steve Willcox, MS, Executive Director of the American Lung Association of North Carolina; and J. Spencer Atwater, MD, allergist with Mountain Allergy and Asthma Associates in Asheville, NC. Dr. Atwater, Dr. Pleasants, and Mr. Willcox are members of the North Carolina Asthma Childhood Initiative Taskforce. Dr. Atwater, Dr. Pleasants, Mrs. Kast, and Mr. Willcox are members of the North Carolina Asthma Advisory Board.

The prevalence of asthma in the United States is high, and the American health care system—national, state, and local groups—is directing considerable time, energy, and funds toward improving recognition and management of this condition. Where asthma is concerned, appropriate interventions can have a substantial, positive effect on quality of life, outcomes, and health care–related costs. Such interventions can provide pharmacists with avenues to offer their skills as a part of a concerted health care team approach and, as a result, further these efforts.

In this section, several national, state, and local initiatives will be described for pharmacists looking to combine resources with organizations and associations, provide a service, or increase their skills.

National Level Initiatives

Guidelines. On a national level, the health care community’s interest in improving asthma outcomes is reflected in the development of the 1991 and 1997 National Asthma Education and Prevention Programs (NAEPP) Expert Panel Asthma Guidelines. However, implementation of those recommendations, although substantial, has been slow. A study of an HMO in California about 5 years after the first guidelines were produced found significant underutilization of anti-inflammatories and overutilization of symptom relief agents.⁴⁸ Another study in Philadelphia evaluating compliance with the 1991 guidelines showed underuse of inhaled steroids, particularly in the low-literacy population.⁴⁹ These same problems exist today and will probably persist unless additional efforts are put forth.

To increase use of the guidelines, the NAEPP continues to explore new strategies such as developing confidence- and skills-building strategies for physician education using small interactive groups and problem-based learning models. Most recently, the NAEPP created new partnerships with local asthma coalitions, acknowledging that grassroots efforts have enormous potential to improve the quality of life for patients with asthma. 

Pharmacists can support these efforts by providing PC in the guideline areas that continue to need improvement, such as the use of peak flow meters, development of asthma action plans, use of anti-inflammatories, and patient education, which needs to be more consistent and complete.

Some organizations already have begun to focus on promoting the pharmacist’s role in improving guideline use. In 1995, the National Institutes of Health (NIH) published “The Role of the Pharmacist in Improving Asthma Care” (1995 NIH Publication No. 95-3280), which discusses how pharmacists can improve the care of asthmatics by serving as members of a health care team. 

Surveillance  Asthma is a nonreportable disease, and thus, true prevalence is unknown. Therefore, another area in which national initiatives can benefit from local efforts is in surveillance. Surveillance—having data available over time—is an important basis for any public health program, and it is necessary on national, state, and local levels. To assist program planning and evaluation efforts, the following basic questions will need to be answered about asthma in the population: (1) How much asthma is there? (2) How severe is asthma? (3) How well managed is asthma? and (4) What is the total cost of asthma? 

The Centers for Disease Control and Prevention (CDC) actively participates in asthma surveillance at the national level, provides funding to state health agencies for surveillance, and is building models of asthma surveillance. In addition, CDC’s National Center for Environmental Health and its Air Pollution and Respiratory Health branch are working with state and local health agencies across the country to optimize asthma management.

Education: Certification/ Reimbursement Opportunities  Not only can pharmacists assist in such efforts, many of these initiatives can supply pharmacists with additional skills thereby helping them reach their goal of being reimbursed for providing extra health care. Several national professional organizations offer training programs or evaluate the benefits of physician extenders in the care of asthma. The American Pharmaceutical Association (APhA) recently initiated asthma education programs for pharmacists, and its APhA Foundation is conducting a demonstration project called Project ImPACT at ambulatory sites in the Northeast United States to evaluate a team-based model involving pharmacists, school nurses, and other health care providers to improve the management of asthmatic children. 

The American Lung Association (ALA), the Association of Asthma Educators (AAE), and the North Carolina Asthma Advisory Board are all promoting the concept of a certified asthma educator (CAE). Right now, the CAE is not officially recognized by the health care system. But when the National Certification Board of Asthma Educators, an independent board initiated in part by the ALA, defines the process and the exam, the CAE will be officially recognized nationally and possibly by third-party payers. In the meantime, there have been several intensive educational programs and asthma certificate programs that come “close” to serving as the CAE process, although not generally recognized by third-party payers except on a micro level in some settings. 

The main focus of the AAE, which consists of a variety of health care providers including nurses, nurse practitioners, physician assistants, respiratory therapists, pharmacists, and physicians, is to help spearhead a national effort to develop asthma educator certification. Currently, the National Certification Board of Asthma Educators’ Nominations Committee, which includes a pharmacist, allergist, pulmonologist, primary care physician, and representatives from nursing, respiratory therapy, environmental health, and education, is devoting its time to this national effort as well, by identifying potential candidates for a National Certification Board of Asthma Educators who will define the CAE process. 

Asthma certificate programs can serve a variety of purposes. 

Although that same insurance payer may say the practitioner has to take the national examination in order to continue getting reimbursed, it also is possible that pharmacists and other health care professionals who successfully complete one of these certificate programs may be grandfathered as CAEs by the National Certification Board. This will certainly be a debated topic.
Because the U.S. Congress has not yet recognized the CAE as it 
did the Certification of Diabetic Educators when it approved reimbursement for diabetes education in the Medicare system (and therefore in the individual state’s Medicaid system), recognition of the CAE could be on a state-by-state basis or an insurer-by-insurer basis. There is already a national asthma educator certification examination in Canada.

State and Local Initiatives

Certainly efforts to improve asthma on a national level are important because information can be disseminated to a wider audience, but ultimately their success will depend on state and local initiatives. At least 60 state or local asthma coalitions across the United States have been formed and many more are developing. Pharmacists should research if their community is forming an asthma initiative and consider participating because the pharmacy profession must be represented in order to optimize efforts to improve care of asthma patients. Posting local and state coalitions on the NAEPP web site (www.nhlbisupport.com/asthma/ index.html) is encouraged to facilitate communication and opportunities for collaboration.

The first step to convincing groups to offer such state and local initiatives is proving the burden of asthma exists in that area. One 

example is data that were collected on the North Carolina Medicaid population in which approximately 13% of children 14 years of age and younger have asthma. In school-age children, asthma was the second most common chronic illness. In North Carolina, the data showed that $23 million was paid by Medicaid during fiscal year 1997 for asthma-related services in this population, thereby proving an economic burden.

A method that can be used to evaluate prevalence is a tool called the International Study of Asthma and Allergy in Children (ISAAC) survey.⁵⁰ 

In North Carolina, the survey was conducted on 13- and 14-year-olds in the middle schools. Preliminary data from this pilot project suggested that the prevalence of asthma is greater than previously recognized in this age group.

Because of the prevalence of asthma and its effect on health care costs, several local and state asthma initiatives in North Carolina are either already in place or in development. Two major initiatives are the North Carolina Childhood Asthma Initiative and the North Carolina Asthma Advisory Board. 

The North Carolina Childhood Asthma Initiative The North Carolina Childhood Asthma Initiative was created to develop a comprehensive approach to the diagnosis and management of the state’s asthmatic children. It was also designed to help develop new asthma coalitions and support existing ones to help improve management of asthma at the grassroots level. The initiative’s task force consisted of the Division of Human and Health Services, Division of Women’s and Children’s Health, and health care providers such as asthma specialist physicians, nurses, nurse practitioners, pharmacists, epidemiologists, and statisticians. Its main goals were to:.

(1) determine the prevalence, distribution, and health consequences of childhood asthma, 

(2) identify components of effective community-based asthma management initiatives,

 (3) determine public awareness and educational needs to identify and control the effects of asthma among school-age children, and 

(4) identify appropriate environmental interventions. 

Some important efforts undertaken by this group include helping develop more than 20 new asthma coalitions in the state, getting local health departments involved in environmental interventions for asthma patients, facilitating physician educational programs, and assisting in surveillance activities.

The North Carolina Asthma Advisory Board  Created in 1998, the North Carolina Asthma Advisory Board consists of pediatric and adult asthma specialist physicians, primary care physicians, nurses, nurse practitioners, pharmacists, the ALA of North Carolina, the director of the North Carolina Childhood Asthma Initiative, a respiratory therapist, and others. The initial goal of the Advisory Board was to promote optimal medical management of asthma. To begin this process, the Board has offered educational programs for physicians, pharmacists, nurses, and other health care providers.

Recently the major focus of the Advisory Board has been to promote the concept of the CAE in North Carolina. To help facilitate this effort, the Advisory Board has promoted two rigorous asthma educational programs: A program from the United Kingdom called the National Asthma and Respiratory Training Center (NARTC) diploma program and the asthma certificate training program for pharmacists, which was approved by the North Carolina Center for Pharmaceutical Care.

The NARTC course includes a distance learning package and work-based experience, as well as some didactic sessions, followed by a day-long examination at the end of the program. It has been offered in the United Kingdom, parts of Europe, and in Canada. To encourage participation in 1999, the Board helped raise more than $50,000 to make the NARTC program free to North Carolina participants; 84 nurses, nurse practitioners, respiratory therapists, social workers, and pharmacists took the program. The Board also will help facilitate the NARTC course in North Carolina in 2000 and to some extent on the national level.

In 1999, approximately 30 pharmacists began participating in the Board-promoted asthma certificate training program for pharmacists. The program, which will take about 6 to 8 months to complete, consists of didactic and workshop sessions, and “skills-development” sessions in which patient cases are presented and discussed by program participants. Outcomes of the asthma patients followed by the participating pharmacists are currently being monitored. The program will be offered on videotape across the state through area health education centers. 

Reimbursement 

For any health care provider to routinely spend in-depth time with asthma patients, reimbursement will be necessary. The most acceptable and politically powerful approach to getting reimbursement by third-party payers would be to have multiple health care disciplines represented, not just pharmacy. However, the terms under which reimbursement will be granted for asthma education and monitoring will probably vary from state to state. 

Currently the goal of both the Advisory Board and the Childhood Asthma Initiative is to help develop a process in North Carolina for CAE that will allow for reimbursement by third-party payers. In North Carolina, the recent passing of the Clinical Pharmacist Practitioner Act may help define the pharmacist’s role with asthma patients and associated reimbursement. The role of the individual state Boards of Pharmacy in the certification process is uncertain.

Part III

Education of Pharmacists for Collaborative Practice

Peter Gal, PharmD, BCPS, FASHP, FCCP; Teresa Devora, BA, CMM; Peter Koval, PharmD, BCPS; and Chris Rubino, PharmD, BCPS, Greensboro Area Health Education Center, Greensboro, NC; School of Pharmacy, The University of North Carolina, Chapel Hill.

The skills pharmacists already have include a good working knowledge of pharmacology, a history of trust and rapport with the public, and a tendency to be very systematic in their practice approach. The obstacle then for many pharmacists is obtaining adequate training to perform disease management and be accepted as physician extenders who contribute to patient care. 
As noted in Part II, the answer may be to include pharmacists in certificate training programs. These programs should optimize pharmacists’ clinical competency and provide a way for the clinical service user to determine that appropriate training has taken place. Because providing clinical services to patients by any health professional is a challenge, it is especially important that pharmacists receive adequate training in the areas in which they wish to provide clinical services. Furthermore, failure to properly adhere to appropriate medical standards can place the pharmacist (and potentially their employer) at considerable medico-legal risk.

Ensuring Quality Programs

Many organizations are working to assure the quality of training programs. In 1999, the American Council on Pharmaceutical Education (ACPE) adopted standards for certificate programs, which became effective January 1, 2000. On the state level, the North Carolina Center for Pharmaceutical Care (NCCPC) has provided oversight and guidance to ensure the quality of its certificate programs.

A common theme of standards for ACPE and NCCPC is the need for an application component to the program. All issues related to the management of disease states should be taught in both didactic and clinical practice application components, not just a didactic and exam format. In addition, strategies for using the skills from any certificate program should be discussed, along with strategies to keep the practitioner current. Mechanisms to provide program participants with appropriate access to patients must be considered in advance to optimize each pharmacist’s chances for success.

As demonstrated by asthma initiatives in Greensboro and Asheville, North Carolina, pharmacists who complete a program with application and exam formats are able to achieve the dual goals of providing clinical services and getting reimbursement for those services. The reasons for success include the following:

After completion of the training, their activities were significantly affected. Seven pharmacists saw patients in an asthma clinic, six saw patients by appointment in physician offices, 13 developed patient treatment plans, and 18 included proper use of peak flow meters as part of their patient asthma education. Recording outcomes data was performed by four pharmacists and billing for clinical services by three. 

This model of certificate training was successful but required considerable commitment from participants and educators. In recognition of this, the format was revised to be user-friendly to the working pharmacist. Keeping a focus on the expectations of physicians, the program now incorporates minimum but acceptable standards and has become the blueprint for all pharmacy certificate programs provided by the Greensboro AHEC. In this model, pharmacists are required to:

Controversy continues surrounding whether certificate training for any or all areas of clinical practice by pharmacists is needed. Some argue that a PharmD or pharmacy license is sufficient; others feel that only board certification as a pharmacotherapy specialist and a pharmacy degree are needed.

In the experience of the Greensboro AHEC, whatever a referring physician, patient, or payer expects of the pharmacist determines what is sufficient. 

Thus, when trying to convince these groups that pharmacists should be given authority to provide collaborative care for asthmatics in their community, a survey should be conducted to find out what is required for this to happen. The high success rate in the Greensboro AHEC supports the value of surveying the potential users of the service and meeting their expected standards. It also speaks to the importance of taking the blueprint of any certificate program and molding it to the individual community’s needs and expectations. In North Carolina, the statewide AHEC program is positioned to facilitate the individualization of programs to meet the needs of the community. In other states, this may require local pharmacy society leadership, and collaboration with physicians and other health care providers in the community. 

Providing physicians with a vision and an incentive for collaborating with pharmacists to provide disease state management can be achieved when the credentials of the pharmacists involved assure the physician of the competence of the pharmacists. Certificate programs are an important opportunity to develop this credibility, provided a description of the program represents an adequate balance of knowledge and practice.

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