Sandra Leal, PharmD, CDE, and her colleagues are demonstrating “impactful” results using a practice model with Hispanic and American Indian patients and fighting for reimbursement for clinical services.

By John Parkinson, Clinical Content Coordinator

Socioeconomic disparities can play a huge role in a patient’s care, especially in a chronic disease like diabetes, where patients are perpetually battling to avoid complications, keep up on their medication regimen, and pay the bills associated with their overall medical management. Faced with such circumstances, it is understandable why some patients fall behind in their care.

In the nearby surrounding area outside of The El Rio Health Center in Tucson, Ariz., more than 70 percent of the local Hispanic and American Indian populations are at or below the poverty level according to the center. Both groups are already at an elevated risk for diabetes, and compounded by their dire economic situation, these two groups would be ground zero for discussing how certain patient populations might be more at risk for complications and problems with their care.

Yet, El Rio has served as a treatment oasis in the diabetes desert for these patients.

This success can be contributed to the combination of Arizona’s collaborative law between clinical pharmacists and providers and the health center’s methodical and passionate approach in applying the practice model based on the collaborative law.

A number of years ago, Arizona passed legislation allowing qualified clinical pharmacists in specified health care settings to implement, monitor, and modify drug therapy as described by written protocols in collaborations with physicians. This practice model is referred to as collaborative drug therapy management (CDTM).

In the past 10 years, El Rio has been a CDTM pioneer in Arizona, leading the way in how clinical pharmacists can help manage diabetes patients including: making sure they adhere to the medication regimens; keep up with necessary tests like regular A1C tests; and monitor other co-morbidities like hypertension.

The El Rio program is led by Sandra Leal, PharmD, CDE. Dr. Leal has received numerous awards in her field and was the first pharmacist in Arizona to receive the authority to prescribed medications.
From 2001 through 2010, Dr. Leal and her colleagues have had over 2,000 patients participate in CDTM. Through the years, Dr. Leal has authored several articles published in medical journals demonstrating how CDTM can keep costs level as opposed to the traditional standard care model, where costs can rise precipitously.

In addition, Dr. Leal has been advocating for reimbursement of such clinical services both in her state and nationally. had an opportunity to sit down with Dr. Leal recently to talk about CDTM, overcoming the barriers for Hispanic and American Indian diabetes patients, and insights into her reimbursement efforts: Can you provide an overview of the diabetes education program at El Rio?

Dr. Leal: We have group classes, which we do in English and Spanish. We are an American Association Diabetes Education (AADE)-accredited site for self management education. We have been using diabetes conversation maps, which is a series of four maps we use with patients on various topics including an overall view of what diabetes is, a nutrition focus, testing your blood sugar, what the A1C means, and preventing complications with good control.

We have other classes where we do an overall basic diabetes curriculum for newly diagnosed patients and they are taught by our nutrition counselor. Can you explain how the CDTM concept works in practice at El Rio?

Dr. Leal: Clinical pharmacists are integrated into the healthcare teams. There are one-on-one visits with patients that are referred in from any of our 16 sites from any other provider who is having trouble controlling the diabetes. Maybe the person is a long standing person with diabetes, and so they’ll refer that person over to the clinical pharmacist.

These are big exams; we get to spend more time with the patients than the providers. This practice model is really complementary because the pharmacist is really spending time on the chronic care and the physician is handling the acute care issues. We triage each other. When I find something that is acute, I make sure that patients get to see the doctor. If the doctor is having a significant issue and needs more time for it to be addressed, they will send the patient over to us.

We work closely with the patient on what the barriers are. A lot of times it might be adherence problems with the medication; it might be issues of affordability of the regimen they are being prescribed; or they have side effects from the medication. We make sure we develop a regimen that is something the patient can take, afford, and that they are having good outcomes.

We not only address the diabetes and all the standards of care, but the co-morbidities―making sure their blood pressure and their cholesterol are under control. We coordinate care so that the patient gets to the eye doctor, and we make sure their vaccines, like the flu shots are up to date.

One of the things we did last year was start screening everyone for depression, because we found depression is related to diabetes control. Sometimes somebody gets referred to us and the depression can be such a huge component. Until we can address that, it is difficult to get a person under control. El Rio was able to maintain or keep level its total charges among patients in the CDTM treatment model versus the diabetes patients who had the traditional care who showed a big uptick in escalating costs in recent years. What specific elements do you attest these successful results to?

Dr. Leal: We have consistently shown a good track record with the standards of care. We not only improved the process, we have the outcomes to back it up. We have seen an improvement in the patients’ A1C data. Typically in our clinic there is a 1.8 percent to 2 percent improvement versus the traditional standard care. We also see improvements with blood pressure and lipids, and these are statistically validated.

We have also addressed adherence. We’ll come in to see a patient for the first time, and although medicine is prescribed, a lot of times when we interview the patient they are not keeping up with their regimen. We readdress it every single visit. We have to make interventions on behalf of the patients because of issues of affordability or side effects. Adherence can really help people be successful. Besides the ability to keep costs relatively steady, what are the ancillary benefits to practicing CDTM?

Dr. Leal: Patient satisfaction is very high. We have people who come into our program, and in just a few weeks, they will refer their own family members or neighbors. I have to explain to them I’m not a physician, but the patients really appreciate a different set of eyes doing a full review of all their medications, not just the ones for diabetes.

Our administration really supports the program. We have had impactful outcomes, and as an organization we have had a lot of publicity, so we are able to apply for grants and different reimbursement models like pay-for performance.

One of the things that has helped make this program stand out is that we start collecting patients’ data from day one. And we continuously try to share the data and the successful outcomes.

I’m always going out to peers to seek reimbursement services (on their behalf). Pharmacists are reimbursed for the product dispensing, but we are not recognized for the clinical services that we provide. It has been my goal to get that recognition. How are you going about trying to get recognition for clinical services reimbursement?

Dr. Leal: We have met with different payers. We have contacted the different private plans in Arizona. We have even gone up to the national level and tried to get recognition through Medicare.

We are part of a federal effort called the Patient Safety and Clinical Pharmacy Services Collaborative (PSPC), where the Chief Medical Officer here, Dr. Martinez, and I are both faculty. The collaborative has been up for three years, and we teach other community health centers how to carry out this practice model; show them how to collect data and outcomes; and compile the data to exhibit on a national level. This way, we can illustrate that there is this impact to integrating clinical pharmacists so that we can get that recognition. Is there any specialized training required for practicing in the CDTM program?

Dr. Leal: If you have a residency, you are qualified for it. Clinical pharmacists tend to have residency training, and it is definitely helpful in applying for the CDTM. You also have to do six hours on every disease state you manage every year. I have hypertension, cholesterol, and diabetes, so I have to do 18 hours this year. You can’t be in a typical pharmacy and deliver this kind of care yet; it is primarily practiced in community health centers, nursing homes, and hospitals. They do have limitations depending on the type of practice. At El Rio you are treating predominately Hispanic and American Indian patients. What are some of the biggest cultural challenges they have in battling the disease?

Dr. Leal: There are issues of disparity with our patients. Many of our patients don’t have a high level of education. There are income barriers for the patients. There are cultural issues like using insulin, for example. They may have had bad experiences historically.

A lot of our patients don’t have health insurance. Approximately 20 percent or so of the population we serve don’t have any. If you think about how expensive diabetes is with all of the medications and all the types of visits, it is very challenging for patients to be able to take care of their needs—even when they want to be compliant.

We also have language barriers. A lot of patients don’t speak English, and I am a Hispanic-American and bilingual, which really helps with the food and the culture and understanding how to incorporate treatment into their lives without huge interruption. What are some of the teaching techniques you have adapted to help these patients?

Dr. Leal: The conversation maps have been helpful, because people trust their peers. The maps are an opportunity for people to sit around the table and have a guided discussion. We really don’t serve as lecturers in this process; we are really more facilitators. The patients learn from themselves. We are there more for clarification and making sure the information being shared is accurate. They remember more, and it is more impactful when it comes from peer interaction.

The map is set up like a road and as you are going through it there are different topic areas and there will be questions around that. For example, for someone who has recently started on insulin, they could share that experience with others in the class who might be considering it or are afraid to. This map will allow for them to have that discussion.

Originally posted by on May 13, 2011.