In August 2012, the American Association of Diabetes Educators highlighted recommendations and research confirming that more than one-third of the 25 million Americans with diabetes don’t take their insulin as prescribed, with 20% intentionally skipping doses and many admitting they inject it in the wrong place or at the wrong time or use the wrong technique, and only 30% of patients receive formal insulin education.
Collaborative Care recently had the opportunity to interview Jerry Meece, a pharmacist, certified diabetes educator and author of the AADE’s recommendations, about what pharmacists are — and should be — doing to address the problem.
Collaborative Care: What are the best practices you've seen in how retail pharmacists approach diabetes care?
Jerry Meece: I think that the best cases are when pharmacists approach their diabetes practices a lot like a physician office works. Think about it.
PCPs use their staff for everything up to — and sometimes including — patient interaction. Some examples:
Making appointments: It doesn’t seem natural at first, but if your staff agrees, we can “train” our diabetes patients to be more aware of our time. You can certainly give a quick answer every time it’s needed, but too often the timing isn’t right and we think we have to stop everything and answer every question to the end. Have patients come back if it becomes involved, so that you can give them your full attention.
Better utilization of staff: Delegate jobs that are repetitive to others. Find a good tech and assign them the title of “chief technician” or something similar, and put that person in charge of such jobs as checking blood glucose if you are doing those in-house, running a lipid panel, weighing, etc. I don’t need to take a patient’s blood-glucose reading — that takes up valuable time. What I do need is to get the results of that check from my tech, so that I can then talk about the results.
Provide a professional setting: Have a semi-private area where you can sit down, even for a few minutes and talk to your patient. It makes such a difference. It doesn’t have to be fancy, but it has to be out of the way where you can listen and talk.
CC: What have some been doing wrong or insufficiently, and what can they do differently?
Meece: I think we can go back to the last statements for good practices and just reverse them.
As pharmacists we’ve long thought that we had to grab every phone, answer every question and do every job ourselves. As a result, we skip over a lot of the essentials in good patient care or don’t do the best job we can with our patients. So make a plan with staff that a patient will most often not come directly up to you and interrupt your work — it would never happen in any other professional office. By having someone intercept the patient to find out what is needed, time is better allocated. What often is the case is that possibly the patient didn’t need to see the pharmacist at all, or not until other issues were resolved, such as billing, cost of a medication, a meter not working, etc. It’s great to interact with the patient who comes in, but just do it at the right time for the best utilization of your time. Delegate.
We don’t get the buy-in from our staff like we should when we start a project such as creating a diabetes care or education center. We need to explain to them why we’re taking on this new program, what it will mean to them — better organization, possible bonuses and raises, stability, etc. — and what it will mean to the pharmacy — more business, income, a higher profile in the community. And that yes, you might be taking more time with certain patients as the program grows, so help out and explain to waiting customers what is going on. Everyone sees the value. If the staff does not buy in and treat it like an important professional aspect of the pharmacy, then it just does not fly.
Poor signage: Too often as pharmacies we try to nudge our way into something, and we wonder why it does not go. Every aspect of the pharmacy, from when the diabetes patient first walks in, should say professionalism and show the practice is a go-to pharmacy for their diabetes needs. Signage and handouts are a good example. Wholesales and pharma companies are great resources for what you need to make a good first impression. These are the areas you certainly don’t want to cut corners on. When a diabetes patient walks in to the store, they should be able to instantly locate a well-stocked up-to-date diabetes center. Carry the most up-to-date supplies — think new shorter needles for syringes and insulin pens — and not only will you as a pharmacist seem knowledgeable about the advantages, but having that chief tech knowledgeable as well is critical to showing people that you are in this business to stay.
CC: What do you see as the future of diabetes care at the retail pharmacy level?
Meece: The future is bright if we take advantage of what we already have in place. For pharmacists to not only survive, but also thrive, they have to move from retail pharmacy to a clinical community pharmacy setting, where the things we just talked about take place. It does not take a lot of money, but it does take focus and effort. Dispensing of information and knowledge in the form of diabetes education will be an important adjunct to dispensing meds.
Pharmacies need to become accredited, or “recognized,” as diabetes self-management training programs by either the American Diabetes Association or the American Association of Diabetes Educators so that they can get reimbursed for working with patients by Medicare and insurance companies. Many pharmacies are doing that just now by attending workshops that help them down this path.
Pharmacists can go a long way toward becoming an integral part of the diabetes team by playing to their strengths, examples of which are increasing adherence with medications, making physicians and patients aware of new technologies that are available and being able to step in as a problem-solver when the opportunity arises.
For example, we know that many diabetes patients skip their insulin doses or put off starting insulin for various reasons. A primary reason could be because needles make them anxious or because they try to avoid the pain of injection.
Adding an insulin pen to their therapy could help with this issue because of the discreteness and because being able to use a new technology like a 4-mm needle that allows single-handed injection and reaches the correct fat tissue for insulin injection is less intimidating and much more comfortable. But many patients are still using the longer 12-mm needles that not only have no advantage, but also require two-handed pinch-up and may even cause hypoglycemia to occur if the injection goes too deep and enters a muscle. We now know that 4-mm insulin pen needles and 6-mm syringe needles work for almost every patient who comes into our pharmacy. Educating patients and physicians about options available to them and backing it up with the latest research is an important part of our work, and this will become even more of a focus as pharmacies offer more opportunities for one-on-one patient consultations. The AADE has pointed that that only 30% of diabetes patients receive formal insulin education, and so education provided by pharmacists might help to close this gap.
Pharmacies are perfectly positioned to take on a lot of the load that is needed to treat the current epidemic of diabetes that is expected to get bigger in the coming years. We are accessible, can utilize staff to multitask and have the facility already in place that will complement our dispensing programs.