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Implementing a Diabetes Management Program in a Community Pharmacy: Part 2 of 3

by Dr. Michael Case Haub

So, what did you learn from your SWOT analysis? Are you offering a needed service in your area? Who is your specific competition, and what are their weaknesses or strengths. Here are some specific things you can do to get started.

Some obvious ideas are to run prescription reports on diabetes medications to find out your diabetes population, ask your diabetes patients if they have had education or would be interested, and contact your competition (discreetly?) to inquire about availability classes, prices etc. It may be helpful to contact local drug/glucometer representatives for support and input. If there is a local diabetes support group, one could contact them. If not, start your own support group for ideas or to assess local population needs. Do you have a good relationship with local physician? Do they see a need? Will you need further diabetes education training? If so, where will you seek it? ( Drake University offers an excellent program.)

Of course, it is important to consider your co-workers. What does your staff think? What does your management think? What do YOU think? Now that you have officially decided that you want to start a diabetes program, what is next?

First of all, you must decide what type of services you are offering. Will the service be education only and center around newly diagnosed or poorly controlled patients? These patients would be good for group sessions, if you have the space.

Another option is to offer diabetes management only. In this case, you would follow patients between physician visits. For this I would recommend individual consults. In order to see the best outcomes, I would recommend both initial education and follow-up consultations. This requires the most time commitment but will be the most gratifying.

Unfortunately, I won't be able to tell you exactly what to do to set up a program in your market, because it is YOUR MARKET. I will include a number of forms that we use in our program and hopefully it will spark some ideas of your own. Remember to be creative, but also don't reinvent the wheel. It is helpful to search for diabetes educational programs and material that is already created instead of starting from scratch.

I would encourage you to become certified as an educator of diabetes. Let's take some time to discuss the various options. One option is to become a Certified Diabetes Educator (CDE). This program is offered by National Certification Board of Diabetes Educators ((NCBDE). You do not have to have an advanced degree, but you have to have 1000 hours of direct patient education to qualify to sit for exam.

Another option is to become Board Certification in Advanced Diabetes Management (BC-ADM). This certification is offered by the American Nurses Credentialing Center (ANCC). For this program, you must have advanced degree (PharmD, PhD, Masters) and 500 hour of direct patient diabetes education to qualify to sit for exam. These exams are discipline specific also (pharmacist exam, nurse exam, etc). After you are certified, I would encourage you to certify your diabetes program as well.

Certifying your program has a lot of benefits. Certification helps ensure reimbursement, will provide increased exposure and marketing, and exudes quality and commitment to continual program development. It will also help you compete against other programs in your market; most likely they will be certified. Going through the certification process will help you define your curriculum and your program goals.

In Iowa , there are two main types of certification. The first is by the American Diabetes Association (ADA). This process is very daunting and expensive. It also requires a large time commitment. I won't go into the details, but you can see all of the requirements at the ADA 's website: .

The second option is certification through the Iowa Department of Public Health (IDPH). The requirements and Iowa law are on their website: They do not have as stringent rules. Another advantage of this certification is that insurances in Iowa are supposed to pay for education provided by IDPH certified diabetes education centers. This route is a great start if wanting to ultimately become ADA recognized!

Let's take some time to discuss your program's curriculum. ADA and IDPH have guidelines to follow about what should be included in a diabetes curriculum. I would encourage you to follow those guidelines. It would be foolish to have to recreate your program to qualify to become certified. Here is an example of what we offer as a curriculum. We offer 10 hours of diabetes education split into 8 hours of group sessions and 2 hours of individual consults. Group sessions are great for interactions and answering questions! The first consult is with clinical pharmacist and the second consult is with a dietitian. We offer flexible class schedules (morning and evening classes) and each class is only 1-2 hours long. Many diabetes education centers may have one day of classes (8-10 hours!). Do you think those patients retain much?

We also offer take home videos, institutional videos, hands on instruction, and grocery store tours. Patients are required to take a pre-test & post-test (actually is same test, but they don't know that) to evaluate progress and must obtain 70% to graduate. If a patient does not pass, they may still graduate that day, once instructor goes over correct answers & patient feels like they understand that concept. If they are still not comfortable, an individual consult is set-up to review certain concepts.

Patients also sign competency check lists after each session to document they understand each session discussed. Once completed this list is sent to the referring physician along with any SOAP/Progress notes.

Your program will need to be able to measure outcomes. What outcomes would you want to measure? Examples are fasting blood glucoses, A1c, weight, ER visits, and last dental exam. I have included a copy of our Diabetes Care Flowsheet. When would you want to measure these outcomes? Ideally, you would measure at baseline, 3 months, 6 months, 9 months, and 12 months. Measuring outcomes is an excellent opportunity to include point-of-care testing for increased revenue and better patient outcomes. You may need additional device to perform these point-of-care tests.

Patient follow-up is a very important step that all programs should have (required for certification). The question is: How will you follow-up? The more common ways are by phone, mailers, at prescription pick-up, or by appointment. Again what outcomes are you following and what level of follow-up is included in price of program?

What do you do if you get no response? This is a common problem encountered when following up with patients. One idea is to send a letter to patient stating you will contact physician about non-compliance to program. Then send letter to referring physician to possibly “bribe” patients with free glucometer test strips (demos) or other incentives for responding. This will benefit all involved, especially the patient.

Another requirement of certification is to have an advisory committee. This is an excellent opportunity to get other disciplines' input/outlook on diabetes education. For the IDPH, the minimum requirements for an advisory board is to have a physician, nurse, dietitian and pharmacist. These members must have 6 hours of CE in diabetes (past 3 years), a current Iowa license and be available to attend meetings. You may want to consider other specialists: podiatrist, ophthalmologist, dentist, personal trainer, nephrologists, or diabetes patients themselves to be part of your committee. The committee must meet annually, but more frequently is recommended. You must also have the minutes taken for recertification.

It is considered good practice that you also have a signed collaborative practice agreement to establish your diabetes educational program. You must have a physician to oversee your program anyway. We are lucky in Iowa to even be able to enter into these agreements! Be very precise about what you can and cannot do in your protocol (no diagnosing!) However, finding a physician can be challenging. Some suggestion are to contact local ADA/JDRF chapters, ask glucometer/drug reps for suggestions, contact county public health department, and ask your diabetes patients (they can be an advocate for you, just as you are an advocate for them!) Remember that you have to file your collaborative practice agreement with the Iowa Board of Pharmacy prior to July 1st, 2008.

Now that you have your curriculum finished and your program is certified… now what? You need patients! Do not buy into the idea that “If you build it, they will come!” It is more appropriate to think “If you market it, they will come.” Advertising is the key to any successful program but traditional advertising is VERY expensive and we all know how small our profit margins already are! In the last portion of this segment we will take a closer look at marketing.

First, look at your SWOT analysis (again!). Play to your strengths and limit your weaknesses. Keep in mind, that we are a direct-to-consumer marketing society (look at drug advertisements during the 6 o'clock news). So, patients will drive your product/service more than focusing on physician detailing. Physicians get tired of listening to drug representatives all day long and you may be viewed as just another representative! On the other hand, once you get a number of patients (with good outcomes) take that data to physicians to market to them. It is a good idea to create a referral form to get a physician's authorization for a patient to be enrolled in your program, and they may have other patients too. Diabetes patients are very time consuming for physicians that is why they try to refer them to other “specialists” (be that specialist).

Here are some other ideas for marketing. You can create brochures to give to patients, physicians, drug representatives, and glucometer representatives explaining your program. Another idea is to offer to speak at local diabetes support groups. Maybe offer a free diabetes update or information session and offer food, a drug representative may help you with this. You can also create flyers as bag stuffers, offer screenings (foot, glucose, etc) at senior center or contact local TV, newspapers about “public service announcements.”

For most of us, marketing a “non-drug” related product/service is outside our comfort zone! Be persistent but don't be pushy. You are still a healthcare professional not a car salesman. Give your marketing “spiel” to your staff so that they may also help market to potential patients or can answer questions about the program. Your patients trust you; don't lose that trust by promising more than you can offer.

At this point you may say: “This is too much work! I don't feel confident about teaching every aspect about diabetes. I am a pharmacist, not a diabetes educator. Who has the time to do all of this?” If this is you, consider working with another accredited program, or a developing program. IDPH/ADA websites have listing of all accredited programs; maybe they could use a pharmacist.

In our next segment we will take a detailed look at billing and reimbursement for your services. It is a very important part to creating a successful program.