1. Disease State Management The Pharmacist’s Role
The profession of pharmacy has been shifting from a practice that is product-focused to a practice that is patient-focused by ensuring that patients receive appropriate drug therapy and by communicating appropriate drug information to improve and promote patient health.
One aspect of delivering care that has become increasingly of interest to pharmacists is disease management (DM). J Manag Care Pharm. 2005;11(6):505-12

2. Why the Interest ??
Chronic diseases account for billions of dollars in annual medical expenditures
Loss of work time and decreased worker productivity contribute to indirect costs
Health care services for chronic conditions are often not coordinated among providers, creating opportunities for overuse or underuse of medical care
People with chronic conditions generally use more health care services, including physician visits, hospital care, and prescription drugs. Increases in the number of people living longer with chronic conditions coupled with rising health care expenditures have spurred health plans, employers, and the government to look for ways to reduce health care use and costs.
Disease management is one approach that aims to provide better care while reducing the costs of caring for the chronically ill. Disease management programs are designed to improve the health of persons with specific chronic conditions and to reduce health care service use and costs associated with avoidable complications, such as emergency room visits and hospitalizations.
Center on an Aging Society, GEORGE TOWN UNIVERSITY
BMJ.2002;325:925

3. Disease State Management Definition
A system of coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts can be implemented
Circulation. 2006;114:

4. Disease State Management Definition
Disease management (DM)
Supports practitioner/patient relationship and plan of care
Emphasizes prevention of exacerbations & complications through the use of evidence-based practice guidelines and patient empowerment strategies
Evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health
Circulation. 2006;114:

5. Disease State Management Benefits
Improve the safety and quality of care
Improve access to care
Improve patient self-management
Improve financial cost containment without sacrificing quality or patient satisfaction
Improve patient quality of life

6. Disease Management Program Components
Population identification processes
Evidence-based practice guidelines
Collaborative practice models (multidisciplinary teams that may include physicians, pharmacists, nurses…)

7. Disease Management Program Components
Patient self-management education (may include primary prevention, behavior modification programs, and compliance/surveillance)
Process and outcomes measurement & evaluation
Monitoring system/feedback loop that include patients and providers

8. Collaborative Drug Therapy Management (CDTM)

9. Collaborative Drug Therapy Management (CDTM)
“A collaborative practice agreement between one or more physicians and pharmacists wherein qualified pharmacists working within the context of a defined protocol are permitted to assume professional responsibility” for certain tasks
Pharmacotherapy 2003;23:

10. Collaborative Drug Therapy Management (CDTM)
Tasks include:
Performing patient assessments
Ordering and evaluating drug therapy-related tests
Selecting, initiating, monitoring, continuing and adjusting drug regimens
Assessing patient response to therapy
Counseling and educating a patient on medications
Administering medications
Pharmacotherapy 2003;23:

11. How Does it Work ?
As a first step, a disease management program must identify the population group
Programs target individuals with a specific disease that is chronic in nature and costly
Individuals with multiple conditions may also benefit

12. DM Program Characteristics
The diseases typically targeted by DM programs have the following characteristics:
Prevalent chronic condition
High resource utilization
Potential for lifestyle modification to improve outcomes
A variety of treatment options
A high risk of negative outcomes

13. DM Programs Examples Ann Acad Med Singapore 2010;39:861-7 Depression
Management
Asthma/COPD
Diabetes
Congestive Heart Failure Management
Coronary Heart Disease Management
Osteoporosis
Arthritis
Hypertension
Ann Acad Med Singapore 2010;39:861-7

14. How Does it Work ?
Multidisciplinary team of providers are recruited (e.g. physicians, pharmacists, nurses, dieticians psychologists) to assist individuals in managing their condition(s)
Practice guidelines based on clinical evidence ensure consistency in treatment across target population

15. How Does it Work ?
The goal of disease management is to encourage patients to:
Use medications properly
Understand and monitor their symptoms more effectively
Change their behavior
Clinical, economic and quality of life outcomes are evaluated to assess success of interventions

16. The Pharmacist Role Assist in the identification of individuals
Conduct monitoring for specific diseases (e.g. DM, HTN)
Provide patient education (e.g. glucose monitoring)
Provide advice on disease management
Assist with medication adherence
Identify & manage drug-related problems
Evaluate outcomes of programs (clinical, economic, QOL)

17. The Pharmacist Role
Conduct outcomes research to form the basis for treatment guidelines
Ensure the ongoing involvement of the pharmacy and therapeutics (P&T) committee in the disease management process
Educate other pharmacists and physicians about treatment guidelines
Use health system databases to track drug expenditure patterns and health care professionals' adherence to health care management regimens

18. The Pharmacist Role - Examples
Asthma Management
Provide educational programs about the disease
Conduct periodic review of the patient's inhaler technique
Perform ongoing monitoring of peak-flow function tests
Manage chronic medication use, including compliance assistance

19. The Pharmacist Role - Examples
Diabetes Management
Provide educational programs about the disease
Regularly monitor both self-tested and lab tested glucose levels
Educate patients on how to use glucose monitoring equipment
Monitor patient compliance with prescribed therapies and appointments
Screen for drug interactions and adverse drug reactions
Provide medication management and review

20. The Pharmacist Role - Examples
Hypertension & Cholesterol Management
Educate patients about these silent diseases
Monitor compliance with medications, diet and exercise
Screen for drug interactions and adverse drug reactions
Perform periodic blood pressure checks
Perform periodic cholesterol level checks

21. Organizations Offering DM Programs
Hospitals
Inpatient setting
Ambulatory setting
Pharmaceutical companies
Community pharmacies

22. Organizations Offering DM Programs Community Pharmacies
Desirable setting for providing DM for several reasons:
People visit pharmacies more often than any other health care facility
Community pharmacies account for dispensing the majority of prescriptions
Accessibility of pharmacists creates the opportunity for patients and pharmacists to develop rapport
Prescription databases allow pharmacists to readily retrieve patient-specific information to screen for high-risk patients and identify potential drug-related problems
J Manag Care Pharm. 2005;11(6):505-12

23. Perceived Barriers to DM Programs
Limited time
Limited staff
Limited space
Reimbursement issues
High cost
Limited patient acceptance
Lack of knowledge about disease management
J Manag Care Pharm. 2005;11(6):505-12

24. Pharmacist Qualifications
To provide DM services, a pharmacist must be a registered pharmacist & complete a disease specific certification program
National Institute for Standards in Pharmacist Credentialing (NISPC) adopted the designation of Certified Disease Manager (CDM) for those pharmacists successfully completing one of the disease management exams