Pharmacist builds medical homes for patients with chronic conditions

Robb Malone, PharmD, pioneered pharmacist-centered care at UNC.

When “John Doe” came into the University of North Carolina (UNC) Internal Medicine Practice with heart failure, diabetes, and chronic kidney disease, “He had all the comorbidities that, if left unmanaged, would result in a rapid decline of his health. His primary care physician and I knew he was at risk for hospitalization, a major cardiac event, or even worse,” Robb Malone, PharmD, CPP, recently told Pharmacy Today.  Besides a host of chronic illness, Doe was poor, underinsured, and illiterate — all risk factors for falling through the cracks of a large health care system.  But Malone was part of the team that made sure that didn’t happen. Under the care model that Malone designed with Diabetes Program co-coordinator Betsy Shilliday, PharmD, and their Internal Medicine colleagues, Doe lived years longer than anyone expected.

Today, the model of care behind the Diabetes Program is a key piece of the model driving the creation of patient-centered medical homes throughout UNC Health Care. Meanwhile, Malone has risen through the ranks from co-coordinator of the program to Assistant Medical Director of the Internal Medicine Practice to Vice President of Practice Quality and Innovation for UNC Health Care, while still caring for patients with diabetes and other chronic conditions.

Two pharmacists with laptops
In 1999, the UNC School of Medicine contracted with UNC Hospital’s Department of Pharmacy and two pharmacists for a 1-year pilot in hopes of finding innovative ways to improve care of indigent patients. The school wanted to demonstrate how it was delivering innovative, high-quality care to the uninsured. When a past Chair of the Department of Medicine, David Ontjes, MD, asked longtime colleague, Betty Dennis, PharmD, MS, CDE, CPP, FASHP, if pharmacists could do anything to help, a plan was made to incorporate pharmacists into a primary care practice to deliver diabetes care. “We had 1 year to prove [to the School of Medicine] that pharmacists could do something. Time was short and the budget was tight; we had just enough for two pharmacists and a couple of laptops,” Malone said.

The School of Medicine’s mission is to improve the health of North Carolinians, and as a state-funded medical school, UNC cares for a large population of the underserved and underinsured. These vulnerable patients are at risk for receiving incomplete or fragmented care. Malone and colleagues wanted to put an end to that, starting with UNC’s Internal Medicine Practice. “There had to be a pharmacist in the office from the time the doors opened until the time they closed. We were always there for our patients, the providers, and staff,” Malone recalled.

Closing the cracks
In a practice where 13 full-time physician spots were divided among roughly 100 physicians, Malone’s and Shilliday’s presence alone brought perhaps the most continuity the practice had seen. During that first year, they had to establish the program, enroll patients, develop rapport with staff and providers, and evaluate the service delivered. Perhaps most critical to their early success, they created a registry of patients in the practice with diabetes, which was invaluable in the time before widespread adoption of complete electronic medical records. “In the beginning, no one could tell you with certainty how well the practice was doing compared to national standards of quality. Further, you couldn’t just ask the doctors, ‘Who are your patients with diabetes?’ Nobody could tell you,” Malone said.

At first, practice staff didn’t entirely understand why Malone and Shilliday were there, so the two worked behind the scenes— first in a utility room and then from a cart in the hallway—until they had gained the support of key physicians and staff. “[Malone] had a way of building acceptance of a new model of care within our practice that’s beyond the skills of being a pharmacist. He had a vision and found like-minded people to test it out,” said Darren DeWalt, MD, MPH, who was a Robert Wood Johnson Clinical Scholar with the University when Malone came aboard.

Every morning, Malone looked up each patient on the paper schedule to determine which had diabetes and which were failing treatment. “Most patients were failing because the system was failing. Physicians and staff were working hard to provide quality care, but they lacked the informatics and support they needed to do it reliably, especially for the most vulnerable patients. Many of these patients were uninsured, they were working poor who didn’t qualify for Medicaid, or they didn’t have a car or phone or couldn’t read,” he said. Those were the patients he wanted to see.

Every afternoon, from his cart in the hallway, Malone would grab passing physicians and ask if he could have a moment with their patients who had been identified as needing intervention early that day. With the physician’s approval, Malone would get the patient started on insulin or recommend other adjustments to medications. “We looked for people that likely needed insulin, but there was probably a reason they weren’t on it—maybe a resident didn’t know how to tell the patient they needed it or didn’t want to tell them.”

DeWalt, now Associate Professor of Medicine at UNC, said, “Most residents don’t know how to inject insulin. There were a lot of facets of diabetes care that we didn’t know as residents. Robb really understood what a person with diabetes is going through.”

Malone or Shilliday would see patients for the first 15 to 30 minutes of their visit. They interviewed, took histories, and educated patients. Many of the patients who were seen in clinic were followed by telephone for further care. Eventually, both became Certified Diabetes Educators, and the program came to include a class recognized by the American Diabetes Association and led by Malone, a dietitian, and a nurse practitioner.

Malone’s and Shilliday’s clinical recommendations were overwhelmingly approved by the physicians and resulted in the creation of protocols through which the two pharmacists were authorized to prescribe medications with verbal orders.

“I might recommend a medication or a dosage adjustment and the doctor would almost always agree to it, but then the doctor would have to write the prescription, and sometimes things would fall through the cracks,” Malone said.

Then, in 2000, a new law was passed in North Carolina authorizing pharmacists to prescribe, and Malone and Shilliday became Clinical Pharmacist Practitioners. North Carolina and New Mexico are the only states that authorize this advanced practice. “So we were able to close another crack that patients could fall through. We could skip that step of handing off the medication recommendation,” said Malone.

The diabetes care program also closed the gaps between physician visits while making more efficient use of the physician’s time during visits and improving appointment access. “Where the doctor used to see someone today and tell him to come back in 6 weeks, he or she could now tell them to come back in 12 weeks. This would allow our physicians to see some of their other patients or create capacity to see more new patients. Internal Medicine physicians knew that the pharmacists and program would take care of things in between,” Malone said.

Later, the diabetes care program added a new, novel position to the team: care assistants. Care assistants follow patients by phone between visits and act as visit facilitators when patients came to see their physician. This change allowed pharmacists to see more patients in one-on-one pharmacy clinic visits. Pharmacists would see patients as many as three times between physician visits. And in 12 weeks, when it’s time for patients to see their physician again, they often tell Malone, “I want to see you.” Malone emphasized that he is not replacing the physician, but because he provides continuous care between physician visits, patients recognize the importance of his contribution in managing their issues. “It’s reassuring to know that other people are working together to take care of the patient between visits with me. It opened my eyes to team-based care,” DeWalt said.

The program has grown beyond pharmacists and care assistants to include a dietitian, social worker, and nurse practitioner, as well as physician assistants. A randomized controlled trial of 217 patients, published in the American Journal of Medicine in 2005, showed that glycosylated hemoglobin levels, blood pressure, and aspirin use had all improved among patients in this model compared with standard diabetes care.

Soon the model was implemented in chronic care beyond diabetes, including anticoagulation, chronic pain, and heart failure. To integrate these programs into the practice, Malone was made Assistant Medical Director in 2006.

Increasing access to care
As Assistant Medical Director, Malone said, “I had to learn a lot about scheduling and using staff efficiently.” He didn’t just learn about scheduling; he made it better, said Michael Pignone, MD, MPH, Malone’s supervising physician and Chief of Internal Medicine. “He’s great at seeing a challenge, collecting the information, and getting faculty on board so he can see the solution through,” Pignone said.

Under Malone’s direction, the practice reduced no-shows and made better use of all available appointment slots. “One way [he improved the system] was by not prespecifying what kind of patient can go into which slots,” Pignone said. “If a 40-minute slot is only for a new patient and there is no new patient, that slot goes unused when you could have made two 20-minute slots.”
When the health care system launched its Patient Access and Efficiency (PAcE) initiative in 2005 to improve patient access system wide, Malone led his practice’s participation in the project. His success led to his becoming a PAcE faculty member and change manager in 2007, a role through which he helped make similar improvements within other divisions of the Department of Medicine. The university’s rate of wasted appointments was decreased by nearly 10%.

Taking innovation into the future Malone’s success in making systemwide improvements led to his appointment in 2010 as Vice President of Practice Quality and Innovation for UNC Health Care. In this role, he is preparing the health care system to meet the requirements of health care reform.

Working for the health care system and with physicians throughout the School of Medicine, Malone spearheaded the process to get UNC Family Medicine and Internal Medicine recognized by the National Committee for Quality Assurance (NCQA) as level-three patient-centered medical homes and recognized for diabetes care. UNC’s Endocrine Practice and Diabetes Care Center also earned NCQA diabetes care recognition. The UNC Heart & Vascular Center at Meadowmont earned heart and stroke care recognition, and University Pediatrics at Highgate become a level-two patient- centered medical home.

Now Malone is working to bring patient-centered care to about 18 departments and more than 50 practices on campus. Through a plan loosely based on the diabetes care model and the success of the PAcE initiative, his office has hired health coaches, analysts, and programmers to help spread a focus on quality and continuous improvement throughout the system’s outpatient practices. “We are spreading the idea of what we think the country’s new health care system is going to be: coordinated teams working at the top of their licenses, using data and information technology to support care delivery, and working with patients to achieve high quality, efficient care,” he said.

Malone’s influence can also be seen at Carolina Advanced Health, a new practice and innovation of Blue Cross and Blue Shield of North Carolina and UNC Health Care. “A lot of inefficiency comes from regulation that we don’t have any control over and a lack of critical information that we cannot access as patients may receive care from disparate providers or health care systems,” he said. “In this new practice, everything is shared 50–50. The payer is our partner and our success is their success. This ultimately leads to better outcomes for our patients.”

Patients are treated for one or more of several chronic conditions in a model much like the one Malone set up for diabetes in 1999. To improve patient access, appointments are offered at nontraditional hours. “It’s an advanced primary care practice that’s taking team-based care and the patient-centered medical home concept to a new level,” Malone said.

But Malone’s impact doesn’t stop at the state line. “A lot of the stuff that Robb’s developed is being used all over the country,” DeWalt said. “He’s really had a national impact.” Still, Malone doesn’t lose sight of the patients. He continues to provide diabetes care weekly in the Internal Medicine Practice.

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