Collaborative Diabetes Medication Management: Advanced Practice Clinicians Working with Pharmacists

Advanced practice clinicians are often faced with difficult decisions in the management of medications for patients with diabetes who present to the convenient care clinic. As children prepare to go back to school, advanced practice clinicians in local convenient care clinics can collaborate with pharmacists to determine the individual risk factors for each patient.

In diabetes management, individualized treatment regimens start with behavior modification. In addition, medications are often required to achieve glycated hemoglobin (A1C) goals. Patients and their families may be unaware of the importance of medication adherence in the management of diabetes, however.

Children with diabetes often struggle with understanding medication administration and injectable routes¹and frequently lack the motivation to maintain medication adherence. They tend to do best when families are involved to help manage prescriptions. Because of this, adherence counseling efforts for this population are often targeted at the caregivers.

Advanced practice clinicians are perfectly suited to collaborate with other professionals, such as pharmacists, on the medication counseling needed for children and adolescents with diabetes. This type of interprofessional care of medication regimens promotes the Institute of Medicine’s 6 goals in evidence based medicine: patient centeredness, effectiveness, efficiency, safety, timeliness, and equitability.²

The emphasis on initiating and addressing medication counseling is particularly important because only 20% to 30% of chronic disease medications are refilled by patients with diabetes and other chronic diseases.³Pharmaceutical counseling should be considered for patients with diabetes who present to the convenient care setting with any complaint. Medication counseling in this model of care delivery will allow for collaboration between the patient, family, and other health care professionals. This team approach has been shown to be an effective method of improving medication regimen efficacy and adherence.⁴The convenient care setting is a pivotal framework for implementation of such care, as children present with a myriad of complaints that are often unrelated to their diabetes and medication regimen.

In a recent study, 100 patients who were on a regimen of 4 or more medications and who had a diagnosis of uncontrolled diabetes (A1C >7.5) were selected for collaborative diabetes medication counseling and management. The A1C levels of the patients were measured at the beginning and end of the intervention period. At the onset of project implementation, patients on the polypharmaceutical regimen were seen by a nurse practitioner (NP) who reviewed the patient’s medication regimen in depth. The patients were then referred to a pharmacist to answer any patient questions. Each medication was reviewed and determinations were made regarding the best time of day to take medications and whether combination drugs might be available to replace multiple prescriptions. Cost was also reviewed, and the best options were considered. Patients at high risk for medication errors and nonadherence were counseled, along with their caregiver, on the importance of medication adherence.⁵

Following the meeting with the pharmacist, the NPs worked with patients and their families to identify areas of medication nonadherence, answering questions on existing prescriptions and emphasizing the importance of the maintenance regimen for diabetes. Six months after implementation of the care plans, follow-up A1Cs were reviewed. The results demonstrated a statistically significant improvement in the A1C levels, which shows that there may be value in advanced practice clinicians, such as NPs, initiating pharmaceutical counseling with patients and their families in the community setting.⁵

With the advent of the school year and flu season soon after, advanced practice clinicians will have ample opportunities to implement drug therapy counseling in conjunction with a multidisciplinary team. Advanced practice clinicians can provide an important foundation in the convenient care setting for medication management for children with diabetes and their families, as collaboration among professionals is pivotal for medication adherence.^6,7

Kristene Diggins is a doctorally prepared nurse practitioner (NP), who has recently completed her MBA. Dr. Diggins works as the manager of professional practice for MinuteClinic, striving to enhance the practice of convenient care for patients and providers. She has worked as a provider in convenient care for 8 years and also teaches as NP adjunct faculty for Kaplan University. Kris enjoys international medical opportunities, as her career goal is to enhance health care access, globally.

References

1) Saletsky RD, Trief PM, Anderson BJ, Rosenbaum P, Weinstock RS. Parenting style, arent-youth conflict, and medication adherence in youth with type 2 diabetes participating in an intensive lifestyle change intervention.Fam Syst Health.2014;32(2):176-185. doi: 10.1037/fsh0000008.

2) Supply chain services professional’s role in achieving the Institute of Medicine’s six aims for improvement. Association for Healthcare Resource & Materials Management website.www.ahrmm.org/ahrmm/news_and_issues/issues_and_initiatives/IOM6/. Published 2015.

3) Odegard PS, Carpinto G, Christensen DB. Medication adherence program: adherence challenges and interventions in type 2 diabetes.J Am Pharm Assoc (2003). 2013;53(3);267-272. doi: 10.1331/JAPhA.2013.12065.

4) Lee JK, Grace KA, Taylor AJ. Effect of a pharmacy care program on medication adherence, persistence, blood pressure, and low-density lipoprotein cholesterol.JAMA. 2006;296(21): 2563-2571.

5) Diggins K. Family nurse practitioner/pharmacist collaborative medication counseling in patients with diabetes.J Nurse Pract.2014;10(9):741-744. doi: 10.1016/j.nurpra.2014.05.011.

6) Fletcher J, Hogg W, Farrell B, et al. Effects of nurse practitioner and pharmacist counseling on inappropriate medication use in family practice.Can Fam Physician.2012;58(8):862-868.

7) McGivney, MS, Meyer, SM, Duncan-Hewitt, W, Hall, DL, Good, JV, Smith, RB. Medication therapy management: its relationship to patient counseling, disease management, and pharmaceutical care.J Am Pharm Assoc (2003).2007;47(5):620-628.