It’s noon at Plaza Pharmacy and Wellness Center in Gainesville, Texas. In walks a woman in her late twenties who recently learned she has diabetes. She hurries past the aisles filled with pills and bandages and enters a conference room where 10 other patients are seated. The owner of the pharmacy, who is a Certified Diabetes Educator (CDE), is getting ready to start a group counseling session.
Similar scenes are playing out daily in some surprising venues, including independent pharmacies, pharmacy chain retail clinics, supermarket pharmacies, dieticians’ private practices, and urgent care clinics. These care centers are staffed by nurse practitioners (NPs), physician assistants (PAs), pharmacists, dietitians, and nutritionists trained to help patients manage a slew of chronic conditions, including diabetes, asthma, hypertension, and heart disease.
On August 26, the United States Preventive Services Task Force (USPSTF) issued a final recommendation that adults who are overweight or obese, and who also have at least one risk factor for heart disease, be offered or referred to behavioral counseling interventions. These interventions promote a healthy diet and physical activity to help prevent heart disease.
For adults who are overweight or obese and who have high blood pressure, high cholesterol, or high blood sugar, evidence shows that intensive behavioral interventions can help reduce their risk of cardiovascular disease, according to the USPSTF.
Getting Ready for the Baby Boomers
You could say that Jerry Meece, R.Ph., CDE, the owner of Plaza Pharmacy and Wellness Center, was clairvoyant when he decided to expand his pharmacy services to include counseling for patients with chronic diseases.
Meece told Healthline, “Twenty years ago, I knew it was going to be the wave of the future. The baby boomers were getting older. I read that chronic disease was going to be a much bigger issue and certainly it has become that way. About 40 percent of adults are going to have diabetes in their lifetime. Two-thirds of our country is overweight. Chronic disease is what’s taking place and that’s what the driver is in pharmacy today.”
These days, Meece’s chronic care program includes one-on-one counseling and group counseling on diabetes, asthma, hormone replacement therapy, and cardiovascular disease. Meece said that many chronic diseases are interrelated.
“If you are treating diabetes, you are still counseling about cardiovascular disease because diabetes is a cardiovascular disease," Meece said. "You can’t really say, this is a dyslipidemia patient, a hypertensive patient, or a person with diabetes. If you are overweight and have hypertension, I almost guarantee you have dyslipidemia. If you have dyslipidemia and are overweight, I can almost guarantee you are hypertensive and you very possibly have diabetes.”
Many of the chronic care patients Meece serves are taking multiple medications. “Patients are taking 8 to 14 drugs a month. About 60 to 70 percent of patients who come into our pharmacy are on some kind of chronic care medicine. The majority of them are on multiple medications for multiple diseases,” said Meece.
Teaching Patients How to Cope
One of the key pieces of Meece’s diabetes education program, which is accredited by the American Academy of Diabetes Educators, is helping patients learn how to overcome obstacles in managing their disease. Meece does the majority of the diabetes education, and a nurse and a dietician are also part of the program.
“Sometimes patients are really completely out of control with their diabetes. Their A1C should be around 7 [percent]. We see people with 10, 12, and 14 percent A1C, which is a very high level, and it means they are on the fast track to blindness, kidney failure, and possibly amputations," Meece said. "We help them understand through motivational interviewing to recognize what they really want to do, what their barriers are, and how we help them get past these barriers."
Making a daily commitment to exercise is crucial in managing many chronic diseases, especially diabetes, but patients often find it is easier said than done.
“Seventy-five percent of all chronic care is identical. You have to do the same thing day in and day out to manage your disease. If you mention and we agree that one of your goals is to exercise five days a week for ten minutes, I may ask, 'What may stand in the way?' If you say, ‘I live in a section of town that is not conductive to exercise,’ I can tell you that you have to think of another way. For example, you can go to the track with a friend,” Meece said.
Jerry Meece (center) with Kathie Robinson, MS, RD, LD, CDE (left) and Joan Walterscheid, RN, CDE. Meece, Robinson, and Walterscheid work together on diabetes counseling.
Receiving support from other patients in a group meeting can be especially helpful for keeping diabetes patients on the right path.
“In the group sessions we are all talking about diabetes. If one person says, ‘I can’t exercise because my knees hurt,’ if you are facilitating and doing the right thing, another person offers the suggestion, ‘I go to the Y and swim. I’ll take you with me.’ They are helping solve problems for the whole group," Meece said.
Patients who have asthma can easily end up in an emergency room if they don’t monitor and manage their condition. Meece said, “It’s a no brainer to see what an asthmatic patient needs. They have a set group of inhalers and a peak flow meter. If we can teach them how to use it effectively we can save [the healthcare system] millions of dollars.”
Meece coordinates his care of asthma patients with their physicians. In this role, he instructs patients in how to use a peak flow meter, a preventive inhaler, and a rescue inhaler.
“Most people with asthma need two kinds of medicine: a chronic use preventive medicine and a rescue inhaler. If the patient is instructed right, they are using their peak flow meter early in the day and it almost predicts what their day is going to be like. Being able to understand that keeps the ER admissions and hospitalizations down, because it’s a predictor of your lung function before you realize what your lung function is getting ready to undergo. It’s checking to see how your airway is moving air back and forth,” said Meece.
Make no mistake. Patients who avail themselves of chronic care counseling may not be able to manage their condition after just a few sessions. “It’s hardly ever three sessions and out because we can talk about what fits your lifestyle today, but chronic disease changes from person to person and it changes in the same person from day to day," Meece said.
Convincing patients that staying ahead of their chronic disease is one of the most important things they can do is key, explained Meece, who described pharmacists like himself as “filling in for what the doctor doesn't have time to do.”
“Chronic care management is talking to a person who has a chronic disease, like diabetes, a condition that is 24/7, 365 days, and telling them that if you do everything right for 25 years nothing will happen to them; you don’t end up in the ER, you don’t go blind, and you don’t lose your feet,” said Meece.
Clinics, Clinics, Everywhere
In-store clinics have been exploding in pharmacy chains nationwide over the past several years. But now these clinics have expanded into chronic care management.
CVS/pharmacy was early to the in-store clinic boom. In July 2006, CVS acquired MinuteClinic. Today, there are more than 850 MinuteClinics in 29 states and the District of Columbia. This year, the chain expects to add 150 clinics. There will be a total of 1,500 clinics by the end of 2017.
In addition to MinuteClinic’s usual scope of services, such as treating sore throats, administering flu shots, and caring for patients with acute problems, over the past couple of years, MinuteClinic has expanded to add monitoring and screening services to one-on-one visits. MinuteClinic now offers chronic disease monitoring, which includes point of care testing and patient coaching for type 2 diabetes, high cholesterol, and high blood pressure.
The clinics, which are located inside CVS pharmacies, are staffed by NPs and PAs.
A CVS/Pharmacy MinuteClinic.
Angela Patterson, MinuteClinic’s chief Nurse Practitioner Officer, who oversees the organization’s 2,500 PAs and NPs, told Healthline that the growth of MinuteClinic was fueled by a need for more accessible, convenient, quality healthcare options as a result of the following factors:
- a national primary care provider (PCP) shortage
- an increased number of patients who are obtaining health insurance through the Affordable Care Act
- a nationwide epidemic of obesity and related conditions, such as high blood pressure and diabetes
- the aging baby boomer population
“All of these factors are putting an incredible amount of pressure on our country’s PCP workforce,” said Patterson.
MinuteClinic also connects with patients' other doctors to ensure continuity of care. “The results of screening tests and visits are sent to the patient’s PCP with the patient’s permission, so there is integration, or a collaboration, that happens in communities," Patterson said. "We consider ourselves a safety net for the work of our primary care colleagues.”
MinuteClinic also helps patients find a PCP if they don’t have one. “Each clinic develops and maintains a local resource list of area PCPs who are accepting new patients, and we review that with patients and help them plug back in so they are connected with regular care,” Patterson said.
A CVS/Pharmacy MinuteClinic.
Convenience is a huge factor in the success of these clinics. MinuteClinic operates seven days a week and no appointment is necessary. Fifty percent of patients visit on evenings, weekends, and holidays, according to Patterson.
MinuteClinic’s chronic care support is also closely tied to wellness initiatives, such as smoking cessation and weight management services.
“It’s not uncommon for someone with high blood pressure or diabetes to have other conditions, such as dependence on tobacco, struggling with weight problems, and issues with cholesterol. We are definitely focused on helping to provide patients education, and coaching how best to care for these conditions and enhance their own self-management decision-making,” said Patterson.
Patterson said screening and monitoring services for blood sugar levels, as well as comprehensive foot exams, are available for diabetes patients.
Like Meece, MinuteClinic providers believe that supporting patients is crucial. “Our providers have gone through motivational interviewing training to help enhance engagement with patients and help support the conversations," Patterson said.
Shopping for Care in Supermarket Pharmacies
Supermarket pharmacies are also taking the lead when it comes to helping chronic care patients.
Take the case of Schnucks. Founded in north St. Louis in 1939, Schnucks has grown to include 98 stores in Missouri, Illinois, Indiana, Wisconsin, and Iowa. The supermarket chain has 94 in-store pharmacies.
In 2008, Schnucks launched a specialty pharmacy division to help patients living with chronic conditions. Schnucks Specialty Pharmacy consists of five locations in Missouri and Illinois that focus on chronic conditions, including HIV, hepatitis, multiple sclerosis, rheumatoid conditions, transplants, fertility, and other high maintenance, high cost conditions.
Dave Chism, R.Ph., director of pharmacy services at Schnucks, told Healthline, “Pharmacists working at the specialty pharmacies possess an advanced knowledge base of the conditions and medications used to treat these conditions. Several of our specialty pharmacies and pharmacists have collaborative relationships operating inside hospitals, clinics, physicians’ offices, or non-profit service providers providing direct clinical support to the medical teams and patients.”
Chism said that the focus is on ensuring patients are receiving education and training on their medications, coordinating and maximizing out-of-pocket assistance, monitoring therapy results, coordinating refills, and providing free home delivery. “It is really a concierge pharmacy program that coordinates everything so the patient can focus on themselves and their overall health,” he said.
Schnucks recently took its chronic care offerings one step further by offering outpatient infusion services to those in need of intravenous medications.
Schnucks Infusion Solutions is a full-service home infusion pharmacy that focuses on all self-administered infusion therapies, including for multiple sclerosis, rheumatoid arthritis, and cancer.
The Dietitian Will See You Now
Dietitians are also stepping up to the plate, offering counseling for chronic care patients.
Anita Mirchandani, M.S, R.D, C.D.N, spokesperson for the New York State Dietetic Association, has a private practice in New York City where she provides one-on-one counseling to chronic care patients.
“Chronic care requires constant communication and monitoring, especially for diabetes and cardiovascular disease, or indicators such as high cholesterol, high blood pressure, and high triglycerides, said Mirchandani.
Mirchandani‘s interventions include a consistent review of patients’ food intake and their physical activity.
“It's important to monitor food intake in relationship to medication dose so there is no stress or strain on the body related to being in the chronic care disease state. I also look out for food/medication interactions, ensuring that the body is responding well to pharmacological treatments. The benefit of medical nutrition therapy in such situations is prevention of disease progression. By having a dietitian accountable for intake and activity, there's a consistent focus on improving the patient’s health,” Mirchandani said.
Mirchandani usually sees patients once a week between 10 am and 7 pm on weekdays. If there is an urgent request, she adjusts her schedule. She also offers assistance via text messages to help patients make better real-time decisions. What should they eat at a restaurant? How should they modify a recipe? In addition, she offers a post-session recap to help patients focus on short-term goals.
Peering into the Crystal Ball
Will the need for chronic care services continue to grow? Patterson thinks so. “There are a number of variables going on that are identifying folks with these conditions, folks who really need attention right now. It’s a strong trend that will continue for years to come; there’s the baby boomer population, the increased incidence of these conditions, and certainly the PCP shortage,” she said.
These trends are pushing formerly acute care centers to expand their scope. For example, while most urgent care clinics specialize in treatment for minor emergencies, these clinics are also marching into chronic care territory.
According to a recent article in Forbes, American Family Care (AFC), the largest independent chain in the country with 128 clinics, says that about 20 percent of its business now comes from chronic care management for people who either can’t wait to see their doctors or don’t have one at all. Seventy-five percent of AFC’s clients are repeat visitors.
Meece predicts that the trend to provide chronic care management will continue, and providers who enter the chronic care arena will need a higher level of interviewing skills and more training.
“You can’t just tell patients what to do and expect them to go off and do it. They need support and a follow-up mechanism," Meece said. "We know that just providing information to chronic care patients is not enough. You have to help them develop coping skills, work through survival skills, and help them to answer their own questions about managing their own disease."