Location
- Located within a Community Health Network physician office based endocrinology clinic on the north side of Indianapolis
- Community endocrinology clinic hours of operation: 7:00 am – 5:00 pm
- Intensive Insulin Clinic hours of operation are consistent with normal clinic hours with fluctuation based on day of the week:
- Monday 7:00 am – 3:30 pm
- Tuesday 8:30 am – 5:00 pm
- Wednesday 7:00 am – 3:30pm
- Community endocrinology clinic already has waiting area, check-in desk, office supplies, general medical testing supplies, some demonstration tools, and available office/consultation room for pilot program use
Staffing Requirements
- One pharmacist working about 8 hour days, Monday through Wednesday (0.61 FTE)
- Will work at primary care physician office other days of week (total 1 FTE)
- Pharmacist:
- Must have completed at least an Ambulatory Care PGY2
- Must be certified as a CDE (Certified Diabetes Educator) or equivalent and BC-ADM (Board Certified-Advanced Diabetes Management) within two years of hire
- Must become pump-trained for various patient pumps available on own time
- Current clerical staff of endocrinology clinic will aid in scheduling initial visits, reminder calls, and administrative tasks
- Pharmacist will be responsible for scheduling all follow-up appointments
- Current Community Health Network Medication Assistance Program team will be utilized based on patient need
Referral Process
- Patients seen at Community Health Network’s endocrinology clinic on the north side of Indianapolis are complex patients referred by their primary care provider
- Endocrinologists at this endocrinology clinic will refer their complex patients to the pilot clinic who utilize or require any of the following:
- U-500 insulin
- Insulin pumps
- Continuous blood glucose monitoring (CBGM)
- To do so, endocrinologists will submit a referral request via the electronic medical record
- Current clerical staff of endocrinology clinic will schedule initial visit once referral is received
Billing Process
- Incident-to physician referral CPT code 99211 (Medicare $18.93 per visit; Private estimate $21.77 per visit)
- CBGM CPT code 95250 (Medicare $159 per monthly visit; Private estimate $302 per monthly visit)
Length of Patient Visits
- Initial and follow-up visits (complex): 60 minutes
- All patients considered complex per clinic referral criteria
- There will be no time allotted between patient visits
- Community’s goal to have charting completed during visit
- Additional four hours of pharmacist project time allotted outside of clinic hours
Pharmacist-Patient Interaction
- Visit frequency will be monthly until adequate control attained
- Initial and follow-up visits may include any of the following:
- Patient will bring their medications and/or devices to be documented and evaluated by pharmacist
- Pharmacist will print and evaluate CBGM results
- Pharmacist will educate on CBGM device and use upon initial placement and as needed at follow-up visits
- Pharmacist will educate on insulin pump device and use
- Pharmacist will alter medication regimen per CDTM
- Pharmacist will educate on disease state, current medication side effects, and additional monitoring
- Pharmacist will check and/or discuss blood glucose results with patient
- Pharmacist will check A1C every 3 months and discuss results with patient
- Pharmacist will educate on lifestyle modifications and considerations specifically related to insulin use and CBGM (diet, exercise)
- Pharmacist to schedule follow-up appointment at end of initial visit
Visit Documentation
- All documentation will be completed and stored on the electronic medical record
- Electronic medical record documentation including progress note will be available to the clinic’s endocrinologists for review 72 hours following completed visit
No-Show and Non-Compliance Plans
- Pharmacist will explain no-show policy at patient’s initial visit
- If patient misses three visits, the clinic will send a letter to discharge the patient, after utilitzing all other means to contact the patient prior to the third missed visit
- If patient is non-compliant to the intensive insulin clinic’s recommended interventions, the pharmacist will explain the risks and repercussions of uncontrolled diabetes
Data to be Measured
- Pilot Intensive Insulin Clinic success will be measured utilizing retrospective data looking at cost avoidance specifically regarding:
- Lowering A1C
- Reduced hospitalizations
- Documented in EMR for each visit
- Daily home blood glucose readings and in-office blood glucose readings
- CBGM recorded data
- Blood pressure
- Changes in A1C reflected against patient’s goal
- Microalbumin/SCr ratio, if values available
- Patient reported ED visits and hospitalizations related to diabetes
- Patient’s vaccination history, as well as last foot and eye exam
- Pharmacist progress note, including any and all recommendations made
CDTM protocol
- An addendum to Community Health Network’s current Collaborative Practice Agreement for the treatment of diabetes must be created specifically addressing insulin, insulin pumps, and continuous blood glucose monitoring protocol in Type 1 and Type 2 Diabetes Mellitus[1]
- Existing physician buy-in at this endocrinology clinic will allow for easy addendum to existing CPA
- Pharmacist will adjust medications, educate on disease state, pump, and CBGM based on current appropriate guidelines and clinical judgement established in the physician-initiated protocol
- If situations arise outside scope of CDTM, the appropriate endocrinologist will be consulted
Reference:
[1] M Dorrell, oral communication, February 14, 2017.