Program Description

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.