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case study Preventive care program

1513Am J Health-Syst Pharm—Vol 69 Sep 1, 2012

c a s e s t u d y

Design and implementation of a pharmacist-directed preventive care program

Bethany L. Murphy, MichaeL J. rush, and Karen L. Kier

Bethany L. Murphy, pharM.D., is Assistant Professor of Pharmacy Practice, Union University, Jackson, TN; at the time research was conducted she was Pharmacy Practice Resident, Ohio Northern University (ONU) HealthWise, Raabe College of Pharmacy, ONU, Ada. MichaeL J. rush, pharM.D., cDe, BCACP, is Director, ONU HealthWise; and Karen L. Kier, M.sc., ph.D., Bcps, BCACP, is Professor of Clinical Pharmacy and Director of Assessment, Raabe College of Pharmacy, ONU.

Address correspondence to Dr. Rush at the Raabe College of Phar- macy, 205B, Ohio Northern University, 525 South Main Street, Ada, OH 45810 ([email protected]).

The authors have declared no potential conflicts of interest.

Copyright © 2012, American Society of Health-System Pharma- cists, Inc. All rights reserved. 1079-2082/12/0901-1513$06.00.

DOI 10.2146/ajhp110384

Though pharmacists currently have well-established roles in both acute and chronic care

settings through activities such as medication monitoring, disease management, and medication ther- apy management (MTM), the role of the pharmacist in the preventive care setting is less defined.1,2 While pharmacists may participate in com- ponents of preventive care such as immunizations and disease screen- ings, involvement in comprehensive preventive care programs has been limited. Many organizations, both outside and within the profession of pharmacy, recognize that pharma- cists can have an important effect on public health through programs ad- dressing topics such as health screen- ings, health education, and disease prevention.3-5 This article describes an effort to reduce health care costs by improving health and wellness of individuals by implementing a dis- ease state clinic and MTM clinic at a small rural university.

Background Ohio Northern University (ONU)

is a small, rural, private university

Purpose. The design and implementa- tion of pharmacist-directed preventive care services within a university-based, employee health and wellness clinic are described. Summary. Ohio Northern University (ONU) HealthWise is a multidisciplinary employee health and wellness clinic located on the campus of ONU that offers medication therapy management, disease manage- ment, nutrition counseling, and physical wellness coaching services. A pharmacist- directed preventive care program based on recommendations from the U.S. Preventive Services Task Force (USPSTF) was designed for incorporation into the clinic. Using an electronic search tool provided by USPSTF, pharmacists are able to provide a review of recommended preventive services that are appropriate for each individual patient. Whenever possible, pharmacists within the clinic perform the screenings and other in- terventions that are recommended by USP-

STF; when necessary, patients are referred to other health care providers to receive recommended interventions. To date, nine patients have participated in the preventive care program. For these nine patients 112 recommendations have been reviewed by pharmacists in the clinic. Of these, 16 were found to be inappropriate after further dis- cussion with the patients and 36 were veri- fied as already completed by the patient, resulting in a total of 60 unmet recommen- dations. Of these 60, 52 recommendations were met through interventions by the pharmacist in the clinic, while 5 possible screenings were declined by patients and 3 unmet recommendations required referral to a provider outside of the clinic. Conclusion. A pharmacist-directed preven- tive care service offered within an employee health clinic helped ensure that employees receive appropriate screenings and preven- tive care according to current guidelines. Am J Health-Syst Pharm. 2012; 69:1513-8

of approximately 3500 students that employs approximately 675 fac- ulty and staff. The university is a self-insured employer, with over 900 covered lives, including retirees and employees of ONU, as well as their dependents.

The university-funded ONU HealthWise clinic consists of an interdisciplinary team of four phar- macists, one nurse, two exercise physiologists, and a nutrition coach. Historically, the clinic has provided pharmacist-led disease management

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and MTM services for employees and retirees who are members of the university’s health insurance plan. Disease management services for patients with hypertension, diabetes mellitus, and hyperlipidemia have been established and include the monitoring of clinical symptoms and laboratory test results, patient education, and the provision of ther- apeutic recommendations to the pa- tient’s primary provider. A tobacco- cessation clinic was also created to provide education and to assist pa- tients dependent on tobacco.

MTM services for patients tak- ing multiple medications are of- fered during disease management appointments and are also provided on request for employees or retirees not participating in disease manage- ment services. In addition, exercise and nutrition coaching are provided to these patients by other health care professionals on the team. Participa- tion in the ONU HealthWise clinic is voluntary and free of charge to employees, retirees, and dependents, with patients being recruited via ad- vertisements highlighting the various services offered.

Problem Though the traditional ONU

HealthWise clinic has had great suc- cess in assisting patients with the management of chronic diseases, it was recognized that only a select portion of the university population, those with the specific chronic dis- eases listed, would benefit from the services offered.6

Analysis and resolution In order to better assist the entire

patient population served by the ONU HealthWise clinic, the decision was made to incorporate a preventive care program into the clinic, provid- ing assistance to healthier members who may not qualify for the disease management and MTM services. By focusing on optimizing treatment for patients with chronic diseases as well

as preventing disease in healthy indi- viduals, the ONU HealthWise clinic is expected to further improve employee health status and achieve additional cost savings for the university.

Preventive tool. The preventive care program was developed based on guidelines from the U.S. Preven- tive Services Task Force (USPSTF), a panel of experts formed by the Agency for Healthcare Research and Quality that reviews evidence and provides recommendations regard- ing various preventive services. These services are assigned a grade based on the evidence available.7 Evidence rat- ings of A and B represent preventive services that should always be offered to patients for whom the service is indicated. An evidence rating of C represents a service that could be considered in certain individuals, a rating of D indicates that the service should be discouraged in patients, and a rating of I indicates that there is uncertainty regarding the balance of risks and benefits for the recom- mendation.8 The USPSTF then makes recommendations about how these services should be put into practice based on the level of evi- dence. In addition, because USPSTF refers to guidelines from the Centers for Disease Control and Prevention (CDC) regarding adult immuniza- tions, vaccination schedules pro- vided by CDC are used to ensure that patients are current with the recom- mended immunizations.9

During the development of the preventive care program, any recom- mendation with an evidence rating of A or B was chosen for inclusion in the list of possible recommenda- tions to be made to patients, with the exception of those regarding sexually transmitted diseases, which were not included due to the sensitivity of the relationship between the employee and the self-insured employer. Al- though several of the recommended screenings may require referral to another health care professional for completion, the majority of screen-

ings are conducted by the pharmacist at the clinic.

USPSTF provides an online search tool that allows health care profes- sionals to search for patient-specific recommendations for screening, education, and preventive medi- cine using basic information about patients, such as age, sex, sexual activity status, pregnancy status, and tobacco-use status.10 This tool was chosen for use in the ONU HealthWise clinic in order to ac- quire a list of the most appropriate, evidence-based recommendations for discussion with each patient. In addition to providing individualized recommendations for patients, the search tool provides the rationale for the suggested interventions, as well as information for both the health care provider and the patient regarding the specific screening itself.

When developing the preven- tive care program, it was recognized that the services recommended by the USPSTF guidelines could be addressed in one of several ways, in- cluding through (1) objective screen- ing, (2) a screening questionnaire, (3) patient education, (4) verification by the pharmacist, and (5) referral to an outside health care professional. Each recommendation included in the program was placed into one of these categories.

Preventive recommendations. Monitoring tools. The first category of preventive care recommendations includes those that can be addressed by the pharmacist using monitor- ing tools that provide objective re- sults.11-14 For example, in the ONU HealthWise clinic, blood pressure can be measured quickly using blood pressure cuffs and stethoscopes or automated blood pressure cuffs, screening for obesity can be per- formed by weighing and measuring the patient to calculate a body mass index, and point-of-care testing machines can be used to screen for lipid disorders and diabetes mellitus.

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1515Am J Health-Syst Pharm—Vol 69 Sep 1, 2012

These point-of-care tools require little training and often can provide rapid results in the clinic. In addition, bone densitometry machines that use ultrasound waves to screen for osteo- porosis are available and helpful in allowing the pharmacist to identify women who may require more in- depth screening.15 As results from these objective measurements for hypertension, obesity, lipid disorders, diabetes mellitus, and osteoporosis are obtained, pharmacists can use them to make decisions regarding the patient’s need for further inter- ventions and follow up to address any issues that may be found during screening.

Screening questionnaire. The sec- ond category of preventive care rec- ommendations includes those that can be assessed by the pharmacist through a screening questionnaire. For example, the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire-2 is recommended by USPSTF for use in depression screening.16 Likewise, the CAGE (Cutting down, Annoyance by criticism, Guilty feeling, Eye- openers) questionnaire is a simple, four-question test that can assist with screening for alcohol abuse.17 Within the ONU HealthWise clinic, any problems found through the use of these questionnaires result in immediate referral of the patient to another health care provider for further assistance and support. Similarly, there are simple work sheets available to calculate the Framingham 10-year risk score for men and the 10-year stroke score for women based on patient data, which USPSTF recommends for screen- ing for appropriate aspirin use for the primary prevention of cardio- vascular disease in each patient.18 After calculating the risk score, the pharmacist can appropriately re- fer to materials from the USPSTF guidelines, indicating levels at which aspirin use is or is not of greater benefit than risk.19

Another preventive recommenda- tion involves screening for the use of folic acid in women of childbearing age. Women for whom folic acid supplementation is recommended are asked whether they take a mul- tivitamin that includes 400–800 mg of folic acid or another form of folic acid supplement. If the answer is yes, this recommendation is considered met. If the pharmacist identifies an individual who is not receiving ap- propriate supplementation, the phar- macist provides information about the rationale and importance of this recommendation, encouraging the patient to begin the appropriate use of folic acid.20

Patient education. Another catego- ry of possible preventive recommen- dations includes those that require the pharmacist to provide education by discussing their recommenda- tions with the patient. These include making recommendations from the USPSTF guidelines regarding the importance of breast-feeding after pregnancy,21 a healthy diet in the gen- eral population,22 and tobacco cessa- tion.23 During a preventive care ap- pointment, the pharmacist provides this education orally to the patient and with an informational handout. If needed, patients are referred to additional programs. For example, within the ONU HealthWise clinic, all patients for whom diet counseling is recommended are provided with the opportunity to speak one-on-one with a nutrition coach. Likewise, pa- tients interested in tobacco cessation are referred to this service within the ONU HealthWise clinic.

Additional screenings. The last category of preventive recommenda- tions includes those screenings that must be conducted by a health care provider outside of the ONU Health- Wise clinic. With these screenings, it is still important that the pharmacist verify the patient’s medical history. For example, with screenings for breast cancer, colorectal cancer, and cervical cancer, the pharmacist asks

the patient when the screening was last performed.24-26 Since screening for an abdominal aortic aneurysm is normally performed only once, patients for whom this screening is recommended are asked if it has ever been performed.27 If the patient is currently in compliance with the recommended screening interval, no further discussion is required, and the patient is encouraged to continue following the screening recommenda- tions. If the patient has never received the particular screening or is due to be rescreened, the pharmacist discusses the importance of that screening with the patient and refers him or her to the necessary health care provider to receive the screening. The patient is provided with a list of the screenings that need outside follow-up, and this list is faxed to the patient’s primary health care provider.

Several preventive services that have an evidence rating of A or B apply only to specific subsets of the population and therefore require further information from the patient before the service is recommended. The recommendations for BRCA mutation testing for breast and ovar- ian cancer28 and chemoprevention of breast cancer29 fall into this cat- egory. For these services, additional assessment of the patient’s risk and family history allows the pharmacist to identify whether testing or chemo- prevention is necessary. Pharmacists ask the necessary questions as rec- ommended by USPSTF guidelines and then advise the patient regarding follow-up with a physician for testing or treatment.

In addition to reviewing appro- priate recommendations from the USPSTF guidelines, patients occa- sionally may have questions regard- ing recommendations for various screenings that may have been sug- gested by others. In these instances, the pharmacist involved in the ap- pointment can review the level of evidence of those recommendations with the patient and provide infor-

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mation about why the screening may or may not be appropriate.

Development of a provider man- ual. In order to ensure a standardized process when making preventive rec- ommendations, a provider manual was developed. This manual details the exact steps to take regarding each recommendation, including any ad- ditional questions that should be asked and any specific information that should be provided to the pa- tient. Educational handouts for each recommendation are also included in the manual for easy access. This man- ual ensures that all clinic pharmacists have the appropriate tools and follow the appropriate steps when conduct- ing these appointments.

Figure 1 is an example of a visit note prepared by a pharmacist dur- ing an individual appointment in the ONU HealthWise clinic. All records of the preventive care appointment are maintained in a patient chart that includes visit notes from other por- tions of the ONU HealthWise clinic.

Follow-up. Six months after the initial preventive care appointment with the pharmacist, a patient with re- ferrals to outside health care providers are contacted to verify that the patient has made progress toward meeting the recommendation. If not, additional encouragement and education are provided to patients at this time. Since the USPSTF guidelines are updated and changed periodically as evidence changes, it is important that preventive care appointments not be considered a one-time occurrence. Yearly appoint- ments may be appropriate to address screenings that should be completed annually, discuss updates to the guide- lines, and perform new screenings for the patient based on age.

Initial outcomes. To date, nine patients have participated in the preventive care program. For these nine patients, 112 recommendations have been reviewed by pharmacists in the ONU HealthWise preventive care program. Of these 112 potential recommendations, 16 were found

to be inappropriate after further discussion with the patients and 36 were verified as already completed by the patient, resulting in a total of 60 unmet recommendations. Of these 60, 52 recommendations were met through interventions by the phar- macist in the clinic, while 5 possible screenings were declined by patients. Three unmet recommendations re- quired referral to a provider outside of the ONU HealthWise clinic. From the 52 screenings performed within the clinic, nine possible new health issues were identified, including one case of possible undiagnosed depres- sion, one unmet recommendation for aspirin use, one unmet recom- mendation for folic acid supple- mentation, and six cases of obesity. An additional 4 screenings that had been suggested to patients from an outside source were discussed and advised against, based on the level of evidence from the USPSTF guide- lines. Due to the success of the first 9 patients, preventive health screening has been incorporated into the rou- tine practice of the clinic.

Discussion The HealthWise preventive servic-

es program represents an opportu- nity for pharmacists to fulfill an im- portant role in patient care. Although many other health care practitioners are capable of addressing preventive care recommendations, pharmacists are readily accessible to patients and already participate in many patient care activities into which preventive services could easily be incorporated. This case study highlights one setting in which pharmacists can provide such services, though similar pro- grams could easily be designed for incorporation into other settings. For example, in the community phar- macy setting, this program could be modified to provide a review of the USPSTF recommendations for an in- dividual, with referral to other health care providers for all required inter- ventions. Such reviews can provide

a benefit in encouraging preventive care and require very few resources.

In a future evaluation of the pre- ventive care program in the ONU HealthWise clinic, a determination of specific cost savings will be benefi- cial in determining the exact worth of pharmacist involvement in this area. Because it is often difficult to determine the cost savings associated with disease prevention, especially in the short-term, literature dealing with the cost of disease can provide an estimation of the potential ben- efit of prevention. For example, the high initial direct costs of treatment associated with myocardial infarc- tion plus subsequent coronary ar- tery bypass graft surgery (estimated at $30,000 per patient in 2002)30 and ischemic stroke (estimated at $15,000–$20,000 per patient in 1990)31 indicate that the appropri- ate use of aspirin recommended through the clinic has the potential to decrease health care spending for both the participant and the insurer by assisting with the prevention of these costly complications. Because of the high cost associated with heart disease and many other diseases, proper prevention and education are expected to lead to a reduction in long-term expenditures.

In the future, the program will gather data regarding the rate at which patients choose to receive follow-up from outside providers and the rate at which these providers accept referrals. In addition, patient satisfaction regarding the preventive care portion of the ONU HealthWise clinic will be analyzed through the semiannual survey that is sent to all clinic patients. By continuing to gather these data, a complete assess- ment of the benefits of this program will be made.

Conclusion A pharmacist-directed preven-

tive care service offered within an employee health clinic helped ensure that employees receive appropriate

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1517Am J Health-Syst Pharm—Vol 69 Sep 1, 2012

Figure 1. Example of a visit note prepared by a pharmacist during an individual appointment in the HealthWise clinic. CAGE = Cutting down, Annoyance at criticism, Guilty feeling, Eye-openers, PRIME-MED PHQ-2 = Primary Care Evaluation of Mental Disorders Patient Health Questionnaire-2.

Patient demographic information

Age: 58 years Sex: female Pregnant: no Tobacco use: no Sexually active: yes

Recommendations retrieved from the search tool

1. Alcohol misuse: screening and behavioral counseling—men, women, and pregnant women 2. Aspirin to prevent cardiovascular disease: women age 55–79 years to prevent ischemic strokes 3. Breast cancer antigen mutation testing for breast and ovarian cancer: women, increased risk 4. Breast cancer preventive medication discussion: women, increased risk 5. Breast cancer screening with mammography: women 50–74 years 6. Cervical cancer: screening—women who are sexually active 7. Colorectal cancer: screening—adults, beginning at age 50 years and continuing until age 75 years 8. Depression: screening—adults age 18 years or older—when staff-assisted depression care supports are in place 9. Healthy diet: counseling—adults with hyperlipidemia and other risk factors for cardiovascular disease

10. High blood pressure: screening—adults 18 years or older 11. Lipid disorders in adults: screening—women 45 years or older, increased risk for coronary heart disease 12. Obesity: screening and intensive counseling—obese men and women 13. Osteoporosis: screening—women 65 years or older and younger women at increased risk 14. Type 2 diabetes mellitus: screening men and women—sustained blood pressure 135/80+ mm Hg

Select examples of additional information required for discussion of recommendations

1. Aspirin to prevent cardiovascular disease: information necessary to calculate the patient's Framingham 10-year risk percentage is required 2. Breast cancer antigen mutation testing for breast and ovarian cancer: additional information regarding a family history of breast or ovarian

cancer is required 3. Cervical cancer: information regarding time of last screening, if ever, is required 4. Osteoporosis: additional information regarding risk factors for osteoporosis is required

Recommendations determined to be unnecessary for the patient and rationale

1. Aspirin to prevent cardiovascular disease: not recommended based on patient’s Framingham risk score 2. Breast cancer antigen mutation testing for breast and ovarian cancer: patient not at increased risk based on family history 3. Breast cancer preventive medication discussion: patient not at increased risk based on family history 4. Osteoporosis: patient not over age 65 years and not at increased risk

Recommendations determined to have already been met

1. Cervical cancer: patient was screened nine months prior 2. Colorectal cancer: patient screened with colonoscopy three years prior

Recommendations performed by the pharmacist

1. Alcohol misuse: CAGE questionnaire performed 2. Depression: PRIME-MED PHQ-2 question screen performed 3. Healthy diet: education regarding diet was provided by pharmacist, offer to speak further with nutrition coach was made 4. High blood pressure: screening performed 5. Lipid disorders in adults: screening performed using point-of-care testing 6. Obesity: weight, height, and body mass index obtained 7. Type 2 diabetes mellitus: screening performed using point-of-care testing

Recommendations referred to an outside health care provider

Breast cancer screening with mammography: patient has never been screened

Potential problems found through screening by the pharmacist

Depression: screening test was positive, referred to physician for further diagnosis

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screenings and preventive care ac- cording to current guidelines.

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3. Promoting the pharmacist’s role in public health. J Am Pharm Assoc. 2006; 46:311-2.

4. The role of the pharmacist in public health. Washington, DC: American Pub- lic Health Association; 2006.

5. American Society of Health-System Pharmacists. ASHP statement on the role of health-system pharmacists in public health. Am J Health-Syst Pharm. 2008; 65:462-7.

6. Bright D, Rush M, Kroustos K et al. Pre- liminary results from a university-based disease state management program fo- cused on hypertension, hyperlipidemia, and diabetes. J Am Pharm Assoc. 2011; 51:264-5. Abstract.

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18. National Heart, Lung, and Blood Insti- tute. ATP III guidelines at-a-glance quick desk reference. Washington, DC: U.S. De- partment of Health and Human Services; 2001.

19. U.S. Preventive Services Task Force. As- pirin for the prevention of cardiovascular disease: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2009; 150:396-404.

20. U.S. Preventive Services Task Force. Folic acid for the prevention of neural tube de- fects: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2009; 150:626-31.

21. U.S. Preventive Services Task Force. Primary care interventions to promote

breastfeeding: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2008; 149:560-4.

22. U.S. Preventive Services Task Force. Behavioral counseling in primary care to promote a healthy diet: recommenda- tions and rationale. Am J Prev Med. 2003; 24:93-100.

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