A Collaborative Care Model for Chronic Disease Management in Diabetes - Involvement of Community Pharmacists in Complex Care Plans, a Pilot Study
A Collaborative Care Model for Chronic Disease Management in Diabetes - Involvement of Community Pharmacists in Complex Care Plans, a Pilot Study
This project is an initiative to bring physicians, nurses, community pharmacists and patients together in collaborative planning in the management of diabetes, which aligns with the collaborative, team based aspects of family medicine as a community based discipline. Alberta funds both physicians and community pharmacists to complete a comprehensive assessment and plan for patients with qualifying medical conditions. Our research hypothesis is that a collaborative approach between healthcare providers involved in delivering care will improve individual patient outcomes with the primary outcome being improved glycemic control. Health care utilization and medication adherence will also be assessed. This project will compare the results of comprehensive annual health care plans implemented over a period of twelve months with or without involvement from community pharmacists. It is hypothesized that involvement of community pharmacists and their collaboration with physicians will lead to improved outcomes.
Research question: Does involvement of a community pharmacist in formulating and following a complex care plan for diabetic patients in conjunction with the patient's clinical team (physician and chronic disease management nurse) improve outcomes including glycemic control, health care utilization and medication adherence.
Hypothesis: Collaborative complex care planning for diabetic patients with the primary care physician, chronic disease management nurse and community pharmacist leads to improvement in patient health outcomes, decreases hospital visits and visits to family physician and emergency room and improves medication adherence.
Aim of the study: The aim of this study is to serve as a pilot in exploring if collaborative care provided by physicians, chronic disease nurse and community pharmacists in formulating and following complex care plans leads to better clinical outcomes when compared to care plans that are formulated and followed in isolation by the physician and chronic disease nurse. This study would be the basis for a future in depth project comparing outcomes of care plans completed in isolation by the pharmacists or physicians with those created in a collaborative environment. Our long-term objectives are improvement in patient outcomes, reduction in health care expenditure as well as preventing duplication and potential discordance of comprehensive care plans.
Methodology
Patients and study design: This is a single centre prospective case control pilot study.
A cohort of 25 eligible diabetic patients at the South Health Campus Family Medicine Teaching Clinic (an outpatient academic family medicine clinic in Calgary, Alberta) will be studied and compared against a group of 25 control diabetic patients. The intervention would be involvement of patient's community pharmacist with their clinical team in formulating the complex care plan and following up with the patient on a monthly basis. The control is a set of patients who have complex care plans completed by their clinical team with no coordination with the pharmacist.
Inclusion Criteria:
Exclusion Criteria: