Reaching out in Richmond

Virginia’s Daily Planet and CrossOver use Project IMPACT to bring diabetes care to the less fortunate

All patients with diabetes face challenges: maintaining a healthy diet, adhering to prescribed medications, monitoring blood glucose levels, and other clinical measurements. Patients who have to deal with these challenges in addition to homelessness, poverty, or other severe socioeconomic barriers are at serious risk for health complications.

In Richmond, VA, pharmacists and other health professionals work to care for these vulnerable patients at the Daily Planet, a federally qualified health center that opened in 1969 and now sees about 6,000 unique patients a year, and CrossOver Health Care Ministry, a three-location free clinic that is the largest in the state and serves nearly 6,000 patients annually.

To help bring the best possible care to their vulnerable patients, both the Daily Planet and CrossOver participate in the APhA Foundation’s Project IMPACT: Diabetes program. The sites share a common mission and location, and their Community Champions—the Daily Planet’s Jean-Venable “Kelly” Goode, PharmD, BCPS, FAPhA, FCPP, and CrossOver’s Sallie Mayer, PharmD, MBA, BCPS, CDE—are also both colleagues on the Virginia Commonwealth University (VCU) School of Pharmacy faculty. Goode also serves on the APhA Board of Trustees.

While the Daily Planet and CrossOver provide patient care differently, Goode and Mayer, as well as their colleagues, use the Project IMPACT model to offer care to some of the highest-risk patients with diabetes in the country.

Daily Planet: Empowering the underserved

Because the Daily Planet is a federally qualified health center, it receives funds from the government to provide a wide range of services. “We offer comprehensive services,” Goode explained, which means aside from primary care, behavioral health, optometry, and oral health, the Daily Planet provides “case management, job placement, laundry and shower services, and a post office.”

In all their interactions with patients, the Daily Planet staff focuses on empowerment, Goode said. Offering services to help homeless patients live independently is part of that, as is their unique spin on Project IMPACT. Goode and Lisa Price-Stevens, MD, MPH, FACP, the Daily Planet’s Medical Director and primary care physician, see patients at the same time, directly collaborating on the care they provide.

“It’s a partnership between the two of us and the patient, so we’re working to empower the patient for the care that they’re receiving,” Goode said. “The care is about self-management.” Price-Stevens agreed, telling Pharmacy Today, “If I had to rename the project, I would call it ‘Diabetes Empowerment.’”

“When we change therapies or medications, we work with the patients,” Goode continued. “[Price-Stevens] and I figure out what works best, and we say to the patient, ‘This is what we think; what do you think? Are you willing to increase your dose? Are you willing to titrate your dose?’” Price-Stevens noted that this patient empowerment and sharing in decision making helped increase adherence and compliance.

To kick off Project IMPACT for the approximately 80 patients enrolled in the program, the Daily Planet set up a dedicated ‘diabetes day.’ The day was centered around lunch with a dietitian and a nutrition class; patients were scheduled for either morning and afternoon patient care sessions with Price-Stevens and Goode. Combining these encounters in a single day helped the Daily Planet streamline the start of its Project IMPACT program.

In the months since the start of Project IMPACT, Daily Planet patients have “dropped numbers across the board,” Goode told Today. “Patients love it.” She noted that patients have access to care much more frequently since the program started, with some patients coming in for visits every week. “For our patients to have access to these services [helps them] to feel loved and empowered,” Goode said.

Goode shared one success story about a woman who had just recently called the Daily Planet’s medical assistant to tell her about her most recent blood glucose reading. “She just had to tell somebody that she finally had a blood glucose at 120 [mg/dL],” Goode said. “She’d never had one that low before!”

CrossOver: Diverse patients at risk

When Mayer and her CrossOver colleagues started enrolling patients in Project IMPACT, they realized that they faced a welcome problem: their enrollment goal wasn’t anywhere near the number of patients interested in the program. More than 100 patients at CrossOver and its partners, Fan Free Clinic and Goochland Free Clinic, are engaged in Project IMPACT, quite a few more than the initial target of 60. “Even if we’re not going to include them in the IMPACT dataset,” Mayer said, “we’ve kept enrolling patients. This project enabled us to initiate much-needed services that patients and providers find valuable.”

A unique challenge for CrossOver is the diversity of patients it serves. The clinic operates multiple sites, each with a different mixture of patients. For example, Mayer explained, the main CrossOver clinic is located in inner-city Richmond and serves a large Spanish-speaking population, about a third of all its patients. At a more rural site located in Goochland, VA, about a half-hour outside of Richmond, however, the clinic caters to a less transient population, including several older patients who have used the clinic for many years.

For all the diverse CrossOver patients, Mayer said, Project IMPACT has been very effective so far. “Our patients in the free clinic have extreme socioeconomic barriers,” she told Today. “We’re spending a lot of time … really finding out about our patients’ history of diabetes, finding out what’s worked for them in the past, and helping them come up with new solutions to improve their quality of life.”

CrossOver has been able to incorporate collaborative practice agreements at all of its sites, allowing Mayer and her colleagues to make a real difference in their patients’ medication regimens. “When we see patients, we’re actually doing a lot of intensification of medication therapy: starting people on insulin, starting people on ACE inhibitors,” she explained. “We’re doing a whole lot of medication [and immunization] interventions as well as educational interventions.”

To help document these interventions, Mayer’s ambulatory care resident Tonya Maywer, PharmD, and the CrossOver staff developed their own SOAP note, since the sites weren’t equipped with electronic medical records. “It enables us to collect the information that we need for the project and also document our educational interventions and medication interventions more clearly, [as well as] our time with patients.”

CrossOver, like the Daily Planet, owes a lot of its success to a close working relationship between a pharmacist and a physician. Patients newly diagnosed with diabetes are automatically referred to the clinic by Michael Murchie, MD, CrossOver’s Associate Medical Director.

“We’ve had our biggest successes with those patients we’ve seen right when they get out of the hospital … where we’ve been able to sit down with them and spend an hour or two and teach them, and determine an individual plan for upcoming visits,” Mayer said. “[Murchie] has been a big proponent for us in the community. I think it’s one reason we’ve been able to be so successful.”

Next steps

For CrossOver, the future of the Project IMPACT model will rely on the clinic’s ability to find the resources to continue. As a free clinic that receives no federal funding and accepts no public or private insurance, CrossOver deals with this challenge often.

Mayer noted that she and her colleagues have already started thinking of ways to overcome this barrier, however. For instance, community pharmacists often volunteer their time at CrossOver and are usually assigned to staff the onsite pharmacy. “What we found is that a lot of the community pharmacists want to do more with patients,” Mayer said. “We are beginning to train pharmacists to do more clinical diabetes interventions … and volunteer in our free clinics.” Through Project IMPACT, she added, two volunteer pharmacists have received their diabetes certification through the VCU School of Pharmacy, and one has already started working at the clinic.

Project IMPACT helped Goode and her Daily Planet colleagues realize that behavioral therapy plays a significant role in dealing with homeless patients with diabetes. As a result, they’ve brought a part-time psychiatrist and a behavioral health therapist on board specifically for the Daily Planet’s medical clinic patients. Project IMPACT helped bring this about “because we’re with these patients so much that we’re able to see them beyond just normal follow-up care,” Goode explained.

These future plans both reinforce an observation Price-Stevens made about working with at-risk patients. “I use the old proverb that it takes a village to care for a Daily Planet patient,” she told Today. “It’s for our benefit and it’s for the patient’s benefit to have a team effort.”


APhA Foundation making an IMPACT

Project IMPACT (Improving America’s Communities Together): Diabetes is a national initiative of the APhA Foundation that aims to improve care for patients with diabetes through community-based interdisciplinary teams that include pharmacists.

This project scales previous Foundation initiatives such as the Asheville Project, Patient Self-Management Program for Diabetes, and the Diabetes Ten City Challenge into 25 communities across the United States. As part of the program, the Foundation provides communities with tools, resources, guidance, and support to facilitate their success.

Pharmacy Today will profile these Project IMPACT communities over the coming months, bringing you stories of innovative and unique diabetes care programs from coast to coast. Read next month’s issue to find out about the program’s implementation at schools and colleges of pharmacy.

For more information about Project IMPACT: Diabetes, visit the APhA Foundation’s website at www.aphafoundation.org.