Even as the COVID-19 pandemic has led to innovations in care delivery, it has also highlighted the continued importance of something as basic as strong human relationships. The work of Anne McDonnell, PharmD, MBA, BCOP, CPPS, exemplifies this. McDonnell is an Ambulatory Medication Safety Pharmacist at Brigham and Women's Hospital (BWH) in Boston, Massachusetts.
Pre-COVID, McDonnell was performing medication reconciliation at two Brigham-affiliated clinics. The no-show rate was approximately 40 to 50 percent when she saw patients there.
Then, COVID-19 forced McDonnell to shift to telehealth. Initially, she continued her medication reconciliation work. However, the longer the clinics remain closed, it became apparent that patients with chronic diseases like diabetes mellitus may need additional support.
By May 2020, coordinated efforts established pharmacist-led diabetes mellitus clinics at two Brigham-affiliated community health centers. It might seem counterintuitive, but the move to virtual visits has helped McDonnell to develop deeper relationships with patients. Maybe it’s because she’s now connecting with them when they’re in their homes. It may also be because she’s now learning more about the complexities of their lives. She estimates that her no-show rate is now less than 10 percent per week.
Says McDonnell, “It seems like patients are buying in. I’ve had a chance to build rapport with them. They’re getting a call from a pharmacist on every Monday, Tuesday, or Wednesday, and they’re answering the phone. That’s promising because, if they didn’t want to talk to me, they wouldn’t answer!”
In a recent interview, McDonnell and Sonali Parekh Desai, MD, BWH Director of Quality, Department of Medicine and Director of Ambulatory Patient Safety, talked about the lessons they’ve learned about patient-centered care, the social determinants of health, population health, and health equity while implementing a diabetes management telehealth program.
On identifying patients for pharmacist-led telehealth support
Anne McDonnell (AM): The easiest way is through [primary care] provider referral because the providers really know their patients. We also have a group [within the Brigham] that works with us called Population Health Management. They identify, through a series of reports, patients who have A1Cs that are above our targets. We also have a registry report that was built for the work that we do. We use these tools to identify patients with uncontrolled type 2 diabetes and then we ask if they want to participate. If they agree to it, then they’re booked to meet with me for a pharmacy telehealth visit.
Sonali Parekh Desai (SPD): As we saw different risk factors emerge for patients who were getting sicker with COVID — things like their underlying chronic diseases, including hypertension and diabetes — we decided to focus on higher-risk populations, particularly at two local health centers where we've been working. This program helps us address population health, primary care, patient safety, ambulatory medication safety, health equity, and other issues we’ve been working on across our health system.
On how COVID-19 has highlighted barriers to health
SPD: The telehealth model helps us focus on asking patients about their barriers to care. It helps us think of the upstream components of health that might not get addressed during a regular visit because [a provider might be] focusing on the physical exam or laboratory tests or other aspects of the patient’s care.
AM: In face-to-face visits [prior to COVID-19], I wouldn’t have thought to ask about food insecurity. I’d say things like, “Eat more protein if you can,” but I never stopped to ask, “Are you able to get food? Where are you getting your food from?” Fortunately, I work with a health center that has food available for patients to pick up during the pandemic. I’m now also asking if patients can get their medications. Sometimes I see large jumps in A1C, and a patient will say, “I lost my job. I can’t afford my medications,” or “I don’t want to leave my house.” We’ve had a lot of people who were afraid to go outside because they had family or friends who got COVID-19. [These conversations] have given us a lot of insights into the problems people are facing when they’re managing chronic diseases.
On the importance of understanding what matters most to patients
AM: It’s about meeting the patients where they are. We help patients understand the consequences of long-term diabetes, and then customize every plan so we can gradually lower their A1Cs.
For example, I’m working with someone who wants to get pregnant. I have to make sure that the medications she is taking right now are appropriate for somebody trying to get pregnant or who might be pregnant. I have to help her understand why it’s important to control her blood sugars. Her goals are going to be very different from someone who, say, lost their insurance, and had a huge jump in their blood sugars because they lost access to care, and now we’re gradually starting the patient back on medications. For that person, I might say, “You’re only in your early 60s. You could have 20 years ahead of you. Let’s help you get better control of your blood sugars. That way, in 10 or 20 years, you’ll be living your normal life, and not dealing with the consequences of uncontrolled diabetes.” The goal is to frame it in a way that doesn’t scare patients, and help them understand how their participation in their own care can make things better.
On job satisfaction and joy in work
AM: Part of the reason I became a pharmacist is because I enjoy working with patients. It’s great to build relationships where I can call people and say, “Hey, this is Anne,” and they know it’s Anne from the pharmacy at the clinic. It makes me happy to establish connections that help them manage their diabetes. I think it’s going to take us a while to show the trends in the A1C data, especially because there are so many complex needs during the pandemic. But, in certain patients I’m calling, based on medications that we’ve been prescribing, we are seeing an overall downward trend in fasting blood glucose in the morning. It makes you feel like you’re accomplishing something.
SPD: Getting a better understanding of the factors that drive the health outcomes we're seeing, and then putting systems in place to address those factors, has been so rewarding as a practitioner. We, as leaders in quality, must think about what it means to deliver high-quality care. It has to include equitable care. That’s something we’re thinking about with every quality improvement program we put in place.
On the power of collaboration
AM: One of the things I’m proudest of in this whole process has been the collaboration. When providers send me a note saying, “This patient would benefit from your services” and add a couple of lines to help me understand who the patient is and where they’re coming from, [it’s as though] the provider is saying, “I trust you to take care of my patient.”
I also enjoy working with the interpreters, and the clinic social workers and visiting nurses who help us coordinate care have been amazing. I never feel like I’m managing anything on my own because I’m not. We work as a team.
SPD: The pandemic has forced a lot of rapid collaboration that [can normally] take a lot of time to achieve. That's been a positive outcome of all of this. We have longstanding relationships with primary care, population health, and the health centers, and it’s been great to think creatively with them. We’ve been coming up with new ways to deliver care that make sense for patients and for the entire clinical care team.
On adaptations they hope to continue post-COVID
AM: If you had told us [before COVID] that we’re going to have all these patients doing telehealth visits, getting access to mail-in prescriptions, and we’d help them get food, I’m not sure I would have believed you. It shows what we can do when we come together as a team.
SPD: It’s worth noting that having true pharmacist-led medication safety efforts across ambulatory care is an area of opportunity and growth because we can see its value. As we think about the delivery of chronic disease management, there are probably a myriad of health conditions for which telehealth or video visits can be even more productive than an in-person visit. Not all conditions are best suited for telehealth, but we’ve found that there are conditions — including diabetes, inflammatory bowel disease, and rheumatoid arthritis — that can be managed through a combination of telehealth and in-person visits. If the focus of a visit is to discuss barriers to self-management of the disease or medications shared decision-making, a telehealth visit may be more productive and appropriate than an in-person visit. Also, with telehealth, patients don’t need to drive or take public transportation to the hospital or health center, take time off work, get childcare, or handle all the logistics that can sometimes prevent patients from seeking care. Figuring out which of these opportunities exist and focusing on them can make a big impact, especially in chronic disease management.
Editor’s note: This interview has been edited for length and clarity. To learn more from Sonali Parekh Desai, MD, join us at the IHI Primary Care Summit 2020 (October 21-23), a three-day virtual conference. Dr. Desai will be a Summit panelist.