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From Educating Students to Educating Patients; the Hands-on Field of Managed Care Pharmacy | NEWS-Line for Pharmacists

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FEATURE STORY 04/01/2007
Author: Kelly Dolde  
From Educating Students to Educating Patients; the Hands-on Field of Managed Care Pharmacy
Sometimes the best ideas come from the mind of a 3-year-old. That's what Catherine E. Cooke, PharmD, BCPS, PAHM, discovered while baking with her young daughter.

"My daughter is 3 and cannot read yet. We were in the kitchen and decided to make a cake. After looking at the box, she told me we needed water and two eggs. I realized she was able to read the recipe because the back of the box had clear pictures of water and eggs, showing her exactly what was required. And I thought, ‘This is what we need to do in pharmacy!' The printouts and patient package inserts people receive today from their pharmacies are lengthy, the print is small and the language can be confusing if not scary. I'm now writing a paper with Dr. Richard Safeer, Medical Director of Preventive Medicine at CareFirst BlueCross BlueShield (BCBS), to address this problem. The paper offers advice on how we can improve the way our pharmacy literature communicates to patients."

Finding innovative solutions in unexpected places is just one skill that Cooke, independent consultant in healthcare quality and research and clinical assistant professor at the University of Maryland (UMB), has brought to her pharmacy career—a pursuit that began one morning while she was a senior in high school. "I woke up and knew I was going to become a pharmacist. I had heard my mother's friend speaking positively about the helpfulness of pharmacists while she was training to become a nurse and it turned out that I had distant relatives who worked in pharmacy. But my father was very cautious about my choice and encouraged me to select a college that wasn't simply a pharmacy school because so many people change their course of study as undergraduates. So I went to the University of Iowa and stayed in pharmacy."

Cooke was also drawn to teaching. "It wasn't until I got to my very last year of the five year program while we were doing rotations that I realized many faculty members worked at the practice sites we were visiting. I never thought that I could both teach and do practical work. At that point, I realized I wanted to be a teacher, which meant I needed to get my PharmD. I chose the Medical University of South Carolina and then moved back to the cold to complete a residency in managed care/ambulatory care at the Philadelphia College of Pharmacy and Science (now University of the Sciences in Philadelphia)."

After completing a residency, Cooke was hired to integrated managed care into the pharmacy curriculum at the University of Maryland. "As a new faculty member, one of my responsibilities was to develop a practice site in Managed Care. I found Potomac Physicians, PA, a multi-office medical group, owned by CareFirst BCBS that was operating similarly to a staff-model HMO. They had a facility in the Inner Harbor in Baltimore and I approached the Medical Director, Dr. Carol Reynolds, who wanted to know what value I could add to their center since they already had a pharmacy. I explained that my role would be to work with the pharmacist who owned the in-center pharmacy and analyze the patients' regimens. I told her how I could meet with patients, the pharmacist, and the doctors to help optimize drug therapy regimens and pinpoint why some patients weren't thriving. In the beginning, physicians would refer patients who were not responding well to their medication in terms of blood pressure control and I would do a limited physical assessment and interview the patient. Then I would consult with the physician to make adjustments to therapy and work with the pharmacist to implement a plan to improve medication adherence. Over time, clinical pharmacy services expanded to allow patient, physician and claims-based referrals for several chronic, medically managed disease states such as diabetes, dyslipidemia, smoking cessation, and coronary artery disease (CAD). Evaluations of pharmacy services revealed improvements in hypertension control, diabetes control and improvements in quality-of-life. Results were positive and I was asked to expand services to a second location, Security Health Center in Randallstown, Maryland."

Most recently, Cooke has left Security Health Center to work on what she calls, the VP project—short for "Visiting Pharmacist." "This model has been used in the nursing community for a long time so why not apply this model to the pharmacy community? I'm seeing Medicare recipients who've chosen pharmacy coverage with Medi-First Prescription Drug Plan. I go to the homes of patients, interview them to obtain a medical and medication history and identify challenges they're having with their drug therapy. I then collaborate with the patient's primary care provider and pharmacy to adjust the patients' drug therapy regimens to improve outcomes. For the patients, this extra treatment is appreciated. Their pharmacy benefit provides not only coverage for the price of a pill but additional cognitive services where someone is looking at them from an informational perspective."

Through these programs, Cooke has discovered that many patients aren't following their assigned regimen because they haven't fully understood the instructions given to them. "We've been looking into health literacy and how pharmacists communicate with patients. There are patients who are unable to read but even patients with a full education might struggle to understand health-related concepts. I think I'm a pretty educated person, but there was one occasion when I took my child to her pediatrician who told me something about my daughter that I interpreted one way, but I found out later that I had not understood the full scope of his recommendations. Future work needs to address how to implement effective changes." In addition to co-authoring articles with Dr. Safeer and other health literacy experts, Cooke is working on developing illustrative educational materials for her patients.

In addition to her clinical work in managed care, Cooke has started her own residency program in Managed Care/Ambulatory Care at UMB. "A student chooses the year-long program and I manage their post doctorate work. They receive training at clinical practice sites with me and other faculty in addition to working with CareFirst BCBS on formulary management." Many of her residents are focused on managed care or ‘population-based' care and less focused on direct patient care. But Cooke asks, "How can you make decisions for a large group of patients if you've never made a decision for one? If you haven't performed in this one-on-one capacity, how can you effectively manage people who do?" For this reason, Cooke requires the Managed Care/Ambulatory Care residents in her program to see many patients, maybe more than residents in other comparable programs in the country.

Cooke also frequently publishes research studies on various topics. "I enjoy the pursuit of scholarly activity and I enjoy conducting research. Bringing the research into publication is the final step of the process. "If you don't publish, you're not sharing your knowledge. My current research focus is cardiovascular disease and women's health disparities in prescribing and treatment effectiveness. Last year, we published two studies in different managed populations. The first study evaluated American Indians/Alaska Natives with CAD and found a 41.3% prescription rate for statins. Men were more likely than women to receive a statin. Interestingly, we found that men 65-79 years were more adherent to their statin therapy than women in this same age group. In the second study, we evaluated low-density lipoprotein (LDL) levels and goal LDL attainment. Men were more likely than women to have their disease controlled, 51.0% vs. 36.7%, respectively."

Cooke noted that, "You would think that men and women with the same disease would be equally likely to receive appropriate therapy and achieve goals, but that is not the case. The next step is for us to understand the reasons behind this disparity and to develop interventions to correct it."

Cooke explains that the patient isn't the only one who benefits. She says that she too benefits from the sense of helping others. "I enjoy managed care or ‘population-based' work but the challenge with only doing that is you lose the one-on-one interaction." It is this one-on-one interaction that is the most professionally satisfying for Cooke. "Just last week, a new patient called to let me know that his provider had changed everything according to my suggestions. I said, ‘That's great. I'm glad your doctor is helping you out.' He said, ‘No, dear, you helped me.' Another patient who I've seen for several years now, was referred to me for uncontrolled diabetes. Despite having adequate healthcare coverage and being in the system-of-care, this was the first time her hemoglobin A1c was controlled. When I saw her and shared the good news from her laboratory report, she broke into tears saying that this was the first time her sugar had been good. That's what makes me continue to do this work. There's nothing that touches you like making someone feel better."

Catherine E. Cooke, PharmD, BCPS, PAHM, received her bachelor of science in pharmacy from the University of Iowa in 1992. She earned her doctor of pharmacy in 1994 from the Medical University of South Carolina and completed her residency in managed care/ambulatory care in 1995 at the Philadelphia College of Pharmacy and Science. She is an independent consultant in healthcare quality and research and a clinical assistant professor at the University of Maryland School of Pharmacy. She received the Innovative Practice Award from the Maryland Pharmacists Association in June 2003.

Kelly Dolde is a freelance writer from Baltimore, Maryland and is on the Editorial Staff of NEWS-Line for Pharmacists.
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