Title : Chronic disease management and prevention: Implementing clinical pharmacists into a patient's care team
Abstract:
Relevance and Significance: Cardiovascular diseases have been the leading cause of death and among New Jerseyans1. Hypertension is a significant risk factor and nationally, almost half of those with hypertension are not in control2. Evidence shows that a team-based care approach to chronic disease management is successful in facilitating communication and coordination and leads to empowered patient care2. Incorporating clinical pharmacists into the healthcare team has been shown to improve access to primary care, improve prevention and management of chronic disease and medication adherence, and enhance patient outcomes. As integral members of the care team, clinical pharmacists reinforce the value of a collaborative approach to delivering clinical services, particularly for patients with chronic diseases. As experts in medication therapy, clinical pharmacists are ideally positioned to manage medications for patients with chronic conditions. They help patients optimize and adhere to their treatment regimens while evaluating and adjusting care plans to better support improved health outcomes.
Program Summary: The Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) program supports Zufall Health Center, a federally qualified health center, to implement a clinical pharmacist-based lifestyle change program. It is delivered through the program flow as a three-session cycle, offered in person, via telehealth, or through a hybrid model to address participant access needs. The program combines Medication Therapy Management with patient-centered lifestyle counseling using motivational interviewing. Session 1 focuses on review of screening results and medications, identification of barriers, and goal setting with education on cholesterol, blood pressure, and blood glucose management. Session 2 emphasizes follow-up, progress review, barrier resolution, care plan updates, and coordination with the primary care team. Session 3 centers on evaluating progress, developing a sustainable maintenance plan, and transitioning participants to ongoing care and additional services as needed.
Program Evaluation: Health outcomes, including blood pressure, weight, blood glucose, and cholesterol, are documented in the electronic medical record at baseline and follow-up in alignment with WISEWOMAN program requirements. A case manager also maintains a tracking spreadsheet to monitor progress, session completion, and outreach needs. Participant engagement is supported through proactive reminders, phone calls, flexible visit formats, and transportation coordination. Since launch in 2023, 47 participants have completed the three-session lifestyle change program. Program evaluation compares baseline and follow-up clinical measures and incorporates participant survey feedback. To date, 18 participants have demonstrated documented improvements in clinical outcomes, care engagement, and behavior change.
Research-based: There is strong evidence that incorporating pharmacists into the health care team, chronic disease related health outcomes (e.g., blood pressure, blood glucose, cholesterol, smoking cessation) and adherence to prescribed medication improves2. Patients who have cardiovascular diseases or other comorbidities are often at risk for adverse drug events due to polypharmacy and use of high-risk medications3. Pharmacists are uniquely positioned to address medication safety issues, improve adherence through education, and educate on evidence-based lifestyle practices3.
