The Asheville Project
Recognizing the pivotal role pharmacists can play in chronic disease management in local communities.
The City of Asheville, North Carolina, put itself on the health care map in 1996 when it embarked on a novel approach that elevated the role of pharmacists in order to better manage diabetes among its citizens. The impressive clinical results and a decline in direct medical costs have led many public and private employers and health care stakeholders to reevaluate their own practices and benefit designs in order to replicate Asheville’s success.
Driving Force. John Miall, then Director of Risk Management for the City of Asheville, North Carolina, recognized a deal that was too good to pass up when, in 1996, he was approached by the North Carolina Center for Pharmaceutical Care (NCCPC) and Mission St. Joseph’s Health System to take part in a pilot disease management program. He understood personally and professionally the toll chronic conditions like diabetes and hypertension were taking upon friends, family and colleagues. His job was to mitigate risk for the City, meaning he knew the financial implications as well. So he was quickly on board with the NCCPC to help conduct a year-long study to observe the impact pharmacists can have on disease management.
The Origin of a Solution. In 1985, the National Heart, Lung, and Blood Institute (NHLBI) launched the National Cholesterol Education Program (NCEP), which sought to reduce illness and death from coronary heart disease (CHD) nationwide by reducing the percent of Americans with high blood cholesterol. Through educational efforts directed at health professionals and the public, the NCEP was raising awareness and understanding about high blood cholesterol as a risk factor for CHD and the benefits of lowering cholesterol levels as a means of preventing it.
Leadership at the North Carolina Pharmacists Association, the Pharmacy Director from Missions Hospital and a group of University of North Carolina Chapel Hill pharmacists were intrigued by the NCEP and the challenge it put forth to health care providers. They recognized that improving medication compliance among people suffering from diabetes and hypertension –a combination of risk factors shown to lead to heart disease, the foremost cause of death in the United States and a significant cost driver in health care—was essential to combating these chronic diseases. They suspected, but needed to prove, that adherence to medical treatment could result in significantly better health outcomes and save money. They also believed that pharmacists could play a pivotal role in counseling patients, performing basic patient exams, tracking data and communicating with the patients’ doctors when problems arose.
Initial Focus. The program focused upon diabetic patients at first and was later expanded to include asthma, lipid management and hypertension. Related studies on depression were also undertaken.
Area pharmacists who agreed to be part of the study took part in training and education for the diabetic program. Then, eligible employees and/or volunteers had to complete all of the enrollment paperwork and surveys before they were assigned to a certified pharmacist care manager. The patients’ physicians were notified about their participation. Patients took part in nine-hour educational courses established by the American Diabetes Association and received a benefit card to waive any co-pays associated with diabetes. Participants were then required to attend regular meetings with their pharmacist, have regular appointments with their doctor, and complete routine lab work periodically.
Biggest Challenges. Sometimes the biggest hurdle can be just overcoming the mental barriers that keep one from even getting started. “How were we going to develop a plan for an outcomes-based demonstration project? How were we going to fund the project? How were we going to find a payer and gain support of physicians?” Dan Garrett, then president of the North Carolina Society of Hospital Pharmacists had many questions from the start—with no prototype on which to base the project. The cooperation and collaboration that took place among the aforementioned stakeholders was quite remarkable and a testimony to the synergistic spirit and expertise that can fuel innovative benefit design projects on a community level and within business coalitions. “How were we going to get a project with such complex magnitude underway and make sure we had taken care of all the details? When we decided to start! We knew we were making this up as we went along, so we simply began to care for patients.”
Measuring ROI. Within three months, individuals in the study were taking better care of themselves in terms of diet, sleep, and exercise. Miall believes that simply having someone to talk with about their health concerns benefited these patients, likening pharmacists to coaches.
Six months into the project, clinical outcomes were improving along with physical and mental health. Even cost savings were being realized.
Miall recalls the initial start-up expenses totaled $14,000—of which $8,000 was payment to pharmacists for their initial and intermittent patient assessments and routine visits, and $6,000 was payment for formal diabetes education at the Diabetes Center of Mission St. Joseph’s Health System. “Compared to our $4 million-per-year benefit program, $14,000 is a drop in the bucket. If you’re preventing one diabetic patient from facing an amputation in the future by improving his/her care now, you’re saving between $30,000 and $50,000” explains Miall.
The peer reviewed studies conducted from the Asheville Project’s inception show the progression of clinical results and cost savings (See Literature Review).
Expansion & Replication. Although the City of Asheville did expand its program to include asthmatic patients, the project actually spawned much larger efforts nationwide. Most notably, the Diabetes Ten City Challenge was built upon the same structure, utilizing community-based pharmacist coaching, evidence-based diabetes care guidelines and self-management strategies. With support from GlaxoSmithKline, the American Pharmacists Association Foundation began to further test the model in 2005 when stakeholders from the following sites agreed to take part:
- Charleston, South Carolina
- Chicago, Illinois
- Colorado Springs, Colorado
- Cumberland, Maryland
- Honolulu, Hawaii
- Milwaukee, Wisconsin
- Northwest Georgia
- Pittsburgh, Pennsylvania
- Los Angeles, California
- Tampa Bay, Florida
Clinical outcomes for the 573 patients who participated in the program for at least one year improved while total health care costs per patient per year were reduced compared with projected costs in the absence of the program.
 Miall J. An Investment in Health Officers a High Return for All. Pharmacy Times. October 1998;28. http://www.ncpharmacists.org/displaycommon.cfm?an=1&subarticlenbr=41.
 National Heart, Lung, and Blood Institute. National Cholesterol Education Program. http://www.nhlbi.nih.gov/about/ncep/.