This article describes a pharmacist-led diabetes care program implemented at a local free clinic for underserved Hispanic patients with low or no income. Patients are referred to the pharmacist after diagnosis with diabetes for a consultation that includes disease state education, diet/lifestyle education, medication management, and follow-up. The pharmacist works with patients to ensure timely follow-up and adequate medication adjustments to achieve goals. In its first 16 months, this service led to a statistically significant decrease in A1C for Hispanic patients, with an average 2 percentage point reduction in A1C.
Key Points
Pharmacists can play an integral role in successful diabetes management for underserved patients by providing education and assistance in obtaining medications.
Low- or no-income Hispanic patients experienced a statistically significant reduction in A1C while participating in a pharmacist-led intervention.
The Hispanic, or Latinx, population is the largest minority group in the United States and comprises people of Cuban, Mexican, Puerto Rican, South American, and Central American descent and other Spanish cultures and races (1). According to the Centers for Disease Control and Prevention, Hispanic or Latinx people are more likely to have type 2 diabetes (17%) than non-Hispanic White people (8%) and have a higher chance of developing diabetes during their life (50%) compared with the average U.S. population (40%) (1).
The majority of Hispanic people living in the United States (61.4%) identify as being of Mexican descent, with Mexico being the top origin country of the U.S. immigrant population (2,3). According to a 2020 Organization for Economic Cooperation and Development (OECD) report, 73% of the population in Mexico is overweight, and 34% of Mexicans with obesity are categorized as having morbid obesity (4). Projections from the OECD estimate that overweight-related diseases will reduce life expectancy in Mexico by more than 4 years over the next 30 years (4). A 2016 study found that women of Mexican descent are at higher risk of overweight or obesity than their non-Hispanic White counterparts, and this higher risk also increases their risks of chronic inflammation, insulin resistance, and chronic diseases, including type 2 diabetes (5). Hispanic people in the United States may face additional challenges in accessing health care; they have the highest uninsured rate of any racial/ethnic population, and 71% report that they are not fluent in English (2).
Yakima County, located in central Washington, has the state’s largest Hispanic or Latinx population and the highest percentage of people who are uninsured (6). This county has also been designated by the Health Resources and Services Administration as a medically underserved area, defined as having a shortage of primary care health services for residents within a geographical area (7).
Yakima County has an agriculture-based economy with a high population of migrant workers (8). According to a study done to assess workplace exposures and protective practices of Hispanic warehouse workers, a variety of adverse health effects have been attributed to exposure to chemicals in agricultural warehouse settings (9). Agriculture work exposes farmworkers and migrant workers to a variety of occupational risks and hazards and is physically demanding, which can lead to musculoskeletal and soft-tissue disorders (10).
The Yakima Union Gospel Mission Medical Care Center (YUGM MCC) is the largest free clinic in the state of Washington, as measured by patient visits (11). This clinic averages >9,000 patient visits per year, but has only five paid employees (two physicians, two office staff, and one medical assistant [MA]). More than 200 medical professionals volunteer their time at the YUGM MCC, including specialist physicians, pharmacists, nurses, MAs, physical therapists, and chiropractors. Student and resident pharmacists, physicians, and nurses from local health care professional colleges also volunteer at the YUGM MCC. The clinic is funded by government programs and through community donations (11). In 2021, a pharmacist began offering diabetes management services at the YUGM MCC.
This article describes the implementation of the pharmacist-led diabetes care service at YUGM MCC and analyzes its impact on patients’ A1C levels.
Research Design and Methods
The pharmacist-led services at YUGM MCC were developed with the primary focus on diabetes management. The founding pharmacist was a faculty member at Washington State University College of Pharmacy and Pharmaceutical Sciences, and his time at the YUGM MCC was funded by a combination of grants and a university salary. The grant was obtained in June 2020, with much of the remainder of 2020 focused on completing a memorandum of understanding and a collaborative drug therapy agreement (CDTA) allowing the pharmacist to prescribe medications for diabetes at the YUGM MCC. The clinical service started in February 2021 and slowly expanded based on referrals from other providers in the clinic once patients received a diagnosis of diabetes. The pharmacist’s clinical practice evolved over time; initially, the pharmacist was in the clinic for one 8-hour day per week, but after having difficulty scheduling and rescheduling patients, the schedule was split into two 4-hour clinic days, which has been the model for more than 1 year.
Patient Population
Patients seen in the clinic are predominantly migrant farm workers from Mexico who are uninsured. These patients have a variety of acute and chronic medical conditions that are managed at traditional primary care clinics across the county. The pharmacist-led service sees patients who are referred by other primary care providers. Almost all of the referrals to date have been for diabetes management, although the pharmacist does help to manage conditions secondary to diabetes and ensure that all medications are appropriate, including those for the treatment of respiratory, cardiovascular, and other endocrine conditions. All of the services offered through the pharmacist-led clinic are covered by the CDTA, which was approved by the medical and clinic directors and the pharmacist.
Medication Procurement
Procuring affordable medications is one of the challenges in caring for patients at the YUGM MCC. The clinic staff does this through a variety of methods, including identifying low-cost generic medications when possible and partnering with local pharmacies to identify discount programs when available. Some patients have the means to purchase low-cost, generic medications such as metformin at a pharmacy when necessary. Many prescription medications are offered through discount programs at local pharmacies, and the providers and pharmacists collaborate to get medications at the lowest cost to patients.
Two other methods for obtaining medication at the YUGM MCC include drug company sample programs and pharmaceutical company patient assistance programs (PAPs). Many pharmaceutical companies have programs through which providers can request samples on a regular basis. YUGM MCC uses these programs to obtain long- and rapid-acting insulins, glucagon-like peptide 1 (GLP-1) receptor agonists, and other medications.
Once patients are initiated on sample medications, providers have had success in transitioning them to PAPs for continued access. When patients qualify for these programs and are accepted, they receive requested medications for up to 1 year, after which they can reapply.
Another option for helping patients obtain medications is Americares, a health-focused relief and development organization (12). This organization provides medication and medical supplies to people who have been affected by poverty or disaster (12). The YUGM MCC has an established partnership with Americares and receives donated medicines to bridge gaps in managing patients’ acute and chronic conditions. YUGM MCC relies on Americares for medications and supplies for a wide range of conditions, including type 1 and type 2 diabetes. Americares has provided insulin syringes, insulins, metformin, GLP-1 receptor agonists, and various combination medications when they are available for ordering.
Patient Visits
All pharmacist visits at YUGM MCC are conducted in person. Consideration has been given to offering telehealth visits, but because of the need for frequent laboratory tests and challenges some patients face in securing regular access to a computer or smartphone, telehealth visits are not currently offered. The pharmacist-led visits vary in length. Typically, an initial encounter is 40–60 minutes in length and includes the pharmacist, an interpreter, and occasionally a scribe. The clinic does not have the electronic interpreter services, so translation is provided by staff and volunteers who speak fluent Spanish. Much of the initial visits are spent helping patients understand diabetes, getting a detailed description of their diet and lifestyle, and discussing medications. Visits vary by patients’ needs but typically include most of the following:
Introductions and a description of the pharmacist’s role in collaborating with providers in the clinic to manage medical conditions
Education about diabetes, why health care professionals are concerned about elevated blood glucose, and diabetes complications that can occur over time if blood glucose is not managed
Discussion about patients’ dietary patterns and lifestyle choices
Education about basic nutrition, including carbohydrates, proteins, and fats and their roles in diabetes
Discussion of opportunities for patients to change their diet to affect their blood glucose, including how such changes could be sustainable
Discussion about available medication options, how the medications work, and which medications patients may prefer
After the initial encounter, patients are scheduled for subsequent 30-minute follow-up visits. Topics covered during follow-up appointments also vary but typically include more in-depth discussions about the same components, as needed.
Data Collection and Analysis
Data for this analysis were manually collected from the clinic’s electronic medical records system without patient identifiers and aggregated in Microsoft Excel. Specifically, sex, ethnicity, starting and most recent weight, medications, and A1C levels while patients were under the pharmacist’s care were collected. Statistical analysis involved comparing patients’ A1C levels from their initial visit to their most recent visit using the Mann-Whitney U test in Microsoft Excel.
The Washington State University Office of Research Assurance found this research to be exempt from the need for review by the institutional review board (IRB #19521).
Results
From the start of this service to the time of writing, the pharmacist had seen 65 patients. Sixty-two patients (95%) were seen primarily for diabetes management, of whom 41 (66.1%) continued to receive care from the pharmacist and had multiple A1C results documented, while three (4.8%) attended one appointment and did not return to the clinic for follow-up. Five patients (8.1%) were seen by the pharmacist for an initial appointment but then transferred to the care of another provider within the same clinic. At the time of writing, 13 more patients (20.1%) had been seen initially but had not yet had a second A1C test. These patients were going to be seen by another clinic provider for other chronic medical conditions anyway, so that provider also took over their diabetes care.
The patients being seen by the pharmacist had an average age of 51 years and had been seen by the pharmacist for an average of 10 months. Over half were male (25 of 41 [60%]), and all were Hispanic. Table 1 shows the medications selected for each patient. The patients being seen by the pharmacist had a statistically significant (P <0.001) decrease in average A1C from the initial visit to the most recent visit. The average reduction in A1C from the initial to the most recent value was 1.99 percentage points (SD 1.75, range 0.7 to −6.2).
Medications Selected for Pharmacist-Managed Patients
| Medication(s) . | n (%) . |
|---|---|
| Metformin alone | 6 (15) |
| GLP-1 receptor agonist alone | 2 (5) |
| Metformin + basal insulin | 2 (5) |
| Metformin + GLP-1 receptor agonist | 14 (34) |
| Metformin + sulfonylurea | 1 (2) |
| Metformin + short- or rapid-acting insulin | 1 (2) |
| Basal insulin + GLP-1 receptor agonist | 2 (5) |
| Basal insulin + short- or rapid-acting insulin | 1 (2) |
| Dipeptidyl peptidase 4 inhibitor + thiazolidinedione | 1 (2) |
| Metformin + basal insulin + GLP-1 receptor agonist | 4 (10) |
| Metformin + short- or rapid-acting insulin + GLP-1 receptor agonist | 2 (5) |
| Metformin + basal insulin + short- or rapid-acting insulin | 4 (10) |
| Metformin + sodium–glucose cotransporter 2 inhibitor + GLP-1 receptor agonist | 1 (2) |
| Medication(s) . | n (%) . |
|---|---|
| Metformin alone | 6 (15) |
| GLP-1 receptor agonist alone | 2 (5) |
| Metformin + basal insulin | 2 (5) |
| Metformin + GLP-1 receptor agonist | 14 (34) |
| Metformin + sulfonylurea | 1 (2) |
| Metformin + short- or rapid-acting insulin | 1 (2) |
| Basal insulin + GLP-1 receptor agonist | 2 (5) |
| Basal insulin + short- or rapid-acting insulin | 1 (2) |
| Dipeptidyl peptidase 4 inhibitor + thiazolidinedione | 1 (2) |
| Metformin + basal insulin + GLP-1 receptor agonist | 4 (10) |
| Metformin + short- or rapid-acting insulin + GLP-1 receptor agonist | 2 (5) |
| Metformin + basal insulin + short- or rapid-acting insulin | 4 (10) |
| Metformin + sodium–glucose cotransporter 2 inhibitor + GLP-1 receptor agonist | 1 (2) |
Discussion
This analysis sought to identify the glycemic impact of a pharmacist-led diabetes care service in a free clinic for low- or no-income Hispanic patients. Our results for this small-scale study are consistent with the literature in other patient populations. A 2016 study by Sullivan et al. (13) evaluated the impact of a clinical pharmacist on glycemic control in veterans with type 2 diabetes in a rural, outpatient clinic. Patients in that study were referred for pharmacist-managed therapeutic monitoring, and the results showed mean A1C reduction of 2.8 percentage points (P <0.001), which is similar to the mean decrease seen in our study. A 2010 meta-analysis of randomized controlled trials evaluated the effect of any pharmacist intervention on glycemic control in populations with diabetes (14). That analysis showed that pharmacist intervention significantly lowered A1C and fasting blood glucose. An RCT involving patients with an A1C >9.0% evaluated a pharmacist intervention consisting of the use of registries and targeted patient outreach plus medication management, patient education, and disease (15). It found that significantly more patients in the intervention group improved their A1C by at least 1.0% relative to the control group (67.3 vs. 41.2%, P = 0.02), with median A1C decrease of 1.5% in the intervention group and 0.4% in the control group. These studies underscore the positive impact pharmacists can have in the management of poorly controlled diabetes, as was also shown in this study.
Suboptimal nutrition and physical activity can be contributing causes leading to chronic conditions, including type 2 diabetes. Anecdotally, patients who were managed by the pharmacist in the YUGM MCC had diets that are very high in carbohydrates. Almost all of these patients reported eating tortillas, rice, and beans regularly, as these are staples of Hispanic cuisines. Providing education about portion control for these culturally important foods was essential. Moreover, many patients seen for diabetes management at the clinic reported frequent intake of sugar-sweetened beverages (e.g., juices, sodas, and energy drinks), so encouraging them to eliminate these sugar-sweetened beverages was another important strategy. Much of the initial visits with the pharmacist focused on gathering information about patients’ eating patterns, counseling them on basic nutrition, such as the role of proteins, fats, and carbohydrates in glycemia. Many of these patients did not know that foods high in carbohydrates would affect their blood glucose.
Pharmacists can be a valuable asset when it comes to nutrition counseling for many patients and can provide such information themselves or reinforce messages patients receive from dietitians, diabetes educators, and health care providers. Spending time with patients and discussing various lifestyle pearls can have a lasting impact on many chronic conditions.
There are some limitations to this analysis. First, this project received grant funding to cover the cost of the pharmacist’s time to implement this clinical service. Doing so would not have been possible without that funding. Additionally, the pharmacist was working under a CDTA with a supportive physician. This collaboration would not have been possible in a state that does not allow pharmacists to prescribe medication as part of a CDTA or in clinics where physicians may be less supportive of such arrangements. Finally, this analysis had a very small sample size and was based on care in one location with patients who were from similar ethnic backgrounds. Results may vary in different patient populations and geographical areas. Larger studies are needed to obtain more generalizable results.
The YUGM MCC physicians and pharmacist support continuing this pharmacist-led diabetes service and are looking for grant funding to expand this work to involve more pharmacists and other disease states. The pharmacist is also working on obtaining a diabetes retinopathy screening device to bridge the gap these patients face in accessing optometry/ophthalmology services and ensure optimal eye health in this underserved population. The pharmacist is also exploring further dietary education outreach opportunities for this patient population.
Conclusion
Pharmacists have a proven track record of providing interventions that lead to more optimal glycemic control in people with diabetes. Pharmacists can play an integral role in successful diabetes management in underserved populations by providing patient education and helping patients obtain the medications and supplies they need. Low- and no-income Hispanic patients seen in the pharmacist-led diabetes clinic at YUGM MCC experienced a statistically significant decrease in A1C.
Article Information
Duality of Interest
No potential conflicts of interest relevant to this article were reported.
Author Contributions
N.R.G. conceptualized the study, collected and curated the data, and wrote, reviewed, and edited the manuscript. C.Y. was responsible for the literature search and writing. K.M. conceptualized the study, performed the analysis, and wrote, reviewed, and edited the manuscript. N.R.G. is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
