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Seven-Year Journey of a Collaborative
Disease Management Program

Ming-Ming Tung-Edelman, Pharm.D., Nancy Louie Lee, M.S., Tom Wright, B.S.Pharm., Dean Klopfenstein, B.S.Pharm., CDE, Mike E. Kinard, M.S., Martina M. Fetter, R.N.


Kaiser Permanente Northwest
Portland, Oregon



Challenged with the need to demonstrate the value of clinical pharmacy resources, in 1997 the regional pharmacy department of Kaiser Permanente Northwest (KPNW) developed a centrally managed model of care to deliver population-based care in our integrated health-care delivery system.

Description of the Program

Before 1997, it was difficult for KPNW to define the value of clinical pharmacy services in terms of quality and cost relative to investment. The pharmacist shortage and increasing wages highlighted this challenge. The historical clinical pharmacy model with individual pharmacists setting priorities based on short-term requests of the health-care team was no longer sufficient.

The goals of the new model included the following:

  1. Demonstrate and communicate the program’s contribution to high quality and affordability,
  2. Integrate clinical pharmacy services into health-system priorities,
  3. Focus clinical pharmacy resources on the highest clinical quality and cost priorities,
  4. Use a comprehensive and integrated approach to population-based care with consistent intervention, documentation, and follow up across disease states,
  5. Create a centralized office to coordinate daily workload and serve as an educational clearinghouse and training site,
  6. Implement collaborative drug therapy management based on evidence-based principles and clinical practice guidelines,
  7. Use clinical information systems to streamline standardized documentation of patient information, workload, and communication between pharmacists and other health-care team members,
  8. Use the most appropriate labor resources for each role in the delivery of care,
  9. Create work sites within medical offices that are appropriate to the level of service and that strengthen relationships among health-care team members, and
  10. Provide high satisfaction for patients, clinicians, and staff.
  11. Experience with the Program

The first disease state implemented was dyslipidemia as secondary prevention for patients with coronary artery disease. Over a seven-year period, this collaborative program has expanded to include nursing and additional pharmacy technician staff. The program currently manages about 6000 patients focusing on drug therapy for dyslipidemia and hypertension in patients with diabetes mellitus or cardiovascular disease, aspirin documentation, smoking cessation advice, treatment of depression in selected patients, lifestyle counseling, program-related drug costs, and support of regional drug-cost initiatives. Nurses do the initial patient assessment. Pharmacists initiate medication therapy and laboratory tests by protocol, monitor blood pressure and laboratory results, and adjust medications. Pharmacy technicians help stage clinical follow up and generate communications with patients in maintenance. This collaborative model allows pharmacists, nurses, and technicians to use their skills more effectively, and it enables outreach to a larger number of patients. The use of team-based care, clear entry and exit criteria, and a robust automated clinical record contribute to the program’s operational efficiency and sustainability.

Patients managed by the program achieved better blood pressure and lipid control than those not managed by the program. Results show that 69.7% of patients in the program had blood pressure less than 140/90 mm Hg compared with 66.6% of patients not in the program. LDL values less than 130 mg/dL were achieved for 93.6% of patients in the program compared with 66.9% of non-program patients. In addition, according to patient satisfaction surveys, 99% of patients were extremely or very satisfied with the care they receive, and 80% would definitely recommend the program to a family member or friend. Furthermore, patients had an 8.8% decrease in number of visits to the emergency department and a 21.7% decrease in hospital admissions compared with the previous year. Labor cost/patient for managing drug therapies decreased from $720 in 1997-1998 to $105 in 1999 with the new model implemented.


The value of clinical pharmacy resources can be defined in a centrally managed model of care that delivers population-based, integrated care in an integrated health-care delivery system.