Before meals. Two hours after a meal. At bedtime. Maybe, at 3 a.m.


If you have diabetes, those are the times your doctor might want you to check your blood sugar. As many as four a day. Prick your finger or earlobe, squeeze blood onto a test strip. Run the machine, then record the result. And those supplies cost money. Test strips are one dollar each. Then medications. It adds up.

But without all that, diabetes can get out of control. Patients can lose their sight or a limb. They are also at greater risk for developing heart disease.

Six years ago, a group of pharmacists, an employer, a health-care system, and two universities decided to try to help. A group of pharmacists would coach forty-six patients in managing their diabetes. They would meet with the patients each month, talk to them about their blood-sugar and other lab values.

This experiment was supposed to last just six months. Today, the Asheville Project has grown from forty-six participants with diabetes to 700 people with four different chronic diseases. It is history now, and famous among pharmacists.

It began like this. As far back as 1994, pharmacists in North Carolina had been talking. Many were frustrated that, after all their intensive training in disease management, they’d get on the job and spend most of their time counting pills. Dan Garrett, then president of the North Carolina Center for Pharmaceutical Care, had been talking to people from various North Carolina pharmacy organizations, from the Campbell University School of Pharmacy, and from UNC-Chapel Hill’s School of Pharmacy, including then-dean Bill Campbell. They all wanted to prove that pharmacists could make a difference.

Then Andy Barrett from Pharmacy Network National Corporation, a private company owned by N.C. pharmacists, called Garrett. He’d heard that the city of Asheville was a progressive employer. Garrett lived in Asheville. Did he have any ideas?

Garrett knew John Miall, risk manager for the city of Asheville, through working with him on a United Way campaign. So Garrett took Miall to lunch. Garrett said, we have a group of pharmacists who are chafing to do something besides give out medicine. He proposed to Miall a small experiment. Train pharmacists in counseling patients with diabetes. Have them help manage the patients’ disease. If, after six months, patients are improving and the city is saving money, would Miall consider paying the pharmacists for their time?

Miall knew that insurance costs were rising. Every time somebody had a crisis, had to go to the emergency room, it cost. So he agreed to the experiment. To get patients interested, the city would pick up the cost of co-payments for glucose testing strips and regular diabetes medications.

The Campbell and UNC-Chapel Hill Schools of Pharmacy, together with the Diabetes Care Center at Mission St. Joseph’s Health System in Asheville, provided training to the pharmacists. Each attended a three-day course and earned a certificate in diabetes counseling and medication management through the Mountain Area Health Education Center.

Each patient met with a pharmacist for an initial sixty-minute consultation. The pharmacists trained the patients to make sure they knew how to use the blood-sugar monitors correctly. Then patients met with their pharmacists monthly to review blood-sugar results, discuss their condition, and set goals. The pharmacists also checked the patients’ eyes, skin, and limbs.

At the time, Carole Cranor was a Ph.D. student getting a joint degree from UNC-Chapel Hill’s Schools of Pharmacy and Public Health. When she heard about Asheville, she was eager to help. Before coming to Carolina, she’d been a practicing pharmacist for twenty-five years. She’d tried to make time to talk to patients. “But it was just about impossible,” she says.

So Cranor designed forms that the pharmacists could use to record the interventions they did. Later she would use that data to evaluate the effect of the project on the patients’ clinical values — blood sugar, cholesterol. She would also use quality-of-life questionnaires that the patients completed.

Even before the six months were up, before any of the data were in, Miall called Garrett. Miall wanted to continue the project and pay the pharmacists retroactively to the beginning. Why? Employees were coming to thank Miall, tears in their eyes. They said that the project was the best thing the city had ever done for them.

According to Lynn Hollifield, an occupational health nurse with the city of Asheville, employees who don’t make much money are often so focused on making a living that staying on top of their medical condition takes a lower priority. But regular contact with pharmacists has meant that the pharmacist and the patient’s doctor can intervene before a medical emergency happens.

And the free supplies helped too. Before the project, some employees admitted that, to save money, they had to get creative. They cut blood-sugar test strips in half, reused insulin syringes, or would do without medications and supplies until payday.

So the patients were happy with the services. But were they really healthier? After six months, 75 percent of patients showed at least some improvement in blood sugar. Sixty-three percent of them showed blood sugar in the optimal range, compared to 38 percent of patients before the intervention.

The longer the project went on and the more data we got, the better it was,” Cranor says. In 1999, employees of Mission St Joseph’s joined the intervention. As the project grew, Cranor realized it was big enough that she could write about the evaluation for her dissertation.

She continued to evaluate the project through 2001. At every follow-up, at least 58 percent of patients showed improvements in blood sugar. At some follow-ups, as many as 82 percent of patients showed improvement.

And not only were patients lowering their blood sugar, they were keeping it under control for as long as five years. “The finding that patients who were provided with continued pharmacist counseling were able to keep their blood sugar under control not just in the short run, but over several years, was most impressive,” says Dale Christensen, chair of pharmaceutical and evaluative sciences at the School of Pharmacy and Cranor’s dissertation advisor.

In the final evaluation, total medical costs decreased by $1,622 to $3,356 per patient per year. And more of the money was spent for preventive medications and less on emergency-room and hospital care. There were also signs that employees of the city of Asheville were more productive; every year from 1997 to 2001, their days of sick time taken decreased.

Barry Bunting, the project’s first coordinator and now primary-care specialty codirector at Mission St. Joseph’s, says that he suspected that the project was working, but Cranor’s data helped prove it.

Without the statistical analysis, we would not have been able to publish the results or even know whether those results were statistically important,” Bunting says. “It added validity to what we felt was a success.” The results were published in a group of articles in the March/April 2003 Journal of the American Pharmaceutical Association.

By now, the Asheville Project is old news. But in 1997, when the city decided to begin paying the pharmacists for their counseling, it was, in Cranor’s word, radical. “Pharmacists were actually getting paid to counsel patients,” she says. “To do what they were trained to do.”

Today, the project has expanded to include three other chronic diseases — high cholesterol, high blood pressure, and asthma. Wayne Annico, fifty-seven, receives counseling at Mission St. Joseph’s Diabetes Center for diabetes, high blood pressure, and high cholesterol. Annico says that the free diabetes-testing supplies were what first enticed him to sign up and attend the required counseling and classes.

I’d been a diabetic for close to forty years,” he says. “I was saying to myself, ‘What can they teach me that I don’t already know?’”

His attitude changed after the first class. “It rang a bell that obviously with the lab numbers that I had, I was doing something wrong,” he says. “I had to be willing to listen and make changes in my life.” Now, Annico checks his blood sugar four or five times a day. He eats a modified version of the Atkins diet, tries to exercise, and has his blood pressure checked at least three times a week. About a year ago, he developed an infection in his leg, but because he was monitoring his health so closely, his doctor treated it before it got out of hand. “This is the best I’ve felt in forty-five years,” he says. He volunteers at the diabetes center because “these people have basically saved my life.”

The project is now emulated around the country. Garrett, now senior director of medication-adherence programs at the American Pharmaceutical Association Foundation, is leading similar pilot projects in five sites — in North Carolina with employees of VF Corporation, in cooperation with Mohawk Industries in Georgia, with Ohio State University and the Kroger Company in Ohio, and in Manitowoc County, Wisconsin.

That national reach is something that Bill Campbell had hoped for from the start. Garrett says, “Bill Campbell had the vision to see what impact this could have not only in North Carolina but on a national level. Bill is the person who said, ‘You know, one day this project could have significant impact. We need to name it something, we need to brand it.’” Garrett remembers that it was Campbell who named it “the Asheville Project.”

Today, pharmacists talk about “doing Asheville” in Oregon or in Ohio. Campbell says, “The Asheville Project now is really more of a philosophy.”