Niche Services and the Road Less Taken

"It's not enough to commit to change, you must commit to always changing": a life rule that this pharmacist has embraced.

Do the statements above describe you and your practice? If not, chances are you have a very negative opinion of the rapidly changing landscape in health care. One of my pharmacy school professors made an extremely prophetic statement: “It’s not enough to commit to change, you must commit to always changing.” In our efforts to keep pace with the changes ahead, we must embrace change and be willing to take the road less taken.

As the baby boomers age, health care and medication costs continue to rise. In order to manage these patients both clinically and fiscally, numerous niche pharmacy services continue to surface. These services include, but are not limited to, medication therapy management, adherence programs, immunizations, diabetes care, blood pressure monitoring, smoking cessation, lipid monitoring, asthma management, weight and osteoporosis management, HIV/AIDS services, mental health services, anticoagulation monitoring, and cancer awareness education. These services allow us to move our profession away from the traditional drug curator role and toward the desired role of health care provider.

Changes

Several years ago, we made a conscious effort at our pharmacy to try to tackle some of the most difficult patients. The majority of these patients have no fewer than a half dozen disease states with at least as many medications. Many live in adult care homes, while others are ambulant in the community. We offer special compliance packaging, on-site pharmacy consulting, and medication delivery. We also provide similar services to both mental health and HIV facilities in the area.

Our pharmacy is also certified by each of the major clozapine registries, and we coordinate:

• Obtaining lab values for close to 100 patients
• Screening those lab values to ensure that there has been no significant drop in white blood cell count (WBC) or absolute neutrophile count
• Either faxing or entering those values into the online registry
• Then, assuming there's been no significant drop in WBC or ANC, dispense in 7-,14-, or 28-day increments (per protocol) to ensure the patient's safety

We also coordinate care with our adherence program for patients outside of these facilities to decrease hospitalizations, improve outcomes, and enable these adults to both preserve their independence and prevent a costly transition to assisted or skilled care.

Medication Adherence Programs Work

We often get the question, “What is medication adherence and why is it so important?” Medication adherence means medications are:

• Taken at the right time of day
• Taken with or without food
• Taken completely and refilled appropriately
• Stored correctly

Many of us don’t like having to take medicine, especially not multiple medications daily, but how often do we actually consider the problems that nonadherence can cause? Nonadherence to medication can lead to many problems, including an increase in cost to both the patient and insurer, and lead to a decline in the patient’s overall health.

Poor adherence may give a patient’s physician the false impression that the current medication regimen is not working appropriately, causing the physician to add unnecessary medications to the current regimen. Studies have shown that taking medication with less than 80% accuracy (referred to as medication possession ratio, or MPR) leads to expensive hospital visits, increased admissions to nursing homes and rehabilitation centers, and poor overall outcomes. However, with our program we report these issues to the patient’s provider to ensure the best outcomes.

With this adherence program we offer the following:

Medication Reviews

At our reviews, we offer a simple 30-minute consultation with one of our pharmacists to arm our patients with the tools they need to improve compliance. We provide them with a comprehensive list of their medications, including:

• What they are used for
• How and when they should be taken
• If they should be taken with or without food
• How they can affect other medical conditions
• How they may interact with other medications
• Suggestions for less expensive medications

Synchronized Medication Refills

We offer this service for numerous reasons. Synchronization helps the pharmacist and loved ones to quickly access noncompliance issues and enables the pharmacist to see a patient’ s entire medication regimen, rather than rely on a technician or a computer to check for interactions or duplication in therapy.

Special Packaging

As the number of medications increases, a patient’s ability to remain adherent becomes exponentially more difficult. Another way we offer support to our patients is with our special packaging program. Rather than having medications dispensed in a vial or bottle, a patient’s medications are packaged in a special card that makes it very easy to see if a dose has been missed.

Technology

More than 50% of the population now has a smartphone. Health Park Pharmacy is in the process of interfacing with a smartphone application that will do the following:

• Prompt you with a phone call whenever it is time for you to take your medication
• Verify that you are taking the correct medication with RFID/bar-code verification
• Allow you to report any adverse effects to your doctor or pharmacist immediately
• Enable your pharmacy to monitor how well you are taking your medications
• Allow our pharmacists to make a clinical intervention using Facetime, Skype, or a home visit if a patient's MPR drops below acceptable values.

This service will most likely cost about $100 to $150 per month. That cost is significantly less than the cost of a hospital admission ($25,000+), emergency department visit ($5000 to $10,000), or the cost of a skilled nursing facility (~$7000 per month). With all of these tools, our pharmacy team can help patients maintain independence and live a longer, healthier life.

It’s not easy, but services like these will continue to push our profession forward and away from commoditization.

Steve Adkins, PharmD, is co-owner of Health Park Pharmacy in Raleigh, North Carolina. He has a passion for patient care and mHealth. Over the last 10 years, he has provided one-on-one advice to his patients to improve their health by working with physicians to provide the best plan for each individual. He was inspired to become a pharmacist by Don Deaton and Linda Deaton Adkins. They encouraged him to take a job as a delivery driver at his hometown pharmacy in Danville, Virginia, and it was there that he felt the impact this business had on his community. As a result of these experiences, his goal as a community pharmacist has been to educate patients to improve their health. He hopes to utilize mHealth to take medication adherence and patient care to the next level.