Patients with complex drug regimens for multiple disease states can be at high risk for a host of complications, including worsening disease, hospitalization, medication-related problems, and increased cost. Community pharmacists are ideally placed to manage these patients in a way that can positively impact their health outcomes.
“For disease state management, the pharmacist is the social worker that America never knew they had,” said Travis Wolff, PharmD, co-owner of Med-World Pharmacy in Sapulpa, Oklahoma. “Community pharmacists know the income level, they know the family situation, they know the patients by name, they know if they have transportation or delivery, they know so much about the patients and their lives beyond their drugs, and that knowledge is key.”
Syncing Up for Success
For high-risk patients with multiple prescriptions, med sync is essential, experts say. “You can catch so many med errors and improve so many chronic disease states with sync,” Wolff noted.
Not only does med sync simplify refilling prescriptions for patients, said Randy McDonough, PharmD, co-owner and director of clinical services of Towncrest Pharmacy in Iowa City, Iowa, but it also increases efficiency in the pharmacy and allows implementation of an appointment-based model. “When patients come to pick up their prescriptions we can sit down with them to make sure that we’re monitoring their medical conditions and medications appropriately and make any interventions we need to optimize their medications,” he explained.
Keeping track of complicated drug regimens can be overwhelming for patients, so compliance packaging can play a key role in improving adherence. At Towncrest Pharmacy, the most popular option for high-risk patients is what they call “Supersync,” single-dose packets of multiple pills packaged by a robotic dispensing system, Parata PASS. There are various options for user-friendly prescription packaging, McDonough said, but he cautions that labeling must comply with board of pharmacy regulations.
Holyoke Health Center, with locations in Holyoke and Chicopee, Massachusetts, is a federally qualified health center (FQHC) that serves an underserved, mainly Hispanic population. Its community pharmacy dispenses prescriptions to both health center patients and patients in the community and provides medication therapy management (MTM) for complicated patients. According to chief pharmacy officer Lori Lewicki, RPh, almost all of patients who receive MTM are dispensed their medications in a MedBox: a perforated card with bubble packs for 4 separate daily dosing times. To ensure patient comprehension, MedBoxes are labeled in English, Spanish, and with pictures, since 12% of their patients are illiterate. Med- Box use has been shown to significantly improve adherence and decrease overall medical costs.
With any packaging option, Wolff noted that good communication between the patient and pharmacist is essential, because otherwise, serious medication errors can occur if prescriptions are changed mid-month. McDonough explained that when necessary due to medication changes between refills, patients bring back all their medication packets to have them repacked with the correct new drug.
Pharmacists counseling high risk patients must establish a good rapport with them, McDonough said, “because you’re going to be managing these patients in a different way, it’s more a case management where you’re going to be meeting with them on a regular basis.” Pharmacists should take the time to explain the patients’ conditions and how their medications are affecting the conditions, McDonough added. Motivational interviewing techniques are important, as are asking open-ended questions and identifying what knowledge the patients have and what must be filled in.
Although following practice guidelines is important, Wolff noted that his pharmacy has been successful with patients because “we meet them where they’re at.” He advises that after counseling, particularly regarding nonpharmacological lifestyle changes, the pharmacist should ask the patient, “Is any part of what I told you difficult for you to achieve?” In his diabetes education program, for instance, after reviewing dietary guidelines, pharmacists ask patients, “What are some of the foods you can never give up? What foods are important to your culture, your family?” They then adapt the advice to the patients’ lives, Wolff said, teaching them how to eat the foods they won’t give up in the appropriate quantities and how to adjust their diet elsewhere to compensate.
To effectively manage high-risk patients, pharmacists must understand and address their challenge. Lewicki stressed that pharmacists must consider patients’ health literacy and make sure to convey information in ways their patients can understand. Financial difficulties can pose a barrier to implementing nonpharmacological lifestyle management advice, said Marisa Piers-Gamble, clinical pharmacy coordinator at Holyoke Health Center. “It’s easy for us to tell them how to change their diet, but when they get home it’s a matter of how they can afford it,” she said.
Because many of Holyoke’s patients are Spanish speaking, community health workers (CHW) are a valuable pharmacy resource. In addition to teaching the staff key Spanish words and acting as interpreters for pharmacists during MTM visits and the immunization clinic, they conduct staff cultural competence training in which they explain how illnesses are viewed differently in their patients’ culture. CHWs reach out to patients a few days before their MedBox is set to refill to determine whether there have been changes to the patients’ therapy. MedBoxes are delivered for free; a new program will allow the delivery driver to bring an iPad with which patients with questions can connect to the pharmacist face-to-face. And to overcome transportation difficulties for patients who need to be seen in person at the clinic, Holyoke now uses Uber Health, Lewicki reported.