|by Emily Cosgrave Allison Amick|
Callie Amick and Emily Cosgrave are 2009 Doctor of Pharmacy candidates from Drake University College of Pharmacy and Health Sciences. Callie and Emily wrote this article while on rotation at IPA.
Reprinted with permission from the Iowa Pharmacy Association Journal. The Patient Care Exchange feature of your IPA Journal is intended to provide the opportunity to learn how your colleagues are advancing patient care in their practice. This feature provides a forum to identify challenges and to brainstorm solutions to barriers that may hinder the provision of patient care services.
Dr. Corey Garvin is the pharmacy manager and director of clinical activities for Wester Drug which currently consists of two practice sites: Muscatine and Wilton, Iowa. Dr. Garvin grew up in Muscatine, Iowa, received his B.S. in Pharmacy from the University of Iowa in 1994, and his Pharm.D. from the University of Iowa in 1996. In 1997 he completed a nutritional support/critical care residency in Memphis, Tennessee, and then a fellowship on critical care/infectious disease in 2000 at the University of Toledo in Ohio. Dr. Garvin also served as an assistant professor of infectious disease and critical care at the University of Missouri-Kansas City from 2000-2004. Throughout his post-graduate education, Dr. Garvin also worked part time in various positions including community pharmacy, hospital pharmacy, and poison control. He has been pharmacy manager and director of clinical services at Wester Drug since moving back to Muscatine, Iowa, in 2004. Dr. Garvin is currently serving on the Iowa Pharmacy Association Board of Trustees.
All About Wester Drug
Wester Drug is an independently family owned pharmacy with one stand alone location (Muscatine) and one location within a physicians’ office (Wilton). Like other independent pharmacies, Wester Drug takes pride in being family-oriented and community focused. It even accommodates Dr. Garvin’s schedule as cross country coach at their local school. Wester Drug offers numerous clinical services and programs including a continuous positive airway pressure (CPAP) program, Iowa Medicaid pharmaceutical case management (PCM), immunizations, Medicare MTM services, and an antibiotic callback service Wester Drug also provides consultation to two long term care facilities, one county sponsored home and one independent living home.
Time management and delegation are important at any pharmacy. The same is true at Wester Drug where they utilize their students and technicians in a very efficient manor allowing pharmacists time to focus on the clinical care programs that the stores offer. Wester Drug does not have a residency program, however, they do precept students on rotation from the University of Iowa. Rotation students provide most of the patient counseling, within earshot of a pharmacist, and also participate in the PCM, MTM, long-term care consultation, vaccination programs, and CPAP programs. When it comes to delegating responsibilities to pharmacy technicians Dr. Garvin explains, “We utilize our techs as a physician utilizes their nurses. Technicians are smart individuals who care deeply about patients. Our techs triage patients and patient telephone calls and answer some patient questions under the guidance of our pharmacists.” The technicians at Wester Drug help with basic education of their CPAP service, such as machine maintence, and also do follow up telephone calls. The technicians also handle the billing process and can even write a SOAP note on top of performing the normal dispensing processes. The technicians also answer all phone calls and have been trained to take prescriptions from prescribers. With all of the work that the technicians are allowed to be involved with, it leaves more time available for the pharmacist to help with patient care programs. “The technician serves as a means of enabling these meetings but only if the pharmacist has time” states Garvin.
Clinical Programs in Depth
When asked how Dr. Garvin spends his time in the pharmacy he replied that he spends “50% patient care, 35% dispensing, 15% management.” Programs and services currently offered by Wester Drug include Iowa Medicaid pharmaceutical case management, Medicare Part D MTM service, an influenza and shingles vaccination program, long term care consultation, and CPAP services. These patient care programs are available at both Wester drug locations. At the Wilton location there is also an antibiotic callback program in which the patient is called within 72-96 hours after an antibiotic has been dispensed to follow up, as well as assess the patient’s response and/or adverse reactions. Within this program, which was started in 2003, they have made over 3,500 callbacks so far. Wester Drug established its vaccination program in September of 2006 and gave approximately 350 influenza vaccinations in the year 2006 with hopes of that number doubling in 2007. Their Zostavax program is currently in development. The PCM and MTM programs at Wester drug are also important aspects of care. Since December of 2005 they have provided PCM services to 35 patients and MTM services through Medicare part D to 11 patients in 2006 and 14 already in 2007.
Of all the clinical programs offered at Wester Drug, perhaps the most unique is the Continuous Positive Airway Pressure (CPAP) service. This program was established in December 2005 and approximately 185 patients have been enrolled. In this program the pharmacist performs an initial consultation. At this time he or she goes over the patient’s history and medications, and discusses how medications can play a role in improving the patient’s breathing. Like so many aspects of Wester Drug, Dr. Garvin delegates a lot of the maintence work in this program to the technicians. The technicians handle the education of the machine itself, as well as how to clean the machine with the patient. The technicians also do the mask fittings and call patients periodically to see how the machine is working for them to address any concerns that the patient might have. Wester Drug also offers a service that looks at the average AHI (apnea hypopnea index) over a period of time. Dr. Garvin looks at these numbers provided by the individual’s machine and compares them to the numbers of the diagnosis to assess how effective the therapy is and reports those findings to the patient’s primary care provider.
Reimbursement for Wester Drug’s clinical programs comes from 3rd party (75-80%) as well as some out of pocket payers (20-25%). Usually the patients who are paying out of pocket are utilizing the CPAP program. Programs are evaluated by the income they bring in vs. the time and resources they require, and also by comparing the effectiveness of their programs to other practices offering such programs in literature. Cost is not the only thing that is considered when looking at these clinical programs, as Dr. Garvin is also concerned with the number of patients who benefit and who are more adherent to therapies as a result of them.
Advice for Clinical Program Development
Setting up any clinical based program, let alone numerous programs, has its barriers. When asked what barriers he has come across in his practice setting and how he overcame them, Dr. Garvin stated “The three barriers we have encountered most frequently include resistance from prescribers, resistance from patients, and how to be paid for our services.” He has overcome this resistance by providing patient education and frequent follow ups with patients and their primary care providers. Wester Drug tries to include physicians as much as they can in their approach to patient care which helps with the resistance from them and has even caused some area physicians to seek input from the staff at Wester Drug. As for the patients- “Once they see the value of what we do, they seek our care and, for services not covered by a third-party payer, these patients are more willing to pay out of pocket” states Garvin. Follow ups are also very important in the programs. By following up after a CPAP appointment, or a new antibiotic prescription, it shows the patient how much the pharmacist cares, as well as provides the pharmacist information needed to maintain a good SOAP note and patient profile.
As for implementing a new patient care program, Dr. Garvin’s instruction is “go for it. Have faith in your education that you have something of value to offer patients. My advice before implementing a service though, is have a system in place. Know what your general approach is going to be when that first person comes through the door, from your opening questions, to how you may implement your plan, to actually billing for the service, and following-up with the patient and/or prescriber.” He feels that pharmacy is going to continue to evolve and by becoming proactive in patient care programs and sharing our knowledge on medications, we not only provide ourselves job security, but improve our patients’ quality of life.
The clinical programs that Wester Drug has implemented with the help of Dr. Garvin are a shining example of the great programs community pharmacists can offer. While Dr. Garvin has a lot of advice to offer on setting up and maintaining a clinical program, he also offers this advice from Jim Wester, owner of Wester Drug, “sometimes the most effective therapy we provide is a hug.” Dr. Garvin continues with “Obviously we don’t hug all of our patients, we have a relationship with most, such that we would do so if the situation calls for it. While it is not our goal to use this approach of care to grow our clinical services, it has done so given that patients see us as someone who truly cares and is also knowledgeable about their health.” Incorporating care into clinical programs has proven to be key for Wester Drug’s programs and success.