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Patient Care Exchange Featuring Warren Narducci

Developing Patient Care Programs in a Rural Community Pharmacy
Patient Care Exchange Featuring Warren Narducci PharmD, RPh, FAPhA.


Written by Lynette Martin, PharmD Candidate

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.

Warren Narducci is the owner and pharmacist in charge of Nishna Valley Pharmacy (NVP) located in Shenandoah, Iowa. Prior to owning the pharmacy he was a professor of pharmacy for a number of years at the University of Nebraska Medical Center (UNMC), and he is currently an affiliate faculty member at UNMC, University of Iowa, and Drake University. NVP is an independent rural community pharmacy with areas of emphasis in compounding, home health equipment, and of course patient care services. The facility offers a private consultation room, a semi-private consultation room, a patient assessment room, and a CLIA-waived laboratory. In addition there is a conference room for patient education, which also houses the equipment used for screenings and medication monitoring programs. At the present time Warren works with one full time clinical pharmacist, Paula Carlson Pharm. D., RPh; one part-time pharmacist, Harold Duncan, RPh; and a pharmacy resident, Dana Damrow, Pharm. D., RPh. To assist the pharmacists, two technicians are employed; Ellyan Finnell and a certified technician, Sharon Hall. NVP is contracted to provide pharmacy services at Shenandoah Medical Center where Warren is the Director of Pharmacy. This is a 25 bed critical access acute care/geriatric psychiatric hospital. Throughout his life, Warren has been involved in pharmacy organizations as well as community events. Currently Warren is on the IPA Board of Trustees and in July he will begin a term on the Accreditation Council for Pharmacy Education (ACPE). Previously Warren was the Chair of the Community Pharmacy Residency Program Advisory Committee through APhA (American Pharmacists Association) and the Chair of the Clinical Sciences Section of APhA Academy of Pharmaceutical Research and Sciences. It was recently announced that Warren received the 2005 APhA Community Pharmacy Residency Excellence in Precepting Award. This award is given to preceptors who are leaders, innovators, and mentors as well as have an influential role on residents. Warren will accept this award at the 2006 National APhA Meeting.

Patient Care Services Provided
At NVP the pharmacists strive to provide valuable patient care services to their patients. Together these four pharmacists spend about half of their time on patient care activities and the other half on dispensing, management, and teaching. For each new prescription dispensed, in-depth patient education is provided on the medication and/or medical device. At the pharmacy, patients can be screened for diabetes, hypertension, hyperlipidemia, metabolic syndrome, stroke, and colon cancer. Disease states that are monitored at the pharmacy include diabetes, hypertension, and hyperlipidemia. Monitoring and screenings are performed on current pharmacy patients as well as patients who are referred from a physician or other health care provider. Information is also provided to patients about cancer screenings available to them such as prostate and breast cancers. To monitor progress of the patient, all encounters and interventions are documented in a patient’s paper chart. Additional patient care services provided at NVP include immunizations and ‘brown bag’ medication reviews. Each year the pharmacists administer over 600 immunizations to patients in southwest Iowa. The pharmacy also supplies influenza vaccines for local long term care facilities and home healthcare services. “Brown bag” evaluations are conducted to look for drug interactions, especially non-prescription and herbal; incorrect administration; inappropriate storage; costly drug duplication; and opportunities for cost savings for each patient. In addition the medication profile is reviewed and education is provided for every patient.
A unique patient care service offered at NVP is pain management. This program was created with a grant received from APhA to develop a community pharmacy based pain initiative. “Living with Pain” was designed by NVP pharmacists to give patients an overview of pain and the treatments available. “Living with Pain” includes websites available for patients and health care professionals, a PowerPoint presentation, and one-on-one counseling. This program is used in local hospice programs as well as in patients who require assistance with pain control. Having a compounding facility on site allows for the use of unique dosage forms for pain medications such as injectable medications (intravenous or subcutaneous), lozenges, and topical medications including sprays, lip balms, and transdermals. When appropriate, the patients are provided with an infusion pump and are trained on its use by a pharmacist.
A limitation to patient care services is the financial situations of patients. Up to 90% of the services provided are paid for out-of-pocket by the patient. The other 10% include services that are billed to Iowa Medicaid pharmaceutical case management (PCM) or Outcomes Pharmaceutical Health Care. PCM services are also provided to Farm Bureau patients through Wellmark and an IPA grant from the Community Pharmacy Foundation. NVP has applied for grants through different organizations to help support the disease state management programs. This includes the initiation of the pain management program, hypertension, and metabolic syndrome screening.

Making Time for Patient Care
With so many programs available at the pharmacy how does a pharmacist have time for all of them? To begin with, Warren recommends using technicians to the best of their ability and as allowed by law. To do this he trains technicians well and allows them to perform tasks that do not have to be completed by a pharmacist. He also expects and demands high interest and enthusiasm for learning from pharmacy students and interns. Depending on their educational level, they are involved in counseling and educating patients. As well they can assist with patient care programs.
NVP in collaboration with the UNMC College of Pharmacy offers a community pharmacy residency program. This program is designed to provide residents with the experience necessary to effectively practice in a rural, community setting. One of the main responsibilities of the resident is to maintain the patient care services after they have demonstrated proficiency. Residents are encouraged to begin new programs that are applicable to the patient population the pharmacy serves. In addition the resident is a drug information resource for patients as well as other health care professionals. Overall residents are a great asset to NVP and Warren feels they should be challenged to their fullest extent.

Business Model
Warren believes strongly in patient care services as part of an independent pharmacy. In fact he feels that without patient care services there is little benefit of an independent pharmacy. As a pharmacy owner he is able to develop and implement programs that lead to improved patient outcomes. Being able to choose this type of practice model has guided Warren to personal and professional satisfaction.
As a business owner, Warren feels an important aspect of developing these patient care programs is to determine the financial impact on the pharmacy. Not all programs are going to be successful in bringing in revenue. At a minimum the program needs to add to the bottom line. The business plan should be assessed early in the planning and continue to be assessed over time to enhance services.
Many of the successful programs at NVP were designed to be performed in collaboration with one or more physicians. In part these programs have been more successful because of the relationship between the pharmacist and physician. The development of relationships between the pharmacists and physicians is a slow process. At NVP with each new physician/pharmacist relationship the pharmacist begins by being a resource to the physician as well as providing a basic understanding for what pharmacists can do to improve patient care. As the physician begins to build acceptance the pharmacist will push against the physician’s resistance of pharmacy. This in turn causes the physician to grasp the full concept of disease state management programs and the pharmacist’s role in healthcare beyond dispensing medications. This trusting relationship must be maintained through effective communication, and it is also necessary to keep the physician informed of patient interactions.

What’s to come?
One future goal includes re-implementation of the immunization program, which experienced a downfall over the last two years due to vaccine availability. A second goal is to become part of a national network of pharmacies that provide medication therapy management services under a standard study template through expanded services of Medicare Part D. Another goal is to begin to implement collaborative practice when legislation is passed. The overall goal is to “cement the expanded role of the pharmacist”.

Thank you to Warren for sharing his practice experiences with the pharmacy profession. One important message was clear—be involved in professional organizations. Warren believes strongly in involvement in professional organizations such as the Iowa Pharmacy Association and the American Pharmacists Association. Attending meetings and being active assists in developing and maintaining patient care services and patient management programs. These benefits are tremendous to practice. Warren also believes that in order to maintain patient care programs you must “persevere”. It is difficult to begin and maintain patient care programs with the lack of reimbursement. You have to be willing to invest time and money with no guarantee. If you do not persevere you will never get to the goal of a profitable business.

Lynette Martin is a Doctor of Pharmacy Candidate from Drake University College of Pharmacy and Health Services. She wrote this article while on rotation at the Iowa Pharmacy Association.

Republished at The DELTA Rx Institute website with permission from the Iowa Pharmacy Association and Warren Narducci.

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