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Implementing New Patient Care Services – Zostavax® Immunizations.

Jana Voss is a student pharmacist from Drake University College of Pharmacy and Health Sciences.  She will earn her Doctor of Pharmacy degree in May 2007.  Jana authored this article while on rotation at the Iowa Pharmacy Association

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.

Sarah Boyce is a pharmacist and the patient care coordinator at Reutzel Pharmacy located in downtown Cedar Rapids, Iowa.   Sarah attended the University of Wisconsin School of Pharmacy and graduated with her PharmD degree in 2005.   After graduation, Sarah completed a Pharmacy Practice Residency with an emphasis in community care through the University of Iowa College of Pharmacy at Osterhaus Pharmacy.  After completing her residency, Sarah continued to pursue opportunities to develop pharmacy practice in a community setting and joined the staff of Reutzel Pharmacy.  Reutzel Pharmacy is an independent pharmacy owned by Becky Reutzel, RPh.  In addition to Sarah, Reutzel Pharmacy employs a third pharmacist, Becky Serovy, RPh.  Sarah’s involvement in professional associations includes membership in the Iowa Pharmacy Association (IPA), the Pharmacy Society of Wisconsin (PSW), and the American Pharmacists Association (APhA).  She also regularly volunteers at the Community Health Free Clinic in Cedar Rapids.  

Patient Care Services Provided

At Reutzel Pharmacy, the pharmacists and staff continue to invest in the implementation and maintenance of patient care programs.   As Patient Care Coordinator, Sarah spends more than half of her time coordinating current patient care programs, determining new areas of business growth and marketing, and coordinating the marketing of pharmacy programs with AIM Healthcare (Reutzel Pharmacy’s partner home medical equipment business).  Her remaining time is divided between staff, patient education and prescription dispensing.    

Zostavax® Immunizations

One new and unique service that Reutzel Pharmacy provides is the administration of the Zostavax® (Shingles) vaccine.  Sarah marketed this service to physicians in the Cedar Rapids area by faxing an announcement that they would begin offering the vaccine administration and then followed these faxes with personal office visits.   As a result, Reutzel Pharmacy is now a provider of the vaccine for many area clinics.  Physicians were very receptive and have appreciated the involvement of the pharmacy in providing this vaccine because Zostavax is classified as a Medicare Part D benefit and can be billed through the use of the pharmacy’s prescription processing system.  Most Medicare Part D plans cover the vaccine, as it is the only drug in its class.  Like any other Part D medication, patients will have variable co-pays through their plan.  Currently, the vaccine (drug product) is billed through the patient’s Part D plan and, for 2007 only, the vaccine administration, similar to hepatitis B, is billed under Medicare Part B with 80% of the administration ($15.46) covered by Medicare and 20% ($3.87) covered by the patient’s Medicare supplement.  In 2008, the vaccine product and administration will be billed directly to the patient’s Medicare Part D plan.  To minimize patient confusion and inform patients of how much the vaccine will cost, Sarah processes the claims prior to immunizing the patient. 

Although alternative immunizing practices have been recommended, at this time Sarah feels their current method is the most appropriate.   One alternative method is having a patient pick up the vaccine from a pharmacy and return to the clinic or physician’s office for administration.   This method is problematic due to the fact that Zostavax is a frozen vaccine, and once thawed has only a 30 minute window of studied efficacy.  Another alternative method would be to participate in a protocol or collaborative practice agreement with a standing order from a physician.  Although this method has been successful for influenza and pneumococcal vaccines, Zostavax is a live, attenuated vaccine.  Pharmacists administering this vaccine have a much more complex intake questionnaire dealing with immune status, and therefore Sarah has felt more confident administering the vaccine knowing that the patient has seen a health care provider who is familiar with their previous medical history and current immune status.      

Issues still in place with administering Zostavax include the need to bill both Medicare Part D and Medicare Part B (hopefully to be resolved in 2008), as well as the ordering process which requires pharmacies to order through their wholesaler rather than directly from the manufacturer.  The manufacturer has also had issues with keeping the vaccine in stock for wholesalers with the product frequently on backorder.      

Ongoing Patient Care Programs

Additional patient care programs provided by Reutzel Pharmacy include participation in Iowa Medicaid pharmaceutical case management (PCM), Farm Bureau PCM program, influenza immunizations, CCRx medication therapy management (MTM), smoking cessation counseling, Blood Pressure Club program, Community Health Free Clinic partnership, and bone density screenings.  In addition to these programs, Reutzel Pharmacy provides medication box filling for approximately 20 patients per month; this service helps patients with complex medication regimens adhere to their prescribed therapy.  They also offer free prescription delivery in the Cedar Rapids area.

Over the past year, Reutzel Pharmacy has seen an increase in provider and patient participation in their pharmacy care services.   Currently, Reutzel Pharmacy has around 85 active patients involved in the Iowa Medicaid PCM program and files approximately 6 claims per month.  Sarah and the other pharmacists on staff at Reutzel Pharmacy assess and follow up regularly with 6 Farm Bureau PCM and 6 CCRx MTM patients.   They administer approximately 500 flu shots annually, and in the first three weeks of offering the Zostavax vaccine, have administered approximately 25 immunizations.   In January 2007, Sarah began counseling patients on smoking cessation and has been following up with these participants on a regular basis.  Iowa Medicaid’s decision to cover nicotine replacement therapy for some of their patients has worked to complement smoking cessation counseling done through the PCM program.   Reutzel Pharmacy’s Blood Pressure Club includes either a single blood pressure check by a pharmacist or the purchase of a package for 6 blood pressure checks to be reported back to the physician; there are around 10 patients that participate in this program on a regular basis.  For many years, Reutzel Pharmacy and the Cedar Rapids Community Health Free Clinic have partnered to provide medication dispensing and education to patients with inadequate or no insurance.  Approximately 25 patients from the free clinic visit Reutzel pharmacy each week.   Reutzel Pharmacy focuses on billing their services to third party payers.   “The number of third parties that are willing to pay for pharmacy services is small, but gradually increasing,” says Sarah.  “Our patients appreciate our care, but perhaps would not be able to afford these services without the help of their third party insurance.  Having these services billed for them by our pharmacy certainly provides incentive to them to participate.”

Patients currently participating in these pharmacy services are identified through the dispensing process, by listening to the needs of the patients, and by referrals from other members of the healthcare team.  Sarah reports that “providing immunizations such as flu and shingles has really been ‘a foot in the door’ with many of the area physician offices.  We can use these tangible services as a chance to market our other programs.”  As a result, Reutzel Pharmacy has developed a strong connection with the providers in the community and has received a great deal of positive feedback from providers and patients. 

Making Patient Care Programs Successful

Dividing time between the various patient care programs, staffing, and dispensing can be difficult.   One way Sarah says that Reutzel Pharmacy is able to accomplish a balance is by utilizing their well trained and experienced technicians and support staff.  The technicians and cashier have been valuable by helping the pharmacists to provide a high quality of customer service at the pharmacy counter, over the phone, and in the timely preparation of prescription orders.  Sarah stated that, “Our technicians and support staff is our triage staff.  They are often the first contact our patients have when they call or stop into the pharmacy and they refer patients to the pharmacist when appropriate.”  The way in which the technicians and support staff at Reutzel Pharmacy are so well trained is in part due to the involvement of all of the staff when new programs are initiated and when new developments are made in pharmacy practice; education is crucial to Reutzel Pharmacy staff when new evidence is found and when new drugs come onto the market.   Currently Reutzel Pharmacy does not have pharmacy interns or residents working with them, but the staff looks forward to precepting University of Iowa College of Pharmacy Pharmaceutical Care Rotation students starting this summer.   

Sarah states that the key in initiating patient care programs at Reutzel Pharmacy has been through connections with organizations and information provided by these organizations.   The connections Sarah has made through IPA and other pharmacists she has met in the area through IPA and University- sponsored programs have been great resources.   Sarah states that, “It is so valuable to have someone to ask questions of or provide me with resources.”   Discussions with colleagues, emails, journals, and newsletters have been sources of ideas for the development of new programs.

How do you maintain a program once it is started?  The first step, according to Sarah, is to be well informed about the issues surrounding the provision of that particular patient care program and be excited about the program.  “I experience so much joy in working on a program I am excited about!”  states Sarah.  “It is also important to assess the financial impact on your practice site when deciding whether to maintain a current program; what is the gross and net profit for each program, and how much time and effort is involved.”   As the patient care programs at Reutzel Pharmacy grow, the staff plans to analyze the clinical patient outcomes.


Future Goals

Sarah looks forward to Reutzel Pharmacy being a Pharmaceutical Care Rotation site for University of Iowa students, and hopes to provide an excellent experience for these students.   During the next year, Sarah plans to begin providing at least one new point-of- care testing program, generate increased revenue from Iowa Medicaid and Farm Bureau PCM programs, and to continue to provide the Zostavax vaccine for Cedar Rapids area patients, using this service to strengthen relationships with area physician offices. 


Thank you to Sarah for taking time from her practice to share her experiences with the profession.  Sarah has clearly carried her experience from residency into practice by implementing and continuing several patient care programs at Reutzel Pharmacy.   Sarah is one of the first pharmacists in Iowa to offer the Zostavax vaccine to area patients, and as a result has strengthened the relationships between Reutzel Pharmacy and area prescribers.   Sarah’s excitement for the profession and patient care will be carried over to student pharmacists as they begin Pharmaceutical Care rotations at Reutzel Pharmacy.