Duquesne cares: Providing pharmacist services in a medically underserved community
The Center for Pharmacy Care sits on the edge of Duquesne University’s campus in downtown Pittsburgh. Located on a major bus route and within walking distance for many, the ambulatory care center is a main point of access for primary and urgent care services for members of the community, who are mainly black and economically disadvantaged.
“Within a 10- to 15-mile radius, we didn’t have preventive or wellness services for the community,” Suzanne Higginbotham, PharmD, BCACP, director of the Center for Pharmacy Care, told Pharmacy Today. Duquesne University Mylan School of Pharmacy set up the Center for Pharmacy Care in 2002, and in 2010, opened the Duquesne University Pharmacy, which is the only dispensing pharmacy in the area.
The Duquesne pharmacy school’s Pharmacy Service Centers and Academic Partners Program received the 2015 Pinnacle Award in the Government Agency–Nonprofit Organization–Association category from the APhA Foundation at APhA headquarters on September 16. (See sidebar for information on the other two Pinnacle Award winners.)
The Center for Pharmacy Care is run by pharmacists who see patients, either by appointment or on a walk-in basis, Monday through Friday. Three clinical pharmacists (including Higginbotham), as well as student pharmacists and residents on rotation, provide medication therapy management (MTM) services, smoking cessation counseling services, adult immunizations, extensive point-of-care testing, and more.
While they provide these services to students and faculty on campus, 70% of patients who come to the center are from the community, according to Higginbotham.
“They know we are there, and we’ve established ourselves as a place they can come to get help,” she said.
Patients pay per service based on a sliding-scale fee and are still offered services even if they can’t afford them.
Defining ‘medically underserved’
The population served by the Center for Pharmacy Care falls into what the Health Resources and Services Administration (HRSA) in the U.S. Department of Health & Human Services classifies as a Medically Underserved Area (MUA). According to HRSA, MUAs have a shortage of personal health services based on whole county, group of contiguous counties, group of county or civil division, or group of urban census tracts.
HRSA also categorizes a medically underserved community with the designation of Medically Underserved Populations (MUPs) or Health Professional Shortage Areas (HPSAs).
Communities can fall under just one or all of the HRSA designations. MUPs, along with MUAs, have inadequate numbers of primary care providers, high infant mortality, high poverty, and/or high older adult populations. HPSAs can be geographic, demographic, or institutional and have shortages of primary, dental, or mental health care providers.
Despite a common perception by most Americans that medically underserved communities are in rural areas, many, like the Center for Pharmacy Care, are located in inner-city, urban areas.
Provider status legislation in Congress
According to HRSA data, all 50 states and the District of Columbia include areas designated as medically underserved, making access to health care an issue for many Americans.
The Pharmacy and Medically Underserved Areas Enhancement Act (H.R. 592/S. 314)—federal provider status recognition legislation for pharmacists—could provide relief by enabling patient access to, and coverage for, Medicare Part B services by pharmacists in medically underserved communities. (See Figure 1.)
“If the House bill and Senate bill were approved [and signed into law by the President] and then put into place by pharmacy regulations, it would open up so many doors,” said Higginbotham.
For starters, it would recognize in federal law what pharmacists are already doing—working with other health care providers as a part of the health care team to optimize patient care.
Working with family medicine
The Center for Pharmacy Care provides expanded pharmacy services because it operates as a state-licensed Clinical Laboratory Improvement Amendment (CLIA) facility with the ability for pharmacists to screen patients for diabetes, dyslipidemia, hypertension, pulmonary function, carbon monoxide, bone density, and thyroid conditions.
“We can run all the labs and then send those results to the physician,” said Higginbotham.
The Center for Pharmacy Care has a close working relationship with a small family medicine practice nearby called Smithfield Medical.
“The scope of practice of pharmacists has changed tremendously in the past decade or so,” Michael J. Essig, MD, one of the two physicians at Smithfield, told Today. “They provide new services that I appreciate a lot.”
Essig most often refers patients who have a new diagnosis of diabetes and need help with diet, use of diabetes medications, and proper monitoring of their disease.
He said a second related group of referrals are patients new to using insulin, and he also has a large number of low-income patients who have trouble understanding their complex medical problems and medications. But there are many other cases as well.
“I have referred patients who require assistance with managing their use of warfarin and are in need of point-of-service INR [international normalized ratio] testing. I also send patients who have needs for vaccines that we do not carry in our office,” said Essig.
Higginbotham said they contact a physician with any medical-related issue or problem a patient has. Almost every time, they receive a response from a physician after sending over a recommendation, meaning they get a physician on the phone or through fax who will respond that they have seen the recommendation.
Only dispensing pharmacy in area
If there’s a change in prescription, physicians send it directly to the Duquesne University Pharmacy—which serves as the only dispensing pharmacy in the area. Before they opened in 2010, there hadn’t been a pharmacy in the area for more than 15 years.
Besides dispensing medication, the pharmacy is also filling in gaps of care with screenings, patient education, drug therapy management, and disease state management.
A big component of the pharmacy team’s work is community outreach. The area they serve has one of the highest concentrations of seniors in all of Allegheny County, PA. Many of the seniors also have limited access to transportation.
“We have nine senior high rises we go to on a routine, monthly basis,” Terri Kroh, BSPharm, who serves as director of the Duquesne University Pharmacy, told Today. “We go to them since they can’t come to us.”
The pharmacy team performs blood pressure, cholesterol, and glycosylated hemoglobin (A1C) screenings and just added an anticoagulation service. They also offer free medication delivery services to patients.
“It’s important for our seniors and vulnerable populations to have that connection that someone is spending more than 5 to 10 minutes with [them], someone is listening and caring,” said Kroh.
Provider status: ‘More patients getting services’
Federally qualified health centers (FQHCs) receive grants under Section 330 of the Public Health Service Act (PHS), and to be reimbursed, they must be located in an underserved area.
Many have pharmacists working on the patient care team. APhA President-elect Jean-Venable “Kelly” Goode, PharmD, BCPS, FAPhA, FCCP, is professor and director of the community pharmacy residency program at Virginia Commonwealth University School of Pharmacy, but he also provides patient care services, mainly for chronic conditions, in an FQHC in Virginia for people who are homeless.
She said if provider status were enacted, she would be able to bill for her patient visits, which are more than 500 per year for the roughly 12 hours per week she works at the FQHC.
“This would mean more money to the center and more patients getting services,” said Goode.
Filling in gaps in primary care
Other models across the country have pharmacists filling in the gaps for primary care services.
Andrew Bzowyckyj, PharmD, BCPS, CDE, has a practice site in a medically underserved area of Kansas City, MO, where patients are in need of care but primary care providers are in short supply.
“Lots of patients here seem to have multiple specialists, but it can be difficult for them to regularly see a routine primary care physician, especially at an academic medical center,” Bzowyckyj told Today.
He is based in an endocrinology outpatient clinic at Truman Medical Center in Kansas City but is transitioning into the internal medicine clinic across the street. As a board-certified pharmacotherapy specialist and diabetes educator, patients can see Bzowyckyj more often than they can get in to see their primary care provider, which is about every 3–6 months. This also prevents patients from having to see a different provider for each visit and to rebuild a therapeutic relationship every time.
“I can be a stable provider that the patient can see very regularly,” said Bzowyckyj.
Truman Medical Center is a disproportionate share hospital that serves low-income residents in Kansas City and Jackson County. Many patients are either underinsured or without insurance, and because Missouri is not expanding Medicaid under the Affordable Care Act, the uninsured population is expected to grow.
‘Looking at the patient as a whole’
Bzowyckyj said he will continue to be a safety net provider for patients with diabetes in his new location.
“Obviously we are not the primary care provider, but we have been navigating that space and looking at the patient as a whole when we provide comprehensive medication management,” he said.
Through collaborative practice agreements and referrals, he provides medication management for diabetes patients as well as for patients who have hypertension and high cholesterol.
Oftentimes, Bzowyckyj is the most accessible provider for his patients.
“We are the point person to call. If they are stuck, they call us for help,” said Bzowyckyj.
To resolve the access issue, many health systems rely on nurse practitioners and physician assistants to help with managing a patient’s chronic conditions. However, these providers are often extensions of the physicians they work with, according to Bzowyckyj.
“As a pharmacist, I am able to approach the patient from a different perspective than all of them: through the lens of the medication list to make sure all of the medications are indicated, safe, effective, and convenient,” he added.
Even if a patient is insured, as a pharmacist, Bzowyckyj can help them find more affordable medication alternatives to decrease their out-of-pocket expenses.
In addition, the services he provides can free up primary care providers to care for patients with more immediate needs.
“If we are seeing a patient for a chronic care visit, that opens up, in theory, a physician’s slot for someone who is higher acuity—for instance, someone who has been discharged from the hospital,” said Bzowyckyj, who is also a clinical assistant professor at the University of Missouri–Kansas City School of Pharmacy.
Opening up an opportunity
If pharmacists’ patient care services were covered under Medicare Part B, as H.R. 592/S. 314 would require, the appropriate patients would shift over to Bzowyckyj without the health system being penalized by lack of payment for the pharmacist providing these services, he said.
Although Bzowyckyj is funded by the university as a faculty member, provider status legislation, if passed, would open up an opportunity for the health system to directly employ pharmacists for the sole purpose of providing these services to patients in the outpatient clinic setting.
Two more winners of the Pinnacle Award
The APhA Foundation’s 2015 Pinnacle Awards in three categories were presented at APhA headquarters on September 16. Each year, the Foundation’s Pinnacle Awards program recognizes contributions to health care quality through the medication use process. This year marked the 18th celebration of the awards program, created in 1998. Premier support for the celebration was provided by Merck, and support was also provided by an educational donation by Amgen.
The 2015 winner of the Individual Award for Career Achievement is Magaly Rodriguez de Bittner, PharmD, BCPS, CDE, FAPhA, professor and executive director of the Center for Innovative Pharmacy Solutions at University of Maryland School of Pharmacy. She has dedicated her career to the advancement of pharmacy practice and the development of innovative and sustainable patient care programs.
The 2015 winner of the Group Practice–Health System–Corporation Award is Ohio State University’s College of Pharmacy and division of general internal medicine. Accepting the Pinnacle Award for Ohio State University were Stuart J. Beatty, PharmD, BCACP, CDE, vice chair of clinical affairs and associate professor of clinical pharmacy for Ohio State University College of Pharmacy, and Neeraj H. Tayal, MD, FACP, director of the division of general internal medicine and associate professor of clinical medicine for Ohio State University Wexner Medical Center. In this partnership, pharmacists have been involved in team-based primary care since 2006.