When Steven Chen, PharmD, first moved his pharmacy practice setting from Beverly Hills to the gritty streets of downtown Los Angeles, he had no idea that working with the underserved would be so personally and professionally rewarding. Chen is one of several pharmacists from the University of Southern California (USC) School of Pharmacy who provide medication therapy management (MTM) and clinical services to the uninsured, the poor, and the homeless in safety net clinics in Los Angeles.
With more than 2.7 million uninsured living in Southern California, including an estimated 51,000 homeless people in the area, “physicians are overwhelmed as the demand for services has skyrocketed while the economy has plummeted,” said Chen. He was stunned by the number of patients seeking care at safety net clinics who until fairly recently had stable and secure lives with good jobs and health insurance. “The need for quality care for this changing population is urgent and pharmacy services are essential to helping these patients reach their treatment goals,” said Chen, who manages all of USC’s clinical pharmacists in the safety net clinics.
The USC School of Pharmacy began working with safety net clinics in 2002 under the direction of Kathleen Johnson, PharmD, MPH, PhD, Vice Dean of Clinical Affairs and Outcomes Sciences and Chair of the Titus Family Department at the USC School of Pharmacy (see sidebar), after the receipt of a pharmacy expansion grant from the Health Resources and Services Administration (HRSA). The grant allowed one pharmacist to divide time between three safety net clinics in Los Angeles.
“Our goals were simple in the beginning. We wanted to help with the purchasing and acquisition of pharmaceuticals by these clinics,” said Chen in an interview with Pharmacy Today. “We also established protocol-driven clinical pharmacy MTM programs targeting the highest risk populations, especially those patients who were struggling to get under control.”
Today, the school has received over $15 million in grants to fund more than a dozen pharmacy positions in 12 safety net clinics in the greater Los Angeles area, with plans to add more clinics in the near future. Over the span of 8 years, clinical pharmacists have logged 45,000 individual MTM visits for patients with hypertension, diabetes, dyslipidemia, chronic heart failure, anticoagulation, and other conditions.
USC pharmacists collaborate with several safety net partners in providing MTM. At the John Wesley Community Health (JWHC) Institute, a private nonprofit health agency whose mission is to improve the health and wellness of the underserved population of Los Angeles County, clinical pharmacists provide a comprehensive package of health education including drug information, disease management, and dispensing assistance.
“I have witnessed the dramatic improvement in chronic disease and behavioral health outcomes that resulted after the USC Clinical Pharmacy Program was implemented,” said Paul Gregerson, MD, MBA, Chief Medical Officer at JWHC Institute. “Our patients have consistently provided positive feedback about how the pharmacy services have improved the quality of care at the clinic and made their health care experience more satisfying.” He described the collaboration between the USC School of Pharmacy and the JWHC Institute as the “most valuable and rewarding community partnership we have.”
Ying Wang, PharmD, USC Clinical Pharmacist at QueensCare Family Clinics reviews medications with Domingo Corpus at the East Los Angeles QueensCare Family Clinic.
Clinical pharmacist Ying Wang, PharmD, is one of three full-time pharmacists at QueensCare Family Clinics, a faith-based organization that provides accessible health care for uninsured and low-income individuals and families in Los Angeles County. Pharmacists provide medication counseling and individualized MTM services for high-risk patients by appointment at four of QueensCare’s six clinics. Wang sees about 10 patients per day and each patient visit lasts around 30 minutes.
“I manage a wide variety of disease states in the same day, from anticoagulation to asthma to diabetes,” Wang told Today. Her daily work typically includes assessments of patient health status, resolving medication-related problems, improving adherence, formulating treatment plans, and helping patients meet goals by modifying medication regimens and dosages. Above all, the clinical pharmacists take ownership of each patient’s medication-related outcomes, providing follow-up care and resolving barriers to meeting treatment goals.
Many of Wang’s patients have multiple health problems. One patient that she meets with every week has heart failure, uncontrolled diabetes, hypertension, and dyslipidemia. “When I first met him, I realized immediately that he did not understand his disease states or the purpose of all of his medications because he kept his meds in one big pile,” said Wang. She found out that the patient was taking the same dose of every medication. She also realized that he could not read, “so he didn’t understand the letters on the pillbox,” Wang explained. Once she began working with him every week, the patient started to understand the differences between his medications. “He’s doing really well now. It’s amazing how far we’ve come,” she said.
Steven Chen, PharmD, Associate Professor, University of Southern California School of Pharmacy, checks patient Jason Ruscio at the Center for Community Health in downtown Los Angeles;
Jason Ruscio is one of Chen’s patients at the Center for Community Health at the Weingart Center in downtown Los Angeles. Ruscio was diagnosed with type 1 diabetes at age 37, and has several other medical conditions including epilepsy and nerve problems. “When I got there it wasn’t simply meeting with a [pharmacist] and them saying OK, you need insulin,”said Ruscio, who has been meeting monthly with Chen and clinical pharmacist Michelle Lee, PharmD, CDE, for almost 3 years. “I met with Dr. Chen and a staff of three students. They looked at my numbers that I recorded diligently and we discussed exactly the amount of insulin and the kind of insulin I should be using.” Fairly early on, Chen figured out that Ruscio was allergic to a particular type of insulin and Chen “within an instant found a replacement that was a real game changer for me,” said Ruscio. “Dr. Chen and the pharmacy have been a life saver, and I don’t know if I’d be here without their great work. They realize the gravity of my situation and don’t compromise my needs at all.”
One of the biggest differences between practicing in a safety net clinic compared with other environments is the urgent need for health care quality improvement. “The physicians are great,” said Chen. “The problem is that they are overwhelmed.” In recent years, the volume of patients has increased and patient demographics for safety net clinics have undergone radical changes. “One of our previous clinic partners had a patient population that was almost 100% Latino. Two years into working with them we saw a significant portion of non-Latino patients, which the clinic has never seen before,” explained Chen.
Since launching the safety net collaborations, the USC School of Pharmacy has tracked and published the impact of their clinical pharmacy services on health care quality, which shows substantial improvements in various markers of disease control. For example, patients’ glycosylated hemoglobin (A1C) values have gone down an average of 3.7 points, and blood pressure has dropped by 26/12 mm Hg. In a multivariate analysis comparing patients who received asthma care from a pharmacist versus usual care, those who worked with a pharmacist had nearly a three-fold greater likelihood of achieving asthma control.
The school also tracks pharmacist interventions. “When we evaluated the medication-related problems we identified and resolved among more than 200 patients with diabetes, we found that 80% of our interventions involved problems with quality of care, particularly a drug therapy regimen that was insufficient to meet treatment goals,” said Chen. The next biggest area was medication safety (14%). The most common actions pharmacists take include changing medication doses, adding medications, and substituting medications, all of which are far more common than discontinuing medications, noted Chen.
Data from two clinic partners, QueensCare Family Clinics and the Center for Community Health, show that the pharmacists’ role in refining medication formularies, including optimizing the use of the Pharma Patient Assistance Program (PAP) and purchasing of 340B medications, was associated with a 75% reduction in annual medication costs to the clinics. According to Chen, the formulary costs for QueensCare Family Clinics dropped from about $2 million to about $400,000 annually, while the value of PAP medications acquired doubled from $1 million to $2 million. Formulary costs at the Center for Community Health dropped from $4 million to $1 million.
“When practicing pharmacy in a safety net environment, you have to always figure out the most cost-effective way to treat these patients,” said Wang. “We are limited in resources and constantly challenged with how to develop optimal medication therapy regimens, while limiting costs as much as possible.”
The USC School of Pharmacy continues to expand collaborations with area safety net clinics. Last year the Dean of the school, R. Pete Vanderveen, PhD, BSPharm, launched the USC Medication Therapy and Safety Initiative, which aims to double the school’s collaboration to 24 clinics and medical homes by 2013.
R. Pete Vanderveen, PhD, BSPharm, Dean, University of Southern California School of Pharmacy (left) with Wang (center) and Chen (right).
The pharmacy team was recently awarded a $12 million Center for Medicare and Medicaid Innovation (CMMI) grant, the largest ever received by the USC School of Pharmacy. The grant will bring pharmacists into safety net clinics in Southern California as a way to ensure that patients receive optimal medication therapy while improving medication adherence and safe and appropriate use of medications. The goal is to optimize patient health outcomes while reducing avoidable hospitalizations and emergency room visits, dramatically reducing total health care costs despite a mild increase in medication therapy expenses.
In collaboration with AltaMed Health Services, teams consisting of two pharmacists, two pharmacy residents, and two clinical pharmacy technicians will be located at each of three clinics in Orange County. The clinics are located in communities with large underserved populations that are vulnerable to health disparities and have limited access to care. Four Orange County clinics will serve as control (“usual care”) sites. The invervention will spread to two more clinics in Los Angeles County in year 2, during which a teleclinical pharmacy program will be piloted.
“We’ll provide all patients in each clinic with clinical pharmacy services commensurate with their needs,” said Chen. “At a minimum, all patients will receive medication reconciliation at every visit, and the highest-risk patients will receive individualized comprehensive MTM.”
University of Southern California School of Pharmacy clinical pharmacist Michelle Lee, PharmD; pharmacy resident Tina Patel, PharmD; and patient Oswaldo Chavez.
The USC School of Pharmacy’s partnerships with safety net clinics are the practice of pharmacy at its best. “We strongly believe that pharmacists collaborating with primary care physicians and other health care professionals is the future of the practice of pharmacy,” said Vanderveen. “And the CMS grant, 1 of only about 100 awarded by the federal government among a competitive pool of over 3,000 applicants, is very encouraging. It says that pharmacists are finally on the radar as the medication expert on the health care team who can improve outcomes and save money.”
Want to know more?
Get in touch with Steven Chen at firstname.lastname@example.org