Sandra Leal, PharmD, MPH, FAPhA, CDE, always had a vision of pharmacists being an accessible primary care provider. Growing up in the border town of Nogales, AZ, Leal received her primary care at a pharmacy in Mexico, where her family could find a Spanish-speaking provider.
“Very early on, I selected pharmacy just because of that experience,” Leal said in interviews with Pharmacy Today. She never considered medical school or nursing school. “So it was a really big surprise for me when I did find out pharmacists weren’t health care providers as recognized by the Social Security Act.” Leal enumerated pharmacists’ medical training, clinical skills, challenging coursework, and time investment. “To not have that recognition and to be essentially paid for a product—I just don’t accept that,” she said. “I want to make sure that when I’m contributing to this profession, I’m making an impact to change that and to have people recognize it.”
Leal is the Director of Clinical Pharmacy at El Rio Community Health Center in Tucson, AZ, and the Medical Director at its Broadway Clinic for homeless and mental health populations. At Broadway Clinic, she supervises the medical providers; typically, the medical director position is a physician.
El Rio is a National Committee for Quality Assurance level 3–accredited patient-centered medical home (PCMH) that in April 2012 joined the Arizona Connected Care accountable care organization (ACO). At El Rio, Leal works on projects related to the PCMH and ACO where clinical pharmacists are integrated in treatment teams. She hopes that showing the impact on health outcomes and the improvement in patient safety will lead to finding a sustainable model for revenue sharing and being able to create opportunities in these new models of health care. (See page 59 of June’s Today for more information.)
Leal also serves as Co-Chair for the national Patient Safety and Clinical Pharmacy Services Collaborative (PSPC), as the Community Champion for El Rio’s two sites for the APhA Foundation’s Project IMPACT: Diabetes, and as adjunct faculty at the University of Arizona College of Pharmacy.
In late 2011, Leal started the Change.org petition for provider status. “It’s a very rewarding profession if you can practice to the capacity of what you were trained to do,” she said.
Whenever Leal sits with a person who’s been in the health care system for a while, and they have an intervention together and make changes, she wonders how the patient would have fared without that simple visit to the pharmacist. “I mean, years of prescribing—people still don’t understand what they’re taking. Maybe they’ve had issues with side effects and the medication adherence; affordability,” she noted. “You end up catching so many things that have been overlooked for many, many visits. So I just think it’s a very essential piece that’s missing in the health care system consistently.”
Above: Sandra Leal, PharmD, MPH, FAPhA, CDE, has followed patient Rosa Betancourt since 2005 at El Rio Community Health Center. Here, they review lab results that Leal had ordered before the visit.
Pharmacists have a growing role in making interventions and being part of clinical teams, especially as health care evolves with ACOs and the PCMH. “But you really have to, as a pharmacist, step up and say, ‘I want to take this role, and I want to actively participate, and I want to be part of the team,’” Leal said. “At a very basic level—just to have the opportunity to start reviewing a patient’s chart, making an intervention, making a recommendation, and then taking accountability for what’s happening with the patient.”
At El Rio, one of the first things Leal saw when she became Broadway Clinic’s medical director was “a big gap in just having clinical pharmacy services.” She introduced the role of the pharmacist to that group of providers—nurse practitioners, physicians, medical assistants, behavioral health—and then targeted big-picture changes such as the PCMH concept and accountable care, which allowed the team to focus on chronic care management and preventive care services.
“A lot of times with homeless populations, we’re seeing them very sporadically for care, and it’s usually for acute care” such as foot pain or a toothache, Leal said. Now the team looks more globally at the patient and takes advantage of every opportunity for care instead of only addressing the chief complaint for the day. Having eight clinical pharmacists integrated in the medical home means “we’re still doing, obviously, the very comprehensive medication therapy management and review, but also delving into a lot more preventative care services that go way beyond what our traditional role was before.”
Leal is the preceptor for a group of student pharmacists who are completing a quality improvement project. Here, she meets with Andrew Vo (left) and Aaron Leyba.
Pharmacists are salaried at El Rio. Still, in Leal’s role as medical director, she has to do the budget and figure out whether the program is sustainable, breaking even, or a cost center—and “then try to fill the hole to try to at least be flush so we’re not a cost center,” she explained. Her most stressful time is the budgeting season of September. Every year, Leal sits down with her Chief Financial Officer and tells her “why she should keep adding positions or just continue to fund the current positions that we have. Because we don’t have an easy way to say, ‘Oh, we’re going to see X number of patients and we’re going to produce X revenue and we’ll break even or produce a profit.’”
Across the country, pharmacists are participating in certain pockets of different reform efforts, but without provider status, they’re being excluded from critical elements such as meaningful use in electronic health record implementation, Leal said. “The biggest challenge is just not having recognition [as providers of patient care services] from our state Medicaid plan.” Most of El Rio’s patients aren’t ACO patients or Medicare patients. Because one-third of patients at El Rio have a Medicaid plan, this federally qualified health center receives no direct revenue for clinical pharmacists seeing these patients. Other patients have third-party plans or are uninsured. “Right now, we’re having to go and try to contract with each plan individually. That would be OK if there weren’t 10,000 plans,” she added. “You probably spend most of your day trying to contract with plans” and figuring out the sustainability model “as opposed to actually doing the work that we could be doing—really working with patients.”
Leal believes pharmacists must realize that the profession’s moving toward a major crossroads and become active in seeking a way forward. “Dispensing fees are getting less and less and they keep getting cut. We’re coming to the point where some prescriptions, in some instances, are being given away. How are we going to pay for the professional aspect of pharmacy if we do not actually get compensated for our clinical skills and our interventions?,” she noted. “Product can only take us so far. The evolution of pharmacy is to use our clinical skills and work in that team model.”
Leal graduated as valedictorian of her PharmD class while on a full-tuition scholarship. Going to college at all was a personal struggle. Her parents experienced a lot of different barriers, including not speaking English, and they wanted her to have more opportunities. Her father told her to get more education so she could end up in a better place. “There was a lot of question, just because nobody in my family had gone to college, whether I would be able to make it,” she said. “I just had this very significant will and ambition to go and do something that made a difference.”
At first, Leal wanted to do bench-type research. But in pharmacy school, she started working with patients. “The big struggle for pharmacy that I saw going into it was just that people didn’t understand what a great role pharmacists can fill,” Leal said. “It’s been a personal challenge for me to try to get that message out and make sure people understand the role pharmacists can play because they are a very accessible provider.”
This year, Leal obtained her master’s degree in public health. The secondary degree complemented her work with PSPC, Project IMPACT: Diabetes, and communities in general to figure out how to partner and create opportunities to help people stay healthier. She told Today, “The challenges that our patients are facing every day always seem to revolve around these two big critical elements—health care and education—and the disparities around both of those for certain populations.”
Leal deliberately chose to work in her home state of Arizona, at El Rio, where she can provide care in a culturally relevant way to the people she serves. “You start seeing people here and it’s family,” Leal said. “Patients are just your family. They become you.”
“I find the collaborative approach with the clinical pharmacists to be an essential part of providing excellent patient care. The clinical pharmacists comanage patients with me in a way that improves the outcomes for the individual patient while also teaching me knowledge and skills that I end up using with my other patients as well. Their presence on the clinical team dramatically improves patient engagement and makes my job easier.”
—Joy Mockbee, MD, MPH
Associate Medical Director, Family Medicine
“I was surprised at how efficiently the system works and the number of patients they are able to serve while maintaining quality of care.”
Patient with diabetes
“It is truly a pleasure to be able to collaborate with the pharmacists. ... They are a great source of knowledge for our patients and staff as well. Our team effort is essential to quality care.”
—Kathy Carlos, BSN
Registered Nurse Care Coordinator
“The clinical pharmacy collaborative model at El Rio has been an outstanding way to address diabetic patient needs on both the individual patient level and on a broad-based population level. ... Integrated clinical pharmacists within a team-based outpatient delivery of care model are clearly the right approach for delivering excellent care.”
—Douglas J. Spegman, MD, MSPH, FACP
Chief Quality/Medical Innovations Officer