Lofholm makes MTM work in Marin County

With the right attitude, vision, and management, pharmacists like Paul Lofholm can make the ordinary extraordinary

First impressions can be misleading. Ross Valley Pharmacy at first appears to be a typical independent community pharmacy. Located in a medium-sized medical office building in an aging suburban community, it has a modest front end featuring OTCs, vitamins, and other nonprescription items and even sells a few candy bars.

Closer inspection, however, shows the pharmacy of Paul Lofholm, PharmD—located in Larkspur, CA, where Interstate 580 brings East Bay and Central Valley traffic to the 101 in Marin County, just north of San Francisco—to be anything but typical. If there is one key thing pharmacy owners and managers can learn from Ross Valley Pharmacy, it is that with the right attitude, vision, and management, pharmacists can make the ordinary extraordinary.

Lofholm, President and Founder of Ross Valley Pharmacy and APhA’s 2011 Remington Medalist, is this kind of effective and visionary leader. His pharmacy provides a variety of enhanced services and is a leader in medication therapy management (MTM), immunization, hospice, compounding, and nutritional consulting. These enhanced services are supported by and contribute to its busy dispensing services. “I have been part of the transformation of pharmacy from a chemical-based profession to a patient-centered clinical practice,” this 1964 graduate of the University of California, San Francisco, said in his Remington address, published in the July/August 2011 issue of JAPhA.

“I initially adopted an office-style pharmacy practice with no drugs on display and a patient profile system like that of Eugene White; it was an apothecary practice associated with a group medical practice,” Lofholm explained. From that start, around the time clinical pharmacy was born in the 1966 Ninth Floor Project at his alma mater, Lofholm has succeeded by combining a clinical practice with the hard fiscal realities of independent pharmacy.

Patients—and their children—value MTM

Central to all Lofholm provides is the notion that taking care of patients and looking for better ways to serve them professionally and personally will result in better care and a healthier bottom line. And make no mistake—Lofholm keeps a close eye on the bottom line and works to ensure that all aspects of his practice contribute to the entire enterprise’s economic viability.

As clinical pharmacy morphed to pharmaceutical care and then MTM services, Lofholm changed with the times. His MTM process includes scheduling appointments, meeting in a private area, taking a detailed drug history, and getting input from the prescribers and other caregivers. He told Pharmacy Today that he realized one of the unexpected areas of demand for MTM services was the number of adults who brought in their aging parents for sessions—and their willingness to pay out of pocket for the learned advice of an MTM expert.

“Insurance is a minor issue,” Lofholm said. “Patients who really need MTM will often be very willing to pay for it.”

Lofholm bills for some patients on selected Humana policies and for those enrolled in the Community CCRx prescription drug plan. He also does a handful of compensated sessions each month as a contract provider to OutcomesMTM for patients out of his market area.

Technology as an enabler

“I want to streamline my dispensing activities so that I may have more time with patients,” Lofholm said in his Remington address. To accomplish that, he takes full advantage of technology.

For example, Lofholm has invested in a packaging system that puts multiple medications into pouches to be taken at various times of day. The system not only streamlines the dispensing process but also aids the patient in knowing when to take their medications. The clearly marked pouches from his TCGRx system also make it easier for caregivers to monitor patient adherence. Recognizing the value of this service, Lofholm charges appropriately for the initial set-up and ongoing service.

Lofholm also understands that getting patients to know about and take advantage of his enhanced care services is important to his success. One high-tech method for doing this is a service he subscribes to from Prescribe Wellness. The company works with the pharmacy to identify a service that would benefit from increased patient awareness, Lofholm said. In close cooperation with a staff member, and in a fully HIPAA-compliant manner, the Prescribe Wellness software sorts through data in Lofholm’s Suite Rx pharmacy system and pulls out the names of the people to be contacted.

Lofholm then records a carefully crafted 20- to 30-second message. “Having the message start out by saying, ‘Hi, this is Paul from Ross Valley Pharmacy,’ dramatically improves response rates,” Lofholm explained. The service can detect if the call is being answered by voice message, and if so, it leaves a slightly modified version of Lofholm’s recording.

Ross Valley Pharmacy has successfully used this service to contact patients for MTM, influenza vaccinations, and other services. In one case, Lofholm attracted 60 patients to a compression-hose clinic he was conducting.

Leadership over the years

Lofholm started out early as a thought leader in pharmacy—and has maintained that over his 4 decades in practice. “I was taught [at UCSF] that we were the drug experts,” Lofholm said in his Remington address. “So I became a community pharmacist, clinical faculty member, member of APhA and its House of Delegates, participant in state and local associations, clinical pharmacist, owner, author, consultant, continuing education lecturer, preceptor and leader in pharmacy associations.”

Just after graduation, Lofholm took a position as a clinical pharmacist for the surgical department of a teaching hospital. He and four other pharmacists provided 24–7 coverage, helping physicians with infection treatment, pain management, and antiemetic support. At the time, the total armamentarium for all these conditions would have been no more than 50 drugs, but Lofholm says this team of pharmacists clearly made a difference.

Over the years, Lofholm has found such relationships with physicians, nurses, patient care organizations, and hospital administrators invaluable. He fully realizes that these types of relationships are not immediately available to younger pharmacists eager to initiate enhanced care services. Lofholm suggests that his less experienced colleagues start from where they are by working with patients and then back-fill into meaningful relationships with those patient’s health care providers.

For example, Lofholm told Today of a patient with Parkinson disease. After a meaningful conversation with Lofholm about a minor medication-related problem, the patient mentioned she was participating in a speech therapy program and invited him to address the class. One of the people in the class came to the session with her daughter, a physician assistant, and shortly after meeting Lofholm at the class, the daughter called and made an appointment to bring her father in for an MTM session.

Looking after the bottom line

While many of the new services and programs Ross Valley Pharmacy has adopted have worked well, success in every venture is not guaranteed. Lofholm understands the need for each service to carry its own weight, and he monitors the financial impact of as many aspects of his practice as practical. Each bill is coded to a specific department. Salaries and physical facilities are apportioned out as well. Lofholm said that knowing what services are profitable and which are not is critical to success.

This past fall, Lofholm contemplated selling his diabetes education and nutritional services unit to a local hospital. This pharmacy unit is headed up by a registered dietitian and certified diabetes educator and attracts a fair number of clients. But it has not been generating enough revenue to offset the costs. Lofholm thought that this type of service may be more practical if associated with the hospital. ”The bottom line is the bottom line,” he said.

Lofholm cited the growing need for coordinated transitional care from acute care facilities back to the community as an emerging opportunity. He is working with the local hospital on a number of ways they can work together to meet the needs of emerging accountable care organizations and to reduce hospital readmissions. Lofholm said they were in the process of getting a grant that would support investigating a number of techniques to see what works best. One of these approaches was qualified members of his staff making home visits to newly discharged patients.

Streamlining vaccinations

Last year, Ross Valley Pharmacy administered more than 2,000 influenza vaccinations. Pharmacy staff also administers shingles, tetanus, pneumococcal, and pertussis immunizations. The process for doing these is fast and efficient. Patients coming in for immunizations are routed to a special technician who helps the patient fill out release forms, gathers insurance information, collects payment, and enters data into the pharmacy system.

With the preliminaries complete, the patient is escorted to the administration area where the pharmacist reviews the information, talks with the patient, and if everything is satisfactory, administers the vaccination. Using this model as a template, Lofholm plans to expand the pharmacy’s immunization program into providing a full array of travel vaccinations.

Delegating an extraordinary practice

One final insight from Lofholm is delegation. This skill is critical to the ongoing success of any patient-centered pharmacy, he told Today.

Besides his activities at Ross Valley Pharmacy, Lofholm helps with a veterinary compounding pharmacy, consults with the Lawrence Livermore Labs, is active in Rotary International, and serves on a number of professional society boards and committees. This type of schedule means he is often not onsite at Ross Valley and is not able to make day-to-day decisions in all areas of his practice.

To delegate his responsibilities effectively, Lofholm monitors his team members to determine which specific tasks are best suited to their skills. Once he identifies strengths of a particular pharmacist or technician, he clearly explains the task and asks if the person would like to handle it. Lofholm explain the results he is looking for and emphasizes the task’s importance to the organization. If the person agrees to take on the challenge, Lofholm “lets them run with it” while providing oversight as needed.

This process and Lofholm’s other management and visionary skills have worked well for him over the years at Ross Valley Pharmacy. He continues to provide enhanced care for his patients and career satisfaction for his staff. An independent community pharmacy, yes. Typical, no—and neither is Paul Lofholm.