Twice the IMPACT

Sandra Leal and Marisa Soto team up to serve Tucson’s diverse patient populations

The El Rio Community Health Center in Tucson, AZ, stands out among its fellow Project IMPACT: Diabetes communities because of its diverse patient population and unique clinic sites, but above all else, El Rio is unique in that it actually combines two separate Project IMPACT communities under one umbrella.

Sandra Leal, PharmD, FAPhA, CDE, Director of Clinical Pharmacy at the El Rio Broadway Clinic and one of the two Project IMPACT Community Champions, explained that when she and Marisa Soto, PharmD, CDE, Clinical Pharmacist in the Pascua Yaqui Clinic and the second Community Champion, saw the APhA Foundation’s proposal, they knew it was a “perfect fit.” When they found that both of their practice sites were chosen, they were surprised—and excited to start working.

Leal explained to Pharmacy Today that the Broadway and Pascua Yaqui Clinics serve distinct patient populations—underserved, largely Hispanic patients at Broadway and members of the Pascua Yaqui Native American Tribe at the latter site. With the Yaqui Tribe, Soto and her colleagues work to address cultural and trust issues, while Leal’s challenges include social support and affordability.

Attention to detail

El Rio’s clinical pharmacy efforts in Tucson began 11 years ago, Leal told Today, when the Health Resources and Services Administration Office of Pharmacy Affairs granted the health center a clinical demonstration project award. Leal came on board then to kick off the clinical pharmacy services, and she’s been there since.

“We were very diligent from day one in collecting the impact that we were making on patients,” Leal said. “We essentially created our own electronic health record … [and] track every single intervention for every patient that we were seeing. … We were able to document our impact and then share that.”

El Rio’s meticulous attention to monitoring their successes allowed the health center to expand its clinical pharmacy services to the Pascua Yaqui Clinic. The tribe approached El Rio and asked for a full-time clinical pharmacist position at the reservation clinic, Leal recalled.

“They were convinced not only because their tribal members were supporting us, but also because they were seeing very concrete data,” Leal explained. “They were seeing improvements in their health outcomes; they were seeing improved quality of life.”

Unique patient populations

While Leal and Soto use very similar practice models, their respective sites differ a great deal. “We’ll send student [pharmacists] to rotate with me for 2 weeks, with her for 2 weeks … and the students are always so impressed with the different challenges that we see,” Leal said.

For Leal, the challenge lies with bringing care to an underserved population. “About 75% of the patients we serve live at or below the poverty line,” she told Today. “About 75% of our patients are Hispanic and about 8% are American Indian. … Over a third have no health insurance.”

Introducing patients to clinical pharmacy services took a little convincing at first, Leal said. “When we were starting to work with [patients], I don’t think they necessarily understood what we were going to do,” she recalled. “They thought we were nutrition counselors or we were going to offer some of the same information they already had.”

That wasn’t the plan at El Rio, however. “We take a completely different approach and really focus on their medication regimens, making sure that they understand the complexities and they can afford the regimens,” Leal explained. “If they’re having any concerns or issues with [adverse] effects or not tolerating the medication, we spend a lot of time working with them to understand the importance of taking the medication, addressing adherence and any health literacy issues.”

Another unique characteristic of Leal’s patient population relates to Tucson’s proximity to the Mexican border. “A lot of our patients go into Mexico to get some of their medications and herbal products,” she noted. “So we have to work with them to make sure we’re still addressing their needs.”

Pharmacy with the Yaqui

El Rio’s Pascua Yaqui Clinic is located within the tribal reservation—a “very close-knit environment,” Soto said. “It’s like it’s own little city.” She explained that the health department where the clinic is housed is a meeting area for the tribe. “People are here not just because they have an appointment, but sometimes because they just want to go somewhere and find their friends and talk.” The clinic is located within walking distance for most residents; it’s also very close to the senior center and Head Start program.

Soto noted that the Pascua Yaqui Tribe has invested a great deal in health care. The tribe pays for members’ medications, doctor and specialist visits, labs, X-rays—“whatever needs to be done,” she said. As a result, affordability is less of an issue. Instead, Soto works to build relationships with the population she serves.

“We want the community to know that we care about them as a whole, not just their disease state,” Soto told Today. “We care what happens to them. You really have to put forth that extra effort, but when people know that you are truly, honestly devoted and committed to the community, it’s an overwhelmingly positive response.

“On a day-to-day basis, the biggest thing is [to] personally invest time in my patients outside the clinic,” Soto explained. “I know when it’s their granddaughter’s quinceañera and I know what day it is, and when they come back I remember to ask them about it. … [I] remember things that are important to people, ask people what’s important to them, and make sure that I incorporate that in their visit.

A double dose of IMPACT

Between Leal and Soto, El Rio has enrolled more than 200 patients in Project IMPACT. Leal noted that they were able to integrate the program with their preexisting diabetes care programs while adding a new spin on patient interactions through the Patient Self-Management Credential knowledge assessment test.

The knowledge assessment “really helped us understand where the patient was at the time, even though they might have been seeing us for a while,” Leal said. She told Today that the assessment allowed them to identify gaps in patients’ knowledge and “target the interventions to address those areas where there were deficiencies and, hopefully, improve their overall care.”

Soto experienced some unique reactions when she administered the knowledge assessment. After completing the test, some of her patients actually came to her to critique the questions. For example, patients were asked what they should take with them to exercise: blood glucose meter, medication, extra pair of shoes, or snack. The correct answer is to take a snack, Soto said, because exercise can lower glucose levels.

“But my patient said she would do all of these things!” Soto exclaimed. The patient explained that in addition to a snack, she’d need the meter to find out if her glucose was low, as well as comfortable shoes to avoid an ulcer.

“I was so happy with those responses,” Soto continued, “that they were actually challenging the questions on this assessment tool, that they had gained enough knowledge over the time period that we worked together that they could find flaws in this standardized test.”

The case for pharmacy

Leal and Soto are not just coworkers, they’re also friends. “Marisa and I did our residency together,” Leal recalled. “Sandra and I are like sisters!” Soto laughed. “We’ve known each other forever.”

These pharmacy friends are working hard to advance their profession. Last year, Leal started a petition on asking the federal government to recognize pharmacists as health care providers. So far, she has collected more than 20,000 signatures.

“I think there’s so much opportunity for pharmacists to practice in a way that makes an impact with patients,” Leal told Today. “One of the reasons I went to pharmacy school is because we are the most accessible providers. We bring an expertise that no other profession can replace.

“I think the value of Project IMPACT is getting a national view of what pharmacists can do, and collecting that data on this level is incredible,” Leal concluded. “I’m happy we’re participating in it and our data will be included as part of the outcomes. … It’s going to help us continue to build the case for why we need to be included.”

APhA Foundation making an IMPACT

Project IMPACT (Improving America’s Communities Together): Diabetes is a national initiative of the APhA Foundation that aims to improve care for patients with diabetes through community-based interdisciplinary teams that include pharmacists.

This project scales previous Foundation initiatives such as the Asheville Project, Patient Self-Management Program for Diabetes, and the Diabetes Ten City Challenge into 25 communities across the United States. As part of the program, the Foundation provides communities with tools, resources, guidance, and support to facilitate their success.

Pharmacy Today will profile these Project IMPACT communities over the coming months, bringing you stories of innovative and unique diabetes care programs from coast to coast. Next month, read about Virginia’s CrossOver Health Care Ministry and Daily Planet.

For more information about Project IMPACT: Diabetes, visit the APhA Foundation’s website at