Ross Valley Pharmacy, tucked away inside a larger building of clinics, is not a big place, but it’s very very busy. Its owner, Paul Lofholm, PharmD, has a vision of the pharmacist’s role that goes far beyond simply putting pills in bottles. He sees pharmacists as integral members of the healthcare team who can fill the gaps in patients’ education about their conditions and their medications.
Dr. Lofholm initially saw the need for a diabetes education program after a friend’s son was diagnosed with type 1 diabetes. After helping his friend deal with that crisis, says Dr. Lofholm, “I looked around and said, ‘Well, what do we have in this county, Marin County, to help diabetes patients?’ I found out that we really didn’t have anything.” To fill that gap, he developed a Medicare-certified diabetes education program run by a certified diabetes educator. It took time to fulfill the ADA requirements necessary for Medicare certification, but the program is now in its third cycle of accreditation, and Ross Valley Pharmacy offers classes several times a year.
Dr. Lofholm notes that only eight percent of diabetics go to endocrinologists; all the rest are monitored by internists or, in some cases, pediatricians. He says, “They do not have the staff to do the education, so it doesn’t really get done. That’s why the specialized courses have been successful, frankly, teaching people about lifestyle. The advantage of the pharmacy is that we see the patients frequently because of medication refills. We’ve had a pretty good relationship with physicians being willing to refer, because they simply don’t have the time to do the educational stuff, realistically, nor can they get paid for it.”
In line with the new role of pharmacists as “physician extenders,” Dr. Lofholm offers medication therapy management (MTM) services to his patients. According to the pharmacy website, “MTM is a meeting with the pharmacist to review ALL of your medications, allergies, and conditions.” The service is covered by Medicare under certain conditions. Dr. Lofholm says, “MTM is talking about taking a drug history, analyzing the combination of drugs, asking the patients why they’re taking them, with the idea to get people off drugs that they don’t need, or on drugs that they should be on. We believe that pharmacists are over-trained for what they do, putting pills in bottles, and the question is, how could they more appropriately be used? One of those key issues is MTM.”
Asked how pharmacists are reimbursed for all the time they spend talking to the patients, Dr. Lofhom replies “There is no mechanism. Counseling is an unfunded mandate. It is actually part of the law, but there is no funding for it….We have a medical benefit, a dental benefit, a hospital benefit, a pharmaceutical benefit, but no pharmacist benefit. I am trying to develop legislation to define a pharmacist benefit. Most of the legislation that’s been written has to do with provision of drugs, reducing costs, and formularies. It’s a manufacturing thrust. But does it do any good if I throw 10 drugs at you and you don’t have a clue what they are? We need to make sure that there is some communication between the patient and the pharmacist: ‘Do you know when to take this, why to take it, when to stop taking it?’ We need to try to sort all of that out.”
Dr. Lofholm’s goal is to make his pharmacy a complete “diabetes wellness center” that offers diabetes training, MTM, and support for patients who might drop through the cracks after being hospitalized. He explains, “We here in this county are considering a collaborative effort to set up a diabetes wellness center. The problem today is that there’s not good additional services or follow-up from the acute care hospital to the community.”
“When patients go in for an acute diabetic episode, typically they are elderly, and so they may need to be taught how to use a meter and maybe how to use insulin. Well, then they are discharged, and they have no clue what to do. Discharge orders may not get to the physician for awhile, and although the discharge physician might tell the patient to see his physician within seven days, that may or may not happen. So the problem is that the transition from acute care back to the community is not working very well. We have too many patients falling through the holes. They don’t understand their medicines, maybe they can’t afford their medicines, they don’t know how to use them, etc.”
“So we’re working on a collaboration between the hospitals and pharmacies and local endocrinologists. If the diabetes wellness center were up and running, ideally the discharge orders would come to the diabetes wellness center for us to follow up and make sure the patient sees his primary care physician, etc. The point is to facilitate communication, and ‘oh, by the way, if you need help in nutrition or exercise or medications, we can also help in that regard,’ because the physician may not have the time to spend.” Dr. Lofholm hopes to have the diabetes wellness center functioning by the end of the year.
Dr. Lofholm believes that his pharmacy initiatives could have a salutary effect on the number of adverse medication reactions. “For every dollar that we spend on distributing drugs,” he says, “we spend another dollar for adverse reactions. So the question is, can we prevent adverse effects?” He strongly feels that pharmacist interventions would help do that. “Now that technicians are counting out the pills, we have the pharmacist ideally with time to be spent counseling patients. So we need legislation that will provide compensation for that. And the justification for that would be reducing adverse events and drug usage, thereby cutting costs.”
“My job,” he concludes, “is to optimize the therapy.”