Reimagining Pharmacy Care
Fourth-year pharmacy student Korana Avdagic helps a patient named Helen sort out the long list of medications she's been prescribed to take daily. Photo by Elisabeth Fall/fallfoto.com
The pharmacist is no longer at the back of the store.
UC San Francisco is changing the way you think about your neighborhood drugstore by putting the pharmacist front and center – not just in the store, but also on your health care team.
For Helen, every morning starts with the same ritual: nine pills, six specifically with food. The bright green ones and two others have to be taken three times a day. One of those prescriptions requires three pills for each dose. One set of pills is taken twice daily. Three are just once in the morning and two are once at night.
By the time she’s taken a calcium supplement and two other medications at bedtime, the day’s tally has reached 20 pills, to help control her diabetes, high blood pressure, back pain and other chronic conditions. And that’s not counting the nicotine lozenges throughout the day to help her quit smoking, and fish oil for heart health.
“Every time I go to the doctor, there’s another pill they add,” said Helen, who is in her 60s and asked that her last name not be used. “From the time I get up to the time I go to bed, I take pills. The bin is just overflowing with pill bottles.”
Helen is hardly alone in juggling a dizzying schedule of pills: About 29 percent of American adults take more than five prescription medications every day – mostly due to chronic illnesses – and 82 percent of Americans take at least one daily, according to the Institute of Medicine.
Yet three out of four patients admit that they don’t take their medications as prescribed, and studies show that roughly 40 percent don’t even fill their prescriptions.
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A new initiative by UC San Francisco and Walgreens seeks to turn those numbers around, starting at the neighborhood pharmacy.
“Walgreens at UCSF” is a pilot store that offers the most advanced level of community pharmacy care available in the United States today.
It starts with the store’s unusual layout: Walk inside and the first thing you see isn’t racks of cosmetics or greeting cards; instead there’s a concierge desk where you can arrange a private consultation with a pharmacist or find out whether your prescription is ready. Pharmacists work with every customer to make sure they understand the medication they’re picking up, while also offering services such as the medication management that brought Helen to UCSF.
“This collaboration aims to transform the practice of community pharmacies to enable pharmacists to do what they’re trained to do, which is helping patients manage their health with the right medications and understand how to take them correctly,” said B. Joseph Guglielmo, PharmD, a leader in the field of clinical pharmacy and dean of the UCSF School of Pharmacy, which partnered with the UCSF Medical Center and Walgreens in creating this new facility.
A New Model of Pharmacy Care
For Walgreens, the new facility is an extension of their “Well Experience” stores, which offer expanded health services, are designed to foster increased patient-pharmacist interaction and make them more accessible to community members and patients.
For UCSF, it will serve as a teaching ground for student pharmacists completing their doctoral degree program, a clinical training site for pharmacy residents, and a research facility that explores new pharmacy patient-care models and programs.
The new pharmacy model also comes on the heels of a new California law that took effect on Jan. 1, 2014, expanding the role of pharmacists on the patient care team.
Under the new law, which was based on Senate Bill 493, pharmacists can perform additional health care responsibilities within the realm of their expertise, such as furnishing travel medications, oral contraceptives and smoking-cessation medications, monitoring patient health and adjusting prescriptions, as needed. With additional training and certification, they will be able to provide further care, such as adjusting a patient’s medication therapy.
The new Walgreens at UCSF is located across the street from the UCSF Medical Center, which partnered on this initiative to help reduce hospital readmissions due to medication error. Photo by Bryan Lettvin/Walgreens
Fourth-year pharmacy student Sarah Lynn Fels, left, works with a patient at the MedList Clinic, a special public event for the grand opening of the new Walgreens at UCSF on Feb. 25. Photo by Elisabeth Fall/fallfoto.com
“People already know that they can go to a pharmacist for vaccinations,” said Marilyn Stebbins, PharmD, a clinical pharmacy professor who was an advocate for the new law. “Now, they’ll also be able to go to pharmacists as part of their health care team.”
The new facility, located across the street from UCSF Medical Center on the University’s Parnassus campus, will provide Walgreens pharmacist consultations as a standard of care to every customer, along with other services offered by the School of Pharmacy and Walgreens, such as comprehensive medication reviews for customers who receive prescriptions.
Pharmacists also will work with patients to create and update an accurate, portable medication lists, known as a MedList, to take to their appointments with medical providers, to help decrease drug-to-drug interactions and encourage patient medication adherence.
For the store’s grand opening on Feb. 25, the School of Pharmacy held a special event, called a MedList Clinic, where the public was invited to walk in for free pharmacist consultations.
Helen was among several dozen patients who came to assess whether all of her medications were still necessary, which ones might be conflicting, and which could be simplified to make her medication burden a little lighter.
Working with two UCSF pharmacy students and a faculty member, with her pill bottles arranged neatly on the square card table, Helen discovered that the pain medication she’s taken thrice daily for years comes in a higher dose, which would eliminate six pills per day. The pharmacists also told her those medications could be spread out more, helping her manage her back pain better in the evening, and she could talk with her doctor about getting a full month’s supply, so she doesn’t need to refill them as frequently.
Improving Health at Lower Cost
Roughly 133 million Americans – almost one of every two adults – had at least one chronic illness in 2005, according to the most recent data available from the Centers for Disease Control and Prevention.
Jennifer Cocohoba (center), PharmD, associate professor of clinical pharmacy, reviews patient information with fourth-year pharmacy students Greg Balani and Patricia Kuang. Photo by Elisabeth Fall/fallfoto.com
A MedList Clinic: Perspectives of a Pharmacist and a Student Pharmacist
“Modern medicine has transformed many diseases from urgent, life-threatening conditions into chronic illnesses that can be managed with the right medications,” Guglielmo said. “But that means more and more patients are juggling multiple prescriptions, with complex instructions. And, in many instances, this complicated medication list is inaccurate and incomplete.”
The new initiative builds upon UCSF’s long history of collaboration in teaching, research and patient care between the School of Pharmacy and UCSF Medical Center.
In the 1960s, the school and medical center piloted the first hospital-based clinical pharmacy program in the nation, known as the Ninth Floor Project, which put pharmacists on the hospital floor alongside doctors on their rounds and used their expertise in pharmacology to manage patients’ medications more effectively. That model is now used in nearly every hospital in the nation.
Walgreens at UCSF aims to translate that innovative program to the community level, or “first floor,” ultimately creating a model that links pharmacist-based patient care to primary providers.
It also comes at a time when hospitals are struggling to reduce costly readmissions rates for patients with chronic illnesses. The best place to start that process is to help patients who can manage their illnesses at home through medications, and help them stay out of the hospital.
Medication errors are one of the leading causes of harm to patients, including 7,000 deaths and at least 1.5 million injuries each year, at a cost of over $3.5 billion nationwide, according to the Institute of Medicine.
A number of studies have shown that incomplete medication histories are common upon hospital admission, with as many as 95 percent of patients’ records having at least one error in their list of medications, wrong doses or frequencies, or discrepancies in allergies or prior adverse drug reactions. Additional studies show that discrepancies in medication information occur in up to 70 percent of patients upon hospital discharge.
“Every time a patient is readmitted to the hospital because they did not take their medications, it has a direct impact on both their health and their health care costs,” said Daniel Wandres, PharmD, chief pharmacy officer of UCSF Medical Center. “By creating this three-way partnership, we hope to create a national model for eliminating medication-related readmissions and reducing medication errors nationwide.”
Integral Part of the Primary Care Team
Stebbins, who is one of the leaders of the Walgreens at UCSF program, developed a model of community-based medication management at the PRICE Clinic, in Sacramento.
That work was modeled in February’s MedList “brown bag” clinic, so named for the sacks of pill bottles patients bring with them.
On that particular day, the actual bags came in all colors – some black plastic, some green. One man arrived with a tidy canvas toiletry kit, precisely packed with pill bottles.
Each of the patients left the MedList clinic with a School of Pharmacy medications bag, along with a chart for their refrigerator door of their current MedList, neatly organized with columns showing when and how to take each one.
They also had a wallet-sized version of the list and a green thumb drive with the electronic version that could be shared with their providers, as well as a set of suggestions for them to share and discuss with their doctors, to help make their medications safer or more manageable.
And Helen, like many, also left the clinic with a palpable sense of relief.