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John Pugh, Pharm.D.

Building a collaborative relationship with local physicians and hospitals is a natural extension of clinical services offered by the pharmacy. Prosperity Drug Company is a traditional community pharmacy in a 2,100-square-foot building on the square in downtown Prosperity, S.C. About 1,000 square feet on the first floor is dedicated to the front end as well as a soda fountain. The pharmacy is several hundred square feet, with a staff of five pharmacists. There was no “ah-ha” moment to move to clinical services. I believe the profession has changed since I opened the pharmacy in 2006, as payments have shifted and the focus on patient outcomes has increased. We’ve found opportunities that have led us to expand into clinical services by building collaborative relationships with the physicians and a hospital in our area. The process began when we installed a Medicine-On-Time system in 2012. Originally, it was to service an assisted-living facility. It turned out it wasn’t really what that organization needed, so we started offering the packaging to our patients who still lived at home.

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Getting Connected

Once we started using Medicine-On-Time, we promoted multidose blister packaging. It created a really nice product, and we realized that it was truly helping people sort their meds. In the process of developing this service, we learned a lot about how to manage those patients, and a key component was medication reconciliation. Another door opened when a physician we worked with closely began sharing med lists with patients. We saw this valuable piece of information and began asking patients to share their medication list with us. We often found discrepancies between what the patient was actually taking and what the physician thought he or she was taking. Reviewing the medication list and talking with the patient then allowed us to communicate with the physician to determine exactly what medication regimen the patient should be on.

We saw an opportunity here to improve the health of our patients and share information with the doctor, and our staff started asking providers for med lists proactively.

Prosperity Drug Company, Prosperity, SC
Prosperity Drug Company
Prosperity, SC

About that same time, medication synchronization was gaining traction nationally. We immediately saw the potential for med sync to bridge the gap between our traditional “on demand” pharmacy and the Medicine-on-Time program. We quickly discovered that medication reconciliation was just as important to running an effective sync program as it was for blister packing. Therefore, we ran these programs internally on parallel tracks and simply filled the Medicine-on-Time prescriptions in blister packs instead of vials.

Once we established working lines of communication with our local providers, it gave us a tremendous opportunity to share other pertinent clinical information. For example, why not look at labs, see if a patient has a contraindication to a drug or has tried one and it didn’t work? We met with physicians and explained what we wanted to do. Most are happy to work with you, especially since they don’t have to do any additional work on their end. You just have to ask! Once you start reviewing the med lists, you get a lot of information you can share, and that has helped tremendously.

Get The Information You Need

The med list allows Prosperity Drug staff to connect the dots between pharmacy and physician. I then thought about helping our local hospital with readmissions, so I met with their administration to see how we could get information about our mutual patients. The biggest challenge here was that the hospital does a great job and has an extremely low readmission rate. However, they realized the benefits of collaboration to ensure that their readmission rate stays low. What was important was consistency of information access — reliance on nurses to send over information for patients had room for human error. The IT (information technology) director said the hospital was part of the South Carolina Health Information Exchange (SCHIEx), and our pharmacy could join that network so we could get the information we needed on demand.

It’s been very useful to share data through the health information exchange. For example, using the information we get from SCHIEx allows our staff to get patient weights to check doses (especially on pediatric patients) or see if an elderly patient’s renal function is sufficient for a med that has been ordered. Since many facilities across the state use SCHIEx, we are not limited to our local hospital. Doctors see the value in this level of care, and the doctor’s staff sees Prosperity Drug as the pharmacy “that does it differently.”

Triggers

Accessing SCHIEx means we’re not dependent on the hospital to send us anything. And we can identify the e-scripts that come from the hospital pretty easily. There is an alert that pops up when a script comes through from a doctor at the hospital when there is a discharge. It allows us to say there is something going on and start asking questions.

Triggers: The Time to Collaborate

These are examples of changes to a patient’s medication situation that would prompt pharmacy staff to contact the doctors about coordinating care.
  • A patient moves into a medication reconciliation and management “program.”
  • An Alert for medication therapy management (MTM) services.
  • Drugs that are dosed based on renal function:
  • Metformin (especially dose decreases).
  • DPP-4 inhibitors:
  • Januvia 25 mg or 50 mg
  • Onglyza 2.5 mg
  • Fluoroquinolones:
  • Ciprofloxacin
  • Levofloxacin

The collaborative process begins in the pharmacy when the staff notices a trigger that we’ve created. Once the staff identifies a trigger, a pharmacist can log into SCHIEx to review clinical information. This is a work in progress. As we get better at this process and identifying triggers, we can make notes in our QS/1 system to update what we’ve learned. We have also set up the system so that an alert pops up when there is a new prescription that may indicate a discharge from the hospital. There is a lot of subtlety in this process, so it is imperative to leverage the pharmacist’s expertise. Physicians realize your practice is doing something special when you start making phone calls and say, “Hey, I’ve received the medication list and noticed the patient should be taking 2 grams of metformin a day, but the fill history indicates he or she is only taking 1 gram a day and the patient complains of GI discomfort. Could the patient switch to an extended-release formulation?” Or you have a patient who’s hit the donut hole, and you need to come up with a new strategy so that person can afford his or her diabetes medication. We can come up with a plan using medications the patient can afford and make a recommendation. When we initially meet with the physicians, we explain how this is a value and how we can serve as a resource for them. The doctor will recognize your pharmacy as doing something different, and that’s when you stand out.

The Ideal Physician Partner And How To Communicate

Everybody’s on the same team here in our community in rural South Carolina, because our hospital and physicians are independently owned and locally controlled. Our community doctors admit their own patients to our hospital, so continuity of care is maintained. Our providers have got the end game in mind, which is improved patient outcomes. They are doing it right, and it makes it easier for us to thrive. I think our community is a great testament to how exceptional healthcare can be delivered in rural settings anywhere in America.

In today’s healthcare environment, doctors and hospitals have skin in the game, as far as people taking their medications correctly is concerned, because of quality indicators and metrics. However, much is beyond their control. They prescribe the right medication for diabetes, cholesterol, or blood pressure, but the patient goes home and doesn’t understand what he or she is supposed to do. We’re offering a solution that helps to follow those patients between visits, helping them become adherent to their medication regimen, and resolving any issues before they linger or become a problem.

Documentation In Your Pharmacy System

Just as you need a relationship with doctors in your area, you also need to have relationships with your pharmacy management system vendor. As you look to document your clinical encounters, you probably have features in your software already that will support this new workflow, and you need to work with your vendor to see how best to use the system. Also, talk to other customers who are using the system to document clinical outcomes and see what you can learn. We visited two pharmacies to get ideas for what we wanted to do.

For our needs, outcomes notes in QS/1 work perfectly. As you build up information, you can easily review the patient’s history. That’s another area where pharmacy can step it up. The days of jotting down some notes are over. Use the pharmacy system to document what has happened with a patient, and the staff needs easy access to the information and a streamlined way to note necessary follow-up consultations with the patient or the physician. You want any staff member who is handling the patient file to know exactly where the patient is in the care process, and have the ability to share the information with the physician or hospital and print the file.

It’s Time To Start

Other pharmacists have said to me that they are thinking about adding clinical services but have not begun yet. We have to do this to take care of our patients and stay relevant moving forward! For example, when they hear that Amazon is buying PillPack, some pharmacists get worried about change. It can be intimidating. But are these large, national companies doing medication reconciliation? Do they work with local physicians? How are they dealing with medication changes mid-month? There is still a huge need for independent community pharmacists to go out there and do it better. These clinical pieces are the key to what will make us different from any mail-order operation and provide better outcomes for our patients.

Collaborative Practice: How to Start

  • Community-owned, independent hospitals are a great place to start.
  • There are over 1,400 independent hospitals in the United States:
  • Critical access and short-term acute care hospitals.
  • Approximately 325 of these have between 25 and 100 beds.
  • Work to reduce hospital readmissions!

We don’t have to be a disruptor across the nation — we can be a disruptor in our local area. At Prosperity Drug we make sure we’re doing everything we can to take care of our patients and the people who live in our community. Independents are small — that’s a strength, not a weakness. We have to ensure we’re going out there and coming up with innovative ideas and practicing at the top of our license. We don’t want to miss the opportunity just because we haven’t done it that way before. CT

John Pugh, Pharm.D., has owned Prosperity Drug Company since 2006. He can be reached at jwpugh@prosperitydrug.com.

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