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Expanding pharmacy care in underserved areas

Pilot program demonstrates effective business model for pharmacists in health centers

The Kennedy Pharmacy Innovation Center at the University of South Carolina for years has researched what the business model of assigning a pharmacist to a patient-centered medical home could look like.

The challenge was to prove to stakeholders in other areas of health care it could work in a state where nearly 30 percent of the population lives in rural areas.

Patti Fabel, a clinical associate pharmacy professor and executive director of the Kennedy Pharmacy Innovation Center, made the most of a chance to make that work.

“Here in the College of Pharmacy and in the profession, we already know that pharmacists can have an impact on patient care, particularly when collaborating with physicians,” Fabel says. “But it's the business model piece and the sustainability that is needed which makes it difficult for that to happen.”

When Fabel came into the center as executive director, she felt the next iteration of team-based care could be aimed for rural underserved areas, where the federally qualified health centers that provide health care services to vulnerable communities have fewer resources.

“I pitched the idea of ‘Let’s figure out how we can get pharmacists in more medical practices, particularly in these rural health centers,’ ” Fabel says. “It's one thing to teach and give lip service, but we really need to help these practices and pharmacists and support them in starting it off.”

In 2018, a five-year grant was secured for a demonstration project to promote and expand team-based care with a training program that would integrate pharmacists into primary care practices.

“The hypothesis was that if we can give them just a little bit of funding and a little taste of what a pharmacist could do for them in these small pilots that they'd want more and they would try to figure out a way, through our help, to make it sustainable and keep the pharmacist.”

‘We need to continue doing this’

Fabel and her team rolled out pilot programs in 2021 and 2022 for three types of health centers, each of which would be about 12 weeks long. The funding wouldn't support full-time assistance at a practice, so a pharmacist would only be on site to work one or two days per week.

“Some of these practices were small enough that a full-time pharmacist might be challenging to afford,” Fabel says.

Of the three pilots, one was at a federally qualified health center in the Lowcountry that served Beaufort, Hampton and Jasper counties, which did have an in-house pharmacy and pharmacy staff.

“What we did with them was we took one of their pharmacists out of a dispensing role for two days a week and put him in the clinic doing some work, primarily annual wellness visits. And that one was successful,” Fabel says.

“At the end of the pilot, he was hired full-time into the clinic, and they brought on another pharmacist part-time. So it was successful enough that they said, ‘We need to continue doing this.’ ”

"The hypothesis was that if we can give them just a little bit of funding and a little taste of what a pharmacist could do for them in these small pilots that they'd want more and they would try to figure out a way, through our help, to make it sustainable and keep the pharmacist."

Patti Fabel, USC College of Pharmacy

The other pilots were matches for independent community pharmacies. The goal was to show that integrating a pharmacist into primary care can close gaps in care for patients with chronic diseases in rural areas of the state.

A rural health center that served Fairfield County partnered with Hawthorne Pharmacy, and a patient-centered family practice medical home that served Newberry County partnered with Prosperity Drug Company.

John Pugh, Pharm.D. 2005 and president of Prosperity Drug Co. as well as one of its pharmacists, witnessed a way for pharmacists to work through problems of chronic care management as part of a team.

“What it enables us to do is we can still provide the service,” Pugh says. “If a patient needs it, they know we’re a resource.”

Pharmacists can look at a patient’s fill history and communicate with a doctor to be aware of what’s going on. With a mutual patient, the pharmacist can document the care in a way that’s billable where revenue is shared between the services that’s equitable.

“And a doctor can say, ‘If you think the problems is the patient can’t afford a medication, you’ve suggested a viable solution, let’s go with it.’ Now we’re all working together,” Pugh says.

“I think doctors need the pharmacist perspective. And we oftentimes need the medical perspective,” he says. “Something will come up, we need a phone-a-friend, and they’re there.”

This can go beyond medication and into a patient’s diet.

“Changing what you eat doesn’t really cost you money. Maybe a little bit, because healthier food’s more expensive. But you’re not having a deductible on what you’re eating for lunch. So let’s talk about that,” Pugh says.

Pugh describes these conversations as “motivational interviewing.”

“It’s so people take ownership and it becomes their idea. It’s their health, right?” Pugh says. “It’s our job to make sure they’re educated. They can’t make a good decision without the appropriate inputs.

“That’s our duty. What’s not acceptable is when they don’t know they’re making an unhealthy decision.”

Female pharmacist consults with female patient.

Access for the underserved

One of the pilot program’s consultant collaborators was Kayce Shealy, a 2009 USC College of Pharmacy alumna and now associate dean at the Presbyterian College School of Pharmacy. Shealy helped facilitate development of the sites and connected the pharmacists with resources for the work before being part of the process of analyzing the outcomes.

“I think this is a growing area of pharmacy, particularly those underserved rural areas where access to other providers is not as prevalent,” Shealy said. “What I hope to see is that more of this work is done across the state to where patients are benefiting as well as the practices themselves.”

The pilots were able to shine a light on demonstrating that the value of a pharmacist to a primary care team can be combinations of improving patient outcomes, closing gaps in care, increasing billable revenue and enhancing the satisfaction of patients and providers.

Fabel notes that the end of their trial has coincided with an increase in federally qualified health centers across South Carolina that have incorporated clinical pharmacists into what they do.

“To actually see the pharmacist there during the day helping you with patients, it changes perceptions. And it was great to see their buy-in and excitement with having a pharmacist and willingness to try something different.”

Fabel thinks back to all the presentations she’s made so audiences could understand the role of the pharmacist and how investments in placing them in health care settings can be worth the effort.

“Interestingly enough, I still get emails and contacts today from some of those presentations that I did years ago. It really did plant a seed in some people, even if they weren't quite ready to do it just yet. They thought about it.”