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7/31/2003

State Legislators Attend Demonstration of Pharmacists' Patient Care

Cheryl Thompson

About 1,000 state legislators, their aides, and other persons last week experienced firsthand the variety of health care evaluations and counseling services that pharmacists can provide patients.

The Alliance for Pharmaceutical Care, a collaboration of ASHP and nine other national pharmacy organizations, recruited pharmacists and sponsored a demonstration booth at the annual meeting of the National Conference of State Legislatures (NCSL), July 21–25 in San Francisco.

Visitors to the booth could have a blood sample taken for determination of cholesterol and glucose concentrations, place a heel in a machine that would estimate bone mineral density, blow into a device that would show how well the lungs function, offer an arm for measurement of blood pressure by traditional sphygmometroscope or digital monitor, and present an arm for use in an infrared-based test that would estimate how much of the body was composed of fat.

Pharmacists explained each test result immediately after measurement or, in the case of the blood tests, which required 10 minutes to process, after the attendee visited the other stations in the booth. A full battery of tests and counseling sessions took about an hour and cost visitors nothing but their time and a tiny bit of blood.

Every visitor received a folder of information on the value of pharmacists—controlling health care costs and improving health care—along with a report card for recording the test results from the various stations.

A banner above the booth displayed "Pharmacists Can Save Medicaid Millions" in lights.

ASHP State Government Affairs Director Maria D. Spencer, interviewed the first day of the booth's three-day run, said the message in that banner was one of the things that attracted legislators.

"I've been talking to a lot of them, particularly legislators in states that don't have collaborative drug therapy management," she said.

Responses to Spencer's one-on-one presentations, she said, varied from "Oh, we should do that," "I want to look into that," and "Can you send me some more information" to "Well, I didn't know we didn't have that, but it sounds like something that we should look into further."

West Virginia Sen. Jeffrey V. Kessler (D), representing District 2, a nine-county swath extending north to south through the state's center, learned from Spencer that his state does not permit pharmacists to work with physicians in "formulating the medical prescription plan for patients."

"That's something I was unaware of, and maybe we'll take a closer look at when I get back to town," Kessler said, adding that he asked Spencer to send his staff proposed legislation for his consideration.

Lori Reisner, Pharm.D., an associate clinical professor at University of California at San Francisco (UCSF), operated one of the booth's two bone densitometers that used ultrasound to estimate the bone mineral density of a person's heel. She specializes in managed care and pain management and holds clinical, teaching, and administrative responsibilities at UCSF.Reisner

"One of the persons that came to us actually told us she's had pharmacists do more than her physician," Reisner said. The fact that that person was a legislator, she said, shows "there's a level of confidence" in pharmacists providing patient care.

All but a few of the people Reisner tested during the booth's first day were women, nearly all postmenopausal.

"Most of the people, surprisingly, had had the test done at least once before, either the heel screen or with the bigger—what we call DEXA [dual energy x-ray absorptiometry]—scan," which examines the hip and a few vertebrae, she said. These persons, she explained, wanted to know whether their bone density had changed from the most recent measurement, particularly if they were taking medication to prevent or treat osteoporosis.

As part of the bone-density station, Reisner said, pharmacists counseled patients "on some of the mechanisms or the interventions that they can try, and that includes dietary changes, more weight-bearing exercise, ... dietary sources of calcium. And certainly, you should always recommend that they follow up, particularly if there's a borderline score."

James Palmieri, Pharm.D., BCNSP, an assistant professor at University of the Pacific who runs the pharmacy school's clerkship program in Sacramento, Calif., told visitors the results of their blood cholesterol and glucose tests and explained the importance of managing personal risks for heart disease. On a normal day, he works as a cardiovascular disease management specialist at Mercy General Hospital's heart institute, part of Catholic Healthcare West, a 42-hospital health system.

Palmieri estimated he talked with 30 to 40 people in less than four hours. While most did not know their total or high-density-lipoprotein cholesterol level, he said, "there were a few people who were on cholesterol medications who were just double-checking" their numbers.

Most of the blood samples had been taken from people who had eaten that morning, so their level of low-density-lipoprotein cholesterol had not been detemined, Palmieri said. But he covered risk factors for heart disease and provided general counseling about managing cholesterol levels.

"Everybody seemed to be pretty receptive" to the information he provided, Palmieri said, even persons whose test results indicated that they should seek help from their physician.

Scott Meyers, executive director of Illinois Council of HealtMeyersh-System Pharmacists and Missouri Society of Health-System Pharmacists, helped visitors take a test to measure how much carbon monoxide—from cigarette smoke and environmental sources—was in their breath and counseled those who smoked about the importance of stopping.

"This is my fourth [NCSL] event in the last six years," he said, noting that he worked the pulmonary-function station his first year at the alliance's booth and the body-fat analysis station the second and third years.

Finding that relatively few visitors were current smokers, Meyers pursued his second mission—convince legislators to fund smoking-cessation programs with their state's lawsuit settlement from the tobacco companies.

"I just got done talking with one legislator from New Jersey," he said. "I talked to her about the benefits of smoking-cessation [programs] that pharmacists get involved in, the value that it would bring to states' Medicaid [and] Medicare programs." Other legislators were also interested in Meyers's message, he said, "because they're all dealing with spending that tobacco-settlement money and they want to find the best bang for their buck" while struggling to balance their state's budget.

"One legislator wanted pharmacists to come to the high schools and junior highs and grade schools and talk to the kids about smoking and what the impact would be" if they used tobacco products, he said.

As for Meyers's home state of Illinois, a nearly $1 million grant from the Department of Health to the University of Illinois at Chicago pharmacy school in 2002 funded a four-county program that trained pharmacists in a special smoking-cessation method so they could counsel smokers on how to quit.

"The program seemed to be pretty successful overall," Meyers said, "and I think it really demonstrated the value that pharmacists bring to a process like that because they're accessible when a patient's having problems."

Sometimes sharing the pulmonary-function booth with Meyers was Jeffrey Rochon, Pharm.D., director of pharmacy affairs services for Washington State Pharmacy Association. In that position, Rochon works with pharmacists and pharmacy students to develop pharmacy care services and protocols for collaborative drug therapy management agreements in community settings.

Rochon showed visitors how to blow into a computerized spirometer that was interfaced to a printer. Once a visitor followed his instructions, the printer generated a readout, including two graphs, of various measures of pulmonary function. With that information, Rochon, could help visitors who had asthma decide whether they needed further treatment or their medication regimen was okay.

"The patient really has to puff and blow very hard," he said. "As the provider, we actually are kind of coaching them and teaching them and cheerleading to get them to puff and blow out as much air as possible."

For the most part, Rochon said, visitors had healthy lungs, but he did discover a few people who should seek a follow-up to "see if there's possibly an obstruction or some slight wheezing or a potential for lower lung capacity."

Sandy Bardas, a clinical pharmacist at Stanford Hospital & Clinics in Palo Alto, Calif., said her duties at the bone-density and body-fat assessment stations were similar to what she routinely did at her anticoagulation clinic: provide patient care, perform point-of-care testing, and counsel on the meaning of test values and what a person needs to do next. But at her clinic, Bardas said, she also adjusts the dosage of anticoagulation medication.

When asked by one visitor why pharmacists do the types of services shown at the alliance's booth, Bardas said she told him "it's because pharmacists are interested in total health care."

"You often have to tell people what they don't want to hear," Bardas said after discussing the results of a body-fat analysis with an obese man, "so you have to couch it in a way that they can take one piece of it and, if they make one small change, that's a step forward. So I always try to assess the person and see what change is easiest for them to make, have them make that change, and [then have the person] receive the positive feedback for it so they can move forward. People know if they're overweight, if they're hypertensive, if their heart is bad, or if their blood sugar is high.... They can actually do much better if you take the baby-step approach."

Nnenna Uwzaie, who is enrolled in the nontraditional Pharm.D. degree program at the University of Colorado in Denver, took a day from her experiential rotation in cardiovascular disease management at Catholic Healthcare West to join Palmieri, her preceptor, in the alliance's booth.Uwzaie

"If I know if the person is a legislator, I try to let them why we are doing this—let people know that pharmacists do other things outside of the traditional [dispensing] role," such as cut health care costs, improve patients' quality of life, and achieve better health outcomes, Uwzaie said. "A number of them from the different areas of the country have been surprised. They didn't realize that pharmacists could do that."

Uwzaie, who earned her first pharmacy degree from University of Nigeria, said she has always been interested in helping patients understand their medication regimens and strategies for improving their health status.

Gia Khue Nguyen, Pharm.D., a pharmacy practice resident at Palo Alto Medical Foundation, said she had accompanied her UCSF professors to Sacramento, the state capital, where they explained to legislators pharmacists' value in improving residents' health care, but the alliance's booth was her first experience at a health-screening event.

She worked at the body-fat analysis station, where she delivered bad news to some people.

"But it's how you deliver the message and how you deliver the solution that makes all the difference," Nguyen said. "We're not giving any scientific or any breaking-news solution. It's very simple: diet and exercise—lifestyle modification."

Nguyen said she told visitors about the not-so-obvious ramifications of excessive body fat: increased risks for hypertension, heart disease, osteoporosis, and other chronic conditions.

Bani Tamraz, Pharm.D., a pharmacy practice resident at UCSF, also worked at the body-fat analysis station.

"We're trying to help the legislators be aware that pharmacists can play a critical role in taking care of patients."

The alliance's 40-by-40 booth was surpassed in size only by the slightly larger one sponsored by Physicians Advocating for Patients, a group of medical associations.