Virginia HRSA Project Underway
Virginia Commonwealth University (VCU) School of Pharmacy at Richmond and Central Virginia Health Services (CVHS), an 11-facility health system that serves residents in the central, rural area of the state, began enrolling patients in August in a randomized controlled study to determine the effects of clinical pharmacy services on patients with diabetes mellitus.
The Health Resources and Services Administration (HRSA) awarded CVHS a $250,000 grant in January 2001 as part of a demonstration project program established by the agency in September 2000 to expand and improve clinical pharmacy services at community health centers.
Community health centers are funded under section 330 of the Public Health Service Act to provide primary and preventive health care services in medically underserved areas throughout the United States and its territories.
Community health center demonstration project grant recipients were required to partner with a school of pharmacy to "ensure that the most current practices in clinical pharmacy are incorporated into each health center's standards of care," according to HRSA.
Using the HRSA funding, CVHS hired clinical pharmacist Laura A. Morgan, assistant professor of pharmacy at VCU, in August 2002 to provide drug therapy management services to patients for four days per week at Central Virginia Community Health Center (CVCHC), a CVHS facility serving about 8000 patients in New Canton, Virginia.
The health center has four pharmacists, Morgan said, who dispense drug products to patients who come to the New Canton clinic or use its mail-order service, which serves nine of CVHS's smaller facilities that lack a pharmacy (see sidebar).
Center helps low-income patients obtain medications
Central Virginia Community Health Center (CVCHC) may purchase drugs at a discount through the federal 340B drug-pricing program, said clinical pharmacist Laura A. Morgan.
Patients who obtain drug products through CVCHC's mail-order service also receive pharmaceuticals at a large savings under the 340B program, she added.
About 10% of CVCHC's patients qualify for Medicaid, which has a prescription benefit, Morgan said, but the high cost of medications is a "big barrier" preventing many of the health center's other patients from obtaining their prescribed drugs.
CVCHC's medication assistance program helps patients not covered by private insurance or who do not qualify for Medicaid to obtain drug products at discounted prices through pharmaceutical manufacturer assistance programs, she said.
The health center obtains about $100,000 worth of medications per month through various drug company assistance programs, she added.
Many of the drug companies that provide assistance programs now have "bulk replacement programs," Morgan said, which allows community health centers to dispense drugs to patients enrolled in an assistance program on the day a prescription is written.
Before bulk replacement programs were available, she said, many patients enrolled in assistance programs were often forced to wait up to six weeks before starting a medication while the drug company processed required paperwork.
Providing care. Morgan provides drug therapy management services to patients with diabetes mellitus during 30-minute scheduled visits under a collaborative practice agreement with physicians at CVCHC. She also sees patients on a referral basis to help manage other drug therapy.
Morgan consults with health care providers twice a month about patients with diabetes mellitus at Southern Albemarle Family Practice, one of CVHS's rural clinics located about 30 miles outside of Richmond. Patients at Southern Albemarle obtain their medications from the health system's mail-order program.
Many of Morgan's patients with diabetes mellitus also have hypertension or hyperlipidemia, she said, adding that some patients have all three conditions.
Under Virginia's collaborative practice agreement law, pharmacists can discontinue a patient's drug therapy or adjust a dosage.
But physicians at CVCHS wanted more control over a patient's drug therapy, Morgan said, and so she discusses a patient's regimen with a physician before changing a dosage or telling a patient to stop taking a medication.
"I'm the first clinical pharmacist that has been at this clinic, so the physicians wanted to have final approval of any changes in drug therapy," she said. "I do have some physicians that say to me 'just write in the chart what you are going to do,' but most of the time I definitely discuss the patient with the physician before we make any adjustments. They are still learning what I can do and becoming more comfortable with my skills."
One of the nice things about working for a community health center, Morgan said, is that she has access to a patient's pharmacy records.
"So before I go to see [the patient], I've often already looked at their pharmacy profile, and I have an idea of what medications they are supposed to be taking and what medications they've actually been picking up and how often," she said.
The health center's dispensing pharmacists often identify for Morgan a patient who may need help regulating his or her medications, she said.
"They let me know that I might want to look at a person's chart or see if [a patient] needs to schedule an appointment with me," Morgan said.
Morgan also provides a list of patients that she sees on a regular basis to the pharmacy, she added.
One tool that Morgan said she highly values is her laptop computer, which has a wireless network card that allows her easy access to the clinic's scheduling and pharmacy systems and the Internet.
Billing insurers. Morgan can bill Medicare, Medicaid, and private insurers for providing services incident to a physician's visit, she said.
"If a patient is scheduled for an appointment with me, the visit is billed as incident to the physician whether the patient is private pay, Medicaid, Medicare or private insurance," she said. "If I am seeing patients on a physician's schedule but they are not scheduled for an individual appointment with me, then the patient is not billed for the extra time spent with me. They are only billed for the traditional physician visit at the level the physician deems appropriate."
Morgan said the provider number she uses to bill a patient visit is "mapped" to the supervising provider for that visit.
The supervising provider has to cosign her notes in the chart to meet regulations.
"This is similar to what physicians do with nurse practitioners, physician assistants, and medical residents," she said. "The level at which I bill depends on the extent of the visit. There are specific guidelines that must be met in order to bill at a certain rate." Morgan said her visits are considered focused or expanded focus, which are the two lowest of the five levels of billing.
Morgan's continuance in her job depends on revenue she generates for the health center and whether CVHS receives future funding from HRSA or an outside organization, she said.
As part of her job, Morgan oversees pharmacy students completing a five-week ambulatory care experiential rotation at the clinic.
Study groups. Morgan plans to examine three groups of adults with diabetes mellitus and hypertension or hyperlipidemia, or all three conditions.
Patients at CVCHC will be randomized to receive usual care or usual care with the addition of a clinical pharmacist's services.
The third group will consist of patients at Southern Albemarle Family Practice who receive their prescriptions through CVCHC's mail-order service. Those patients will receive clinical pharmacy services via telephone or mail, Morgan said, adding that she will also mail the patients appropriate information about diabetes mellitus, hypertension, and hyperlipidemia.
Morgan said she plans to enroll 100 patients in each group. She expects to have preliminary data available by next summer.