As part of a lifestyle and aging series, we’re working with renowned photographer Terry Lorant to showcase inspirational leaders in the industry. Each month, we’ll feature one or a few inspirational member(s) of the Amazing Care Network community who is using his or her voice to empower others in the collective aging experience. Read, in their own words, what the Amazing Care Network’s efforts mean to them.
This month, we’re proud to feature Sarah Lorentz, Pharm.D., Director of Partners in Medication Therapy at UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences.
Being here at the School Pharmacy, I wear a lot of different hats. The main way that our programs here have been involved with Amazing Care is through our Partners in Medication Therapy. It’s a program where we use our pharmacist faculty as experts in a variety of clinical areas to provide services for patients who might be interested in learning not only more about their medications, but also about ways that we can optimize their medication regimen. Most people are on several medications, so sometimes we are able to decrease potential side effects or drug interactions; and sometimes we can help save patients money. There are a lot of different opportunities to help patients through the program, and we’re making it available to the Amazing Care Network.
Q: Can you describe some of the kinds of troubles and issues that people come up against and how PMT is able to help?
SL: A couple of stories I can tell you about. One was with a person who had had a kidney transplant. That was a pretty intense type of situation. We’re really fortunate here that we have a faculty member who specializes in people who have failing kidneys and also who’ve had transplant. In this particular situation, the patient was involved with a couple of major medical centers here in the state of California and saw many doctors, as you might expect after this transplant.
In this situation the patient was really frustrated. She was very knowledgeable about her medications, but she had a lot of questions about the connections and if things were moving in the right direction. She just needed a little help to put it all together. So that was something that I think was pretty unique that we could offer here with somebody who had that specialized expertise, but also had some general background and was able to look at the whole regimen all as one piece. We were able to reach out to a variety of the providers and get a lot of her medical records since the places where she was being treated all used Epic, which we use here at UC San Diego. Today there’s a lot more ability to share medical records, rather than having to rely on the memory of the patient or just bits and pieces of labs or other reports.
Otherwise, we have a referral form and we ask a number of questions that we think would be pertinent to background information the pharmacist would need. And then if the patient or caregiver can get access to the other information, that’s great. We can often become involved with requesting the records with the patient’s consent. That does get a little bit more complicated but it’s all still certainly doable.
We worked with another woman who had a husband who was very ill. She called our office very, very frustrated; she just didn’t know what to do next. Her husband was seeing multiple physicians; some of his medications had changed. Her husband’s health situation had also changed pretty dramatically recently. She had a lot of questions and a lot of concerns that some things weren’t being done according to what she thought would be best for him. That particular situation ended up with a home visit, which was something that we could offer because the person lived relatively close to here. So that was very nice to have another set of eyes to reassure her. There were a few recommendations that we wanted to make. But a lot of it was reassurance; yes, these are the right kinds of things to do, she was following guidelines. That was a really successful visit. Those are the types of things that we like to do.
Sometimes we do find things that we’re uncomfortable with. The provider might not be following the guidelines as closely as what might be ideal. But there might be a good reason for this due to the patient’s history, so if we can get some of that information, we’re able to analyze it and make sure that a given medication is really the best option that’s available for the patient.
There are a lot of medications out there, many in the same class and some of them might work a little bit better in certain situations. There are significant cost differences in a lot of the medications as well, and of course the other thing that we delve into is over the counter medications and supplements. Those can get pretty complicated, and sometimes the primary care doctors or the specialists might not really even be aware that the patients are using them. A lot of times some of the supplements really aren’t necessary. People are taking things that they’ve heard from their friends or neighbors have worked for them. And maybe they did. So we take a very objective look and try to give people the very best information that we possibly can.
Q: How did you make the connection with Amazing Care?
SL: We first met Cora several years ago with another project that we were working on and shortly after that she told us about the physician friend of the family idea, and she envisioned that maybe we could do something similar with a pharmacist as well. At that time we were reaching out to employers and health plans and things like that. So it seemed like it might be kind of a nice fit, and I think that it was actually a very creative way to look at providing these services.
Then in the past six months or so, she became aware of the fact that we were having concerns about some of our other clients regarding best way to bill patients for services; not all of these services are covered under a health insurance program. While there are pharmacists in clinics in some settings, there aren’t in all settings, it varies from place to place. Our partnership with Amazing Care has been a really positive thing for us and now we’re able to do further joint marketing.
We’re now out looking at Assisted Living and Independent Living, an area that, believe it or not, is really overlooked by a lot of care providers in the pharmacy world. That population doesn’t necessarily see physicians or other providers as frequently because it’s harder for them to get there. So we’ve done a few pilots in that area and we’re really excited about moving forward with this opportunity with Amazing Care.
Q: Can you talk about some of those pilots? It sounds like interesting research.
SL: A couple of years ago, we went to one of the local Assisted Living centers. We talked with the director about what we wanted to offer and he suggested that we work with the local leadership of the residents. They had lots of questions, it was so much fun. I remember a long discussion about ginger. They had so many questions; they were very excited and interested. Then we came to one of their monthly family meetings where the children and family can participate and we did the presentation for all of them.
At that point we offered appointments on site. The residents filled out paperwork that gave us direct access to their medication records. Most of the of the residents have the staff administer the medications to them. That was really helpful because not only did we have this nice medication list, but we also felt pretty well assured that those medications were actually being given and the patient was taking them. Many medication lists are just lists until we talk it through and find out what people are really using and what they use once in a while and what they use for certain symptoms and others that they don’t use at all. It’s so important to know this, because if you make the assumption that everything that’s on the list is being used, you’re not really going to come up with the right solutions or answers.
Over a couple of days there were at least a dozen patients that we visited, and I think almost all of them did have a family member that accompanied them, which of course was very helpful because they could add a little bit more information to the questions. We also provided them with a medication list that they may or may not have actually been completely aware of because typically the nursing staff has that list. One of the interesting things that happened when we went to see one of the patients was that we saw that she was in a lot of pain. We felt badly that she was so uncomfortable; I don’t remember specifically what was causing the pain, but we went out to the nursing station and found out that she did have orders for some pain medication. She had medication available but it was written as a PRN, which means as needed. She didn’t know what was on the list, and the nursing staff wasn’t at that point in time connecting with her on a regular enough basis that they knew that she was having this pain. The daughter wasn’t aware of the medication either. So we were able to get that sorted out with a very positive outcome.
Q: Can you describe the opportunities that are available to Amazing Care members through your service?
SL: For the most part members work directly through Amazing Care and then come to us for an analysis of the kind of service that’s most appropriate. We have two different opportunities. One is the comprehensive medication review process where we go through everything using medical records, and then the other is what we’re calling coaching where we really don’t have to open up a medical record.
If there are more general questions that people might have about medications, we wouldn’t necessarily need to open up a medical record to write a just a general note; an example would be a question about Medicare Part D. Other examples would be investigational drugs, or somebody who says, “I’ve seen my doctor and they’ve told me that I have this or that diagnosis; what are the types of medications that one could use for this particular diagnosis and what would be the pros and cons?” In these cases we can put together a short document of general information. As a consumer, it’s so hard when you go to look things up just on the internet; you get a lot of information but you don’t necessarily know what to do with it, what to make of it, how much of it is reliable. How much of it is being sponsored by the commercial entity that’s making it? It’s really very difficult. So that’s something that we can offer, something that we certainly can do, and that would come under the coaching umbrella.
Q: The coaching idea sounds to me like something pretty broadly applicable. Can you walk us through a coaching situation?
SL: One of the places where we’ve done some training here with our students at the School of Pharmacy, has been in the area of the Medicare Part D program and how to make the choices on the medication plan, and which Medicare Part D program would work best for someone. You have to be somewhat computer savvy to address these questions, but even if you are it’s sometimes hard to know what all the possible resources are. You can go into the medicare.gov site and then enter in medications, but it’s very helpful to know a lot more about formularies, what’s in a formulary, what drugs are similar, dosing regimens, and other related items. Having that background really provides a lot of insight for people. It’s the kind of thing that I’ve done with family members just personally to help them out because most of the time you can help save them money; depending upon how many medications they’re on, it could be a few thousand dollars over the course of a year if they’re on several medications. So that’s a type of service that would be helpful.
There’s another thing that I can see that we haven’t done yet, but I think that would be really valuable and really reassuring. We have one of our pharmacists here who is an oncology specialist. And I could see that when a patient might have a diagnosis of some type of cancer, they might really want to talk to someone. Even though the oncologists try to spend time with the patients, sometimes you get home and then you have even more questions. And then to try to re-access that person and their expertise is sometimes difficult to do. So, I think sitting down with the pharmacist, they could have a little longer, more involved discussion of various options for some particular type of chemotherapy regimen. Not needing to know anything specific really about the patient but just giving them general options and trying to help them formulate questions when they go to see their health care provider because a lot of it isn’t just getting the information, it’s knowing how to ask the questions and what questions are appropriate.
Q: It’s so complicated, especially when you’re vulnerable in that way. And even with a person that doesn’t have an acute problem like that, I would assume drug interactions are really a major problem in the older population?
SL: That’s absolutely right, and the thing that’s tricky about interactions is that not all interactions are giant events that are going to happen and stop your heart from pumping or something else very serious. Some of them are a little more subtle and insidious. For example, if you have two interacting medications, when you discontinue one, if everything’s been altogether, everything may continue working fine. On the other hand, you may have medications that interact on your list, and if you discontinue one of them, then things may start to crumble. A lot of times we will tell people for example who are on an anticoagulant like warfarin (Coumadin) that has a lot of drug interactions, if everything’s going along just fine but a prescriber takes you off this particular medication, let us know right away. Then we can readjust the dose of warfarin. A lot of things like that happen. Certainly in an older adult population, you have a lot of medications that are on what is referred to as the Beers list. The Beers list is a group of drugs that are tagged to be used cautiously. Even though a drug might be fine today and the next day, to continue it for years on end may not be the ultimate goal.
One of the other things that that we find is that physicians tend not to question their colleagues. They don’t really have time most of the time but a lot of times they don’t feel comfortable doing that kind of thing because they view the other person as the expert. But as pharmacists, our whole career has been built around medication safety and optimizing medication use, and our job is to question anything that seems a little off here or there. A lot of things that run through your mind as the pharmacist; was this considered or not considered? We’ve become used to it being a part of our work; that’s what we do. Our job is to ask questions. I think today we’re finding that a lot of the health care providers have become much more open to a more collegial environment. The thing is to take care of our patients, our patients as best we can.