Author Archives: Joel L. Zive, BS, PharmD, Adjunct Clinical Faculty at the University of Florida College of Pharmacy

Cultural Competency Key to Positive Health Outcomes

Early in my pharmacy career, a hospital social worker referred to me a deaf patient. He had a reputation for being rude and belligerent to providers. After our first encounter, I was no exception. However, after looking at health care from his perspective – slow communication, unthinking providers, long waits in the clinic – I had an idea.

Joel Zive

Joel Zive

Instead of counseling him with a pad and pencil, I counseled him in front of a computer screen. I made the font larger, and we communicated in this fashion. He was ecstatic! I learned that many deaf people communicate with a device called a Telecommunications Device for the Deaf (TDD), with which they can type responses and often learn to do so rapidly. Because I accounted for his unique point of view and modified my interactions with him accordingly, our relationship changed for the better.

For a provider, cultural competency involves understanding patients’ perceptions of their role in health care. When a provider or prescriber has that insight, significant improvements can occur in therapeutic outcomes. For example, cultural competency can aid providers in preventing drug interactions by determining which complementary and alternative medicines their patients use, as well as help improve patient adherence to prescribed therapies. This is especially important in minority communities, in which the devastating effects of diabetes, hypertension, and other diseases take a disproportionate toll.

Establishing this insight takes time that busy practitioners don’t always have. Fortunately, providers increasingly rely on capable, cost-effective partners: community health workers (CHWs). CHWs work in a variety of settings, including community-based organizations, AIDS service organizations, hospitals, and clinics. They are often of the same ethnicity as many patients and live in the neighborhood; in many cases, CHWs have already developed trusting relationships with patients and may have a better understanding of the nuances of how they expect or want to be treated. CHWs are also in a position to uncover problems that patients are unwilling to share with their physicians and other health care providers.

The positive effects of CHW involvement as provider extenders are well documented. For example, at the Gateway Community Health Center in Texas, CHWs played a valuable role in improving outcomes among people with hypertension and diabetes.

A critical area that can be enhanced by community health workers is complementary medicine. St. John’s Wort is one example of an herbal folk remedy that is sometimes used and endorsed by generations of family members for the treatment of depression, but that many patients may not report to their health care providers. This is significant because St. John’s Wort should not be taken with antiretrovirals. CHWs may be more effective than those ‘wearing white coats’ in learning about use of complementary and alternative medications and, when needed, explaining the dangers of drug interactions with sensitivity and compassion.

Research continues into the benefits of employing CHWs in pharmacies. Four pharmacy school professors at the University of Florida – Folakemi Odedina, Ph.D.; Richard Segal, Ph.D.; David Angaran, MS, FCCP, FASHP and Shannon Pressey – did a pilot project to see whether a CHW paired with a single community pharmacy could uncover medication-related problems that were missed by the pharmacist alone and improve outcomes in hypertension (view this short video for more information). In an interview with Real World Health Care, Dr. Segal said they teamed a CHW with a pharmacist to work cooperatively for 11 months to enroll 30 patients with poorly controlled hypertension (>140/90 mm Hg). The CHW was able to gather information about which patients were using complementary medicines as well as the barriers people were experiencing that affected their adherence to prescribed medicines. Together, the CHW and pharmacist developed a medication action plan that was informed by the added information the CHW was able to collect from patients. While four patients were lost to follow up, the 26 remaining patients showed a significant reduction in systolic blood pressure. The pilot program is being scaled up to involve 30 CHWs with funding from the Department of Health and the CDC. Segal concluded that clinical collaboration between pharmacists and CHWs should also be used for other disease areas.

What other ways can community health workers benefit patients in addition to increasing treatment adherence and decreasing the risk of drug interactions? Share your thoughts in the comments section.

Five Ways to Manage the Costs of Your Medicine

While a main precept of the Affordable Care Act is to expand access to health care, in some cases that improved access means more patients are being treated with medications that come with a cost. As a pharmacist, I have to be an insurance sleuth, use common sense, and teach my patients the old-fashioned methods of negotiation.

Joel Zive

Joel Zive

I work in solid organ transplant, HIV, and Hepatitis C medicine. I have patients on regimes ranging from 4 to over 20 medications. For my patients, obtaining consistent, reasonably-priced medications – both over-the-counter and prescription – is vital.

1. Make sure all the medications are at one pharmacy.  It’s important to keep a clinical eye on things for drug interactions. As a bonus, the pharmacist and the patient know what costs need to be examined.

2. Seek out insurance prior authorization.  Some insurance companies require prior authorization to cover certain drugs. Your pharmacist can help you seek prior authorization for medications that require it using software that creates forms specific to each insurance company. Ask if your pharmacist can fill out the form as much as possible before sending it to your doctor.

3. Contact the drug company.  Many pharmaceutical companies offer patient assistance programs or co-pay assistance cards to help eligible patients obtain free medicines, particularly for biologics and expensive drugs. These programs are especially helpful for patients who have insurance gaps and need the medications quickly. Depending on the assistance from a case manager or care coordinator, I have received authorization for medications right away or within 72 hours.

4. Search for a co-pay assistance program that covers your condition.  If your drug company does not offer a patient assistance program or you are not eligible based on your income and insurance coverage, it is possible that a charitable patient assistance program through a non-profit organization such as the HealthWell Foundation may be able to help you.

5. Seek discounts for over-the-counter medications.  Over-the-counter medications can put a strain on the wallet. In many cases, purchasing over-the-counter medications is more expensive than prescription medications covered by insurance. Other items like vitamins, natural supplements, and enteral formulas (also known as ‘milks’) require the patient to do a little negotiating. If you tell the pharmacy or vitamin store you will be taking these items indefinitely, they may be inclined to discount. Also, be on the lookout for buy one get one deals (BOGOs). Finally, enteral formulas can be quite expensive, so if you get prescribed a specially formulated one, ask if you can take a more basic formulation instead. Remember to let your prescriber and pharmacist know which over-the-counter medications and supplements you are using.

In conclusion, while the path to affordable medications is not always easy, there are individuals, programs, and strategies that can help you meet your health care goals.

How do you manage your medications? Share your tips in the comments section.

Categories: General

Three Ways You Can Reduce the Impact of Cardiovascular Disease this American Heart Month

Most of the readers of this blog know that cardiovascular disease (CVD) is the number one killer of men and women in this country. According to the Centers For Disease Control and Prevention, CVD is a leading cause of disability, preventing Americans from working and enjoying family activities. Out-of-hospital cardiac arrests cause the deaths of an estimated 250,000 Americans each year. CVD costs the United States over $300 billion each year.

Joel Zive

Joel Zive

There are many small but significant actions we can take. Here is what you can do to make a difference: empower or continue to empower patients to take care of themselves.

1. Address the cost of heart medication

If the cost of your medicine is an issue, talk to your doctor or contact a patient assistance program that may be able to help with prescription co-pays.

2. Encourage healthy behaviors

Want people to eat better? Give them coupons for healthy food. Exercise? Give them coupons for short-term memberships to health clubs.

The stakes are higher in our country’s current health care landscape. With more people on health insurance than ever before, we need to do everything we can to empower people to seek help before an emergency and talk to their doctor about what they can do to take better care of themselves. This will have a direct effect on deaths from heart disease.

3. Ask your employer about Automatic External Defibrillators

There are instances in which individuals are dealt devastating genetic hands of cards. Recently, the Philadelphia Inquirer highlighted the plight of a Philadelphia family that had a genetic link to hypertrophic cardiomyopathy, a disease of the heart muscle.

For those who do experience heart issues, or even have a major event such as cardiac arrest, Automatic External Defibrillator (AED) devices can significantly increase the likelihood of survival. AEDs have been available for over 20 years, but in recent years, device makers have reduced the size and cost and increased usability of defibrillators, making public access defibrillation viable. “We believe ease of use is one of the most important qualities in an AED because the potential user may not be well-trained in resuscitating a victim of sudden cardiac arrest,” said Bob Peterhans, General Manager for Emergency Care and Resuscitation at Philips Healthcare. “This is consistent with the American Heart Association’s criteria for choosing an AED.”

While risk factors for CVD are often genetic, the majority of CVD is triggered by factors that are controllable: smoking, diet, and exercise. And this is where individual efforts need to be focused.

For more information on preventing CVD, check out the American Heart Association’s guidelines for taking care of your heart, which are broken down by age. The Centers for Disease Control and Prevention also offer an American Heart Month guide to controlling risk factors for cardiovascular disease. You may also want to check out The Heart Truth, a campaign from the National Institutes of Health to make women more aware of the danger of heart disease.

Read more Real World Health Care heart health-related posts:

Are you taking steps to prevent cardiovascular disease? If you, a family member, or a friend has CVD, what is working for treatment? Share your experiences and insights in the comments section.

Adherence Training Key to Improved Coordination of Care, Use of Specialty Drugs

I have been fortunate enough in my career to do humanitarian work in East Africa, and I have witnessed incredible health care service performed despite a paucity of resources. Conversely, one of the many health care tragedies in that part of the world is the downward therapeutic outcome spiral due to unattended simple maladies. An untreated toe could turn into a raging skin infection or worse. A simple break of a person’s leg improperly set could leave that person crippled for life.

Joel L. Zive

Joel L. Zive

In the United States, we have a different set of complex issues affecting our health care system. But there is a beacon of hope with some of the most vexing health care issues:  specialty drugs. Yes, they have annual costs that approach the length of phone numbers, but research and development costs must be taken into consideration.

Yet when one evaluates the pain and suffering these compounds alleviate – sometimes also saving money for our health care system in the areas of solid organ transplant rejection, HIV, Multiple Sclerosis and Cancer for example – real value emerges.

Despite their high expense, there are organizations, including the HealthWell Foundation, that help patients pay for access to these medications. And do not forget social workers, case managers and an army of master insurance billers in doctor’s offices and pharmacies across the country.

Yet these drugs carry with them a promise and a peril: A promise if their regimens, with high pill burden, are adhered to and the side-effects are understood. And a peril to the patient and unnecessary high cost to our health care system.

What person who deals in specialty drugs has not been brought to the brink of tears due to the frustration of non-adherence? Of a transplant patient who never told their pharmacist or transplant coordinator that he stopped taking their immunosuppressive medications and lost their transplanted organ? The efforts of the pharmacists, nurses, prescribers, surgeons, transplant coordinators, social workers that were wasted along with precious time and money are horrifying.

On the other hand, you have a patient newly transplanted or newly diagnosed with a complex disease. Frightened, scared — even angry — wondering whether they can afford medications to stave off dialysis or stay alive. In my career, I have seen first-hand examples of turnarounds in patients’ attitudes and quality of life due to these medications and adherence training:

  • A kidney transplant patient who was on dialysis for years who saw other patients go into dialysis walking, then in a wheelchair, then on a gurney before expiring.
  • Another patient at the dialysis center who announced one day, “I give up.” This individual had sufficient motivation but still needed guidance and assurance he would get his medications in a timely manner. Now, this person is rebuilding a life for himself and his family.
  • A woman tired, frail and scared lying in a hospital bed post-transplant wondering how she will live the rest of her life. With encouragement and adherence training she is now flying cross-country to see her relatives.
  • Another patient was diagnosed with relapsing remitting Multiple Sclerosis in the prime of his life. Yes, he had difficulty dealing with his insurance company and their specialty pharmacy.  But he had help and encouragement from an outside specialty pharmacy. And with patience and persistence from others he is now in graduate school.

What do these examples underscore? That although the United States enjoys an abundance of health care resources compared to Africa, what we’re missing is the coordination of care. Sometimes this is due to the health care system and sometimes this is because of the patient.

There are a couple of strategies providers can employ to improve this situation:

  • This scenario I saw first-hand in Rwanda.  If a pharmacist senses there is something not right mentally with the patient, he can contact a social worker in the clinic for further workup.
  • Another approach includes an agreement among the multidisciplinary team about what the adherence goals  should be. If the goals seem to be remiss, then the pharmacist could be notified, and he could handle the issue or direct it to the appropriate provider.

In both cases, there is feedback among the health care team. In the area of specialty drugs, adherence training can fill and highlight these gaps to the patient’s benefit.  As my colleagues in East Africa have told me, “We admire your health care system.”

We have many issues to be worked out and negotiated in the weeks, months and years ahead.  But let’s use adherence training to give my colleagues overseas something they can aspire toward and emulate.

What other strategies can providers employ to improve coordination of care? How can hospitals, government and health care industry stakeholders coordinate to become part of the solution when it comes to more effective adherence training?

Kaiser Permanente Gives Providers Evidence-Based Tools to Increase Adherence

At an industry conference years ago, I met an HIV-positive patient. We spoke about her treatment as well as her adherence program. “Who takes care of you?” I asked. “Kaiser Permanente,” she responded. Afterward, I did a little research and discovered this was one of the first HMOs created in the United States that takes care of millions of patients. Based in Oakland, California, their goal is “supporting preventative medicine and attempting to educate its members about maintaining their own health.”

Joel L. Zive

Joel L. Zive

Adherence remains a capstone in caring for patients after medications are dispensed and is an especially important issue for indigent populations. But now with implementation of health care reform fast approaching, patients will be required to take even more responsibility for their health, including adherence to medication regimens. Although no integrated health care structure is perfect, Kaiser’s integrative model fascinates me and allows its health care teams to implement successful adherence strategies.

For example, a Kaiser physician at the South San Francisco Medical Center conducted a hypertension study (“Improved Blood Pressure Control Associated With a Large-Scale Hypertension Program”) that compared their program’s results to those at the state and national level. The outcomes are startling:

  • The Kaiser Hypertension control rate nearly doubled, skyrocketing from 43.6 percent in 2001 to 80.4 percent in 2009.  
  • In contrast, the national mean of hypertensive control went from 55.4 to only 64.1 percent during the same time period.

One aspect of this program included using single pill combination therapy, which has been shown to boost adherence. In a slightly different approach to adherence in hypertension, Kaiser Permanente Northern California and UC San Francisco were recently awarded an $11 million grant to fund a stroke prevention program by targeting and treating hypertension among African Americans and young adults.

By Googling “Kaiser Permanente adherence” the Kaiser Permanente Division of Research appears. Their published research draws from Kaiser Permanente units throughout their network, collaborations with academic institutions nationwide, and the HMO Research Network – a consortium of 18 health care delivery organizations with both defined patient populations and formal, recognized research capabilities. These resources provide clinicians and pharmacists with a plethora of study designs and disease states from which to choose and evaluate.

In the study “Determination of optimized multidisciplinary care team for maximal antiretroviral therapy adherence,” for example, a multidisciplinary care team was assigned to patients with new antiretroviral drug regimens. Because this model translated to improved adherence rates, clinical teams around the country now use some variation of a multidisciplinary approach, enabling each discipline’s area of expertise to benefit the patient.

Another article from Kaiser — “Health Literacy and Antidepressant Medication Adherence Among Adults with Diabetes: The Diabetes Study of Northern California (DISTANCE)” – demonstrates that adherence is multifactorial.  This study’s conclusions underscore the importance of health care literacy components, simplifying health communications for treatment options, executing an enhanced public relations campaign around depression and monitoring refill rates.

In my experience, if someone with mental health issues does not take his or her medications, then regardless of disease state, the patient’s treatment falls off the track. I approach these difficult situations by drawing on the conclusions of the above studies:

  • First, is there a different message I could give the patient? Or am I reaching the patient at a level of health care literacy he could understand? For example, I had a deaf patient who found it tiresome writing messages back and forth to me. When I realized he “speaks” to people via a teletype machine, I began communicating with him via word processing software. This made our communications less cumbersome. And this improved adherence to his regime because he was less frustrated.
  • Next, the multidisciplinary approach is quite powerful. When I served HIV-positive patients in the South Bronx, if anything occurred that affected adherence, the prescriber, nurse, social worker or case manager immediately were made aware. Sometimes we would discontinue the regimen and other times we would tweak the regimen and get the patient back on treatment.

The real adherence tragedy for indigent patients is not whether they receive medication, but whether they have access to the tools, education and knowledge they need to take their meds as prescribed. Leveraging articles from resources like Kaiser’s Division of Research may be the solution to reversing the trend of low adherence.

Now we want to hear from you. If you’re a patient, has your doctor or pharmacist worked with you to improve med adherence? If you’re a provider, what resources have you found to be useful when helping patients understand why they should take meds as prescribed? Share your stories in the comments.

Categories: Access to Care