Addressing Language Barriers, Medication Therapy Management at Medicare Part D Outreach Clinics

Pharmacy Times interviewed Rajul A. Patel, PharmD, PhD, pharmacy professor at the University of the Pacific in Stockton, California, and director of the Medicare Part D Outreach Clinics, on his work providing medication therapy management and drug savings advice to Medicare beneficiaries in diverse communities throughout northern and central California.

Question: What are some of the challenges that can arise for pharmacists and providers when treating culturally diverse populations, such as those in central and northern California?

Rajul A. Patel: I think one of the biggest challenges is often the language barrier. Especially if we’re trying to go into some of those underserved, underrepresented areas, English might not be a primary language for those individuals, and there might be a dearth of health care providers who can actually help patients, empower patients, by speaking their language and making sure that the information that's communicated is accurate.

Question: What are the Medicare Part D Outreach Clinics you currently oversee, and why were they important to establish?

Rajul A. Patel: We started this program shortly after the inception of the Part D benefit in 2006. And quickly, we realized it was going to be a wonderful benefit, because for the first time, individuals who had Medicare would have access to a prescription drug benefit under Medicare. Prior to that, most people who had Medicare would either pay out of pocket for their prescription drugs or they would have private insurance, both of which were quite costly. So, that was wonderful.

However, there was a challenge that we immediately saw in that, most of us, during our working years, if our employer is generous enough to provide health insurance, have 4 or 5, maybe 6 different plans from which to choose. Back then, and it hasn't changed too much since, but there were 70, 80, 90, even 100 different Medicare drug plans from which to choose, depending on where you resided. So, that was going to be overwhelming.

One of the first things that we wanted to do was really try to address the cost barrier because you have all of these different plans. Each one has a different formulary or set of medications that they cover, and also a different cost sharing structure. Although they had prescription drug insurance, we wanted to make sure that they were making the best choice. So selecting the plan that best met their needs based on the medications they’re taking, based on the pharmacy they like to go to, and other personal parameters. So we were trying to minimize, if not altogether eliminate, cost-related medication non-adherence.

Then shortly thereafter a few years into the program, we quickly realized, we're sitting down with these individuals who have Medicare, and on average, the patients that we assist, take about 5 to 6 prescription drugs, and about 3 over the counter drugs. And we deploy an army of trained student pharmacists, and they're all overseen by licensed pharmacists. So we thought, okay, we're addressing the cost issue, how about now if we do a comprehensive medication review and try to eliminate, again, barriers to medication nonadherence. So I think that's what's really most critical: The majority of patients that we assist are going to be over the age of 65, and many of them have, as I said, several medications, both prescription and over the counter, and several chronic diseases, and what we're trying to do with our Medicare program is really trying to help minimize those barriers to medication nonadherence.

Question: How can patient education language translation services help to not only reduce common barriers to medication adherence, but also help to improve patient treatment outcomes?

Rajul A. Patel: So when we started providing the medication therapy management services, one of the core pieces of that was creating a personalized medication record. And that was sort of done by hand, by scratch. We created an Excel template and started populating the meds, but it was only available in English. I mean, that's all we could do. So quickly, we realized that was not going to meet the needs for all of our patients, because about 1 in every 5 patients that we assist, English was not their preferred language, so something other than English. We leverage the bi- and multilingual skills of our students, but then we have to leave patients with information so that they’re properly empowered after the intervention is done. And so, a few things with regards to that.

The platform that we found that best met our needs and really was a game changer was the Meducation platform that's now under the First Databank umbrella. And there's a few things in there that really resonated with patients. So number one, the ability to create that personalized medication record, which they're not going to really find in any other health care setting. But then, the ability to—with a simple click of a button—convert everything that was typed up in English into 1 of over 2-and-a-half dozen different languages. That's really helpful, because, if we're helping patients that are Vietnamese speakers or Spanish speakers or Russian speakers, there's going to be a need for those kinds of translation services.

The other thing is oftentimes about 1 in 5 of the patients that we see don't have a high level of formalized education, so sometimes not even a high school graduate. And so the pictogram really is helpful. Based on the pictogram with the sunrise or the sunset or the moon, you can tell the timing of day to take your medication. That was really helpful as well.

And the nice thing is not only the personalized medication record, but also if we wanted to print the individual drug monographs, those are also available in all of these different languages, and for certain products, like injectable products or products used by inhalation, even the videos, the demonstration videos on how to properly use those products are also available. So, we not only share that information with them at the intervention, but then when we print that personalized medication record, it has a unique code, and we show them how they can use that code to access the information thereafter. And that really helped us empower the patients after we were done with the intervention. We would print a copy in English so that they had one for their health care providers. But then we would also print one in their preferred language so that they had it for themselves.

Question: What is the reach and impact of the Medicare Part D Outreach Clinics in central and northern California?

Rajul A. Patel: It's a good question—2 years ago, I could have answered that question very easily, but now it's sort of expanded and I'll explain why. Since the program started in 2007, we've assisted 10,446 Medicare beneficiaries, that's just with their Part D plan, and collectively saved just over $10 million. So, you're looking at just under $1000 per person per annum on the Part D plan optimization. And that has, as you asked, been confined pretty much to northern [and] central California. We go about a 90-mile radius from the university, which is the University of the Pacific in Stockton, California, so as far as San Jose and San Francisco and some other cities.

But the reason I hesitate is because it's changed, because 2 years ago, because of the pandemic, we quickly realized we were not going to be able to have in-person events that year. And so the question then was, do we sort of close-up shop and come back? We were thinking it would be in 2021 when the pandemic was in a much better situation. Or do we see if there's a need for services such that we will apply, or we will provide them virtually? And we actually reached out to all of those patients that we previously assisted, both via email for those who had an email address or by physical mail. We sent them a survey and asked them a series of questions to see what they wanted us to do. The response was quite overwhelming. Even those who had limited access to technology or comfort with technology, if we could help bridge that technology gap, they were very interested in us continuing to provide the services virtually.

So, in 2020, that's exactly what we did. We had all of our events virtually. And last year, we had a hybrid. We had the majority of events that were in person, but we had several virtually. What we did not expect is that we assisted people not only in northern Central California, but the for the first time we helped them in Southern California, and we actually expanded the services to assist beneficiaries in 10 different states and Washington DC over the last 2 years. And this was not through any advertisement and was completely unexpected. But what we found happened is that patients who would come to our events that lived in northern central California, would now tell their relatives who lived in Washington, or Florida, or New York, because now it was a virtual intervention, right, and it simply requires either a phone or a computer and an internet connection. And so we expanded our outreach significantly. Because of that, we're going to continue to provide the majority of our events in person, but also provide some virtual events to accommodate those people who not only live out of state but maybe mobility issue or transportation is an issue to get to one of our events, but they really want that Medicare review and the medication review. Well, now they can do so through the comforts of their own home.

Question: What is the reach and impact of the Medicare Part D Outreach Clinics in central and northern California?

Rajul A. Patel: What happens is every state, right, it's a federal benefit. So, this is all overseen by the Centers for Medicare and Medicaid Services. But every state and every county within the state has different Medicare plans. But it's the same process, right? You're still going through the same meds, the preferred pharmacies, if they have a Medicare Advantage plan, you're looking at their list of preferred providers, and so the process is identical. And honestly, one of the other things that's pretty unique about our program is we have a very close relationship with our regional office in of Medicare, it's based out of San Francisco, and so we work with them closely. But in terms of the intervention, although it might differ depending on where they live in in terms of, again, plan offerings, the intervention is exactly the same. We will still assist them and if they'd like, with their consent, we will enroll them in a new Part D plan. When we do the medication therapy review, we will again provide them everything the differences rather than printed and provide them the information in person. We collect their address, and everything gets sent to them via snail mail.

Question: How can pharmacies use patient education language translation services to address language barriers in the pharmacy and would that require hiring someone who speaks the region’s dominant non-English languages as staff or hiring external translation services?

Rajul A. Patel: I don't think the latter is probably going to make economic sense because although you might be able to hire a staff that speaks the predominant language of patients that the pharmacy serves, what about all of those other their languages and what if that staff member is not present or not working on that day? I think one thing that can be easily integrated is the Meducation platform that First Databank has because it can integrate with the pharmacy software. And therefore, when the typical intervention is happening and the patient is getting the medication along with that drug monograph, well now it can be printed again in their preferred language. I think that's probably the most useful tool because it can be readily accessed and available, regardless of the language proficiency of the staff that's assisting the patient.

Question: What are some other sites of care that would greatly benefit from the ability to access and tap patient education language translation services to aid treatment adherence and outcomes?

Rajul A. Patel: I think it's honestly any platform, I mean, any setting in which there is a review of an individual's medication. Some of the first ones that come to mind, of course, are prescriber’s office. Oftentimes, we all know, there's downtime in the prescriber’s office. You might be sitting there in the waiting room for 20 minutes, 30 minutes, 40 minutes, you might be waiting in the doctor's exam room as well. There could be an opportunity there for staff to actually collect the information, and then periodically, when the patient revisits, update it. But the other setting I think would lend itself very nicely is safety net clinics. Every county in the country has safety net clinics, especially for those individuals who utilize those clinics are going to be uninsured or underinsured. And oftentimes, English, again, is not their primary spoken language. I think those are some of the settings that I think that the platform would lend itself most nicely and benefit the providers that interact with the patient.

Question: Any closing thoughts?

Rajul A. Patel: We just try to continue to make sure that we meet the needs of the patients as best as possible. Over the years, the program has certainly matured. Way back when we started in 2007, in total, we only had 72 patients that we were assisting. I shouldn't say only because that was from 0, so it was very comforting to see that some trusted us with this, with their information, and their medications. And over the years, it's grown. The last year that we had solely in-person events, we had about 1600 people that attended our events.

I think over time you sort of build trust and continue to look for ways to best serve the patients, whether it's, again, by minimizing economic barriers to medication adherence, like through Part D plans ation or helping them find pharmaceutical assistance programs or coupon cards, or it's through the comprehensive medication review and identifying ways that we can minimize those barriers and also provide communication of our findings to their providers with their consent. Again, we're just going to continue to sort of evolve and it's a continuous quality improvement process. We just try to look at what the patients need and how best we can meet those needs.