Public Health Matters Video: Pharmacists as Frontline Health Providers: Collaborating for Better Patient Outcomes

This episode of Public Health Matters with Dr. Christina Madison, the public health pharmacist, delves into the evolving role of pharmacists in health care and explores how collaboration with other healthcare professionals can improve patient outcomes. The discussion focuses on innovative practice models and how they can positively impact patients' lives.

Christina Madison, PharmD, FCCP, AAHIVP: Hello everyone, and welcome to another episode of Public Health Matters. I'm your host, Dr. Christina Madison, also known as the Public Health Pharmacist. I'm so excited to be joined by 2 amazing guests. First and foremost, you have seen her before on my podcast, but Dr. Amina Abubakar, and then we are also joined by her colleague, Dr. Stephen Lewis. Today is a very special episode, because we're going to be talking all about different practice models and how pharmacists can collaborate with other allied health professionals; not just that, but how we can make it profitable, and, more importantly, how you can positively impact your patient’s lives. With that, I will go ahead and let Amina introduce herself, and then hopefully Dr. Lewis will be joining us once again, and we'll go ahead and get started.

Amina Abubakar, PharmD, AAHIVP: Thank you, Christina. Always lovely connecting with you and spreading the word of Public Health Matters and getting pharmacists right there in the forefront of serving our communities and you kind of amplifying the work so others can join in the in the mission. So, I'm excited to be here, and I’m glad Dr. Lewis is back. For those who don't know me, I'm a pharmacist. I'm an independent pharmacy owner in Charlotte, North Carolina, and over the years, I say I found refuge in surviving and thriving, not by myself, but collaborating with other medical providers for us to not only survive, but thrive, while the patients also thrive. So, glad to be here with my partner, Dr. Lewis.

Madison: Yes. By the way, you are being very modest. You are more than just a pharmacist, my dear, you are a serial entrepreneur and own other businesses. But obviously, today's conversation, we're focusing on our collaboration with our other allied health professionals like Dr. Lewis, who I would love to tear a little bit more about your background and your story and how you guys met.

Stephen Lewis, MD, FAAPMR: Well, thank you. Thank you so much for having me on this podcast. And thanks to Amina for bringing me along. I'm a physical medicine and rehabilitation doctor, or a physiatrist. We specialize in helping patients improve function and fitness and overall health background, a team-based physician that work multi-condition rehabilitation. We see a lot of aging patients with multiple chronic conditions, and after years and years and years of seeing the same patients with the same diabetes that progressed and eventually led to amputations and kidney problems and heart problems, I started really getting frustrated right around the time of the Affordable Care Act. I decided that I was going to shift my emphasis from taking care of patients in a team approach after they were already disabled, to trying to figure out ways that I could move upstream and help patients maybe prevent some of these preventable, chronic health conditions that you see out in the community. I kind of one day woke up and just started basically developing software that took into account best practices for chronic disease prevention and community health on a smartphone, and after years and years of working in different settings, I realized that primary care needed help. I sought out potential partners that could go in o a primary care practice and maybe surround vulnerable patients with additional care, additional services out in the community. That brought me… eventually, I was introduced to Troy Trygstad, who is the CEO of the Community Pharmacy Enhanced Services Network (CPESN), and he introduced me to Amina, and then Amina told me what to do next. She's almost always right, too. She really helped shape this vision that we've been bringing along that kind of works with a new type of team; we call it primary self-care. So, we see that primary care is shifting similar to what the World Health Organization sees as 2 divisions, and we're kind of a self-care support division out in the community with rehab doctors, clinical pharmacists, and then we're training community health workers to try to be able to team up to address all of the determinants of health at the right time, and to try to see if we can improve some populations in terms of quality of life and improve care. That's kind of this journey that that I've been on with Amina.

Madison: Well, you're definitely speaking my love language. You said community health worker, you said social determinants of health. I mean, you had me at hello. Interestingly enough, I feel like this concept is definitely something that isn't talked about as much. When we think about preventative care, the aspect of that where it's really getting the patient to be activated, right, which is sort of this concept around primary self-care, is preventing illness prior to it happening, but understanding that the person needs to be empowered. I kind of wanted to know you could talk a little bit about this concept of frailty, because that is something that I didn't know about until I went to the Avant Institute Symposium last year and was really introduced to this concept for the very first time, not realizing that, even just my own mother, who is, you know, almost 70, and I'm seeing all of these things that we become de-conditioned. We can’t do the things that we used to do before. You just really opened my eyes. So maybe if we could talk a little bit about that concept, and then how pharmacy can really help, I think that would be amazing for our listeners to understand and to hear.

Lewis: People have heard the word frailty, but it's not readily integrated into care right now. Since I'm a rehabilitation doctor, the muscles are an important organ system to us rehab doctors. One of the things we're trained to know is that, once you reach age 30, you lose 1-to-2-to-3-to-4% of your strength and your muscles are a big part of helping to rebalance your stress response system, blood pressure. It's a big part of helping eat blood sugar to prevent diabetes, and yet it's a very under-measured, under tested, under prescribed organ system in all of health care. I started exploring a lot about how to start thinking about what this weakness of aging occurs and how it impacts the aging process and all of these chronic health conditions that we see out into the community because it’s a little slightly different lens that I been looking through. In New Jersey, I started getting involved with an academic medical department, and the chairman, her name's Anita Chopra, at the New Jersey Institute for Successful Aging, and she and I started exploring this concept of, how do you look at a patient and their relative systemic vulnerability? That's what frailty really is. It's age-related vulnerability that can be sped up by chronic health conditions, so you got aging plus preventable chronic health conditions, and it can accelerate just overall vulnerability. And that's what frailty is, and, and vulnerability can lead to adverse drug reactions, higher risk. It could lead to poor outcomes from COVID. It could lead to falls. It's a major risk factor for dementia. It's a major risk factor for depression. There are different stages that have been identified that anyone who's interested in health coaching a population can look at the different stages leading to frailty, from fit on 1 end of the spectrum to frail on the other, and then there's stages in between. I's actually the best way to look at what everyone talks about now is population health, and maybe many people in the audience will have heard about population health, but the problem with the old models of population health is that it was very disease specific—diabetes, heart failure—but we know that as you get older, you may have 4 conditions at the same time.

Madison: Absolutely. I love that you're making that distinction. Not to interrupt you, but I do think that there is a difference between physiologic age versus chronologic age, because we've got folks that their chronologic age definitely doesn't match their physiologic age. There are folks that are in their 30s and 40s that like their physiologic age is more like someone in their 60s and their 70s, and it's typically because they've had that weathering effect that occurs from chronic illness and repeat chronic illness that's been either untreated or under treated.

Lewis: It's exactly right, and that's an important concept, of biologic age. We're just at the beginning of being able to actually measure someone's biologic age, as opposed to their chronologic age. People in the audience know that artificial intelligence (AI) is coming, and there were reports just last week that you can take a photograph of someone's retina and an AI scan can give you your overall biologic age based on an AI interpretation of your scan. Why is that important? Well, if you're trying to motivate someone to try to do something with their health, this type of data, I think, is important for that. A lot of health care is still focused on trying to improve this old model, but the new model is everything we're talking about right now. It's, how do you help people understand this trek towards vulnerability and what type of support can you give them and wrap around them? Because we know social determinants puts you at risk for vulnerability, chronic disease, and eventually to frailty. There are other determinants on top of that also; chronic stress from early childhood adverse experiences, things like that, elevate the stress response as a risk factor for frailty. There’s a great need for teams to start to talk about these things so that they share in kind of an approach towards trying to improve it. Frailty is a great example of something that's easy to understand with fitness on 1 end of the spectrum, frailty on the other end: it's a pretty easy concept for a team to understand.

Madison: Yeah, and we all don't get the benefit of having an Amina on our team to motivate us, right? How do we incorporate this? Because we can't multiply more Dr. Abubakar’s out there, so how do we do this?

Abubakar: It’s funny you said that, because that's the whole concept of how we've teamed up and be part of CPESN, was to take that knowledge and disseminate to different communities. Right now, Dr. Lewis is licensed in several states, and we are using the brick and mortar available in the independent pharmacy space, because patients already have trust, and they go there. How can we elevate that space and the knowledge of the individuals in that space to have this new conversation or start early screening? So, if you give an example, when we were working a lot with primary care, Christina, it was actually sad to find all these things, and then the primary care said, “This is great. I'm overwhelmed. I don't know what to do. It's going to take so much time to change this patient's behavior.” I've been a primary care for 30 years, that just doesn't work. And then when I talked to Dr. Lewis, he said, “Yes, because that's the old model. They need new team members that they work together, and that's how we see it.” So, we start referring patients now to this new clinic within these pharmacies that are physically ran by the pharmacist, their technicians, a community health worker, and leveraging technology so Dr. Lewis can be virtually in everyone's clinic. So, whether you're a clinical pharmacist having your own practice, or you actually have a brick-and-mortar pharmacy, bringing this specialist closer to your community—they may not be that many physiatrists in your area, many of them are either in sports medicine or already in them rehabilitation centers. As we are working on duplicating the pharmacist and the community health workers available, Dr. Lewis is inspiring the other physiatrists to come along. So everywhere we go, we're just kind of amplifying and then duplicating. The trainings are there. Dr. Lewis is very passionate. He's always making new videos to make sure everyone is learning. We found that patients are starting to see hope. And I think that's what motivated me to say, “I don't know where we're going, but I could see the recipient of this model, they need it.” Because the first part we saw is the social determinant of health. Before we can tell people to have A1C at goal and blood pressure at goal, patients are coming in because of these vulnerabilities—health literacy, food insecurities. They don't even know what they have. They are giving up; can't afford medications; over-prescribed. We're talking about cognitive decline, and then we're looking at anticholinergic burden. So, pharmacists are already equipped to do those initial screenings, but they just didn't know where they could go to help these patients. This model allows those collaborations to happen.

Madison: That's incredible. So not to kind of get into the nitty gritty of it, but can you kind of describe and maybe give a visual picture of what this looks like in your pharmacy setting? Because I'm thinking that folks are probably getting super excited about this and thinking, “Oh my gosh, maybe this is something that I can do,” but not understanding, what is the physical footprint? How much space do I need to have? What's the technology need? Am I contacting my local health department to get my community health worker, or am I using my pharmacy technicians and then getting them certified as community health workers? Sorry, I'm asking too many questions, but I’m excited. This is a very innovative thing that you guys are doing, and you can show success,

Abubakar: Yes. So, first is that physical observation. We see patients, and year-to-year, you see them decline, okay? You're giving them the same medication—"Hey, Mrs. so-and-so, have a good day!”—and you see them getting worse and worse and worse, and we're giving them their medications every single month. So, it becomes number 1, can we identify who we need to talk to, right? We're making medication synchronization (medsync) calls monthly and asking patients just about the medications. Now we are asking, what are they concerned about while they're at home? Are they concerned about falling? Are they concerned about getting weaker? Are they concerned that they think they're feeling their cognitive health is declining. Patients say yes or they're in pain, right? These identifiers that before we were not asking, now we do. So then when we find those individuals, how does the workflow look like? One, we love collaborating. So, we don't want anyone of these patients to have their provider say, “Who's Dr. Lewis, and what are you guys doing with my patient?” We introduced the concept to the local providers and let them know that our pharmacy is now part of this movement, and we want to help our patients, and here is a blanket referral, here's information. We will work with you, because whatever we find, Dr. Lewis does not step into primary care de-prescribing. It's about us finding out what's going on and sending that information to primary care, and then we work together. So, then it became, well, should a pharmacist do this alone? No. So we had some pharmacy technicians that are now training to be a community health worker. The cheese has moved, and everyone is like, “There's no money in pharmacy. Our reimbursements are going down.” But at the same time, if you look at where the cheese moved, it's moved to a value-based care system, and how do we repurpose our value so our technicians now can proudly say, “I'm a community health worker,” right? We took them through the training for those who were interested to be certified to be a community health worker, and as we started growing and scaling, we did reach out to the health department, the community college, and all these other colleges that are training community health workers, then they don't know where to go, right? So that's who we hire to work with the pharmacist. Then you talk about the footprint. All we really need, most pharmacists right now, most pharmacies already have a vaccine room. I mean, if you don't have a place to give shots, it's time to put it in.

Madison: You're losing money.

Abubakar: You’re losing money, you're losing access points to touch these lives that you can do much more with, right? In our room, we have a stand with a tablet. That's all we need, is a chair and a tablet. The community health worker gets the patient into the room, and Dr. Lewis is on the tablet, speaking to the patient, asking the patient, “stand up, move, raise.” And the community health worker is facilitating. And Christina, what was so interesting is the community health work said, as soon as Dr. Lewis will talk to the patient, the patient would say, “I can't hear,” and we were identifying hearing loss at that moment.

Madison: Which also has been linked to increase in dementia and cognitive decline. It’s amazing, because now we have OTC hearing aids!

Abubakar: Yeah! You see how it's all setting up to where, for our pharmacy now we are set up to have the OTC hearing devices, because we can now identify it at that visit, be able to then give them a solution. And then Dr. Lewis got us to do this grip strength test.

Madison: Oh, I remember you talked about this in the seminar.

Abubakar: Yeah, so that doesn't take space. You have that and you get your patients to do the left and the right hand, and then we record the data, and then the interview continues. And then we get a patient on the plan. When the patient leaves—because they get on an individualized plan—they leave with a tablet if they do not have a smartphone. So, access has been solved, right? We had a patient, I think, yes, this week, that they didn't have a smartphone, but they reached out through one of our technicians because they felt weak. They want to know if anyone could help them, and they don't want to leave their home, they don't want to go to a nursing home. So, they want to know what they need to do. If they don't have a smartphone, we give them a tablet at no cost to the patient. It's a device that we need to connect with them. So that way through the Medicare available codes that we can interact with them through time and coaching, and they're interacting there. They can do a video call. They can use it as a phone. They can receive great messages that are motivating from Dr. Lewis and the team, and they message back. If they do have a phone, then we help them download the app that connects with us. So really, what do you need? Pharmacists that want to be in this space who can see the impact that could have to this aging population, and they just need a private counseling room where they can have this private conversation, and patients can be assessed. Identifying them was easier than you can ever think. Who's walking in with a walker, who's walking in, you know.

Madison: Who wasn’t using a cane, and now they're using a cane, you're watching them, and their gait is unstable, and you're like, “Please don't fall in my pharmacy.”

Abubakar: Patients, I think, have been very, very receptive. I can never forget 1patient who asked our team, “Why did you guys start doing this now? Why didn't you help me a long time ago, before I was double amputated?” It kind of hit home as to, yes, we were just filling the prescriptions, delivering to the patient, taking care for years. She was so excited and motivated, but she asked us this question, and so I told my team that not offering and not telling patients—patients have a choice to say, “No, I don't need this. I'm good”—but not offering this kind of wraparound support…we're going to answer these questions more times than you think. So, think about that.

Madison; Wow. Okay, so now I'm motivated. So how can folks find out more about this? How can they learn the magic, the secret sauce? Tell me more. How can we get resources to folks so that they can get their Dr. Lewis in their area?

Abubakar: Yeah, I think first, we would love to have a place where people convene and have dialogues face-to-face and meet, not just Dr. Lewis, other physicians who are teaming up with pharmacists in different disciplines. We would love to welcome everyone to our upcoming next year at the Avant Institute Symposium. It's called “The Business of Collaboration.” People have collaborated over time. But how is it economical? How does it make business sense for a pharmacist, a high-cost professional, high-cost physicians, how do you make this into a practice? What does the practice of tomorrow looks like? Right? That's what we want, and not just in theory, but shake hands with these providers. Ask them in person: “Do you think, if I go to my provider, what should I tell them?” This is who's available in your networking, not a pharmacist answering on behalf of a physician. I would love at your table, you're sitting with a physician, a nurse practitioner, a PA, a medical student, a pharmacy student, and you're having this dialogue now. While I appreciate all the effort that our profession is doing at a high level, I always believe how you win the battle is also through grassroots. It's that one relationship at a time. We want to do both. While we're changing up the big laws that will allow these things to happen, I feel like there's an immediate opportunity where Dr. Lewis is already bringing his colleagues, he's talking about pharmacists like no one has heard before, so he's a big advocate. Well, we want the pharmacist there, right? They can convene, learn from others, and see that this is one model, but we have plenty, from psychiatrists to primary care, to Alzheimer and dementia. And I have to say, the future is here now because of this model. I have to plug this in Dr. Lewis; Dr. Lewis and our team presented an innovative model to Medicare, and we got granted to become the futuristic practice under the guide model for Alzheimer and dementia patients, not just the patients, but to help the caregivers. We are super excited. Our practice starts next July. So, we've been putting things in place. And we would love for that to be others, too. We have the road map. We're doing it. We would love it to be the new frontier in the United States.

Madison: That's incredible. Dr. Lewis, when you first had this encounter with this incredible human being that is Amina, did you ever think that it would get to this point, to the point where you are right now? I mean, I say that only because, when I when I met you in person, I saw the spark, I saw the twinkle. So, I know, I know you have this vision of the future. But did you ever think it would get this to this point?

Lewis: I had always hoped it would get to this point. I would say that when I met Amina, and we started talking and talking more, and she introduced me to some of the talented people that she works with, and we started expanding our conversations into thought leaders throughout health care. It got to the point where we really realized that we felt the potential to unburden primary care in a way that is not talked about a lot. We're at the point now where we feel like we validated that concept, and now it's a matter of expanding this journey with others that want to be a part of it, and with this partnership with Medicare, it's a value-based bundled payment, very much the future of where primary care is going to go. I think why Medicare loved our model is because they understood that we were unburdening primary care, and they were very specific to us. They said, “Can you take this model and move it to other conditions?” So, you start with dementia, but we also want to move upstream to prevent dementia. We want to move upstream. We want stage 1 congestive heart failure to not go to stage 2, to not go to stage 3. We want early pre-diabetes to not go to diabetes, to numb feet, to kidney problems, to dialysis. We want to move this exact support, self-care support model, and the thing that excites me is that we have the self-care experts in health care coming together. The pharmacists are global leaders in self-care support for medications and the conditions connected to the medications, and now the lifestyle factors connected to the conditions connected to the medications. Combined with a rehab doctor approach focused on preventing the trek to frailty, which very much involves the muscles as you get older and combine that with community health workers that are building skill sets and self-care of social determinants, and having this team synergize to share a common set of outcomes that we all know, sharing outcome measures. It's a new team that's never really been harnessed like this before, and so I think we're super excited to talk more about it at Amina’s symposium, and excited to just continue the collaborating with those that are interested in in helping.

Madison: I think my biggest takeaway from our conversation is that not only are you guys are doing good, but you can do good and have it be a business. That’s the key, right? Because I've got tons of ideas, because, of course, I want to just give everything away for free, but I can't, right? As pharmacy, we have, unfortunately, for many, many years, given away our cognitive services for free. I think now this gives us the permission to really look at, how can I make this a business model as we move away from traditional dispensing, right? Because that's not really value-based care. It's a function. It's something that you know, unfortunately, at some point a machine will probably do, right? But our cognitive skills and our ability to do deductive reasoning, to be that observation, to be that human in the room, to see that person looking and seeing them decline in front of you, and understanding that you can fix that or even slow it, right? So, in a lot of instances, I feel like the hope factor that you talked about, which is so unique to this, is that you're showing people that there's another way. That they don't have to just deal with their chronic illness and just wait for it to get worse, that there's an alternative.

Abubakar: Yes, and so the business case is what we work on constantly. Every Monday afternoon is the business analytics. It's amazing to see that Medicare already has a pathway where they are finding these actions or activities valuable, although right now, pharmacists aren't recognized federally as providers, so they cannot access these codes, but the right provider partner with the right rules, understanding, and putting together the measures, they're able to delegate that activity or that work to the right team members, and they bill for it, and they're able to pay for the time and the expertise of these professionals.

Madison: Amazing. Wow. Well, I could talk with you guys about this forever. You know that.

Lewis: We will, at some point.

Madison: That's the thing, I don't want to steal the thunder, because I know we have a 2-day symposium that is going to be focused on this and really allow for folks to come together in the room and to discuss this in detail, and to be able to make some amazing connections. So, Amina, tell us again, when is the symposium? Where is the symposium? How can folks find out about it, and then, even if they just want to connect with you and Dr. Lewis, just to be in touch with you and to see all of your wonderful creativeness and innovation. How can they do that?

Abubakar: Sure. So, the symposium is January 31 and February 1, 2025. We are covering from, not only seeing these models from a federally qualified standpoint collaboration, from primary care, from specialist care, but also if you wanted to open your own medical practice. Pharmacists right now, with help, have opened their own clinics, and they have brought in physicians, nurse practitioners. So again, rethink pharmacy, right? From that, from legal aspects, from billing aspects, from revenue cycle, all that is all covered. It will be in Charlotte, North Carolina, and Queens University. So, the “queen” city at Queen University. Information is on our website, www.avantinstitute.com, you can find that information there. We have tons of resources Avant Institute, and that's an easy way for you to reach out to us to see what aspects of what we've brought on the institute interests you, and we have a team that can field those questions, whether it's to me or Dr. Lewis, and just continue to follow us. We're on LinkedIn. We post now and then. Dr. Lewis is not really a poster, but we're going to get him there because he shares. Every time we work with him, we get re-inspired about the mission. So, when you ask, did you know it would get to where this is. At first, I thought, “What is he talking about?” At first it was okay, I could feel it or see it, but I just didn't understand it. And every time we spent time, he would have evidence-based, and he would teach us, and I started to see what the end would look like. Especially for a daughter that is helping a father going through Alzheimer/dementia, it started to hit home, of “I wish we could have done something earlier,” right? And so that's kind of what, many people who've joined either know someone or have been impacted by this. It's really awesome. With Medicare telling us “This is so awesome, we would need to expand beyond Alzheimer/dementia,” shows hope and that these pharmacists are available across the United States, so many patients would benefit. We can't do it all. That's why we're sharing the know how the connections. We want everyone to go and build their own preventative clinics.

Madison: Amazing. I would love to see public health start referring to you as well. Every health department in the country has an office of chronic disease prevention and health promotion. This is that. I mean, the mission of that office is to prevent chronic illness, and you guys are doing that at such an amazing scale. I would think that they would just be jumping on it, right? And then also for to be able to—well, I mean, I'm going to put it out there.

Abubakar: Yes, you never know. They'll be listening to you. I'm sure they follow you to see who else is Christina interviewing that can be helpful, right? So, you're right. It is a public health burden,

Madison: Absolutely. Well, this has been an amazing conversation. Thank you, guys, so much for your time, and I'm definitely looking forward to joining you both at the symposium next year. Again, I'm so grateful for the work that you're doing and for the patients that you're helping and the passion that you have for the communities that you serve. Your patients are so lucky to have you; if no one told you today, you're amazing. So, thank you so much for what you do, and I'm so grateful for your time. I'm hoping that folks that are listening to this episode get excited, get that fire in their belly like I did when I heard this for the first time, and start thinking about ways that they can not only do good and be good, but actually make things a business. So, thank you.

Abubakar: Thank you. Christina.

Lewis: Thank you. Thank you.

Madison: This has been another episode of Public Health Matters. Please continue to follow us as part of the Pharmacy Times: Pharmacy Focus podcast series, so that you can tune in for more incredible episodes. I'll include links in the show notes so that you can find out more about Avant Institute, as well as both Dr. Lewis and Dr. Abubakar. Thank you again, and remember, public health matters.

Amina Abubakar, PharmD, AAHIVP is CEO at Avant Pharmacy and Wellness Center. You can connect with her on LinkedIn here.

Stephen Lewis, MD, FAAPMR, is national medical director of the Physiatry-Pharmacy Collaborative (PPC). You can connect with him on LinkedIn here.

The Avant Institute annual symposium will take place January 31st to February 1st, 2025, in Charlotte, North Carolina at Queens University. To learn more about the institute and the resources they offer, you can access their website here. Details on the 2025 Business of Collaborative Care Symposium can be found here. You can follow Avant Institute on LinkedIn here.