Rebecca Grandy, PharmD, BCACP - The Role of the Pharmacist in Value-based Care Pt. 1

Move to Value

Today we get to know Rebecca Grandy, Director of Pharmacy at CHESS Health Solutions, and learn how a clinical pharmacist is an integral part of the care team, not only for improving patient outcomes by being the medication expert, but also by developing relationships with patients and using psychology to ensure medication adherence, resulting in better outcomes at a lower cost.

Rebecca Grandy, welcome to the Move to Value podcast.

Thank you for having me, Thomas.

So, Rebecca, why pharmacy? Can you tell us your story of how you came to be in the role that you sit in today?

I ran out of time and ran out of options, but it was one of the best decisions that I think I've made in my career. I think like a lot of folks who go into healthcare, when I was in high school, I really enjoyed science, really enjoyed math, was good at it and wanted to use those skills, you know, to be helpful to get back to the community. And so when I was in high school, I actually thought I wanted to be a pediatrician because I loved kids, worked at summer camps. I just thought that would be, you know, a great career to combine the things I was good at and the things that I enjoyed. And so then when I went to college, I remember being in my intro to biology class and I walk in and it's a class of like 400 to 500 people and they all want to be physicians. And I'm like, well, I don't really know why I chose pediatrician. Like it just felt like the right fit. I grew up in a rural community and so I think my knowledge of careers and job options was pretty limited, right? And healthcare physician, nurse, that's what you do. And so after being in that intro to biology class and seeing everyone, wanted to be a physician and I was like, well, you know, I'm going to keep my options open, not put too much pressure on myself and just sort of see where I end up going. And I decided to get a biology and chemistry in undergrad. And I knew that would really prepare me for anything in healthcare that I wanted to do. And so I just spent the next few years in college shadowing, learning, volunteering. I volunteered with physical therapist, pediatrician physical therapist. I did respiratory therapy, I did high risk dental clinics, I did medicine, spent some time in an inpatient pharmacy and really never found what I felt was a good fit. And so in my junior year, end of my junior year, I was like, OK, I was like, I'm graduating in a year and I need to make some decisions here because with a biology undergrad degree, you're sort of limited. I knew I didn't want to be a teacher and I didn't want to work in a lab. So I was like, OK, I got to do something here. Luckily, at the time, my roommate, her boyfriend, and a good friend of mine, his dad was a consultant pharmacist. I had never heard of that. You know, really when I thought about pharmacy, I thought about the folks who work in retail, CVS, Walgreens, you know, Walmart, grocery store, and really didn't know much more about pharmacy. I had spent some time in the inpatient pharmacy at UNC Hospitals volunteering, but I was literally taking expired drugs off the shelf and getting rid of them. That's what they needed. So I was willing to do it, but it wasn't that exciting. And so she was like, well, have you looked into pharmacy? So being the per type of person I am, I go to the library, I pull all these books about the career of pharmacy and I'm reading about all the different options. And I'm like, OK, I'm like, I like science, I like math. This pharmacy thing seems like it could be a good fit because I'd already ruled out some of the other professions. And so I ended up applying and I got in. So again, it was sort of that I had explored lots of options, really ran out of choices. I felt it was something that I could be good at, and there were lots of options. And that's how I ended up in pharmacy school.

Nice. And after pharmacy school, what? What did your career path take?

Yeah. And it's one of those things, if you've ever talked to me before and you've heard me talk about pharmacy, I always say my mom still doesn't know exactly what I do. And that's a true statement because pharmacists can do lots beyond, you know, being in the community pharmacy, although those roles are critically important, you know, that they're able to give patients their medicines, but there's lots of roles beyond that. When so when I was in school, we had a professor that came who actually worked at the VA in Durham. And she came and she sort of talked about what she did day-to-day. She also did our hyperlipidemia lecture, which is for high cholesterol. And I just went and asked her. I was like, hey, can I spend some time shadowing you just to see what it is that you do? This sounds like something I could be interested in. And so I went and spent some time at the VA with her. She had residents and students with her. So we spent the first part of the morning she was teaching them, We were reviewing patients for the day. And then we actually got to go see those patients together. And I'll never forget that experience because the way they were able to really take their medication knowledge and expertise and then apply that to a patient who's an expert, you know, who's an expert in their life and combine those two things. I'll never forget. Our particular patient was actually visually impaired, almost to the point of being blind. And so they had tried several different things to help him really manage his medicines, you know, know which bottle was which medicine. And so they had come up with this system of different types of textured stickers and rubber bands. And so hearing them go through those medicines with him and making sure that he knew what they were for, had a good system for remembering them, despite the fact, you know, that he had a visual impairment. I just loved that. I loved the creativity. I loved the learning that was happening. I loved the relationships. I'm a relational person. So seeing them get to spend time with the same patients over and over and develop those relationships and trust, I knew in that moment that's what I want to do in pharmacy. And so that was about midway through pharmacy for me. And then to be able to have a career like that at a VA or in a physician's office, usually it requires some extra training. And so when I finished pharmacy school, I knew that in North Carolina, Asheville, sort of the place that you wanted to be for what they call ambulatory care pharmacy or primary care pharmacy. So came out to Asheville and did a residency and haven't really looked back since.

Very nice, Well, Rebecca, what specific roles do pharmacists play and how do they contribute to improving patient outcomes in the value based care model?

Yeah, You know, pharmacists are the medication experts. You know, we go to school for an additional four years to get a doctorate degree to really know all about the medicines. And one of the physician colleagues that I've worked with, I think she said it better than any way that I could say it. She always talked about a pharmacist and a physician partnership as sort of being like a Venn diagram, right? So the physician has a sphere of knowledge and the pharmacist has a sphere of knowledge and there is some overlap, but you know, she knows so much more about the disease states, the diagnosis, the nuances, but then I know so much more about the medicines, the administration, the interactions. And when you put the two of those things together and complementary skill sets, you know, it can really advance patient care. And so when you think about, you know, value-based care and our move from fee based payments to value based payments, medications are such a big part of that, right? Like there's issues with adherence, there's issues with access. And then once you get past that, you have to think about how do I optimize the medicines? Sometimes that's picking the right medicine for a patient based on their comorbidities, their interactions. Sometimes it's also just taking medicines away and recommending de prescribing. So it can be sort of a combination of all those things. And so because medications are always going to be an important part of chronic conditions, you know, when I think about outcomes and value based care, having a medication expert on the team, I think is crucial for being able to achieve that at, you know, in a way that's patient centered, a way that's cost effective and a way that supports our physician colleagues and, you know, helps with their satisfaction and well-being.

Outstanding. Well, one of the things that we hear a lot about is medication adherence and how important that is for positive outcomes for our patients. How would someone such as yourself address medication adherence issues, especially related to social determinants of health or, or things where it might not just be a conscious decision, but just something that seems more of a struggle than it's worth? And how do you engage patients to make sure that they are going to adhere to those treatment plans so that they will feel better, so they'll become healthier, have better outcomes?

Yeah. Medication adherence is sort of a tricky thing. And it's something that I've worked with, you know, throughout my career. And for me, I think what I think about medication adherence, I think about it in two parts. You know, the first part is almost like the psychology of medication adherence, which I can talk more about. And then the second part is the practical nature of medication adherence, right? Like how do we support the adherence once we've sort of figured out the psychology of it? So when I'm approaching, our team is approaching, you know, a patient around a medication and we're thinking through their adherence, I think it's important to approach it with curiosity about the adherence issue and a nonjudgmental approach. We have no idea why that person is being non adherent. They may not even know they're non adherent, right? So, there's unintentional non adherence and there's intentional non adherence. You know, one example, in my career, I used to work in a heart failure clinic at a cardiology practice. And in the world of heart failure, there's a lot of medicines that we put patients on that are really to preserve the muscle function of their heart. But, you know, when you look at the bottle, it'll say, you know, metoprolol 50 milligrams, take once daily. And then that medicine is very common for blood pressure, for example. And so I would have a patient come in to our clinic and I'm reviewing the medicines, making sure they can get them, making sure they're taking them, and they're like, oh, I'm not taking that one anymore because my blood pressure is fine, right? And so in that example, you know, no one had ever explained, well, yes, your blood pressure is fine, but this medicine also helps preserve your heart. And that's, you know, that's just a simple, like, education intervention. What I have found, though, is usually education is not what people are lacking. There's something else behind it. I think people, from a psychological standpoint, view medications at times as failures, right, as personal failures. I felt that myself. I have a chronic condition. I remember going to my primary care provider and she prescribed a medicine. And she was like, you know, I just want to take a second to acknowledge, like, how are you feeling about this? You know, that you're starting a medicine. And like, that was so refreshing that she asked that because unfortunately, as a society, we do view medications almost as like a personal failure or like, oh, we couldn't handle it on our own. And that's not the case, right? So really talking with people about that and like, what is your goal, right? Our job is not to fix people, is to help people meet their goals. So if your goal is to live healthier, your goal is to play with your grandchildren, Your goal is to be able to, you know, walk a walk a mile. If medication is part of what helps you achieve that goal, really understanding how medications fit into that, you know, thinking really to the psychology of medicine. Another example that stands out for me is insulin. You know, and folks have diabetes, and they get put on insulin. People have lots of strong feelings about that. It could be needle phobia, but it could also be that really in diabetes, like I've heard providers threaten people with insulin, right? Like, if you don't eat right and you don't exercise, I'm going to have to put you on insulin. However, you know, what we know is that because of the progression of the disease, some people, if they were the perfect patient, are going to end up on insulin anyway. So, some of it is just making sure that we as healthcare providers are mindful about the messages that we send and that we're not using insulin as like a last line therapy. I've had patients that have said to me, well, I don't want insulin because when my uncle went on insulin, he lost his limb. You know, he had to have it amputated. And so they view things like that. It's like, oh, that's when you get the bad diabetes, you know, you put on insulin. So I think some of it is just unpacking, you know, what is the root cause of non adherence and how do we deal with the psychology of what's behind that? Some of that has to do with trust, right? So going back to those patient relationships that I was talking about, that they're going to trust me that I have their best interests at heart. And sometimes that's just planting a seed. I may not be able to impact it on that day, but I know if they know that I'm a trusted professional and provider and I'm working with their physician, that over time, you know, we can move towards something that will improve their health outcomes. So that's for that first part that I think through is, OK, what is the psychology of that adherence issue? And then you move to OK, you know, once we've gotten around that or we figured out the issue, are there practical ways that can help someone improve their adherence? And what does that look like that we talk about from, you know, a shared decision making with the person because they're the expert in their life. They know what's going to work. I don't, you know, I can help them brainstorm, but really trying to lead them to a solution. You know, sometimes for people that setting alarms on cell phones, sometimes it's getting, you know, a 90-day fill from a mail order pharmacy. And so to your question, Thomas, when you asked me about social determinants of health, if transportation is an issue, right, they don't have a car or they don't drive, mail order is a great choice. Some people don't want to do mail order and that's OK. They have relationships with their local pharmacist, which I believe those are crucial, you know, and can be really important for a lot of patients as well, you know, pill boxes, pill packaging that a lot of the local pharmacies can do. And so there are lots of practical things that we can help to support adherence as well. And so, you know, having those conversations with patients, again, my job is not to push an agenda on someone. My job is to help them meet their healthcare goals and to give them the knowledge that I have as a medication expert, but knowing full well that, you know, they're the expert in their lives, what they're willing to do, how they feel. And so for folks, you know, who don't want to take medicines, I think some of the conversation is, OK, what are the things that you can't control that puts you at high risk? You know, I just feel that people should be informed, even if like they're not going to do what I recommend, they should be informed, right? So yes, genetics play a part. Yes, if your first degree relative, so mom, dad, brothers, sisters, children have had a heart attack or stroke, you're at higher risk, right? So just kind of getting all that out of the way. But then, OK, what are those things that are in our buckets of control? And that's where, you know, those lifestyle modifications like you mentioned, you know, the physical activity, not even exercise, you know, some of our folks just get it up and moving. Just those activities of daily living can be important. And then also, you know, nutrition, those are things that we can control. We can stop smoking, you know, and then so just helping guide people through some of those decisions as well. I've been very fortunate to have a career that's been rich and team-based care. So usually at my disposal, I've had not only physicians or APPs, I've also had nutritionists and social workers and even peer support specialists that can really support patients, you know, in all those different facets when they're making those decisions about what they want to do to have their optimal health and what their goals are at the time.

Well, that's a great segue into our next question, because I wanted to talk to you about pharmacy collaboration with care providers who aren't pharmacists so you, you mentioned earlier these the two spheres and they don't necessarily overlap. And so I feel like if, if you have a clinical care provider who and then you have a clinical pharmacy care provider, how do you work together? How do you develop a trust so that you can use a team-based approach for the patient, for the for the good so you can achieve the better outcomes. How, how would you go about doing that bridging that gap?

Yeah, that's a great question. And I feel like in my career, I've experienced sort of the full spectrum of what that looks like. So just to tell you a story, like I alluded to the fact that I had worked in a heart failure clinic and cardiology office, and I got that job because of a grant that I was actually partnered with a nurse to try to prevent readmissions for people with cardiology. So, this cardiology office had never had a pharmacist. And so, I remember when we were talking about sort of those early conversations, you know, when we were talking about incorporating the pharmacist into the team, I'm sitting at a table, the scheduler scheduling supervisor is there, the business office supervisor is there, the lead physician is there. And we're talking about my schedule and about how I'm going to see patients and how we're going to coordinate. And finally, and I appreciated this so much, finally the scheduler stops and she goes, can I just ask you, what is it that a pharmacist actually does? Like, what are you going to be doing? You know, and then in that practice. I remember after I was already established and seeing patients, one of the medical assistants, I could hear them down the hallway, was walking back with the patient. And they were explaining, yeah, you're going to meet with our pharmacist first. And you're going to meet with your physician assistant, you know, and they're going to go through all this with you. And the patient goes, what am I? Why am I meeting with a pharmacist? And the medical assistant was like, just sort of like, like word jumble, right? Like just mumbling. And they couldn't really explain it. And so I think some of it, you know, is it just takes time and takes exposure to really understanding how a pharmacist or a pharmacy technician can support you. And what I've found is that, you know, once they understand, they never want to go back. They always want a pharmacist. So even after I left that position, they actually end up hiring 2 pharmacists to be in that role. And so, so some of it is just awareness of OK, kind of going back to my mom, my mom has no idea what I do. But just so making sure that people know that pharmacists can do lots of things. That includes being in the retail pharmacy and the...