BETHESDA, MD 19 July 2010—A $126,500 investment by the federal government in the early part of the 2000s decade helped set the stage for clinical pharmacy services provided by three pharmacists who still practice at their community health center.
"I always tell people it’s that cool job you wanted when you were in pharmacy school that you didn’t know about," said Jennifer Kriedler-Moss, director of pharmacy services at Peninsula Community Health Services in Washington.
The "Peninsula" in her employer’s name is the Kitsap Peninsula, which lies on the opposite side of Puget Sound from Seattle.
When Kriedler-Moss arrived at the Bremerton-based health center, it had dispensaries where the health care providers distributed reduced-price medications, she said. A pharmacist volunteered part-time to answer providers’ questions about medications.
As for Kriedler-Moss, she arrived with a debt of $65,000 from loans for her education at the University of Washington School of Pharmacy.
That debt, she said, decreased by $50,000 in two years because of loan-repayment assistance through the National Health Service Corps (NHSC).
NHSC, part of the Health Resources and Services Administration, seeks to assist underserved communities in recruiting and retaining clinicians who are community responsive and culturally competent and can help meet an area’s health care needs.
About 40% of the patients at health centers supported by the Health Resources and Services Administration lack health insurance, according to NHSC.
Heather McNamee, pharmacy director at Community Health Association of Spokane, received $58,000 in loan-repayment assistance through NHSC.
"What keeps me here is just that ability to work to the extent of my scope of practice, I guess you would say," the Washington State University graduate said. "We get to work under collaborative drug therapy agreements with our provider groups."
The Spokane health center, she said, used part of a grant from the federal Office of Pharmacy Affairs to hire her to start pharmacy and telepharmacy services.
Now the health center has seven pharmacy sites and 42 pharmacy staff members, McNamee said.
El Rio Health Center in Tucson used part of an Office of Pharmacy Affairs grant to hire a Spanish- and English-speaking clinical pharmacist to start disease management services.
Sandra Leal, now El Rio’s director of clinical pharmacy, said she received $18,500 through NHSC—enough to pay off her outstanding loans from her pharmacy education at the University of Colorado.
With her service commitment in an underserved area long behind her, Leal said she stays at El Rio because "I love the practice site."
"It’s exactly the population I want to work with," the Nogales, Arizona, native said. "It’s very amazing what we’ve been able to do in a community health center practice."
Just part of the workday. Among El Rio’s patients with diabetes, the average glycosolated hemoglobin level decreased by 1.9 percentage points to 7.7% in 6 months and remained roughly at that level for the next 18 months, according to an evaluation of clinical pharmacy demonstration projects funded by the Office of Pharmacy Affairs.
The clinical pharmacy services at El Rio have been so successful that the Pascua Yaqui tribal authority uses casino profits to pay the community health center for a pharmacist to provide disease management services at the tribal health center, Leal said.
At Peninsula Community Health, Kriedler-Moss said, collaborative practice agreements enable the pharmacists at the three medical clinics to free up other health care providers to see more patients who have problems getting medical care.
The pharmacists evaluate the patients whose diabetes is not well controlled to see whether a change in medication is needed, she offered as an example. Patients with hypertension are considered candidates for combination products to improve adherence. Through drug interchange, the pharmacists replace medications with ones that are more cost-effective.
"It’s different than just working at a Walgreens, a Walmart, where you’re like, ‘Well, I didn’t hear from your doctor,’" Kriedler-Moss said. "Here we are your doctors. So, we figure out what you should be on, we refill it for you, we figure out how you’re going to pay for it."
McNamee said a survey of Community Health patients several years ago revealed that 86% of them would not have received any pharmacy services or medications if the center’s pharmacy had not been established and able to provide medications at reduced prices.
Every third-year pharmacy student at Washington State University spends a day working under supervision at the medication-renewal site, she said. The health center also serves as a six-week clerkship site for at least 20 fourth-year pharmacy students each year.
Loan-repayment assistance. NHSC does not list pharmacists among the health professionals eligible for its loan-repayment program.
Kriedler-Moss, Leal, and McNamee received their loan-repayment assistance through exception.
The Health Care Safety Net Amendments of 2002 temporarily opened NHSC’s loan-repayment program to pharmacists.
Under a demonstration project for fiscal years 2002–04, pharmacists were eligible for loan-repayment assistance. Participants in the project had to work two years at a primary health care site in an area lacking sufficient numbers of primary care health professionals.
Congress stipulated in the 2002 law that the Health and Human Services secretary evaluate the pharmacists’ participation in the project and submit a report to four congressional committees and subcommittees. Included in the report would be the secretary’s opinion as to whether the addition of pharmacists as permanent members of the NHSC would be feasible and would enhance its effectiveness.
But Congress did not set a deadline for receipt of the evaluative report.
According to a September 2004 report by the Senate Appropriations Committee, 24 pharmacists participated in the demonstration project. The committee stated it was "comfortable" with the conclusions drawn from the data collected on those participants and looked forward to receiving the information "in the coming year."
The evaluative report, said a representative of the Health Resources and Services Administration in a June 30 e-mail, is undergoing clearance and has not been sent to Capitol Hill or released to the public.
Kriedler-Moss, Leal, and McNamee said loan-repayment assistance has been a powerful tool for recruiting and retaining new pharmacy graduates at community health centers, where the pay generally is lower than in other practice settings.
But that assistance at the state level, at least in Washington, is disappearing because of budget problems, Kriedler-Moss said.
"Community health centers are very progressive work areas," she said in advocating loan-repayment assistance for pharmacists. "You offer [new pharmacy graduates] what you can as a nonprofit, you kind of close the gap with the student loan, it ties you into the center. Everybody’s happy."
