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Tuesday, October 28, 2014

Weight Loss Groups: Those who post lose the most!

Howard’s story:
     I retired in 2010 at age 69.  Wayne [Altman, MD, my PCP] said, Howard, you should join these groups that Kerri and I have been running.  I was pre-diabetic, on the threshold of being obese.  I had issues with my blood pressure, glycemic index, cholesterol, and all that stuff.  I was skeptical but I was willing to give it a try, because I’ve dealt with weight issues for all my life, and nothing I’d tried before ever worked (or worked for very long). 

     The secret sauce?  You’re in a group, where we all come from different facets of life.  The thing we have in common is the need to deal with health and fitness.  It doesn’t make a difference if you’re a high-powered executive, or retired, or you work like Stacie.  Over 20 weeks, you bond, and you develop a community, and affection.  These e-lists are set up for each group, and remain even after the group is over.

     I was in Group 4, which began in September 2010.  We had buddies; Gerri was mine.  I was sending emails.  But then I thought: Does she really want to hear this?!  She’s much younger.  I’ll send her an email, and I’ll ask her, Is it too much? I won’t be offended.  Her answer was, Oh, absolutely not!  I love it.  It’s a reminder for her of what SHE had made as a commitment to do in her own life.  It’s support and accountability at the same time. The next week, she shared this, and she suggested Wayne should appoint a nudge to remind the group to do emails.  So I did, sharing a daily email about me and responding to others.  The traffic on the e-list just took off!

     So now we say, Those who post lose the most!  You have to be willing to share your difficulties as well as the successes.  This is for life.  Doing it alone wouldn’t work. 

     I found I was having success.  I decided four months wasn’t enough of a baseline.  So I re-upped with another group.  By June 2011 I lost 30 pounds and eight inches in my waist, and even better, I managed to keep it off.  I sleep like a babe!  I’ve become active – I Nordic walk, power walking with poles, and I go to the gym.

     I’ve been in a regular group or an advanced group since I’ve started.  Although I’ve mastered the exercise and the food piece, my sense is I will always want the connection, the group.  The advanced group meets once a month over ten months.  Also, occasionally we can get together between the monthly meetings. 

     So now I’m giving back, paying it forward.  I serve as a resource for the wellness group program and I’m a regular “guest speaker” at one of the initial weekly sessions of each new 4-month program to share my experience and offer support.  I thank Wayne and Kerri [Hawkins, nutritionist] for saving my life.  All my tests are normal or optimal.  I’m off statins and blood pressure meds, and I just take Vitamin B-12.

     I’m still in contact with my group from 2010, since you develop friendships.  I still post to all the groups I’ve been in, and some people respond, even now.  

Read another story about weight loss.  Thanks to Howard Cloth for sharing his story.

Tuesday, October 14, 2014

Pharmacist-led diabetes disease management: We get to cruise control

This is Part 2 of the story of Sandra Leal, PharmD. Part 1 described her care for an older woman, Maria, at the El Rio Community Health Center, a Federally Qualified Health Center.  Sandra’s program received the Pinnacle Award in September 2014 from the American Pharmacists Association.

     We’re in medical suites, like the other medical providers.  We have appointments for patients who are referred to us for trouble with the control of their diabetes, or who’re struggling to get control, or starting insulin, and have issues with that, e.g., insulin resistance, being afraid of that, etc., so we try to spend a lot of time on the best medication regimen.  With Maria, I spent about 25 minutes yesterday to do an a1C, review her immunizations, and have her vital signs done by a Medical Assistant.  We’re a Diabetes Self-Management Training Site, and a Federally Qualified Health Center, so we have double accreditation, and get paid by Medicare for people like Maria, though here in Arizona, not by Medicaid.

     We’ll handle issues like affordability, complexity of the regimen, and how to fit it into their life.  That’s a big challenge when they’re taking multiple medications for diabetes, usually coupled with cholesterol, nerve pain, depression, etc.  So they take six to twelve medications. That’s a usual amount.  Yesterday 1 had a woman who was taking 18 meds.  Even WITH health insurance, $15 times six to twelve medications is amazingly expensive and unaffordable.  I really try to customize the regimen for their lifestyle.  I really listen to their needs, and work with them. 

     For providers, our automatic trigger is to increase and add another medication.  But it’s better to see why they’re not taking it.  My role as a pharmacist is to focus on that, and really delve into the barriers.  That’s my specialty, which is often overlooked by other medical providers.   Often they’ll send people to the pharmacy just to dispense medication. 

     The most common barriers are not understanding the importance of taking the medication and what it could do for her.  I really spend a lot of time with each medication and what it’d do, connecting it to the lab values.    They might complain about having to go to the bathroom a lot, fatigue, etc.  So I’ll emphasize that they’ll have more energy, and won’t have to get up three times in the night to go to the bathroom.  A lot of times it clicks with people, so they don’t say any longer, I don’t want to take them at all.  We connect the dots for them.  We’ll compromise.  Once we have one success, they come back, asking what else can we do? 

     We have a Collaborative Practice Agreement, so I can initiate insulin, order labs, and generate a referral to other providers.  That makes it more efficient.  We document what we do in the electronic medical record.  We’re med reconciling, adding the mammogram, recoding about the colonoscopy, etc.  That frees up time for the doctor to focus with the patient.  Providers in this model really work well:  it’s more efficient and effective for the patient, because their needs are addressed.

     For a patient like Maria with Type 2 diabetes, her next a1C test is due in three months, so she should come back then.  After that, when we get to “cruise control,” I’ll see her every six months.  When she comes back, we’ll take care of a lot of other issues too, e.g., an eye exam, foot exam, and immunizations.  I’ll make sure we’re doing those on a yearly basis.  We do eye screening here. That used to be a barrier to find transportation, so we worked with a local ophthalmologist to have screening on site. 

     If a patient has another chronic condition, like pain management or depression, we’re basically triaging things for which they should see another provider.  We’d send the patient and we tell the doctor and patient: Focus specifically on depression.  We write it down for the patient:  Your next visit is for depression specifically, because this is impacting your ability to do other things.

Thanks to Sandra Leal, PharmD, MPH, FAPhA, CDE for sharing her story.  Sandra is the Medical Director of Clinical Pharmacists.  Maria is a pseudonym.

Read another story about diabetes care.

Friday, October 10, 2014

Pharmacist-led diabetes disease management: She felt so empowered!

Sandra Leal’s story:
[Sandra and her clinic won the Pinnacle Award last month from the American Pharmacists Association for her clinical pharmacist-led diabetes disease management program.]

My patient Maria is an older woman on Medicare.  I started seeing her in May.  Her a1C [blood sugar level] three months ago was 15.9% – that’s ridiculous!  That’s twice as high as she should be.  She’s not on insulin.  We sat and I talked with her about my concerns, that she was not taking her meds, and didn’t want to take insulin, though that was exactly what she needed.

She was resistant to it, so I wanted her to work on her lifestyle.  She told me a lot about her personal history. She uses a cane since she was injured earlier in life, so it’s hard for her to exercise. 

We compromised, so that she wouldn’t start insulin that day, but the medications she was prescribed, she would take them every day.  We agreed that if her condition improved, she wouldn’t have to consider insulin.  She was medication naïve; she had been prescribed a regimen she wasn’t taking at all.  She had four or five other meds, which she was only taking sporadically, not on a consistent basis.

She felt very empowered after we talked, and did some major life change.  She stopped eating a lot of processed foods, started taking her medications, eating whole foods, and logging her readings.  She said she’d try to go to a dance class.

Yesterday she came back after I’d been calling her for three months.  We did an a1C test here in the clinic, with a point of care test, and her level was down to 7.4, which is amazing!  It improved more than half in that three-month period.  She felt so empowered!  Now our goal is to maintain this level of control. 
Read another story about changing habits related to diabetes.

Thanks to Sandra Leal, PharmD, MPH, FAPhA, CDE of El Rio Community Health Center, a Federally Qualified Health Center in Arizona, for sharing her story.  Sandra is the Medical Director of Clinical Pharmacists.  “Maria” is a pseudonym. 

Monday, October 6, 2014

Needy Meds: Making medicine affordable

Dr. Rich Sagall’s story:
     In the late 1990s, I was still doing Family Medicine and Occupational Medicine.  A medical social worker friend of mine told me about Patient Assistance Programs.  I was in Bangor, Maine and she was in Mississippi.  She had made a small database that she kept on her laptop.  During home visits, she would look up the programs her patients could make use of. 

     I’d taught myself to code HTML.  I thought, this would be a good project to use that, so I started inputting data on patient assistance programs on weekends and after hours.  I put a counter on the website.  I felt guilty about it, because my own visits to the website would inflate the count.  At first, there were maybe 50 visits a day; maybe three of those were mine, so the total really wasn’t so big.  

     Now Needy Meds has grown over the last 17 years.  We have 20 employees, data on 7,000 points of savings (programs, coupons, co-pay cards, camps, etc.), 13,000 free/low cost/sliding scale clinics, and 8,000 to 10,000 visits a day to our website.  We’ve gotten a lot of emails and letters from people about their savings, saying they never knew about patient assistance programs before that.  We make medicine affordable when it’s unaffordable.

     But I can’t tell you about the specific patients we’ve helped.  That’s because of our philosophy:  we want to put the fewest obstacles in the way of people getting the information.  So we don’t have registration, or log-in, or sign-in.  We want access to be anonymous, since some people were concerned about putting their personal information on the Web.  They just type in the drug name, and we give them all the information, including an interactive pdf.

     Now we’re way beyond just medicines; now we have copay cards, coupons, disease-based assistance (programs based on the diagnosis), programs to help people apply for patient assistance programs, including 1,000 state/local government assistance progs, and 3,000 free clinics. 

     We keep all the data current, reviewing every program at least every six months. 

Advice for patient advocates:  Bookmark this site.  There’s no such thing as a free lunch, but sometimes there are free meds.

See a story on the cost of medication, or see Dr. Sagall's blog.

Thanks to Dr. Richard Sagall of NeedyMeds for the interview.