This month, Sanjay Basu, Waymark’s Head of Clinical, took the opportunity to speak with and learn more about Crystal Zhou, a Waymark advisor and Assistant Professor of Pharmacy at the University of California. Waymark includes pharmacists as a core part of our care delivery teams, working with primary care providers to assist patients receiving Medicaid with their many medication-related challenges. Crystal describes her experience as a pharmacist working in collaboration with primary care providers, collaborating with barber shop owners to reduce disparities in hypertension control, and gaining trust among patients and providers.
Sanjay: Thank you for joining me. At Waymark, we include pharmacists to help patients find the right medications, overcome hurdles to getting their prescriptions filled, receive medication education, and titrate common medications for their primary care providers. Can you tell us about your background as a pharmacist, and how you became interested in collaborative care between pharmacists and primary care providers?
Crystal: After pharmacy school, I completed a first-year pharmacy residency and became interested in ambulatory care to work closely with patients. What was most rewarding for me was the ability to follow up with patients. As an ambulatory care pharmacist, I was able to see patients continually after four or eight weeks, and observe their progress, make connections, and build rapport. It’s amazing to see them a year later and have their diabetes and hypertension under control. That's why I wanted to pursue further primary care training, which I did at the University of Washington in Seattle. My focus was in family medicine. The most powerful work I was able to do was working with primary care providers at the University of Washington. They had so many patients that they couldn't follow up with these patients every twoor four weeks to check in on their blood pressure or their blood sugars. The partnership with the physicians was great. There were about 12 to 15 providers, providing plenty of patients to work with. And I had a great experience working with the social workers who collaborated with myself, the providers and the patients. We did home visits to better tailor care plans to patients. That experience, working under a collaborative practice agreement, really brought me into primary care.
Sanjay: How does a collaborative practice agreement work?
Crystal: Depending on which state you're practicing in, a collaborative practice agreement can differ. It details what a pharmacist is able to do in partnership with the physician or provider that they're working with. For example, for hypertension management, an agreement might have a very broad scope, saying that the pharmacist can manage hypertension based on the most recent 2017 ACC/AHA guidelines. Other collaborative practice agreements are much more detailed. The agreement will state the pharmacist can prescribe a first-line medication, which may be a specific class of medication, and the pharmacist must order labs after two weeks. The specifics will vary by institution, by which state you're working in, and by provider.
Sanjay: As you’ve engaged in this work, you've become involved in the Cut Hypertension Program. Can you tell us about that program? What successes have you had using that unique approach?
Crystal: The Cut Hypertension Program is a very unique program based on a model that was first published in 2018 in The New England Journal of Medicine, called the LA Barbershop Study. What we've been doing is trying to mimic the LA Barbershop Study to make it a more sustainable model in our community.
We've focused on training barbers as health coaches in the community. We believe in empowering clients that go to Black barber shops to take charge of their health. We want to provide a comrade, someone that they really trust as a health coach that's both educating them on healthy lifestyle factors and talking to them about the dangers of high blood pressure.
My role in the Cut Hypertension Program is to speak to clients who have uncontrolled blood pressure who may need medication management to get their blood pressure under control. I think what's been truly successful is having a great partnership with the barbers in these shops, who are really interested in making a difference in their community. We’ve focused on barber shops in the Bay Area–one in San Francisco and three active ones in Oakland, with the potential to expand to three more barber shops in Oakland.
We've been able to get patients’ blood pressures under control as long as they follow-up with CHP. It can be difficult because there's a lot of social factors to take into account; for example, some patients are really busy with their jobs and they're not able to make it to their follow-up appointments or they don't have health insurance or medication coverage. We're working with social workers to figure out these barriers for our patients. All in all, as long as we can get the patients into the barbershop to have that conversation, to work with me, we're able to get their blood pressure under control. It's been a great experience.
Sanjay: That’s fantastic. One of the challenges we face at Waymark is explaining the role of pharmacists in the broader multidisciplinary care team, for supporting primary care and patient goals. What would you say is the critical role of a pharmacist in the broader care a patient is receiving?
Crystal: I see myself as providing clinical support to both patients and providers. I specialize in medication management and medication titration, including monitoring for medication side effects and drug interactions. These concerns come up all the time, especially for patients who are taking multiple medications, maybe 10 or more at the same time. Patients often wonder: “Are any of these side effects affecting my health because of all the medications I'm taking?”
I also work in partnership with primary care providers. If they say, “Hey, I need your help managing hypertension,” then I'll say, “All right, give me about three months. I will keep you updated each time I meet with the patient, which will probably be every two to four weeks, depending on how often we're titrating and adjusting medications.” When we're close to goal or I have questions or problems that come up, I'll communicate with the primary care providers to come up with a mutual plan. But if there are no problems, I will send the patient back to their primary care provider after their blood pressure is at goal.
I'm hoping to provide more efficiency in patient care and clinical support to the primary care providers, especially for the patients I've worked with who receive Medicaid benefits. Patients receiving Medicaid often face more barriers to accessing care, and sometimes they have trouble getting appointments with their providers. Often I will reach out, try to make accommodations to see the patients receiving Medicaid benefits and then communicate with their primary care providers as needed. A lot of times they're scheduling complications due to work, so they can't speak to their providers. They miss appointments when work conflicts come up. And then because of the long wait, they don't know when they can get the next appointment. It might not be for another three or six months and their hypertension is uncontrolled. That’s a really great time for me to just step in and say, “Hey, you know, you missed your appointment. Let's talk about what we can do in the meantime. I'll communicate with your provider and then try to get you scheduled with them as soon as possible.”
Sanjay: And how do pharmacists like you establish relationships and build trust among both underserved patients and primary care providers?
Crystal: I'll start with building trust with patients. When I first started as a primary care pharmacist, a lot of patients didn't know why I was there in the clinic. They're like: “You're a pharmacist. Aren't you supposed to be filling medications, working in a pharmacy? What are you doing here sitting in front of me?” In order to establish our relationship, our first visit usually focused on what I do, what my role is. We review their medications and sometimes just talking about their medications and giving them information helps build the relationship. With each follow up appointment, because I get to see them so often, we really build trust. I'm able to answer their questions in a timely manner. They're like, “Wow, I'm gaining so much information from these visits and also managing my health.” I think the frequent follow-ups and the amount of information that they're able to learn has been beneficial to the patients.
For the providers that I work with, it will vary. Some providers take a lot longer to warm up to pharmacists, and others have worked with pharmacists in the past and they really know how to utilize pharmacists. For those who have not worked with pharmacists in the past, what I try to do in the beginning is just set up a baseline meeting to talk about my role. I'll say, “You know, if you wanna test out this as a pilot or, maybe we can talk about a couple of your patients. You can refer three or five to me, and then we can discuss them in detail as I'm seeing the patients and make sure you're happy with what's going on, and that I'm able to provide the support you need.”
A lot of them are very enthusiastic with my ability to follow up with patients very closely. I can follow up with patients every two to four weeks, or even every week (especially for patients with heart failure). And I slowly start to learn what the preferences of providers are, because every provider is a little bit different. Once I start to learn a provider’s preferences and they start trusting that I can actually titrate and manage the medications, I say, “Hey, do you want me to continue communicating with you this frequently? Or do you want me to just send you intermittent notes?” Once we come up with the plan for that monitoring and follow up with the provider, they're usually like, “Okay, if we just keep doing what we're doing, I'm fine with that, or you know, I prefer less frequent notes because we’re very busy.” I'm okay with that too.
Really getting to know all the providers, learning their patterns and what they prefer, I think has been really successful in building trust.