Pharmacists: Allies in Whole Person Care

 Earlier this month, NCACH Communications and Engagement Manager, Sahara, sat down with NCACH’s newest team member, Navind Oodit. Navind is from New York originally, but is living in Seattle as he completes his Masters in Healthcare Administration (MHA) from the University of Washington. Navind was a practicing pharmacist in Washington DC for eight years before leaving the field to join the MHA program. We talked pharmacy, policy, and the differences between serving rural versus urban populations. [Interview edited for clarity]   Tell me a little about you? How did you get to NCACH?As part of the MHA program, it’s recommended to do an internship over the summer… But I also didn’t want to do something just to do it. At the end of April, I learned about NCACH through University of Washington. So I jumped on it… I wanted to see policy work, and things that are different than what a practitioner sees.  The things that we’re doing here [with Accountable Communities of Health] won’t be in effect until 2021. Things that you do now will have an impact in the future. You were a pharmacist before you came to Washington State. Tell me about that:I think health care was always something I wanted to do. I studied biology in undergrad and knew I was more science-oriented. Pharmacy was making huge steps at the time, especially in regards managing disease states such as HIV and Hepatitis C, because there are more drugs being introduced on the market, things were interacting more, so the US and Canada added the required doctorate. So, a pharmacy degree used to be a 5 year bachelor’s in science, now it’s a 4 year undergraduate program and 4 years of doctorate work. Our schooling is very similar to med students.When I was in undergrad, I felt that I was more of a people person, which is how I chose to be a pharmacist. Dentistry, with your hands in someone’s mouth, doesn’t feel like there’s much communication going on. [both laugh]So, I went into pharmacy school thinking I could be a clinician, with the hopes of being a prescriber someday.  The East Coast, though it’s liberal, is not as progressive in healthcare as the West. Pharmacists [in the West] are doing some revolutionary work in the country. Can you give me a few examples of what you mean by that?In most states, pharmacists can only do what is called ‘dispense’. But then some states started offering collaborative agreements to pharmacists, like how Physician’s Assistants, have collaborative agreements to prescribe under doctors for certain medications. We [pharmacists] can write, in some states under certain physicians, and some medications we have full prescribing rights for.  Now what’s happened is Linda [Parlette, NCACH Executive Director, registered pharmacist, and former State Senator] is one who has changed the whole concept of pharmacy. She fought for pharmacists to be able to use their NPI [National Provider Identification numbers – issued to healthcare providers] numbers to be billed directly by healthcare payers. Before this, it was not common for pharmacists to directly bill for services rendered.Pharmacists offer a service called Medication Therapy Management [MTM], especially with the elderly. You meet them at the library, or you go to their house, and tell them ‘bring all of your [medication] bottles.’ It’s a management type of counselling program. There can be a lot of duplication, especially if Doctor X doesn’t know what Doctor Y is prescribing… The pharmacists were not being paid for these services. Just a couple years ago, through UW and through Linda [when she was a Senator]… they not only changed how pharmacists are being paid, but being viewed.[In May 2015, Governor Jay Inslee signed Senate Bill SB5557 into legislation, making Washington the first state in the county to require that pharmacists are included in health insurance provider networks. Learn more]  So now what’s happening is – let’s say you walk into a pharmacy with diabetes that has been diagnosed by your physician. People don’t usually just have diabetes, they usually have high cholesterol, hypertension, etc. Which means they are usually on 4 or 5 different kinds of medication. With the shortage of primary care providers, how do we tap into other providers?What’s happening now is you can see Dr. X who will do the diagnosing, and then you can see someone like me, or another pharmacist, who can then provide MTM or other supportive services, like dosage adjustments or certain vaccinations. University of Washington is doing it now, here in NCACH, Confluence Health is doing it.There’s even a pharmacist here who has opened their own private practice in Wenatchee. This was unheard of to me coming from the East Coast. Where did you practice as a pharmacist?I started out practicing in highly well-known areas in Washington DC like Georgetown, Watergate…Eventually though, I ended up moving over to open up a store, in a very underserved population, near Howard University Hospital. It was an area that was burned down during the Civil Rights movements in the 1960s.... But now you would never think that because it’s been totally gentrified with $2 million homes and condos.But, when I was there, it was a mostly Medicaid population, over 50% Hispanic and African American population, and the way DC was transitioning at the time, a high gay population. What I mean by that though, is that the disease states were ones common to those populations: diabetes, hypertension, hyperlipidemia, HIV+ or AIDs patients… What is more interesting is that I preferred working there than in places like Watergate or Georgetown. I just felt like there was more I could add to the community... And I was there for 8 years, I didn’t move. I was happy, I knew my patient population to the point where you see someone date, get married… and that’s what [many providers] like… that continuity.I left pharmacy work in 2015. I traveled a bit and pursued some things abroad, and then came back to New York. But the game plan was to pursue a graduate degree in healthcare. I ended up moving to Seattle for the Masters of Healthcare Administration program at University of Washington in 2017. Did you ever serve someone who was flanked by Secret Service?Yes [both laugh] Let’s dive into your focus here – what are you working on with NCACH?Sure. So, I’m delving into a few different areas for NCACH’s Opioid response. The first one has to do with Chemical Dependency Professionals (CDPs), they are basically counselling those who are addicted to opioids or trying to wean themselves off. What we’ve found really is that there are barriers to using these types of individuals. The main question – simply put – there is a shortage [of CDPs] in our region, why is there a shortage of CDPs? Christal [Eshelman, Program Manager at NCACH] has developed a list for me of people to interview who specialize in healthcare workforce to learn more about using CDPs in their systems. Are there CDPs being used in the region now?Yes, but not as much as [the providers in the region] would like there to be due to the shortage… What else are you focusing on?The second part of my project is to research the lay-distribution of Narcan (naloxone) in the region. By lay distribution, we are referring to being able to buy Narcan without a prescription. What I’ve learned so far is that it’s available at almost 100% of the pharmacies here without a prescription… Narcan is an opioid overdose reversal agent – meaning that if someone who has overdosed on opioids can sometimes be revived with 1 or 2 Narcan doses. What we need to increase now is awareness. People need to know it’s here and the ways to get it. Having worked in some of our country’s most urban populations, and now being in some of the most rural areas, how do the challenges and barriers differ between serving urban versus rural populations?In New York, DC, other metro areas, access is not a problem. You jump on a train, a metro, there’s always a bus… Here you are talking about two hours to travel sometimes. We are talking about access to healthcare, but in two dimensions: Patients may not have the means to transport themselves to care. The second aspect is that [providers] don’t necessarily want to come out to rural areas…What if your medical system can’t pay a specialist to come out and work in a rural area?When we talk about healthcare systems in rural areas, a question you have to ask is what is the incentive [for providers] to come out here? If you’re not from this type of community, what I mean by that is small-towns, helping your neighbor  – if you aren’t drawn to this type of small-town community – what motivates you to come [practice] out here? I think people want to serve communities like this. I know that there is a push for medical schools to send students to practice medicine in rural communities.In urban areas, I think that people just get lost in the shuffle. When I was working in the DC-area, I the average physician would see someone for about 8 – 12 minutes. How are you really being treated? I think that people in rural areas spend more time with their providers.The challenge is always going to come down to access. I know that NCACH is addressing the social determinants of health. Here, we have a large Hispanic population … [which present] cultural barriers, language barriers… I think that in urban areas people are more readily willing to accept help – it’s just that there are so many people to help. Here in NCACH, populations are smaller, and help isn’t as readily available across the area. You expressed an interest in policy. Are there any health policy levers you can think of to help address some of these challenges?Yeah, so going back to CDPs. CDPs are required to serve 2000 hours after their training to become certified. So one of the things we’re looking at is policies on number of hours required for CDPs, how their licenses apply if they move to a different state… Policies for Medicaid payments for CDPs, who have been shown to help keep relapse rates down in recovery populations.Increasing Narcan (naloxone) access, and removing barriers to obtain it, will also help reduce opioid overdose rates. Now that you have been in healthcare for a while, as a pharmacist, and now in UW’s MHA program, what do you think the future of healthcare is?Programs like this – Accountable Communities of Health and community-based health programs. Healthcare itself has to start with these small movements. If you can adapt something and show proof of it working, other states will start to adopt these things.For instance, I’ve heard of a pharmacist who is seeing patients here in Wenatchee. You won’t see something like this in New York for 10 – 15 years. A lot of states are watching what the ACHs are doing. What are the recommendations and results over the next 5 years – can you show value for patient-centered care? … I really think it needs to start at the top.I think it needs to start with the money aspect – what are we paying for in healthcare? I think that we are going to see an improvement because of the shift to value and quality in healthcare. There’s a thought that if a medical system is being paid for quality of care, and outcomes, then I think we will see a difference in quality of care. Pharmacists as prescribers can also improve complete care – if you see your physician for 10-12 minutes, then you come see me for 10-20 minutes, a specialist in diagnosing and a specialist in medications, then you have seen someone for 30 minutes. That, to me, is complete care.When you think about access to care, what’s open after-hours? A 24-hour pharmacy. If I was working somewhere as a pharmacist with prescribing privileges, I could help provide services and prescribe medications which would reduce the number of people showing up in the emergency room. I don’t think that the US system now is taking full advantage of pharmacists. I think that from 10 years ago, the healthcare system is making huge strides. Because we’re now addressing quality versus fee-for-service.Technology is also definitely part of the solution. Smartphones can help us lose weight, monitor blood pressure, etc. Access to medication is also changing – Amazon just bought a company called PillPack – these new technologies will increase access for all populations. Thank you for your time. We’re excited to learn from your work here at NCACH.Thank you.