Armon Neel Jr.
Eldon Armstrong
Bryan Bray

Armon Neel Jr.

When people first meet Armon Neel, Jr., CGP, FASCP, they usually have no inkling that he's among the most respected, most honored movers and shakers in consultant pharmacy. Neel presides over one of the leading senior care companies in the Southeast, Griffin, Georgia-based Institutional Pharmacy Consultants.  Now, at the pinnacle of his nearly 40-year career, Neel talks about the early innovations that made him a trailblazer in patient-focused pharmaceutical care, what sparked his excitement for consultant pharmacy so many years ago—and why he's even more excited about the future.

A Pioneer in Senior Care
Neel recalls his entree into the long-term care pharmacy arena. "It was about 1968 when I got involved in long-term care. We saw a real need for a clinical pharmacists' input in that arena," he says. "Here was this new health care field, started in 1965, that was looking to take hospital protocols and procedures and make them fit with chronic care. But they didn't fit. It was a different population—a more demanding population of old people with different diseases and chronic diseases that did not heal. The medications didn't work the same way they did in younger patients. Here was a brand new field to pursue, and the prospect of getting involved was very exciting."

Sensing the emergence of a new arena of enormous challenge and opportunity, Neel and his colleagues began coming up with new ideas and new protocols on how to better meet the complex drug therapy needs of geriatric populations. "We were the first in Georgia to computerize medical records in the nursing station, and the first to use unit doses in nursing facilities," he says. "We were the first to initiate a number of different protocols, everything from a liberalized geriatric diet to glucose monitoring for diabetics. We were really the early pioneers of disease state management."

Putting It All Together
Neel eventually decided to retool his company's focus away from dispensing activities and build his practice completely on clinical consulting. At first his consulting activities were narrowly focused on medication use and directly related issues, but as time went on he saw the need to develop a whole new platform for integrated delivery of long-term care in partnership with other health care professionals.

How has the role of consultant pharmacist changed since Neel first started out? "I'll never forget how we opened our practice in 1963 just when Medicare and Medicaid were getting under way," Neel recalls. "It was written into the regulations that long-term care facilities had to employ the services of a consultant pharmacist. Every facility was required to have one. But at the time the physician had control of all aspects of patient care. So what did the pharmacist do? Make sure the prescription labels were correct, and that's about all," Neel recalls.

NOW, Neel says, "IPC pharmacists make 28,000 to 30,000 suggestions a year to the different physicians at the facilities we serve, and about 84% of those recommendations are accepted, so we're pretty much in control of drug therapy management." In IPC-served facilities, he says, patients use drugs at a rate of 4.1 drugs per patient, which is much lower than the national average—one of the lowest medication usage rates in the nation—and hospitalization rates are also substantially lower than the national average. Overall prescribing rates are about 50% lower than the national average.

Not the Retiring Kind
Neel is a big believer in ongoing skills enhancement through continuing education and other avenues. He views this process of continual learning not as a chore, but a pleasure, and he strives to instill the same philosophy in IPC's three dozen employees. Neel added yet another feather to his professional cap in 1997, when he became one of the first in the nation to earn the designation "Certified Geriatric Pharmacist" (CCGP) from the Commission for Certification in Geriatric Pharmacy.

In 2000 Dr. Neel sold his consulting firm to dedicate all his time to the establishment of a private practice in Senior Care Drug Therapy Management, MedicationXpert, LLC. He maintained several of his original clients consisting of skilled nursing facilities and hospitals. He has spent the last four years developing policies, protocols, assessment tools and other technologies necessary to meet the needs of outpatients, as well as institutional geriatric patients. As he watches his practice grow, he sees patients on Monday, Wednesday and Friday in his office practice and Tuesday and Thursday in the institutional settings.

Neel readily admits that, like his father, he's turned out to be a workaholic: "This is not only my profession; it's also my hobby and my pastime," he says.

Eldon Armstrong

Joan Jenkins believes that one of the more positive things she has done to combat her illness was to invite Eldon Armstrong, a consulting and community pharmacist, to speak to the support group she leads for people with vestibular disorders. Jenkins, 52, suffers from bilateral Meuniere’s disease, which causes symptoms of dizziness, equilibrium problems, and faulty depth perception. In addition to Meuniere’s, she suffers from hypertension, diabetes, and allergies, and takes up to nine different drugs to manage her conditions.When leaving her home, Jenkins often must use a wheelchair. In 1993, her afflictions became so bad she was forced to quit her job supervising a college laboratory.

Before meeting with Joan’s support group, Armstrong asked for a list of medications taken by the group members to have some insight on what would be discussed with the members. “He took his time with everyone and answered all our questions,” Jenkins says. “When he left,we sat there with our mouths open.”At that point Jenkins knew she had to hire Armstrong for a personal consultation. “It’s the best investment I’ve made since I’ve had this disease.”

Armstrong is currently the owner of a medical equipment supply company and three apothecary pharmacies, as well as the president of Sandlapper Consultant Pharmacists in Columbia, South Carolina. He decided in 1997 to turn his full attention to the work he’d dreamed about for years: providing medication assessment and problem solving by appointment to people in his community. “It’s fun,”Armstrong says, when asked what motivates him to pursue this type of practice. “It’s challenging and rewarding, and the fun element is knowing that I’m helping people.”

To meet comfortably with patients, Armstrong consults in an office separate from his pharmacies that includes a full-time assistant who manages the office and sets appointments. His fee is $60, and a typical appointment lasts about 40 minutes.

Launching His Career
Armstrong received his B.S. in pharmacy from the University of South Carolina (USC) in 1969, then enlisted in the U.S.Army from 1970 to 1973, during the Vietnam War. His five-year program at USC included course work in clinical pharmacy, medical rounds with physicians, and duty in the emergency room.“I got excited about the idea of pharmacists as much more than mere handlers of medication,” he says.

During his tour in the Army, Armstrong trained as a medic. “I thought the things they taught me were ludicrous in regards to my work as a pharmacist—how to resuscitate people, CPR, first aid, injections— but I’ve probably incorporated them all into my practice,” he emphasized. Armstrong was also assigned to one of the nation’s first sterile preparation pharmacies, where he learned how to prepare intravenous solutions, infusions, and injectables.

After leaving the Army,Armstrong launched his civilian career by purchasing a pharmacy and becoming a long-term care consultant. He maintained patient profiles in his community pharmacy, kept tabs on patients’ diseases and allergies, and looked for medication problems as long ago as 1977. “I thought, don’t just do this stuff in the nursing homes, get out and apply it wherever I go, and offer it to people coming into the pharmacy,” he recalls.

Specialty Training
Over the years Armstrong has taken every opportunity to enhance his knowledge about specific diseases and to fill niches where he feels there is a need. For example, in 1995 he completed ASCP’s pharmacotherapy traineeship in Parkinson’s disease. “I saw a population where I could make a difference, even though it’s small— only one to two percent of people over 65,” he adds. “There’s no cure, the treatment always involves medication, and the specialists who diagnose these patients rarely provide what I call ‘continual care.’ I felt there were gaps that could be filled by a pharmacist, and I’ve built up a special expertise for which I’m known here in South Carolina.”

Armstrong has also received special training in anticoagulation management and completed the GeroPsych/ Behavior Disorders Traineeship through ASCP, a program designed to prepare pharmacists in providing pharmaceutical care to geriatric patients with psychiatric and behavior disorders. He became a Certified Geriatric Pharmacist in 1999.Among his areas of special knowledge are Alzheimer’s disease, smoking cessation, immunization administration, natural medicines, and female hormone replacement therapy.Armstrong is heavily involved in efforts in South Carolina to coordinate services for Alzheimer’s patients, building on contacts and background he’s acquired since 1994, when the governor appointed him to a slot on a statewide Alzheimer’s council. In 1998 Armstrong was president of the board of the directors for his region’s Alzheimer’s Association.

Educating Patients
Throughout his years as a pharmacist, Armstrong determined that there is a great need to educate patients on their medications and to collaborate with physicians on patient care. He calls his approach “advanced pharmacy care.”

When selecting the space for his office practice, Armstrong kept convenience, safety, and privacy in his mind. “It’s important, especially for older patients, to feel comfortable and safe in the surroundings,” he explains.As for privacy, he wants patients to feel they can open up about whatever concerns they have,which he feared would not happen if he consulted with them in a space in one of his pharmacies. “It’s important to maintain their confidence,”Armstrong notes.“When they feel safe and private, I’ve found that patients will tell me things they haven’t told anyone else.”

Another advantage to an office-based practice is that time management is so difficult in a regular pharmacy setting. “Here, the most important piece of equipment is my clock,” he says. “It’s located over the patient’s shoulder, where I can see it clearly.” Before appointments Armstrong provides patients with an informed consent sheet that details his background, services, and fees. Patients also fill out a detailed history form that they mail or fax to him so he has advance information about their diseases and medications.

Patients are instructed to bring all their medications to the appointment, including over-the-counter items. “You have to be especially vigilant with the elderly,”Armstrong says. “They are definitely the highest users of medications, and they don’t like to give away something they paid money for. By their way of thinking,‘If it helped me two years ago, it will help me now,’ so I want to examine everything.”

To make his time with patients as efficient as possible,Armstrong carefully reviews their history questionnaire, researches specific areas when necessary, puts together a preliminary report, and formulates the sequence of questions to ask in an effort to better pinpoint problems in patients’ medication management.When the patient first arrives, Armstrong takes his or her blood pressure and pulse, then asks questions. “I typically open the interview by asking them to tell me in their own words their reason for being there,” he explains. “It always goes beyond what they told me on the phone.”

As he looks at the patient’s medications, he probes into how they are being taken and why the patient is taking something differently from the directions outlined on the label. “I’ll ask, when did you start this, and why?” Besides teaching them about each medication and providing tips for organizing and storing it, Armstrong provides written information and patient education leaflets.

Armstrong said his office likes to keep notes in the charts and do followups. Sometimes it might involve a phone call, or maybe the patient is to send information back to the office. If a serious problem comes up he will call the patient’s physician, but when things he uncovers are not urgent he will explain to the patient what to mention to the physician at the next appointment and provide written “talking points” as guidance.

Individualizing Therapy
Jenkins’ first appointment with Armstrong last April resulted in a decrease in the number of medications she was taking, as well as reduced costs by switching to a less expensive but equally effective multivitamin.After his consultation, he supplied her with a detailed chart listing her medications and how she should take them—tailoring his recommendations specifically to her eating habits, sleep patterns, and lifestyle.

Through his guidance, Joan changed from estrogen pills to estrogen patches and was able to cut back on the amount of diazepam she was taking. He is currently attempting to find ways to alleviate her allergies and tinnitus. “He’s a problem solver,” an exuberant Jenkins says.“What he is doing is super-important to people like me who are on multiple medications.”

A bright and articulate woman, Jenkins says that one of the most frustrating aspects of her disease is how it confuses her thought patterns.“When you come across somebody like Eldon, who isn’t suggesting invasive procedures, who isn’t trying to add medications but is instead working to replace them or take them away, you are so overwhelmed with gratitude and so thankful you found him.”

Armstrong makes her feel comfortable, she says, and never rushes her or acts as though her concerns are trivial. “Any question I bring up, he immediately starts asking about things I never thought of. He’s a wonderful resource, he’s warm and compassionate, and no matter what silly little question I ask, he never makes me feel it’s not important.” Her physician appreciates having Armstrong’s help with a case as complicated as hers, Jenkins says.

“Anything to help me, he’s all for it, and whatever Eldon charges me, it’s worth every penny.”

Insurance Doesn't Reimburse
Armstrong wishes there were an alternative to having patients pay out of pocket, but he came to realize he might never launch his dream practice if he waited for insurance companies to cover his services. “I’m afraid that the only ones who can access me right now are those who can afford to pay cash,” he says. “The insurance companies have not caught up with the needs of patients, and I could not wait for that to happen.” Patients are free to submit claims to their insurance companies to try being reimbursed for Armstrong’s care, but very few have been successful thus far, he says.

When requested, Armstrong will provide consultations in patients’ homes, but there are additional charges for that, including mileage. On special requests, Armstrong will go into nursing homes without a longterm care contract to conduct medication reviews for individual patients, as long as the family agrees to absorb the costs and there is a signed order by the physician. “I’ve gone into assisted living facilities, I’ve worked with home health agencies, he says….You have to figure out your costs and what you need to operate on.”

When necessary and the patient is willing, Armstrong also prepares detailed reports for physicians for a nominal fee.These are not shared with the patient, because, Armstrong explains, they are based strictly on the patients’ medications and the history he or she provides—which may be incomplete.Therefore, the report involves some guesswork on Armstrong’s part. “It doesn’t represent the patient’s chart completely, and the premise in keeping it confidential is that the doctor will feel more comfortable if the patient doesn’t have a preset expectation that the report will result in a particular course of action. I base the report on the best information I have, but I’m willing to be wrong.”

Armstrong stresses that “it’s not my goal to replace the doctor or his services. My goal is to empower the patient.When I send information to physicians, I might ask questions like, ‘Would you consider running this test?’ Or the document could be taken more in the way of an educational report. Doctors are terribly busy and can be confused by pharmacists who want to be ‘junior physicians.’We need to be respectful of the their turf.”

Many times Armstrong only knows by talking to a patient whether the physician took his suggestions. Recently he learned from a 70-yearold woman with whom he’d consulted that her physician followed every recommendation he’d made to eliminate duplicate therapies. “She saved money by his eliminating two prescriptions and reduced her costs on estrogen, which is a big deal at her age. From a compliance standpoint, the biggest problem I run into isn’t forgetfulness,”Armstrong says, “it’s patients deliberately not taking the full dose to save money.”

Another patient, who takes tamoxifen and an anti-anxiety medication, is so reliant on Armstrong’s advice that she will not follow her physician’s treatment changes until Armstrong reviews them. “This lady told me,‘I’m afraid of medications. I know someone who died from an adverse drug reaction.’” When appropriate, Armstrong will refer his clients to other specialists, such as nutritionists, podiatrists, massage therapists, and mental health counselors.

Volunteerism and Promotion
Armstrong’s philosophy that “there’s no end to learning”works synergistically with his drive to help others and his need to make the most of his knowledge and talents.As a result, promoting his consulting practice fits naturally into activities he’s involved in anyway: public speaking, volunteerism, and networking with other health care professionals.

As an example of how networking can pay off in referrals, Jenkins found Armstrong when she asked her local pharmacist to recommend a speaker. Now, after her successful consultation, she is urging other members of her support group to take advantage of Armstrong’s services.

Armstrong gives speeches to church groups,women’s clubs, organizations for the elderly, and community groups in settings ranging from large auditoriums to private homes. “I always allow plenty of question and answer time, and one answer I’m very comfortable giving when necessary is,‘I don’t know. But I can find out for you.’”

Other promotional tools Armstrong uses are printed pamphlets for the public, mailings to physicians, and radio advertising. He’s already known locally for a two-minute television spot he wrote and produced in the late 1980s for a show called “Your Family Pharmacist,”which continued for three years, and for an hour-long radio talk show he hosts each week.

Armstrong’s story about how he became involved in the radio show illustrates his propensity for recognizing and making the most of opportunities. While serving as a guest on a local call-in show he noticed that the host wasn’t very prepared. He felt he could do better and decided to develop a proposal for a show called “Your Prescription for Help,”which would feature health news, medication information, and guest appearances by physicians.

“We did the first one as an air check, and it was really successful,” says Charlie Benton, sales manager at WISW Radio. “He gets a large volume of calls, and there are always people waiting on the line. He’ll talk about new vitamins, new cures—a wide variety of topics.” Benton says he’s even taken to following Armstrong’s advice about vitamins and diet.“He gives good, practical information, and he’s a good listener. People are attracted to him because of his wisdom and his sympathetic ear.”

Physician Referrals
Sometimes physicians refer patients to Armstrong, especially for his Parkinson’s disease expertise. He has developed medication management protocols outlining specific goals for physicians to sign off on, indicating their agreement with Armstrong’s plan. Once, after putting together detailed recommendations for a Parkinson’s patient and sending it to the physician,Armstrong heard nothing back. So he accompanied the patient, a middle-aged man, to his next appointment.

“[The physician] was not offended at all. He sat down and reviewed the things we’d provided to him, which had been sitting in the patient’s chart. This physician spends a lot of time talking with patients but isn’t very organized, which is why he hadn’t yet read my recommendations. He said, ‘Let’s do this and this and this,’ and I asked,‘Would you consider doing this progressively under a protocol, and allow me to work with the family?’” The physician agreed.

Right now,Armstrong averages three to five appointments a week in his community consulting practice. Clearly, without income from his traditional consulting contracts (e.g., nursing homes, assisted living facilities), he would not be able to continue. “We’re right at that plateau,” he says. “We get a lot of inquiries, but a lot of people feel it’s not affordable. On the other hand, many of the people who use my services actually offer to pay me more money than I charge. It’s been so valuable to them.”

Armstrong plans to keep promoting and building his practice, and to work with other pharmacists to help them establish a similar concept. “My vision is of a network of senior care pharmacists around the nation,” he says. “I think we are already forming that in a loose fashion, but I’d like to see it more formalized.”

The work I’m doing now is the realization of the vision I had more than 20 years ago. “It’s great to be able to bring my dream from 1978 into the 21st century.”

Bryan Bray

In an attractive two-story brick building on Westover Terrace in Greensboro, North Carolina, Bryan Bray, PharmD, sees patients in a busy internal medicine practice.The “Patient Guide to Greensboro Medical Associates” lists Bray as one of eight physician extenders, along with three nurse practitioners and four physician assistants. These extenders are in collaborative practice with the building’s 17 physicians, who also specialize in gerontology, cardiology, endocrinology, gastroenterology, hematology/oncology, and rheumatology.

Although it is not listed in the brochure, a bold black-and-white sign in front of the building lists “Senior Care” at the top of the list of physician specialties. Several of the physicians, physician assistants, and nurse practitioners are responsible for the care of elderly patients in nursing facilities, and this core group is called, appropriately, the “Senior Care Group.”

Bray’s position as physician extender at Greensboro Medical Associates evolved directly from his professional relationship with one of the Senior Care Group’s internal medicine physicians as he practiced as a consultant pharmacist for PharMerica at local nursing facilities.

First Steps
With the administrative support of Larry Long, senior pharmacy manager at PharMerica’s Greensboro site, Bray marketed his services in anticoagulation drug therapy monitoring to Art Green,MD, an internist and gerontologist. Bray and Green had established a solid professional relationship over the years, as they both interacted as consultant pharmacist and physician at one of the larger facilities they visited that used PharMerica’s anticoagulation service.

Green’s experience with Bray and his company had been a positive one, which was further enhanced when Bray requested that Green serve as a general medicine clerkship preceptor for the University of North Carolina’s (UNC) External Doctor of Pharmacy program in January 1998. Green agreed to be a preceptor for Bray’s full-time, one-month required clerkship in general medicine. Having a physician as a preceptor in the UNC external PharmD program is not common, but Bray saw an opportunity for advanced learning in a practice he had come to appreciate and admire.

Anticoagulation Monitoring
In November 1998, Bray, as an employee of PharMerica and contractor to the clinic, began providing anticoagulation drug therapy monitoring services for Greensboro Medical Associates. He made a positive impression on the staff at the clinic during his clerkship in early 1998, but implementation of the clinic still took several months, as details needed to be discussed and agreements reached regarding clinic hours covered, office/work space provided, referral protocols, approved medical record forms, reimbursement methods, equipment availability, and the contract between the clinic and PharMerica.

Bray and Long marketed the service to the clinic as much as to their own company.Time spent in the physician office and not in the facilities as a consultant created a void in consultant coverage that needed to be filled. Serving as director of clinical services has its advantages, however, and Bray, with Long’s support, was able to overcome any potential obstacles or challenges presented by either group.The anticoagulation service became a reality, and Bray became a physician extender in the clinic.

A Gratifying Testimonial
“I love him! I have been seeing Bryan since he started here two years ago. This is so much better than the way it was before I started seeing him. I used to go to the lab, have my blood drawn, and then, in two or three days, I would get a phone call to let me know how my blood was and what dose of my medication I needed to be on. This is quicker and more convenient for me.”

That’s how one of Bray’s patients—a frail-appearing yet very conversational 70-year-old woman on warfarin therapy for prophylaxis of deep venous thrombosis and stroke—describes the positive impact of his services.

At this visit, she is complaining that being on anticoagulant therapy is “ruling” her life. Bray is in the process of adjusting her dose in order to achieve an international normalized ratio (INR) value in the recommended range. Her INR had been too high at the last visit; at this visit it is subtherapeutic. Bray discusses her diet with her, asks the usual questions he asks during anticoagulation clinic followup visits, examines the leg in which a thrombus had developed in the past, listens to her heart, and phones in a new warfarin prescription to her pharmacy.

“Being able to make an intervention, a change in pharmacotherapy or an educational/counseling intervention, and seeing the impact on patient care is what I enjoy most about working in this practice setting,” says Bray. “I like making changes in patients’ drug regimens and being responsible for the outcomes. I like the professionalism this setting creates for the pharmacist. The patients see me as the authority on medications, and the physicians use me as a resource for medication and therapeutic questions. I have to stay on top of the current literature, and I like this learning experience. Not to mention the fact that I get to apply this knowledge on a day-to-day basis and witness the outcomes.”

An Expanded Palette of Services
Within a few months of the start-up of the anticoagulation clinic, Bray added his expertise in diabetes, osteoporosis, asthma and chronic obstructive pulmonary disease (COPD), hyperlipidemia, and hypertension management to the clinic for referral by several clinic physicians who had come to personally trust his judgment and recognize his skills. Having completed three certificate programs in diabetes, asthma, and preventive cardiology as part of his external PharmD clerkship requirements in 1998, Bray was well prepared for the challenge of incorporating a variety of patients into his practice. David Grove,MD, PhD, a cardiologist in the clinic, says, “Bryan does a great job. It is wonderful to have an expert in the field of pharmacotherapy with us.” Grove refers patients to Bray for anticoagulation services, as well as “polypharmacy adjustment,” and he considers Bray an excellent resource for questions regarding drug interactions.

For Bray to be able to see up to 25 patients in a full day, working Tuesdays and Thursdays and half days on Wednesdays and Fridays, he needs an assistant.Tonya Nelson, a certified medical assistant (CMA), is responsible for performing many duties, making Bray’s work as a physician extender much easier and allowing him to spend more time conversing with patients and managing their drug therapy. Nelson, who attended Guilford Technical College and received a twoyear associate degree in Applied Science, is employed by PharMerica as a pharmacy technician and assists Bray on Tuesdays and Thursdays, more often if her schedule permits. She checks vital signs and uses the “CoaguChek” machine for INR testing. She brings the patients in from the medical practice’s waiting area, documents their vital signs, including weights and CoaguChek results, puts patients at ease while they are waiting to see Bray, and helps Bray locate charts or lab results.

Anatomy of a Busy Practice
The space provided by the clinic for Bray and Nelson consists of a large anteroom with several tall shelves filled with charts, a couple of tables, a chair, and scales like those commonly seen in a physician’s office.This is where Nelson brings the patients first and collects the first set of data for the patient visit.Two smaller rooms with windows are located side by side and open directly off the larger room. Charts are placed in clear racks on each door when there is a patient waiting to be seen by Bray. One room is used as an office with a telephone, desk, chair, and two chairs for patients and family members, while the other room is a treatment room with an examination table plus small foot stool and two chairs. Both rooms are used interchangeably for patient consultations. For anticoagulation patient visits, Nelson directs the patient into one of the rooms and checks the INR with one of the practice’s two CoaguChek machines.While Bray finishes his visit with one patient in one room, Nelson is checking INRs or making another patient comfortable in the other room until Bray comes in.At the end of the day, he uses his office to make the last of his telephone calls to patients and pharmacies, as well as to catch up on necessary paperwork.

“Paperwork is probably the least enjoyable part of this job,” Bray says. “Often I feel as though I just document information to satisfy billing purposes only, and it has nothing to do with the patient’s problem. I’ve spent a lot of time making sure I understand the documentation guidelines. To some degree, I face the same pressures that physicians do under a fee-for-service format.There are patients who need more time, especially for education and monitoring purposes, but because of the fee I receive for that particular encounter, I have to move things along and see a certain number of patients per hour. This creates pressure and often makes me run behind, which is stressful.”

Bigger Things Ahead?
North Carolina’s Clinical Pharmacist Practitioner Act, recently passed by the state legislature, provides guidelines and requirements for collaborative practice, including necessary documentation, between pharmacists and physicians.A pharmacist who meets these requirements is designated a “clinical pharmacist practitioner” (CPP) and works with a supervising physician in collaborative practice.

Very similar to regulations governing physician assistants and nurse practitioners, the new North Carolina law requires that the supervising physician review and countersign chart documentation and orders written by the CPP within seven days. What is new for pharmacists in this state is that when this act becomes law, Bray will be able to write prescriptions on his own, without having to leave his office every time he writes a prescription to track down a supervising physician to cosign it.The CPP’s progress notes will be signed off as reviewed by the supervising physician within seven days, comparable to the procedure for physician assistants and nurse practitioners.

According to the Clinical Pharmacist Practitioner Act, Bray’s services must be specific in regard to the patient, the pharmacist, the physician, and the disease.To meet this requirement, Bray’s patients are referred to him by physicians for the initial visit. The referral form states the patient’s name, Bray’s name, the referring physician’s name, and the reason for the referral, which is usually anticoagulation monitoring or management of a specific disease—for example, diabetes, hyperlipidemia, hypertension, asthma/COPD, and osteoporosis.

Sometimes polypharmacy is the reason for referral.Although not classified specifically as a disease, polypharmacy is a valid problem that physicians face every day, especially in the older adult population. Being able to refer these particular patients to a pharmacist is advantageous in a busy medical practice.

In addition to state regulations, Bray must follow the rules set by insurance companies for documentation and continuity of care.A patient must be seen by a physician on every third visit to the clinic. Because anticoagulation drug therapy monitoring can require a patient to be seen several times in a month, Bray has to be careful and make sure a physician visit is scheduled between patients’ appointments with him to satisfy those requirements. Other requirements by insurance companies include specific documentation regarding the billing of services “incident to” the primary provider.

A supervising physician is assigned to Bray each day he practices at the clinic. It is this physician who cosigns prescriptions for the patients Bray sees, and it is this physician whom Bray bills “incident to” on medical office forms for his own consultations with patients.The medical practice takes care of the actual billing of the insurance companies for Bray’s services.

Prerequisites of Success
When asked what experiences, skills, or characteristics have enabled him to be successful in this type of senior care practice, Bray credits his experience as a nursing facility­ based consultant pharmacist for the past 10 years as great preparation for his current activities. “In a lot of ways, I am doing nothing more than extending what I do in a nursing home to a community, office-based setting. The majority of my patients are elderly with multiple chronic diseases and complex,multiple medication regimens.”

Most of the patients Bray sees are taking 7­10 medications and receiving treatment for several comorbid conditions. He is often in a position to identify medication-related problems in patients who have not been referred specifically for polypharmacy evaluations, but rather for disease state management in a particular area. Just as in nursing facilities, a review of medication regimens by a pharmacist in an office-based practice is a valuable and needed service for older patients on multiple chronic medications. Not only is Bray in a position to identify medication-related problems in older patients, he can resolve them himself on site during the clinic visit.

He credits well-developed communication skills for his success in educating his patients about their disease states and pharmacotherapy. “You have to be able to communicate on the level of the patient and be able to give positive reinforcement to ‘good behavior,’” he says. Bray asks questions and listens intently to what his patients are saying. He provides feedback to them on what they are doing right and wrong in selfmanaging their diseases and conditions. In the small amount of time he has to spend with each patient, he strives to make complete assessments of problems, use good clinical decision- making skills to resolve those problems, and communicate a plan of correction to patients in a way they can understand.

Up Close and Personal
Bray’s assessments involve a definite physical component. He believes that “pharmacists need to be able to confidently touch patients.” It is completely routine for him to have diabetic patients remove their shoes and socks so that he can check their feet for abrasions and wounds or perform a sensitivity test with a fine filament. The stethoscope he wears around his neck is not there for ornamentation. Lung sounds may indicate the need for a higher dose of a bronchodilator metered dose inhaler. He also firmly believes that pharmacists should be able to monitor the use of medications in terms of therapeutic response of their patients. Using his physical assessment skills provides him with data to make his clinical decisions. During his assessments, Bray may discover new findings, or indications of new problems, which are then triaged to the physician for follow-up.

In Bray’s words, pharmacists nearly have to have a “brain transplant” in order to successfully coordinate activities in a physician office-based practice. Performing a comprehensive patient assessment and appropriately documenting the findings are not things most pharmacists have been trained to do.The pace can be hectic during the workday. “You don’t have time to sit down with a chart for 30 minutes and review it fully.You have to be able to identify important data in the chart quickly, take a very thorough history through a patient interview, assess the patient and the problem and make a clinical decision in a 15- or 30- minute office visit with someone you have never met before.”

Unique Rewards
Despite the challenges, Bray really enjoys community-based senior care practice.The patient interaction is quite exhilarating, especially when he is in a position to improve drug therapy. He likes to tell the story of one diabetic patient who came to see him a while back.At the time of the initial visit, the man was using 70 units per day of 70/30 human insulin and his blood glucose was not adequately controlled. After seeing Bray then and during several follow-up visits, he was gradually changed from his insulin regimen to oral therapy and his diabetes is better controlled. Even when his recommendations and interventions don’t produce dramatic improvements, Bray enjoys the patient interaction—and the patients say they really enjoy his expert attention.

At another memorable visit, an elderly woman asked Bray to call in a new prescription to her pharmacy. She made the statement that “my pharmacist” is at that particular location. Bray responded in a mock hurt voice, “I thought I was your pharmacist.” She hastened to reply, “Oh, you are, you are my pharmacist!”

That patient, and many others Bray has seen, has come to see that pharmacists are not always found working behind the dispensing counter. Increasingly, senior care pharmacists like Bray are found behind desks in physician office­based practices. But don’t expect him to stay behind the desk for any length of time.This is one senior care pharmacist who likes to stay moving and make personal contact with the patients in his care. His patients wouldn’t have it any other way.

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