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Putting the patient
first
Carol Lazaruk is breathing much easier these days, and it's not just because she hasn't smoked a cigarette for six months. It's also because she knows she can count on her pharmacist for support.
At Calgary Co-Op’s pharmacies, the goal
optimal patient healthcare
drives the business
PHOTOS Carlos Amat Photography
by Karen Welds
Top, L-R: Sonal Ejner, Carol Lazaruk (patient), Nadine Hammoud, Judy Roberts. Bottom, L-R: Carol Lazaruk; Sonal Ejner and Carol.
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Not only does she call me every two weeks, but whenever I’m at the pharmacy she’ll ask me how things are going. And I can phone her anytime,” says Lazaruk of Sonal Ejner, pharmacy manager and certified respiratory educator at Crowfoot Calgary Co-op in Calgary, Alberta. “Two years ago I went to a smoking cessation clinic, and the people there were really good, but they didn’t do this kind of follow-up. This personal touch really helps.” Karl Valois echoes those comments when asked about his pharmacist, Ryan Keller, pharmacy manager at Calgary Coop’s Rocky Ridge location. His doctor referred him to Keller, a certified diabetes educator, to start insulin therapy. After two face-to-face appointments, “we’re in touch now from week to week,” says Valois. “He’ll email or text me, or I’ll email him. I also do groceries at the Co-op twice a week and go to see him. Sometimes we talk for just a few seconds, and that’s all I need. He’s great.” Both Lazaruk and Valois enthuse not only about the time saved by being able to talk with their pharmacist in this way, but also the time gained to manage their health. “I can breathe a lot easier now and I’m using less medication,” says Lazaruk, who has COPD. “Sonal has definitely changed my perception of what pharmacists can do. But she also leaves the final decisions completely up to me. That’s important. In this day and age, people have to look after their own health.” Valois agrees. Despite losing 50 pounds in the first year after diagnosis, his bloodglucose readings “were beyond the scope of most meters,” he says. While insulin therapy has performed a “miracle” to bring those
numbers down, he knows the last few steps to reach the normal range are up to him. Valois likens Keller’s support to that of a “game plan” to follow and adjust as required. “I’d say this is definitely a novel approach for pharmacists. We can all hope that more will do it.” Time on your side At Calgary Co-operative Association Ltd., optimal patient care is simply a matter of time. Literally. The chain of 24 co-operatively owned supermarkets with pharmacies is taking concrete steps to ensure pharmacists have the time to counsel patients on all prescriptions and, more recently, to deliver expanded services. “With the pressures of generic pricing, we’re seeing other pharmacies with one pharmacist and three techs or assistants on duty to cut costs. That will never happen here,” says Trent Lane, pharmacy director. “Our policy provides guaranteed overlap and time for breaks. A new pharmacy always starts with three pharmacists and a four-hour overlap between one and five. When we reach a certain volume we’ll add an assistant, and then as volume grows we’ll maintain a one-to-one ratio between pharmacists and assistants or technicians.” At the Crowfoot location, which dispenses more than 300 scripts a day, four pharmacists and four assistants are typically on duty during the afternoon peak period, says Ejner. The pharmacists use this time to conduct previously booked appointments for injections, medication reviews and care plans (the latter for those with chronic conditions). With Alberta’s implementation of the Pharmacy Services Framework in July 2012, all of these services are billable. February 2013 Drugstore Canada
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Calgary Co-op at a glance
Background One of the largest retail cooperatives in North America, with more than 440,000 members and operating 24 supermarkets with pharmacies, as well as gas bars, car washes, liquor stores, travel offices and home healthcare centres. Established in 1956; the first pharmacy opened in 1965. Pharmacy staff 106 pharmacists, 76 assistants, 3 regulated technicians. Pharmacy hours of opening 9 am to 9 pm on weekdays; 9 am to 6 pm on Saturdays; 10 am to 6:00 pm on Sundays. Website www.calgarycoop.com Top, L-R: Sonal Ejner, Judy Roberts, Nadine Hammoud. Bottom, L-R: Trent Lane; Ryan Keller.
“Pharmacist overlap is absolutely essential for services,” says Ejner, adding that head office can also provide an additional floater pharmacist during clinic days (see sidebar, page 18). Booking appointments during set blocks of time is also important. “We tried to squeeze them in during the rest of the day but it was too disruptive to workflow. We can make exceptions for those who can’t make it between two and four in the afternoon, but for the most part people are making the effort, the same as they would for a doctor’s appointment. Public response has been great.” Customers also have no problem taking their prescriptions to the front checkout for payment, since there are no registers at the dispensary. “This is a huge benefit,” says Keller at the Rocky Ridge Co-op. A cash-free dispensary not only saves time because “you’re not ringing in diapers and bread,” but it also makes for a much more professional environment. Indeed, it’s company policy that the pharmacist is “always the last point of contact with the patient for all prescriptions, including refills. That time is for a final check with the patient, not to ring in purchases,” says Keller. Both Keller and Ejner estimate that a third of their time now goes to clinical services. For Ejner, that includes two days a month to conduct spirometry clinics (one day to test, one day to review results) that rotate through all 24 locations. When not in appointments, they use scheduled overlap to follow up with patients by phone or, in Keller’s case, by email or text as well. “I’m helping to fill a gap in health care for sure, particularly in terms of the follow-up education,” says Ejner. While the transition to clinical services can be a challenge in time management, adds Keller, it’s a relative pleasure compared to previous jobs, when it would “just be me and four techs, filling 300 prescriptions a day. I could never go back to that.” Strong home base To prepare for the transition to professional pharmacy services, Calgary Co-op grew its head-office contingent from a department of one in 2006 to four personnel today: a director, two operations managers and a pharmacy professional services manager. From this base,
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the company has been able to improve store-level efficiencies and implement services (see sidebar, page 18) during a time of intense economic upheaval due to drug plan reform, and without having to reduce hours of opening or compromise its commitment to pharmacist scheduling. In fact, “our bottom line keeps getting stronger,” says Lane. The company also increased investments in training and communications. Pharmacists can apply for tuition for certification programs; as well, the company posts opportunities for specialty training. For example, this year it is sending four pharmacists to the travel medicine certification program in Maastricht, the Netherlands. Nadine Abou-Kheir is one of those four pharmacists, and the opportunity meets her personal goal to complete an advanced-training program every year. It began in 2010, when the pharmacy manager at the West Springs location became a certified diabetes educator (CDE). The following year she became an injecting pharmacist, and in 2012 she obtained additional prescribing authority. She now dedicates half her day to expanded services, most of it appointmentbased. “This is primary care in action,” she says, adding that one of her staff pharmacists is training to become a CDE and the other is an asthma educator and injecting pharmacist, thanks to the support of head office. On the communications front, head office hosts monthly meetings or conference calls between pharmacy managers, and quarterly gatherings of staff pharmacists, assistants and technicians “to talk about any issues they may have,” says Lane. The annual pharmacy conference includes an open discussion forum, and annual performance reviews dedicate time to personal objectives. While not all pharmacists are ready for advanced training, a positive momentum is building, says Lane. “We are trying to shape staff ’s thinking so that they see expanded services as the way of the future,” notes Ejner. “We need to keep in mind that regulated technicians will be playing a major role in the technical side of dispensing. While the right drug for the right patient is still very valuable, and you’ll always need pharmacist counselling for that, we are encouraging staff to do more. As well, the
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Story more we can do now, the more suggestions will come forward to streamline the process.” This one-on-one approach to communications and change management also ultimately builds patient demand. Public acceptance “doesn’t happen through advertising or store posters,” explains Lane. “Until something actually applies to a person, it doesn’t really sink in. Therefore we focus on one-onone communication between the pharmacist and the patient to communicate the value of a particular service to a particular patient. This not only needs the right work environment, where pharmacists aren’t too busy or stressed, it also needs pharmacists who believe in the value of the service, whether or not they personally provide it.” “We truly work as a team,” agrees AbouKheir. “For example, if a staff pharmacist sees a person with diabetes who is struggling, they promote my expertise and book an appointment on my behalf. This happens all the time. We cover each other during appointments, or when I’m out of the pharmacy to give a presentation. We’re working harder and smarter, together.” Their efforts are paying off. Since the company began tracking governmentfunded professional services in 2012, rev-
enue has doubled month after month. “In the last two months, we have increased our revenue generated by professional service fees by between 120% and 165% each month,” says Lane. Most precious commodity When all is said and done, Calgary Coop operates on the premise that time is its own reward. When you make time for professional services, then pharmacist commitment, consumer support and financial growth will follow. Equally important, fulfillment on the job leads to fulfillment outside the job. Turnover is low among the pharmacy staff, with an average tenure of 10 years. “Our entire corporate structure from the CEO down focuses on quality of life, on having a life outside of work,” says Lane. “When I was a pharmacist elsewhere, I remember that all I could do at the end of the day was collapse on the couch. That’s no way to live. Our goal is to give pharmacists the tools and the work environment not only to do their job, but also to enjoy their job—and have enough energy at the end of the day to enjoy their lives outside the job. Happy employees are loyal, productive employees.”
Karen Welds is a journalist and editor with two decades of experience in the pharmacy industry, including eight years as editor of Pharmacy Post (precursor to Drugstore Canada).
Growing slate of services Calgary Co-op leverages its pharmacists with advanced training by offering mobile clinics throughout the chain. It seeks out medical devices and outside partners to engage patients, and uses centralized services to reduce costs and improve efficiencies, says Judy Roberts, pharmacy professional services manager. “Head-office support is focused on providing the resources, work conditions and environment for pharmacists to pursue their passions. We seek innovative ways for our patients to get benefit from the knowledge and services that our pharmacists offer.”
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Here’s a summary of its services: ✔ Diabetes health One of the five certified diabetes educators and a local chef co-host an education session and cooking class up to eight times a year at the locations with community kitchens. ✔ Heart health Three months a year, more than 1,000 customers book appointments for cardiac assessments using CardioVision equipment administered by technicians from Healthwave Diagnostechs. Pharmacists then review the results with participants. Customers pay $15 to help cover costs. ✔ Injections In addition to flu shot clinics, some of Calgary Co-op’s injecting pharmacists regularly administer testosterone, B12, travel vaccines, Gardasil, Humira and Zostavax. ✔ Central compounding A specialty compounding centre prepares unique meds, including veterinary products, for all locations within 24 to 48 hours.
✔ Central adherence packing Using PacMed pouches, Calgary Co-op provides 24-hour turnaround on compliance packs for all locations. ✔ Gluten awareness The company’s latest program, launching in May, includes training pharmacists to conduct gluten-intolerance tests and counsel patients on results. Current signage already identifies more than 600 gluten-free foods stocked throughout the supermarkets. ✔ Spirometry tests In partnership with Peak Pulmonary Consulting labs, the company’s two certified respiratory educators conduct a mobile spirometry clinic at all locations once a year. The pharmacists conduct the test on day one; two to four weeks later, they return to review the results and develop care plans. Fuelled by doctor referrals, there is currently a waiting list.