Diabetes Care and the Impact of Adherence

Todd Eury:

Hey there. Hey there, pharmacy community. Welcome to this webinar and podcast. So if you're listening after this live opportunity to be together, we thank you for taking the time to listen to this podcast.

Todd Eury:

Please be interactive during this gathering. Send us your questions through our messenger. Brady Chatfield, he is a member of the RxSafe team. He will be helping us to field those questions and put those questions into our panel and our session. I want this to be interactive.

Todd Eury:

This is Beyond the Vial: Transform your Pharmacy series. This is about diabetes care and the impact of adherence, and before we get started, I want to give a shout out and a thank you to Bill, and his command, and his lead of the RxSafe team.

Todd Eury:

I love seeing Bill and Brady in their command center with all of that technology behind them because it's one of my sweet spots of when I entered pharmacy quite many years ago, but welcome, Bill. Thank you so much for having us.

William Holmes:

Todd, it's always a pleasure to be a part of this amazing organization that you've put together.

William Holmes:

As we've talked so many times, the challenges that the independent pharmacy owners face today are numerous. They have come to an amazing rescue, I think, would be the good word to use in this pandemic in administering hundreds of millions of shots to people with the vaccine to try to get us through it. Without that amazing first-line of healthcare literally five minutes away from... I think it's 90% to 95% of the population, think of where we would be.

William Holmes:

So first of all, let me say, "Thank you," a heart-felt thank you, to every pharmacy and every pharmacist in our communities that do so much to help everyone every day. The mission is caregiving, and you've really proven that even at your own risk. Many pharmacists have been sick, and some have died in this mission, and it's a tall order, so again, thank you. Thank you so much.

William Holmes:

My honor and privilege to sponsor this even and many like it is just to underscore how much we care and how much we really thank you for what you do.

William Holmes:

So that's what we do when we get up every single day is how can we improve the community health across our country, and so Todd, thank you for this opportunity, and we'll turn it back over to you.

Todd Eury:

Thank you, Bill. You've been such a consistent partner to our pharmacy owners, and the stories that we hear, the interviews that I've done, the privilege that I've had to work with your team, with Nicole, with Brady, and with your customer base. It's just been amazing, and it's taught me a lot about service.

Todd Eury:

I want to talk about that word before we jump in, and before we interview, and before we get into our guests. This is about our patients. This is about our communities. No one knows that better than the pharmacy owners who are submerged, and invested, and have made their homes in communities in serving for their patients.

Todd Eury:

There's 34.2 million Americans that have diabetes. It is such a serious, chronic disease state, and I think we overlook it sometimes because we get so used to hearing about it over and over again, but it's rising, and it's taking a backseat to our pandemic, but we have to be cognizant in adherence and driving adherence to save lives, save money, save our communities.

Todd Eury:

I want to welcome our panel. I'm so excited about this rockstar panel. We have four amazing individuals that I have talked to many a times and have worked with many a times including Dr. Lisa Faast, who is the CEO of DiversifyRx.

Todd Eury:

She's an innovator. She does not stand still. If you are linked up with her on LinkedIn is is a treasure trove of information daily that's coming from Lisa and her team. I want to say welcome, Lisa. Thank you for coming.

Lisa Faast:

Thank you everybody. Appreciate it.

Todd Eury:

Dr. Gary Welch. Dr. Welch is the co-founder and Chief Scientific Officer of Silver Fern Healthcare. Gary, this is the first time that I've had the absolute pleasure of having you a part of a panel, and I'm really looking forward to your participation.

Garry Welch:

Thanks, Todd. It's a pleasure to be here.

Todd Eury:

And no one that I have talked to in specialty pharmacy, the fusion of pharmacy, the fusion of community pharmacy, an award-winner from the NCPA, a real shining star in our industry, Ghada Abukuwiak, with Caremed Pharmacy. Welcome back to the Pharmacy Podcast Nation.

Ghada Abukuwaik:

It's my honor being with you today. Thank you.

Todd Eury:

And our special guest who I reached out to first from all the guests because her writings, blogs, podcasts that she's participated in really caught my attention. Her passion for the patient, specifically those suffering with diabetes, and why we have her as our featured guest today. Dr. Ani Rostomyan. She's a board certified clinical pharmacist and holistic health coach. Dr. Ani, welcome.

Ani Rostomyan:

Thank you everyone. Thank you, Todd, and it's a pleasure to be here. It's an honor to be here. Thank you for invitation.

Todd Eury:

Absolutely. So, wow. 34 million Americans. People that rely on their providers to guide them through this disease state, and how people that are not adherent are crashing, and they're suffering, and it's causing them not only more pain from a physical perspective and even death. It's causing their families strain and pain. It's causing them financial woes, and that's because of the lack of adherence really digging into their disease state and taking ownership of their disease state.

Todd Eury:

There are of those millions, millions within those millions that are living with diabetes, and they're doing great with it, and there's a balance between the patients that don't and the patients that do, and I think that there's a wide difference between the attitudes, the pharmacist support, the physician support, and the technology, and the packaging that's being used in the midst of all of this.

Todd Eury:

Community pharmacies are so accessible to our patients. I don't know if patients even realize that pharmacists have such a deep understanding and information resource to them as people that may be suffering with diabetes.

Todd Eury:

So I kind of want to jump right in, and I'm going to start with Dr. Ani first, and that is can you kind of set the groundwork for us today as we dig into this topic? What are the top reasons for non-adherence, Dr. Ani?

Ani Rostomyan:

Again, good morning everyone. Thank you, Todd, for the question. This is one of the biggest questions and dilemmas we're facing right now as healthcare providers, and I do manage diabetes at my work every single day. I talk to at least eight to 10 patients daily, whether it's telehealth visits, or whether it's just face-to-face now already, more patients coming in, and what I've learned the past six years, it's not more medications that really help patients. It's not more healthcare dollars spent per patient on diabetes programs and everything.

Ani Rostomyan:

It's the mindset, and a lot of times we do see that our students, our pharmacy students that I work with, no one's learning how to interview a patient for chronic disease. No one's learning to ask for their pains, and family situation, and social determinants of health where whether you can advise the best, healthiest diets to your patient, but if your patient is struggling with basic necessities and providing food for the entire family, and they're not hearing you. You hear patients say, "Yes, yes," but you could tell patients are not in tune with you.

Ani Rostomyan:

So I always say more medications doesn't mean better care. It's the mindset that we need to work first before even interview patients for their health habits, medication adherence, and lifestyle.

Ani Rostomyan:

A lot of the patients I work with for Las Angeles County Department of Health Services, we do work with the most underserved population, migrant workers, people who are undocumented, and they really have trouble even finding housing or basic necessities.

Ani Rostomyan:

For them to understand what we're talking about on a daily management of diabetes it's already a struggle, so we have to meet our patients where they are. We can't just say, "You know? Diabetes, this is the MyPlate handout. This is the exercise routine you have, and these are your medications. You should go home and take care of it."

Ani Rostomyan:

So it's a daily work, and I think every patient has their own unique needs that we, as healthcare providers, need to understand, but at the same time, do we have enough time to give to those patients within our healthcare system? Do we have more than 15, 20 minutes a day to give to one patient for that? That was my biggest problem to realize that we're not designing this care around our patients.

Ani Rostomyan:

Our patients have to accommodate to the 15 minute increments that we have for them, and it's not working, and I feel like sometimes we do give and make the same approach consistently and expect different results, and it's just not happening. We have to do something different. That's my core understanding.

Ani Rostomyan:

More medications doesn't mean better diabetes care as we see, and patients mindset. If the patient is not there mentally, and physically, and a level of understanding nothing's happening. That's my core understanding.

Todd Eury:

Dr. Ani, that is a perfect segue for the data and the experience that Dr. Welch brings to the table and to the panel today.

Todd Eury:

Silver Fern has concentrated on behavioral health as a major component of diabetes care, and with that I want to turn it over for Dr. Welch's opening to this event. Thank you, Dr. Welch, for being here.

Garry Welch:

Thanks, Todd. Well, thanks Ani for the tee-up because it kind of sparks in my mind a few things. One is that we need to unpack that patient's story, and we have to do it in kind of smart digital ways, and get that information into the treatment plan, and disrupt the whole healthcare system so we have different people with different skills that can help the patient, and it's a blend of digital and in-person. You kind of have to get to that ecosystem.

Garry Welch:

And underpinning that is a couple of big things in my mind. I'd like to get back to that, but one is that the business models of all the silos of healthcare, who delivers care, who administers it, who provides all the goods and services that wrap around it, the business models, we have to study them and see why different groups do what they do because it makes a lot of sense for their behavior.

Garry Welch:

If you unpack a pharmaceutical manufacturing, or [PBM 00:11:58], or retail pharmacy they've all got their business models. They're all connected, but they have their own metrics and why they can and can't do things.

Garry Welch:

So I think this is great to be here in this group that's looking at the role of community pharmacies because I look at the primary care network. We've had this COVID eruption that actually brought digital health into a kind of reality. There's like 20% is the virtual proportion now of clinic visits. It's stabilizing it there.

Garry Welch:

We've got these extended teams that can include pharmacists, and community health workers, and health coaches, and nurses, and we've also got a loosening up of the regulations so people can get paid to do things that they were locked out from doing, and so this is a beautiful unlocking of the system.

Garry Welch:

[inaudible 00:12:50] came through this disastrous event, but that's just... We've got to make the most of that and not let things slide back.

Garry Welch:

So I think when you look at the patient's story, they've got a family that they're embedded in. You need to find out what are they doing? What would they want to work on? Where are they getting stuck? And that unlocks a lot of things in terms of psycho-social issues, social determinants, so I fully agree, Ani, that that's really... How do you get that story digitally quickly based on clinical research and real frontline community health standards? That's kind of what we've done.

Garry Welch:

Just to rap on that point, the reason I co-founded Silver Fern is because we built these tool sets in community health centers, multi-disciplinary teams including pharmacists, and I realized that to get it out to the 34 million, you've got to just get out of the system, start a digital health company, find different people to hang out with, and start really finding those champions of really change and who the care-delivery groups that really want to do this, and then what are the business leaders that will support that because it makes sense for them and their pain points. So I fully agree with your perspective, Ani.

Todd Eury:

Ghada, I want to bring you into the conversation because the majority of your patients are always comorbid with the multiple disease states that you're managing within your patients as a specialty pharmacy, as a community pharmacy, and also as a diabetes self-management educator and program developer.

Todd Eury:

So kind of stemming from what Dr. Ani and Dr. Welch have said, I want you to launch your insights into better diabetes management.

Ghada Abukuwaik:

I totally agree with Dr. Ani and Dr. Garry regarding the motivational interviewing, the adherence coaching, that the pharmacy... That can play a big role different than the standard counseling.

Ghada Abukuwaik:

Just having a kind of a mindset with the pharmacist, vital sign. The medication adherence is a vital sign to be checked in each patient interaction, and making the kind of approach, as Dr. Ani mentioned. Less is more.

Ghada Abukuwaik:

Whenever we're going to be able to make the medication, to make the medication less, in this way, this is going to be increased the adherence for the patient.

Ghada Abukuwaik:

There are so many different approaches, and there are so many different challenges that we find for the adherence. I'm going to say a few of them.

Ghada Abukuwaik:

Minimizing the number of medications by having the combo. Let me say giving a patient one pill instead of a few different pills that are going to treat the diabetes. Sometimes that's going to be a big impact on a patient.

Ghada Abukuwaik:

Addressing the financial and physical barrier. Delivery is one big thing. There are so many transportation issues that the patients find to get their medication.

Ghada Abukuwaik:

Having be alert of potential barriers. Sometimes for the hospital patient, discharge. They're not able to get their mediation in the evenings, or in the holidays, or at the weekends. Be familiar as a pharmacist, community pharmacist, with the payer formularies in order to choose the most cost-effective medication for the patient. Addressing the prior authorization promptly to minimize the delay in the therapy for the patient.

Ghada Abukuwaik:

Helping the patient to find the free or low-cost medications by giving them generics, by checking with them about assistance programs, discount cards. That's all going to help them to make sure that they are really taking their medications.

Ghada Abukuwaik:

Communicate effectively with patient by educating them about the risks and the benefits. Checking with them about the side effects that they're going... They may have when they're going to start the new medications.

Ghada Abukuwaik:

Having a kind of a work as a team with the technicians. If the technicians find or hear that a patient is mentioning the cost, right away to check with the pharmacist and try to communicate with the patient to have alternative issues, alternative results, to help the patient.

Ghada Abukuwaik:

Considering special populations. That's really big. With the culture and language barrier, at the same time we have a few patients with this... Let me say psychiatric patients. How are we going to be able to follow up with them to provide frequent follow-up in a way of a positive reinforcement.

Ghada Abukuwaik:

So there are so many challenges in the adherence, but mainly what we've found in a community pharmacy, our pharmacy, the synchronization and compliance packaging through the RapidPak makes the adherence really, really high and improving the issues with our patients, and we may consider that in a different... Through the webinar right now, we may consider this two solutions that the pharmacists call the patients in monthly calls to check on their medication, and at the same time to follow up if they have any kind of side effects.

Ghada Abukuwaik:

In that call, monthly call, we can address all the issues, especially that we check on them when we put the medication in the compliance package with the RapidPak making sure that the patient is taking all the meds, the necessary meds, the maintenance one that designed only for this specific patient in the morning or in the evening. Those two [inaudible 00:18:48] synchronization and compliance package really improve the adherence with the patients, with our patients.

Todd Eury:

Thank you for that, Ghada. I want to bring in Dr. Lisa Faast, and she's become a barometer for me in being that litmus test of processes, technology through DiversifyRx, really believing in key performance indicators and follow-up to ensure what she promotes because she's a pharmacy owner to other pharmacy owners. It has to work.

Todd Eury:

So Lisa, that's why I have you here because you almost become our gauge of best practices, so I want to hear your ideas in bringing together our three guests today and what you've done for your own patients throughout the years.

Lisa Faast:

Yeah. Thank you for having me, Todd, and I'm so glad that everybody went first because you guys hit on all the clinical points of this problem, and I think ultimately as somebody who started my career in a heavy Hispanic, very poor area of California, I think when it comes to adherence, there's this issue with patients that they know it's serious, but they don't really, truly understand the consequences.

Lisa Faast:

When doctors or pharmacists speak, "Well, in 15 years your kidneys will go." Well, right now I'm not worried about 15 years from now. I'm worried about buying food for my family and affording my medication.

Lisa Faast:

As a patient, and I know in my own life our concerns are much more short term. You know? Most of us don't invest for the long term in our finances, much less in our health, and I think there's this just dichotomy between patient education and awareness and really, truly understanding and internalizing the information.

Lisa Faast:

And big food and big marketing, I had this, "Ah ha," a couple days ago as I was kind of prepping for this webinar, and I had diabetes on my mind. I was watching a TV commercial about Honey Nut Cheerios, and love Honey Nut Cheerios. Nothing against them, but they're able to make their health claims about being heart healthy because of the amount of fiber that they have.

Lisa Faast:

And I'm sitting here thinking, "You know? Diabetics don't have a disease in a silo. They rarely just have diabetes." They often have so many other things, so I happened to be sitting with some family, and it's like, "Hey. What do you guys think of that?" They're like, "Oh, that's..." You know?

Lisa Faast:

I had a little dialogue, and it's like... But the last thing a diabetic needs to be eating is a big bowl of Honey Nut Cheerios? And there's just all of these mixed messages, and how do we expect the laymen, the regular patient, as Dr. Ani mentioned that are often from other cultures, other languages? How do we expect everybody to decipher through this language if you're not monitoring them.

Lisa Faast:

And so kind of back to what you were talking about, Todd, with KPIs. I think there's very critical KPIs when it comes to patient... You know? The patient adherence score to me is paramount, and that's what the beauty, as Ghada was saying, of the RxSafe packaging and the compliance packaging is you know when patients are getting refilled. You know that they're getting all the medications they need, but to me there's step beyond that.

Lisa Faast:

How many of those patients are you actually verifying? You're not just filling medication to fill medication, but are you verifying with them? Are you verifying with the family member? Because obviously sometimes you're dealing with elderly patients or different cultures that they don't even speak the language.

Lisa Faast:

To me, there's always that step further, and just like when you're measuring morphine equivalent milligrams for pain patients, you need to be measuring these patients. Get them to understand why testing their blood sugar. What is your percentage of diabetic patients that actually test their blood sugar and log it?

Lisa Faast:

And if you're really into caring about these patients, you can create subset of KPIs that really help you monitor those patients and take better care of them.

Lisa Faast:

And again, get them to understand why because they have to understand the why. You know? In everything. All of this human behavior. I loved how you opened up, Dr. Welch, with the human behavior component. You have to understand why you're doing it, and you have to have a good why if you're ever going to be compliant.

Lisa Faast:

And to me, I think the data helps patients to understand the why, and I think that's why those marketing materials of amputations and the horrible-ness, but that's how you kind of get the shock for them to understand the why of daily management of their disease that isn't going to get bad for a really long time, but why today is important for that disease.

Todd Eury:

Dr. Ani, my dad reminded me that medication reminds him daily that he has an issue, and he doesn't like that. He's very active. He walks. He exercises. To look at him as an outsider, a 74-year-old man, you would never know that he's on the medication that he is, and he lives as freely as he can.

Todd Eury:

So when I'm listening to Lisa talk about multiple meds, and KPIs, and making sure what works and what doesn't I think of that diabetic patient who typically takes multiple medications, and has that complicated drug regime. And really needs to understand how important it is without constantly being reminded that they're having some kind of disorder or sickness.

Todd Eury:

So in your experience, what have you done to set a precedence and set an [inaudible 00:24:13] to get past that challenge? To get past that obstacle with your patients that are diabetic?

Ani Rostomyan:

Oh, absolutely. Great question, Todd. I want to start with saying that human nature is non-compliant. We all are non-compliant, and even me. I don't like taking medications. I know I can barely handle a seven or 10-day course of prescription for acute conditions if I'm given that.

Ani Rostomyan:

But imagine the daily life of patients who have to take seven to 10 medications, and they have to be compliant, and they're questioned by their doctors, by nurses, and the pharmacist on top of it asking questions. A lot of my patients, they say, "I feel like I'm punished when I'm given more medication, or my medication doses are increased, my insulin dose is increased." They feel they didn't do well as a patient. They failed. They failed their own disease.

Ani Rostomyan:

And the stigma around diabetes kind of... The whole thing about medications is I have to just live with it. My parents had it. I have to just not talk about it. I'm going to get all these medications, and I just have to do my very best.

Ani Rostomyan:

Patients feel punished, and a lot of times the approach that we hear from them, their doctors, saying that, "If you don't bring your A1c to this percent, I'm going to have to start you on insulin." That's kind of like verdict. They feel like, "Okay. This means I didn't do well," and they kind of go into this denial mode saying, "You know what? In that case, I'm not taking anything."

Ani Rostomyan:

My encouragement for patients, and we do this daily. With everyone, the approach is different. There's no one-size-fits-all regiment that works with every patient, and we always meet them where they are. We have to meet our patients where they are. What can you do? What are the methods? If you're tech-savvy, what are the reminders that you have for yourself that you can do to increase adherence? If you incorporate lifestyle modifications, the ones that we're advising, you may take less medication?

Ani Rostomyan:

So it seems like, "Oh, the picture is getting better. I can take less medications at some point in my life."

Ani Rostomyan:

So it's a lot of mind work that unfortunately healthcare providers either are not trained or not able to utilize because of time constraints. We're not going to sit with a patient for one hour and see what works, which we do, actually, but not for all health systems.

Ani Rostomyan:

So every patient is unique, and a lot of times if the patients are not tech-savvy they're not being honest, and they're not... They're selectively not good historians.

Ani Rostomyan:

Saying, "Are you... How many times a week do you miss your medications?" None. I take all of them, but there's tons. Bottles are full of tablets. You know?

Ani Rostomyan:

It's human nature, and I feel like pharmacists are well-equipped and trained with addressing the root cause in non-punitive ways. I hear you. I'm non-compliant too. I miss my medications. When you come from that space that it's okay. If you missed your metformin yesterday, that's absolutely fine, so then patient opens up.

Ani Rostomyan:

So it really brings up the best in you as a healthcare provider getting the true story. We don't know what's happening in their homes every week. We can't manage their medication compliance from our end, but honest and sincere conversation and empathy. I think that can work magic. Absolutely.

Todd Eury:

So as I'm thinking of what you're saying, Dr. Ani, I think of that behavioral component immediately in making our patients feel better as they move through treatment, and I think of the technologies that we have in place, messaging, reminders, adherence packaging through the RxSafe platform.

Todd Eury:

Dr. Welch, what has your firm and agency discovered in diabetes patients specifically that you can share with our pharmacists and our pharmacy owners today that can kind of help a common denominator, per se, of where they can start if they see that their patients, in fact, are non-adherent?

Garry Welch:

Well, we're a digital health company that came out of clinical research and a big hospital system. We were in the community health center part of it.

Garry Welch:

So we were developing these digital tools that are basically assessments asking in little bites, "What is going on with your self-management behaviors? Where are you getting stuck? What do you want to work on? What would you do? What are you doing?"

Garry Welch:

And then exploring other psycho-social issues like depression, or other behavioral health issues, or social determinants, the things that are going on at home, the tough things about not enough money, or transportation, or there's legal problems, or maybe there's some racism.

Garry Welch:

So we've got it down to these little bites of assessments that can... You can do them with a tech survey now, so we can blast it out away from the pharmacy, away from the clinic, or whatever they're sitting in and start to get little bites of that patient's story.

Garry Welch:

Was it medication taken? Maybe it's about monitoring of blood sugars or CGM. Maybe it's physical activity and so on.

Garry Welch:

And so you kind of unlock these little stories about the patient's life, and you pull that into your treatment plan and the workflow, and the right team member can be assigned to say, "Well, I can do some work on that. I've got... I can do texting, or I can call them, or see them when they come in, or maybe I'll just give them a PDF or something where they can start to get some grounding."

Garry Welch:

And so I feel like what we're doing with Silver Fern is we're coming out of clinical research with this digital tool that's going to start unlocking with the questions, smart questions, very practical ones, simple ones down to level grade four or five, and they may be sophisticated questions, but you just make them very simple.

Garry Welch:

And then when you get that information, what are you going to do with it? Because it's kind of a responsibility if you kind of unlock the box, and someone says they're depressed, and you can hold a mirror up to that family and say, "Did you know that this patient is actually depressed? We've done the PHQ-9, and it's nine questions, and we scored it automatically up in the cloud, and this patient's depressed. Can we get some help?

Garry Welch:

And then the patient has options, and they'll say, "Well, what can do about that?" So you look at the ecosystem and see what you can offer.

Garry Welch:

And we find when we talk to different... Whether it's ACOs, or health plans, or employee groups, or digital health companies there's different resources that that particular system will have and different things that they can do in a pharmacy.

Garry Welch:

I see one of the great opportunities is really pick up where primary care's never going to get to in the short term which is people need to know. They need the information. They need motivation. They need specific skills to learn, and you could be the place at like the Minute Clinic going from just these acute care things you walk in with. You could become the care management extender of primary care, and you could really add value once you get the business model locked in, and that's where Lisa's kind of world is is it an employee who's self-insured? Is it a digital health company that's bought... That carves out a group, and they have their clients which is health plans. Is it some other [inaudible 00:31:47]? Is it the pharma sort of sector where adherence is such an opportunity, and there's money left on the table? Maybe you can pull some sort of the sort of big players in the pharmaceutical world to say, "Is it PBM or manufacturers?"

Garry Welch:

Say, "Yep. This sounds like a great idea, and we're going to invest in it and help you build capacity in your community pharmacy, and let's get going here and really turn the engine on," because we already know what to do.

Garry Welch:

But I think this kind of digital sort of little questionnaire bites that go out to a smart phone survey via text, that's the way to get those little bites, and then you run with it, and pull it into your treatment planning and your care team.

Garry Welch:

So that's what kind of what we're trying to... We're trying to find those champions, and it sounds like this is a wonderful community and a great opportunity for community pharmacists to differentiate themselves and to really take this sort of gap that's in the marketplace.

Todd Eury:

I had never met a community of providers of healthcare more than that community pharmacy owner that's meeting their patients where they are. They know those patients. They know what they're going through. The financial strains. Maybe some legal issues like Dr. Ani was bringing up.

Todd Eury:

Ghada, I want to come back to you because of your unique position in your community, and that is back to that comorbidity stage, and if we could offer nontraditional services like screenings, recommendations of lifestyle, diet changes, providing that holistic approach to diabetes care, can you talk to me about any of your experience with your patients in leveraging those nontraditional services? And how they can take that same collaborative approach. How our pharmacy owners can take that same collaborative approach with the physicians.

Ghada Abukuwaik:

I'm going to start first with the type of care that the pharmacist gives to their patient. That is kind of 95% of the treatment and the solution. How the patient feel that we really care about them, that we really love to see them in a better situation. The rewards that we give them every month or every time they come and visit us. I believe that is the main, vital treatment that I see with my patients. That is really big. The emotion and the love that they feel with their community pharmacy.

Ghada Abukuwaik:

I will just mention one of the traditional things that I find is really amazing, especially with my diabetes patients, is the continuous glucose monitoring. My 80% patients come to me are looking for this kind of glucose monitoring that it's really helped them a lot to check their blood sugar.

Ghada Abukuwaik:

But if I will go back and mention about the different kind of nontraditional approaches with our patients, we have the weight loss program that is really amazing to understand how is the lifestyle changes, the healthy lifestyle, how it's going to make a positive impact on our life, on our diabetes, on our blood pressure, on anxiety, on our just being happy and living our life.

Ghada Abukuwaik:

Having a hosting of community events with our patients and having a dietician talking about different kind of food, and what is make us happy. Different kind of... Make these kind of events a kind of fun... Let me say it in this way because when people hear that this is going to be about diabetes, they wouldn't come, but if they hear that there's something kind of funny. We're going to have some kind of dancing in our event, and we're going to have this dietician who's going to talk about this kind of food, we see that the number of people... Let me say from 10% it's going to go up right over to 50%.

Ghada Abukuwaik:

So this kind of emotions, even our host events, hosting events in the pharmacy, make a big difference.

Ghada Abukuwaik:

So the weight loss program is really big. Having dietician in our events is really big. Our goal, if we reach 80% adherence with our total number of patients, we feel that we are happy because as Dr. Ani and Dr. Welch mentioned that each case is different, and it's not going to be easy to have the adherence 100% with everyone, and we are one of them. We don't like to take medications.

Ghada Abukuwaik:

So those kind of things that we do at the pharmacy, and we believe that we see a great impact on our community.

Todd Eury:

I have to shift back to you, Dr. Ani, for a second, and I have a follow-up question for Lisa

Todd Eury:

You have an amazing Instagram. You're very personal with your social media, which is such an important part of being a provider today. We can't hide behind the fact that, "Hey. I don't want people to know my name," or, "I don't want to be a public speaker," or anything like that. You're in it now, and social media is just the way that we're communicating, and you're doing a lot of education for providers, and you brought up a collaboration with dieticians.

Todd Eury:

I kind of want to go off what Ghada just prefaced and kind of dick down into that collaboration and where you've had the most success.

Ani Rostomyan:

Oh, absolutely. Todd, I wanted to also add that our patients really like us explaining complex concepts in medicine in very simple ways, so some social media platforms are an excellent opportunities for us to give the information about nutrition in a simple way or visual, so they love that. They like simplified because they don't like to think, "Oh. What's proteinuria? What's the diabetic kidney disease," or, "What is the coronary artery disease that's going to happen to me in 10 years."

Ani Rostomyan:

I don't want to hear about it. I want to hear, "What can I eat?" What can actually you can give me? What suggestions?

Ani Rostomyan:

So registered dieticians are an excellent source for great nutrition information, and we as pharmacists are, again, very well-trained in nutrition, but they're in addition to what we are telling to patients. They're emphasizing the importance of, "Okay. So why do I need fiber in my diet plan? What is fiber?"

Ani Rostomyan:

And a lot of times the collaboration, and in my institution we have the PCMH which is patients in our medical home model, collaboration of variety of specialties around the patient. No one's chasing the providers anymore. Patient is in the center. Everyone works around them. Interdisciplinary team works around them with social workers, dieticians, pharmacists, nurses, doctors to make your health better. Excellent addition to our healthcare team.

Ani Rostomyan:

I also wanted to mention that with that said, our patients like tangible rewards for their health behavior changes. We're human. We don't care if we're not going to die in 30 years from heart attack, but we care what can we get today for our good behavior. We want to be incentivized and rewarded for it.

Ani Rostomyan:

So I feel like health plans have great work here to do to incentivize patients for better A1c, lower A1c, lower BMIs, and that's something that I've always said. If that works, let's try it. Let's try making this patient's copays lower than they are if their numbers are better, so that's one of the approaches.

Ani Rostomyan:

But again, multidisciplinary team is the way to go with chronic disease. There's no more doctor and patient duo relationship. That's not working anymore. It's many people involved in one patient's care.

Todd Eury:

Lisa, you really dig into what's working for pharmacy owners and what's not. I think you test it on yourself first before you push it out to anybody else. What is working for communications? Is it newsletters? Is it email? Is it texting? Is it social media?

Todd Eury:

Dr. Ani does an amazing job in social media, but not enough people are probably replicating what she's doing, nor do some of these pharmacy owners have time, so what have you and the DiversifyRx think thank come up with?

Lisa Faast:

Yeah. Video is where it's at, and I talk to pharmacy owners every day that, just as you said earlier, they don't want to be the face. They don't want to be the name, but I tell them, "You have to." People respect people who they know. You can't be just a faceless corporation. That's what makes us different as independent pharmacy owners, and I tell them it doesn't have to be a production.

Lisa Faast:

We all have in our head when you do a video you need the professional lighting, and you need the boom microphone, and you need all this stuff, but frankly, our cell phones for the last few years take more than good enough video, and so I try to tell pharmacy owners to be really authentic and create that relationship via social media.

Lisa Faast:

So when you're unboxing a new supplement... I think it was Dr. Ani who was talking about patients love getting that immediate feedback that they're making improvements which is one of the reasons why I love supplements that have some sort of test behind them.

Lisa Faast:

Todd, I know you know Berkeley Life, but Berkeley Life, I think, is a great supplement for diabetes. As we're talking about diabetic patients, I'll kind of wrap into that I think if more independent pharmacy owners understood how they can monetize diabetic patients by taking better care of the patient they actually get to create more profit for themselves and better outcome for the patient.

Lisa Faast:

I think more pharmacists and more independent pharmacies in particular would take even better care of these diabetic patients, but when you have a supplement like Berkeley Life which, for those of you that don't know, it helps increase your body's nitric oxide levels which helps with circulation, so if you're talking about neuropathies and all kinds of things that happen with diabetes, well, they've got this great little saliva test, and so you can have patients come in, and test their little saliva, and see that they don't have what they should, and then they take the supplements, and then when they come back in the next time you see them maybe in a week, maybe in a month, it's like, "Hey. Here's your nother little saliva test, and, oh my gosh, it's pink. It's more pink that it was last time."

Lisa Faast:

You get that positive feedback, and that's why I think compliance is so hard with diabetes is because it's like there's not a benefit. There's this far-off consequence, but there isn't a benefit, and I loved what you said of incentivizing by copays.

Lisa Faast:

In the COVID pandemic, everybody knows that you don't have to pay for a COVID vaccine. The government and all the powers that be are behind this movement to ensure that people get the COVID care that they need.

Lisa Faast:

Well, diabetes has a much bigger impact financially. I mean, as crappy as COVID is, longer term, diabetes has a much heavier impact, so it's like how can we take that and throw it in there.

Lisa Faast:

Back when I was doing my own PBM, and helping employers, and creating all these benefits that was a part of every single one of our plans is we gamified their health in the sense that if they did they things that we wanted them to do, they got incentives, and maybe that was lowering a copay, or maybe it was a cash card to use on supplements, or those kinds of things, but I think patients need those feedbacks, and I think pharmacy owners... You asked what's working, Todd.

Lisa Faast:

To me what's working is taking care of that whole patient. Not just dispensing their prescriptions, because we all know from a business standpoint of pharmacy that just isn't working anymore. There's just not a profit there which, to me, time equals money, but also money equals time.

Lisa Faast:

And so when pharmacy owners feel crunched for money, they automatically crunch back time, and then they lose that ability to have those relationships and those really important clinical conversations with patients.

Lisa Faast:

So if we can teach, and that's the mission I'm on is to teach pharmacy owners how to monetize these patients in other ways that are ultimately helping in their therapeutic outcomes, but now they have more money which equals now they have more time, and it just benefits everybody when pharmacists are paid for their time adequately by being able to sell a product that actually helps a patient achieve their outcome.

Lisa Faast:

So to me that's what's working now, Todd, is diversifying the revenue, using really cool supplements that help target specific patients, and it's a win-win for everybody.

Todd Eury:

So I want to encourage the listeners if you're listening live, if you're listening to this as a podcast, to reach out to the RxSafe team who have the network beyond the technology, beyond the common denominator, of adherence packaging through the RapidPak. The connections to organizations like DiversifyRx, like Lisa, like Berkeley Life because I think it's all-encompassing. It's not separated anymore. There are no silos around RxSafe. They're more of an interconnector organization than they are this standalone technology that fits nicely in the corner of your pharmacy and doesn't take up a lot of space in your pharmacy space at all.

Todd Eury:

But I want to ask about that behavioral aspect, again bringing this up through Dr. Welch, and that is you're hearing providers. You're hearing people that are out there actually doing this. What cases have you heard? I want to hear about the victory that you have to share with us through data that show that specific plans, specific treatments, specific engagements that are consistent between the pharmacist and the patient is now proving to be better outcomes. If you could share some of that data with us.

Garry Welch:

Well, I haven't worked directly with pharmacy groups. We've worked mostly with health plans, and I've come out clinical research and hospital networks, but if I kind of think of some of the themes that have bubbled up here, what Lisa has just spoken, one of the things is really who we're grounded in professionally, and we've joined as a digital health company coming out of sort of clinical research the American College of Lifestyle Medicine which is a new sub-specialty that looks at intensive lifestyle, and really it's really like shifting out the cultural problem we have, and it's a cultural problem, that the food we have around us, the way we live every day, the amount of activity we get... We'll just sit on computers here for hours.

Garry Welch:

These lifestyle fundamentals have shifted, and we have to swap out the modern American diet in particular, which is highly processed food, a lot of chemicals. It doesn't have fiber. It doesn't have a lot of plant in it. It's got a lot of salt, and simple sugars, and all these things that drive our biological systems crazy, and including driving diabetes.

Garry Welch:

The American College of Lifestyle Medicine is almost like a grounding new professional platform for us to gravitate to, so if the community pharmacists join the American College of Lifestyle Medicine, for example, which tends to be a lot of younger doctors who've kind of had these same epiphanies that Ani's talking about.

Garry Welch:

They'll say, "Well, patients won't take the meds, and we've got a procedure ordered, and now there's a diagnostic we've got to do, and it's kind of depression." We'll hold their hand on the way down. They try on themselves this lifestyle medicine, more of a plant-based, clean food, and they flip out all the processed food and sugar-sweetened beverages, and when you do that experiment those numbers, those control rates for A1c, blood pressure, blood lipids, they suddenly start moving. The weight loss happens. People feel more in control of their systems. They can feel it. They feel better.

Garry Welch:

And so that's the experiment these lifestyle medicine practitioners do on themselves, and they say, "I'm going to do this in my practice, and now I'm going to go and talk to my organization, start shaking the cage," and so I feel like the community pharmacists, if they would join that army... It's a small army, but it's a fast-growing subspecialty. That's another way I kind of see hope.

Garry Welch:

And so when you ask what has worked, we worked with outbound call centers, nurses, chronic care nurses for health plans, who manage state employees with chronic diseases who have come out of the high-risk strat, and they're identified with diabetes that are going to be the 5% who have 50% of the cost.

Garry Welch:

So they get the attention, so they get outbound calls, and they use what we call a behavior diagnostic to find out about the self-management struggles. What are the psycho-social issues? What are the social determinants?

Garry Welch:

And then they have different conversations, and that's the thing that I've been really struck by is that when patients start having open questions, and exploration, and then they see holding a mirror up to them about what's going on. They say, "Yeah. You're right. I probably do need to try that. What do you suggest?" And you go on a journey to try something.

Garry Welch:

Usually, the fundamentals are about basic lifestyle foundations that you have to shift because we all live in a kind of crazy ecosystem every time we walk out the door or the way our houses are set up.

Garry Welch:

So I feel like there's a lot of hope, but the data that we've had coming out of those experiments with health plan chronic care teams which would be the same you could do in a community pharmacy is that when you just relate to people different, and you use the digital piece to get this information from the patients asynchronously when they're at home. You get a text survey that comes from a pharmacist, and they recognize. They'll tell you their story. Little bites of information go back to the team, goes into the treatment plan, and you can help them in very tailored ways.

Garry Welch:

The last thing is you roll this up to data visualization, like realtime onboarding, what patients are doing what modules, and telling you what data, and then you use that kind of rolled up population data to say, "Well, what programs do we need to design? And how do we kind of change the incentives here so that people can move towards the good?" So that's kind of what we've found.

Todd Eury:

Ani, I want to hear back from you on the technologies that you have utilized through your time. Not only are you caring for patients, but you're teaching other pharmacists how to become better diabetes treatment providers. So what technologies have you employed throughout your time in pharmacy?

William Holmes:

Todd, could I jump in for just a second?

Todd Eury:

Sure.

William Holmes:

I wanted to tell a very interesting story. I'm sorry, Ani. Just this perfect, perfect add-on for Dr. Welch.

William Holmes:

I was watching a program on TV a couple days ago that was a very interesting research around diabetes. They tracked two adult males from India, one from a big city, and one from the country, and they were talking about the DNA that was being turned on and turned off inside the womb before these people were born, and what it basically tracked was incontrovertible and very, very interesting.

William Holmes:

We talk about education, education, education. I think we've missed a piece called prevention. You know? If we're talking to people in these communities, and especially the poor communities, and we're telling them, "Here's where we are. Here's what's going on," one thing is to say, "You shouldn't be ashamed. You shouldn't be ashamed that you have this disease state. Let's work on it. Let's get on top of it. Let's make you healthy for the rest of your life, but let's tell the rest of your family and your friends that you can avoid this potentially becoming diabetic," because when you get programmed in the womb because your mother was in a very poor area of the world and ate a very simple diet that you become, in your body, able to very, very efficiently convert food because you have to to survive. You don't get much intake, caloric and valuable intake.

William Holmes:

And they took this gentleman from a big city and tracked him, and he didn't have diabetes even though he was now on this Western diet full of salt, full of sugar, and all the other chemicals that we have here, and then they took this fellow who came from a poor part of India in the country where the diet of his mother was very simple, and his system simply couldn't adapt to the very rich diet that he just... Unwittingly, you stop in a Dunkin Donuts. You're eating the Cheerios in the morning.

William Holmes:

And the story here is it appears from the research that if people were to be careful about their diet knowing that this is potentially in their DNA, we might avoid having millions more people become diabetic.

William Holmes:

And so I thought that might be interesting, Dr. Welch, to just comment if you're aware of that, and then I'm sorry, Ami. We'll jump back over to you.

Garry Welch:

I think there's a huge literature that doesn't bubble up to the consciousness of healthcare professionals necessarily, definitely not to the public, that these kind of shifts are happening in the culture and our society, but the biology we have has not changed, and it's not going to change quickly, and so that's kind of the mismatch.

Garry Welch:

So you talk to people who grew up 50 years ago, they'll see in the country in India people who are starting to get wealthier would shift what they eat. They'd have a refrigerator. They would eat different. They wouldn't take [inaudible 00:53:28] to school, and they would see the shift, incomes, the obesity, and all these pro-inflammatory kind of cardiovascular, Type II diabetes, chronic kidney disease, dementia, all these kind of mental health problems. They all come with this pro-inflammatory diet and this shift in the way that we live.

Garry Welch:

And so the default is not... The default we have when we walk out the door or the way our houses are set up, that's the problem, and it's not the people, and it's not battering them on willpower. It's really just helping them to kind of just look upstream and say, "Where is this coming from?"

Garry Welch:

And then once they say, "Okay. It's a bit crazy here, but there are still good options, and I'm going to find some delicious food that I can afford that's right around here, and I'm going to eat it, and I'm going to get better and work with my clinical team, and look at the numbers, and I'll feel better," and so it's kind of like an engine you turn on.

Garry Welch:

But that epiphany isn't happening, and it's not that you want everyone to go towards remission because there is the DiRECT trial which is a UK trial which is a fascinating one where they basically got people to lose 30 pounds on a short sprint of restriction to 800 calories, and then they got them back to real food at a much lower level, probably 30% than they had before, and guess what? 80% of the diabetes turns off if they've had diabetes within six years.

Garry Welch:

So that's Roy, Roy Taylor's work, in the UK. The DiRECT trial. That's a very rigorous trial. They've repeated it in the Middle East, actually, and so there's that hope, and nobodies going to go to switching to that intense lifestyle change and losing 30 pounds. It's never going to happen to most people, but you can kind of see where we could head in terms of not just going on an 800 calorie diet to get 30 pounds off, and so the fat comes out of the pancreas and the liver, and it resets the insulin resistance. It's more that we've got to look at our culture and say, "This is kind of crazy, but we can really get smart, and families can protect themselves," and guys like you can be there to support them on that journey to start really shifting out these cultural habits that are hurting us, and just replace them with good ones, and just help families sort of health literally, and then start to thrive.

Garry Welch:

I think that's the role that you guys could take because I don't think primary care's going to take that role for quite a long while because they don't have the resources. Their business models are very crimped by the broader systems. Who owns their organization? It's usually a big hospital, or it's a big practice group. It's not... Their model is fee-for-service sick care, and with good people. They're good people doing a model that we kind of got used to, but we're in a bit of a rut.

Garry Welch:

So it think there's definitely a way out, and your story definitely was sort of caught up with that in my mind.

Todd Eury:

Bill and Gary, thank you for that because that really meshes two viewpoints together, and what I wanted to follow up with was with Ani with regards to technology and the leverage of technology.

Todd Eury:

The reason why I asked that is technology is supposed to make things easier or repetitive so we can catch the outcomes over and over again so that we can make adjustments later in making things better. So with that, Ani, if you could comment on some successes you've had with leveraging technology.

Ani Rostomyan:

Oh, absolutely Todd. I also wanted to say that this year ADA 2021 updates are bringing diabetic technology into the picture and mentioning that incorporating this in chronic care management will improve outcomes. Yes, but it's limited. We don't have all of our patients who qualify for CGMs getting it, and there's a lot of barriers and a lot of hoops there we have to jump around to get them what they need.

Ani Rostomyan:

I also wanted to mention that involvement of technology is not one way. It has to be two way with providers, and we need to have more providers who are educated how to interpret that data.

Ani Rostomyan:

It's the data that provider will get. 24 hour measurement of your so-and-so patients and blood glucose readings. How are you well-trained to, first of all, be willing to go into that, interpret, and have a conversation with your patient?

Ani Rostomyan:

CGMs are going to be the future of the diabetes care for sure. In 1990s, the glucometers were the thing. You know? The new thing that just came out, and everyone was fascinated. Oh. We can have a home blood glucose monitor.

Ani Rostomyan:

This year and on, CGMs are going to be the new technology that pharmacists are going to be... They will have to learn more about it. They will have to offer it and educate patients how to utilize that data.

Ani Rostomyan:

But I wanted to also go back to the behavior change and say that food behavior change changes the entire culture of the entire household, and I always tell the patient, "When you change this behavior, when you change your health habits, your entire family will eat differently," and unfortunately diabetes is getting younger. It's not a want from our side to eat healthier. It's a must.

Ani Rostomyan:

We have to lead by our example because in 10 years our kids are going to have... I'm not saying prediabetes. Our kids are going to have Type II diabetes in their 20s. This is a sad reality. This is not a thing of, "Oh, this is new healthy eating behavior I have to adopt." No.

Ani Rostomyan:

If we as healthcare providers are not following what we're preaching, our patients are not going to trust us. Whether it's technology adherence, whether it's good amount of education we give they're going to go home and say, "You know what? That pharmacist didn't seem like they're following a healthy diet, and my doctor is not really in tune with what I'm doing. It's not important."

Ani Rostomyan:

So CGMs are the future, but they have to become more accessible. We're having big issues with coverage, so that's another huge part of the financial aspect of diabetes care.

Todd Eury:

I wish we had another hour, but we are going to wrap up for this webinar. I want to extend a very special thank you for Dr. Lisa Faast participation from DiversifyRx, as well as Dr. Gary Welch with Chief Scientific Officer from Silver Fern Healthcare.

Todd Eury:

Thank you so much, Ghada, for always being available to the pharmacy podcast nation, and what you do, and the feedback that you give to the RxSafe team, and your leadership at Curemed Pharmacy.

Todd Eury:

And a special thank you to our featured speaker today, Dr. Ani Rostomyan. We have to get more of your information out through Instagram. I'm going to start replicating what you're doing on our page, but in our show notes if you're listening to this as a podcast we will have connections to LinkedIn of all of our hosts and all of our panelists.

Todd Eury:

And last but absolutely, certainly not least, the team as RxSafe. You've been so consistent. You have been this gong that's been banging for years now in support of community pharmacy leveraging technology, better technology, better ways of doing things through adherence and your adherence packaging through the RapidPak, and Bill, just want to say, "Thank you," and Brady, thank you so much for doing this.

William Holmes:

Todd, it's been a pleasure. I learned something every single time, and then we start to develop these relationships with other amazing people that share our passion.

William Holmes:

I just wanted to close with a couple thoughts. First, I lost my 94-year-old father to medication error and adherence problems. He had declining vision, and just wasn't able to manage all his vials. He would still be here today if we'd have had some easy way of producing a strip pack for daily medication for ease-of-use for patients.

William Holmes:

125,000 people a year die unnecessarily for non-adherence. Many of them are the people we talked about today. $500 billion spent unnecessarily in our healthcare ecosystem which takes away from the resources that are needed for other people and other causes.

William Holmes:

Education, education, education. I think that's what we talk about, Todd, and that's what you do such an amazing job with with your outreach to some 70,000 people that participate in your network.

William Holmes:

And I just want to say very, very, very sincerely adherence, adherence, adherence. Everybody talks about it, and then a lot of pharmacy owners think, "Well, I just can't do it. I can't afford it. I can't find a way to do it," but adherence packaging helps the community in many, many ways.

William Holmes:

First of all, it frees up time for the pharmacist. Instead of filling eight vials, you fill a single strip. Number one.

William Holmes:

Number two, we have testimonials all over our website from patients that were in this category of not so able to get educated, not so able to get information, not so easy to travel, not so easy to afford things who have been put on these adherence packaging systems by the pharmacist, and they repeatedly say, "I feel better."

William Holmes:

Larry at [McDonald 01:02:58] Pharmacy said, "My A1c is under control for the first time in my life, and my doctor noticed it and asked me what changed, and I told him about the adherence packaging that my pharmacist recommended that I go on."

William Holmes:

And so that underlying theme of let's get these patients adherent is over, and over, and over repeated, and we know it.

William Holmes:

Everyone benefits. The patient benefits. The pharmacist benefits. The doctor benefits. The family benefits. The healthcare ecosystem benefits, and it is truly affordable. Please look into it. I beg you to do that on behalf of your patients in the community.

William Holmes:

It's cost-effective. It's cheaper to fill four prescriptions in a strip pack than in vials, so you don't have to charge for the service. I'd say 99% of the 300 people, 300 pharmacies, that run our RapidPaks today don't charge for it. They offer it, and they advertise it. We help them advertise it. We bring them new patients.

William Holmes:

And so we are out here trying to get this message out to the community, and Todd does a great job of that, and I'll leave with one question. If not the community pharmacist, then who?

Todd Eury:

If not the community pharmacist, then who? And it has to be the community pharmacist, so please reach out to our team. This panel has been absolutely incredible. Thank you so much for participating on this.

Todd Eury:

I think this probably gives way to an extension into individualizing some of these interviews to really build upon what we've talked about today.

Todd Eury:

And with that, I thank you, pharmacy owners. Pharmacists out there doing what you're doing, especially during this time of the pandemic. God bless all of you. We love you. We'll do whatever we can to help you.

Todd Eury:

Please reach out to RxSafe, or the pharmacy podcast network, or Lisa at DiversifyRx. And with that, have a great day.

William Holmes:

Thank you.

Brady Chatfield:

Thanks, everybody.