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Savon Pharmacy

CAROL STREAM, Ill. -- It's mid-morning at the busy pharmacy inside a Jewel-Osco combination store humming with suburban shoppers, and pharmacist Patti Nelson is working to keep one of her favorite diabetic patients out of the hospital.

Nelson is one of more than 100 pharmacists at Albertson's, parent company of Jewel-Osco, conducting retail pharmacy's largest and most comprehensive diabetic care program. Her charge this morning is a cheerful middle-aged man of Hispanic origin named "Mike," who speaks haltingly in English and moves with the careful deliberation of someone still recovering from major heart surgery.

Nelson sits with her patient in a private office near the pharmacy and quickly checks is blood pressure and blood sugar levels on glucometer while chatting about his daily outine, diet, medications and lingering health concerns. Finally, she prints out a computer report that will update his physician on his daily glucose readings and general condition.

"This tells us where his glucose readings are," said Nelson, the head pharmacist and disease management specialist at Jewel-Osco's pharmacy here just west of Chicago. "I give him a copy and fax it to his doctor so she has it as a permanent part of her record."

Some physicians, she added, have become so dependent on her services that they "just expect the information I gather here" because those doctors are "able to see everything going on very clinically on a day-by-day basis, including adjustments in medication, to help them determine treatment."

Throughout her 15-minute appointment with Mike, Nelson displays the personal touch and caring manner associated with family doctors and nurses--but without the intimidation that patients often feel with doctors in a more clinical setting.

Anthony Provenzano, Albertson's director of disease management programs, said the chain's patient care pharmacists "work very closely with physicians, especially in diabetes.

"We can be the eyes and ears of the physician, and if something happens with the patient, we can catch it early, before it becomes a big problem," Provenzano said.

"Nobody wants the pharmacist to be the diabetic police. But we can ask [patients] how they're doing and if they're testing themselves regularly," Nelson pointed out. "I'm not going to growl at them because their numbers are too high, but I might be able to give them assistance. Sometimes they have a hard time, and that's a perfect opportunity for us.

"We're a big chain and a big, busy pharmacy" said the Jewel-Osco pharmacist. "But that doesn't mean I can't know my patients. And the only way to do that is to step out from behind that counter and be involved with them. And they're more than glad to have that kind of relationship."

A network of specialists

A companywide effort to expand those relationships is now a lynchpin in the chain's new pharmacy business model. Led by the Jewel-Osco and freestanding Osco drug store divisions it acquired with its purchase of retail giant American Stores in 1999, Albertson's has become what may be the drug store industry's leading practitioner of patient care services and disease management for diabetic patients.

Albertson's patient care activities are concentrated in the Chicagoland market, home to Jewel-Osco. It was here that the chain launched its first diabetic care centers at a handful of Osco and Jewel-Osco pharmacies in the early 1990s--and it's here that many of its certified diabetic educators and diabetic care specialists are located. And although Albertson's also uses Des Moines, Iowa, as a test market for health-screening or disease management initiatives, Chicago remains its top patient care testing ground.

"Because I'm here, we tend to start our programs here," said Provenzano. "But then they spread. The diabetes program is widespread across the country and growing at a faster and faster rate now."

Indeed, Albertson's diabetic care pharmacists now are spread throughout 15 states. By this fall, some 115 of its pharmacists--more than any other chain--had been accredited to counsel patients with diabetes and help them monitor and manage the diseases associated with the condition. Dozens more are in line to receive training

In addition, about 15 Albertson's pharmacists working in the company's Osco, Jewel-Osco or Savon drug or combo store sites are fully licensed certified diabetic educators. Each of them must undergo rigorous clinical and nutritional training and log a minimum of 1,000 hours of face-to-face patient education and diabetes disease management before earning a CDE.

At the Carol Stream store, Nelson also is piloting a new health and education program for asthmatics that Provenzano said soon will be rolled out nationally. For either diabetic or asthma patients, Nelson said: "Most appointments take less than an hour, and it's fairly simple. But you have to assess patients' understanding as you go, and you can't do everything at one time. We might only be able to talk about their glucose meter today, and then in a week we'll talk about that insulin pen they also just got."

Nelson promotes herself as a diabetic care specialist through word of mouth, store signage, by handing out her card and simply by talking with patients as they have their prescriptions filled. Besides teaching individual patients how to monitor their blood glucose levels, take their insulin and perform other health-related tasks, she and other diabetes care pharmacists also may help conduct classes for patients referred by their physicians or health plans. Albertson's patient care division charges roughly $50 to $60 for each educational seminar, which can consist of multiple classes on various aspects of diabetes including treatment, diet, exercise and complications.

The health/nutrition connection

As a diabetic care specialist in a food/drug combination store, Nelson has another disease management capability in her toolkit, as well: access to the various foods, dietary advice and nutritional expertise provided by the grocery side of the store and by Albertson's corporate dietician for Jewel-Osco, Melissa Joy Buoscio. Armed with informational brochures from Buoscio and other dietitians, Nelson can help diabetic patients manage their condition with a broader spectrum of services that includes nutritional counseling--even occasional walks into the food aisles of the store.

"I may walk out in the aisle and show them a package and say 'Did you notice how many carbohydrates are in this?' And I'll help them find a substitute," Nelson said.

Albertson's leaders think the long-running marriage of food and pharmacy gives Jewel-Osco some distinct advantages over traditional drug store retailers: it exposes thousands of weekly supermarket shoppers to its healthcare services and allows its pharmacists to offer a nutritional aspect to their counseling and patient care efforts.

Exploiting the links between food and pharmacy also allows Jewel-Osco to offer patients a broadly focused patient education program in diabetes, asthma, smoking cessation, women's health and other areas of health, said Provenzano. "There's a lot of people doing education--but no one can have the advantages pharmacy has, and that's in the convenience we offer," he said. "The fact that we have the benefit of having grocery and pharmacy together ties in the nutritional and gives us one big healthcare package that is hard to match."

The Jewel-Osco division has exploited that potential by hiring a corporate nutritionist/certified diabetic educator and giving her an extremely high profile. Buoscio is featured prominently in ad circulars, store brochures and local Chicago media, dispensing advice about healthy eating, prevention and the dietary aspects of diabetes, high cholesterol and other conditions. Under the company's branded "Nutrition in Focus" program, Buoscio also provides healthy eating recipes. She also develops patient education and marketing materials with clinically oriented pharmacists like Nelson for the branded Albertson's Diabetes Care Program.

"It's the one part of health care in this setting that pharmacists don't have strength in," said Nelson. "So it's great to have a dietitian. We can ask her."

As a certified diabetic educator, Buoscio can also round out the chain's diabetic care program. "We try to find out what the customer base is like ... and tailor [disease management and healthy eating programs] to them," she said. "We want to get the word out we have these wonderful free programs. I also try to promote the diabetes and other disease state management programs as much as possible. So I get my hand in a lot of promotional events like grand openings, where I'll have a booth and show customers what's available."

More than 40 Albertson's or Jewel-Osco locations this fall also will serve as hub sites for "Eating Healthy with Diabetes," a customer education campaign held in stores during Diabetes Awareness Month in November. The company uses outside dietitians, under contract, to conduct store tours and nutritional seminars.

"With diabetes and nutrition, you can't separate the two," said Provenzano. "There's no one specialist who can handle all the things a diabetes patient needs, so it's very important that our pharmacists work with other healthcare professionals. We want to be a team member with the doctor and the nurse educator to help the patient--and definitely with the dietitian. It's a multidisciplinary team approach."

Footing the bill

In effect, Nelson and others serve as front-line troops in the pharmacy profession's long and difficult campaign to win recognition and reimbursement for managing patients' disease states.

Patients like Mike are an unwitting ally in that effort. They are among a growing number of patients willing to pay cash for the extra services a pharmacist trained in diabetic care can provide. But more and more, patients enrolled in classes or one-on-one private sessions with Osco pharmacists belong to a health maintenance organization or provider group willing to foot the bill for those services.

"Mike will pay a small fee for printing that report," said Nelson. "It isn't a lot, but for that small fee, I certainly see all his pharmacy business, all his OTC business and probably all his grocery business."

But cash payments direct from patients are only a small part of the reimbursement plan, said Provenzano. The future of disease management by pharmacists, he said, depends on negotiations with managed care plans and plan sponsors and a universal recognition of the role of pharmacists like Patti Nelson.

"We've shot ourselves in the foot over the years," he said. "Pharmacy has given away its services forever, and the whole purpose was to get the customer into your store and make all your money off the products you sell.

"We need to change that and be recognized [for] the services we offer," he added. "Patients and payers need to see that those services are valuable and have positive effects on patients and their health care."

Along those lines, the pharmacy team works very closely with Albertson's managed care marketing staff, headed by Mark de Bruin, "to get as much managed care support as possible" for its disease management efforts, Pro-venzano explained. More and more, he said, Albertson's pharmacy divisions are working with local healthcare plans and provider networks to line up support and reimbursement for those programs before money and time is committed to their rollout.

"As we show our outcomes, managed care plans are starting to look more favorably on our programs and starting to reimburse for them. ...We're actually turning the corner on that. We have contracts with several managed care plans around the country ... and some local ones, as well, like Blue Cross of Illinois, where our pharmacists who are GDEs in Illinois can get reimbursed for diabetes services."

In addition, said Provenzano, Albertson's is in the midst of launching a new disease management effort on a national scale, under contract to a major health plan whose identity he wasn't yet ready to reveal.

Over the next two or three years, said Provenzano, "We think it's going to snowball, as we get more data that can show results."

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