Outpatient pharmacies are established for a number of reasons: to service unique patient needs, to offer 340B benefits, and to help improve the bottom line. The Kansas City CARE Clinic (KC CARE) is a private, nonprofit clinic founded in 1971, providing quality care, access, research, and education primarily to underserved, underinsured, or uninsured patients. KC CARE promotes health and wellness by providing quality services in primary care, behavioral health, and oral health. In addition, the clinic provides services not commonly available elsewhere, including HIV care, Hepatitis C treatment, and a Transgender Health Clinic (see SIDEBAR 1). With a full-time staff of 175, plus a volunteer staff numbering over 700, KC CARE is one of the largest community health clinics in the country, and is funded exclusively through donations, grants, and special events (see SIDEBAR 2 for the clinic’s founding principles).

In 2015, KC CARE achieved Federally Qualified Health Center (FQHC) status, making it eligible for the 340B program, which provides significant cost savings on medications for qualified organizations. Participation in the 340B program allowed for expansion of clinic services, namely the addition of an outpatient pharmacy to serve patients from its three clinic locations.

Origins of the Outpatient Pharmacy

Two years ago, while working at the retail specialty pharmacy located next door to what would become the KC CARE pharmacy, clinic representatives recruited me to open the outpatient pharmacy. Working in the retail specialty pharmacy provided me with extensive experience serving patients with HIV and Hepatitis C; patients with these viruses made up a significant number of KC CARE patients.

Identifying a location for the outpatient pharmacy was straightforward, given that the clinic already utilized a dispensary area to render patient assistance services. As is permitted in Missouri, the dispensary was run by a physician at that time who provided donated medication samples to patients through pharmacy and nursing staff (KC CARE no longer dispenses medication samples). The dispensary space was redesigned, and the outpatient pharmacy was built in its location. After receiving its license in March 2016, the pharmacy began serving patients in September that year.

Increasing Patient Access to Medications

KC CARE’s outpatient pharmacy mandate is to increase patient access to medications. Because 67% of our patients are uninsured, maximizing the 340B program is critical to controlling drug costs.

When patients visit the clinic and receive a prescription, they are advised that they have the option of utilizing the outpatient pharmacy on location, or having prescriptions filled at an offsite retail pharmacy. Insured patients utilize the clinic pharmacy when the insurance company permits; otherwise, they utilize offsite retail pharmacies, including the large retail specialty pharmacy next door, which has extensive contracts with insurance companies. Uninsured patients often prefer to use the clinic outpatient pharmacy. Because KC CARE contracts with the specialty retail pharmacy, the clinic benefits in both situations.

The KC CARE pharmacy team comprises a director of pharmacy, a staff pharmacist, and two pharmacy technicians. A pharmacy information system and 340B software are utilized. In addition, a pharmacy dispensing robot ensures medications are prepared correctly and improves workflow; approximately 90% of prescriptions are filled with the robot, which holds about 200 medications. The pharmacy operates from Monday through Friday from 8:30am to 5pm, closing for lunch from 12:30pm to 1pm.

Overcoming Challenges

Gaining the breadth of knowledge necessary to open an outpatient pharmacy was challenging and required significant networking with other organizations that had experience in this pursuit. The clinic’s chief operating officer and the director of pharmacy built relationships with several organizations that had opened outpatient pharmacies; networking with these contacts provided important financial and legal guidance, as well as direction for managing building inspections, licensing, and grant applications. In addition, local independent pharmacies provided guidance critical to our operational success. Some structural changes were required to bring the building into compliance with regard to security. Because of my previous experience managing a pharmacy, the regulatory requirements were familiar.

A significant challenge in opening the outpatient pharmacy was that the initial staffing model provided for a single pharmacist. In recent years, the addition of a staff pharmacist has improved efficiency.

Benefits Realized

The benefits of implementing an outpatient pharmacy for KC CARE include:

• Access to a One-Stop-Shop for Care. One of the primary goals of opening an outpatient pharmacy was to provide patients with all of their care in a single location. Beyond filling prescriptions, social services case management is available, including a team of community health workers who help patients sign up for insurance and enroll in health care plans under the Affordable Care Act. In addition, patients can receive psychiatric and behavioral health services. Individuals with chronic diseases, including diabetes, HIV, and Hepatitis C, can receive all of their care at the clinic and have all of their prescriptions filled at the onsite pharmacy. When patients leave KC CARE, they have everything they need until their next visit. This is especially significant for our patient population, some of whom are homeless or have limited resources. For these patients, finding transportation to and from appointments and pharmacies can be a challenge, so providing the opportunity to take care of all their medical and pharmaceutical needs in one trip is extremely valuable. This convenience impacts medication adherence, as making a second stop at an off-site pharmacy often is not possible for many of our patients.
• Cost Savings. The outpatient pharmacy offers many medications to patients for only $4 and often can provide a 90-day supply. Financial assistance is also made available; if a patient cannot afford the $4 generic, a full-time technician is dedicated to enrolling patients in assistance programs through the drug manufacturers. Because many KC CARE patients are uninsured, they have limited opportunities to obtaining their prescriptions elsewhere. We oversee all of the paperwork, order refills, and manage their medications; this service is key as many patient assistance programs require that medications be delivered to the physician’s office. In addition, the outpatient pharmacy has access to grants for patients who cannot afford medications and do not qualify for manufacturer assistance. Grant candidates must have income below an established poverty level and must be receiving care for certain disease states. These grants are especially helpful for patients who are between jobs, or who are working but do not yet qualify for insurance. One of the most rewarding experiences is when a patient, who previously received a grant, returns to report that they are back on their feet and can now afford their medication.
• Staff Convenience. When our staff uses clinic services, they also qualify to use the outpatient pharmacy. Our insurance company is in-network, so staff members are assured of receiving the lowest price for their medications and can pick them up after their shift.

Future Goals

Looking to the future, opening a second pharmacy location would be useful; at this time, patients who visit the other two clinics must travel to the main clinic to receive their medications. In addition, it would be prudent to move the outpatient pharmacy to a different location within the building, as the pharmacy is currently located in the center of the clinic, causing significant hallway congestion and creating privacy concerns. Ideally, the pharmacy should be accessible from the front door, but our current layout requires that patients be buzzed in and walk through the clinic to the back, where the pharmacy is located.

Additional funding would be extremely helpful to expand pharmacy services. Our recently added vaccination program would benefit from a larger budget, which would allow KC CARE to expand the number of vaccines provided to patients. Mail order options would benefit our patients and would likely require additional workspace and staff to ensure proper management.

Conclusion

Where an unmet patient need exists, implementing an outpatient pharmacy can improve care and ensure affordable access to medications. For a facility that qualifies, opening an outpatient pharmacy to take advantage of 340B benefits can provide important services to an underserved population.

Kamile Johnson, PharmD, AAHIVP, is the director of pharmacy services at Kansas City CARE Clinic. She received a BS in Biology and a Doctor of Pharmacy from the University of Pittsburgh. Her professional duties include hiring and developing pharmacy staff, implementing and improving workflow processes, managing relationships with contract pharmacies, overseeing 340B operations, and helping maintain regulatory and compliance measures. Kamile’s professional interests include caring for patients with HIV and chronic disease states, becoming an expert 340B provider, and professional development in risk and compliance of health care services.