Pharmacy Leader Interview:
Kristi Stice

Kristen Engelen
Kristi, it’s a pleasure to meet you. I’m hoping to start with you taking us through how you got into the field of pharmacy and what brought you to your current role.

Kristi Stice
Sure. Got into pharmacy in high school. I knew I was interested in some sort of healthcare career, and we had a healthcare explorers program, so I got to spend time with different aspects of healthcare.

How can I improve patient care and play into the science and the math and the biology and chemistry and all those things that I love?

Kristi Stice
That’s how I landed in pharmacy. I got really lucky that when I started pharmacy school, I loved it and have been loving it ever since. I’m truly an advocate for the profession, for sure, ever since my first experience.

Kristi Stice
I worked at a community pharmacy, a compounding pharmacy, and had a lot of fun my first year at pharmacy school. I spent the rest of my pharmacy school career in an acute care setting. I was at a large hospital in the St. Louis area and got to see all kinds of aspects of pharmacy. I shadowed a nuclear pharmacy, I did a summer in research, then did a PGY1 residency with a focus in clinical coordination.

Kristi Stice
My first job was a clinical coordinator at a 100-bed community hospital. I grew the pharmacy services there. We went from four pharmacists in a basement verifying orders to, nine years later, pharmacists fully deployed, up on the floor – pharmacists doing medication histories in the ED, side-by-side rounds with the hospitalists.

Kristi Stice
Then I moved closer to family in central Illinois, where I went back to the bedside while awaiting some leadership opportunities. I ended up as a director of a 300-bed community hospital. But I always wanted to do the ambulatory side, so I moved to the Kansas City area, where I’m now in the ambulatory specialty space, and having a lot of fun. That’s how I got to where I am now.

Kristen Engelen
Thank you for sharing. Tell me about your current scope of work and the am-care setting now.

Kristi Stice
Sure. I am now overseeing not only the ambulatory specialty space, but the 340B Program as well. Underneath me are what we call our ambulatory clinical lead pharmacists. We have pharmacists in five clinics now, going to be expanding to six and seven here in the next month. Rheumatology, neurology, oncology, GI, which includes hepatitis C, and then we are expanding to dermatology, and pulmonology – and we also have infectious disease, which is primarily our HIV clinic.

Kristi Stice
We have pharmacists embedded in those clinics in addition to what we call AMACs – or Ambulatory Medication Access Coordinators – which are college-educated super techs who handle all the details, holding the patient’s hands through each process, like prior authorization navigation – really supporting the pharmacists, helping everybody work at the top of their license.

Kristen Engelen
I wonder if that plays into innovations in the space. When you think about how you put that specialty program together and expanded it across multiple disease states, what are you most proud of?

Kristi Stice
From the very first clinic, the challenge was trying to convince the providers why we needed a pharmacist in that space. They’d ask, what’s a pharmacist going to do for me? They’d assume a pharmacist is just going to get in the way of patient care and slow things down. But now we have clinics asking for pharmacists. This last space with dermatology, as we were onboarding, the physician said, “I want a pharmacist in my clinic.” That I think is amazing in of itself and speaks as a testament to the work that our colleagues and team are doing – we’re getting requests to be embedded in different clinics.

Kristen Engelen
What sort of feedback do you think is the most important that has driven that change in the psychology of the provider? What is it that you’re providing that they’re really excited about?

Kristi Stice
I think helping with medication selection, and not only initial selection, especially when we have a very complicated case. If the patient is not responding to this, that, or the other, the pharmacist can assist patients in between physician visits.

Kristi Stice
We can catch things early on and then tee up suggestions for the physician. That helps hold the patient in care rather than them showing up at an urgent care or an ER visit.. We can help catch issues early and intervene early for optimal outcomes. When pharmacists serve as patients’ providers between visits, they can help intervene to support optimal outcomes – and help all members of the care team work at the top of their license.

Kristen Engelen
Tell me a little bit more about that monthly cadence. Who is reaching out to the patient? What does that look like?

Kristi Stice
When a patient is new to specialty therapy, a pharmacist will do monthly calls for the first three months. Then, if the patient is stable, outreach can happen up to every six months. Anytime patients need a refill, an ambulatory medication access coordinator reaches out to answer patients’ questions and, as necessary, brings the pharmacist back into the loop.

Kristi Stice
In that refill call, they also ask questions about, are there any adherence issues? Are there any side-effect issues? If they’re alerted to some sort of issue, then they bring that to the pharmacist, and can immediately give a warm hand off to that pharmacist and they can have them on the line like that. Even when it’s not the pharmacist calling, it’s either the pharmacist or the AMAC calling and connecting with that patient and doing that monthly touch base.

Kristen Engelen
Tell me a little bit about the economics of the program. Would you say that it’s a nice to have or a need to have? How does the clinical pharmacist team help to generate revenue?

Kristi Stice
Most of our revenue is obviously through the 340B benefit, but know that this service is to all patients and clinics whether or not they fill with our affiliated specialty pharmacy. Of course, we tout the white glove service – the access and the monitoring – that we provide, but we’ve been able to realize some of the benefits of 340B to help the expansion of care within our clinics.

Kristi Stice
Also, we also seek alternative funding for our patients. If there are patients that can’t afford their medication and / or aren’t covered by insurance, we also go above and beyond to find grants, find alternative funding, find a way for our patients to afford the medication. I think that’s another piece that the physicians have been really satisfied by. We’ll stop at nothing to make sure that the therapy that the patient needs is also affordable for the patient so that they can continue to be adherent and receive the care that they deserve.

Kristen Engelen
That’s definitely one of the biggest points of specialty management – ensuring that the patients are able to access the medication at the right time, at the right dose, at the right cadence, without any side effects. Were you able to measure any of those patient-affiliated experiences? How did you decide to set up the program? What sort of KPIs do you measure now?

Kristi Stice
Yep. Of course, all the things required by accrediting bodies. We are a dual-accredited pharmacy, so of course, we track things like adherence and are we answering our calls on time and things like that. We are working towards some of those clinical KPIs.

Kristi Stice
There aren’t many standards for specialty clinical KPIs like there are for fields such as primary care. There are validated tools like the PROMIS 10 and the RAPID3 that we can use in some of our rheumatology patients – and PROMIS 10 can be used across multiple disease states. That’s what we track to see how we can improve. But we also track patient satisfaction – and we have very highly satisfied patients – because we know patient satisfaction is important.

Kristen Engelen
Is there anything in particular that you wanted to share about the role that you’re playing and the program that you’ve developed?

Kristi Stice
I think one other program that I wanted to mention, just because I feel that it is unique, is our medication refill service. This is an area where pharmacists and technicians triage medication refills coming into the organization. Rather than them dropping into a provider inbox to address their refills, they come to our pharmacy team where our team works on a protocol to assess and approve the refills if they meet clinical criteria.

Kristi Stice
That saves the providers from having a crazy full inbox and having to deal with all those requests. Also, it’s great patient care because we’re doing all the lab monitoring, we’re doing all the interactions. There’s several things that we catch.

Kristi Stice
If they’re due for a lab, if they’re due for a visit, we can give a courtesy refill and connect them to care so that there are no gaps in care, and again, help support adherence. That’s a unique service that I feel like we’re providing.

Kristi Stice
We recently implemented some software to assist with that, that actually pulls… We were doing a manual chart review, and now it pulls a lot of the chart components up automatically for a more rapid review by the pharmacist. Then we only have to dig where necessary for some more details, but it allows us to more efficiently process those refills and assess those patients clinically.

Kristen Engelen
That sounds like a really interesting way to reduce the time between refill request and dispensing of the medication. Has that been the patient experience as well?

Kristi Stice
Yes. Our target is to refill meds in under 48 hours, but for over half of our patients, our turnaround is less than 24 hours. Of course, we don’t have as many staff on the weekends, so usually it’s those Mondays where the turnaround times are a little bit longer. I’m happy patients have been satisfied by the quick turnaround in those refill requests.

Kristen Engelen
For sure.

Kristi Stice
It also decreases the volume because you’re not having pharmacists sending a first, second, third request for those medications.

Kristen Engelen
Now that you’re established in your network, what are providers asking for next?

Kristi Stice
Like I said, everybody wants a pharmacist in the clinic, which I absolutely love. I wish we had the revenue to support all of that. Now providers are starting to ask for pharmacists to be even more integrated into the clinic in terms of seeing patients – so are there opportunities for us to build for those services? One is prep services – preexposure prophylaxis – do patients really need to see a provider for that? Can they see a pharmacist under collaborative practice agreement instead?

Kristi Stice
Also, can that work be expanded to the more rural areas and can that be done via telehealth? We do have some telehealth abilities. Our pharmacists can do some telehealth over Zoom, and have before, but that’s an area that we’re looking further into. Can we expand our access beyond just our metro area?

Kristen Engelen
Tell me about value-based reimbursement. Is that an area that affects specialty?

Kristi Stice
Right now, we serve an underserved population, so we are not at any at-risk agreements or anything like that at this time. I haven’t given a whole lot of thought to the impact of value-based care on specialty, but when it comes to things like adherence and clinical outcomes, we know the pharmacy and the pharmacists and the pharmacy teams do that and do that well.

Kristi Stice
I think that that’s only going to further grow the opportunities for pharmacists in the inventory space. I moved my family quite a distance because I truly believe that ambulatory is a growing space for pharmacy, and I’m excited about where it’s going. I think as we switch to pay for performance, that opportunities for pharmacists in the space are going to continue to grow away from fee for service.

Kristen Engelen
Agreed. It still remains a challenge to have pharmacist work reimbursed. That has certainly been the experience with RXLive as well – how do we find a way to subsidize the time of the pharmacist so that we can be revenue generating instead of a cost center?

Kristi Stice
I think it’s great that specialty has allowed for that to happen. We’re going to start in the specialty clinics and work our way towards primary care because we know there’s a need there. But increasing access to care is the goal of 340B, and we’re going to get there.

Kristen Engelen
Potentially reducing overall cost, because if you have a better-managed specialty, theoretically, then the overall cost of the patient’s care may be reduced in the long run.

Kristi Stice
Right.

Kristen Engelen
All right. Well, Stephen, those are the majority of the questions that we had talked about going through. Is there anything else that you’d like to ask?

Stephen Bilotta
My only question is you’ve lived in a few different places – who has better food? Is it St. Louis? Is it Kansas City? I’ll start with that one.

Kristi Stice
I am fully embracing Kansas City, and have tried just about every barbecue place that is well known around here. Even though it’s not the oldest in the city, I am a big fan of Joe’s, and my entire family is going to get Joe’s Bar-B-Q Sauce for Christmas. So I am loving the Kansas City barbecue.

Kristi Stice
I wish I could say the same for the Royals, but growing up in the St. Louis area, I’m a Cardinal fans through and through. However, I like that Cardinals Red is also Chiefs Red, so I am fully embracing the Chiefs.

Stephen Bilotta
So you fly into the radar with your Cardinals pride, allowing people to assume it’s Chiefs.

Kristi Stice
Right. Yes. My son at school today wore his Chiefs sweatshirt with his Cardinals socks.

Kristen Engelen
That’s great.

Stephen Bilotta
Great. I appreciate it, Kristi.

Kristi Stice
I’m here any time. Thank you so much for the opportunity, and great to meet you, Kristen. I look forward to hearing the great things with RXLive going forward.

Kristen Engelen
Thank you for joining, and thank you for being patient with us as we figure out exactly what we want this podcast to become.

Kristi Stice
I’m here any time.

Kristen Engelen
All right, thank you. Take care.

Kristi Stice
Yep. Thanks so much. Bye-Bye.

Kristen Engelen
Bye-bye.