Mobile Pharmacists | Victoria Reinhartz, PharmD, Mobile Health Consultants, Inc

Transcript Disclaimer: This transcript is generated using speech-to-text technology and may contain errors or inaccuracies.

Mike Koelzer, Host: [00:00:00] Victoria for those that haven't come across you online, introduce yourself and tell our listeners. What we're talking about today. 

Victoria Reinhartz, PharmD: My name is Victoria Reinhartz. I'm the founder and CEO of Mobile Health Consultants, Inc, which is an organization that helps to empower EMS and mobile integrated health teams across the nation.

Mike Koelzer, Host: When I hear a paramedic. I'm thinking. All right. They're mobile for me. The question is how mobile 

Victoria Reinhartz, PharmD: is mobile. Yeah. So you have the right idea. So we, we really do mean mobile and, uh, and mobile can mean different things to different people. For some people we think it's just remote, especially now in this day and age with tele-health and things.

And, and so, you know, it's going to depend on the community and on the program. But what we're talking about here is, you know, there has been an over surgeons and overuse of the 9 1 1 system. So we know that we have an access to care issue, and we know that patients are calling 9 1 1 and being transported to the ER, or visiting the ER, unnecessarily for chronic diseases.

Because more 

Mike Koelzer, Host: So now with COVID and things are, this has always been going on. 

Victoria Reinhartz, PharmD: So, you know, I mean, this has been something that we've been dealing with for years, right. That is. Discrepancy and the true access to care issues that minorities and underserved populations are experiencing are just highlighted, probably more so over the last year with the pandemic.

But you know, this is an issue that's been around for years. So a lot of EMS teams across the nation and also Firebase teams and health systems are launching what we call community paramedicine programs or mobile integrated health programs. And so these are utilizing paramedics, providing them some additional training and things like chronic disease and social determinants of health and sending them out into the community to address those community needs and increase the access to care.

And so when you have a base of a community paramedic to meet this need, uh, you can also integrate other healthcare professions. And then that becomes a mobile integrated health team. And so it's really what it sounds like. And we are utilizing vehicles and these are emergency response vehicles that are run by EMS personnel as the backbone, but also other health care professionals.

And we actually go visit patients in their homes on a proactive basis and on a scheduled basis in order to identify what their disease and social needs are and how to resolve those. And to break this cycle of calling 9 1 1, and ending up in the hospital, 

Mike Koelzer, Host: the 9 1, 1 that's so damn expensive to get people into an ER.

I imagine that the pencil pushers are saying, let's find a way to decrease this, but from a healthcare side, are they. Ideas that you would rather see happen preventatively versus in the emergency room. I'm going to guess that you're saying no, it's not. Cost-related is that 

Victoria Reinhartz, PharmD: right? Well, you know, I think that if you want to get people's attention, you talk about costs, right?

Cause you're right. Money makes the world go round. And the good thing about an approach like this, is that any way it's implemented, you're going to have an impact on the bottom line and you're going to have improvement in health outcomes. At least that's what we are finding across the nation.

So, you know, there's several hundred different mobile integrated health and paramedicine teams across the nation. And they look differently in every community. So, you know, we have some programs that are falls focused and they do home safety assessments and things. We have some programs that are more like hospitals on wheels and do you know everything from imaging to acute care management in the field.

And then we have programs that are more chronic disease focused. And so when you talk about prevention, you know, I feel. Incredibly passionate about this being a solution to not only resolve the access to care issues, but to focus on prevention, right? That's that, that's the epitome of what we do is we see the patient proactively before they have a nine 11 call in order to address their disease, address their medications, address.

Socio Economic issues in order to, you know, bring their prevention focus, um, to the forefront. 

Mike Koelzer, Host: So my question is kind of a moot point. It's not like 9 1 1 care or some other care we're talking about preventative care. So that question never even comes up in the first place, 

Mike: correct? Yeah. The idea is that we utilize this as a preventative care model so that you eliminate the access to care issues.

Victoria Reinhartz, PharmD: We'll come, we'll come to you. And so by doing that, we can reduce the 9 1, 1 utilization. We can reduce the number of ER visits, and we can reduce the number of [00:05:00] hospitalizations 

in grand rapids. Here. I know that the fire department is the first respondent to any, I think, any call, is that true nationwide or is that different in different states?

Victoria Reinhartz, PharmD: That's going to depend on, you know, what the first responder system looks like in that state. And so, you know, when you call 9 1, 1, there's a, there's a dispatch section of, of what we think about as public safety. And they are going to ask specific questions and they're going to route the appropriate team to the location, depending on, you know, how the caller, uh, I guess, answers those questions 

Mike Koelzer, Host: in grand rapids, the fire department will go for everything, you know, a twisted ankle or things like that.

But in some states they do it differently, well in any community, they probably do it differently. Right. They might send out the EMS more and things like that, depending on what they have set up. 

Victoria Reinhartz, PharmD: Correct. That's absolutely correct. 

Mike Koelzer, Host: So, Victoria, are you a teacher or a business person I saw on your profile?

How much do you love to teach? How did this start then? Did this start as a business venture or a teaching venture or. 

Victoria Reinhartz, PharmD: So in my heart, I'm both I think. And, uh, this was a crazy idea if you can believe it, right. I'll do all the great things. Start as a crazy idea to somebody. So I have been a faculty member now for almost six years at Lecom school of pharmacy in Bradenton, Florida, and I knew that I wanted to continue to practice.

So that's why I accepted a practice role, practice faculty role. And I knew that I wanted to do something with underserved populations. And so I actually originally started within the department of health here in Manatee county, within their tuberculosis clinic. Why you want to 

Mike Koelzer, Host: help underprivileged. 

Victoria Reinhartz, PharmD: Well, you know, my first job coming out of pharmacy school was with Target and I was a pharmacy manager for them for several years in Sarasota, Florida.

And I found that a lot of my patients were really positively impacted over the years that I was with them. And I found that I really loved the concept of medication therapy management. And I was having a lot of success in that area, but I, I knew that, you know, Sarasota, Florida is, uh, is, is not an incredibly poor area.

It's not, it's not correct. Yeah. So there's, there's a lot of money in Sarasota, Florida, and I really felt like. You know, yes, I am having success with these, with these people who have adequate resources. Right. Um, but I felt like my skill set was not being utilized for the population that most needed me.

And so that was a primary goal. When I took the faculty role was, you know, figuring out how to utilize the skills that I have for a population that really would benefit a little bit more. Did you 

Mike Koelzer, Host: I think it would be more of a challenge where you were unchallenged with the people that had ways to, I don't know, buy their way out of something or buy their way into something?

Or was it something in your 

Victoria Reinhartz, PharmD: heart? I think this intrigues me 

Mike Koelzer, Host: because I don't have feelings like that. 

Victoria Reinhartz, PharmD: No, I think it was both. I think it was both because, you know, I was a new graduate. Right. And I learned a lot about the concepts of pharmacy management. I learned a lot about clinically, you know, managing medications and the big issues that come up.

And I learned a lot about what was, you know, statistically something we learned and what's clinically actually relevant to my patient. Right. Um, and so I think it was a really great first opportunity to learn. Um, but you know, I've found that over time, the patients that really appreciated me most were the ones that were struggling in some way.

Right. 

Mike Koelzer, Host: They 

I appreciate. you more That makes sense. 

Victoria Reinhartz, PharmD: I can see that. Yeah. So, you know, the, the elderly who were completely isolated in by themselves and didn't didn't have support and were, could, you know, or were having loss of eyesight and couldn't fill their pill box and needed my help or, and, you know, I found that those were the interactions that really.

That really was most impactful not only to the patient, but to me as a professional. And so that's where I started to realize, you know, the patients that have access to everything they need are not the ones that really need me. 

Mike Koelzer, Host: And they maybe don't appreciate you 

as much then. Yeah.

Victoria Reinhartz, PharmD: Sometimes, you know, sometimes it can be tough for people that are used to having really quick and efficient access to everything that they want. But, but my patients in Sarasota where fantastic, 

Mike Koelzer, Host: they're 

probably not listening. Victoria, come on come on. What are the odds of them turning into a pharmacy podcast?

Let's go after em their big gaudy jewelry, they lay their purse on a thing and their diamonds are knocking all the counter stuff 

over. 

Victoria Reinhartz, PharmD: We can tell [00:10:00] definitely that you've owned a pharmacy for a while. So, you know, there is a lot of entitlement, but I think it's anywhere right. 

Mike Koelzer, Host: What's your first connection then to say.

Victoria Reinhartz, PharmD: You know, when I was a faculty and I started within the tuberculosis clinic, I kind of was brought into as a consultant to figure out, um, you know, they had, they had gotten a grant for establishing, you know, a mobile team or a paramedicine program. And they brought me in to say, what do we need from a medication side?

And this is where, you know, our group at the department of health here in Manatee started to really explore. Okay. So what does this look like? Does this look like the paramedics drive home to home? Does this look like we get a bus and drive the bus to specific neighborhoods? And, you know, honestly, there is no one direct answer and mobile can look different for every single community.

Um, so we have communities where, you know, they do a bus type format where they have primary care providers on the bus and drive the bus to Anita community and sit there every Monday, Wednesday, and Friday. Um, we have, you know, programs like ours, where we send paramedics and licensed clinical social workers and pharmacists out to, um, individual homes through, you know, SUV type vehicles.

So it's, it's different in every community and, and mobile is, you know, defined around how do we meet that need? It's not predetermined, uh, based on, you know, something prescriptive. 

Mike Koelzer, Host: While you were still in the early stages of your career, you had already seen mobile taking place. It's kind of foreign to me.

I mean, when I was a kid, I used to go to the bookmobile 

Victoria Reinhartz, PharmD: bookmobiles, big old 

Mike Koelzer, Host: van, you know, the oversized Winnebago and you'd go on and find books. And they were always like probably the same books and we'd probably read them over and over 

Victoria Reinhartz, PharmD: it. Yeah, but that was the best day, right? The book fairs, the bookmobile, those were, those are the best days.

Uh, this concept around mobile too. When we look at the news, we're seeing things constantly like pharmacists going above and beyond and delivering medication to patients' homes, or, you know, pharmacies. We just saw, you know, an article last week about a pharmacist who was, you know, going out in the middle of the night to a patient's home to deliver vaccines because he didn't want it to go to waste.

And, you know, there's, it's pretty consistent. I think when you're in healthcare that you have a patient with an issue and you're like, I could solve this problem. Right. Like if I have a vehicle, I know what needs to be done. I could go visit the patient or I could drop off, you know, whatever the paperwork to the, the Medicaid office or, or whatever it is that needs to be done.

I think we've all probably had that moment where you were like, Hmm, if I were mobile, I could solve this problem right now. It didn't have to do 

Mike Koelzer, Host: with mobility. It may not even be a problem you're seeing, I would already have been taken care of. I mean, there's financial stuff in that, but because of the mobile issue, Can often be the problem that you say, oh, it's a mobile issue, right?

Victoria Reinhartz, PharmD: Yes. And also, you know, there is the qualitative component that you get out of being mobile that you don't when you're contained within, you know, a four walls or in a location. So, you know, you get a lot greater insight into a patient's home life. Uh, what their true situation is, you get a better idea of, uh, you know, how they're able to navigate their home, whether they're feeding themselves the type of the, you know, the types of resources that they have within the home.

Um, and so that can really, you know, influence and impact your understanding of what I need to do to meet this patient where they're at. I even do 

Mike Koelzer, Host: that in the pharmacy when I'm there. And you're sending people home with like eight medicines and they ask you a question and you're like, Ugh, can't believe I'm just sending this patient home with this, because if they had that question.

This is an off to a good start, but you don't see any of the home dynamics on top of that. It's like, oh my gosh. 

Victoria Reinhartz, PharmD: Yeah. And, and, you know, there's, there's pieces specifically with the medication that can really be catastrophic, you know, when you go into a home and you've, you're, you're giving them, you know, eight new medicines today because they're being discharged from the hospital, but you walk in and there's a whole shoe box of pills that they're, you know, digging out of every day.

And they, you know, the first thing they're trying to do is dump the eight new ends into the big shoe box with all the old ones. And, there's just so much room for error and it's huge. Yeah. 

Mike Koelzer, Host: You see this and I'm trying to find the link finally that says you now have made it your own [00:15:00] business versus seeing it and maybe helping others.

When was that transition? 

Victoria Reinhartz, PharmD: I started working with the paramedicine team here in Manatee county, our EMS chief. And I realized that, you know, the benefit would be to actually launch the pharmacist and send the pharmacist and the paramedic together into the home. So we've been doing that now for, for several years, we actually published last year, we did a cost benefit analysis of, you know, how much does it take to run our entire program.

And then what is the difference in, in system utilization and reducing costs for our patients? And so we realized that, you know, there really is a huge benefit on a cost level and outcomes level for this model. And I kind of fell in love with it. We knew we were making a difference, we knew it. And so, um, in fact, we had such good success within the first year that the county actually expanded our program.

And so, um, we were really detailed with keeping track of outcomes and what was happening to our patients and collecting data. And so at the end of three years, when we actually crunched the numbers and we saw how dramatic the difference was, that was, I think that was a shock moment to all of us. Really.

That's cool. Yeah. So for every $1 spent on program implementation, uh, we realized that we saved $4 and 2 cents. 

Mike Koelzer, Host: I imagine that you're targeting somebody who you thought somehow they were going to end up in the ER within the year or something. Right. Correct. How'd you know that from past trips there or something, or?

Victoria Reinhartz, PharmD: Yeah, so patients get referred to us if they have called nine 11 more than three times in 30 days. And so then they get enrolled with us and we start seeing them on a regular basis. And then we try throughout their time with us to set them up for success. So identify any of the problems, resolve those problems, reconnect the patient into care.

You know, do a lot of education, connection to resources, communication with their physician team, you know, set them up for things like home health, get them insurance, uh, identify and resolve all of the drug interactions and side effects and, and the nastiness that can happen with the medications. And so we resolve all of that.

And then when the patient is ready and if they've met the goals that we've identified and set throughout the program, then they graduate from our program. And then what we do is we track afterwards, what is the change in pattern of their prior utilization versus now? How often are they calling 9 1 1?

And are they still? 

Mike Koelzer, Host: Do they have a bailout number? I imagine they call like instead of nine 11, it's like, don't call nine. I mean, they must have a bail out number. Right. Cause they're probably in the habit 

Victoria Reinhartz, PharmD: of calling something. Yes. And so that's one of the very first things that we do, right.

As we start to identify all of their issues, we give them a cell phone number. And so they call the paramedic team if they are starting to feel unwell. Right. And so we have a discussion about what's truly an emergency and what's not, but we go through the symptoms of their diseases. And, you know, we say if A, B or C happen, instead of calling nine one, one, call us, we'll come see you.

Right. So within an hour or two, we'll come see you and we'll check you out and we'll try to, you know, resolve what's going on for you 

Mike Koelzer, Host: reminds me of my siblings. Don't tell mom. 

Victoria Reinhartz, PharmD: Yeah. In some ways it is right. In some ways it's, uh, and you know, I won't say, uh, Mike, that we don't have patients that are stubborn.

We have patients that will visit them and then we'll leave and they'll turn around and call 9 1 1, right. If we, if we make them mad maybe or something. Uh, but, but yeah, so, so we've done this model, we've we, after our first three years, we did our study and, you know, I realized that we've had this incredible success and I feel passionate about this model.

And I think it is an excellent use of our skill set as pharmacists. And so that's where the business piece came in. I felt like I just have this calling to, you know, be available and help to provide not only direct patient care services, but also clinical education for teams across the. 

Mike Koelzer, Host: In your local area, Victoria, did you turn it into your own?

Were you getting paid separately or were you with an organization, the hospital or whatever, getting paid? 

Victoria Reinhartz, PharmD: No. So I donate my time as faculty. So when I started the paramedic program in Florida, and so we really started to, you know, um, have the pharmacist go out with the paramedics, we would do that two to three days a week.

And that was my time as faculty. So that's why it was so important for me to be a practice faculty. Will 

Mike Koelzer, Host: it always be set up then as a faculty [00:20:00] position across the nation? Or do you have any thoughts of saying no, here's how somebody could do this as a. Job not associated with a health organization 

Victoria Reinhartz, PharmD: kind of thing.

That is my long-term goal is to teach teams how to incorporate pharmacists when you don't have a pharmacy school nearby. Right? Yeah. So we were able to do a pilot program because I had, you know, a faculty role and was able to donate that time. Right. So I was getting a paycheck, but I was, my paycheck was from the university.

They're kind of like paying you to test it almost correct? Yes. So my clinical hours were being paid for by the university. But again, that was part of the reason why we did a cost benefit analysis is to show that even if you paid a pharmacist full time, if your program is focused on disease management and community risk reduction, that it is by far, you know, pays for itself in, in the terms of, you know, including a pharmacist on your team.

Now, most teams, you know, are not going to need a full-time pharmacist. And so that's part of what I do also is educating them about, you know, which patients are going to need pharmacist's intervention, which patients are likely to have the most medication challenges, um, and how to possibly incorporate pharmacists for, you know, ways to increase revenue as well.

What's 

Mike Koelzer, Host: the most that you would ever send to a. 

Victoria Reinhartz, PharmD: Really two to three, depending on what the individual patient's needs were, you know, if you needed, um, if you had a lot of social issues and a lot of chronic disease issues, then maybe three, right. You might send like a social worker or the pharmacist and the paramedic, um, or a nurse and a paramedic or, right.

So it kind of depends on what the patient's individual needs are. Um, and so I think three is the maximum that we have ever done in COVID the maximum is two. So since the pandemic we have, we have max it out at two, in a person's house. Do you 

Mike Koelzer, Host: make use of any of the video things like, have you ever been along, like you've had two of you and the third person, as you know, on a screen being carried by parents?

A, you know, who's letting them talk to this other social worker or 

Victoria Reinhartz, PharmD: something like that. Yeah. So the telehealth piece is really valuable and in the terms of mobile integrated health or para-medicine, so we have teams, you know, across the nation that are, are playing a huge role within tele-health. And so what that would look like is the team goes into the home, they help set up the tele-health device, or they actually, in some situations run the tele-health device, um, there, while the tele-health visit is occurring, right?

So you might have a physician or a nurse practitioner that is on that telehealth device. And in the home you have the patient with the paramedic or with the social worker. Um, the advantage to having the paramedic backbone to these programs is really because. You know, so much of disease management is physical assessment.

And, you know, if I go, if I go into a home by myself, Mike, and I say, I think the patient's having a heart failure exacerbation, the physician, you know, is like, okay, Victoria, well, that sounds great, but I need a physical assessment. Right. And that's not your, that's not your specific training area. Right. But if I'm there and the paramedics there, um, and the paramedic can do the physical assessment piece.

And then I can say, and here's his other med history and what the other medications are. And here's the medication that would fix the current problem. Then you have extremely complimentary skills for a physician or a nurse practitioner on telephone. 

Mike Koelzer, Host: My mother-in-law God bless her. My favorite mother-in-law.

I have to say this in case she's listening to sometimes the odds of her listening to this will be 10 times worse than someone in Sarasota listening to this. 

Victoria Reinhartz, PharmD: I have a favorite mother-in-law also. Yeah, I have one, 

Mike Koelzer, Host: my siblings in law, I guess my wife's siblings, you know, say, well, we bought mom this, but she's just not using it as a tablet with Facebook or, you know, a Kindle with, you know, books on or something.

She's got no interest, you know? And so a lot of these people, why would they want to get into this stuff 10 years left with their life or something like that? They don't know the right side up of a computer 

Victoria Reinhartz, PharmD: pad. It's true. You know, that's the issue with tele-health is that if these people could independently navigate tele-health and could independently navigate the internet and they had access to all of that technology and knew how to utilize it, then they wouldn't be con you know, constantly calling nine 11.

They 

Mike Koelzer, Host: would learn it before they pick up the phone and down 

Victoria Reinhartz, PharmD: nine one one. Yeah. Well, they'd be able to probably navigate the healthcare system. And so, um, yeah, so, so telehealth, [00:25:00] without a strategic plan for how to set that up successfully is not by itself or independently. The answer to the access to care of problems.

Mike Koelzer, Host: I was interviewing Neil smaller, a pharmacist out east a couple of weeks ago, talking about the COVID thing. And he said, This was not done correctly. You needed to take the over 75 year old people and say, look. Show up at your closest high school, bring your ID. We'll take care of you. What you're telling these people that go on and sign up online and maybe even a double password, you know, where they get texted their code, you know, and then it's like, they don't know what the hell is going on with that.

And this is very stereotype, but the age of the people that can figure that stuff out are not the people that need the 

Victoria Reinhartz, PharmD: shots then. Yeah, no, you're right. And so again, that's just one more way of how the pandemic has, has highlighted this population that that really is not getting access to what they need.

And you know, there's things like remote patient monitoring and stuff too, where paramedicine teams and in mobile integrated health teams have been really instrumental for. You know, going in and setting up remote blood pressure devices and scales and things so that we can collect data on patients and identify when they're having an acute issue or maybe aren't taking their medicine and things.

But again, the patient's not going to know how to set all of that up. Most of the time, 

Mike Koelzer, Host: one of my guests, we were talking about having an Amazon echo there or something like that. And just saying, you know, good morning, Sally, and then waiting for Sally to say good morning. And she doesn't say goodbye.

Something could be wrong there. It might just be that the damn thing's unplugged or something, but it could be that there's bigger issues, but sometimes it's as simple as that, you know, because if you don't make it that simple, well, then you have problems. If it's on a phone or a pad or something, it's like, well, they probably just couldn't 

Victoria Reinhartz, PharmD: find it.

Yeah, absolutely. No, it's been, it's been really incredible. And you know, CMS has finally piloted what we call , which is, uh, emergency treat triage and transport model for EMS, which, uh, allows for possible payment. Even if you don't transport the patient to the ER. So in that sense, you know, the world of EMS and pharmacists are similar.

We don't, as pharmacists, we don't get paid unless we dispense a product. Right. And an EMS, they don't get paid unless they transport a patient to the hospital, they don't get paid 

Mike Koelzer, Host: unless they transferred a patient. Correct. I didn't know 

Victoria Reinhartz, PharmD: that. Yeah. Is that across the board? 

Mike Koelzer, Host: I didn't know that you'd think that they would show up and wrap an ankle or something like that.

I never knew that. 

Victoria Reinhartz, PharmD: Yeah. So that's why this is such a huge initiative because this is for the first time exploring payment for either transporting the patient to a more appropriate location, like an urgent care or, you know, a dialysis center or whatever it is that's caused this acute issue that we're dealing with right now, or, you know, triaging them in, uh, in the home and setting them up with a telehealth visit right there in the home.

Mike Koelzer, Host: So they don't even get paid if they go to something short of a hospital, if they don't get paid, if they go to an urgent care center or something. 

Victoria Reinhartz, PharmD: Correct. In fact, that is not protocol like there was prior to this initiative, there are no nationwide accepted protocols for transporting patients anywhere other than the ER.

Yeah. So, that is not an accepted, uh, use of EMS historically. And so now this is huge in that sense that for the first time, you know, we are going to empower these teams to utilize their skill sets in the home, to transport the patient, uh, if necessary to a more appropriate location and still get compensated for that time, it almost 

Mike Koelzer, Host: seems like there wasn't enough incentive for this thing to change.

I mean, if the ER gets paid for having a patient brought there in, if the EMS only gets paid for having a patient brought there, it almost sounds like doing anything short of that. Profitable. So why would you start a program like this? 

Victoria Reinhartz, PharmD: You're right. And I think that's why it's taken as long as it has. Um, so many of us have been starting programs like this and pushing for programs like this, because we see the difference that it makes.

And we know that overall, this is the direction that healthcare needs to take and that the same system is a broken system. And so, yeah, it really is completely upending the world of EMS, as we know it in, in a good way. Right. And it's just like pharmacist services, right. So how long have we known that?

It's, you know, what's up here in my brain is what you need from me as a pharmacist, more so than to dispense another pill to you that you probably don't need. I'm trying 

to 

Mike Koelzer, Host: think of the winners and losers in [00:30:00] this, and I'm thinking. Gas companies, entire companies may not be winners in this ever. They always want to see vehicles and things on the road.

And so on short of that though, the EMS, they pretty much want this across the board. Are there any people in the EMS community that would be fighting you on this and saying. This is good for you, but stay away from this portion of the business. Is there anyone that you think would fight this system of improvements or at least as what you see as improvement?

And I would tend to agree as improvements. 

Victoria Reinhartz, PharmD: I think anytime that there is change, it can be scary to people, right? So just like there are pharmacists that say, Nope, I don't want to do MTM. I don't want to, I don't want to get involved in managing that disease. I have this skill set. I've been doing this for 20 years and I don't have any interest in learning, you know, how to do that a different way.

Um, so just like you have that in our profession and people that are resistant to change. Sure. Sometimes you might have that within the world of EMS or in fire based systems. But I think that, you know, a lot of it. EMS teams and paramedics are realizing they see the same patient over and over, and the issue never gets fixed.

And, you know, you ask a good paramedic and they'll tell you when they leave a patient's home. Yeah. We'll be back there next week. We'll be back because she, this patient doesn't have what she needs or he's definitely not stable, or his condition is not controlled. And I know I'm going to be seeing him again next week and it wears them down.

And so I think that, you know, overall more and more. First responder teams are realizing that a model like this is absolutely necessary. I 

Mike Koelzer, Host: get screwed a lot of times. Right. They probably know that we can't bring Mrs. Smith again to the hospital. We were just there four days ago, but they probably can't just ignore her call.

So they then go there and it's a money loss for them because they have to check in on her and so on. 

Victoria Reinhartz, PharmD: Yeah. So, I mean, if the patient wants to go to the hospital, then they take them to the hospital. Oh, I see. It's not really their call. Yeah. I mean, you know, they can tell the patient, you know, you're, you're not meeting any criteria that would cause me to say, yes, you need to go to the hospital.

Um, but if a patient is complaining of, you know, a, B and C symptoms, they will, they will take them. Yeah. Yeah. So, I mean, when you talk about teams that are, you know, are, is there anybody that is against this model? You know, Anytime that there's change, you know, you'd have to think about new things, right?

Like, does our software need to change? Does our training for our teams need to change? You know, do we have to revise our liability policies and reevaluate that? Right. And the answer to all of those things is yes, all of those elements are going to have to change to meet the need. Um, but you know, if we look at 2016 was when my program in Manatee county was started by our EMS chief.

And, you know, I think at the time there were like 15 or 16 programs in Florida and maybe like 60 nationwide. Now you're looking at, I don't know, several hundred, 300, 400 maybe across the nation. So more and more we're recognizing that this is definitely a successful model. 

Mike Koelzer, Host: So a pharmacist is listening to this Victoria and is that way jumping the gun for them to say.

I'm going to call Victoria and hire her for her services, because she's going to teach me how to, maybe enjoy my job a little bit better because I'm doing something different and maybe more impactful and things like that. Be I want to make money on that, or are you more like getting hired by. Uh, city that you'd come in and sort of be the consultant for like raising everybody up in this program.

You know, the EMS is the fire department, the city to pay for it and the hospitals. And so on what role do you see yourself playing or are you playing 

Victoria Reinhartz, PharmD: right now? Really at this time, I'm, my services are geared more towards, you know, EMS entities. So cities or private ambulance companies, or, you know, fire based teams or health systems that are launching a team because, you know, I have the know-how to.

Support them from the beginning and help them create a program that is going to be structured in a way that is meaningful, that allows them to track the appropriate things and also includes the disease and medication management piece, which is one of the reasons why our team has been so successful here in Manatee county, Florida.

Um, now that being said, I do feel that in the years [00:35:00] coming, I probably will need to create a training program for pharmacists that are looking into some sort of arena within community health and doing some sort of mobile health care. Because again, you know, the model is spreading. We know that we have more and more programs being established across the nation.

And I would say the number of people contacting me in general to say, how can I get a pharmacist is definitely increasing. And so there is room for this, uh, you know, in, in years, coming for pharmacists 

Mike Koelzer, Host: groups are calling you and saying, Hey, I see what you do as a pharmacist in we're thinking of this, but how would I get a pharmacist 

Victoria Reinhartz, PharmD: on my team for this?

Correct? Yes. Yeah. So it's really exciting. And you know, I think. It's a part of that, you know, age old battle as pharmacists, where people are like, I'm sorry, wait a minute. You're a pharmacist. What do you do? Why are, why are you calling from Walgreens? Nope, Nope. I don't work in a pharmacy. I don't dispense any product.

You know, it's all clinical guidance and expertise. And I think that is something that EMS is realizing at this point, right. That a pharmacist on the team can provide guidance in so many different areas. And I, I would say that, especially over the last year, I have done a lot of clinical education around, you know, um, chronic disease, education, medication, education, um, how things like COVID are going to impact MIH teams, et cetera.

So, um, there's a lot to be gained from having the pharmacist expertise and as more teams recognize that. Yeah, I think they're, they're wondering the same thing. Like, hold on a minute now, how can we. 

Mike Koelzer, Host: I have this guy on my team and I've tasked him with trying to set up the medicine synchronization. And I only do it when I feel guilty enough to try it again, because it just doesn't work for us.

Either I'm stupid or lazy or something, it just doesn't work for us. And so about every year I feel guilty and I kind of try it again. And this guy said to me, if I didn't know better, I would think someone's on purpose trying to sabotage this, you know, cause you talked to Mr. Smith and you have an hour meeting with them and you set everything up and do this.

And then the next day he comes into another pharmacist or team member. That's not, wasn't working on him with this and like asking for a refill that he wasn't supposed to, you know, need for a certain amount of time. Do you ever walk out of these houses and say, okay. C'mon Gladys, what the hell we just talked about yesterday and now you're doing this.

Do you ever get really frustrated 

Victoria Reinhartz, PharmD: with people? Sure. And I think sometimes, you know, it's okay to call them on it a little bit. Right. It, you know, and a big part of it is establishing a relationship that you can be real together as part of that patient provider, you know, trust. And so you're, you're literally coming into their home, they're their safe place.

And, you know, the trust level has to be really high there. And so establishing that relationship, uh, you know, really through evidence, sometimes it takes two or three visits before that patient starts to warm up to you. And you want to listen to what you're saying. And sometimes it takes two months or three months before the patient wants to really listen to what you say.

Um, Yeah. You know, so it is a balance of when to let that frustration show and when not to let it, and when not to let it show, right. 

Mike Koelzer, Host: Sometimes they want a little 

Victoria Reinhartz, PharmD: kick. Maybe they get going. Yeah. Yeah. So, uh, you know, and, and we're not above that. Paramedics, paramedics are real people and. Uh, they actually are probably more likely to be super real with a patient about what's going to happen if they don't control their diabetes or control, you know, their blood pressure or whatever it is.

Um, and I think that's, there's beauty in that too, right? If they are out there in the field and they see the worst of the worst. And, um, they'll tell it like it is. And, uh, you know, I, I think that is another reason why it's beneficial is it eliminates the barrier of the white coat, so to speak 'cause 

Mike Koelzer, Host: these paramedics.

I mean, they see the worst when someone doesn't do something correctly and then they fall or whatever, and have to truly have to go to the hospital, especially if they've taken this patient in before, you know, or seen something bad happen because their habit wasn't up to par yet. So Victoria, when I was a kid, one of my goals was when I got older, I wanted to ride on the back of a vehicle and just hold on for dear life.

There's only two professions that do this. Now there's a waste management person that still gets to, [00:40:00] you know, hit the buttons and then step on the back of the truck and hold on. And. Fireman. I don't really see myself being either of those, but I wonder if, well, I'm just going to come out and ask it. Have you ever written on the back of a truck just holding on?

Victoria Reinhartz, PharmD: Oh yeah. I'm sure that teams would, uh, really view that as a liability reduction strategy. You haven't done that with all this work? No, of course not. I don't think so. We ride in an SUV, so it's not an emergency. It's not as cool. It's an emergency response vehicle. So if there is an emergency, you're the one you're going to.

If you're the closest responding, 

Mike Koelzer, Host: um, they may be in people's houses and then they might get called right in the middle of one of these things, right? 

Victoria Reinhartz, PharmD: Our teams do what we call self dispatching. And so we have a schedule throughout the day. Um, but sometimes there are breaks or intervals within that schedule in case a patient has an urgent issue and needs us to swing by.

Right. So, um, so we specifically structure our day with some. Quote, unquote downtime. And so, you know, during that period of downtime, you will respond to nine 11 calls. If you're the, if you're the closest unit. So sometimes it's a really fun day. I will say that you never know what you're going to get.

Um, and sometimes it is, uh, you know, an incredibly traumatic day, depending on right. What, what call you're going to 

Mike Koelzer, Host: and potentially do they call you from a meeting? Like if you're meeting with somebody, for whatever in their home and two dispatches that are needed, one, let's say from another car, do they ever pull the paramedics out of the house and say, look, we know you're having this meeting, but there's, someone's having a heart attack a mile 

Victoria Reinhartz, PharmD: away.

Yeah. If there is not adequate, uh, if there's not an adequate number of ambulances on the road to handle that, then yes. But they don't 

Mike Koelzer, Host: plan on that. They don't plan that. We're going to interrupt you a ton. It's not like this. They just do. To fill in dead time. It's like, this is the primary purpose. They might use them for overflow, 

Victoria Reinhartz, PharmD: correct?

Yeah. So you have your, you know, your EMS stations or your fi for Firebase system, your fire stations, you know, structured all throughout your county and each area of your county, the paramedicine program, or the mobile integrated health program is additional. And on top of that. And so they do not have the responsibility of covering for a specific zone.

And so the only situation where they would be interrupted from a call is if, you know, for some reason you were on surge, because every single one of your ambulances were dispatched on another call, or, you know, if there was a situation where it was like, Like the neighbor, right? Like if you're at apartment a and the apartment upstairs, then of course you say, okay, we just got notice that your neighbor upstairs is having an issue.

We're gonna, we're going to go up there right now because yeah. We're the closest. So in that sort of situation, of course they would pull you. Um, but, but really your intention is not to cover the zone. Your intention is to be a bonus. 

Mike Koelzer, Host: So, Victoria, what would be your coolest gig? Like right now, someone's listening to this.

Who would be the coolest person to hear from what would you like to do for. And how would you like to get paid for that? 

Victoria Reinhartz, PharmD: I think by far the thing I think would be the coolest right now is if you are, you know, on the executive level, in a health system and you are exploring how to launch a paramedicine program, which is going to save them money, tons of money.

Yeah. And it's going to save 

Mike Koelzer, Host: Even like I was talking to a guest last week about Medicare advantage stuff, you know, it's going to save everybody a ton of money. Right. Especially when these are repeated by 9, 1, 1 people. 

Victoria Reinhartz, PharmD: Yeah. So especially if you have a, a high percentage of uninsured patients or if you're, you know, being heavily dented on readmissions within 30 days, 

Mike Koelzer, Host: don't hospitals say like, we will not turn you down for emergencies.

Things like that. Isn't that like the hospital oath or something, and don't people know that. And that's why they call 9 1 1 sometimes instead of setting up an appointment, 43 days out with them. 

Victoria Reinhartz, PharmD: Yeah, absolutely. And they know that they're going to get care when they walk in there. Put your hand over your heart.

Yeah. Right. I have, uh, I have chest pain. You get right in with that. That's the truth for sure. The 

Mike Koelzer, Host: movie star with that one, people come up and ask them for your autograph and stuff. Well, it's not your autograph at your signature, but you pretend like it's your autograph, 

Victoria Reinhartz, PharmD: it's your signature for, for care.

Yeah, that's right. So, yeah. So I, I mean, I think that would be the coolest right now is, you know, if you're trying to figure out how to create a [00:45:00] robust disease management program with a local EMS entity or a fire entity, or even if you're trying to create a hospital-based program, then I think that, you know, I definitely, this, this is like a dream.

I would love to do that for them to call you. Yeah. Find me on LinkedIn. And 

Mike Koelzer, Host: you're going to travel there for a few days and have meetings. What are you going to do with this place once they call you? 

Victoria Reinhartz, PharmD: Yeah, so we would set up. Virtual meetings, because there's really no sense in, in the expenditures on either party's side of, of going in person at this point until they're actually, you know, uh, able to define where their biggest pain points are, what type of program they want.

So there's a variety of questions that need to be answered to start. And there's the concept of, you know, we need the data to show, uh, what numbers you want to move and where, where you need the change. And then once we look at those numbers and we'd start to look at the resources in the area from an EMS standpoint, then, uh, we start to put together what it would look like for a program.

And that's when I probably would travel to me in person to really meet the team members that we would be working with and establish this person. What is your 

Mike Koelzer, Host: financial picture? And do you have different levels of things? Are you working just as the consultant? Are you working on individual parts of this?

Where are you? Where do you want to go? If you're 

Victoria Reinhartz, PharmD: not there yet. Yeah. So there's three different, uh, three different ways that teams can hire me to, I guess, provide services for them in some way. So number one is clinical education for your team. And so that could look like, you know, a couple hours of clinical education on a specific area.

Or it could look like regular consistent clinical education throughout the year, in which case that would look like, you know, payment on retainer for continued education based on whatever comes up within your team. So in that setting, it looks like, you know, really understanding the team, becoming familiar with the clientele of the team, the types of patients you have and the program goals that your team is working every day to achieve.

And then coming up with tailored education specifically for paramedics and these niche areas that will empower your medics in the field to know what to do when certain clinical situations arise. 

Mike Koelzer, Host: What's an example of something that you would be teaching them pharmacists wise, that they don't know already from assessment-wise 

Victoria Reinhartz, PharmD: Just as an example in the last month, some of the education that I've provided is number one, how to do medication reconciliation.

Oh, So there is a structured stepwise approach, you know, uh, logistics within that, in this particular situation, you would have paramedics that are doing medication reconciliation in the home after hospital discharge. You know, another example is, um, understanding like your top five medicines for heart failure and what they're doing and, you know, w should a patient be taking furosemide every day, or what does a heart failure management protocol for, for fluid management look like on the outpatient side?

Um, you know, things like when, what, at what level of weight gain should the patient be contacting their physician? 

Mike Koelzer, Host: You guys are always bringing up weight gain on these. I think all my guests get together and throw that in for an intervention. So, but what just came to me though, is that you're not teaching about like, What happens with an overdose on these top five medicines?

No, they already, well, not that you would overdose on some of those, but they already know that you're teaching, like how to keep somebody home on this. Like, let's look for side effects that might be problematic. And what can be done with conversations versus saying, oh, this person's whatever holding onto fluids, we'll take him to the ER or something 

Victoria Reinhartz, PharmD: like that.

Yes. Correct. 

Mike Koelzer, Host: Yeah. All right. So that's one level and then you mentioned three. 

Victoria Reinhartz, PharmD: Yeah. So the second level is consulting for programs who are developing what their protocols should be, or, you know, for, for programs that want some sort of evaluation, you know, of how well they're doing in specific areas, or if they know that they are struggling to, you know, capture.

Outcomes data with their, their current EHR, their current software. And they're trying to figure out how to build that in? What does that look like? Which metrics do we need to track? You know, those sorts of pieces, those are all examples of different consulting services that they could bring me on.

And that is done typically on project-based depending on how many hours and the length of time commitment for, um, you know, helping them tackle that [00:50:00] from, you know, beginning conceptualization to the end, uh, which could be anything from, you know, a write-up of, of an evaluation of their program to, you know, working side-by-side with them every week to update and implement, uh, you know, new PHRs or softwares.

And so that's the second phase as some sort of, of consultation for program development or, um, evaluation. And then the third piece is actually a direct patient. And so that would look like, you know, something small scale, which would be, you know, we would like a pharmacist to review our type, you know, top five, most medically complex patients every week, or it could be Jeff or it could be full-scale where they actually implement a pharmacist.

And in that case, uh, they would be, uh, hiring me to train their pharmacist and place the pharmacist in their location. You're three 

Mike Koelzer, Host: levels there, which one of those was like a blind executive saying we need to get this going because we need to save money. Somehow. 

Victoria Reinhartz, PharmD: That is all three levels by. 

Mike Koelzer, Host: Oh, I got ya.

I got you. Those are all parts of 

Victoria Reinhartz, PharmD: that. Yep. So I would do the consulting piece around how to develop the program, connecting with the existing resources, working with the EMS teams, and working with the hospital teams. Um, and I would be helping provide the training so that it would include the clinical education piece and also incorporating a pharmacist, uh, in whatever way, shape or form they wanted.

So if they wanted to use their own pharmacists, then I would train that pharmacist for this unique role. And if they wanted to have a pharmacist brought in and staff separately, then I would do that. 

Mike Koelzer, Host: And that's in that question. I always forget that there's work involved. Sometimes I wanted a level just where I could sit back and say, Here's what you should do.

Here's my idea. Now pay me for it. I mean, they can listen to this and say, yeah, that sounds good. But where it comes down to is getting it done, getting things, setting up the right people, the right process and all that kind of stuff. 

Victoria Reinhartz, PharmD: Yeah. And you know, it is an investment. Right. And so I think that it goes back to one of the biggest issues in this concept of mobile health: funding is who wants to pay for something proactively to save money in the long run.

And that's, that's again, not the philosophy of our, our current health system, but, uh, we do know that it's, it's worth it. And so, um, if any, uh, if anybody is listening and you're ready to shake it up and you're ready to do things through what we definitely foresee as being the future of healthcare, then yeah.

I'm here. I'm here. 

Mike Koelzer, Host: I only have three listeners per episode. I listened to next week's guest to see how much of an asshole I am to them. And then my dog, I forced her to listen to it. We 

Victoria Reinhartz, PharmD: did say my patients from Sarasota are listening, right? No, 

Mike Koelzer, Host: they're not listening. That's why I gave you freedom to talk about their gaudy rings and putting their purse on the counter and knocking all that crap over.

So, Victoria, what do you want to be doing in five years? Tell me what your week looks like business 

Victoria Reinhartz, PharmD: wise in five years. You know, I will, I will admit that in some ways I hate this question and I'll be honest about it because I will say, and for anybody that's listening, this is, this is advice I would give as well.

I have gotten to where I have gotten, because I said yes to strange opportunities and situations where. Um, there was a door that started to open and I said, do I want to walk through that door though? Do I want to say yes to that? Um, and it has been really rewarding for me. Right. So, you know, I would have not gotten my faculty role if I hadn't said yes to being a keynote speaker at an event.

And I would not have discovered paramedicine if I didn't say yes on top of all my other responsibilities. I'll come in and do some consulting for you about this grant and how to figure out the med management piece. And, you know, I think that, um, I think that saying yes to things that you're not sure of.

What you're going to like is how to get, um, a lot of really amazing opportunities. And that's what happened to me. Um, and so when you say, where do you want to be in five years? I don't know. I could say yes to something tomorrow. That completely changes, you know, the course of what I want to end up doing or could open, you know, a fourth branch of my business.

I don't, I don't totally know, but if, again, you know, in the dream world, I would be working with health systems to partner them with paramedicine teams. I would be [00:55:00] establishing pharmacists within paramedicine teams across the nation. I would have, uh, you know, clinical education that is being provided regularly from my company, from my business to EMS teams.

I would, I feel like I, I definitely want at least one day a week that is direct patient care, direct education. You know, you, you said in the beginning, you said, yes, yes. You said, who are you? So what are you or your teacher? Are you a business woman or you're a pharmacist? And the truth is that I'm all of those.

And I love teaching. I love it. And I love it. Helping people. And I also feel that, um, having some direct patient care really does keep me rooted in what my patient population, my incredibly vulnerable disadvantaged, um, socioeconomically disadvantaged patient population is dealing with. And so I would still want to have at least one day a week where I have some sort of teaching lecturing or direct patient care or on the boots, you know, working with a team in some way to help, you know, directly resolve their problems, 

Mike Koelzer, Host: dealing with individual people in their home.

Would that be okay for teaching or do you want to teach a bigger multitude? I don't 

Victoria Reinhartz, PharmD: I think it's too small. I think that you still have. The ability to gain from that for you to 

Mike Koelzer, Host: gain from it, actually. 

Victoria Reinhartz, PharmD: Yeah. So I mean, obviously the patient will benefit, right. There's value there to the patient. Um, but I continue to, to ensure that I am fresh and that I am capable and that I'm learning about whatever my individual patient is dealing with.

Right. Um, you know, I think that, to put it in perspective, so right now I still have my faculty role. I'm running my own business. I, you know, I'm a mom of two crazy girls kids, by 

Mike Koelzer, Host: the way I saw them online. 

Victoria Reinhartz, PharmD: Thank you. Thank you. They are SAS. They are sassy. Uh, they're great though. They're great. Um, So, so I have a lot of different things that I'm doing, but do you know what I'm doing for two days next week?

I'm vaccinating. Like I'm going into the hospital, I'm working a vaccination shift because it really does help me completely understand. All right. So when somebody wants to hire me for a vaccination program, yeah. You know, next month I have seen the struggles with registration. I have seen the struggles with physical space and how the layout of a clinic or the logistics of an operation goes.

Um, I have firsthand, firsthand. And so I am able to, through doing something first hand, I am still able to identify where the gaps are that we are not meeting or where teams are not efficient. 

Mike Koelzer, Host: 70 hours a week doing that. I mean, you can just pop in for a day and do it. Right. All right. Here's the other extreme?

What would it be like to only work with employees? And I don't mean pharmacists. I mean, other trainers let's say that this grows and you've got like a bunch of people, like you, not as talented because you're the head honcho. So they're as talented. They should go do their own thing, but very close. What if you only could talk to them?

Would that drive you crazy? Would you still need some, like all the interactions you talked about? Cause some people dream of being in a situation where they're only talking to their employees, not talking to any customers, but do you think you'd still like to be talking to these C-suite people at the hospitals or doing this or you're fine.

Let someone else do all that? 

Victoria Reinhartz, PharmD: No, I, I feel like. I am most comfortable in my own brain being an ideas person and switching it up and discussing new ways to do things and, uh, and figuring out how we can be more efficient and, um, with employees. Yeah. But, with employees, you're in a teaching role. That's true.

Right. So anytime you have somebody that works for you or works within your business, or you're, you know, you're the lead on helping them to see the best way to execute a project, uh, then, then you're in a teaching role. Right? So, so if, if you're working with an employee you're teaching that's or you should be, or you're doing it wrong.

Yeah. I think I'm just one person. That's my thought. If you're, if you're working with an employee and they're not gaining something out of their time with you, a new perspective, a different way to do things, you know, [01:00:00] guidance or instruction. Yeah, you're teaching them yeah. Feedback on how they could be doing something better.

Um, learning about a new venture that the businesses are doing, or a new way that healthcare, you know, professionals are being evaluated and ABC measures, you know, they're learning from you in some way, hopefully, or we're doing it wrong. 

Mike Koelzer, Host: Let's say you were at the level where you could only teach your employees.

You're not going to Mrs. Smith's house. You're not doing any vaccinating. You're not talking remotely to some pharmacist somewhere you're only talking to your employees. Would that drive you crazy or what? I mean, you think you'd want some outside stuff still to, 

Victoria Reinhartz, PharmD: yeah, because then, you know, I need to be learning too, and I need to be growing.

And I'm not saying that you can't learn an incredible amount from your employees, but their job is not to teach me about things or help me develop, that's my job to help them. So you're going to get 

Mike Koelzer, Host: that full circle by going around to 

Victoria Reinhartz, PharmD: somebody else, being in, in a position where the majority of your role is working with employees, um, helping them, you know, execute projects or, or oversee departments.

And, uh, you know, I think there's a lot to be gained from that, but I think that, you know, networking, going to conferences, learning new ways of doing things myself, um, shadowing, different teams and figuring out, you know, what's a different approach to how, uh, this model of care can be done. I feel like all of those pieces.

You know, help me develop personally, Victoria, what a pleasure having you on. Oh, thanks so much. I have enjoyed chatting so much. 

Mike Koelzer, Host: Yeah. Likewise, best wishes on things. Everything you're saying was really cool. I made a lot of sense, but especially like that four to one payoff, it's like a no brainer to get 

Victoria Reinhartz, PharmD: that's going.

Yeah. Thank you. I'm hopeful as well. And, and I know that, you know, as this method of care expands across the nation, that more and more teams are going to need people that have experience navigating from the health system to the EMS side. For sure. 

Mike Koelzer, Host: Very cool. All right, Victoria, take care. Thanks so much.