Joan Jenkins believes that one of the more positive things she has done to combat her illness was to invite Eldon Armstrong, a consulting and community pharmacist, to speak to the support group she leads for people with vestibular disorders. Jenkins, 52, suffers from bilateral Meuniere’s disease, which causes symptoms of dizziness, equilibrium problems, and faulty depth perception. In addition to Meuniere’s, she suffers from hypertension, diabetes, and allergies, and takes up to nine different drugs to manage her conditions.When leaving her home, Jenkins often must use a wheelchair. In 1993, her afflictions became so bad she was forced to quit her job supervising a college laboratory.

Before meeting with Joan’s support group, Armstrong asked for a list of medications taken by the group members to have some insight on what would be discussed with the members. “He took his time with everyone and answered all our questions,” Jenkins says. “When he left,we sat there with our mouths open.”At that point Jenkins knew she had to hire Armstrong for a personal consultation. “It’s the best investment I’ve made since I’ve had this disease.”

Armstrong is currently the owner of a medical equipment supply company and three apothecary pharmacies, as well as the president of Sandlapper Consultant Pharmacists in Columbia, South Carolina. He decided in 1997 to turn his full attention to the work he’d dreamed about for years: providing medication assessment and problem solving by appointment to people in his community. “It’s fun,”Armstrong says, when asked what motivates him to pursue this type of practice. “It’s challenging and rewarding, and the fun element is knowing that I’m helping people.”

To meet comfortably with patients, Armstrong consults in an office separate from his pharmacies that includes a full-time assistant who manages the office and sets appointments. His fee is $60, and a typical appointment lasts about 40 minutes.

Launching His Career

Armstrong received his B.S. in pharmacy from the University of South Carolina (USC) in 1969, then enlisted in the U.S.Army from 1970 to 1973, during the Vietnam War. His five-year program at USC included course work in clinical pharmacy, medical rounds with physicians, and duty in the emergency room.“I got excited about the idea of pharmacists as much more than mere handlers of medication,” he says.

During his tour in the Army, Armstrong trained as a medic. “I thought the things they taught me were ludicrous in regards to my work as a pharmacist—how to resuscitate people, CPR, first aid, injections— but I’ve probably incorporated them all into my practice,” he emphasized. Armstrong was also assigned to one of the nation’s first sterile preparation pharmacies, where he learned how to prepare intravenous solutions, infusions, and injectables.

After leaving the Army,Armstrong launched his civilian career by purchasing a pharmacy and becoming a long-term care consultant. He maintained patient profiles in his community pharmacy, kept tabs on patients’ diseases and allergies, and looked for medication problems as long ago as 1977. “I thought, don’t just do this stuff in the nursing homes, get out and apply it wherever I go, and offer it to people coming into the pharmacy,” he recalls.

Specialty Training

Over the years Armstrong has taken every opportunity to enhance his knowledge about specific diseases and to fill niches where he feels there is a need. For example, in 1995 he completed ASCP’s pharmacotherapy traineeship in Parkinson’s disease. “I saw a population where I could make a difference, even though it’s small— only one to two percent of people over 65,” he adds. “There’s no cure, the treatment always involves medication, and the specialists who diagnose these patients rarely provide what I call ‘continual care.’ I felt there were gaps that could be filled by a pharmacist, and I’ve built up a special expertise for which I’m known here in South Carolina.”

Armstrong has also received special training in anticoagulation management and completed the GeroPsych/ Behavior Disorders Traineeship through ASCP, a program designed to prepare pharmacists in providing pharmaceutical care to geriatric patients with psychiatric and behavior disorders. He became a Certified Geriatric Pharmacist in 1999.Among his areas of special knowledge are Alzheimer’s disease, smoking cessation, immunization administration, natural medicines, and female hormone replacement therapy.Armstrong is heavily involved in efforts in South Carolina to coordinate services for Alzheimer’s patients, building on contacts and background he’s acquired since 1994, when the governor appointed him to a slot on a statewide Alzheimer’s council. In 1998 Armstrong was president of the board of the directors for his region’s Alzheimer’s Association.

Educating Patients

Throughout his years as a pharmacist, Armstrong determined that there is a great need to educate patients on their medications and to collaborate with physicians on patient care. He calls his approach “advanced pharmacy care.”

When selecting the space for his office practice, Armstrong kept convenience, safety, and privacy in his mind. “It’s important, especially for older patients, to feel comfortable and safe in the surroundings,” he explains.As for privacy, he wants patients to feel they can open up about whatever concerns they have,which he feared would not happen if he consulted with them in a space in one of his pharmacies. “It’s important to maintain their confidence,”Armstrong notes.“When they feel safe and private, I’ve found that patients will tell me things they haven’t told anyone else.”

Another advantage to an office-based practice is that time management is so difficult in a regular pharmacy setting. “Here, the most important piece of equipment is my clock,” he says. “It’s located over the patient’s shoulder, where I can see it clearly.” Before appointments Armstrong provides patients with an informed consent sheet that details his background, services, and fees. Patients also fill out a detailed history form that they mail or fax to him so he has advance information about their diseases and medications.

Patients are instructed to bring all their medications to the appointment, including over-the-counter items. “You have to be especially vigilant with the elderly,”Armstrong says. “They are definitely the highest users of medications, and they don’t like to give away something they paid money for. By their way of thinking,‘If it helped me two years ago, it will help me now,’ so I want to examine everything.”

To make his time with patients as efficient as possible,Armstrong carefully reviews their history questionnaire, researches specific areas when necessary, puts together a preliminary report, and formulates the sequence of questions to ask in an effort to better pinpoint problems in patients’ medication management.When the patient first arrives, Armstrong takes his or her blood pressure and pulse, then asks questions. “I typically open the interview by asking them to tell me in their own words their reason for being there,” he explains. “It always goes beyond what they told me on the phone.”

As he looks at the patient’s medications, he probes into how they are being taken and why the patient is taking something differently from the directions outlined on the label. “I’ll ask, when did you start this, and why?” Besides teaching them about each medication and providing tips for organizing and storing it, Armstrong provides written information and patient education leaflets.

Armstrong said his office likes to keep notes in the charts and do followups. Sometimes it might involve a phone call, or maybe the patient is to send information back to the office. If a serious problem comes up he will call the patient’s physician, but when things he uncovers are not urgent he will explain to the patient what to mention to the physician at the next appointment and provide written “talking points” as guidance.

Individualizing Therapy

Jenkins’ first appointment with Armstrong last April resulted in a decrease in the number of medications she was taking, as well as reduced costs by switching to a less expensive but equally effective multivitamin.After his consultation, he supplied her with a detailed chart listing her medications and how she should take them—tailoring his recommendations specifically to her eating habits, sleep patterns, and lifestyle.

Through his guidance, Joan changed from estrogen pills to estrogen patches and was able to cut back on the amount of diazepam she was taking. He is currently attempting to find ways to alleviate her allergies and tinnitus. “He’s a problem solver,” an exuberant Jenkins says.“What he is doing is super-important to people like me who are on multiple medications.”

A bright and articulate woman, Jenkins says that one of the most frustrating aspects of her disease is how it confuses her thought patterns.“When you come across somebody like Eldon, who isn’t suggesting invasive procedures, who isn’t trying to add medications but is instead working to replace them or take them away, you are so overwhelmed with gratitude and so thankful you found him.”

Armstrong makes her feel comfortable, she says, and never rushes her or acts as though her concerns are trivial. “Any question I bring up, he immediately starts asking about things I never thought of. He’s a wonderful resource, he’s warm and compassionate, and no matter what silly little question I ask, he never makes me feel it’s not important.” Her physician appreciates having Armstrong’s help with a case as complicated as hers, Jenkins says.

“Anything to help me, he’s all for it, and whatever Eldon charges me, it’s worth every penny.”

Insurance Doesn't Reimburse

Armstrong wishes there were an alternative to having patients pay out of pocket, but he came to realize he might never launch his dream practice if he waited for insurance companies to cover his services. “I’m afraid that the only ones who can access me right now are those who can afford to pay cash,” he says. “The insurance companies have not caught up with the needs of patients, and I could not wait for that to happen.” Patients are free to submit claims to their insurance companies to try being reimbursed for Armstrong’s care, but very few have been successful thus far, he says.

When requested, Armstrong will provide consultations in patients’ homes, but there are additional charges for that, including mileage. On special requests, Armstrong will go into nursing homes without a longterm care contract to conduct medication reviews for individual patients, as long as the family agrees to absorb the costs and there is a signed order by the physician. “I’ve gone into assisted living facilities, I’ve worked with home health agencies, he says….You have to figure out your costs and what you need to operate on.”

When necessary and the patient is willing, Armstrong also prepares detailed reports for physicians for a nominal fee.These are not shared with the patient, because, Armstrong explains, they are based strictly on the patients’ medications and the history he or she provides—which may be incomplete.Therefore, the report involves some guesswork on Armstrong’s part. “It doesn’t represent the patient’s chart completely, and the premise in keeping it confidential is that the doctor will feel more comfortable if the patient doesn’t have a preset expectation that the report will result in a particular course of action. I base the report on the best information I have, but I’m willing to be wrong.”

Armstrong stresses that “it’s not my goal to replace the doctor or his services. My goal is to empower the patient.When I send information to physicians, I might ask questions like, ‘Would you consider running this test?’ Or the document could be taken more in the way of an educational report. Doctors are terribly busy and can be confused by pharmacists who want to be ‘junior physicians.’We need to be respectful of the their turf.”

Many times Armstrong only knows by talking to a patient whether the physician took his suggestions. Recently he learned from a 70-yearold woman with whom he’d consulted that her physician followed every recommendation he’d made to eliminate duplicate therapies. “She saved money by his eliminating two prescriptions and reduced her costs on estrogen, which is a big deal at her age. From a compliance standpoint, the biggest problem I run into isn’t forgetfulness,”Armstrong says, “it’s patients deliberately not taking the full dose to save money.”

Another patient, who takes tamoxifen and an anti-anxiety medication, is so reliant on Armstrong’s advice that she will not follow her physician’s treatment changes until Armstrong reviews them. “This lady told me,‘I’m afraid of medications. I know someone who died from an adverse drug reaction.’” When appropriate, Armstrong will refer his clients to other specialists, such as nutritionists, podiatrists, massage therapists, and mental health counselors.

Volunteerism and Promotion

Armstrong’s philosophy that “there’s no end to learning”works synergistically with his drive to help others and his need to make the most of his knowledge and talents.As a result, promoting his consulting practice fits naturally into activities he’s involved in anyway: public speaking, volunteerism, and networking with other health care professionals.

As an example of how networking can pay off in referrals, Jenkins found Armstrong when she asked her local pharmacist to recommend a speaker. Now, after her successful consultation, she is urging other members of her support group to take advantage of Armstrong’s services.

Armstrong gives speeches to church groups,women’s clubs, organizations for the elderly, and community groups in settings ranging from large auditoriums to private homes. “I always allow plenty of question and answer time, and one answer I’m very comfortable giving when necessary is,‘I don’t know. But I can find out for you.’”

Other promotional tools Armstrong uses are printed pamphlets for the public, mailings to physicians, and radio advertising. He’s already known locally for a two-minute television spot he wrote and produced in the late 1980s for a show called “Your Family Pharmacist,”which continued for three years, and for an hour-long radio talk show he hosts each week.

Armstrong’s story about how he became involved in the radio show illustrates his propensity for recognizing and making the most of opportunities. While serving as a guest on a local call-in show he noticed that the host wasn’t very prepared. He felt he could do better and decided to develop a proposal for a show called “Your Prescription for Help,”which would feature health news, medication information, and guest appearances by physicians.

“We did the first one as an air check, and it was really successful,” says Charlie Benton, sales manager at WISW Radio. “He gets a large volume of calls, and there are always people waiting on the line. He’ll talk about new vitamins, new cures—a wide variety of topics.” Benton says he’s even taken to following Armstrong’s advice about vitamins and diet.“He gives good, practical information, and he’s a good listener. People are attracted to him because of his wisdom and his sympathetic ear.”

Physician Referrals

Sometimes physicians refer patients to Armstrong, especially for his Parkinson’s disease expertise. He has developed medication management protocols outlining specific goals for physicians to sign off on, indicating their agreement with Armstrong’s plan. Once, after putting together detailed recommendations for a Parkinson’s patient and sending it to the physician,Armstrong heard nothing back. So he accompanied the patient, a middle-aged man, to his next appointment.

“[The physician] was not offended at all. He sat down and reviewed the things we’d provided to him, which had been sitting in the patient’s chart. This physician spends a lot of time talking with patients but isn’t very organized, which is why he hadn’t yet read my recommendations. He said, ‘Let’s do this and this and this,’ and I asked,‘Would you consider doing this progressively under a protocol, and allow me to work with the family?’” The physician agreed.

Right now,Armstrong averages three to five appointments a week in his community consulting practice. Clearly, without income from his traditional consulting contracts (e.g., nursing homes, assisted living facilities), he would not be able to continue. “We’re right at that plateau,” he says. “We get a lot of inquiries, but a lot of people feel it’s not affordable. On the other hand, many of the people who use my services actually offer to pay me more money than I charge. It’s been so valuable to them.”

Armstrong plans to keep promoting and building his practice, and to work with other pharmacists to help them establish a similar concept. “My vision is of a network of senior care pharmacists around the nation,” he says. “I think we are already forming that in a loose fashion, but I’d like to see it more formalized.”

The work I’m doing now is the realization of the vision I had more than 20 years ago. “It’s great to be able to bring my dream from 1978 into the 21st century.”  

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