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AAKP Innovator Series: Advancing Kidney Health Through Optimal Medication Management

An Interview with: Wendy St. Peter, PharmD, FASN, FCCP, FNKF

Wendy St. Peter, PharmD, FASN, FCCP, FNKF, is a Professor in the College of Pharmacy at the University of Minnesota. Dr. St. Peter serves as the Director of the AKHOMM Initiative.

Tell us about your most impactful experience with a kidney patient, personally or professionally, and what impressions that left on you as a fellow human being?
Very early in my career as a clinical pharmacist on the kidney care team at Hennepin County Medical Center in Minneapolis, I met an African American patient (JM) who had very poorly controlled diabetes, kidney failure, and was receiving hemodialysis. He was an amazing man with an upbeat attitude despite his medical conditions. JM had a beautiful voice and he used to sing the national anthem at the University of Minnesota Gopher athletic events. I got to know JM through his frequent hospital admissions. Over time, I came to know him so well that I asked him whether he’d be interested in coming with me to help teach in one of my pharmacy classes. I asked him to share his real-life perspective on living with kidney disease with students. I also asked him to talk about how pharmacists could help people with kidney disease manage their medications.

At first, JM would meet me at the college to participate in my class, but over the years, he received several amputations due to progressive diabetes and became wheelchair bound. He still wanted to continue coming to class, so I would pick him up at his apartment and bring him to class. He was a true star at stimulating students’ interest in learning about kidney disease. He was so passionate about sharing his kidney disease journey and so patient with students as they asked him endless questions. I was crushed when one of my colleagues told me he had passed away. His life ended before it should have because of diabetes and progressive kidney disease. 

After JM died, I made a vow to myself to do everything I could to prevent others from traveling JM’s kidney disease journey. This was a time when we had only one medication class (ACE-i) to reduce progression of chronic kidney disease (CKD). Today, we have several proven therapies that reduce both CKD progression and improve heart health. New value-based kidney care models are being promoted by the Centers for Medicare & Medicaid Services (CMS). These care models provide opportunities to engage pharmacists as kidney care-team members specifically focusing on improving patient medication management.

Explain the key objectives of the Advancing Kidney Health Through Optimal Medication Management (AKHOMM) initiative and when was it initiated.
Our overarching mission is to ensure every person with kidney disease receives optimal medication management through team-based care and that teams include a pharmacist to ensure that medications are safe, effective, and can be used by patients as intended. A group of pharmacists that had specialty training in kidney diseases started the initiative in June 2020 after the Centers for Medicare and Medicaid Services (CMS) announced plans to roll out new value-based financial models to improve healthcare for individuals with kidney disease. Given the shortage of nephrologists and nephrology nurses, we recognized that these new care models provided an incentive for nephrology practices to team up with clinical pharmacists. Pharmacists, as part of the kidney healthcare team, can improve patients’ medication and health literacy to help empower them to effectively engage in shared decision-making with their healthcare team. An engaged patient is more likely to understand why they are prescribed each medication and how it works, the importance of sticking to their medication schedule, and knowing what to do if they miss a medication dose. Importantly, the pharmacist can answer any medication-related questions that they may have. Pharmacists can also assist in getting all healthcare team members on the same page about a patient’s medications. Patient and patient advocates are an integral part of our AKHOMM initiative. Everything we are doing from creating continuing education programs for pharmacists and other practitioners as well as developing our Learning and Action collaborative has been informed by the patient voice.

Over the past several years, we have had the pleasure of you presenting on the AKHOMM at several AAKP National Patient Meetings as well as our annual Policy Summits. AAKP appreciates your energy and empathy for patients and their families. Can you tell our national and global audiences how you have evolved into the role as the initiative’s director?
All AKHOMM team members feel so honored to be working with AAKP to advance your mission of educating and engaging patients and care givers, as well as advocating for policies to improve treatment for patients with kidney diseases. The AAKP mission is synergistic with the AKHOMM initiative, and we appreciate the enthusiasm and support that AAKP has given to us! I have also been fortunate to be able to work closely with the National Kidney Foundation and the American Society of Nephrology on a number of initiatives, which has given me a large global network of colleagues, patient advocates, practitioners, educators, researchers, and policymakers that helped me effectively launch this initiative. However, this initiative wouldn’t have gone anywhere without the passion and dogged effort of the multitude of pharmacists, patients, patient advocates, patient advocacy bodies like AAKP, Home Dialyzers United, nephrologists, policy experts, researchers, and workgroup leaders that are involved in AKHOMM. Our initiative grew so quickly that we needed a second person to help lead, and I was excited when Dr. Rebecca Maxson took on the role as Assistant Director earlier this year.

Chronic kidney disease patients and those on dialysis or living with a transplant are prescribed many medications. They must manage their regimen coordination with their doctors and nurses. This can be difficult, and patients may need extra support from their healthcare team to understand and manage what is prescribed. Explain how AKHOMM intends to help patients manage their prescribed medications better and more safely? 

When the healthcare team is large (as is typical for patients with CKD, on dialysis or experiencing a kidney transplant) and medication management is not coordinated between team members, it can be DIFFICULT and EXHAUSTING for patients. Why? because patients find themselves in the problematic position of having to provide that coordination, without having all the medication knowledge needed to determine the best approach. In focus groups, patients have told us that their doctors don’t talk to each other, and they get nervous when they are prescribed a new medication and may not know how it will react in their body with their other medications. Additionally, they may get conflicting advice on their medications from different healthcare practitioners. AKHOMM is advocating that nephrology practices include a clinical pharmacist to work with the care team to provide comprehensive medication management (all medications). We train pharmacists to work with each patient to assess their medical conditions, evaluate each medication, and make sure that each medication is safe, effective, and can be used by the patient as intended. Once the medication therapy problems are resolved and the medication list is up-to-date, the pharmacist can provide that information (and rationale for changes) to the nephrologist, other doctors and other care team members so the patient doesn’t have to be the arbitrator.

We have top-notch clinical pharmacists across the country that focus on working with patients that have many medical conditions and complex medication regimens. But we recognize that many pharmacists don’t have the specialty training to work effectively with patients with kidney disease. So AKHOMM is developing training modules for clinical pharmacists to teach them about the specific critical aspects of kidney disease and the medications used to slow CKD progression and to lessen symptoms common with CKD. Importantly, we are using information from kidney patient focus groups to train pharmacists (and doctors and nurses) on the patient’s need for medication information and how to empower patients to be a part of the team! We also recognize that most nephrology practices and many primary care practices aren’t used to working with clinical pharmacists day-to-day. So, we are also designing and offering a Learning and Action Collaborative (LAC) to help care teams effectively integrate pharmacists and comprehensive medication management into their practice. The LAC will provide mentors and coaches to help healthcare teams optimize and coordinate medication management so everyone—including the patient is on the same page. 

The kidney patient population is very diverse, and many also manage other co-morbid conditions such as diabetes, gout, auto-immune disease, mental health, and more, which also have prescription treatments. Can you explain how and why AKHOMM is training pharmacists for this challenge.
African Americans have a 3.4 times higher risk of developing kidney failure than Whites and those with Hispanic ethnicity have 1.5 times higher risk. We also see higher risk in American Indians and other minoritized groups.

We will never make a dent in the progression of kidney disease unless we address health and medication-related disparities in these communities.

AKHOMM is determined to train pharmacists and other practitioners to address health and medication-related disparities in our kidney community. We obtained a grant to conduct focus groups with African Americans across the country with CKD, on dialysis, or having a transplant. We also conducted focus groups with nephrologists that predominantly had African American patients in their practice. We gathered rich information from patients that I hope to be able to share in more detail at future AAKP national and global meetings. We received great ideas from the practitioner focus groups on working successfully with African American patients with kidney disease. The information from patients and practitioners will be used to create education modules that will be used to train pharmacists and other practitioners on gaining community and patient trust. More specifically, inquiring about social determinants of health, respectively listening to patient’s concerns, understanding patient’s health care goals, understanding what their health literacy needs are, and helping to empower patients to participate in shared decision-making. All our training modules will be reviewed by a diverse Curriculum Advisory Panel that includes several patients/patient advocates to make sure we are addressing patient concerns and issues. We hope to get further grant funding in the future to focus on other minoritized communities with kidney disease.

Currently, pharmacy schools are training students to implement comprehensive medication management. They learn about treating diabetes, hypertension, gout, mental health, and immune therapies. Unfortunately, most don’t incorporate a significant amount of training focused on the specifics of treating patients with chronic kidney disease, having a transplant, or receiving dialysis. About 50% of graduating pharmacy students continue their education by completing a first residency year to improve their clinical skills, and some of those add on a second residency year in a specialty area, such as organ transplantation. Our first set of AKHOMM training modules are focused on expanding background of those pharmacists that have finished pharmacy school, have done at least a first-year residency (or practiced several years) and are board certified in an area of clinical pharmacy. These are the pharmacists that work directly with patients to resolve complex medication therapy problems. Future curriculum development will be focused on community pharmacists and pharmacy students.

As a highly esteemed researcher and leader in pharmacy medicine, you know that it is not easy to develop a fresh and novel approach to enhance care for patients. AAKP members are curious about what you draw upon, internally as a person, to keep your drive, optimism, and focus on patients to get you through the tough task of driving a new national initiative?
I draw upon my experiences with patients like JM, who have inspired me to keep my eye on the ball—which is improving quality of life and health of all kidney patients through optimizing medication management. New value-based financial models in kidney care uniquely provide exciting opportunities to add a pharmacist to the kidney care team to focus in on patients’ medication therapy problems and to help them resolve those problems. Pharmacists are the medication experts. We are trained to educate patients about their health conditions and medications. We have tools to help patients obtain the medications they need and improve adherence to medications. And we can help patients avoid drug interactions, reduce the chance of side effects, and make changes in their medications if side effects occur. Who else is best equipped to complete these tasks? Our patients need and deserve what well-trained clinical pharmacists can do for them. This is what drives me day-to-day.

Final question: AAKP patients think this last question reveals a lot about a person – who is one of your heroes and why?
My heroes are patient advocates with kidney disease that are using their voices to advocate for new therapies to treat chronic kidney disease or symptoms of kidney disease and better kidney care for themselves and fellow patients. I know so many selfless advocates that devote much of their time and passion to making a better and more equitable world for other individuals with kidney disease. They are the heroes.

For more information on the Advancing Kidney Health through Optimal Medication Management initiative:

Dr. Wendy St. Peter is a Professor in the College of Pharmacy at the University of Minnesota. She received her Doctor of Pharmacy degree and adult medicine fellowship from the University of Texas Health Science Center. She was a clinical pharmacist at Hennepin County Medical Center in Minneapolis where she provided medication therapy management for patients with kidney diseases. Dr. St. Peter’s career has been focused on improving medication management and drug safety in patients with kidney disease. She conducts health outcomes research using Medicare and other data sets. She is a co-investigator with the United States Renal Data System (USRDS). She has served on several national technical expert panels for medication-related safety and quality measurement and served on the Board of Directors of the Kidney Health Initiative. 

Watch Dr. Wendy St. Peter’s presentations at recent AAKP events.

Innovation Starts with Research: Including Patients at the Table
Advancing Kidney Health Through Optimal Medication Management: Patient perceptions of pharmacist’s role in their healthcare

Opportunities: Research and Policy on the Horizon Advancing Your Kidney Health Through Optimal Medication Management
(1:12 time mark)

Disease Management: Managing Medications – Pharmacists and Patients Working as a Team

One Year Later – Progress, Achievements, Barriers: Executive Order on Advancing American Kidney Health Initiative (Professional and Industry Perspective) Barriers to Optimal Medication Use