Downtown Doctor Revolutionizes Diabetes Care

August 23, 2012

By Teya Vitu

One day, insurance companies may reimburse clinical pharmacists for treating diabetes patients directly.

Dr. Sandra Leal lives and works Downtown.

When that day comes, credit can go to Dr. Sandra Leal, director of the clinical pharmacy program at the El Rio Community Health Center, 839 W. Congress Street in the Menlo Park Neighborhood.

From this Downtown health center, Leal pioneered the model program for clinical pharmacists to essentially become the diabetes doctor for diabetes patients. Leal’s model is being replicated across the country.

“The model is integrating a clinical pharmacist into a treatment team to put in a pharmacist during the time a prescription is written or before the prescription is written instead of after,” Leal said.

“I have my own exam room. The doctor will refer patients. This is a volunteer program,” she said. “This is where Dr. Arthur Martinez (El Rio’s chief clinical officer) was essential. He convinced the medical staff to take part.”

Leal has worked with about 1,300 diabetes patients since joining El Rio in 2001 and has expanded El Rio’s clinical pharmacist staff from just herself to five El Rio centers now having clinical pharmacists onboard with another one at the Pascua Yaqui Health Clinic.

“I cannot exclusively see diabetes patients on my own,” Leal said. “We always collaborate with the (patient’s primary care) doctor. We really try to work on the chronic conditions so that doctors can work more on acute cases.”

Leal developed more of a team-based care – and the patient definitely is part of the team.

Leal’s model calls for the clinical pharmacist to perform a comprehensive audit of the patient’s charts, lab work, medications, vaccines, tests and any other diabetes factors.

“We address all the standards of care for diabetes,” Leal said. “We give these patients a major tune-up. Ten years ago nobody was doing this to this level of intensity. The results have shown improved health outcomes.”

Doctors and pharmacists can only do so much for the diabetes patient. A lot of diabetes care is up to the patient: insulin injections, eating properly and so on. What Leal has learned in her 11 years at El Rio is that many diabetes patients have paltry knowledge of the condition.

A large part of Leal’s model revolves around patient education.

“About two-thirds of our patients are on insulin,” she said. “In general practice, only one-third are on insulin. The patients are resistant. We spend time and explain to them why they have to do it. What’s the benefit to them. We give them our direct phone number.”

Hospitals across the country have adopted Leal’s model, but insurance companies have yet to provide full reimbursement or recognize clinical pharmacists as primary health care providers.

This revolutionary idea of clinical pharmacists working directly with patients is run-of-the-mill medicine south of the border. Leal learned this while growing up in Nogales, Ariz.

“My parents didn’t speak English,” Leal said. “We always went to Mexico for health care. You walked into the pharmacy and could get treatment. To me, that was primary care. The pharmacist was my doctor growing up. I never considered any other field. I made a decision in high school that I would be a pharmacist.”

Leal does not live in the Foothills or Sam Hughes Neighborhood. She lives in Barrio Viejo, is more likely to speak Spanish on the job, and likes to wear Mexican dresses.

“I spend about 60-70 percent of my day speaking Spanish,” she said. “Not because they don’t speak English, but they may just feel more comfortable with Spanish.”

Tucson was just up the road as she was growing up in Nogales.

“We used to come to the big city,” she said. “I said I want to live Downtown some day.”

That day came while she was still in residency at the Southern Arizona Veterans Administration Health Care System after her earning her pharmacy doctorate at the University of Colorado.

Leal bought a small plot of land and built an exposed adobe house with a flat roof and wood ceiling. An old door she found at a 4th Avenue shop serves as the dining room table.

“There was no house on it. I had this built about 12 years ago,” she said. “It’s perfect. I work a mile a way. I’m at the university a lot.”

Her eight-year-old daughter, Soli, adores their modest, 1,500-square-foot house.

“She always says ‘You built the perfect house,” Leal said. “We have the perfect view of A Mountain. This is the perfect place for friends to come and watch the fireworks.”

Leal finds that she can get a lot of what she needs for day-to-day life in Downtown.

“It doesn’t bother me,” she said. “I put it in perspective. A lot of people have to drive many, many miles to get to work. We use the 17th Street Market. We love to go to South Tucson to Food City. We love to go and try new restaurants all the time. Café Desta is one of our favorites right now and it’s so close.”

When she came back to Tucson to do her residency, she had not heard of El Rio. She got a pharmacy job at University Medical Center and the next year saw an opening for a clinical pharmacist at El Rio.

“My ultimate goal was to end up in an ambulatory care clinic,” she said. “They said ‘We want you to start a diabetes clinic. That’s where we want to improve our care.’”

That position came only with a two-year grant. She continued to work at UMC two weekends a month and as a Walgreens pharmacist the other two weekends.

“I always had a Plan B,” Leal said.

Her position continued to get funded, these days subsidized by the El Rio Health Center Foundation. Still, until the insurance industry covers medical care provided by clinical pharmacists, Leal will have to rely on grants and subsidies.

But from the start, she has had Martinez and Tony Felix, director of pharmacy, on her side.

“They let me do what I needed to do,” she said. “They didn’t have any restrictions. They allow me the opportunity to be creative.”