Dave Dixon
Welcome to Voices in Pharmacy Innovation, the podcast where we spotlight bold ideas and groundbreaking practices that are transforming pharmacy practice and healthcare care delivery. I'm Dave Dixon, professor and chair at the Virginia Commonwealth University School of Pharmacy and core faculty member of the Center for Pharmacy Practice Innovation. In each episode, we'll sit down with pharmacists, healthcare care leaders, and change makers who are rethinking how pharmacy can improve patient care and push the boundaries of what's possible in our profession. Together, we'll share stories, explore new models of practice, and amplify the voices driving pharmacy innovation forward. Today, I'm thrilled to have Dr. Tana Kaefer with us on the podcast. Dr. Kaefer is Director of Clinical Services with Brimo Pharmacies. She's at the forefront of innovation and community-based pharmacy practice and a fierce advocate for advancing pharmacist roles in community settings. If you didn't listen to last month's podcast, I highly recommend checking it out before listening to this episode as we had Dr. Salgado on who gave a great overview of the current status of some of the issues facing community practice and what's happening particularly here in Virginia. But our conversation today with Dr. Kaefer will be from the boots on the ground perspective. And I can think of no better individual to have on to provide that perspective. So Tana, thanks so much for joining us on today's podcast.
Tana Kaefer
Thank you so much for having me. I'm excited to be here and and share some some, maybe some best practices.
Dave Dixon
Fantastic. So before we jump into your work, can you tell our listeners a little more about your background?
Tana Kaefer
Absolutely. So I am born and raised pharmacist. My dad was actually an independent pharmacist in my hometown. So I grew up um in the pharmacy setting and didn't know I wanted to be a pharmacist. That kind of came later in high school. And then I decided, yeah, you know, this, I saw how my dad was taking care of the community and that, and being that pillar in the community. And that seemed exciting to me. And so I decided to go to pharmacy school. And actually in pharmacy school, I wanted to do everything but community practice, not because I didn't love community practice, but because I wanted to make sure that was my place. And so a lot of my rotations were acute care, lots of different hospital outside of community. And really what I found was I like taking care of people longitudinally. And that community practice was my way of doing that. And so seeing patients through the continuum of their life, taking care of not just them, but then their kids, their pets, all of those things. So I really embraced community pharmacy again and decided at the very last minute to do a community-based pharmacy residency. And anytime I'm in front of an audience, I'm that might not be familiar with that. I I like to push that community-based residency changed my career immensely. I would not be where I am today without that experience, that year of experience into diving deeper into community practice and really learning not just how to be a clinician, but how to also integrate the business sense into being a clinician. So that really set my career on fire for me. And I did my residency at Brimo Pharmacy. And I happened they happened to have an opening when I finished my residency. And I have been there now for 22 years. And as you mentioned, I'm the director of clinical services. So I oversee all of the clinical services that are happening ah um amongst both of our locations. So we have a community-based pharmacy. And we also have a long-term care pharmacy as well.
Dave Dixon
That's fantastic. I think that's an incredible origin story, if you will, for how you got into pharmacy and eventually getting back into community practice. And I think it's also important to mention, Tana, where did you obtain your PharmD degree and where did you complete your residency?
Tana Kaefer
Oh, yes. Virginia Commonwealth University.
Dave Dixon
Oh that's right. That's right.
Tana Kaefer
Yes. Yes. I remember interviewing with VCU and actually they were the only school that I applied to. And they said to me, why are you only applying here? Or what makes you want to apply to VCU? And I was like, well, this is the only place I'm applying. And they're like, wow, that's like putting all your eggs in one basket. And I was like, well, I like to say it's putting all your eggs in the right basket. So it it worked out very well. And I continue to enjoy the ongoing relationship I have with VCU. It has also driven my career in a positive direction. So thank you again for having me and and being a role model to me, Dave.
Dave Dixon
Phenomenal. I had to get that plug in there. So let's transition and and take a deeper dive and learn a bit more about your work and what you're seeing in practice. So maybe as a good starting point, tell us a little bit more about Brimo Pharmacies and and walk us through what a typical day in your role looks like.
Tana Kaefer
Yes, I wish there was a typical day. And there is not. So I I manage a lot of moving parts, right? So I do a mix of administrative, you know, program growing programs, um trying to find different programs to bring into the pharmacy. And I have a very good mix of patient care with things that I do. So I have some contracts with employers where I do chronic disease state management. um I do pharmacogenetic testing. I do hormone consulting. A big part of my job at BRIMO is precepting. So I precept not only IPPE and APPE students, I also precept our PGY1 community-based resident. So that takes up a lot of my time. And basically, anything that I can do that helps sustain this business model of paying my salary and also allowing me to take care of patients. So no day is the same, I will say. And it really changes um depending on what's happening. One of the things that I've gotten really good at over the years is being able to pivot. when things that we have been doing stop working or, you know, new opportunities come our way, being able to pivot very quickly to be able to to implement some of these things into our practice. um So that's, it's, there's a lot of moving parts for sure.
Dave Dixon
Yeah, I can imagine that each and every day is a bit different. And I know that, as you mentioned, you're involved in quite a large number of clinical programs, which I think is really terrific and illustrates the variety of opportunities that do exist in community practice. And certainly there's the clinical knowledge is is a big part of that. But I also got a sense that some of the the business aspects also matter significantly. Maybe if you would kind of expand on kind of the the the importance, particularly for our ah students or trainees or early career individuals that might be listening thinking back to to pharmacy school and some of those business type courses that maybe weren't as as interesting or thrilling at the time. But maybe if you would just kind of expand on ah the value of that and and how that plays a role in your day to day.
Tana Kaefer
Absolutely. So I will just say up front that VCU prepares students because I take their students on rotation. They are the some of the best clinicians I've worked with. And so the clinical knowledge is so important to to get that in school. But as you mentioned, that business side, we can't you can't do everything, right? And those APPEs, those residencies um really help develop that knowledge. So I grew up in a family-owned business, but I won't say that, I mean, maybe that set me apart in the beginning a little bit, but I don't really recall being super involved in a lot of those business decisions. But as I've come to Brimo and they really just started from our founder really, embracing the concept of pharmacists providing care. And yes, we have this dispensing side and that's not going away, but how do we pull those pharmacists into really providing the care? This is when, you know, the PharmD became mandatory and all of that. Like we have this great sense of knowledge. And what I feel like is the secret sauce of my community-based residency is the fact that not only did I become a great clinician and have a lot of guidance and how to take care of patients and practice-based guidelines and all of those, but it taught me the inner workings of how to start something how to grow something and how to sustain something. And I think that that's something that we don't see in some of the other residencies because, you know, students get put into a place that's already set up. They have no idea how they're getting paid. They have great clinics and great opportunities and they become awesome clinicians. But then when they go out and try to create a job or create an opportunity, which is what I think a lot of students want to do, right? They have this this drive to take care of patients, but they don't know how to get paid to do that. And so I feel like community-based residencies really are that secret sauce of teaching you how to implement a business model and how do you coach your staff members to be excited about new programs, right? You can't be a team of one. You have to engage the the whole staff. And so that takes a lot of leadership and management experience. And that's a lot of what we focused on during my residency. And then, of course, as I continued with Remo, that is a huge core value is growing as a leader and and managing effectively. So that during school, learning those little concepts, but then practicing them became really the the secret sauce, really, with um trying to to understand that, yes, I love providing patient care, but I can't do it for free because no one can pay me as a pharmacist to do that. So what do I need to do to market myself and to market my services so that I can sustain my job as a pharmacist here?
Dave Dixon
Yeah. Well said. And I think that's a good segue maybe to talking a little bit about what what kind of services or what opportunities are out there that could potentially be revenue generating. you know what What are the opportunities on that side of things? Again, the dispensing, that transactional relationship, it's always going to be a part of pharmacy practice. It's an important part of pharmacy practice. But thinking about those other types of services that you're providing, What what advice would would you give someone, again, looking to sort of maybe build out these services? Where where should they start? What does that revenue generation process look like?
Tana Kaefer
So, Dave, something that I'll bring up here is my partnership and my involvement with CPESN Virginia, which is Community Pharmacy Enhanced Services Network. And Virginia has a network. And without going into the details of that, they have really helped drive and are driving a lot of what I'm getting ready to talk about. So one thing is having a synchronization program within the pharmacy. So not only does that allow us to manage our inventory and manage our staff of when we're going to be filling prescriptions, but it also allows us to have a cohort of patients that then we can tap into and talk about these other clinical services that we have to do. So, for example, um we at BRIMO, we have been my entire career very involved in immunizations and not just adult immunizations. Now we are a VFC or Virginia Vaccines for Children's provider. um We also have a very robust travel pre-travel health clinic. And so by And realizing the gaps in our patients that are are currently our patients, we can easily review their immunization status. We can see where these gaps occur. We can target them for certain immunizations based on their medications, based on their disease states, you know, based on other things that might be going on. so I feel like our synchronization program has been the core of all of our other clinical services because those patients are not tied to our pharmacy, but loyal to our pharmacy, right? Because we fill all of their medications. We package them. We deliver them in certain situations. and so And we get to know these patients because we talk to them every month. So it's not just a transactional, here's your medicine. It's very much what has changed? Have you been to the hospital? What transitions have you had? And then we can, using technology, target certain care plans for these patients based on these changes that have happened, whether that be an immunization care plan or whether that be gosh, they had a change in their hypertension medication. So should I trigger a plan to follow up with them about what their blood pressure is? Do they know what their goals are? um So like the synchronization program is really the anchor to what we're doing. And and the reason I brought up CPESN is because they are really jumping on board with this now to try to help save some of these community pharmacies who maybe dabbled in sync, but didn't really go all in. And I will tell you that when Brimo went all in on sync 15 years ago, not sure the timeline, we had significant growing pains. Significant. I mean, we ended up replacing our staff maybe one or two times, basically, with getting the right people in the right positions with the right mindset to really embrace this model because it was it was not an option. It was a, you have to be doing this if you're going to survive in pharmacy. And so I feel like CPESN is driving that even better now. They have a lot of data that they're pushing out to pharmacies based off of their dispensing information and what patients they should specifically be targeting based on fill history. So this is all work we did a while ago. And now I feel like other pharmacies are realizing, wow, this this this is the anchor to all the other clinical programs.
Dave Dixon
Yeah, I couldn't agree more. I think the patients that I see in clinic that are participating in medication synchronization programs are undoubtedly have better adherence and are more engaged in the health in their health and managing their chronic diseases. And even in some of our clinical practice guidelines, thinking back to the new hypertension guidelines that came out last fall, medication synchronization is discussed several times in the guideline as a key strategy for improving adherence. So I'm kind of glad to see that's happening. So We have to not just continue to educate the public about this resource and getting more pharmacies on board, ah but also think about the the prescribers and and other healthcare professionals to increase awareness that that that valuable resource is available.
Tana Kaefer
Absolutely. and And I love that you bring in the providers because that's a lot of education that we provide and how will we take care of patients differently. So we're not just autofilling their meds every month. We talk to these patients every month. When there's changes, we're communicating, hey, you need to stop this medicine. You need to start this one. This one needs to be pulled out of your bubble pack. you know, those types of of operational things that make a big difference, right? I mean, yes, those higher level clinical programs are awesome, but if patients aren't taking the medications that we're prescribing, they don't understand the importance of managing their disease states, then we've missed the ball.
Dave Dixon
Completely agree. You mentioned prescribers. So good segue to kind of talk about how do you try to build and maintain relationships with prescribers in your community? And I know that that can be a challenge in our healthcare system. at times can be quite fragmented. So I'd love to hear any tips or tricks that our listeners could could use to try to build those relationships.
Tana Kaefer
Yes. And so this year, actually, BRIMO is celebrating its 50-year anniversary. So we've been in the Richmond area for 50 years in 2026, which means that we've been around for a long time. And so our name is out there and prescribers know that we are doing things to take care of patients differently. So I think that our longevity here has has certainly helped. And also, we are able to identify when we see certain things happening in the pharmacy, what are pain points for these prescribers? So we don't necessarily go to them with programs. It's, wow, I can tell this is a pain point for them. How can we change what we're doing to better assist them? And I will say that it is It's much easier to work with independent prescribers, so so ones that own their own practice. And something I'm excited to to continue to work on is mid-level practitioners that are now able to have their own practice setting, and we can get to that later. But figuring out what their pain points are. And to give you an example I mentioned we have a very robust pre-travel health program. And so we have providers that, you know, will refer patients to us. And while we're able to do the immunizations under our statewide protocol, a lot of the malaria medications, traveler's diarrhea, those types of things, we need to have a prescription. And so we found that these providers that were referring to us frequently Why don't we set up a CPA with them? Then that way we don't have to bother them every single time we have a patient that needs these medications and we're going to do it under, you know, specific guidelines. And so really it's determining what what they need and how can we help. And some other examples, we have invested in a marketing person at the pharmacy that This used to be a pharmacist. Now it's a pharmacy technician. And this person gets out into the community and goes to business networking meetings and determines what are these practice providers needing. So these practice managers go to these meetings and they talk about their pain points. Well, what can BRIMO do to help with these pain points? That's how we've gotten new partners with pharmacogenetic testing. That's how I've grown some of my hormone consulting and certainly how we've grown our senior care and synchronization program. Like we're here to solve problems.
Dave Dixon
I love that. And I love the idea of finding the pain points and finding ways to help our colleagues' lives be more, you know, easygoing in terms of trying to navigate patient care and focus on on what they do best and and their role, you know, within the healthcare system. So I really like that approach. You've mentioned statewide protocols a couple of times, so I want to make sure we we talk about that. So if you could give our listeners a sense of of what's been your experience in trying to implement the statewide protocols that we have in place here in Virginia and your experience from the payment side of things, which of course is always front and center anytime we have new clinical opportunities.
Tana Kaefer
Yes. The statewide protocols, I am very excited where our practice is going in Virginia. I think we are advanced compared to other some other states and then behind as we compare to some states. So the statewide protocols have allowed us at BRIMO to certainly streamline our immunizations where we can do this under the pharmacist MPI. We don't need to worry about updating our protocol with the Board of Nursing. you know, that was the previous way to be able to give immunizations and community practice And so the statewide protocols for immunization have been a game changer for us, for sure. The other statewide protocols, um so naloxone, you know, the test and treat strep flu, I will say that I'm frustrated in how slowly it's being Patients are being aware that we have this available and are are wanting to to utilize these services. And then I think back to sometimes you're ahead of the game, right? Sometimes you're just so forward thinking that it's too early to start something and you just got to wait to the right time. And so I feel like As we continue to work through these statewide protocols and as we refine them more to where they're more user-friendly for pharmacists and more guideline-based versus very stricted with what we need to do, I think that it's going to be a great thing because of the shortage of primary care in and Virginia. Now, we had a grant where we were able to offer test and treat as a free service at Bremo. And we had very few patients take us up on this. And so when I think back to when immunizations were first introduced into pharmacy practice back in like 1998, which, by the way, I was in my dad's pharmacy when this happened. And I remember ordering flu vaccine and I remember ordering five vials of flu vaccine and us being like, wow, I hope we can give all of these. wow And now, oh my gosh, five vials, 50 doses. I can do that in 30 minutes, right? And so from 1998 to now, look where we've come. I mean, pharmacists are owning the immunization space. And so I also think that growing pains with the test and treat And I I do want to answer your question a little bit more about payment and what Dr. Salgado talked about as far as getting pharmacists credentialed. At BRIMO, we were on board with this, and we knew that there were going to be growing pains. And we knew that there wasn't going to be immediate payment and support for another pharmacist to do this. But also You have to have that belief that pharmacists were meant to do this work. And if we don't invest in it now, you have to spend money to make money, right? And so you really have to invest in that idea that pharmacists are going to go into this role. And BRIMO has always had that vision, right? And so we got all of our pharmacists credentialed. We can do any of the protocols now. But now we don't have the patients. And so patients, meaning patients coming into our pharmacy, like physical people um that want to have these services. So we invested in a platform to bill for medical billing. And it has it has paid for itself over, I will tell you, um because of the amount of immunizations that we do and some of our DME that we bill through this platform. But it's a learning curve. Right. And it's something new and it's difficult and it's hard. And I always tell my team, we're trailblazers. We're the ones that are going to identify all the problems because we're the ones that are trailblazing. And so, yeah. Lucky for us that we're on this forefront of doing it, but also unlucky for us is that we're the ones that identify all the problems and hopefully solve them before other people have to to go down this trail. um And that's the work we're willing to do because that's the belief we have. And this is where pharmacy practice is going and specifically community practice is going. Did that answer your question?
Dave Dixon
Absolutely. And I think that change is hard, right? It's difficult. It's messy. And there are other external factors going on within you know the healthcare system from a a policy perspective and, of course, related to payment. And we're also going to be dealing with this growing shortage of of primary care. And so I think pharmacies like Bremo, like the work that you're doing, is just really critical in terms of laying that foundation to ensure that in the future that we can provide health care to people. Because otherwise, I think there's going to be a lot of folks falling through the the the cracks.
Tana Kaefer
Can I make another comment that folks that are listening and, you know, gosh, well how is Brimo doing all these things? I think it's important to note that we didn't start doing all of these things, right? This is something that it it started with a vision from our founder, Dan Herbert. He passed away during my residency and his daughter, Catherine Carey, took over Brimo. And really, she had this vision of what pharmacists were going to look like. And we've stumbled along the way. We've done a lot of things that didn't work. But really, what our core goes back to is our core values. Like, what are our core values and how do we live towards those core values. And a lot of that starts with, do you have the right people on your team? Because we realized when we started some of these programs, we did not. And so we had to have tough conversations and tough decisions. And really, it hasn't been easy, but we've stayed our course and stayed true to our core values and and where we want to see pharmacy practice go. And a lot of that is from the leadership that we get from from Catherine and the the management team at Brimo so that we understand what our goals are. Right. and And everybody understands what our culture is and realizing that some people don't fit into that culture. Toxicity can be, you know, can spread through a team very quickly, right? And so we have to, we have been very diligent over the years to make sure that not only do we invest in our support staff and our team, but also we make sure that their goals and vision align with our core values. And that's a big part of how we've been successful is getting better at hiring smarter, right?
Dave Dixon
Yeah, that's certainly a critical aspect. And you got to have everyone on the boat rowing in the same direction, right?
Tana Kaefer
Correct.
Dave Dixon
Well, thank you for walking us through kind of your experience, some of the successes and challenges along the way. And again, thank you for sharing so much with us. Before we close out, I do have a few more questions here that we like to ask our guests. So what resources have you found most influential in your thinking about innovation and pharmacy practice?
Tana Kaefer
So I have a lot of organizations um that have been very influential in my pharmacy career. I already mentioned CPESN, certainly VCU, CPPI. We've done work together in the past, APHA, NCPA, and really all of these kind of their theme is going outside of our current state to get ideas and really talking to thought leaders across the country. And second, investing in education, investing in sending your staff to these meetings where they can, wow, this is happening somewhere else. And maybe it can't happen exactly like this in Virginia, but it sparked an idea in me of what we can do. So I'm one of those people, I don't think about what can't work. I think about what can. So what pieces can we take from what these innovators across the country are doing and bring it back to our practice to grow and be better? And I think you have to leave your own four walls and and your own and your own state sometimes to realize that there's so much out there that we don't know. and there's so many clinical pearls that we can take from all of these practice settings. It's been the reason that I personally have been so successful in finding clinical programs.
Dave Dixon
Love that. Definitely professional networking and love the the idea of really getting out outside of your comfort zone and be willing to to try something new. think that's a great, great idea. How should pharmacy education and training evolve to prepare students for practice in this changing landscape?
Tana Kaefer
Well, I kind of already alluded to it early earlier. So as I mentioned, I feel like pharmacy students have amazing clinical knowledge. I I am always amazed when they come into my practice site and the things that they're able to do and synthesize and look at primary literature and break it down. I just it it is It's very rewarding to see the education that these students are getting. and Now, again, transitioning to how they integrate that knowledge and expertise onto the healthcare team. So how do I pay for myself? How do I get paid? This job that I'm doing, what does that look like? And are there billable codes that I can do? So I think we don't talk enough information. well, not when I was in school enough about this medical billing piece. I mean, that's really a huge place that pharmacy is going. And maybe that's collaborating with providers. But maybe as we continue to grow in this test and treat and statewide protocol place, maybe there's codes that pharmacists you know, can bill more readily with other plans besides Medicaid. And so we are providers in Virginia, and that's been going on for quite some time, longer than I've been a pharmacist, but we don't really capitalize on that. And I think that pharmacy students need to realize that that's available and they need to understand that medical side and how they integrate into that piece. Because having a team without a pharmacist is I don't even have an analogy for it. I'm like, how how do you function? you know, I'm not sure because because of that expertise that we bring. And so I I know the pharmacy students have that knowledge and they're so beneficial with that. Now their thinking needs to transition to what's the payment piece. If you don't understand the work you're doing and how you're getting paid, you can't grow that position if you're not understanding where that money is flowing from.
Dave Dixon
Couldn't agree more. Our last question. So what's something you're looking forward to in the next six to 12 months? And this could be personally or professionally. I know you travel a lot, so I don't know if you want to clue us into any of your upcoming travel plans.
Tana Kaefer
So no, no upcoming travel plans. However, I will tell you that my son, and this might make me a little emotional, he's going graduating in a year. So I can't even like imagine that. So really focusing on college visits and what is he going to do with the rest of his life? And, you know, right it's crazy to me. I put his graduation date on my calendar and I, I literally just stopped and was like, wow, I can't believe we're we're at this point. So personally, that's kind of where I am. Professionally, I will tell you something that's on my goal list this year is really trying to engage with mid-level practitioners. So we know that nurse practitioners can practice on their own and they have been wonderful partners for us. And so I'm interested in collaborative practice, remote patient monitoring with a lot of these mid-level practitioners because a lot of them are independently practicing, right? So it's hard for us to get into these huge health systems, even though the providers want us there. However, with these mid-levels, I feel like there's a lot of potential and I am very excited to see where those relationships go in the future.
Dave Dixon
I think that's a great idea and and a great way to kind of close out here. Tana, I want to thank you so much for taking the time to share your perspective and your passion for community practice, which again is really the the core of of pharmacy practice and honestly the core of healthcare, care in my opinion. um Please let our listeners know where they can connect with you to learn more about your work.
Tana Kaefer
Absolutely. You can check out our website. So bremo, B-R-E-M-O-R-X.com. And you can connect with me via email. My first name, Tana.kaefer at bremoRx.com. And we'll put that in the show notes for our listeners as well. We also are on Facebook, Instagram, um and LinkedIn. So you can find Brimo and follow us. We have lots of fun posts and ideas, and you can really get to know who we are as a company.
Dave Dixon
Fantastic. Well, thank you again. And I want to thank our listeners for tuning in to this episode of Voices in Pharmacy Innovation. If you enjoyed today's episode, please subscribe, share it with a colleague, and join us next time as we continue to spotlight the innovations that are shaping the future of pharmacy practice and health care. Thank you for listening to today's episode. Voices in Pharmacy Innovation is published monthly. You can listen on Apple Podcasts, Spotify, or by visiting our website linked in the show notes. If you have any questions or comments, you can contact us through our email cppi at vcu.edu. We appreciate your engagement and look forward to having you join us next month.