Dave Dixon - Intro
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 leaders, and changemakers 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. Crystal Zhou with us on the podcast today. Dr. Zhou is an associate professor at UCSF School of Pharmacy and director of community-based practice innovation.
She is also the lead pharmacist of the Cut Hypertension Program, which will be the focus of today's episode. Hypertension remains the leading contributor to morbidity and mortality worldwide. Yet only about one in four adults achieves adequate blood pressure control.
The burden is disproportionately borne by Black communities, particularly in underserved areas. Today, I'm pleased to welcome Dr. Zhou to the podcast to discuss the Cut Hypertension Program, an innovative community-based model that leverages Black barbershops and salons as trusted spaces for health promotion, outreach, community engagement, and hypertension management.
Crystal, thanks so much for joining us on today's podcast.
Crystal Zhou
Thanks so much for inviting me to be here. I have been wanting to chat with you for some time, actually, about the CUT Hypertension Program, so I am very excited to have you on today.
Dave Dixon
Before we jump into that, I would love to hear a bit more about your background and how you got into pharmacy and found your way running this program or being involved in this program.
Crystal Zhou
Sure. This probably goes back to my undergraduate career where I went to Guatemala on a medical mission. And during the medical mission, I was one of the only people who didn't know how to speak Spanish.
And so they didn't allow me to work with the patients directly in the patient care rooms. And instead, they put me in the pharmacy that they had built. And I was handing out, I don't even know what it is now, but they were deworming pills. That's what they told me back then.
And so I was handing out these pills to all of these patients who were coming through, and I just felt like I was being really helpful. This was like a cure pill for them, and everyone was so thankful for being able to get that. That's actually what started my interest in pharmacy. And so I went on to complete my PharmD degree at UC San Diego, and then completed a first-year PGY-1 residency at UCSF and a second-year ambulatory care residency at the University of Washington. And actually this job at UCSF is my first job out of residency. And I just knew ever since I completed my second-year residency that I wanted to do some more community-based work. Whatever it was, bringing pharmacy or healthcare into the community, I wanted to be someone who was out there and bringing healthcare into the field.
Dave Dixon
It's really fascinating that your start was sort of with global health outreach projects. I know that's something that most schools of pharmacy, including ours, are heavily involved in. And it's such a great opportunity for students to get to meet and interact with individuals that come from different backgrounds. And it's really, really cool that's kind of what inspired you.
So let's jump in and learn a bit more about the Cut Hypertension Program. So maybe as a good starting point, if you could just tell our listeners how the program began, where did it start?
Crystal Zhou
Sure. So the Cut Hypertension Program is definitely born out of evidence that Black barbershops can be community-based places of healthcare and health promotion. And the space actually really builds upon the relationship that the barbers have with their current clients and that trust that's been built over years and years of cutting their clients' hair.
And so because of that relationship, we decided to leverage, hey, there is this existing relationship, a lot of trust that the clients have in their barbers. Why don't we train these barbers to become health coaches and actually educate their clients on high blood pressure?
And we chose high blood pressure because that's one of the published studies that said blood pressure management within these barbershop spaces works really well when you put a pharmacy in connection with the barbers and work together with their clients.
And so our program, the Cut Hypertension Program, has since held at least five different health coaching sessions, and we've trained over 60 barbers to become the health coaches in the Bay Area.
And that spans San Francisco all the way to Vallejo. Actually, Sacramento is our farthest site. So we've trained all of these barbers who either own or work in certain barbershops and are willing to engage their clients in health promotion, healthy eating habits, healthy lifestyle habits, and talk to them about their blood pressures.
In fact, their role is to check the blood pressure of everyone who walks in the door that's willing to get their blood pressure checked. And then when they catch someone who has high blood pressure, that's where I come in and do the management within their shops.
Dave Dixon
Such a clever idea. I mean, especially you mentioned trust, right? And I think that there's, I think we would all agree that the person that cuts our hair is probably one of the most trustworthy people that we interact with, right?
I know I've had my own experiences where I go in and they have a trainee and they offer, you know, a discounted price. And I'm always like, I don't know. But I think that's just such a clever idea. And obviously, trying to meet our patients, you know, where they live, work, and play in the community, right? Exactly. So you mentioned your role as the pharmacist. So I'd love to hear a bit more about your role as the lead pharmacist in the program and how this work might differ from a traditional ambulatory care or community pharmacist role.
Crystal Zhou
That's a great question. I think there are many similarities, but also many differences in my role. So I do treat myself as an ambulatory care pharmacist when I am in the barbershop space. I'm still managing hypertension. Sometimes I have to talk about other chronic conditions like diabetes, gout, asthma, or COPD as they come up because our patients do tend to be complex.
But what's very different is I don't always get to review the electronic medical record when a patient walks in. So with these barbershop community spaces, they're open to all comers. So it could be a Kaiser patient. It could be a county patient. It could be a UCSF patient.
And I'm not connected with the EHRs for all of these institutions. So what I have to do is basically start from scratch when I first meet the patients, figure out exactly where they get their healthcare, where their primary care home is, and then from there start to piece together their health records, their comorbidities, the medicines that they're taking. So it's a bit more complex than working within a health system as an ambulatory care pharmacist. I feel like I'm an ambulatory care pharmacist, but also a detective part-time trying to figure out what else is going on, which is part of the fun of the work that I do. And I'm also really excited that I get to offer these services to some patients who don't have insurance or they do have insurance, but they're not connected with a primary care home. And so part of our job as the Cut Hypertension Program is we find their primary care home for them. We try to help them schedule an appointment with their primary care so that they are engaging with primary care because I have to collaborate with their primary care providers in order to manage the hypertension.
Dave Dixon
Okay. So, yeah, that's definitely quite a challenge having individuals from many different backgrounds, different health systems, et cetera, folks without insurance. So, yeah, I agree. I think if you're going into ambulatory or in community practice, you have to be part detective, right? I think part detective and maybe even a minor in psychology might be helpful.
So maybe it would be helpful to kind of walk through, I think you mentioned a little bit about a typical patient interaction, but maybe from the context of the program, maybe give us a sense of what does that look like?
Crystal Zhou
Sure. And so the first time I meet a patient, it's usually after they've been screened by a barber. So the barbers are regularly checking the blood pressures of their clients. They fill out a Qualtrics form for us that's secure.
And if the blood pressure is over 130 over 80, it basically pings my team on the back end. So one of our coordinators will reach out, they'll call the patient, schedule them and say, hey, you know, when is your next haircut? Because we're trying to schedule you your haircut with an appointment to see our pharmacist for your high blood pressure.
And so there's a lot of jigsaw puzzle going on here with the different schedules. But eventually, they'll coordinate a time that the patient or the client is in the barbershop, but I'm also there seeing patients. So I meet the patient for the first time. And like I said earlier, I'll do a very extensive intake to figure out exactly what's going on. Am I able to prescribe?
And so I do have a collaborative practice agreement with one of our community health centers. It's Roots Community Health Center. And so my collaborative practice is actually under the supervising physician for our program there. And everything I do, I document in the Roots Community Health Center electronic medical record, and then we forward it to their PCP as a means of communication. So all the interventions I'm doing, even lifestyle modifications, I'm documenting as a SOAP note.
And then either I will print it out for the patients to take with them, or if I have access to the provider's email, or maybe it is a UCSF patient, I can then send it as a secure message to their PCPs. And that's how the encounter at the barbershop is included in their electronic medical record. And so I'll see these patients probably every two to four weeks, especially if we're doing active medicine titration. And once they're more stable, it's probably every month until we get them consistently to a goal blood pressure of less than 130 over 80. And then they graduate from our program.
Dave Dixon
That's great. So I love the communication aspect, right, in closing the loop with the other care providers, right? Because I know that's often a concern and understandably so. And so I think that's a really important piece.
One aspect that you mentioned is the collaborative practice agreement, medication management. How does laboratory monitoring work, right? Because I'm sure that's something that outsiders looking in might ask, you know, how are we ensuring safety with some of our antihypertensive classes, of course, our ACEs and ARBs, where we have some routine monitoring for those medications. So how does that work?
Crystal Zhou
That's a great question. So we basically borrowed the idea of point of care, Chem 7 testing, from the original barbershop study that was published in the New England Journal of Medicine. So if patients don't have health insurance or they live really far from a laboratory, what we'll do is bring in an i-STAT machine.
So they use these i-STAT machines. It's about the size of a brick. It's very large. And we draw a point of care blood from their finger. We put it into a cartridge. And then this machine gives us the Chem 7 values. So if patients are taking ACEs or ARBs or thiazide diuretics and I'm actively titrating them in the barbershop, then we can check a lab at the next visit.
But I usually recommend if they are connected to primary care, they have a regular lab that they go to, that they actually ask their primary care providers for a lab order. And that's just another way to engage their primary care providers. Like, hey, your patient is going up on their hydrochlorothiazide. It's time to check a lab and make sure everything is still safe. So I prefer that. And that's also what patients are most familiar with. But if there's no other way to get the lab, then we'll do the Chem 7 in the barbershop.
Dave Dixon
Yeah, that's a great strategy. And again, I love the idea of looping in the other care providers and getting them involved. Another question related to sort of the operational piece, what does the no-show rate look like? Would you say that patients are more engaged because this is a setting where maybe they're already going there anyway for the next haircut or again, a more accessible location within the community? What does that look like?
Crystal Zhou
Yeah, and this is a question that we are trying to solve and problem solve every single day. But the no-show rate that I've experienced depends on if it's an existing client of the barbershop versus a new client that we are trying to bring in.
And so let me take a step back here because the original barbershop model that's evidence-based and that's published is actually using patients from their own barbershops. So existing clients who have been going to their barbershops for 10, 15, sometimes even years.
They're very established. They do not miss a haircut. They will be there every two, three, or four weeks depending on their haircut. So we found that existing clients who have a very longstanding relationship will seldom miss their appointments. They are almost, I would say, 95% there unless there's an emergency that happens.
For patients that we have been trying to refer from clinics, those patients tend to have maybe a 50-50 chance of a no-show. And I think there are many reasons for that.
One is it's not a routine that they're used to going to this barbershop. They're not really familiar with the barbers there. The other thing I've discovered is a lot of people now, especially post-pandemic, cut their own hair. Or they've had someone come to their homes to cut their hair or style their hair for them. And so this concept of going to a barbershop is pretty foreign for them, even after just five years or so.
And so the no-show rate tends to be a little bit higher. And the reason why we are even entertaining these clinic referrals is because we found that when you start working with a barbershop, they have a good amount of existing clients with hypertension. But over time, because it's the same clients, the number of people that enroll in the program plateaus. And so I'm just seeing the same people over and over again.
And it plateaus really quickly. I would say within the span of three months or so, we've basically enrolled everyone that needs to be enrolled and we're treating them, graduating them probably within six to eight months. And so then what do you do with the barbershops? We don't want to just leave them hanging. They've been trained as health coaches. We do refresh workshops with them where they practice their blood pressure measuring techniques. They practice their health coaching skills.
And so what we've tried doing is bringing in external patients from clinics who are actually interested in having their patients come to our services in the community.
And a lot of times these patients don't go see their primary care providers, but they possibly hang out in the neighborhood where the barbershops are. So we're still trying to work through this, but that no-show rate tends to be higher for patients who have not been established in these barbershops.
Dave Dixon
Yeah, that makes a lot of sense, but I certainly hadn't thought about that, that yeah, you would sort of saturate the barbershop population and then for new patrons, that trust hasn't been built yet, right? It's kind of a challenge to get them to re-engage. It's also somewhat comforting to know that this issue still, you know, is a struggle for all of us, right?
Crystal Zhou
No matter the success of the program, getting our patients to be present, to show up. And, you know, they have a lot going on, obviously. And there's so many barriers to care. But it's a challenge that we all deal with.
Dave Dixon
Tell us a little bit about the clinical outcomes that you've seen in terms of blood pressure control.
Crystal Zhou
So the clinical outcomes that we are capturing right now are blood pressure control, so getting to goal either less than 140 over 90 or 130 over 80, depending on their primary care provider's preference. But I think the other outcome that we're trying to capture is re-engagement or even just engagement with their primary care homes. A lot of patients, when they first meet with them, say, you know, I saw my primary care provider maybe a year ago or over a year ago. One patient that I saw hadn't seen our primary care provider in seven years. So yeah, some of these clients or patients are just not engaging with their primary care very much.
And so a lot of the preventative care measures, lab checks are just not happening. I talk to them about that during the visits. And a part of our program is to really try to re-engage them with care. I always tell them, we're just managing blood pressure here, but there are so many other things that could go on, right? Even during cough, cold, and flu season.
If something happens to you, I'm not the person to come to, right? Your primary care provider is the best person to reach out to. And so before graduating, we always make sure they have a primary care provider that's regularly seeing them or they've at least met with their primary care provider once so they know who to connect with and who to go to for these prescription refills as well.
So those are the two main outcomes that we've been collecting through this program.
Dave Dixon
Yeah, I think we often forget how difficult it is to navigate the healthcare system or whatever healthcare access we have. And so I think that's great that there's sort of that effort to try to help them understand, right, how to use this resource, what it's not for. And then, of course, when they do have issues, that, yes, you should see your primary care provider as well.
What other successes beyond sort of the clinical oriented outcomes? You know, how would you view the success of this program? How would you define that?
Crystal Zhou
Yeah. And one of the criteria for graduation is actually that the patient has made meaningful lifestyle changes. And we've had several patients who've come into our program. You know, they continuously eat fast food every day. They used to not work out and now, by the time they graduate, they are eating fast food maybe once a month. They're trying to cook for themselves, eat more healthy with their entire family. They're going to the gym five times a week. If they don't have access to a gym, they're becoming really creative with YouTube videos and different tools around the house as weights. I always recommend, you know, water bottles to start and people have started using canned foods, which is great.
So I think that's part of what defines success for the patients is that one, they have their blood pressure under control, but two, they're also able to live a healthy lifestyle because many come in and they just don't know what to do.
They're a bit lost and they're looking for recommendations, which this program is really good at giving lifestyle recommendations as well. Our health coaches are trained to do that. So they're very good at reiterating some of the lifestyle changes, too.
Dave Dixon
Yeah, that's terrific. And that carries with them, right? And then the impact of that goes beyond just blood pressure control. And obviously, at blood pressure, we often see dyslipidemia, insulin resistance, diabetes, overweight, obesity, all these things are connected. So it's great that your program sort of goes beyond that and really focuses on those lifestyle changes.
So it will certainly link to some of the evidence-based trials that has come out of the work in the show notes. And I certainly would direct listeners to check those out. I'd love to hear your thoughts, though, and sort of like what's the secret sauce of this intervention? What makes it work?
Crystal Zhou
I wish I had a really good answer for you for this question. But I do think the secret sauce is the relationship. The relationship that I build with the patients, the relationships that's already existing with their barbers, and the fact that my team becomes really close with the barbers who work there. And so their clients or my patients see that we have a good relationship going as well. And they see how much our program really cares about their health and their blood pressure. And that's what makes them come back. Or for a lot of our patients who don't come back, it's really logistical reasons. Maybe they just can't get to the shop. Or a lot of them are facing many, many deaths in their family.
And so it catches them off guard. They thought they could commit to the program. And all of a sudden, they can't come because there's just so much going on with their family. So I would say if I had to pick something as the secret sauce, it's really the relationship that we're able to build with these patients and meeting them where they are.
Dave Dixon
Right, right. No, that's great. So I'm sure that there have likely been other groups and entities across the country that may have reached out to you all over the years about maybe either replicating this project in some shape or fashion. I know that there's been others that have taken other community-based approaches in terms of providing this type of care in sort of faith-based organizations, local fire departments. So if you were to sort of think about maybe one major piece of advice to groups that may be looking to either replicate or do a similar type of model in their community? What would that piece of advice be?
Crystal Zhou
The biggest piece of advice I have to give is finding a team that has a lot of dedication. It was not easy to start this program, and it's also not easy to find barbershops who are willing to commit to this model.
Even though we have 60-plus barbers who are health coach trained, we've probably approached over 100, 150 barbers, and they're not interested in this. They've been trained to barber and cut hair. They don't want to talk to their clients about high blood pressure. So I do think it takes finding the right people, which is the biggest barrier. And then when you find the right people, gaining their trust, teaching them what it is that we do. Myself, our coordinators, and our physician, we show up in their space, we show them what it means to have an appointment in the barbershop. And space, they have to be able to have space for us to be there in person. Or if I'm not there in person, at least a quieter space for there to be some sort of laptop or tablet so that I can Zoom with the patients and interact with them that way. Because for the Sacramento patients, that's a really far drive for me. So I don't actually drive two and a half hours out into the East Bay. We'll do these video visits with our clients there.
But again, finding the right people, I think, is the biggest piece of advice I have. And that just takes a lot of time, a lot of really thorough and deep conversations to make sure they are committed. Because some people do drop out halfway through after knowing what the program requires, and they realize they're not able to provide all of that to the program.
Dave Dixon
Right. Really comes full circle, once again, relationships, right? Exactly. Back to the secret sauce. Well, thank you so much for going through and sharing some details and sort of behind the scenes of the Cut Hypertension Program. I really do appreciate that. And I'd like to transition now and then kind of zooming out a bit and thinking about, you know, in your own kind of practice, what resources have you found to be influential in your own thinking around innovation and pharmacy practice or obviously as it relates to the program?
Crystal Zhou
Yeah, I love innovating and I love thinking out the box. And I wish I could be just a tad more creative. But then I also have to pull myself back down to reality and think what's actually feasible. Right. And so the most useful resources that I've actually been in contact with are the payers. Payers who are willing to work with us, they've taught us a lot about different reimbursement models, what types of payment models we're allowed to use with this type of innovative model.
Community healthcare worker services are something that we're looking into billing for our barbers. And so I wouldn't have known this unless we've met with some of these payers to talk about our model, see if they're interested in investing. And because money is really at the crux of everything here, payment and reimbursement for these services is really important. So we don't bill any of our patients, but we have partnered with many health plans to get reimbursed for the services that I provide, that our coordinators provide, and also for our lead physician or supervising physician. So that's my biggest piece of advice is, you know, there may not be resources you can find online, but think about financial sustainability or sustainability of any innovative program long term and try to talk to those people who are sitting in the seats of those that can help to sustain the program.
Dave Dixon
Yeah, that's a great idea. And then just a quick follow-up is that commercial, Medicaid, Medicare, some combination, I'm assuming not Medicare, obviously, but between Medicaid. Yeah, not Medicare. That's a pipe dream. But between Medicaid and commercial, what does that look like?
Crystal Zhou
Yeah, it's mostly Medicaid programs right now, and we are in conversations with some commercial insurances as well. Fantastic.
Dave Dixon
So certainly our listeners often include students, other trainees. So, and obviously being in academia, you know, we all think about this, but how should pharmacy education and training evolve to prepare students for providing this type of care or practicing in this kind of community-based intervention?
Crystal Zhou
This is actually something I've been thinking about over the past couple of years, too. And once I have some time, I do plan to create an elective for students on innovative pharmacy practice models.
And my hope was to send them out into the community, find something that is in need, and try to brainstorm, sustainability included, how they would create a program to meet that need. And the idea would be to see if they could build a program and eventually sustain it over one to two years that they are a part of this elective.
And in addition to that, I do hope that in the curriculum, there could be some time dedicated to innovative practice models just so that students are able to see what else is out there other than traditional pharmacy practice.
Dave Dixon
Yep. No, it's great. And there's definitely a demand for that, right? I mean, I'm sure you're experiencing the same thing we are, where there's a lot more interest in, I don't like the phrase non-traditional, but just thinking about other avenues for applying their education and in unique ways and being entrepreneurial, like you said.
So what's something that you're looking forward to in the next six to 12 months? This could be personal, professional, both.
Crystal Zhou
Yeah, so our program is actually expanding exponentially.
We are in talks with a larger payer, and I won't say the name of the payer just in case things don't go right. But if this payer commits, we would really be active in most of the Bay Area and be able to see more patients in the Bay Area, work with their clinics to figure out how best to refer them. The other model that we are piloting right now is working with an insurance company and having them send us a list of patients with uncontrolled hypertension.
Our program will reach out to those patients and see if they are interested in participating in our program. And so far, we've actually had a lot of luck just randomly texting these people. They don't even know who we are. But we've got about a 20% response rate so far. So out of 600 patients, that's pretty significant. So I'm really looking forward to the volume increasing exponentially over the next couple of months.
And we've also hired a nurse practitioner for our Sacramento area. So just lots of different things coming down the pipeline for us. And I'm looking forward to how else we can serve the community.
Dave Dixon
Yeah, that's phenomenal. And wish you the best of luck with that. And thank you, certainly, I want to thank you for joining us and sharing your story and discussing the transformative Cut Hypertension Program. I think it's one of the most influential and innovative programs that's involved pharmacy and for pharmacists in recent years. So congratulations on the work that you're doing. Please let our listeners know where they can connect with you to learn more about your work.
Crystal Zhou
Sure. So you can always email me, crystal.zhou at ucsf.edu, or the Cut Hypertension Program has a website. It's cuthypertension.org. So that'll have all of our team members' information as well as contact information if you would like to reach out and learn more about our program.
Dave Dixon
Fantastic. Well, 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 healthcare.
Closing
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.