Innovations

Abstract

Lucas Smith, PharmD, pharmacy manager at Buena Vista Drug in the Colorado town of Buena Vista—with a population of just under 3,000—is at the center of an initiative that’s using pharmacists on health care teams to help achieve public health goals in the state.Smith’s pharmacy and 11 other community pharmacy sites—mainly in rural areas where access to care is limited—are part of a partnership between the Colorado Department of Public Health and Environment and the University of Colorado Skaggs School of Pharmacy & Pharmaceutical Sciences. In this partnership, pharmacists and final-year PharmD candidates provide clinical services to increase the rate of control of hypertension and diabetes in the Medicaid population.Smith graduated from the school in May 2014. Now, as a new practitioner, Smith runs one of the community pharmacies that’s integrating diabetes, and now hypertension counseling, into care for all patients—not just Medicaid patients—whom the pharmacy serves.So far, about 15 patients in the program come in once a month for counseling. Many patients are referred to the program through their provider, but Smith also recruits them directly t the pharmacy. “I hand [the patient] their metformin or insulin and ask if they would like to participate in the program,” Smith told Pharmacy Today.Colorado’s public health department eyes pharmacistsTop: Lucas Smith, PharmD, is pharmacy manager at Buena Vista Drug. Above: Brett Bowman, 2016 PharmD candidate, measures the cholesterol of a patient enrolled in the diabetes education program.View Large Image Figure ViewerDownload (PPT)View Large Image Figure ViewerDownload (PPT)“We found out that not only did pharmacists want to do disease management work, but student pharmacists in the state were already being placed in diabetes disease management clinics in pharmacies,” Tara Trujillo, MNM, community clinical linkages coordinator at the Colorado Department of Public Health and Environment, told Today.In addition to supporting the delivery of patient care, student pharmacists in these clinics have facilitated the collection and reporting of data back to the department of health to show the value of pharmacy-based care delivery.Since 2010, Colorado University had been running diabetes clinics with the aid of student pharmacists who are supervised by pharmacists. The department of health wanted to expand on that and provide the same services to hypertensive patients through the CDC grant. The CDC grant is focused on including community pharmacists on the patient’s care team in order to achieve this.State health departments give programs a boost“State health departments have a lot of power in terms of being a convener and connector,” CDR Lori Hall, PharmD, U.S. Public Health Service, told Today.Including the program in Colorado, CDC is funding projects in every state plus the District of Columbia. The grants specifically name pharmacists in strategies for state health departments to consider in the prevention and management of chronic health conditions. CDC grant money given to state health departments is rarely available to pharmacies directly.Time and time again, pharmacists have demonstrated their ability to provide chronic disease patient care services. These programs can be strengthened through partnerships with state health departments—entities that are connected to several different partners pharmacists can work with. Just as states serve as individual laboratories for democracy, they are also fertile ground for testing new health care models.Programs in Colorado and other states, such as Ohio and Utah, have been able to hit the ground running because of projects that were already in place before the states received grants from CDC.“When we launched this project, most of this was considered new work for states, but higher-performing states that have tracked the work of pharmacy were a bit more prepared,” said Hall.Working toward reimbursementTop: Smith reviews a patient’s medication profile with Bowman and makes a recommendation on medication therapy to the patient’s health care provider. Above: Smith administers an influenza vaccine to a patient.View Large Image Figure ViewerDownload (PPT)Through two CDC grants, Utah expanded its hypertension medication adherence program to diabetes medication adherence, using pharmacists on care teams and linking patients to community clinical services.The precursor to the CDC grants was a project with Intermountain Healthcare, one of the largest health care systems in Utah and the surrounding region. Pharmacists were ultimately successful in getting patients’ blood pressure under control and helping them better manage their medications when they were allowed to follow up with the patients, according to Teresa Roark, MPH, health systems co-ordinator for the Utah Department of Health’s Healthy Living through Environment, Policy and Improved Clinical Care Program.The CDC grant to the Utah health department will fund at least one project that includes a sustainable payment mechanism for pharmacists to provide nondispensing services. It will also help pharmacies to bill and provide diabetes self-management education as well as seek ways to educate public health networks on the potential role pharmacists can play and the issues they have around reimbursement.“I’m really excited about the project around reimbursement because that’s not happening in Utah,” Roark told Today. “The health department has been able to instigate this system change through partnerships.”Power of partnershipsExisting programs get a boost because the state health department can initially fund the work and offer additional resources. “Some pharmacy schools have excellent projects going on, but they don’t have the backing to achieve reach across their state,” said Hall.Top: Bowman works in the pharmacy to fill a prescription for a patient. Above: Smith talks to an eligible patient about the education program and discusses how meeting with a pharmacist can help improve his health and medication management.View Large Image Figure ViewerDownload (PPT)Like Colorado, Ohio’s CDC grant work has benefited from collaboration with a university partner. The Ohio State University (OSU) College of Pharmacy has worked with federally qualified health centers (FQHCs) and 340B-eligible pharmacies to train OSU student pharmacists and pharmacy residents to provide medication therapy management (MTM) services to patients with diabetes and high blood pressure. Based on this work, the Ohio Department of Health was able to identify partners who could help enhance their public health program.According to Barbara Pryor, MS, manager of the chronic disease section at the Ohio Department of Health, the Ohio Pharmacists Association (OPA) set up the health department’s initial contact with Ohio State University (OSU) to discuss the MTM project. The university also had a good relationship with the state-level agency representing FQHCs.“OSU’s access to the network of FQHCs and their ability to place pharmacy residents with FQHCs participating in our MTM project were significant assets when we were designing the program plan,” Pryor told Today.Currently, patients are seen by pharmacists, residents, and student pharmacists at a few FQHC pilot sites, but there are plans for expansion.Pryor said phase two of the project will engage an additional five to seven FQHCs, some that have newly hired pharmacists on staff and include community pharmacy connections. And through a more recent CDC-funded grant, MTM activities will be expanded to primary care physician practices partnering with a community pharmacy to develop additional MTM models.“We also formed the state’s first MTM Consortium, consisting of the seven colleges of Pharmacy, ODH [Ohio Department of Health], OPA, the Ohio Association of Community Health Centers, [and] practitioners across the state in FQHC and community settings to coordinate activities statewide and to engage Ohio’s five Medicaid managed care plans in supporting MTM for their patients with hypertension and diabetes,” said Pryor.Referring patients to pharmacist servicesIn Colorado, local care coordinators are able to look at claims data and identify patients who could potentially benefit from the services at Smith’s pharmacy and others.They can do this because Colorado’s Medicaid system is set up through Regional Care Collaborative Organizations (RCCOs), which coordinate the care for Medicaid patients in the state and identify networks of care at the local level for them.According to Trujillo, a coordinator at the RCCO connects the pharmacist and provider.“State health departments have a lot of power in terms of being a convener and connector.”“That coordinator is the point of contact for the pharmacist to be able to say: ‘This patient completed the 6-month program, or ‘This person asked for more services.’ And hopefully the RCCO can help provide those,” said Trujillo.Trujillo said the team-based model of care will promote population health.Wesley Nuffer, PharmD, assistant professor at the University of Colorado Skaggs School of Pharmacy & Pharmaceutical Sciences, who has led the initiative from the pharmacy side in Colorado, said having a strong endorsement from a provider is important.“We want providers to write a prescription [for patients] to attend these classes. Otherwise, patients attend one or two classes, and attrition starts to kick in,” Nuffer told Today.Trujillo said providers have had only good things to say about working with pharmacists.“They don’t feel like it’s a burden but more of a benefit because their patients are able to get special attention,” said Trujillo.In Utah, most primary care providers identify and then refer patients who are struggling with managing their chronic condition to the pharmacy program.Nicole Bissonette, MPH, program manager at the Utah Department of Health, said the program can also look at population health data and approach providers in areas that have high rates of diabetes and hypertension to see if they want to work on projects together or help connect pharmacies with the health systems.Data collection to track resultsAccording to Ohio’s Pryor, the data collected from the initial three FQHC sites demonstrated a resolution of a variety of drug-related problems and impressive improvements in medication adherence and disease control rates for more than 500 patients who received MTM consults.In the first 6 months of the project, patients with diabetes in control increased from 0% to 44.8%, and patients with hypertension in control increased from 0% to 68.6%, said Pryor.Smith and his wife, Jill, are owners of Buena Vista Drug. Jill Smith helps with marketing for the store.View Large Image Figure ViewerDownload (PPT)But there are challenges—mainly a relevant data collection tool that all participating sites can use.“As Ohio’s MTM project moves into phase two and expands from FQHCs that share electronic health records [EHRs] to primary care practices and community pharmacies that do not share the same EHR, communication among providers, data collection, and analysis will be a challenge,” said Pryor.Nuffer and his team at the University of Colorado use an electronic database, which was built at the school of medicine, to collect data at the pharmacy sites participating in the Colorado public health department project.View Large Image Figure ViewerDownload (PPT)They are also collecting data on why a patient may not have taken their medication.“We’ve tried to emphasize this, and it’s another big piece of the data for us,” said Nuffer.At 6 months, patients are also asked questions related to quality of life to find out how their condition may be affecting their quality of life, according to Nuffer.“The ultimate goal is to produce a program that can be reproducible anywhere in [the United States] where you could use a community pharmacy and put together a formalized program, with the goal of showing that these patient health outcomes are improving when patients are going through the clinics,” said Nuffer.Nuffer said he would like to broaden the clinic services based on an individual community’s needs—providing smoking cessation or weight loss, for instance. Lucas Smith, PharmD, pharmacy manager at Buena Vista Drug in the Colorado town of Buena Vista—with a population of just under 3,000—is at the center of an initiative that’s using pharmacists on health care teams to help achieve public health goals in the state. Smith’s pharmacy and 11 other community pharmacy sites—mainly in rural areas where access to care is limited—are part of a partnership between the Colorado Department of Public Health and Environment and the University of Colorado Skaggs School of Pharmacy & Pharmaceutical Sciences. In this partnership, pharmacists and final-year PharmD candidates provide clinical services to increase the rate of control of hypertension and diabetes in the Medicaid population. Smith graduated from the school in May 2014. Now, as a new practitioner, Smith runs one of the community pharmacies that’s integrating diabetes, and now hypertension counseling, into care for all patients—not just Medicaid patients—whom the pharmacy serves. So far, about 15 patients in the program come in once a month for counseling. Many patients are referred to the program through their provider, but Smith also recruits them directly t the pharmacy. “I hand [the patient] their metformin or insulin and ask if they would like to participate in the program,” Smith told Pharmacy Today. Colorado’s public health department eyes pharmacistsView Large Image Figure ViewerDownload (PPT)“We found out that not only did pharmacists want to do disease management work, but student pharmacists in the state were already being placed in diabetes disease management clinics in pharmacies,” Tara Trujillo, MNM, community clinical linkages coordinator at the Colorado Department of Public Health and Environment, told Today.In addition to supporting the delivery of patient care, student pharmacists in these clinics have facilitated the collection and reporting of data back to the department of health to show the value of pharmacy-based care delivery.Since 2010, Colorado University had been running diabetes clinics with the aid of student pharmacists who are supervised by pharmacists. The department of health wanted to expand on that and provide the same services to hypertensive patients through the CDC grant. The CDC grant is focused on including community pharmacists on the patient’s care team in order to achieve this. “We found out that not only did pharmacists want to do disease management work, but student pharmacists in the state were already being placed in diabetes disease management clinics in pharmacies,” Tara Trujillo, MNM, community clinical linkages coordinator at the Colorado Department of Public Health and Environment, told Today. In addition to supporting the delivery of patient care, student pharmacists in these clinics have facilitated the collection and reporting of data back to the department of health to show the value of pharmacy-based care delivery. Since 2010, Colorado University had been running diabetes clinics with the aid of student pharmacists who are supervised by pharmacists. The department of health wanted to expand on that and provide the same services to hypertensive patients through the CDC grant. The CDC grant is focused on including community pharmacists on the patient’s care team in order to achieve this. State health departments give programs a boost“State health departments have a lot of power in terms of being a convener and connector,” CDR Lori Hall, PharmD, U.S. Public Health Service, told Today.Including the program in Colorado, CDC is funding projects in every state plus the District of Columbia. The grants specifically name pharmacists in strategies for state health departments to consider in the prevention and management of chronic health conditions. CDC grant money given to state health departments is rarely available to pharmacies directly.Time and time again, pharmacists have demonstrated their ability to provide chronic disease patient care services. These programs can be strengthened through partnerships with state health departments—entities that are connected to several different partners pharmacists can work with. Just as states serve as individual laboratories for democracy, they are also fertile ground for testing new health care models.Programs in Colorado and other states, such as Ohio and Utah, have been able to hit the ground running because of projects that were already in place before the states received grants from CDC.“When we launched this project, most of this was considered new work for states, but higher-performing states that have tracked the work of pharmacy were a bit more prepared,” said Hall. “State health departments have a lot of power in terms of being a convener and connector,” CDR Lori Hall, PharmD, U.S. Public Health Service, told Today. Including the program in Colorado, CDC is funding projects in every state plus the District of Columbia. The grants specifically name pharmacists in strategies for state health departments to consider in the prevention and management of chronic health conditions. CDC grant money given to state health departments is rarely available to pharmacies directly. Time and time again, pharmacists have demonstrated their ability to provide chronic disease patient care services. These programs can be strengthened through partnerships with state health departments—entities that are connected to several different partners pharmacists can work with. Just as states serve as individual laboratories for democracy, they are also fertile ground for testing new health care models. Programs in Colorado and other states, such as Ohio and Utah, have been able to hit the ground running because of projects that were already in place before the states received grants from CDC. “When we launched this project, most of this was considered new work for states, but higher-performing states that have tracked the work of pharmacy were a bit more prepared,” said Hall. Working toward reimbursementThrough two CDC grants, Utah expanded its hypertension medication adherence program to diabetes medication adherence, using pharmacists on care teams and linking patients to community clinical services.The precursor to the CDC grants was a project with Intermountain Healthcare, one of the largest health care systems in Utah and the surrounding region. Pharmacists were ultimately successful in getting patients’ blood pressure under control and helping them better manage their medications when they were allowed to follow up with the patients, according to Teresa Roark, MPH, health systems co-ordinator for the Utah Department of Health’s Healthy Living through Environment, Policy and Improved Clinical Care Program.The CDC grant to the Utah health department will fund at least one project that includes a sustainable payment mechanism for pharmacists to provide nondispensing services. It will also help pharmacies to bill and provide diabetes self-management education as well as seek ways to educate public health networks on the potential role pharmacists can play and the issues they have around reimbursement.“I’m really excited about the project around reimbursement because that’s not happening in Utah,” Roark told Today. “The health department has been able to instigate this system change through partnerships.” Through two CDC grants, Utah expanded its hypertension medication adherence program to diabetes medication adherence, using pharmacists on care teams and linking patients to community clinical services. The precursor to the CDC grants was a project with Intermountain Healthcare, one of the largest health care systems in Utah and the surrounding region. Pharmacists were ultimately successful in getting patients’ blood pressure under control and helping them better manage their medications when they were allowed to follow up with the patients, according to Teresa Roark, MPH, health systems co-ordinator for the Utah Department of Health’s Healthy Living through Environment, Policy and Improved Clinical Care Program. The CDC grant to the Utah health department will fund at least one project that includes a sustainable payment mechanism for pharmacists to provide nondispensing services. It will also help pharmacies to bill and provide diabetes self-management education as well as seek ways to educate public health networks on the potential role pharmacists can play and the issues they have around reimbursement. “I’m really excited about the project around reimbursement because that’s not happening in Utah,” Roark told Today. “The health department has been able to instigate this system change through partnerships.” Power of partnershipsExisting programs get a boost because the state health department can initially fund the work and offer additional resources. “Some pharmacy schools have excellent projects going on, but they don’t have the backing to achieve reach across their state,” said Hall.Like Colorado, Ohio’s CDC grant work has benefited from collaboration with a university partner. The Ohio State University (OSU) College of Pharmacy has worked with federally qualified health centers (FQHCs) and 340B-eligible pharmacies to train OSU student pharmacists and pharmacy residents to provide medication therapy management (MTM) services to patients with diabetes and high blood pressure. Based on this work, the Ohio Department of Health was able to identify partners who could help enhance their public health program.According to Barbara Pryor, MS, manager of the chronic disease section at the Ohio Department of Health, the Ohio Pharmacists Association (OPA) set up the health department’s initial contact with Ohio State University (OSU) to discuss the MTM project. The university also had a good relationship with the state-level agency representing FQHCs.“OSU’s access to the network of FQHCs and their ability to place pharmacy residents with FQHCs participating in our MTM project were significant assets when we were designing the program plan,” Pryor told Today.Currently, patients are seen by pharmacists, residents, and student pharmacists at a few FQHC pilot sites, but there are plans for expansion.Pryor said phase two of the project will engage an additional five to seven FQHCs, some that have newly hired pharmacists on staff and include community pharmacy connections. And through a more recent CDC-funded grant, MTM activities will be expanded to primary care physician practices partnering with a community pharmacy to develop additional MTM models.“We also formed the state’s first MTM Consortium, consisting of the seven colleges of Pharmacy, ODH [Ohio Department of Health], OPA, the Ohio Association of Community Health Centers, [and] practitioners across the state in FQHC and community settings to coordinate activities statewide and to engage Ohio’s five Medicaid managed care plans in supporting MTM for their patients with hypertension and diabetes,” said Pryor. Existing programs get a boost because the state health department can initially fund the work and offer additional resources. “Some pharmacy schools have excellent projects going on, but they don’t have the backing to achieve reach across their state,” said Hall. Like Colorado, Ohio’s CDC grant work has benefited from collaboration with a university partner. The Ohio State University (OSU) College of Pharmacy has worked with federally qualified health centers (FQHCs) and 340B-eligible pharmacies to train OSU student pharmacists and pharmacy residents to provide medication therapy management (MTM) services to patients with diabetes and high blood pressure. Based on this work, the Ohio Department of Health was able to identify partners who could help enhance their public health program. According to Barbara Pryor, MS, manager of the chronic disease section at the Ohio Department of Health, the Ohio Pharmacists Association (OPA) set up the health department’s initial contact with Ohio State University (OSU) to discuss the MTM project. The university also had a good relationship with the state-level agency representing FQHCs. “OSU’s access to the network of FQHCs and their ability to place pharmacy residents with FQHCs participating in our MTM project were significant assets when we were designing the program plan,” Pryor told Today. Currently, patients are seen by pharmacists, residents, and student pharmacists at a few FQHC pilot sites, but there are plans for expansion. Pryor said phase two of the project will engage an additional five to seven FQHCs, some that have newly hired pharmacists on staff and include community pharmacy connections. And through a more recent CDC-funded grant, MTM activities will be expanded to primary care physician practices partnering with a community pharmacy to develop additional MTM models. “We also formed the state’s first MTM Consortium, consisting of the seven colleges of Pharmacy, ODH [Ohio Department of Health], OPA, the Ohio Association of Community Health Centers, [and] practitioners across the state in FQHC and community settings to coordinate activities statewide and to engage Ohio’s five Medicaid managed care plans in supporting MTM for their patients with hypertension and diabetes,” said Pryor. Referring patients to pharmacist servicesIn Colorado, local care coordinators are able to look at claims data and identify patients who could potentially benefit from the services at Smith’s pharmacy and others.They can do this because Colorado’s Medicaid system is set up through Regional Care Collaborative Organizations (RCCOs), which coordinate the care for Medicaid patients in the state and identify networks of care at the local level for them.According to Trujillo, a coordinator at the RCCO connects the pharmacist and provider.“State health departments have a lot of power in terms of being a convener and connector.”“That coordinator is the point of contact for the pharmacist to be able to say: ‘This patient completed the 6-month program, or ‘This person asked for more services.’ And hopefully the RCCO can help provide those,” said Trujillo.Trujillo said the team-based model of care will promote population health.Wesley Nuffer, PharmD, assistant professor at the University of Colorado Skaggs School of Pharmacy & Pharmaceutical Sciences, who has led the initiative from the pharmacy side in Colorado, said having a strong endorsement from a provider is important.“We want providers to write a prescription [for patients] to attend these classes. Otherwise, patients attend one or two classes, and attrition starts to kick in,” Nuffer told Today.Trujillo said providers have had only good things to say about working with pharmacists.“They don’t feel like it’s a burden but more of a benefit because their patients are able to get special attention,” said Trujillo.In Utah, most primary care providers identify and then refer patients who are struggling with managing their chronic condition to the pharmacy program.Nicole Bissonette, MPH, program manager at the Utah Department of Health, said the program can also look at population health data and approach providers in areas that have high rates of diabetes and hypertension to see if they want to work on projects together or help connect pharmacies with the health systems. In Colorado, local care coordinators are able to look at claims data and identify patients who could potentially benefit from the services at Smith’s pharmacy and others. They can do this because Colorado’s Medicaid system is set up through Regional Care Collaborative Organizations (RCCOs), which coordinate the care for Medicaid patients in the state and identify networks of care at the local level for them. According to Trujillo, a coordinator at the RCCO connects the pharmacist and provider.“State health departments have a lot of power in terms of being a convener and connector.” “That coordinator is the point of contact for the pharmacist to be able to say: ‘This patient completed the 6-month program, or ‘This person asked for more services.’ And hopefully the RCCO can help provide those,” said Trujillo. Trujillo said the team-based model of care will promote population health. Wesley Nuffer, PharmD, assistant professor at the University of Colorado Skaggs School of Pharmacy & Pharmaceutical Sciences, who has led the initiative from the pharmacy side in Colorado, said having a strong endorsement from a provider is important. “We want providers to write a prescription [for patients] to attend these classes. Otherwise, patients attend one or two classes, and attrition starts to kick in,” Nuffer told Today. Trujillo said providers have had only good things to say about working with pharmacists. “They don’t feel like it’s a burden but more of a benefit because their patients are able to get special attention,” said Trujillo. In Utah, most primary care providers identify and then refer patients who are struggling with managing their chronic condition to the pharmacy program. Nicole Bissonette, MPH, program manager at the Utah Department of Health, said the program can also look at population health data and approach providers in areas that have high rates of diabetes and hypertension to see if they want to work on projects together or help connect pharmacies with the health systems. Data collection to track resultsAccording to Ohio’s Pryor, the data collected from the initial three FQHC sites demonstrated a resolution of a variety of drug-related problems and impressive improvements in medication adherence and disease control rates for more than 500 patients who received MTM consults.In the first 6 months of the project, patients with diabetes in control increased from 0% to 44.8%, and patients with hypertension in control increased from 0% to 68.6%, said Pryor.But there are challenges—mainly a relevant data collection tool that all participating sites can use.“As Ohio’s MTM project moves into phase two and expands from FQHCs that share electronic health records [EHRs] to primary care practices and community pharmacies that do not share the same EHR, communication among providers, data collection, and analysis will be a challenge,” said Pryor.Nuffer and his team at the University of Colorado use an electronic database, which was built at the school of medicine, to collect data at the pharmacy sites participating in the Colorado public health department project.View Large Image Figure ViewerDownload (PPT)They are also collecting data on why a patient may not have taken their medication.“We’ve tried to emphasize this, and it’s another big piece of the data for us,” said Nuffer.At 6 months, patients are also asked questions related to quality of life to find out how their condition may be affecting their quality of life, according to Nuffer.“The ultimate goal is to produce a program that can be reproducible anywhere in [the United States] where you could use a community pharmacy and put together a formalized program, with the goal of showing that these patient health outcomes are improving when patients are going through the clinics,” said Nuffer.Nuffer said he would like to broaden the clinic services based on an individual community’s needs—providing smoking cessation or weight loss, for instance. According to Ohio’s Pryor, the data collected from the initial three FQHC sites demonstrated a resolution of a variety of drug-related problems and impressive improvements in medication adherence and disease control rates for more than 500 patients who received MTM consults. In the first 6 months of the project, patients with diabetes in control increased from 0% to 44.8%, and patients with hypertension in control increased from 0% to 68.6%, said Pryor. But there are challenges—mainly a relevant data collection tool that all participating sites can use. “As Ohio’s MTM project moves into phase two and expands from FQHCs that share electronic health records [EHRs] to primary care practices and community pharmacies that do not share the same EHR, communication among providers, data collection, and analysis will be a challenge,” said Pryor. Nuffer and his team at the University of Colorado use an electronic database, which was built at the school of medicine, to collect data at the pharmacy sites participating in the Colorado public health department project. They are also collecting data on why a patient may not have taken their medication. “We’ve tried to emphasize this, and it’s another big piece of the data for us,” said Nuffer. At 6 months, patients are also asked questions related to quality of life to find out how their condition may be affecting their quality of life, according to Nuffer. “The ultimate goal is to produce a program that can be reproducible anywhere in [the United States] where you could use a community pharmacy and put together a formalized program, with the goal of showing that these patient health outcomes are improving when patients are going through the clinics,” said Nuffer. Nuffer said he would like to broaden the clinic services based on an individual community’s needs—providing smoking cessation or weight loss, for instance.