Jose Alvarez clutches a red drawstring bag as he hobbles into a small office. He leans his crutches against the wall and takes a seat in the corner. His seven pill bottles, of varying heights, create a miniature skyline of orange and white.
A heavyset man with a scraggly beard, Alvarez has diabetes, high blood pressure and asthma. He's here at this clinic in East Los Angeles for his 2 p.m. appointment with Sangeeta Salvi.
"I was in denial for a very long time," Alvarez, 42, says about his diabetes. Now he comes in every three weeks to discuss his medications, diet and exercise with Salvi.
Despite the white coat slung over the back of her chair, Salvi isn't a physician, but a pharmacist.
She's one of a growing number moving out from behind grocery store pharmacy counters across the country and seeing patients in new ways, part of a push to reduce healthcare costs, address social issues that impede people's health and ease a national shortage of primary-care physicians.
Steven Chen, a USC clinical pharmacy professor, runs this pilot initiative at 10 clinics belonging to AltaMed, a nonprofit clinic network that serves largely low-income populations in L.A. and Orange counties.
In a healthcare system that often seems impersonal and intimidating, pharmacists can act as a much-needed sympathetic ear and source of advice, spending extra time with patients.
"That's the reason why we've been very successful," Chen says, "because someone is taking the time to sit with the patient."
Team-based medical care, in which multiple healthcare professionals work together to treat a patient, is a central feature of the Affordable Care Act. But as different workers collaborate, there's concern that pharmacists could overstep their bounds.
"Every member of the team is critical but not interchangeable," says Reid Blackwelder, board chair of the American Academy of Family Physicians.
Pharmacists' role is fundamentally different from doctors'; whereas doctors try to diagnose a root problem, pharmacists just try to make the symptoms better. Pharmacists are best trained to determine appropriate uses and dosages of medications to help patients with their problems.
Nearly 90% of patients with chronic illnesses take medication as the first line of treatment. In the United States, between a third and a half of patients don't take their medicines properly, which — along with poor prescribing and diagnoses — costs the healthcare industry as much as $290 billion a year, according to the New England Healthcare Institute.
On average, clinical pharmacists in the USC program find 10 drug-related problems per patient — things such as taking the wrong dosage or missing a needed medicine.
But they also act as a sort of medical counselor, helping patients with a range of issues, including diet, exercise and stresses of all kinds. Many pharmacists taking part in the USC initiative — funded by a $12-million federal grant — also call insurance companies and drug manufacturers to make sure patients can get needed medications.
"Our patients need that," says Rosie Jadidian, director of pharmaceutical services for Community Clinic Assn. of Los Angeles County. "They're waiting on bus schedules, and their lives are organized in different ways. They need that one-stop shopping."
Sitting face-to-face in her cramped office, their knees almost touching, Salvi and Alvarez review the medicines he's taking.
Three times a day. Eight milligrams. Before meals. When I wake up.
Pharmacists at AltaMed clinics are paired with patients they can help most: those with chronic illnesses.
When Salvi first started treating Alvarez, she realized he was using only a quick-relief inhaler, not one for long-term control.
Now that he's taking the preventive inhaler regularly, Alvarez, who lives in Boyle Heights, says he hasn't experienced much shortness of breath.
"It's only been a month and a half, two months, and I've noticed a difference," he says.
Salvi says the fast-paced work of clinical pharmacy was more appealing than working behind a counter.
"We're directly involved in their care," says Salvi, who's been treating patients at AltaMed clinics for two years. "We develop a strong relationship."
Patients usually see their pharmacists once a month, while they see their primary-care doctors a few times a year. And pharmacist visits are typically longer, lasting up to an hour.
Alvarez has had diabetes for more than 10 years. He lost his job as a chef last year because of a foot ulcer that made it impossible for him to stand all day in the kitchen. After he lost a toe in January, he decided to start trying to keep his diabetes under control.
After consulting her notes, Salvi asks Alvarez whether he's still eating eggs and two pieces of wheat toast for breakfast. He says he's reduced it to one slice.
"I used to drink a two-liter Coke by myself at lunch," he says. Now, he has half a 23-ounce Arizona iced tea with his midday meal, but he's working to cut that out too, he says.
Salvi tells him that breaking a habit cold turkey is always difficult. "Remember to take baby steps," she says.
Clinical pharmacists are part of a burgeoning number of recent medical interventions that aim to increase access to medical care. Across the country, patients can see a nurse or a pharmacist at new retail clinics, urgent-care clinics and kiosks. Some patients can also now talk to a healthcare professional on video chat.
"It's probably exhilarating and also a little overwhelming," says Dr. Ateev Mehrotra, a Harvard Medical School professor who studies innovations in healthcare delivery.
Because these innovations often take care out of the hands of doctors, many of them also help with the shortage of providers across the country that worsened with the expansion of health insurance under the Affordable Care Act.
The nationwide shortfall of primary-care doctors is expected to grow to about 45,000 by 2020. Almost a quarter of Californians already live in a primary-care shortage area, according to state data.
A California law went into effect last year that allows pharmacists to bill for medical care — seen as a step toward solidifying their expanded roles outside pharmacies. Congress is considering a similar bill, but critics say that an already costly healthcare system can't afford to pay another provider.
Early data from the AltaMed initiative shows that bringing in a clinical pharmacist saves money overall by reducing hospitalizations and other expensive medical treatments, but initially increases costs both to pay the pharmacists and to provide more medicines.
Historically, that's made clinical pharmacists a hard sell because clinics haven't been financially responsible if a patient ends up in the hospital, so there is little incentive to pay for the extra service. That's slowly changing with the Affordable Care Act, as payment models shift so providers are rewarded if patients stay healthy, and penalized if they don't.
At AltaMed clinics, pharmacists' schedules are almost always booked.
Salvi takes Alvarez's blood pressure one last time. With a smile, she tells him she thinks they've covered everything for the day.
She tentatively schedules him an appointment in three weeks, because he's not sure when he'll be free next month.
"I'm sure we'll be calling you anyways," Salvi says. "You know how we are."