Dr. Melody Hartzler
"Beyond Medication"

Dr. Hartzler leads the Pharm to Table team to help patients better manage chronic disease through functional and integrative medicine. In this podcast, she talks about the challenges nurses and discharge providers face to fully understand and educate patients about the medications that they take. Understanding time constraints and patient scheduling, she offers advice on how to support and educate patients via educational videos or programs like theirs. Most importantly, she talks about the need for reconciliation of current medications and looking at the patient as a whole.

Transcription of Podcast

Julie Soukup  2:32  
Okay, cool. Hi, I'm Julie Soukup, with another episode of take one patient Podcast. I'm very excited to talk today with Mellie Hartzler. She's a clinical pharmacist. And she also is the CEO of a very cool company called farm to table. I actually researched and found her a little bit when working with my dad and actually kind of starting to see some different options outside of just pure medication for him. And I would love her first to really introduce herself a little bit about her background, and kind of dive into what farm to table is, again, what makes it a little different.

Melody Hartzler  3:09  
Awesome. Well, thanks for having me. I'm excited to share about our, our process and what functional medicine is. So my name is Melody like she mentioned. I also go by Dr. Hartzler in the clinical clinical space, but I am I have my doctorate of pharmacy from Ohio Northern University, and I've done a residency postgraduate at the VA in Columbus, Ohio. And that was a clinical training program that was focused on outpatient care. So, um, the VA has been really progressive with that. And so pharmacists are involved in primary care teams renal, Renal Care, home based primary care, lots of other things. And so, so I took that and over my career, over the last like 12 or so years, I've been working in different family medicine practices, helping patients with chronic diseases, mostly diabetes, I also became a pump trainer. So I see patients via collaborative practice. So many states have collaborative practice agreements available for pharmacists to enter into with physicians or potentially nurse practitioners and PAs, that allow us to adjust and make changes, start new therapies, monitor therapies. So Ohio's been pretty progressive with our ability to do that. So So I work alongside the primary care team and function as a clinical specialist within that area as far as chronic disease, but over time, I have realized that a lot of chronic disease is not just you know, you're not deficient in a medication, right? Except with the exception, I guess, of type one diabetes as far as being deficient in insulin, but for the rest of the time, like we're not deficient in Prozac or deficient in, you know, statins or any of those things. Really, there's a lot of nutrition components to a lot of chronic disease. And so I started by just educating that patients with diabetes about carb counting and the Mediterranean diet and and slowly through my own health journey learns more about the relationship between gut health and the rest of the body as far as allergies and immune function. And then as I start to learn more about that started to pull in, like the gut health connections to metabolic disease, and started to incorporate that with my patients, and even nutrient depletions how those impact your mental health and anxiety and depression and some of the inflammation components, and so it's all really connected. And, and so a functional medicine approach, which is what we do at farm to table we're a group of clinical pharmacists that focus on addressing the root causes of these chronic conditions. As we do that we do this that we look for the root cause. And so if someone has IBS do they have IBS, because they're missing a medication that stops slows down or speeds up their gut? No, it's because there is some kind of whether it's an allergy or an inflammation response going on. It could be bacterial imbalance, which is one of the most well studied imbalances. So a lot of people with IBS, especially IBS, D have what's called SIBO, or small intestinal bacterial overgrowth. Or maybe they have issues in the large intestine with with overgrowth of bacteria, or maybe like Candida or infections, fungal infections, so So addressing the root cause of the infection, fixes the symptoms, and sometimes it's stress related, we talked about, I mean, every single podcast we ever released, we talked about stress and how stress impacts our health from a chronic disease standpoint, and increases our cortisol, it decreases our digestive enzymes, you know, we're not meant to be like running from a bear for the rest of our life, right? Where you know, that response and that increased heart rate, decrease blood flow to your you know, parasympathetic, you know, state of that calming state. That is not meant to be all the time. And so, with our psychological stressors, and lots of the things going on in the modern day world, we end up being stressed more than, than we should be. And that impacts just so many different things in our in our health. And so I think, you know, that that aspect, so we use health coaches, in that aspect to help people really identify what are the stressors, sometimes we use, you know, recommend psychologists or cognitive behavioral therapy or whatever that looks like. So that's a big key of patients with past trauma, sometimes that is a black and why they're not getting well. And so that, again, we involve our, whatever referral source we have in that person's community for cognitive behavioral therapy, and sometimes EMDR, which is eye movement, desensitization reprocessing therapy. And so there's lots of different things beyond you know, what our traditional medical model is where we just give drugs for, you know, treating these these chronic conditions. So nutritions, like, you know, Psych and psycho spiritual, psychosocial things are really important, the gut health piece, and even just the nutrient depletion piece. So many medications actually cause nutrient depletions. And so every person with a statin should really be on Kokyu time alongside their statin cookie tag, 100 milligrams, but there's other nutrient depletions that are less common that can really play out and people and sometimes it depends on their genetics, and how long they've been taking the medication and what other medications that are depleting similar nutrients they're taking. And I know, your clinicians that are listening to this have probably seen my list of patients that are 20 Plus medications. And so when you add this nutrient is depleted slightly by this medication, oh, it's not a big deal. But when you add 10 of those medications that deplete magnesium, then that can be a big deal for people. And magnesium is super important in the body. And iron is another thing, I mean, PPIs there's millions of people on proton pump inhibitors, and it's changing the way we digest foods is changing the way we absorb iron changing our microbiome. And so just thinking about those things from a different perspective, like how can we actually get rid of your heartburn by addressing it with a nutrition dietary gut, you know, microbiome balance and help people to get off these medications so they can absorb their nutrients the way that they should be?

Julie Soukup  8:57  
Right on I think that was what was really cool about your company and the approach that you guys were going to is you know, you're really assigned to a pharmacist, you know, who's gonna be really saying you know, these are the things you're taking and these are the areas that you should be supplementing or looking more on your diet or counseling or whatever and I thought you know that kind of bigger broader view as as you're you know, saying functional medicine or or not just giving a quick fix of a medication but looking at a really taking the time to look at a bigger picture of a patient to ensure that they're really not are like paying Peter to pay Paul or

Melody Hartzler  9:34  
whatever, like we know why exactly. Yeah. So many people get put on medications because they have a side effect with one so Okay, let's treat the side effects with this medication and then this medication it just snowballs into, they come in and I've had patients you know, dump and trash bag of things on the counter and say I need all these refills. It's like holy moly, like how are you even walking like in here and driving and doing all these things when you're taking this many things and so much of it I mean Obviously, the American way is we want to pill for every ill, we want to just get better quick. And unfortunately, like to really get better. It's not a quick process. It's I mean, it can be if somewhat depending on how long someone's been sick, but it does require efforts from the patient on exercise, nutrition planning, you know, doing a stress reduction, things sleeping, I mean, that's a huge thing is just getting sleep. And sometimes it's like, well, people are paying us to tell them, You need to sleep more, you need to de stress you need to do these things, but but sometimes they need help and figuring out like how they how they do that, and how they implement that. But there's, we have so much data on, if you get less than seven hours of sleep, you know, you have increased risk for hypertension, metabolic disease, it the list goes on, and so, so importance of, you know, just getting that rest and this fast paced society where, you know, we're burning candles at all ends, and I can be, you know, one of those people sometimes. And you know, you have to take a step back and say, you know, this isn't, this isn't worth it, and I need to take care of my body and get the sleep that it needs. And I mean, we have Dave on shift working, and that third shift, you know, people have less longevity, decreased lifespan, and you know, hormone imbalances are super prevalent in that population. And so, I mean, some people have to work their shift, we have to have people the hospital third shift. So I mean, it's just part of it. But I think, you know, supporting your body, however you can, in that process with with the nutrition and decreasing stress is super important. Sure. Well, and you kind

Julie Soukup  11:31  
of bring up a point, and I think it's interesting to think about is, you know, taking one medication away, that may not be working, you're getting weird side effects. But here's another here's another one, kind of is that culture, not always, not all pharmacists, not all to church nurses. But why do you think that is? Is it as far as like, let's prescribe something else? Do you think it's more of that we're learning more about like, the what, what is available outside of that? Or do you think it's a time constraint? Like, where do you think kind of that comes from? Or is it mostly a time constraint? And that's the gap you guys are filling is yeah, he discharged. But let us really help you as long as that.

Melody Hartzler  12:11  
Yeah, I mean, I think part of it is a time constraint. So in the functional medicine model, with Institute of functional medicine talks a lot about this is that, you know, we have to hear the patient's story. And a lot of times that story, you know, might take them like 45 minutes to tell me like from birth to now like, what is going on? When was the last time you felt well? Did your parents get divorced? And then you started having symptoms? Was there some kind of other trauma? Did you have a car accident? Like what is that timeline look like for how this started to come to be? And certainly when you go to the ER or you go to the hospital, or if Family Medicine primary care visit, you're getting 15 minutes to tell them what is wrong with you, they can't connect all those dots from the past in that 15 minutes. And it's very much a okay, this is what we need to focus on today. Even if you have 20 things going on, you can only focus on so many in that 15 minute appointment. And ultimately, the easiest thing for them to do is say, well, here's a medication, come back and tell me in two weeks, if that works, where and even at the discharge point, I think one of the challenges there is that the people that are caring for the patients of the hospital are not the people that are following up with them on the outpatient side. And like it used to be used to be your family medicine provider would come and round to the hospital, you know, write your orders and you would you know follow up with them leader and there's very few there are still out there. But there's very few, you know, primary care internist that actually round and and do the outpatient care. And the specialty side, we see that more still. But on the primary care side, we don't, or internal medicine side, we see more of the hospitalist model where the hospitalist are caring for you in the hospital, and then your team over here is caring for your outpatient side certainly is better quality of life for those individuals. But for that continuity of care. It's a little bit challenging. And so I think when we're when we're discharging, we're like, Okay, this is, you know, medically what is going to stabilize you and get you home, but it's not really thinking about a kidney to keep you from coming back. But it's not really thinking about like long term like, is this the best thing for your health? Is this the, you know, most, you know, beneficial, you know, choice and they don't have that relationship with a patient in that hospital and that short term period to feel to know like, is that patient going to go home and drink, you know, two gallons of Mountain Dew or four liters of Mountain Dew and come right back here if I don't give them this medication or this insulin or whatever the situation might be? So I think that's one of the challenges is that they're, they're not in a long term relationship when you're in that hospital setting. I do think there's probably like, the D prescribing piece at the Med reconciliation, you know, at the end is is really important on that discharge is okay, do Do we do we need this long term? So I had a patient that I was trying to figure out why he was on the PPI he had been on a PPI for, like 10 years. I asked him, Have you ever had heartburn? Nope, never had heartburn. Okay. Have you ever had a scope that showed you know you had erosion or you know, Barrett's esophagus or anything like that? Nope, nope, never had that. Okay, looking back and records, nothing is leading to any of those things. So finally, I find that this patient started a PPI in a hospital admission when he was in the ICU for something else. And so is basically his PPI for stress ulcer prophylaxis that now he got discharged on and took for 10 years before someone questioned it. Wow. So those are the kinds of situations that when we're at that discharge point to say, hey, like, is this person have heartburn? Did they come in on this medication? Do they need to leave on this medication? I mean, there's other simple things like people get discharged on a statin that's different than the one they have at home. And they start taking both of them. Because the hospital formulary was different than their home formulary. I mean, I have most recent, my most recent practice that I was in, I was overseeing the transitions of care process from the family medicine side. So we would get the discharge summaries from the hospital. And we would make the call within the 48 business day hours to to help reconcile the meds. And so often, I think one of the other challenges is patients don't have because they don't have that relationship, they don't have the trust with the hospital provider, like they do with their family medicine provider. So half the time we're like, oh, I didn't do any of that stuff. I didn't do this stuff to the person at the hospital told me to do, because I wanted to see what what Dr. So and So here at your office things. Yeah. And so that's challenging, right, though the patient, you know, we're like, hey, you need to do XYZ, you need to pick up this prescription and, you know, move forward, and they and they didn't even do it. So and then sometimes that ends up with them back in the hospital on a readmission. Sometimes, they're, you know, not getting the prescription at the pharmacy, because it's costing too much. And the communication from the pharmacy back to a hospital is much more difficult than the communication to an outpatient facilities. So I think one of the biggest challenges and all of this is just that continuity of care between all those those those players that are part of the care team.

Julie Soukup  17:15  
Right? Well, and as you said, I mean, even to when you're getting discharged, or that's fast, and the pace that is a necessity in the healthcare system to just be able to provide the amount of patient care that's needed for the amount of providers that are needed. I recognize that that the youth are taking like, Okay, let's take a step back. And like, tell me about you know, they don't have

Melody Hartzler  17:37  
rights. No, no, and even in family medicine, they don't either.

Julie Soukup  17:41  
And it's interesting, you say that, because you you almost kind of you know, people typically if you're going to be prescribed, like, and I don't actually know, I mean that like an area, precedent or thing? I don't know for sure. But I feel like you would have to talk to somebody before you're just handed, you know, some of his medication. Yes, some of the other things, were just handing No, you know, no problem when they could be related to that other aspects. And I think we're really cool things that you guys are kind of doing is looking at that whole hope to be like, you know, the goal is to not just be popping pills forever. Yeah. You know, I think you hit really interesting on is, you know, taking that step back, like if we were going to give advice, like, as we said, Nobody has that 45 minutes, right? We were gonna give advice or communication advice to, you know, discharge nurse or pharmacist or anyone that's kind of in that space, where they're caught in a pattern where they're just go, go, go go go? Well, and they only have you know, three to five minutes. What kind of would you suggest is even though is most important? Is it taking a step back and really looking at it? Is it giving the patient resources to go to? Or where do you see that as the communication aspect that can be improved?

Melody Hartzler  18:55  
Yeah, I mean, the best thing is really like the communication with the patient. I know a lot of times we get list and we record reconcile a list from the pharmacy, or maybe from the Family Medicine office, and then the hospital, you know, does the thing. But I find so often at least in the hospitals around here that there will be all kinds of medications on their discharge summary that the patients have never taken. They've never taken or they weren't taking at the time. And so I think just the spending the time with the patient, they're the best. I mean, I will say some patients aren't good historians, and we have to rely on the list and we might even be able to communicate with you. But if you can communicate with the patient, like trust what the patient says they're taking, and I think there's this like, we don't want to take things off the list that like should be on there. But if the patient's not taking it like it shouldn't be on their list, right? I mean, we can communicate in a different way to say hey, like this was on your list, but they're saying they're not taking it make sure we pass on the information. But so often, I mean, there's just like old things. They were in the hospital for delivering the baby 10 years ago when they've got their meds still on Um, they're from from that. And so, um, so yeah, so I think making sure that we are doing a good job at really communicating with a patient when we can. And circling in like the one of the challenges with this environment of people going to multiple pharmacies is that they might get this med from this pharmacy and this med from this pharmacy and this med from this pharmacy. And sometimes we just contact one pharmacy to get a list. So the patient again can be that person that says, oh, actually go to Meijer and Kroger and here because I get fuel points here and I get a coupon here. So yeah, luckily, the like gift cards for transferring from pharmacy to pharmacy have like calmed down a little bit. But I had a situation. A neighbor of mine when I was in residency, went to the hospital, he ended up having Rhabdo from a drug interaction, but it was because rhabdomyolysis were muscle breakdown and causing him kidney damage. But he had gotten a blood pressure medication called delta ism from one doctor and a statin from another doctor and filled them at separate pharmacies, but the statin was on like the $4 list. So it didn't hit the insurance to alert this other pharmacy that he had that combination. But that combination is what resulted in this hospitalization. Because it was all this discombobulated. You know, getting one thing here getting another thing here and people were, you know, communicating. And so I think, from an outpatient perspective, like we always have to be asking patients every visit and as part of the process, but I think a lot of I mean, I've worked with a lot of nurses and LPNs and Emmys over the years. A lot of times they'll just ask the questions, pharmacies to pharmacy technicians, do you have any medication changes? And patients might not even remember that they Oh, yeah, I did have a medication. So they might say no. And I'm like, Well, let me let me go through the list with you, you go through the list. And they actually did have like several things that were not correct on your list. So I think we just have to, I mean, remember that our job is to make sure this as accurate as possible. And it's not always going to be possible. Because there's you know, a lot of things outside of our control. And we don't have one master system for everything. But the most important thing is to like go through all the medications, not just say, Hey, are you still taking Lisinopril but are you taking in less than a pro 10 milligrams once a day, and make sure that you know that full prescription is correct. I see the hospitals again around here a lot that will have a different strength strength, and then say like two tablets instead of one tablet, but the patient isn't really taking it like that. And so that can be confusing, um, just how the it got selected in the system. So just going through in detail with the patient, I think will identify a lot of a lot of things. And I don't know how each person's discharge process is structured, do they have time to talk to the patient, hopefully, if they're doing discharge counseling, but I think even at the forefront and the er, you know, doing a better job about figuring that out with the patient is really helpful. So if places aren't engaging the pharmacy team for the ER portion, or just doing it on the back end, maybe maybe starting to engage the pharmacist in the ER, for med rec or a part of the pharmacy team. I mean, some hospitals will use pharmacy interns to do that some hospitals will use pharmacists, pharmacy technicians that have been trained in medication reconciliation, so So yeah, so doing it from the whole, you know, full loop there.

Julie Soukup  23:24  
Yeah. And it's interesting, you say that too, because even like clarifying and getting more information and clear, like clearing that up and clarifying the medication could be could be even done originally even kind of by a nurse. I mean, if you're asking, you're trying to kind of clarify him. And it's interesting you say that because, you know, medical memory just partnered with one of our hospitals where they're so strapped on the pharmacy, and he actually started sending video messages using our app to the patients about things. Information. It's like a key No, but I feel like I still need to have that conversation. Yeah, the room to room was super hard. But so he would sit like look at the medications and then have almost like a two three minute video conversation. That's great. Okay, go wash it wash it when they got home. But it was it almost seems like you know, not going room to room to room gave me a few minutes to edge. Okay, there are different options, like what you have. Options are things that you should look at, in conjunction with that, and so, use some of the, you know, taps either, you know, send that information for you like, here's a custom or even like videos of like, Hey, this is a general information that you should know about taking cardiovascular medication, here's all the risks, benefits and all that which a few of our pharmacists have even started doing so that at least the patient can go home and say, Okay, I need to do a little more digging. And here's resources like your company that are out there that can do it. And you guys do that a ton on your podcast of you know, here's, I'm even looking at it's like, you know foundation health, nutrition, asleep of movement. Stress and all, that could provide a lot of mediums to maybe either minimize or get off some of some of them.

Melody Hartzler  25:09  
Yeah, I mean, ultimately, what we're trying to do from a functional medicine standpoint is support like the biochemistry of the body and how the body is supposed to function. So if we have too much of something, or too little of something like that's throwing off off the balance, which is one of the reasons why pharmacists have a little bit of an advantage in this space is because we've done a lot more biochemistry in our background than a lot of other health care professionals. Also, from the supplement standpoint, like pharmacology is similar to how, you know, it's it's all how does this interact with receptors and, and produce an effect? So did you know deep diving into supplement interactions to is there's, you know, we have more limited data on on how supplements interact with medications, but definitely spent a little bit more time talking about resources for that then than some of the other healthcare professional groups? Awesome. Well, that

Julie Soukup  26:02  
is so you've been so informative, and I think even what you're saying is for anyone who's kind of falling in the same communication pattern with patients is taking that step back, have a nurse take a step back to just really look at it, and even just vocalizing Hey, there's a ton of resources that are out there that you should look at, you know, to kind of see different ways of of managing this whole piece versus just sharing this one prescription. So thank you so much. Thanks for having me. Appreciate it. Farm to Table is what it's called. It's

Melody Hartzler  26:33  
a RM Yes, farm. Farm, I should say or m dot life.

Julie Soukup  26:41  
Okay, yeah, farm to table dot life is what it is.

Melody Hartzler  26:44  
I'll give the link to our podcast or podcast is called Table Talk. That'll link to our podcast is on the page as well.

Julie Soukup  26:49  
Awesome. Thank you so much for you and we'll talk to you about I'm sure soon.

Melody Hartzler  26:56  
Okay, thanks.

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