NORTH BAY -- Two of Sonoma County's biggest federally qualified health centers are in the process of opening in-house pharmacies at key locations, a move aimed at further integrating primary care services with the hopes of improving outcomes for patients who struggle with prescription medications.

Both Santa Rosa Community Health Centers and Petaluma Health Center are following the lead of another North Bay FQHC, Marin Community Clinics, which opened an on-site pharmacy about a year ago. Since then, Marin's safety-net provider has seen a dramatic improvement in reducing repetitive visits from patients, many of whom struggled with medications and ended up either back at clinics or in emergency rooms for treatable conditions, said Linda Tavazsi, CEO of Marin Community Clinics.

While having a pharmacy within a nonprofit health setting isn't unheard of, certain expertise are required and not every location is well suited for the service, depending on whether there is enough patients that come to a centralized location. Startup costs can be a hindrance as well, Ms. Tavazsi said of the program, known as the 340b Drug Pricing Program and Pharmacy Affairs overseen by the Health Resources and Services Administration.  Until the Marin pharmacy, none existed in the North Bay, where the networks of clinics provide a significant share of primary care services. 

"It was a little scary because I didn't know 340b so well, but the evolution has been unbelievable," Ms. Tavazsi said. "The most striking thing is when we started the pharmacy in-house, 30 percent of our patients would never pick up their drugs at outside pharmacies.

"From 30 percent noncompliant, we are now at 1 percent," she said. "We started doing 10 to 20 prescriptions per day. Last week we did 423 in one day."

At safety-net health centers across the North Bay, patients, many low income and of immigrant status, often face language barriers with medications and instructions, or a general unfamiliarity with the retail pharmacies, and as such face difficulty navigating the system as a whole, officials said. So having a pharmacy on-site, where physicians can confer directly with pharmacists and the patient all at once, has great potential to correct seemingly intractable communication or transportation issues that can lead to less favorable outcomes.

At Santa Rosa Community Health Centers, the estimated number of patients who face challenges with prescription compliance is similarly about 30 percent, according to Naomi Fuchs, CEO.  The expansion of Medi-Cal under the Affordable Care Act is adding further motivation, she said.

"Access to affordable medications has always been an issue for our patients," Ms. Fuchs said. "It's hard to improve their health if they can't get the medications. Why this has come up now is because we used to be able to offer these kinds of medications only to uninsured and Medicare patients. As a result of the (Affordable Care Act), we can now offer them to Medi-Cal patients, which are two-thirds of our patients."

Ms. Fuchs said the new pharmacies could serve between 30 percent and 40 percent of its 40,000 patients. The Santa Rosa safety-net provider is in the process of setting up a pharmacy first at its Southwest Community Health Center on Lombardi Court within the next month and another later this year at its Vista Health Center.

Petaluma Health Center likewise will open a pharmacy at its main location in the coming month or so, according to Ciera Rudin, community relations manager.

The forthcoming pharmacies in Santa Rosa and Petaluma are both being developed by Pat Ianturno, a retired pharmacist now running his own consultancy, IMG Holdings, who also set up the pharmacy at Marin Community Clinics with the help of well-known Marin pharmacist Paul Lofholm.

Mr. Iantorno said all of the in-house pharmacies -- each about 400 or 500 square feet -- have been or are being developed with private funding, and each is staffed with three to four independent pharmacists, not clinical staff.  Pharmacies at the health centers are only for patients of those centers, many of them on Medi-Cal.

Mr. Iantorno declined to reveal the price tag of establishing the pharmacies, though he said it costs "several hundred thousand dollars" for each pharmacy.  The health centers pay a small administrative fee for pharmacists to run the program and make sure it's compliant with federal regulations on pharmacies.

"We are getting private funding for it, creating the model and we are staffing it and then going to manage it for them," he said.

Mr. Ianturno, a native of San Diego, said he's worked with a number of different providers in setting up pharmacies, including small medical office buildings. But the recent developments with the North Bay FQHCs is perhaps one of just a few in the country, he and Ms. Tavazsi said.

"I had the largest wholesaler come in and say this is the only program of its kind," Mr. Ianturno said of the Marin Community Clinics pharmacy. Any returns on running the pharmacy are reinvested into the health centers or into possible expansion to new health centers, he said, adding that he's receiving inquiries from health centers in Napa and in the Central Valley.

The 340b program lets the nonprofit providers capitalize on discounted medications, in the range of 20 to 50 percent lower, from large pharmacy chains and pharmaceutical companies. That enables the providers to then pass along those savings to low-income patients such as those at an FQHC, sources said.

It's also another example of the evolving roll of health centers, and how primary care is getting more sophisticated as providers adapt to new incentives under health care reform that encourage efficient , outcome-based care , said Mark Knight, a Santa Rosa-based health care consultant who works with many of the region's FQHCs.

"It's one of those things that's a growing trend," he said. "Not a lot of (health centers) have done it but they're all looking at it. Pharmacies are required to make these drugs available at an affordable price," he said. "The reason for that is so those organizations like an FQHC can pass on their savings to the patients. That's the real benefit.

"If you develop your own pharmacy, it just makes it that much easier to administer. If you separate the pharmacy from where (the patients are) going for primary care, that creates issues."

Mr. Ianturno, in explaining what initially motivated him, echoed that sentiment, noting that a range of providers are coming together, from physician to nurses to pharmacists, all at once to address patient needs.

"We integrated the cultures," he said.  "The patient is treated like a patient in the clinic and when they go to the pharmacy, they're still treated like a patient, not a customer."