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Pharmacist-driven continuous glucose monitoring in community and ambulatory care pharmacy practice: A scoping review

BACKGROUND

Continuous glucose monitoring (CGM) devices improve clinical outcomes and facilitate achieving patient-specific goals. However, opportunities and barriers to implementation of pharmacist-driven CGM services are not well-described.

OBJECTIVES

This scoping review was conducted to identify opportunities and barriers to implementing pharmacist-driven CGM services in the community and ambulatory care setting. Clinical outcomes resulting from pharmacist-driven CGM were also explored.

METHODS

A health librarian searched Ovid MEDLINE, Cochrane CENTRAL, Embase, Web of Science, Scopus, International Pharmaceutical Abstracts using keywords and subject headings from inception through December 2, 2022 to identify studies describing pharmacist or pharmacy-based CGM programs. No publication type, date limits, language restrictions, or other filters were applied. The database search was supplemented by a search of Google Scholar and a citation search of preselected gold standard articles.

RESULTS

The scoping review initially identified 942 citations of which 249 passed abstract screening and 11 were included in the review. Among studies, the most common design was retrospective, populations varied, control groups were not consistently used, follow-up was primarily short, and sample sizes were small. One study evaluated pharmacist-driven CGM in a community pharmacy setting. Ten studies took place in the ambulatory care setting. Barriers to initiating pharmacist-driven CGM as a clinical service include educational, logistical, workflow, and financial incentive. Beneficial outcomes from pharmacist-driven CGM include improved quality of life, increased empowerment, and improved glycemic control.

CONCLUSION

There is lack of strong evidence to support pharmacist-driven CGM in the community pharmacy setting. However, small studies suggest pharmacist-driven CGM is feasible and beneficial in the ambulatory care setting. Further exploration of how educational, logistical, workflow, and financial barriers can be overcome is warranted, given potential for improved clinical outcomes.

Flip the Pharmacy's impact on comprehensive medication management performance

BACKGROUND

Clinically integrated networks of community pharmacies are expanding partnerships with health care payers for sustainable provision of patient care services. The Pennsylvania Pharmacists Care Network (PPCN), a part of CPESN USA, launched its first payer program in 2017 with a Medicaid managed care organization for comprehensive medication management (CMM). Some PPCN pharmacy teams have participated in Flip the Pharmacy, a national practice transformation initiative.

OBJECTIVES

This study aimed to determine whether pharmacy participation in Flip the Pharmacy was associated with a greater rate of CMM encounters than in nonparticipating pharmacies within a statewide clinically integrated network.

METHODS

This project was a retrospective quantitative study. CMM encounter data including total number of encounters and total number of eligible members were extracted from monthly reports. Generalized estimating equations were used to assess the association between Flip the Pharmacy participation and CMM encounter rates.

RESULTS

Of 103 pharmacies that participated in the CMM program in 2019 and 2020, 77.7% of pharmacies (n = 80) were included in analyses. Of these, 31.3% (n = 25) participated in Flip the Pharmacy. Overall, 80 pharmacies documented 8460 patient encounters through the CMM program. On average, pharmacies participating in Flip the Pharmacy recorded 1.67 times the rate of encounters compared with non-Flip the Pharmacy pharmacies (95% CI 1.10-2.54), controlling for single versus multiple pharmacy sites and weekend hours. On average, pharmacies participating in Flip the Pharmacy recorded 1.18 times the rate of initial encounters (95% CI 0.84-1.59) and 2.06 times the rate of follow-up encounters (95% CI 1.22-3.48) compared with non-Flip the Pharmacy pharmacies.

CONCLUSION

Participation in Flip the Pharmacy in Pennsylvania was associated with greater engagement and completion of encounters within a payer program for CMM. Continued practice transformation efforts are needed to ensure the sustainability of community pharmacy practice as it continues to expand into payment for patient care services.

Coaching strategies for the Flip the Pharmacy practice transformation initiative in Pennsylvania independent community pharmacies

BACKGROUND

Flip the Pharmacy (FtP) is a nationwide initiative to scale practice transformation in community pharmacies. Participating pharmacies are coached through monthly practice transformation initiatives and document their patient-care activities through Pharmacist electronic Care (eCare) Plans.

OBJECTIVES

The objective of this study was to identify peer coaching strategies to facilitate practice transformation in Pennsylvania community pharmacies.

METHODS

This was a qualitative study using semistructured interviews with practice transformation coaches and pharmacy champions participating in Pennsylvania's FtP program. The interview guide was informed by the Consolidated Framework for Implementation Research and elicited information using the intervention characteristics, inner setting, characteristics of individuals, and process domains. Interviews were conducted in person or via telephone over a 3-month period. An inductive qualitative thematic analysis was performed to identify coaching strategies.

RESULTS

A total of 18 key informants were interviewed: 6 pharmacy champions and 12 practice transformation coaches. The following 5 coaching strategies emerged: (1) learn to use the pharmacy's specific Pharmacist eCare Plan software, (2) build a trusting relationship with the pharmacy, (3) engage all pharmacy team members in practice transformation, (4) adapt communication strategies to the pharmacy's preference, and (5) tailor goals to the pharmacy's stage of practice transformation.

CONCLUSION

This study elicited 5 peer coaching strategies to support community pharmacy practice transformation initiatives. These findings can be used to further practice transformation efforts in community pharmacies through FtP and other initiatives aimed at expansion of community pharmacy patient care services.

Community pharmacist-provided opioid intervention frequencies and barriers

BACKGROUND

Community pharmacists are well-positioned to engage in opioid-related harm reduction activities (i.e., opioid interventions). However, several barriers to providing these interventions have been identified. Comparing the frequencies of opioid interventions and identifying which barriers are perceived to have the highest impact in providing interventions will yield valuable information for increasing opioid use disorder (OUD) care access within pharmacies.

OBJECTIVES

To (1) characterize the frequency of 9 opioid interventions in community practice settings and (2) assess community pharmacists' perceptions of what impact 15 key barriers have on providing opioid interventions.

METHODS

This was a multi-state, cross-sectional, and descriptive survey study. Opioid interventions evaluated included prevention (e.g., OUD screening) and treatment (e.g., OUD resource referral); barriers encompassed confidence and knowledge, work environment, provider interactions, and patient interactions. Respondents were recruited from 3 community pharmacy practice-based research networks in the Midwest and South regions of the US. Recruitment and telephone survey administration occurred between December 2021 and March 2022. Descriptive statistics were computed and open-ended items were reviewed to identify common themes.

RESULTS

Sixty-nine of 559 pharmacists contacted (12.3%) completed the survey. All opioid interventions were reported to be provided less frequently than indicated in practice. Screening and referral interventions were provided least frequently, at 1.2 and 1.6 times on average, respectively, to the last 10 patients for which respondents felt each intervention was needed. Patient refusal, minimal or no reimbursement, inadequate staffing and time, and negative patient reactions were identified as the highest-impact barriers to providing opioid interventions. Approximately 26% of respondents agreed or strongly agreed that pharmacy school adequately prepared them to provide opioid interventions in practice.

CONCLUSION

Prioritizing the resolution of pharmacy work environment barriers will support pharmacists in routinely providing opioid interventions. Changes in Doctor of Pharmacy curricula and continuing education are also indicated to further prepare pharmacists to engage in opioid-related harm reduction.

Strategies for implementing the Appointment-Based Model at a rural independent chain of community pharmacies

BACKGROUND

The Appointment-Based Model (ABM) is a care model that helps community pharmacists streamline their medication dispensing workflow while simultaneously integrating patient care into the medication preparation process through medication synchronization. Implementation of the ABM has varied across community pharmacies. Further studies that identify tailored implementation approaches are needed to support broad adoption of the ABM in practice.

OBJECTIVES

(1) To determine facilitators and barriers to ongoing adoption and implementation of the ABM at a small chain of rural independent pharmacies where adoption has stalled and (2) to identify implementation strategies to support further adoption of the ABM at these pharmacies METHODS: This project was an exploratory, mid-implementation study. Semistructured interviews were conducted with pharmacy staff who participated in the ongoing implementation and use of the ABM at the pharmacies. Interviews elicited stakeholder-centered perspectives on (1) experiences with the ABM to date, (2) processes and roles for the ABM, and (3) opinions on how implementation of the ABM could be improved at the pharmacies. Rapid qualitative assessment methodology was used for analysis to identify facilitators and barriers and to select implementation strategies.

RESULTS

Thirty-one pharmacy personnel were interviewed: pharmacists (n = 10), pharmacy technicians (n = 7), and fill clerks (n = 14). The research team identified 6 facilitators and 4 barriers to the implementation of the ABM at the pharmacies. Five implementation strategies were selected based on the facilitators and barriers: (1) capture and share local knowledge across pharmacy sites, (2) conduct educational outreach visits, (3) conduct ongoing training, (4) prepare patients to be active participants in the ABM, and (5) organize clinician implementation team meetings.

CONCLUSIONS

Development of a stakeholder-driven implementation approach may support further implementation and adoption of the ABM in practice.

Pharmacist peer coaching in a traditional community chain pharmacy: Implementation and perceptions

OBJECTIVE

To determine pharmacists' perceptions of peer coaching techniques designed to enhance pharmacists' provision of targeted medication reviews for adherence in traditional chain community pharmacies.

METHODS

A peer coaching method was designed and implemented by a community-based pharmacy resident. Pharmacies within a traditional community chain were selected from a region that spans parts of western Pennsylvania and eastern Ohio. Individualized peer coaching was provided face-to-face with pharmacists within pharmacy workflow. After the full coaching intervention was complete, semi-structured interviews with coached pharmacists were conducted to qualitatively assess their perceived impact of the coaching. Interviews were conducted by a member of the investigative team to limit bias. Interviews were audio-recorded and transcribed, and then they underwent full thematic analysis.

RESULTS

Five major themes were elicited from the coached pharmacists' interviews: (1) tailor coaching to pharmacist skill level, (2) empower pharmacists with strategies to conduct clinical interventions and self-assess, (3) teach patient engagement strategies, (4) include all team members to promote engagement, and (5) utilize peer coach's experience with the intervention.

CONCLUSION

Themes from this project can help guide the implementation of peer coaching programs in community pharmacies. Effective peer coaching is an important approach to increase the uptake and effectiveness of a variety of community pharmacist-led enhanced patient care services.

Medication synchronization adoption and pharmacy performance

BACKGROUND

While medication synchronization programs are becoming a staple in community pharmacies, a standard process needs to be identified to provide consistent positive outcomes. Many studies demonstrate how medication synchronization affects individual level patients but have not examined how medication synchronization affects the pharmacy's performance. Because community pharmacies are calibrated based on performance to adherence measures for all patients, it is important to understand whether resource-intensive interventions, such as medication synchronization, lead to improved performance.

OBJECTIVES

The aims of this study were to 1) examine pharmacy characteristics associated with medication synchronization adoption and 2) examine whether medication synchronization is associated with pharmacy-level performance on select medication adherence and utilization measures.

METHODS

This study used a cross-sectional design. Community pharmacies participating in the North Carolina Community Pharmacy Enhanced Services Network (NC CPESN℠) program were included in this study. Pharmacy performance was measured as summary score of pharmacy's performance on seven risk-adjusted measures which were used to measure pharmacy's performance in the program. Adoption of medication synchronization was measured as a binary variable capturing whether the pharmacy offered med sync at the time the survey was administered.

RESULTS

Surveys were received from 160 out of 268 participating pharmacies (59.7% response rate) with a total of 155 pharmacies being included in the analytic sample. Pharmacies that adopted medication synchronization were more likely to have a clinical pharmacist on staff (c = 5.4, p = 0.019). Holding all else constant, medication synchronization adoption was not significantly associated with total medication adherence performance (p = 0.371).

CONCLUSION

Medication synchronization has proven successful in improving individual patient level adherence but may not change a pharmacy's overall performance in adherence for all patients. Further research is needed to examine how effective implementation might contribute to whether a medication synchronization program leads to meaningful gains in adherence for all patients.

A Student Pharmacist Quality Engagement Team to Support Initial Implementation of Comprehensive Medication Management within Independent Community Pharmacies

In 2017, the Pennsylvania Pharmacists Care Network (PPCN), an enhanced pharmacy services network, and STRAND Clinical Technologies partnered to launch a payor contract with a Pennsylvania Medicaid Managed Care Organization for the provision of comprehensive medication management (CMM) at PPCN pharmacies. PPCN and the Community Leadership and Innovation in Practice Center at the University of Pittsburgh School of Pharmacy partnered to create the Quality Engagement Team (QET), a group of student pharmacists formed with the intent to support the initial implementation of this contract. The QET supported the pharmacies through biweekly phone calls, which led to increased pharmacist engagement and produced impactful patient encounter stories that were then reported back to the payor. We utilized Active Implementation Frameworks and select implementation strategies from the Expert Recommendations for Implementing Change project throughout the implementation period. The QET supported the successful implementation of this payor contract, which saw an increase in CMM encounters completed by the pharmacists during each month of the four-month contract period. Students, pharmacists and the payor each derived meaningful benefits from this initiative. Student pharmacists can be a powerful asset in the implementation of payor programs within an enhanced pharmacy services network, resulting in the mutually beneficial and sustainable support of the network.