Strategies for community-based medication management services in value-based health plans

Impact of a Public Health Awareness Campaign on Patients' Perceptions of Expanded Pharmacy Services in South Dakota Using the Theory of Planned Behavior

Background: Pharmacists can offer medication expertise to help better control diabetes and cardiovascular disease (CVD) and improve patient outcomes, particularly in rural communities. This project evaluated the impact of an awareness campaign on perceptions of expanded pharmacy services. Methods: The “Your Pharmacists Knows” campaign included a 30-s commercial, print material, and media announcements. A non-randomized pre-post study was completed using a modified theory of planned behavior (mTPB) to assess knowledge, attitude, perceived benefits and norms, and perceived control. A 73-item survey was administered to a convenience sample (n = 172) across South Dakota. Regression models to assess intent and utilization were conducted using age, gender, race, education, population, and insurance status as predictors for mTPB constructs. Results: Most common predictors were female gender and higher education level (p < 0.001). All mTPB constructs were significant predictors of intent to use services (p < 0.001). Knowledge and perceived control had the largest influence on intent. Additionally, there was significant improvement in post-campaign service utilization (p < 0.001). Conclusions: This campaign positively influenced intent to seek and utilize services in rural communities where pharmacies may be the only healthcare option for miles. Through targeted campaigns, patients with diabetes or CVD may find access to services to better manage their conditions.

Incorporating medication therapy management into community pharmacy workflows

Medication Therapy Management (MTM) is a group of pharmacist-provided services that optimize individual patients' drug therapy outcomes. Since community pharmacies' primary business platform is the dispensing of medications, and providing MTM services is a secondary source of revenue, pharmacies with limited resources are operationally challenged when trying to efficiently deliver both types of services. To address this problem, we follow a queueing network approach to develop an operational model of a community pharmacy workflow. Through our model, we derive structural results to determine conditions for a pharmacy to achieve economies of scope when providing both prescription and MTM services. We also develop a process simulation to compare different scenarios according to our economies of scope model, varying in provided services, personnel, service demand, and other operational variables. Outcomes examined include profitability, service rate, and sensitivity of some operation variables to profitability. Based on our results, we provide practical insights to help community pharmacy administrators and healthcare policy makers in their decision process.

Ensuring quality qualitative research reporting in community pharmacy: a systematic literature review

OBJECTIVES

To evaluate the reporting quality for a sample of community pharmacy qualitative research articles based on the Standards for Reporting Qualitative Research (SRQR) guidelines, data interpretation and use of theory.

METHODS

A systematic literature search was conducted using Ovid MEDLINE to identify qualitative research related to community pharmacy. Data were extracted and evaluated based on the SRQR standards, data interpretation level and use of theory. Adherence to standards was analysed using descriptive statistics.

KEY FINDINGS

Eighty-one studies were retrieved through the database search (n = 81). Then, 31 studies met the inclusion criteria after screening abstracts and full texts. Twelve out of 21 SRQR were present in more than 80% of the studies. However, essential standards, such as research approach, reflexivity and trustworthiness techniques, were absent or partially present in 30 (97%) studies, 30 (97%) studies and 21 (68%) studies, respectively. Data interpretation level was descriptive in 27 (87%) studies and interpretive or partially interpretive in 4 (13%) studies. Theory was absent in 19 (60%) and implied, partially integrated or retrospectively applied in 12 (40%) of the studies.

CONCLUSION

Trustworthiness and quality of qualitative inferences within community pharmacy research could be enhanced with increasing awareness about reporting; the approach and paradigm, reflexivity, trustworthiness techniques, data interpretation level and theoretical use.

Experiences of key stakeholders with the implementation of medication reviews in community pharmacies: A systematic review using the Consolidated Framework for Implementation Research (CFIR)

BACKGROUND

Though medication reviews have shown positive patient outcomes, they are still not widely implemented in community pharmacies. Published reviews on their implementation often include several other pharmacy services, making them non-specific. Using the Consolidated Framework for Implementation Research (CFIR) to focus solely on the experiences of different stakeholders with the implementation of medication reviews will help to better understand relevant facilitators and barriers.

OBJECTIVES

To critically appraise, synthesise and present the available evidence on experiences of key stakeholders with the implementation of medication reviews and to identify barriers and facilitators to its implementation in community pharmacies.

METHODS

A systematic literature search was conducted in four databases for studies published in English, Spanish or German. Key search terms included: implementation, pharmac*, medication review, facilitator, barrier. Study selection, quality assessment and data extraction were performed by two independent reviewers. Findings were mapped directly against the constructs of the CFIR.

RESULTS

Out of 924 retrieved records 24 articles from 9 countries met the inclusion criteria. Key facilitators identified included pharmacists' openness to practice change and a high degree of patient satisfaction post medication review. Attracting patients to the service was stated as challenging due to an unawareness of the scope and potential benefit of a medication review. The dominant barrier was inadequate remuneration, as it impacted all additional resourcing and ultimately the viability of the service. Further barriers included difficult professional relationships with doctors and little mandate from health authorities. Most reports were from the employed pharmacists' perspective and concerned the inner setting, other perspectives were under-reported.

CONCLUSIONS

Results of this systematic review illustrate different stakeholders' experiences and add to the understanding of challenges in the implementation process. Nevertheless, findings also highlight how scarce reporting of external stakeholders' views is and that filling this gap can unveil hidden barriers and facilitators.

REGISTRATION

PROSPERO register (CRD 42019122836).

A Conceptual Framework of the Way Forward to a Community Pharmacist-General Practitioner Collaborative Medication Therapy Management Model for Chronic Diseases in Malaysian Primary Care: A Qualitative Study

BACKGROUND

There is a growing global interest in formulating such policies and strategic plans that help devise collaborative working models for community pharmacists (CPs) and general practitioners (GPs) in primary care settings.

OBJECTIVE

To conceptualize a stakeholder-driven framework to improve collaboration between CPs and GPs in Malaysian primary care to effectively manage medicines in chronic diseases.

DESIGN AND SETTING

A qualitative study that involved individual semi-structured interviews of the leadership of various associations, guilds, and societies representing CPs, GPs, and Nurses in Malaysia.

METHODS

This study collected and reported data in accordance with the guidelines of the Consolidated Criteria for Reporting of Qualitative Studies. Key informants were recruited based on purposive (expert) sampling. Interviews were transcribed verbatim and data were coded based on the principles of thematic analysis in NVivo.

RESULTS

A total of 12 interviews (5 CPs, 5 GPs, and 2 nurses) were conducted. Five themes emerged: Theme 1 highlighted a comparison of community pharmacy practice in Malaysia and developed countries; Theme 2 involved current practices in Malaysian primary care; Theme 3 encompassed the advantages of CP-GP collaboration in chronic diseases; Theme 4 highlighted the barriers which impede collaboration in Malaysian primary care; and Theme 5 delineated the way forward for CP-GP collaboration in Malaysia.

CONCLUSION

The actionable insights obtained from the Malaysian stakeholders offered an outline of a framework to enhance collaboration between CPs and GPs in primary care. Generally, stakeholders were interested in CP-GP collaboration in primary care and identified many positive roles performed by CPs, including prescription review, adherence support, and patient education. The framework of the way forward includes: separation of CP and GP roles through a holistic revision of relevant legislation to grant an active role to CPs in chronic care; definition of protocols for collaborative practices; incentivization of both stakeholders (CPs and GPs); and design and implementation of an effective regulatory mechanism whereby the Malaysian Ministry of Health may take a leading role.

Advanced pharmacy practice experience students at the intersection of education and practice transformation

BACKGROUND AND PURPOSE

Community pharmacy practice is transforming from traditional dispensing roles, and advanced pharmacy practice experiences (APPEs) could be a viable mechanism to assist pharmacies during transformation. A new type of APPE is described and the design, outcomes, and feedback from the first students and pharmacies piloting this rotation are discussed.

EDUCATIONAL ACTIVITY AND SETTING

A four-week elective APPE was designed to position fourth-year students as facilitators for community pharmacy transformation activities. The first transformation activity was clinical documentation using electronic care plans (eCare plans). Students spent a majority of the rotation in the pharmacy with only the first week and one day a week thereafter at the college of pharmacy. Students assessed current pharmacy workflow, developed an implementation plan, trained pharmacy staff, and created protocols and resources.

FINDINGS

Four student pharmacists completed the rotation during May, June, and August 2019. Student knowledge was assessed through a 12-question pre- and post-quiz on implementation science and the pharmacist eCare plan. Following orientation activities, students' scores increased from an average 44% to 86%. Course evaluations showed students learned about pharmacy business management and recognized challenges in teaching staff new concepts. All students indicated appreciation for innovative activity involvement and helping a pharmacy advance its practice.

SUMMARY

Early findings from this elective indicate a successful learning experience for students and pharmacy owners. The students gained skills in teaching, facilitation, and practice management, while pharmacy owners benefitted from staff training and implementation resources.

Community Pharmacists' Perceptions of Patient Care Services within an Enhanced Service Network

BACKGROUND

Pharmacists are positioned as an accessible source of patient care services (PCS). Despite the adversity community pharmacies continue to face, the expanding opportunity of offering PCS continues to be a pathway forward.

OBJECTIVE

To identify community pharmacists' perceptions to deliver PCS within an enhanced service network.

METHODS

One-on-one semi-structured phone interviews were conducted as part of a mixed-methods approach. Interview transcripts were analyzed using a consensus codebook to draft thematic findings. Participants were recruited from an electronic survey targeting community pharmacists from the New York chapters of the Community Pharmacy Enhanced Services Network (CPESN).

RESULTS

Twelve pharmacists were interviewed with four main themes identified. The majority of study participants were pharmacy owners (92%) devoting an average of 15 h/week to PCS and 8 h/week addressing social barriers. The main themes identified include: (1) perceptions of pharmacy profession, (2) reimbursement models and sustainability of PCS, (3) provision of patient care services, and (4) how PCS address social determinants of health.

CONCLUSIONS

Offering PCS opportunities for patients is a direction many community pharmacists have embraced and are working to succeed. Ongoing research is needed focusing on community pharmacists' self-perceptions of the clinical impact and role they hold in an evolving healthcare system.

Medication Therapy Management: Current Challenges

Medication therapy management (MTM) services have evolved as a means for pharmacists and other providers to assist patients and caregivers in improving therapeutic outcomes and reducing health care expenditures. More than a decade has passed since the Medicare Modernization Act of 2003 provided pharmacists with the opportunity to deliver MTM services to Medicare beneficiaries. MTM continues to offer pharmacists the opportunity to use their knowledge; yet, pharmacists have reported challenges with service delivery. Identifying the challenges that affect MTM services in pharmacy practice is necessary in order to seek improvement to MTM delivery. This narrative review explores the current challenges pharmacists face with MTM delivery, summarizes potential solutions for addressing challenges, and seeks to incite further debate, service reconfiguration, and ultimately service improvement of pharmacist-provided MTM services.

Looking Back at US Pharmacy’s Past to Help Discern Its Future

Objective: To review specific literature that aimed to predict the future of US pharmacy, beginning in the late 1980s. Data Sources: Articles were identified from searching MEDLINE, CINAHL, Google Scholar, and references of relevant articles. The following combinations of search terms were used: future, pharmacy, prediction, and forecast. Study Selection and Data Extraction: The following inclusion criteria were applied: (1) full-text commentary, review, or original research and (2) focused predominantly on the pharmacy in the United States. Data on predictions for the future of pharmacy were extracted. Data Synthesis: We selected 3 articles published between 1988 and 2006, with each aiming to project the future for the following decade. We examined each prediction in light of the current knowledge. Relevance to Patient Care and Clinical Practice: Educators, practitioners, and other stakeholders should consider reflecting on the changes in pharmacy for the past 3 decades and applying both historical and emerging trends to improve patient care and sustain practice in the third decade of the 21st century and beyond. Conclusion: Most of the predictions for the future of pharmacy from the past 3 decades materialized, with some still in progress (reimbursement for pharmacy services), whereas others manifested in unexpected ways (transition from shortage to excess of pharmacists). Current forces shaping pharmacy include, but are not limited to, growing spending and use of specialty drugs, automation of pharmacy operations, growth of pharmacy in the digital health enterprise, and growing consumer interest in the use of analytical pharmacy that tests drugs before dispensing.

Implementation process for comprehensive medication review in the community pharmacy setting

OBJECTIVES

To (1) describe the implementation process for comprehensive medication reviews (CMRs) among community pharmacies (e.g., processes for prioritizing patients, staffing, and information collection) and (2) examine factors associated with community pharmacies' CMR information collection process.

METHODS

A survey was administered to the pharmacist responsible for implementation of CMRs (i.e., the lead pharmacist) in the community pharmacy (n = 87). The survey included questions about pharmacy characteristics, satisfaction with the NC community pharmacy enhanced services network (NC-CPESN) program, and implementation of CMRs. Frequencies and means were calculated to describe the sample characteristics and pharmacies' CMR implementation process. A multiple linear regression was conducted to examine which characteristics were associated with the CMR information collection process.

RESULTS

The majority of pharmacies in the sample were either independently owned single stores (46.5%) or multiple stores under the same independent ownership (41.6%). Most pharmacies used pharmacists (97.7%) or pharmacy technicians (65.5%) for patient outreach for CMRs. A small percentage of pharmacies used administrative staff to conduct patient outreach for CMRs (9.2%). Information for prescription medications (89.5%), indication (80%), and medication adherence (81.1%) was routinely collected. Information such as date of last dose for prescription medications (48.4%) and lifestyle factors, such as physical activity (21.1%), diet (29.5%), and alcohol (31.6%), was collected less routinely. Having a clinical pharmacist (P = 0.025) and pharmacist overlap hours (P = 0.009) significantly improved the CMR information collection process.

CONCLUSION

Although CMRs are important interventions for improving patient outcomes, more guidance is needed on how to effectively implement them. This would allow the process to be efficient and assure implementation with fidelity across all community pharmacies. In addition, staffing appears to influence the quality of CMR information collection. Future research is warranted on CMR implementation to develop efficient staffing models and standardize the process of information collection.

Comprehensive medication reviews: Optimal delivery setting and recommendations for quality assessment

OBJECTIVES

To propose a metric evaluating the quality of comprehensive medication reviews (CMRs), and to discuss the optimal setting for CMR delivery.

SUMMARY

First, we provide a current assessment of the quality of CMRs performed in community, payer, and health system/clinic settings, with recommended opportunities for improvement. Thereafter, a companion metric for CMR quality is discussed, because this is critical to ensuring that patients are not just receiving CMR services, but that CMRs reflect evidence-based recommendations supporting optimal patient outcomes.

CONCLUSION

Based on the data currently available, accessibility to electronic medical records would enhance patient-specific recommendations to optimize CMR delivery and patient outcomes. Future studies may help to identify additional factors, such as pharmacist-physician collaboration in clinic and use of evidence-based recommendations, that can further enhance CMR quality.

Payers’ Perspectives on Pharmacist-Directed Care in a Community Pharmacy Setting

Background: The United States is spending an increasing share of its national income on health care while American citizens are not receiving the commensurate benefit of longer, healthier lives. Pharmacists are in a position to provide high-quality care; however, a paucity of data exists on payers’ perspectives on insurance reimbursement for pharmacist-provided, community-delivered clinical services. Objective: To understand payers’ perspectives toward pharmacist-provided community-delivered advanced clinical services. Methods: A 15-minute online survey was administered to determine payers’ preferences and attitudes of impact about care being provided in a community pharmacy setting by a pharmacist. Results: The study recruited 50 payers from a diverse set of US organizations. The likelihood for reimbursement for a suite of pharmacist-provided, community-delivered clinical services was likely/very likely (66%), neutral (22%), and unlikely/very unlikely (12%). Pharmacists were viewed positively by payers for the provision of these services. Payers think that more clinical services should be offered in the community pharmacy. Trust in pharmacist-provided information services on general health and medications, and pharmacist competency were strongly positive. Conclusions and Relevance: A quantitative assessment of payer attitudes for pharmacist-provided, community-delivered advanced clinical practice was positive. Payers were positive about pharmacist contributions to the provision of heath and medication information. Continued development and deployment of advanced clinical services at the community pharmacy appears to be a financially viable model.

Primary Care Pharmacist Services Align With Payment Reform and Provider "Joy of Practice"

The implementation and expansion of primary care (PC) pharmacist medication optimization and management services has been hindered mainly by the lack of a payment mechanism for PC providers to engage pharmacist services. If pharmacists expect to be included in new PC team-based payment models, we need to actively engage in ongoing PC practice transformation discussions with PC organizational leaders. In this commentary, examples of integrated PC pharmacist services and payment models are provided to (1) reinforce the feasibility of pharmacist integration into expanded PC teams and (2) share with PC leaders, payers, and policy makers.

Patient care activities by community pharmacists in a capitation funding model mental health and addictions program

BACKGROUND

Community pharmacists are autonomous, regulated health care professionals located in urban and rural communities in Canada. The accessibility, knowledge, and skills of community pharmacists can be leveraged to increase mental illness and addictions care in communities.

METHODS

The Bloom Program was designed, developed, and implemented based on the Behaviour Change Wheel and a program of research in community pharmacy mental healthcare capacity building. We evaluated the Bloom Program as a demonstration project using mixed methods. A retrospective chart audit was conducted to examine outcomes and these are reported in this paper.

RESULTS

We collected 201 patient charts from 23 pharmacies in Nova Scotia with 182 patients having at least one or more follow-up visits. Anxiety (n = 126, 69%), depression (n = 112, 62%), and sleep disorders (n = 64, 35%) were the most frequent mental health problems. Comorbid physical health problems were documented in 57% (n = 104). The average number of prescribed medications was 5.5 (range 0 to 24). Sixty seven percent (n = 122) were taking multiple psychotropics and 71% (n = 130) reported taking more than one medication for physical health problems. Treatment optimization was the leading reason for enrollment with more than 80% seeking improvements in symptom management and daily functioning. There were a total of 1233 patient-care meetings documented, of which the duration was recorded in 1098. The median time for enrolling, assessing, and providing follow-up care by pharmacists was 142 min (mean 176, SD 128) per patient. The median follow-up encounter duration was 15 min. A total of 146 patient care encounters were 60 min or longer, representing 13.3% of all timed encounters.

CONCLUSIONS

Pharmacists work with patients with lived experience of mental illness and addictions to improve medication related outcomes including those related to treatment optimization, reducing polytherapy, and facilitating withdrawal from medications. Pharmacists can offer their services frequently and routinely without the need for an appointment while affording patient confidentiality and privacy. Important roles for pharmacists around the deprescribing of various medications (e.g., benzodiazepines) have previously been supported and should be optimized and more broadly implemented. Further research on the best mechanisms to incentivize pharmacists in mental illness and addiction's care should be explored.

Integration Strategies of Pharmacists in Primary Care-Based Accountable Care Organizations: A Report from the Accountable Care Organization Research Network, Services, and Education

BACKGROUND

The accountable care organization (ACO) is an innovative health care delivery model centered on value-based care. ACOs consisting of primary care providers are increasingly becoming commonplace in practice; however, medication management remains suboptimal.

PROGRAM DESCRIPTION

As experts in medication management, pharmacists perform direct patient care and assist in the transition from one provider to another, which places them in an ideal position to manage multiple aspects of patient care. Pharmacist-provided care has been shown to reduce drug expenditures, hospital readmissions, length of stay, and emergency department visits. Although pharmacists have become key team members of interdisciplinary teams within traditional care settings, their role has often been overlooked in the primary care-based ACO. In 2015, Nova Southeastern University College of Pharmacy founded the Accountable Care Organization Research Network, Services, and Education (ACORN SEED), a team of pharmacy practice faculty dedicated to using innovative approaches to patient care, while providing unique learning experiences for pharmacy students by partnering with ACOs in the South Florida region. Five opportunities are presented for pharmacists to improve medication use specifically in primary care-based ACOs: medication therapy management, annual wellness visits, chronic disease state management, chronic care management, and transitions of care.

OBSERVATIONS

Several challenges and barriers that prevent the full integration of pharmacists into primary care-based ACOs include lack of awareness of pharmacist roles in primary care; complex laws and regulations surrounding clinical protocols, such as collaborative practice agreements; provider status that allows compensation for pharmacist services; and limited access to medical records. By understanding and maximizing the role of pharmacists, several opportunities exist to better manage the medication-use process in value-based care settings.

IMPLICATIONS/RECOMMENDATIONS

As more organizations realize benefits and overcome barriers to the integration of pharmacists into patient care, programs involve pharmacists will become an increasingly common approach to improve outcomes and reduce the total cost of care and will improve the financial viability of primary care-based ACOs.

DISCLOSURES

No outside funding supported this research. The authors report no conflicts of interest related to this manuscript. Study concept and design were contributed by Joseph, Hale, and Eltaki, with assistance from the other authors. Prados and Jones took the lead in data collection and data interpretation and analysis, with assistance from the other authors. The manuscript was written primarily by Joseph and Hale, along with the other authors, and revised primarily by Seamon and Gernant, along with the other authors.

A Statewide Medication Management System: Health Information Exchange to Support Drug Therapy Optimization by Pharmacists across the Continuum of Care

Background  While evidence generally supports the use of medication management technology, systems are typically implemented and evaluated piecemeal rather than as part of a comprehensive model for medication management. Systems to support drug therapy optimization, increasingly a key role of pharmacists in our healthcare system, have not yet been reported.

Objective  Our objective is to describe the design, implementation, and use of health information technology to support the hospital and community pharmacists' management of medications for high-risk patients statewide in the “Pharm2Pharm” model of care. Our aims were to make it easier for the pharmacists to access information needed to identify and resolve drug therapy problems using best practices for medication management and communicate with other members of the care team.

Methods  The pharmacist's roles and the medication management processes guided the design of the supporting technology, which was implemented after the Pharm2Pharm model was launched and the pharmacists' technology needs were assessed. Priorities for technology included sending care transition documents from hospital to community pharmacist securely and efficiently, access to medical records, including medications and laboratory results, documentation, and patient tracking. Implementation and use of the technology were documented.

Results  Communications, medication management, and population management solutions were implemented to support the Pharm2Pharm model. The pharmacists delivering services through this model adopted and meaningfully used this technology to support their work.

Conclusion  Implementing technology with value outside of the Pharm2Pharm model was a strategic approach to investment. This work emphasizes the importance of shifting the focus of technology from supporting a specific piece of the medication management process to supporting the goal of optimizing medication regimens. Health information exchange systems can provide important technology needed to integrate pharmacists into care teams as they are deployed to improve patient outcomes.

Organisational and extraorganisational determinants of volume of service delivery by English community pharmacies: a cross-sectional survey and secondary data analysis

OBJECTIVES

This study aimed to identify the organisational and extraorganisational factors associated with existing variation in the volume of services delivered by community pharmacies.

DESIGN AND SETTING

Linear and ordered logistic regression of linked national data from secondary sources-community pharmacy activity, socioeconomic and health need datasets-and primary data from a questionnaire survey of community pharmacies in nine diverse geographical areas in England.

OUTCOME MEASURES

Annual dispensing volume; annual volume of medicines use reviews (MURs).

RESULTS

National dataset (n=10 454 pharmacies): greater dispensing volume was significantly associated with pharmacy ownership type (large chains>independents>supermarkets), greater deprivation, higher local prevalence of cardiovascular disease and depression, older people (aged >75 years) and infants (aged 0-4 years) but lower prevalence of mental health conditions. Greater volume of MURs was significantly associated with pharmacy ownership type (large chains/supermarkets>>independents), greater dispensing volume, and lower disease prevalence.Survey dataset (n=285 pharmacies; response=34.6%): greater dispensing volume was significantly associated with staffing, skill-mix, organisational culture, years open and greater deprivation. Greater MUR volume was significantly associated with pharmacy ownership type (large chains/supermarkets>>independents), greater dispensing volume, weekly opening hours and lower asthma prevalence.

CONCLUSIONS

Organisational and extraorganisational factors were found to impact differently on dispensing volume and MUR activity, the latter being driven more by corporate ownership than population need. While levels of staffing and skill-mix were associated with dispensing volume, they did not influence MUR activity. Despite recent changes to the contractual framework, the existing fee-for-service reimbursement may therefore not be the most appropriate for the delivery of cognitive (rather than supply) services, still appearing to incentivise quantity over the quality (in terms of appropriate targeting) of services delivered. Future research should focus on the development of quality measures that could be incorporated into community pharmacy reimbursement mechanisms.

Application of the Consolidated Framework for Implementation Research to community pharmacy: A framework for implementation research on pharmacy services

BACKGROUND

Community pharmacies are an increasingly important health care setting with opportunities for improving quality and safety, yet little is understood about determinants of implementation in this setting.

OBJECTIVE

This paper presents an implementation framework for pharmacy based on the Consolidated Framework for Implementation Research (CFIR).

METHODS

This study employed a critical review of 45 articles on professional services provided in community pharmacies, including medication therapy management (MTM), immunizations, and rapid HIV testing.

RESULTS

The relevant domains and associated constructs for pharmacy services were as follows. Intervention Characteristics ultimately depend on the specific service; of particular note for pharmacy are relative advantage and complexity. The former because implementation of services can pose a cost-benefit challenge where dispensing is the primary role and the latter because of the greater challenge implementing multi-faceted services like MTM compared to a discrete service like immunizations. "In terms of Outer Setting, pharmacies are affected by patient needs and acceptance, and external policies and incentives such as reimbursement and regulations. For Inner Setting, structural characteristics like pharmacy type, size and staff were important as was pharmacists' perception of their role and available resources to provide the service. Key Characteristics of Individuals include training, preparedness, and self-efficacy of the pharmacist for providing a new service. Few studies revealed relevant Process constructs, but if they did it was primarily related to engaging (e.g., champions).

CONCLUSIONS

As pharmacists' roles in health care are continuing to expand, a framework to inform implementation research in community pharmacy (and other) settings is crucially needed.