Improving the Experience of Providing Care in Community-Based Pharmacies

This study applied a human factors and ergonomics approach to describe community-based pharmacy personnel perspectives regarding how work environment characteristics affect the ability to perform the duties necessary for optimal patient care and how contributors to stress affect the ability to ensure patient safety. Data were obtained from the 2021 APhA/NASPA National State-Based Pharmacy Workplace Survey, launched in the United States in April 2021. Promotion of the online survey to pharmacists and pharmacy technicians was accomplished through social media, email, and online periodicals. Responses continued to be received through the end of 2021. A data file containing 6973 responses was downloaded on 7 January 2022 for analysis. Qualitative thematic analysis was applied for developing operational definitions and coding guidelines for content analysis of the data. The patterns of responses for the dependent variables were compared among community-based practice setting types (chain, supermarket/mass merchandiser, and independent) and work positions (manager, staff pharmacist, technician/clerk, and owner). Chi-square analysis was used for determining statistically significant differences. The findings showed that personnel working in community-based pharmacies reported undesirable work environments and work stress that affected their ability to perform assigned duties for optimal patient care and ensure patient safety. Four work system elements were identified that were both facilitators and barriers to the ability to perform duties and ensure patient safety: (1) people, (2) tasks, (3) technology/tools, and (4) organizational context. Acknowledging local contexts of workplaces, giving adequate control, applying adaptive thinking, enhancing connectivity, building on existing mechanisms, and dynamic continuous learning are key elements for applying the HFE (human factors ergonomics) approach to improving the experience of providing care in community-based pharmacies.

Work System and Process Designs for Community Pharmacy-Medical Clinic Partnerships to Improve Retention in Care, Antiretroviral Adherence, and Viral Suppression in Persons with HIV

The objective of this project was to collect and analyze information about work systems and processes that community pharmacy-medical clinic partnerships used for implementing the Patient-Centered HIV Care Model (PCHCM). Paired collaborations of 10 Walgreens community pharmacies and 10 medical clinics were formed in 10 cities located throughout the United States that had relatively high HIV prevalence rates and existing Walgreens HIV Centers of Excellence. Patient service provision data and most significant change stories were collected from key informants at each of the clinic and pharmacy sites over an 8 week period in 2016 and through in-depth phone interviews. Written notes were reviewed by two authors (J.C.S. and O.W.G.) and analyzed using the most significant change technique. The findings showed that half of the partnerships (n = 5) were unable to fully engage in service implementation due to external factors or severe staff turnover during the project period. The other half of the partnerships (n = 5) were able to engage in service implementation, with the most impactful changes being related to strong patient care systems, having a point person at the clinic who served as a connector between sites, and having pharmacists integrated fully into the health care team.

Pharmacist Segments Identified from 2009, 2014, and 2019 National Pharmacist Workforce Surveys: Implications for Pharmacy Organizations and Personnel

Background/Objective: Findings from the 2009 and 2014 National Pharmacist Workforce Surveys showed that approximately 40% of U.S. pharmacists devoted their time primarily to medication providing, 40% contributed a significant portion of their time to patient care service provision, and the remaining 20% contributed most of their time to other health-system improvement activities. The objective of this study was to characterize the U.S. pharmacist workforce into segments based on the proportion of time they spend in medication providing and patient care services and compare changes in these segments between 2009, 2014, and 2019. Methods: Data from 2009, 2014, and 2019 National Pharmacist Workforce Surveys were analyzed. Responses from 1200 pharmacists in 2009, 1382 in 2014, and 4766 in 2019 were used for analysis. Respondents working in the pharmacy or pharmacy-related fields reported both their percent time devoted to medication providing and to patient care services. Medication providing included preparing, distributing, and administering medication products, including associated professional services. Patient care services were professional services designed for assessing and evaluating medication-related needs, monitoring and adjusting patient's treatments, and other services designed for patient care. For each year of data, pharmacist segments were identified using a two-step cluster analysis. Descriptive statistics were used for describing the characteristics of the segments. Results: For each year, five segments of pharmacists were identified. The proportions of pharmacists in each segment for the three surveys (2009, 2014, 2019) were: (1) medication providers (41%, 40%, 34%), (2) medication providers who also provide patient care (25%, 22%, 25%), (3) other activity pharmacists (16%, 18%, 14%), (4) patient care providers who also provide medication (12%, 13%, 15%), and (5) patient care providers (6%, 7%, 12%). In 2019, other activity pharmacists worked over 45 hours per week, on average, with 12 of these hours worked remotely. Patient care providers worked 41 hours per week, on average, with six of these hours worked remotely. Medication providers worked less than 40 hours per week, on average, with just one of these hours worked remotely. Regarding the number of patients with whom a respondent interacted on a typical day, medication providers reported 18 per day, patient care providers reported 11 per day, and other activity pharmacists reported 6 per day. In 2009, 8% of patient care providers worked in a setting that was not licensed as a pharmacy. In 2019, this grew to 17%. Implications/Conclusions: The 2019 findings showed that 34% of U.S. pharmacists devoted their time primarily to medication providing (compared to 40% in 2009 and 2014), 52% contributed a significant portion of their time to patient care service provision (compared to 40% in 2009 and 2014), and the remaining 14% contributed most of their time to other health-system improvement activities. Distinguishing characteristics of the segments suggested that recent growth in the pharmacist workforce has been in the patient care services, with more being provided through remote means in organizations that are not licensed as pharmacies. The findings have implications for pharmacist training, continuing education, labor monitoring, regulations, work systems, and process designs. These changes will create new roles and tasks for pharmacy organizations and personnel that will be needed to support emerging patient care services provided by pharmacists.

Retail clinics colocated with pharmacies: A Delphi study of pharmacist impacts and recommendations for optimization

OBJECTIVES

To identify workforce issues likely to affect pharmacists working in retail clinics (RCs) colocated with community pharmacies and to generate recommendations for optimizing health, cost, and operations outcomes.

DESIGN AND PARTICIPANTS

A Delphi expert panel process using researchers with pharmacist workforce research experience was used. Panelists responded to 2 surveys of 3 rounds each. In survey 1, panelists used a 4-point linear numeric scale to rate the importance of 15 impact factors on pharmacists working in the RC/pharmacy setting. In survey 2, panelists used a 3-point linear numeric scale to rate the importance of recommendations for optimal outcomes. Recommendations were structured around elements from collaboration theory, a framework for evaluating critical areas for success in merged operations.

MAIN OUTCOME MEASURES

Consensus was defined as ≥ 80% rating an impact "very" or "moderately" important (survey 1) and "very" important (survey 2). Impact factors were rank-ordered by ratings and numeric scoring. Selected comments about consensus items were reported.

RESULTS

The 8-person panel had 100% response rates for both surveys. 12 of the 15 impact variables achieved consensus (survey 1). The highest ranking impacts were ability to establish collaborative relationships, relationships with coworkers, including nurse practitioners, and location of the RC relative to the pharmacy. Of 15 recommendations (survey 2), 5 achieved consensus and focused heavily on information sharing and early and ongoing collaboration among all stakeholders.

CONCLUSION

Clinical, economic, health care quality, and patient preference data suggest that RCs colocated with pharmacies are likely to play a permanent role in U.S. health care. RCs can affect pharmacists and pharmacies positively or negatively. Positive impacts are most likely where establishing collaborative partnerships with all stakeholders, including patients, throughout planning, implementation, and operation are emphasized. With only about 3% of pharmacy operations colocated with RCs now, attention and resources should be devoted to developing and testing models based on collaboration principles.

Continuous Medication Monitoring (CoMM): A foundational model to support the clinical work of community pharmacists

BACKGROUND

Under the Continuous Medication Monitoring (CoMM) approach, community pharmacists prevent, identify, resolve, and document drug therapy problems during the dispensing process.

OBJECTIVE

To describe the patients receiving CoMM interventions and the pattern of delivery of CoMM interventions.

METHODS

Pharmacy dispensing and clinical records were reviewed for patients filling at least one prescription and receiving at least one continuous medication monitoring intervention at a community pharmacy from April 2014 through March 2015. The proportion of patients receiving an intervention type and the number of interventions per patient were computed.

RESULTS

Nearly 2500 patients received 16,986 continuous medication monitoring interventions over the year. The average age of the patients receiving the interventions was 59.1 years, and they filled an average of 8.0 unique medications. An average of 6.8 interventions was delivered to each patient. About half (49.7%) of interventions addressed drug therapy problems. The pharmacists delivered 3.0 patient counseling and education and 3.4 drug therapy problem interventions per patient on average.

CONCLUSION

There are many opportunities to improve patients' medication use that can be identified and addressed under a Continuous Medication Monitoring model. Movement to this model of practice is desirable, but changes are needed to facilitate the shift.

Establishing pathways for access to pharmacist-provided patient care

OBJECTIVE

To describe the pathways being established for access to pharmacist-provided patient care and supply recommendations for the next steps in this process.

DATA SOURCES

A series of reports published by the American Pharmacists Association regarding pharmacist-provided patient care services.

SUMMARY

Community pharmacies and integrated health organizations have emerged as the two predominant pathways for patient access to pharmacist-provided patient care. We view these two pathways as complementary in helping cover patients' entire medication therapy needs as they traverse acute and chronic health care services. However, gaps in access to pharmacist-provided care remain, especially during transitions in care.

CONCLUSION

In further establishing pathways for access to pharmacist-provided patient care, we propose that the application of collaboration theory will help close gaps that currently exist between health care organizations. Such an approach carries risk and will require trust among participating organizations. This approach is also likely to require updating and contemporizing pharmacy practice acts and other statutes to allow pharmacists to practice at maximum capacity within new models of care. To perform their new roles and create sustainable business models to support these new functions, pharmacists will need to be paid for their services. To this end, changes will need to be made to payment and documentation systems, incentives, and contracting approaches to develop proper reimbursement and accounting for pharmacists' new roles.

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

BACKGROUND

Health plans are moving away from a volume-driven payment structure toward value-driven and risk-based contracts. There is very limited information on commercial payers' perspectives on coverage of medication management services (MMS) in value-based alternative payment models. While some health plans have experience with Medicare Part D Medication Therapy Management (MTM) programs, this experience does not promote the integration of pharmacists as health care team members.

OBJECTIVES

The study objectives were to: (1) understand the evaluation process that health plan executives would use to determine benefit coverage for pharmacist-provided MMS in value-based health plans, (2) identify the facilitators and barriers that affect pharmacist-provided MTM services at the community pharmacy level, and (3) propose strategies for pharmacist-provided MMS in value-based health plans.

METHODS

This study used qualitative research methods that involved structured key informant interviews with commercial health plan executives and focus groups with community pharmacists who had experience providing MTM services.

RESULTS

Health plan executives agreed conceptually that MMS could be a valuable program and recognized its potential. However, the most substantial barriers that health plan executives expressed were funding MMS in today's fee-for-service payment models; lack of physician infrastructure to implement and manage MMS; and difficulty in collecting timely, accurate data to execute and assess MMS programs. Community pharmacists identified the most serious barrier to altering health outcomes through MTM as the current lack of integration of MTM with a coordinated health care team. MTM services are conducted as a separate program by pharmacists who do not have access to patient health records, are time-constrained, and poorly incentivized.

CONCLUSIONS

The findings can inform the development of successful strategies for pharmacist-provided MMS that align with emerging value-based health plans and alternative provider payment models. Current MTM program barriers and facilitators are identified that could be addressed in future Part D MTM program policy changes.

Assessment of Pharmacy Manpower and Services in New England

OBJECTIVES

This study assessed longitudinal trends in pharmacy staffing and services in the 6 New England states by comparing survey results from 2008 and 2013.

METHODS

A validated 32-item survey was mailed in 2008 and 2013 to a random sample of 2000 pharmacists. Each sample represented approximately 15% (2008) and 13% (2013) of the active rosters.

RESULTS

Response rates were 24% in 2008 and 23% in 2013. In all, 45% of 2013 respondents reported a pharmacist position vacancy in the past 12 months versus 62% in 2008. In all, 12% of 2013 respondents agreed or strongly agreed with a statement regarding pharmacists' shortage versus 77% in 2008. Disease management services were reported to be offered by 23% of 2013 respondents versus 28% in 2008. Reasons for not offering the services in 2013 included the lack of staffing (61%), expertise (28%), and reimbursement (29%). In 2008, these results were 74%, 33%, and 31%, respectively.

CONCLUSIONS

The pharmacist shortage within New England was alleviated during 2008 to 2013. Participation of pharmacists in disease management services did not follow staffing trends as fewer pharmacists reported providing services. Key barriers to services provision persist and consideration of how to resolve them (medication therapy management reimbursement and additional education) should be explored.

A segmentation analysis for pharmacists' and patients' views of pharmacists' roles

BACKGROUND

Pharmacists' roles in health care systems are expanding. However, some patients are slow to accept and make use of this expanded role.

OBJECTIVES

The objectives for this study were to identify and describe segments of pharmacists and patients based upon their perceptions of the pharmacist's role in serving as an advisor on medication use.

METHODS

Data were collected from random samples of pharmacists and patients in 1995, 1998, 2001, 2004, 2007, and 2010. Overall, 1518 pharmacists (overall response rate = 47%) and 1278 patients (overall response rate = 42%) were surveyed from 1995 through 2010. Factor analysis was applied to a Counselor Role Orientation measure and identified three factors for use in segmentation analysis. The factors were: (1) Time Pressures, (2) Reliance on Physician, and (3) Pharmacist Restrictions. Segmentation analysis was conducted using a two-step cluster analysis with an agglomerative hierarchical clustering method and a log-likelihood (probability) distance measure. Descriptive statistics were used to describe identified segments.

RESULTS

Cluster analysis identified four segments which were named: (1) All Low, (2) Time Pressures, (3) Reliance On Physician, and (4) All High. The largest segment for pharmacists was Time Pressures (45% of pharmacists) and for patients was Reliance on Physician (50% of patients). Composition of the four segments was consistent over time between the years 1995 through 2010.

CONCLUSIONS

The pattern of findings suggested a cycle of dysfunction in which many pharmacists, hindered by Time Pressures, do not provide patient care beyond the dispensing of a product. In turn, patients, relying on their physician for advice about medications, do not acknowledge the pharmacist as an advisor for medications. This cycle has reinforced dysfunctional behaviors and creates no motivation for either party in this dyadic relationship to change.

Evaluating the economic impact of a targeted medication intervention program

OBJECTIVE

To calculate the return on investment (ROI) for a targeted medication intervention program developed by corporate management of a community pharmacy.

DESIGN

Retrospective analysis and cross-sectional survey.

SETTING

Regional community pharmacy chain in North Carolina.

PARTICIPANTS

Targeted medication interventions completed from February 1, 2010, to July 31, 2010, were included in the retrospective analysis. Community pharmacists employed by the pharmacy chain that completed the questionnaire were included in the cross-sectional analysis.

INTERVENTION

Targeted medication intervention services were provided to the patient and documented by the pharmacist.

MAIN OUTCOME MEASURE

The ROI for a community pharmacist-provided targeted medication intervention program.

RESULTS

Of the 180 pharmacists, 69 completed the questionnaire (38% response rate). The average time to complete one targeted medication intervention was calculated to be 22.63 minutes. The total cost for providing a targeted medication intervention program during the study time frame was $15 760.86. Total revenue was $15 216.00; therefore, the program resulted in an ROI to the pharmacy chain of negative 3%.

CONCLUSION

This 6-month study resulted in an ROI to the pharmacy chain of negative 3%. Under the current reimbursement model, for this program to break even, the average time to complete one targeted medication intervention must equal 21.85 minutes or less.