News From NACCHO Public Health Perceptions of Community Pharmacy Partnership Opportunities G. Erin Roberts, MPH; Sara E. Rubin, MPH, MA; Jaclyn K. Smith, BA; Alex J. Adams, PharmD, IOM; Donald G. Klepser, PhD, MBA rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
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he implementation of the Affordable Care Act may challenge traditional health care delivery models, as millions of newly insured Americans seek care. Pharmacists are well positioned to help absorb this increased demand for health care services through collaboration with physicians and other health care professionals.1 Pharmacists can improve community health by broadening access to care, sharing health education messages, and reporting health information through state immunization registries.2 Pharmacists can extend the reach of public health as a result of their accessibility.3 Approximately 95% of Americans live within 5 miles of a community pharmacy.4 Furthermore, many community pharmacies offer evening or weekend hours, with some open 24 hours a day. In addition to accessibility, the role of pharmacists has expanded beyond dispensing prescriptions. Pharmacists now offer immunizations, point-of-care testing, patient counseling and education, chronic disease medication management, and selected primary care services under physician-led protocols.5-8 These expanded roles leverage the extensive training and education that pharmacists receive in pharmacology, pharmaceutics, and medication and disease management. In addition, pharmacists understand the importance of linking patients to appropriate care and of reporting vital data to public health agencies.9 Given the benefits of pharmacy and public health collaboration, a growing number of state and local health departments across the country are actively partnering with their community pharmacies. The University of Nebraska Medical Center (UNMC) partnered with the National Association of County & City Health
J Public Health Management Practice, 2015, 21(4), 413–415 C 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
Officials (NACCHO) on a study to explore the opportunities and challenges of such collaboration.
● Study Overview From May to November 2014, UNMC, the principal investigator for the study, and NACCHO convened a series of 7 focus groups in the following locations: Lansing, Michigan; Omaha, Nebraska; Minneapolis, Minnesota; Boise, Idaho; Baltimore, Maryland; Portland, Oregon; and Seattle, Washington. Focus group participants included professionals from state and local health departments, state pharmacy associations, state public health laboratories, and academic research centers. The size of each focus group varied from 7 to 10 participants. Focus group participants shared their perceptions of partnerships with community pharmacy and of related opportunities to improve public health. Researchers initially set out to understand public health officials’ perceptions of the patient care benefits of pharmacybased point-of-care testing. The focus group discussions, however, revealed additional areas of interest for pharmacy involvement in public health services. Author Affiliations: Environmental Health & Pandemic Preparedness, National Association of County & City Health Officials, Washington, District of Columbia (Ms Roberts); Foundation Programs, NACDS Foundation, Arlington, Virginia (Ms Rubin and Dr Adams); and Department of Pharmacy Practice, UNMC College of Pharmacy, Omaha, Nebraska (Ms Smith and Dr Klepser). The “Advancing Public Health: Exploring Partnerships Between Public Health Officials and Community Pharmacies on Point-of-Care-Testing” focus group study is funded by the NACDS Foundation. Dr Klepser has received grant funding from the NACDS Foundation and is a developer of the NACDS Point-of-Care Testing Certificate Program. Dr Klepser is also a consultant for Arkray Inc. Correspondence: G. Erin Roberts, MPH, Environmental Health & Pandemic Preparedness, National Association of County & City Health Officials, 1100 17th Street NW, Seventh Floor, Washington, DC 20036 ([email protected]). DOI: 10.1097/PHH.0000000000000276
413 Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
414 ❘ Journal of Public Health Management and Practice Key discussion themes included general perceptions of the pharmacy profession; pharmacy-delivered patient care services, including immunization and point-of-care testing; and information sharing between pharmacies and state and local agencies for the purpose of disease surveillance.
● Main Findings: Public Health Perceptions of Community Pharmacy Partnership Opportunities Focus group participants held positive perceptions of community pharmacy partnerships and saw them as contributing to a common public health mission. Participants viewed pharmacies as convenient, accessible locations that could positively impact local and state health outcomes. The degree to which participants had previously worked with community pharmacies varied by jurisdiction, as did perceptions of pharmacists’ capabilities. Many participants did not know that, since the 1990s, entry-level pharmacy education requires at least 6 years of training, culminating in a doctor of pharmacy degree. Some participants did not know about, or were unclear on, the types of services—including the types of immunizations—that pharmacists could offer in their respective states. Participants identified a need to educate the public and other health care professionals on pharmacists’ training and abilities to facilitate the delivery of public health services in pharmacy settings. Participants identified opportunities around patient services, particularly immunizations and point-of-care testing. Some participants expressed that pharmacydelivered patient care services could reduce burden on understaffed or underfunded public health clinics. Many participants expressed interest in increasing pharmacy-based immunization rates in their communities; emphasis was often placed on increasing adolescent immunizations. Many participants supported the expansion of pharmacy-administered vaccines to include the full adult immunization schedules recommended by the Advisory Committee on Immunization Practices. Participants viewed pharmacists as important partners in increasing community uptake of vaccines, especially vaccines with multiples doses. During discussion of human papillomavirus vaccines, some participants noted that pharmacists could help patients complete their 3-dose regimens (ie, patients who received the first dose at a physician’s office could receive their second and third doses at a pharmacy). Participants felt that aggregate community health outcomes could be improved by public health agencies co-
ordinating immunization campaigns with community pharmacies. Participants also shared their views on pharmacybased point-of-care testing services. Participants proposed expanding point-of-care testing services beyond influenza and group A streptococcal pharyngitis, with greatest interest in testing for sexually transmitted infections and chronic conditions such as hepatitis C virus. Point-of-care testing prompted considerable discussion around the validity and reliability of Clinical Laboratory Improvement Amendments–waived tests; privacy, confidentiality, and counseling; and linkage to care. Participants recommended appropriate protocols to minimize false-negatives and recommended followup with patients who initially tested negative, in addition to follow-up with those testing positive. Most participants agreed that pharmacists are highly qualified to perform point-of-care testing services and offer the added benefit of accessibility. Participants agreed that point-of-care testing for infectious disease could be beneficial both for public health surveillance and for patient wellness. Discussion of immunizations and point-of-care testing led to an area of great interest: information sharing between pharmacies and public health entities. Every focus group at some point discussed the value of pharmacy data for public health surveillance and the role of information sharing in public health and pharmacy partnership. In focus group locations where pharmacies routinely report data to state registries, participant perceptions of information sharing with pharmacies seemed to be more positive from the outset of discussion. There was variation by state in the processes for data reporting and in the level of interoperability between pharmacy management systems and state immunization information systems. While recognizing some barriers to full interoperability exist, participants saw value in having access to pharmacy immunization and point-of-care testing data. As one example, participants saw benefits to pharmacies reporting point-of-care test results to health departments for disease surveillance purposes. Participants also discussed mandatory and nonmandatory reportable diseases and the extent to which pharmacies already were or could be reporting data. Opportunities around information sharing extended mainly to opening up reporting channels to pharmacies and to ensuring that pharmacies received the proper training on state reporting standards. The focus group study prompted new collaborations between health departments and pharmacy stakeholders. The Lansing, Michigan, focus group, for instance, has resulted in a joint effort between the Michigan Department of Community Health and community pharmacies to pilot pharmacy-based hepatitis C virus
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Community Pharmacy and Public Health Partnership
testing at 8 pilot sites. This study has shed light on opportunities for new and continued partnership between public health and community pharmacy. Overall, participants showed optimism toward collaboration and felt community pharmacies could contribute to meeting the public health missions of state and local health agencies.
3.
4.
● Conclusion 5.
Public health professionals at the state and local levels view community pharmacy as an important partner that can help improve community health outcomes. These focus groups have revealed opportunities for collaboration around pharmacy-based patient services and information sharing. Given the value of these focus groups to understanding how community pharmacy and public health can collaborate to improve public health, NACCHO and UNMC will continue this study to include additional focus groups in 2015.
6.
7.
8.
REFERENCES 1. Smith MA. Pharmacists and the primary care workforce. Ann Pharmacother. 2012;46(11):1568-1571. 2. Rubin SE, Schulman RM, Roszak AR, Herrmann J, Patel A, Koonin LM. Leveraging partnerships among community
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pharmacists, pharmacies, and health departments to improve pandemic influenza response. Biosecur Bioterror. 2014;12(2): 76-84. Rosenfeld LA, Etkind P, Grasso A, Adams AJ, Rothholz MC. Extending the reach: local health department collaboration with community pharmacies in Palm Beach County, Florida, for H1N1 influenza pandemic response. J Public Health Manage Pract. 2011;17(5):439-448. National Association of Chain Drug Stores. NACDS 2011-2012 Chain Pharmacy Industry Profile. Alexandria, VA: National Association of Chain Drug Stores; 2011. Giberson S, Yoder S, Lee MP. Improving Patient and Health System Outcomes Through Advanced Pharmacy Practice: A Report to the U.S. Surgeon General. Rockville, MD: Office of the Chief Pharmacist, US Public Health Service; 2011. Chisholm-Burns MA, Kim LJ, Spivey CA, et al. US pharmacists’ effect as team members on patient care: systematic review and meta-analyses. Med Care. 2010;48(10): 923-933. Hogue MD, Grabenstein JD, Foster SL, Rothholz MC. Pharmacist involvement with immunizations: a decade of professional advancement. J Am Pharm Assoc. 2006;46(2): 168-179. Ross LA. Pharmacists as mid-level practitioners/providers. Ann Pharmacother. 2011;45(6):810-812. American Immunization Registry Association. Survey of Immunization Reporting to Immunization Information Systems by Major U.S. Pharmacies: A Summary of the Methods, Successes and Challenges of Pharmacy-IIS Interfaces. Washington, DC: American Immunization Registry Association; 2015.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
T
he implementation of the Affordable Care Act may challenge traditional health care delivery models, as millions of newly insured Americans seek care. Pharmacists are well positioned to help absorb this increased demand for health care services through collaboration with physicians and other health care professionals.1 Pharmacists can improve community health by broadening access to care, sharing health education messages, and reporting health information through state immunization registries.2 Pharmacists can extend the reach of public health as a result of their accessibility.3 Approximately 95% of Americans live within 5 miles of a community pharmacy.4 Furthermore, many community pharmacies offer evening or weekend hours, with some open 24 hours a day. In addition to accessibility, the role of pharmacists has expanded beyond dispensing prescriptions. Pharmacists now offer immunizations, point-of-care testing, patient counseling and education, chronic disease medication management, and selected primary care services under physician-led protocols.5-8 These expanded roles leverage the extensive training and education that pharmacists receive in pharmacology, pharmaceutics, and medication and disease management. In addition, pharmacists understand the importance of linking patients to appropriate care and of reporting vital data to public health agencies.9 Given the benefits of pharmacy and public health collaboration, a growing number of state and local health departments across the country are actively partnering with their community pharmacies. The University of Nebraska Medical Center (UNMC) partnered with the National Association of County & City Health
J Public Health Management Practice, 2015, 21(4), 413–415 C 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
Officials (NACCHO) on a study to explore the opportunities and challenges of such collaboration.
● Study Overview From May to November 2014, UNMC, the principal investigator for the study, and NACCHO convened a series of 7 focus groups in the following locations: Lansing, Michigan; Omaha, Nebraska; Minneapolis, Minnesota; Boise, Idaho; Baltimore, Maryland; Portland, Oregon; and Seattle, Washington. Focus group participants included professionals from state and local health departments, state pharmacy associations, state public health laboratories, and academic research centers. The size of each focus group varied from 7 to 10 participants. Focus group participants shared their perceptions of partnerships with community pharmacy and of related opportunities to improve public health. Researchers initially set out to understand public health officials’ perceptions of the patient care benefits of pharmacybased point-of-care testing. The focus group discussions, however, revealed additional areas of interest for pharmacy involvement in public health services. Author Affiliations: Environmental Health & Pandemic Preparedness, National Association of County & City Health Officials, Washington, District of Columbia (Ms Roberts); Foundation Programs, NACDS Foundation, Arlington, Virginia (Ms Rubin and Dr Adams); and Department of Pharmacy Practice, UNMC College of Pharmacy, Omaha, Nebraska (Ms Smith and Dr Klepser). The “Advancing Public Health: Exploring Partnerships Between Public Health Officials and Community Pharmacies on Point-of-Care-Testing” focus group study is funded by the NACDS Foundation. Dr Klepser has received grant funding from the NACDS Foundation and is a developer of the NACDS Point-of-Care Testing Certificate Program. Dr Klepser is also a consultant for Arkray Inc. Correspondence: G. Erin Roberts, MPH, Environmental Health & Pandemic Preparedness, National Association of County & City Health Officials, 1100 17th Street NW, Seventh Floor, Washington, DC 20036 ([email protected]). DOI: 10.1097/PHH.0000000000000276
413 Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
414 ❘ Journal of Public Health Management and Practice Key discussion themes included general perceptions of the pharmacy profession; pharmacy-delivered patient care services, including immunization and point-of-care testing; and information sharing between pharmacies and state and local agencies for the purpose of disease surveillance.
● Main Findings: Public Health Perceptions of Community Pharmacy Partnership Opportunities Focus group participants held positive perceptions of community pharmacy partnerships and saw them as contributing to a common public health mission. Participants viewed pharmacies as convenient, accessible locations that could positively impact local and state health outcomes. The degree to which participants had previously worked with community pharmacies varied by jurisdiction, as did perceptions of pharmacists’ capabilities. Many participants did not know that, since the 1990s, entry-level pharmacy education requires at least 6 years of training, culminating in a doctor of pharmacy degree. Some participants did not know about, or were unclear on, the types of services—including the types of immunizations—that pharmacists could offer in their respective states. Participants identified a need to educate the public and other health care professionals on pharmacists’ training and abilities to facilitate the delivery of public health services in pharmacy settings. Participants identified opportunities around patient services, particularly immunizations and point-of-care testing. Some participants expressed that pharmacydelivered patient care services could reduce burden on understaffed or underfunded public health clinics. Many participants expressed interest in increasing pharmacy-based immunization rates in their communities; emphasis was often placed on increasing adolescent immunizations. Many participants supported the expansion of pharmacy-administered vaccines to include the full adult immunization schedules recommended by the Advisory Committee on Immunization Practices. Participants viewed pharmacists as important partners in increasing community uptake of vaccines, especially vaccines with multiples doses. During discussion of human papillomavirus vaccines, some participants noted that pharmacists could help patients complete their 3-dose regimens (ie, patients who received the first dose at a physician’s office could receive their second and third doses at a pharmacy). Participants felt that aggregate community health outcomes could be improved by public health agencies co-
ordinating immunization campaigns with community pharmacies. Participants also shared their views on pharmacybased point-of-care testing services. Participants proposed expanding point-of-care testing services beyond influenza and group A streptococcal pharyngitis, with greatest interest in testing for sexually transmitted infections and chronic conditions such as hepatitis C virus. Point-of-care testing prompted considerable discussion around the validity and reliability of Clinical Laboratory Improvement Amendments–waived tests; privacy, confidentiality, and counseling; and linkage to care. Participants recommended appropriate protocols to minimize false-negatives and recommended followup with patients who initially tested negative, in addition to follow-up with those testing positive. Most participants agreed that pharmacists are highly qualified to perform point-of-care testing services and offer the added benefit of accessibility. Participants agreed that point-of-care testing for infectious disease could be beneficial both for public health surveillance and for patient wellness. Discussion of immunizations and point-of-care testing led to an area of great interest: information sharing between pharmacies and public health entities. Every focus group at some point discussed the value of pharmacy data for public health surveillance and the role of information sharing in public health and pharmacy partnership. In focus group locations where pharmacies routinely report data to state registries, participant perceptions of information sharing with pharmacies seemed to be more positive from the outset of discussion. There was variation by state in the processes for data reporting and in the level of interoperability between pharmacy management systems and state immunization information systems. While recognizing some barriers to full interoperability exist, participants saw value in having access to pharmacy immunization and point-of-care testing data. As one example, participants saw benefits to pharmacies reporting point-of-care test results to health departments for disease surveillance purposes. Participants also discussed mandatory and nonmandatory reportable diseases and the extent to which pharmacies already were or could be reporting data. Opportunities around information sharing extended mainly to opening up reporting channels to pharmacies and to ensuring that pharmacies received the proper training on state reporting standards. The focus group study prompted new collaborations between health departments and pharmacy stakeholders. The Lansing, Michigan, focus group, for instance, has resulted in a joint effort between the Michigan Department of Community Health and community pharmacies to pilot pharmacy-based hepatitis C virus
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Community Pharmacy and Public Health Partnership
testing at 8 pilot sites. This study has shed light on opportunities for new and continued partnership between public health and community pharmacy. Overall, participants showed optimism toward collaboration and felt community pharmacies could contribute to meeting the public health missions of state and local health agencies.
3.
4.
● Conclusion 5.
Public health professionals at the state and local levels view community pharmacy as an important partner that can help improve community health outcomes. These focus groups have revealed opportunities for collaboration around pharmacy-based patient services and information sharing. Given the value of these focus groups to understanding how community pharmacy and public health can collaborate to improve public health, NACCHO and UNMC will continue this study to include additional focus groups in 2015.
6.
7.
8.
REFERENCES 1. Smith MA. Pharmacists and the primary care workforce. Ann Pharmacother. 2012;46(11):1568-1571. 2. Rubin SE, Schulman RM, Roszak AR, Herrmann J, Patel A, Koonin LM. Leveraging partnerships among community
9.
❘ 415
pharmacists, pharmacies, and health departments to improve pandemic influenza response. Biosecur Bioterror. 2014;12(2): 76-84. Rosenfeld LA, Etkind P, Grasso A, Adams AJ, Rothholz MC. Extending the reach: local health department collaboration with community pharmacies in Palm Beach County, Florida, for H1N1 influenza pandemic response. J Public Health Manage Pract. 2011;17(5):439-448. National Association of Chain Drug Stores. NACDS 2011-2012 Chain Pharmacy Industry Profile. Alexandria, VA: National Association of Chain Drug Stores; 2011. Giberson S, Yoder S, Lee MP. Improving Patient and Health System Outcomes Through Advanced Pharmacy Practice: A Report to the U.S. Surgeon General. Rockville, MD: Office of the Chief Pharmacist, US Public Health Service; 2011. Chisholm-Burns MA, Kim LJ, Spivey CA, et al. US pharmacists’ effect as team members on patient care: systematic review and meta-analyses. Med Care. 2010;48(10): 923-933. Hogue MD, Grabenstein JD, Foster SL, Rothholz MC. Pharmacist involvement with immunizations: a decade of professional advancement. J Am Pharm Assoc. 2006;46(2): 168-179. Ross LA. Pharmacists as mid-level practitioners/providers. Ann Pharmacother. 2011;45(6):810-812. American Immunization Registry Association. Survey of Immunization Reporting to Immunization Information Systems by Major U.S. Pharmacies: A Summary of the Methods, Successes and Challenges of Pharmacy-IIS Interfaces. Washington, DC: American Immunization Registry Association; 2015.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
