Lucinda L. Maine

Availability of Primary Care Providers and Pharmacists in the United States

OBJECTIVE To determine the rural distribution of primary care providers (primary care physicians, physician assistants, nurse practitioners, and nurse midwives) and pharmacists. DESIGN Five-digit ZIP code mapping to study the availability of primary care providers and pharmacists, alone and in combinations, in rural areas and ZIP code-based health professional shortage areas (HPSAs). National averages for annual physician visits for hypertension, asthma, and diabetes were used to estimate the sufficiency of the rural physician supply. SETTING Rural areas of the United States. RESULTS In rural areas, all providers were present in lower densities than national averages, particularly in HPSAs. The primary care physician supply was insufficient to meet national averages for office visits for hypertension, asthma, and diabetes. Among available providers, the most prevalent co-presence was primary care physician with pharmacist. HPSAs showed very low physician density (1 per 22,122), and the most prevalent providers were pharmacists. States varied widely in provider density. CONCLUSION Despite longstanding efforts and the expansion of managed care, primary care providers remain in short supply in rural areas, especially ZIP code-based HPSAs. Making the best use of available providers should be encouraged. The continued shortfall of primary care providers in rural areas, particularly HPSAs, makes it logical to use other available providers and combinations to increase health care access. Pharmacists could increase care for patients with conditions treated with medications. Other available providers, based on skills and work site, could also offset shortages.

Health Literacy Practices and Educational Competencies for Health Professionals: A Consensus Study

Health care professionals often lack adequate knowledge about health literacy and the skills needed to address low health literacy among patients and their caregivers. Many promising practices for mitigating the effects of low health literacy are not used consistently. Improving health literacy training for health care professionals has received increasing emphasis in recent years. The development and evaluation of curricula for health professionals has been limited by the lack of agreed-upon educational competencies in this area. This study aimed to identify a set of health literacy educational competencies and target behaviors, or practices, relevant to the training of all health care professionals. The authors conducted a thorough literature review to identify a comprehensive list of potential health literacy competencies and practices, which they categorized into 1 or more educational domains (i.e., knowledge, skills, attitudes) or a practice domain. The authors stated each item in operationalized language following Blooms Taxonomy. The authors then used a modified Delphi method to identify consensus among a group of 23 health professions education experts representing 11 fields in the health professions. Participants rated their level of agreement as to whether a competency or practice was both appropriate and important for all health professions students. A predetermined threshold of 70% agreement was used to define consensus. After 4 rounds of ratings and modifications, consensus agreement was reached on 62 out of 64 potential educational competencies (24 knowledge items, 27 skill items, and 11 attitude items), and 32 out of 33 potential practices. This study is the first known attempt to develop consensus on a list of health literacy practices and to translate recommended health literacy practices into an agreed-upon set of measurable educational competencies for health professionals. Further work is needed to prioritize the competencies and practices in terms of relative importance.

Cultivating 'habits of mind' in the scholarly pharmacy clinician: report of the 2011-12 Argus Commission.

The American Association of Colleges of Pharmacy (AACP) Argus Commission is comprised of the five immediate past AACP presidents and is annually charged by the AACP President to examine one or more strategic questions related to pharmacy education often in the context of environmental scanning. Depending upon the specific charge, the President may appoint additional individuals to the Commission. President Crabtree requested that the 2011-12 Argus Commission examine the following questions as part of his examination of critical issues of excellence and relevance in academic pharmacy: • What is core with respect to the scientific foundation of clinical education? • How and when do we teach this foundational material? • How can we infuse an attitude of inquisitiveness and scholarly thinking in pharmacists and other health care professionals? • How can we nurture emerging scientists among our students and young faculty? • What ultimately will keep our graduates from being technicians vs. professional clinicians? The work of the Argus Commission was advanced significantly by examining related reports and projects from outside pharmacy and from engaging in dialogue with education leaders across the health professions. When the Commission met in December 2011 they were joined by leaders from academic dentistry, allopathic and osteopathic medicine, nursing, optometry, physicians assistant, public health, veterinary medicine and health administration programs. The meeting began with a presentation by Cynthia Bauerle, Ph.D., Senior Program Officer for PreCollege and Undergraduate Science Education at the Howard Hughes Medical Institute (HHMI) based in Chevy Chase, MD. HHMI and the Association of American Medical Colleges have collaborated on several projects to ensure that the scientific foundation for physician education remains contemporary and strong. They jointly published the “Report of Scientific Foundations for Future Physicians Committee”1 in 2009, which the Argus Commission considered carefully in its work. Dr. Bauerle presented an on-going HHMI project referred to as the NEXUS Project2. The National Experiment in Undergraduate Science Education is relevant to all programs in health professions education which depend on the adequate undergraduate preparation of future clinical scientists in core competencies in mathematics, physics, chemistry and biology. This four year project which began in early 2010 involves grantees at four universities (Purdue University, University of Maryland College Park, University of Maryland Baltimore County and the University of Miami) and draws heavily upon the scientific foundations for future physicians report as the project teams work to significantly modify the pedagogical approach for teaching and assessing learning in the fundamental building blocks of science at the undergraduate level. Throughout the full day meeting and subsequent analysis by the Argus Commission, participants acknowledged the continuum of learning and competency attainment so vital to ensuring that future pharmacists and colleagues across the spectrum of the health professions are inquisitive learners and problem solvers comfortable in applying both the scientific method and evidence-based content to the identification and resolution of clinical issues/problems at the individual patient and population levels. This begins far down the pipeline in pre-collegiate education and continues throughout the period of pre-professional and professional education with an ultimate goal of creating a scientific thinker with the requisite abilities to apply that knowledge in practice.

Pharmacy Executive Leadership Issues and Associated Skills, Knowledge, and Abilities

OBJECTIVES To identify challenges that current and future pharmacy executives are facing or will face in the future and to define what skills, knowledge, and abilities (SKAs) are required to successfully negotiate these challenges. DESIGN Delphi method for executive decision making. SETTING Civilian pharmacy profession. PARTICIPANTS 110 pharmacists who graduated from the GlaxoSmithKline Executive Management Program for Pharmacy Leaders. INTERVENTIONS Two iterations of the Delphi method for executive decision making separated by an expert panel content analysis. MAIN OUTCOME MEASURES Round 1--participants were asked to identify five major issues they believed to be of greatest importance to pharmacy leaders in the next 5-10 years and name specific SKAs that might be needed by future leaders to successfully deal with those issues. An expert panel reviewed the issues, classified issues into specific domains, and titled each domain. Round 2-participants rated the SKAs on a 7-point scale according to their individual assessment of importance in each domain. RESULTS For Delphi rounds 1 and 2, response rates were 21.8% and 18.2%, respectively. More than 100 total issue statements were identified. The expert panel sorted the issues into five domains: management and development of the pharmacy workforce, pharmacy finance, total quality management of work-flow systems, influences on the practice of pharmacy, and professional pharmacy leadership. Five of the top 15 SKAs-and all four highest ranked items--came from the professional pharmacy leadership domain, including ability to see the big picture, ability to demonstrate the value of pharmacy services, ability to lead and manage in an ethical manner, and skills for influencing an organizations senior leadership. CONCLUSION Through successful integration of communication skills, critical thinking, and problem solving techniques, future public-sector pharmacy executives will be better equipped to effectively position their organizations and the profession for the challenges that lie ahead.

Pharmacists And Technicians Can Enhance Patient Care Even More Once National Policies, Practices, And Priorities Are Aligned

In the past thirty to forty years, new clinically oriented roles have emerged for pharmacists, commensurate with their training and consistent with national goals to improve the safety of, access to, and cost of health care. Pharmacists in all settings spend an increasing portion of their time filling these roles, as evidenced more recently in the community pharmacy sector by the success of pharmacy-based immunization programs and such new venues as retail pharmacy clinics. Pharmacy technicians are also assuming new roles and responsibilities, providing services previously delivered only by pharmacists. However, both trends are hindered by current policy. Of particular concern are inconsistent state-level scope-of-practice laws, the lack of mechanisms to reimburse pharmacists for services provided, the need to recognize pharmacists as health care providers, and the need to establish national standards for the preparation of pharmacy technicians. The optimal deployment of the pharmacy workforce will require the closer alignment of pharmacy practice and policy with each other and with the nations health care priorities.

Assessing quality in pharmacy education in an era of rapid expansion

OBJECTIVES To describe measures used to evaluate the quality of U.S. pharmacy graduates in an era of rapid increases in the number of pharmacy colleges and schools (CS) and students and to assess if the expansion has influenced such measures. SETTING United States. PRACTICE INNOVATION Institutional research used by CS and the pharmacy accrediting organization in evaluating the knowledge, skills, and abilities of pharmacy graduates. MAIN OUTCOME MEASURES Scores on the North American Pharmacist Licensure Examination (NAPLEX) and survey data from CS graduates, faculty, and preceptors. RESULTS Mean first-time NAPLEX pass rates over time are comparable for older and newer CS and for main versus branch campuses. Graduates, faculty, and preceptor survey results affirm that faculty, preceptors, and students perceive the quality of pharmacy education to be very high. CONCLUSION The increase in pharmacy programs and graduates has not thus far affected educational quality based on available objective and subjective measures.

The Path Forward: The Future of Graduate Education in the Pharmaceutical Sciences: The Report of the 2010-2011 Research and Graduate Affairs Committee

According to the Bylaws of the American Association of Colleges of Pharmacy (AACP), the Research and Graduate Affairs Committee (RGAC) shall provide assistance to the Association in developing its research, graduate education, and scholarship agenda. This assistance may include facilitating colleges and schools in formulating and advancing legislative and regulatory initiatives, and nurturing collaborative activities with organizations sharing an interest in issues related to the pharmaceutical sciences. President Rod Carter presented the following charge for the 2010-11 RGAC: Utilizing the report titled “The Path Forward: The Future of Graduate Education in the U.S.”1 from the Commission on the Future of Graduate Education, critically examine the current status of graduate programs in colleges and schools of pharmacy across the spectrum of pharmaceutical sciences and recommend actions by AACP and/or its member colleges and schools that would allow pharmacy graduate programs to flourish in this envisioned future. President Carter further recommended that the Committee consider key past reports, including those of former Research and Graduate Affairs Committees, AACP task forces and council reports. The Committee met in person in Crystal City, Virginia, in October 2010 and communicated subsequently by conference calls and other electronic communication. During the October meeting the committee was fortunate to have Patricia McAllister, Vice President of Government Relations and External Affairs from the Council of Graduate Schools (CGS) and staff for the “Path Forward” report, meet with the Committee to summarize the issues and recommendations contained in this April 2010 analysis of graduate education. The Committee also considered the recently released report from the National Research Council which offers a data-based assessment of doctoral programs in 62 fields in the United States.2

Continuing Our Collaboration to Create Practice-Ready, Team-Oriented Patient Care Pharmacists

National efforts to achieve a health care system that improves individual patient outcomes, advances the health status of the population and is more cost effective validate the profession’s decision in the early 1990s tomove to the entry-level PharmD.The epidemic of chronic illness, aging of the population and increased power and complexity of pharmacotherapeutics are all part of this calculus. Adoption of the all PharmD resulted from the combined analysis of the education, practice and regulatory interests in pharmacy and major curriculum changes by the colleges. Pharmacy has an important history of such tripartite collaboration which led to the creation of the independent accrediting agency for degree programs in 1932. Continuing in this tradition of strength, the Accreditation Council for Pharmacy Educationworked closely with its founding partners (AmericanAssociation of Colleges of Pharmacy, American Pharmacists Association and National Association ofBoards of Pharmacy) throughout the planning and execution of the September 2012 summit. The manuscripts documenting the content and outcomes of the invitational conference are published in this issue of the Journal. Several consistent and important themes were articulated by plenary and panel presenters and echoed through thework of the small groups.We heard that the profession, but more importantly the public and our colleague health professional partners, want and need the academy to prepare pharmacists to meet the competencies identified by the Institute of Medicine. IOM states that we need clinicians who are patient-centered and prepared to deliver evidence-based care in interprofessional teams using informatics and tools of quality improvement to enhance safety and patient outcomes. The clarion call seemed to be “practice-ready for team-based care” as the intended outcome of our PharmD programs. There was no dispute about the value of postgraduate residency training to prepare specialists and to accelerate the maturation of pharmacists’ clinical skills. However, attendees at the conference expressed a clear expectation of practice readiness upon graduation and licensure. The second consensus position reached at the ACPE conference was that we need a myriad of attributes broadly defined as within the affective domain. Among the priorities noted in this regard are excellent communication skills, critical thinking, professionalism, leadership, and cultural competence, all in the context of interprofessional teamwork. Equipping pharmacists to command the scientific knowledge to expand clinical practice in pharmacogenomics was an additional top priority. Collectively, this all requires pharmacists to embrace informatics and fully incorporate such skills into their work in all settings. What surprises came from the summit? The biggest surprise was that there were no real surprises! Interprofessional practice, patient safety and quality, informatics, pharmacogenomics, enhanced communications skills are well-established areas for curricular intensification. Educators agree that we are not at the point where any of these constructs are mature or fully integrated into the PharmD curriculum. However these clearly fall into the current competencies for accredited programs. Their emphasis will certainly be stronger as the American Association of Colleges of Pharmacy (AACP) Center for the Advancement of Pharmacy Education competency panel completes its current work. AACP will publish a new guiding document for subsequent incorporation into curricula and accreditation standards. The fact that therewere no specific surprises does not suggest that there were no challenges identified by summit participants. The challenges, alongwith the “not quite there yet” curricular outcomes, must receive adequate attention in the standards revision process that will be initiated by ACPE later this year. Summit attendees recognized that the most vulnerable component of the current educational model is the lack of mature, authentic pharmacy practices where students can observe, learn Corresponding Author: LucindaMaine, PhD, Executive Vice President, AACP. 1426 Prince St., Alexandria, VA 22314. Tel: 703-739-2330, ext. 1021. E-mail: lmaine@aacp.org American Journal of Pharmaceutical Education 2013; 77 (3) Article 43.

Interprofessional education for collaborative practice: views from a global forum workshop

Institute of Medicine, Washington, DC, USA, University of Rochester, Rochester, USA, University of Washington, Seattle, USA, U.S. Department of Veterans Affairs, Washington DC, USA, Ghent University, Ghent, Belgium, American Association of Colleges of Pharmacy, Washington DC, USA, University of California, San Francisco, San Francisco, USA, Association of Schools of Public Health, Washington DC, USA, and Josiah Macy, Jr. Foundation, New York, USA,

Call to action: expansion of pharmacy primary care services in a reformed health system.

The AACP Argus Commission is comprised of thefive immediate past AACP presidents and is annuallycharged by the AACP President to examine one or morestrategicquestionsrelatedtopharmacyeducationofteninthe context of environmental scanning. Depending uponthe specific charge, the President may appoint additionalindividuals to the Commission.The 2009-10 Argus Commission was charged to ex-amine the topic of the pharmacist’s contribution to pri-mary healthcare delivery in the context of nationalhealthcare reform and identify the resources of the Acad-emy and the profession needed to engage in the nationalconversation. The charge further requested the ArgusCommission to scan the environment to determine theopportunitiesforexpansionofprimaryhealthcarecapacityto include pharmacists’ unique contributions to quality,cost, and access as medication use specialists on the team.President Baldwin invited representatives from edu-cation associations of various disciplines recognized asprimary healthcare providers to meet with the ArgusCommission. This included the following individuals:Sandra Carlin Andrieu, Ph.D., President-elect of theAmerican Dental Education Association and ADEA Ex-ecutiveDirectorRichardW.Valachovic,D.M.D.,M.P.H.;Carol A. Aschenbrener, M.D., Executive Vice President,Association of American Medical Colleges; Timi AgarBarwick, Executive Director, Physician Assistant Educa-tion Association and Dana Sayre-Stanhope, Ed.D., PA-C,Physicians Assistants Program Director, Emory Univer-sity School of Medicine; Jean E. Johnson, Ph.D. (repre-senting American Association of Colleges of Nursing),Senior Associate Dean for Health Sciences Programs,School of Medicine and Health Sciences, The GeorgeWashington University; and Harrison Spencer, M.D.,M.P.H., President and CEO, Association of Schools ofPublicHealth. StephenShannon,D.O., M.P.H.,Presidentand CEO, Association of American Colleges of Osteo-pathic Medicine provided input for the meeting but wasunable to attend.The Argus Commission drew upon the issue briefprepared by Manolakis and Skelton and a copy of thepaperwasalsodistributedforreviewbytheinvitedguestsprior to the meeting. Argus Commission members rec-ommend that all individuals who have interest in thepharmacist’s role in primary care should review this doc-ument.