Margie E. Snyder

Exploring successful community pharmacist-physician collaborative working relationships using mixed methods

BACKGROUND Collaborative working relationships (CWRs) between community pharmacists and physicians may foster the provision of medication therapy management services, disease state management, and other patient care activities; however, pharmacists have expressed difficulty in developing such relationships. Additional work is needed to understand the specific pharmacist-physician exchanges that effectively contribute to the development of CWR. Data from successful pairs of community pharmacists and physicians may provide further insights into these exchange variables and expand research on models of professional collaboration. OBJECTIVE To describe the professional exchanges that occurred between community pharmacists and physicians engaged in successful CWRs, using a published conceptual model and tool for quantifying the extent of collaboration. METHODS A national pool of experts in community pharmacy practice identified community pharmacists engaged in CWRs with physicians. Five pairs of community pharmacists and physician colleagues participated in individual semistructured interviews, and 4 of these pairs completed the Pharmacist-Physician Collaborative Index (PPCI). Main outcome measures include quantitative (ie, scores on the PPCI) and qualitative information about professional exchanges within 3 domains found previously to influence relationship development: relationship initiation, trustworthiness, and role specification. RESULTS On the PPCI, participants scored similarly on trustworthiness; however, physicians scored higher on relationship initiation and role specification. The qualitative interviews revealed that when initiating relationships, it was important for many pharmacists to establish open communication through face-to-face visits with physicians. Furthermore, physicians were able to recognize in these pharmacists a commitment for improved patient care. Trustworthiness was established by pharmacists making consistent contributions to care that improved patient outcomes over time. Open discussions regarding professional roles and an acknowledgment of professional norms (ie, physicians as decision makers) were essential. CONCLUSIONS The findings support and extend the literature on pharmacist-physician CWRs by examining the exchange domains of relationship initiation, trustworthiness, and role specification qualitatively and quantitatively among pairs of practitioners. Relationships appeared to develop in a manner consistent with a published model for CWRs, including the pharmacist as relationship initiator, the importance of communication during early stages of the relationship, and an emphasis on high-quality pharmacist contributions.

Graduating Pharmacy Students’ Perspectives on E-Professionalism and Social Media

Objective. To determine the use patterns of social media among graduating pharmacy students, characterize students’ views and opinions of professionalism on popular social media sites, and compare responses about social media behavior among students seeking different types of employment. Methods. All graduating pharmacy students (n=516) at Purdue University, The University of Findlay, Butler University, and Midwestern University were invited to complete a survey instrument during the fall semester of 2011. Results. Of 212 (41%) students who responded to the survey, 93% (194/209) had a social media profile. Seventy-four percent (120/162) of participants felt they should edit their social media profiles prior to applying for a job. Conclusions. Many graduating pharmacy students use social media; however, there appears to be a growing awareness of the importance of presenting a more professional image online as they near graduation and begin seeking employment as pharmacists.

Evaluation of specialized medication packaging combined with medication therapy management: Adherence, outcomes, and costs among medicaid patients

Background:This study evaluates the effect of a program combing specialized medication packaging and telephonic medication therapy management on medication adherence, health care utilization, and costs among Medicaid patients. Research Design:A retrospective cohort design compared Medicaid participants who voluntarily enrolled in the program (n=1007) compared with those who did not (n=13,614). Main outcome measures were medication adherence at 12 months, hospital admissions and emergency department visits at 6 and 12 months, and total paid claim costs at 6 and 12 months. Multivariate regression models were used to adjust for the effect of age, sex, race, comorbidities, and 12-month preenrollment health care utilization. Results:Measures of medication adherence were significantly improved in the program cohort compared with the usual care cohort. At 6 months, adjusted all-cause hospitalization was marginally less in the program cohort compared with the usual care cohort [odds ratio=0.73, 95% confidence interval (CI), 0.54–1.0, P=0.05]. No statistically significant differences were observed between the 2 cohorts for any of the other adjusted utilization endpoints at 6 or 12 months. Adjusted total cost at 6 and 12 months were higher in the program cohort (6-month cost ratio=1.76, 95% CI,1.65–1.89; 12-month cost ratio=1.84, 95% CI,1.72–1.97), primarily because of an increase in prescription costs. Emergency department visits and hospitalization costs did not differ between groups. Conclusions:The program improved measures of medication adherence, but the effect on health care utilization and nonpharmacy costs at 6 and 12 months was not different from the usual care group. Reasons for these findings may reflect differences in the delivery of the specialized packaging and the medication therapy management program, health care behaviors in this Medicaid cohort, unadjusted confounding, or time required for the benefit of the intervention to manifest.

Adherence: a review of education, research, practice, and policy in the United States

Objective To describe the education, research, practice, and policy related to pharmacist interventions to improve medication adherence in community settings in the United States. Methods Authors used MEDLINE and International Pharmaceutical Abstracts (since 1990) to identify community and ambulatory pharmacy intervention studies which aimed to improve medication adherence. The authors also searched the primary literature using Ovid to identify studies related to the pharmacy teaching of medication adherence. The bibliographies of relevant studies were reviewed in order to identify additional literature. We searched the tables of content of three US pharmacy education journals and reviewed the American Association of Colleges of Pharmacy website for materials on teaching adherence principles. Policies related to medication adherence were identified based on what was commonly known to the authors from professional experience, attendance at professional meetings, and pharmacy journals. Results Research and Practice: 29 studies were identified: 18 randomized controlled trials; 3 prospective cohort studies; 2 retrospective cohort studies; 5 case-controlled studies; and one other study. There was considerable variability in types of interventions and use of adherence measures. Many of the interventions were completed by pharmacists with advanced clinical backgrounds and not typical of pharmacists in community settings. The positive intervention effects had either decreased or not been sustained after interventions were removed. Although not formally assessed, in general, the average community pharmacy did not routinely assess and/or intervene on medication adherence. Education National pharmacy education groups support the need for pharmacists to learn and use adherence-related skills. Educational efforts involving adherence have focused on students’ awareness of adherence barriers and communication skills needed to engage patients in behavioral change. Policy Several changes in pharmacy practice and national legislation have provided pharmacists opportunities to intervene and monitor medication adherence. Some of these changes have involved the use of technologies and provision of specialized services to improve adherence. Conclusions Researchers and practitioners need to evaluate feasible and sustainable models for pharmacists in community settings to consistently and efficiently help patients better use their medications and improve their health outcomes.

Collaborative Drug Therapy Management: Case Studies of Three Community-Based Models of Care

Collaborative drug therapy management agreements are a strategy for expanding the role of pharmacists in team-based care with other providers. However, these agreements have not been widely implemented. This study describes the features of existing provider–pharmacist collaborative drug therapy management practices and identifies the facilitators and barriers to implementing such services in community settings. We conducted in-depth, qualitative interviews in 2012 in a federally qualified health center, an independent pharmacy, and a retail pharmacy chain. Facilitators included 1) ensuring pharmacists were adequately trained; 2) obtaining stakeholder (eg, physician) buy-in; and 3) leveraging academic partners. Barriers included 1) lack of pharmacist compensation; 2) hesitation among providers to trust pharmacists; 3) lack of time and resources; and 4) existing informal collaborations that resulted in reduced interest in formal agreements. The models described in this study could be used to strengthen clinical–community linkages through team-based care, particularly for chronic disease prevention and management.

Predictors of Medication-Related Problems Among Medicaid Patients Participating in a Pharmacist-Provided Telephonic Medication Therapy Management Program

To identify predictors of medication‐related problems (MRPs) among Medicaid patients participating in a telephonic medication therapy management (MTM) program.

Developing collaborative relationships between pharmacists and other health professionals

integrating pharmacy services into a patient-centered medical home More than 40 years ago, the idea for what may be a landmark opportunity for pharmacy was introduced. In 1967, the American Academy of Pediatrics (AAP) first presented the concept of the medical home, with a focus on having a central location for a child’s medical information.1 In the 4 decades since that publication, the vision for the patientcentered medical home (PCMH) has evolved. In March 2007, the American Academy of Family Physicians, AAP, American College of Physicians, and American Osteopathic Association issued a joint statement on the principles of the PCMH.2 The guiding principles of patient care within the PCMH model include (1) a personal physician, (2) a physician-directed medical practice that provides team-based patient care, (3) whole-person orientation in which the physician focuses on all health care needs of the patient in collaboration with the health care team, (4) coordinated and integrated care, (5) quality and safety as hallmarks of care, (6) enhanced access to care, and (7) appropriate payment for value-added care.2 Using these guiding principles, the National Committee for Quality Assurance (NCQA) has developed Physician Practices Connections (PPC)–Patient Centered Medical Home (PCMH) recognition to qualify a physician practice to be eligible for financial incentives and ciples of the PCMH model and the NCQA standards, a number of collaborative opportunities exist for integrating pharmacy services into a successful PCMH. Pharmacists can be a key health care partner to provide team-based, coordinated, integrated care with a focus on quality, safety, and enhanced access. Pharmacists already have shown successful evidence-based care in chronic conditions and demonstrated improved clinical outcomes using the concepts of patient self-management.4,5 One vital component to successful integration of pharmacy services in a PCMH is developing collaborative relationships with physicians and other members of the health care team in the practice.

A needs assessment of unused and expired medication disposal practices: A study from the Medication Safety Research Network of Indiana

BACKGROUND Access and availability of unused and expired medication (UEM) due to improper disposal and storage is a serious issue, potentially leading to abuse and environmental concerns. OBJECTIVE To describe the extent of the UEM issue in Indiana (U.S. State), identify patient beliefs about UEM, and determine any association between those beliefs and various personal/demographic characteristics. RESULTS A needs assessment was conducted among community pharmacy patients. A convenience sample of 200 patients from 15 community pharmacies that are part of a practice-based research network (PBRN) in Indiana completed a survey concerning UEM beliefs and behaviors from Feb-March, 2014. Approximately 40% of patients were aware of a UEM take-back location in their community, although only 15% had utilized a UEM take-back location. Seventy-seven percent of patients were willing to drive to a take-back location to return UEM. Particularly vulnerable populations lacking knowledge regarding UEM and access to proper disposal were identified. CONCLUSIONS While states have made efforts to increase accessibility for UEM return, there remains a need for more disposal locations for both non-controlled and controlled medication.

Pharmacists' experiences with a telephonic medication therapy management program for home health care patients.

OBJECTIVE This study was designed to better understand perceived barriers and facilitators to providing medication therapy management (MTM) services by pharmacists who recently provided telephonic MTM services to home health care patients. These services were provided as part of a randomized, controlled trial (RCT) to develop suggested quality improvement strategies for future service design. DESIGN This was a qualitative study. A semi-structured individual interview format was used to elicit responses. SETTING Interviews were conducted by phone with participants. PARTICIPANTS All pharmacists who recently provided telephonic MTM services as a part of an RCT participated in this study. INTERVENTIONS Pharmacists were asked questions regarding their perceptions of the services, training opportunities, patient perceptions of the services, interactions with physicians, and suggestions for improvement. General demographic information was collected for each pharmacist and summarized using descriptive statistics. Interview data were analyzed using inductive qualitative methods to reveal key themes related to facilitators and barriers of MTM services in home health care patients. MAIN OUTCOME MEASURES The main outcome measures were major themes identified from pharmacist interviews pertaining to barriers, facilitators, and quality improvement strategies for telephonic MTM delivery. RESULTS A total of four pharmacists (i.e., 100% of those who participated in the prior RCT) were interviewed. Several themes emerged from the analysis, including: communication and relationships, coordinating care and patient self-management, logistics, professional fulfillment, service delivery and content, and training opportunities. CONCLUSIONS This study provides possible strategies to overcome barriers and facilitate service provision for future telephonic MTM services.

Perceptions of Spanish-speaking clientele of patient care services in a community pharmacy.

BACKGROUND A paucity of studies exists that have assessed community pharmacy preferences of Spanish-speaking patients living in areas of the U.S. with rapidly growing Hispanic populations. The qualitative approach to this research affords a unique opportunity to further explore perceptions of the Spanish-speaking population. OBJECTIVES To identify perceptions of Spanish-speaking patients living in the U.S. with a focus on the care provided in community pharmacies, as well as to determine their satisfaction with community pharmacies. METHODS Participants were recruited after weekly Spanish-speaking church services for approximately one month. Qualitative, semi-structured individual interviews to identify perceived unmet patient care needs were conducted in Spanish and transcribed/translated verbatim. Qualitative thematic analysis was used to summarize findings. A written questionnaire was administered to collect patient satisfaction and demographic information, summarized using descriptive statistics. RESULTS Twelve interviews were conducted by the principal investigator. Primary themes included lack of insurance coupled with high medical care costs serving as a barrier for acquisition of health care, difficulty accessing timely and convenient primary care, perceived negative attitudes from pharmacy personnel, lack of Spanish-speaking health care providers, and the provision of verbal and written medication information in English. CONCLUSIONS The results of this study suggest a great need for health care providers, including pharmacists, to expand outreach services to the Spanish-speaking community. Some examples derived from the interview process include increasing marketing efforts of available services in the Spanish language, hiring Spanish-speaking personnel, and offering medical terminology education classes to Spanish-speaking patients.