Todd D. Sorensen

Pharmacy-Related Health Disparities Experienced by Non–English-Speaking Patients: Impact of Pharmaceutical Care

OBJECTIVES To identify the availability of foreign language services in pharmacies near a medical clinic serving a large immigrant population and determine whether the type of observed drug therapy problems differed between English- and non-English-speaking patients at this clinic. SETTING A community health care center in a diverse neighborhood of Minneapolis, Minnesota. PARTICIPANTS 40 pharmacies near the clinic and in the surrounding Minneapolis-St. Paul area known to provide services to patients in languages in addition to English and 91 clinic patients, including 38 for whom English was not their primary language, seen for full pharmaceutical care assessments. INTERVENTIONS Comprehensive drug therapy assessments were conducted for English- and non-English-speaking patients (with assistance from interpreters) in a primary care setting secondary to physician referral. Patient-specific data and the results of the pharmacists assessment were recorded in a patient management database. MAIN OUTCOME MEASURES Language services provided by area pharmacies, frequency of drug therapy problems in English- and non-English-speaking patients, and the status of patients medication conditions before and after provision of pharmaceutical care. RESULTS Of the six primary languages other than English (Vietnamese, Hmong, Laotian, Somali, Spanish, and Cambodian) spoken by clinic patients, written or verbal information was available for five languages in one or more area pharmacies. The clinic pharmacist completed comprehensive assessments for 91 patients via 230 patient encounters, identifying 186 drug therapy problems. Problems related to adherence were significantly more prevalent in non-English-speaking patients compared with English-speaking patients (31% versus 12%). In all 91 patients, the percentage achieving desired drug therapy outcomes improved by 24% after a pharmacist joined the team of clinic providers. CONCLUSION Despite the availability of clinic-based interpreters and foreign language services in pharmacies, adherence-related problems are significantly more common in non-English-speaking patients. Pharmacists committed to providing pharmaceutical care must consider the impact of language barriers when working to optimize drug therapy outcomes.

Current practices and state regulations regarding telepharmacy in rural hospitals

PURPOSE Telepharmacy practices in rural hospitals in several states were examined, and relevant policies and state laws and regulations were analyzed, along with issues to be addressed as the use of telepharmacy expands. METHODS Telepharmacy initiatives in rural hospitals were identified through a survey of the 50 state offices of rural health. Telephone interviews were conducted with board of pharmacy directors in selected states with successful telepharmacy programs. Interviews were also conducted with the individual hospitals regarding the type of telepharmacy activities, funding, and impact on medication safety. The information was analyzed to identify themes and to assess whether state laws and regulations followed recommendations by the National Association of Boards of Pharmacy (NABP) and the American Society of Health-System Pharmacists. RESULTS Although telepharmacy is addressed in NABPs model pharmacy practice act, many state boards are just beginning to address it. The model act addresses the practice of pharmacy across state lines, and the state board directors interviewed generally agreed that pharmacists should be licensed in the state where they are providing the service. States differed on whether a pharmacist should be required to be physically located in a licensed pharmacy and how much time the pharmacist should have to spend onsite. Telepharmacy models being implemented in hospitals in several states incorporate long-distance supervision of pharmacy technicians by pharmacists. The models being implemented vary according to area, state regulations, hospital ownership, and hospital size and medication order volume. Most hospitals reported that they track medication error rates, and some said error rates have improved since telepharmacy implementation. CONCLUSION The application of telepharmacy in rural hospitals varies across the United States but is not widespread, and many states have not defined regulations for telepharmacy in hospitals.

Pharmaceutical Care Leadership: An Innovative Pharmacy Practice Residency Model

OBJECTIVE To describe the establishment of the Pharmaceutical Care Leadership Residency Program (PCLRP), a residency experience that prepares graduates to take responsibility for leading practice change in pharmacy. SETTING University-based residency program focused on delivery of pharmaceutical care in ambulatory care settings. PRACTICE DESCRIPTION AND INNOVATION: Currently, ambulatory care pharmacy practice is in a position analogous to that of institutional-based clinical pharmacy in the 1960s and 1970s in that practice in this arena is not well established and tremendous opportunity for growth exists. Just as early residency programs in the institutional environment specifically emphasized the development of leaders who would advance clinical pharmacy, residencies in the ambulatory setting could now do much to further pharmaceutical care practice. The 24-month PCLRP experience combines elements of a traditional pharmacy practice residency with specific leadership development activities designed to help residents develop the skills required for establishing influence, practice-based leadership, leadership through teaching, and professional advocacy. MAIN OUTCOME MEASURES Individuals completing this program will possess a complement of skills and experience not often found in new pharmacy practitioners. They will be prepared to pursue a variety of career paths that focus on advancement of pharmaceutical care practice. RESULTS Program graduates report feeling better prepared and more confident in their ability to accept responsibility for leading practice change. They have also been successful in establishing new pharmaceutical care practices during the residency experience. CONCLUSION The success of pharmacys professional transformation is dependent on the professions ability to help individuals develop the knowledge, skills, and values required to lead this initiative. The residency program meets this challenge by placing a unique emphasis on developing leadership skills as they relate to establishing influence, pharmaceutical care practice development, teaching, and professional advocacy.

Student pharmacist perspectives of rural pharmacy practice

OBJECTIVE To evaluate the level of interest of upper-level doctor of pharmacy students in rural pharmacy practice, rural pharmacy ownership, and a proposed rural pharmacy practice model. DESIGN Cross-sectional study. SETTING Minnesota, North Dakota, and South Dakota in October through December 2003. PARTICIPANTS Third- and fourth-year professional student pharmacists at the University of Minnesota, North Dakota State University, and South Dakota State University. INTERVENTION Self-administered questionnaire completed by study participants. MAIN OUTCOME MEASURES Student interest in rural pharmacy practice and potential future directions for maintaining access to medications and the knowledge of pharmacists in rural communities. RESULTS Of 177 respondents, 62.7% has given serious consideration to practice in rural communities with populations of 5,000 or fewer residents. Of these 111 students, 81% would be interested in the proposed practice model explained in the survey. Of the 108 total students expressing interest in the proposed rural pharmacy practice model, 63% had not previously given serious consideration to pursuing ownership (full or partnership) of a community pharmacy. CONCLUSION Students from the schools that have traditionally supplied the majority of Minnesota rural pharmacists indicated an interest in practicing in rural areas as long as opportunities align with their personal and professional interests.

The limitation of good intentions: Prescribing medications for the uninsured

Identifying affordable drug therapy options for individuals who lack prescription drug insurance is a problem frequently encountered by prescribers. Medication samples and manufacturer-sponsored assistance programs represent sources often used to address affordability issues. However, these sources have the potential to introduce health disparities through various mechanisms, including reduced access to the drug of choice, consistencies with access, and drug regimen complexities that adversely affect adherence. Prescribers should consider all sources of affordable medications and openly discuss treatment options and the anticipated outcomes of each with patients to ensure the prescribing of agents that optimize outcomes while balancing patient affordability.

Refinement of strengths instruction in a pharmacy curriculum over eight years.

Objective. To develop, refine, and integrate introductory-level strengths instruction within a doctor of pharmacy (PharmD) curriculum. Design. Over 8 years, student pharmacists completed the StrengthsFinder assessment tool and identified their top 5 Signature Themes (talents). They then participated in either Web-based learning modules or live workshops designed to facilitate professional development. Assessment. Students preferred the live instruction over Web-based learning modules. Post-instruction evaluations demonstrated that students discussed their Signature Themes with peers, preceptors, and family members. Pharmacists working with students in strengths-related activities reported that the students applied the information in the practice setting. Both pharmacists and students recommended that this material be required for all students. Conclusions. Identifying a role in pharmacy that aligns with ones personal talents is critical for the success of pharmacy graduates. Strengths instruction is an important component of professional and career development, and can aid in identifying roles.

The Active Implementation Frameworks: A roadmap for advancing implementation of Comprehensive Medication Management in Primary care

Implementation of evidence-based health services interventions is complex and often limited in scope. The Active Implementation Frameworks (AIFs) are an evidence-based set of frameworks to use when attempting to put into practice any innovation of known dimensions. This article describes the novel application of the AIFs to facilitate the implementation and improvement of Comprehensive Medication Management (CMM) in primary care practices to optimize medication use and improve care for patients.

Maximizing medication therapy management services through a referral initiative.

PURPOSE The implementation and effects of an initiative to refer patients to receive medication therapy management (MTM) services after hospital discharge are described. METHODS A check box to order an MTM appointment was added to the discharge medication order form printed for hospitalized patients in an integrated health system. Hospitalists were informed about MTM services and encouraged to refer hospitalized patients to the service who were at risk for adverse drug events or medication nonadherence. A retrospective case series review was conducted to evaluate documented MTM encounters, comparing the number of patients seen at the MTM practice for hospital follow-up during the four months before and after the initiatives implementation. Secondary endpoints included revenue generated by MTM encounters and the percentage of patients with documented drug therapy problems due to medication nonadherence. RESULTS A total of 313 encounters were included in the analysis (142 preimplementation and 171 postimplementation). The percentage of MTM hospital follow-up encounters significantly increased from the preimplementation period to the post-implementation period, from 30.28% (n = 43) to 63.74% (n = 109) (p < 0.001). After the referral initiative was implemented, MTM hospital follow-up encounters were more likely to reveal medication nonadherence, compared with regular office visits (odds ratio, 2.1; 95% confidence interval, 1.01-4.34; p = 0.039). CONCLUSION The implementation of an initiative to refer hospitalized patients to an MTM service in an integrated health system increased the percentage of recently discharged patients seen in an MTM practice; patients seen postimplementation were more likely to be nonadherent to their medication regimen.

A qualitative evaluation of medication management services in six Minnesota health systems

PURPOSE The initiation, establishment, and sustainability of medication management programs in six Minnesota health systems are described. METHODS Six Minnesota health systems with well-established medication management programs were invited to participate in this study: Essentia Health, Fairview Health Services, HealthPartners, Hennepin County Medical Center, Mayo Clinic, and Park Nicollet Health Services. Qualitative methods were employed by conducting group interviews with key staff from each institution who were influential in the development of medication management services within their organization. Kotters theory of eight steps for leading organizational change served as the framework for the question guide. The interviews were audio recorded, transcribed, and analyzed for recurring and emergent themes. RESULTS A total of 13 distinct themes were associated with the successful integration of medication management services across the six healthcare systems. Identified themes clustered within three stages of Kotters model for leading organizational change: creating a climate for change, engaging and enabling the whole organization, and implementing and sustaining change. The 13 themes included (1) external influences, (2) pharmacists as an untapped resource, (3) principles and professionalism, (4) organizational culture, (5) momentum champions, (6) collaborative relationships, (7) service promotion, (8) team-based care, (9) implementation strategies, (10) overcoming challenges, (11) supportive care model process, (12) measuring and reporting results, and (13) sustainability strategies. CONCLUSION A qualitative survey of six health systems that successfully implemented medication management services in ambulatory care clinics revealed that a supportive culture and team-based collaborative care are among the themes identified as necessary for service sustainability.

StrengthsFinder signature themes of talent in doctor of pharmacy students in five midwestern pharmacy schools

Objective. To describe student pharmacists’ Signature Themes from the Clifton StrengthsFinder across 5 Midwestern pharmacy institutions and to compare themes by gender, institution, and undergraduate population. Methods. Student pharmacists completed the StrengthsFinder 2.0 assessment and received their top 5 Signature Themes. Themes were organized and examined by domains (Executing, Influencing, Relationship Building, Strategic Thinking). The distribution of the themes was compared between student pharmacists and undergraduates and themes and domains were compared by institution and gender. Results. Although results varied by institution, the top 5 themes among the 1244 of 1250 students (99.5%) who completed the assessment were: Achiever, Harmony, Learner, Responsibility, and Empathy. Female student pharmacists had more themes in Executing and Relationship Building, while males had more themes in Influencing and Strategic Thinking. Pharmacy students exhibit more Executing domain talents and fewer Influencing domain talents compared with undergraduates. Conclusion. Signature Themes were consistent among student pharmacists across 5 Midwestern colleges of pharmacy.