COLLABORATIVE PRACTICE AGREEMENTS (CPAS) IN CHAIN COMMUNITY
PHARMACIES: STRATEGIES FOR IMPLEMENTATION AND SCALABILITY
by
Jennifer L. Bacci
PharmD, University of Pittsburgh, 2011
Submitted to the Graduate Faculty of
Graduate School of Public Health in partial fulfillment
of the requirements for the degree of
Master of Public Health
University of Pittsburgh
2015
UNIVERSITY OF PITTSBURGH
GRADUATE SCHOOL OF PUBLIC HEALTH
This essay is submitted
by
Jennifer L. Bacci
on
April 20, 2015
and approved by
Essay Advisor:
David Finegold, MD
Director
Multidisciplinary MPH Program
Graduate School of Public Health
University of Pittsburgh
_________________________________
Essay Readers:
Kim C. Coley, PharmD, FCCP
Professor
Pharmacy and Therapeutics
School of Pharmacy
University of Pittsburgh
_________________________________
Melissa S. McGivney, PharmD, FCCP, FAPhA
Assistant Dean for Community Partnerships
Associate Professor
Pharmacy and Therapeutics
School of Pharmacy
University of Pittsburgh
ii
_________________________________
Copyright © by Jennifer L. Bacci
2015
iii
David Finegold, MD
COLLABORATIVE PRACTICE AGREEMENTS (CPAS) IN CHAIN COMMUNITY
PHARMACIES: STRATEGIES FOR IMPLEMENTATION AND SCALABILITY
Jennifer L. Bacci, MPH
University of Pittsburgh, 2015
ABSTRACT
Collaborative practice agreements (CPAs) facilitate collaborative, interdisciplinary
patient care by serving as a mutually agreed upon written plan between physicians and
pharmacists delineating the primary care and medication management functions of pharmacists.
CPAs have not been widely implemented. This study aims to (1) identify solutions for external
barriers affecting the implementation and scalability of CPAs, and (2) develop a model for
operationalizing CPAs within chain community pharmacy organizations. Of major public health
significance, determining how to implement and scale CPAs is critical to ensuring all people
access to primary care services in their own communities and improving patient outcomes and
quality and reducing medication misuse, preventable ADEs, and health care expenditures. This
study employed the National Implementation Research Network’s conceptual model of
implementation to determine the multilevel influences affecting the uptake and dissemination of
CPAs. Key informant interviews were conducted with licensed pharmacists who hold either a
pharmacy staffing or clinical management position within a traditional, supermarket, or mass
merchant chain with pharmacies located in New York, Ohio, Pennsylvania, and/or West
Virginia. The semi- structured interview script was developed based on the Systems Engineering
Initiative for Patient Safety (SEIPS) model of work system and patient safety. Interviews were
conducted until data saturation was achieved. The data underwent thematic analysis guided by
iv
the conceptual model and the SEIPS work system framework. This study revealed that there are
multiple strategies to facilitate the implementation and scalability of CPAs. These strategies
include establishing physician relationships, enhancing pharmacists’ education and training,
addressing patients’ perception, structuring time and workload, and advocating for CPA laws at
the state level and provider status at the national level. Strategies for addressing these needs can
be incorporated into a model for operationalizing CPAs within chain community pharmacy
organizations.
There must be coordination between the patient, the community pharmacists,
and the physician in order for CPAs to be implemented successfully. District and corporate
management can create opportunities to support patient, pharmacist, and physician coordination
and is critical to replicating CPAs. Collaboration with professional organizations and schools of
pharmacy can be essential to scaling CPAs within an organization.
v
TABLE OF CONTENTS
PREFACE .................................................................................................................................... IX
1.0
INTRODUCTION ........................................................................................................ 1
1.1
OBJECTIVES ...................................................................................................... 4
1.2
METHODS ........................................................................................................... 4
1.2.1
Qualitative Research Design ........................................................................... 4
1.2.2
Data Collection and Analysis .......................................................................... 8
1.3
RESULTS ............................................................................................................. 9
1.3.1
Theme 1: Establish physician relationships ................................................ 12
1.3.2
Theme 2: Enhance pharmacists’ education and training .......................... 14
1.3.3
Theme 3: Address patients’ perceptions ..................................................... 15
1.3.4
Theme 4: Structure time and workload ...................................................... 16
1.3.5
Theme 5: Advocate for CPA laws and provider status .............................. 17
1.3.6
Proposed Model for Operationalizing CPAs ............................................... 19
1.4
DISCUSSION ..................................................................................................... 22
1.4.1
1.5
Limitations ..................................................................................................... 26
CONCLUSION .................................................................................................. 26
APPENDIX: KEY INFORMANT INTERVIEW QUESTIONS............................................ 28
BIBLIOGRAPHY ....................................................................................................................... 33
vi
LIST OF TABLES
Table 1. Description of chain community pharmacy organizations (n=8)……………………....10
Table 2. Demographics of clinical pharmacist managers (n=10)………………………………..11
Table 3. Demographics of community pharmacists (n=9)……………………………………....11
Table 4. Proposed strategies for establishing physician relationships……………………..…….13
Table 5. Proposed strategies for enhancing pharmacists’ education and training ………............15
Table 6. Proposed strategy for addressing patients’ perceptions…………………………...……16
Table 7. Proposed strategies for structuring time and workload……………………………..….17
Table 8. Proposed strategies for advocating for CPA laws and provider status…………………19
vii
LIST OF FIGURES
Figure 1. Conceptual Framework for Implementation of CPAs Between Pharmacists and
Physicians for Medication Management in Chain Community Pharmacies……………………...5
Figure 2. Proposed Model for Operationalizing CPAs with Chain Community Pharmacy
Organizations……………………………….……………………………………………………20
viii
PREFACE
The author would like to acknowledge the following individuals for their contributions to and
mentorship during the duration of the research study described in this essay: Kim C. Coley,
PharmD, FCCP; Olufunmilola K. Odukoya, BPharm, PhD; Alex J. Adams, PharmD; Kyle
McGrath, PharmD Candidate 2015; and Melissa Somma McGivney, PharmD, FCCP, FAPhA.
ix
1.0
INTRODUCTION
Patient safety is a growing concern for the United States (US) health care system.
Improper and unnecessary medication use caused health care costs in excess of $200 billion in
2012. These costs accounted for about 8% of health care spending in 2012. Medication errors
significantly contribute to inappropriate medication use in this country. An adverse drug event
(ADE) occurring as a result of a medication error is considered preventable. A 2006 Institute of
Medicine committee estimated that at least 1.5 million preventable ADEs are occurring yearly in
the US. Medication errors result in approximately 4 million avoidable hospital admissions and
1.4 million avoidable office visits yearly. Prescribing errors are the largest cause of medication
errors in the hospital while inadequate prescription monitoring is the largest in the outpatient
setting. The avoidable cost opportunity from medication errors is estimated to be $20 billion.
Medication nonadherence, delayed evidence-based treatment practice, suboptimal use of
medication generics, and mismanaged polypharmacy are other contributors to the rising costs of
inappropriate medication use in this country (Murray & Valkova, 2013).
Quality metrics have been implemented by many health care organizations to improve
patient safety and reduce improper and unnecessary medication use. The National Committee
for Quality Assurance (NCQA) has implemented the HEDIS measures while Medicare
Prescription Drug Plans (PDPs) and Advantage Plans (MA-PDs) are evaluated based on the Star
Ratings (National Committee for Quality Assurance [NCQA], n.d.; Centers for Medicare &
1
Medicaid Services [CMS], 2015). It has been widely demonstrated that pharmacists are able to
improve the quality and effectiveness of medication use and contain or reduce health care costs
through medication management (Giberson, Yoder, & Lee, 2011; Avalere Health LLC, 2014;
Chisholm Burns et al., 2010; Isetts et al., 2008; Bunting & Cranor, 2003; Bunting, Smith, &
Sutherland, 2003; Smith, Giuliano, & Starkowski, 2011).
Comprehensive medication
management is the standard of care that ensures that each patient’s medications are individually
assessed for indication, safety, efficacy, and adherence (PCPCC Medication Management Task
Force, 2012). Community pharmacists are among the most accessible health care practitioners to
people throughout the country trained to provide medication management. There are more than
60,000 community-based pharmacies that employ more than 170,000 pharmacists in the
community setting (National Association of Chain Drug Stores [NACDS], 2011). Pharmacists
engaging with physicians in collaborative practice agreements (CPAs) could better enable
patients to receive high-quality, interdisciplinary medication management in their own
communities.
CPAs are a formal agreement in which a licensed provider makes a diagnosis, supervises
patient care, and refers patients to a pharmacist under a protocol that allows the pharmacist to
perform specific patient care functions.
These functions may include performing patient
assessment, ordering and/ or interpreting drug-related laboratory tests, and selecting, initiating,
monitoring, continuing, or adjusting patients’ drug regimens. Pharmacists’ abilities to perform
these functions are determined by their scope of practice in the state in which they practice.
Regardless, CPAs facilitate patient access to primary care and medication management by
serving as a mutually agreed upon written plan between physicians and pharmacists the
pharmacists’ functions within a collaborative, interdisciplinary health care team (Hammond et
2
al., 2003).
CPAs between pharmacists and physicians for medication and disease state
management have been documented in the literature but are limited to individual practitioners in
select communities (Tallian et al., 2012; George, Molina, Cheah, Chan, & Lim, 2010; Howard et
al., 2003).
Efficiency is the factor limiting the wide-scale implementation of CPAs. Determining
how to scale CPAs is critical to moving beyond these pockets of success and ensuring that all
patients have access to primary care and medication management services. Implementation
barriers have been well defined in the literature (Tallian et al., 2012; George et al., 2010; Howard
et al., 2003; Bryant, Coster, Gamble, & McCormick, 2009). Moving beyond these barriers has
been identified as a priority for the Centers of Disease Control and Prevention (CDC) as
evidenced by their recent release of multiple resources in support of CPAs and pharmacists’
patient care services (Centers for Disease Control and Prevention [CDC], 2013). Identifying
opportunities for growth and barriers limiting growth are essential next steps in scaling this
health service.
Scaling CPAs has multiple implications for stakeholders. Patients benefit from the
increased individualized attention to their medications and health. They are educated about their
medications and collaborate in their care allowing for increased self-efficacy. They also benefit
from improved outcomes and fewer ADEs and side effects from medications. Providers receive
assistance in managing patients’ complex drug regimens. This collaboration allows them to be
more efficient with their time by focusing their efforts on the diagnostic and treatment selection
process and providing medical care.
Providers can see more patients are a result.
Comprehensive medication management ensures that payers will only be paying for medications
that are safe, appropriate, and effective for their members. Fewer hospitalizations from ADEs
3
and improved quality metrics will result further benefiting the payers. CPAs between physicians
and pharmacists for comprehensive medication management is one solution that can assist this
country in improving patient outcomes and quality and reducing medication misuse, preventable
ADEs, and health care expenditures. However, we need to understand how to scale CPAs to
grant all patients access to medication management to make it a reality.
1.1
OBJECTIVES
The objective of this qualitative study was to determine how to implement and scale
CPAs within chain community pharmacy organizations to enable pharmacists to collaboratively
care for patients in their own communities. This study advanced on two specific aims: (1)
identify solutions for external barriers affecting the implementation and scalability of CPAs, and
(2) develop a model for operationalizing CPAs within chain community pharmacy organizations.
1.2
METHODS
1.2.1 Qualitative Research Design
The research team at the University of Pittsburgh School of Pharmacy partnered with the
National Association of Chain Drug Stores (NACDS) Foundation to complete this study. The
study was developed using a conceptual framework for the implementation of CPAs between
pharmacists and physicians for medication management in chain community pharmacies adapted
4
from the National Implementation Research Network (Fixsen, Naoom, Blase, Friedman, &
Wallace, 2005). The adapted conceptual model is displayed in Figure 1.
Figure 1. Conceptual Framework for Implementation of CPAs Between Pharmacists and
Physicians for Medication Management in Chain Community Pharmacies
The source is the practice or program to be implemented. The destination is the practitioners and
organization that adopt the practice or program. The communication link is the individuals or
groups actively working to implement the practice or program. The feedback is the regular flow
of information about program and personnel performance. The influences affect the people,
organizations, and/ or systems (Fixsen et al, 2005).
The study utilized semi-structured key informant interviews. The research team chose to
include chain community pharmacy organizations with pharmacy locations in New York, Ohio,
Pennsylvania, and/ or West Virginia. A chain community pharmacy was defined as a company
5
that operates 4 or more pharmacies open to the general public. These pharmacies include
traditional drug store formats and pharmacies located in supermarkets and mass merchants
(NACDS, 2011).
The study design was limited to 4 states for feasibility because of the
numerous chain community pharmacy organizations across the country. The research team
selected to include chains with pharmacy locations in New York, Ohio, Pennsylvania, and/ or
West Virginia because of the variability in the states’ CPAs laws. New York does not allow
CPAs between pharmacists and prescribers in the non-hospital outpatient setting. In Ohio, the
practice of pharmacy includes managing an individual’s drug therapy subject to a consult
agreement with a physician and limits pharmacists to only adjusting drug therapy. Pennsylvania
legalized CPAs in the outpatient setting in 2010 but restricts pharmacists to only modifying or
discontinuing drug therapy. Pharmacists in West Virginia can implement and modify drug
therapy under CPAs in all practice settings (McBane et al., 2015).
Participants had to be employed by a chain community pharmacy organization that met
the inclusion criteria described above and be licensed pharmacists who were either a clinical
pharmacist manager or “ground level” pharmacist providing patient care. A clinical pharmacist
manager was defined as a licensed pharmacist who holds a management position overseeing
clinical services within his/ her organization. A “ground level” pharmacist providing patient
care, herein referred to as a community pharmacist, was defined as a licensed pharmacist at the
pharmacy or local level providing care to patients on a regular basis.
The semi-structured key informant interviews (Appendix A) were designed to identify
community pharmacy organizations’ successes in implementing and scaling CPAs and seek
stakeholder input as to possible solutions to barriers limiting the wide-scale implementation of
CPAs within chain community pharmacies and resources or tools that could assist chain
6
community pharmacies in scaling CPAs for medication management. The interview questions
were developed based on the Systems Engineering Initiative for Patient Safety (SEIPS) model of
work system and patient safety. The model provides a context for the interactions between the
five components of a work system that contribute to process, patient, and employee and
organizational outcomes.
The five components are person, tasks, tools and technologies,
environment, and organizational conditions (Carayon et al., 2006). Probing questions were
designed to elicit facilitators and barriers affecting these 5 components of a work system. The
questions were also designed to account for the organization’s experience with CPAs. It was
anticipated that the participants’ organizations would fall into 3 groups. The groups were
organizations who had established CPAs, organizations who had attempted to establish CPAs,
and organizations who had not attempted to establish CPAs. The research team also sought input
from national and regional CPA experts during the design of the semi-structured script. The
questions were piloted with 2 chain community pharmacists who have local clinical
responsibilities within their organizations.
Clinical pharmacist managers who met the study’s inclusion criteria were identified by
the NACDS Foundation. An NACDS Foundation representative made the initial contact with
the clinical pharmacist managers via email. This email introduced the research study and alerted
the clinical pharmacist managers that they would be contacted by the study’s primary
investigator with additional information. The primary investigator then recruited the clinical
pharmacist managers via email. They were contacted up to 3 times via email for recruitment.
Once a clinical pharmacist manager consented to participate, they were asked to provide the
names and contact information for 4 to 6 community pharmacists within their organization
practicing in New York, Ohio, Pennsylvania, or West Virginia. The primary investigator then
7
recruited the community pharmacists via email. They were contacted up to 3 times via email for
recruitment.
1.2.2 Data Collection and Analysis
Individuals who consented to participate completed a 20-minute, face-to-face or
telephonic key informant interview with the primary investigator. Interviews were conducted
until saturation was reached to ensure an adequate sample size. Saturation was defined as the
point at which the investigators were not gathering any new information (Curry, Nembhard, &
Bradley, 2009; Guest, Buhle, & Johnson, 2006).
The interviews were audio recorded and transcribed by a co-investigator. All identifying
information was removed during the transcription process. The other research team members
were blinded to participants’ identities and their employers and only had access to de-identified
interview transcripts. The transcripts were then analyzed using a generic qualitative approach
(Kahlke, 2014). Two investigators independently read and coded the transcripts using deductive
and inductive coding strategies (Elo & Kyngäs, 2008; Joffe & Yardley, 2004; Pope, Ziebland, &
Mays, 2000). Sentences and phrases from the interviews that carried meaning were labeled with
codes. The investigators met to discuss line-by-line coding decisions made by each. Coding
disagreements were resolved through discussion. The investigators kept one code list using the
qualitative data management software Atlas.ti (version 6.2; Atlas.ti, Berlin, Germany) to which
continual edits were made. A senior investigative panel reviewed the transcripts and codes for
gaps, inconsistencies, and new interpretations to improve the validity of the analysis. The coded
text was grouped into categories to identify major themes. The research team met to collectively
agree upon themes and a model for operationalizing CPAs within chain community pharmacies
8
(Krueger, 2000).
Additional methods used to validate the finding include methodological
triangulation (Jick, 1979), peer debriefing (Plummer-D’Amato, 2010), audit trail documentation
and reflective journal (Rodgers & Cowles, 1993), and presentation of verbatim quotes (Fosse,
Harvey, McDermott, & Davidson, 2002).
The study was approved as exempt by the University of Pittsburgh Institutional Review
Board (IRB).
1.3
RESULTS
In all, 26 chain community pharmacy organizations met the inclusion criteria. Eight
chains (31%) participated in the study. Table 1 summarizes the characteristics of the participants
chains. A total of 17 key informant interviews were conducted from August 2014 to March
2015.
Two interviews were conducted with 2 individuals from the same organization.
Participants included 10 clinical pharmacist managers from 8 chain community pharmacy
organizations and 9 community pharmacists from 4 chain community pharmacy organizations.
Tables 2 and 3 summarize participating clinical pharmacist managers’ and community
pharmacists’ demographics, respectively.
9
Table 1. Description of chain community pharmacy organizations (n=8)
Type of chain community pharmacy organization, No. (%)
Supermarket
4 (50)
Mass merchant
2 (25)
Traditional
1 (12.5)
Independent
1 (12.5)
Number of pharmacy locations, Mean (Range)
1498 (8-4,575)
Number of states with pharmacy locations, Mean (Range)
21.6 (1-49)
Patient care expectations of pharmacists, No. (%)
All pharmacists are expected to provide patient care services
7 (87.5)
Some pharmacists are expected to provide patient care services
1 (12.5)
Company wide CPAs, No. (%)
Immunizations
6 (75)
Rapid diagnostic testing
1 (12.5)
Limited CPAs^, No. (%)
Rapid diagnostic testing
^
3 (37.5)
Immunizations
2 (25)
Point-of-care testing
2 (25)
Limited CPAs are non-company wide CPAs or CPAs in specific states,
regions, or pharmacies.
10
Table 2. Demographics of clinical pharmacist managers (n=10 from 8 chains)
Type of chain community pharmacy organization, No. (%)
Supermarket
5 (50)
Mass merchant
3 (30)
Traditional
1 (10)
Independent
1 (10)
Female, No. (%)
6 (60)
Years in current organization, Mean (Range)
17 (5-36)
Years in current organization, Mean (Range)
5.3 (0.67-18)
Level within organization, No. (%)
Corporate or national level
9 (90)
Local or district level
1 (10)
Table 3. Demographics of community pharmacists (n=9 from 4 chains)
Type of chain community pharmacy organization, No. (%)
Supermarket
7 (78)
Mass merchant
2 (22)
State practicing in, No. (%)
New York
7 (78)
Pennsylvania
2 (22)
Female, No. (%)
4 (44)
Years in current organization, Mean (Range)
7.3 (1-14)
Years in current organization, Mean (Range)
2.3 (1-4)
11
Upon undergoing thematic analysis, the majority of the strategies identified by
participants to minimize the effect of external barriers on the implementation and scalability
CPAs fell into the SEIPS model domains of person, tasks, and environment.
Participants did
identify barrier within the tools and technology domain; however, no potential strategies to
overcome the barriers were identified.
Participants also identified barriers within the
organization domain. These barriers were excluded from the final analysis because they were
unique to specific organizations rather than being a common challenge among all of the
participating organizations.
The qualitative analysis revealed the following five dominant
themes.
1.3.1 Theme 1: Establish physician relationships
Both clinical pharmacist managers and community pharmacists alike emphasized the
importance of physician relationships to collaborative practice. The participants shared many
strategies for establishing and maintaining relationships with physicians.
Establishing
relationships among the community pharmacists and their local providers at the ground level was
a commonality among the strategies identified.
Support from chain management and
partnerships with schools of pharmacy or professional organizations increased the community
pharmacists’ capacity to build and maintain their relationships through increased access to
resources. Proposed strategies for building relationships with physicians with verbatim quotes
are described in Table 4.
12
Table 4. Proposed strategies for establishing physician relationships
Proposed Strategy
Verbatim Quotes
Establish collaborations that “I’ve helped some providers…I would carry vaccines that they
are beneficial to the physician felt were cost prohibitive and we set up a program where they
and the community
could get access to vaccines they could otherwise not afford to
stock.” (Community pharmacist, Supermarket)
Provide pharmacists with the “We also do a lot of doctor detailing…so, building the
resources and time to build relationship not only with the doctor, but with the office
relationships with providers
staff…I think a big thing is consistency. So you’re not [going
to] go to a place one time and they’re [going to] trust you.”
(Community pharmacist, Supermarket)
Hire an employee to be in the “We have a person [whose] job is to be out in our communities
community working with the in all states visiting providers, visiting hospitals…talking to
“ground level” pharmacists to the, about all of the programs we’re driving. It creates some
develop
providers
relationships
with awareness and the providers that are interested follow-up with
us…” (Clinical pharmacist manager, Supermarket)
Perform outreach with the “…helping cross that barrier between pharmacy and the
assistance of state pharmacist physician group [is] probably something everyone could
associations and schools of benefit from that maybe state associations could help drive…”
pharmacy
(Clinical pharmacist manager, Supermarket)
13
1.3.2 Theme 2: Enhance pharmacists’ education and training
Pharmacists’ education and training was another challenge cited most commonly by
clinical pharmacist managers because one of their responsibilities is ensuring that all community
pharmacists are able to provide patient care services proficiently.
Currently, practicing
community pharmacists may have a Bachelor of Science in Pharmacy (BS Pharm) and/ or a
Doctor of Pharmacy (PharmD) degree. Practicing pharmacists with a PharmD received more
training centered around the provision of patient care rather than just of the science of medicines
and provision of drug product. These differences in training pose a challenge to organizations
striving to provide standardized patient care services through out their company. The most
common method for addressing this challenge is to train all pharmacists in each new patient care
service; however, additional training is expensive and time-consuming. It typically involves
some sort of computer-based training or pulling pharmacists out of the pharmacy. Staff turnover
and ensuring that all pharmacists are adequately trained in all patient care services further
complicates the issue. Proposed strategies for overcoming these challenges and enhancing
pharmacists’ education and training with verbatim quotes are described in Table 5.
14
Table 5. Proposed strategies for enhancing pharmacists’ education and training
Proposed Strategy
Verbatim Quotes
Develop industry standards for “…standardization related to additional…training or retraining
additional training required of required would be helpful.” (Clinical pharmacist manager,
pharmacists
Mass Merchant)
Identify store- and regional- “…it’s about develop a champion pharmacist within that store
level
pharmacist
champions who can become the regional champion to teach the
who can provide hands-on newcomers and students…” (Clinical pharmacist manager,
training and ensure all new Mass Merchant)
hires and students are trained.
1.3.3 Theme 3: Address patients’ perceptions
Participants identified a need for educating people about how pharmacists provide care.
People generally view pharmacies as the place where they get their medicines. People are not
aware of the interventions that pharmacists make on a daily basis to ensure that they get the right
medicine at the right time. Furthermore, they may not be aware of the education and training
pharmacists’ receive to help people manage their medications. Lastly, people are not aware of
the services that pharmacists offer such as medication therapy management (MTM), disease state
education, and preventative services. Educating the public will be critical to ensuring people use
the services pharmacists are able to provide through CPAs. Clinical pharmacist managers
identified that the first step to addressing patients’ perceptions might be to ensure that
pharmacists are appropriately placed in communities. Appropriate placement includes ensuring
15
that a pharmacist’s knowledge and skill set match the medication- and health-related needs of the
community in which they work. This proposed strategy for addressing patients’ perceptions with
a verbatim quote is described in Table 6.
Table 6. Proposed strategy for addressing patients’ perceptions
Proposed Strategy
Verbatim Quotes
Match the pharmacist to the “I think it’s finding the right situation because no two
population
to
ensure populations are exactly the same…you might have a Hispanic
pharmacists are able to meet speaking population and matching them up with Hispanic
their communities needs
speaking pharmacists that can really…speak to them. Sight
and hearing impaired is another area that has come up
recently…” (Clinical pharmacist manager, Mass merchant)
1.3.4
Theme 4: Structure time and workload
Community pharmacy workflow is a major challenge identified by both clinical
pharmacist managers and community pharmacists that must be addressed in order to successfully
implement and scale CPAs. Traditionally, community pharmacy workflow has been designed to
support the dispensing of high volumes of medications.
As a result, staffing is typically
allocated based on prescription volume. This workflow geared toward producing prescriptions
has presented a challenge as community pharmacy has begun to transition from a productoriented industry to a service-oriented industry.
Pharmacy teams have had to identify
opportunities to adapt this workflow to better incorporate patient care. Proposed strategies for
16
optimizing community pharmacy workflow to facilitate patient care with verbatim quotes are
described in Table 7.
Table 7. Proposed strategies for structuring time and workload
Proposed Strategy
Verbatim Quotes
Elevate the responsibilities of “We
need
to
create
deeper
career
paths
for
our
technicians through training technicians…elevate their role…tech check tech frees the
and career guidance
pharmacists up by elevating the role of the technician.”
(Clinical pharmacist manager, Mass merchant)
Use a central fill facility and “…we have [a] central fill facility, a pharmacy support center
call center
so we’re taking the traditional work our of our stores to five
our pharmacists time to perform clinical duties.” (Clinical
pharmacist manager, Supermarket)
Allocate staffing hours based “Every clinical offering has…a different metric for the amount
on prescription volume and of time associated with [it]…that’s how [the pharmacy teams]
clinical services
earn the time.” (Community pharmacist, Supermarket)
1.3.5 Theme 5: Advocate for CPA laws and provider status
All pharmacists identified the legal challenges presented by state and federal law.
Pharmacists’ scope of practice and ability to enter into a CPA is defined at the state level and
varies widely.
Understanding the nuances of states’ laws is particularly challenging for
management in chain community pharmacy organizations with locations in multiple states.
Clinical pharmacist managers described how some states’ legislation limit CPAs to a specific
17
physician’s patient population. This stringent legislation requires community pharmacists to
establish multiple CPAs in order to have a wide impact. Having multiple CPAs places the
burden of identifying eligible patients on the pharmacists and their teams within an already
challenging workflow.
Other states do not restrict CPAs to specific physicians’ patient
populations allowing chain community pharmacy organizations to partner with third party
agencies to establish CPAs.
Provider status legislation at the federal level also poses a challenge to collaborative
practice. Currently, pharmacists’ patient care services are not considered a reimbursable service
under Medicare Part B. As a result, community pharmacists have limited opportunities to be
reimbursed for their patient care services. Achieving provider status would create opportunities
for community pharmacy to develop financially sustainable business model for patient care
services. Legislation for provider status currently exists and has been introduced in the Senate
and House of Representatives. All participants described the importance of advocating for this
legislation. These proposed strategies for advocating for CPAs laws and provider status with
verbatim quotes are described in Table 8.
18
Table 8. Proposed strategies for advocating for CPA laws and provider status
Proposed Strategy
Partner
with
third
Verbatim Quotes
party “…it’s basically a third party staffing agency that coordinates
agencies that have physician [the] contract with the collaborative physicians.” (Clinical
contacts in each state
pharmacist manager, Mass merchant)
Advocate for national provider “It is working through the headquarters and forming those
status by participating in state relationships on a national level that can really help you
and
national
organizations,
professional influence [policy]…but if everybody is working at it from the
lobbying
and same channels you have to lose some of the competition”
communicating with state and (Clinical pharmacist manager, Mass merchant)
federal
legislators,
and
collaborating with competitors
1.3.6 Proposed Model for Operationalizing CPAs
Solutions to the barriers affecting the implementation and scalability of CPAs, as
described above, can be incorporated into a model for operationalizing CPAs within chain
community pharmacy organizations. This model is depicted in Figure 2.
19
Figure 2. Proposed Model for Operationalizing CPAs within Chain Community
Pharmacy Organizations
The triangle at the top of the model represents coordination among the pharmacist,
physician, and patient. This coordination is essential to practicing collaboratively. Community
pharmacists can work to build a level of coordination with their patients and local prescribers at
their own community pharmacy. Willing pharmacists, prescribers, and patients with open lines
of communication is the only absolute requirement of collaborative practice. The other layers of
the model, including district management, corporate management, and professional organizations
and schools of pharmacy, can increase the community pharmacist’s capacity to practice
collaboratively.
20
District management can support community pharmacists by implementing strategies that
facilitate collaborative practice and patient care at a local level. The study participants described
that these strategies include strategically placing pharmacists into communities so that their skill
sets match their communities’ needs, identifying and training pharmacist champions to further
support community pharmacists practicing collaboratively, and ensuring community pharmacists
have access to the community and professional resources they might need to practice
collaboratively. Corporate management can support community pharmacists by developing and
implementing strategies to facilitate collaborative practice and patient care company-wide. The
study participants described that these strategies include incorporating patient care into the
organization’s vision for the future as the vision guides the company and its policies and
procedures, enhance workflow design to maximize community pharmacists’ opportunities to
interact with patients and other health care providers, and adjust the staffing model to meet
patient care needs rather than just dispensing needs. Having the support of district and corporate
management is critical for replicating collaborative practice within the chains.
Lastly, chain community pharmacy organizations can partner with professional
organizations and schools of pharmacy to further support their collaborative practice efforts.
Through these partnerships, chains community pharmacy organizations can establish and
disseminate leading practices to inform their collaborative practices, and advocate for policies to
enhance community pharmacists’ abilitites to care for patients. These partnerships are critical to
scaling collaborative practice within chains.
21
1.4
DISCUSSION
This study provides a deeper look into how chain community pharmacy organizations can
implement and scale CPAs. Implementation barriers have been widely noted (Tallian et al.,
2012; George et al., 2010; Howard et al., 2003; Bryant, Coster, Gamble, & McCormick, 2009).
However, patients clearly need access to high-quality, collaborative primary care and medication
management in their own communities. Community pharmacists have the knowledge and skills
to partner with other health care providers to provide this care as the most accessible health care
practitioners (NACDS, 2011). This study identifies strategies that chain community pharmacy
organizations can implement to assist their community pharmacists in practicing collaboratively.
First, community pharmacists must establish relationships with physicians. Community
pharmacists developing a level of coordination with physicians is the first step and most critical
piece to collaborative practice. A model for developing collaborative working relationships
(CWRs) between pharmacists and physicians and a description of their professional exchanges
has been previously published (McDonough & Doucette, 2001; Snyder et al., 2010).
The
pharmacists in this study provided specific strategies for establishing and maintaining
relationships with prescribers in the current health care environment. Most of the participants
mentioned the importance of visiting the office to meet with the physicians and office staff faceto-face, often called “doctor detailing,” to establishing a CWR in order to overcome the barrier
of providing patient care in different locations. Furthermore, participants noted that pharmacists
need to routinely visit the physician office in order to build trust over time and sustain
relationships. Although not required, chain management support increases pharmacists’ capacity
to build these relationships by providing resources such as additional staffing to enable a
pharmacist to leave the pharmacy. Providing resources might benefit the chain community
22
pharmacy organization if the resulting collaborations allow pharmacists to more efficiently fill
prescriptions (Chui, Stone, Odukoya & Maxwell, 2014).
This study also brings new perspectives to the existing issue of the education and training
pharmacists need in order to provide care in the community setting. Some participants felt that
all community pharmacists should be providing patient care; others thought only certain
community pharmacists should provide patient care. Regardless, all participants described the
challenges associated with training practicing pharmacists, including the significant cost and
struggles presented by staff turnover. Currently, all community pharmacists are required by law
or their organization to receive training prior to providing any new patient service regardless of
their degree or post-graduate training.
This environment might have resulted from our
profession’s struggle to convince others of pharmacists’ ability to care for patients outside of the
provision of drug product. Yet, the constant need to certify pharmacists in skills they received as
part of their training in pharmacy school, might dilute the value of the PharmD. A professionwide discussion to resolve these issues will be critical to moving forward. This discussion needs
to include the level of training or certification that practicing pharmacists need to continue to
receive to provide patient care, whether pharmacists’ continual training should be influenced by
their degree or post-graduate education, and the utility of standardized, on-the-job training for
pharmacists regardless of their organization
Study participants also described a need for addressing patients’ perceptions of
community pharmacists and the care they are willing and able to provide to their patients. This
issue has been well documented in the literature (Oyelami-Adeleye, Abate, &Blommel, 2011;
Smith, Cannon-Breland, & Spiggle, 2014; Eades, Ferguson, & O’Carroll, 2011).
The
participating pharmacists identified that a first step to addressing this issue is ensuring that
23
community pharmacists are appropriately placed into communities. Selection and placement are
critical organizational components within implementation science that, when present, enable and
support patient care over the long term (Fixsen et al., 2005). This would require matching patient
populations’ health- and medication- related needs with pharmacists’ skill sets thereby ensuring
the pharmacists’ are equipped with the skills and expertise to care for the community in which
they work (Bacci, McGrath, Pringle, Maguire, & McGivney, 2014). The goal of this strategic
placement of pharmacists would be to eliminate any unnecessary barriers to the provision of
patient care, such as language or communication barriers (Gonzalvo, Schmelz, & Hudmon,
2012). It will be critical to understand a community’s health needs prior to selecting and placing
a pharmacist. Community pharmacists should partner with public health and other medical
professionals to determine how to best assess community’s health needs by adapting an existing
public health framework to meet the profession’s needs (Centers for Disease Control and
Prevention [CDC], 2014).
It will also be critical to optimize community pharmacy workflow in order to provide
patient care through CPAs in community pharmacies.
Many strategies have already been
developed including workflow redesign (Angelo & Ferreri, 2005), automation (Angelo,
Christensen, & Ferreri, 2005), and the appointment-based medication synchronization program
(Holdford & Inocencio, 2013). The participants in this study also stressed the importance of
elevating the responsibilities of community pharmacy technicians and allocating staffing hours
based on prescription volume and clinical services. Future work should further explore the
possible utility of these two strategies in optimizing workflow, including assessing workflow
efficiency in states that require technician certification versus those that do not.
24
Finally, all participants acknowledged the facilitative role of collaborative practice
legislation at the state level and provider status legislation at the national level in scaling
collaborative practice in the community. Pharmacists’ ability to enter into CPAs is determined at
the state level and is variable across the country (McBane et al, 2015; Isasi & Krofah, 2015). As
identified by participants, certain states limit CPAs to a specific prescriber’s population requiring
pharmacists to have multiple CPAs in order to have a large impact. This is a controversial issue
among the pharmacy and medical communities.
However, the success of CPAs for
immunizations might provide valuable insight. Routine immunization by pharmacists to patients
in their communities began in the mid 1990s (Hogue, Grabenstein, Foster, & Rothholz, 2003).
Now, pharmacists are able to give flu vaccine in all 50 states. It is estimated that 20% of
seasonal flu vaccinations given to adults during the 2010-2011 season were administered by
pharmacists (Gamble, 2011). Immunizing pharmacists increased patient access to preventative
care and has had a major impact on public health. The pharmacy and medical communities
should explore population-based versus individual CPAs. Population-based CPAs would not be
limited to a specific prescriber’s population for public health issues such as rapid diagnostic
testing for certain infectious diseases. In these instances, it is imperative to identify potential
cases quickly to prevent the spread of disease, initiate therapy and connect patients to higher
levels of care. On the other hand, it might be most appropriate to have individual CPAs that are
limited to a specific prescriber’s population when a pharmacist is managing patients’ chronic
diseases and therapies.
25
1.4.1 Limitations
One potential limitation of this study is that the research team was only able to recruit
community pharmacists from New York and Pennsylvania.
The study did not include
community pharmacists from Ohio and West Virginia. However, the results were most likely
not affected because New York and West Virginia CPA laws are similar to Pennsylvania.
In addition, this study did not include physician input. Previous work has demonstrated
that physicians find it difficult to build relationships with chain community pharmacists because
of the commercial aspect of chain community pharmacy and the frequent movement of
pharmacists among pharmacy locations. As a result, they are reluctant to work with chain
pharmacists (Bradley, Ashcroft, & Noyce, 2012). Including physician input might further clarify
the model for operationalizing CPAs in chain community pharmacies.
Lastly, participants also had limited experience with CPAs for services other than
immunizations. Participants anticipated potential barriers in implementing and scaling CPAs
rather than reflecting on previous successes and challenges. It will be critical to reevaluate and
adapt the model as chain community pharmacy organizations gain more experience in
implementing and scaling CPAs company-wide and as community pharmacy practice continues
to advance.
1.5
CONCLUSION
Pharmacists engaging with physicians in CPAs could better enable patients to receive
high-quality, interdisciplinary primary care and medication management in their own
26
communities.
This study revealed that there are multiple strategies to facilitate the
implementation and scalability of CPAs.
These strategies include establishing physician
relationships, enhancing pharmacists’ education and training, addressing patients’ perception,
structuring time and workload, and advocating for CPA laws at the state level and provider status
at the national level. Strategies for addressing these needs can be incorporated into a model for
operationalizing CPAs within chain community pharmacy organizations.
There must be
coordination between the patient, the community pharmacies, and the physician in order for
CPAs to be implemented successfully.
District and corporate management can create
opportunities to support patient, pharmacist, and physician coordination and is critical to
replicating CPAs. Collaboration with professional organizations and schools of pharmacy can be
essential to scaling CPAs within an organization. Future directions include partnering with
public health and medical professionals to adapt and evaluate a framework for assessing
community health that enhances pharmacists’ ability to care for the communities in which they
practice and developing best practices for physician-pharmacist communication when practicing
in physically separate spaces.
27
APPENDIX: KEY INFORMANT INTERVIEW QUESTIONS
Initial Questions for all Interviewees:
1. How do you see your organization’s vision for the future of community pharmacy and
community pharmacists’ contributions to patient care?
2. In what patient care/ medication management activities is your organization currently
engaged?
3. Does your organization currently have CPAs established for the provision of medication
management? Has your organization attempted to establish CPAs for the provision of
medication management?
Questions for Group 1 (organizations who have established CPAs)
1. What successes has your organization had implementing and scaling CPAs for the
provision of medication management?
2. What has made your organization successful in these endeavors?
a. At
which
level
of
your
organization,
did
these
facilitators
present
(national/corporate, regional/ state, local/ district)?
3. How were your pharmacists able to successfully form collaborative working relationships
with physicians/ other practitioners?
4. How has your organization been able to replicate your successes?
28
5. What challenges did your organization face during the implementation and scaling
process and how did your organization overcome these barriers?
a. At
which
level
of
your
organization,
did
these
challenges
present
(national/corporate, regional/ state, local/ district)?
6. What challenges had your organization encountered in maintaining and growing CPAs
and how has your organization overcome these barriers?
a. At
which
level
of
your
organization,
did
these
challenges
present
(national/corporate, regional/ state, local/ district)?
7. What tools or resources would help your organization maintain and grow your CPAs?
a. What tools would be required at the corporate level, at the regional level, and at
the local level?
Questions for Group 2 (organizations who have attempted to establish CPAs):
1. What challenges did your organization face when implementing CPAs?
a. At
which
level
of
your
organization,
did
these
challenges
present
(national/corporate, regional/ state, local/ district)?
b. Which of these challenges has your organization been able to overcome? How
was your organization able to over them?
2. What would need to happen for your organization to revisit establishing CPAs?/ What
would need to occur for your organization to revisit establishing CPAs?
3. What tools or resources would your organization desire to assist you in establishing/
implementing CPAs?
a. What tools would be required at the corporate level, at the regional level, and at
the local level?
29
Questions for Group 3 (organization who have not attempted to establish CPAs):
1. What has prevented your organization from implementing CPAs?
a. At
which
level
of
your
organization,
did
these
challenges
present
(national/corporate, regional/ state, local/ district)?
b. Which of these challenges has your organization been able to overcome? How
was your organization able to over them?
2. What would need to happen for your organization to establish CPAs?/ What would need
to occur for your organization to establish CPAs?
3. What tools or resources would your organization desire to assist you in establishing/
implementing CPAs?
a. What tools would be required at the corporate level, at the regional level, and at
the local level?
Ending Questions for all Interviewees
1. If we were to develop a toolkit of these resources, how would your organization want to
be able to access it?
2. In your opinion, what challenges need to be overcome so CPAs for the provision of
medication management can be implemented in ALL community pharmacies?
Facilitator Probing Questions
1. Personnel related facilitators
a. What skills and knowledge do your pharmacists possess that have contributed
to your successes?
b. What personality characteristics do your pharmacists possess that have
contributed to your successes?
30
c. How did your organization identify and approach physicians regarding
collaborative practice agreements?
d. How have collaborating physicians contributed to your successes?
2. Task related facilitators
a. How has workflow contributed to your successes?
b. How has the job demands (ie: workload, time pressure, cognitive load)
contributed to your successes?
3. Tools and technology related facilitators
a. What tools and technology have contributed to your successes?
4. Environment related facilitators
a. How has the physical environment (layout, work station design, etc)
contributed to your successes?
b. How has state political environment contributed to your successes?
c. How have state laws contributed to your successes?
d. How have payment/ reimbursement models contributed to your successes?
5. Organization related facilitators
a. What coordination, collaboration, and communication has been required to be
successful?
b. How has organizational culture contributed to your successes?
c. How have performance evaluation, rewards, and incentives contributed to
your success?
Barrier Probing Questions
1. Personnel related barriers
31
a. What pharmacist skills and knowledge barriers have your encountered?
b. What pharmacist personality characteristics barriers have you encountered?
c. What physician- related barriers have you encountered?
2. Task related barriers
a. What work flow barriers have you encountered?
b. What job demands (ie: workload, time pressure, cognitive load) related
barriers have you encountered?
3. Tools and technology related barriers
a. What tools and technology barriers have you encountered?
4. Environment related barriers
a. What physical environment (layout, work station design, etc) barriers have
you encountered?
b. What political barriers have you encountered?
c. What barriers have state laws presented?
d. What barriers have payment/ reimbursement models presented?
5. Organization related barriers
a. What coordination, collaboration, and communication barriers have you
encountered?
b. What organizational culture barriers have you encountered?
c. What performance evaluation, rewards, and incentives barriers have you
encountered?
32
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