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Implementation of targeted medication adherence interventions within a community chain pharmacy practice: The Pennsylvania Project Jennifer L. Bacci, Stephanie Harriman McGrath, Janice L. Pringle, Michelle A. Maguire, and Melissa Somma McGivney
Received February 26, 2014, and in revised form May 24, 2014. Accepted for publication July 15, 2014.
Abstract Objective: To identify facilitators and barriers to implementing targeted medication adherence interventions in community chain pharmacies, and describe adaptations of the targeted intervention and organizational structure within each individual pharmacy practice. Design: Qualitative study. Setting: Central and western Pennsylvania from February to April 2012. Participants: Rite Aid pharmacists staffed at the 118 Pennsylvania Project intervention sites. Main outcome measures: Qualitative analysis of pharmacists’ perceptions of facilitators and barriers experienced, targeted intervention and organizational structure adaptations implemented, and training and preparation prior to implementation. Results: A total of 15 key informant interviews were conducted from February to April 2012. Ten pharmacists from “early adopter” practices and five pharmacists from “traditionalist” practices were interviewed. Five themes emerged regarding the implementation of targeted interventions, including all pharmacists’ need to understand the relationship of patient care programs to their corporation’s vision; providing individualized, continual support and mentoring to pharmacists; anticipating barriers before implementation of patient care programs; encouraging active patient engagement; and establishing best practices regarding implementation of patient care services. Conclusion: This qualitative analysis revealed that there are a series of key steps that can be taken before the execution of targeted interventions that may promote successful implementation of medication therapy management in community chain pharmacies. Keywords: Medicare Star Ratings, Pennsylvania Project, community pharmacy, targeted interventions, medication adherence, medication therapy management. J Am Pharm Assoc. 2014;54:584–593. doi: 10.1331/JAPhA.2014.14034
Jennifer L. Bacci, PharmD, is Community Pharmacy Research Fellow, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA; at the time of research she was Postgraduate Year 1 Community Pharmacy Resident, Rite Aid Pharmacy/School of Pharmacy, University of Pittsburgh,Pittsburgh, PA. Stephanie HarrimanMcGrath, PharmD, is Community Pharmacist, Rite Aid Pharmacy, Pittsburgh, PA. Janice L. Pringle, PhD, is Associate Professor of Pharmacy & Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA. Michelle A. Maguire, PharmD, is clinical pharmacist, Southeast, Inc., Columbus, OH; at the time of research she was Postgraduate Year 1 Community Pharmacy Resident, Forbes Pharmacy/School of Pharmacy, University of Pittsburgh, PA. Melissa Somma McGivney, PharmD, FCCP, FAPhA, is Assistant Dean of Community Partnerships and Associate Professor of Pharmacy & Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA. Correspondence: Jennifer L. Bacci, PharmD, School of Pharmacy, University of Pittsburgh, 736 Salk Hall, 3501 Terrace St., Pittsburgh, PA 15261. Fax: 412–624–8175. E-mail: [email protected] Disclosure: Stephanie Harriman McGrath is a full-time employee of Rite Aid Pharmacy. Funding: Transcription was supported by the University of Pittsburgh School of Pharmacy. Dr. Pringle’s efforts were funded in part by the Pharmacy Quality Alliance. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Pharmacy Quality Alliance. Acknowledgments: Jesse McCullough, PharmD, for assisting in preparing the manuscript; Brian Bobby, PharmD, for providing advice and assisting with project coordination; Susan Price, Lois Edmondston, and Michael Keyes, MSCD, for providing medication adherence data; and Brandon Antinopoulos, PharmD, Daniel Yarabinec, PharmD, and Amanda Tomich, PharmD, for recruiting participants. Author information continued at the end of the text on p. 592.
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A
ppropriate medication use is an important factor in improving health care quality and reducing unnecessary health care costs.1,2 Quality measures have been implemented to improve the quality of medication utilization.1 Although many health-related organizations have publically acknowledged the pharmacists’ role in improving health care quality, pharmacists are often an underutilized resource.3–6 A significant limitation is the question of how pharmacists can effectively implement patient care services within the workflow of the traditional community pharmacy. The financial implications of the Star Rating system’s adherence measures implemented by The Center for Medicare & Medicaid Services (CMS) have caused community pharmacy organizations to strive to understand how patient care services can be effectively incorporated into workflow.7,8 The most heavily weighted Star measures include adherence to long-term medications, which community pharmacists are in an ideal position to influence.9 The implementation of the Star Rating system to rate and reimburse Medicare Part D prescription drug plans (PDPs) and Advantage plans (MA-PDs) on specified quality measures has created a way to incentivize Medicare plans to improve health quality. The higher a
At a Glance
Synopsis: This qualitative study—the result of a partnership among a community pharmacy chain, a school of pharmacy, a managed care organization, and a quality improvement technology company—identifies a series of key steps that can lead to more successful implementation of medication therapy management services. Participating pharmacies were grouped as either “early adopters” (defined as meeting all five medication adherence metrics) or “traditionalists” (defined as meeting two or fewer medication adherence metrics). Key informant interviews identified five themes regarding the implementation of targeted interventions: all pharmacists’ need to understand the relationship of patient care programs to their corporation’s vision; providing individualized, continual support and mentoring to pharmacists; anticipating barriers before implementation of patient care programs; encouraging active patient engagement; and establishing best practices regarding implementation of patient care services. Analysis: Community pharmacists are physically isolated from other pharmacists because of the distance between pharmacy locations. Creating a learning community could allow them to solve common challenges as a group. These key factors have also been identified as critical when integrating pharmacists into health care settings other than community pharmacies.
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Medicare plan’s Star Rating, the higher the quality bonus payment (QBP) it receives from CMS.10 This payment structure may have multiple implications for community pharmacy.7 PDPs and MA-PDs may reward the pharmacies that contribute to their Star Ratings by demonstration of improvement of certain quality measures. QBPs can be used to incentivize pharmacies through a pay-for-performance (P4P) model.7,11 Previous research has demonstrated pharmacists’ ability to positively affect medication-related outcomes targeted interventions.12–14 The “Discussion on Taking Medications Diabetes Pilot Program” (DOTxMED) conducted by APhA demonstrated that pharmacist-led targeted adherence interventions can improve medication adherence.12 Yet, many implementation barriers arise when implementing such services. Barriers widely cited in the literature include lack of time, trained personnel, and reimbursement.15–18 The profession still lacks a model for implementing community pharmacy–based interventions effectively and efficiently. Establishing a model would allow community pharmacies to continually adjust their services in responses to the adapting health care system. In this study, we focus on identifying implementation facilitators, barriers, and strategies to guide the implementation of similar innovations aimed to improve patient medication-related outcomes within the dispensing workflow.
Background The Pharmacy Quality Alliance (PQA) is a membershipbased alliance with the goal of improving medication use through the establishment of performance measures.19,20 PQA supported the launch of five demonstration projects with the goal of testing various data sources as a means of measuring pharmacy performance in 2008.21 The Pennsylvania Project began in 2008 as a partnership among PQA, Highmark Blue Cross Blue Shield, CECity, and Rite Aid Corporation as one of the PQAfunded demonstration projects.21 The goal of Phase I of the Pennsylvania Project was to provide pharmacists working in Rite Aid pharmacies in central and western Pennsylvania with an electronic platform, ASPIRE (Pharmacy Quality Solutions, Washington, DC) to view a pharmacy performance report.21 The report showed composite patient adherence scores for each pharmacy. The PQA-endorsed portion of days covered (PDC) measure was the adherence metric used, which was calculated using claims data provided by Highmark.21 The composite patient adherence metric reflected the percentage of Highmark patients who were at or above a specified PDC threshold for each therapeutic class evaluated. Composite adherence scores were reported for five targeted therapeutic classes: angiotensin converting enzyme inhibitors (ACEIs) and/or angiotensin j apha.org
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receptor blockers (ARBs), beta blockers (BBs), calcium channel blockers (CCBs), cholesterol-lowering therapies (statins), and oral antidiabetic medications. These drug classes were chosen because the medications are used primarily in high-cost, chronic diseases. The University of Pittsburgh School of Pharmacy joined the partnership for Phase II of the demonstration project in 2010. The goal of Phase II was to determine the effect of pharmacist-performed targeted interventions on pharmacies’ composite adherence scores. Pharmacists from the 118 pharmacy intervention sites were trained in the Screening and Brief Intervention (SBI) model and motivational interviewing.22,23 Pharmacy team members used surveys to identify patients at risk of being nonadherent to their medications. When a patient was identified as being at risk for nonadherence based on their survey score, the pharmacist conducted a targeted intervention using motivational interviewing techniques, with the intent of identifying the patient’s cause of nonadherence and assisting the patient in finding individualized methods to improve his or her medication adherence.24–26 The Pennsylvania Project investigators are exploring financial incentive models that could provide a new source of revenue for community pharmacies in the current environment of decreasing prescription reimbursement rates. Pharmacists performing targeted interventions within community pharmacies have the potential to improve Star Ratings and can contribute to the movement toward payment for quality of care in community pharmacy practice. This study was meant to stimulate discussion in the community pharmacy and payer communities about how P4P models could be implemented to provide incentives for pharmacists to continue to positively influence patient care.
Objective The goal of this qualitative study was to understand how individual community pharmacists are implementing the innovation of pharmacist-led targeted medication adherence interventions at the point of dispensing. Specifically, we sought to (1) identify facilitators and barriers to implementing targeted medication adherence interventions in community chain pharmacies and (2) describe adaptations of the intervention and organizational structure within each individual pharmacy practice.
Methods
Qualitative research design This study was based on principles of implementation science, the study of how evidence-based interventions are executed in a real-world setting.27 It focused on individual adopter characteristics, intervention adaptation, and organizational structure adaptation. 586 JAPhA | 5 4:6 | NOV /DE C 2 0 1 4
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Rogers et al described how the characteristics of individual adopters can be classified according to their degree of innovativeness. “Early adopters” are individuals who are among the first to implement new innovations. “Traditionalists” are those who are resistant to change and the last to implement new innovations.27–29 Adaptations, which are additions or changes, can also affect implementation. Adaptations can be made to the intervention or to the organizational structure or environment in which it is being implemented. The organizational structure in community chain pharmacy practice includes the workflow, and the roles and responsibilities of pharmacy team members.27,30 The Pennsylvania Project included 118 intervention sites. Investigators were provided data in February 2012 by the primary investigator (J.L.P.) of the Pennsylvania Project to classify a pharmacy as an early adopter or traditionalist practice. The number of medication adherence metrics met by each pharmacy was the determinant for classification of early adopter and traditionalist practices. Early adopter practices were defined as pharmacies meeting all five medication adherence metrics. Traditionalist practices were defined as pharmacies meeting two or fewer medication adherence metrics. Key informant interviews were conducted with pharmacists staffed in early adopter and traditionalist pharmacies. The primary investigator (J.L.B.) conducted the first three interviews with pharmacists during evening hours, when prescription volume was low. The research team realized they needed a more efficient method of conducting the interviews that was less disruptive to patient care workflow in the pharmacies and thus adjusted the interview method. Under the revised methodology, the primary investigator and a co-investigator (J.L.B. and M.A.M., respectively) traveled to the pharmacies. The primary investigator stepped into workflow at each location so the pharmacist interviewee could step out of workflow. The co-investigator conducted the interviews with the pharmacists. This interview process was not disruptive to patient care and limited the distractions to the interviewee. Interviews were approximately 10–15 minutes in duration and conducted in private areas, such as patient consultation rooms or pharmacy waiting areas. The key informant interviews used a semistructured script developed from the previously described implementation science principles.27,30 The interview questions were vetted by individuals not involved with the Pennsylvania Project. They were then piloted with two community pharmacists at one intervention pharmacy that did not meet the study inclusion criteria. Table 1 contains the interview questions used. The interviewees completed a brief demographic survey to gather information about their professional background and practice sites. Interviews were conducted Journal of the American Pharmacists Association
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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.31,32 The University of Pittsburgh Institutional Review Board (IRB) classified this study as exempt from review. Data collection and analysis The interview dialogue was audiotaped and transcribed. Transcription occurred as the interviews were completed, allowing the investigators to read, code, and assess saturation continuously. The transcripts were analyzed using a generic qualitative approach.33 Two investigators (J.L.B. and M.A.M.) independently read and coded the transcripts. Sentences and phrases from the interviews that carried meaning were labeled with codes. The investigators then met to discuss coding decisions, accounting for the line-by-line reading conducted by each investigator. The investigators resolved coding disagreements through discussion. They 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 during the coding process. A senior investigative panel (S.H.M., J.P., M.S.M.) reviewed the transcripts for any gaps, inconsistencies, or new interpretations to improve the validity of the analysis. The coded text was grouped into categories to identify major themes. The research team then met to discuss the content of the coded interviews to collectively agree on themes.34,35 Data from the demographic survey were analyzed using descriptive statistics.
Results In all, 39 early adopter practices and 7 traditionalist practices met inclusion criteria based on interim adherence metrics in February 2012. Qualifying pharmacies were recruited for participation via fax and telephone. Participation was voluntary for pharmacists, and recruitment continued until data saturation was achieved.
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One pharmacy declined participation because of recent pharmacist turnover at the location. A total of 15 interviews were conducted from February 2012 to April 2012. Ten pharmacists from early adopter practices and five pharmacists from traditionalist practices were interviewed. Table 2 summarizes the demographics of the 15 interviewees. The qualitative analysis revealed the following five dominant themes. Theme 1: Need to understand the relationship of the patient care programs to the corporate vision The PQA Demonstration Project was introduced to the pharmacies at the beginning of the seasonal influenza vaccine campaign. Two other clinical programs were implemented during the demonstration project: increased opportunities for the provision of and compensation for MTM services, and the community pharmacy chain’s own adherence tool. This adherence tool provided pharmacists with individual patients’ PDC scores based on their refill history in the dispensing system. The pharmacists questioned how each program fit into the chain pharmacy’s vision for the provision of patient care. Pharmacists in both early adopter and traditionalist practices felt overwhelmed by the number of clinical initiatives and in determining how to prioritize these new programs in addition to their established dispensing and immunization responsibilities. The interviews uncovered these concerns through the following responses: ❚❚ “One of the difficulties we had was that there are, you know, four or five things going on at the same time, and trying to implement everything is just kind of [overwhelming].” (interview 15, early adopter) ❚❚ “And now we have our own [adherence] service so basically the PQA [project] really should go out the window because we have our own service, now you’re just duplicating it.” (interview 11, early adopter)
Table 1. Questions used in interviewing key informants about the PQA Demonstration Project Domain Questions Preparation and training
Facilitators and barriers Intervention adaptation Organizational structure adaptation Implementation pearls
From your perspective, what is/are the goal(s) of the Pharmacy Quality Alliance (PQA) program? What training did you receive before implementing the PQA project? How did your training and support prepare you to implement the PQA program? What additional training and support would have been helpful before starting the PQA project? What strategies did your pharmacy use when implementing the program that you felt were successful? What strategies did your pharmacy use when implementing the program that you felt were unsuccessful? How did you adapt the program to your pharmacy practice when implementing? How did you adapt the workflow in your pharmacy to implement this program? What advice do you have for other pharmacists implementing this program or similar innovations in their pharmacy?
Abbreviation used: PQA, Pharmacy Quality Alliance. Journal of the American Pharmacists Association
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Table 2. Demographic data of key informants interviewed about PQA demonstration project Early adopters + Early adopters traditionalists No. (%) (n = 10) No. (%) (n = 15) Mean age (years) Gender
Women Men Degree BSPharm PharmD Years as practicing pharmacists Years in current position Weekly prescription volume Number of staff pharmacists Services offered MTM (in person) MTM (Mirixa) MTM (Outcomes)a Immunizations Pill box fills Synchronized refill program Smoking cessation Diabetes education Automated refill reminders Genetic testing Drive through Delivery Total hours open per week Hours of pharmacist overlap per week Hours of ancillary help per week
36.6 7 (46.7) 8 (53.3) 8 (53.3) 7 (46.7) 12.4 8.2 1,364 2.2 4 (26.7) 1 (6.7) 10 (66.7) 15 (100) 4 (26.7) 1 (6.7) 1 (6.7) 4 (26.7) 14 (93.3) 0 (0) 11 (73.3) 14 (93.3) 80.7 23.5b 133.5
36.9 5 (50) 5 (50) 5 (50) 5 (50) 12.2 9 1,378 2.3 1 (10) 1 (10) 6 (60) 10 (100) 3 (30) 1 (10) 1 (10) 2 (20) 9 (90) 0 (0) 8 (80) 10 (100) 82.6 23.5b 137.4
Traditionalists No. (%) (n = 5) 36 2 (40) 3 (60) 3 (60) 2 (40) 12.8 6.6 1,336 2 3 (60) 1 (20) 5 (100) 5 (100) 1 (20) 0 (0) 0 (0) 2 (40) 4 (80) 0 (0) 3 (60) 4 (80) 76.8 0 125.7
Abbreviations used: PQA, Pharmacy Quality Alliance; MTM, medication therapy management. a All pharmacists were required to register with Outcomes during data collection. b Only three stores had pharmacist overlap.
Pharmacists felt that continual training and mentoring, with opportunities for sharing best practices with their peers, would resolve their concerns. Theme 2: Continual support and mentoring needed Pharmacists from all practices expressed the desire for continual, onsite, individualized training and support from other pharmacists and management. They felt the support should include assistance with prioritizing the clinical and dispensing initiatives, feedback about how well they were implementing the targeted adherence interventions, and updates about the PQA demonstration project. The pharmacists who received onsite, individualized training felt more comfortable implementing the targeted adherence interventions. In this way, the pharmacists felt that a more structured support system would promote successful implementation. Comments included the following: ❚❚ “Through several meetings it comes together a little more every time. But initially, everybody just felt like they were thrown out there into something new.” (interview 6, early adopter)
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“I feel like our district managers come in and try to push [the PQA project]…try to break it down for us and explain it. And how [my district manager] broke it down to me really helped me.” (interview 6, early adopter) ❚❚ “Just somebody checking in more often…we don’t forget about the project…or go over results every now and then on how we’re doing. You know, when you don’t hear anything back it’s hard to gauge where you’re at with it.” (interview 3, early adopter) The pharmacists expressed the desire to communicate with their peers regarding best practices. They felt a forum to share successful and unsuccessful implementation strategies with other pharmacists would facilitate implementation. Responses to the question “What additional training and support would have been helpful prior to starting the project?” included: ❚❚ “They just kind of said, you know, ‘Come up with a method that works for you.’ I guess it was kind of hard…I don’t know how they would have been able to point us in the right direction since we were kind of the first group to do it. So, I felt a little unJournal of the American Pharmacists Association
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prepared starting it and a little confused.” (interview 3, early adopter) “Examples of how pilot stores…went about implementing the program [would have helped].” (interview 3, early adopter)
Theme 3: Anticipate barriers Pharmacists from both early adopter and traditionalist practices experienced barriers; however, the barriers they faced were different. The barriers faced by early adopters related to the patient population they were serving and their desire to provide more collaborative, interprofessional patient care, including the following: ❚❚ “We just have a lot of patients that practice polypharmacy…when their prescriptions are all over the place it’s really hard to keep on top of it.” (interview 3, early adopter) ❚❚ “I don’t think most physicians are too receptive [to the recommendations].” (interview 2, early adopter) Pharmacists from traditionalist practices faced barriers related to inconsistent staffing and patient population needs of specific communities, which are expressed through the following comments: ❚❚ “I was having issues in the store itself with the technicians because they were brand new technicians…” (interview 5, traditionalist) ❚❚ “Drive-through, because a lot of people like the drive-through at this store, so we try not to talk to them for privacy…” (interview 4, traditionalist) ❚❚ “Neither me nor my partner speaks Spanish, and I would say…a very large percentage of our patients are Spanish-speaking.” (interview 7, traditionalist) ❚❚ “Right now we’re in an area [where] people aren’t on medical assistance…[their income is] just high enough that they don’t qualify…they skip their medication because of the fact they just couldn’t afford it.” (interview 5, traditionalist) Pharmacists from early adopter practices faced barriers in the later stages of the implementation process, whereas pharmacists from traditionalist practices faced environmental barriers in the early stages that hindered their abilities to implement the interventions. Furthermore, early adopters faced barriers that they would be able to solve on their own at the individual practice level through relationship building with patients and practitioners in the area. Traditionalists had barriers at the pharmacy level that they were unable to solve on their own. Theme 4: Active patient engagement is a key facilitator All of the pharmacists interviewed from early adopter practices had already established a daily workflow that incorporated patient interaction and the development Journal of the American Pharmacists Association
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of patient–pharmacist therapeutic relationships, allowing easy integration of the targeted interventions. Comments regarding patient engagement included the following: ❚❚ “The other pharmacists and I know almost every single patient by their name as well as their medicines, their background, their families’ social histories, so most people that come in here we monitor their compliance.” (interview 9, early adopter) ❚❚ “This location is really patient goal oriented…and education oriented.” (interview 2, early adopter) Pharmacists from the traditionalist practices found engaging their patients to be challenging because of the barriers discussed in Theme 3. Theme 5: Establish best practices The pharmacists expressed their desire to hear what was working and/or not working for other pharmacists. They were eager to share the best practices they had developed. The practices that were best able to implement the targeted adherence interventions were those that developed their own method of identifying target patients, of flagging those patients’ prescriptions to alert staff that the pharmacist wanted to have a discussion with those patients, and of increasing the patient’s exposure to the pharmacist. Pharmacists in the successful practices found it helpful to set short-term goals for their team. Comments regarding these implementation strategies included the following: ❚❚ “Usually when I was checking [prescriptions], I could tell by looking at their profile, and you could put a little note in their bag, or stick one of the surveys in their bag, and then they could see it.” (interview 1, early adopter) ❚❚ “I tried for a while…to make sure that I as a pharmacist was the one at the register. I felt like people were a lot more inclined to help us, you know, answer questions and fill out the survey, or, you know, we were right there able to talk to them.” (interview #3, early adopter) ❚❚ “Making sure that we got our five a day. And then as a pharmacist we would check in on the website… and print out the gaps and…try to focus on one disease state and…narrow the gaps on those.” (interview 6, early adopter) The pharmacists initially felt overwhelmed trying to target all patients. The rollout of the community pharmacy chain’s own adherence tool helped the pharmacists focus their efforts where they would be maximized. The most successful practices used the pharmacy-specific adherence data provided on the online platform, ASPIRE, to identify problem drug classes in combination with the patient-specific adherence data to identify individuals who were nonadherent based on their refill history in the medication dispensing system. The pharmacists shared the following thoughts on the j apha.org
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benefits of having access to transparent pharmacy- and patient-specific data: ❚❚ “Through the combination [it] can be less overwhelming…based on what our corporate is doing through our [own adherence tool] in combination with the…PQA, which gives you a sheet to ask, figure out why they may be less compliant.” (interview 13, early adopter) ❚❚ “We cut down the workload a little bit by being more selective on trying to bring up the scores through the people who may have been bringing the scores down.” (interview 13, early adopter) The pharmacists felt that one of the most important keys to successful implementation of these targeted interventions was pharmacist and staff persistence. The pharmacists shared the following thoughts: ❚❚ “You just have to be persistent, and you have to keep at it…it’s not something that you see instant gratification for, instant results.” (interview 7, traditionalist) ❚❚ “Every person is different. And I mean, you don’t give up just because people are resistant.” (interview 6, early adopter)
Discussion This study affords a deeper look into how pharmacists have successfully implemented targeted, quality-driven patient interactions into traditional community chain pharmacy workflow. Implementation difficulties and the lack of widespread acceptance of pharmacists have been widely noted.17–20 However, patients clearly need to receive more focused, medication-related care in their own communities. Community pharmacists have the knowledge and skills to provide this care while being the most accessible health care practitioner.36,37 We learned that there is a series of key steps that can be taken to achieve successful implementation in a short amount of time, even in medium-volume community pharmacies. First, interviewed pharmacists said it is imperative for the frontline pharmacists and ancillary staff to understand the purpose of patient care initiatives they are being asked by management to implement and how they complement other services offered within their organization. We learned that the pharmacists and their staff felt more motivated and willing to implement the service once they understood what the targeted interventions were contributing to their organization and to patient care. The pharmacists shared that this motivation and willingness directly affected the amount of time it took for their teams to implement the interventions within workflow. This essential step is often overlooked during the implementation process but is an integral step to ensure success. Creating a common vision facilitates growth of an effective climate and culture
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within a company. Creation of this type of environment enhances an organization’s readiness to implement.27 Once readiness is achieved, the next key step seems to be providing continual, individualized, onsite training. A new finding we learned from the pharmacists is that the one-on-one training and mentorship needs to be provided by a pharmacist or manager. The pharmacists in this study attended live sessions, during which they were trained to provide targeted interventions using motivational interviewing principles. Multiple previous studies have demonstrated the importance of training when implementing new community-based services to increase pharmacists’ knowledge and skills.38–41 Fitzgerald et al38 specifically demonstrated that live training sessions can improve pharmacists’ readiness to perform targeted interventions. The pharmacists we interviewed shared that the live training provided them with an awareness of targeted interventions and motivational interviewing. The pharmacists most valued the opportunity to brainstorm methods for implementation in their practice during the individualized mentoring sessions. They felt these mentoring sessions allowed their teams to more quickly adapt their workflow to incorporate the interventions. Other studies have demonstrated the importance of communication during the implementation process, whether it be in the form of onsite visits or a consultative service. This follow-up posttraditional live training assists pharmacists in troubleshooting implementation barriers as they arise.38,42 The results of this study reinforce that the provision of both live group training and onsite individualized mentoring can facilitate success when implementing a new program; also, that the pharmacists most value individualized mentorship from other pharmacists or managers. Regional clinical managers within chain community pharmacies could potentially be used to fulfill this need for individualized training and mentorship when implementing new patient care programs. The pharmacists we interviewed emphasized the importance of anticipating barriers before implementation. Surprisingly, we found that time was not the most commonly cited barrier in this study as it was in previously published studies.17,18 The pharmacists involved in the Pennsylvania Project identified staff-related barriers, such as high turnover, and patient-related barriers, such as language and socioeconomic status, as their largest obstacles. Some of the barriers that the pharmacists identified are factors that have previously been identified as potential facilitators of practice change in community pharmacy: relationships with physicians, pharmacy layout, manpower/staff, and external support and assistance.42 Anticipating and resolving barriers before execution directly affects the speed and extent of intervention implementation and dissemination.27 These barriers could have the potential to facilitate successful implemenJournal of the American Pharmacists Association
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tation of a program if they are identified and resolved prior to program initiation. Management could prospectively address barriers when placing pharmacists and staff in individual community pharmacy locations. Finally, the pharmacists felt that identifying and sharing best practices among colleagues is a critical component of the implementation process. They commonly cited their individual struggle to identify potential targeted interventions based solely on pharmacy-specific composite adherence data accessible on the Web-based platform. Community pharmacists are physically isolated from other pharmacists because of the distance between pharmacy locations. This geographical isolation resulted in the pharmacy teams working individually to figure out how to target the appropriate patients using the available data. Creating a learning community, a “community of practice,” for the pharmacists could allow them to solve common challenges as a group by providing them a communication mechanism through which to share their success stories and struggles.29,43 The pharmacists’ struggle to identify potential interventions based on aggregate data was resolved when the community pharmacy chain developed its own adherence tool. Pharmacists were most successful when they used pharmacy-specific adherence data on the Web-based platform and patient-specific adherence data within the dispensing system. The Web-based platform helped pharmacists identify problem drug classes. They could then target patients on medicines in those drug classes and use the surveys to identify patients who were at the highest risk of nonadherence. The chain’s patient-specific adherence tool helped pharmacists identify patients who were already nonadherent. Pharmacists were then able to use the surveys to assess the factors contributing to the patients’ nonadherence. To the best of our knowledge, this strategy of using pharmacy- and patient-specific data to target patients has not yet been reported in the literature. Overall, successful implementation could be designed with an appreciation for these factors. These key factors have also been identified as critical when integrating pharmacists into health care settings other than community pharmacy. Research done in patientcentered medical homes has also demonstrated the challenge of time management and prioritization, the perceived significance of specific traits on successful implementation, and the benefits of utilizing peer mentoring during the implementation process.44,45 These similar findings suggest that consideration of the key factors identified by this study could facilitate successful implementation of pharmacist-provided services in other health care settings as well. This qualitative analysis also led us to ask more questions that will help us understand how to better care for community-based patients, including how to efJournal of the American Pharmacists Association
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fectively match patient populations’ drug- related needs to pharmacists’ skill sets. For example, the needs of a primarily Spanish-speaking community could be best met by a Spanish-speaking pharmacist, a low socioeconomic community would be best served by a pharmacist with extensive knowledge of Patient Medication Assistance Programs (PMAPs), and an ethnic community with medication-related beliefs would be best served by a pharmacist with knowledge of that culture.46 PMAPs can help patients who are unable to afford their medicines; however, it must be noted that PMAPs could affect a plan’s Star Rating because there would not be insurance claims for any medicines received through assistance programs. Finally, this project led us to understand how to better conduct research in a busy community pharmacy. This method could be replicated in future studies that seek to interview community pharmacists. We were also able to work with pharmacy district management, who assisted by alerting all Pennsylvania Project intervention pharmacies that a colleague may be contacting them to participate in a research study and that the primary investigator should be permitted to work in their pharmacy. All potential participants were contacted so we were able to ensure actual participant confidentiality. Performing research in community pharmacy requires support from management, communication with all potential team members, and a way to ensure patient care is not disrupted during the research process.
Limitations One limitation to this study is that is was conducted within one national chain with low- to medium-volume pharmacies. Results may not be generalizable to highvolume pharmacies, other corporations, or independent pharmacies with significantly different business models. State laws may also present a limitation to the generalizability of the study because all pharmacists interviewed practiced in the same state. For example, early adopters identified that communication with physicians was an implementation barrier. This same issue may not be identified as a barrier by pharmacists practicing in states that allow and have implemented collaborative practice agreements between community pharmacists and physicians.47 In addition, the number of aggregate medication adherence metrics that were at or above goal was used as a proxy measure of implementation to identify pharmacies for participation in this study. It is possible that external factors rather than a pharmacy team’s implementation of the targeted medication adherence intervention caused their adherence metrics to be at goal, resulting in pharmacies being incorrectly labeled as early adopters. Although the influence of these external barriers on the metrics presents a limitation, a significant finding of this study was the presence of a culture of frej apha.org
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quent patient interaction in each early-adopter practice identified. This norm would also have contributed to the early-adopter practices’ medication-adherence metrics. Two different pharmacists conducted the interviews, allowing for variability in how the questions were asked and the level of probing. However, in analyzing the transcripts, similar responses were obtained by both interviewers. The interviewees may have been less inclined to share their negative experiences with the interviewers for multiple reasons. Both of the interviewers were pharmacists and were completing the study as part of their residency training. One of the interviewers (J.L.B.) was completing her residency within the chain community pharmacy that employed these pharmacists. She had interacted with some of the participants before their recruitment for the study for patient care purposes. Several attempts to elicit barriers were made by the interviewers throughout the discussion to overcome this limitation. Finally, participants who were offered workflow coverage may have been more inclined to participate in the study.
Conclusion Pharmacists performing targeted interventions within community pharmacies have the potential to improve Star Ratings when implemented successfully and are thus contributing to the movement toward payment for quality of care in community pharmacy practice. This study revealed that successful implementation of targeted interventions is possible. Key steps should be taken before the execution of targeted interventions to promote successful implementation in community chain pharmacies using a similar online platform. These key steps are to understand the relationship of patient care programs to the corporate vision; provide individualized, continual support and mentoring to pharmacists; anticipate barriers prior to implementation of patient care programs; encourage active patient engagement; and establish and share best practices regarding implementation of patient-care services. Further studies should investigate how we can better care for our patients in the community in a financially viable way, how to appropriately place pharmacists in communities based on their skill set and on the community’s medication-related needs, and develop best practices for physician–pharmacist communication when practicing in physically separate spaces. Author information continued from p. 584. Previous presentations: American Pharmacists Association Annual Meeting, New Orleans, LA, March 10, 2012; Pennsylvania Pharmacists Association Midyear Meeting, Camp Hill, PA, January 26, 2013.
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References 1. Nau DP. Quality and the future of health care. In: Warkholak TL, Nau DP, eds. Quality & safety in pharmacy practice. New York: McGraw-Hill Medical; 2010:3–8. 2. McBane S, Trewet CB, Havican SN, et al. Tenets for developing quality measures for ambulatory clinical pharmacy services. Pharmacotherapy. 2011;31(7):115e–134e. 3. Giberson S, Yoder S, Lee MP. Improving patient and health system outcomes through advanced pharmacy practice. A report to the U.S. Surgeon General. Office of the Chief Pharmacist, U.S. Public Health Service. December 2011. http://www. usphs.gove/corpslink/pharmacy/sc_comms_sg_report.aspx. Accessed July 15, 2013. 4. Rucker NL. Medicare Part D’s medication therapy management: shifting from neutral to drive. Insight on the issues, Number 64, AARP Public Policy Institute, Washington, DC, June 2012. 5. Morrison CM, Glover D, Gilchrist SM, et al. A program guide for public health: partnering with pharmacists in the prevention and control of chronic diseases. http://www.cdc.gov/dhdsp/programs/nhdsp_program/docs/Pharmacist_Guide.pdf. Accessed June 22, 2013. 6. Patient Centered Primary Care Collaborative. The patient-centered medical home: incorporating comprehensive medication management to optimize patient outcomes. http://www.accp. com/docs/positions/misc/CMM%20Resource%20Guide.pdf. Accessed June 22, 2013. 7. Nau DP. Aligning financial incentives in quality. In: Warkholak TL, Nau DP, eds. Quality & safety in pharmacy practice. New York: McGraw-Hill Medical; 2010:229–239. 8. American Pharmacists Association, Academy of Managed Care Pharmacy. Medicare star ratings: stakeholder proceedings on community pharmacy and managed care partnerships in quality. J Am Pharm Assoc. 2014; 54:228–240. 9. Pharmacy Quality Alliance. Executive update on medication quality measures in Medicare Part D star ratings. http:// www.pqaalliance.org/files/2012UpdateOnMedicarePartDStar Ratings.pdf. Accessed June 19, 2012. 10. Pharmacy Quality Alliance. PQA measures used by CMS in the star ratings. http://www.pqaalliance.org/images/uploads/ files/2013%20Update%20on%20Medicare%20Plan%20Ratings.pdf. Accessed June 2, 2013. 11. Inland Empire Health Plan. Pay for performance (P4P) program. https://ww3.iehp.org/en/providers/pharmaceutical‐services/ pharmacy‐p4p‐program. Accessed October 13, 2014. 12. American Pharmacists Association. DOTxMED: pharmacistdelivered interventions to improve care for patients with diabetes. J Am Pharm Assoc. 2012;52:25–33. 13. Brennan TA, Dollar TJ, Hu M, et al. An integrated pharmacybased program improved medication prescription and adherence rates in diabetes patients. Health Affairs. 2012;31(1):120– 129. 14. Touchette DR, Rao S, Dhru P, et al. Identification of and intervention to address therapeutic gaps in care. Am J Manag Care. 2012;18(10):e364–e371. 15. Lounsbery JL, Green CG, Bennett MS, Pedersen CA. Evaluation of pharmacists’ barriers to the implementation of medi-
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33. Kahlke RM. Generic qualitative approaches: pitfalls and benefits of methodological mixology. Int J Qual Meth. 2014;13:37–52.
16. Dunlop JA, Shaw JP. Community pharmacists’ perspectives on pharmaceutical care implementation in New Zealand. Pharm World Sci. 2002;24:224–230.
34. Krueger R. Focus groups: a practical guide for applied research. Thousand Oaks, CA: Sage Publications; 2000.
17. Osborne MA, Snyder ME, Hall DL, et al. Evaluating Pennsylvania pharmacists’ provision of community-based patient care services to develop a statewide practice network. Innovations. 2011;2:1–9. 18. Nadaira N, Ouellet C, René-Henri N, et al. Factors influencing a community pharmacist’s interventions in asthma care. Can Pharm J. 2009;142:240–246. 19. Pharmacy Quality Alliance. PQA Mission. http://www.pqaalliance.org/. June 19, 2012. 20. Nau DP. Measuring pharmacy quality. J Am Pharm Assoc. 2009;49:154–163. 21. Doucette WR, Conklin M, Mott DA, et al. Pharmacy Quality Alliance: five phase I demonstration projects: descriptions and lessons learned. J Am Pharm Assoc. 2011;51:544–550. 22. Fitzgerald N, McCaig D, Watson H, et al. Development, implementation and evaluation of a pilot project to deliver interventions on alcohol issues in community pharmacies. Int J Pharm Pract. 2008;16:17–22. 23. Sheridan J, Wheeler A, Chen LJ, et al. Screening and brief interventions for alcohol: attitudes, knowledge and experience of community pharmacists in Auckland, New Zealand. Drug Alcohol Rev. 2008;27:380–387. 24. Pringle JL, Boyer A, Conklin MH. The Pennsylvania Project: pharmacist intervention improved medication adherence and reduced health care costs. Health Aff. 2014;33(8):1444–1452 . 25. McGivney MS, Meyer SM, Duncan-Hewitt W, et al. Medication therapy management: its relationship to patient counseling, disease management, and pharmaceutical care. J Am Pharm Assoc. 2007;47:620–628. 26. Possidente CJ, Bucci KK, McClain WJ. Motivational interviewing: a tool to improve medication adherence? Am J Health-Syst Pharm. 2005;62:1311–1314. 27. Rabin BA, Brownson RC, Haire-Joshu D, et al. A glossary for dissemination and implementation research in health. J Public Health Manag Pract. 2008;14:117–123. 28. Dearing JW. Evolution of diffusion and dissemination theory. J Public Health Manag Pract. 2008;14:99–108. 29. Rogers EM. Diffusion of innovations. 5th ed. New York: Free Press; 2003. 30. Berkel C, Mauricio AM, Schoenfelder E, Sandler IN. Putting the pieces together: an integrated model of program implementation. Prev Sci. 2011;12:23–33. 31. Guest G, Bunce A, Johnson L. How many interviews are enough?: an experiment with data saturation and variability. Field Methods. 2006;18:59–82.
35. Garcia GM, Snyder ME, McGrath SH, et al. Generating demand for pharmacist-provided medication therapy management: identifying patient-preferred marketing strategies. J Am Pharm Assoc. 2009;49:611–616. 36. Weinberger M, Murray MD, Marrero DG, et al. Effectiveness of pharmacist care for patients with reactive airways disease: a randomized controlled trial. JAMA. 2012;288:1594–1602. 37. Jones JM. Record 64% rate honest, ethics of members of congress low. http://www.gallup.com/poll/151460/record‐rate‐honesty‐ethics‐members‐congress‐low.aspx. Accessed October 13, 2014. 38. Fitzgerald N, Watson H, McCaig D, Stewart D. Developing and evaluating training for community pharmacists to deliver interventions on alcohol issues. Pharm World Sci. 2009;31:149– 153. 39. Armour C, Bosnic-Anticevich S, Brillant M, et al. Pharmacy asthma care program (PACP) improves outcomes for patients in the community. Thorax. 2007;62(6):496–502. 40. Sinclair HK, Bond CM, Stead LF. Community pharmacy personnel interventions for smoking cessation. Cochrane Database Syst Rev. 2004;(1):CD003698. 41. Dhital R, Whittlesea CM, Milligan P, et al. The impact of training and delivering alcohol brief interventions on the knowledge and attitudes of community pharmacies: a before and after study. Drug Alcohol Rev. 2013;32:147–156. 42. Roberts AS, Benrimoj SI, Chen TF, et al. Practice change in community pharmacy: quantification of facilitators. Pharmacotherapy. 2008;42:861–868. 43. Duncan-Hewitt W, Austin Z. Pharmacy schools as experts of practice? A proposal to radically restructure pharmacy education to optimize learning. Am J Pharm Educ. 2005;69(3):Article 54. 44. Kozminski M, Busby R, McGivney MS, et al. Pharmacist integration into the medical home: qualitative analysis. J Am Pharm Assoc. 2011;51(2):173–183. 45. Goldman J, Meuser J, Rogers J, et al. Interprofessional collaboration in family heath teams: an Ontario based study. Can Fam Physicians. 2010;56:e368–e374. 46. Gonzalvo J, Schmelz A, Hudmon KS. Community pharmacist and technician communication with Spanish-speaking patients: needs assessment. J Am Pharm Assoc. 2012;52:363–366. 47. Centers for Disease Control and Prevention. Select features of state pharmacist collaborative practice laws. State law fact sheet. http://www.cdc.gov/dhdsp/pubs/docs/Pharmacist_State_ Law.PDF. Accessed October 13, 2014.
32. Curry LA, Nembhard IM, Bardley EH. Qualitative and mixed methods provide unique contribution to outcomes research. Circulation. 2009;119:1442–1452.
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Implementation of targeted medication adherence interventions within a community chain pharmacy practice: The Pennsylvania Project Jennifer L. Bacci, Stephanie Harriman McGrath, Janice L. Pringle, Michelle A. Maguire, and Melissa Somma McGivney
Received February 26, 2014, and in revised form May 24, 2014. Accepted for publication July 15, 2014.
Abstract Objective: To identify facilitators and barriers to implementing targeted medication adherence interventions in community chain pharmacies, and describe adaptations of the targeted intervention and organizational structure within each individual pharmacy practice. Design: Qualitative study. Setting: Central and western Pennsylvania from February to April 2012. Participants: Rite Aid pharmacists staffed at the 118 Pennsylvania Project intervention sites. Main outcome measures: Qualitative analysis of pharmacists’ perceptions of facilitators and barriers experienced, targeted intervention and organizational structure adaptations implemented, and training and preparation prior to implementation. Results: A total of 15 key informant interviews were conducted from February to April 2012. Ten pharmacists from “early adopter” practices and five pharmacists from “traditionalist” practices were interviewed. Five themes emerged regarding the implementation of targeted interventions, including all pharmacists’ need to understand the relationship of patient care programs to their corporation’s vision; providing individualized, continual support and mentoring to pharmacists; anticipating barriers before implementation of patient care programs; encouraging active patient engagement; and establishing best practices regarding implementation of patient care services. Conclusion: This qualitative analysis revealed that there are a series of key steps that can be taken before the execution of targeted interventions that may promote successful implementation of medication therapy management in community chain pharmacies. Keywords: Medicare Star Ratings, Pennsylvania Project, community pharmacy, targeted interventions, medication adherence, medication therapy management. J Am Pharm Assoc. 2014;54:584–593. doi: 10.1331/JAPhA.2014.14034
Jennifer L. Bacci, PharmD, is Community Pharmacy Research Fellow, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA; at the time of research she was Postgraduate Year 1 Community Pharmacy Resident, Rite Aid Pharmacy/School of Pharmacy, University of Pittsburgh,Pittsburgh, PA. Stephanie HarrimanMcGrath, PharmD, is Community Pharmacist, Rite Aid Pharmacy, Pittsburgh, PA. Janice L. Pringle, PhD, is Associate Professor of Pharmacy & Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA. Michelle A. Maguire, PharmD, is clinical pharmacist, Southeast, Inc., Columbus, OH; at the time of research she was Postgraduate Year 1 Community Pharmacy Resident, Forbes Pharmacy/School of Pharmacy, University of Pittsburgh, PA. Melissa Somma McGivney, PharmD, FCCP, FAPhA, is Assistant Dean of Community Partnerships and Associate Professor of Pharmacy & Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA. Correspondence: Jennifer L. Bacci, PharmD, School of Pharmacy, University of Pittsburgh, 736 Salk Hall, 3501 Terrace St., Pittsburgh, PA 15261. Fax: 412–624–8175. E-mail: [email protected] Disclosure: Stephanie Harriman McGrath is a full-time employee of Rite Aid Pharmacy. Funding: Transcription was supported by the University of Pittsburgh School of Pharmacy. Dr. Pringle’s efforts were funded in part by the Pharmacy Quality Alliance. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Pharmacy Quality Alliance. Acknowledgments: Jesse McCullough, PharmD, for assisting in preparing the manuscript; Brian Bobby, PharmD, for providing advice and assisting with project coordination; Susan Price, Lois Edmondston, and Michael Keyes, MSCD, for providing medication adherence data; and Brandon Antinopoulos, PharmD, Daniel Yarabinec, PharmD, and Amanda Tomich, PharmD, for recruiting participants. Author information continued at the end of the text on p. 592.
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A
ppropriate medication use is an important factor in improving health care quality and reducing unnecessary health care costs.1,2 Quality measures have been implemented to improve the quality of medication utilization.1 Although many health-related organizations have publically acknowledged the pharmacists’ role in improving health care quality, pharmacists are often an underutilized resource.3–6 A significant limitation is the question of how pharmacists can effectively implement patient care services within the workflow of the traditional community pharmacy. The financial implications of the Star Rating system’s adherence measures implemented by The Center for Medicare & Medicaid Services (CMS) have caused community pharmacy organizations to strive to understand how patient care services can be effectively incorporated into workflow.7,8 The most heavily weighted Star measures include adherence to long-term medications, which community pharmacists are in an ideal position to influence.9 The implementation of the Star Rating system to rate and reimburse Medicare Part D prescription drug plans (PDPs) and Advantage plans (MA-PDs) on specified quality measures has created a way to incentivize Medicare plans to improve health quality. The higher a
At a Glance
Synopsis: This qualitative study—the result of a partnership among a community pharmacy chain, a school of pharmacy, a managed care organization, and a quality improvement technology company—identifies a series of key steps that can lead to more successful implementation of medication therapy management services. Participating pharmacies were grouped as either “early adopters” (defined as meeting all five medication adherence metrics) or “traditionalists” (defined as meeting two or fewer medication adherence metrics). Key informant interviews identified five themes regarding the implementation of targeted interventions: all pharmacists’ need to understand the relationship of patient care programs to their corporation’s vision; providing individualized, continual support and mentoring to pharmacists; anticipating barriers before implementation of patient care programs; encouraging active patient engagement; and establishing best practices regarding implementation of patient care services. Analysis: Community pharmacists are physically isolated from other pharmacists because of the distance between pharmacy locations. Creating a learning community could allow them to solve common challenges as a group. These key factors have also been identified as critical when integrating pharmacists into health care settings other than community pharmacies.
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Medicare plan’s Star Rating, the higher the quality bonus payment (QBP) it receives from CMS.10 This payment structure may have multiple implications for community pharmacy.7 PDPs and MA-PDs may reward the pharmacies that contribute to their Star Ratings by demonstration of improvement of certain quality measures. QBPs can be used to incentivize pharmacies through a pay-for-performance (P4P) model.7,11 Previous research has demonstrated pharmacists’ ability to positively affect medication-related outcomes targeted interventions.12–14 The “Discussion on Taking Medications Diabetes Pilot Program” (DOTxMED) conducted by APhA demonstrated that pharmacist-led targeted adherence interventions can improve medication adherence.12 Yet, many implementation barriers arise when implementing such services. Barriers widely cited in the literature include lack of time, trained personnel, and reimbursement.15–18 The profession still lacks a model for implementing community pharmacy–based interventions effectively and efficiently. Establishing a model would allow community pharmacies to continually adjust their services in responses to the adapting health care system. In this study, we focus on identifying implementation facilitators, barriers, and strategies to guide the implementation of similar innovations aimed to improve patient medication-related outcomes within the dispensing workflow.
Background The Pharmacy Quality Alliance (PQA) is a membershipbased alliance with the goal of improving medication use through the establishment of performance measures.19,20 PQA supported the launch of five demonstration projects with the goal of testing various data sources as a means of measuring pharmacy performance in 2008.21 The Pennsylvania Project began in 2008 as a partnership among PQA, Highmark Blue Cross Blue Shield, CECity, and Rite Aid Corporation as one of the PQAfunded demonstration projects.21 The goal of Phase I of the Pennsylvania Project was to provide pharmacists working in Rite Aid pharmacies in central and western Pennsylvania with an electronic platform, ASPIRE (Pharmacy Quality Solutions, Washington, DC) to view a pharmacy performance report.21 The report showed composite patient adherence scores for each pharmacy. The PQA-endorsed portion of days covered (PDC) measure was the adherence metric used, which was calculated using claims data provided by Highmark.21 The composite patient adherence metric reflected the percentage of Highmark patients who were at or above a specified PDC threshold for each therapeutic class evaluated. Composite adherence scores were reported for five targeted therapeutic classes: angiotensin converting enzyme inhibitors (ACEIs) and/or angiotensin j apha.org
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receptor blockers (ARBs), beta blockers (BBs), calcium channel blockers (CCBs), cholesterol-lowering therapies (statins), and oral antidiabetic medications. These drug classes were chosen because the medications are used primarily in high-cost, chronic diseases. The University of Pittsburgh School of Pharmacy joined the partnership for Phase II of the demonstration project in 2010. The goal of Phase II was to determine the effect of pharmacist-performed targeted interventions on pharmacies’ composite adherence scores. Pharmacists from the 118 pharmacy intervention sites were trained in the Screening and Brief Intervention (SBI) model and motivational interviewing.22,23 Pharmacy team members used surveys to identify patients at risk of being nonadherent to their medications. When a patient was identified as being at risk for nonadherence based on their survey score, the pharmacist conducted a targeted intervention using motivational interviewing techniques, with the intent of identifying the patient’s cause of nonadherence and assisting the patient in finding individualized methods to improve his or her medication adherence.24–26 The Pennsylvania Project investigators are exploring financial incentive models that could provide a new source of revenue for community pharmacies in the current environment of decreasing prescription reimbursement rates. Pharmacists performing targeted interventions within community pharmacies have the potential to improve Star Ratings and can contribute to the movement toward payment for quality of care in community pharmacy practice. This study was meant to stimulate discussion in the community pharmacy and payer communities about how P4P models could be implemented to provide incentives for pharmacists to continue to positively influence patient care.
Objective The goal of this qualitative study was to understand how individual community pharmacists are implementing the innovation of pharmacist-led targeted medication adherence interventions at the point of dispensing. Specifically, we sought to (1) identify facilitators and barriers to implementing targeted medication adherence interventions in community chain pharmacies and (2) describe adaptations of the intervention and organizational structure within each individual pharmacy practice.
Methods
Qualitative research design This study was based on principles of implementation science, the study of how evidence-based interventions are executed in a real-world setting.27 It focused on individual adopter characteristics, intervention adaptation, and organizational structure adaptation. 586 JAPhA | 5 4:6 | NOV /DE C 2 0 1 4
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Rogers et al described how the characteristics of individual adopters can be classified according to their degree of innovativeness. “Early adopters” are individuals who are among the first to implement new innovations. “Traditionalists” are those who are resistant to change and the last to implement new innovations.27–29 Adaptations, which are additions or changes, can also affect implementation. Adaptations can be made to the intervention or to the organizational structure or environment in which it is being implemented. The organizational structure in community chain pharmacy practice includes the workflow, and the roles and responsibilities of pharmacy team members.27,30 The Pennsylvania Project included 118 intervention sites. Investigators were provided data in February 2012 by the primary investigator (J.L.P.) of the Pennsylvania Project to classify a pharmacy as an early adopter or traditionalist practice. The number of medication adherence metrics met by each pharmacy was the determinant for classification of early adopter and traditionalist practices. Early adopter practices were defined as pharmacies meeting all five medication adherence metrics. Traditionalist practices were defined as pharmacies meeting two or fewer medication adherence metrics. Key informant interviews were conducted with pharmacists staffed in early adopter and traditionalist pharmacies. The primary investigator (J.L.B.) conducted the first three interviews with pharmacists during evening hours, when prescription volume was low. The research team realized they needed a more efficient method of conducting the interviews that was less disruptive to patient care workflow in the pharmacies and thus adjusted the interview method. Under the revised methodology, the primary investigator and a co-investigator (J.L.B. and M.A.M., respectively) traveled to the pharmacies. The primary investigator stepped into workflow at each location so the pharmacist interviewee could step out of workflow. The co-investigator conducted the interviews with the pharmacists. This interview process was not disruptive to patient care and limited the distractions to the interviewee. Interviews were approximately 10–15 minutes in duration and conducted in private areas, such as patient consultation rooms or pharmacy waiting areas. The key informant interviews used a semistructured script developed from the previously described implementation science principles.27,30 The interview questions were vetted by individuals not involved with the Pennsylvania Project. They were then piloted with two community pharmacists at one intervention pharmacy that did not meet the study inclusion criteria. Table 1 contains the interview questions used. The interviewees completed a brief demographic survey to gather information about their professional background and practice sites. Interviews were conducted Journal of the American Pharmacists Association
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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.31,32 The University of Pittsburgh Institutional Review Board (IRB) classified this study as exempt from review. Data collection and analysis The interview dialogue was audiotaped and transcribed. Transcription occurred as the interviews were completed, allowing the investigators to read, code, and assess saturation continuously. The transcripts were analyzed using a generic qualitative approach.33 Two investigators (J.L.B. and M.A.M.) independently read and coded the transcripts. Sentences and phrases from the interviews that carried meaning were labeled with codes. The investigators then met to discuss coding decisions, accounting for the line-by-line reading conducted by each investigator. The investigators resolved coding disagreements through discussion. They 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 during the coding process. A senior investigative panel (S.H.M., J.P., M.S.M.) reviewed the transcripts for any gaps, inconsistencies, or new interpretations to improve the validity of the analysis. The coded text was grouped into categories to identify major themes. The research team then met to discuss the content of the coded interviews to collectively agree on themes.34,35 Data from the demographic survey were analyzed using descriptive statistics.
Results In all, 39 early adopter practices and 7 traditionalist practices met inclusion criteria based on interim adherence metrics in February 2012. Qualifying pharmacies were recruited for participation via fax and telephone. Participation was voluntary for pharmacists, and recruitment continued until data saturation was achieved.
RESEARCH
One pharmacy declined participation because of recent pharmacist turnover at the location. A total of 15 interviews were conducted from February 2012 to April 2012. Ten pharmacists from early adopter practices and five pharmacists from traditionalist practices were interviewed. Table 2 summarizes the demographics of the 15 interviewees. The qualitative analysis revealed the following five dominant themes. Theme 1: Need to understand the relationship of the patient care programs to the corporate vision The PQA Demonstration Project was introduced to the pharmacies at the beginning of the seasonal influenza vaccine campaign. Two other clinical programs were implemented during the demonstration project: increased opportunities for the provision of and compensation for MTM services, and the community pharmacy chain’s own adherence tool. This adherence tool provided pharmacists with individual patients’ PDC scores based on their refill history in the dispensing system. The pharmacists questioned how each program fit into the chain pharmacy’s vision for the provision of patient care. Pharmacists in both early adopter and traditionalist practices felt overwhelmed by the number of clinical initiatives and in determining how to prioritize these new programs in addition to their established dispensing and immunization responsibilities. The interviews uncovered these concerns through the following responses: ❚❚ “One of the difficulties we had was that there are, you know, four or five things going on at the same time, and trying to implement everything is just kind of [overwhelming].” (interview 15, early adopter) ❚❚ “And now we have our own [adherence] service so basically the PQA [project] really should go out the window because we have our own service, now you’re just duplicating it.” (interview 11, early adopter)
Table 1. Questions used in interviewing key informants about the PQA Demonstration Project Domain Questions Preparation and training
Facilitators and barriers Intervention adaptation Organizational structure adaptation Implementation pearls
From your perspective, what is/are the goal(s) of the Pharmacy Quality Alliance (PQA) program? What training did you receive before implementing the PQA project? How did your training and support prepare you to implement the PQA program? What additional training and support would have been helpful before starting the PQA project? What strategies did your pharmacy use when implementing the program that you felt were successful? What strategies did your pharmacy use when implementing the program that you felt were unsuccessful? How did you adapt the program to your pharmacy practice when implementing? How did you adapt the workflow in your pharmacy to implement this program? What advice do you have for other pharmacists implementing this program or similar innovations in their pharmacy?
Abbreviation used: PQA, Pharmacy Quality Alliance. Journal of the American Pharmacists Association
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Table 2. Demographic data of key informants interviewed about PQA demonstration project Early adopters + Early adopters traditionalists No. (%) (n = 10) No. (%) (n = 15) Mean age (years) Gender
Women Men Degree BSPharm PharmD Years as practicing pharmacists Years in current position Weekly prescription volume Number of staff pharmacists Services offered MTM (in person) MTM (Mirixa) MTM (Outcomes)a Immunizations Pill box fills Synchronized refill program Smoking cessation Diabetes education Automated refill reminders Genetic testing Drive through Delivery Total hours open per week Hours of pharmacist overlap per week Hours of ancillary help per week
36.6 7 (46.7) 8 (53.3) 8 (53.3) 7 (46.7) 12.4 8.2 1,364 2.2 4 (26.7) 1 (6.7) 10 (66.7) 15 (100) 4 (26.7) 1 (6.7) 1 (6.7) 4 (26.7) 14 (93.3) 0 (0) 11 (73.3) 14 (93.3) 80.7 23.5b 133.5
36.9 5 (50) 5 (50) 5 (50) 5 (50) 12.2 9 1,378 2.3 1 (10) 1 (10) 6 (60) 10 (100) 3 (30) 1 (10) 1 (10) 2 (20) 9 (90) 0 (0) 8 (80) 10 (100) 82.6 23.5b 137.4
Traditionalists No. (%) (n = 5) 36 2 (40) 3 (60) 3 (60) 2 (40) 12.8 6.6 1,336 2 3 (60) 1 (20) 5 (100) 5 (100) 1 (20) 0 (0) 0 (0) 2 (40) 4 (80) 0 (0) 3 (60) 4 (80) 76.8 0 125.7
Abbreviations used: PQA, Pharmacy Quality Alliance; MTM, medication therapy management. a All pharmacists were required to register with Outcomes during data collection. b Only three stores had pharmacist overlap.
Pharmacists felt that continual training and mentoring, with opportunities for sharing best practices with their peers, would resolve their concerns. Theme 2: Continual support and mentoring needed Pharmacists from all practices expressed the desire for continual, onsite, individualized training and support from other pharmacists and management. They felt the support should include assistance with prioritizing the clinical and dispensing initiatives, feedback about how well they were implementing the targeted adherence interventions, and updates about the PQA demonstration project. The pharmacists who received onsite, individualized training felt more comfortable implementing the targeted adherence interventions. In this way, the pharmacists felt that a more structured support system would promote successful implementation. Comments included the following: ❚❚ “Through several meetings it comes together a little more every time. But initially, everybody just felt like they were thrown out there into something new.” (interview 6, early adopter)
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❚❚
“I feel like our district managers come in and try to push [the PQA project]…try to break it down for us and explain it. And how [my district manager] broke it down to me really helped me.” (interview 6, early adopter) ❚❚ “Just somebody checking in more often…we don’t forget about the project…or go over results every now and then on how we’re doing. You know, when you don’t hear anything back it’s hard to gauge where you’re at with it.” (interview 3, early adopter) The pharmacists expressed the desire to communicate with their peers regarding best practices. They felt a forum to share successful and unsuccessful implementation strategies with other pharmacists would facilitate implementation. Responses to the question “What additional training and support would have been helpful prior to starting the project?” included: ❚❚ “They just kind of said, you know, ‘Come up with a method that works for you.’ I guess it was kind of hard…I don’t know how they would have been able to point us in the right direction since we were kind of the first group to do it. So, I felt a little unJournal of the American Pharmacists Association
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prepared starting it and a little confused.” (interview 3, early adopter) “Examples of how pilot stores…went about implementing the program [would have helped].” (interview 3, early adopter)
Theme 3: Anticipate barriers Pharmacists from both early adopter and traditionalist practices experienced barriers; however, the barriers they faced were different. The barriers faced by early adopters related to the patient population they were serving and their desire to provide more collaborative, interprofessional patient care, including the following: ❚❚ “We just have a lot of patients that practice polypharmacy…when their prescriptions are all over the place it’s really hard to keep on top of it.” (interview 3, early adopter) ❚❚ “I don’t think most physicians are too receptive [to the recommendations].” (interview 2, early adopter) Pharmacists from traditionalist practices faced barriers related to inconsistent staffing and patient population needs of specific communities, which are expressed through the following comments: ❚❚ “I was having issues in the store itself with the technicians because they were brand new technicians…” (interview 5, traditionalist) ❚❚ “Drive-through, because a lot of people like the drive-through at this store, so we try not to talk to them for privacy…” (interview 4, traditionalist) ❚❚ “Neither me nor my partner speaks Spanish, and I would say…a very large percentage of our patients are Spanish-speaking.” (interview 7, traditionalist) ❚❚ “Right now we’re in an area [where] people aren’t on medical assistance…[their income is] just high enough that they don’t qualify…they skip their medication because of the fact they just couldn’t afford it.” (interview 5, traditionalist) Pharmacists from early adopter practices faced barriers in the later stages of the implementation process, whereas pharmacists from traditionalist practices faced environmental barriers in the early stages that hindered their abilities to implement the interventions. Furthermore, early adopters faced barriers that they would be able to solve on their own at the individual practice level through relationship building with patients and practitioners in the area. Traditionalists had barriers at the pharmacy level that they were unable to solve on their own. Theme 4: Active patient engagement is a key facilitator All of the pharmacists interviewed from early adopter practices had already established a daily workflow that incorporated patient interaction and the development Journal of the American Pharmacists Association
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of patient–pharmacist therapeutic relationships, allowing easy integration of the targeted interventions. Comments regarding patient engagement included the following: ❚❚ “The other pharmacists and I know almost every single patient by their name as well as their medicines, their background, their families’ social histories, so most people that come in here we monitor their compliance.” (interview 9, early adopter) ❚❚ “This location is really patient goal oriented…and education oriented.” (interview 2, early adopter) Pharmacists from the traditionalist practices found engaging their patients to be challenging because of the barriers discussed in Theme 3. Theme 5: Establish best practices The pharmacists expressed their desire to hear what was working and/or not working for other pharmacists. They were eager to share the best practices they had developed. The practices that were best able to implement the targeted adherence interventions were those that developed their own method of identifying target patients, of flagging those patients’ prescriptions to alert staff that the pharmacist wanted to have a discussion with those patients, and of increasing the patient’s exposure to the pharmacist. Pharmacists in the successful practices found it helpful to set short-term goals for their team. Comments regarding these implementation strategies included the following: ❚❚ “Usually when I was checking [prescriptions], I could tell by looking at their profile, and you could put a little note in their bag, or stick one of the surveys in their bag, and then they could see it.” (interview 1, early adopter) ❚❚ “I tried for a while…to make sure that I as a pharmacist was the one at the register. I felt like people were a lot more inclined to help us, you know, answer questions and fill out the survey, or, you know, we were right there able to talk to them.” (interview #3, early adopter) ❚❚ “Making sure that we got our five a day. And then as a pharmacist we would check in on the website… and print out the gaps and…try to focus on one disease state and…narrow the gaps on those.” (interview 6, early adopter) The pharmacists initially felt overwhelmed trying to target all patients. The rollout of the community pharmacy chain’s own adherence tool helped the pharmacists focus their efforts where they would be maximized. The most successful practices used the pharmacy-specific adherence data provided on the online platform, ASPIRE, to identify problem drug classes in combination with the patient-specific adherence data to identify individuals who were nonadherent based on their refill history in the medication dispensing system. The pharmacists shared the following thoughts on the j apha.org
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benefits of having access to transparent pharmacy- and patient-specific data: ❚❚ “Through the combination [it] can be less overwhelming…based on what our corporate is doing through our [own adherence tool] in combination with the…PQA, which gives you a sheet to ask, figure out why they may be less compliant.” (interview 13, early adopter) ❚❚ “We cut down the workload a little bit by being more selective on trying to bring up the scores through the people who may have been bringing the scores down.” (interview 13, early adopter) The pharmacists felt that one of the most important keys to successful implementation of these targeted interventions was pharmacist and staff persistence. The pharmacists shared the following thoughts: ❚❚ “You just have to be persistent, and you have to keep at it…it’s not something that you see instant gratification for, instant results.” (interview 7, traditionalist) ❚❚ “Every person is different. And I mean, you don’t give up just because people are resistant.” (interview 6, early adopter)
Discussion This study affords a deeper look into how pharmacists have successfully implemented targeted, quality-driven patient interactions into traditional community chain pharmacy workflow. Implementation difficulties and the lack of widespread acceptance of pharmacists have been widely noted.17–20 However, patients clearly need to receive more focused, medication-related care in their own communities. Community pharmacists have the knowledge and skills to provide this care while being the most accessible health care practitioner.36,37 We learned that there is a series of key steps that can be taken to achieve successful implementation in a short amount of time, even in medium-volume community pharmacies. First, interviewed pharmacists said it is imperative for the frontline pharmacists and ancillary staff to understand the purpose of patient care initiatives they are being asked by management to implement and how they complement other services offered within their organization. We learned that the pharmacists and their staff felt more motivated and willing to implement the service once they understood what the targeted interventions were contributing to their organization and to patient care. The pharmacists shared that this motivation and willingness directly affected the amount of time it took for their teams to implement the interventions within workflow. This essential step is often overlooked during the implementation process but is an integral step to ensure success. Creating a common vision facilitates growth of an effective climate and culture
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within a company. Creation of this type of environment enhances an organization’s readiness to implement.27 Once readiness is achieved, the next key step seems to be providing continual, individualized, onsite training. A new finding we learned from the pharmacists is that the one-on-one training and mentorship needs to be provided by a pharmacist or manager. The pharmacists in this study attended live sessions, during which they were trained to provide targeted interventions using motivational interviewing principles. Multiple previous studies have demonstrated the importance of training when implementing new community-based services to increase pharmacists’ knowledge and skills.38–41 Fitzgerald et al38 specifically demonstrated that live training sessions can improve pharmacists’ readiness to perform targeted interventions. The pharmacists we interviewed shared that the live training provided them with an awareness of targeted interventions and motivational interviewing. The pharmacists most valued the opportunity to brainstorm methods for implementation in their practice during the individualized mentoring sessions. They felt these mentoring sessions allowed their teams to more quickly adapt their workflow to incorporate the interventions. Other studies have demonstrated the importance of communication during the implementation process, whether it be in the form of onsite visits or a consultative service. This follow-up posttraditional live training assists pharmacists in troubleshooting implementation barriers as they arise.38,42 The results of this study reinforce that the provision of both live group training and onsite individualized mentoring can facilitate success when implementing a new program; also, that the pharmacists most value individualized mentorship from other pharmacists or managers. Regional clinical managers within chain community pharmacies could potentially be used to fulfill this need for individualized training and mentorship when implementing new patient care programs. The pharmacists we interviewed emphasized the importance of anticipating barriers before implementation. Surprisingly, we found that time was not the most commonly cited barrier in this study as it was in previously published studies.17,18 The pharmacists involved in the Pennsylvania Project identified staff-related barriers, such as high turnover, and patient-related barriers, such as language and socioeconomic status, as their largest obstacles. Some of the barriers that the pharmacists identified are factors that have previously been identified as potential facilitators of practice change in community pharmacy: relationships with physicians, pharmacy layout, manpower/staff, and external support and assistance.42 Anticipating and resolving barriers before execution directly affects the speed and extent of intervention implementation and dissemination.27 These barriers could have the potential to facilitate successful implemenJournal of the American Pharmacists Association
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tation of a program if they are identified and resolved prior to program initiation. Management could prospectively address barriers when placing pharmacists and staff in individual community pharmacy locations. Finally, the pharmacists felt that identifying and sharing best practices among colleagues is a critical component of the implementation process. They commonly cited their individual struggle to identify potential targeted interventions based solely on pharmacy-specific composite adherence data accessible on the Web-based platform. Community pharmacists are physically isolated from other pharmacists because of the distance between pharmacy locations. This geographical isolation resulted in the pharmacy teams working individually to figure out how to target the appropriate patients using the available data. Creating a learning community, a “community of practice,” for the pharmacists could allow them to solve common challenges as a group by providing them a communication mechanism through which to share their success stories and struggles.29,43 The pharmacists’ struggle to identify potential interventions based on aggregate data was resolved when the community pharmacy chain developed its own adherence tool. Pharmacists were most successful when they used pharmacy-specific adherence data on the Web-based platform and patient-specific adherence data within the dispensing system. The Web-based platform helped pharmacists identify problem drug classes. They could then target patients on medicines in those drug classes and use the surveys to identify patients who were at the highest risk of nonadherence. The chain’s patient-specific adherence tool helped pharmacists identify patients who were already nonadherent. Pharmacists were then able to use the surveys to assess the factors contributing to the patients’ nonadherence. To the best of our knowledge, this strategy of using pharmacy- and patient-specific data to target patients has not yet been reported in the literature. Overall, successful implementation could be designed with an appreciation for these factors. These key factors have also been identified as critical when integrating pharmacists into health care settings other than community pharmacy. Research done in patientcentered medical homes has also demonstrated the challenge of time management and prioritization, the perceived significance of specific traits on successful implementation, and the benefits of utilizing peer mentoring during the implementation process.44,45 These similar findings suggest that consideration of the key factors identified by this study could facilitate successful implementation of pharmacist-provided services in other health care settings as well. This qualitative analysis also led us to ask more questions that will help us understand how to better care for community-based patients, including how to efJournal of the American Pharmacists Association
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fectively match patient populations’ drug- related needs to pharmacists’ skill sets. For example, the needs of a primarily Spanish-speaking community could be best met by a Spanish-speaking pharmacist, a low socioeconomic community would be best served by a pharmacist with extensive knowledge of Patient Medication Assistance Programs (PMAPs), and an ethnic community with medication-related beliefs would be best served by a pharmacist with knowledge of that culture.46 PMAPs can help patients who are unable to afford their medicines; however, it must be noted that PMAPs could affect a plan’s Star Rating because there would not be insurance claims for any medicines received through assistance programs. Finally, this project led us to understand how to better conduct research in a busy community pharmacy. This method could be replicated in future studies that seek to interview community pharmacists. We were also able to work with pharmacy district management, who assisted by alerting all Pennsylvania Project intervention pharmacies that a colleague may be contacting them to participate in a research study and that the primary investigator should be permitted to work in their pharmacy. All potential participants were contacted so we were able to ensure actual participant confidentiality. Performing research in community pharmacy requires support from management, communication with all potential team members, and a way to ensure patient care is not disrupted during the research process.
Limitations One limitation to this study is that is was conducted within one national chain with low- to medium-volume pharmacies. Results may not be generalizable to highvolume pharmacies, other corporations, or independent pharmacies with significantly different business models. State laws may also present a limitation to the generalizability of the study because all pharmacists interviewed practiced in the same state. For example, early adopters identified that communication with physicians was an implementation barrier. This same issue may not be identified as a barrier by pharmacists practicing in states that allow and have implemented collaborative practice agreements between community pharmacists and physicians.47 In addition, the number of aggregate medication adherence metrics that were at or above goal was used as a proxy measure of implementation to identify pharmacies for participation in this study. It is possible that external factors rather than a pharmacy team’s implementation of the targeted medication adherence intervention caused their adherence metrics to be at goal, resulting in pharmacies being incorrectly labeled as early adopters. Although the influence of these external barriers on the metrics presents a limitation, a significant finding of this study was the presence of a culture of frej apha.org
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quent patient interaction in each early-adopter practice identified. This norm would also have contributed to the early-adopter practices’ medication-adherence metrics. Two different pharmacists conducted the interviews, allowing for variability in how the questions were asked and the level of probing. However, in analyzing the transcripts, similar responses were obtained by both interviewers. The interviewees may have been less inclined to share their negative experiences with the interviewers for multiple reasons. Both of the interviewers were pharmacists and were completing the study as part of their residency training. One of the interviewers (J.L.B.) was completing her residency within the chain community pharmacy that employed these pharmacists. She had interacted with some of the participants before their recruitment for the study for patient care purposes. Several attempts to elicit barriers were made by the interviewers throughout the discussion to overcome this limitation. Finally, participants who were offered workflow coverage may have been more inclined to participate in the study.
Conclusion Pharmacists performing targeted interventions within community pharmacies have the potential to improve Star Ratings when implemented successfully and are thus contributing to the movement toward payment for quality of care in community pharmacy practice. This study revealed that successful implementation of targeted interventions is possible. Key steps should be taken before the execution of targeted interventions to promote successful implementation in community chain pharmacies using a similar online platform. These key steps are to understand the relationship of patient care programs to the corporate vision; provide individualized, continual support and mentoring to pharmacists; anticipate barriers prior to implementation of patient care programs; encourage active patient engagement; and establish and share best practices regarding implementation of patient-care services. Further studies should investigate how we can better care for our patients in the community in a financially viable way, how to appropriately place pharmacists in communities based on their skill set and on the community’s medication-related needs, and develop best practices for physician–pharmacist communication when practicing in physically separate spaces. Author information continued from p. 584. Previous presentations: American Pharmacists Association Annual Meeting, New Orleans, LA, March 10, 2012; Pennsylvania Pharmacists Association Midyear Meeting, Camp Hill, PA, January 26, 2013.
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