Pharmacist-Community-Based Organization Collaboration to Address Health-Related Social Needs.

BACKGROUND: Community-based organizations (CBOs) help address community issues, including health-related social needs (HRSNs). Community pharmacies are positioned to collaborate with CBOs to help their patients identify and address HRSNs to optimal medication use. OBJECTIVES: To develop and evaluate two models of community pharmacy-CBO collaboration to address HRSNs facing patients taking medications. METHODS: Two different pharmacy-CBO models were studied. The CBO-initiated model had two CBOs assess and refer clients to a community pharmacy to address HRSN-related medication concerns. In the pharmacy-initiated model, pharmacists screened patients for HRSNs, addressed those related to medication costs and referred patients to a CBO for other HRSNs. Documented HRSNs were extracted and analyzed. Participating pharmacy and CBO staff were interviewed. The interview recordings were transcribed and coded, using rapid qualitative analyses. RESULTS: The CBO-initiated model screened 23 clients with 17 receiving a comprehensive medication review. In the pharmacy-initiated model, 39 patients were screened for HRSNs with 6 patients having medication costs issues addressed at the pharmacy and 23 patients being referred to the CBO. The most common HRSNs were high stress levels (43%), lack of confidence filling out forms (36%), feeling overwhelmed (34%), and inability to get food (27%). Patient-related themes from interviews were patient willingness to participate in the service, obstacles patients faced in obtaining medication therapy and establishing patient trust. Pharmacy-related and CBO-related themes included fitting new activities into workflow, importance of time management and good communication and establishing relationships between pharmacy and CBO personnel. CONCLUSION: Both pharmacy-CBO models effectively identified clients in need of medication management services or patients with HRSNs affecting medication optimization. Limited trust between the patient and the party to which they were referred was an obstacle to successful referral. Developing pharmacy and CBO personal relationships is a vital key in planning and coordinating these pharmacy-CBO collaboration models.

Patient preferences and willingness-to-pay for community pharmacy-led Medicare Part D consultation services: A discrete choice experiment.

INTRODUCTION: Community pharmacies currently offer Medicare Part D consultation services, often at no-cost. Despite facilitating plan-switching behavior, identifying potential cost-savings, and increasing medication adherence, patient uptake of these services remains low. OBJECTIVES: To investigate patient preferences for specific service-offering attributes and marginal willingness-to-pay (mWTP) for an enhanced community pharmacy Medicare Part D consultation service. METHODS: A discrete choice experiment (DCE) guided by the SERVQUAL framework was developed and administered using a national online survey panel. Study participants were English-speaking adults (≥65 years) residing in the United States enrolled in a Medicare Part D or Medicare Advantage plan and had filled a prescription at a community pharmacy within the last 12 months. An orthogonal design resulted in 120 paired-choice tasks distributed equally across 10 survey blocks. Data were analyzed using mixed logit and latent class models. RESULTS: In total, 540 responses were collected, with the average age of respondents being 71 years. The majority of respondents were females (60%) and reported taking four or more prescription medication (51%). Service attribute levels with the highest utility were: 15-min intervention duration (0.392), discussion of services + a follow-up phone call (0.069), in-person at the pharmacy (0.328), provided by a pharmacist the patient knew (0.578), and no-cost (3.382). The attribute with the largest mWTP value was a service provided by a pharmacist the participant knew ($8.42). Latent class analysis revealed that patient preferences for service attributes significantly differed by gender and difficulty affording prescription medications. CONCLUSIONS: Quantifying patient preference using discrete choice methodology provides pharmacies with information needed to design service offerings that balance patient preference and sustainability. Pharmacies may consider providing interventions at no-cost to subsets of patients placing high importance on a service cost attribute. Further, patient preference for 15-min interventions may inform Medicare Part D service delivery and facilitate service sustainability.

Leadership aspiration: An intersectional analysis of racial and gender equity in pharmacy.

BACKGROUND: The glass ceiling is a metaphor used to describe an invisible barrier that prevents an underrepresented group from rising beyond a certain level. Among pharmacists, underrepresented groups face various barriers and limitations to their successes. OBJECTIVES: The purpose of this study was to apply the intersectionality framework to data collected from the 2019 National Pharmacist Workforce Study (NPWS) to understand the association of gender and race with leadership aspiration among pharmacists, including differences in perceived barriers and attractors for pursuing leadership. METHODS: The 2019 NPWS was conducted using an electronic Qualtrics survey. Three e-mails containing the survey link were sent to a systematic random sample of 94,803 pharmacists through the National Association of Boards of Pharmacy Foundation e-profile system. The 2019 NPWS had an overall response rate of 6% (5705/94,803). A total of 8466 pharmacists clicked on the survey link, resulting in a usable response rate of 67.3% (5705/8466). Data were analyzed in SPSS software using descriptive and Pearson's r and chi-square test statistics. RESULTS: Black, Indigenous, and People of Color (BIPOC) pharmacists reported holding 10.7% of all leadership positions. Leadership positions included manager, assistant manager, executive, dean, director, chief pharmacy officer, owner or partner, and other leadership position types. White men and women reported the lowest interest in leadership (38.8% and 37.7%), whereas Black men (65.1%), Latinas (59.2%), Black women (58.5%), and Latinos (57.1%) had the highest interest in leadership. "The ability to make an impact" was the most frequently selected attractor for wanting to pursue leadership, selected by 92.5% and 79.6% of Black men and women, respectively, 77.8% of Other women, and 76.9% of Latinos. At graduation from pharmacy school, the student debt loan average of all graduation years ranged from $63,886 (± $73,701) for Other men to $112,384 (± $105,417) for Black women. Higher student loan debt was positively correlated with wanting to pursue a leadership position (r = 0.22, P < 0.001). Black women graduating 2011-2019 had the highest student loan debt at graduation ($194,456 ± $88,898). CONCLUSION: Interest in leadership positions by BIPOC pharmacists compared with reported leadership roles were inversely correlated. Understanding the discrepancy in interest in leadership and reported leadership positions held, particularly with relation to race and gender, is essential to understanding equity in pharmacy leadership. Further research is warranted to understand the factors that impede the ascension of women and underrepresented pharmacists into leadership positions.

Evaluation of a modified and abbreviated scale for assessing chronic illness care for medication therapy management practice.

BACKGROUND: The central goals of MTM align with those of the Chronic Care Model (CCM). However, reliable and valid assessments are needed to estimate the extent to which components of MTM care delivery are consistent with the CCM. The Assessment of Chronic Illness Care (ACIC) is a 34-item scale for administration in primary care offices to estimate the extent to which chronic care delivery aligns with the six elements of the CCM. The ACIC appears to be responsive for care delivery interventions aimed at improving various chronic illnesses. However, the potential value of the ACIC as a measure for evaluating MTM delivery is unknown. OBJECTIVE: A modified and abbreviated version of the ACIC could be a useful evaluation tool for pharmacist-provided medication therapy management (MTM). The objective of this study was to assess the construct and criterion-related validity, and internal consistency, of the abbreviated (12-item) "MTM ACIC." METHODS: The abbreviated MTM ACIC was administered to pharmacists employed at 27,560 community pharmacies. Construct validity and internal consistency were estimated through principal components analysis, item-to-total correlations, and Cronbach's alpha estimate of internal consistency. To assess criterion-related validity, a univariate negative binomial model estimated the association between ACIC scores and pharmacy-level MTM completion rates. RESULTS: A one-component model accounted for 64% of the variance, and Cronbach's alpha was 0.95. Scores on the abbreviated MTM ACIC were associated with MTM completion rates (rate ratio: 1.02; 95% CI: 1.01 to 1.03). CONCLUSION: The abbreviated MTM ACIC exhibited acceptable construct and criterion-related validity and internal consistency and could serve as a valuable tool for evaluating chronic illness care within the MTM setting.

Evaluation of financial outcomes under a value-based payment program for community pharmacies.

BACKGROUND: Value-based payment models have been shown to limit health care spending and waste while improving quality of care. Evidence from value-based pharmacy programs (VBPPs) is needed to guide the use of these mechanisms in health care. OBJECTIVE: To evaluate financial outcomes of a VBPP implemented in 73 community pharmacies for about 40,000 commercial beneficiaries of Wellmark, Inc. METHODS: Beneficiaries were attributed to pharmacies based on the number of prescriptions dispensed. The VBPP paid community pharmacies a per capita payment based on their performance on a set of metrics to deliver care the pharmacists believed was necessary to optimize the beneficiaries' medication therapy and associated outcomes. Financial outcome variables were analyzed for the calendar year of 2018, including total cost of care, hospital admissions, and emergency department (ED) visits. Hospital admissions and ED visits were identified through claims data. Generalized linear models were used to test the effect of the VBPP on each of the outcome variables by comparing outcomes for beneficiaries attributed to the pharmacies participating in the VBPP (73 pharmacies) to Wellmark's beneficiaries attributed to nonparticipating pharmacies (847 pharmacies). Independent variables used in the models to control for possible confounding included beneficiary demographics and complexity scores, region code, accountable care organization (ACO) attribution, beneficiary product type (health maintenance organization (HMO), preferred provider organization (PPO), and several disease indicator variables. RESULTS: Analyses showed in 2018 that the per beneficiary per month total costs of care for the beneficiaries going to the VBPP pharmacies (N = 15,463) was $30.48 (4.5%; 95% CI = -6.2% to -2.7%) lower than that of the non-VBPP group (N = 140,717). The hospital admission rate for the VBPP group was 5.1% lower but was not statistically significant (95% CI = -12.9% to 3.3%). Similarly, the ED visit rate for the VBPP group was 2.1% lower than the non-VBPP group but did not reach statistical significance (95% CI = -8.6% to 3.3%). CONCLUSIONS: With the growing need for solutions to improve quality of care while reducing health care costs and waste, a value-based payment program using performance-determined capitated payments to community pharmacies offering enhanced clinical services significantly reduced total costs of care in a commercial population with one or more chronic conditions. Future work with this promising model is encouraged. DISCLOSURES: No external funding was obtained to support this study. Devolder and Heggen are employed by Wellmark, Inc. Doucette is supported by the Deborah K. Veale Professorship in Healthcare Policy at the University of Iowa. The authors have no other potential conflicts of interest to disclose.

National Pharmacist Workforce Study (NPWS): Description of 2019 Survey Methods and Assessment of Nonresponse Bias.

National Pharmacist Workforce Studies (NPWS) have been conducted in the U.S. every five years since 2000. This article describes the online survey methods used for the latest NPWS conducted in 2019 and provides an assessment for nonresponse bias. Three waves of emails containing a link to the online survey were sent to a random sample of about 96,000 pharmacists licensed in the United States. The survey asked about pharmacist employment, work activities, work-life balance, practice characteristics, pharmacist demographics and training. A total of 5467 usable responses were received, for a usable response rate of 5.8%. To assess for nonresponse bias, respondent characteristics were compared to the population of U.S. pharmacists and a benchmark, while a wave analysis compared early and late respondents. The pharmacist sample-population comparison and the benchmark comparison showed that the NPWS respondents had a higher percentage of female pharmacists and a lower proportion of young pharmacists compared to the population of U.S. pharmacists and the benchmark sample. In some contrast, the wave analysis showed that the early respondents had a higher percentage of males and older pharmacists compared to the late respondents. Both the wave analysis and the benchmark comparison showed that the NPWS respondents (and early respondents) had a lower percent of pharmacists with a PharmD degree than did the late respondents and the benchmark group. These differences should be considered when interpreting the findings from the 2019 NPWS.

A user-centered evaluation of medication therapy management alerts for community pharmacists: Recommendations to improve usability and usefulness.

BACKGROUND: Community pharmacists provide comprehensive medication reviews (CMRs) through pharmacy contracts with medication therapy management (MTM) vendors. These CMRs are documented in the vendors' web-based MTM software platforms, which often integrate alerts to assist pharmacists in the detection of medication therapy problems. Understanding pharmacists' experiences with MTM alerts is critical to optimizing alert design for patient care. OBJECTIVES: The objectives of this study were to 1) assess the usability and usefulness of MTM alerts for MTM vendor-contracted community pharmacists and 2) generate recommendations for improving MTM alerts for use by community pharmacists. METHODS: This was a convergent, parallel mixed-methods evaluation of data collected from 3 sources, with individual pharmacists contributing data to one or more sources: 1) community pharmacists' submissions of observational data about MTM alerts encountered during routine MTM provision, 2) videos of naturalistic usability testing of MTM alerts, and 3) semi-structured interviews to elicit pharmacists' perspectives on MTM alert usefulness and usability. MTM alert data submitted by pharmacists were summarized with descriptive statistics. Usability testing videos were analyzed to determine pharmacists' time spent on MTM alerts and to identify negative usability incidents. Interview transcripts were analyzed using a hybrid approach of deductive and inductive codes to identify emergent themes. Triangulation of data (i.e., determination of convergence/divergence in findings across all data sources) occurred through investigator discussion and identified overarching findings pertaining to key MTM alert challenges. These resulted in actionable recommendations to improve MTM alerts for use by community pharmacists. RESULTS: Collectively, two and four overarching key challenges pertaining to MTM alert usability and usefulness, respectively, were identified, resulting in 15 actionable recommendations for improving the design of MTM alerts from a user-centered perspective. CONCLUSIONS: Recommendations are expected to inform enhanced MTM alert designs that can improve pharmacist efficiency, patient and prescriber satisfaction with MTM, and patient outcomes.

An evaluation of community pharmacies' actions under value-based payment.

OBJECTIVE: To determine actions taken by community pharmacies to be successful under a value-based pharmacy program (VBPP). METHOD: An exploratory sequential mixed methods approach was used to evaluate pharmacies participating in the VBPP, with qualitative data collected and analyzed in the first phase, followed by quantitative measurement through a 30-item survey instrument in the second phase. RESULTS: The qualitative data showed that participating pharmacies were more involved with adherence and cardiovascular and diabetes metrics than with other metrics. Depression metrics received the lowest overall involvement. For total cost of care, different approaches were used; 5 pharmacies used the dashboard to identify likely high-cost patients they could try to manage, and 4 pharmacies monitored adherence to avoid complications that could contribute to increased cost. For the survey response rate was 72.6% (n = 53). The mean perception of level of success was 53.06 ± 20.15 (mean ± SD). Activities with the highest priority were adherence (1.98 ± 0.97) and diabetes care (2.04 ± 0.83), and the activity with the lowest priority was depression care (3.60 ± 1.10). The most frequently mentioned challenge was time availability, and the most common improvement suggestion was better communication between the insurer and providers. CONCLUSION: In conclusion, this study found that community pharmacies were transforming their practices to be successful under a commercial value-based payment program. The pharmacies tended to build on care processes already established (e.g., medication adherence, patients with diabetes or cardiovascular conditions) and developed new processes to address emerging metrics and associated patient needs (e.g., collecting and documenting blood pressure and hemoglobin A1c levels). Future research is needed to identify best practices for patient care and pharmacy success under broad VBPPs such as the one studied here.

Community pharmacists' and residents' decision making and unmet information needs when completing comprehensive medication reviews.

OBJECTIVE: To (1) characterize community pharmacists' and community pharmacy residents' decision making and unmet information needs when conducting comprehensive medication reviews (CMRs) as part of medication therapy management and (2) explore any differences between community pharmacists and community pharmacy residents in CMR decision making and unmet information needs. DESIGN: Thirty-to 60-minute semistructured interviews framed using a clinical decision-making model (CDMM) were conducted with community pharmacists and residents. SETTING AND PARTICIPANTS: Participants were recruited from practice-based research networks and researchers' professional networks. Eligible participants had completed or supported the completion of at least 2 CMRs in the last 30 days. OUTCOME MEASURES: Two researchers independently coded transcripts using a combination of inductive and deductive methods to identify themes pertaining to community pharmacists' and residents' decision making and unmet information needs in the provision of CMRs. Discrepancies among researchers' initial coding decisions were resolved through discussion. RESULTS: Sixteen participants (8 pharmacists and 8 residents) were interviewed. Themes were mapped to 5 CDMM steps. Participants primarily used subjective information during "case familiarization"; objective information was secondary. Information used for "generating initial hypotheses" varied by medication therapy problem (MTP) type. During "case assessment," if information was not readily available, participants sought information from patients. Thus, patients' levels of self-management and health literacy influenced participants' ability to identify and resolve MTPs, as described under "identifying final hypotheses." Finally, participants described "decision-making barriers," including communication with prescribers to resolve MTPs. Although pharmacist and resident participants varied in the types of MTPs identified, both groups cited the use and need of similar information. CONCLUSION: Community pharmacists and residents often rely primarily on patient-provided information for decision making during CMRs because of unmet information needs, specifically, objective information. Moreover, confidence in MTP identification and resolution is reduced by communication challenges with prescribers and limitations in patients' ability to convey accurate and necessary information.

Iowa community pharmacies' experiences with Medicaid managed care.

OBJECTIVES: To describe Iowa community pharmacies' experiences and satisfaction with the transition to Medicaid managed care and conduct a qualitative evaluation of the effect of Medicaid managed care on 3 independent community pharmacies. DESIGN: Cross-sectional descriptive study. Mixed methods were used: the quantitative phase was a mailed survey and the qualitative phase involved interviews. SETTING AND PARTICIPANTS: The mail survey was sent to Iowa-registered community pharmacies whose names and addresses were obtained from the Iowa Board of Pharmacy website. Interviews with pharmacists and other pharmacy staff were conducted at 3 Iowa independent community pharmacies. OUTCOME MEASURES: Pharmacy satisfaction and experiences with the Iowa Medicaid managed care program. RESULTS: The 265 returned surveys yielded a 27.4% response rate. Eight pharmacists and pharmacy staff were interviewed in the qualitative phase. Mean satisfaction with the Medicaid managed care organizations (MCOs) was 3.1 on a scale of 1-7, with 1 being extremely dissatisfied, and 7 being extremely satisfied. Respondents were most satisfied with the ease of joining the plans' pharmacy networks (mean = 4.1) and least satisfied with the availability of payment for nondispensing-related services (2.3), plans' communication with patients (2.7), and plans' communication with pharmacies (3.0). Pharmacies also reported problems with patients' access to prescriptions. The MCOs ranked lowest in satisfaction when compared with the largest private payer, the largest Medicare Part D plan, and the previous state-run Medicaid program. The themes that emerged from the interviews were as follows: confusion caused by multiple MCOs, plan-communication challenges, product-coverage challenges, problems related to durable medical equipment, and payment challenges. CONCLUSION: The transition from a state-run fee-for-service Medicaid program to Medicaid managed care in Iowa created many challenges for community pharmacies. Different procedures and product coverage across the 3 MCOs were particularly problematic.

Factors associated with comprehensive medication review completion rates: A national survey of community pharmacists.

BACKGROUND: Completion rates for medication therapy management (MTM) services have been lower than desired and the Centers for Medicare and Medicaid Services has added MTM comprehensive medication review (CMR) completion rates as a Part D plan star measure. Over half of plans utilize community pharmacists via contracts with MTM vendors. OBJECTIVES: The primary objective of this survey study was to identify factors associated with the CMR completion rates of community pharmacies contracted with a national MTM vendor. METHODSL: Representatives from 27,560 pharmacy locations contracted with a national MTM vendor were surveyed. The dependent variable of interest was the pharmacies' CMR completion rate. Independent variables included the pharmacy's progressiveness stratum and number of CMRs assigned by the MTM vendor during the time period, as well as self-reported data to characterize MTM facilitators, barriers, delivery strategies, staffing, selected items from a modified Assessment of Chronic Illness Care, and pharmacist/pharmacy demographics. Univariate negative binomial models were fit for each independent variable, and variables significant at p < 0.05 were entered into a multivariable model. RESULTS: Representatives from 3836 (13.9%) pharmacy locations responded; of these, 90.9% (n = 3486) responses were useable. The median CMR completion rate was 0.42. Variables remaining significant at p < 0.05 in the multivariable model included: progressiveness strata; pharmacy type; scores on the facilitators scale; responses to two potential barriers items; scores on the patient/caregiver delivery strategies sub-scale; providing MTM at multiple locations; reporting that the MTM vendor sending the survey link is the primary MTM vendor for which the respondent provides MTM; and the number of hours per week that the pharmacy is open. CONCLUSIONS: Factors at the respondent (e.g., responses to facilitators scale) and pharmacy (e.g., pharmacy type) levels were associated with CMR completion rates. These findings could be used by MTM stakeholders to improve CMR completion rates.

Alerts for community pharmacist-provided medication therapy management: recommendations from a heuristic evaluation.

BACKGROUND: Medication therapy management (MTM) is a service, most commonly provided by pharmacists, intended to identify and resolve medication therapy problems (MTPs) to enhance patient care. MTM is typically documented by the community pharmacist in an MTM vendor's web-based platform. These platforms often include integrated alerts to assist the pharmacist with assessing MTPs. In order to maximize the usability and usefulness of alerts to the end users (e.g., community pharmacists), MTM alert design should follow principles from human factors science. Therefore, the objectives of this study were to 1) evaluate the extent to which alerts for community pharmacist-delivered MTM align with established human factors principles, and 2) identify areas of opportunity and recommendations to improve MTM alert design. METHODS: Five categories of MTM alerts submitted by community pharmacists were evaluated: 1) indication, 2) effectiveness; 3) safety; 4) adherence; and 5) cost-containment. This heuristic evaluation was guided by the Instrument for Evaluating Human-Factors Principles in Medication-Related Decision Support Alerts (I-MeDeSA) which we adapted and contained 32 heuristics. For each MTM alert, four analysts' individual ratings were summed and a mean score on the modified I-MeDeSA computed. For each heuristic, we also computed the percent of analyst ratings indicating alignment with the heuristic. We did this for all alerts evaluated to produce an "overall" summary of analysts' ratings for a given heuristic, and we also computed this separately for each alert category. Our results focus on heuristics where ≤50% of analysts' ratings indicated the alerts aligned with the heuristic. RESULTS: I-MeDeSA scores across the five alert categories were similar. Heuristics pertaining to visibility and color were generally met. Opportunities for improvement across all MTM alert categories pertained to the principles of alert prioritization; text-based information; alarm philosophy; and corrective actions. CONCLUSIONS: MTM alerts have several opportunities for improvement related to human factors principles, resulting in MTM alert design recommendations. Enhancements to MTM alert design may increase the effectiveness of MTM delivery by community pharmacists and result in improved patient outcomes.

Consumer decision making for using comprehensive medication review services.

OBJECTIVES: To identify main factors associated with older adults' decision making for using a Medicare Part D comprehensive medication review (CMR) service. DESIGN: Cross-sectional self-administered mailed survey. SETTING AND PARTICIPANTS: The survey was conducted from December 2016 to February 2017. Sampled subjects were 1) at least 65 years of age, 2) taking at least 1 prescription medication, and 3) a Medicare Part D beneficiary living in Florida (n = 310), Washington (n = 310), Wisconsin (n = 310), or Pennsylvania (n = 310) or active members of an Iowa senior registry (n = 460). MAIN OUTCOME MEASURES: Responses to survey items assessing factors in the domains of internal need, external influences, perceived risks of using CMRs, and alternatives comparison that may affect older adults' decision to use CMRs. RESULTS: The overall completed response rate was 24% (n = 381). About 28% of respondents (n = 105) reported being a CMR recipient. Recommendations from a pharmacist (P < 0.0001) or a physician (P = 0.0350), pharmacist's communication in previous encounters (P = 0.0007), perceived susceptibility to medication-related problems (P < 0.0001), and positive outcome expectancy (P = 0.0147) were positively associated with consumers' decision to participate in CMRs, whereas perceived functional risk (P < 0.0001), access to general counseling in previous experiences (P = 0.0145), and family or friends' influence (P = 0.0065) were negatively associated factors. CONCLUSION: CMR uptake remains low after being available for years. Recommendations from health professionals and understanding of service benefits were identified as main factors affecting consumers' decision making for participating in CMRs. Policy makers could consider 1) seeking collaboration with community pharmacists and physicians and 2) addressing key components and benefits of CMRs in older adults as new promotion strategies.

Variation in Medication Therapy Management Delivery: Implications for Health Care Policy.

BACKGROUND: Medication therapy management (MTM) program evaluations have revealed mixed outcomes, with some studies finding favorable outcomes and others finding no differences between patients who received MTM versus those who did not. One possible reason for outcomes variability is differences in delivery of MTM programs. The Chronic Care Model (CCM) provides a framework for how health care organizations can improve care for the chronically ill through 6 elements: organization of health care, delivery system design, clinical information systems, decision support, self-management, and linkages to community resources. OBJECTIVE: To apply the CCM to understand variation in MTM delivery and formulate policy recommendations. METHODS: This study used a mixed-methods descriptive analysis of MTM delivery. Investigators conducted visits to a purposeful sample of MTM practices to observe MTM and interview participants. The pharmacists and staff of these practices completed a modified Assessment of Chronic Illness Care (ACIC). Pairs of investigators analyzed interview transcripts to identify themes. Demographics and ACIC scores were summarized using descriptive statistics. After analysis, investigators discussed overarching themes and policy implications organized by CCM elements. RESULTS: Seven practices participated, and 87 participants were interviewed. Based on ACIC scores, MTM patient volume, and payer mix, practices were categorized as Early Maturity Level or Later Maturity Level. From the model, organization of health care themes included whether MTM was the practice's core competence, belief/confidence in the MTM process, lack of formal rewards, and the influence of organizational goals and external environment. Delivery system design themes pertained to the extent that MTM processes were formalized. Clinical information systems themes were the extent to which systems were influenced by payers, efficiency strategies, and the accuracy and availability of information. In considering clinical decision support themes, alert design limitations and variation in user approaches to alerts based on experience were noted. We observed strong support for patient self-management; when present, barriers were attributed to the patient, MTM provider, or payer. Referral to community resources was minimal. Numerous policy implications were identified. CONCLUSIONS: Our research identified numerous ways by which MTM delivery varies, particularly by MTM practice maturity level. These findings provide evidence for several policy changes that could be considered to optimize MTM delivery, encourage alignment with the CCM, and promote practice maturation. DISCLOSURES: This research and a portion of Snyder's salary were supported by grant number K08HS022119 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. Snyder reports consulting fees from Westat for an evaluation of the CMS Enhanced MTM program. The other authors have nothing to disclose. Portions of this research have been presented as abstracts at the following conferences: (a) 2017 Academy Health Annual Research Meeting; June 25-27, 2017; New Orleans, LA; (b) 2015 American Society of Health-System Pharmacists Clinical Midyear Meeting; December 4-8, 2015; New Orleans, LA; and

Continuous Medication Monitoring (CoMM): A foundational model to support the clinical work of community pharmacists.

BACKGROUND: Under the Continuous Medication Monitoring (CoMM) approach, community pharmacists prevent, identify, resolve, and document drug therapy problems during the dispensing process. OBJECTIVE: To describe the patients receiving CoMM interventions and the pattern of delivery of CoMM interventions. METHODS: Pharmacy dispensing and clinical records were reviewed for patients filling at least one prescription and receiving at least one continuous medication monitoring intervention at a community pharmacy from April 2014 through March 2015. The proportion of patients receiving an intervention type and the number of interventions per patient were computed. RESULTS: Nearly 2500 patients received 16,986 continuous medication monitoring interventions over the year. The average age of the patients receiving the interventions was 59.1 years, and they filled an average of 8.0 unique medications. An average of 6.8 interventions was delivered to each patient. About half (49.7%) of interventions addressed drug therapy problems. The pharmacists delivered 3.0 patient counseling and education and 3.4 drug therapy problem interventions per patient on average. CONCLUSION: There are many opportunities to improve patients' medication use that can be identified and addressed under a Continuous Medication Monitoring model. Movement to this model of practice is desirable, but changes are needed to facilitate the shift.

Pharmacy performance while providing continuous medication monitoring.

OBJECTIVES: The aim of this work was to assess the effects of continuous medication monitoring (CoMM) on: 1) total costs of care; 2) proportion of days covered (PDC) rates; and 3) use of high-risk medications by older patients. DESIGN: Cohort design. SETTING AND PARTICIPANTS: A reimbursed CoMM program was implemented in a community pharmacy to manage problems with medications being dispensed to beneficiaries of a commercial insurer. Pharmacists assessed medications being dispensed, interacted with patients in the pharmacy, and documented their actions. Claims data compared the pharmacy performance for 3 study groups after 12 months of CoMM: group 1, patients with prescriptions dispensed only at the study pharmacy; group 2, patients with prescriptions dispensed from the study pharmacy and other pharmacies; and group 3, patients with no prescriptions dispensed by the study pharmacy. For the analyses, individuals in group 1 (CoMM-only group) were matched with those in group 2 and group 3 by age band, gender, risk category, and utilization band. MAIN OUTCOME MEASURES: The variables of interest were per-member per-month total health care costs, medication adherence (PDC), and the use of high-risk medications in older adults. RESULTS: At 12 months, per-member per-month total costs of care were significantly lower (P < 0.05) for group 1 versus group 2 ($309 difference) and for group 1 versus group 3 ($298 difference). At 12 months the average PDC for group 1 was significantly higher than for group 2 (3.8% difference) and group 3 (2.6% difference). No significant differences were found in the use of high-risk medications. CONCLUSION: A CoMM program in a community pharmacy was associated with lower total costs of care and better medication adherence. Paying pharmacists to proactively address the safety, effectiveness, and adherence of medications at the time of dispensing can support optimization of medication therapy.

Informal learning processes in support of clinical service delivery in a service-oriented community pharmacy.

The evolving health care system necessitates pharmacy organizations' adjustments by delivering new services and establishing inter-organizational relationships. One approach supporting pharmacy organizations in making changes may be informal learning by technicians, pharmacists, and pharmacy owners. Informal learning is characterized by a four-step cycle including intent to learn, action, feedback, and reflection. This framework helps explain individual and organizational factors that influence learning processes within an organization as well as the individual and organizational outcomes of those learning processes. A case study of an Iowa independent community pharmacy with years of experience in offering patient care services was made. Nine semi-structured interviews with pharmacy personnel revealed initial evidence in support of the informal learning model in practice. Future research could investigate more fully the informal learning model in delivery of patient care services in community pharmacies.

Influences on the frequency and type of community pharmacy services.

OBJECTIVES: To describe services provided by community pharmacies and to identify factors associated with services being provided in community pharmacies. DESIGN: Cross-sectional national mail survey. SETTING AND PARTICIPANTS: Pharmacists actively practicing in community pharmacies (independent, chain, mass merchandisers, and supermarkets). OUTCOME MEASURES: Frequency and type of pharmacy services available in a community pharmacy, including medication therapy management, immunization, adjusting medication therapy, medication reconciliation, disease state management, health screening or coaching, complex nonsterile compounding, and point-of-care testing. RESULTS: With a 48.4% response rate, the survey showed that community pharmacies offered on average 3 of the 8 services studied. Pharmacy chains and supermarket pharmacies reported providing significantly more services than did mass merchandise pharmacies. The number of pharmacy services provided was positively associated with involvement in an interprofessional care team, innovativeness, and perceived workload. The number of pharmacy services was negatively correlated with having 3.5 or more pharmacy technicians on duty. CONCLUSION: Pharmacy chains and supermarkets are providing the most pharmacy services among community pharmacy settings. The number of services provided was associated with innovativeness, technician staffing, and perceived workload. Also, involvement with an interprofessional care team supported greater service delivery. Community pharmacies vary in their provision of services beyond dispensing.

Effect of Clinical and Attitudinal Characteristics on Obtaining Comprehensive Medication Reviews.

BACKGROUND: Comprehensive medication reviews (CMRs) consist of in-depth reviews of patients' medications to identify effectiveness or safety problems and often generate cost savings for individuals. Despite their advantages, CMRs are not widely obtained. Previous studies found that older age, female sex, and experience of side effects were associated with obtaining a medication review. OBJECTIVE: To quantify the association between attitudinal and clinical factors with intention and predict future behavior to obtain a CMR among Medicare Part D beneficiaries. METHODS: A sample of Medicare Part D beneficiaries from 1 health care plan (n = 660) completed a 14-item survey over the telephone assessing factors that were hypothesized to affect their intention and behavior to obtain a CMR. The survey collected medication use history and health care information with the medication user self-evaluation tool, health status, adherence, intention to obtain a CMR, and demographic characteristics. Subjects subsequently were informed that they could obtain a CMR from their pharmacies. Claims data were obtained that indicated which subjects received a CMR. Two dependent variables were predicted: intention to schedule a CMR using a multivariate linear regression model and receipt of a CMR using a logistic regression and including intention as a predictor variable. RESULTS: The mean age of participants was 76.6 (SD = 7.61) years; 71% were female; and participants took an average of 5.2 (SD = 3.18) medications. The intention to have a CMR was 2.85 (SD = 1.41) on a 5-point scale, and 5.6% of the participants actually had a CMR. Worrying about medications doing more harm than good, number of pharmacies where participants obtained their medications from, number of medications, and number of medical conditions predicted intention to obtain a CMR. Patients who perceived their health status to be poorer compared with others their age were more likely to have a CMR. Intention to obtain a CMR was not associated with receipt of a CMR. CONCLUSIONS: Stakeholders should target patients who perceive their health to be poor for a CMR, hence expanding the scope of CMRs and increasing the number of older adults benefiting from this service. DISCLOSURES: This study was funded by a grant from the Agency for Healthcare Research and Quality (1R18HS018353). Frank is an employee of Outcomes MTM. Pendergast has received grants from the NIH, NIA, and PICORI. Farris has received grants from NIH and speaker fees from Chulalongkorn University, Bangkok, Thailand, and the American College of Clinical Pharmacy. All other authors declare that they have no conflicts of interest. Study concept was developed by Farris, Pendergast, Chrischilles, and Doucette. Pendergast, Frank, Farris, and Aneese collected the data, with assistance from Chrischilles and Doucette. Data interpretation was performed by Farris, Marshall, Salgado, and Aneese, with assistance from the other authors. The manuscript was written by Farris, Salgado, and Aneese, with assistance from the other authors, and revised by Salgado and Marshall, assisted by the other authors.

Estimating the cost of unclaimed electronic prescriptions at an independent pharmacy.

OBJECTIVES: The increasing rate of e-prescribing is associated with a significant number of unclaimed prescriptions. The costs of unclaimed e-prescriptions could create an unwanted burden on community pharmacy practices. The objective of this study was to calculate the rate and costs of filled but unclaimed e-prescriptions at an independent pharmacy. METHODS: This study was performed at a rural independent pharmacy in a Midwestern state. The rate and costs of the unclaimed e-prescriptions were determined by collecting information about all unclaimed e-prescriptions for a 6-month period from August 2013 to January 2014. The costs of unclaimed prescriptions included those expenses incurred to prepare the prescription, contact the patient, and return the unclaimed prescription to inventory. Two sensitivity analyses were conducted. RESULTS: The total cost of 147 unclaimed e-prescriptions equaled $3,677.70 for the study period. Thus, the monthly cost of unclaimed e-prescriptions was $612.92 and the average cost of each unclaimed prescription was $25.02. The sensitivity analyses showed that using a technician to perform prescription return tasks reduced average costs to $19.33 and that using a state Medicaid cost of dispensing resulted in average costs of $18.54 per prescription. The rate of unclaimed e-prescriptions was 0.82%. CONCLUSION: The percentage of unclaimed e-prescriptions in this pharmacy was less than 1%. In addition to increased cost, unclaimed e-prescriptions add inefficiency to the work flow of the pharmacy staff, which can limit the time that they are available for performing revenue-generating activities. Adjustments to work flow and insurer policies could help to reduce the burden of unclaimed e-prescriptions.