Successful Development and Implementation of a Large Virtual Interprofessional Education Activity Applying the Social Determinants of Health.

Interprofessional education (IPE) activities provide students insight into healthcare teams, shared decision-making, and social determinants of health (SDOH). Virtual IPE activities with large student populations or across multicampus have not been evaluated. The study aimed to explore the interprofessional competency growth in students, across several disciplines, following participation in a large-scale, virtual IPE activity. Students from pharmacy, medicine, social work, and physician assistant programs across Tennessee participated in an IPE patient case and SDOH in fall 2020 and fall 2021. Pre- and postsurveys included Likert ranking of 16 statements based on the 2011 Interprofessional Education Collaborative (IPEC) framework. A total of 607 students completed surveys (overall response rate, 76%). Wilcoxon signed-rank tests were performed on the pre-/postsurvey data, in aggregate and by discipline. Significant increases in all IPEC competency statements were seen, both in aggregate (100% of statements with p < 0.001) and in pharmacy (100% of statements with p < 0.001) and medicine subgroups (94% of statements with p < 0.001). Implementing large virtual IPE activities involving a complex patient case and SDOH significantly increased student IPEC competency outcomes for participating students, whether in aggregate or on a discipline-specific basis.

Improving Pharmacy Students' Clinical Knowledge on Providing Care for Patients Belonging to the LGBTQ+ Community.

A 12-question survey instrument was developed, pilot-tested, and administered to 191 pharmacy students in their first professional year after engaging in a learning activity focusing on topics across five categories with clinical relevance to providing care to the LGBTQ+ community. A paired student t-test was performed on survey tool pre-test and post-test survey responses, with p < 0.05 considered significant. A total of 183 usable pre-test and post-test survey responses were received. Statistically significant differences between the pre-test and post-test correct responses were observed for scenarios involving proper pronoun use, hormone therapy (HT) counseling, immunization best practices, and communication hesitancy. The greatest knowledge change was reported in the categories of immunization best practices (48.9%), HT counseling (33.6%), and pronoun use (22.8%). Active learning assignments are effective teaching strategies to promote clinical knowledge in providing inclusive and culturally competent care to LGBTQ+ patients. Clinical topic areas including proper pronoun use, HT counseling, immunization best practices, privacy, risk awareness, and communication hesitancy are effective curricula additions for pharmacy colleges to advance inclusive curricula concerning providing care to the LGBTQ+ community.

Use of Rapid Assessment Procedures when analyzing qualitative data in pharmacy research.

Qualitative research analytics and methodology are a useful part of many research projects. However, qualitative data analysis may be time intensive causing delays in results. This is especially problematic in time-sensitive projects where there an urgent need for results and a rapidly evolving situation being studied, such as during health crisis or early stages of project implementation. An emerging body of literature around the use of Rapid Assessment Procedures (RAP) suggests that this method of qualitative assessment provides more efficient coding and categorizing of data without comprising rigor. The objectives of this manuscript are to: 1) describe how RAP can be used in pragmatic healthcare research studies and 2) provide an example of when RAP was applied to a qualitative research study in the healthcare setting. RAP includes 5 core features: 1) use in combination with quantitative outcomes or process data (mixed methods approach), 2) quick timeline from start to finish (weeks to months), 3) population of interest participation in planning and implementing the research, 4) team approach to research process, and 5) iterative cycle of data collection and analysis. Use of RAP provides key stakeholders and decision makers the ability to generate solutions to problems faster than ever before without compromising rigor, a method needed now more than ever. The progression of healthcare and clinical management is moving at an unprecedented rate, and RAP allows researchers to stay ahead by providing quicker results for better outcomes.

The Tennessee Medicaid medication therapy management program: early stage contextual factors and implementation outcomes.

BACKGROUND: First investigated in the 1990s, medication therapy management (MTM) is an evidence-based practice offered by pharmacists to ensure a patient's medication regimen is individualized to include the safest and most effective medications. MTM has been shown to a) improve quality of patient care, b) reduces health care costs, and c) lead to fewer medication-related adverse effects. However, there has been limited testing of evidence-based, a-priori implementation strategies that support MTM implementation on a large scale. METHODS: The study has two objectives assessed at the organizational and individual level: 1) to determine the adoption, feasibility, acceptability and appropriateness of a multi-faceted implementation strategy to support the MTM pilot program in Tennessee; and 2) to report on the contextual factors associated with program implementation based on the Consolidated Framework for Implementation Research (CFIR). The overall design of the study was a hybrid type 2 effectiveness-implementation study reporting outcomes of Tennessee state Medicaid's (TennCare) MTM Pilot program. This paper presents early stage implementation outcomes (e.g., adoption, feasibility, acceptability, appropriateness) and explores implementation barriers and facilitators using the CFIR. The study was assessed at the (a) organizational and (b) individual level. A mixed-methods approach was used including surveys, claims data, and semi-structured interviews. Interview data underwent initial, rapid qualitative analysis to provide real time feedback to TennCare leadership on project barriers and facilitators. RESULTS: The total reach of the program from July 2018 through June 2020 was 2033 MTM sessions provided by 17 Medicaid credentialed pharmacists. Preliminary findings suggest participants agreed that MTM was acceptable (µ = 16.22, SD = 0.28), appropriate (µ = 15.33, SD = 0.03), and feasible (µ = 14.72, SD = 0.46). Each of the scales had an excellent level of internal (> 0.70) consistency (feasibility, α = 0.91; acceptability, α = 0.96; appropriateness, α = 0.98;). Eight program participants were interviewed and were mapped to the following CFIR constructs: Process, Characteristics of Individuals, Intervention Characteristics, and Inner Setting. Rapid data analysis of the contextual inquiry allowed TennCare to alter initial implementation strategies during project rollout. CONCLUSION: The early stage implementation of a multi-faceted implementation strategy to support delivery of Tennessee Medicaid's MTM program was found to be well accepted and appropriate across multiple stakeholders including providers, administrators, and pharmacists. However, as the early stage of implementation progressed, barriers related to relative priority, characteristics of the intervention (e.g., complexity), and workflow impeded adoption. Programmatic changes to the MTM Pilot based on early stage contextual analysis and implementation outcomes had a positive impact on adoption.

Screening for social determinants of health in community pharmacy: Identifying best practices, barriers, and strategies for success.

The social determinants of health (SDOH) play a key role in patients' access to health care and medications. There exists an area of opportunity to leverage community pharmacists to make a large impact in identifying and incorporating an understanding of a patient's SDOH into their treatment plan. Community pharmacies are accessible and trusted avenues for health care interventions. With the advancement of appointment-based models as well as the increased training of support personnel, community pharmacies may be well suited for this public health task. However, there are major challenges such as paradigm shifts in workflow, reimbursement, and training that must be addressed to make this endeavor successful. This commentary explores the sparse literature related to community pharmacists conducting screening for social risk factors to identify best practices and barriers to implementation and outlines how screening for social needs aligns with the Pharmacists' Patient Care Process.

Impact of STEADI-Rx: A Community Pharmacy-Based Fall Prevention Intervention.

OBJECTIVES: To evaluate the effects of a community pharmacy-based fall prevention intervention (STEADI-Rx) on the risk of falling and use of medications associated with an increased risk of falling. DESIGN: Randomized controlled trial. SETTING: A total of 65 community pharmacies in North Carolina (NC). PARTICIPANTS: Adults (age ≥65 years) using either four or more chronic medications or one or more medications associated with an increased risk of falling (n = 10,565). INTERVENTION: Pharmacy staff screened patients for fall risk using questions from the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) algorithm. Patients who screened positive were eligible to receive a pharmacist-conducted medication review, with recommendations sent to patients' healthcare providers following the review. MEASUREMENTS: At intervention pharmacies, pharmacy staff used standardized forms to record participant responses to screening questions and information concerning the medication reviews. For participants with continuous Medicare Part D/NC Medicaid coverage (n = 3,212), the Drug Burden Index (DBI) was used to assess exposure to high-risk medications, and insurance claims records for emergency department visits and hospitalizations were used to assess falls. RESULTS: Among intervention group participants (n = 4,719), 73% (n = 3,437) were screened for fall risk. Among those who screened positive (n = 1,901), 72% (n = 1,373) received a medication review; and 27% (n = 521) had at least one medication-related recommendation communicated to their healthcare provider(s) following the review. A total of 716 specific medication recommendations were made. DBI scores decreased from the pre- to postintervention period in both the control and the intervention group. However, the amount of change over time did not differ between these two groups (P = .66). Risk of falling did not change between the pre- to postintervention period or differ between groups (P = .58). CONCLUSION: We successfully implemented STEADI-Rx in the community pharmacy setting. However, we found no differences in fall risk or the use of medications associated with increased risk of falling between the intervention and control groups. J Am Geriatr Soc 68:1778-1786, 2020.

A Scoping Review of Active-Learning Strategies for Teaching Social Determinants of Health in Pharmacy.

Objective. To review current conceptualizations and measurements of active-learning education within Doctor of Pharmacy degree programs as it pertains to social determinants of health (SDOH) and to determine the gaps and limitations in available literature. A secondary objective was to assess simulation-based educational methods related to SDOH in pharmacy.Findings. Sixteen articles were eligible for inclusion. Many simulation-based and non-simulation-based teaching strategies are described. The majority of articles included active-learning activities related to social/community context and health/health care, the other three 3 social determinants of health domains: education, economic stability, and neighborhood/built community, were not equally addressed. In the studies included in this review, schools and colleges of pharmacy did not appear to not be integrating all five components of SDOH into active learning curricula. The sparsity of literature and lack of diversity in published types of simulated experiences and assessments may suggest there is room for innovation in this area.Summary. More research is needed in order to fully characterize conceptualizations of social determinants of health in Doctor of Pharmacy degree programs in order to ensure students are provided with a full understanding of the SDOH factors that affect patient outcomes.

The Tennessee medication therapy management program: A hybrid type 2 effectiveness-implementation trial study protocol.

BACKGROUND: Pharmacist-led medication therapy management (MTM) programs are considered evidence-based and have clearly defined core components. Despite this, MTM programs are often implemented without fidelity due to notable implementation barriers, such as physician-pharmacist relationships and pharmacist access to patient medical records. To improve MTM implementation, the Tennessee Medicaid program developed a MTM intervention that incorporates implementation strategies to address some of the known barriers to implementation (e.g., formalizing pharmacist-physician relationships through collaborative practice agreements, ensuring pharmacists' access to medical records). OBJECTIVES: The purpose of this hybrid type 2 effectiveness-implementation study is to (1) assess the effectiveness of the MTM pilot program in Tennessee (e.g., medication adherence, healthcare utilization, quality and cost of care) and (2) assess the implementation of the MTM pilot program (e.g., feasibility, appropriateness, acceptability, penetration). METHODS: The Tennessee MTM pilot program is being assessed as a hybrid type 2 effectiveness-implementation study with a quasi-experimental design. A mixed methods approach (QUAN + QUAL) for the purpose of complementarity (e.g., answering related research questions). Data will include surveys, interviews, MTM platform encounter information, and medical and pharmacy claims. Initial analyses will include data between January 2018 and December 2019. CONCLUSION: The study will further add to the evidence base of MTM interventions by testing an intervention that addresses known barriers to implementation and simultaneously collecting data on effectiveness and implementation to speed up MTM translation. The Tennessee MTM program is expected to serve as a guide to other states seeking to expand pharmacist-delivered clinical services to their Medicaid members, particularly those intending to incorporate MTM into programs seeking to improve primary care delivery. Further, by improving the implementation of MTM, the pilot program is expected to improve the reliability of MTM program benefits including healthcare quality and cost and patient outcomes.

Implementation process for comprehensive medication review in the community pharmacy setting.

OBJECTIVES: To (1) describe the implementation process for comprehensive medication reviews (CMRs) among community pharmacies (e.g., processes for prioritizing patients, staffing, and information collection) and (2) examine factors associated with community pharmacies' CMR information collection process. METHODS: A survey was administered to the pharmacist responsible for implementation of CMRs (i.e., the lead pharmacist) in the community pharmacy (n = 87). The survey included questions about pharmacy characteristics, satisfaction with the NC community pharmacy enhanced services network (NC-CPESN) program, and implementation of CMRs. Frequencies and means were calculated to describe the sample characteristics and pharmacies' CMR implementation process. A multiple linear regression was conducted to examine which characteristics were associated with the CMR information collection process. RESULTS: The majority of pharmacies in the sample were either independently owned single stores (46.5%) or multiple stores under the same independent ownership (41.6%). Most pharmacies used pharmacists (97.7%) or pharmacy technicians (65.5%) for patient outreach for CMRs. A small percentage of pharmacies used administrative staff to conduct patient outreach for CMRs (9.2%). Information for prescription medications (89.5%), indication (80%), and medication adherence (81.1%) was routinely collected. Information such as date of last dose for prescription medications (48.4%) and lifestyle factors, such as physical activity (21.1%), diet (29.5%), and alcohol (31.6%), was collected less routinely. Having a clinical pharmacist (P = 0.025) and pharmacist overlap hours (P = 0.009) significantly improved the CMR information collection process. CONCLUSION: Although CMRs are important interventions for improving patient outcomes, more guidance is needed on how to effectively implement them. This would allow the process to be efficient and assure implementation with fidelity across all community pharmacies. In addition, staffing appears to influence the quality of CMR information collection. Future research is warranted on CMR implementation to develop efficient staffing models and standardize the process of information collection.

Do comprehensive medication review completion rates predict medication use and management quality?

OBJECTIVES: Little is known about how Medicare Part D Comprehensive Medication Review (CMR) affects quality of medication use and management. In this study, changes of plan level CMR completion rates over time were examined and their associations with medication use and management related (MUMR) quality measures. METHODS: Using Medicare Part D plan Star Rating and contract information data, a longitudinal data set was developed with CMR completion rate and 17 MUMR measures. T-tests and one-way Analysis of Variance were used to examine the variation of CMR rates between contracts and over time, respectively, as well as the regression adjusted associations using fixed-effects and ordinary least squares models, verified by Generalized Estimating Equations. RESULTS: CMR completion rates increased substantially from contract year 2013-2016, with a larger increase among Medicare Advantage Prescription Drug Plans than stand-alone Prescription Drug Plans. Prior year's CMR completion rates had marginally positive effects on 4 of the 17 MUMR measures: medication adherence with statin drugs, continuous beta blocker treatment, and pharmacotherapy management of chronic obstructive pulmonary disease exacerbation (systemic corticosteroid or bronchodilator). Increasing CMR completion also was associated with increased chronic use of atypical antipsychotics by elderly beneficiaries in nursing homes, an unintended outcome and a reflection of poor quality of care. CMR completion rates in the same year had even more limited associations with other MUMR measures. CONCLUSIONS: At plan level, CMR completion rates had limited and inconsistent association with other MUMR measures. Although our research used an observational study design, the associations observed have policy implications to the Center for Medicare & Medicaid (CMS) Star Ratings program and quality bonus payments, as well as implications for plans' quality improvement.

Systematic review of medication synchronization in community pharmacy practice.

BACKGROUND: Medication non-adherence costs more than 100 billion dollars in avoidable hospitalizations yearly. As a result, community pharmacies have implemented medication synchronization programs to improve adherence. One function of most medication synchronization programs is the alignment of all of a patient's medications to refill on a single date. While aligning refills is a standard aspect of most programs, other features vary making it difficult to identify which program components lead to improved adherence. OBJECTIVE: To review available literature and identify core components of medication synchronization and associated implementation techniques in community pharmacy. METHODS: A systematic review was performed by searching electronic databases for studies, reviews, and other sources for grey literature discussing medication synchronization in community pharmacy settings. Studies were eligible for inclusion if they documented the operation of medication synchronization program in a community pharmacy. A framework analysis identified common themes present in the literature. RESULTS: Twenty-six studies met criteria for final inclusion in this review. The majority of studies were retrospective cohorts, commentaries, and implementation guides. A wide variety of core components were included as part of medication synchronization program descriptions in the available literature. Several core components were identified as consistent throughout most of the published literature. These components were the identification and enrollment of patients, inclusion of a medication review and patient assessment, the alignment of refills, a formal process for preparation of medications, and the delivery of medications and other services. CONCLUSIONS: This review identified several common themes of medication synchronization in the literature, which could help standardize medication synchronization within community pharmacy and facilitate future research. Themes found in this review provide the foundation upon which a consensus definition of medication synchronization can be built.

Testing the organizational theory of innovation implementation effectiveness in a community pharmacy medication management program: a hurdle regression analysis.

BACKGROUND: Many state Medicaid programs are implementing pharmacist-led medication management programs to improve outcomes for high-risk beneficiaries. There are a limited number of studies examining implementation of these programs, making it difficult to assess why program outcomes might vary across organizations. To address this, we tested the applicability of the organizational theory of innovation implementation effectiveness to examine implementation of a community pharmacy Medicaid medication management program. METHODS: We used a hurdle regression model to examine whether organizational determinants, such as implementation climate and innovation-values fit, were associated with effective implementation. We defined effective implementation in two ways: implementation versus non-implementation and program reach (i.e., the proportion of the target population that received the intervention). Data sources included an implementation survey administered to participating community pharmacies and administrative data. RESULTS: The findings suggest that implementation climate is positively and significantly associated with implementation versus non-implementation (AME = 2.65, p < 0.001) and with program reach (AME = 5.05, p = 0.001). Similarly, the results suggest that innovation-values fit is positively and significantly associated with implementation (AME = 2.17, p = 0.037) and program reach (AME = 11.79, p < 0.001). Some structural characteristics, such as having a clinical pharmacist on staff, were significant predictors of implementation and program reach whereas other characteristics, such as pharmacy type or prescription volume, were not. CONCLUSIONS: Our study supported the use of the organizational theory of innovation implementation effectiveness to identify organizational determinants that are associated with effective implementation (e.g., implementation climate and innovation-values fit). Unlike broader environmental factors or structural characteristics (e.g., pharmacy type), implementation climate and innovation-values fit are modifiable factors and can be targeted through intervention-a finding that is important for community pharmacy practice. Additional research is needed to determine what implementation strategies can be used by community pharmacy leaders and practitioners to develop a positive implementation climate and innovation-values fit for medication management programs.

Development of a medication synchronization common language for community pharmacies.

OBJECTIVES: To develop a common language for the medication synchronization process in community pharmacies. METHODS: A systematic and iterative process was used to create and refine a common language for medication synchronization. First, a review of all available medication synchronization-related documents was completed. Second, a systematic scoping literature review was conducted to determine what core components of medication synchronization have been implemented by community pharmacies. Third, semistructured interviews were conducted with community pharmacists and key stakeholders to identify principles and successful practices. Findings from the document review, systematic scoping review, and semistructured interviews were integrated to develop a medication synchronization common language. Finally, researchers and key stakeholders refined the initial draft by means of a systematic process. RESULTS: This process generated a medication synchronization common language that includes common language for the philosophy and values of medication synchronization. This profile also includes descriptions of core components with activities to be conducted for each of the identified 5 core components. The 5 core components are: 1) identification and enrollment of patients; 2) completion of a medication review and patient assessment; 3) alignment of medication refills; 4) preparation for medication delivery; and 5) delivery of medication and other services. CONCLUSION: The development of a common language for medication synchronization will allow for the promotion of consistency in implementation and operation of these programs across community pharmacies. Consistency in implementation will allow for better interpretation of patient outcomes such as adherence and other clinical measures.

Supporting Community Pharmacies with Implementation of a Web-Based Medication Management Application.

OBJECTIVE: Community pharmacists' role in clinical care is expanding in the United States and information systems are needed that extend beyond a dispensing workflow. As pharmacies adopt new systems, implementation support will be needed. This study identifies the barriers and facilitators experienced by community pharmacies in implementing a Web-based medication management application and describes the implementation strategies used to support these pharmacies. METHODS: Semistructured interviews were conducted with 28 program and research staff that provides support to community pharmacies participating in a statewide pharmacy network. Interviews were recorded, transcribed verbatim, and analyzed for themes using the Expert Recommendations for Implementing Change (ERIC). RESULTS: Findings suggest that leadership support, clinical training, and computer literacy facilitated implementation, while lack of system integration, staff resistance to change, and provider reluctance to share data served as barriers. To overcome the barriers, implementation support was provided, such as assessing readiness for implementation, developing a standardized and interoperable care plan, and audit and feedback of documentation quality. CONCLUSION: Participants used a wide array of strategies to support community pharmacies with implementation and tailored approaches to accommodate pharmacy-specific preferences. Most of the support was delivered preimplementation or in the early phase of implementation and by program or research staff rather than peer-to-peer. Implementing new pharmacy information system requires a significant amount of implementation support to help end-users learn about program features, how to integrate the software into workflow, and how to optimize the software to improve patient care. Future research should identify which implementation strategies are associated with program performance.

Description of drug therapy problem resolution in a statewide care management program.

OBJECTIVE: To describe drug therapy problem (DTP) resolution as part of a statewide, team-based care management program. METHODS: This was a retrospective, observational study of DTPs documented between March 1 and August 31, 2015. Data were retrieved from a Web-based platform 5 months after the observation period. DTPs were placed into groups based on the credentials of the person who documented the DTP. Next, they were identified as being documented in a transitional or nontransitional care setting. DTPs were further classified into 1 of 3 categories: medication adherence, discrepancy, or optimization. Lastly, DTP resolution was assessed. Results were analyzed using descriptive statistics. RESULTS: During the 6-month study period, 135,100 DTPs were documented, with 99% (n = 133,847) being documented by social work care managers, nurse care managers, and pharmacy staff personnel. Pharmacy staff personnel documented the majority of DTPs (51.5%), and the majority of DTPs (55%) were identified in the transitional care setting. Nurse care managers resolved more discrepancy DTPs (59.3%), whereas pharmacy staff personnel resolved more optimization DTPs (47.2%). Social work care managers resolved more medication adherence DTPs (68.6%). CONCLUSIONS: Pharmacy staff personnel primarily identified and resolved opportunities to optimize medication use, whereas nurse care managers primarily identified and resolved medication discrepancies. Social work care managers primarily identified and resolved problems related to medication adherence. When each member of the interdisciplinary care team functioned at the top of their license, all types of DTPs were effectively identified and resolved.