Pharmacist assessments and care to improve adult vaccination rates: A report from project IMPACT vaccine confidence.

BACKGROUND: Neglect of vaccination needs among adults results in a needless burden of hospitalization, suffering, and death. America's community pharmacists deliver a substantial portion of adult vaccinations, yet many Americans still have unmet vaccination needs. OBJECTIVES: This study evaluated rates of vaccine contraindications, acceptance, and willingness to be vaccinated among ambulatory adults. PRACTICE DESCRIPTION: This was a prospective, multisite, multistate, observational study conducted in three waves between October 2021 and August 2023. PRACTICE INNOVATION: Pharmacists conducted comprehensive vaccination need assessments. EVALUATION METHODS: The primary outcomes were numbers of vaccination needs per participant and vaccinations administered, scheduled, or declined. RESULTS: Pharmacists identified a mean of 1.8-2.2 unmet vaccination needs per adult assessed, more than in pilot studies. Participants had already received 61%-74% of vaccinations recommended for them hence 26%-39% of needs were unmet at baseline. The leading vaccination needs were COVID-19, influenza, zoster, tetanus-containing, and pneumococcal vaccines. From a baseline mean of 59.1% for these five vaccinations, pharmacists increased the mean percentage vaccinated to 73.2%. When an option for scheduling future vaccination was added to the process, declinations dropped from 46%-18%. CONCLUSION: This study provides insight into adult vaccine acceptance, willingness, and declination behaviors not described elsewhere. Offering options for future vaccination reduced declination rates. Pharmacists resolved substantial proportions of adult vaccination needs. The signal that apportioning adult vaccines needed, but not received on day of assessment, across several months could help resolve unmet vaccination needs warrants additional research, especially with the rising number of vaccines recommended for adults.

Solutions for Atrial Fibrillation Edvocacy (SAFE): Improving Awareness And Access To Afib Screening For Detection And Referral For Treatment.

Background: Atrial Fibrillation (Afib) can lead to stroke and heart failure, and early detection of Afib is an effective method of preventing these life-threatening conditions. An estimated 2.7 million Americans are living with Afib1, a number that is expected to rise dramatically in the coming years. Methods: The aim of this demonstration project was to create an additional access point in the community at local pharmacies for Afib screening, detection, and referral to physicians for follow-up and initiation of evidence-based therapy when appropriate. This prospective research study was conducted with 14 community pharmacies across the US, in which a total of 650 patients were screened for Afib. Pharmacists conducted SAFEty Risk Assessments that consisted of completion of a Stroke Risk Scorecard and EKG determination utilizing AliveCor's KardiaMobile® 6L device. Results: In 552 (82.5%) of 669 total EKG readings, a "normal" rhythm was detected, and in 117 (17.5%) EKG readings an abnormal detection occurred. A total of 12 out of 650 patients (1.8%) received EKG readings of Afib, which is greater than double the expected prevalence of Afib in the US (0.81%), a statistically significant finding (p < 0.0001). Other notable findings included 42 (6.3%) EKG readings of Wide QRS, and 26 (3.9%) EKG readings of tachycardia. A total of 44 patients were referred to physicians for follow-up on their risk for Afib. Conclusions: Community pharmacies offer a unique, valuable access point for patients to receive Afib screenings. Pharmacists are well positioned to make a significant contribution in the cardiovascular health of their patients and increase the value of team-based health care.

Effect of an Innovative Immunization Practice Model to Improve Population Health: Results of the Project IMPACT Immunizations Scaled Demonstration.

Background: U.S. adult vaccination rates remain low. Community pharmacists have skills and opportunity to improve this shortcoming. This study sought to evaluate an innovative practice model on identification of unmet vaccination needs and their resolution. Methods: This prospective, multi-site, multi-state, observational study was conducted in 22 community pharmacy practices in Iowa and Washington. Adults receiving influenza vaccination, medication therapy review, prescriptions for diabetes or cardiovascular disease, or another clinical encounter with a participating pharmacist from December 2017 through November 2019 were included. Pharmacists reviewed vaccination forecasts generated by clinical decision support technology based on their state immunization information system (IIS) to identify unmet vaccination needs, educate patients, and improve vaccination rates. The primary outcomes were numbers of vaccination forecast reviews, patients educated, unmet vaccination needs identified and resolved, and vaccinations administered. Secondary outcomes included numbers of vaccination declinations; times a forecasted vaccine was not recommended because a contraindication was identified by the pharmacist; and times the patients declined a forecasted vaccine due to self-reported vaccination despite lack of documentation in the state IIS. Descriptive statistics were calculated. Results: Pharmacists reviewed vaccination forecasts for 6,234 patients. The vaccination forecasts predicted there were 11,789 vaccinations needed (1.9 per person). 6,405 of the 11,789 unmet vaccination needs (54.3%) were fulfilled during the study period, including 60% on the same day. Of the forecasted needs, 1,085 (9.2%) were found to be previously administered and 59 (0.5%) contraindicated. The remaining patients received information about their personal vaccination needs and recommendations to be vaccinated. Conclusion: Availability of vaccination histories during patient encounters allowed pharmacists to identify and resolve adult vaccination needs in independent and chain community practice settings.

Evaluating the Impact of Year-Long, Augmented Diabetes Self-Management Support.

This was a randomized controlled study to test a scalable intervention model addressing the need for ongoing diabetes support. The study included individuals receiving care in a Federally Qualified Health Center (FQHC) with HbA1c >8. The aim of this project was to determine whether augmenting diabetes self-management education (DSME) with support for an economically vulnerable population might better meet patient needs and reduce morbidity and premature mortality. The intervention utilized pre and post comparisons and was designed to test the efficacy of a telephonic diabetes support intervention to increase patient engagement in self-care and with the health care system as a means to improve clinical outcomes. There were significant improvements in HbA1c, body mass index, low-density lipoprotein cholesterol, triglycerides, and depression screening scores in the year following DSME. However, there was no statistically significant difference between the 2 groups. This randomized controlled study demonstrated that comprehensive face-to-face care with consistent assessment and documentation over time in FQHCs produce clinically significant and predictable improvement for people with diabetes. The addition of structured provision of telephonic support overlapping in time with the comprehensive face-to-face process of care in this environment did not produce statistically significant clinical or behavioral care improvement.

Evaluation of the Impact of an Innovative Immunization Practice Model Designed to Improve Population Health: Results of the Project IMPACT Immunizations Pilot.

The goal of the initiative was to evaluate the impact of an innovative practice model on identification of unmet vaccination needs and vaccination rates. This was accomplished through a prospective, multisite, observational study in 8 community pharmacy practices with adults receiving an influenza vaccine with a documented vaccination forecast review from October 22, 2015 through March 22, 2016. When patients presented for influenza vaccinations, pharmacists utilized immunization information systems (IIS) data at the point of care to identify unmet vaccination needs, educate patients, and improve vaccination rates. The main outcome measures were the number of vaccination forecast reviews, patients educated, unmet vaccination needs identified and resolved, and vaccines administered. Pharmacists reviewed vaccination forecasts generated by clinical decision-support technology based on patient information documented in the IIS for 1080 patients receiving influenza vaccinations. The vaccination forecasts predicted there were 1566 additional vaccinations due at the time patients were receiving the influenza vaccine. Pharmacist assessments identified 36 contraindications and 196 potential duplications, leaving a net of 1334 unmet vaccination needs eligible for vaccination. In all, 447 of the 1334 unmet vaccinations needs were resolved during the 6-month study period, and the remainder of patients received information about their vaccination needs and recommendations to follow up for their vaccinations. Integration of streamlined principle-centered processes of care in immunization practices that allow pharmacists to utilize actionable point-of-care data resulted in identification of unmet vaccination needs, education of patients about their vaccination needs, a 41.4% increase in the number of vaccines administered, and significant improvements in routinely recommended adult vaccination rates.

Patient credentialing as a population health management strategy: a diabetes case study.

When given the opportunity to become actively involved in the decision-making process, patients can positively impact their health outcomes. Understanding how to empower patients to become informed consumers of health care services is an important strategy for addressing disparities and variability in care. Patient credentialing identifies people who have a certain diagnosis and have achieved certain levels of competency in understanding and managing their disease. Patient credentialing was developed to meet 3 core purposes: (1) enhance patient engagement by increasing personal accountability for health outcomes, (2) create a mass customization strategy for providers to deliver high-quality, patient-centered collaborative care, and (3) provide payers with a foundation for properly aligning health benefit incentives. The Patient Self-Management Credential for Diabetes, a first-of-its-kind, psychometrically validated tool, has been deployed within 3 practice-based research initiatives as a component of innovative diabetes care. Results from these projects show improved clinical outcomes, reduced health care costs, and a relationship between credential achievement levels and clinical markers of diabetes. Implementing patient credentialing as part of collaborative care delivered within various settings across the health care system may be an effective way to reduce disparities, improve access to care and appropriate treatments, incentivize patient engagement in managing their health, and expend time and resources in a customized way to meet individual needs.

Improving outcomes for diverse populations disproportionately affected by diabetes: final results of Project IMPACT: Diabetes.

OBJECTIVE: To improve key indicators of diabetes care by expanding a proven community-based model of care throughout high-risk areas in the United States. DESIGN: Observational, multisite, pre-post comparison study. SETTING: Federally qualified health centers, free clinics, employer worksites, community pharmacies, departments of health, physician offices, and other care facilities in 25 communities in 17 states from June 2011 through January 2013. PARTICIPANTS: 1,836 patients disproportionately affected by diabetes representing diverse ethnicities, insurance statuses, and social and economic backgrounds. INTERVENTION: Pharmacists were integrated into local, interdisciplinary diabetes care teams and provided customized diabetes education and medication consultations to patients. MAIN OUTCOME MEASURES: Clinical measures included glycosylated hemoglobin (A1C), body mass index, systolic and diastolic blood pressures, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglycerides, and total cholesterol. Process measures included smoking status, eye examination status, foot examination status, and influenza vaccine status. RESULTS: Pharmacist patient care services for those underserved or disproportionately affected by diabetes resulted in a statistically significant and clinically relevant decrease in mean A1C levels (-0.8%). Other outcome indicators were below target levels at baseline and decreased significantly but not by clinically relevant amounts (LDL-C, -7.1 mg/dL; triglycerides, -23.7 mg/dL, and total cholesterol, -8.8 mg/dL). The mean increase in HDL-C (+0.6 mg/dL) was not statistically significant or clinically relevant. Among evaluable patients who were not at target for process measures at baseline, 51.7% of 453 patients received eye examinations, 72.0% of 271 patients received foot examinations, 41.7% of 307 patients received influenza vaccinations, and 9.3% patients of 270 quit smoking during the project. Of the communities involved in the study, 92% intend to sustain pharmacists' services. CONCLUSION: Project IMPACT: Diabetes results show significant improvement in patients' clinical outcomes and demonstrate that all patients, even those with tremendous barriers to appropriate diabetes care, benefit from patient-centered, interdisciplinary health care teams that include pharmacists.

Integrating pharmacists into diverse diabetes care teams: implementation tactics from Project IMPACT: Diabetes.

OBJECTIVE: To describe local implementation tactics used by the 25 Project IMPACT: Diabetes communities and partnering organizations to help patients who are disproportionately affected by diabetes. SETTING: Care was delivered in 25 communities within 17 states at federally qualified health centers, community pharmacies, free clinics, employer work sites, medical clinics, physician offices, and other settings. PRACTICE DESCRIPTION: In addition to pharmacists, practices included physicians, nurse practitioners, dietitians, physician assistants, social workers, behavioral therapists, and other types of health professionals. Insurance status and the predominant ethnicity of patients differed between communities. Each community had at least one community champion responsible for leading local implementation who was supported by an American Pharmacists Association Foundation community coordinator and Foundation staff. PRACTICE INNOVATION: The key innovations within each of the 25 communities were the integration of pharmacists on diabetes care teams, use of the Patient Self-Management Credential for Diabetes at baseline, and collection of a standardized minimum dataset. Communities deployed other practice innovations to support the care model, including group education classes, grocery store tours, joint provider visits, and provision of patient incentives. EVALUATION: The specific components of each community's implementation and innovation were aggregated via postproject surveys. Clinical and process measures were also collected and are published separately. RESULTS: Each community is characterized based on the people involved and the care delivered. Aspects of the communities described include health care provider teams, population characteristics, practice settings, care components, data collection methods, incentives provided, and self-reported service sustainability. CONCLUSION: Pharmacists can be integrated successfully into a diverse array of practice settings and teams to help a wide variety of patients through the provision of team-based, patient-centered care. Flexibility in implementation strategies allows for customization of the care provided to best meet population needs.

Clinical and economic outcomes of a pilot project examining pharmacist-focused collaborative care treatment for depression.

OBJECTIVE: To assess the clinical and economic impact of a pharmacist-focused health management program for patients with depression. DESIGN: Prospective, nonrandomized, proof-of-concept investigation. SETTING: Asheville, NC, from July 2006 through December 2007. PARTICIPANTS: Employees or adult dependents with depressive symptoms who agreed to enroll in an employer-sponsored treatment program conducted at two ambulatory clinics where consultative services were provided. Participants were included in the analysis if they participated in the program for at least 1 year and had two or more documented visits with a pharmacist. INTERVENTION: Outpatient-based pharmacists provided assessment, self-management services follow-up, and treatment recommendations to primary care providers within a collaborative care management model. MAIN OUTCOME MEASURES: Changes in severity of depressive symptoms and impact on overall health care costs for employers and beneficiaries. RESULTS: Of the 151 beneficiaries referred to the program, 130 (82%) remained under pharmacist care for a minimum of 1 year and were included in the aggregate analysis. Statistically significant improvements were observed for Patient Health Questionnaire (PHQ)-9 scores from baseline to endpoint (11.5 ± 6.6 to 5.3 ± 4.7 [mean ± SD], P < 0.0001). The clinical response rate was 68% with a 56% remission rate. In economic subgroup analysis (n = 48), annual medical costs decreased from an average of $6,351 per enrollee to $5,876, which was lower than the projected value ($7,195). Total health care costs to the employer increased from $7,935 per enrollee to $8,040, which was lower than the projected value ($9,023). CONCLUSION: Patients in the first year of the program had significant improvement in the PHQ-9 clinical indicator of depression severity. Total health care costs per patient per year were reduced compared with projected costs without the program. Employers expressed their appreciation for this collaborative care program and continued to offer this voluntary health benefit after the study's conclusion.

Diabetes Ten City Challenge: final economic and clinical results.

OBJECTIVE: To assess the economic and clinical outcomes for the Diabetes Ten City Challenge (DTCC), a multisite community pharmacy health management program for patients with diabetes. DESIGN: Quasiexperimental observational analysis, pre-post comparison. SETTING: Employers at 10 distinct geographic sites contracting with pharmacy providers in the community setting. PARTICIPANTS: 573 patients with diabetes who had baseline and year 1 medical and pharmacy claims and two or more documented visits with pharmacists. INTERVENTIONS: Community-based pharmacists provided patient self-management care services via scheduled consultations within a collaborative care management model. MAIN OUTCOME MEASURES: Changes in health care costs for employers and beneficiaries and key clinical measures. RESULTS: Average total health care costs per patient per year were reduced by $1,079 (7.2%) compared with projected costs. Statistically significant improvements were observed for key clinical measures, including a mean glycosylated hemoglobin decrease from 7.5% to 7.1% (P = 0.002), a mean low-density lipoprotein cholesterol decrease from 98 to 94 mg/dL (P < 0.001), and a mean systolic blood pressure decrease from 133 to 130 mm Hg (P < 0.001) over a mean of 14.8 months of participation in the program. Between the initial visit and the end of the evaluation period, influenza vaccination rate increased from 32% to 65%, eye examination rate increased from 57% to 81%, and foot examination rate increased from 34% to 74%. CONCLUSION: DTCC successfully implemented an employer-funded, collaborative health management program using community-based pharmacist coaching, evidenced-based diabetes care guidelines, and self-management strategies. Positive clinical and economic outcomes were identified for 573 patients who participated in the program for at least 1 year, compared with baseline data.

The Diabetes Ten City Challenge: interim clinical and humanistic outcomes of a multisite community pharmacy diabetes care program.

OBJECTIVE: To assess clinical and humanistic outcomes 1 year after initiating the Diabetes Ten City Challenge (DTCC), a multisite community pharmacy health management program for patients with diabetes. DESIGN: Interim observational analysis of deidentified aggregate data from participating employer clients. SETTING: 29 employers at 10 distinct geographic sites contracting for patient care services with pharmacy providers in the community setting. PARTICIPANTS: 914 patients with diabetes covered by self-insured employers' health plans who received 3 or more months of pharmacist care and had an initial glycosylated hemoglobin (A1C) measurement. Community-based pharmacists were trained in a diabetes certificate program and reimbursed for clinical services. INTERVENTIONS: Community-based pharmacists provided patient care services using scheduled consultations, clinical goal setting, a validated patient self-management program tool, and health status monitoring within a collaborative care management model. MAIN OUTCOME MEASURES: Changes in key direct and surrogate outcomes, including glycosylated hemoglobin (A1C), low-density lipoprotein (LDL) cholesterol., blood pressure measurements, and body mass index; influenza vaccinations; foot examinations; eye examinations; numbers of patients with goals for nutrition, exercise, and weight; and patient satisfaction. RESULTS: At initial visit compared with 1 year, mean A1C decreased from 7.6% to 7.2%, mean LDL cholesterol decreased from 96 to 93 mg/dL, and mean systolic blood pressure decreased from 131 to 129 mm Hg. Increases were seen for influenza vaccination rate (from 43% to 61%), eye examination rate (from 60% to 77%), and foot examination rate (from 38% to 68%) for the initial visit to the end of the analysis period. For all patients in DTCC, those who perceived that their overall diabetes care was very good to excellent increased from 39% to 87%. Overall, 97.5% reported being very satisfied or satisfied with the diabetes care provided by pharmacists. CONCLUSION: Employers demonstrated a willingness to offer a voluntary health benefit to employees and their dependents with diabetes that uses pharmacists to help participants achieve self-management goals. Patients participating in the first year of DTCC had measurable improvement in clinical indicators of diabetes management, higher rates of self-management goal setting, and increased satisfaction with diabetes care. Based on results of previous studies, these positive trends are expected to drive a corresponding decline in projected total direct patient medical costs.

Definition of medication therapy management: development of professionwide consensus.

OBJECTIVE: To describe events leading to development of a professionwide consensus definition of medication therapy management (MTM) and attendant programs and services and present the document (definition, services, and program requirements) resulting from the process. DATA SOURCES: Author's own knowledge and records of events. SUMMARY: Following the late 2003 passage of the Medicare Prescription Drug Improvement and Modernization Act, the pharmacy profession had a need to act quickly to define MTM so that a consensus definition would be available as regulations implementing the Medicare Part D benefit were being written. The American Pharmacists Association facilitated this process by convening a broad working group of members and other involved parties to draft a preliminary definition. The Pharmacy Practice Activity Classification was used to check elements of the definition for consistency with services being offered in a wide variety of settings. A professionwide stakeholders conference was then convened with representatives from each of 11 national pharmacy organizations. This group, following a daylong meeting in late May 2004 and several weeks of e-mail messages and conference calls, finalized the MTM definition, which was then approved by the chief executive officers of all 11 groups. CONCLUSION: Through the extraordinary efforts of the numerous organizations and participants, the MTM Services Definition is one that is applicable within diverse pharmacy practice segments, whose services are feasible for a majority of practitioners to implement, and whose elements are supported by a profession-wide consortium of 11 national professional pharmacy organizations. This historic achievement is the first step on a journey to find the best ways to effectively deliver MTM services to patients.

Patient self-management program for diabetes: first-year clinical, humanistic, and economic outcomes.

OBJECTIVE: To assess the outcomes for the first year following the initiation of a multisite community pharmacy care services (PCS) program for patients with diabetes. DESIGN: Quasi-experimental, pre-post cohort study. SETTING: 80 community pharmacy providers with diabetes certificate program training who were reimbursed for PCS by employers in Greensboro, N.C., Wilson, N.C., Dublin, Ga., Manitowoc County, Wis., and Columbus, Ohio. PATIENTS: 256 patients with diabetes covered by self-insured employers' health plans. INTERVENTIONS: Community pharmacist patient care services using scheduled consultations, clinical goal setting, monitoring, and collaborative drug therapy management with physicians and referrals to diabetes educators. MAIN OUTCOME MEASURES: Changes in glycosylated hemoglobin (AIC), low-density lipoprotein cholesterol (LDL-C), blood pressure, influenza vaccinations, foot examinations, eye examinations, patient goals for nutrition, exercise, and weight, patient satisfaction, and changes medical and medication utilization and costs. RESULTS: Over the initial year of the program, participants' mean A1C decreased from 7.9% at initial visit to 7.1%, mean LDL-C decreased from 113.4 mg/dL to 104.5 mg/dL, and mean systolic blood pressured decreased from 136.2 mm Hg to 131.4 mm Hg. During this time, influenza vaccination rate increased from 52% to 77%, the eye examination rate increased from 46% to 82%, and the foot examination rate increased from 38% to 80%. Patient satisfaction with overall diabetes care improved from 57% of responses in the highest range at baseline to 87% at this level after 6 months, and 95.7% of patients reported being very satisfied or satisfied with the diabetes care provided by their pharmacists. Total mean health care costs per patient were $918 lower than projections for the initial year of enrollment. CONCLUSION: Patients who participated in the program had significant improvement in clinical indicators of diabetes management, higher rates of self-management goal setting and achievement, and increased satisfaction with diabetes care, and employers experienced a decline in mean projected total direct medical costs.

Regional osteoporosis screening, referral, and monitoring program in community pharmacies: findings from Project ImPACT: Osteoporosis.

OBJECTIVE: (1) To identify patients at risk for osteoporosis through community pharmacy-based bone mineral density (BMD) screening, to refer at-risk patients to primary care and/or specialty practice physicians, and to follow-up with at-risk patients; (2) to treat and manage osteopenic and osteoporotic patients referred to the pharmacy for medication therapy management services; and (3) to test a payment methodology for pharmacists who deliver community health management services to a population at risk for or diagnosed with osteoporosis. DESIGN: Single-cohort observational study. SETTING: Ukrop's Super Markets, Inc. Grocery and Pharmacy, a 29-store chain with 22 pharmacy locations in Richmond, Virginia. PARTICIPANTS: Consumers with one or more known risk factors for osteoporosis in Ukrop's customer service area. INTERVENTION: During the initial phase (health promotion and disease prevention) of the project, pharmacy-based osteoporosis screening with referral and follow-up was provided to consumers who responded to Ukrop's screening promotions. The second phase-provision of collaborative community health management services focused on osteoporosis monitoring and management--is ongoing and includes patients who are at risk for or diagnosed with osteoporosis and are covered by a regional payer. MAIN OUTCOME MEASURES: Results of screenings; responses of patients and physicians to notifications; and long-term results during collaborative care. RESULTS: The pharmacists screened 532 patients and were able to contact 305 of these patients for follow-up interviews 3 to 6 months later. The stratification for risk of fracture was 37%, high risk; 33%, moderate risk; and 30%, low risk. A total of 78% of patients indicated that they had no prior knowledge of their risk for future fracture. In the moderate- and high-risk categories, 37% of patients scheduled and completed a physician visit, 19% had a diagnostic scan, and 24% of those patients were initiated on osteoporosis therapy subsequent to the screening. Participating pharmacies received payment for both the osteoporosis screening and the collaborative health management services. CONCLUSION: Pharmacists can play a useful role in the identification, education, and referral of patients at risk for osteoporosis through pharmacy-based BMD screening. Patients are willing to pay for pharmacy-based osteoporosis screening services. Third-party payers are willing to compensate pharmacists for collaborative community health management services.