Impact of a Multicomponent Educational Intervention on Community Pharmacy-Based Naloxone Services Implementation: A Pragmatic Randomized Controlled Trial.

BACKGROUND: Despite US naloxone access laws, community pharmacists lack training and confidence in providing naloxone. OBJECTIVE: To assess the impact of the Empowering Community Pharmacists program on pharmacists' knowledge, perceived barriers, attitudes, confidence, and intentions regarding naloxone services implementation, as well as naloxone prescriptions dispensed. METHODS: A 3-month pragmatic randomized controlled trial was conducted from December 2018 to March 2019. Alabama community pharmacists were recruited by mail, email, phone, and fax and randomized to intervention (monthly resources/reminders + educational webinar) or control (monthly reminders only). Outcome measures were assessed via online surveys at baseline (T1), immediately post-intervention (T2), and 3 months post-intervention (T3), including naloxone knowledge (%correct); perceived barriers, attitudes, confidence, and intention regarding naloxone services implementation (7-point Likert-type scale; 1 = strongly disagree, 7 = strongly agree); and number of naloxone prescriptions dispensed. Mean differences between control and intervention from T1 to T3 were assessed using 2-way mixed analysis of variance and adjusted analyses were conducted using generalized estimating equations with negative binomial distribution to assess associations between variables. RESULTS: Of 55 participants (n = 27 intervention, n = 28 control), most were female (80.3%), white (80.6%), in independently owned pharmacies (39.1%). Increases in mean [SD] confidence (5.52 [1.03]-6.16 [0.74], P < 0.0005) and intention (5.35 [1.51]-6.10 [0.96], P = 0.023) occurred from pre- to post-program within the intervention group and were statistically significant compared with control (confidence P = 0.016, intention P = 0.014). Confidence (exp(ß) = 1.46, P = 0.031) and perceived barriers (exp(ß) = 0.75, P = 0.022) were associated with number of naloxone prescriptions dispensed. CONCLUSION AND RELEVANCE: The Empowering Community Pharmacists program improved community pharmacists' confidence and intention regarding naloxone services implementation. Other states can adapt program elements according to their laws. CLINICALTRIALS.GOV IDENTIFIER: NCT05093309.

Enhancing pharmacy personnel immunization-related confidence, perceived barriers, and perceived influence: The We Immunize program.

OBJECTIVES: Pharmacy personnel need practical strategies to incorporate nonseasonal vaccination services into pharmacy workflow. The objective of this study was to evaluate participants' confidence, perceived barriers and facilitators, and perceived influence on decision-making related to immunization services before and after the We Immunize program to assess program effectiveness. DESIGN: Randomized controlled trial. SETTING AND PARTICIPANTS: A total of 62 pharmacist-technician pairs from community pharmacies in Alabama and California participated in the randomized controlled trial. All participants were offered a 1-hour live immunization update. Intervention participants were also offered a 2-hour enhanced training at the beginning of the study period and tailored monthly feedback for 6 months. OUTCOME MEASURES: A survey was administered at baseline and after the intervention. Likert-type scales were used to rank level of agreement and differences were analyzed using paired-sample t tests and 2-way mixed analysis of variance. RESULTS: Sixty-seven participants completed both baseline and postintervention surveys (37 intervention; 30 control). Within the intervention group, participants' confidence in determining pneumococcal vaccine appropriateness (P = 0.027), confidence in pneumococcal vaccine-related patient interactions (P = 0.041), perceived external support (P = 0.016), and perceived influence on immunization services (P < 0.001) significantly improved. No change was observed within the control group. Compared to control participants, intervention participants showed a greater degree of change in perceived external support (P = 0.023) and influence on immunization services (P = 0.005) from baseline to post intervention. Neither confidence related to the herpes zoster vaccine nor marketing activities improved over the study period in either the intervention or control groups. CONCLUSION: Immunization training, including educational interventions and tailored feedback, can be used to positively impact pharmacy personnel's confidence in providing pneumococcal vaccinations and perceptions related to environmental support and influence on immunization services. This, in turn, may increase immunization activities within community settings.

A pharmacy-based referral program to assist low-income Medicare beneficiaries.

OBJECTIVES: The Certified Aging Resource Educated Specialist (C.A.R.E.S.) Program was developed to increase pharmacist awareness of available programs for Medicare patients with limited income and to integrate an efficient referral process into the pharmacy workflow. The objective is to describe the program in terms of pharmacy personnel satisfaction, pharmacy personnel knowledge, and network outcomes including enrollment and referrals. SETTING: Alabama community pharmacies. PRACTICE DESCRIPTION: The C.A.R.E.S. Program, a partnership between the School of Pharmacy and the Alabama Department of Senior Services, has recruited pharmacists, pharmacy technicians, and pharmacy students to participate on a voluntary basis since its launch in 2015. PRACTICE INNOVATION: Pharmacies with at least one pharmacist who completed the comprehensive training program can enroll in the pharmacy network. Enrolled pharmacies receive a referral kit containing referral cards and prestamped envelopes. Pharmacy personnel identify patients who appear to have limited income or fall into the Medicare coverage gap and refer these patients to local Aging and Disability Resource Centers (ADRCs). ADRC counselors contact and screen referred patients for all available benefits, including the Medicare Savings Program and the Low-Income Subsidy. EVALUATION: One hundred seventy-nine pharmacy personnel have completed the 1-hour introductory continuing pharmacy education, with 99 completing the full 3-hour training. Knowledge was assessed before and immediately after training with an online survey and compared using a paired samples t test. RESULTS: Mean knowledge scores increased significantly (P < 0.001). Twenty-nine pharmacies have enrolled in the pharmacy network. As a result of this pharmacy referral system, 130 patients have been screened for subsidy programs by ADRC counselors. CONCLUSION: To our knowledge, this is the first identifiable program connecting local pharmacies and ADRCs, equipping pharmacists with the knowledge and means to provide long-term solutions for patients. Other states might consider replicating this partnership to develop similar programs to benefit Medicare beneficiaries with limited income.

Qualitative Investigation of Community Pharmacy Immunization Enhancement Program Implementation.

Background: Despite widely available nonseasonal immunization services in community pharmacies, actual pharmacist-administered vaccines are not yet optimal. A flexible choice multicomponent intervention, the "We Immunize" program, was implemented in Alabama and California community pharmacies, with the goal to enhance pneumococcal and zoster immunization delivery. Limited research has been done to qualitatively understand factors influencing immunization service expansion. Objective: Explore pharmacist perceptions of the We Immunize program in terms of its acceptability, impact, and real-world feasibility, and pharmacist-perceived facilitators and barriers influencing success in immunization delivery enhancement. Methods: This practice-focused qualitative research used semistructured telephone interviews with 14 pharmacists at the completion of the 6-month intervention. Results: Major program implementation facilitators were technician inclusion, workflow changes, training and feedback, goal setting, and enhanced personal selling and marketing activities. Multiple pharmacies increased the number of delivered pneumococcal and zoster immunizations, and increased revenue. Many pharmacists felt professional image, knowledge, skills, roles, and personal satisfaction were enhanced, as were technician knowledge, skills, and roles. Program flexibility, along with multiple perceived benefits, increases the potential for success. Conclusions: The We Immunize program appears to have been viewed positively by participating pharmacists and was seen as having a beneficial impact on immunization delivery in the community pharmacies in which it was implemented.

The Moderating Power of Impulsivity: A Systematic Literature Review Examining the Theory of Planned Behavior.

The theory of planned behavior (TPB) states that behavioral intention is the best predictor of actual behavior change. However, intention explains only a portion of the variance in behavior. Of specific interest is the question of which moderating or mediating variables can be leveraged to aid health promotion interventions utilizing the tenets of behavioral economics (delay discounting and commitment contracts) in the intention-behavior pathway. Impulsivity has been postulated to fill this role and may be applied to multiple behaviors. We aim to determine if impulsivity moderates the association between intention and actual behavior in the TPB, to discover what other variables may moderate or mediate this association, and to apply the findings to future studies in the field of behavioral economics. To this end, a systematic review was conducted using the PubMed, PsychINFO, and Embase online databases. Eligible studies in peer-reviewed journals published prior to November 2021 were selected. Thirty-three studies were included in the final review, examining physical activity, diet, preventive health, mental health, addiction, and medication adherence behaviors. Three main concepts emerged: (1) impulsivity moderates the association between intention and behavior change; (2) self-efficacy moderates the association between intention and behavior change; and (3) planning and self-efficacy contribute to moderated mediation. This review demonstrates a gap in the literature regarding the application of the TPB to the intention-behavior pathway for health behaviors. Future studies in behavioral economics may leverage the variables of impulsivity, self-efficacy, and planning to predict follow-through in this area and to develop targeted change initiatives.

Public Perceptions of Community Pharmacy-Based Naloxone Services: A National Cross-Sectional Survey.

Little is known about the general public's perceptions regarding community pharmacist-delivered naloxone services at the national level. Accordingly, the purpose of this study was to describe the US general public's awareness, knowledge, beliefs, comfort, perceived barriers, abilities, and communication preferences related to community pharmacy-based naloxone services. A national, online cross-sectional survey was conducted in September 2021 among US adults ≥18 years recruited via Amazon Mechanical Turk (MTurk). Primary outcome measures were assessed via 5-point Likert-type scales, including: (1) naloxone awareness and knowledge; (2) naloxone beliefs; (3) comfort with pharmacist-provided naloxone; (4) perceived barriers to pharmacy-based naloxone; (5) opioid overdose competencies, concerns, and readiness; and (6) preferred pharmacist-patient naloxone communication strategy. Analyses included descriptive statistics and logistic regression models to assess predictors of preferred communication strategies. Of 301 respondents, 82.1% were White, 48.8% female, and mean 43 years. Eighty-five percent were unaware of pharmacy-provided naloxone and mean [SD] knowledge score was low (29.3% [16.8]). Mean [SD] beliefs (3.78 [0.61]) and comfort (3.70 [0.54]) were positive, while perceived barriers were low/neutral (2.93 [0.78]). For communication, 54% preferred general advertisement, 32.9% universal offer, and 13.3% targeted offer. The odds of preferring a general advertisement or universal offer over a targeted offer increased with greater awareness (AOR:4.52; p = 0.003) and comfort (AOR:3.79; p = 0.003), and decreased with greater competence (AOR:0.35; p = 0.001). Although awareness and knowledge regarding community pharmacy-based naloxone services was low, beliefs and comfort were positive and perceived barriers were low/neutral. General or universal offers of naloxone were preferred over targeted approaches. Future studies should test the impact of communication strategies on naloxone uptake.

Medicare Annual Wellness Visits: A Scoping Review of Current Practice Models and Opportunities for Pharmacists.

OBJECTIVE: To explore the existing practice models and practice opportunities surrounding pharmacist-delivered Medicare Annual Wellness Visits (AWVs), with the goal of improving patient access through advanced pharmacy-based health services. DATA SOURCES: English-language articles published in peer-reviewed journals from January 2011 to March 2018 were reviewed by searching PubMed and Google Scholar databases using permutations of terms such as "pharmacist/pharmacy," "Medicare," "Annual Wellness Visit," "develop/development," and "implement/implementation." STUDY SELECTION AND DATA EXTRACTION: Original articles reporting resources (inputs), processes, and programmatic outcomes (uptake and delivery, interventions made, financial models, satisfaction) of pharmacist-delivered AWV services were retained. DATA SYNTHESIS: Eight articles describing 6 unique studies representing current pharmacist-delivered AWV practices were included in the final review. All identified articles used observational study designs and were published in peer-reviewed journals from 2014 to 2017. Five studies utilized staff (in-house) pharmacists working in internal or family medicine clinics via collaborative practice agreements; one study described a model for outsourcing AWV services through a community pharmacy. Pharmacists completed 37 to 300 AWVs and performed both medication- and non-medication-related interventions, with a mean of 3.5 to 5.4 interventions/patient. Quarterly revenue ranged from $3750 to $22 340 (USD), with 40 pharmacist-hours required for initial program development. IMPLICATIONS FOR PATIENT CARE AND CLINICAL PRACTICE: This scoping review will serve as a guide for pharmacists wishing to implement AWV services in their own practices. CONCLUSIONS: There is opportunity for ambulatory/community pharmacists to expand their practices to include AWV services in states that allow collaborative practice agreements. Interprofessional collaboration between physicians and pharmacists can optimize and aid adoption of pharmacist-delivered AWV services.

Impact of a multi-component immunization intervention on pneumococcal and herpes zoster vaccinations: A randomized controlled trial of community pharmacies in 2 states.

BACKGROUND: The purpose of this study was to assess the impact of the We Immunize Program on structures, processes, and outcomes of pneumococcal and herpes zoster pharmacy-based immunization services. METHODS: Pharmacy-technician pairs from 62 Alabama and California community pharmacies participated in a 6-month randomized controlled trial (intervention = 30/control = 32). All received immunization update training; intervention participants also received practical strategies training and monthly telephonic expert feedback. Completion of immunization service structure and process activities were analyzed using Fisher's Exact and one-way Mann-Whitney U tests. The primary outcome, change in number of pneumococcal, herpes zoster, and total vaccine doses administered, was assessed using one-way Wilcoxon signed rank and Mann-Whitney U tests. Associations between program and vaccine doses across time were explored using generalized estimating equations (GEE). RESULTS: Intervention pharmacies completed more structure (median 12.00 versus 9.00, p = 0.200) and process activities (median 8.00 versus 7.00, p = 0.048) compared to control. Statistically significant increases in the median number of pneumococcal vaccine doses (7.50-12.00 doses, p = 0.007), and total vaccine doses (12.50-28.00 doses, p = 0.014) were seen from baseline to post-intervention within the intervention group. However, these changes were not statistically significant when compared to the control group (pneumococcal p = 0.136, total p = 0.202). Changes in median herpes zoster vaccine doses did not reach significance among intervention (8.50-9.00, p = 0.307) or control (9.00-13.00, p = 0.127) pharmacies. CONCLUSIONS: Practical strategies training combined with tailored expert feedback enhanced existing pneumococcal immunization services in community pharmacies. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02615470.

Implementation of a Medicare Plan Selection Assistance Program Through a Community Partnership.

Objective. To describe the implementation and outcomes of a sustainable Medicare Plan Selection Assistance Program conducted through a partnership between Auburn University Harrison School of Pharmacy (AU) and the Alabama State Health Insurance and Assistance Program (SHIP) since 2013. Methods. The program's goal is to assist Medicare beneficiaries in Medicare Part D plan selection. Reported outcomes included Medicare beneficiaries' plan cost savings and satisfaction, and pharmacy students' self-reported changes in knowledge and attitudes. Results. Each year, more than 80 pharmacy students assist more than 120 beneficiaries; at least 10 events are held covering 6-10 Alabama counties. On average, Medicare beneficiaries had a projected savings of $278.71 (2013), $1,081.66 (2014), $842.84 (2015), and $1,382.90 (2016) after enrolling in a new plan, and most students reported perceived increased ability to help beneficiaries select the most appropriate Medicare Part D plan. Conclusion. The program produced positive outcomes for both beneficiaries and students. Other pharmacy schools may consider partnering with their State Health Insurance and Assistance Program to deliver a similar program to benefit their students and Medicare beneficiaries.

Parental acceptance of human papillomavirus vaccinations and community pharmacies as vaccination settings: A qualitative study in Alabama.

PURPOSE: To determine parents' knowledge and attitudes regarding human papillomavirus (HPV) vaccinations in their adolescent children and to describe parents' perceptions of adolescent vaccinations in community pharmacies. METHODS: In-depth interviews were completed with parents or guardians of children ages 11-17 years from Alabama's Lee and Macon counties. One-hour long, open-ended telephonic or in-person interviews were conducted until the saturation point was reached. Using ATLAS.ti software and thematic analysis, interview transcripts were coded to identify themes. RESULTS: Twenty-six parents were interviewed, most of whom were female (80.8%) and white (50%). A total of 12 themes were identified. First, two themes emerged regarding elements facilitating children's HPV vaccination, the most common being positive perception of the HPV vaccine. Second, elements hindering children's vaccination contained seven themes, the top one being lack of correct or complete information about the HPV vaccine. The last topic involved acceptance/rejection of community pharmacies as vaccination settings, and the most frequently cited theme was concern about pharmacists' clinical training. CONCLUSIONS: Physician-to-parent vaccine education is important, and assurances of adequate pharmacy immunization training will ease parents' fears and allow pharmacists to better serve adolescents, especially those who do not see physicians regularly.

Pharmacists' Attitudes and Perceived Barriers to Human Papillomavirus (HPV) Vaccination Services.

Use of non-traditional settings such as community pharmacies has been suggested to increase human papillomavirus (HPV) vaccination uptake and completion rates. The objectives of this study were to explore HPV vaccination services and strategies employed by pharmacies to increase HPV vaccine uptake, pharmacists' attitudes towards the HPV vaccine, and pharmacists' perceived barriers to providing HPV vaccination services in community pharmacies. A pre-piloted mail survey was sent to 350 randomly selected community pharmacies in Alabama in 2014. Measures included types of vaccines administered and marketing/recommendation strategies, pharmacists' attitudes towards the HPV vaccine, and perceived system and parental barriers. Data analysis largely took the form of descriptive statistics. 154 pharmacists completed the survey (response rate = 44%). The majority believed vaccination is the best protection against cervical cancer (85.3%), HPV is a serious threat to health for girls (78.8%) and boys (55.6%), and children should not wait until they are sexually active to be vaccinated (80.1%). Perceived system barriers included insufficient patient demand (56.5%), insurance plans not covering vaccination cost (54.8%), and vaccine expiration before use (54.1%). Respondents also perceived parents to have inadequate education and understanding about HPV infection (86.6%) and vaccine safety (78.7%). Pharmacists have positive perceptions regarding the HPV vaccine. Barriers related to system factors and perceived parental concerns must be overcome to increase pharmacist involvement in HPV vaccinations.

How Do Pharmacists Assist Medicare Beneficiaries with Limited Income? A Cross-Sectional Study of Community Pharmacies in Alabama.

BACKGROUND: Many Medicare beneficiaries have limited income and report problems paying for their medications. Programs are available to assist these low-income individuals. However, these programs are underused because of lack of general awareness and perceived complexity of program applications. OBJECTIVES: To (a) determine the frequency of encounters by pharmacists with Medicare beneficiaries who cannot afford prescription drugs; (b) identify strategies that pharmacists use to assist Medicare beneficiaries who cannot afford prescription drugs; and (c) explore what pharmacists know about programs for Medicare beneficiaries with limited income. METHODS: This study used a mixed-mode survey of 350 randomly sampled community pharmacies located in 32 counties in Alabama with a high proportion of Medicare beneficiaries who were potentially eligible for low-income subsidy programs. Measures included frequency of encounters by pharmacists with Medicare beneficiaries who could not afford their medications, strategies used to assist Medicare beneficiaries, and pharmacists' knowledge of programs for Medicare beneficiaries with limited income. RESULTS: Of 350 surveys sent, 12 were nondeliverable, and 151 were completed (response rate=44.6%). About 50% of respondents reported encountering Medicare beneficiaries who could not afford their medications at least weekly. Various strategies were reported, including refiling claims that were previously denied every day (40.7%), contacting insurance companies at least once per week (43.2%), and loaning medications at least 2-3 times per month (29.1%). Only 12.6% reported referring beneficiaries to the Aging and Disability Resource Centers (ADRCs) to assess eligibility for limited-income programs. When asked about programs for beneficiaries with limited income, the answers were predominantly "don't know for sure." CONCLUSIONS: Several strategies were used by pharmacists in an attempt to help limited-income Medicare beneficiaries obtain their medications. Lack of knowledge about financial assistance programs for limited-income individuals and the role of ADRCs in helping to screen individuals for benefits and complete applications warrants immediate attention. Improving pharmacists' knowledge on this topic may be an effective mechanism for providing a long-term solution for their patients. DISCLOSURES: This study was funded by the Alabama Department of Senior Services. The sponsor played no active role in the design, methods, data collection, analysis, or preparation of this manuscript. The authors have nothing to disclose. This paper was presented at the American Pharmacists Association meeting in Baltimore, Maryland, in 2016. Study concept and design were contributed by Westrick. Hastings and McFarland were responsible for data collection, along with Westrick. Data interpretation was performed by Westrick, L. Hohmann, and Hastings, with assistance from McFarland. All authors were involved with manuscript preparation.