Community Pharmacists and Technicians: Impacting Public Health One Service at a Time

The United States has many areas that are largely rural. For example, according to the recent US Census, the state of Iowa is approximately 40% rural.

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In rural communities, pharmacies are the backbone of the health care system. On a national scale, 89% of Americans live within 5 miles of a community pharmacy. Without a local pharmacy in rural communities, services such as dentistry, family medicine, and general medicine struggle to maintain viability.¹

The further a patient must travel to receive the care and medications they need increases the risk of disease state complications and hospital admissions, placing an increased burden on our health care system. Rural health disparities impact patient care.

This is where pharmacists play a central role in patient care as the most accessible health care provider a patient may encounter. As the pharmacy profession continues to help meet patient needs in chronic disease state management, expanded roles and opportunities continue to ensure that access is not a barrier to health equity.

The profession continues to see pharmacists and pharmacy technicians step up in providing point-of-care testing services, HIV, STD/STI screenings and testing, chronic medication management (CMM), pharmacy technicians as community health workers (CHWs), and a number of other innovative solutions.

Current Landscape of Community Pharmacy Services

Pharmacists have and continue to play a large role in combating public health initiatives in the United States. The COVID-19 pandemic increased this role and awareness of the services offered via pharmacists and pharmacy technicians.

These services have included an increase in telehealth services, point-of-care testing (POCT), medication therapy management (MTM), and expanded roles of pharmacy technicians to include immunization administration. Many of these services were available prior to the pandemic, but we have seen an increase in availability and marketing of these services by pharmacies/pharmacists and increased desirability from patients.

Telepharmacy

In 2001, North Dakota was the first state to enact legislation to allow telepharmacy services in their state.² Following that enactment, growth in telepharmacy services had been slow until the pandemic enacted emergency legislation for pharmacists to perform COVID-19-related activities, including telepharmacy.

The National Association of Boards of Pharmacy defines telepharmacy as “the practice of pharmacy by registered pharmacists located within US jurisdictions through the use of telepharmacy technologies between a licensee and patients or their agents at distances that are located within US jurisdictions.”³ Telehealth, the use of telecommunications to distribute health related services and information, is allowed in some form in all 50 states.³

However, telepharmacy has experienced growth, but there are 22 states have either not implemented telepharmacy in any capacity or have done so with very strict policies.³ Telepharmacy is a vital practice that allows pharmacists to reach patients both near and far who may have limited access to health care. Although the pandemic allowed for increased use of telepharmacy services during emergency legislation, individual states need to have legislative change for the continued sustainability of telepharmacy.

MTM

MTM is a service utilized by many community-based pharmacies nationwide. Its consensus definition is a distinct service or group of services that optimize therapeutic outcomes for individual patients.⁴ It is a service that can include comprehensive medication reviews (CMR) and targeted intervention programs.

In 2020, Outcomes completed more than 7 million MTM interventions and reached over 23 million patients.⁵ Although MTM was a service that was available long before the pandemic, it has shown continued growth during the pandemic and after. It is a continued success story of enhanced services being offered in the community pharmacy setting by trained pharmacists and technicians.

Pharmacy Technicians as Immunizers

While the roles and responsibilities for pharmacists are ever evolving, so have the roles and responsibilities for technicians. In 2017, a new law was passed in Idaho as the first state to allow pharmacy technicians to administer immunizations with Rhode Island and Utah following suit shortly after.⁶

Since then, many different immunization administration training programs have emerged for pharmacy technicians to become trained as certified immunizers. These trainings proved to be essential after the US Department of Health and Human Services (HHS) issued guidance under the Public Readiness and Emergency Preparedness (PREP) Act authorizing trained pharmacy technicians in all states to administer certain immunizations under the supervision of a qualified pharmacist to patients 3 years of age and older during the COVID-19 pandemic.

This emergency act was only temporary and ended when the federal Public Health Emergency Declaration ended on May 11, 2023. There has been extended coverage to the PREP Act for COVID-19 vaccines, seasonal flu vaccines, and COVID-19 tests through December 2024 for pharmacists, pharmacy interns, and pharmacy technicians to administer to individuals three years of age and older.⁷ 

To ensure sustainability of certified technicians immunizing, states need to enact permanent changes in legislation. As of April 2023, there were 21 states that allow pharmacy technicians to administer the same vaccines to the same age ranges as a pharmacist.

Two additional states allow pharmacy technicians to administer vaccines with some additional restrictions.⁸ This leaves 28 states that currently do not have legislation allowing technicians to continue to immunize after the extended PREP Act expires.

Diabetes Prevention Program (DPP)

DPP is another program that is an excellent example of how outpatient pharmacy continues to combat public health concerns by allowing pharmacies to enroll to aid patients in preventing or delaying the onset of type 2 Diabetes. Pharmacists can promote, screen, and offer the National DPP Lifestyle Change Program to their patients and communities—and many insurers and employers are reimbursing for the program.

A large pharmacy chain across the United States began to offer this course in 2015 and has seen a 5.2% average weight loss achieved at the 6-month mark and increasing to 6.3% at the 12-month mark.⁹ These programs are interprofessional, usually including certified diabetes educators (CDE), registered dieticians, and a PharmD.⁹ Community-based pharmacy is already involved in a myriad of services to help the community and this program serves as another example.

Future of Pharmacy Service Innovation and Expanded Services

Point-of-Care Testing and Test and Treat

Several studies have demonstrated the value that pharmacies provide through expansion of access to care with POCT and pharmacy-based management of infectious diseases—such as influenza and Group A streptococcal pharyngitis.

POCT services not only increase patient access points to health care but also shorten the time between the onset of symptoms and treatment while maintaining and improving antimicrobial stewardship. Additionally, by following standards of care, pharmacists have been shown to provide safe and effective management with high patient satisfaction rates and decreased health care cost expenditure. Implementing POCT services into local pharmacies helps to decrease these costs even further by eliminating extra fees associated with emergency department and urgent care facilities.

For example, in Iowa, all pharmacies are eligible to provide test and treat services for individuals 6 years of age and older. Along with testing for influenza, strep, and COVID-19, pharmacies can prescribe treatment following a positive test result via the statewide protocols developed by the Iowa Board of Pharmacy in collaboration with the Iowa Department of Public Health.

Test and treat allows for the screening and treatment to be completed during a single encounter with a pharmacist, thereby improving access to care and patient outcomes. By providing readily available POCT followed by immediate access to treatment without needing to make an appointment several days in the future, pharmacists can accurately provide care to shorten the course of these common illnesses. Patients can have their diagnosis and treatment in a fraction of the time that they may be accustomed to waiting.

Mobile Clinics

Distance and travel are major contributors to health inequities. In addition to providing POCT services, the pharmacy profession continues to be innovative in getting patients the preventative care that they need.

Mobile clinics, such as the University of Iowa Mobile Clinic and VaxiTaxi help to meet patients where they are to provide access to care. The University of Iowa Mobile Clinic engages health sciences students and practitioners to address gaps in care by providing services including HIV and hepatitis C testing, blood glucose, blood pressure, cholesterol, and vitals testing, in addition to COVID-19 vaccinations among other services.¹⁰

Services such as VaxiTaxi, focus solely on providing immunizations to rural, homebound, and high-risk populations.¹¹ Mobile clinics help to address important social determinants of health by reducing barriers to health care and improving the patient-pharmacist relationship.

Pharmacy Technicians as CHWs

As the pharmacist-patient relationship is recognized and respected, it’s important to note the expanding role of the pharmacy technician in being present and engaged in patient lives. Oftentimes, the first point of contact when patients enter a community pharmacy is with a pharmacy technician or other support personnel.

Naturally, pharmacy technician duties overlap with many CHWs, who often serve as connectors and develop acute awareness of the patient’s social determinant of health factors that impact their care. The American Public Health Association defines CHWs as “frontline public health workers who are trusted members of and/or have an unusually close understanding of the community served.”²

This trusting relationship enables CHWs to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.

A new opportunity emerging is the role of pharmacy technicians as CHWs. Continuing Education Provider CEImpact in collaboration with the Missouri Department of Health and Senior Services has developed a 16-week CHW training certificate program for pharmacy technicians that provides them with the understanding, tools, and resources needed to help effectively communicate with patients, provide education, connect patients with local community resources, and oversee referral processes, including follow-up and monitoring.¹³ CHWs help patients and their families navigate the health care system, access local community services and non-local resources, as well as promote the adoption of healthy behaviors.

Community-based pharmacy has long played a role in combating public health concerns, but the profession is more poised than ever before to take on a larger role in addressing the concerns of the community. With the current advancements in services offered by pharmacists and/or pharmacy technicians and the ongoing expansion of state pharmacy legislation, pharmacists and technicians are able to expand the role they have in patient care.

Community-based pharmacy services are reaching new heights and community-based pharmacists and technicians are able to have a larger impact than ever before.

References

1. National Association of Chain Drug Stores.Re: Health Care Workshop, Project No.P131207 http://www.nacds.org/ceo/2014/0508/supplemental_comments.pdf.
2. Alexander E, et al. Am J Health Syst Pharm. 2017;74(9):e236-e241. doi:10.2146/ajhp170039. Accessed July 17th, 2023.
3. Henecke C. State-by-State Telepharmacy Regulation Analysis Whitepaper. TelePharm. Published online 2023:1-4. Accessed July 18, 2023. https://blog.telepharm.com/state-by-state-telepharmacy-regulation-analysis.
4. National Board of Medication Therapy Management, Thomas, D. & Tran, J. (2020, September 1). Medication Therapy Management. National Board of Medication Therapy Management. https://nbmtm.org/mtm-reference/medication-therapy-management/
5. Home Page. Outcomes. January 6, 2023. Accessed July 18, 2023. https://getoutcomes.com/.
6. McKeirnan K. Techs’ role in Immunization Administration expands. Pharmacy Times. January 4, 2022. Accessed July 18, 2023. https://www.pharmacytimes.com/view/techs-role-in-immunization-administration-expands.
7. Fact sheet: HHS announces intent to amend the Declaration under the PREP Act for medical countermeasures against COVID-19. HHS.gov. April 14, 2023. Accessed July 18, 2023. https://www.hhs.gov/about/news/2023/04/14/factsheet-hhs-announces-amend-declaration-prep-act-medical-countermeasures-against-covid19.html.
8. Pharmacist Immunization Authority. NASPA. April 25, 2023. Accessed July 18, 2023. https://naspa.us/resource/pharmacist-authority-to-immunize/.
9. How pharmacists can participate. Centers for Disease Control and Prevention. February 14, 2023. Accessed July 18, 2023. https://www.cdc.gov/diabetes/prevention/pharmacists.html.
10. Mobile Clinic. Accessed July 18, 2023. https://iowamobileclinic.org/.
11. Vaxi taxi offers mobile vaccinations. College of Pharmacy - The University of Iowa. December 15, 2021. Accessed July 18, 2023. https://pharmacy.uiowa.edu/news/2021/12/vaxi-taxi-offers-mobile-vaccinations.
12. Support for Community Health Worker Leadership in determining workforce standards for training and credentialing. Accessed July 18, 2023. https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2015/01/28/14/15/support-for-community-health-worker-leadership.
13. Community Health Workers. CEimpact. Accessed July 18, 2023. https://www.ceimpact.com/chw.