Experts: Pharmacists, Community Health Workers Key to Success in Missouri Vaccine Gap Program

In an interview with Pharmacy Times®, Jake Galdo, managing network facilitator at Community Pharmacy Enhanced Services Network (CPESN) Health Equity, and Annie Eisenbeis, director of practice development at the Missouri Pharmacy Association, discussed the vaccine gap closure program implemented across the state and the important role that pharmacists and community health workers (CHWs) played in its coordination, implementation, and success in local communities.

Pharmacy Times®: Can you provide a brief or overview of what the vaccine gap program at CPESN Missouri entailed?

Annie Eisenbeis, Director of Practice Development, Missouri Pharmacy Association: Yes. So, it actually started out as a request from our state Department of Health. A couple years ago, when the federal Health Resources and Services Administration (HRSA) COVID uninsured program ended, about 3 days before that was projected to end, they called and said, “Hey, we want to do a statewide program to cover uninsured patients needing COVID vaccines at pharmacies, but we don't have the manpower to oversee that, so can you just let us know what you need and provide data on number of doses and budget?” And they needed that by Friday. This was on a Tuesday. So, we turned that around in 3 days and requested a $4.2 million budget over the course of 2-and-a-half years, in addition to a pilot that was utilizing just med-sync pharmacies, or CPESN Missouri pharmacies providing med-sync, and tying in longitudinal vaccine education in these 5-to-15-minute encounters. So that was about $800,000. So, we ended up receiving a $5 million grant almost 22 months later, when the COVID vaccine now had a cost and the bridge access program from the CDC was starting. We were not allowed to include the cost of vaccines in this grant budget, it was specifically mentioned we couldn't do that. So, we quickly talked to the state and said, “We don't want to reinvent the wheel and have all of this money just sitting there, not doing anything to help the population and patients in Missouri.” So, we pivoted and threw a lot of different ideas and spaghetti at the wall to say, “what's a huge barrier that we can overcome with $5 million dollars?”

Basically, one of our pharmacists, the lead luminary for CPESN Health Equity and a luminary for Missouri, Tripp Logan, said, “Okay, though, let's back up, guys, because I think this is really just, how do we have a big splash and show the impact that pharmacies can have on vaccine rates in Missouri? “And so, okay, yes, so let's build that on the med-sync model and build off of that. So basically, it's a templated model that can be slotted in for any primary or preventative care word other than vaccine. So, we have our vaccine gap closure program, but you could slot in anything there. So we, in the first phase, utilized med-sync, so any patient who was in the pharmacy’s med-sync program could receive an additional 5-to-15-minute encounter or intervention with the pharmacist and the CHW, and then building on that to say, “Well, now you've seen how your med-sync program can allow you to do this,” – because it's within your pharmacy software, we don't have to get different software, we don't have to train staff somewhere else – now we're going to say, “let's shift the concept of med-sync to be longitudinal care and education and an additional touch point that other health care providers don't have.” So, we're tying all of that into phase 2, then, that is still the same intervention, just 5-to-15-minute conversation about vaccine eligibility and hesitancy and addressing those barriers, and saying, now you can add patients that don't fill medications here or aren't on chronic medications, you can still input them into your pharmacy system to provide this longitudinal care. And then we dove into, okay, now we have that that bucket, and that's just in the conversation and outreach with CHWs and pharmacy teams.

So now we're going to say phase 3, since we have this additional budget of $5 million, phase 3 and 4, we expanded to the community. We know our community pharmacies impact more than just the patients that walk in their door. So, we're going to do these vaccine clinics at various organizations, entities; basically, anywhere that the patient doesn't have access to vaccine education or vaccinations, that's considered a clinic. So, leaving the pharmacy walls or opening early or staying late, including even home visits for homebound patients. And because it was a grant that focused on vulnerable, uninsured and high-risk individuals, we added a health equity incentive to say if you also are doing this for uninsured or underinsured patients, diving into that.

I’m giving a really long, high-level overview, but it's such an amazing project, so I'm almost done. With the phase 4, then expanded into, okay, we went back to the drawing board and said we had these vaccine clinics for the community. The problem is, how do we close the gap for patients who either need a second dose of something and they don't use my pharmacy, or they're eligible for another vaccine? Let's say they got a flu shot, but they're eligible for pneumonia too, and we didn't bring that to the clinic. How do we make sure that this patient has access to that when they don't use my pharmacy, and they won't use my pharmacy either, it's not going to be covered here, they don't get transportation here, they use the VA, somewhere else, right? And so that's where we plugged in our CHW-trained pharmacy technicians to coordinate that care anywhere. So now they have the information of a community member who's needing care, a second dose, an additional vaccine, and they can coordinate getting that vaccine appointment anywhere.

Pharmacy Times: Why are community pharmacists and community health care workers ideal for helping bridge the vaccination gap in their local communities?

Jake Galdo, Managing Network Facilitator, CPESN Health Equity: Yeah, since you described everything and anything under the sun, I might, you know, chime in a little bit here. And I think the big aspect of this is that we are where people live, born, grow, work, age, die. We are in those communities. And the nuance, though, and I love your question about pharmacists and CHWs, because I think that's the proverbial dream team, right? My expertise is understanding medications. My pharmacy technician’s expertise is the production of the medication and triaging issues and helping, you know, maintain access. The CHW’s expertise is understanding their community and the resources in those communities, and so we can all put it all together. And you know, it's really interesting, because it's about wearing the different hats. You know, we started this by introducing ourselves saying we have multiple hats. A pharmacy technician is not allowed to do vaccine education. That's not in their scope of practice, but a pharmacy technician can immunize. They can do the stabby-stabby. Alternatively, a CHW is not allowed to immunize, not in their scope of practice, but they can educate. So then imagine the dialog and the change that happens when you have the person educating you telling you, “This is good for your community. I go to your church; I go to your community center. I believe in this. I grew up with you. This is great for you.” And they say, “You know what? I think I do want a vaccine. When should I get it?” And then that person can say, right now, from me. Because they're able to do both, because it's a cross-trained technician-CHW, and it's just transforming practice.

Eisenbeis: Yeah, I'd probably add too that our CHWs are focusing on vaccine hesitancy in a different lens. So, as pharmacists, we probably approach it a lot more clinically to educate patients, and they're approaching it from either access or all of the other things that impact vaccine hesitancy that are not clinical. So, when you tie those two together, it's just been a kind of a silver stabby-stabby, instead of a silver bullet.

Pharmacy Times: How was your team able to weave together so many different professions in such an effective manner? Were there any challenges?

Eisenbeis: I think that's not our team, so much as the build and infrastructure of CPESN. So, the fact that CPESN is built on local infrastructure, local pharmacies, and local relationships, whether that's with patients or local health departments or other organizations. And then we also have utilized that local relationship, even between the pharmacies, to then add a regional component. So, Missouri, we broke it up into about 5 regions, because Kansas City or St. Louis are very different from our southwest and northern populations. We actually also hold all of those relationships within the regions of the state for our pharmacies to coordinate, cooperate, and share best practices at a regional level, so that then we bring that back to the state as well. So, I really think it goes back to the boots on the ground, the people that do this and love working in their communities every day, and filtering that back up, versus the other way around.

Galdo: Well, I think Annie, the other aspect of it is it's being neighborly, right? We're helping each other. And when you help each other, you just continue to lift everyone up. And so, you know, your question is, how many different professionals did we engage? We had the state, we had researchers, we had pharmacists – there's a lot of people, to your point, and it's because we're all going at the same role, which is to lift up our neighbors, to lift up our communities, and we're doing it in tandem with each other, not in a competitive spirit. We're doing it collaboratively and transparently and making sure that we emphasize or highlight each other, right? I'm going to be tongue in cheek, and I'll give an example. Annie. She is our primary investigator. She drove this. This was her brainchild, leading CPESN in Missouri, that brought this all to fruition. Yet in the very nature of her answering this question, she didn't say me.

Eisenbeis: I will say too, I'm really good at bringing smarter minds than mine together.

Pharmacy Times: What can pharmacists and other key stakeholders take away from this program?

Eisenbeis: This program highlights the benefit of involving community pharmacy in a whole host of other areas. So again, we said vaccine gap closure program, but this has so many more implications to close gaps in communities that are also maybe dependent on, what is the gap in that community, and is it different from this one, and the community pharmacy team being able to close and impact those gaps. The other is it brings us to the table at new conversations that maybe we weren't getting our foot in the door in other spaces. So, we're actually able to have conversations that we're not getting lumped in with strictly dispensing contracts, for example, or dispensing services. And then even when we say pharmacy services, we're not strictly talking about medication adherence or adherence packaging. We're expanding the line of services that pharmacy and pharmacy teams, especially those with CHWs, can offer. And I know Jake can speak to the health equity line of service. So, I'm going to punt that to you, Jake,

Galdo: Well, you know, and it goes back, what can we take away? We can take away, you know, to piggyback off of that, we can take away a sustainable model of business at a pharmacy that's focused on health equity services. Right? We can bring in revenue to care for people in different ways, and those different ways could be as simple as calling a dog food company to ship dog food to the patient for their pets, so that they can now afford co-pays for their medications. Or it is awareness that co-pays are a barrier, and how do we overcome them? And how do we bifurcate the whole idea of a pharmacy is only product-based, but it really is service as well, and how do we show and express that value in different ways? But ultimately, the key takeaway is, you can do it too, right? Because we're seeing this happen, and we're facilitating programs like this in other states now, because the opportunities are there, the need is there, and we can do that as pharmacies and CHWs.

Eisenbeis: And I think too, pharmacy has a value add that's not just the medication experts, and this program shows that the entire team can add value to the pharmacy service that impacts the whole health care system through follow-up and monitoring. Those aren't happening elsewhere. That's why gaps exist. And so, we are able to close those gaps because we have the extensive follow-up and monitoring through those relationships and touch points. And then the last thing I'll say is, I think the overall too, is that pharmacy can change the system. So let's do it.