Implementing Pharmacist Advocacy Initiatives: A Step-by-Step Review Based on Experience

Prior to the COVID-19 pandemic, I thought advocacy was someone else’s job. I did not believe that my voice or presence could effect change among our state’s regulations or laws. This belief has since been upended. What I learned is that anyone, at any age, can be an advocate—but along with motivation, you must also have a strategic process to convey effective messaging.

In June 2021, I was tasked by my health system leadership to ensure retention of the COVID-19 waiver for pharmacists to administer vaccinations in Pennsylvania. I partnered with the government relations director, Nicole Fedeli, to identify this in written communication to members of the Pennsylvania General Assembly. This waiver was critical to ensure that pharmacists could continue to independently order and administer COVID-19 vaccinations under the Public Readiness and Emergency Preparedness (PREP) Act¹ beyond September 30, 2021, the expiration date imposed by the Pennsylvania General Assembly. Without an extension, the following COVID-19 vaccination efforts by pharmacists would expire:

• The ability to vaccinate all, without a specific physician order;
• The ability to administer COVID-19 vaccinations; and
• The ability to vaccinate individuals aged between 6 and 17 years.

This could slow vaccination efforts overall, especially in children, as the Pfizer COVID-19 vaccine was granted emergency use authorization on May 10, 2021, in those aged 12 to 15 years, and a broader rollout was imminent at that time.² Additionally, if vaccination privileges were taken away from pharmacists, the number and type of providers who could administer vaccines would be limited. By placing this additional burden on nurses and physicians, it could divert resources and time away from direct clinical care for patients who are critically ill. It was truly a time when pharmacists in Pennsylvania had to rise to the needs of our communities, and the effort required the state’s support.

Assigned to ensure that pharmacists were positioned to better serve our communities and combat the pandemic, I accepted this advocacy role, much to my own surprise, and locked arms with a strategic government relations partner. She not only encouraged me to serve in this role, but also welcomed my collaboration as we approached legislators and committee leadership for support.

Our advocacy strategy involved 3 key considerations to counter a 3-fold challenge. First, the legislature’s fall session was abbreviated, with only 6 session days before the waiver expiration. We needed to act fast. Second, a must-pass legislative vehicle needed to be identified, to which we could attach waiver-related language. Third, we were in the midst of a COVID-19 surge that was different from its predecessors. Patient volume in our system’s hospitals was higher than it had ever been, and we were experiencing a critical workforce shortage. We laid out 4 steps, outlined below, to achieve our goals.

Process to Implement Advocacy

Step 1: Idenify an Advocacy Goal

Once a goal is identified, there is a need to set clear objectives for the desired outcomes. I learned to accept that it takes time to achieve advocacy goals. Making legislative change is not expedient. To supplement your primary goal, you can develop checkpoints, or secondary goals, to help you along the way.

Although legislation had been introduced to expand the pharmacist scope of practice and clinical services in most states,³ we were informed by Pennsylvania’s House and Senate leadership and committee staff of the unrealistic chances of this legislation moving forward in the abbreviated fall session. We were encouraged to narrow our request to that which would allow pharmacists to independently order and administer COVID-19 vaccines and adhere to reporting requirements. Through these discussions, I was able to establish a strong rapport with committee members. Gaining a better understanding of their viewpoints, even opposing ones, only furthered our chances of achieving any secondary goals. I suggest trying to discern where compromises can be made. It is better to do this in the planning phase than on the fly when you are fully engaged in dialogue and debate.

In August 2021, after considering all the variables, we determined that our call to action was retention of the COVID-19 waiver for pharmacists to administer vaccinations beyond September 30, 2021.

Step 2: Frame the Message

When developing a communication, tailor it to the audience. Our communication was sensitive to the constraints and political undertones of the government.

Given our conversations with House and Senate leadership, we knew legislators were rallying around actions to stabilize the economy and return to prepandemic activities. Therefore, we structured our data-driven advocacy request to align around that premise: that a successful COVID-19 vaccination program is essential to further stabilizing the economy and safely returning to prepandemic activities.⁴ As such, all residents would benefit from local access to the most accessible of all health care providers—the pharmacist.

Although I was passionate about the issue, I discovered that the data need to prevail. To express my conviction, I described anonymous patient examples that allowed others to connect to my purpose and cause, and I had plenty to describe. In January 2021, I assumed the role of director of our urban Pittsburgh vaccine hub, UPMC Mercy-Southside, and provided clinical and operational leadership for our Southwest Pennsylvania vaccine community and school district efforts. With my team, we led and aligned 180 direct COVID-19 vaccine workers and nearly 1000 volunteers to oversee 98 community clinics and 144 school district sites.

Step 3: Develop a Strategy

We developed a multipronged communication approach to reach out to pharmacy leaders, including those in other academic medical centers and health systems across the state. Although some of those entities were competitors, everyone acknowledged the shared value in finding common ground for causes that impact the larger public health infrastructure. We quantified our outreach efforts in a coalition letter with 2 health systems, boasting vaccination of more than 1 million Pennsylvanians as of August 2021.

As we circulated our position, the legislators were receptive and we engaged the Hospital and Health System Association of Pennsylvania, which rallied behind the effort by providing advocacy and support. That support included an opportunity to testify before the House Professional Licensure Committee on September 20, 2021, for an informational session on the pharmacist’s role in COVID-19 vaccinations.⁵

On September 29, 2021, our efforts resulted in unanimous passage of the waiver extension through March 31, 2022, in both the Pennsylvania House and Senate chambers.^6-8 These waivers have since been extended several times.

Furthermore, in July 2022, our secondary goals were achieved when Pennsylvania’s governor, Tom Wolf, amended the Pharmacy Act. It retains these 3 COVID-19 regulatory waivers regarding immunizations⁹:

• Pharmacists and pharmacy interns are authorized to administer influenza and COVID-19 vaccines to individuals 5 years and older;
• Pharmacists who hold an active Authorization to Administer Injectables license are permitted to delegate the authority to administer influenza and COVID-19 vaccines to other licensed individuals, such as certified registered nurse practitioners, physician assistants, and registered nurses; and
• The pool of eligible supervisors of pharmacy interns during administration of COVID-19 and influenza vaccines is increased, including not just supervising pharmacists but physicians, physician assistants, and certified registered nurse practitioners.¹⁰

It is important to note that this legislation does not apply to any other immunizations, and it does not authorize pharmacy technicians to administer immunizations.9 Additionally, the federal PREP Act remains in effect at the time of this writing, until October 2022 (unless renewed); the act supersedes
state rules and allows pharmacists to administer COVID-19 vaccines to individuals aged at least 3 years.

Step 4: Communicate and Connect

The process of supporting a cause for our profession can be highly rewarding. As pharmacists, we must take charge to enact change.

My advice is to sign up to receive newsletters from your state and federal representatives. These communications can provide insight on where they stand regarding health care issues and any committee assignments that may impact pharmacy scope, licensure, or payment. It is important to identify any related past work and use it to thank and connect with them. Information on state or federal representatives can be located online and they can be contacted via email, telephone, social media, or in person. Remember, these individuals represent you.

Acknowledgement: The author would like to thank Ms Fedeli for her editorial review and oversight of this article. These contributions warranted including Ms Fedeli as a co-author.

About the Authors

Alfred L’Altrelli, PharmD, is the senior director of pharmacy at UPMC Presbyterian-Shadyside and an adjunct professor and program director
for Pharmacy Administration Residencies and fellowship at UPMC and the University of Pittsburgh School of Pharmacy, all in Pennsylvania.

Nicole Fedeli is the director of public policy and engagement at UPMC Government Relations in Pittsburgh, Pennsylvania.

References

1. Guidance for licensed pharmacists, COVID-19 testing, and immunity under the PREP Act. HHS. April 8, 2020. Accessed September 13, 2022. https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/authorizing-licensed-pharmacists-to-order-and-administer-covid-19-tests.pdf

2. Coronavirus (COVID-19) update: FDA authorizes Pfizer-BioNTech COVID-19 vaccine for emergency use in adolescents in another important action in fight against pandemic. News release. FDA; May 10, 2021. Accessed September 13, 2022. https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-pfizer- biontech-covid-19-vaccine-emergency-use

3. Russell T. Assessing state, federal legislation alignment with expansion
of pharmacist’s role on care team. Pharmacy Times. May 4, 2022. Accessed September 13, 2022. https://www.pharmacytimes.com/view/assessing-state-federal-legislation-alignment-with-expansion-of-pharmacist-s-role-on-care-team

4. Report to Congressional Committees. COVID-19: continued attention needed to enhance federal preparedness, response, service delivery, and program integrity. United States GAO. July 2021. Accessed September 13, 2022. https://www.gao.gov/assets/gao-21-551.pdf

5. House committee meetings: professional licensure. Pennsylvania House of Representatives. September 20, 2021. Accessed September 13, 2022. https://www.legis.state.pa.us/cfdocs/legis/CMS/ArchiveDetails.cfm?SessYear=2021&MeetingId=1814&Code=34&Chamber=H

6. Bill information: regular session 2021-2022: House Bill 1861. Pennsylvania General Assembly. September 30, 2021. Accessed September 13, 2022. https://www.legis.state.pa.us/cfdocs/billInfo/BillInfo.cfmsyear=2021&sind=0&body=H&type=B&bn=1861

7. Waived and suspended licensing regulations. Pennsylvania Department of State. Accessed September 13, 2022. https://www.dos.pa.gov/Pages/COVID-19-Waivers.aspx

8. Pennsylvania HB1861. TrackBill. Accessed September 13, 2022. https://trackbill.com/bill/pennsylvania-house-bill-1861-an-act-amending-the- act-of-april-9-1929-p-l-177-no-175-known-as-the-administrative-code-of- 1929-in-temporary-regulatory-flexibility-authority-further-providing-for- definitions-and-for-temporary-regulatory-flexibility-authority/2141233/

9. COVID pharmacy waivers. Pennsylvania Pharmacists Association. Accessed September 13, 2022. https://www.papharmacists.com/page/covidwaivers

10. The General Assembly of Pennsylvania, House Bill No. 2679, Session of 2022. Pennsylvania General Assembly. June 15, 2022. Accessed September 13, 2022. https://www.legis.state.pa.us/cfdocs/legis/PN/Public/btCheck.cfm?txtType=PDF&sessYr=2021&sessInd=0&billBody=H&billTyp=B&billNbr=2679&pn=3252