Pharmacists as Influencers of Patient Adherence

Pharmacists can make the most of their interactions with patients.

Our pharmacies are involved in a pilot program working with local primary care providers to coordinate care for Medicaid recipients. As part of that pilot, an analysis was performed for high-risk patients who were targeted for coordination efforts. These patients visit their primary care physician an average of 4 times per year and have 9 outpatient visits per year with specialists; physical therapists; and home health care, behavioral health care, and nutrition professionals. What’s even more astounding is that these patients are presenting to their community pharmacy 35 times per year.

So, community pharmacists have the advantage of 35 face-to-face encounters with our patients. What are we as community pharmacists doing to make the most of this opportunity?

Over time, community pharmacy has adapted to the comfort zone of sitting back in the pharmacy and waiting for our patients to come through the door. As we shift from the pill-centric model to patient-centric model, we must start looking at how our activities influence total cost of care. Not the cost of pills, not copayments, not generic versus brand, not tier 1 versus tier 2, but the total cost to the health care system. How we interact with patients and other health care providers matters as the impetus becomes outcomes-focused, not “right pill, in right bottle, to the right patient.”

Individualizing Patient Goals

No 2 patients are the same. Consider this scenario. You are the community pharmacist for 2 patients with a diabetes diagnosis. Patient 1 has a prescription for metformin 500 mg, 1 tablet 3 times daily, with “HbA1cv= 12.2mg/dl” written on the prescription. Patient 2 presents with a prescription for metformin 500 mg, 1 tablet 3 times daily, with “HbA1c = 7.5mg/dl” written on the prescription. The encounters you have with these 2 patients should be completely different based on the patient’s priorities, health care goals, and the challenges specific to the individual. A more realistic view of the scenario today is that these 2 patients present with a prescription for metformin and there is no mention of HbA1c.

If a face-to-face encounter occurs, we deliver a generic message that is not tailored toward any specific outcome. Since the term “medication therapy management” has been coined, we have put so much emphasis on comprehensive medication reviews and inefficiently carving out the hour-long engagement with a patient to discover drug therapy problems that we have forgotten the value of the 2- to 5-minute encounters that are happening multiple times a year. We are seeing these patients more than any other health care provider.

Using these quick touch points, we can really develop an invested relationship with these patients and together navigate a path of resolution to improve specific outcomes. Tailor the message and education to the patient. Ask about his or her outcomes and be accountable for helping your patient reach goals. Think about the approach quantitatively and identify the problem(s) and how you can help to correct them. Offer specific suggestions for improvement and allow the patient to share in the decision-making.

For example, a patient who was “extremely busy” and “just forgot” to take his medication for 5 of 7 days could be taught to set a reminder in his phone and counseled to take the medication. Find out what is reasonable for the patient. If a patient makes the active decision not to participate in improving adherence, we still have a responsibility to equip that patient with all the resources and education to know the consequences of nonadherence.

Improve Efficiency With Technology

Community pharmacists are being asked to participate in health care reform by improving the value of care that we deliver and to achieve this in a setting where budgets cuts lead to reduced dispensing fees and reimbursement. We are forced to examine the changing structure of delivering value or increasing the volume.

What is a feasible and economical way to identify patients who are most at risk for poor adherence? We have all heard the cliche, “work smarter, not harder,” and the technology that we choose in our pharmacies can critically impact our ability to reach our high-risk patients most efficiently. In a 2006 study published in the Journal of the American Pharmacists Association, Kreling et al investigated characteristics of the current community pharmacy practice environment and the perception of 611 pharmacists about aspects of their work environment.¹ More than one-half of the pharmacists in community pharmacy settings reported that equipment and technology increased their level of productivity, quality of care, financial performance, and job satisfaction. Our dispensing systems should be providing us with the bells and whistles to help us identify poor adherence.

If you do not have a dispensing system that has upgraded adherence features, it is time to consider a change. Pharmacy software and add-on programs in the marketplace can offer a wide variety of analytics to help you (1) identify patients who need your attention, (2) generate patient-specific reports cards to alert others involved in the care of the patient, and (3) focus on patient-specific metrics to guide encounters. A process of prescriber notification should be included in work flow when patients have not been adherent to drug regimens.

Culture of Change

Where do we start as community pharmacists if we want to influence outcomes? Some would argue that it starts within your own community pharmacy. Your entire staff should be challenged to think and act “patient-centric.” While it is important to maintain the basic principle of getting the right drug to the right patient, are we really committed to being accountable for improving adherence and moving the mark on improving patient outcomes within our patient panel? Every single member of your staff, whether it is you as the pharmacist, the technician, or the delivery person who ultimately completes the final step of ensuring the patient gets the appropriate medications, must understand that the practice of pharmacy does not operate in a silo. We are not the only health care workers involved in the care of the patient, and we must be committed to ensuring that we are connected and in communication with everyone touching a patient.

What are you doing about patients who choose to fill only 1 of their 4 medications consistently? Does your staff know to alert you to these issues, or do they simply process the order as they seek to meet the challenge of getting the medicine to the patient quicker than your competitor? Determine the most efficient process, and train your staff to utilize technology to communicate missing information to other members of the health care team.

Seizing the Opportunities

How do we capitalize on those 35 visits a year? How do we make the most of a 3-minute counseling session after we discover that someone is 26 days late in filling his or her lisinopril? How do we get paid to do this? The opportunities that come with value are infinite. But we have to seek them out. We have to look for the gaps that are there today and be creative at partnering with others to close those gaps. Those partners may not be traditional partners for pharmacy. The legacy triad of pharmacist, physician, and patient is rapidly losing out to the pharmacist, physician, patient, home health care manager, daughter, parish nurse, specialist, hospital critical care pharmacist, insurance company, and discharge planner, etc.

Nationally, we have spent over $3 billion in health care due to preventable drug events, and 66% of those events occurred during the patient transition to another level of care.² The opportunities for community pharmacists to identify and resolve drug therapy problems are abundant, and more importantly, no other health care provider has the opportunity to see a patient as often as we do. Community pharmacists are the best trained and best prepared to focus on identifying medication misuse and developing patient-centered strategies to resolve drug-related problems. After all, this will be critical to our survival.

Joseph Moose, PharmD, is a fourth-generation pharmacist with Moose Pharmacies and currently manages the Concord, NC, location. Dr. Moose earned his Doctor of Pharmacy at Campbell University in 1990. He is the co-chair of the NC Medicaid Drug Regimen Review Board, a member of the Pharmacy and Therapeutics Committee for NC Medicaid, a member of the NCPA Patient Care Committee, and an adjunct assistant professor at the UNC Eshelman School of Pharmacy. He serves as a community pharmacy preceptor for Wingate, Campbell, and UNC-Chapel Hill students. Dr. Moose is actively involved in the North Carolina Association of Pharmacists and the National Community Pharmacists Association. He received the Community Care Pharmacist of the Year Award from NCAP in 2008. He was named winner of the Pharmacy Times 2012 Next-Generation Pharmacist™ Award.Ashley Branham, PharmD, BCACP, is the director of clinical services at Moose Pharmacy in Concord, North Carolina. Branham received her Doctor of Pharmacy from Campbell University. She has completed a community pharmacy residency at the UNC Eshelman School of Pharmacy and Moose Professional Pharmacy in Concord. She also completed a postgraduate year 2 community pharmacy residency with a focus in academia with the UNC Eshelman School of Pharmacy and Moose Professional Pharmacy (2010).Dr. Branham also works as a clinical pharmacist with Carolinas Health System. She is currently a preceptor for student pharmacists completing advanced pharmacy practice with the UNC Eshelman School of Pharmacy.

References

• Kreling DH, Doucette WR, Mott DA, et al. Community pharmacists’ work environments: evidence from the 2004 National Pharmacist Workforce Study. J Am Pharm Assoc. 2006;46(3):332-339.
• Overview of the CMS Innovation Center Goals and Objectives: Patient Protection and Affordable Care Act. Pub L No. 111-148, §2702, 124 Stat (2010).