The Perfect Ingredient: Vaccine Education With Pharmacy Community Health Workers

The best meal can’t be prepared without the ingredients, cooks, and of course, the chef’s secret sauce. Health care has long been looking for that “secret sauce.” The “sauce” that brings communities together and engages trusted local health care providers to address local needs.

No one understands a community better than the people who live in the community. For this reason, if no other, the local community pharmacy can be the binder which brings all the ingredients of the “secret sauce” together. Community pharmacies and their pharmacy community health workers (CHWs) are integral components of the neighborhood, trusted to bring not only health care but also caring, compassionate problem solving to patients who depend on them. From medication synchronization to health equity, the local community pharmacy stands at the intersection of health care and social determinants of health.

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This relationship is the “secret sauce” the Missouri Pharmacy Association, Community Pharmacy Enhanced Services Network (CPESN) of Missouri (MO), and CPESN Health Equity brought to the Missouri Vaccine Gap Closure program. Together, they brought pharmacy quality metrics and operations, mixed it with educational outreach and health equity expertise, and brought vaccine gap closure to patients in their communities.

Vaccines, and more importantly vaccinations, are one of the most cost-effective medical treatments known. Providing vaccinations for preventable diseases not only saves lives, but immunizations also save health care dollars. Even knowing the value of vaccinations, however, health care providers struggle to bring this message to patients and struggle to provide those vaccinations. Patients are sometimes unaware of vaccines, ill-informed of the benefits of vaccines, suffer from needle fear, or have any other of the countless reasons that lead to gaps in care with respect to vaccinations. This problem, which occurs in the general population, is exacerbated within vulnerable populations. To close these gaps, the Missouri Pharmacy Association (MPA), CPESN-Missouri, and CPESN Health Equity were awarded a statewide Missouri Department of Health grant for pharmacists and pharmacy CHWs to address vaccination gaps in care.

The Ingredients

Medication Synchronization Operations

Folding in new clinical and health equity services at a pharmacy is just like ‘folding in the cheese.’ Everything must be in place for success – otherwise, the sauce breaks. In this case, a minimum requirement is medication synchronization.

The best medication synchronization program is one that empowers the entire pharmacy team and staff. A minimum requirement within CPESN Missouri is training and engagement with at least 1 pharmacist and 1 CHW/pharmacy technician per pharmacy. Integration into current workflow and existing technology is vital. In the Missouri Vaccine Gap program, initial training included a focus on moving pharmacies to shift medication synchronization operations to a longitudinal education and care process. This was crucial for scalability and successful implementation of quality services. Finally, established medication synchronization programs with educational interventions build upon established relationships, rapport, and a routine follow-up and monitoring process. This creates an environment for identifying and resolve care gaps, social needs, and health-related disparities.

Financial Opportunities

Centers for Medicare and Medicaid Services (CMS) created a new vaccine hesitancy education code in 2022. G0310 is “immunization counseling by a physician or other qualified health care professional when vaccine(s) not administered on the same date of service for 5-15 minutes”. This is the foundation for the program and grant received by the MPA that was awarded by the Centers for Disease Control and Prevention (CDC) and the Missouri Department of Health and Senior Services (DHSS) Bureau of Immunizations. Supported by CDC and DHSS, this program demonstrates that community pharmacy teams, specifically CHWs, can deliver vaccine hesitancy education statewide in a consistent, high-quality manner. This CPT code is billable to Missouri Medicaid – allowing a sustainable model of care after the project ends.

Health Equity Expertise

The program also focused on utilizing CHW-trained pharmacy technicians. Earlier grant work from MPA developed a state-approved pharmacy-based CHW training course. This specific course was not requested; however, many of the pharmacy-based CHWs were trained in this ACPE- and Missouri Credentialing Board-approved course.

Longitudinal education interventions were provided by CPESN MO pharmacy teams with health equity expertise. This expertise consisted of at least a pharmacist and a CHW-trained pharmacy technician or social determinants of health (SDoH) expert. SDoH experts were pharmacy technicians trained in SDoHs and health equity while awaiting enrollment in the CHW course. Pharmacists determined vaccine eligibility and provided clinical counseling, while CHW-trained pharmacy technicians or SDoH experts managed monthly medication synchronization calls to screen and address vaccine hesitancy and SDoH barriers. These technicians played a crucial role in guiding patients from initial reluctance to cautious consideration and ultimately to acceptance of vaccines.

The Chefs

Any kitchen, as described in the movie Ratatouille, requires multiple stakeholders – from the head chef to the busser. And just like any kitchen, a successful healthcare program requires multiple stakeholders. This program engaged:

Accountable Pharmacy Organization: CPESN USA is the leader in joining payors, pharmacies, and communities together to provide enhanced health services locally. As a Clinically Integrated Network (CIN), CPESN USA pharmacy providers collectively deliver health services to improve quality of care for patients in their local communities and lower the total cost of care. CPESN USA incorporates innovation and technology to empower its networks of pharmacies to succeed in optimizing patient outcomes. CPESN Missouri and CPESN Health Equity partnered together to provider this specific program.

Pharmacies: CPESN Missouri is comprised of over 120 independently-owned pharmacies – from independents to regional grocery stores. These pharmacies are organized in various regions with regional leadership that meets monthly for quality improvement, best practice development, and support. To be eligible for the Missouri Vaccine Gap Program, pharmacies were required to be an MPA business member, have a CPESN MO pharmacy in good standing, a CPESN HE pharmacy in good standing, and have an established medication synchronization program.

CHWs: SDoH experts were pharmacy technicians trained in social determinants of health and health equity while awaiting enrollment in the CHW course with CEimpact. Pharmacists determined vaccine eligibility and provided clinical counseling, while CHW-trained pharmacy technicians or SDoH experts managed monthly medication synchronization calls to screen and address vaccine hesitancy and SDoH barriers. These technicians played a crucial role in guiding patients from initial reluctance to cautious consideration and ultimately to acceptance of vaccines.

State Leadership: The Missouri DHHS, Bureau of Immunizations, provided grant funding for this program through a contract with the MPA. This was an expansion of previous years-long partnership that included the support and encouragement of CHWs integrated into community pharmacies.

Researchers: The research aimed to demonstrate the impact of pharmacy teams on closing vaccine gaps, showcase the sustainability and scalability of a program based on medication synchronization, and highlight the expansion of services through CHW-trained pharmacy technicians. CPESN HE provided de-identified data to the University of Missouri-Kansas City School of Pharmacy (UMKC SOP) and Purdue University for data analysis.

The Meal

In the first 6 months, over 28,000 interventions have occurred representing over $700,000 paid to pharmacies for patient care services. Some interventions have focused on a specific vaccine the patient may be eligible for and others have broadened the session to address broader issues of vaccine hesitancy and supporting access to vaccinations. The focus on education and hesitancy is built on an already established and trusted relationship between patients and the pharmacy team.

Over 91 pharmacies with 200+ providers have been engaged in the first half of the program (Jan – June 2024) with over 22,000 patients engaged in >75% of Missouri zip codes. Approximately 17% of patients had identified health-related social needs that were also triaged by CHWs.

Strikingly, preliminary data show an approximately 6.6% gap closure rate. And not all vaccines are the same – gap closure for influenza is less than 6.6% – showing this service can help improve immunization rates in other routine vaccines, also considering that the typical flu shot “season” has not started yet.

And what’s the socioeconomic benefit? Pharmacies generated service-based revenue through CHW-led education. And society saved $8.7M – because each vaccine administered saves the healthcare system $4637.

What’s Next?

The program only continues to grow. In July 2024, over 13,000 more interventions occurred. And a new phase launched in the last week of July as well. The next part of the Missouri Vaccine Gap Program takes the vaccine hesitancy education to communities and layers on novel vaccine verification, coordination, and health equity incentive payment models. For example, even though the program does not pay for vaccines, a pharmacy could offer free influenza and COVID-19 vaccines to a homeless shelter – and not lose money.

CPESN Health Equity is facilitating and supporting similar vaccine hesitancy education programs with CHWs and SDoH experts in more and more states. All pharmacies can be equipped to develop service-based health equity revenue. The pharmacies just need to find that perfect ingredient – a pharmacy-based CHW.