50 Stories from 50 States: Midwest

About the Pharmacy

Maryville Pharmacy
Maryville, IL
www.maryvillepharmacy.com

Meet the Team

Pharmacist Lead Contact:

• Harry Zollars, PharmD

Faculty Lead Contact:

• Miranda Wilhelm, PharmD

Student Pharmacist:

• Sara Rhymer 

Description of Pharmacy

Maryville Pharmacy is a single entity family-owned, independent pharmacy serving the Saint Louis Metro East in Madison County, IL. The pharmacy performs a wide range of services, including but not limited to traditional pharmacy dispensing, compounded/customized prescriptions, adherence packaging, medical equipment sales and prescriptions, advanced wound care products, bracing products, compression garment products, mastectomy-related products and counseling, delivery services, 24-hour access, 340b dispensing, and much more.  

Maryville Pharmacy also allows for the improved access to patients who are uninsured or underinsured to decrease the financial burden for some life-saving medications, especially for those living with type 2 diabetes. A large population of English as a Second Language (ESL) patients who use 340b clinics for their healthcare seek services that can help address their health literacy needs on top of easing the financial burden of prescription medications, much of which may be left unmet. Maryville Pharmacy has been a contract pharmacy with the 340b Federally Qualified Health Center for more than 5 years and have developed a cordial and productive relationship with the local clinic and their providers. 

Pharmacy Story

Initial Presentation:
A 54yo female patient (JC) came to Maryville Pharmacy to pick up new prescriptions prescribed by a 340b clinic from a nearby town.  While filling medications for diabetes, the pharmacist noted that the patient primarily spoke Spanish and spoke English as a second language. The patient had difficulty asking questions and trouble understanding the instructions on the labels.  The pharmacist offered to counsel in Spanish with the patient’s permission and took prescriptions back to redo the labels and writing in the appropriate language.  The patient initially recognized the insulin but was not familiar with the “pen” devices.  

​Background:
JC’s provider had prescribed:

• Levemir 100 units/ml pens 60 units daily for treatment of diabetes mellitus
• Jardiance 25 mg for treatment of diabetes mellitus
• Amlodipine 10 mg for treatment of hypertension
• Simvastatin 80 mg for treatment of hypercholesterolemia
• Fluoxetine 20 mg for treatment of moderate depressive disorder
• Previous history showed prior use of insulin in vials, a trial of Zestril 20mg daily, Zocor 40mg nightly, and occasional treatments for antibiotics/antifungals (many treatments around diabetes treatment put on hold due to financial constraints according to pharmacy database)

​Patient Report:
The patient reported:

• Lack of knowledge of indications for non-insulin products.
• No supplies for testing blood glucose or any samples of pen needles for Levemir.
• No reported symptoms of hypoglycemia or any other pressing concerns.

​Physical Observation:
Pharmacist observed that patient was overwhelmed and confused about treatment for medications overall and needed time to counsel for what each medication would do.

​Intervention:
1. Education: Using basic Spanish, pharmacist counseled patient on directions for Levemir insulin, injection technique, disposal and hygiene around injections, risk of low blood sugar and measures for what to do if it happens. All other medications discussed with indications, directions, and side effects.

2. Provider Consult: Pharmacist called provider for new prescriptions for needles and testing supplies for blood glucose. In speaking with nurse, pharmacist advised that most often switching between insulin vials and pens can be confusing with patients and that ancillary supplies should be considered. Counseling on insulin pen use hygiene also performed. Needles provided to patient as well as testing supplies.

3. Follow Up: Pharmacist would determine use of testing supplies and knowledge base growth for how blood glucose was taken as well as indications/side effects of new medications.  

Outcomes of Care Provided:
Outcome 1: Health Literacy

With pharmacist intervention of counseling in patient’s preferred language, patient would have received more direct information about the purpose of treatment and the likelihood of side effects.  

• The pharmacist asked the patient, “Do you have trouble at other pharmacies to understand what your medications are for?” She reported “There’s no other pharmacies that are willing to help communicate in Spanish with me. It also takes a lot of my time and energy to translate prescriptions when I get home.”

​Outcome 2: Adherence – Diabetes

Pharmacy staff worked to improve adherence with workflow measures to allow for better adherence and to more easily accommodate the patient’s lifestyle.

• JC got her medications by a pharmacist on the next visit to promote regular adherence to medications prescribed.  

​Outcome 3: Inter-Professional Care

Clear and direct communication between staff at clinic and pharmacy allowed for optimal care for patient. Should in the future there be collaborative practice agreements be made, pharmacy staff could auto-initiate prescriptions to help fill gaps in therapy that are common with diabetes like the use of pen needles with insulin pens or to provide testing supplies when not provided at the clinic.

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State/Federal Connections/Advocacy/Impact:

The care provided to JC was made possible through Maryville Pharmacy’s participation in the Illinois Community Pharmacy Enhanced Network (I-CPEN), Illinois’ CPESN USA network. The Illinois Pharmacists Association as well as Southern Illinois University Edwardsville School of Pharmacy also provide many resources and knowledge bases for pharmacies and patients in the area. Maryville Pharmacy and other independent, family-owned pharmacies are important access points for patients from many lifestyles to provide personalized care at all health literacies, much of which are provided in extremely trying times during the COVID-19 pandemic. 

About the Pharmacy

Williams Brothers Health Care Pharmacy
Paoli, Indiana
www.williamsbrotherspharmacy.com

Meet the Team

Faculty Lead Contact:

• Lola Adeoye-Olatunde

​Pharmacist Lead Contact:

• David Ford

​Trainee Contact:

• Katie Hettinger 

Description of Pharmacy

Williams Brothers Health Care Pharmacies include 7 family-owned, independent pharmacies serving rural areas in central and southern Indiana. The Paoli location is the only pharmacy with a drive through and delivery services in town and is one of only 4 pharmacies in the entire county, servicing a rural, underserved population. Other services offered at this site include medication synchronization, 340B, home care including durable medical equipment (DME) billing, delivery, and set-up. 

Pharmacy Story

Initial Presentation:
KF, a 72-year-old male patient presented to Williams Brothers Health Care Pharmacy to pick up an antibiotic and other medications after discharge from a local mental health facility. We did not have the medications and KF was a new patient to us. KF was very agitated and nervous, stating he had been discharged several days prior and had been without his meds that whole time.

Background:
KF had been prescribed 19 medications including the following, which are relevant to this story.

For mental health:

• Seroquel 100 mg every morning and 300 mg every evening
• Buspar 5 mg twice daily
• Risperdal 0.5 mg twice daily
• Depakote DR 500 mg three times daily  

For a bacterial infection:

• Bactrim DS twice daily x 10 days

​Patient Report:
KF reported not "feeling right" and that he was told not to drive, yet he had driven himself to the pharmacy because he had no other way to get his medications. He also provided a phone number for a family member to help gather more background information.

Physical Observation:
Patient was agitated, anxious and confused. He was having trouble putting thoughts together and was tearing open packages in the store and in his vehicle trying to "find" his medicine.

Intervention:
Care Coordination:

The pharmacist called other pharmacies, local doctors and mental health facilities until he successfully located the patient’s prescriptions. These prescriptions were delivered to the patient’s home the next day.

The patient’s daughter in law was called. She was several hundred miles away and was unaware that KF had been hospitalized. She provided details regarding the patient’s long-term psychiatric history and a history of non-compliance. The pharmacist called a local mental health organization to seek advice and follow up care for the patient. Hoosier Uplands was contacted to coordinate follow-up care for the patient to ensure his basic needs were met.

Safe Transportation:

When KF tried to drive home, the pharmacy staff observed him driving in circles, speeding up and slowing down often, almost striking a person in the parking lot. The pharmacy sent 2 pharmacy technicians out to check on him. A pharmacy technician drove the patient home in his car and was then driven back to the pharmacy by another technician.

Outcomes of Care Provided:
Outcome 1: Compliance

The next month we were able to fill all the patient’s medications and deliver them to KF.

​Outcome 2: Follow-up Care Coordination

KF was in a healthier frame of mind and was very grateful in our conversations with him over the phone over the next month. Our delivery driver stopped in to see the patient for well checks for several weeks after our initial contact, which was really appreciated. Found a family practice physician to take care of KF after discussing the situation and his needs.  

​Outcome 3: Readmission Avoidance

KF was able to remain out of the hospital and mental health facility and is on his own to current date

State/Federal Connections/Advocacy/Impact:

The care provided to KF was possible due to the above-and-beyond care patients can expect to deserve from pharmacies in the Community Pharmacy Enhanced Services Network (CPESN) Indiana network. The touchpoints Williams Brother’s pharmacy team can make for homebound patients, such as KF, through their delivery services was an integral part of the follow-up care provided for KF. If reimbursement for these touchpoints was more readily available, pharmacy teams could continue and expand their impact in a larger way.

About the Pharmacy

About the Pharmacy

Greenwood Pharmacy
Waterloo, IA
www.greenwoodpharmacy.com 

Meet the Team

Faculty Lead Contact:

• Stevie Veach

 Pharmacist Lead Contact:

• Robert Nichols

 Resident Pharmacist:

• Kaitlyn Pegump 

Description of Pharmacy

Greenwood Pharmacy is one of five family-owned, independent pharmacies and has been serving the communities of Waterloo, Cedar Falls, Evansdale, and surrounding areas since 1987. This pharmacy is located in a designated Health Professional Shortage Area (HPSA) and Medically Underserved Area (MUA) by the United States Health Resources and Services Administration. Services offered at this site include medication synchronization, immunizations, comprehensive medication reviews, home delivery, diabetic shoes, long-acting injections, point of care testing, and medication compounding.

Pharmacy Story

Initial Presentation:
A mother and her 12-year-old son (BH) came to Greenwood Pharmacy for a pharmacogenomics consult.

Background:
Patient’s doctor had prescribed:

• Amphetamine Salts IR 10mg and 5mg
• Escitalopram 5 mg

​Patient Report:
The mom reported:

• Son takes Adderall 10mg in the morning and 5mg at noon. Also takes 7.5mg of Lexapro.  
• Previously on Vyvanse 160mg. Medicine was lowered and switched to allow for him to eat and grow. Mom reports eating got better with this change.
• Mom reports his mind/education has been stunted. She reports his impulses, ticks, repeating, blurting, moving constantly, banging on things (symptoms) are not controlled.  
• Mom reports he cannot focus or sit still long enough to start a math worksheet, read, or learn without someone constantly there holding his hand-and then barely.

​Intervention:
Specimen Collection and Lab Testing:  

Performed initial consult, comprehensive medication review, and specimen collection for lab testing.  

Results Review and Education:

The pharmacist educated the patient’s parents on the impact of their child's pharmacogenetic profile.

• Poor Response to Amphetamine salts (COMT: Low COMT Activity)
• The patient's genotype result predicts a reduced therapeutic response to amphetamine stimulants. If prescribed, amphetamines should be administered at the lowest effective dose, and dosage should be individually adjusted
• Normal Sensitivity to Escitalopram (CYP2C19: Normal Metabolizer)
• Escitalopram can be prescribed at standard label-recommended dosage and administration

Communication With Provider

Communicated pharmacogenomics results with ordering prescriber with recommendations for therapeutic improvement.  

• Pharmacogenomic testing results suggest a reduced therapeutic response to amphetamine stimulants. May require a higher dose to see expected therapeutic effect. It will be important to manage the benefit of improved therapeutic effects with higher risk of adverse effects at larger doses.
• Escitalopram can be prescribed at standard label-recommended dosage and administration.

Planned Follow-Up to determine if the provider made any medication changes based on the pharmacogenetic profile.  

​Outcomes of Care Provided:
Outcome 1: Therapy Change - Adderall to clonidine

The pharmacist followed up with the mother to evaluate therapeutic improvement and changes made by the provider.  

• Mother reports changes have been made to medications and she is seeing improvements in her son’s behavior. Provider changed Adderall to clonidine. This medication was in the standard precautions category of the pharmacogenomics report.  

Outcome 2: Additional Therapy - Add Qelbree samples

Provider is wanting to add Qelbree (viloxazine), a selective norepinephrine reuptake inhibitor. This is in the same drug class as Atomoxetine. Pharmacogenomics results did not evaluate viloxazine. A review of the pharmacokinetics suggests more favorable effects on this patient with viloxazine than atomoxetine. Recommend standard dosing precautions.

​Outcome to the Pharmacy

• The pharmacist documented each of these encounters with the patient's mother in the Pharmacist eCare Plan so that each pharmacist on the team could view the patient’s progress and continue his care.
• The pharmacy provides this as a cash-based service. The pharmacy is paid for providing meaningful care to help improve patient quality of life.

State/Federal Connections/Advocacy/Impact:

The care provided was made possible through our participation with CPESN Iowa. The support of the network to find payer partnerships while negotiating payment for patient care services allows us to focus our efforts on providing enhanced services like pharmacogenomic testing that can have a positive impact on the trajectory and precision of a patient's care. 

About the Pharmacy

Greenwood Pharmacy
Waterloo, IA
www.greenwoodpharmacy.com 

Meet the Team

• Jim Hoehns, Pharm.D., BCPS, FCCP
• ​Matthew Witry, Pharm.D. Ph.D. 

Description of Pharmacy

Greenwood Pharmacy is one of five family-owned, independent pharmacies and has been serving the communities of Waterloo, Cedar Falls, Evansdale, and surrounding areas since 1987. This pharmacy is located in a designated Health Professional Shortage Area (HPSA) and Medically Underserved Area (MUA) by the United States Health Resources and Services Administration. Services offered at this site include medication synchronization, immunizations, comprehensive medication reviews, home delivery, diabetic shoes, long-acting injections, point of care testing, and medication compounding.

Pharmacy Story

A Community Pharmacy and Family Medicine Collaboration to provide for  Chronic Care Management to Older Adults 
Waterloo is one of the larger, more diverse communities in Iowa. MercyOne Northeast Iowa Family Medicine Clinic (MNEIAFM) provides primary care to the community and serves as a training site for many future health care providers. To advance the clinic’s position as a Patient-Centered Medical Home (PCMH), we were looking for ways to improve the pre-visit planning process to maximize the impact of clinic appointments where physicians must serve complex patients in often too brief appointments.   Pre-visit planning includes anticipating future care needs, such as immunizations or identifying care gaps for chronic conditions.  A large part of pre-visit planning includes medication review. We know the community pharmacist has special knowledge about how patients use their medications and our team wondered  “can we prospectively get input from the community pharmacist to help with pre-visit planning?”

​We created a business agreement with Greenwood Pharmacy to have community pharmacists (CPs) provide pre-visit planning to their Medicare patients who were enrolled in the clinic’s Chronic Care Management (CCM) program.  The clinic provided Greenwood Pharmacy CPs with access to, and training on using the clinic electronic health record (EHR).  A pre-visit templated CP note was created in the clinic EHR to streamline communication.  Each week, the clinic provided Greenwood Pharmacy a list of patients who had a physician visit scheduled the following week.  The CPs reviewed pharmacy records and the clinic EHR to identify potential drug therapy problems (DTPs) and document their note in the clinic EHR.  The clinic physicians reviewed the CP pre-visit notes at the start of the patient encounters.  Time tracking software in the EHR tracked captured both CP time and clinic staff time providing CCM services.  CCM revenue was prorated and shared between the clinic and Greenwood Pharmacy based upon CCM billing time each party contributed.  

​Almost all (94%) of the 153 eligible subjects agreed to enroll in the joint CCM service.  During the 8-month evaluation period, 95 patients received one or more pre-visit medication review. Greenwood CPs made 169 drug therapy recommendations for 107 patient visits.  The physician acceptance rate of CP recommendations was 76%.  There were 92 CCM claims billed and total CCM revenue was $3,585 (clinic:  $1792, Greenwood Pharmacy:  $1793).  Ten of 11 Family Medicine physician participants “agreed” or “strongly agreed” that CP pre-visit recommendations were helpful to their practice.  Dr. Anthony Day, MD, Program Director at MNEIAFM noted, “the amazing thing about this project is that utilizing the Chronic Care Management model, the pharmacist was reimbursed for their time helping with drug therapy without taking reimbursement out of the primary care physician’s pocket. This strategy should be very usable in communities all over the country.”

​This project demonstrates how the unique position and expertise of community pharmacists can be leveraged to identify and communicate drug therapy recommendations before clinic encounter and also  provide a mechanism for payment for their services. 

State/Federal Connections/Advocacy/Impact:

This project was supported by a grant from the Iowa Pharmacy Association Foundation.  Allowing the community pharmacists at Greenwood Pharmacy access to the clinic EHR was instrumental for our project success.  Pharmacists are not designated as “Qualified Healthcare Professionals” and are unable to bill CMS directly for CCM services.  Rather they are considered “clinical staff” whose services must be billed incident to a physician.  We created a business agreement between Greenwood Pharmacy and MNEIAFM for the physician clinic to bill for CCM services which were completed by the community pharmacist.  While this was a success, pharmacists need to be recognized as health care providers to greatly simplify this process.  The level of reimbursement realized by the community pharmacist in this project was inadequate to make this a financially feasible model.  

About the Pharmacy

Osterhaus Pharmacy
Maquoketa, IA
https://www.osterhausrx.com/

Meet the Team

Faculty Lead Contact:

• Stevie Veach

Pharmacist Lead Contact:

• Matthew Osterhaus

​Student Pharmacist Contact:

• Katelyn Mouser 

Description of Pharmacy

Geographic Description: Maquoketa is a small town in rural Eastern Iowa. It is located in between several other small towns and is home to just over 6000 residents. The nearest large city is over 30 miles away.  The patient population includes Maquoketa, which is a largely Caucasian community, approximately 92%. About 24.6% of the population lives at or below the poverty line. The median household income is $44,610. Services offered include: medication synchronization, adherence packaging, medication therapy, management, durable medical equipment, long term care consultation services, hospice consultation services, immunizations, travel vaccinations, diabetic shoes, breasts prosthesis/post mastectomy products, Medicare open enrollment consultation

Type of Practice: We are part of a network of 6 independently owned community pharmacies. 

Pharmacy Story

Initial Presentation:
A 50-year-old male [John] called Osterhaus Pharmacy one Friday afternoon. He currently lives in South Dakota and was back in town to help move his mother into a nursing home. While he was in town, he started to get a runny nose and sore throat and was concerned that he may have COVID and did not want to expose his elderly mother or the other at-risk residents of the care facility. Because John was from out of town, he did not have a connection with a primary care office in the area and was not able to get into any local doctor’s office to get tested.

​Intervention:
We were able to get him in for a test the same day. Less than an hour later, John was able to be notified of his negative test and was able to go back to moving his mother into her new home without fear of spreading infection to her or anyone else. 

State/Federal Connections/Advocacy/Impact:

State Legislation: Iowa has passed “Test to Treat” legislation in May 2021 This new law allows pharmacists to provide point-of-care testing in an outpatient pharmacy setting and enter into collaborative practice agreements with local physicians in order to provide patients with appropriate medications if a test is positive without having to be seen by a physician as well. This legislation initially included only Influenza and Strep Throat point of care tests, but it was expanded to include COVID-19 testing as well as the demand for testing increases.

Federal Legislation: According to the Department of Health and Human Services in April 2020 as a part of the PREP Act, pharmacists nationwide are able to provide point of care testing for COVID-19 using a test that has received an emergency use authorization from the FDA.

State Advocacy: Iowa is a rural state, and it can be difficult to travel to find a primary care provider. But 90% of Iowans do live within 5 miles of a pharmacy, making pharmacists a much more accessible health care provider to many patients. The Iowa Pharmacy Association continues to support pharmacists in expanding their scope of practice and practicing at the top of their license and providing advanced patient care services.

About the Pharmacies

Pexton Pharmacy
Harlan, Iowa  
http://www.pextonpharmacy.com/healthmart2/

Bedford Drug 
Bedford, Iowa 
https://www.facebook.com/BedfordDrugCo/  

Meet the Team

Faculty Lead Contact:

• William Doucette, PhD

Pharmacist Lead Contact:

Pexton Pharmacy

• Tina Dotzler, RPh

Bedford Drug

• Mike Schweitzer, RPh

Student Pharmacist:

• Courtney Schenkelberg 

Description of Pharmacy

Pexton Pharmacy

Pexton Pharmacy is a family-owned independent pharmacy located in Harlan, Iowa in Shelby County. This pharmacy is located in a Primary Care Health Professional Shortage Area (HPSA). Services provided at Pexton Pharmacy include medication synchronization, point-of-care testing for COVID-19, influenza and strep, immunizations against COVID-19, influenza, shingles, pneumococcus and others, as well as blood pressure checks, medication management and medication packaging to support medication adherence.

Bedford Drug

Bedford Drug is an independent pharmacy located in Bedford, Iowa – one of only two pharmacies in Taylor County. This pharmacy is located in a Primary Care Health Professional Shortage Area (HPSA). Services provided at Bedford Drug include medication synchronization, immunizations against COVID-19, influenza and others, as well as blood pressure checks, medication management and medication packaging to support medication adherence.

Pharmacy Story 

Self-Measured Blood Pressure (SMBP) program

As part of the CDC-funded 1815 Project in Iowa, a team at the University of Iowa College of Pharmacy and the Iowa Department of Public Health coordinated with about a dozen pharmacies that are members of Community Pharmacy Enhanced Services Network (CPESN) Iowa to implement a Self-Measured Blood Pressure (SMBP) program. In the SMBP program community pharmacists identified patients likely to benefit from the SMBP program, offered them the service and trained interested patients to use an automated blood pressure meter at home. Then, the patients regularly reported their BP readings to the pharmacists, who monitored the BP readings and provided advice to the patients and their prescribers as needed to get their blood pressure under control.  

The goal of the SMBP program is to help patients with uncontrolled blood pressure reach their target blood pressure. The program engages patients to actively track their blood pressure, which also can improve their medication adherence. The SMBP program provides a good option for measuring BP during the pandemic, when patients are less likely to go to the clinic for visits and a blood pressure check. This story highlights two patient stories, one from each of two rural pharmacies participating in the SMBP program: Pexton Pharmacy in Harlan, Iowa and Bedford Drug in Bedford, Iowa.

Pexton Pharmacy Patient Identification  

Patient A had hypertension and had very high blood pressure readings when he started the SMBP program. His average blood pressure reading was 153/96 and he had several readings with diastolic over 100.  The patient and pharmacist had been working on compliance and lifestyle modifications but that was just not enough.  

Pexton Pharmacy Intervention

The pharmacist then recommended a medication change [coincidentally,] the same day the patient ended up in the ER with BP readings of 157/100 and 140/103. The medications were changed and the patient tracked the effects at home, through the SMBP program.

Pexton Pharmacy Outcomes of Care Provided

Patient A was able to get his weekly average blood pressure down to 135/86, which is near his BP goal. Patient A has expressed gratitude that the pharmacist had enrolled him in the SMBP program and helped him get his blood pressure under control.

Bedford Drug Patient Identification

Patient KS was a healthy 40ish year old female with no chronic health issues. One day she noticed a high pulse rate on her Fitbit, did not feel well and visited the clinic.  At her initial appointment, her blood pressure was 150/100 with a 95 pulse.  She was prescribed HCTZ 25 mg and told to come back in 14 days for a checkup.  

Bedford Drug Intervention

At the time of dispensing the HCTZ, the pharmacist at Bedford Drug also started KS on their SMBP program.  He trained her to use the automated BP monitor and educated her about what to watch for  and when to take action. That evening KS had a BP of 150/110 and she realized her BP was very high. She returned to the ED where she was observed and was prescribed Metoprolol ER.  

Bedford Drug Outcomes of Care Provided

Patient KS responded well to the added medication, and she was able to get her blood pressure under control with recent average readings of 114/74. She has not had repeat trips to the ER. 

State/Federal Connections/Advocacy/Impact:

The care provided to these patients through the Self-Measured Blood Pressure program was supported in part by the Iowa Department of Public Health through funds from the CDC’s Project 1815 (Improving the Health of Americans through Prevention and Management of Diabetes and Heart Disease and Stroke). This project coordinated with members of the Community Pharmacy Enhanced Services Network (CPESN) Iowa – a clinically integrated network of over 120 progressive community pharmacies throughout Iowa. Pharmacies are key healthcare access points for many rural patients like those in this story. However, to support such accessible and effective care by pharmacists, they need to be formally recognized as healthcare providers.  

About the Pharmacy

Balls Foods Price Chopper Pharmacy
Leavenworth, KS
www.ballsfoods.com

Meet the Team

Faculty Lead Contact:

• Sarah Oprinovich

​Pharmacist Lead Contact:

• Lesley Johnson

​Student Pharmacist:

• Bryttnye Perkins 

Description of Pharmacy

Initial Presentation:
A 60-year-old female patient [Darla] presented to her follow-up appointment in the Balls Food Stores chronic disease management program for employees with diabetes and cardiovascular disease. Prior to the visit, the student pharmacist and preceptor completed a thorough drug utilization review, adherence assessment, and assessment of control for each diagnosis within the scope of the program. During the visit, the student pharmacist conducted a medication history interview, provided education, and obtained blood pressure and weight measurements.

Background:

• Darla’s medical history is significant for Type II Diabetes Mellitus, Hypertension, Osteoarthritis, Coronary Artery Disease (s/p PCI, h/o AMI), Class III Obesity, and GERD.
• Darla’s prescribed medications include:  
  • Acetaminophen ER 650 mg 1-2 tablets daily
  • Amlodipine 5 mg daily
  • Aspirin 81 mg daily
  • Atorvastatin 80 mg daily
  • Carvedilol 12.5 mg twice daily
  • Clopidogrel 75 mg daily
  • Glimepiride 4 mg twice daily
  • Jardiance 25 mg daily
  • Lisinopril 40 mg daily
  • Magnesium Oxide 400 mg daily
  • Metformin ER 500 mg 4 tablets daily
  • Ozempic 1 mg injected subQ weekly
  • Pantoprazole 40 mg daily

Patient Report:

• Darla reported she had not taken amlodipine for 2 months. The amlodipine omission was an error in transition of care between two pharmacies.  
• She reported furosemide 20 mg daily had been discontinued by the cardiologist 6 months ago. Other blood pressure medications were unchanged at that time.
• She denied symptoms of hypertensive end-organ damage including: headache, swelling, or vision changes.

​Physical Observation:

• Blood Pressure: 206/113 mmHg and 185/109 mmHg on repeat
• Pulse 68 bpm

Intervention:

• The pharmacist found a previous amlodipine prescription on hold in Darla’s profile and filled it immediately, instructing the patient to take it before leaving the pharmacy.
• The pharmacist referred Darla to her primary care physician and urged her to see the provider today.
• The pharmacist educated the patient on the importance of self-monitoring blood pressure.

​Outcomes of Care Provided:

• A hypertensive urgency was discovered and addressed between physician visits.
• Darla was able to see her primary care physician the same day, and her amlodipine was increased to 10 mg daily and hydrochlorothiazide 12.5mg daily was initiated.  

Outcome to the Pharmacy:

• A transition of care error was uncovered and addressed. A quality control report was made to improve future transitions for medication synchronization patients.
• A possible emergency room visit was avoided. Additionally, without the chronic disease management program, the patient would not have seen the provider for several more months and would have been at much higher risk for a cardiac event. Because the pharmacy is part of a self-insured company, the cost savings from an avoided emergency room visit is substantial.

State/Federal Connections/Advocacy/Impact:

This program is part of the covered benefit offered to employees insured through Balls Food Stores and is made possible by relentless support and advocacy from the Director of Pharmacy to ownership. Progress made toward Provider Status would allow this type of chronic disease management to extend outside the realm of self-insured employers to a greater number of public and private insurance plans. Expanded prescriptive authority would increase access to medications covered under the prescription insurance benefit, such as tobacco cessation therapy where a delay in obtaining the prescription undermines the patient’s quit attempt. 

About the Pharmacy

Merriman Drugs
Livonia, MI
https://www.merrimandrug.com/ 

Meet the Team

Faculty Lead Contacts:

• Brittany Stewart, RD, PharmD
• Aline Saad, PharmD

Pharmacist Lead Contact:

• Hanadi Thomas-Salamey RPh

Student Pharmacists:

• Hassan Khatib
• Melanda Nazee 

Description of Pharmacy

Merriman Drugs is a single family-owned independent pharmacy serving the Detroit metropolitan area located in Livonia, Michigan. From the United States Census Bureau, the median income of residents in Livonia is $38,489. The pharmacy serves an aging population with a majority of the patients being over 65 years old and insured. The population is predominantly white with a small group of Middle Eastern and African-American patients. The pharmacy fills approximately 3,000 to 3,500 prescriptions per month. The pharmacy offers face-to-face access, medication reconciliation, clinical medication synchronization, immunizations, comprehensive medication reviews, creation of personal medication records, a private setting to discuss medications, medication consultation, home delivery, home visits, and naloxone dispensing. The pharmacy site is also an IPPE and APPE rotation site for students at Wayne State University’s School of Pharmacy. 

Pharmacy Story

Background:
Merriman Drugs is an independent pharmacy that has served the community well since 1956. Hanadi Thomas (RPh), a Wayne State University pharmacy graduate and preceptor for more than 10 years, purchased Merriman Drugs with her business partner/co-owner about 2 years ago. Hanadi became the lead pharmacist and sought to increase patient care services and advance practice for the community of patients that have been filling prescriptions there for many years. This community encompasses low-income families and elderly patients that struggle with access to care. Many patients that were filling their prescriptions at Merriman Drugs for years previously were not up to date with immunizations and were unaware that they were even eligible for many vaccines.

​Shortly after Hanadi took ownership of the pharmacy, COVID began sweeping the nation early in 2020. Since the pandemic began, many patients lost access to their healthcare needs and felt anxious about the future of their health. Furthermore, the COVID pandemic exacerbated the nation’s physician shortage and prohibited access to physicians for many patients. In response to the COVID19 pandemic challenges and to address the needs of its community, the Merriman Drug pharmacy team was determined to provide quality care to patients and ensure that all its patients have routine and continuous access to immunizations, patient care services, and prescription services. Accordingly, the Merriman Drugs pharmacy team built a comprehensive immunization service at the pharmacy that did not previously exist. The service included provision of influenza, pneumococcal, shingles, COVID, MMR, hepatitis A, hepatitis B, HPV, and meningococcal vaccines.  

Through these services, Merriman Drugs pharmacy team played a critical role in providing access to vaccinations to its community to prevent infectious diseases and to improve public health efforts.  

Patient Report:
Many patients in the Livonia community were worried about their healthcare needs and were either unable to get to the pharmacy or leave their house during the COVID-19 pandemic. The Merriman Drugs pharmacy team was committed to improving public health and disease prevention by advocating for and administering routine immunizations to the community in addition to COVID vaccines.  

​Intervention:
To meet patients’ healthcare needs and increase vaccination efforts, Merriman Drugs partnered with various community stakeholders. In a joint effort with BMC pharmacy, owned by Heather Thomas RPH, Merriman Drugs pharmacy team provided three vaccination clinics at Walled Lake School District that allowed patients to receive flu shots, COVID boosters, and COVID vaccines for children. In addition, the Merriman Drugs pharmacy team hosted their annual flu clinic at St. John Armenian Church, an event they have been holding for the last 8 years. Furthermore, the Merriman Drugs pharmacy team was offering home visits to patients who were not able to leave their houses, ensuring access to care and vaccines. These vaccination clinics and home visits presented a great opportunity for the 4th year APPE students from Wayne State University rotating at Merriman Drugs to join the frontline workers in battling the pandemic by vaccinating hundreds of patients.  

To document and foster patient education, the Merriman Drugs pharmacy team generated the Michigan Care Improvement Registry (MCIR) reports for its patients. As the pharmacist and patient discussed the report, they assessed vaccine eligibility, addressed vaccine hesitancy, dispelled common myths and misconceptions about vaccines, and built trust. These immunization records, stapled to prescription bags, promoted discussions of vaccination and increased immunization rates in the community.  

​Outcomes of Care Provided:
Outcome 1:

Two hundred students were vaccinated at the Walled Lake School District through the Merriman Drug and BMC pharmacy vaccination clinics. The principle of the Walled Lake Schools was much appreciative of these services as he stated: “Thank you Hanadi, Heather, and everyone involved. The safety of the Walled Lake School community is paramount, and we were happy to begin the journey to ensure vaccines are available to students/families who would like them.” In addition, fifty patients received their flu shots during the annual flu clinic at St. John Armenian Church.  

Outcome 2:

The Merriman Drugs pharmacy team administered 7 vaccinations to patients in the safety of their own homes. Without this personalized care, these patients would not have been vaccinated and would remain prone to contracting diseases. These patients were incredibly grateful for Merriman Drugs’ accommodating their personal and healthcare needs.  

​Outcome 3:

Finally, pharmacy students who were engaged in these vaccination clinics experienced first hand the role of a pharmacist in patient care delivery during unprecedented times of a pandemic. Having the opportunity to participate in such outreach clinics to underserved populations and communities with poor access to care reinforces their commitment to the values that underpin the pharmacy profession.

​Outcome to the Pharmacy:

​The Merriman Drugs pharmacy team extended their time, efforts, and resources to provide vaccinations to their community during times of need. The pharmacy was compensated through patients’ insurances, when available, for provided vaccinations. 

State/Federal Connections/Advocacy/Impact:

This pandemic highlighted the role of pharmacists as essential healthcare providers serving as key access points for patients. The Community Pharmacy Enhanced Services Network (CPESN) requires all member pharmacies to provide immunization screening for ACIP recommended immunizations. In order to implement this screening process at many community pharmacies, and effectively deliver vaccinations, additional staffing will be required to ensure financially feasible care that all patients can access and receive. 

About the Pharmacy

GuidePoint Pharmacy
Crosby, MN
https://www.guidepointpharmacyrx.com/ 

Meet the Team

Faculty Lead Contact:

• Andrew Traynor

Pharmacist Lead Contact:

• Alison Kingsbury

Student Pharmacist:

• Alyssa Butterfield 

Description of Pharmacy

At GuidePoint, pharmacists help guide their patients by pointing them in the direction of good health. GuidePoint Pharmacies are family-owned, independent pharmacies that value patient-centered healthcare above all else. Thirteen GuidePoint Pharmacies serve communities throughout the state of Minnesota. The interaction described above took place at the Crosby location in Crow Wing County, which predominantly serves a rural, low-income, middle-aged population. Crow Wing County is a non-metro county that is designated as a Health Professional Shortage Area in primary care, dental care, and mental health care by the United States Health Resources and Services Administration (HRSA). Services offered at this site include health screenings (cholesterol, blood pressure, glucose), Medication Therapy Management, immunizations, medication synchronization, compliance packaging, naloxone dispensing, and more.

Pharmacy Story

Initial Presentation:
A 45-year-old female [Marie] is a regular patient at GuidePoint Pharmacy with a past medical history of depression and schizophrenia. She presents today to receive her monthly dose of her long-acting injectable (LAI) antipsychotic. The pharmacy software automatically prompts the technician to administer PHQ-9 (depression screening) and GAD-7 (anxiety screening) assessments at each pharmacy visit. Marie accepts and completes the questionnaire while waiting. Marie scores a 10 and 5 respectively, which are documented within an electronic care plan, and sent to the provider. The pharmacist compares her scores today with previous screenings and notices an upward trend on her PHQ-9, indicating increased depression symptoms.

Background:
Marie’s medication list includes two mental health medications:

• Venlafaxine 75 mg ER capsule: Take 3 capsules by mouth daily
• Haloperidol decanoate 100 mg/1 mL oil: Inject 100 mg intramuscularly every 4 weeks

​Patient Report:
The pharmacist is able to check in with Marie to inquire about her medications and her feelings overall. Through their conversation, the pharmacist gathered that Marie is struggling with daily activities.  

​Physical Observation:

• Throughout the visit, Marie occasionally responds to stimuli that aren’t present, alluding to positive symptoms of schizophrenia.  
• Despite several months of therapy, Marie appears dispirited today aligning with her increased PHQ-9 score.  

​Intervention:​
Education: 
The pharmacist instructs Marie to continue taking her medications as prescribed but that they may be adjusted to help better manage her symptoms. The pharmacist ensures Marie that she will communicate with her provider to discuss other potential options. Additionally, the pharmacist also:

• Empathizes that living with mental illness can be frightening but reminds her that she is not alone. Though she may still be struggling, finding the right medication and dose is challenging but it can ultimately help her feel herself again.
• Instructed her to seek emergency medical care immediately if she experiences worsening thoughts or thoughts of suicide in addition to providing the National Suicide Prevention Hotline number (800-273-8255).

Communication to provider:

The pharmacist informs Marie that her completed questionnaires are documented electronically and shared with her provider to help meet her goals. The pharmacist also composes a letter highlighting today’s interaction as well as recommendations for alternative medication and a dosage increase.

Follow-up:

The pharmacist promises to follow up with Marie within the next several days to update her on the status of their requests. The pharmacist also encourages Marie to continue completing PHQ-9 (depression screening) and GAD-7 (anxiety screening) questionnaires at each visit.

​Outcomes of Care Provided:
Outcome 1: Alternative Therapy - Trintellix

Marie’s profile was updated to reflect the discontinuation of venlafaxine. Her provider responded to the recommendation the following day to prescribe Trintellix 10 mg daily as an alternative to treat Marie’s depression.  

• Marie thanked the pharmacist for taking the time to listen. She admits “I would not have given medication another try without your help. You took the extra step to help me even though you have plenty of prescriptions to check. Most of all, you made the entire process so easy.”  
• Marie is optimistic that she can “live a normal life again without worrying about my mood or hallucinations.”

Outcome 2: Dose Increase - Haloperidol

The provider also followed the recommendation to increase Marie’s LAI based on the behavior described during their encounter. The following month, Marie is proud to share that she has not been experiencing any hallucinations since her last injection.

​Outcome to the Pharmacy

• Each encounter with Marie was documented by the pharmacist as an electronic care plan, allowing for transparency in the care provided, communication between all members of the healthcare team, and a monitoring tool to track Marie’s progress towards her personal health goals.
• Clear and thorough documentation of each encounter with Marie demonstrates the quality and impact of care provided, ultimately allowing the pharmacy to receive insurance reimbursement.
• Outcomes achieved in these encounters provide evidence that pharmacists can intervene early in patient care to achieve patient goals and prevent further disease progression. 

State/Federal Connections/Advocacy/Impact:

Primary care focuses on providing holistic, patient-centered care in a team-based setting. It relies heavily on care coordination in order to build patient-provider relationships, assist in navigating the complex healthcare system, empower patient involvement in their own healthcare, effectively manage chronic conditions, and emphasize preventative care. Primary case-oriented care has proven to be effective in achieving better patient outcomes. Since 2008, primary care clinics in Minnesota have been able to demonstrate continuous improvements in reducing chronic diseases due to the Statewide Quality Reporting Measurement System. Despite its impact, primary care remains largely underfunded and the COVID-19 pandemic exacerbated pre-existing health disparities, provider shortages, and barriers to care within the United States healthcare system.

Pharmacists can help support providers and fill in gaps of care by offering primary care services within the community. Expanding services using pharmacists not only strengthens the primary care workforce but also alleviates the strain placed on current providers, fosters interprofessional collaboration, and promotes health equity. Depression and anxiety screenings are measurable and can be easily implemented into community pharmacy workflow. The service described above was made possible during an Introductory Pharmacy Practice Experience. CPESN Minnesota supports GuidePoint Pharmacy by offering payment reimbursement for services and care provided to patients. However, recognizing pharmacists as national providers is imperative for continuing to improve community health as well as creating equitable access to care. 

About the Pharmacy

Balls Foods Price Chopper Pharmacy
Grandview, MO
www.ballsfoods.com

Meet the Team

Faculty Lead Contact:

• Sarah Oprinovich

​Pharmacist Lead Contact:

• Molly Kabella

​Resident Pharmacist:

• Taylor Mize 

Description of Pharmacy

Balls Food Stores is a locally owned chain of 29 grocery stores and 19 pharmacies located across the Kansas City Metropolitan area. The interaction described above took place at the Grandview, MO location in Jackson County, Missouri. Jackson County is designated as a medically underserved, non-rural area for primary care. Grandview is home to approximately 26,000 residents, and racial diversity is greater than the average demographics for rest of the state. The percent of owner-occupied housing is significantly less than the state average, and the percent of families speaking a language other than English at home is nearly 10%. Approximately 18% of people under age 65 years old are uninsured, and 14.6% of Grandview residents live in poverty. The prescription volume at this location is about 600 prescriptions per week and growing. Services offered at this site include medication synchronization, medication therapy management, immunizations, employee chronic disease management, and point-of-care testing. 

Pharmacy Story

Initial Presentation:
A 55-year-old male patient [Steve] presented to the pharmacy with all his medication bottles for a transition of care visit and comprehensive medication review after transferring his medications from another pharmacy. The visit included a review of medications, and medication reconciliation.  

Background:

• Steve’s medical history is significant for type II diabetes, high blood pressure, congestive heart failure (CHF), and high cholesterol.
• Steve’s social history is significant as he is experiencing homelessness and living in a van. His medication storage includes a pill organizer and a Ziplock bag. He does have medical and prescription insurance coverage through Medicare. He visits the pharmacy daily to monitor his blood pressure.
• Steve’s prescribed medications follow guideline-directed medical therapy for each diagnosis.  

Patient Report:

• Steve reported self-medicating with prednisone he had on hand from a previous prescription that should have been completed.
• Steve was confused regarding whether he should continue or discontinue spironolactone.
• Steve reported difficulty organizing his medications as he had retained some old pharmacy prescription bottles.

​Physical Observation:

• Blood Pressure 125/74mmHg, previous pharmacy readings are within treatment goal with occasional low blood pressure readings.
• Prescription bottles from both pharmacies were mixed.
• There were two strengths of carvedilol in the patient’s supply that he was taking interchangeably.

Intervention:

• The pharmacist instructed Steve to stop taking prednisone because it was no longer needed.
• The pharmacist instructed Steve to restart his spironolactone for CHF because the prescription was current and no documentation was received to indicated a discontinuation. The pharmacist contacted the prescriber to confirm.
• The pharmacist confirmed the correct carvedilol dose and discontinued the incorrect dose. Steve was educated on his appropriate dose.
• The pharmacist educated Steve on improving medication adherence and counseled on each medication.
• The pharmacist filled the pill organizer for the next week while instructing Steve on how to independently complete the task in the future.

Outcomes of Care Provided:
Outcomes of Care Provided:

• A medication without a current indication was discontinued. Not stopping this medication could have caused worsening diabetes.  
• Duplicate medications were discovered and resolved, and an abandoned medication was restarted. The impact of these outcomes could have helped to avoid a potential hospitalization for the patient.
• Steve felt more confident and comfortable managing his medications.
• The pharmacist made a positive relationship with an extremely vulnerable patient opening an avenue to healthcare.

Outcome to the Pharmacy:

• The pharmacy did not receive remuneration directly for this service. It could be speculated that his adherence may be better maintained to provide revenue through prescription dispensing. The resident pharmacist spent about 35 minutes with the patient. 

State/Federal Connections/Advocacy/Impact:

Without the support of a pharmacy resident, this type of service with no remuneration would be impossible to provide. Using a resident pharmacist lessens the financial loss to the pharmacy, but this would still be an unsustainable service. This particular patient has Medicare, so attaining Provider Status would allow for billing the patient’s medical benefit for this service, which is also financially beneficial to the medical insurance provider in terms of improved health outcomes. Especially in an area similar to the one depicted with lack of access to primary care providers, pharmacists can provide impactful care to complex patients by assisting with medication management and monitoring between physician visits, but this level of care is impossible to offer widely with no financial remuneration.

About the Pharmacy

Mandan Pharmacy 
Mandan, ND
https://www.chistalexiushealth.org/bismarck/mandan-pharmacy

Description of Pharmacy

We’ve been in business for 6-7 years and one of the things we are most proud of at our pharmacy is patient care. Our pharmacy serves the general population and children, and we offer anticoagulation and drug consultations at an assisted living facility. Mandan Pharmacy has been able to build strong relationships with its patients. Patients trust the pharmacy team, and care about the pharmacy as much as the pharmacy cares about them. When patients have to switch pharmacies, they are always sad to leave. 

Pharmacy Story

Impactful Patient Story:
Any opportunity while working with anticoagulation patients or doing medication reviews. Making medication changes, like stopping medications, can make a patients’ medication experience easier.

State/Federal Connections/Advocacy/Impact:

In North Dakota, pharmacists do not have provider status, so they are limited in their practice. Fortunately, Mandan Pharmacy is part of a Collaborative Practice Agreement with their neighboring clinic, so they have the opportunity to work with physicians.  

I am a member of North Dakota Society of Health-Systems Pharmacists. I advocate for pharmacy practice by inspiring pharmacy residents to pursue clinical pharmacy practice, especially in Bismarck where this type of practice is uncommon.  (-Maya Robinson) 

About the Pharmacy

Shrivers Pharmacy and Wellness
Athens, Ohio
https://www.shriverspharmacy.com/Pharmacy-Locations-Hours/Athens-Ohio/ 

Meet the Team

Faculty Lead Contact:

• Jennifer Rodis

​Pharmacist Lead Contact:

• Rebecca Lahrman

​Student Pharmacist(s):

• Jessica Schrader 

Description of Pharmacy

Shrivers Pharmacy and Wellness is an independently owned pharmacy within an independent chain that serves South East Ohio with eight locations. Located in Athens Ohio, a rural county with a large public university, the pharmacy has a unique opportunity to serve underserved patients and teach future practitioners. Services offered include Comprehensive Medication Reviews (CMRs), vaccines (influenza, travel, and COVID-19), medication synchronization, delivery, free children’s and prenatal vitamins, COVID-19 testing, Medicare plan evaluations, hospice services, durable medical equipment, and monoclonal antibody (mAb) therapy for COVID-19.  

Pharmacy Story

Initial Presentation:
A 58-year-old female patient, Barbara, called Shrivers pharmacy asking about pharmacogenomics as she had heard Shriver’s Pharmacy offered the testing through her psychiatry office. The pharmacist called her to discuss how pharmacogenomics might be able to help her find a better medication to help with her depression and anxiety. Over the past few decades, Barbara had tried over nine medications and had struggled with adverse side effects and lack of efficacy. During Barbara's initial comprehensive medication review with the pharmacist, they discussed a most recent side effect, hot flashes, which were being treated as hormonal hot flashes with estrogen.

​Background:
Most notably Barbara had tried three different antidepressant medications to treat her depression and anxiety. One medication caused considerable fatigue during the day and insomnia at night; this was severe enough to limit Barbara’s ability to work. Another medication caused hot flashes, and the third antidepressant significantly raised her blood pressure. Barbara was feeling frustrated and hopeless regarding her mental health due to lack of success with multiple medications.

Patient Report:

• The patient’s pharmacogenomics report provided insight into general drugs classes she would be a poor responder to and confirmed the lack of effectiveness of some of the antidepressant medications she had already tried.
• The report also provided evidence for altered drug metabolism, which additionally explained the side effects the patient had experienced.
• Lastly, the report showed altered steroid metabolism. This likely was contributing to her menopausal symptoms and lack of efficacy with estrogen therapy.

​Intervention:
​After discussing the results with her psychiatry provider, the pharmacist started the patient on a new antidepressant as a standalone therapy. The patient reported “finally feeling like herself again”. She was able to return to work and enjoy her day-to-day routine. The pharmacist was able to use the pharmacogenomic results to provide Barbara confidence with her medication changes, as she had been hesitant to try any new medications due to previous side effects. Because of the incidental finding of her altered estrogen response, the pharmacist also referred Barbara to Shrivers Compounding Pharmacy to find better hormonal treatment. ​

Outcomes of Care Provided:
Outcome to the Pharmacy

• The pharmacist documented the pharmacogenomic report and medication changes within the eCare Plan (community pharmacy electronic medical record) to help communicate the changes. Reports were sent to the ordering provider and her primary care provider.  
• The lab work and education provided allowed the pharmacy to receive compensation for their time and develop relationships with a new patient and provider. The patient was able to see improvement in her depression and anxiety which led to a better work life and personal life, for which she was very thankful.  
• The patient was also referred to the compounding pharmacist for hormonal therapy to continue to optimize her medication therapy and quality of life. 

State/Federal Connections/Advocacy/Impact:

This care was made possible because of the partnership with Ohio State University and the Partner for Promotion program through which final year pharmacy students complete a year-long Advanced Pharmacy Practice Experience (APPE) to develop clinical services with partner practice sites. Through Partner for Promotion, student pharmacists collaborate with practicing community pharmacists and pharmacy faculty at the college to create the infrastructure for the pharmacogenomics service, including the documentation system and protocol. A pharmacy practice resident also supported the service development team.   Additionally, due to passage of SB 256 in 2019, pharmacists in Ohio are recognized as providers with capabilities to contract with insurance plans and bill for provision of care. This opportunity has shifted the historical view of pharmacies as solely dispensing medications and has opened opportunities for pharmacists across the state. Moving toward more value-based care has especially enhanced access for patients to care in underserved areas such as South East Ohio. 

About the Pharmacy

ONU Healthwise Pharmacy
Ada, Ohio
https://www.onuhealthwisepharmacy.com/

Description of Pharmacy

The ONU HealthWise Mobile Health Clinic is a pharmacist-led, interdisciplinary, primary care service located in a medically underserved rural area.  The clinic features a team of pharmacists, postgraduate year-one pharmacy residents, student pharmacists, medical residents and physicians providing collaborative care to the medically underserved of Ohio.  The “primary care office on wheels” overcomes many barriers to care including transportation, access to a healthcare provider and cost.  The mobile clinic serves as an extension of the clinical services of ONU HealthWise that includes an independent community pharmacy, a telehealth-based non-dispensing pharmacy services center, a drug and health information center and disease state management and wellness services.  The service was established in 2010 and has been recognized locally, regionally, and nationally for its innovative and transformative practices.  The practice has successfully documented improvements in health outcomes for the community it serves. The team has published these outcomes in several nationally peer-reviewed publications as well as presentations at national and state conferences. The practice serves as a training site for postgraduate students as well as PharmD students from the Raabe College of Pharmacy at Ohio Northern University.   

Pharmacy Story

Prior to the Covid-19 pandemic, the mobile health clinic provided services related to cardiovascular health, diabetes management, tobacco cessation services, and medication management for no cost. In March 2021, Ohio Governor Mike DeWine designated the ONU HealthWise mobile clinic as a Covid-19 mass vaccination regional clinic. 

Initially, HealthWise established 10 unique clinic locations within the assigned region that included Hardin, Logan, Union, Marion, Crawford and Wyandot counties to provide better access to individuals in healthcare provider shortage areas including rural and underserved. In the first sixty days of the clinic, the ONU HealthWise team provided 3,230 total vaccines including 2,198 Janssen, 911 Moderna, and 121 Pfizer.  The mobile clinic logged 2,593 miles in those 60 days. As the pandemic continued and vaccine efforts across the nation intensified, the mobile clinic expanded its reach to over 30 sites in more than 10 counties within Ohio offering initial vaccines and booster doses to pediatric and adult patients. 

Locations of sites included fire stations, fair grounds, churches, state buildings, schools, factories, community centers, nursing homes, assisted living centers, low-income housing areas, libraries and recreational centers. In addition to providing all available Covid-19 vaccinations, the clinic also provided all available vaccines recommended by Advisory Committee on Immunization Practices (ACIP) to patients ages three and up. The ONU HealthWise team continues to educate about Covid-19 as well as provide vaccines to adults and children with booster and first-time shots. 

As of November 18, 2021, the team has given 3,402 Moderna, 6,131 Janssen, and 1091 Pfizer since January 2021. The ONU HealthWise Drug and Information Center provides Covid-19 health information outreach with a weekly newspaper column published in 3 local media sources.  The team has presented over 20 community presentations to help promote Covid-19 vaccines.  

State/Federal Connections/Advocacy/Impact:

In Ohio, there is legislation that provides a means for identification of Health Professional Shortage Areas (HPSA) and Medically Underserved Areas/Populations (MUA/P). This legislation recognizes the Governor’s Certified Shortage Areas under the federal Rural Health Clinic (RHC) legislation.  ONU HealthWise is located and serves within the Governor’s Certified Shortage Area. The ONU HealthWise Mobile Health Clinic’s mass vaccination clinic was one of fourteen governor-appointed mass Covid-19 vaccine clinics in the state of Ohio, and only one of four that were mobile in structure.  ONU HealthWise mobile clinic expanded its operation with the designation of a mass vaccination clinic to additional Governor’s Certified Shortage Areas allowing for more shortage areas beyond our traditional areas to have access to vaccines. The Ohio pharmacy immunization regulations, further expanded by the PREP Act, allowed the pharmacy team to provide any vaccine recommended by Advisory Committee on Immunization Practices (ACIP) to patients ages three and up.  This extended scope coupled with the mobile structure of the clinic allowed the pharmacy to provide greater access to care for the individuals served. 

About the Pharmacy

The Medicine Shoppe Pharmacy
Rapid City, SD
https://rapidcity.medicineshoppe.com/

About the Pharmacy

Aurora St. Luke’s Outpatient Pharmacy
Milwaukee, WI 
https://www.aurorahealthcare.org/services/pharmacy/

Meet the Team

General Faculty Lead Contact:

• Sarah Ray, PharmD, BCPS, FAPhA

Pharmacist Lead Contact:

• Amy Mahlum, PharmD, BCACP

​Student Pharmacist:

• Ashley Alter, PharmD 

Description of Pharmacy

Advocate Aurora Health is a health system that is located within Wisconsin and Illinois. Within the health system, there are approximately 70 community pharmacy sites. The heart transplant immunization service is offered at the Aurora St. Luke’s Outpatient Pharmacy, which is located in Milwaukee, WI. This pharmacy is on-site at Aurora St. Luke’s Medical Center, where the heart transplant team has successfully completed over 1,000 heart transplants. The Outpatient Pharmacy serves a wide variety of patients including patients discharged from the hospital, patients being seen for clinic appointments, and team members. The pharmacy uses a dispensing software system that is integrated with the health system’s electronic health record. This allows the pharmacy to access pertinent provider notes, labs, and vitals to address medication questions and for providers to see a patient’s medication list and dispense history. In addition to the heart transplant immunization service, other services offered at this site include comprehensive medication reviews, immunizations, needle disposal, naloxone dispensing, medication take back, blood pressure screenings, device teachings, compliance packaging, and delivery of prescriptions to patients prior to discharge.

Pharmacy Story

Initial Presentation:
Patients who are listed as heart transplant candidates have to complete many steps to prepare for a potential transplant. One of these steps is ensuring appropriate immunization status. This is where the Aurora St. Luke’s Outpatient Pharmacy comes into play. The Outpatient Pharmacy at Aurora St. Luke’s Medical Center has an immunization collaborative practice agreement (CPA) in place with the on-site heart transplant clinic. Shortly after a patient becomes a candidate for a heart transplant, a heart transplant nurse coordinator places an immunization referral to the Outpatient Pharmacy. Once the referral is placed and received by the pharmacy, the pharmacist is able to utilize the immunization CPA.

Intervention:
​Upon referral, the pharmacist is able to review the patient’s immunization history and labs via the electronic health record, including labs for hepatitis A, hepatitis B, Haemophilus influenzae type b. If the necessary labs are not available, the pharmacist communicates via the electronic health record with the heart transplant nurse coordinators to coordinate next steps. Once all lab results are received and the immunization history is reviewed, the pharmacist develops their immunization recommendations and sends them to the heart transplant clinic for approval. The heart transplant team then approves the immunization recommendations, and the Outpatient Pharmacy begins the process of scheduling and administering immunizations.

Outcomes of Care Provided:

• Timely scheduling of vaccines is crucial for heart transplant candidates. Patients who are currently on the transplant list could be contacted for a potential transplant at any time. Following transplantation, patients are immunocompromised and no longer qualify for live vaccines, in addition to having to defer inactivated vaccines for a period of time. Therefore, it is very important to administer certain immunizations, especially live vaccines, as soon as possible.
• ​The heart transplant immunization CPA utilized in the Aurora St. Luke’s Outpatient Pharmacy is needed because the heart transplant clinic recommends patients to receive certain immunizations that may fall outside the typical recommendations from the Centers for Disease Control (CDC) and the Advisory Committee on Immunization Practices (ACIP). Therefore, this immunization CPA allows heart transplant candidates convenient access to vaccines that may not be as commonly available in the community pharmacy setting, such as Haemophilus influenzae type b, meningococcal, and varicella.
• ​The Aurora St. Luke’s Outpatient Pharmacy’s ability to access the electronic health record is vital to this immunization CPA, as it allows the pharmacist to review labs, such as the hepatitis B panel, to determine whether or not a patient actually needs the vaccine. If the lab result is not present in the patient’s electronic health record, the pharmacist can recommend the patient gets the lab drawn. In addition, the pharmacist is able to document in the electronic health record, maintaining regular contact with all members of the patient’s transplant team. 

State/Federal Connections/Advocacy/Impact:

The heart transplant immunization collaborative practice agreement and administration of immunizations is made possible through several different Wisconsin pharmacy statutes. Wisconsin statute 450.033 allows pharmacists to perform any patient care activity delegated to them by a physician. In regards to immunizations, Wisconsin statute 450.01 (22) allows pharmacists to have a vaccination protocol and to establish procedures, record-keeping, and reporting requirements for administration of a vaccine. In addition, Wisconsin state statute 450.035 outlines training requirements necessary to be certified as a vaccinator.