50 Stories from 50 States: Northwest

About the Pharmacy

White's Pharmacy
Sitka, AK
https://www.sitkapharmacies.com/whites-pharmacy

About the Pharmacy

Shaver Pharmacy and Compounding Center
Pocatello, ID
https://www.shaverpharmacy.com/

Description of Pharmacy

Shaver Pharmacy & Compounding Center is a locally-owned community pharmacy serving the rural area of Pocatello, Idaho. This pharmacy is located in a designated medically underserved area where 9.4% of the population is uninsured and 17.2% are below the poverty line. Services offered at this site include conventional prescription filling, sterile and nonsterile compounding, durable medical equipment, Medicare open enrollment, medication therapy management, mastectomy supplies and fitting, and much more. Shaver’s Pharmacy has currently implemented all 19 protocols finalized from ISU which includes: cold sores, uncomplicated UTIs, erectile dysfunction, statins in diabetes, mild burns, mild acne, acute migraine, pinworms, strep, pink eye, canker sore, naloxone, emergency contraception, flu prophylaxis and treatment, motion sickness, and hemorrhoids. Like the story above, any patient can come in for any of these conditions above. If they meet the inclusion criteria, they can be evaluated and prescribed medication in the pharmacy saving themselves time and money by avoiding a trip to the urgent care or emergency room.

Pharmacy Story

Initial Presentation:
A husband, wife, and their three young children - 5, 2, and 1 years old - presented to the pharmacy after being notified they were exposed to strep throat over Christmas. Since they were experiencing symptoms, the mother wanted the family tested for strep throat. The mother filled out the intake questionnaire for her husband, herself and her 5-year-old son that indicated they qualified for a CLIA-waived strep throat test.

​Background:
Because two children were under 5 years of age, they were excluded from treatment based on pharmacy protocol.

​Patient Report:
The mother reported her son was the first to feel unwell with a fever a couple days ago, but that his fever subsided on the day of presentation. All presented with similar symptoms, and she was worried they all contracted strep at Christmas. She did not want to spread it to others at a New Years Eve party they were invited to.

​Physical Observation:
The parents and younger children (1 and 2 years old) presented with a fever, no cough, and sore throat. The older child (5 years old) presented with a sore throat and no cough. There was a lack of white spots.

​Intervention:

1. Diagnosis and Treatment: The pharmacist initiated a CLIA-waived strep test to the wife, husband, and 5-year-old son that all came back positive for strep throat. The following actions were taken:
   1. The father and mother were prescribed Amoxicillin tablets.
   2. The son was prescribed an Amoxicillin suspension.
   3. The family’s pediatrician was contacted and a prescription for antibiotics was sent to the pharmacy for the girls due to their similar strep-like symptoms.
2. Follow up phone call the next day to check on symptom improvement and medication effects. The mother was appreciative of the quick, convenient, care provided to her family the day prior.

​Outcomes of Care Provided:
Outcome 1: Cost and time savings to patient

The family was able to walk in without an appointment, get diagnosed, and pick up medication all in one place within 20 minutes, making it more time and cost efficient than an urgent care visit. Since two of the children were too young to be treated under the pharmacy’s protocol, the mother called their pediatrician and was able to get prescriptions sent over to the pharmacy that same day. This saved the mother the trouble of having to take sick kids to wait in the doctor’s office and then separately to the pharmacy to pick up medication. The pharmacist who provided the care stated, “As a mother of two, I understand how challenging it can be to coordinate care for young children and how life changing it is to find a location where I can have quick and efficient care for my children all in one place.”

Outcome 2: Positive public health intervention

Since all family members tested positive, they did not go to the New Year’s Eve party, and it prevented the unnecessary spreading of strep throat to others.

​Outcome to the Pharmacy

• The pharmacist documented the encounters with each family member and sent a notice via eFax to the family’s primary care provider within the hour to let them know about the diagnosis and treatment of their shared patients.
• The family was insured and was able to bill their insurance for the prescriptions prescribed but had to pay cash price for the CLIA-waived tests since their insurance did not recognize pharmacists as providers.

State/Federal Connections/Advocacy/Impact:

The care provided to this family was made possible through the passing of House Bill 182 that granted pharmacist prescriptive authority for: conditions that don’t require a new diagnosis, emergency situations, minor/self-limiting conditions, or conditions diagnosed through a CLIA-waived test (like the story above).

At Idaho State University, faculty and students are helping to turn this law into practice. Through their work, 19 prescribing protocols have been finalized and are free to any pharmacy in the state that would like to implement them. Each protocol includes a patient intake questionnaire, inclusion and exclusion criteria, pharmacist and patient education, prescription label, billing template, case vignette, and questionnaire interpretation to guide treatment and referral decisions. Protocols can vary between pharmacies as protocols are up to pharmacist’s discretion and best practice.

Pharmacies are one of the most accessible and affordable health care providers for many patients, especially in rural states like Idaho. In order to make providing this level of care financially feasible at pharmacies, the next step for pharmacy practice advancement is to be recognized as health care providers. This will help ensure pharmacist provided services are billable to all insurances and available to people in all communities through their local pharmacy.

About the Pharmacy

CVS Pharmacy 
Beaverton, OR
https://www.cvs.com/

Description of Pharmacy

The specific CVS pharmacy where this interaction took place was in Beaverton, Oregon. This community is located outside of a major city and with a population growing each year access to providers in a timely manner can be difficult. At CVS, we strive to be the most accessible health care providers to the patient. Pharmacists provide face-to-face access during regular operational hours which spans up to 12 hours per day. When issues arise, patients can contact their local pharmacist and get the care they need. In this situation, providing clinical outcomes through medication reconciliation and comprehensive medication reviews can prevent critical issues before they occur.

Pharmacy Story

A female patient in her mid-thirties presented to CVS pharmacy with a prescription for furosemide 20 mg once daily for five days to help with lower extremity edema. The patient had just visited her doctor with concerns of increased swelling with unknown cause. Her primary care provider wanted to run a trial course of a diuretic to help bring the patient some relief. When processing the prescription, a notification appeared warning of a potential allergy interaction. The patient has a sulfa allergy listed due to a reaction with a previous sulfa antibiotic where she experienced hives and throat swelling. As a pharmacy intern, I discussed with the patient about the potential for a cross reaction and counseled her on the signs and symptoms that are possible of an allergic reaction. The patient was grateful for catching this interaction and felt that for her own comfort and safety, she would like to switch to an alternative medication. I then contacted her health care provider and explained the potential interaction as well as provided alternative diuretics for consideration. The provider agreed and switched to spironolactone at equivalent dosing to help reduce the patient's swelling while not putting the patient at risk of an allergic reaction.

This clinical outcome helped prevent a potential harmful interaction for the patient and provided potential cost savings to the patient. If a reaction had occurred from the initial therapy, the patient would have presented to the emergency room, as she did previously on their first allergic reaction, costing thousands of dollars in care. The patient was very grateful to the pharmacy team for catching this interaction and expressed how knowing this alternative medication would be safe, helped reduce potential anxiety around taking this new medication.

State/Federal Connections/Advocacy/Impact:

In Oregon, pharmacists have the ability to prescribe certain medications which brings patient care even more accessible to certain populations. Medications like birth control or smoking cessation can be handled by a pharmacist without the need for patients to see their provider each time. Through collaborative practice agreements pharmacists can work at the top of their license while providing care to patients in need. Especially during this pandemic, the strain on providers has grown and patients are not able to see their providers for months on end. Pharmacists are a great tool in bridging that care gap and providing care and knowledge to patients.

About the Pharmacy

Duvall Family Drugs
Duvall, WA
https://www.duvallfamilydrugs.com/

Meet the Team

Faculty Lead Contact:

• Jennifer Bacci, PharmD, MPH, BCACP

​Pharmacist Lead Contact:

• VanderHouwen, RPh  

​Student Pharmacist(s):  

• Sean Hwang
• Andrew Ly 

Description of Pharmacy

Duvall Family Drugs is an independent community pharmacy that has been a cornerstone for patient care in the Snoqualmie Valley and for patients in Woodinville as well as the South Monroe area that are predominantly suburban for over 35 years. The pharmacy serves across all age groups and across generations with some families. This pharmacy provides crucial services to their community including vaccinations, medication dispensing, counseling, etc., and these have expanded and evolved in light of the COVID-19 pandemic.

In the last few years, Duvall Family Drugs has participated with Flip the Pharmacy, a 24-month program that helped accommodate new workflows in navigating towards enhanced clinical services and sustainable workflows to improve patient outcomes. Kari VanderHouwen, RPh, has been the owner of Duvall Family Drugs for the last 29 years and transformed the practice of providing care for the community - especially in response to the COVID-19 pandemic. When the primary care physician who shared the building space next to the pharmacy had closed their practice, the space consisting of four private fully fitted examination rooms was utilized to provide vaccinations, antigen and PCR testing, as well as administration of REGEN-COV for those in the community. 

Pharmacy Story

One day a woman brought in her elderly parents who were known patients of Duvall Family Drugs. The family was well known to the pharmacy as they, like much of the community, had been patients with the pharmacy for many years. Both parents had tested positive for COVID-19 a few days prior and at this time (Fall 2021), Duvall Family Drugs was one of the few community pharmacies in the area that provided the REGEN-COV therapy. The mother has a history of Alzheimer’s and at the time became anxious upon presentation because she did not understand what was happening. Kari VanderHouwen, RPh, owner and a pharmacist at Duvall Family Drugs, was the provider who took in the patient to administer the monoclonal antibody therapy.  

In the clinic room, the patient became combative with the initial blood pressure reading, and this posed a challenge with the administration of the monoclonal antibody therapy in an outpatient setting, as it requires multiple injections. The pharmacist described the difficulty in gathering vitals due to the patient’s confusion and saw how she held onto her coat which served as a source of security throughout the interaction. Upon observing the patient’s fear and confusion, the pharmacist identified that the patient needed further support in calming her down and sought to create a safe environment. Often the care of patients by community pharmacists goes beyond the expected filling, verifying, and counseling. “I looked at her and held her hands and told her how much I needed her to stay healthy and not be hospitalized.” The pharmacist told her patient, “I am not trying to hurt you; I’m trying to keep you safe.” The pharmacist calmed the patient throughout the visit, administered the four injections of REGEN-COV, and sat with her for an hour following the administration to monitor for any adverse effects.  

After the monitoring period, both the patient and her daughter thanked the pharmacist and her team for the incredible work in providing lifesaving therapies for the community while maintaining the necessary work pharmacies play in this community. The pharmacist described this as being one of the most memorable interventions that demonstrates the resilience, grit, and care independent pharmacies like hers exhibit for the greater community. The pharmacists shared, “It has been extremely stressful, but also extremely rewarding. We want to keep our community safe. We were the ones the community turned to when the outbreaks occurred. In providing the COVID-19 related services with testing, vaccinations, and REGEN-COV administration, we can keep everyone and their kids safe to live their life and go to graduations and sporting events. This is who we are and what we have always been here for.”

State/Federal Connections/Advocacy/Impact:

Pharmacists within Washington state are recognized as healthcare providers since 1979 with Senate Bill ESSB 5557 and as such are allowed to perform patient care services such as monitoring and managing medications, ordering and interpreting lab orders, as well as prescribing via collaborative drug agreements. This status allowed for greater sustainability in practice for Washington pharmacists and have more prescriptive authority for services under a Collaborative Drug Therapy Agreement (CDTA) for medication management within our scope, such as naloxone and oral contraceptives. However, pharmacists are currently limited to billing for patients with commercial health plans and cannot be reimbursed for health care services well within our scope of practice. This places a constraint in sustainability on both access to services for patients with Medicare, like the elderly woman in the patient story, and the reimbursement that will allow for continued care for the community provided by the pharmacies.

This limiting factor is the reason for the currently proposed Pharmacy and Medically Underserved Areas Enhancement Act which would allow for further accessibility of care for patients with Medicare and expanding the services offered this this population. The recognition of the role of pharmacists as providers for their community was highlighted following the rollout of the REGEN-COV therapy. Duvall Family Drugs was one of the few community pharmacies that stepped into the role of administering the therapy while also continuing to provide traditional pharmacy services. The resilience and dedication in providing care demonstrated by the incredible teams across community pharmacies, like as Duvall Family Drug, underscore the need for pharmacists to be recognized as federal providers to broaden accessibility for vital healthcare services to all.