Community-based pharmacy is evolving from a place of product distribution into a healthcare destination.
By Athena Ponushis and Nidhi Gandhi, Pharm.D.
Many pharmacists who spend time filling prescriptions keep hearing of a future where their role will be more focused on the patient, not the product. It’s anticipated that their attention will shift from dispensing to providing convenient clinical care. Some forward-thinking pharmacies are already enabling pharmacists to live in this awaited world, helping patients manage their medication experience and documenting interventions. These pharmacies are sharing their innovative models and schools are studying the impact, providing a window into the future of community-based pharmacy practice.
Picture pharmacists having routine interactions with patients to review, optimize and synchronize medications rather than just episodic or transactional meetings at the counter. Pharmacists will collaborate with primary care practices as part of an integrated healthcare team, making recommendations on one shared medical record, reinforcing patient care plans. Patients who want care on demand go to their pharmacists for point-of-care testing, immunizations and travel consults, or prescriptions for contraception, smoking cessation and HIV prevention. Imagine pharmacogenomic screenings being commonplace, as pharmacists look at genetics to predict drug response and tailor treatments. So goes the perceived evolution of community-based pharmacists, from performing clinical interventions to becoming initial clinicians, ushering in a time when community pharmacies are considered essential to the healthcare landscape.
“We are training our student pharmacists for the future and this is the future we see,” said Linda Garrelts MacLean, interim dean, clinical professor of pharmacotherapy at Washington State University College of Pharmacy and Pharmaceutical Sciences. “I believe that community pharmacies are going to be the place where care is delivered, that access to the learned intermediary, someone who can assess, evaluate, prescribe when appropriate and even more importantly, refer when necessary.”
Washington state has been progressive on a number of pharmacy fronts since the 1970s. MacLean and Dr. Julie Akers, clinical associate professor of pharmacotherapy at WSU, are finalizing a study on the effectiveness of pharmacy treatments, comparing the care pharmacists provide for minor illnesses and self-limiting conditions to what is offered at more traditional settings, such as physician offices, urgent care centers or hospital emergency departments. The study will inherently set a baseline to measure how enhanced pharmacy services are influencing quality of care and access to care.
Once analyzed, MacLean believes the study will provide evidence that community pharmacists can contribute to caring for patients, compelling other states and pharmacies to replicate services and treat common ailments such as strep throat, urinary tract infections and severe headaches, including migraines. Akers has found, through surveys and anecdotally, that patients are confident in receiving care from pharmacists. It may take a little education (patients don’t always know what training pharmacists have had or what services are being offered) but once they know, Akers has not seen any hesitation in a patient’s willingness to be seen by a pharmacist.
“More involved direct patient care is the future of pharmacy practice, and schools need to ensure that they are graduating practice-ready pharmacists who are prepared to move into that role. Schools should take the time to fully assess their curriculum, making sure it is robust enough to where they are going to have pharmacists who are confident and ready to go start these services,” Akers said. “Also ensuring that they are building strong advocacy with their students so that as students want to move toward this future, they understand the legislative and regulatory framework of what they are allowed to do within their state and how to overcome any barriers.”
At WSU, student pharmacists take an intensive, weeklong, point-of-care and clinical services course at the beginning of their second year. Rather than re-create the material the state pharmacy association had created for continuing education for practicing pharmacists, faculty collaborated with the association, giving students access to online modules that they complete over the summer before school begins. Students spend the entire first day of class going condition by condition, reviewing key guidelines through patient cases, deciding whether to use prescriptive authority, refer to a more advanced care setting or recognize that over-the-counter self-care products are appropriate for that case.
“What I find interesting is that prior to this course, our students have completed their over-the-counter self-care pharmacotherapy course, and in that course it’s over-the-counter or refer because the patient needs a prescription. So it’s always comical when we’re doing these patient cases that the students’ automatic response is, ‘We have to refer because that’s what we’ve learned before.’ It’s changing that mindset for them, realizing that as an advanced care practitioner pharmacist, you can handle some of these minor illnesses and conditions with prescriptive authority,” Akers said.
Other days are dedicated to immunizations. Students are certified in immunization administration and receive specialty training on pediatric immunization. Students learn how to screen for HIV, strep and influenza, practicing throat and nasal swabs on themselves or a team member before going through a rubric-graded assessment, ensuring they can collect the sample without it being contaminated. They have open practice laboratory sessions and breakout sessions where they learn how to run a travel consultation, interact with a patient and do the paperwork.
“We began this course after getting approval from our full faculty to move it forward as required curriculum for all of our graduates. That’s what was most important: getting all of our faculty to recognize that we truly believe as a program that this is the future of pharmacy,” Akers noted. “We really believe that this is the base knowledge that’s required for an entry-level pharmacist.”
The Path Forward
In its 2018 report, “The Next Transition in Community-Based Pharmacy Practice,” the American Pharmacists Association found that pharmacists are trained to perform certain tasks but often experience work settings that are not conducive to such practice. The study found that new roles abound for community pharmacists in this “new patient-centered, medication experience era,” but stressed the difference between professional identity and commercial identity. To change perceptions of community pharmacy, the APhA encouraged pharmacists to see transformation “through the patient’s eyes.” From the patient’s vantage point, a medication experience is not clinical, it’s personal.
The Council of Deans formed a task force to find opportunities to improve community-based practice and give viable recommendations to AACP and member institutions to pursue such possibilities and make them realities. The task force chair, Dr. Jennifer Adams, associate dean for academic affairs, director of interprofessional education, clinical associate professor at Idaho State University College of Pharmacy, said the task force will structure recommendations in three separate areas.
First, advancing pharmacy technician practice. Pharmacists must have good support staff if they are going to take on new roles, so elevating pharmacy technicians is crucial. “What are the types of tasks pharmacy technicians can do? What can we train them to do if they don’t already have that level of training, and what’s appropriate there, in terms of scope? What needs to be reserved for pharmacists?” Adams asked. “The way Idaho has tackled this is really from the perspective of delegating, allowing pharmacists to delegate tasks to technicians as long as those tasks are appropriate for their education, training and experience.” An example would be immunization administration. Determining if it’s the right immunization for that patient at that time would be the responsibility of the pharmacist, but the actual administration could be done by a technician. Same with point-of-care testing: the pharmacist would decide to do the test but the technician could administer it. Some pharmacies are delegating the accuracy checking of the dispensing process to technicians. “Data show that when they are delegated that task and given that authority, pharmacy technicians are actually more accurate than pharmacists because they tend to have fewer distractions,” Adams added.
Second, advancing the scope of pharmacy practice. “Our university has been closely involved with our board of pharmacy and our state association and we have navigated relationships with legislators to advance scope of practice,” Adams said. The Idaho board looked at other boards of pharmacy, but also looked at medicine and nursing, examining how their licensees were regulated and found they regulate based on this concept of standard of care.
“What our board of pharmacy learned from our healthcare colleagues was, pardon the pun, but pharmacists tend to be really prescriptive in their regulations. We write out the exact details of how hot the water in the pharmacy needs to be, the amount of counter space that needs to be provided, we get way into the weeds, rather than saying the facility needs to be appropriate so that the practitioners in the facility can provide the appropriate standard of care,” Adams said. “So there is nuance, and sometimes it’s unnerving for pharmacists to begin to think that way, but our board of pharmacy in Idaho has shifted all of our regulation to a standard of care model, which allows pharmacists to practice at the top of their education and training and not be restricted by their license.”.