Giving Vaccines a Boost

In Prescott’s paper, he asserted that the pharmacy profession is well positioned to help the medical community achieve higher vaccination rates. Pharmacists are authorized to administer vaccines to adults in all 50 states. Student pharmacists or interns are also permitted to administer immunizations in all 50 states, with most requiring completion of a certificate training program and/or pharmacist oversight. Only 27 states can offer vaccines to patients of any age; the remaining states have age restrictions in place, according to American Pharmacists Association (APhA) data. Immunizations by pharmacists are expanding beyond the influenza vaccine to include shingles and vaccines needed for international travel, among others, making these services more accessible.

“Screening for vaccines that patients need is a critical piece that can happen in the pharmacies,” said Dr. Lauren Angelo, associate dean, academic affairs, Rosalind Franklin University of Medicine and Science, and author of Immunization Handbook for Pharmacists. “Pharmacists are on the front lines, especially in community pharmacies where they are able to look through patients’ profiles to identify what vaccines they need. It’s also a great opportunity to get students involved when we talk about screening for what vaccines patients need.”

Increased Involvement

The types of vaccines pharmacists can administer and to what age groups is state-specific, said Angelo, but immunization by pharmacists is expanding. “I think what we’re going to see when the new recommendations from the Advisory Committee on Immunization Practices (ACIP) are published in the MMWR is language added around shared clinical decision-making for several vaccines,” she predicted. “Pharmacists specifically [will be relied upon] to work with patients and other providers to determine if a patient needs a vaccine that is part of shared clinical decision-making. That’s a big change we’ll see. When we talk about advocacy and education, that’s something that will need to be enhanced because pharmacists will be relied on to provide answers.”

She added that publications over the years have demonstrated that as pharmacists are involved in administering immunizations, rates have increased. “There are still gaps so we have our work to do to help close those gaps.” At the ACIP meeting in June, the group recommended shifting to a shared clinical decision-making model for several vaccines, which may open the door to pharmacists administering a broader range of immunizations to wider populations. As such, it will become more crucial that pharmacy graduates are prepared with the required training. Part of AACP’s Core Entrustable Professional Activities for new pharmacy graduates includes ensuring that patients have been immunized against vaccine-preventable diseases. Pharmacists have to be ready to jump in and help, particularly when the country is dealing with outbreaks such as measles or Hepatitis A, Angelo said.

She noted that it’s becoming an expectation that immunization is part of students’ pharmacy training. “A lot of employers are expecting new graduates to have already been trained. We are not seeing as many employers providing that training to their employees. Many want them to already have their certificate of completion. It’s becoming a new expectation of the market.”

Community Collaboration

Some schools of pharmacy are involved in collaborative efforts to expand immunizations in their communities. The Center for Pharmacy Care at the Duquesne University School of Pharmacy won APhA’s national award for community outreach in 2017 for its efforts to expand vaccine coverage. “The university is surrounded by an area that’s pretty underserved; residents don’t have a lot of access to healthcare,” said Dr. Suzanne Higginbotham, director of the school’s Center for Pharmacy Care, Residency Programs and Continuing Pharmacy Education. “We were teaching pharmacy students point-of-care testing and had a few pharmacy faculty who were interested in ambulatory care services and thought we could serve employees in the surrounding area and hone in on a need we had,” she explained, describing how the center got its start 12 years ago. “We started out with basic services like blood pressure screening and flu vaccines, and then focused on preventive care services and expanded to all vaccinations to adults.”

The center has some partner organizations, including YMCAs, churches and shelters, but often screenings and vaccines are provided at community events. The center administered more than 3,000 vaccines last year, which included 18 types of vaccines in the adult population. While students are not permitted to administer vaccines in Pennsylvania, Higginbotham said they are involved at every turn. “They do assessments, paperwork and documentation afterwards,” she continued. “We have them advocating on behalf of patients. It’s not about just giving a flu shot but going beyond to see what the full needs assessment is for our patients.”

Training is also woven into the curriculum, with a full semester in the second year devoted to immunization delivery and the science behind immunobiology. A certificate program is embedded in the course, which was expanded to give students more time on skills assessment to broaden that content.

Higginbotham reflected on the hurdles to getting immunization rates up, noting, “Doing a full immunization needs assessment is important out in the community, not stopping with just the top immunizations we tend to give. Access and bringing patients up to date with all immunizations is key. That’s one of the barriers in preventive care. We have lower numbers in adults in vaccination rates.” She added, “Another barrier is reimbursements for pharmacists. There are only certain ones we can bill for. Being able to be reimbursed for your services is important in community-based pharmacies. We can’t sustain that business model if we can’t be reimbursed for our services.”

Her advice for pharmacy schools that want to explore opportunities to increase vaccinations is to develop a concept of networking and have pharmacists willing to go out into the community and rely on each other. “It’s not a one-person job,” she emphasized. “Develop good partnerships with your community organizations. That was key. We went into our community and asked what their need was instead of assuming we knew what they needed. It was a great collaboration with our surrounding community, and the university was very helpful. We were able to find out more ways we can work with each other on healthcare needs. It really is a collaboration.”

Being Proactive With Patients

Another success story comes from the University of Washington School of Pharmacy, where a team submitted a proposal in 2016 for a one-year demonstration project to improve pharmacists’ use of vaccination systems. Project VACCINATE, one of three projects selected, received national funding from the CDC and National Association of Chain Drug Stores. The project specifically targeted four adult immunizations: flu, pneumococcal, pertussis and shingles.

“When the RFP came out, we started putting out feelers to our community partners,” said Dr. Jennifer Bacci, assistant professor. “We have such a collaborative environment here in the state and we had two community pharmacy partners interested in being involved: Bartell Pharmacy and QFC, which is a local Kroger banner.” The team worked with 40 Bartell locations and 30 QFC locations in western Washington.

The project’s main goals, Bacci noted, were “to increase adult immunizations for the four targeted vaccinations, to increase the use of immunizations information systems within these 70 pharmacies and to design and pilot a value-based payment model. We implemented an immunization platform that enabled proactive vaccine forecasting. When you search a patient in the system, it will bring up their history and will forecast upcoming vaccine needs. Pharmacists can use that information along with information about medications to make recommendations for vaccines that the person may need. When a patient got vaccinated in the pharmacy, it was documented back into the state registry via the platform.”

Compared with the previous one-year time period, the team saw a 15 percent increase in target vaccines administered, and 83 percent of vaccines were documented into the state registry. “We were able to optimize reporting through the platform,” she added. Individual sites determined how to engage staff, which sometimes included student pharmacists working as interns. Dr. Peggy Odegard, associate dean for professional pharmacy education and professor, said immunization training is a key part of Washington’s School of Pharmacy curriculum.

“Our curriculum includes immunization certification in the first year,” Odegard said. “Students in years 1-4 are involved in administering vaccines and in school outreach activities when those are available to help support the community. Students receive the same certification that pharmacists in Washington are able to take, so it’s a consistent program built into the curriculum.” She noted that the University of Washington School of Pharmacy took the lead on exploring the pharmacist’s role in immunization care more than 20 years ago through a grant-funded demonstration project.

“That training was then spread throughout the country. It acted as the basis for a lot of pharmacy immunizations across country,” she continued. “We felt that was a critical skill for graduating pharmacists to have. We are aware that employers in Washington in many cases require immunization certification on hire for all their pharmacists. It’s a necessary curricular piece so graduates are eligible for hire.”

Bacci and Odegard said the next steps for pharmacists in the state are to think about quality improvement and using their accessibility to increase public health. “The number of stakeholders we had was absolutely critical,” Bacci emphasized. “We embraced the concept of an immunization neighborhood. We had representation from independent pharmacies to make sure what we were doing could be generalizable. State Medicaid was there for the payer perspective. The state and local health jurisdictions and state pharmacy association also participated.”

Odegard said input from physician stakeholders was vital as well. “We had a focus group and we brainstormed ways to enhance immunizations. They were very impressed with what pharmacists are doing and felt it was added value to patient care. As a group, we identified an opportunity to improve electronic medical records so all health providers can be connected and easily communicate vaccination status. Currently, various providers need to go into the registry to see the vaccine status for their patient. In between states there are limitations on or no connectivity.” She and Bacci agreed that optimizing information systems, which is critical in achieving population health, is the next issue to tackle.

They also point to training as the key to improved immunization rates at the participating pharmacies. “Helping the pharmacist feel comfortable in using the system, how to navigate it, how to make a personalized recommendation within the setting of a busy pharmacy was quite helpful,” Odegard explained. “Training to strengthen recommendations and creating systems to reach out to patients proactively was important. A patient gets information from various medical professionals and the pharmacist can help frame the individual benefits of the vaccine for each person. We focused the training on making a patient-centered, proactive recommendation.”

Both advised reaching out to patients rather than waiting and reacting to a request for assistance. “We have a critical opportunity in this age of the media and information that’s not correct about vaccines that patients access on the Internet,” Odegard said. “With the number of people not trusting vaccination information…it’s really critical that we don’t wait for them to come to us. We want to provide accurate, individualized information so the patient understands what’s needed.” While technology has certainly helped their efforts, Bacci noted, “one key lesson is that it’s still about communication between the patient and the pharmacist and the language we use to help address vaccine hesitancy and provide a strong, explicit recommendation. Community pharmacists have such an intrinsic motivation to provide immunizations for the health of their community.”

Jane E. Rooney is managing editor of Academic Pharmacy Now.