50 Stories from 50 States - Mid-Atlantic

About the Pharmacy

Apple Discount Drugs
Salisbury, MD
https://www.appledrugs.com/

Description of Pharmacy

Apple Discount Drugs is a large independent, retail pharmacy located on the rural, Eastern Shore of Maryland. The Apple Discount Drugs organization consists of three retail pharmacy locations and a closed-door home-infusion pharmacy. Apple Discount Drug’s primary facility, located in Fruitland, MD, is not only a retail pharmacy location but also includes within the 20,000 square feet location several specialty pharmacies and services, that include an assisted living pharmacy complete with adherence packaging and medication synchronization services for both assisted living facilities and retail patients, a compounding lab, full-scale durable medication equipment, full-service respiratory services, and COVID vaccinations (4000+ given) and rapid-test diagnostic (2500+ given) services for the community. Apple Discount Drugs serves a Tri-County area of the lower Eastern Shore of Maryland. This area has been traditionally underserved regarding access to healthcare. This area is underserved by both primary and specialty care. The pharmacy services approximately 400 Medicare patients through Diabetes Self-Management Education and Support (DSMES), 500 patients through Medication Therapy Management (MTM), and 2,000 patients through medication synchronization and adherence packaging.

Apple Discount Drugs also plays a tremendous role as an experiential education site for pharmacy students and volunteers. While on site, these individuals spend their time actively taking part in patient interactions. These interactions include immunization administration, point-of-care testing, diabetes education (both individual and class settings), medication therapy management, and medication reconciliations. Apple also has an accredited PGY-1 Community Pharmacy Residency in conjunction with the University of Maryland Eastern Shore School of Pharmacy. The pharmacy resident is involved in the above patient interactions but takes a more leadership and advisory approach. The resident splits their time between the academic responsibilities of the University and the public health outreach efforts of Apple Discount Drugs.

Pharmacy Story

A 40-year-old Hispanic male arrives at a pop-up mobile vaccination clinic in his hometown for a COVID-19 vaccine. He is joined by his teenage son who serves as his translator. His skin is swarthy from toiling under an unforgiving sun, and his blemished hands reflect the hard work that has allowed him to provide for his family. The gentleman appears apprehensive as his eyes dart back and forth from the volunteer administering the vaccine to his son as they exchange in conversation. He seems to relax as his son assures him in their native tongue. This scenario is all too common among undocumented immigrants living in the United States. Their fear of deportation, coupled with the lack of access to affordable healthcare puts them at an extreme disadvantage for obtaining preventive healthcare services, including potentially life-saving immunizations.

Patients of undocumented status often times depend on the role of safety-net health systems for care; however, this reactive approach to healthcare, combined with low socioeconomic status and limited English proficiency, serves as a major pitfall for this population. Additionally, those that may have access to a Federally Qualified Health Center (FQHC) for preventive care may have other barriers, including more difficulty scheduling time off work, to seek care. By delivering COVID-19 vaccinations directly to this population at their convenience, we were able to provide them with essential preventive care services.

As the COVID-19 pandemic raged across the globe, Federal Emergency Management Agency’s (FEMA) approach to public health crises within the United States shifted to a much broader inclusion of healthcare professions. This agency collaborated with several states, specifically the health departments, to coordinate mass vaccination efforts across the country, including an effort stemming from Hobbs, New Mexico. Pharmacists had the opportunity to serve alongside individuals from various professions, backgrounds, and states, including emergency medical technicians, nurses, paramedics, pharmacists, and physicians. Pharmacists from the University of Maryland Eastern Shore (UMES) School of Pharmacy and Health Professions were deployed to this mobile vaccination clinic as a team of six from. From our base in Hobbs, NM, we travelled across the east and southeastern regions of New Mexico and served as volunteer vaccinators at mobile vaccination clinics in remote underserved sites of Hobbs, Roswell, Clovis, Ft. Sumner, and Tecumcari, New Mexico, including community colleges, churches, high schools, and detention centers of the local communities. The opportunities to serve this population were abundant, as the group was able to interact with the community in very intimate settings to gain insight into their experiences (or lack thereof) with healthcare. The most common barriers to obtaining healthcare included access to care, the language barrier in the absence of a translator, and those fearful of deportation due to undocumented status. Due to the nature of the free vaccine clinics, limited patient information was collected, only the necessary demographic information, allergies, and history of COVID-19 vaccination. The mass mobile vaccination clinic offered and designed by FEMA with guidance from the New Mexico Department of Health proved to be the missing piece of the puzzle that connected the population with necessary preventive care to protect them against the risks of developing severe cases of COVID-19. Citizens that partook of our services continually expressed their gratitude for our time, expertise, and efforts to improve their health along with the overall health of their communities. The care provided to this underserved population was possible due to federal and state funding programs.

State/Federal Connections/Advocacy/Impact:

The Public Readiness and Emergency Preparedness Act (PREP Act) 5th Amendment Medical for Medical Countermeasures Against COVID-19 provided the federal legislative policy to provide expanded patient care services.  On January 31, 2020 the former Secretary Alex M. Azar II declared a public health emergency effective January 27, 2020 for the entire United States to aid in the response of the health care community COVID-19 outbreak.  Subsequently the Amendment was renewed four additional times, the latest in January 21, 2021.  On August 19, 2020 the former Secretary amended the declaration to add additional categories of Qualified Persons.  As the result of this amendment it added additional qualified persons under the PREP Act.  On May 19, 2020 the Office of the General Council issued an advisory opinion concluding that licensed pharmacists are “qualified persons” under the declaration of the PREP ACT and preempts state law that would otherwise prohibit pharmacists from ordering and administering authorized COVID-19 tests.  Under the covered immunity provision, a state-licensed pharmacist pharmacy interns under the direct supervision of a pharmacist and pharmacy interns licensed or registered in their respective State Board of Pharmacy are eligible.  Both pharmacists and interns are subject to having completed all required immunization training that the state requires and completed.  The Pharmacy Intern must have completed a practical training ACPE program and the Pharmacist must complete a minimum of 2 hours ACPE approved immunization related training and maintenance of the required records as prescribed in the respective jurisdiction. 

About the Pharmacy

Barnabas Health Retail Pharmacy – Cooperman Barnabas Medical Center
Livingston, NJ  
https://www.rwjbh.org/our-locations/pharmacies/barnabas-health-retail-pharmacy-at-saint-barnaba/

Meet the Team

Faculty Lead Contact:

• Lucio R. Volino

Pharmacist Lead Contact:

• Cathy King

Student Pharmacist(s):

• Gargi Adenkar 

Description of Pharmacy

The Barnabas Health Retail Pharmacy (BHRP) network currently operates eight pharmacies that offer convenient pharmacy services to the general public, patients recently discharged from the hospital, and RWJBarnabas Health employees across New Jersey. The patient intervention took place at the flagship pharmacy located within the Cooperman Barnabas Medical Center location. The pharmacy offers enhanced clinical- and community-based services to support care transitions, immunizations, medication adherence, medication therapy management, naloxone without a prescription, and free medication access to uninsured patients through the Dispensary of Hope program. Our on-site pharmacies also address patient discharge medication and specialized wound care supply needs after medical appointments, clinic visits, outpatient procedures, and inpatient hospitalizations.  

Working within the community, our Clinical Pharmacist and Advanced Pharmacy Practice Experiential (APPE) rotation student pharmacists provide an array of educational outreach programs and presentations to underserved populations and seniors within the community. The pharmacy team supports population health initiatives through collaborations with local senior centers, health departments, and grant-funded facilities. Working with the New Jersey Reentry Corporation, we deliver two weekly education programs on preventive care and chronic conditions to people with histories of incarceration as they pursue professional jobs and training opportunities. Involvement and education are critical elements of BHRP’s presence in the community. 

Pharmacy Story

Initial Presentation:
A 73-year-old female patient came to Barnabas Health Retail Pharmacy to receive the vaccinations her oncologist had recommended. She recently underwent a splenectomy due to cancerous pancreatic cysts. Because her natural immunity had been compromised after the surgery, due to her spleen being removed, her oncologist referred her to the pharmacy to receive her vaccines.  

Background:
The patient’s doctor had recommended the following vaccines:

• ​Hiberix used to prevent Haemophilus influenzae type b (1 dose)
• Bexsero used to prevent Meningitis B (2 doses)
• Menveo used to prevent meningococcal disease (2 doses)

​Patient Report:
The patient reported significant concerns with:

• Vaccine coverage by insurance
• Why she was not receiving 2 doses of Hiberix like the other vaccines
• Potential side effects from the second doses of the Bexsero and Menveo vaccines

​Physical Observation:
The patient had called the pharmacy several times before her scheduled second dose appointment to discuss her concerns. She also expressed worry and hesitancy during her appointment.

​Intervention:

• Ensured vaccines were covered by low-income insurance and co-pay was affordable.
• Education: The pharmacist both educated and addressed the patient’s specific concerns regarding the vaccines. The pharmacist took the following actions:
• Educated on how one dose of Hiberix for adults who have had their spleen removed has been studied to confer adequate immunity  
• Explained how the second doses of the Bexsero and Menveo vaccines were the same shots as the first dose and would help boost her immunity  
• Discussed potential side effects experienced, including soreness or redness at the injection site, fatigue, muscle pain, and headache, after receiving both meningococcal vaccines

​Outcomes of Care Provided:
Outcome 1: Compliance - Vaccines  

• After the pharmacist had answered the patient’s questions, she felt more comfortable receiving both vaccines. She did not avoid or reschedule her second dose appointment.  
• Knowing that she would not experience side effects that were different from those with her first dose, she appeared much more relaxed before receiving both of her second doses.
• Immediately after vaccine administration, the patient mentioned feeling the vaccine going into her arm and expressed some concern. The pharmacist reassured her that the sensation was common and could be expected. During the twenty-minute observation period, the patient mentioned feeling fine, and overall, was happy with the experience.  

​​Outcome 2: Vaccine Accessibility  

• The patient was relieved that her copays for the vaccines were affordable. She was grateful that the pharmacist was able to remove the financial barrier that could have prevented her from getting the vaccines. 

State/Federal Connections/Advocacy/Impact:

Barnabas Health Retail Pharmacies provide comprehensive care through integrated collaborations with the RWJBarnabas Health System, Rutgers Biomedical and Health Sciences, New Jersey State Department of Health, and local health departments. In addition to education, we address financial barriers associated with medication access by offering assistance programs such as Federal 340B and the Dispensary of Hope, which is a charitable distributor.  We understand the critical roles that pharmacists play within the healthcare system and want to showcase the value that community pharmacies have in supporting improved patient care and preventive services. It is vital for community pharmacies to serve as resources and centers for patients to receive comprehensive clinical services.

About the Pharmacy

Middleport Family Health Center

Middleport, NY

https://www.middleportfamilyhealth.com/ 

Meet the Team

Faculty Lead Contact:  

• Christopher Daly

​Pharmacist Lead Contact:  

• Rachel Rosman

​Pharmacy Resident:  

• Matthew Butler 

Description of Pharmacy

Middleport Family Health Center is a family-owned, independent pharmacy serving the small, rural town of Middleport and surrounding areas in Western New York. The interaction described  above took place in Middleport, which serves predominantly low-income households (Median household income was $46,382 in 2019).  This pharmacy is located just outside of Orleans County, which is considered a Primary Care, Mental Health, and Medically Underserved area for low-income individuals by the United States Health Resources and Services Administration.  Services offered at this site include medication synchronization, adherence packaging, vaccines, medication disposal, diabetes care/education classes, COVID testing services, and more.

Pharmacy Story

Initial Presentation:
A few months ago, our delivery driver, Ryan, had been recovering at home for a few days after an intensive eye surgery. During this time, he had developed a deep understanding and felt empathetic of the struggles that many patients face, such as those with transportation issues, mobility issues, and other various obstacles. Because of this, Ryan had developed a personal care assistant role through the pharmacy to help identify and aid patients with poor social determinants of health.

​Background:
Patient #1 suffered a traumatic brain injury, leaving him without the ability to transport himself.

Patient #2, Patient #1’s wife, has severe social anxiety.

Patient Report:
Patient #1 reported walking to the nearest village miles away for groceries and laundry, and Patient #2 reported not leaving the house for years due to social anxiety.

​Physical Observation:
Upon observation of the patient’s home environment, it was identified that both patients would benefit from additional transportation services in order to improve their overall quality of life.  

​Intervention:
The delivery driver scheduled times to transport the patients to different locations, such as grocery stores, laundromats, provider appointments and social spaces, such as coffee shops, in order to help the patients get both the necessary health and humanistic services.

The delivery driver coordinated with the pharmacist to help identify patients who would benefit from these additional services. Coordination was made between the delivery driver and the providers office in order to successfully transport the patients to their appointments.

​Outcomes of Care Provided:
Outcome 1: Improved Quality of Life/Personal Health Impact

Both patients report having an improved outlook on life and overall quality of life. Patient #2 described how her anxiety has improved since the delivery driver has started to offer these transportation services. Below are quotes from the 2 patients:

“This has helped so much, just getting out of the house” - Patient #1

“My one friend told me I’m not as miserable as I used to be! Before you started coming around, I would just lay in bed and didn’t even know what the point of living was anymore.”  - Patient #2

​Outcome to the Pharmacy

• This intervention allowed the pharmacy to expand its impact on the local community through community service, which bettered outcomes for the 2 patients and helped to advertise the social determinants of health services that the pharmacy offers.

State/Federal Connections/Advocacy/Impact:

The care provided was made possible through Middleport Family Health Center participation in Community Pharmacy Enhanced Services Network of WNY, Western New York’s CPESN USA network. Negotiation of payment for patient care services through CPESN allows Middleport Family Health Center to, not only dispense necessary medication to patients, but also to provide services to patients with poor social determinants of health, as evidenced by the above story. Pharmacies are key health care access points for many patients, but in order to make providing this level of  care financially feasible at pharmacies, we need to be recognized as health care providers to be  able to ensure this level of care is available to people in all communities through their local pharmacy.  

About the Pharmacy

Kinney Drugs

Essex Junction, VT

https://kinneydrugs.com/

Description of Pharmacy

Kinney Drugs is a multiple-location chain with 100 locations throughout Vermont and upstate NY. The specific location discussed is in Essex Junction, Vermont, located in a designated Primary Care Health Professional Shortage Area (HPSA) for low-income individuals and a designated Medically Underserved Area (MUA) by the United States Health Resources and Services Administration. The average per capita income of the area is $39,878 with a 7.1% poverty rate. As part of the Community Pharmacy Enhanced Services Network (CPESN), Kinney Drugs pharmacy offers face-to-face access, medication reconciliation, clinical medication synchronization, immunizations, comprehensive medication reviews, and personal medication record compilation. The pharmacy also offers CPESN enhanced pharmacy services including collection of vital signs, home delivery/home visits, tobacco cessation, durable medical equipment, point of care testing, and naloxone dispensing. We also offer specialty medication compounding through our sister company Noble Health Services. 

Pharmacy Story

Amidst the COVID-19 pandemic, SARS-CoV-2 PCR testing is in high demand. Kinney Drugs receives dozens of calls a day from patients requesting COVID-19 testing, from employees seeking a PCR test for their employers to parents seeking testing options for their children to return to school. Kinney Drugs offers asymptomatic COVID-19 PCR tests at no cost to the patient. The process is simple. Patients must schedule a testing appointment on the website at their desired Kinney Drugs location (testing days vary by location). Appointments are scheduled via eTrueNorth, the company that processes the tests and requires an email address to schedule. Appointments are available in 15-minute increments from 9:30am to 3:30pm and fill up quickly. Testing is performed in a contactless manner via our prescription drive-thru window by a pharmacist or pharmacy intern. Each patient is given a basket containing a nasopharyngeal swab, a specimen vial, and hand sanitizer. The patient is instructed to sanitize their hands before beginning the test. We then instruct the patient to remove the swab from the packaging and perform an anterior nasal swab on themselves by swabbing in a circular motion from the nostril opening to the bridge of the nose for 10 seconds in each nostril. The patient is then instructed to place the swab in the specimen vial, seal the vial, and return it along with the hand sanitizer and basket via the drive-thru window. The specimen vial is then labeled with patient-specific information, placed in a biohazard bag, and stored in a cooler until the testing day is over. Tests are packaged and picked up by UPS at the end of the day. Patients can expect to receive their COVID-19 test results within three to five business days but often receive their results within 48 to 72 hours of testing. Patients express gratitude for the service, particularly those traveling across the Canadian border. Our pharmacy is located just 40 miles from the Canadian border and is uniquely positioned between Burlington and Montreal. Given the requirement by the Canadian government of a negative COVID-19 PCR test within 72 hours before travel from the United States to Canada, many Canadian citizens utilize our testing service to see their families on the weekends while working during the week. Kinney Drugs administered approximately one hundred tests per month, working hard to keep the community safe and prevent the spread of COVID-19.

State/Federal Connections/Advocacy/Impact:

Kinney Drugs is able to provide point of care COVID-19 PCR testing throughout Vermont as a result of updated guidance from the U.S. Department of Health and Human Services (HHS) on COVID-19 procedures. While HHS previously prevented pharmacists from administering point of care diagnostic tests, the Public Readiness and Emergency Preparedness (PREP) Act has allowed pharmacists to pursue this role if desired. The Vermont Pharmacists Association (VPA) has also been a key advocate for expanding the roles of pharmacists in Vermont, helping pharmacists to serve as front-line immunizers in our state for over a decade. As a result, State of Vermont Governor Phil Scott declared February 2021 Pharmacists’ Month in Vermont, shedding light onto all we do as health care providers and allowing us to better serve our patients. 

About the Pharmacy

Sun Ray Drugs
Philadelphia, PA 
https://sunraydrugs.com/ 

Meet the Team

Faculty Lead Contact:

• Elizabeth Harris

​Pharmacist Lead Contact:

• Elissa Devenny

Resident:  

• Trisha Patel 

Description of Pharmacy

Sunray Drugs is an independent pharmacy chain across the greater Philadelphia, Pennsylvania area. In addition to its 22 retail pharmacy locations, the company also manages a specialty pharmacy with a focus in hepatitis C, medication-assisted treatment for substance use disorders, and a number of other therapeutic areas. The interaction described above took place at the 52nd Street retail pharmacy location, in West Philadelphia. This pharmacy is located in an area with a primary care health professional shortage. Philadelphia Block Group 6, a 0.03 square mile area with a population of 1,307, has a median age and household income of 30.6 years and $23,156 respectively. Approximately 92% of the population has attained a high school degree and 17% a bachelor’s degree or higher.1 The pharmacy provides patients with free delivery and adherence packaging, immunizations and long-acting injectable antipsychotics, medication therapy management, and HCV and HIV point-of-care testing services.

Pharmacy Story

Initial Presentation:
A 56-year-old female patient presents to the pharmacy to pick up her medication refills. While waiting for the refills, the pharmacist and pharmacy students asked her if she would be interested in hepatitis C virus (HCV) point-of-care testing. The patient was initially hesitant, but with counseling and explanation of the test, the patient agreed. Her test results were found to have detectable HCV antibodies.

​Intervention:
The student pharmacist screened the patient using an OraQuick® HCV Rapid Antibody Test. After 20 minutes of test processing, the student contacted the patient to inform her that her results were reactive and to arrange for confirmatory testing the following week at one of the partnering medical clinics.

Sunray Drugs provides point-of-care testing services for HCV and human immunodeficiency virus (HIV). The pharmacy collaborates with local medical clinics where patients who test reactive for HCV are sent for same-day confirmatory lab work and treatment. Through this collaboration, the pharmacy also provides rideshare services for those patients who might not have a means of transportation. If treatment is deemed necessary after confirmatory lab work, the clinic sends the patient’s HCV medication prescription to Sunray Specialty Pharmacy. The pharmacy team collaborates with the prescriber to guarantee that the prior authorization form is completed appropriately, as this will help to ensure coverage for the patient. Prescriptions are dispensed and either delivered to the patient’s house or made available to pick up at any of the Sunray Drugs retail locations. Along with initial medication counseling and a check-in one week following the initiation of therapy, Sunray Specialty Pharmacy performs monthly telephonic reassessments  with patients who are taking HCV medications to evaluate safety, efficacy, and adherence to treatment.

​Outcomes of Care Provided:
Pharmacy staff contacted the medical clinic to determine that the patient did not attend her confirmatory lab appointment. Case managers from the medical clinic continue to attempt contact with the patient to reschedule her appointment.

Some of the most common barriers to care encountered by recipients of point-of-care testing services include a lack of follow-up to the diagnostic lab appointment, not picking up medications for antiviral therapy, and non-adherence to medications. To help minimize barriers, the pharmacy team contacts the patient at multiple steps throughout the process. First, the patient is provided a ride share service to aid in transportation to the lab appointment on the same day that they completed the HCV antibody test at the pharmacy. If the patient prefers to go on a different day, the pharmacy coordinates with the clinic to ensure an appointment and ride share is scheduled on the day of the patient’s choosing. The pharmacy team reaches out to the clinic to follow-up on patients who require a lab appointment. Unfortunately, some patients do not respond to continued outreach provided by the medical clinic to reschedule missed lab appointments and medical care. Despite facing barriers in the referral and follow-up process, providing these services has increased awareness of hepatitis C in the community. Additionally, the point-of-care services provided by the pharmacy have been able to successfully connect many patients to care. Many community members have shown interest and gratitude to the services provided at the pharmacy.  

State/Federal Connections/Advocacy/Impact:

The CLIA-waived point-of-care testing services provided to this patient were made possible through a CLIA Certificate of Waiver provided by the Centers for Medicaid and Medicare Services (CMS) as well as a laboratory license issued by the state of Pennsylvania. Additionally, testing was provided for free through grant funding as pharmacists work to navigate the reimbursement model with several Medicaid managed care organizations (MCOs) for medical billing. Pennsylvania Clinical Laboratory Regulations currently require that Laboratory Directors hold a doctoral degree in pharmacy and have two years of laboratory experience. Collaborative drug therapy management laws in the state do not permit the initiation of drug therapy and pharmacists are only able to order additional labs for confirmatory testing if the patient is already under a written collaborative practice agreement with the patient’s healthcare provider. With a globally low rate of linkage to medical care (confirmatory testing and antiviral therapy initiation), changes to state rules and regulations permitting pharmacists to function in a “test and treat” model would likely increase this patient population’s access to medical care and achieve a higher rate of sustained virologic response.

About the Pharmacy

Cook’s Pharmacy
Kingston, PA 
http://cookspharmacykingston.com 

Meet the Team

Faculty Lead Contact:  

• Danielle Kieck, PharmD  

​Pharmacist Lead Contact:  

• Danielle Kieck, PharmD

​Student Pharmacist(s):  

• Carly Lewis 

Description of Pharmacy

Cook’s Pharmacy is a family owned, single store, independent pharmacy that serves patients in Northeastern Pennsylvania, more specifically located in Kingston, PA. The median household income for people in Kingston, PA is $51,554, 4.1% of people in the area are without healthcare coverage and 13.6% are below the federal poverty line. The average age of people living in Kingston is 40 years old.  Services offered at this pharmacy include vaccinations, medication synchronization, pill packaging, medication therapy management, diabetes self-management education, health screenings and more.

Pharmacy Story

Initial Presentation:
During a routine medication therapy management (MTM) encounter, a 76-year-old, female patient [RS] expressed that she was not feeling well and had been experiencing chest pain in the morning. She described the pain as being dull and feeling like pressure on her chest. The patient also mentioned that she had been seeing halos the previous day and had been experiencing nausea and stomach upset occurring 4 out of 7 days a week for a few months. This aroused the pharmacists' concern about possible digoxin toxicity.

​Background:
Doctor had prescribed medications for heart failure and Afib:  

• Digoxin 0.125mg one tablet by mouth once a day (HF/AFIB)
• Losartan 25mg one tablet by mouth once a day (HF)
• Metoprolol Succinate 25mg one tablet by mouth once a day (HF)
• Furosemide 40mg one tablet by mouth once a day (HF)
• Eliquis 5mg one tablet by mouth once a day (AFIB)

Patient Report:
The patient reported:  

• • Chest pain and severe pressure on her chest. She does not normally get chest pain, and it lasted for about three hours in the morning.
• • Vision changes the night before the MTM encounter that involved seeing halos.  
• • GI upset that included having nausea 4 out of 7 days a week for a few months.

​Physical Observation:
None. This was a phone encounter.

​Intervention:
Education:  

The pharmacist educated RS on the similarities between her symptoms described, and the symptoms commonly associated with too high of digoxin levels in the body. The following actions were taken:  

o Urged RS to go to the emergency department. RS refused.  

o Contacted the patient’s cardiologist and primary care doctor.

​Planned follow-up call for 3 days later to check in on patient symptoms and whether she went to the emergency room or talked to her doctor.  

​Outcomes of Care Provided:
Outcome 1: Lab Work Obtained – Digoxin Level

After contacting the patient's primary care physician, we were able to aid in the coordination of a mobile phlebotomy service to visit the patient's home and obtain her labs the following week. Her digoxin level came back at 1.8ng/mL, which is above the recommended level of 0.5-0.8ng/mL in patients with heart failure. Her cardiologist was contacted with this information. The patient was thankful for the pharmacy’s help in coordinate the mobile phlebotomist due to limited transportation and difficulties leaving the house.

Outcome 2: Dose Decrease - Digoxin  

The cardiologist agreed with the recommended dose decrease and decreased the patient's dose of digoxin to 125mcg 1 tablet by mouth once daily five days per week. Even though the patient refused the pharmacists initial recommendation to seek immediate medical attention, during the follow-up call to explain the dose change, she expressed appreciation for the help with getting her medications adjusted.

​Outcome 3: Compliance - Digoxin

During the follow-up call to explain the dose change, the pharmacist identified an adherence concern. The patient had a diagnosis of dementia and often times fills medications too early or late. Even though the patient refused a pharmacy packaged pillbox, she did say she would have her sister help her use a pill box to help keep track of her medications, which she had not been open to in the past. As the pharmacist built trust with the patient, she became more willing to contact the pharmacy with questions and ask for assistance.

​Outcome to the Pharmacy:​

• The pharmacist documented each of these encounters with RS in the Pharmacist eCare Plan (community pharmacy electronic medical record) so that each pharmacist on the team could view the patient's progress and continue her care.  

• The pharmacist built better relationships with the patient’s medical team and learned more about services available for home bound patients (i.e. mobile phlebotomists).

• The encounter was reimbursed through the patient’s insurance after the MTM encounter was completed during a follow-up call once the digoxin concern was resolved. 

State/Federal Connections/Advocacy/Impact:

The care provided to RS for her emergent issue related to potential digoxin toxicity was not reimbursed. The pharmacy was eventually reimbursed by patient’s insurance for the MTM encounter that was completed at a later date. Pharmacies, especially family-owned independent pharmacies, are comfortable and easy health care access points for many patients like RS, but in order to make providing this level of care financially feasible at pharmacies, pharmacists need to be recognized as health care providers to be able to ensure this level of care is available to people in all communities through their local pharmacy.  

About the Pharmacy

Hilltop Pharmacy
Pittsburgh, PA
https://www.hilltoppharmacyrx.com/  

Meet the Team

Faculty Lead Contacts:

• Dr. Gale Garmong
• Dr. Tiffany Hatcher

Pharmacist Lead Contact:

• Dr. Alex Rothey

Student Pharmacist:

• Natalie Klek 

Description of Pharmacy

Hilltop Pharmacy is a small, family-owned single location independent pharmacy in Pittsburgh, PA. It participates in PPCN and Flip the Pharmacy (FtP). FtP aims to elevate the profession of pharmacy by supporting pharmacies in transforming their workflows to emphasize patient care and clinical services.₁ Hilltop’s services include adherence packaging, medication synchronization, immunizations, blood pressure readings, smoking cessation, medication therapy management and diabetes education classes.

Hilltop Pharmacy serves many underserved patients. Hilltop Pharmacy’s patient population is inclusive of a neighboring Medically Underserved Population recognized by the Health Resources and Services Administration (HRSA).₂ This classification gives data on populations who lack adequate accessible primary health care services.₂ The median household income is $35,375 in Hilltop’s Census tract.3 Hilltop’s patients refer to their pharmacist Alex Rothey, PharmD, as “Dr. Alex”, often coming in with various health care-related questions looking to her as their primary access point to healthcare. More recently, when COVID-19 vaccinations became available, Alex and the team at Hilltop worked tirelessly to organize vaccination clinics for first responders and patients. These clinics grew eventually to vaccinate over 16,000 people (and counting) in Allegheny County. 

Pharmacy Story

Initial Presentation:
RB is a 54-year-old African American woman who had been visiting the pharmacy for daily blood pressure readings, as requested by her doctor, to document any improvements after increased adherence to taking her blood pressure medications. Through these encounters, RB was identified as eligible for care under her Medicaid plan’s Asthma/COPD management program through the Pennsylvania Pharmacists Care Network (PPCN), Pennsylvania’s CPESN network.

​Background:
This asthma/COPD management program consisted of an initial meeting where the patient completed the Asthma Control Test (ACT), then monthly follow-up meetings to assess adherence to medications and symptoms. RB’s initial ACT score was 9, placing her in the very poorly controlled category. Her prescribed asthma medications were Flovent HFA 220 mcg for daily use and an albuterol inhaler to be used as needed.

Patient Report:
RB complained of shortness of breath, coughing and difficulty breathing. She initially reported breathlessness after walking to the pharmacy to get her blood pressure checked. The patient expressed concerns regarding her general well-being and health due to a family history of cardiac conditions.

​Physical Observation:
After a short discussion with RB, the pharmacy team identified she was confused between her maintenance inhaler to control her asthma and her rescue inhaler for immediate relief. The patient had incorrectly labeled her inhalers, utilizing her albuterol inhaler daily for “control” and her Flovent inhaler for rescue. This mix-up between the two inhalers was most likely contributing to the patient’s prior complaints and symptoms.

​Intervention:

1. Asthma education and management techniques: the student pharmacist was able to inform the patient which inhaler she should use daily (Flovent), and which should be used on an as-needed basis (albuterol), utilizing demonstration inhalers.
2. Follow-up discussions occurred at the next blood pressure reading to assess if the patient was able to utilize her maintenance inhaler correctly.  
3. Following the recommendation of her pharmacist, RB received both her Shingrix and influenza vaccinations.

​Outcomes of Care Provided:

1. Patient education: RB’s knowledge of her disease states increased significantly. Since this patient came in on a regular basis for blood pressure readings for several weeks, it allowed for conversations not only about her blood pressure but also managing her asthma.  
2. Medication adherence: After filling both her controller inhaler and rescue inhaler, she was able to pick up both and use them correctly.  
3. Additional services: RB’s blood pressure readings were tracked in a journal. As her blood pressure improved, she was excited to be able to tangibly see the numbers decrease.

Pharmacy Outcomes:

The pharmacy was able to document the patient encounters as part of an eCarePlan that was submitted to CPESN for billing to RB’s Medicaid plan through the aforementioned PPCN program, which provided a source of revenue to the pharmacy for the care provided. The eCarePlan data submitted facilitates longitudinal tracking of patient outcomes across the PPCN network, as well as helps Hilltop track RB’s care moving forward.  

State/Federal Connections/Advocacy/Impact:

The services provided to RB were billable through a contract with the patient’s Medicaid plan through PPCN. PPCN engages with payers to demonstrate how network pharmacies can deliver value to their members, secures contract opportunities for payment to make that patient care sustainable, and supports the pharmacies in their provision of care. Toward this goal of supporting pharmacies, PPCN, the University of Pittsburgh School of Pharmacy, and the Pennsylvania Pharmacists Association led a Cardiovascular Disease Management Student Pharmacist Summer Intern Program. This program, supported by a grant from the Pennsylvania Department of Health and the CDC, placed student pharmacists at PPCN and FtP sites to initiate and maintain clinical services collaboratively with their pharmacist preceptor and team. Having a student pharmacist intern dedicated to patient care services at Hilltop facilitated identifying and meeting RB’s need for care.  

This case demonstrates how patients may utilize pharmacy services due to their accessibility, which may result in the identification and resolution of additional, unrelated drug therapy problems. Additionally, it shows the impact student pharmacists can make when learning about and supporting community pharmacy-based patient care services and highlights the role of schools of pharmacy in supporting community practice transformation.

Having a payment mechanism, like an enhanced service network contract, in place to cover the staff time needed to provide these patient care services is critical to ensuring the pharmacy can continue offering them to patients like RB. Granting pharmacists Provider Status under Medicare Part B would open additional opportunities for reimbursement of valuable encounters such as this.

About the Pharmacy

Bremo Pharmacy
Richmond, VA
https://bremorx.com/

Meet the Team

​Faculty Lead Contacts:

• Kelly Goode
• Sharon Gatewood

Pharmacist Lead Contact :

• Tana Kaefer

PGY1 Community-Based Pharmacy:

• Leighton Mascari 

Description of Pharmacy

Bremo Pharmacy is an independent community-based pharmacy in Richmond, Virginia with two locations, a closed-door, long-term care (LTC) pharmacy and a community-based pharmacy. Both pharmacies are located in a suburban area near two large hospital systems, including an academic teaching hospital. The community-based location primarily serves older adults and sponsored residential persons living in the community. 

Pharmacy Story

Background:
The COVID-19 pandemic restrictions for medical offices and reduced scheduling availability caused providers and patients to seek other settings to receive their long-acting injectable (LAI) antipsychotics medication administration. Additionally, local psychiatry offices were conducting virtual televisits; therefore, patients were unable to get their LAI medication administered during their office visit.  Bremo Pharmacy received a steady growth of referrals from local healthcare offices resulting in the expansion and enhancement of a pharmacist provided medication administration service for LAIs.  

Medication administration is included in the scope of practice for pharmacists in the Commonwealth of Virginia and Bremo had been providing injections of medications to some patients.  However, the increase in referrals provided an opportunity to create an appointment-based model for medication administration.  

Patient Report:
Patients needed more convenient access to LAI medication.

Intervention:
​A 4-month small prospective convenience sample study was conducted to evaluate patient satisfaction and perceptions of the LAI medication administration service in the community-based pharmacy during the COVID-19 pandemic.

​Outcomes of Care Provided:
Outcome 1: Outcome 1 Patient Satisfaction

Patients agreed that they were satisfied with the privacy while receiving an LAI by a pharmacist and felt comfortable with receiving this service at the pharmacy. The pharmacist was trusted by the patients, and they felt the pharmacist listened carefully to them during the administration appointments. Patients commented that the LAI medication administration service could be better if “it wasn’t so far away from home” and “I wouldn’t change nothing”.  

Outcome 2: Patients were satisfied with using the pharmacy compared to other healthcare settings for the administration of their LAI medication. The patients agreed that the pharmacist was as knowledgeable or more about the service provided, and the service was as convenient or more than a similar service received elsewhere, yet the community-based pharmacy was not physically near the patient’s home nor their work.

​Outcome to the Pharmacy:

​During the 4-month study period, 40 patients were enrolled in the LAI medication administration service.  Payment for this service is paid out of pocket by the patient. However, for some LAI medications, the fee is waived, and payment is received from a medication manufacturer through a patient assistance program. Additionally, Bremo Pharmacy piloted a Behavioral Health Integration (BHI) program with a local psychiatry office to receive payment for services and to further collaborate with providers in medication monitoring associated with LAIs.

State/Federal Connections/Advocacy/Impact:

This story creates a framework for an appointment-based model for pharmacists to provide a medication administration service in a community pharmacy and supports the need for a pharmacist role in mental health services, such as medication administration beyond the current pandemic further developing interprofessional collaboration for the benefit of the patient.  

The implementation of this service is an opportunity for community-based pharmacists to be involved in outpatient mental health treatment of patients. High patient satisfaction with the LAI medication administration service provides evidence for the continued offering of this service at the community-based pharmacy. According to the data in the small study, patients are willing to travel to a pharmacy that is not near their home or work to receive these services. Therefore, increasing the number of community-based pharmacists providing this service could improve patient access to medication administration services, which could improve adherence. Increased adherence improves the health of patients and decreases healthcare costs, providing savings to payers, specifically in the decrease of hospitalization rates related to patient non-adherence. 

About the Pharmacy

Bellevue Pharmacy
Washington D.C.
http://www.bellevuepharmacyrx.com/pharmacy-contact-us

Description of Pharmacy

Bellevue Pharmacy is in the Bellevue, Washington, DC. a residential neighborhood in far Southeast and Southwest Washington, D.C. While an emerging neighborhood, the median income of Bellevue is $31,725, and while 87 percent of its residents possess a high school diploma, only 12 percent have graduated from a college or university. Located in Ward 8, there are still many health disparities that still plague this population. Ward 8 is considered both medically underserved and a place where there is a healthcare shortage. Services offered at the pharmacy include: medication reconciliation, medication synchronization, provision of adherence tools (Bubble Pak), delivery, and In-Service for Partner Agency. 

Pharmacy Story

Patient Story: 
A large part of the business at Bellevue Pharmacy stems from partnerships with several community mental health clinics in the area. One clinic, MBI Health Center, receives medications exclusively from Bellevue for one of their ACT (Assertive Community Treatment) teams.  One patient started off with having her medication delivered to the clinic. Through the partnership with her physician, nurse, case manager and her pharmacy, she started getting better and became more independent. Over the course of 6 months, because she lived in the neighborhood, she started to come and pick up her medications form the store every month. She was on three oral medication and a long acting injectable to treat her schizophrenia and her mood disorder.  

​Outcomes of Care Provided:
As part of the services, provided to each patient affiliated with a community mental health clinic, each person’s medication is reviewed for duplicates and effectiveness. Most persons medications are placed in bubble packaging. This allows for monthly reconciliation of all meds and requires synchronization.  This ensures that each patient’s regimen is complete and facilitates adherence.  

Personal/Public Health Impact of Care Provided: 
Mental Health America shares important information related to mental health in Black/African American communicates saying, “Overall, mental health conditions occur in Black and African American people in America at about the same or less frequency than in White Americans. However, the historical Black and African American experience in America has and continues to be characterized by trauma and violence more often than for their White counterparts and impacts emotional and mental health of both youth and adults.” A statistic to support this is that Black and African American people living below poverty are twice as likely to report serious psychological distress than those living over 2x the poverty level.1 Bellevue pharmacy aims to support adequate medication therapy, including the use of adherence tools, to help increase positive health outcomes for patients.  

​Care Providers Involved:
Partnerships with a community health clinic includes frequent communication with the provider, nurse and case manager. With the community pharmacist leading the team, there is assurance that patients are receiving the correct medications.

About the Pharmacy

Moundsville Pharmacy
Moundsville, WV
https://www.moundsvillepharmacy.com/ 

Meet the Team

Pharmacist Lead Contact:  

• Elizabeth Laughlin 

Description of Pharmacy

Pharmacole Inc includes four independent pharmacies serving the northern panhandle of West Virginia. The interaction above took place at the Moundsville location, which services a variety of patient populations including low-income and elderly populations. In addition to dispensing, services offered at this site include medication packaging, compounding, free delivery, immunizations and COVID-19 PCR testing.

Pharmacy Story

Initial Presentation:
A 70-year-old male patient [Ernie] was contacted by Moundsville Pharmacy with a reminder to complete his Shingrix series, the series of vaccines that protect patients against Shingles. Patient presented a few days later to receive immunization at Moundsville Pharmacy.  

​Background:
Ernie had received his first dose of Shingrix in September. He had not responded to initial  

reminders about being due for his second dose in early November.

​Patient Report:
The patient reported:

• He was spacing his immunizations out and did not want to receive this immunization too close to his COVID-19 booster or annual flu shot.

​Intervention:

1. Education: The pharmacist educated Ernie about the importance of completing the Shingrix series to ensure 90% immunity to the Shingles virus.  
2. Immunization: Ernie received his second Shingrix vaccine in early December.

​Outcomes of Care Provided:
Outcome 1: Compliance – Immunization Schedule

Due to the trust built between Ernie and the pharmacist, he received second Shingrix vaccine within the appropriate time schedule at the pharmacist’s recommendation.

• Ernie was thankful that he could complete his series within the same insurance year to prevent additional costs.  

Outcome to the Pharmacy:  

The pharmacist documented the encounter with Ernie in the Pharmacist eCare Plan, which allows for documentation of the care provided in the pharmacy, so that each pharmacist on the team could view the patient's up to date immunization records. 

State/Federal Connections/Advocacy/Impact:

Shingrix is the only older adult immunization which is covered by either commercial or Medicare part D insurance. Therefore, this patient population is often subject to a large copay for the first Shingrix immunization. This cost is often due to beginning of the year deductibles or coverage gaps. As a service at Moundsville pharmacy, there is a major focus at the end of the year to help patients catch up or complete their series before the end of the coverage year. This added service ensures that the patient is more likely to complete the series with less financial burden.

The care provided to Ernie was made possible through Moundsville Pharmacy’s participation in West Virginia’s CPESN USA network. Pharmacies are key health care access points for many patients, like Ernie, but in order to make providing this level of care financially feasible at pharmacies, pharmacists need to be recognized as health care providers to be able to ensure this level of care is available to people in all communities through local pharmacies. 

About the Pharmacy

Waterfront Family Pharmacy
Morgantown, WV
https://www.mygnp.com/pharmacies/waterfront-family-pharmacy-morgantown-wv-26501/

Meet the Team

Faculty and Pharmacist Lead Contact:

• Gretchen Garofoli 

Description of Pharmacy

According to the 2017 US Census, Morgantown is home to 31,073 people, along with 138,176 in the metropolitan area. This city is located 75 miles south of Pittsburgh, and is home to West Virginia’s largest university, West Virginia University, which has approximately 30,000 full-time students. The influx of such a large number of students brings the median age down to 24 years. Morgantown has a median income of $32,400 and an unemployment rate below the state average at 4.2%. The racial makeup of the city is 89.7% White, 4.1% African American, 0.1% Native American, 3.4% Asian, 0.1% Pacific Islander, 0.6% from other races, and 2.0% from two or more races. 

Pharmacy Story

West Virginia emerged as a leader in the COVID-19 vaccination effort with first doses of COVID-19 vaccinations completed at all long-term care facilities in the state of West Virginia by the end of December 2020.  The vaccination team from West Virginia University School of Pharmacy continued to administer vaccinations in a variety of settings including long-term care facilities, other healthcare provider offices, manufacturing plants, West Virginia University, area schools, and to patients in their respective pharmacies.  Their vaccination efforts focused in Morgantown, WV, as well as some of the surrounding rural communities. Most of these vaccination efforts were done through Waterfront Family Pharmacy, an independent community pharmacy located adjacent to an urgent care clinic in Morgantown, WV.  

As many involved in the vaccination effort nationwide encountered, the team was faced with a lot of vaccine hesitancy.  One patient encounter will forever stand out due to the lengths that the patient went to in order to be vaccinated by a particular pharmacist.  The pharmacist, who is faculty at West Virginia University and practices at an independent community pharmacy, also does online continuing education programs for a nationwide audience.  After listening to the pharmacist present on COVID-19 vaccinations for a few months, one of the employees of the continuing education company confided in the pharmacist that he had not received his COVID-19 vaccine and would only be comfortable receiving his first dose from her.  The pharmacist replied that she was licensed in West Virginia, Pennsylvania, and Virginia, so if he could make it to one of those states from his home state of California, she would vaccinate him.  After a few e-mail exchanges the patient decided that he would fly into the Pittsburgh, Pennsylvania airport, which is approximately an hour and a half from Morgantown, WV.  The pharmacist ordered the COVID-19 vaccine through the statewide process that included picking up the vaccine from the local hub.  She packed up all of her supplies necessary for an off-site vaccination clinic and met the patient between Morgantown, WV and the Pittsburgh, PA airport.  She went through the vaccine screening questionnaire with him, answered his questions, and addressed his concerns.  He had not had any vaccinations administered in over 12 years due to a negative experience with a blood draw.  A conversation was had that he was due for multiple other vaccinations including a Tdap booster and an influenza vaccine.  The pharmacist then administered the first dose of his COVID-19 vaccine while utilizing breathing techniques to keep the patient relaxed.  The patient was monitored for 30 minutes since he had not had any vaccinations in a number of years and due to his apprehension.  The patient was given his vaccination card and provided with information on when he should schedule his second dose of his COVID-19 vaccine.  The patient then drove back to the airport to catch his flight and the pharmacist drove back to her practice site to utilize the remaining doses of the vaccine.  After the patient received his second dose of his COVID-19 vaccine his significant other reached out to the pharmacist who had administered the first dose of his vaccination with concerns as the patient believed that the vaccine was administered too high on his arm and it “hurt more and was not in the same location that [the pharmacist in Morgantown, WV] administered it.”  This patient is a prime example of why we need to take our time and listen to the concerns of our patient.  This patient was not hesitant because he did not believe in vaccines, but because he had a fear of the needles utilized to administer the vaccine.  Patients lack confidence in vaccines for numerous different reasons and the “one size fits all” approach does not work.  Pharmacists, pharmacy technicians, and student pharmacists all need to listen to our patients so that we can address their concerns in a caring and compassionate manner.  The patient in this story had confidence instilled in vaccines after receiving the first dose of his COVID-19 vaccine, but that was decreased when he received his second dose due to the improper injection technique.  The patient was concerned about the potential for shoulder injury related to vaccine administration, as well as the vaccine not working as well if it was injected improperly.  The original vaccinating pharmacist again answered his questions and reassured him.  The patient decided that when it was time for his COVID-19 vaccine booster he would considering flying to the location of the first pharmacist again in order to receive his vaccine.  As this story demonstrates, it is always best practice to slow down, not rush, and give each patient our best during each and every encounter.