Community pharmacy has been working hard to build the competencies, programs, and technology base to make a real impact on patient outcomes. Here we’ll take a look at the technology tools and clinical programs in place at two pharmacies, Mitchell’s Drug Stores and Shrivers Pharmacy, that are finding success. There are areas of pharmacy operations and currently available technology that can drive positive outcomes, but we’ll see that it takes more than just flipping a switch to be successful.
BUILDING FROM ADHERENCE
Lacy Epperson, Pharm.D., is the director of pharmacy clinical services at Mitchell’s Drug Stores in Neosho, Mo., which operates three community pharmacies and one long-term care pharmacy. One of the community pharmacies is newly opened and runs on a cost-plus model that does not accept insurance, in an effort to reduce costs for patients. “Our adherence programs, beginning with med sync, are the foundation for clinical services,” says Epperson. “This is where everything starts for us in our efforts to get the best outcomes for our patients.”
Andrea Kowalski, Pharm.D., who is director of clinical services at Shrivers Pharmacy, also views med sync as a foundational program when it comes to managing and improving patient outcomes. Shrivers Pharmacy operates multiple locations in southeastern Ohio and West Virginia, offering retail, long-term care, hospice, durable medical equipment, and 340B.
“Medication synchronization is the outcomes-focused program that is most readily available to pharmacies and is easiest to implement,” says Kowalski. It is all about establishing a routine in which patients are expecting to have an interaction each month with the pharmacy. From the patient’s point of view, it’s convenient to pick up all their medications at the same time.
For the pharmacy, this doesn’t just streamline workflow, but more importantly it creates known opportunities for interacting with the patient and defined times to review care opportunities and offer additional services.
At Shrivers, the med sync workflow is the start of what Kowalksi calls a deeper dive into the patient’s care. “We take the opportunity each month to review all their medications against current guidelines,”says Kowalski.“We’re also making sure that they are up to date on their vaccines and looking for other care opportunities that they can benefit from.”
The role that med sync plays as the jumping off point for patient care programs means that you need to ensure you are maximizing the number of patients enrolled. Lacy Epperson says that the traditional benchmark for community pharmacy is an 80% participation rate, a goal that they have reached at Mitchell’s Drug Stores. It is, however, important to set med sync program participation goals after taking a pharmacy’s patient base into account.
THE 80% GOAL
An 80% participation rate in a med sync program is indeed a good number to start with, because it reflects the typical split between chronic and acute medications dispensed at many community pharmacies. “The commonly cited goal is 80%,” explains Epperson, “because ideally you will enroll every patient filling prescriptions for chronic conditions in your med sync program. But the right goal is going to be based on the business model of the pharmacy. Whenever I talk about med sync, I point out that it’s not a one-size-fits-all program.”
Epperson suggests beginning by answering a few questions. What does the pharmacy’s business look like? Does the pharmacy service chronic care patients, or is it located next to a clinic or urgent care center writing a lot of acute prescriptions? In fact, Epperson has different med sync participation rate goals for each of the Mitchell’s Drug Stores locations. She reports taking into account the type of practice and the patient demographics.
But once you can set and achieve an appropriate med sync program participation goal, Epperson emphasizes, a robust program really opens the door for many other opportunities for clinical services and for bringing order to pharmacy operations. “A solid enrollment level in our med sync program helps us to structure our workflow, understand our scheduling better, and really to gain a better level of control of our very busy businesses,”says Epperson.
Epperson offers one important example about how to use med sync in a creative way that does not fit the standard application to patients on multiple medications. “One common situation we’re seeing more,” says Epperson, “is patients on expensive birth control or expensive inhalers, but otherwise not chronic care patients. They benefit greatly from being in our med sync program, because we can use the interactions built into that program to ensure that they don’t unexpectedly find themselves in need of a refill that leads to a gap in therapy. We will call them ahead of their refill date and make sure that we are taking care of them.”
FROM MED SYNC TO CARE SYNC
When there is a strong participation rate in a med sync program, you then have the base for building out further adherence and outcomes focused programs. At Shrivers the goal is to make use of the anticipatable patient visits prompted by med sync as opportunities for longer interactions. “We want to raise the level of our patient interactions to a more therapeutic and clinical level,” says Andrea Kowalski. “Med sync means that we are better able to control the flow of people into the pharmacy. If we know that a patient on 15 medications is coming in this week to pick up his prescriptions, then we can be prepared to talk to him about his medications and review any open care opportunities and programs that may improve outcomes.”
For example, a patient might be a good candidate for a vaccine. Kowalski reports that Shrivers is currently putting a big emphasis on ensuring that patients are up to date on the Shingrix vaccine.
At Mitchell’s Drug Stores, Epperson reports that the goal is to build from med sync to what she calls care sync. “We work hard to standardize all the elements of our programs and create very efficient processes that offer a wide range of care opportunities,”she says.“We call it care sync to recognize the fact that what we are doing goes above and beyond providing patients with medications.”
Epperson breaks down the efforts at Mitchell’s Drug Stores into three key elements: The first, as we’ve learned, is traditional med sync. The second is adherence packaging, with both strip and bubble card options. The third is a new and quickly growing medical-at-home program. “Medical at home combines med sync and packaging with extra clinical services appropriate for patients in need of the higher levels of care that you would normally see in a long-term care setting,” says Epperson. Then, on top of these core care services, there are many different clinical service programs that Mitchell’s Drug Stores can offer patients, which include diabetes care and vaccine clinics, according to Epperson.
Andrea Kowalski points to a behavioral health monitoring program at Shrivers that has been making a big impact on outcomes since 2020. “This program focuses on patients taking an anti-anxiety med or an antidepressant,” she explains. Pharmacy staff use a PHQ-9 and GAD7 (Patient Health Questionnaire and General Anxiety Disorder) questionnaire to assess current anxiety or depression levels. Based on the results, Kowalski reports, Shrivers can then counsel the patient to ensure that they understand how their medications work or even, on occasion, reach out to prescribers with recommendations.
Shrivers then makes follow-up calls to patients and re-administers the test as appropriate. “The use of the assessment questionnaire in this program gives us a tangible measure of how we’re helping patients manage mental health,” says Kowalski. “We have found that patients really do want to talk with us about their mental health and their medications. And as we monitor the assessment scores over time we are able to demonstrate that having this interaction with a pharmacist is really beneficial for those patients.”
Kowalski offers several more examples of counseling services that Shrivers offers that help achieve better outcomes. “We offer diabetes care,”says Kowalski.“We talk to patients about their glucose levels and their medications with the goal of ensuring that they understand everything that goes into managing their diabetes on a daily basis.”
For another example, Kowalski notes that the pharmacy has, at times, had payers that would provide at-home blood pressure monitors for patients with hypertension. “We would show the patient how to use the monitor and educate them about their medications,” says Kowalski, “and then call them at home to check on the readings. This was really helpful during the pandemic, and it shows that the pharmacy can have a positive impact on patient health and outcomes whether we see the patient in person or check in remotely.”
SETTING GOALS, STANDARDIZING PROCESSES
Lacy Epperson has found that the best outcomes come when two things are true of a pharmacy’s operations. First, the pharmacy needs to have well-defined processes and the right technology in place to support programs and service offerings. Second, it is important that staff are educated on how to use the technology appropriately to meet the pharmacy’s care goals.
The technology suite for adherence programs at Mitchell’s Drug Stores starts with the med sync features in the PioneerRx pharmacy management system, according to Epperson. Then the pharmacy adds adherence packaging, with effective integration to the pharmacy management system. “We use strip packaging automation from RxSafe,” says Epperson. “And we also use Dispill blister packaging. We’re moving away from that because we can streamline and automate much more successfully with strip packaging automation, and it’s more convenient for our patients.”
The benchmark, whichever technology providers a pharmacy uses, is that staff can easily navigate workflow steps, for example to pull patients into a certain med sync cycle or to add them as a medical-at-home patient. “You want to know that you can take these steps very quickly, efficiently, and correctly,”says Epperson.“The technology also has to be easy to teach. I’m not a tech guru, but I can still teach anyone on my team to use our technology to implement our programs.”
Epperson is a firm believer that it is easiest to use pharmacy technology when pharmacy staff understand the goals of the process. For example, the task may be to dispense a short fill for a prescription, but that one step is actually part of a series of goals. “The immediate goal is to use the short fill to sync the medication with all others for the patient so that he or she has one pickup date each month for all prescriptions,” says Epperson. “When this is the case, then our goal is to sync up provision of services for that patient as well. We are then able to achieve our highest-level goals, which are to be as efficient as possible in the pharmacy, to ensure that we address all elements of the patient’s overall care, to make a positive impact on outcomes, and to provide the highest level of customer service.”
Epperson reports a recent addition to Mitchell’s Drug Stores technology capabilities that’s had a positive impact. “We added what I see as a very productive feature about six months ago,” she says, “which is an option for patients to receive a HIPAA-compliant link to fill out a questionnaire before receiving their medications for the month. They can tell us about any changes they’ve experienced and if they need anything that is not a monthly medication, such as an inhaler, nausea medication, or a cream. We are seeing a high response rate to this new patient touchpoint compared to phone calls, because it’s easier for many of our patients to be able to click that link on their lunch break or at home when the pharmacy isn’t open. This is a really integrated process that has not required a lot of time for us to implement.”
While modern pharmacy systems and automation are rich in features that improve outcomes through dispensing oriented programs such as med sync and packaging, Andrea Kowalksi notes that there’s still a gap in the market when it comes to documentation and billing for services. “This has been one of the biggest challenges for us,” says Kowalski. “Developing and implementing programs that improve outcomes has not seemed nearly as difficult as documenting and billing for them.”
As a result, Kowalski has worked to develop in-house tools that combine with features in Shrivers’ Rx30 pharmacy system to meet the pharmacy’s needs. “When we first started with the clinical services,” says Kowalski, “I developed intake forms that the pharmacist would print and fill out with a pen. They would fax that to our corporate office, where we had somebody who would enter that data and bill for it. Then the pharmacist also would go in and complete an eCare plan in Rx30 as well. That was a lot of extra steps and a lot of paper. More recently I have developed an electronic intake form that our pharmacist can fill out and submit that goes directly to a live spreadsheet that houses all the data for these encounters.”
Pharmacists are still filling out a Pharmacist eCare Plan separately. “It’s still not ideal,” says Kowalski. “I think that the market is aware of the need for better tools for documenting and billing for service, but we haven’t found the perfect solution yet at Shrivers.”
This centralized spreadsheet is also a help in Kowalski’s work to get the word out about the importance of clinical programs in improving outcomes. “I’m writing a research paper on our behavioral health services,” she explains. “Now that I have that data in electronic form, I can pull out what I need and analyze it much more readily.”
PHARMACISTS IMPROVE OUTCOMES
Getting the best outcomes means having the systems and processes in place that enable a pharmacy to meet the different needs of large numbers of patients. As Lacy Epperson notes, you want your technology to support the workflows that move patient care toward your goals seamlessly.
“We are getting better outcomes and we see that through higher true adherence rates, not just our fill rates,” says Epperson. “The flip side of this is that, for patients who are not adherent, we are able to identify them much more easily and focus on the critical interventions that we need to make with them. We know that this is impactful, and it is something that we can excel at as a truly local and independent pharmacy.”
Once you develop a program that is truly outcomes focused, you have a repeatable process and a consistent touchpoint with your patients each month. You are also strengthening relationships with providers in the community, notes Epperson. “Providing an extra level of care can be something unique to independent pharmacies,” she says.
“It’s really hard for many people to access healthcare,” adds Andrea Kowalski. “There are so many underserved patients. Our goal at Shrivers is to fill in the gap, and that means doing much more than just dispensing prescriptions. We achieve the best outcomes when our pharmacists are also stepping in to help with clinical programs and services.” CT