Perceptions of pharmacists' integration into patient-centered medical home teams

A Goffmanian analysis of impact of unclear professional identity and role negotiation of pharmacists in primary care: A multiple case study

BACKGROUND

Professional identity and its development is a focus of research, education, and practice. But, there is a lack of how professional identity impacts changes in pharmacists' roles in practice, which are particularly prevalent in primary care teams.

OBJECTIVES

This research uses Goffmanian theory, micro-sociologic interactional theory, to describe the outcomes of role negotiation in integrated primary care teams.

METHODS

This is a multiple case study done per Yin, which used interviews and documents to collect data. Interviews used a storytelling format to gather information on the pharmacist's role and negotiation with their team. Four to six interviews were done in each case. Data was analyzed in an iterative manner using the Qualitative approach by Leuven including narrative reports being created for each case.

RESULTS

Five cases were recruited but three cases were completed. In each case, the pharmacist was passive in role negotiation and allowed other actors to decide what tasks were of value. Likely this passivity was due to their professional identities: supportive and "not a physician". These identities led to a focus on the pharmacists' need to develop. This multi-case study demonstrated that pharmacists' professional identity led to passivity being valued and expected. Whether pharmacists self-limited, which has been previously seen, needs to be better defined. But unclear archetypes reduced tasks identified as unique to the pharmacist.

CONCLUSION

Goffmanian theory highlighted a key success for future pharmacist role negotiation, a clear professional identity by both pharmacists and society, including team members. Until that occurs, there is a risk of underuse in primary care team settings.

Integration of Health Coaches in a Whole Health Team Model of Chronic Pain Care: a Qualitative Study

OBJECTIVE

Health coaching has shown promise in helping patients manage their chronic disease and in improving health outcomes, yet the implementation of health coaching in healthcare systems is understudied. Further, evidence suggests that interdisciplinary care teams may be more effective in treating chronic pain than usual care. As such, we sought to examine the benefits and drawbacks to embedding health coaches within interdisciplinary pain care teams ("Whole Health Teams").

DESIGN

As part of a multisite clinical trial (at five Veterans Health Administration sites) investigating the effectiveness of a Whole Health Team (WHT) approach to care for patients with chronic pain, qualitative interviews gathered data on how the experience of treating patients in the WHT differed from the experience treating patients outside the WHT, as well as provider experiences coordinating patient care within the WHT.

PARTICIPANTS

Twenty-two WHT members, study investigators, and study coordinators.

APPROACH

Data were analyzed using a rapid analysis approach.

RESULTS

Overall, stakeholders perceived considerable synergy within the interdisciplinary pain care team. Each provider brought a different perspective to the patient's health concerns, which stakeholders felt was valuable and increased patient progress towards goals. The team model was also viewed as efficient because everyone was committed to working together and communicating as a team. Logistically, however, stakeholders noted challenges to working as a team, especially regarding patient goal setting. Furthermore, multiple stakeholders believed the care team model required a high degree of dedication to teamwork and communication among its members to be successful.

CONCLUSIONS

Embedding health coaches within interdisciplinary pain care teams may improve care processes and accelerate patient progress. Successful implementation would require adequate training, role clarification, and expectation setting to facilitate good communication across all care team members. Additional research is needed to evaluate the clinical outcomes of integrating health coaches on WHTs versus other implementation approaches.

Clinic Design for Safety During the Pandemic: Safety or Teamwork, Can We Only Pick One?

OBJECTIVE

This article aims to illustrate the design considerations of team-based primary care clinics in response to the pandemic.

BACKGROUND

Due to COVID-19, physical distancing became a critical practice in our daily life, especially in healthcare settings where healthcare professionals must continue providing care to patients despite the manifold risks. Many healthcare facilities are implementing physical distancing in their clinic layouts, and healthcare professionals are adjusting their behaviors, so they can stay away from each other.

METHODS

A total of four team-based primary care clinics were studied to identify their lessons learned regarding safety measures and space usage during the pandemic.

RESULTS

The four team-based primary care clinics made changes to the clinic design (e.g., waiting areas, exam rooms, team workspaces), operational protocols (e.g., in-person huddles, social gatherings, staff work locations), and usage of spaces (e.g., outdoor spaces, utility rooms). Such changes enabled the implementation of safety measures during the pandemic. However, healthcare professionals also reported challenges regarding their team communication and coordination due to physical distancing and separation.

CONCLUSIONS

Our findings suggest that the physical distancing may in fact contribute to less effective teamwork and patient care and negatively affect staff well-being. In this article, we ask healthcare system leaders and designers to continue supporting both safety and teamwork by paying attention to the flexibility and spatial relationships among healthcare professionals rather than fully sacrificing teamwork for safety. Also, now is the time when multidisciplinary collaborations are needed to establish and validate guidelines that can improve both factors.

Designing for Effective and Safe Multidisciplinary Primary Care Teamwork: Using the Time of COVID-19 as a Case Study

Effective medical teamwork can improve the effectiveness and experience of care for staff and patients, including safety. Healthcare organizations, and especially primary care clinics, have sought to improve medical teamwork through improved layout and design, moving staff into shared multidisciplinary team rooms. While co-locating staff has been shown to increase communication, successful designs balance four teamwork needs: face-to-face communications; situational awareness; heads-down work; perception of teamness. However, precautions for COVID-19 make it more difficult to conduct face-to-face communications. In this paper we describe a model for understanding how layout affects these four teamwork needs and describe how the perception of teamwork by staff changed after COVID-19 precautions were put in place. Observations, interviews and two standard surveys were conducted in two primary care clinics before COVID-19 and again in 2021 after a year of precautions. In general, staff felt more isolated and found it more difficult to conduct brief consults, though these perceptions varied by role. RNs, who spent more time on the phone, found it convenient to work part time-from home, while medical assistants found it more difficult to find providers in the distanced clinics. These cases suggest some important considerations for future clinic designs, including greater physical transparency that also allow for physical separation and more spaces for informal communication that are distanced from workstations.

The impact of clinic design on teamwork development in primary care

BACKGROUND

Traditional clinic design supports a high-volume, hierarchical practice model. New design models are evolving to foster a high-functioning team delivery model.

PURPOSE

The goal of this study was to determine whether new design models, specifically colocation, improve care team development.

METHODOLOGY/APPROACH

A quasi-experimental design was used in this study to obtain validated teamwork development scores and patient satisfaction data to compare clinic design models. We took advantage of a difference in designs of primary care clinics among several clinics within the same care system in the Upper Midwest region of the United States. The participants were staff members of the primary care delivery teams in the studied clinics. The intervention was a redesign of staff space in the clinic. Our measures included a validated measure of team development and a commonly used patient satisfaction tool that were both in use at our institution at the time of the study.

RESULTS

Teamwork scores were significantly higher in clinics where the primary work space of the entire team was colocated than in clinics where providers were in spaces separate from other team members. The differences in scores held across team roles, including providers, registered nurses, and licensed practical nurses. Patient satisfaction was not different.

CONCLUSION

Colocation in clinic design appears to have a significant impact on team development across primary care team member roles.

PRACTICE IMPLICATIONS

Primary care practice leaders should consider colocated clinic designs if their goal is to optimize care team development in support of team-based care delivery models. A more precise understanding of colocation that includes aspects such as distance to and visibility to teammates might help improve design in the future.

Informing collaborative relationships between community pharmacists and health care professionals in primary care practices

BACKGROUND

Collaborative relationships between community pharmacists and health care professionals in primary care practices can assist with the provision of medication and disease management services in community pharmacy settings.

OBJECTIVES

The objective was to describe the attitudes of providers working in primary care practices with on-site pharmacist collaborators to understand how to facilitate similar collaborations with pharmacists in community pharmacy settings.

METHODS

This qualitative study was conducted among physicians, nurse practitioners, and nurses of 3 primary care practice sites in the Commonwealth of Pennsylvania. A demographic survey and a semistructured interview were conducted to elicit feedback on participant perceptions about building relationships with community pharmacists. Interviews were audio-recorded and transcribed. A qualitative analysis was performed to identify emerging themes using an inductive approach. Demographic data were summarized using descriptive statistics. This study was approved by the University's Institutional Review Board.

RESULTS

Nineteen interviews were conducted. Fifty-eight percent of participants were physicians and 68% were female with a mean age of approximately 46 years. Five themes were identified: (1) Pharmacists were highly valued and were effective team members to promote coordination of medication-related care; (2) Direct access to pharmacists facilitates efficient communication and effective patient care; (3) Trust is the foundation of an effective collaboration between pharmacists and providers; (4) Pharmacists demonstrating responsibility for patients enables collaboration with providers who view themselves as stewards of patient care; and (5) Providers believe that community pharmacists' dispensing requirements may limit their ability to participate in patient care.

CONCLUSIONS

The following strategies to establish relationships with primary care practices are suggested: pharmacists should initiate face-to-face relationships with providers in practices; communication and patient interventions should be conveyed directly to providers and be conducted by the same person; and pharmacists need to demonstrate their commitment to patient care by following up promptly on patient interventions.

The Contribution of Pharmacists and Pharmacy Technicians to Person-Centred Care within a Medicine's Optimisation in Care Homes Service: A Qualitative Evaluation

Pharmacists and pharmacy technicians seek to improve person-centred care. Improvements to systems for care homes seeks to reduce medicines waste and inefficiency, particularly through supporting care home staff, to enhance safer administration of medicines. A complex evaluation used qualitative design and utilised narrative enquiry, and team members and key stakeholders were interviewed. Framework analysis was used, aligning findings to a person-centred care framework for older people. The Medicines Optimisation in Care Homes (MOCH) team brokered improvement practices across care homes to enhance person-centred care. The framework analysis confirms that the team used ‘authentic attention’ in relation to the residents’ experiences and flexibility in relation to negotiating medication. The importance of transparency of processes and systems in medicines management is highlighted, alongside requirements for person-centred care to make explicit the reason for taking a medication, and the continuous discussion with a range of stakeholders about the continuing need for particular medications. The outcome of the evaluation includes insights into a new area of pharmacy practice in community, based on the skills, knowledge, and experience of pharmacists and pharmacy technicians working in the care home sector. Further study is needed into the efficacy and outcomes of medicines management interventions.

Trends in Clinical Pharmacist Integration in Family Medicine Residency Programs in North America

(1) Objective: To determine the change in prevalence of clinical pharmacists as clinician educators within family medicine residency programs (FMRPs) in North America and to describe their clinical, educational and administrative scope over time. (2) Methods: A systematic review of the literature was performed starting with an electronic search of PubMed and Embase for articles published between January 1980 and December 2019. Studies were included if they surveyed clinical pharmacists regarding their clinical, educational, or other roles in FMRPs in the United States or Canada. The primary outcome was the change in prevalence of clinical pharmacists in North America. Secondary outcomes included: demographic information of clinical pharmacists, change in the prevalence in Canada and United States, and descriptions of clinical services, educational roles, and other activities of clinical pharmacists within FMRPs. (3) Results: Of the 65 articles identified, six articles met the inclusion criteria. The prevalence of clinical pharmacists as clinician educators in FMRPs in North America has grown from 24% to 53% in the United States (U.S.) and from 14% to 47% in Canada over the study period. The clinical and educational roles are similar including: the direct patient care, clinical education, and interprofessional education and practice. (4) Conclusion: The prevalence of clinical pharmacists in FMRPs is growing across North America. Clinical pharmacists are highly educated and trained to support these clinician educator positions. While educational roles are consistent, clinical pharmacists’ patient care roles are unique to their clinical site and growing.

Spatial Influences on Team Awareness and Communication in Two Outpatient Clinics: a Multiple Methods Study

BACKGROUND

Healthcare organizations are moving their primary care teams out of private offices into shared workspaces for many reasons, including teamwork improvement and cost reduction.

OBJECTIVE

Identify the specific aspects of layout and design that enable two fundamental processes of high-functioning teams: communication and situation awareness.

DESIGN

This was a multi-method study employing qualitative interviews, floor plan analysis, observations, behavior mapping, and surveys.

PARTICIPANTS

Two primary care clinics in a large, integrated healthcare system in the upper Midwest, with Clinic S in a suburban location and Clinic A in a rural setting. In the two clinics, a total of 36 staff members were interviewed, 57 (66% response rate) staff members were surveyed, and 2013 individual-points were recorded during 63 behavior mapping observations.

MAIN MEASURES

Communication encounters, team members' perception of the environment and teamwork, visibility, distance, functional pathways, and self-reported mode and frequency of staff communication.

KEY RESULTS

Observations, interviews, and surveys identified environmental factors that predict staff awareness and communication patterns. Visibility impacts situation awareness. Frequency of face-to-face communication increases with visibility and proximity between workstations (e.g., Clinic A nurses' intra-role communication without workstation proximity vs inter-role communication with workstation proximity: 22.6% [11.4, 33.9] vs 77.4% [66.1, 88.6], p = 0.001) and with staff members' functional paths. Visual exposure to patients predicts staff's concerns about their communication (Clinic S: 2.29 ± 0.81 vs Clinic A: 3.20 ± 0.84, p < 0.001).

CONCLUSIONS

Design and layout of team spaces have important influences on the way that team members work together. The organizational goals of the healthcare system, particularly which staff members need to work together most frequently, should drive the specific design solution.

Using the PACT Resources Framework to Understand the Needs of Geriatric Primary Care Teams

OBJECTIVES

To identify the perceived organizational resources required by healthcare workers to deliver geriatric primary care in a geriatric patient aligned care team (GeriPACT).

DESIGN

Cross-sectional observational study using deductive analyses of qualitative interviews conducted with GeriPACT team members.

SETTING

GeriPACTs practicing at eight geographically dispersed Department of Veterans Affairs (VA) healthcare systems.

PARTICIPANTS

GeriPACT clinicians, nurses, clerical associates, clinical pharmacists, and social workers (n = 67).

MEASUREMENTS

Semistructured qualitative interviews conducted in person, transcribed, and then analyzed using the PACT Resources Framework.

RESULTS

Using the PACT Resources Framework, we identified facility-, clinic-, and team-level resources critical for GeriPACT implementation. Resources within each level reflect how the needs of older adults with complex comorbidity intersect with general population primary care medical home practice. GeriPACT implementation is facilitated by attention to patient characteristics such as cognitive impairment, ambulatory limitations, or social support services in staffing and resourcing teams.

CONCLUSION

Models of geriatric primary care such as GeriPACT must be implemented with an eye toward the most effective use of our most limited resource-trained geriatricians. In contrast to much of the literature on medical home teams serving a general adult population, interviews with GeriPACT members emphasize how patient needs inform all aspects of practice design including universal accessibility, near real-time response to patient needs, and ongoing interdisciplinary care coordination. Examination of GeriPACT implementation resources through the lens of traditional primary care teams illustrates the importance of tailoring primary care design to the needs of older adults with complex comorbidity.

Clinical pharmacist facilitators in primary care: a descriptive study of their roles and services provided in general practices of southern New Zealand

INTRODUCTION Internationally, the inclusion of pharmacists into general practice as clinical pharmacy facilitators has improved patient outcomes. However, clinical pharmacists are relatively new to southern New Zealand general practices and their range of services has not been studied. AIMS To describe the implementation of clinical pharmacist services in general practices in the Southern region; to examine the tasks conducted by clinical pharmacy facilitators; and to determine the characteristics of patients who access this service. METHODS The establishment and development of the clinical pharmacy facilitator role was determined by documentation held within the local Primary Health Organisation. The activities performed by clinical pharmacy facilitators were collected from patient medical records for the period 31 March 2015 to 31 March 2018. To describe the characteristics of patients receiving these services, a retrospective case note review of patients seen by the facilitators was conducted. RESULTS The clinical pharmacy facilitator role was initiated with three pharmacists in three geographical locations across the region. Within 18 months, the number of facilitators was increased to eight. As a result of collaboration with the general practice team, 42% of referrals came from general practitioners directly. Overall, 2621 medicine-related problems were identified in 2195 patients. Dosage adjustment was the most common recommendation made by pharmacy facilitators. They consulted mostly older patients and patients taking five or more medicines. DISCUSSION With effective collaboration, clinical pharmacy facilitators can play a key role in optimisation of medicines therapy.

Backstage Staff Communication: The Effects of Different Levels of Visual Exposure to Patients

OBJECTIVE

This article examines how visual exposure to patients predicts patient-related communication among staff members.

BACKGROUND

Communication among healthcare professionals private from patients, or backstage communication, is critical for staff teamwork and patient care. While patients and visitors are a core group of users in healthcare settings, not much attention has been given to how patients' presence impacts staff communication. Furthermore, many healthcare facilities provide team spaces for improved staff teamwork, but the privacy levels of team areas significantly vary.

METHOD

This article presents an empirical study of four team-based primary care clinics where staff communication and teamwork are important. Visual exposure levels of the clinics were analyzed, and their relationships to staff members' concerns for having backstage communication, including preferred and nonpreferred locations for backstage communication, were investigated.

RESULTS

Staff members in clinics with less visual exposure to patients reported lower concerns about having backstage communication. Staff members preferred talking in team areas that were visually less exposed to patients in the clinic, but, within team areas, the level of visual exposure did not matter. On the other hand, staff members did not prefer talking in visually exposed areas such as corridors in the clinic and visually exposed areas within team spaces.

CONCLUSIONS

Staff members preferred talking in team areas, and they did not prefer talking in visually exposed areas. These findings identified visually exposed team areas as a potentially uncomfortable environment, with a lack of agreement between staff members' preferences toward where they had patient-related communication.

Perceptions of Integration of the Clinical Pharmacist into the Patient Care Medical Home Model

INTRODUCTION

The patient-centered medical home (PCMH) model is a multidisciplinary, team-based approach to healthcare that focuses on actively involving the patient in clinical decision making. The Veterans Health Administration (VA), while desiring to be a national leader in the delivery of primary care services, used the principles of the PCMH model to design the patient-aligned care team (PACT). The purpose of this study, was to explore the perception of the PACT members after integration of a clinical pharmacist to the PACT.

METHODS

This was a single-center cross-sectional study conducted at an integrated Veterans Health Administration system. We electronically surveyed PACT staff practicing within VA-Tennessee Valley Health Care System as of October 1, 2016 using a modified version of the Medicine Medication Use Processes Matrix (MUPM) containing 19 items on five theoretical grouping of processes (evaluation and management, monitoring, medication review, documentation, and education) and two groupings(clinician satisfaction and access).

RESULTS

Ninety-one complete responses were received. Perceptions were positive, with 79% rated as either 4 ("moderate contribution") or 5 ("major contribution"). Individual responses based on discipline, with the exception of the medical support assistant were rated positive, specifically job satisfaction.

CONCLUSIONS

This study evaluated the perceptions of clinical pharmacist integration into the PACT model. Respondents perceived clinical pharmacist beneficial.

Perspectives of Non-Pharmacy Professionals in Long-Term Care Facilities on Pharmacist-Involved Medication Management in South Korea: A Qualitative Study

Despite a rapid increase in both the number of long-term care facilities (LTCFs) and their residents in recent years, the concept of pharmacist-involved medication management is relatively new in South Korea. The objective of this study was to identify the perspectives of non-pharmacy professionals regarding the development of pharmacist-involved medication management in LTCFs. Employing a snowball sampling strategy, this study relied on semi-structured, one-on-one, in-depth interviews with twelve non-pharmacy professionals in LTCFs. The inductive thematic analysis and the constant comparative method were employed for the analysis. Participants revealed the need for pharmacist-involved medication management systems in LTCFs at the intrinsic and environmental levels. Through pharmacist-involved medication management, participants desired "medication review/reconciliation" and "pharmaceutical education/counseling". The barriers to be overcome included "the authorization of pharmacists' roles", "the financial stability of LTCFs", "role awareness among coworkers", and "the professional development of pharmacists". In this study, we advanced our understanding of non-pharmacy professionals' perceptions of pharmacist-involved medication management in LTCFs. The results of this study can be applied in other Asian countries where the development of pharmacist-involved medication management for the institutionalized elderly is relatively new.

Pharmacist-provided services and community pharmacist integration into a patient-centered medical home: A qualitative study of primary care clinic staff perceptions

OBJECTIVES

To describe patient-centered medical home (PCMH) staff members' views toward community pharmacist involvement in patient care within the PCMH and to identify areas in which pharmacist-provided services can improve the quality of care in their clinics.

DESIGN

Qualitative semistructured interview study.

SETTING

One primary care clinic.

PARTICIPANTS

Multidisciplinary clinic staff members.

OUTCOME MEASURES

Views of staff toward implementing a community pharmacist into their clinic and top pharmacist services to help improve medication management within the clinic.

RESULTS

A total of 14 staff members of the clinic participated in the study. Participants included physicians, clinical staff members such as registered nurse assistants, licensed practical nurses, and medical assistants, and clinic management. Key themes included the following: the clinic was open to implementing pharmacy services; the providers would be very receptive to pharmacist recommendations; the clinic is willing to try different pharmacist integration models to see what works best within the workflow; the pharmacist must be readily available for consultation; the pharmacist should hold an introductory meeting with the clinic; opinions vary on the best timing of pharmacist appointments with patients; and ideas vary about the best location for pharmacist consultations. The top 5 pharmacist services mentioned by participants included chronic condition management, medication reconciliation training, Beers List education, diabetes education, and adherence counseling.

CONCLUSION

Primary care clinic staff support the integration of pharmacy services. Further research is needed to apply the results to other clinics and to identify barriers and opportunities in the implementation process.

Factors influencing the acceptance of referrals for clinical pharmacist managed disease states in primary care

OBJECTIVE

Clinical pharmacists use population health methods to generate chronic disease management referrals for patients with uncontrolled chronic conditions. The purpose of this study was to compare primary care providers' (PCPs) referral responses for 4 pharmacist-managed indications and to identify provider and patient characteristics that are predictive of PCP response.

DESIGN

Retrospective cohort study.

SETTING

This study occurred in an academic internal medicine clinic.

PARTICIPANTS

Clinical pharmacy referrals generated through a population health approach between 2012 and 2016 for hypertension, chronic pain, depression, and benzodiazepine management were included.

MAIN OUTCOME MEASURES

Proportion of referrals accepted, left pending, or rejected and influencing provider and patient characteristics.

RESULTS

Of 1769 referrals generated, PCPs accepted 869 (49%), left pending 300 (17%), and rejected 600 (34%). Compared with referrals for hypertension, benzodiazepine management, and depression, chronic pain referrals had the lowest likelihood of rejection (odds ratio [OR] 0.31; 95% CI 0.19-0.49). Depression referrals had an equal likelihood of being accepted or rejected (OR 1.04; 95% CI 0.66-1.64). Provider characteristics were not significantly associated with referral response, but residents were more likely to accept referrals. Patient characteristics associated with lower referral rejection included black race (OR 0.39; 95% CI 0.18-0.87), higher systolic blood pressure (OR 0.98; 95% CI 0.97-0.99), and missed visits (OR 0.24; 95% CI 0.07-0.81).

CONCLUSION

The majority of referrals for clinical pharmacists in primary care settings were responded to, varying mostly between acceptance and rejection. There was variability in referral acceptance across indications, and some patient characteristics were associated with increased referral acceptance.

Home healthcare professionals' perspectives on quality dimensions for home pharmaceutical care in Japan

AIM

In Japan, home pharmaceutical care (HPC) has recently been provided to home-bound older adults who have difficulties in accessing a community pharmacy, for regular medicine supplies and medication management. Although the number of HPC services provided has increased, HPC is not always carried out by clinically well-trained pharmacists, causing differences in the quality of HPC provided. The aim of the present study was to establish the quality dimensions of HPC (i.e. components that impact the quality of HPC) from the perspectives of home healthcare professionals.

METHODS

Semistructured interviews and focus groups were carried out with nine home healthcare teams, comprising 61 multidisciplinary professionals including pharmacists, doctors, nurses, care managers, home helpers, medical social workers and other relevant stakeholders involved in home healthcare. Participants' responses were analyzed using thematic analysis. Identified themes were then categorized using Donabedian's framework (structure, process and outcome).

RESULTS

Nine themes and 27 subthemes emerged, including: structure (pharmacist factors, pharmacy factors and external factors), process (before HPC, during HPC, after HPC and outside of HPC) and outcome (impact on patients and impact on other healthcare professionals).

CONCLUSION

This study has identified quality dimensions of HPC from multidisciplinary home healthcare professionals' perspectives. These findings might be used to inform aspects of HPC that require improvement. In order to evaluate the quality of HPC, a set of indicators based on the identified quality dimensions could be developed. Geriatr Gerontol Int 2019; 19: 35-43.

Qualitative analysis of community pharmacists' opinions on their involvement in reducing potentially inappropriate prescribing

PURPOSE

Older people are at risk of potentially inappropriate prescribing (PIP) due to polypharmacy arising from multi-morbidity. Despite available explicit criteria to reduce PIP, it is highly prevalent. Whilst community pharmacists have the required knowledge to help reduce PIP, they are not currently engaged with the problem. This study explores the views of community pharmacists on their potential involvement in reducing PIP and determines the challenges to its implementation.

METHODS

Semi-structured interviews with pharmacists working in community pharmacies in Ireland. The theoretical domains framework (TDF) was used to develop the topic guide and to analyse the transcripts. Domains of highest relevance for PIP reduction were identified based on their frequency or whether the participants emphasised the impact of constructs within a domain. Local ethical approval was obtained.

RESULTS

Of 18 participants, 12 were female, median age was 30 years (IQR, 27-35) with a median of 6 years (IQR, 3-8) of experience. Seven TDF domains were identified as relevant to PIP reduction. Pharmacists were uncertain about their role in reducing PIP and reluctant to challenge physicians' prescribing decisions. Challenges pertained to the environment, knowledge, social influences, professional role and identity.

CONCLUSIONS

Pharmacists welcomed new responsibilities in reducing PIP as part of their daily practice but expressed a need for removal of social and environmental barriers as well as, provision of relevant guidelines and education about PIP. This study provides useful insights into the target domains for overcoming barriers of pharmacist involvement in reducing PIP.

The role of network ties to support implementation of a community pharmacy enhanced services network

BACKGROUND

Limited evidence exists on how to integrate community pharmacists into team-based care models, as the inclusion of community pharmacy services into alternative payment models is relatively new. To be successful in team-based care models, community pharmacies need to successfully build relationship with diverse stakeholders including providers, care managers, and patients.

OBJECTIVES

The aims of this study are to: (1) identify the role of network ties to support implementation of a community pharmacy enhanced services network, (2) describe how these network ties are formed and maintained, and (3) compare the role of network ties among high- and low-performing community pharmacies participating in an enhanced services network.

METHODS

Using a semi-structured interview guide, we interviewed 40 community pharmacy representatives responsible for implementation of a community pharmacy enhanced services program. We analyzed for themes using social network theory to compare network ties among 24 high- and 16 low-performing community pharmacies.

RESULTS

The study found that high-performing pharmacies had a greater diversity of network ties (e.g., relationships with healthcare providers, care managers, and public health agencies). High-performing pharmacies were able to use those ties to support implementation of NC-CPESN. High- and low-performing pharmacies used similar strategies for establishing ties with patients, such as motivational interviewing and assigning staff members to be responsible for engaging high-risk patients. High-performing pharmacies used additional strategies such as assessing patient preferences to support patient engagement, increasing patient receptivity towards enhanced services.

CONCLUSIONS

Community pharmacies may vary in their ability to develop relationships with other healthcare providers, care management and public agencies, and patients. As enhanced services interventions that require care coordination are scaled up and spread, additional research is needed to test implementation strategies that support community pharmacies with developing and maintaining relationships across a diverse group of stakeholders (e.g., healthcare providers, care managers, public health agencies, patients).

Engaging with In-need Rural Patient Populations through Public Health Partnerships

A public health partnership was established between a state Medicare Regional Care Collaborative Organization (RCCO), the state health department, a pharmacy school and three community pharmacies located in rural Colorado to optimize the utilization of a free public health service provided through each pharmacy. Fourth-year pharmacy students were allocated year-round by the University of Colorado to support disease management and medication therapy management (MTM) services offered to patients in three rural towns served by the RCCO. Faculty from the school of pharmacy reviewed data provided by the RCCO to identify patients who could benefit from MTM or disease state management (DSM) services. These patients were contacted and encouraged to take advantage of these free pharmacy-based services. Additionally, a number of targeted interventions were performed within these populations to optimize their health. Concerted efforts were made to improve information flow and communication between these pharmacy sites and partnering medical offices. Additionally, pharmacy students were successfully integrated in to medical offices to work alongside medical providers in these communities. This manuscript describes the implementation and coordination of this project as well as the impact these pharmacies had on the communities they served.

Communication between pharmacists and primary care physicians in the midst of a U.S. opioid crisis

BACKGROUND

Effective communication between prescribers of opioids and community pharmacists can contribute to maximizing appropriate pain management and reducing opioid misuse and diversion. While much of the education and training available on reducing opioid misuse and diversion stresses the importance of interprofessional communication between prescribers and pharmacists, few studies have been explored those communication patterns directly.

OBJECTIVE

The objectives of this manuscript are to present and explore key emergent themes from a qualitative study around the nature, frequency, and content of communication between primary care physicians (PCPs) and pharmacists focusing on opioids.

METHODS

Interviews were conducted with 48 PCPs and 60 community pharmacists across four states in the U.S.: Washington, Idaho, Kentucky and Arkansas.

RESULTS

Convergent results from both samples indicated that the content of communication usually centers on questions of dosing, timing of the prescription, and/or evidence of potential misuse/diversion. When communication was focused on relaying information about a patient and/or clarifying questions around the prescription, it appeared positive for both parties. Results also indicated that close physical proximity between PCPs and dispensing pharmacists contributed to more positive and useful communication, especially when the clinics and pharmacies were part of the same healthcare system. Many pharmacists reported hesitancy in "questioning" a physician's judgement, which appeared related to commonly held beliefs of both pharmacists and physicians about the respective roles of each in providing patient care. Pharmacists reported difficulty in reaching PCPs for discussion, while PCPs reported it was easy to reach pharmacists.

CONCLUSIONS

Physician and pharmacist communication around opioids can be mutually beneficial. When prescribers and pharmacists are co-located, higher levels of trust and teamwork are reported, which in turn seems to be related to more open and positive communication. Additional research is needed to identify interventions to increase mutually-valued communication that improves the quality of decision-making around opioids.

Perspectives of practising pharmacists towards interprofessional education and collaborative practice in Qatar

Background Healthcare is provided by a variety of different professionals, including pharmacists who are integral members of the team, and all are expected to work collaboratively to provide quality care. Little is known about the perceptions of pharmacists in Qatar towards interprofessional collaboration. Positive attitudes towards interprofessional education are essential to successful implementation of interprofessional collaboration. Therefore, to develop effective collaboration strategies in practice settings, it was essential to survey the attitudes of practising pharmacists towards collaboration. Objective To explore the awareness, views, attitudes and perceptions of practising pharmacists in Qatar towards interprofessional education and collaborative practice. Setting Community, hospital and primary healthcare settings in Qatar. Methods This was a two-staged sequential explanatory mixed method design. It utilised a quantitative survey (Stage 1), based on a modified version of the Readiness for Interprofessional Learning Scale. This was followed by a qualitative stage, utilising focus groups (Stage 2). Main outcome measures (1) Qatar pharmacists' attitudes towards interprofessional education and collaborative practice; (2) Practising pharmacists' perspectives in relation to enablers, barriers and recommendations regarding interprofessional education and collaborative practice. Results 63% of the practising pharmacists (n = 178) responded to the survey. Three focus groups followed (total n = 14). High scores indicating readiness and positive attitudes towards interprofessional education were reported for pharmacists working in hospital, community and primary healthcare settings. Qualitative analysis identified three overarching themes in relation to the enablers, barriers and recommendations for practising pharmacists working collaboratively. The enabling themes were: professional and patient related benefits, and current positive influences in Qatar; the barriers were patients' negative perceptions; the status of the pharmacy profession and current working practices and processes; the recommendations related to improving patients' perceptions about pharmacists and enhancing the status of pharmacy profession in Qatar. The findings from this study highlighted two major observations: the lack of existence of collaborative practice and hierarchy and power play. Conclusion Pharmacists demonstrated willingness and readiness to develop interprofessional learning and collaborative practice with significant steps already taken towards improving collaborative working practices in different care settings.

Exploring healthcare professionals' perceptions of the anesthesia assistant role and its impact on patients and interprofessional collaboration

To practice interprofessional collaboration (IPC), understanding the roles of each profession in the team is key. Anesthesia assistants (AAs) are a relatively new addition to the Canadian healthcare system. As a result, its role in the delivery of anesthesia care can be misunderstood by other healthcare professionals. Using an exploratory multiple case study design, this article explores healthcare professionals' perceptions of the AA role and its impact on patients and IPC. Sixteen semi-structured, in-depth interviews were conducted with a purposive sample of nine healthcare professions from inside and outside the peri-operative care unit in two urban, acute care, university-affiliated teaching research hospitals in Ontario. A thematic analysis of the interview transcripts identified five overarching themes: limited understanding of the AA role, improved patient-centred care, improve IPC and interprofessional education, ongoing challenges, and the future direction for professional growth. Results indicated that despite regular clinical practice collaboration, participants have a limited understanding of AAs in terms of their educational prerequisites, scope of practice, and roles. One reason for this lack of understanding is that there is a high variability of titles and clinical duties for non-physician anesthesia providers. The diverse range of anesthesia services provided by AAs can also become a barrier to the full understanding of their scope of practice and roles. The limited understanding of the AA role was reported as one of AAs' ongoing challenges. It prevents AAs from realising their full scope of practice. Participants suggested that AAs' professional growth should focus on promoting and expanding their role. Understanding other healthcare professionals' perceptions of AAs will assist them to become better ambassadors for their role, and to more effectively promote and practice IPC. Ultimately, this will result in improved interprofessional teamwork to deliver effective and efficient patient care.

Attitudes and attributes of pharmacists in relation to practice change - A scoping review and discussion

BACKGROUND

Multiple barriers and facilitators to the uptake of cognitive services in pharmacy practice have been identified. Pharmacists' attitudes and attributes have been described as barriers and facilitators in relation to the uptake of extended pharmacy services, in addition to those of a more systemic nature.

OBJECTIVES

To systematically scope and review the literature describing pharmacists' attitudes and attributes in relation to the implementation of cognitive services or role extension and to critically analyze and discuss their relevance as barriers or facilitators.

METHOD

A scoping review of the literature on attitudes and attributes of pharmacists in relation to pharmacy practice was performed, including 47 articles on attitudes and 12 on attributes, forming the basis for a critical analysis within theoretical frameworks.

RESULTS

Pharmacists' attitudes toward role extensions and new pharmacy service models are generally positive and their personal attributes and personality traits appear favorable for roles as health professionals. Pharmacists perceived a number of barriers to the uptake of extended roles.

CONCLUSION

Pharmacists' attributes, including personality traits, and attitudes favor the implementation of cognitive and patient-focused health care services and should not be regarded as major barriers to the uptake of extended pharmacy practice roles. Framing their attitudes and attributes within the theories of planned behavior and personality trait theories indicates that individual motivation needs to be underscored by systemic support for pharmacy practice change to succeed on a wide scale.

Provider Perception of Pharmacy Services in the Patient-Centered Medical Home

BACKGROUND

Despite the positive data on clinical outcomes, cost savings, and provider experience, no study has surveyed providers to evaluate what pharmacy services they find to be worthwhile.

OBJECTIVE

To determine what clinical, cost/access, and educational pharmacy services providers in a patient-centered medical home (PCMH) consider worthwhile and the perceived barriers to successful pharmacist incorporation.

METHODS

A cross-sectional online survey was distributed to primary care physicians, nurse practitioners, and physician assistants in a PCMH physician group.

RESULTS

The survey response rate was 78%. Top-tier clinical services were identified as medication counseling, reconciliation, adherence assessment, polypharmacy assessment, and drug information. Formulary review was the only top-tier cost- or access-related service. Top-tier educational services included new black-boxed warnings, drug market withdrawals, and new drug reviews. Ninety-one percent of providers were comfortable referring to a pharmacist for diabetes medication selection and dose titration, but no other disease state eclipsed 75%. More than twice as many providers found the pharmacy service to be very or extremely valuable when the pharmacist is physically located in the office versus virtual interactions (70% vs 34%).

CONCLUSION

Top-tier clinical, cost/access, and educational services considered worthwhile by providers in a PCMH have been identified. In addition to these services, when developing or evaluating a pharmacy service, special attention should be paid to provider preference for physical location in the office and perceived barriers to the pharmacist availability, concern over complex disease management competency and patient confusion as to the role of the pharmacist.

Are we ready to accept the challenge? Addressing the shortcomings of contemporary qualitative health research

BACKGROUND

Qualitative approaches represent an important contributor to health care research. However, several researchers argue that contemporary qualitative research does not live up to its full potential. By presenting a snapshot of contemporary qualitative research in the field of social and administrative pharmacy, this study challenges contributors to the field by asking: Are we ready to accept the challenge and take qualitative research one step further?

PURPOSE

The purpose of this study was to initiate a constructive dialogue on the need for increased transparency in qualitative data analysis, including explicitly reflecting upon theoretical perspectives affecting the research process.

METHODS

Content analysis was used to evaluate levels of theoretical visibility and analysis transparency in selected qualitative research articles published in Research in Social and Administrative Pharmacy between January 2014 and January 2015.

MAIN FINDINGS

In 14 out of 21 assessed papers, the use of theory was found to be Seemingly Absent (lowest level of theory use), and the data analyses did not include any interpretive endeavors. Only two papers consistently applied theory throughout the entire study and clearly took the data analyses from a descriptive to an interpretive level. It was found that the aim of the majority of assessed papers was to change or modify a given practice, which however, resulted in a lack of both theoretical underpinnings and analysis transparency.

CONCLUSION

This study takes the standpoint that theory and high-quality analysis go hand-in-hand. Based on the content analysis, articles that were deemed to be high in quality were explicit about the theoretical framework of their study and transparent in how they analyzed their data. It was found that theory contributed to the transparency of how the data were analyzed and interpreted. Two ways of improving contemporary qualitative research in the field of social and administrative pharmacy are discussed: engaging with social theory and establishing close collaboration with social scientists.

The facilitators and barriers associated with implementation of a patient-centered medical home in VHA

BACKGROUND

The patient-centered medical home (PCMH) is a team-based, comprehensive model of primary care. When effectively implemented, PCMH is associated with higher patient satisfaction, lower staff burnout, and lower hospitalization for ambulatory care-sensitive conditions. However, less is known about what factors contribute to (or hinder) PCMH implementation. We explored the associations of specific facilitators and barriers reported by primary care employees with a previously validated, clinic-level measure of PCMH implementation, the Patient Aligned Care Team Implementation Progress Index (Pi(2)).

METHODS

We used a 2012 survey of primary care employees in the Veterans Health Administration to perform cross-sectional, respondent-level multinomial regressions. The dependent variable was the Pi(2) categorized as high implementation (top decile, 54 clinics, 235 respondents), medium implementation (middle eight deciles, 547 clinics, 4537 respondents), and low implementation (lowest decile, 42 clinics, 297 respondents) among primary care clinics. The independent variables were ordinal survey items rating 19 barriers to patient-centered care and 10 facilitators of PCMH implementation. For facilitators, we explored clinic Pi(2) score decile both as a function of respondent-reported availability of facilitators and of rating of facilitator helpfulness.

RESULTS

The availability of five facilitators was associated with higher odds of a respondent's clinic's Pi(2) scores being in the highest versus lowest decile: teamlet huddles (OR = 3.91), measurement tools (OR = 3.47), regular team meetings (OR = 2.88), information systems (OR = 2.42), and disease registries (OR = 2.01). The helpfulness of four facilitators was associated with higher odds of a respondent's clinic's Pi(2) scores being in the highest versus lowest decile. Six barriers were associated with significantly higher odds of a respondent's clinic's Pi(2) scores being in the lowest versus highest decile, with the strongest associations for the difficulty recruiting and retaining providers (OR = 2.37) and non-provider clinicians (OR = 2.17). Results for medium versus low Pi(2) score clinics were similar, with fewer, smaller significant associations, all in the expected direction.

CONCLUSIONS

A number of specific barriers and facilitators were associated with PCMH implementation, notably recruitment and retention of clinicians, team huddles, and local education. These findings can guide future research, and may help healthcare policy makers and leaders decide where to focus attention and limited resources.

The achievement of public health services in pharmacy practice: A literature review

BACKGROUND

It is known that pharmacists are currently contributing to public health; however, the extent of this contribution as reported in the literature has not been examined. Investigating the ways that pharmacists are currently participating in public health is critical for the profession of pharmacy, pharmacy educators, and the public health community.

OBJECTIVES

The purpose of this study was to determine the reported contributions of pharmacy to each of the ten essential services of public health, and which of the five core competencies of public health were most frequently utilized in those contributions.

METHODS

A PubMed search was used to extract references that included both the words pharmacy and services in the title or abstract, and the words public health in any part of the document. A total of 247 references were extracted and categorized into the essential services and core competencies.

RESULTS

The essential services Inform, Educate, and Empower, and Link to/Provide Care were more frequently represented in the literature, and the core competency of Health Policy and Administration was most frequently utilized.

CONCLUSION

To further contribute to and integrate their contributions within population health, pharmacists must consider ways to strategically contribute to the essential services of public health and seek to increase competency in public health.

The Medical Home and Care Coordination in Disaster Recovery: Hypothesis for Interventions and Research

In postdisaster settings, health care providers encounter secondary surges of unmet primary care and mental health needs that evolve throughout disaster recovery phases. Whatever a community’s predisaster adequacy of health care, postdisaster gaps are similar to those of any underserved region. We hypothesize that existing practice and evidence supporting medical homes and care coordination in primary care for the underserved provide a favorable model for improving health in disrupted communities. Elements of medical home services can be offered by local or temporary providers from outside the region, working out of mobile clinics early in disaster recovery. As repairs and reconstruction proceed, local services are restored over weeks or years. Throughout recovery, major tasks include identifying high-risk patients relative to the disaster and underlying health conditions, assisting displaced families as they transition through housing locations, and tracking their evolving access to health care and community services as they are restored. Postdisaster sources of financial assistance for the disaster-exposed population are often temporary and evolving, requiring up-to-date information to cover costs of care until stable services and insurance coverage are restored. Evidence to support disaster recovery health care improvement will require research funding and metrics on structures, processes, and outcomes of the disaster recovery medical home and care coordination, based on adaptation of standard validated methods to crisis environments. (Disaster Med Public Health Preparedness. 2015;9:337–343)

Knowing the patient: A qualitative study on care-taking and the clinical pharmacist-patient relationship

BACKGROUND

Previous studies have found clinical pharmacists (CPs) and clinical pharmacy specialists (CPSs) in direct patient care have positive effects across various patient outcomes. However, there are also other kinds of care-taking occurring in pharmacy-run clinic appointments that produce value for patients.

OBJECTIVE

To identify and characterize how CPs/CPSs in direct care clinics develop and practice care-taking behaviors which advance the pharmacist-patient relationship.

METHODS

Semi-structured CP/CPS interviews were conducted once per year for two years (46 year 1, 50 year 2) along with direct observations of clinical pharmacy work as part of an anticoagulation improvement intervention. Participants were from Veterans Health Administration (VHA) medical centers and VHA community-based outpatient clinics in the Northeastern U.S. Interviews were transcribed verbatim and thematically analyzed using NVIVO 10 software.

RESULTS

It was found that CPs/CPSs practice "knowing the patient" in ways related to, but distinct from this practice in the nursing literature. For CPs/CPSs, knowing the patient occurred over time, and it produced familiarity and trust between CPs/CPs and patients. A reciprocal relationship developed in which patients came to rely on CP/CPSs for other types of assistance. Patterns of knowing the patient and being known by the patient manifested in three distinct ways: 1) identifying the patient's unmet needs, 2) explaining other medications, and 3) helping the patient navigate the system.

CONCLUSION

This research identifies an action, knowing the patient, whereby CPs use their knowledge of the patient to deliver individualized care. This study contributes to the developing literature on pharmacist-patient relationships and pharmacist-patient communication.

Balancing collaborative and independent practice roles in clinical pharmacy: a qualitative research study

BACKGROUND

Clinical pharmacists (CPs) with a scope of practice operate as direct care providers and health care team members. Research often focuses on one role or the other; little is understood about the dynamic relationship between roles in practice settings.

OBJECTIVE

To identify the challenges CPs face in balancing dual roles as direct care providers and health care team members and the implications for CP effectiveness and quality of care.

METHODS

Pharmacists were interviewed with a primary purpose of informing an implementation effort. Besides the implementation, there were emergent themes regarding the challenges posed for CPs in negotiating dual roles. This study is, therefore, a secondary analysis of semistructured interviews and direct observation of 48 CPs, addressing this phenomenon. Interview data were entered into NVivo 10 and systematically analyzed using an emergent thematic coding strategy.

RESULTS

Pharmacists describe role ambiguity, where they perform as direct providers or team members simultaneously or in quick succession. They note the existence of a "transaction cost," where switching causes loss of momentum or disruption of work flow. Additionally, pharmacists feel that fellow providers lack an understanding of what they do and that CP contributions are not evaluated accurately by other health professionals.

CONCLUSION

It is a challenge for CPs to balance the distinct roles of serving as collaborators and primary providers. Frequent role switching is not conducive to optimal work efficiency or patient care. Our findings suggest concrete steps that medical centers can take to improve both CP worklife and quality of patient care.