Early skills laboratory warnings: Laboratory faculty perspectives on student barriers for progression to experiential education

INTRODUCTION

This study characterized faculty perceptions of student barriers to achieving an Entrustable Professional Activities (EPA) level 2 or higher in the Patient Care Provider domain.

METHODS

Pharmacy skills laboratory faculty participated in a nominal group technique (NGT) session. Participants reflected on two questions: "What behaviors would result in a student not achieving a rank of EPA readiness level 2 or higher?" and "What knowledge and skills would result in a student not achieving a rank of EPA readiness level 2 or higher?" Participants developed a ranked list using silent brainstorming, idea generation, clarification, and discussion.

RESULTS

Two NGT sessions were conducted. Group 1 reported (lack of) professionalism, (inability to perform) physical skills, (lack of) critical thinking and interpreting data gathered during physical skills, and (inability to achieve) programmatic outcomes and mile makers exams as barriers. Group 2 ranked behaviors as lack of independence, not taking roles and responsibilities seriously, inability to follow instructions, lack of classroom engagement, and disorganized and unable to prioritize. Group 2 ranked knowledge and skills of significant errors when making medication recommendations, inability to identify accurate medication history, inability to perform tasks with time constraints, poor patient communication, and inability to identify resources.

CONCLUSIONS

Pharmacy skills laboratory faculty can identify behaviors, knowledge, or skills that may prevent a student from achieving an EPA readiness level 2 or higher such as lack of professionalism and poor critical thinking skills and should be empowered to identify early warning signs for students' success and progression to experiential education.

The Lean Six Sigma Define, Measure, Analyze, Implement, Control (LSS DMAIC) Framework: An Innovative Strategy for Quality Improvement of Pharmacist Vaccine Recommendations in Community Pharmacy

Community pharmacies represent a highly accessible and convenient setting for vaccination. However, setting-specific barriers exist which contribute to suboptimal vaccination rates, particularly for pneumococcal vaccinations. One proven quality improvement framework growing in use within healthcare settings is Lean Six Sigma (LSS). This paper describes the application of the LSS framework in select locations of a national pharmacy chain. The implementation of a training program for improved recommendation techniques to promote higher rates of pneumococcal vaccinations in high-risk adult populations is also addressed. A mixed-methods approach including pre/post quasi-experimental design and in-depth key informant interviews was used.

A social media microinfluencer intervention to reduce coronavirus disease 2019 vaccine hesitancy in underserved Tennessee communities: A protocol paper

Background

Central to effective public health policy and practice is the trust between the population served and the governmental body leading health efforts, but that trust has eroded in the years preceding the pandemic. Vaccine hesitancy among adults is also a growing concern across the United States. Recent data suggest that the trustworthiness of information about the coronavirus 2019 (COVID-19) vaccine was a larger concern than the vaccine’s adverse effects or risks.

Objective

This study aims to describe the methods used to create a public health microinfluencer social media vaccine confidence campaign for the COVID-19 vaccine in underserved Tennessee communities. A secondary objective is to describe how the Social-Ecological Model (SEM) and Social Cognitive Theory may address vaccine hesitancy using community pharmacies.

Methods

In late 2020, 50 independent community pharmacies in underserved communities across Tennessee were involved in a public health project with the State of Tennessee Department of Health and the University of Tennessee Health Science Center College of Pharmacy. The project involved a 3-pronged, pharmacy-based COVID-19 vaccination outreach project, including (1) social media messaging (i.e., microinfluencer approach), (2) community partner collaboration, and (3) in-pharmacy promotion. Quantitative and qualitative data will assess the quality and effectiveness of the program. Social media outcomes will also be assessed to measure the impact of the microinfluencer social media training.

Results

Project implementation is planned for 6 months (January 2021 to June 2021) after an initial month of planning by the research team (December 2020) and preceding several months of assessment (July 2021 and beyond).

Conclusions

Novel, theory-based approaches will be necessary to improve vaccine confidence. One approach to promoting public health, derived from the SEM, may be to use trusted microinfluencers on social media platforms, such as local community pharmacists and community leaders.

The Tennessee Medicaid medication therapy management program: early stage contextual factors and implementation outcomes

BACKGROUND

First investigated in the 1990s, medication therapy management (MTM) is an evidence-based practice offered by pharmacists to ensure a patient's medication regimen is individualized to include the safest and most effective medications. MTM has been shown to a) improve quality of patient care, b) reduces health care costs, and c) lead to fewer medication-related adverse effects. However, there has been limited testing of evidence-based, a-priori implementation strategies that support MTM implementation on a large scale.

METHODS

The study has two objectives assessed at the organizational and individual level: 1) to determine the adoption, feasibility, acceptability and appropriateness of a multi-faceted implementation strategy to support the MTM pilot program in Tennessee; and 2) to report on the contextual factors associated with program implementation based on the Consolidated Framework for Implementation Research (CFIR). The overall design of the study was a hybrid type 2 effectiveness-implementation study reporting outcomes of Tennessee state Medicaid's (TennCare) MTM Pilot program. This paper presents early stage implementation outcomes (e.g., adoption, feasibility, acceptability, appropriateness) and explores implementation barriers and facilitators using the CFIR. The study was assessed at the (a) organizational and (b) individual level. A mixed-methods approach was used including surveys, claims data, and semi-structured interviews. Interview data underwent initial, rapid qualitative analysis to provide real time feedback to TennCare leadership on project barriers and facilitators.

RESULTS

The total reach of the program from July 2018 through June 2020 was 2033 MTM sessions provided by 17 Medicaid credentialed pharmacists. Preliminary findings suggest participants agreed that MTM was acceptable (μ = 16.22, SD = 0.28), appropriate (μ = 15.33, SD = 0.03), and feasible (μ = 14.72, SD = 0.46). Each of the scales had an excellent level of internal (> 0.70) consistency (feasibility, α = 0.91; acceptability, α = 0.96; appropriateness, α = 0.98;). Eight program participants were interviewed and were mapped to the following CFIR constructs: Process, Characteristics of Individuals, Intervention Characteristics, and Inner Setting. Rapid data analysis of the contextual inquiry allowed TennCare to alter initial implementation strategies during project rollout.

CONCLUSION

The early stage implementation of a multi-faceted implementation strategy to support delivery of Tennessee Medicaid's MTM program was found to be well accepted and appropriate across multiple stakeholders including providers, administrators, and pharmacists. However, as the early stage of implementation progressed, barriers related to relative priority, characteristics of the intervention (e.g., complexity), and workflow impeded adoption. Programmatic changes to the MTM Pilot based on early stage contextual analysis and implementation outcomes had a positive impact on adoption.

Facilitating pneumococcal vaccination among high-risk adults: Impact of an assertive communication training program for community pharmacists

BACKGROUND

Community pharmacies are vital access points to provide a range of vaccines to adults, including pneumococcal vaccines; however, despite a growth in the number of vaccines given at these sites, the most recent rates of adults being immunized against pneumococcal disease remain below the goals set by Health People 2020. Low patient awareness is a leading reason for suboptimal vaccination rates, suggesting that a need exists to improve provider communication in recommending pneumococcal vaccination in high-risk adults.

OBJECTIVES

To evaluate the impact of a communication training program to improve pharmacist promotion of the pneumococcal vaccine among high-risk adults in Tennessee.

METHODS

A multiphase training program was initiated in partnership with 2 regions of a nationwide community pharmacy chain (n = 100) focusing on improving evidence-based, presumptive recommendations related to pneumococcal vaccination. All locations were randomized to one of 3 arms on the basis of training intensity: (1) no training; (2) online training only; and (3) online and in-person simulation training. The program focused on improving evidence-based, pharmacist vaccine recommendations using health behavior theories, sales techniques, and improvisation provided through online and in-person simulation training. Changes in vaccinations (compared with the same 6-month period in the previous year) and provider self-efficacy were evaluated by Mann-Whitney U tests, chi-square tests, and general linear models.

RESULTS

Completing the full training program led to nominal changes in pharmacist self-efficacy across the 6 items measured (P > 0.05). Overall counts of all pneumococcal vaccines were lower (-11.3%) across all stores in the period after training; however, a small increase (2.1%) was observed in the stores that underwent the full training, versus changes of -22.0% (P = 0.084) and -9.4% (P = 0.199) in control and online-only training comparisons, respectively.

CONCLUSIONS

Pharmacists' vaccine-related self-efficacy may be improved through an evidence-based communication training program, but a more holistic focus on all recommended adult vaccines may be necessary to realize meaningful improvements.

Extent of and Reasons for Vaccine Hesitancy in Adults at High-Risk for Pneumococcal Disease

Purpose:

To determine the extent of and reasons for hesitancy toward vaccination among adults at high-risk for pneumococcal disease.

Design:

Cross-sectional.

Setting:

Online survey in March-April 2019 via QuestionPro.

Subjects:

Tennessee adults (18-64 years) at high-risk of pneumococcal disease (n = 1,002).

Measures:

Modified version of the validated Vaccine Hesitancy Scale assessed vaccine-related beliefs, reasons for hesitancy, external influences on vaccination, and prior vaccination

Analysis:

Descriptive and inferential statistics provided an overview of the responses and comparisons among subgroups. Logistic regression determined the odds of being hesitant using the listed beliefs and influencers as predictors. Thematic analysis was performed on the qualitative data gathered from free response questions throughout the survey.

Results:

Analysis included 1,002 complete responses (12% response rate [total viewed = 8,331]) with 34.3% indicating hesitancy toward one or more recommended vaccinations, with 53% of which indicating hesitancy to the pneumococcal vaccine despite it being recommended by the Advisory Committee on Immunization Practices (ACIP) for all respondents. The odds of vaccine hesitancy or resistance were higher in minorities (OR: 1.6; 95% CI: 1.19-2.11), those not believing others like them get vaccinated (OR: 1.82; 95% CI: 1.262-2.613), and respondents recalling negative media about vaccines (OR: 2.56; 95% CI: 1.797-3.643).

Conclusions:

Patients at high-risk of pneumococcal disease lack awareness of the need for the recommended vaccine, and provider education may need improving to increase vaccination in this population.

30. Impact of Pharmacist Assertiveness Training in Recommending Pneumococcal Vaccination among High-Risk Adults

Background

Community pharmacies have become vital access points to provide a range of vaccines to adults, including pneumococcal; however, despite growth in vaccines given at these sites, the most recent rates of adults being immunized against pneumococcal disease remain below goals set by Health People 2020. A lack of patient awareness is a leading reason for low vaccination rates, suggesting that a need exists to improve provider communication in recommending pneumococcal vaccination in high-risk adults.

Methods

A multi-phase, pharmacy-based intervention was launched in west and middle Tennessee locations of a nationwide community pharmacy chain focusing on improving evidence-based, presumptive recommendations related to pneumococcal vaccination. All locations were randomized to one of three arms based on training intensity: 1) no training; 2) online training only; and 3) online and live simulation training. The program focused on providing assertive recommendations and managing potential hesitancy guided by multiple health communication theories and community-based hesitancy data provided to each pharmacy by the study team. Primary endpoints included changes in pneumococcal vaccinations (counts over 6-month periods [July-December] in 2018 and 2019) and provider vaccine-related self-efficacy and were evaluated by generalized linear models.

Results

A total of 100 pharmacies were enrolled and 50 pharmacists completed their assigned training element. Completing the full training program (i.e., online and live) led to improvements in pharmacist self-efficacy related to being influential in vaccine-related decisions and not being helpless in managing resistance (both p< 0.05). Overall counts of all pneumococcal vaccines were lower (-11.3%) across all stores in the period following training; however, a small increase (2.1%, P=0.084) was observed in the stores that underwent the full training, versus decreases of 22.0% and 9.4% in control and online-only training comparisons, respectively.

Conclusion

Results suggest that provider vaccine self-efficacy can be improved through an evidence-based communication training program but substantial improvements in specific vaccinations may need to leverage a more holistic focus on all recommended adult vaccines.

Disclosures

Justin Gatwood, PhD,MPH, AstraZeneca (Grant/Research Support)GlaxoSmithKline (Grant/Research Support)Merck & Co. (Grant/Research Support) Tracy Hagemann, PharmD, GSK (Grant/Research Support)Merck (Grant/Research Support)

Longitudinal examination of perceived stress and academic performance of first-year student pharmacists

INTRODUCTION

First-year pharmacy students (P1s) may experience a number of stressors that may affect academic performance due to the transition into a professional program. Study objectives were to evaluate student demographic and pre-pharmacy factors associated with perceived stress among P1s, analyze relative change in perceived stress over the P1 year, and assess associations between perceived stress and academic performance.

METHODS

The Perceived Stress Scale (PSS-10) was administered three times to P1s: during orientation, midpoint of fall semester, and midpoint of spring semester. Data were also collected using school records, including demographics, P1 fall grade point average (GPA), P1 spring GPA, and P1 year GPA. Paired-sample t-tests, independent samples t-tests, Analysis of Variance, correlational analysis, and multiple linear regression were conducted.

RESULTS

Of 202 P1s, 201 (99.5%) completed the orientation survey administration and 110 (54.5%) completed all three administrations. PSS-10 score significantly increased across survey administrations. Differences in PSS-10 scores at orientation were noted based on gender and race/ethnicity (P < .05), with female and minority students experiencing greater levels of stress. PSS-10 score (spring administration) was significantly, inversely correlated to P1 fall GPA, spring GPA, and year GPA (P < .05). Undergraduate science GPA, PSS-10 score (orientation administration), and age were included in the final version of the regression model as significant predictors of P1 year GPA.

CONCLUSIONS

Perceived stress increased over the P1 year, and higher perceived stress was associated with lower P1 academic performance. Future studies should examine strategies to assist P1s in managing stress.

Exploring Pharmacy Technician Roles in the Implementation of an Appointment-Based Medication Synchronization Program

The objective of this study was to qualitatively explore the role of pharmacy technicians in the implementation of an appointment-based model (ABM) medication synchronization program. The purposeful sampling of technicians working within six different locations of a supermarket chain pharmacy in Mississippi and Tennessee was carried out, and the technicians were interviewed between January and April 2018. A semi-structured interview guide was developed based on the Consolidated Framework for Implementation Research (CFIR). Questions gathered information around pharmacy technician demographics and CFIR domains (process, inner setting, outer setting and intervention characteristics). Interviews were audiotaped and transcribed. Two members of the research team performed thematic content analysis. Six full-time, certified pharmacy technicians with 8.3 ± 2.7 years of experience were interviewed. Findings suggest that including hands-on experience with program software is needed during training to successfully implement ABM. A barrier to implementation was the time needed to complete ABM tasks as compared to other tasks. Although some barriers exist regarding implementation, technicians believe that overall, this program has positive benefits for patients. Results from this study signify that ABM implementation can be challenging. Better ABM portal integration with the pharmacy patient profile and appropriate workforce budgeting are key to continued success.

The Tennessee medication therapy management program: A hybrid type 2 effectiveness-implementation trial study protocol

BACKGROUND

Pharmacist-led medication therapy management (MTM) programs are considered evidence-based and have clearly defined core components. Despite this, MTM programs are often implemented without fidelity due to notable implementation barriers, such as physician-pharmacist relationships and pharmacist access to patient medical records. To improve MTM implementation, the Tennessee Medicaid program developed a MTM intervention that incorporates implementation strategies to address some of the known barriers to implementation (e.g., formalizing pharmacist-physician relationships through collaborative practice agreements, ensuring pharmacists' access to medical records).

OBJECTIVES

The purpose of this hybrid type 2 effectiveness-implementation study is to (1) assess the effectiveness of the MTM pilot program in Tennessee (e.g., medication adherence, healthcare utilization, quality and cost of care) and (2) assess the implementation of the MTM pilot program (e.g., feasibility, appropriateness, acceptability, penetration).

METHODS

The Tennessee MTM pilot program is being assessed as a hybrid type 2 effectiveness-implementation study with a quasi-experimental design. A mixed methods approach (QUAN + QUAL) for the purpose of complementarity (e.g., answering related research questions). Data will include surveys, interviews, MTM platform encounter information, and medical and pharmacy claims. Initial analyses will include data between January 2018 and December 2019.

CONCLUSION

The study will further add to the evidence base of MTM interventions by testing an intervention that addresses known barriers to implementation and simultaneously collecting data on effectiveness and implementation to speed up MTM translation. The Tennessee MTM program is expected to serve as a guide to other states seeking to expand pharmacist-delivered clinical services to their Medicaid members, particularly those intending to incorporate MTM into programs seeking to improve primary care delivery. Further, by improving the implementation of MTM, the pilot program is expected to improve the reliability of MTM program benefits including healthcare quality and cost and patient outcomes.

Stages of Change: Moving Community Pharmacies From a Drug Dispensing to Population Health Management Model

Given their clinical training and accessibility, community pharmacists are well positioned to support primary care, especially in providing medication management services. There is limited evidence, however, on implementation of community pharmacist-led services in coordination with other health care providers. The aim of this study was to examine the implementation process of community pharmacies in North Carolina participating in a Medicaid population health management intervention. We conducted semistructured interviews with 40 representatives from high- and low-performing community pharmacies from June to August 2017. We analyzed for themes organized around Rogers's Stages in the Innovation Process in Organizations. Community pharmacies employed numerous implementation strategies such as developing relationships with providers and redefining job responsibilities to ensure pharmacists and pharmacy technicians are working at the top of their license. Findings also revealed differences in the implementation process among high- and low-performing pharmacies. Continued research is needed to determine which implementation strategies improve program performance.

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).

Testing the organizational theory of innovation implementation effectiveness in a community pharmacy medication management program: a hurdle regression analysis

BACKGROUND

Many state Medicaid programs are implementing pharmacist-led medication management programs to improve outcomes for high-risk beneficiaries. There are a limited number of studies examining implementation of these programs, making it difficult to assess why program outcomes might vary across organizations. To address this, we tested the applicability of the organizational theory of innovation implementation effectiveness to examine implementation of a community pharmacy Medicaid medication management program.

METHODS

We used a hurdle regression model to examine whether organizational determinants, such as implementation climate and innovation-values fit, were associated with effective implementation. We defined effective implementation in two ways: implementation versus non-implementation and program reach (i.e., the proportion of the target population that received the intervention). Data sources included an implementation survey administered to participating community pharmacies and administrative data.

RESULTS

The findings suggest that implementation climate is positively and significantly associated with implementation versus non-implementation (AME = 2.65, p < 0.001) and with program reach (AME = 5.05, p = 0.001). Similarly, the results suggest that innovation-values fit is positively and significantly associated with implementation (AME = 2.17, p = 0.037) and program reach (AME = 11.79, p < 0.001). Some structural characteristics, such as having a clinical pharmacist on staff, were significant predictors of implementation and program reach whereas other characteristics, such as pharmacy type or prescription volume, were not.

CONCLUSIONS

Our study supported the use of the organizational theory of innovation implementation effectiveness to identify organizational determinants that are associated with effective implementation (e.g., implementation climate and innovation-values fit). Unlike broader environmental factors or structural characteristics (e.g., pharmacy type), implementation climate and innovation-values fit are modifiable factors and can be targeted through intervention-a finding that is important for community pharmacy practice. Additional research is needed to determine what implementation strategies can be used by community pharmacy leaders and practitioners to develop a positive implementation climate and innovation-values fit for medication management programs.

Supporting Community Pharmacies with Implementation of a Web-Based Medication Management Application

OBJECTIVE

Community pharmacists' role in clinical care is expanding in the United States and information systems are needed that extend beyond a dispensing workflow. As pharmacies adopt new systems, implementation support will be needed. This study identifies the barriers and facilitators experienced by community pharmacies in implementing a Web-based medication management application and describes the implementation strategies used to support these pharmacies.

METHODS

Semistructured interviews were conducted with 28 program and research staff that provides support to community pharmacies participating in a statewide pharmacy network. Interviews were recorded, transcribed verbatim, and analyzed for themes using the Expert Recommendations for Implementing Change (ERIC).

RESULTS

Findings suggest that leadership support, clinical training, and computer literacy facilitated implementation, while lack of system integration, staff resistance to change, and provider reluctance to share data served as barriers. To overcome the barriers, implementation support was provided, such as assessing readiness for implementation, developing a standardized and interoperable care plan, and audit and feedback of documentation quality.

CONCLUSION

Participants used a wide array of strategies to support community pharmacies with implementation and tailored approaches to accommodate pharmacy-specific preferences. Most of the support was delivered preimplementation or in the early phase of implementation and by program or research staff rather than peer-to-peer. Implementing new pharmacy information system requires a significant amount of implementation support to help end-users learn about program features, how to integrate the software into workflow, and how to optimize the software to improve patient care. Future research should identify which implementation strategies are associated with program performance.