Healthcare Resource Utilization in Medicare Beneficiaries Obtaining Medication Synchronization.

BACKGROUND: An appointment-based medication synchronization (ABMS) is a service which aligns patients' chronic medications to a predetermined routine pickup date and includes a comprehensive medication review or other clinical appointment at the pharmacy. We compared healthcare utilization outcomes (outpatient, inpatient, emergency department visits, and pharmacy utilization) of Medicare beneficiaries enrolled in a med-sync program to beneficiaries not enrolled in such a program. METHODS: This retrospective cohort study included Medicare beneficiaries obtaining medications from pharmacies providing ABMS. All Medicare inpatient, outpatient, emergency, and pharmacy claims data from 2014 to 2016 obtained from the Research Data Assistance Center (ResDAC). These pharmacy claims were used to create medication-synchronized (med-sync) (n=13,193) and non-med-sync (n=156,987) cohorts. All patients were followed longitudinally for 12 months before and after a 2015 index/enrollment date. Baseline characteristics were utilized to create a logistic regression model for propensity score matching. A 1:1 greedy nearest neighbor matching algorithm was adapted for sequentially matching both cohorts. Difference-in-differences (DID) was used to compare mean changes in healthcare utilization outcomes (outpatient, inpatient, emergency department visits, and pharmacy utilization) between cohorts. RESULTS: After matching, 13,193 beneficiaries in each cohort were used for analysis. DID for mean of healthcare utilizations were significantly lower in the med-sync cohort compared to the non-med-sync cohort for outpatient visits (DID:0.012, p=0.0073) and pharmacy utilization (DID:0.013, p<0.0001). There was no significant DID for inpatient and emergency department visits between cohorts. CONCLUSION: Outpatient and pharmacy utilization changes were significantly lower in the med-sync cohort compared to the non-med-sync cohort in the 12-months after enrollment. Lower pharmacy utilization could be due to reducing duplicate prescriptions during synchronized refills or optimization of therapy during medication reviews if patients are enrolled in ABM med-sync.

Preparing community pharmacy teams for health information exchange (HIE).

BACKGROUND: Health information exchanges (HIEs) facilitate health care professionals' electronic sharing of patient information across different organizations. When community pharmacists have access to HIE, they can further contribute to improved patient outcomes. However, several implementation challenges are noted, which impede sustained pharmacist access to HIE. To our knowledge, no bidirectional HIE interface design and pharmacy team-informed implementation process has been documented. In response, our research team designed and developed an HIE interface prototype for use specifically by community pharmacy teams to access local HIE data through their pharmacy dispensing software. OBJECTIVES: To 1) identify barriers, facilitators, and recommendations for using HIE data in community pharmacies and 2) create a curated list of resources addressing identified implementation needs to aid future implementation of a fully functional, bidirectional HIE interface by community pharmacy teams. METHODS: Pharmacists, pharmacy technicians, and patients from three pharmacy sites within the Community Pharmacy Enhanced Services Network of Indiana participated in individual semi-structured interviews. Interview questions were mapped to select constructs across all domains of the Consolidated Framework for Implementation Research. Interview transcripts were deductively coded. A subset of participants participated in Evidence-Based Quality Improvement sessions to iteratively update planned resource items needed to support future HIE implementation. RESULTS: We interviewed 23 total participants: 8 pharmacists, 8 pharmacy technicians, and 7 patients. Five facilitators, four barriers, and two recommendations were identified. These were further characterized into four key implementation needs: instruction on how to use HIE; guidance on workflow and team roles; resources that are patient-facing; and resources that are provider-facing, resulting in 16 planned implementation resources. CONCLUSION: Our study provides the first-of-its-kind list of pharmacy team-informed resources to facilitate sustainability and scalability of HIE implementation in community pharmacies.

Usability Evaluation of a Community Pharmacy Health Information Exchange Interface Prototype.

OBJECTIVE: Few community pharmacies have access to health information exchange (HIE) data. We conducted a first-of-its-kind usability evaluation of an HIE interface prototype (referred to throughout as the "HIE-Pioneer mock-up") developed with pharmacists and pharmacy technicians to aid future implementation in community pharmacies. METHODS: Community pharmacists and pharmacy technicians were recruited to complete usability evaluations with the HIE-Pioneer mock-up. Each usability evaluation lasted up to 60 minutes. System usability scale (SUS) scores were collected from each participant following each usability evaluation session and summarized with descriptive statistics. Usability evaluation videos were reviewed for common usability attributes, such as the impact of identified usability problems, learnability, and efficiency. Time on task, task success rates, and prototype utilization were also recorded. RESULTS: Sixteen total participants completed usability testing across three community pharmacies. The average SUS score was 69.7 (scale 0-100, where 100 is the best), with pharmacists on average reporting higher satisfaction than technicians (74.1 vs. 65.3, respectively). Altogether, we identified 23 distinct usability problems. Key problems identified included needed clarification in tool label names and accessibility of HIE links within the existing workflow. Overall, the usability of the HIE-Pioneer mock-up generally fostered pharmacy professionals' ease of learning and efficiency. CONCLUSION: Our study identified key areas, and potential solutions, to improve the usability of the HIE-Pioneer mock-up. Overall, pharmacy professionals viewed the HIE-Pioneer mock-up positively, with good satisfaction ratings. The HIE-Pioneer mock-up provides a blueprint for future HIE implementation in community pharmacy settings, which would increase community pharmacy teams' access to HIE data nationwide. Community pharmacy access to bi-directional HIE is expected to improve communication among more health care professionals involved in patient care and equip pharmacy professionals with needed information for improved clinical decision-making.

Strengths and limitations of a novel "Flip the Pharmacy" practice transformation coach advanced pharmacy practice experience.

BACKGROUND AND PURPOSE: Flip the Pharmacy (FtP) helps community pharmacies "flip" from dispensing- to patient-centered care models with assistance from practice transformation coaches ("coaches"). Purdue University College of Pharmacy created a novel advanced pharmacy practice experience (APPE) positioning students to serve as FtP coaches with oversight from four faculty coaches. This communication describes the APPE's design, characterizes preliminary student coaching outcomes, and identifies the APPE's strengths and limitations. EDUCATIONAL ACTIVITY AND SETTING: Twelve pharmacies were coached by APPE students. The APPE was designed to enhance student knowledge and skills in the scaled implementation of advanced patient care services through structured weekly activities: Week 1, student orientation and training; Week 2, preparing for pharmacy visits; and Weeks 3 and 4, conducting pharmacy visits. Students also performed recurring tasks each week, including managing social media accounts. FINDINGS: Twenty-eight students completed the APPE. Students conducted 81 in-person and 105 virtual visits. Faculty coaches were estimated to need 40 to 50  hours each month for coaching-related activities; involving student coaches reduced faculty coach time by approximately 50%, with faculty spending 20  hours on average per month vs. students spending 50.84  hours. APPE strengths included intentional weekly structuring and oversight and careful student transitions; limitations included minimal pharmacy vendor knowledge and limited rapport-building with pharmacies. SUMMARY: Early experiences demonstrated several benefits, including optimized faculty coach time and student exposure to practice transformation. Future endeavors to implement similar APPEs should incorporate strategies to enhance pharmacy vendor knowledge and strengthen relationship-building with participating pharmacies.

Opioid Use Disorder Curricular Content in US-Based Doctor of Pharmacy Programs.

OBJECTIVES: To characterize the instructional settings, delivery methods, and assessment methods of opioid use disorder (OUD) content in Doctor of Pharmacy (PharmD) programs; assess faculty perceptions of OUD content; and assess faculty perceptions of a shared OUD curriculum. METHODS: This national, cross-sectional, descriptive survey study was designed to characterize OUD content, faculty perceptions, and faculty and institutional demographics. A contact list was developed for accredited, US-based PharmD programs with publicly-accessible online faculty directories (n = 137). Recruitment and telephone survey administration occurred between August and December 2021. Descriptive statistics were computed for all items. Open-ended items were reviewed to identify common themes. RESULTS: A faculty member from 67 (48.9%) of 137 institutions contacted completed the survey. All programs incorporated OUD content into required coursework. Didactic lectures were the most common delivery method (98.5%). Programs delivered a median of 7.0 h (range, 1.5-33.0) of OUD content in required coursework, with 85.1% achieving the 4-hour minimum for substance use disorder-related content recommended by the American Association of Colleges of Pharmacy. Just over half (56.8%) of faculty agreed or strongly agreed that their students were adequately prepared to provide opioid interventions; however, 50.0% or fewer perceived topics such as prescription interventions, screening and assessment interventions, resource referral interventions, and stigma to be covered adequately. Almost all (97.0%) indicated moderate, high, or extremely high interest in a shared OUD curriculum. CONCLUSION: Enhanced OUD education is needed in PharmD programs. A shared OUD curriculum was of interest to faculty and should be explored as a potentially viable solution for addressing this need.

Disparities in Medicare beneficiaries' receiving medication synchronization.

BACKGROUND: Medication synchronization (med-sync) aligns patients' monthly or quarterly chronic medications to a predetermined single pickup date at a community pharmacy. The study objective was to examine med-sync enrollment disparities based on Medicare beneficiaries' predisposing, enabling, and need characteristics. METHODS: This was a retrospective cohort study using a Medicare dataset of beneficiaries receiving medications from pharmacies that self-identified as providing med-sync. Medicare beneficiaries who were continuously enrolled in fee-for-service medical and pharmacy benefits during the study period (2014-2016) were included. Study cohorts (med-sync and non-med-sync patients) were defined, and bivariate and multivariable logistic regression analyses were performed. Andersen's Health Services Utilization Model guided our inclusion of predisposing, enabling, and need characteristics to examine for association with med-sync enrollment. RESULTS: A total of 170,180 beneficiaries were included, of which 13,193 comprised the med-sync cohort and 156,987 comprised the non-med-sync cohort. Bivariate logistic regression analysis revealed statistically significant differences (P < 0.05) in cohorts based on age, geographic region, type of residence, number of unique chronic medications, comorbidities, outpatient visits, and inpatient hospitalizations. Beneficiaries had higher odds of being enrolled in med-sync with increasing age (adjusted odds ratio [AOR] 1.003 [95% CI 1.001-1.005]) and if they resided in the Northeast (AOR 1.094 [95% CI 1.018-1.175]), South (AOR 1.109 [95% CI 1.035-1.188]), and West (AOR 1.113 [95% CI 1.020-1.215]) than those in the Midwest. Beneficiaries residing in nonmetro areas had lower odds of enrollment (AOR 0.914 [95% CI 0.863-0.969]) than those in metro areas. Beneficiaries with previous fewer inpatient hospitalizations (AOR 0.945 [95% CI 0.914-0.977]) were more likely to be enrolled, and those with more outpatient visits (AOR 1.003 [95% CI 1.001-1.004]) were more likely to be enrolled. Those taking a higher number of oral chronic medications (AOR 1.005 [95% CI 1.002-1.008]) had greater odds of enrollment in med-sync. CONCLUSIONS: Med-sync program expansion opportunities exist to address potential enrollment disparities based on age, geographic region, metropolitan area, and prior health utilization. Further studies are needed to develop and examine strategies among pharmacies to improve med-sync enrollment outreach to these subgroups of patients.

Community pharmacist-provided opioid intervention frequencies and barriers.

BACKGROUND: Community pharmacists are well-positioned to engage in opioid-related harm reduction activities (i.e., opioid interventions). However, several barriers to providing these interventions have been identified. Comparing the frequencies of opioid interventions and identifying which barriers are perceived to have the highest impact in providing interventions will yield valuable information for increasing opioid use disorder (OUD) care access within pharmacies. OBJECTIVES: To (1) characterize the frequency of 9 opioid interventions in community practice settings and (2) assess community pharmacists' perceptions of what impact 15 key barriers have on providing opioid interventions. METHODS: This was a multi-state, cross-sectional, and descriptive survey study. Opioid interventions evaluated included prevention (e.g., OUD screening) and treatment (e.g., OUD resource referral); barriers encompassed confidence and knowledge, work environment, provider interactions, and patient interactions. Respondents were recruited from 3 community pharmacy practice-based research networks in the Midwest and South regions of the US. Recruitment and telephone survey administration occurred between December 2021 and March 2022. Descriptive statistics were computed and open-ended items were reviewed to identify common themes. RESULTS: Sixty-nine of 559 pharmacists contacted (12.3%) completed the survey. All opioid interventions were reported to be provided less frequently than indicated in practice. Screening and referral interventions were provided least frequently, at 1.2 and 1.6 times on average, respectively, to the last 10 patients for which respondents felt each intervention was needed. Patient refusal, minimal or no reimbursement, inadequate staffing and time, and negative patient reactions were identified as the highest-impact barriers to providing opioid interventions. Approximately 26% of respondents agreed or strongly agreed that pharmacy school adequately prepared them to provide opioid interventions in practice. CONCLUSION: Prioritizing the resolution of pharmacy work environment barriers will support pharmacists in routinely providing opioid interventions. Changes in Doctor of Pharmacy curricula and continuing education are also indicated to further prepare pharmacists to engage in opioid-related harm reduction.

Planning for health information exchange: Perspectives of community pharmacists in the Community Pharmacy Enhanced Services Network of Indiana.

BACKGROUND: Community pharmacists are one of the most accessible health professionals and provide many different services. However, lack of access to complete patient information is a barrier to making meaningful patient interventions. OBJECTIVES: To determine (1) current and desired health information access among community pharmacists in the Community Pharmacy Enhanced Services Network (CPESN) of Indiana and (2) design considerations for a health information exchange tool for use by community pharmacists. METHODS: This voluntary study was conducted over an 8-day survey period in which 40 pharmacies within the CPESN Indiana network were contacted during regular business hours and asked to take part in a 15-minute telephone survey. Questions asked were informed by the following Consolidated Framework for Implementation Research intervention characteristics domain constructs: relative advantage, evidence strength and quality, adaptability, trialability, complexity, costs, and design quality and packaging. RESULTS: Of the 40 contacted pharmacies, 32 (80%) completed the survey. Most pharmacies reported access to immunization registry data; no other routine access was reported by any pharmacy. In questions assessing the relative advantage of Health Information Exchange (HIE) access compared with their current information access, at least 84.4% said that they agreed or strongly agreed with all statements. When choosing the data element most desirable to have access to via HIE in a community pharmacy, the most frequently selected choices were updated medication orders (n = 18, 56.3%), progress notes (n = 5, 15.6%), and laboratory tests (n = 4, 12.5%). Suggestions to improve ease of implementation included integration within dispensing software and clinical decision-making support features, such as alerts for pertinent lab values. CONCLUSION: Integrating HIE data into community pharmacies would provide community pharmacists with access to important patient data, and pharmacists believed that this would improve their practice. Future research should explore whether implementation of this type of tool leads to better patient outcomes and improved pharmacist job satisfaction.

Preparing for the spread of patient-reported outcome (PRO) data collection from primary care to community pharmacy: a mixed-methods study.

BACKGROUND: Medication non-adherence is a significant public health problem. Patient-reported outcomes (PROs) offer a rich data source to facilitate resolution of medication non-adherence. PatientToc™ is an electronic PRO data collection software originally implemented at primary care practices in California, United States (US). Currently, the use of standardized PRO data collection systems in US community pharmacies is limited. Thus, we are conducting a two-phase evaluation of the spread and scale of PatientToc™ to US Midwestern community pharmacies. This report focuses on the first phase of the evaluation. The objective of this phase was to prepare for implementation of PatientToc™ in community pharmacies by conducting a pre-implementation developmental formative evaluation to (1) identify potential barriers, facilitators, and actionable recommendations to PatientToc™ implementation and (2) create a draft implementation toolkit. METHODS: Data collection consisted of demographics, observations, audio-recorded contextual inquiries, and semi-structured interviews with staff (e.g., primary care providers, pharmacists, pharmacy technicians) and patients during 1-day site visits to a purposive sample of (1) primary care practices currently using PatientToc™ and (2) community pharmacies in Indiana, Wisconsin, and Minnesota interested in the future use of PatientToc™. Post-visit site observation debriefs were also audio-recorded. Verbatim transcripts of all recordings were coded using deductive/inductive approaches and intra-/inter-site summaries were produced identifying potential barriers, facilitators, and actionable recommendations mapped to the Consolidated Framework for Implementation Research constructs. A stakeholder advisory panel engaged in an Evidence-Based Quality Improvement (EBQI) implementation process. This included "member checking" and prioritizing findings, and feedback on the adapted PatientToc™ application, implementation strategies, and accompanying toolkit for community pharmacy implementation. RESULTS: Two primary care practices, nine pharmacies, and 89 individuals participated. Eight major themes (four barriers and four facilitators) and 14 recommendations were identified. Throughout the four EBQI sessions, the panel (1) confirmed findings; (2) designated high priority recommendations: (a) explain PatientToc™ and its benefits clearly and simply to patients, (b) ensure patients can complete questionnaires within 10 min, and (c) provide hands-on training/resources for pharmacy teams; and (3) provided feedback on the adapted PatientToc™ application and finalized toolkit items for initial community pharmacy implementation. CONCLUSIONS: Adoption of electronically captured PROs in community pharmacies is warranted. The implementation strategies systematically developed in this study can serve as a model for implementation of technology-driven health information patient care services, in the understudied context of community pharmacies.

Adaptation and validation of the patient assessment of chronic illness care in United States community pharmacies.

BACKGROUND: Roles for United States (US)-based community pharmacists in caring for persons with chronic conditions have greatly expanded. The Patient Assessment of Chronic Illness Care (PACIC) was developed to assess patients' perspectives of care received. However, successful application of this instrument in community pharmacies is uncertain. The objective of this study was to adapt the PACIC for use in community pharmacies (CP-PACIC), assess validity of the CP-PACIC and examine CP-PACIC scale score differences relative to patient characteristics. METHODS: This cross-sectional study surveyed chronically ill adults in Indiana, US who receive care from pharmacists in community pharmacies. The modified CP-PACIC scale consisted of 20-items, which were rated on a 5-point Likert scale from 0 (none of the time) to 4 (always). The total possible score ranged from 0 - 80. An exploratory factor analysis (EFA) was conducted to assess performance and dimensionality. CP-PACIC validity, including face validity, construct validity (via exploratory factor analysis) and internal consistency were assessed. Relationships between patient characteristics and scale scores were evaluated using appropriate statistical tests. RESULTS: Five hundred forty-six respondents' data were analyzed. EFA revealed a 2-factor solution (termed advanced pharmacy chronic illness care (AP) and traditional pharmacy chronic illness care (TP) subscales) accounting for 64.7% of variance; all 20 items were retained. The total 20-item CP-PACIC scale had a Cronbach's alpha (internal consistency) of 0.96; with a 12-item AP subscale Cronbach's alpha of 0.97 and 8-item TP subscale Cronbach's alpha of 0.89. Median total score was 12.0 [interquartile range = 27.3]. Median CP-PACIC sores varied across many respondent demographics (i.e., survey administration type, age, sex, education, health condition, number of pharmacy services received, community pharmacy type) such as whether respondents participated in one or more pharmacy service or not (29 vs. 10; p < .001). CONCLUSIONS: Unlike the original 5-subscale (patient activation, delivery system design, goal setting, problem solving, and follow-up/coordination) PACIC, analysis demonstrated a 2-factor (AP, TP) solution for the CP-PACIC scale with good internal consistency. As there are no standardized evaluation tools that exist, community pharmacies could find great value in using this CP-PACIC tool to benchmark performance and inform quality improvement strategies for patient care delivery.

Evaluation of a modified and abbreviated scale for assessing chronic illness care for medication therapy management practice.

BACKGROUND: The central goals of MTM align with those of the Chronic Care Model (CCM). However, reliable and valid assessments are needed to estimate the extent to which components of MTM care delivery are consistent with the CCM. The Assessment of Chronic Illness Care (ACIC) is a 34-item scale for administration in primary care offices to estimate the extent to which chronic care delivery aligns with the six elements of the CCM. The ACIC appears to be responsive for care delivery interventions aimed at improving various chronic illnesses. However, the potential value of the ACIC as a measure for evaluating MTM delivery is unknown. OBJECTIVE: A modified and abbreviated version of the ACIC could be a useful evaluation tool for pharmacist-provided medication therapy management (MTM). The objective of this study was to assess the construct and criterion-related validity, and internal consistency, of the abbreviated (12-item) "MTM ACIC." METHODS: The abbreviated MTM ACIC was administered to pharmacists employed at 27,560 community pharmacies. Construct validity and internal consistency were estimated through principal components analysis, item-to-total correlations, and Cronbach's alpha estimate of internal consistency. To assess criterion-related validity, a univariate negative binomial model estimated the association between ACIC scores and pharmacy-level MTM completion rates. RESULTS: A one-component model accounted for 64% of the variance, and Cronbach's alpha was 0.95. Scores on the abbreviated MTM ACIC were associated with MTM completion rates (rate ratio: 1.02; 95% CI: 1.01 to 1.03). CONCLUSION: The abbreviated MTM ACIC exhibited acceptable construct and criterion-related validity and internal consistency and could serve as a valuable tool for evaluating chronic illness care within the MTM setting.

Impact of pharmacist prescribing through direct pharmacy access policies on access to hormonal contraception.

BACKGROUND/OBJECTIVE: This study assesses the impact of direct pharmacy access (DPA) policies that allow pharmacists to prescribe hormonal contraceptives on women's access by comparing access among 3 groups: (1) women in a state without DPA (Indiana), (2) women in a state with DPA, but not using DPA, and (3) women in a state with DPA and using DPA. METHODS: This cross-sectional survey, including a scale to measure access to contraceptives, perception items, and demographics, was distributed through Amazon Mechanical Turk (Amazon.com, Inc). Kruskal-Wallis tests and linear regression analysis were used. RESULTS: The sample size was 316. When controlling for education, income, and age, the women not using DPA (in Indiana and a DPA state, respectively) reported significantly higher levels of approachability (P < 0.001 and P < 0.001, respectively), acceptability (P < 0.001 and P < 0.001, respectively), availability and accommodation (P < 0.001 and P = 0.009, respectively), affordability (P < 0.001 and P < 0.001, respectively), and appropriateness (P < 0.001 and P < 0.001) access than the women using DPA. The women using DPA reported significantly lower levels of privacy access than those not using DPA in a DPA state (P = 0.004) when controlling for education, income, and age. However, 78.9% of women using DPA agreed DPA made obtaining contraceptives easier. Most of the women who had never used DPA were previously unaware of DPA (81.1% in DPA states and 86.2% in Indiana) but felt that it would improve access (82.8% and 80.0%, respectively). CONCLUSION: Understanding the effects of DPA policies on women's access to contraceptives can inform future policies and support implementation. Lower levels of access across all dimensions among those using DPA may be influenced by imperfect implementation and failure to legislatively enable the sustainability of this service rather than pharmacists' ability to improve women's access.

Validation and threshold identification of a prescription drug monitoring program clinical opioid risk metric with the WHO alcohol, smoking, and substance involvement screening test.

BACKGROUND: Prescription drug monitoring programs (PDMPs) are critical for pharmacists to identify risky opioid medication use. We performed an independent evaluation of the PDMP-based Narcotic Score (NS) metric. METHODS: This study was a one-time, cross-sectional health assessment within 19 pharmacies from a national chain among adults picking-up opioid medications. The NS metric is a 3-digit composite indicator. The WHO Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) was the gold-standard to which the NS metric was compared. Machine learning determined optimal risk thresholds; Receiver Operating Characteristic curves and Spearman (P) and Kappa (K) coefficients analyzed concurrent validity. Regression analyses evaluated participant characteristics associated with misclassification. RESULTS: The NS metric showed fair concurrent validity (area under the curve≥0.70; K=0.35; P = 0.37, p < 0.001). The ASSIST and NS metric categorized 37% of participants as low-risk (i.e., not needing screening/intervention) and 32.3% as moderate/high-risk (i.e., needing screening/intervention). Further, 17.2% were categorized as low ASSIST risk but moderate/high NS metric risk, termed false positives. These reported disability (OR=3.12), poor general health (OR=0.66), and/or greater pain severity/interference (OR=1.12/1.09; all p < 0.05; i.e., needing unmanaged-pain screening/intervention). A total of 13.4% were categorized as moderate/high ASSIST risk but low NS metric risk, termed false negatives. These reported greater overdose history (OR=1.24) and/or substance use (OR=1.81-12.66; all p < 0.05). CONCLUSIONS: The NS metric could serve as a useful initial universal prescription opioid-risk screener given its: 1) low-burden (i.e., no direct assessment); 2) high accuracy (86.5%) of actionable data identifying low-risk patients and those needing opioid use/unmanaged pain screening/intervention; and 3) broad availability.

A user-centered evaluation of medication therapy management alerts for community pharmacists: Recommendations to improve usability and usefulness.

BACKGROUND: Community pharmacists provide comprehensive medication reviews (CMRs) through pharmacy contracts with medication therapy management (MTM) vendors. These CMRs are documented in the vendors' web-based MTM software platforms, which often integrate alerts to assist pharmacists in the detection of medication therapy problems. Understanding pharmacists' experiences with MTM alerts is critical to optimizing alert design for patient care. OBJECTIVES: The objectives of this study were to 1) assess the usability and usefulness of MTM alerts for MTM vendor-contracted community pharmacists and 2) generate recommendations for improving MTM alerts for use by community pharmacists. METHODS: This was a convergent, parallel mixed-methods evaluation of data collected from 3 sources, with individual pharmacists contributing data to one or more sources: 1) community pharmacists' submissions of observational data about MTM alerts encountered during routine MTM provision, 2) videos of naturalistic usability testing of MTM alerts, and 3) semi-structured interviews to elicit pharmacists' perspectives on MTM alert usefulness and usability. MTM alert data submitted by pharmacists were summarized with descriptive statistics. Usability testing videos were analyzed to determine pharmacists' time spent on MTM alerts and to identify negative usability incidents. Interview transcripts were analyzed using a hybrid approach of deductive and inductive codes to identify emergent themes. Triangulation of data (i.e., determination of convergence/divergence in findings across all data sources) occurred through investigator discussion and identified overarching findings pertaining to key MTM alert challenges. These resulted in actionable recommendations to improve MTM alerts for use by community pharmacists. RESULTS: Collectively, two and four overarching key challenges pertaining to MTM alert usability and usefulness, respectively, were identified, resulting in 15 actionable recommendations for improving the design of MTM alerts from a user-centered perspective. CONCLUSIONS: Recommendations are expected to inform enhanced MTM alert designs that can improve pharmacist efficiency, patient and prescriber satisfaction with MTM, and patient outcomes.

Positive deviants for medication therapy management: A mixed-methods comparative case study of community pharmacy practices.

BACKGROUND: To optimize medication use in older adults, the Centers for Medicare & Medicaid Services (CMS) launched Medication Therapy Management (MTM) services as part of Medicare Part D policy; however, strategies for achieving high quality MTM outcomes are not well understood. OBJECTIVE: The objective of this study was to generate hypotheses for strategies contributing to community pharmacies' high performance on policy-relevant MTM quality measures. METHODS: This mixed-methods comparative case study was guided by the Positive Deviance approach and Chronic Care Model. The study population consisted of pharmacy staff employed by a Midwestern division of a national supermarket-community pharmacy chain. Data consisted of demographics and qualitative data from semi-structured interviews. Qualitative and quantitative data were analyzed deductively and inductively or using descriptive statistics, respectively. MTM quality measures used to evaluate participant pharmacies' MTM performance mirrored select 2017 Medicare Part D Plans' Star Rating measures. RESULTS: Thirteen of 18 selected case pharmacies (72.2%) participated in this study, of which 5 were categorized as high performers, 4 moderate performers, and 4 low performers. Eleven pharmacists, 11 technicians, and 3 student interns participated in interviews. Eight strategies were hypothesized as contributing to MTM performance: Strong pharmacy staff-provider relationships and trust, Inability to address patients' social determinants of health (negatively contributing), Technician involvement in MTM, Providing comprehensive medication reviews in person vs. phone alone, Placing high priority on MTM, Using available clinical information systems to identify eligible patients, Technicians using clinical information systems to collect/document information for pharmacists, Faxing prescribers adherence medication therapy problems (MTPs) and calling on indication MTPs. CONCLUSIONS: Eight strategies were hypothesized as contributing to community pharmacies' performance on MTM quality measures. Findings from this work can inform MTM practice and Medicare Part D MTM policy changes to positively influence patient outcomes. Future research should test hypotheses in a larger representative sample of pharmacies.

An evaluation of the spread and scale of PatientToc™ from primary care to community pharmacy practice for the collection of patient-reported outcomes: A study protocol.

BACKGROUND: Medication non-adherence is a problem of critical importance, affecting approximately 50% of all persons taking at least one regularly scheduled prescription medication and costing the United States more than $100 billion annually. Traditional data sources for identifying and resolving medication non-adherence in community pharmacies include prescription fill histories. However, medication possession does not necessarily mean patients are taking their medications as prescribed. Patient-reported outcomes (PROs), measuring adherence challenges pertaining to both remembering and intention to take medication, offer a rich data source for pharmacists and prescribers to use to resolve medication non-adherence. PatientToc™ is a PROs collection software developed to facilitate collection of PROs data from low-literacy and non-English speaking patients in Los Angeles. OBJECTIVES: This study will evaluate the spread and scale of PatientToc™ from primary care to community pharmacies for the collection and use of PROs data pertaining to medication adherence. METHODS: The following implementation and evaluation steps will be conducted: 1) a pre-implementation developmental formative evaluation to determine community pharmacy workflow and current practices for identifying and resolving medication non-adherence, potential barriers and facilitators to PatientToc™ implementation, and to create a draft implementation toolkit, 2) two plan-do-study-act cycles to refine an implementation toolkit for spreading and scaling implementation of PatientToc™ in community pharmacies, and 3) a comprehensive, theory-driven evaluation of the quality of care, implementation, and patient health outcomes of spreading and scaling PatientToc™ to community pharmacies. EXPECTED IMPACT: This research will inform long-term collection and use of PROs data pertaining to medication adherence in community pharmacies.

Experiences Applying Technology to Overcome Common Challenges in Pharmacy Practice-Based Research in the United States.

Despite the importance of pharmacy practice-based research in generating knowledge that results in better outcomes for patients, health systems and society alike, common challenges to PPBR persist. Herein, we authors describe PPBR challenges our research teams have encountered, and our experiences using technology-driven solutions to overcome such challenges. Notably, limited financial resources reduce the time available for clinicians and researchers to participate in study activities; therefore, resource allocation must be optimized. We authors have also encountered primary data collection challenges due to unique data needs and data access/ownership issues. Moreover, we have experienced a wide geographic dispersion of study practices and collaborating researchers; a lack of trained, on-site research personnel; and the identification and enrollment of participants meeting study eligibility criteria. To address these PPBR challenges, we authors have begun to turn to technology-driven solutions, as described here.

Evaluating the effects of a multidisciplinary transition care management program on hospital readmissions.

PURPOSE: To measure the effect of a pharmacist-initiated transitions of care (TOC) program on rates of 30-day all-cause readmissions and primary care follow-up. METHODS: A retrospective cohort study was conducted to evaluate a pharmacist-initiated TOC program for patients discharged from hospitals of a large health system from September 2015 through July 2016. Discharged patients of 13 primary care physicians (the intervention cohort) received TOC program services, and discharged patients seen by 12 other primary care physicians (the control cohort) received usual care. Patients in both cohorts were followed for 90 days. The primary outcome was 30-day all-cause readmissions, and secondary outcomes were 14-day primary care visits, TOC pharmacist identification and resolution of medication therapy problems (MTPs), and transition care management (TCM) billing. Multivariable modeling was performed to test the associations of patient receipt of TOC services with 30-day readmissions and 14-day primary care visits, with controlling for patient demographics and baseline healthcare utilization. RESULTS: A total of 492 patients received the TOC intervention, and 379 were followed in the usual care cohort. Among intervention patients, 960 MTPs were identified, and 85.7% of identified MTPs were resolved. Moreover, 9% of intervention cohort patients were readmitted within 30 days, compared to 15% of control cohort patients, and this effect was significant in the multivariable model (odds ratio, 1.82; 95% confidence interval, 1.15-2.89; P = 0.0108). Rates of primary care visits did not differ significantly between the groups; 65% of intervention group visits were billed using TCM codes. CONCLUSION: A pharmacist-initiated TOC program was effective in reducing 30-day all-cause readmissions.

Medication Therapy Management: Current Challenges.

Medication therapy management (MTM) services have evolved as a means for pharmacists and other providers to assist patients and caregivers in improving therapeutic outcomes and reducing health care expenditures. More than a decade has passed since the Medicare Modernization Act of 2003 provided pharmacists with the opportunity to deliver MTM services to Medicare beneficiaries. MTM continues to offer pharmacists the opportunity to use their knowledge; yet, pharmacists have reported challenges with service delivery. Identifying the challenges that affect MTM services in pharmacy practice is necessary in order to seek improvement to MTM delivery. This narrative review explores the current challenges pharmacists face with MTM delivery, summarizes potential solutions for addressing challenges, and seeks to incite further debate, service reconfiguration, and ultimately service improvement of pharmacist-provided MTM services.