The MinnesotA Rural Health

The MinnesotA Rural HealthAssociation Presents:Pharmacist Accessin Rural MinnesotaTim Stratton, Ph.D., BCPS, FAPhAAssociate ProfessorCollege of Pharmacy, DuluthUniversity of Minnesota➢Outline the steps in pharmacist training➢Describe the concept of “pharmaceutical care” and give examples of drug therapy problems➢Describe other patient-care and administrative contributions of pharmacists ➢Describe the challenges facing pharmacists in rural MNWhat comes to mind when most people hear the word, “Pharmacist”Pharmacy Practice:It’s all about the patient…… whether in the community setting…,… or in the hospital or nursing home➢At least two years pre-pharmacy➢almost 75% of current class have degrees➢Four years in Doctor of Pharmacy (Pharm.D.) professional program➢Three years didactic, Early Practice Experiences➢Final year Advanced Practice Experiences➢Qualified to practice after passing NABPLEX➢Optional: One-year General Clinical Residency (Adult Medicine)➢Optional: Advanced Specialty Residency or Fellowship Training➢Optional: Board of Pharmaceutical Specialties (BPS) Certification➢Pharmacist sits down with patient in office-like setting/exam room➢Identifies existing drug therapy problems, or tries to prevent potential drug therapy problems➢Pharmacist reports outcome of patient visit back to patient’s prescriber➢Model for MN Medication Therapy Management (MTM) Program➢Additional drug therapy needed (28%)➢Dosage too low (20%)➢Noncompliance (19%)➢Adverse drug reaction (14%)➢Ineffective drug (8%)➢Unnecessary drug or no indication (6%)➢Dosage too high (5%)2004 -Peters Institute of Pharmaceutical CareUniversity of Minnesota College of Pharmacy●CLIA-waived finger-stick tests for cholesterol and blood glucose●Quantitative ultrasound heel bone density testing to screen for osteoporosis ●Spirometry testing for chronic obstructive pulmonary disease (COPD –emphysema and chronic bronchitis)State has recognized that…➢Pharmacist intervention with high-risk patients can improve therapeutic outcomes➢Improving therapeutic outcomes saves Minnesota MA program moneyGreater percentage of rural residents receive Minnesota MA than urban residentsPatient requirements:➢Covered by Minnesota MA, GAMC, or MinnesotaCare➢Taking 4 or more prescriptions –and –➢Meds are being used to treat or prevent 2 or more chronic conditions –or –➢Patient has had a previously-identified DTP that has resulted in, or is likely to result in significant nondrug MA, GAMC, MinnCare costsS.F. 973 –84th Legislative Session (2005-2006)Pharmacist requirements:➢Minnesota-licensed pharmacist➢Received Pharm.D.degree on/after May,1996➢Or completed structured,comprehensive education program approved by Board of Pharmacy➢Practicing in ambulatory care setting as part of an interprofessional team➢Or developed a structured patient care process that is offered in a private setting➢Make use of electronic patient record systemMTM services:➢Assessments of patient’s health status➢Perform a comprehensive med review to identify, resolve and prevent DTPs, including ADRs➢Formulate medication treatment plans➢Monitor/evaluate patient’s response to therapy➢Effectiveness & safety▪MTM services (cont.):➢Verbally educate and train patient toenhance patient understanding andappropriate use of medications➢Provide information, services andresources to enhance patient adherence to therapy➢Document care delivered and communicate essential information to patient’s primary care provider✓Watchful waiting✓Non-drug self-treatment✓Nonprescription drug✓treatment✓Referral to more intensive✓level of care✓“BTC” Emergency contraception➢Institute of Medicine Reports➢Missing info from prescription/order➢Unreadable info on prescription/order➢Prescribed drug not on formulary➢Drug not covered by patient’s insurance➢Patient cannot afford drug➢Dosage change after prescription dispensed (e.g., lamotrigine)➢Instructions relayed by patient inconsistent with sig on prescription➢MD calls with diagnosis to check on which drugs available vs. locums tenem who simply prescribes what she/he accustomed to➢DVM sends pet owners to pharmacy with verbal orders for Rx meds➢DDS checks on “problem patients”➢Consults (IHS MDs, hospital inpatients, discharge patients)➢Serve on committees of local hospital/CAH, enabling facility to meetlicensure/accreditation requirements➢Manage formulary & inventory of drugs used in the hospital, improving economic performance of facility➢Conduct monthly chart reviews for local LTCF as required by Medicare➢Collaborative practice agreements with MDs, e.g., manage Coumadin® patientsTowns w/ population < 5000Represents total population > 216,000A. Traynor and T. Sorensen College of Pharmacy➢Reduced reimbursement rates from insurers➢Medicaid cuts➢Greater % of pop. dependent on MA in rural areas ➢Competition –“big box” retailers, Mail Order,➢Challenges recruiting regular and relief staff ➢Spousal issues for graduates➢Workload management➢Transition of ownership➢Independent pharmacies: 48% of rural, 29% ofurbanA. Traynor and T. SorensenCollege of PharmacyA Fragile Environment➢Challenges to the ability to deliver pharmacy services in rural areas➢Cumulative effects➢102 non-metro MN pharmacy closures since 1996 vs. 87 closures in seven-county metro1➢Nine of 38 pharmacy closures in rural MN resulted in a community with no local pharmacy access from 1996-199921.MN Dept of Health ORHPC 10/20032.Moscovice I, et. al. Rural Health Research Center, UMN, July 2001➢Age of Pharmacist –Desired age of retirement ➢Revenue of Pharmacy➢Presence of other health providers/services in community➢Distance to next nearest community withpharmacy➢Experience recruiting regular and relief staffA. Traynor and T. SorensenCollege of PharmacyAbility of pharmacy owners to sell practice will likely affect continued availability of pharmacy services in many communities➢70 communities have independently-ownedpharmacies. Average age of owner = 50+ years➢The average difference between current age ofpharmacy owners and the age by which they wouldideally sell their pharmacy was 7.6 years.➢This difference was less than 2 years in 18communitiesA. Traynor and T. SorensenCollege of PharmacyDistance to Next Nearest Community with a Pharmacy (Avg. = 21.7 miles)Miles to Nearest Pharmacy0 TO 56 TO 1011 TO 1516 TO 2021 TO 2526 TO 3030+More than 25% exceed 25 milesA. Traynor and T. Sorensen College of PharmacyDifficulty of Recruiting Staff Pharmacists inRural Communities (n = 81)How difficult has it been to recruit full-time staff pharmacists in the last 5 years?24681012141618Very Difficult Moderately Difficult Somewhat Difficult Not DifficultHow difficult has it been to recruit part-time staff pharmacists in the last 5 years?5101520Very Difficult Moderately Difficult Somewhat Difficult Not DifficultA. Traynor and T. Sorensen College of PharmacyHow often have you had to change plans because a relief pharmacist was not available?51015202530RarelyOccasionally FrequentlyDifficulty of Recruiting Relief Pharmacists inRural Communities (n = 81)510152025303540Very Difficult Moderately Difficult Somewhat Difficult Not DifficultHow difficult is it to find a relief pharmacist when you need one?A. Traynor and T. Sorensen College of Pharmacy➢Most small rural communities are serviced by independent pharmacies ➢Rural pharmacists are aging➢Independent owners would like to sell➢Communities are at-riskWill the next generation of pharmacists fill the need?A. Traynor and T. SorensenCollege of Pharmacy➢“Have you given or would you give serious consideration to practicing in a town with a population of 5000 people or lessafter graduation?”111 Yes66 No➢“Have you given serious consideration to pursuing ownership (full or partnership) of a community pharmacy?”47 Yes130 No➢For those not interested in community pharmacy ownership,76.9% reported that responsibilities and time commitmentwere of moderate or great influence in their consideration.A. Traynor and T. SorensenCollege of Pharmacy➢Large Population of Seniors in Rural MN➢nearly 1/2 of rural seniors lacked Rx coverage vs. to 1/3 of urban seniors➢Scope of Medication Use➢rural residents are more dependent on medications due toa higher prevalence of chronic conditions➢Rx Payment and Margins➢Rural pharmacies 18% cash sales vs. 13% in urban➢Limits on Rx volume and revenue growth➢independent pharmacies: 93% of revenue from Rx sales➢Today’s pharmacists are being trained to provide more direct patient care –particularly useful in rural communities as providers of first contact care➢Rural pharmacists make many contributions to other local healthcare entities including CAHs and LTCFs ➢More rural pharmacies are independently owned;economic and HR challenges have greater impact than on urban pharmacies➢MN has 128 one-pharmacy towns, several of which are at risk for losing their pharmacy services when the owner retires。