Exam 2 Flashcards
Health
A state of complete well being
-Physical, mental, social
Not merely the absence of disease or infirmity
Disease
Objective phenomenon/professional construct
Characterized by altered or abnormal functioning of the body
Medical term for a pathological change in the structure or function of the body or mind
Illness
Subjective phenomenon/lay construct
Includes both physical and social state
Response of the person to a disease
Sick role
Person is excused from social/normal role responsibilities because of a disease or illness
Rights of the sick person:
-Not responsible or blamed for their condition
-Not responsible for inability to meet normal obligations
Person may seek advice from science or legitimate source to legitimize their condition
Such man’s 5 stages of illness
- Symptom experience
-Initial stage of illness
-varies from individual to individual
-Signs vs symptoms - Assumption of sick role
-Individual makes decision that they are sick - Medical care contact
—Professional within the health care system
-Stage may continue with dissatisfaction - Dependent patient
-Decision to transfer control and accept the prescribed treatment
a. sick individual is now a patient
B. Most adhere to treatment
C. Family or lay referral system play role
-Not easy to accept patient role - Recovery or rehabilitation
-Decision to relinquish patient role
-Easier in comparison to decisions at other stages
-Health care provider and lay caregivers withdraw legitimization
-Acceptance of condition
differences in illness experience
-Interpret symptoms to build “illness templates”
-“Illness templates” describe patient perception of their illness and how they think it may be treated
Interpretation is based on a patients:
-Awareness of health literature
-Personal health experiences
-religious beliefs
-family and social contacts
-cultural expectations
-self learning efforts
Leventhal’s common sense model of illness
- Identity
-The label the patient places on the disease and the symptoms associated with it - Cause
-Patient’s perception of how they got the disease - Timeline
-Patient’s sense of how long the disease will last (acute vs chronic) - Consequences
-Patient’s expectation of the outcome of the disease - Cure/control
-Patient’s perception of how the illness can be cured or controlled
Explanatory models of illness
-The way patients explain their health conditions and consequences
-To understand a patient’s explanatory model of illness it is important to ask what, why, how and who questions
Why are these questions important?
-Be able to understand the culture of western/biomedicine and its conflicts
-Western medical model/biomedicine (the body is a machine)
-Others
A. Illness more as an imbalance of forces/unseen forces
B. Yin-yang
Szasz and Hollander’s Model of Care
Activities and passivity model
-Oldest
-None or little interpersonal communication
-Active practitioner and passive patient
-Parent/infant relationship
Guidance-cooperation model
-Patient is capable of interpersonal communication
-Patient can perform independent action but still require professional attention (acute infection)
-Parent/adolescent relationship
Mutual participation Model
-Patient and practitioner are both powerful and interdependent
-Practitioner has medical expertise, patient has personal experience
-Patients with chronic diseases
-Adult/adult relationship
The consumer model of care
-Great patient autonomy in decision making
-Emphasizes patients’ rights
-Patient is an informed and skeptical buyer of medical care
-Patients right to choose care and the provider’s obligation to serve the patient is emphasized
-Providers are sellers who respond to the needs of the patient
Patient centered model of care
-Focus is on the whole person versus the body
Practitioners view illness through
-Understanding the patient’s ideas about what is wrong
-Eliciting the patient’s feeling (especially fears) about the illness
-Assessing how the problem affects the patient’s daily life
-Discovering the expectation of the patient regarding treatment
The biophysical model of care
A shift in western medicine from the biomedical model to a biopsychosocial model
-Biomedical model era (acute infectious disease was major killer)
Biopsychosocial model
-chronic diseases is major killer
-Consider psychosocial issues such as poverty, place of residence, environmental pollution, stress, diet, exercise
Pharmacist role in health, illness and disease
Your role will depend on patient’s response to illness
Self-care
-Make OTC recommendations
-Set expectations for symptom timeline/management
-Triage to higher level of care
Consult healthcare provider:
-Fill prescriptions and provide consultations
-Address adherence concerns
-Set expectations for treatment course
-depending on your scope of practice you may be the provider that a patient sees
Social Determinants of Health
Conditions in the environment in which people are born, live, learn, work, play, worship and age that affect a wide range of health, functioning, and quality of life outcomes and risks
5 domains of SDOH
- Education Access and Quality
-People with higher levels of education are more likely to be healthier and live longer
2030 Ex: Increase proportion of high school graduates in college the October after graduating, increase proportion of 8th graders with reading skills at or above the proficient level, increase the proportion of children who are developmentally ready for school - Health care access and quality
-The ability to get needed services in a timely manner impacts health
2030 ex: Reduce proportion of people who can’t get prescription medicines when they need them, increase the proportion of people with a usual PCP, increase knowledge of HIV status, Increase proportion of pregnant women who receive early and adequate prenatal care - Neighborhood and built environment
-The safety of one’s physical environment impacts health
2030 ex: reduce rate of minors and young adults commiting violent crimes, Increase proportion of adults with broadband internet, reduce the number of days people are exposed to unhealthy ai, increase the proportion of adults who walk or bike to get to places - Social and community context
-relationships and interactions with family, friends, co-workers and community members impacts health
2030 ex: reduce proportion of children who have a parent who has been in jail, increase proportion of children whose family reads to them, eliminate very low food security in children, reduce bullying of transgender students - Economic stability
-Employment and income impact ability to afford food, housing, healthcare, and education. All contribute to overall health
2030 Ex: Reduce proportion of people living in poverty, increasing employment in working-age people, reduce proportion of families that spend more than 30% of income on housing
current approaches to address SDOH
Payers and health systems mine utilization and payment data
-identify vulnerable populations
-connect patients programs or providers
Screening at physician visits
-Tools embedded in EHR or clinical reminders to ask SDOH questions
-Referral to resource
Screening by ambulatory care pharmacists in health systems:
-Part of the patient encounter
-Internal flagging of patient due to claims data
Limitations in addressing SDOH
Time constraints
-SDOH screening is not prioritized given number of competing responsibilities and short appointment times
Lack of training
-Providers are not educated on how to screen for SDOH needs and where to refer patients for support
Discomfort with screening questions
-Can feel awkward to ask about money, home stability, food security
-Concern about identifying a need and not knowing where to refer next
How to discover limitations in SDOH?
-Include them in pre-appointment screening forms
-Delegate to people on team who are able to screen/ask these questions
-Be creative in practice on how to incorporate these questions into appointments
Pharmacist approach to SDOH
Collect data to identify patients who may have SDOH needs
-Data about health service use
-Screen all patients using SDOH screening tool
Assess any identified needs
Develop a care plan
Implement plan
Follow up
Role of pharmacist in addressing SDOH
-Pharmacist can have impacts at the patient, practice, and community level
-Many patient level impacts
-What impacts can the pharmacist have at a broader level?
Patient level SDOH interventions : Provide culture sensitivity training
Provide culturally sensitive patient education
-Cultural sensitivity training is a required component of pharmacy school
-Training of health literacy
-Implicit bias awareness
-Develop skills for working with an interpreter
Medication affordability
Patient level SDOH intervention
-Suggest OTC or non OTC intervention
-Generic substitution or recommending cost-effective alternative
-Connect patients with discount cards, copay assistance cards, manufacturer patient assistance programs
-Assist patients with obtaining insurance coverage or selecting a part D plan
Medication adherence interventions
Patient level SDOH intervention
-disease state and medication education
-recommending combo pills to reduce pill burden
-Automatic refill services, 90 day fills, medication refill reminders
-Med sync programs
-Offering pill boxes or blister package services
-Med delivery
-Use of claims or fill data to identify at risk patients
Primary preventions strategies
Practice level SDOH interventions
-Immunizations, health screenings, point of care testing, education, smoking cessation.
-Triage health concerns and minimize unnecessary healthcare utilizations
Social need screening and referral
Practice level SDOH interventions
-Ask about social history
-Identify SDOH related needs
-Connect to appropriate resources
*remember screening tools discussed earlier in this lecture
Interdisciplinary collaboration
Practice level SDOH interventions
-collab with physicians and suggest cost effective treatment, assist in formulary and prior authorization process
-Collab with social work and reduce hospital readmissions and improve transitions of care
-Collab with community health workers and connect patients to appropriate resources to meet social and economics needs
Community engagement
Community level SDOH interventions
Develop local relationships
Serve and volunteer in the community
Participate in community clean up activities or building community gardens
Community needs assessment and planning
Community level SDOH intervention
-active listening to patients needs and advocate for change
-Contribute to body of knowledge and data on health disparities research
Political advocacy
Community level SDOH intervention
-Advocate for social change
-Support policies regarding public and environmental safety
-Leverage relationships with local health departments to advocate for community
-seeking elected positions
Models used in community pharmacy
Pharmacists screen and refer to community based organizations (CBO)
Partner with community health worker (CHW)
SDOH specialist screens patient and refers to county health departments or CBOs
Barriers to pharmacist interventions
Demonstrating value of pharmacists’ services that address SDOH
Billing and reimbursement
Building appropriate community connections and referral processes
Health Disparities
A particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage
*Affect groups of people who have systematically experienced greater obstacles to health based on:
-Racial or ethnic group
-Religion
-Socioeconomic status
-Gender
-Age
-Mental Health
-Cognitive, sensory, physical disability
-Sexual orientation
-Geographic location
-Any other characteristic historically linked to discrimination or exclusion
Maternal Mortality
could include:
-Higher disease incidence or prevalence of
-Poorer health outcomes
-Greater morbidity
-Premature or excessive mortality
-Higher rates of risk behaviors
-Greater burden of disease
Poorer health related quality of life or daily functioning
Healthcare disparity
Differences among populations groups in the availability, accessibility and quality of healthcare services aimed at the prevention, treatment, and management of diseases and their complications including screening, diagnostic, treatment, management, and rehabilitation services
*Difference in access to care and quality of services
Ex:
Primary care:
Individuals of racial and ethnic minority groups are significantly less likely to have a usual source of primary care and are more likely to report a facility or hospital as their usual source of care (rather than an individual clinician)
SDOH and disparities
Inequities in SDOH can lead to health disparities
-Health care access and quality (Insurance coverage, access to an coverage of vaccines, and cancer screenings)
-Neighborhood and built environment (housing and air quality—>exposure to air toxins)
-Social and community context
-Economic stability (employment and income)
-Eduction access and quality
Causes of disparities
- Structure and organization of healthcare systems
- Healthcare provider biases, prejudices and uncertainty in treating underserved populations
- Mistrust stemming from historical mistreatment of particular patient groups
- Healthcare operates in society at large and is impacted by systemic racism, sexism, heterosexism, classism, xenophobia, ageism, ableism etc.
Implicit bias
Attitudes, preferences, and beliefs about social groups that operate outside of human awareness or control
Implicit bias among health professionals
Healthcare professionals hold implicit and explicit biases associating men with careers and surgery and women with family and family medicine
*Women were less likely to hold these explicit biases, but still held them implicitly
*There is a significant positive relationship between level of implicit bias and lower quality of care
Pharmacists role in disparities and inequities
Pharmacists are well positioned to reduce health disparities and inequities
-Ranked one of the most trusted professions
-Highly accessible
- Determine unmet needs in the community
- Practice cultural humility
- Advocate for policies that advance health for all
Ex: chronic disease state management, expand point of care testing, increase preventative care services
Health Equity
The attainment of the highest level of health for all people
Health Inequity
Differences in health which are not only unnecessary and avoidable but, in addition, are considered unfair and unjust
Equity and equality
Equality is sameness
-Giving everyone the same tools and support regardless
(everyone is given the same bike –> some people can’t use it, too small, too big)
Equity is providing everyone with the same tools and support that is needed for them to be successful
(everyone is given a bike that personally fits them)
Upstream cause for Health inequity, Health disparities and inequities in SDOH
Cause of Health inequity –> Same things that cause health disparities
Cause of Health disparities –> Inequities in the SDOH
Causes of inquities in SDOH –>
Look upstream
- A variety of models and frameworks have been developed to understand the SDOH and Health equity
- Although the models shown on the following slides are different, pay attention to the factors furthest upstream
Ex: Structural Discrimination, social/institutional inequites, Discriminatory beliefs and Institutional power
Upstream from SDOH
Immediate upstream factors include the laws, regulations, policies, governing bodies and organization that perpetuate power imbalances
Even further upstream we see inequities stem from discriminatory practices and beliefs such as structural racism, classism, sexism, etc.
Achieving Health Equity
Valuing everyone equally
Focused societal efforts to address avoidable inequalities, historical and contemporary injustices, and health and healthcare disparities
-Efforts to remove obstacles to health such as poverty, discrimination, unequal access to good jobs or fair play, and unequal access to quality education, housing or safe environments
Bravemans 4 step process for advancing Health Equity
- Identify disparities and what inequities lead to those disparities
- Look upstream to change policies, laws, systems, environments, and practices that reduce the inequities in opportunity to be health
- Evaluate efforts in both the short and long term
- Reassess strategies and next steps based on progress
Pharmacist role in health equity
- Identify health disparities in your practice
- Look upstream for causes of disparities and obstacles limiting access to fair opportunities for health
- Design targeted interventions
- While caring for individual patients, advocate for change in the community or health system to address upstream social inequities
- Monitor impact through population health data
- Re-assess and modify interventions as needed
Public Health
The activities that society undertakes to assure the conditions in which people can be healthy, including organized efforts to prevent, identify, and counter threats to the health of the public
The Health Impact pyramid
Conceptual framework for public health action
-Actions at the base of the pyramid require less individual effort and have the greatest population impact
-Interventions at the top of the pyramid are designed for an individual, however, if universally and effectively applied, could have a large population effect
Potential problems intervening at the base of the pyramid:
-Actions may address social and economic structures of society and can be seen as controversial if the public feels government should not control these areas
Health Impact pyramid: Socioeconomic factors:
-Social determinants of health
-Poverty reduction
-Improved eductation
-Sanitary environment and living conditions
The Health Impact Pyramid: Changing the context to make Individuals’ default decisions healthy
-Interventions that change environmental context to make the default decision healthy regardless of education, income or other societal factors
-Individuals would need to expend significant effort to NOT benefit from these interventions
Ex: Fluoridated drinking water, iodization of salt, Passing smoke-free laws and taxing tobacco
The Health Impact pyramid: Long lasting protective interventions
-One time or infrequent protective interventions that do not require ongoing clinical care
-Requires reaching an individual vs a population effort
Ex: Immunization, colonoscopy, smoking cessation
The Health Impact Pyramid: Clinical Interventions
-Ongoing clinical interventions especially those to prevent cardiovascular disease
-Evidence based care
EX: Blood pressure or cholesterol control
The Health Impact pyramid: Counseling and education
Conseling and Education
-Education provided during clinical encounters or other settings
Problems intervening at top of pyramid
Primordial Prevention
Goal: Prevent the risk factors for disease, illness, injury, or poor health outcomes
EX: smoking bans, laws, mandating insurance coverage
Primary prevention
Goal: Prevent the disease, illness, injury or poor health outcome from occuring
EX: vaccines, brushing teeth/flossing
Secondary prevention
Goal: Reduce the impact of the disease, illness, injury, or poor health outcomes
-Early detection and treatment
EX: Mammograms, cancer screenings, labs
Tertiary prevention
Goals: Minimize the long-term impact of disease, illness, injury, or poor health outcomes
EX: Most medical care/treatment, stroke rehabilitation
Pharmacists role in public health
-Antimicrobial stewardship and infection control
-Substance abuse prevention, education, and treatment
-Prevention of controlled substance diversion
-Managing drug product shortages
-Immunizations
-Tobacco cessation
-Emergency preparedness and response
-Promoting population health
….Many more….
Role of vaccinations in public health
Eradication of diseases (small pox in 1980)
Elimination of diseases from many areas of the world (Polio, Tetanus, Rubella)
Control of diseases
Prevention of diarrhea from rotavirus and diseases associated with HPV infection
Vaccinations fall in long-lasting protective interventions
Strategies to improve vaccination rates
socioeconomic factors:
-Interventions addressing barriers of vaccine cost and healthcare access (Vaccines for children, Pharmacist ability to vaccinate)
Vaccines fro children -> Provides public purchased vaccine, for eligible children, at no charge to VFC enrolled public and private providers
Changing the context to make individual default decisions healthy
-Interventions that make getting vaccinated the easy choice (School vaccination requirements, other vaccine requirements)
Clinical Interventions
-Workflow strategies that encourage consistent efforts to vaccinate
-Development and use of information systems that support vaccination efforts (WIR)
Counseling and education
-Provide patient-specific counseling and education on immunizations
-Provide strong recommendations to vaccinate
-Use SHARE acronym to guide counseling
Justice and autonomy of Vaccination exemptions
Benefits: Prevent adverse effects of vaccine in the individual child, freedom to express autonomy
Burden: Individual child is at risk of preventable infection but will be protected by herd immunity at low levels of exemption; high levels of non-medical exemptions lead to outbreak of disease in society
Barriers to Vaccination
Patient
1. Limited access to health care
2. Vaccine cost
3. Low Awareness among adults about recommended vaccines and their benefits
4. Concerns about vaccine safety
Health Care Provider
1. Multiple competing priorities
2. Challenges in coordinating care among multiple providers
3. Complicated immunization schedule
4. Vaccine cost and reimbursement
How to overcome vaccine barriers
Educate patients on why vaccines are still valuable and be able to recognize the pattern of fall in vaccine rates –> outbreak
Specific communication strategies pharmacists use to increase likelihood of a patient accepting a recommendation
Providers should give a strong vaccine recommendation for patients
-Powerful motivator for patients to comply with vaccination recommendations –> Number one reason parents decide to vaccinate
-Use a presumptive approach when discussing vaccine recommendations
(Assume parents will choose to vaccinate)
Take time to answer questions
Address underlying distrust
SHARE
S -> Share why the vaccine is recommended for that particular patient
H -> Highlight positive benefits of the vaccine
A -> Address patient questions in lay terms
R -> Remind that vaccines not only protect the patient, but their loved ones around them
E -> Explain the potential costs of the disease
Challenges that affect a pharmacist’s ability to provide vaccinations
Immunization services increase the pharmacist’s work satisfaction but also made it more challenging (especially pediatrics)
Concerns:
-Time consuming
-Legal liability
-Reimbursement
-Keeping up to date on recommendations
-Appropriate timing of immunizations
Tobacco use as a public health concern
Remains the leading cause of preventable disease and death in the US
-Smoking is a risk factor for many diseases including cancer, cardiovascular, and lung diseases
Health disparities in tobacco use and populations that may benefit from interventions
By Race and Ethinicity:
Highest among non-hispanic American Indian or Alaskan Native
By Sexual Orientation:
Highest among bisexual adults
By disability status:
Adults with a disability smoked more than adults w/o a disability
Adults with more severe GAD or Depression smoked more cigarettes
Adults in Wisconsin that were:
-More poor
-Less educated
Had higher levels of smoking tobacco
Interventions to address tobacco use: Smokefree policies
-Expand and implement comprehensive smokefree air laws so that 100% of the U.S population is covered
-Ensure comprehensive smokefree air laws cover public places and places of employment and do not exempt gaming venues, such as casinos
-Implement 100% smokefree air laws and policies in multi-unit housing, including all forms of subsidized housing
Interventions to address tobacco use: Regulation of Tobacco Products
-Require pictorial health warnings on cigarette packages and advertisements
-Reduce the level of nicotine in tobacco products to minimally or nonaddictive levels
-Eliminate flavors in tobacco products –> menthol cigarettes
Interventions to address tobacco use: Retail policies
Place-Based Strategies: limit the type, location, and quantity of tobacco retailers
-Mandating that pharmacies be tobacco-free
-Restricting tobacco sales near schools
-Strategies to reduce the number of retailers (such as maximizing the distance between retailers and placing caps on the number of retailers in a region, usually through the use of tobacco retailer licensing)
Product-Focused Strategies:
-Increasing prices for tobacco products through tax and non-tax mechanisms
-Prohibiting the sale of flavored products
Community level interventions for tobacco cessation
Quitlines:
-Ensure the services provided by quitlines and the promotion of such services are designed, evaluated, and delivered in a manner that maximally leverages their potential to reduce tobacco-related health disparities
-Improve integration between healthcare system and quitline service providers including referral through EHRs
Mass media campaigns:
-Evidence supports use of mass media campaigns to prevent initiation of tobacco use, increase quitline calls, increase smoking cessation and reduce tobacco use among adults and youth
Organizational Level interventions for tobacco cessation
School-based tobacco prevention programs
Smokefree college campus policies
Worksite-based interventions:
-Increase health plan coverage of cessation treatment
-Improved wages to improve living conditions, reduce stress, and decrease likelihood of smoking
-Employer support of available and accessible cessation resources
-Financial incentives to quitting
-Reduce workplace barriers to accessing care: working hours, time off, etc
-Engage labor unions in tobacco control efforts
-Eliminate disparities in smoke free workplace polices
Healthcare System Interventions:
-Brief intervention performed at every encounter with a patient
-Initiate cessation services or pharmacotherapy in the ER or during hospital admissions
-Modify EHRs to require screening and documentation of tobacco use status
-Understand and address barriers to care related to insurance
—>Copayments, duration limits, limits on number of quit attempts covered
Interpersonal Level interventions for tobacco cessation
Household Smokefree Rules
-Voluntary adoption of rules for a smokefree home at the household level (in places where smoking is not already prohibited by an ordinance, public housing regulation, or property management policy)
-Smokefree policies in multi-unit housing
-Comprehensive smokefree policies at the tribal, territorial, state, and local levels
-Promote smokefree personal vehicles
-Consider role of social support or support person in quitting
Individual level interventions for tobacco cessation
Individual programs, efforts, and interventions should…
-Consider cultural influences on tobacco use
-Encourage community input and engagement
-Recognize cultural diversity within populations experiencing higher rates of tobacco use
-Be widely available and easily accessible
-Be delivered in a person’s preferred language
Pharmacists roles in addressing tobacco use
Ask every patient about tobacco use –> Use the 5 A’s
1. Associate tobacco screening with other screenings
—Blood pressure, asthma, CV risk assessment
—Consider use of technicians or interns in the screening process
2. Proactively identify patients who may benefit from assistance
—Family member who smokes, child with chronic otitis media or asthma symptoms, patient frequently filling COPD rescue inhaler therapy
—Inpatient setting - providing NRT
- Keep over-the-counter NRT products within view of the pharmacist
—Assist patients in selecting products
—Provide appropriate counseling or answer questions as needed - Provide behavioral change counseling through motivational interviewing
- Prescribe FDA approved cessation medications if within your authority or scope of practice!
- Promote smokefree environments and policies
—Home, workplace, community - Assist in prevention activity and education
—Be involved in tobacco use and prevention education programs in schools and community - Professional advocacy
—Promote expanded roles of pharmacist in tobacco cessation efforts
—Support reimbursement of pharmacists for cessation services provided - Remove tobacco products from the pharmacy
The 5 A’s
Ask –> Ask about tobacco use
Advise –> Advise tobacco users to quit
Assess –> Assess readiness to make a quit attempt
Assist –> Assist with the quit attempt
Arrange –> Arrange follow up care
Patient barriers to addressing tobacco use
- Psychological and physical dependence
—Cravings/withdrawal, loss of way to cope with stress, risk of weight gain, interference with relationships - Access to and potential cost of services
- Inconsistently asked about tobacco use or advised to quit by a provider
- Unaware of available resources or coverage options
- Tobacco surcharge imposed by health insurance plans
—Under the ACA some health insurance plans can charge higher premiums for people who use tobacco. These premiums can be imposed on patients seeking cessation services and retroactively applied. May discourage seeking cessation counseling services or medications.
—Of note some states have chosen to eliminate the tobacco surcharge
Pharmacist barriers to addressing tobacco use
- Reimbursement
—Varies state to state and payer to payer
—Often pharmacists are NOT reimbursed separately for the service provided, they are only reimbursed for medications sold/dispended
—Provider status in some states allow pharmacists to bill for the service - Time constraints
- Workflow interruptions
- Inconsistent screening for tobacco use
Mortality and morbidity of prescription opioid misuse and abuse in Wisconsin
Many middle aged to younger people die from opioid abuse (18-64)
More men die from prescription opioid abuse
Public health crisis:
-Overdose deaths
-Overdose casualties
-Mortality rate
-Neonatal abstinence syndrome
-Injection drug use
-Spread of HIV and HCV
-Foster care system
-Robberies
Wisconsin’s response:
News laws
-PDMP
-Naloxone carrying by law enforcement and first responders
-Treatment programs in rural areas and as an incarcertation alternative
Pharmacist role in Opioid epidemic: Naloxone Standing Order
Naloxone Standing Order:
- All pharmacists who meet the requirements of the standing order can
dispense naloxone without a patient-specific prescription
- Can be dispensed to a patient at risk of overdose or someone in a
position to assist a patient at risk (e.g. law enforcement, family,
friends, etc.)
Pharmacists role in prescription drug abuse prevention: Disposal
- Permanent collection receptacles
—-> Allowed since 2014
-Concerns: safety, liability, cost
-Mail-back program
-Drug take back events
—–>Held twice per year (April & October) - Approximately 120,000 pounds of drugs taken back in Wisconsin each year
Pharmacists role in prescription drug abuse: Non-vaccine injections
-Since 2017, pharmacists in Wisconsin are allowed to administer
medications to patients with a valid prescription order
–> Requires additional training
–> Online trainings developed by PSW and UW Division of Pharmacy
What is the barrier for Naltrexone
Key barrier for pharmacies is
lack of reimbursement;
provider status will address
this within the Medicaid
population
Harm Reduction
Harm reduction, or harm minimization, is a range of public health policies designed to lessen the negative social and/or physical
consequences associated with various human behaviors, both legal and illegal
Needle exchange effectiveness in preventing spread of HIV
-40% of PWID share syringes
-Infection Risk: 1 in 160
-Nonurban areas have been
significantly affected due to a
traditional lack of services
-Syringes are not drug
paraphernalia in Wisconsin; no
prescription required
** Referral to services **
Point of Care Testing use in detecting HIV
-92% of new HIV cases are
transmitted by someone unaware
of the HIV+ status
-Additional access point
-Rapid test takes less than 20
minutes
** Referral to services or additional
testing should be a key
component of any HIV POC testing
agreement **
PREP role in preventing OPIOID abuse
Additional access point for
pharmacists to receive preexposure prophylaxis (PrEP)
–> Adherence is a key component
of PrEP efficacy
–> Counseling, testing, treatment,
and referral should all be
considered
Also calls for decriminalization of xylazine and fentanyl testing strips
PDMP
Requirments:
–> Prescribers must check a patient’s PDMP record before dispensing a
monitored prescription drug
–> Prescribers can delegate this task to another person (e.g. nurse,
medical assistant, etc.)
As a tool:
1. Concerning patient history
flags
-Early refill
-Concurrent benzo/opioid
treatment
-Long term opioid therapy
-Multiple prescribers / pharmacies /
same-day prescriptions
-High daily dose of opioids
- Law enforcement alerts
-Arrest for unlawful possession
-Report of theft
- Overdose - Medical coordinator
dashboard
-High prescribers
-High MME
CDC opioid guidelines for pharmacists
- Communication is key!
-Know all medications a patient is taking
-Ensure patients know what to avoid taking concurrently to opioids
-Ask about side effects - Look for red flags in prescription orders – forged, prescription from
outside the area, cash payments, early refills, multiple prescribers - Verify suspicious prescriptions
- Consult the PDMP
- Talk to the prescriber!
CDC guidelines prescriber guidelines
Try non-opioid therapy first
Establish realistic pain goals
Use immediate-release opioid at first
Start low and go slow!
Prescribe no more than needed
Check PDMP
Test patient for illicit use
Connect patients with treatment if needed
Future changes in opioid prevention of abuse
- National PDMP
- Mandatory e-prescribing
- Quantity limits
- Buprenorphine prescribing by pharmacists
Pharmacists role?
1. Proper treatment of those who need opioid medications
2. Opioid screenings
3. Educate your patients
4. Advocate for safe storage and disposal
5. Expand access to treatment services
6. Collaborative practice and team-based care
Four Most common barriers to filling a new prescription
▪ Financial hardship (56%)
▪ Fear or experience of side effects (46%)
▪ Generic concerns about medications (32%)
▪ Lack of perceived need for the medication (25%)
Medicare Part D low income subsidy
Medicare program to help people with limited income and resources pay Medicare Part D premiums,
deductibles, coinsurance, and other costs
Qualifying for Extra Help Program
▪ Automatically qualify if: full Medicaid coverage, help from the patient’s state paying Part B premiums,
SSI benefits
▪ Applying for Extra Help: based on income and resources
Coverage for 2025
▪ Premium and deductible: $0
▪ Generic medications: up to $4.90
▪ Brand name medications: up to $12.15
▪ After $2000 in total drug cost, $0 for covered drugs
Medicare prescriptiopn payment plan
New payment option that allows patients to spread out their out-of-pocket Medicare Part D drug
costs across the year
-There is NO COST to participating in the plan and all Part D plans MUST offer this option
How plan works for patients:
▪ Patient does not pay for drug at the pharmacy and instead gets sent a monthly bill from their plan
▪ Bill is calculated based on what patient would have paid for any prescriptions they get plus
the previous month’s balance divided by the number of months left in the year
▪ In a single calendar year patient will not pay more than what they would have paid out-of-pocket to
the pharmacy if they weren’t participating in the plan
▪ Plan is best for people who have a difficult time managing high drug costs early in the
calendar year
Manufacturer co-pay cards
What are they?
▪ Discounts provided by brand-name drug manufacturers to lower patient out-of-pocket
costs for a specific medication
How do they work?
▪ Patient can find a copay card online, activate card/offer, present card to pharmacy
Who are they for?
▪ Patients WITH private health insurance taking a brand-name drug
Patient Assistance Programs (PAPs)
What are they?
▪ Manufacturer sponsored program to offset brand name drug costs for uninsured or underinsured (regardless of insurance status)
▪ Nonprofit organizations (frequently financially supported by drug manufacturers) that offer provide
financial assistance for copays or insurance premiums
How do they work?
▪ Apply for program (strict financial eligibility criteria)
▪ Manufacturer sponsored: patient will receive drug in mail from manufacturer at no cost or receive a
prepaid debit card from the manufacturer to use at the pharmacy
▪ Nonprofit organization: coordinate directly with pharmacy or physician office to pay a patient’s
outstanding balance or directly reimburse patients for their out-of-pocket costs
Who are they for?
▪ Patients with financial hardship in affording a brand-name drug
Pharmacy Coupons/Discounts
Who are they for?
▪ Any patient with difficulty affording a generic drug
Limitations:
▪ Coupon prices changes frequently and vary by pharmacy and zip code
▪ Typically most useful for generic medications, not brand name drugs
▪ Amount paid by patient does not count toward deductible or annual maximum
▪ Often require patients or providers to shop around for lowest prices
▪ Time consuming and confusing if patient fills medications at different pharmacies
▪ Often NOT accepted by independent pharmacies
Recent trends in pharmacy closures
Risk for closures was greater for:
▪ Independent pharmacies vs. chain pharmacies
▪ Urban neighborhoods vs. rural
▪ Predominantly Black and Latinx neighborhoods vs. predominantly White
neighborhoods
▪ Neighborhoods with higher poverty rates vs. lower poverty rates
▪ Neighborhood with higher uninsurance rates vs. lower uninsurance rates
In recent years pharmacy closures exceeded pharmacy openings (chain pharmacies declined)
Impact:
▪ Closures could worsen existing racial and ethnic disparities in:
▪ Access to pharmacies
▪ Access to medications
▪ Access to essential health care services
▪ Vaccinations
▪ Naloxone dispensing
▪ Contraception prescribing
How can pharmacies and communities overcome physical access to medications? m
Pharmacy
Medications:
▪ Home delivery
▪ Mail order (drones!)
▪ Med-to-beds on hospital discharge
Services:
▪ Telehealth/telepharmacy
▪ Home visits
Community
▪ Transportation programs
(vouchers, rideshare, etc.)
▪ Senior/community helpers
Healthy People 2030 leading health indicator related to chronic disease management
Increase control of high blood pressure in adults
Three chronic disease focus areas for Wisconsin
-Heart Disease
-Stroke
-Diabetes
Comprehensive medication management
Standard of care that
ensures each patient’s medications are individually assessed to determine
that each medication is appropriate for the patient, effective for the medical
condition, safe given the comorbidities and other medications being taken
and able to be taken by the patient as intended.
▪ Not limited to a single type of pharmacy or health care setting
Ex:
1) Performing or obtaining necessary assessments of the enrollee’s health status;
2) Ordering, performing, and interpreting laboratory tests, including pharmacogenomics tests, appropriate to support the enrollee’s
personalized medication treatment;
3) Formulating a medication treatment plan;
4) Monitoring and evaluating the enrollee’s response to therapy, including safety and effectiveness;
5) Performing a comprehensive medication review to identify, resolve, and prevent medication-related problems, including adverse
drug events;
6) Providing verbal or written, or both, counseling, education, and training designed to enhance enrollee understanding of test results
and appropriate use of the enrollee’s medications;
7) Providing information, support services, and resources designed to enhance enrollee adherence with the enrollee’s therapeutic
regimens;
8) Coordinating and integrating medication therapy management services within the broader health care management services being
provided to the enrollee;
9) Initiating or modifying drug therapy under a collaborative agreement with a practitioner;
10) Prescribing medications pursuant to protocols approved by the state board of pharmacy; and
11) Administering medications
Collabrative Practice agreements in CMM
CPA outlines the role to develop an
individualized medication plan that achieves the intended goals of therapy
and includes appropriate follow-up to determine patient outcomes
Broad outcomes of CMM
1) Better care (avoidance of adverse effects, optimized dosing for effectiveness, adding
needed therapy, improved clinical measures)
2) Reduced costs (total cost of medical care, cost of medications, reduced hospital
admissions, reduced emergency department visits)
3) Positive patient experience (satisfaction, engagement, willingness to refer)
4) Positive provider experience (decrease physician workload, view pharmacist as critical
member of the team, more time to focus on professionally meaningful aspects of work,
high job satisfaction for pharmacists)
5) Improved access to care (decrease wait time for services, increased volume of patient
visits)
Implementation challenges of CMM
-Lack of an existing (or consistent) payment structure to reimburse CMM
as a service
▪ Staffing/time constraints
▪ Insufficient management support
▪ Physical design of the practice setting
▪ Lack of awareness of CMM value
▪ Lack of access to patient medical information
▪ Limitations and variation in pharmacist scope of practice, including
collaborative practice agreement opportunities
STIs
Long term consequences of untreated STIs:
▪ Potential to infect others
▪ Infertility and other reproductive health concerns
▪ Complications in fetal health; infant morbidity and mortality
▪ Increased risk of acquiring other STIs such as HIV
▪ Increased risk for certain types of cancer
▪ Impact on mental health
Syphillis cases are on the rise as well as other sexually transmitted diseases
Barriers to STI prevention and care
- Lack of comprehensive sexual education
- Access to testing and treatment
- Inflexible clinic hours, transportation or affordability of care for minors - Confidentiality concerns
- Dependents accessing care with parents’ insurance - Bias and stigma
-Sexual health remains a taboo topic
-Young people report feeling “judged” by providers when asking for sexual
health care
Reproductive justice
Approach that is broader
than reproductive rights
* Framework recognizes
reproductive freedom is
intertwined with social
justice issues including race, class, gender, and economic
status
Three pillars:
1. Right to have children
2. Right to not have children
3. Right to parent in a safe environment
Barriers to optimal contraceptive care
- History of reproductive injustices
- Knowledge deficits
▪ Patient misperceptions about contraceptive safety
▪ Lack of provider knowledge to offer most appropriate method or lack of
training to place IUD - Cost and insurance coverage
▪ Many insurance plans cover contraception with no patient cost-sharing
though there are exemptions
▪ Limits on quantity or days supply
▪ Ex. not allowing more than 1 month supply at a time
Barriers to optimal contraceptive care
- Multiple medical appointments
▪Appointments to discuss methods, additional appointments for
placement - Geographic location
▪More than half of counties in the U.S. lack OB-GYNs creating
contraceptive deserts in rural areas - Bias, fear, and lack of gender-inclusive care
- Political landscape
Public health concern of maternal and infant mortality
▪Maternal mortality in the U.S. is the highest among highincome countries and has been rising since 1990
(Organization for Economic Co-operation and
Development (OECD))
▪Infant mortality remains consistently higher in the U.S.
than in other OECD countries.
▪Significant health disparities exist in maternal and infant
mortality
Barriers to optimal maternal care
▪Awareness of pregnancy and need for prenatal care
▪Unintended pregnancy (unplanned or unwanted
pregnancy)
▪Language
▪Distance to clinic
▪Ability to obtain an appointment in timely manner
Barriers to optimal maternal care continued
▪Time commitment to prenatal and pregnancy care
▪Lack of health insurance
▪Lack of partner support or inadequate support networks
▪Lack of care continuity in postnatal period
▪Limited supply of OB-GYN providers in some areas
Barriers to pharmacist interventions in reproductive and sexual health
▪Lack of reimbursement
▪Time
▪Lack of resources/connection to community partners
▪For example, pharmacist cannot perform confirmatory
screening for STIs
▪Some services may be outside of pharmacist’s scope
(depending on practice site or state)
▪Navigating the political landscape
Emergency
any incident, whether natural, technological, or
human-caused, that requires responsive action to protect life or
property
Four phases of emergency management
- Reduction (Risk Mitigation):
▪ Identifying and analyzing long-term risks to human life and property from natural or nonnatural hazards
▪ Taking steps to eliminate these risks (if possible) or reducing their impact - Readiness (Preparedness):
▪ Developing operational systems before an emergency happens - Response:
▪ Actions taken immediately before, during, or directly after an emergency to save lives and
property - Recovery:
▪ Coordinated efforts and processes used to bring about immediate, medium, and long-term
regeneration of a community following an emergency
Strategic National Stockpile
Supply of antibiotics, chemical antidotes, antitoxins, life-support medications,
intravenous administration devices, airway maintenance supplies and medical
and surgical supplies
▪ Operated by the CDC
▪ Created to supply state and local entities with drugs and supplies in a public
health emergency such as an environmental disaster, epidemic or terrorist
attack
* NOT an immediate source of medications → restocks local and state public
health agencies with supplies when local resources are depleted
Push package
▪ If SNS is activated, the first allotment of supplies is a “12-hour Push Package”
▪ Push Packages are stocks of drugs and medical supplies strategically located
across the United States so they could arrive in a disaster area within 12 hours
*Additional supply can be sent if needs exceed the Push Package
Pharmacist risk mitigation role in response to natural disaster
▪Regional and local risk analysis:
▪ Analyze probabilities that specific disasters or emergencies may occur
▪ Ensure hospital/pharmacy SOPs are individualized and prioritized based on
possible events of area
▪ Local emergency drills:
▪ Implement periodic emergency drills
▪ Drills should be specific to type of emergency and use appropriate timelines
Pharmacist preparation role in response to natual disaster
▪ Pharmacists should create, provide and promote guidelines for emergency standard operating
procedure (SOP)
▪ Emergency SOP should include:
▪ List of personnel to contact
▪ Prioritized based on person’s role, proximity to pharmacy/hospital and resources they can provide
▪ Disaster-specific actions
▪ Pharmaceutical stockpile management
▪ Ensure proper storage, handling, security of medications
▪ Communication management
▪ Plan for communication if certain modalities are down during disaster
▪ Protection of resources
▪ Paper records of suppliers/manufacturers, pharmacy programs have sufficient back ups, fire extinguishers etc
▪ Staff protection
▪ List of protective equipment, recommended PPE and immunizations, safety checks for mental health of staff
Pharmacist response role in natural disaster
▪Maintaining health records
▪ Record keeping may need to change based on emergency (ex. if EHR is not
accessible)
▪ Design alternative record keeping to be easy to follow, capture maximum
information on durable material
▪Manage transportation routes of pharmaceuticals
▪ Work with government agencies regarding transport routes
▪ Communicate information about delays in transport of medications
▪ Implement and follow all steps of the emergency SOP
Pharmacist recovery role in natural disaster
▪ Complete post-recovery analysis
▪ Document lessons learned
▪ Summarize best practices
▪ Application of lessons learned to the SOP
▪ Update SOPs based on any lessons learned when using the SOP in an emergency
▪ Resuming operations
▪ Relocate to safe, temporary operating environment if necessary
▪ Remove wreckage and debris from original operating location
▪ Repair and reconstruct damages
▪ Consider psychological, demographic, and economic impacts on staff and workflow
Epidemic
an outbreak of disease that spreads quickly and affects
many individuals at the same time
Pandemic
outbreak of disease that occurs over a wide geographic
area (such as multiple countries or continents) and typically affects
a significant portion of the population
▪ An epidemic that has spread international
Pharmacist communication and information sharing during a pandemic
Prepare for:
- Counseling visitors and family members who may have concern and anxiety due to the fear of the unknown
Ex:
▪ Increased phone calls
▪ Directing family members that come to the facility
- Poor or confusing communication or information and
misinformation
Ex:
▪ Communicate and collaborate with institutional, local and state Incident Command Centers
▪ Seek reliable information sources
▪ Seek local information for current quarantine or treatment recommendations
▪ Be an advocate for local citizens and be vigilant for emerging issues
▪ Keep staff well informed through frequent communication
-informing the pharmacy workforce
Ex:
▪ Stay up to date on latest information about symptoms, testing, and case definitions
▪ Share information with pharmacists at other institutions facing same crisis
▪ Use network groups to keep colleagues at other institutions informed of
new information, guidelines and issues
▪ Perform literature searches and communicate with drug manufacturers to
obtain unpublished information for emerging and investigational regimens
Pharmacist supply chain management during a pandemic
Prepare for:
challenges securing anticipated stocks of medications and
supplies
▪ Supply chain disruption may occur due to pandemic or public health emergency
▪ Ex. PPE shortage during early COVID-19 pandemic
▪ Issues to address and things to do:
▪ Report unusual sales volumes for medications or patient complaints
▪ Determine mechanisms for obtaining drugs NOT on the market during regular and off
hours
▪ Report supply chain issues (drug shortages or PPE) to key facility staff and local/state
health departments
Pharmacist role in pharmacy operations during pandemic
▪ Prepare for: supplying rapid response kits to support timely access to
treatment
Examples:
▪ Prepare rapid response kits for supportive care and investigational therapies as they
become available.
▪ Kits should contain information for treatment algorithms, dosing and administration guidelines
and pharmacist contact information
▪ Make kits available in relevant patient care units such as the ED or ICU
Prepare for: leading facility in medication use and safety to ensure
safe patient care
Examples:
▪ Ensure appropriate education and drug administration and dosing
guidelines are available to guide medical, nursing and pharmacy staff
Pharmacist role in infection prevention and control
▪Prepare for:
requests to dispose of potentially contaminated
medications and supplies
▪ Family members of potential disease cases may have unused medications
they want to throw away
Examples:
▪ Determine local/state health department recommendations for disposing of
unused medication products and supplies that have been dispensed to a
patient
▪Prepare for:
updating policies and procedures to ensure integrity
of drug supply
Examples:
▪ Develop or revise policies and procedures pertaining to drug delivery to
meet infection control precautions
Pharmacist role in infection prevention and control continued
Prepare for:
protecting workforce from exposure
Examples:
▪ Orient and educate workforce on infection control precautions
▪ Use standard respiratory precaution
▪ Wear gloves, frequent hand washing, use face masks
▪ Ensure staff have been medically cleared and fit tested for respirator use
▪ Limit contact with patients: use telephone counseling, drop off prescriptions at home,
avoid handling checks or cash – use credit card billing
▪Prepare for:
monitoring pharmacy staff for signs and symptoms of
infection
Examples:
- Prepare process for checking temperature of workers once per shift
▪ If fever, cough, and shortness of breath are present send worker to
designated treatment site
▪ If a family member is sick, put employee on sick leave
▪ Notify occupational health services
Pharmacist role in patient care
▪Prepare for: surge in patients and visitors
▪ Patients may seek pharmacy as source of care if local hospitals are closed or
under quarantine
Examples:
▪ Adjust staffing to handle increased traffic, phone calls, and other electronic
communication
▪ Manage staff to accommodate revised or expanded responsibilities with
appropriate sleep/rest cycles
▪ Prepare information for patients/visitors for education and awareness
programs
▪ Report patient surges to key facility staff and public health officials
▪Prepare for:
caring for the “worried well”
Examples:
▪ Provide information and reassurance through education and awareness
programs
▪ Remind patients to get other appropriate vaccines
Pharmacist role in patient care continued
Prepare for: requests for ineffective prevention and treatment
options
Examples:
▪ Issues to address and things to do:
▪ Provide patients with the most current treatment and prevention
information
Prepare for: team-based care and providing expertise on
interprofessional team
Examples:
▪ Collaborate with key players (ex. microbiologists) and communicate on
interprofessional issues needed to optimize patient care
▪ Be proactive and flexible in assuming new responsibilities within a
pharmacist’s scope of practice
Pharmacist role in patient care continued
Prepare for: treating sicker patients
Examples:
▪ Review CDC information for education and awareness
▪ Help triage patients in accordance with institution and emergency
preparedness plan
▪ Inform key facility staff and contact local/state health departments for
guidance and instructions
▪ Ex. quarantine instructions
Why is the impact of medication use on the environment a current and growing concern?
Current concerns:
The US health care system alone is responsible for a large portion of global/national greenhouse gas emissions
*Clinical care is the single largest contributor to health care emissions
Growing concerns:
World population is aging (increasing lifespan) and so an increasingly aging population uses a greater number of medications
Increase in total population:
More people -> more medication use
How do medications enter the environment and what is their impact?
Direct pharmaceutical pollution
-Active pharmaceutical ingredients are detected in the environment
Typically found in: sewage, surface water, waste-water treatment effluent
Other ways medications get into environment:
-Livestock treatments
-Treatment of pets
-Inappropriate disposal of medicine
-Aquaculture treatments
-Manufacturing process
All leads to impacting receiving water which can affect environment and us
What is the impact of pharmaceuticals in the environment
Negative impacts on organisms in aquatic environments
-Hormonal effects
-Psychotropic effects on behavior
-Poisoning of animals
-Antibiotic disruption of aquatic food chain
Antimicrobial resistance among humans
Potential widespread, chronic human exposure to unintended medications -> wastewater treatment plants are not designed to remove pharmaceuticals and their metabolites
Why is environmental plastic an important concern
-Healthcare is one of the largest waste producing sectors in the US
*None have revolutionized the medical industry over the past century as have single use plastics in syringes, IV bags, catheters, test kits, and gloves
*Most plastics are not recycled and end up in landfills and natural environments
Plastic disposal pollution
Inappropriate disposal of plastic causes pollution of the environment
-Blockage of drainage systems causes flooding and disease transmission
-Pollution of land, oceans, and natural animal habitats
-High income countries sell their waste to low income countries
Appropriate disposal of plastic is not sustainable
-Accumulation in landfills, eventual breakdown contaminates environment
-Burning of plastic releases chemicals into the environment
-Known human health effects
What two types of medications contribute to greenhouse gases
Anesthesia gases
Metered dose inhalers
How can pharmacists minimize waste in their health care setting
Patient Care
▪ Discourage unnecessary tests and treatment
▪ Optimize medication regimens and lifestyle
to reduce medication burden
▪ Use the lowest effective dose to treat any
given condition
▪ Reduce dispensed quantities
▪ Educate patients on options to donate
unused medications
▪ Educate prescribers on optimal medication
choices
Organization
▪ Effectively manage pharmacy inventory and
supplies to avoid expired products
▪ Purchase inventory and supplies from
“green” companies
▪ Request information about their sustainability
practices!
▪ Purchase inventory and supplies that are
better for the environment
▪ Actively request these types of products –
How does a focus on preventive care reduce the environmental impact of health care
Can reduce the overall demand for health care services which in turn reduces
the environmental impact of health care. This can further improve health through a better
environment
