The MinnesotA Rural Health

The MinnesotA Rural Health Association

Presents:

Pharmacist Access in Rural Minnesota

Tim Stratton, Ph.D., BCPS, FAPhA

Associate Professor

College of Pharmacy, Duluth

University 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 MN

What comes to mind when mostpeople 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 ExperiencesFinal 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 Care

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 money

Greater percentage of rural residents receive Minnesota MA than urban residents

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 costs

Minnesota-licensedpharmacist

ReceivedPharm.D.degreeon/afterMay,1996

Orcompletedstructured,comprehensiveeducationprogramapprovedbyBoardofPharmacy

Practicinginambulatorycaresettingaspartofaninterprofessionalteam

Ordevelopedastructuredpatientcareprocessthatisofferedinaprivatesetting

Makeuseofelectronicpatientrecordsystem

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

Verbally educate and train patient to enhance patient understanding and appropriate use of medications Provide information, services and

resources 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/orderUnreadable info on prescription/orderPrescribed drug not on formulary

Drug not covered by patient’s insurancePatient 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 tenemwho simply prescribes what she/he accustomed to

DVM sends pet owners to pharmacy with verbal orders for Rx medsDDS checks on “problem patients”

Consults (IHS MDs, hospital inpatients, discharge patients)

Serve on committees of local hospital/CAH, enabling facility to meet

licensure/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® patients

Towns w/ population< 5000

Represents total population > 216,000

A. Traynor and T. SorensenCollege 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% of urban

A. Traynor and T. SorensenCollege of Pharmacy

A Fragile Environment

Challenges to the ability to deliver pharmacy services in rural areasCumulative 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 1996-19992

1.2.

MN Dept of Health ORHPC 10/2003

Moscovice I, et. al. Rural Health Research Center, UMN, July 2001

Age of Pharmacist –Desired age of retirementRevenue of Pharmacy

Presence of other health providers/services in community

Distance to next nearest community with pharmacy

Experience recruiting regular and relief staff

A. Traynor and T. SorensenCollege of Pharmacy

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