Kelly Mathews, PharmD

Corporate and academic partnerships help prepare new graduates for the world of specialty pharmacy.

Given the expanding pipeline of breakthrough drugs and the increasing demands placed on pharmacists in a changing health care industry, today’s pharmacy graduates are being thrust into a highly complex work environment.

Pharmacists are asked to do far more in their daily roles than ever before—whether they are collaborating with physicians as part of a medical home model or instructing patients on how to use a mobile pharmacy app. They are also spending much more time working with third-party payers.

This is due, in part, to the move toward accountable care and data sharing, but also because of more rigid prior authorization requirements for high-cost drugs. Even retail pharmacy roles are evolving as many pharmacists are expected to provide preventive care services alongside traditional pharmacy services.

Nowhere is this level of complexity more evident than in the world of specialty pharmacy, where pharmacists must possess deep expertise in patient education, adherence strategies, and pharmacology along with knowledge of all the latest therapies. Drug manufacturers have come to expect these advanced skill sets from their limited distribution partners.

This means that specialty pharmacies with highly trained staff members have a distinct competitive advantage that translates into significant revenue potential.

Taking on the Challenge Through Innovative Partnerships 

Expecting new pharmacy graduates to come out of universities possessing all of these skills is not realistic. However, the specialty pharmacy industry can ensure that students are better prepared to quickly get up to speed on these practices through a combination of specialized clinical knowledge and real-world experience.

Specialty pharmacies that expect to be hiring new graduates over the next several years will have to invest in education in one form or another—either in the academic setting or among recent graduates entering their workforce. It simply makes sense to partner with academic institutions to expand the breadth of this knowledge among more students, thus widening the pool of potential candidates who already have some understanding of specialty pharmacy practices.

Today’s leading specialty pharmacies should be looking for unique ways to partner and support pharmacy schools through a variety of channels. These avenues could include basic efforts such as allowing experienced pharmacists to guest-lecture in specific courses.

For pharmacies that want to make more significant investments, it could mean partnering with a university to develop meaningful curriculum and coursework related to specialty pharmacy and offering rotations where students can gain on-the-job experience.

Rotations are especially critical since real-world practical knowledge is the most effective way to help students bridge the gap between coursework—which in today’s industry climate can become outdated in less than a year&mdash;and actual practice.

Although in years past a shortage of pharmacists was the biggest concern for the future, today’s challenge is the on-the-job readiness and skills of these graduates. To capitalize on this increased demand, pharmacy schools have opened all over the country during the last decade.

As a result, more than 14,000 pharmacists are set to graduate this year alone. Some experts say that the glut of new schools is not necessarily in the best interest of students or hiring organizations—especially if these institutions are not supplying the most advanced and relevant coursework.

With such a sizable potential talent pool, organizations can now afford to hand-pick candidates who have the skills and interest needed to enter the demanding field of specialty pharmacy. This is certainly an area where corporate and academic partnerships can pay off.

By partnering with a top school and developing curriculum specific to their needs, specialty pharmacies can ensure that they are preparing the “best of the best” students while screening potential candidates for job offers before graduation. Most pharmacies already have some type of continuing education program for their employees—some even develop tailored curriculum through customized training programs.

A select few, however, are taking this commitment and extending it into pharmacy schools. For example, Walgreens Specialty Pharmacy partners with Duquesne University Mylan School of Pharmacy for its formal post graduate year 1 (PGY1) residency program.

Residents gain insight into pharmacy practice management issues on the job that can prepare them to take on the challenges of caring for patients with specialized needs.

A Broader Partnership Provides Mutual Benefits 

Avella Specialty Pharmacy has taken this commitment even further by offering rotations and specialized curriculum through its academic partnership. Avella collaborated with Midwestern University to develop a 10-week elective class designed to serve as an introduction to specialty pharmacy.

The program was developed to be mutually beneficial to students, the organization itself, and its pharmacists. Students are exposed to the basics of specialty pharmacist roles and responsibilities prior to graduation.

Avella gains a valuable avenue for reaching out to those individuals most interested and prepared to enter this field; in fact, the program is well-integrated within Avella’s own recruiting efforts. At the same time, it gives Avella’s pharmacists an opportunity to give back to the communities they serve while “paying it forward” to the next generation.

Course didactics include an introduction to specialty disease states including inflammatory medicine disease (rheumatology, dermatology, gastroenterology), HIV, hepatitis C, oncology, and multiple sclerosis. Coursework, developed and administered by Avella pharmacists, also includes patient education—related instruction based on the highly specialized needs of these populations.

Given that many faculty instructors might not have the advanced training and certifications necessary to develop this type of curriculum, this partnership gave Midwestern the ability to leverage the current knowledge of working pharmacists and provide its students with meaningful and practical information. Another value of this partnership is Avella’s advanced pharmacy practice experience rotation, offered to Midwestern students in the last year of their program.

Students shadow an Avella pharmacist preceptor across a variety of functions including patient management programs in multiple specialty disease states, data analysis, third-party payer reviews, and product development. They also gain experience in sterile and nonsterile compounding pharmacy areas.

The course and rotation serve 2 important purposes for students. These opportunities expose them to an area of pharmacy that they may not even consider when choosing potential avenues to pursue upon graduation.

For those who decide to go this route, it also advances their knowledge of specialty pharmacy and sets their expectations for what these pharmacist roles entail. According to a survey conducted at the beginning and conclusion of the Midwestern elective class, participating students exhibited improvements in their understanding of and confidence in core concepts, including specialty disease states, pharmacist interactions, adverse drug event and adherence management, financial assistance, and home administration.

Based on this success, Midwestern has committed to continue the program and is interested in potentially adding additional coursework designed to expose students to the unique demands of the specialty pharmacy industry. Future goals also include a partnership in the development of a PGY1 residency with a focus in specialty pharmacy scheduled to start this year, further refining new graduate training into well-qualified practitioners.

Preparing for the Specialty Pharmacy of Tomorrow 

As drug manufacturers continue to look to specialty pharmacies to provide advanced clinical knowledge as well as patient education, advocacy, and support, the industry will need to support higher learning that is up-to-date and meaningful for this dynamic area. Pharmacies can lead this charge by pursuing unique partnerships with leading academic institutions.

As a result, patients, pharmacists, and the entire industry will benefit from knowledge sharing and better preparedness for the challenges that lie ahead. 

 earned her PharmD degree from the University of Arizona in 2009. Kelly completed a PGY1 community pharmacy residency in affiliation with Midwestern University in 2010. She continued working at Avella Specialty Pharmacy National Distribution pharmacy in Phoenix, Arizona. She is the director of clinical services, where her responsibilities include overseeing specialty disease patient management programs and precepting pharmacy students across the country.

Articles

Corporate and academic partnerships help prepare new graduates for the world of specialty pharmacy. 

University Partnerships: Empowering the Next Generation of Pharmacists 

Mobile adherence apps are a great boon to patients who face the responsibility of taking oral chemotherapy drugs as directed without in-person supervision by clinicians.

Much of our progress to date in improving cancer survival rates has been attributed to breakthrough medications, including oral chemotherapy agents that patients can take at home. This trend shows no sign of stopping, with many exciting drugs introduced in early 2015 and more in the pipeline. Recently approved oral therapies include Ibrance (palbociclib) for metastatic breast cancer and Farydak (panobinostat) for multiple myeloma.

That’s good news for patients, who generally prefer oral therapy over intravenous (IV) therapy. Oral therapy eliminates the hassles of receiving IV therapy in a clinical setting, which may be especially important for patients who have transportation issues, work, or other obligations to travel frequently, or live a significant distance from a treatment center. Clinicians are also generally supportive of oral therapy, since it is not accompanied by complications such as infections and clotting, which can be caused by IV therapy.

Nonadherence Challenges with Oral Therapies 

One of the positive aspects of traditional IV therapy, however, is that patients are closely monitored by clinicians who administer this treatment directly, ensuring adherence. Conversely, oral chemotherapy agents can put more responsibility on patients, caregivers, and/or family members in terms of ensuring that individuals take these medications on time and as directed.

One might assume that patients with cancer would adhere to their medication regimens simply due to the serious and life-threatening nature of their illness, but this is often untrue. These patients may be on complex treatment regimens and have many emotional and physical issues related to their condition—all of which can make medication nonadherence (especially due to forgetfulness) a common problem. Oncology drugs frequently cause a mental fog referred to by many as “chemo brain,” meaning that the therapy itself may be contributing to lower adherence rates. Patients may also simply feel better and stop taking their medication. Alternatively, they could be bothered by adverse effects (AEs) or concerned about the high cost of therapy.

In a survey of 418 oncology patients regarding obstacles in cancer treatment, it was revealed that 10% of these individuals stopped taking their medication, 7% never filled their original prescription, and 9% did not regularly refill their medication.

The results of another study showed that 24% of 53 breast cancer patients missed at least 1 dose of tamoxifen per week, with a patient survey indicating that forgetting doses was the most common reason for nonadherence.

Given that nonadherence negatively affects the ability of a drug regimen to control or eradicate cancer, this is a serious issue. The good news is that among patients who stopped taking their medications, nearly half indicated that additional counseling or intervention would have corrected their behavior.

Research also shows that nonadherence to anticancer agents has become more prevalent due to the increased number of agents and required duration of use, increased combinations of oral therapy with different patterns of administration, polypharmacy, and the advancing age of patients with cancer.

Together, these issues have created a “perfect storm” of challenges that affect a significant percentage of patients. As such, the issue of adherence has been cited by the World Health Organization as the single most important yet modifiable factor that can affect treatment outcomes.

Strategies to Engage and Support Patients 

The issues related to adherence in oncology patients are clear, but limited research has been done to determine which approaches and interventions have a measurable impact on adherence rates. Also, given that the drivers of nonadherence are extremely varied, interventions must be targeted to address each patient’s specific issues.

For example, today’s new technologies—from apps to portals to mobile monitoring devices&mdash;may help address forgetfulness and memory issues, which are among the most common causes of nonadherence. Education and support from pharmacists can help patients understand the importance of taking medication as directed and assist these individuals in dealing with AEs. Delving into these opportunities further, we can see a whole host of potential strategies that can be integrated into a total adherence management program.

Mobile Apps Put Adherence Resources in Patients’ Hands 

The popularity of mobile health care apps makes them a strong potential platform for high-tech adherence interventions. The field of mobile health is growing exponentially in response to consumer demand. More than 100,000 mobile health apps have already been published for smartphones worldwide. Consumers are also showing specific interest in using new tools for their medication management needs. More than 72% of all individuals recently surveyed said they would like to refill prescriptions through digital channels.

Although clinical studies are still in development to test the measurable impact of mobile adherence apps in the oncology space, other research has been done to determine their potential for different population segments. For example, the results of a recent study conducted by Avella Specialty Pharmacy and mscripts showed that patients with HIV using mobile adherence apps that feature refill and dosage reminders were 2.9 times more likely to be adherent with antiretroviral therapies.

These reminders took the form of in-app notifications, e-mails, and text messages.

In addition to offering reminder functionality, these apps (along with patient portals for those who prefer nonmobile access) can be used to track adherence data at the pharmacy and provider levels. These data can be valuable in helping to monitor adherence, identify challenges, and intervene in cases where patients are struggling to take medication as prescribed.

Text messaging programs are also showing promise in improving adherence for patients with chronic conditions. One study’s findings suggest that members opting into a text message reminder program have significantly higher chronic oral medication adherence compared with members opting out of text message reminders and that the use of a text message reminder program assists in preserving higher rates of adherence over time.

New mobile monitoring and other adherence technologies are also emerging as an innovative way to support patients with complex health care and drug therapy needs. The mobile monitoring space includes a wide variety of tools: from in-home scales that send data to providers for real-time monitoring of congestive heart failure patients to mobile-optimized glucose monitors that collect and share information about a patient’s blood sugar control.

In the area of medication adherence, “smart” pill bottles and medication boxes are among the recent product introductions. For example, the GlowCap, created by technology provider Vitality, is a pill bottle cap designed to replace the conventional cap provided by pharmacies. The electronic cap flashes and plays a subtle ringtone when it is time for the next dose and its wireless transmitter sends a signal to a reminder light plug that also flashes. If the cap is not opened, the transmitter dials the patient’s telephone with an additional reminder such as “It’s time to take the pill in your green GlowCap bottle.” The cap also creates weekly adherence reports that can be e-mailed to family members or caregivers and monthly reports that can be submitted to a health care provider.

A recent study of the GlowCap technology tested the impact of this product on patients with gastrointestinal stromal tumors (GISTs), a cancer of the gastrointestinal tract.

Patients were being treated with Gleevec (imatinib), which is indicated by the FDA for treatment of patients with KIT-positive GISTs that cannot be surgically removed and/or have spread to other parts of the body. In these Gleevec-treated GIST patients, increased adherence was documented over the course of a 4-month period. Patients using the technology maintained higher adherence levels month after month, with the lowest level at 83% during the fourth month compared with 73.3% for the control group. In turn, increased adherence led to fewer hospitalizations, reduced inpatient length of stay, and lower medical costs.

While there is a greater cost associated with these devices compared with text messaging and mobile apps, the impressive results achieved by products like these may warrant investment from health care organizations. Some pharmacies and pharmaceutical manufacturers are already partnering to make these products available to oncology patients for certain drug therapies at no additional charge.

Electronic pill bottles and packaging may be just the beginning of smart adherence technologies. Some companies are now developing edible “chips” that can be implanted into medication and which send a signal to a receiver located in a skin patch. The receiver records medication-related information, including the date, time, and dose taken. It is likely, however, that many patients would have concerns associated with “ingesting” their adherence technology—even through devices that are safety tested. As a result, it remains to be seen whether these advances can achieve a high level of adoption in chronically ill patients.

Technology alone will likely not solve the adherence dilemma for oncology patients. Some patients may be struggling with issues beyond simply forgetting to take their medication on time or make timely requests for refills. Instead, they may have serious concerns about the medication itself, misconceptions about drug therapy, or financial issues that make it difficult to pay for the cost of these drugs. These are all reasons why highly trained specialty pharmacists will never be replaced by today’s technology. These clinical experts provide a level of care, education, and guidance that cannot be underestimated. This is especially critical in offering support to oncology patients who are dealing with serious medical issues that may sometimes feel overwhelming. Staff members who offer both compassion and clinical expertise can serve as a critical extension of a patient’s overall care team. For example, pharmacists can help patients understand what to expect from their medication regimen, what AEs are common, and what to do if these AEs become a serious issue.

If patients are having trouble affording the cost of their medications, specialty pharmacies can step in to help. Financial assistance is available to many patients through pharmaceutical programs and nonprofit groups. Patients are typically not aware of these programs and will not know how to navigate the application process. In addition, by working with payers and pharmacy benefit managers for prior authorization assistance, specialty pharmacies can help patients get access to the drugs at a more affordable price.

While the impact of “high-touch” interventions isn’t always as measurable, the results of some small studies suggest they can make a real difference in adherence rates over time. A randomized trial tested the effectiveness of a tailored intervention to promote adherence to oral chemotherapeutic agents in 45 adult patients with cancer. After receiving education and coaching support, 80% of the patients receiving this intervention refilled their medications after 2 months compared with 65% of the control group.

An unexpected finding from the study cited above is that system barriers also interfered with adherence. These are factors that were not related to the patient’s actions or physical/emotional state. Examples of system barriers include late specialty pharmacy deliveries, ordering of incompatible medications, and unclear instructions regarding when to start oral agents. This is why specialty pharmacies must have expertise and experience not just in clinical matters, but also in fulfillment and operations-related functions. They must also work closely with a patient’s own health care provider to ensure that clear instruction and treatment planning are carried out from the day a prescription is submitted until treatment is no longer needed.

While innovative oncology drugs continue to fill the pipeline, it is clear that improving outcomes for these patients is a multifaceted challenge beyond just providing the right drug therapy. This is a challenge, however, that our industry is now willing and able to take on. Specialty pharmacies will play a large role in these efforts over time, just as they have taken on greater responsibilities in providing patient education, care, and support.

Empowerment of pharmacists and engagement of patients themselves may also be accomplished, in part, through use of the latest technologies, which are being introduced at a rapid pace. While adherence is a widespread challenge, it stands to reason that oncology patients—who are dealing with serious, often life-threatening health issues&mdash;should be among the early adopters of these new tools and devices. 

		Trends in the 2012 Eisai Oncology Digest: insurance and cost obstacles in cancer treatment. 

. Published online: November 20, 2012. www.ajmc.com/journals/evidence-based-oncology/2012/2012-2-vol18-n5/Trends-in-the-2012-Eisai-Oncology-Digest-Insurance-and-Cost-Obstacles-in-Cancer-Treatment.

		Murthy V, Bharia G, Sarin R. Tamoxifen non-compliance: does it matter? 

. 2002;3(11):654. doi: http://dx.doi.org/10.1016/S1470-2045(02)00895-1.

		Lester J. Safe handling and administration considerations of oral anticancer agents in the clinical and home setting. 

		Annex I: behavioural mechanisms explaining adherence. In: Sabato E, ed. 

Adherence to Long-Term Therapies—Evidence for Action

. Geneva, Switzerland: World Health Organization; 2003. www.who.int/chp/knowledge/publications/adherence_annexes.pdf.

		Is healthcare service online enough to satisfy patients? The Accenture Conncected Health Pulse Survey. Accenture; 2012. www.accenture.com/SiteCollectionDocuments/PDF/Accenture-Is-Healthcare-Self-Service-Online-Enough-to-Satisfy-Patients.pdf.

		Avella and mscripts to present mobile health study findings at the 2015 Armada Specialty Pharmacy Summit [press release]. Phoenix, Arizona: Avella Specialty Pharmacy. April 14, 2015. http://news.avella.com/news/armada-specialty-pharmacy-summit-2015.

		Foreman KR, Stockl KM, Le LB, et al. Impact of text messaging program on patient medication adherence. 

. 2012;34(5):1084-1091. doi: 10.1016/j.clinthera.2012.04.007. www.ncbi.nlm.nih.gov/pubmed/22554973.

		Patient Adherence Comparison: Avella GlowCap Users vs Non-users. Phoenix, Arizona: Avella Specialty Pharmacy. https://avella.uberflip.com/h/i/17209907-avella-glowcap-case-study.

		Banks MA, Persily GL. Campus perspective on the National Institutes of Health public access policy: University of California, San Francisco, library experience. 

. 2010;98(3):256-259. doi:10.3163/1536-5050.98.3.015. www.ncbi.nlm.nih.gov/pmc/articles/PMC2901012.

Kelly Mathews earned her PharmD degree from the University of Arizona in 2009. She completed a PGY1 community pharmacy residency at The Apothecary Shops in affiliation with Midwestern University in 2010. Kelly is director of clinical services at Avella Specialty Pharmacy National Distribution pharmacy in Phoenix, Arizona, where her responsibilities include overseeing specialty disease patient management programs and precepting pharmacy students across the country.

Improving Medication Adherence for Oncology Patients Through High-Tech Interventions

The health care industry is undergoing a dramatic shift, and this has affected the type of pharmacy training, specialized skills, and knowledge that are in demand by employers. Health care reform did much more than just extend health coverage to the uninsured; it introduced new concepts like accountable care, in which health care teams, that include pharmacists, work together to improve quality and better manage costs. 

	At the same time, new health information technology resources have made data sharing between physicians, pharmacists, and other clinical professionals an important part of ongoing care practices. This has transformed the daily job of the pharmacist as we know it. Whether this focus on collaboration means counseling patients to manage the adverse effects of multiple, complex drugs or tracking medication adherence, it is no longer enough to simply understand the basics of pharmacy practice to secure top-paying positions or promotions. Instead, pharmacies, such as Avella, expect clinicians to have the clinical expertise needed to support patients and understand the “bigger picture” of a physician’s overall treatment plan.

Board Certifications Evolve Along with the Health Care Industry

	Across the entire industry, pharmacists have a much bigger part to play in the facilitation of care and the engagement of patients. This includes delivering chronic condition management support and taking other opportunities to leverage specialized skills and expertise. Fortunately, board-certification opportunities are evolving along with these industry needs. While general education and residency requirements have also expanded over time, these certifications now give students and graduates the opportunity to pick an extremely focused area of specialization. Many of these areas—such as ambulatory care pharmacy&mdash;are of particular interest to health care organizations looking to improve patients’ outcomes and control costs. 

	Ambulatory care pharmacy practice is defined by the Board of Pharmacy Specialties (BPS) as “the provision of integrated, accessible health care services by pharmacists who are accountable for addressing medication needs, developing sustained partnerships with patients, and practices in the context of family and community.” This certification aims to give graduates the advanced knowledge and expertise needed to support at-risk patients with chronic conditions who may be taking multiple medications. The same patient population also happens to be the focus of many payers and health systems that are hiring pharmacists to support new care management and population health programs. These programs are often designed to provide extra support to patients to help them better manage their health and health care decisions.

	There is no doubt that interest in board certification is growing. According to the BPS, the number of pharmacists who have become certified in a specialty by the BPS alone has doubled every 5 years (from 3600 in 2002 to more than 18,000 in 2013). Many pharmacists are now attaining dual credentials. Board certifications include pain management, nuclear pharmacy, oncology, HIV, and pharmacotherapy. Critical care pharmacy and pediatric pharmacy are 2 recently introduced certifications, with first examinations scheduled this year. 

An Opportunity for Growth Demands Highly Specialized Expertise

	Employers are looking for these types of certifications in new hires, and current employees may wish to consider obtaining such credentials if they are seeking opportunities for advancement. Board certification can showcase an individual’s ability to manage specialized fields of work and the treatment of complex disease states. This is especially important in the specialty pharmacy space. Specialty pharmacy is among the fastest growing segments of pharmacy care. By 2020, specialty drug spending is expected to reach $400 billion, approximately 9% of all health care spending in the nation, according to America’s Health Insurance Plans’ (AHIP) Specialty Drugs Issue Brief. Around half of current specialty drug spending is for therapies that treat cancer, rheumatoid arthritis, and multiple sclerosis, AHIP noted. 

	What does this mean for pharmacy students and recent graduates? Specialty pharmacies will increasingly be looking for prospective employees with niche skill sets.

	At Avella, we are excited to see new board certifications being introduced, especially those in the areas of specialized medication therapy and complex disease states. Specialty pharmacy is a highly unique sector and requires a distinct set of skills and knowledge. For example, some of our pharmacists have received certification as practicing HIV pharmacists from the American Academy of HIV Medicine. HIV management is a strong area of clinical expertise for our organization, along with fertility, hepatitis C, oncology, ophthalmology, and inflammatory disease in the areas of rheumatology, dermatology, and gastroenterology. Since we treat many immunocompromised patients, certifications in immunization are important in our hiring process, as well. We also look to hire certified specialty pharmacists, as well as individuals certified in oncology. 

	For our existing employees, we encourage membership in pharmacy organizations and certification. Avella has made a commitment to reimburse these costs, along with those associated with other continuing education requirements. Pharmacists are also invited to attend and present at clinical conferences.  

	It is obvious from the current trajectory of board certifications that we can expect even greater specialization opportunities to come. At Avella, we’d like to see more certifications applicable to specific clinical areas, such as inflammatory disease, fertility, or multiple sclerosis, along with advanced studies in the areas of pharmacoeconomics, compounding, and

	managed care. With so many options already available, however, the process of selecting the right certification can be overwhelming and confusing to students and graduates. These individuals would be well served by talking with their counselor or seeking an actively practicing mentor in the industry to help with decision making, especially given that the choice of certification can have implications for both entry-level jobs and opportunities for advancement.

	Graduates looking to differentiate themselves in a competitive field may find that the knowledge and expertise demonstrated by the right board certifications can put their résumé on top of the pile within hiring organizations. 

Kelly Mathews earned her PharmD from the University of Arizona in 2009 and completed a postgraduate year 1 community pharmacy residency in affiliation with Midwestern University in 2010. She works at Avella Specialty Pharmacy National Distribution pharmacy in Phoenix, Arizona, where she is the director of clinical services, with responsibilities that include overseeing specialty disease patient management programs and precepting pharmacy students across the country. 

Here is 1 pharmacy's perspective on the value of board certifications in a dynamic industry. 