Local Health Care Partnerships Are Strongly Associated With Successful Enhanced Community Pharmacy Services

DECEMBER 11, 2018
Kea Turner, PhD, MPH, MA; Chelsea Renfro, PharmD; and Stefanie Ferreri, PharmD
Surveying Community Pharmacies in 3 Domains
Incorporating community pharmacists into team-based care models is recommended as a strategy for improving health care access and quality while reducing health care costs.1,2
However, there is limited evidence on what drives effective implementation of team-based care models that include community pharmacists. Implementation science, or the study of what promotes the adoption and integration of interventions and policies into health care settings, can be applied to these team-based care models to identify what factors contribute to effective implementation. One area of implementation science that is particularly relevant for team-based care is relationship quality. This refers to how effectively 2 individuals or organizations communicate as well as their shared vision of what actions are needed to improve patient care.3,4   

Pharmacy participation in team-based care models requires high-quality relationships among pharmacies and other health care organizations, such as primary care practices (PCPs), so that patient care plans and information can be shared across organizations. These models also require relationships between community organizations, including care management agencies, and pharmacies to effectively engage hard-to-reach patients and to ensure that patients have all the resources necessary to manage their health care. Perhaps most important, team-based care models require strong relationships between patients and pharmacies because delivery of enhanced services is dependent on patient engagement and trust. To understand the role of relationships in team-based care models, we conducted individual interviews with 40 pharmacists participating in the Community Pharmacy Enhanced Services Network (CPESN) in North Carolina. We explored pharmacies’ relationships with community organizations such as care management and public health agencies, health care organizations like PCPs, and patients. 

Community Organization Ties Strongly Associated With Readiness
Pharmacies varied in the strength of their relationships with health care organizations and patients. However, we found the greatest diversity in relationship quality with community organizations. Some pharmacies had never worked with a community organization, while other pharmacies had developed high-quality, long-standing relationships with their local community organizations. Some pharmacies, for example, had worked with community organizations in their area for several years prior to the CPESN program, making it easier to get buy-in from those agencies for CPESN. These pharmacies described efforts to get to know local community organizations, such as attending community events, facilitating a dialogue about how the 2 entities could work together to improve patient care, and having meetings to learn about their work. Many of these pharmacies also noted aspects of previous partnerships, such as working with aging agencies to integrate pharmacy services into meal delivery programs for elderly individuals and working with local health departments to help sponsor public health events, including blood pressure screenings open to the public.

One pharmacist said, “We were working with our health department way before CPESN. We realized we were in the midst of this opioid crisis, and at the same time, our health department was dealing with the same issue. We set up a meeting to learn about their programs and kept the dialogue open for opportunities to work together.”

Once partnerships were established, pharmacies indicated, it was much easier to approach community organizations about CPESN. For example, one pharmacist explained the importance of building a relationship over time to establish trust before collaborating on a project like CPESN.

“We didn’t start out coordinating services together. It takes a long time to build up that trust, to get them to see why our services our valuable. We had to show them we do good work and that we really care about patients just like they do before we can expect them to partner with us,” the pharmacist said.

Pharmacies that worked with care managers described getting advice from them on how to best engage hard-to-reach patients, having care managers join pharmacists on home visits, and having care managers reinforce recommendations made by the pharmacist.

Implications for the Evolution of Community Pharmacy Practice
Overall, in interviewing pharmacies participating in CPESN, we learned of the importance of building high-quality relationships with community and health care organizations, as well as patients, and maintaining those relationships over time. Team-based care models are difficult to implement. These models require information sharing and trust across diverse organizations that might not have any history of collaboration. To increase the likelihood of successful implementation, it is critical to focus on building high-quality relationships prior to implementation. Pharmacies in our study that did not have prior relationships with community or health care organizations described encountering implementation barriers, such as resistance to change (eg, care managers or PCPs that were unwilling to discuss or share patient information). To scale up and spread team-based care models that include pharmacists, it may be important to assess pharmacies’ experience with relationship building. Pharmacies identified as having little to no experience may need additional implementation guidance on how to foster these relationships, such as building collaborations in which more experienced pharmacies can share best practices.
 
Kea Turner, PhD, MPH, MA, is an assistant professor in the Department of Health Services Research, Management and Policy at the University of Florida in Gainesville.

Chelsea Renfro, PharmD, is an assistant professor in the Department of Clinical Pharmacy and Translational Science and coordinator of Simulation-Based Education at the University of Tennessee Health Science Center in Memphis. 

Stefanie Ferreri, PharmD, is a clinical professor at the University of North Carolina (UNC) Eshelman School of Pharmacy at UNC at Chapel Hill.


References
  1. Smith M, Bates DW, Bodenheimer T, Cleary PD. Why pharmacists belong in the medical home. Health Aff (Millwood). 2010;29(5):906-913. doi: 10.1377/hlthaff.2010.0209.
  2. Smith M, Bates DW, Bodenheimer TS. Pharmacists belong in accountable care organizations and integrated care teams. Health Aff (Millwood). 2013;32(11):1963-1970. doi: 10.1377/hlthaff.2013.0542.
  3. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4:50. doi: 10.1186/1748-5908-4-50.
  4. Safran DG, Miller W, Beckman H. Organizational dimensions of relationship-centered care theory, evidence, and practice. J Gen Intern Med. 2006;21(suppl 1):S9-S15. doi: 10.1111/j.1525-1497.2006.00303.x.


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