The MinnesotA Rural Health Association Presents: Pharmacist Access in Rural Minnesota

1. 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

2. Learning Goals • 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

3. What comes to mind when most people hear the word, “Pharmacist”

4. … whether in the community setting…, … or in the hospital or nursing home Pharmacy Practice: It’s all about the patient…

5. Training for Today’s Pharmacist • At least two years pre-pharmacy • almost 75% of current class have degrees • Four years in Doctor of Pharmacy (Pharm.D.) professional program • Three years didactic, Early Practice Experiences • Final year Advanced Practice Experiences • Qualified to practice after passing NABPLEX • Optional: One-year General Clinical Residency (Adult Medicine) • Optional: Advanced Specialty Residency or Fellowship Training • Optional: Board of Pharmaceutical Specialties (BPS) Certification

6. Pharmaceutical Care • 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

7. Drug Therapy Problems(26,238 patient encounters) • 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 University of Minnesota College of Pharmacy

8. Today’s pharamcists are taught how to conduct pPoint-of-care testing • 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)

9. Minnesota Medical Assistance Medication Therapy Management (MTM) Program 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

10. Minnesota Medical Assistance Medication Therapy Management (MTM) Program Patient requirements: • Covered by Minnesota MA, GAMC, or MinnesotaCare • Taking 4 or more prescriptions – and – • Meds are being used to treat or prevent 2 or more chronic conditions – or – • Patient has had a previously-identified DTP that has resulted in, or is likely to result in significant nondrug MA, GAMC, MinnCare costs S.F. 973 – 84th Legislative Session (2005-2006)

11. Minnesota Medical Assistance Medication Therapy Management (MTM) Program Pharmacist requirements: • Minnesota-licensed pharmacist • Received Pharm.D. degree on/after May, 1996 • Or completed structured, comprehensive education program approved by Board of Pharmacy • Practicing in ambulatory care setting as part of an interprofessional team • Or developed a structured patient care process that is offered in a private setting • Make use of electronic patient record system S.F. 973 – 84th Legislative Session (2005-2006)

12. Minnesota Medical Assistance Medication Therapy Management (MTM) Program MTM services: • Assessments of patient’s health status • Perform a comprehensive med review to identify, resolve and prevent DTPs, including ADRs • Formulate medication treatment plans • Monitor/evaluate patient’s response to therapy • Effectiveness & safety S.F. 973 – 84th Legislative Session (2005-2006)

13. Minnesota Medical Assistance Medication Therapy Management (MTM) Program • MTM services (cont.): • 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 S.F. 973 – 84th Legislative Session (2005-2006)

14. Pharmacists as Providers of First-Contact Care • Watchful waiting • Non-drug self-treatment • Nonprescription drug • treatment • Referral to more intensive • level of care • “BTC” Emergency contraception

15. Pharmacists as Patient Advocates: Liaising with Prescribers • Institute of Medicine Reports • Missing info from prescription/order • Unreadable info on prescription/order • Prescribed drug not on formulary • Drug not covered by patient’s insurance • Patient cannot afford drug • Dosage change after prescription dispensed (e.g., lamotrigine) • Instructions relayed by patient inconsistent with sig on prescription

16. How RPhs and Prescribers Interact (particularly in rural towns) • MD calls with diagnosis to check on which drugs available vs. locums tenem who simply prescribes what she/he accustomed to • DVM sends pet owners to pharmacy with verbal orders for Rx meds • DDS checks on “problem patients” • Consults (IHS MDs, hospital inpatients, discharge patients)

17. Other Pharmacist Activities • 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

18. 128 “One-Pharmacy Towns” Towns w/ population< 5000 Represents total population > 216,000 A. Traynor and T. Sorensen College of Pharmacy University of Minnesota

19. Issues Facing Rural Pharmacy Practice… • 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. Sorensen College of Pharmacy University of Minnesota

20. A Fragile Environment • Challenges to the ability to deliver pharmacy services in rural areas • Cumulative effects • 102 non-metro MN pharmacy closures since 1996 vs. 87 closures in seven-county metro1 • Nine of 38 pharmacy closures in rural MN resulted in a community with no local pharmacy access from 1996-19992 • MN Dept of Health ORHPC 10/2003 • Moscovice I, et. al. Rural Health Research Center, UMN, July 2001

21. Factors Contributing to Risk Score • Age of Pharmacist – Desired age of retirement • Revenue 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. Sorensen College of Pharmacy University of Minnesota

22. Communities At Risk Ability of pharmacy owners to sell practice will likely affect continued availability of pharmacy services in many communities • 70 communities have independently-owned pharmacies. Average age of owner = 50+ years • The average difference between current age of pharmacy owners and the age by which they would ideally sell their pharmacy was 7.6 years. • This difference was less than 2 years in 18 communities A. Traynor and T. Sorensen College of Pharmacy University of Minnesota

23. Distance to Next Nearest Community with a Pharmacy (Avg. = 21.7 miles) More than 25% exceed 25 miles A. Traynor and T. Sorensen College of Pharmacy University of Minnesota

24. Difficulty of Recruiting Staff Pharmacists in Rural Communities (n = 81) How difficult has it been to recruit part-time staff pharmacists in the last 5 years? How difficult has it been to recruit full-time staff pharmacists in the last 5 years? A. Traynor and T. Sorensen College of Pharmacy University of Minnesota

25. Difficulty of Recruiting Relief Pharmacists in Rural Communities (n = 81) How often have you had to change plans because a relief pharmacist was not available? How difficult is it to find a relief pharmacist when you need one? A. Traynor and T. Sorensen College of Pharmacy University of Minnesota

26. So, where are we? • Most small rural communities are serviced by independent pharmacies • Rural pharmacists are aging • Independent owners would like to sell • Communities are at-risk Will the next generation of pharmacists fill the need? A. Traynor and T. Sorensen College of Pharmacy University of Minnesota

27. NDSU/SDSU/U of Minnesota Student Survey 2004/2005 (n = 91/86) • “Have you given or would you give serious consideration to practicing in a town with a population of 5000 people or less after graduation?” 111 Yes66 No • “Have you given serious consideration to pursuing ownership (full or partnership) of a community pharmacy?” 47 Yes130 No • For those not interested in community pharmacy ownership, 76.9% reported that responsibilities and time commitment were of moderate or great influence in their consideration. A. Traynor and T. Sorensen College of Pharmacy University of Minnesota

28. The Positive Economic Impact of Medicare Part D • Large Population of Seniors in Rural MN • nearly 1/2 of rural seniors lacked Rx coverage vs. to 1/3 of urban seniors • Scope of Medication Use • rural residents are more dependent on medications due to a higher prevalence of chronic conditions • Rx Payment and Margins • Rural pharmacies 18% cash sales vs. 13% in urban • Limits on Rx volume and revenue growth • independent pharmacies: 93% of revenue from Rx sales A. Traynor and T. Sorensen, College of Pharmacy, University of Minnesota

29. Summary • Today’s pharmacists are being trained to provide more direct patient care – particularly useful in rural communities as providers of first contact care • Rural pharmacists make many contributions to other local healthcare entities including CAHs and LTCFs • More rural pharmacies are independently owned; economic and HR challenges have greater impact than on urban pharmacies • MN has 128 one-pharmacy towns, several of which are at risk for losing their pharmacy services when the owner retires