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Medication Management in Rural America

By Ashley Merritt posted 04-17-2019 13:19

  

           This Thursday when I finished my day at the VA community based outpatient clinic, I went to a local independent pharmacy to cover a closing shift.  While I was there I met their APPE student and asked her, “What do you want to do when you get out of pharmacy school?”  She grinned ruefully and replied, “I would like to work in a primary care clinic, but I want to move back home after school so I know that’s probably not going to happen.”  Her response resonated with me.  After all, I was in the same position only five years ago.  For me, graduating and accepting a clinical position at a local independent pharmacy chain right out of college was a dream come true.  Clinical pharmacy positions in rural southeast Missouri are a rare gem.  Then, with all the glee of a childhood bully, real life threw a bucket of cold water on me.  I quickly realized all of the skills I had so carefully developed throughout pharmacy school were essentially as foreign as a flying car to the local medical community.  Without the benefit of a marketing course, I had to find a way to get patients, providers, clinic ancillary staff, and pharmacy staff to buy into the benefits of utilizing a pharmacist for medication management services.  I often found myself feeling isolated, struggling with burnout, and fighting push back against changing the status quo.

            Health care providers in rural areas face unique challenges.  Access to care due to transportation issues, geographic distance, low physician to patient ratios, and closures of small hospitals across the United States continue to be barriers for rural patients.  Rural Americans also tend to be older, sicker, poorer, and less educated than their urban counterparts1.    Given these factors, wouldn’t the local health care community jump at the chance to have a pharmacist on the team?  Well…it depends.

            In non-metropolitan areas, 46.7% of primary care physicians were 55 or older2 in 2014.  As I began my enthusiastic crusade to expand services, I encountered all sorts of physicians-from equally enthusiastic 70 year olds to 40 year olds with no desire to participate in team-based care.  For the most part, my providers were over 50 and had never had any experience with a pharmacist as a part of the interdisciplinary care team.  After arranging meetings with the local primary care clinics, many providers were open to the idea after learning about our education, the type of services we could provide, and how medication management could benefit patients and affect their clinics’ quality measures (and ultimately, their bottom line).  In 2014 and 2015 when I was organizing these meetings, most of my providers were unaware of how CMS quality measures would be impacting their reimbursement (MACRA who?).

            What can be done to help pharmacists struggling to improve medication management for their patients in rural areas? Some pharmacy schools have helped to address the issue by incorporating rural health education programs or electives into their curricula to give student pharmacists a better grasp on the challenges and rewards of rural health.  There are an expanding number of residency programs available throughout the country, but not nearly enough as demand for pharmacy residencies continues to exceed supply with 1,300 to 1,800 applicants who do not match annually2.  But what of education beyond the classroom?  Beyond residency?  The profession of pharmacy demands that we as pharmacists be dedicated lifelong learners.  How do we help facilitate learning for our practicing pharmacists, particularly in rural environments?

            The challenge for rural pharmacists seeking quality continuing education is that they are often the only pharmacist on site.  Arranging coverage to attend an out of town conference is nearly an act of Congress.  Even sneaking in a call or webinar on their lunch break may prove to be impossible.  How do we think out of the box to provide high quality learning opportunities to these pharmacists? There are emerging models of tele-learning in the medical community in which specialists provide case-based learning opportunities to their primary care colleagues.  Arguably, the most well-known of these is Project ECHO which initially began as a way to help treat patients with hepatitis C and has since expanded to include HIV, chronic pain, endocrinology, and other complex medical conditions3.   The question then becomes, how can we apply this ideology to the practice of pharmacy?  Not just for those who are in primary care clinics, but for those providing medication management services across the spectrum of health care: independent pharmacies, chain pharmacies, long term care facilities, hospitals, and all other avenues where medication management is provided. 

            Creating a culture of health learning, seeking ways to facilitate participation in continuing education opportunities, and networking with peers is crucial to the expansion and delivery of pharmacist led medication management services in rural areas.  I personally believe grassroots efforts such as the local, regional, and state affiliates of national pharmacy organizations are key.   Leveraging a local network of support would expedite the dissemination of innovative health care and medication management practices to both peers and collaborators. 

            Other barriers to implementation of medication management services in rural areas to address are lack of knowledge about payment models and marketing strategies for expanded pharmacy services and recruitment of new practitioners to rural areas.  While there is a plethora of information about these topics individually, it is rare to find specific examples applied in rural health systems and often lack insight about how to start from scratch.  In general, I doubt most pharmacy school graduates will feel comfortable showing up at their local health system to pitch an ambulatory care pharmacy business model to the c-suite.    For that matter, recruiting new graduates, especially residency trained pharmacists to rural areas can be a struggle-just as it is for the other health professions.  Unfortunately, pharmacists are often excluded from state debt forgiveness programs and there are limited opportunities for assistance through federal avenues.  In 2016, the average student loan debt was $157,425 for PharmD graduates4.

            This is our call to action.  How do we prepare our students, our practicing pharmacist, and our communities in rural America for integrated medication management services?  How do improve access to care for millions of rural Americans?  I think the answer lies with you and me as individuals promoting excellence in pharmacy practice…or as I like to call it “drinking the Kool-Aid,” touting the importance of medication management services far and wide.  Improving student and practicing pharmacists’ knowledge around health disparities in rural areas, payment models, business plans, and marketing of pharmacy services is integral to expanding access to these services. 

 

  1. Rural Healthcare Workforce. Rural Health Information Hub Website. https://www.ruralhealthinfo.org/topics/health-care-workforce. Revised July 19, 2018. Accessed April 8, 2019.
  2. Problems of Rural Life. In: Schmitz A, ed. Social Problems: Continuity and Change. Online edition: Saylor Academy; 2012.
  3. Kalinoski G. Residency Programs: Not Enough to Go Around. Drug Topics Website. https://www.drugtopics.com/clinical-news/residency-programs-not-enough-go-around. Published August 14, 2017. Accessed April 8, 2019.
  4. Refinancing Loans After Pharmacy School. Pharmacy Times Website. https://www.pharmacytimes.com/contributor/timothy-o-shea/2016/09/refinancing-student-loans-after-pharmacy-school. Published September 8, 2016. Accessed April 8, 2019.

 

 

 

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