24 minute read
Tackling Social Determinants of Health
from DSN-0821
by ensembleiq
Tackling the Big Obstacles
Pharmacies turn their attention to factors driving disparities in health
By Sandra Levy
It takes a village to raise a child.
Many retail chain and independent pharmacies are heeding this proverb, as evidenced by the extent to which they are working fervently to address the social determinants of health, as well as the health disparities that impact many patients in the communities they serve.
To be sure, tackling the varied and complex circumstances that affect many of these patients’ lives is a Herculean task, one that requires innovative strategies and investments to yield a cornucopia of benefits.
It appears that retailers are leaving no stone unturned, pursuing strategies that include delivering personalized care, launching medication therapy management and medication adherence programs, partnering with community and religious leaders, collaborating with health systems, offering free health screenings and addressing transportation and food security issues.
Helping the Vulnerable
Lewis Drug, a retail chain with 56 stores across South Dakota, Minnesota and Iowa, is a forerunner in implementing numerous strategies to address social determinants of health.
Bill Ladwig, senior vice president of professional services at Lewis Drug, emphasized that the COVID-19 pandemic has made the need to address social determinants of health more visible, especially with the urgent need to get more people in underserved communities vaccinated against COVID-19.
To reach that goal, Lewis Drug is working with city, state, county, religious and business leaders, as well as other influencers who can identify patients who are resistant to getting the vaccine and who are most in need of education.
“We are going outside of the traditional pharmacy realm. We’re meeting patients’ expectations with new ideas and novel
More than 825 Health Mart pharmacies in 46 states are participating in the Federal Retail Pharmacy Program with the Centers for Disease Control and Prevention. Health Mart has trained
more than 4,200 pharmacy staff members to administer vaccinations.
opportunities,” Ladwig said. “It’s much more efficient to use the assets readily available to you than it is to create something new. Since early on, we have been working with local entities who know where these people are.”
Through these alliances, Lewis Drug has vaccinated workers at beef and turkey plants, and dairy sites in South Dakota.
The outreach effort also is proving to be a conduit for Lewis Drug’s pharmacists to have conversations on a broad spectrum of potential opportunities, including making sure patients get other vaccines, like pneumococcal or Tdap, Ladwig said.
Combatting vaccine hesitancy in communities that are impacted by social determinants of health also is Walgreens’ bailiwick.
Stacey Emmons, Walgreens director of patient outcomes performance, said the retailer is taking a multifaceted approach.
“As part of our commitment to drive health equity, we launched vaccine equity initiatives to increase access to vaccinations,” she said. “We provide education that
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As it ramped up its vaccination effort, Health Mart activated roughly 100 pharmacies per week and built out an online vaccine scheduler amid other digital infrastructure.
helps with vaccine hesitancy and have created partnerships with community and religious leaders to help us meet the needs of each of these communities.”
CVS Health also is forging ahead to increase COVID-19 vaccination rates with a strategy that includes proactive patient outreach, community-based partnerships and vaccine clinics, as well as robust, education-focused marketing. The retailer is working with its extensive network of community-based leaders and nonprofit organizations, including free and charitable clinics, faith-based organizations and others, to reach vulnerable patients.
Rebecca Ferrick, a CVS Health spokesperson, said that because of these efforts, more than one-third of the nearly 24 million vaccines that CVS Pharmacy administered as of June 9 have gone to underrepresented minority communities, including Black, Hispanic and Native American patients, a mark higher than the overall national average.
Irving, Texas-based Health Mart and the Health Mart Atlas network of independent pharmacies are also playing an integral role in COVID vaccine administration in underserved and rural communities.
In fact, more than 825 Health Mart pharmacies across 46 states are participating in Health Mart’s Federal Retail Pharmacy
HELPING THE HELPERS
Addressing social determinants of health can be a daunting challenge. These retail pharmacies are making the endeavor less burdensome.
The Compliance Team
Based in Spring House, Pa., The Compliance Team offers a Community Pharmacy accreditation program that includes several standards to help pharmacies address a range of social determinants of health.
Sandra Canally, founder and CEO, said that patient education and access to food and transportation, contribute to whether patients will comply with their drug regimen.
“We accredit many supermarket pharmacies, who provide nutritional counseling with dietitians, to make sure patients are making the right food choices,” Canally said. “Are patients close enough to the pharmacy to pick up their medications? Do they need a ride from someone, or if they are unable to come for the refills, does the pharmacy offer delivery services? Do they feel safe traveling to the pharmacy on public transportation? Do they have access to a primary care physician, and do they understand their doctor’s instructions? As an accreditor, we look at all of these things because they are connected to a patient’s ability to stay on their drug regimen.”
The Community Pharmacy accreditation program also includes standards for pharmacies to address patients’ financial hardships. “Many patients are unable to pay for medications,” Canally said. “Many times the manufacturer can help patients pay for the drugs, and there are drug discount cards available.”
The Compliance Team also offers a certification for immunizations and point-of-care testing. Beyond the Community Pharmacy accreditation program, The Compliance Team’s value-based care program encompasses additional pharmacy services that drive patient adherence and outcomes.
—S.L.
As part of its COVID-19 vaccination push, Walgreens has used mobile vaccine clinics — including one that traveled to various Chicago neighborhoods and a coast-to-coast bus tour.
Program with the Centers for Disease Control and Prevention. To date, 1,370 community pharmacies have administered 1 million COVID vaccine doses.
“Health Mart pharmacy teams are reaching some of the most vulnerable to COVID-19,” according to the CDC’s Social Vulnerability Index,” said Eyad Farah, president of Health Mart and Health Mart Atlas.
Farah noted that Health Mart has facilitated COVID-19 vaccination training for more than 4,250 pharmacy staff members. It also secured 1,275 digital data loggers needed for proper vaccine storage and activated about 100 new stores a week amid the pandemic.
Health Mart also provided an online vaccine scheduler, a patient administration documentation tool and a resource platform to centralize access to vaccine training, tools and resources, as well as streamlined required daily activity reporting.
Beyond their expansive plans to aid in vaccination administration, pharmacies also are finding ways to solve patients’ transportation problems. Take the case of Walgreens, which entered a partnership with Uber.
“Our pharmacists are reaching out to patients to discuss if they’re eligible for a vaccine, and if they say, ‘I can’t get to the pharmacy’ or ‘I’m in an area where I don’t
— STACEY EMMONS, DIRECTOR OF PATIENT OUTCOMES PERFORMANCE, WALGREENS
have transportation,’ they can then educate the patient to use the Uber app or to contact Uber to set up an arrangement for that transportation,” Emmons said.
Additionally, Walgreens has local mobile clinics that stop in various communities across the country. “This makes it easy for people to come into these mobile clinics that might not necessarily be able to reach a pharmacy due to transportation,” Emmons said.
To further increase access to vaccines, CVS is using mobile vaccination vans and has launched community-based clinics, working closely with nonprofit organizations, including the YMCA.
“We’ve also partnered with Lyft and nonprofit partners to help underserved communities access vaccination appointments by providing free or discounted rides for those in need,” Ferrick said. “Lyft’s universal vaccine access campaign is a partnership of companies, community organizations and individuals working together to make sure everyone has access to affordable, reliable transportation to get to vaccination appointments when they need to.”
Getting Creative
Besides addressing transportation problems, a growing trend among retailers to forge collaborative relationships between pharmacists and healthcare providers also exists. Lewis Drug stands out for its success in this area. The chain has embedded four pharmacists in clinics in the Sanford Health System.
“We found that these pharmacists are a great conduit to patients because it’s in a different environment,” Ladwig said. “You’re in the physician’s office and you are able to impact knowledge in an environment where it may be more fruitful. You can’t plant seeds in a desert and expect them to grow. You have to nurture them. We’re trying to create environments. We’re using pharmacists in clinics to be a better conduit to impact more people.”
Not only are collaborative partnerships emerging, but personalized care models are taking root.
Walgreens’ initiatives in the south and west sides of Chicago, including Chatham, open a window on how an approach to personalized care can improve the health of patients with chronic diseases.
“We’re working on how pharmacists can continue to support medically underserved areas through diabetes education, addressing any barriers to taking their medications, making recommendations for health screenings and immunizations as well,” Emmons said.
Additionally, Walgreens has a program to support pediatric asthma outreach and education in Chatham, where there is a high prevalence of pediatric asthma.
As part of the program, Walgreens pharmacists educate pediatric patients and their caregivers about their disease state. “We help their caregiver to understand the asthma disease state so they can feel more comfortable helping their child at home to use an inhaler,” Emmons said. “It’s important that they are using the appropriate technique and identifying the trigger that will cause an asthma flare. We are helping to support taking care of the patient by educating the parent and guardian and, in turn, creating a stronger relationship with those patients and caregivers.”
HELPING THE HELPERS
Addressing social determinants of health can be a daunting challenge. Here’s a look at retail pharmacies making the endeavor less burdensome.
EnlivenHealth
The Raleigh, N.C.-based division of Omnicell provides advanced digital technology solutions for intelligent patient engagement and communications. The EnlivenHealth Patient Engagement Platform, which is deployed at more than 30,000 retail pharmacies nationwide, incorporates technology applications that enable pharmacies to identify which patients are most in need of targeted interventions, including those impacted by social determinants of health-related issues, and then implements a range of therapies that increase medication adherence, improve quality scores and drive patient retention. EnlivenHealth’s patient engagement solutions optimize pharmacy workflows by automating repetitive pharmacy tasks. This frees up pharmacists to practice at the top of their license and provide high-value, revenue-generating services, such as vaccinations, point-of-care testing and medication therapy management counseling. Enliven Health pioneered the development of Medication Synchronization, or Med Sync, a system designed to align prescription refills to a convenient single date each month to coincide with appointment visits. Patients enrolled in an appointment-based program, such as Med Sync from EnlivenHealth, are three times more likely to remain adherent to their medications, according to the company. With Med Sync, patients can get more done on a single monthly trip as opposed to having to make multiple trips over the course of 30 days, increasing their chances of positive health outcomes. EnlivenHealth also provides omnichannel communications solutions that enable retail pharmacies to create a uniquely personalized patient experience. “Retail pharmacies face the challenge of how to communicate the appropriate message, through the right channel, to effectively engage patient populations with key social determinants of health indicators,” said Kim Howland, head of product development at EnlivenHealth. “Our new personalized communications solution can target vital healthrelated information in ways these patients understand and that have a measurable impact on better health outcomes.”
—S.L.
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Walgreens has taken a data-driven approach to the health interventions it suggests to patients, informing pharmacy team members which patients would benefit the most from a personalized conversation and clinical services.
Walgreens also employs smart analytics models to help power personalized interventions that are helping the chain identify patients who have chronic disease states and to drive medication adherence.
“Using these smart analytics models, we’re able to identify for the pharmacy team, the patients who need personalized conversations the most, and then triage interventions through the patient’s preferred channel,” Emmons said. “If a patient is new to therapy, our pharmacists are going to follow up with them a few days after starting their medications to ensure there aren’t any side effects or answer questions they have. They also can have ‘late to refill’ or prescription abandonment conversations. There’s a multitude of different opportunities our pharmacists have to deliver personalized care and have those one-on-one conversations with patients.”
An important component of providing personalized care includes a focus on patient engagement, which opens up doors to being able to offer an array of solutions for patients impacted by social determinants of health.
CVS Pharmacy’s HealthTag pilot program in Louisiana and West Virginia provides proof on the importance of encouraging a dialogue between pharmacists and patients. The program allows pharmacy employees in those locations the ability to deliver personalized messages when patients pick up their prescriptions.
“The community services are organized by Unite Us, a leading social care coordination platform that is collaborating with Aetna to help some of our most vulnerable members more easily access social services within their community,” Ferrick said.
The Unite Us HealthTag pilot program is designed to have pharmacy employees help close lifestyle gaps for patients. “By analyzing Aetna Medicaid’s claims data, we can identify patients who are filling their prescriptions at CVS pharmacies that are participating in this pilot program,” she said.
When those patients come to a CVS Pharmacy to pick up their prescription, the HealthTag opportunity alerts the pharmacy employee to talk with the patient about program options through Unite Us that meet their lifestyle needs. Once a patient is enrolled in the Unite Us platform, they’re connected with community-based organizations to help address their specific needs.
“The community-based organizations also can help with issues that aren’t as directly connected to a person’s health, but certainly have an influence on their well-being, such as housing services in the area,” Ferrick said. “Through this program, we’re able to improve the health of individuals and communities by providing people who need help the most with local resources through a trusted person they see on a regular basis, such as their pharmacist.”
CVS Health also is engaging with its members in vulnerable communities more often, using communications channels they are likely to see and respond to, such as text messages instead of emails or phone calls.
“We also tailor messages to ensure that people are both aware of their health risks and where they can get the support that works for them,” Ferrick said. “We’re tailoring support and treatment options for members by their individual health history and demographic patterns based on age, gender, education level, geography, income and race.”
Walgreens also has made tools and supporting programs available to its pharmacists within their daily workflow. For instance, Walgreens has a clinical platform that helps identify patients who may have refills coming up so that its pharmacists and pharmacy team members can call and engage them and make sure they are filling their medications on time.
“We have the ability to identify patients who are late to refilling their medications and to contact those patients to see if there are any
— EYAD FARAH, PRESIDENT, HEALTH MART AND HEALTH MART ATLAS
barriers they are experiencing to refilling that medication,” Emmons said. “Are they experiencing side effects, transportation or cost issues and then providing solutions to help solve those barriers, as well as preventing prescription abandonment.”
Walgreens uses MTM services to help trigger and identify for its pharmacists and pharmacy team members if there is an opportunity to discuss medication adherence, as well as various chronic health conditions.
“We’ve found that it’s really important to identify how the patient prefers to be contacted,”Emmons said. “There’s such a variance in how a patient wants to receive information from the pharmacy and how it is going to be useful for them. Looking at what channel, whether it be a personalized phone call or through digital engagement, such as email, use of an app, push notification or texting, you are really engaging the patient in their preferred channel.”
Lewis Drug’s Ladwig concurred that having conversations with patients is crucial, but many people are too busy and they don’t ask for help.
“How can we as pharmacists be good stewards of our ability to contact patients to get them to be better patients?” he said. “We are trying through MTM, but the biggest obstacle is that when we ask people for consultations on medications, they often say, ‘I’m fine, I don’t need anything’ and don’t get engaged in the conversation. Pharmacists want to help people to be healthier. That’s the bridge, and it’s what we emphasize.”
To that end, Lewis Drug also made an investment to offer its Smart Pack compliance pill pack and Smart Sync adherence packaging to patients for free, although the pharmacy does not receive reimbursement. “We bought a machine years ago, and are doing the packing at fill operations,” Ladwig said. “It’s a huge win for patients, especially daughters who are caregivers. The No. 1 reason people are hospitalized is because they don’t know how to take or understand their medications or the side effects.”
Affordability in Focus
Retail pharmacies also are doing their part to offer free and low cost health services.
For example, CVS has committed $100 million to improving community health through its support of free clinics since 2006. “Our Project Health events have delivered more than $134 million in free healthcare services to over 1 million Americans in diverse
HELPING THE HELPERS
Sharps Compliance
As a biomedical and hazardous waste management company, Sharps Compliance customizes waste services based on the location and distinct needs of pharmacies to ensure that a variety of hazardous substances and materials are properly removed from the communities they serve. Kathryn Kane-Neilson, Sharps’ clinical specialist for regulatory compliance, said the improper storage and disposal of unused medications threaten both human health and the natural environment. “Unsecured drug wastes can end up in wrongful hands for illicit means or accidental misuse, and improper disposal via flushing or landfill leachate can contaminate public waterways.” Houston-based Sharps’ MedSafe collection receptacles are Drug Enforcement Administration- and Americans with Disabilities Act-compliant steel units installed in retail pharmacies for public use to dispose of expired, unused or otherwise unwanted prescription and over-thecounter medications. “A retail pharmacy that installs a MedSafe serves as a pillar of public health for their communities by enabling safe and convenient disposal of substances harmful to both human and environmental health,” Kane-Neilson said. “Additionally, Sharps’ TakeAway Medication Envelopes are a discreet means for the public to dispose of their unwanted medications in the privacy of their own homes.” Kane-Neilson pointed out that hazardous materials, such as littered or loosely discarded sharps, also pose a distinct public health risk, particularly in communities with limited resources. “Sharps’ Complete Needle system, which is sold in retail pharmacies, supplies individuals who self-inject their medications a safe and convenient means of disposing of the sharps waste,” she said. Sharps also maintains an updated blog that addresses regulated waste issues plaguing public health, from avoiding public needlestick injury to safe medication storage at home.
—S.L.
The care concierge at CVS Pharmacy’s HealthHUB locations are just one example of the chain’s efforts to better engage patients. In Louisiana and West Virginia, its HealthTag pilot is encouraging personalized dialogue between pharmacists and patients at the time of prescription pickup.
communities with large numbers of uninsured or underinsured people,” Ferrick said.
Through its investments and collaboration with local partners, CVS Health also is able to provide underserved communities across the country with quality housing, economic support and educational training opportunities. Some of these collaborations in 2020 included CVS Health’s continuation of its longstanding support of the National Association of Free and Charitable Clinics members for wraparound services for underserved patients, delivering funding for 65 clinics in 17 states.
“We also provided more than $5 million in combined support to Feeding America to reduce food insecurity among vulnerable populations, which increased dramatically during the COVID-19 pandemic,” Ferrick said.
CVS Health’s no-cost, community-based screening program, Project Health, helps people without regular access to health care
HELPING THE HELPERS
STChealth
STChealth’s tools empower pharmacies to address social determinants of health and improve individuals’ quality of life. “Because nine in 10 Americans live within 5 miles of a community pharmacy, pharmacies can influence public health unlike other healthcare providers, but to maximize time and resources, new technologies are needed,” said Kyle Freese, chief epidemiologist at STChealth. The company provides epidemiologic analytics so pharmacies can perform targeted outreach and education. These insights inform decisions surrounding inventory, operating hours and where additional community engagement is needed. “At the patient level, STChealth’s Clinical Services platform allows pharmacists to identify gaps in vaccine coverage in real time and provide the opportunity to educate patients on the benefits of vaccination,” Freese said.
—S.L.
CVS Health’s COVID-19 vaccination strategy has included proactive patient outreach, communitybased partnerships and vaccine clinics alongside educational marketing. The chain has administered nearly a third of its 24 million vaccine doses to underserved populations.
understand their risk for chronic conditions and connect to free or low-cost providers and services to support their unique healthcare needs. Through Project Health, the company hosts events at CVS Pharmacy locations, offering free biometric screenings, including blood pressure, cholesterol, glucose level and body mass index to detect early risks of chronic conditions, such as diabetes, hypertension and heart disease before they become life-threatening.
Following these screenings, participants can meet with a nurse practitioner, who can provide referrals for treatment and advice on follow-up care, which is particularly important given that some people have delayed or put off primary care during the COVID-19 pandemic.
While no one can predict what new strategies will surface as retail and independent pharmacies continue to help battle social determinants of health, it appears that the momentum is building.
Doug Hoey, CEO of the National Community Pharmacists Association, said that because of the relationships that independent pharmacies have with patients, they are privy to the social determinants of health issues that impact their patients’ lives and will have a continued opportunity to intervene on their behalf.
“The independent pharmacist often has a good perception of many of the social determinants of health that affect their patients, such as whether they live alone or lack transportation,” Hoey said. “The patient trusts the pharmacist. It’s a great opportunity for pharmacists to be involved, particularly since the technology is there to record the results of some of those conversations.”
Emmons said she is confident that Walgreens will continue its efforts. “The pandemic has really been a case study in how our pharmacists and pharmacies are able to show up and support addressing disparities in care and being a local healthcare provider,” she said. “Through that we’re taking that opportunity to make sure we are continuing to build on the initiatives and partnerships we’ve begun, and look forward to continuing that in the future.”
Ferrick echoed Emmons’ sentiments about pharmacies’ abilities to be leaders in helping patients overcome health disparities. “Your health is intrinsically linked to where you live and spend most of your time, which is why we are committed to addressing social determinants of health at the community level,” she said. “Given our combined scale and presence in nearly 10,000 communities, CVS Health has an unprecedented opportunity to improve the health of individuals.”
Health Mart’s Farah also said that he is optimistic about community pharmacies’ future role in addressing social determinants of health. “From vaccinations to point-of-care testing to patient education, community pharmacies continue to be the compassionate and trusted provider you can lean on,” he said. “They take the time to listen and care. So naturally, they are the problem solvers for America’s most complex healthcare issues.”
Finally, Ladwig envisions pharmacists’ role will evolve to be more like health coaches, and that in pharmacy deserts, which are rural areas where there are no pharmacies due to attrition, pharmacies are going to be central in healthcare delivery.
His prediction is already playing out in Howard, S.D., where Lewis Drug built a pharmacy to compensate for the nearest pharmacy being located 30 miles away. Lewis plans to open a telepharmacy at Horizon Clinic in Howard and will embed a pharmacist and a multilingual pharmacy technician in the clinic to serve an immigrant population.
“How do we create a health hub here?” Ladwig said. “Pharmacists are not providers, but they offer incredible service. How do we combine with the local healthcare entity to be able to support the health in that community? We’re trying to figure out what a hybrid looks like and to be an intermediary access pharmacy combined with a health hub down the road may be the solution. The endgame here is to get a trust factor in these communities.” dsn
