IPA Journal Jan/Feb/Mar 2023

8515 Douglas Avenue, Suite 16, Des Moines, IA 50322

Phone: 515.270.0713 Fax: 515.270.2979

Email: ipa@iarx.org | www.iarx.org

PUBLICATION STAFF

Allison Hale, Managing Editor

Kate Gainer, PharmD

Emmeline Paintsil, PharmD, MSLD, BCPS

Elizabeth Orput, PharmD

Kellie Staiert, MPA

Laura Miller

OFFICERS

CHAIRMAN

Christopher Clayton, PharmD, MBA – Manchester

PRESIDENT

Cheri Schmit, RPh – Ames

PRESIDENT-ELECT

John Hamiel, PharmD – Evansdale

TREASURER

CoraLynn Trewet, PharmD – Ankeny

SPEAKER OF THE HOUSE

Heather Ourth, PharmD, BCPS, BCGP – Ackworth

VICE SPEAKER OF THE HOUSE

Wes Pilkington, PharmD – Waterloo

TRUSTEES

REGION #1

Robert Nichols, PharmD, BCPS – Waterloo

REGION #2

Pamela Wiltfang, PharmD, MPH, BA, CHES – North Liberty REGION #3

John L'Estrange, PharmD, RPh, BCACP – Des Moines REGION #4

Grant Houselog, PharmD, CSPI – Sergeant Bluff AT LARGE

Micaela Maeyaert, PharmD, BCPS, DPLA – Spirit Lake

Morgan Herring, PharmD, BCPS, FAPhA – West Des Moines

Jackie Gravert, PharmD, MPH – Cedar Rapids

Angie Spannagel, PharmD, BCACP – Dubuque

HONORARY PRESIDENT

Betty Grinde, RPh – Story City

PHARMACY TECHNICIAN

Tammy Sharp-Becker, CPhT, CSPT – Des Moines

STUDENT PHARMACISTS

Nirjan Bhattarai – Drake University

Sidney Vancil – University of Iowa

The Journal of the Iowa Pharmacy Association is a peer reviewed publication. Authors are encouraged to submit manuscripts to be considered for publication in the Journal. For author guidelines, see www.iarx.org/journal.

“The Journal of the Iowa Pharmacy Association” (ISSN 1525-7894) publishes 4 issues per year: January/February/March issue; April/ May/June issue; July/August/September issue; and October/November/December issue by the Iowa Pharmacy Association, 8515 Douglas Avenue, Suite 16, Des Moines, Iowa 50322. Periodicals postage paid at Des Moines, Iowa and additional mailing offices. POSTMASTER: Send address changes to: The Journal of the Iowa Pharmacy Association, 8515 Douglas Ave., Suite 16, Des Moines, IA 50322. Published quarterly, The Journal is distributed to members as a regular membership service paid for through allocation of membership dues. Subscription rates are $100 per year, single copies are $30. Printed by Mittera; Graphic design done by the Iowa Pharmacy Association.

Mission

MOVING FORWARD IN 2023

of all that adversity, the profession (all of you) rose to the challenge. You kept moving forward. You adapted. You innovated and improvised. You made the profession better. And I believe that you have positioned the profession on the cusp of historic changes that will forever improve the profession of pharmacy.

New beginnings – moving forward.

IPA President

Cheri Schmit, RPh Senior Manager, Product & Solutions Marketing, Cardinal Health

While I am not sure when you will be reading this article, I am writing it in January 2023. During December, I find my thoughts to be sentimental and reflective. But in January, I always look forward to the start of a new year and all the promise it holds. I am not really one to make resolutions, mostly because I know I will quickly break them, but I do love the hope and promise that a new year holds: the chance for a fresh start, the hope for a better year and the excitement of upcoming events and activities.

As I was pondering what to write, I happened to read the journal posting that Ashley Temple posted on Tom’s Caring Bridge site, and the theme was “new beginnings – moving forward.” This post reminded me that a “new beginning” or a new year is not always what we planned, and we need to be flexible and willing to adapt our plans. As I read the article, I was once again struck by the fact that no matter what situation Tom Temple is in or has faced, and no matter how difficult or frustrating, he has always faced each challenge with a positive and grateful attitude. He hasn’t dwelled on the past or the negative—he’s just kept moving forward with hope and positivity.

Tom’s resilience, hope and positivity has been mirrored in the pharmacy profession. The last few years have certainly been difficult, frustrating, and full of adversity. I don’t think any of us planned or hoped for the challenges that faced our practice settings. All of us have dealt with mental health challenges and extreme stress in one way or another. Reimbursement, staffing and supply chain issues have touched all of us and challenged us in ways we never imaged. And yet, in the face

At the IPA Annual Meeting in Cedar Rapids this past September, the House of Delegates passed policy 22-U2: Standard of Care Model for Pharmacist Practice. This policy separates the pharmacist, and the care and services provided by the pharmacist, from the drug distribution process and the physical location where the pharmacist practices. This policy aligns with the regulation of other healthcare professionals, holding them to a standard of practice. It also allows for the scope of practice, or the services and care provided by the pharmacist, to be more flexible versus regulated by legislative code. And importantly, patient safety is still the number one priority.

One might also argue that this policy improves public health by expanding access to care. Over 90% of Americans live within five miles of a pharmacy. In rural and underserved areas in the state of Iowa, the pharmacist may be the only healthcare professional conveniently accessible to the patient. The United States is projected to face unprecedented physician shortages in the coming decade, and this will undoubtedly be magnified in rural and underserved areas. Pharmacists in all practice settings will be impacted and may be part of the public health answer to this physician shortage.

“A ‘new beginning’ or a new year is not always what we planned, and we need to be flexible and willing to adapt our plans.”

Strategic planning at the IPA Board Retreat in November 2022

IPA Pharmacist Day on the Hill 2023

During the pandemic, pharmacists in all practice settings in the state of Iowa stepped into new roles, provided new services, and collaborated with providers, health systems, hospitals, care facilities, public health, community groups and more to fill gaps and save lives. Pharmacists are nimble, and this policy allows the profession to be nimble and adapt to the needs of communities and patients within the boundaries of their education and training. This policy is a step forward to a new beginning for the profession, allowing pharmacists to practice at the level of their education and training.

I hope you were able to join us for Pharmacist Day on the Hill at the State Capitol in January. This legislative session is also a new beginning. In November, many first-time legislators were elected, and districts were redrawn. Chances are you have at least one new legislator in your district. It is important for all legislators, especially the new ones, to hear from you and your patients. They need to hear your stories and understand the value you bring to your community—the community they were elected to serve. They need to understand why pharmacists should be allowed to practice to their level of education and training, in addition to the urgent need to

appropriately pay them for the product, care, and services provided.

I urge you to join grassroots advocacy efforts to contact your legislators when IPA requests it and to consider hosting legislators at your practice setting. If you are unsure about how to get involved, join one of the upcoming “Ask IPA Anything” webinars or contact Seth or Brett on IPA staff.

I have no doubt this year will not go exactly as we hoped or planned. There will be challenges, disappointments, and adversity. But I have full confidence that Iowa pharmacists will continue to adapt, innovate, and rise to the challenge. Maybe, just maybe, this is the year Iowa pharmacists take one step closer to provider status. Regardless of what this year has in store for our profession, I am excited about the possibilities and the hope of a better tomorrow for Iowa pharmacists.

New beginnings – moving forward. ■

“Regardless of what this year has in store for our profession, I am excited about the possibilities and the hope of a better tomorrow.”

OBESITY…GUIDELINES, DRUGS AND TIKTOK!

Author: Wendy Mobley-Bukstein, PharmD, BCACP, CDCES, CHWC, FAPhA; Associate Professor of Pharmacy Practice, Drake University; Ambulatory Care Pharmacist, Primary Health Care East Side Clinic

In 2013, obesity was classified as a chronic medical condition by the American Medical Association. 2021 National Health and Nutrition Examination Survey (NHANES) data tells us that 41.9% of Americans are obese.1 Obesity complicates comorbid chronic conditions such as heart disease, type 2 diabetes, stroke and certain types of cancer.1 Studies have shown that obesity also disproportionately affects certain ethnic/racial groups.2 There has been a correlation with lower socioeconomic status and lower education level too.3 Adults, children and adolescents experience similar social determinants of health and health inequities. In order to create more equitable accessibility to education, information and treatment, it is imperative that we as accessible healthcare providers be up-to-date on the guidelines and the best way to help the people in our communities.

ADULT OBESITY GUIDELINES

In 2013, the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society published the guideline for the Management of Overweight and Obesity in Adults. These guidelines were published prior to pharmacologic therapies that are available today, except for orlistat. These recommendations focused on five critical questions that guide providers in the evaluation and treatment of obesity. They focus on the benefits of weight loss, comprehensive lifestyle interventions, weight loss maintenance, and risk versus benefit of bariatric surgery.4

In 2016, the American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE) published evidence-based clinical practice guidelines that incorporated both body mass index (BMI) and weight-related complications. These guidelines also focused on nine critical questions with 123 recommendations that have specific statements associated with them. These evidence-based recommendations allow for screening, diagnosis, evaluation, selection of therapy, treatment goals and individualized care. These guidelines included the use of pharmacotherapy. The guidelines evaluated five products and their respective key clinical trials: orlistat, lorcaserin (removed from the market in 2019), phentermine/topiramate ER, naltrexone ER/bupropion ER, and liraglutide 3mg.(Table 10) The guideline took it a step further and outlined preferred medications for comorbid medical conditions.5 (Table 11)

In both guidelines, bariatric surgery is recommended for individuals where benefits outweigh risks and the BMI is >40 kg/m2 without comorbid conditions or BMI >35 kg/m2 if comorbid conditions exist.

ADOLESCENT & PEDIATRIC OBESITY GUIDELINES

The Centers for Disease Control and Prevention (CDC) states that obesity is affecting 14.4 million kids in the U.S. To address this critical

health urgency, on January 9, 2023, the American Academy of Pediatrics (AAP) released their clinical practice guidelines for the Evaluation and Treatment of Children and Adolescents with Obesity.6 The guidelines have key action statements and consensus recommendations for pediatricians and other primary care providers who see children. These recommendations include an algorithm for screening, diagnosis, evaluation, and treatment of children and adolescents with obesity. Comprehensive therapy is based on four areas of treatment: motivational interviewing, intensive health behavior and lifestyle treatment, weight loss pharmacotherapy for individuals with obesity >12 years of age, and bariatric surgery for individuals with obesity over the age of 12.6 (Appendix 1)

The recommendation in the guideline outlines the following medications that can be used in pediatric obesity:* orlistat (12 years and older); liraglutide (12 years and older); metformin (if the child has type 2 diabetes, polycystic ovary syndrome or prediabetes, 10 years and older); phentermine (for short-term use of 3 months, 16 years or older), topiramate (headache prophylaxis and seizure control), phentermine/ topiramate (off-label use in 12-17 year-olds) or lisdexamfetamine (if the child has ADHD, off-label use).6

Bariatric surgery is recommended for BMI >35 kg/m2 with clinically significant disease such as metabolic diseases or cardiovascular disease or BMI >40 kg/m2 without comorbid conditions.

CONCLUSION

The current drug shortages being seen in the U.S. are numerous. We are seeing shortages of semaglutide for both obesity and diabetes indications (Wegovy and Ozempic). With guidelines and such positive weight loss results, these drugs are being used by EVERYONE looking to shed a few pounds, not just those individuals who meet the obesity criteria. These drugs are considered the new “quick fix” to weight loss and are part of a Hollywood weight loss craze after going viral on the social media platform, TikTok. It is our responsibility to educate on the benefits and risks of using these medications.

The prescribing of Ozempic to patients who need Wegovy for weight loss is causing a downstream supply issue with other products like Trulicity and Mounjaro. These have become mainstays of treatment for patients with type 2 diabetes. Due to the drug shortage, we have many patients who are waiting for their medication to be available. Most will have to begin the medication titration over because they have been out of drug, and they will have negative adverse effects if they go back to the dose they were taking prior to the shortage.

Obesity is a medical condition that has long term effects on health. It knows no boundaries. There are guidelines and clinical literature available to help us navigate the best way to help the people in our communities with obesity. We can advocate for our patients and recommend the best pharmacotherapy for each individual patient, if that is what is best for them. Be the resource in your community.

Current Approved Pharmacotherapy Options Available for Adults 18 Years and Older

Weeks 1-4: 0.25mg weekly

Weeks 5-8: 0.5mg weekly

Semaglutide (subcutaneous injection) Wegovy

Increases glucose-dependent insulin secretion, decreases inappropriate glucagon secretion, slows gastric emptying, acts in the areas of the brain involved in regulation of appetite and caloric intake

Liraglutide (subcutaneous injection) Saxenda

Weeks 9-12: 1mg weekly

Weeks 13-16: 1.7mg weekly

Weeks 17 and maintenance: 2.4 mg weekly

Week 1: 0.6 mg daily

Week 2: 1.2mg daily

Week 3: 1.8mg daily

Week 4: 2.4mg daily

Week 5 and maintenance: 3 mg daily

Severe Adverse Effects: Acute kidney injury, pancreatitis, diabetic retinopathy

Common Adverse Effects: Nausea, vomiting, diarrhea/ constipation, injection site reaction, headache

Contraindications: Pancreatitis, medullary thyroid cancer

Phentermine: reduces appetite secondary to CNS effects, including stimulation of the hypothalamus to release norepinephrine

Phentermine/ Topiramate (tablet) Qsymia

Topiramate: weight management may be due to effects on appetite suppression and satiety enhancement based on the following potential mechanisms: blocks neuronal voltage dependent sodium channels, enhances GABA(A) activity, antagonizes AMPA/kainite glutamate receptors, and weakly inhibits carbonic anhydrase

Orlistat (capsule) Xenical, Alli (OTC)

Reversible inhibitor of gastric and pancreatic lipases; inhibits absorption of dietary fats by 30%

3.75mg/23mg daily for 14 days; increase as tolerated to 7.5mg phentermine/46mg topiramate daily for 12 weeks. If >3% baseline body weight has not been lost then switch to every other day dosing and discontinue after 1 week taper. For those individuals getting results, the dose can be tapered up every 14 days to a max dose of 15mg phentermine/92mg topiramate taken once daily. Evaluate weight loss after 12 weeks of therapy at max dose. If >5% of baseline weight has not been lost then gradually taper off over at least 1 week prior to discontinuation.

Xenical: 120mg TID with each main meal; can start with 60mg to improve GI tolerability;

Consider discontinuation after 3 months if weight loss is less than 4-5% of baseline weight

Alli: 60mg TID with each main meal containing fat; max dose OTC is 180mg/day

Increased heart rate, constipation, dry mouth, headache, sleep disorder (insomnia), decreased bone mineral density, increased SCr, decreased serum sodium bicarbonate

Suicidal Ideation

Contraindications: Hyperthyroidism, glaucoma, MAOIs therapy within 14 days, pregnancy, psychiatric disturbances

Fat soluble vitamin deficiency (A,D,E,K), steatorrhea, oily stools, oily rectal leakage, bowel urgency, flatulence with discharge, frequent bowel movements, abdominal pain and distress, headache, back and lower extremity pain

Warnings: Hepatotoxicity, increased urinary oxalate

Naltrexone: pure opioid antagonist

Bupropion: Weak inhibitor of neuronal uptake of dopamine and norepinephrine

Naltrexone/ buproprion (tablet) Contrave

Exact mechanism of combination is unknown; thought to be due to effects on areas of the brain involved in regulation of food intake: the hypothalamus and mesolimbic dopamine circuit

Week 1: naltrexone 8mg/bupropion 90mg (1 tablet) daily

Week 2: 1 tablet twice daily

Week 3: 2 tablets in the morning, 1 tablet in the evening

Week 4: 2 tablets twice daily

Max dose is naltrexone 32mg/ bupropion 360mg daily (4 tablets/day); Consider discontinuation after 3 months if weight loss is less than 4-5% of baseline weight

Drug Interactions!

Headache, sleep disorders, nausea, constipation, vomiting

Suicidal ideation/behavior has been reported

Contraindications: Concomitant use of MAOIs, uncontrolled hypertension, seizure disorder

Limited supply and in some areas on backorder

No current limitations on drug distribution

No current limitations on drug distribution

No current limitations on drug distribution

No current limitations on drug distribution

References:

1. https://www.cdc.gov/obesity/data/adult.html. Accessed 2.21.2023.

2. https://stacks.cdc.gov/view/cdc/106273. Accessed 2.21.2023.

3. https://www.cdc.gov/mmwr/volumes/66/wr/mm6650a1.htm?s_cid=mm6650a1_w. Accessed 2.21.2023.

4. https://www.ahajournals.org/doi/full/10.1161/01.cir.0000437739.71477.ee#T4. Accessed 2.21.2023.

5. https://www.endocrinepractice.org/article/S1530-891X(20)44630-0/fulltext. Accessed 2.21.2023.

*Please contact IPA for full pediatric drug table and dosing information.

6. https://publications.aap.org/pediatrics/article/151/2/e2022060640/190443/Clinical-Practice-Guideline-for-the-Evaluation-and?autologincheck=redirected. Accessed 2.21.2023.

A NEW ERA: CONTINUED ACCREDITATION & “THE ONES”

The College of Pharmacy and Health Sciences (CPHS) has been granted continued accreditation by the American Council on Pharmaceutical Education (ACPE) for the maximum eight-year period, extending the accreditation until 2030-2031. The program was found to be compliant in all 25 standards.

The College has also been assisting Drake University with a new bold and audacious campaign. Launched in October 2021, ‘The Ones: Drake’s Campaign for the Brave and Bold’ is meant to build upon the University’s commitment to transforming lives and strengthening communities. Now over a year since its launch, we reflect on how the PharmD program lives out the priorities and initiatives of the campaign. It is with the assistance of the Iowa pharmacy community that we carry out these priorities, build a strong vision for the future, and continue our mission to prepare today’s learners to be tomorrow’s healthcare leaders.

“The Ones” Campaign Priorities: Every Bulldog a Changemaker – Our goal is for every student pharmacist to use their knowledge and talent to make a positive difference in the world. That’s why our curriculum, initiatives, and community partnerships equip students with the necessary skills to identify solutions for pressing concerns in healthcare and improve patient outcomes. The Drake Entrepreneurial Leadership Tools for Advancement (DELTA) Rx Institute provides entrepreneurial internships, competitions, awards, and additional learning opportunities to promote a spirit of innovation among students.

Revitalizing Democracy – As democracy is continuously challenged, our College creates an environment for democratic discourse, dialogue, and action. Through the curriculum, annual legislative activities, association memberships, and internship opportunities, student pharmacists are informed and understand the power of their voice.

Digital Proficiency – Students are navigating the monumental digitalization of society and the healthcare industry on their way to becoming tomorrow’s leaders. We are supporting them on this journey through a wide range of clinical experiences and the dual-degree option with the Master of Science in Health Informatics.

Student Experience – We continue to build on the exceptional experience of student pharmacists, ensuring that they learn with, about, and from each other through

interprofessional education and a robust collection of student organizations and committees.

Strengthening the Heartland – Drake student pharmacists learn what it means to help bolster the economic, social, and cultural vibrancy of rural America by providing virtual and in-person healthcare in communities across the state through DELTA Rx internships within community pharmacies. The College’s Joe and Gordon Alexander Pharmacy Scholarship provides financial assistance to student pharmacists planning to practice in rural Iowa upon graduation. The College is also supporting rural Iowa with the Cultivate Program, which trains high school students to work in rural Iowa pharmacies.

Creating Access to Opportunity – We encourage and empower individuals from all backgrounds to enhance their lives and the lives of others through education. With the creation of scholarships, accelerated programs, and partnerships with other universities, we are embracing opportunity as a fundamental right.

Transforming Every Day - With an emphasis on innovation and continuous improvement, our students become leaders and visionaries to improve the pharmacy profession, transform lives, and strengthen communities. The College continues to garner resources to assist students with professional development opportunities and scholarships.

Amidst our efforts to contribute to the strong foundation of Drake’s next great era, there are several other new initiatives:

• Launch of the online Certificate in Psychopharmacotherapy for healthcare practitioners and PharmD students in Summer 2022.

• Launch of the online MS in Clinical Psychopharmacology for practicing psychologists to increase access to essential mental health care in Iowa and other states.

• Creation of a College Diversity, Equity, and Inclusion Committee with professor and clinical pharmacist Anisa Hansen (PH’02) named director.

• Announcement of the creation of three inaugural scholarships supported by former faculty and alumni: the Nita Pandit Student Research Award, the June F. Johnson Scholarship, and the Steven R. and Karen L. Herwig Pharmacy Scholarship.

• Renewal by the Iowa Governor’s STEM Advisory Council of pharmaceutical professor Pramod Maha-

Dean & Professor Drake University CPHS

Renae Chesnut, EdD, MBA, RPh

Photo Credit: Drake University CPHS

jan’s Iowa STEM ScaleUp proposal for ‘SoapyCilantro: A Practicum for Hands-On Introduction of Iowa’s Teachers and Students to Precision Medicine.’

A few other recent College highlights:

• Alumni Todd Lee (PH’97) and CoraLynn Trewet (PH’03) received 2023 CPHS Alumni Achievement Awards, and Emmeline Paintsil (PH’18, GR’20) received the 2023 CPHS Young Alumni Achievement Award.

• Alumni Charlie Hartig (PH’09) and Iowa State Rep. John Forbes (PH’80) received Drake University Alumni Achievement Awards in 2022, and Jessica Nesheim (PH’09) received the Drake University Young Alumni Achievement Award in 2023.

• Alum Gregg C. Brown (PH’78, LW’81) was the 2022 Weaver Medal of Honor recipient and lecturer.

• Molly Nelson (PharmD Candidate 2023) was one of three Next-Generation Future Pharmacist Award finalists in 2022, adding to Drake’s record as the program with the most finalists (13) and award winners (3).

As a result of the work of our faculty, staff, preceptors, alumni, and students this year, the College of Pharmacy and Health Sciences will help Drake University usher in its next great era and secure a more vibrant future for those who follow in our footsteps. To all the IPA members who support the College of Pharmacy and Health Sciences and assist us in these endeavors, thank you for your commitment! You can learn more about ‘The Ones: Drake’s Campaign for the Brave and Bold’ at theones.drake.edu. ■

Drake student pharmacists and faculty at the Iowa State Capitol during IPA's Pharmacist Day on the Hill on January 25, 2023.

Student pharmacists administered influenza vaccines during the annual clinic for students, faculty, and staff on Drake’s campus.

Drake alumni, students, and faculty gathered at the APhA Annual Meeting Iowa Reception in San Antonio, Texas in March 2022.

Mike Daly, Associate Professor and pharmacist at The Iowa Clinic, works with a student in the Master of Science in Health Informatics and Analytics program.

Anna Laire (P4) and Associate Professor of Pharmacy Practice Darla Eastman received the 2022 IPAF Poster Presentation Award at IPA Annual Meeting.

Molly Nelson (P4) was named one of three Next-Generation Future Pharmacist Award Finalists for 2022, announced by Pharmacy Times and Parata Systems.

A NOD TO PRECEPTORS

Pharmacy education requires a blending of didactics: classroom instruction, applied practice laboratory training, and experiential education. With respect to the latter, the active engagement of preceptors is tantamount in determining programmatic quality.

It is essential for pharmacy students to directly witness the application of their therapeutic knowledge in the treatment and management of disease, as well as gain a working knowledge of technology that aids in the medication-use safety process and drug administration and delivery.

At present, our program records indicate 882 active preceptors of which 472 hold adjunct faculty appointments. These practitioners are spread across 19 states and 5 countries.

Paying tribute to those who precept students is most fitting. I cannot adequately convey in words how appreciative we are for all that they do for our students. Serving as a preceptor is one of the most selfless acts of a healthcare professional. By doing so, these individuals, who ‘layer’ student education onto their very demanding days as a healthcare provider, are explicitly undertaking the responsibility for helping to shape the profession’s progeny. That is a weighty responsibility! The tutelage of future practitioners is critical to development of the fundamental tools needed to provide patient care.

I know well the vast majority of our preceptors. They are a highly dedicated lot who consistently exhibit the highest professional ideals. When it comes to exhibiting “professionalism,” they most definitely ‘walk-the-talk.’

Although mentoring adds to the many challenges faced by preceptors, there are also associated benefits. Interestingly, in talking to preceptors, they consistently share

how much more they gain overseeing students versus feeling a sense of burden.

Serving under the watchful eye of experienced practitioners is fundamentally important to student success and has tremendous bearing in helping to shape the attitudes and beliefs of aspiring pharmacists. While translating theoretical learning into real-world clinical practice is the overarching responsibility of a preceptor as noted previously, it is equally important to stress how much impact soft-skill development (e.g., communication skills, interpersonal engagement with patients and other providers, punctuality, professional appearance) and inculcating the highest professional ideals can have in shaping students’ future aspirations and how they eventually comport themselves professionally.

Moreover, preceptors likewise can have great impact on students’ level of future external engagement well beyond daily responsibilities for patient care, such as service through civic groups as well as state, regional, and national professional associations. Witnessing preceptor volunteerism is powerful. In short, preceptor influence and impact on overall student growth and development cannot be overstated.

I admire tremendously the dedication of preceptors and what their efforts mean to our profession. I know I speak for the entire College family in noting how grateful we are for their dedicated service. Their countless contributions add immensely to the wonderful success of our program. Through this special ‘nod to preceptors,’ I wish to express heartfelt thanks for ALL that they do. ■

Dean & Professor UI College of Pharmacy

Donald E. Letendre, BSPh, PharmD, FASHP

Teachers and Preceptors of the Year at the Dean’s Appreciation Dinner

Dean Letendre speaks to guests at the Dean’s Appreciation Dinner

Kelsey King, IPPE Preceptor of the Year, Iowa City Hy-Vee #1281

Ryan Jacobsen, Faculty Preceptor of the Year

Photo Credit: The University of Iowa College of Pharmacy

Y o u N e e d a

Q I P r o g r a m

Mistakes happen. Risky processes become normalized and your operations can shift slightly with staffing changes, new products, and new procedures.

The APMS Patient Safety Organization (PSO) provides Pharmacy Quality Commitment+ (PQC+) Compounding, a confidential, highly secure, continuous quality improvement program. Track and analyze how, when, and where the risk in your workflow occurs so you can reduce Rx corrections and operational costs.

Our program includes:

A web-based reporting portal to collect patient safety events

Tools to chart, graph, and analyze data

Expert advice, tips, and safe practices

Resources to help you meet accreditation and quality improvement requirements

Support to build a just culture of safety

QA Continuing Education and training opportunities

Patient Safety Organizations (PSOs) provide a safe space for members to conduct patient safety work. When you partner with our PSO for your Quality Improvement activities, the collection of quality assurance data and patient safety work is in a protected environment.

We are passionate about medication safety in community pharmacy and are here to walk you through the entire process. Our customer service team has years of experience in pharmacy and is excited to help.

IPA PHARMACY TECHNICIAN ADVANCEMENT SCHOLARSHIPS

IPA recognizes that supporting pharmacy technician advancement is crucial to the sustainability of our healthcare system, most notably in rural communities. IPA has awarded 42 Pharmacy Technician Advancement Fund scholarships to pharmacy technicians across Iowa, providing 100% reimbursement for the Pharmacy Technician Certification Exam (PTCE), Pharmacy Technician Certification Board (PTCB) and CEimpact Pointof-Care Testing programs, and other advanced credentials and certifications offered by PTCB.

This scholarship is made possible with grant funding received from the Iowa Department of Health and Human Services (DHHS) and PTCB. Congratulations to the following scholarship recipients!

Christine Adkins, Jennie Edmundson Hospital

Kelly Andersen, MercyOne Des Moines

Kayla Behrens, Drilling Pharmacy

Julie Berger, Winneshiek Medical Center

Tracie Capoccioni, MercyOne Waterloo

Sandra Cary, MercyOne Clear Lake Pharmacy

Zack Church, Hy-Vee

Melissa Dahna, Drilling Pharmacy

Heather Darling, Donlon Pharmacy

Travis Dibbet, UnityPoint at Home

Amanda Eden, MercyOne

Karla Eilts, Rex Pharmacy

Emily Eyheralde, Owl Pharmacy

Dannette Fahrney, Spring City Pharmacy

Anna Fishel, MercyOne Waterloo Medical Center

Lisa Gross, Hy-Vee #1544

Shannon Hahn, NuCara Pharmacy #9

Gabriella Hammer, St. Anthony Regional Hospital

Brenda Harders, Spencer Municipal Hospital

Christine Hare, Main at Locust Pharmacy

Leah Hunter, UnityPoint at Home

Kim Hurlburt, Spencer Hospital

Lori Jennings, Spencer Hospital

Emily Kedzie, Walgreens

Isaac Kim, MercyOne Regency Pharmacy

Jacob Klein, SafeNetRx

Tracy Kleinschrodt, GRX Holdings

Judy Kruse, MercyOne Waterloo Pharmacy

Dane Messersmith, Methodist Jennie Edmundson Hospital

Kimerly Metcalf, CVS Pharmacy, Target

Angela Moore, Spencer Hospital

Toni Pieken, Rex Pharmacy

Mckayla Pint, MercyOne North Iowa

Ashley Reiter, Osterhaus Pharmacy

Christopher Ruiz, All Care Health Center

Sue Schmitz, MercyOne

Shaylee Shedenhelm, Spring City Pharmacy

Nicole Simons, Owl Pharmacy

Emily Stecklein, MercyOne Medical Center

Melanie Stennes, Donlon Pharmacy

Chelsea Willis, Manning Pharmacy

Samantha Wright, Whiting Family Pharmacy

1815 UPDATE

To recognize the work of pharmacists in ambulatory clinic, community and hospital pharmacies, IPA is providing technical assistance and support to 21 pharmacies across the state on initiatives around diabetes, hypertension and hyperlipidemia. The participating pharmacies are working on establishing accredited DSMES programs, increasing referrals to surrounding DSMES programs, expanding MTM services for patients with diabetes, hypertension and hyperlipidemia, as well as providing services under Collaborative Practice Agreements (CPAs). IPA staff submitted the Mid-Year grant report in January and are in the beginning stages of planning for the next iteration of the DP18-1815 program. It is expected that Community Health Workers will be a large focus of the CDC for the next cycle of funding. To be notified of future opportunities to work with IPA and Iowa HHS on these initiatives, please contact IPA’s Director of Professional Affairs, Emmeline Paintsil, at epaintsil@iarx.org.

VACCINE EQUITY GRANT

In December 2022, IPA staff completed a media training led by Wixted & Co. to develop communication skills for engaging with legislators and the media in communicating the strategic and legislative priorities of the association. At the end of the year, IPA staff requested a grant extension and additional funding for work under the COVID-19 Vaccine Equity Grant. IPA was awarded an additional $75,000 in funding and an extension through December 31, 2023. IPA intends to continue working on all four activities under the grant including: Promote Vaccine Confidence; Develop Messaging; Engage Trusted Messengers and Support Grassroots Style Outreach. To learn more about this project, contact Emmeline Paintsil at epaintsil@iarx.org.

HEALTH DISPARITIES GRANT

IPA staff have been focused on the development of 2023 IPA Goes Local programming and accompanying workshops. IPA plans to host 7-8 National Alliance on Mental Illness (NAMI) Mental Health Provider Trainings in addition to ACPE accredited educational programming. In response to the current landscape and needs of the profession, the focus of the educational programming has been changed to understanding and treating obesity as a complex disease and its intersectionality with health disparities. To learn more about this project or collaborate with IPA, contact Emmeline Paintsil at epaintsil@iarx.org.

AMENDMENTS TO IPA BYLAWS

At the end of 2022, the IPA membership voted in favor of amendments proposed by the Bylaws Review Committee and IPA House of Delegates. The newly adopted Bylaws better reflect IPA’s current values and mission. Changes include: updated language to be more inclusive and representative of all pharmacy professionals, including non-practicing and non-traditional members; increasing pharmacy technician representation on the IPA Board of Trustees from one member to two; adding the Vice Speaker of the House as a non-voting member of the IPA Executive Committee; and changing term limits for the IPA Treasurer and IPA Delegates. Visit www.iarx.org/governingdocs to review the updated Bylaws.

HIV PREVENTION PROJECT

2023 marks the fifth year of a five-year project IPA has been leading that implements free HIV and HCV screenings in community pharmacies. This project is in collaboration with the Iowa Department of Health and Human Services’ (HHS) Bureau of HIV, STI, and Hepatitis.

Pharmacists can play an important role in fighting the HIV epidemic by offering testing services. Testing within the project allows patients confidentiality, as they are not required to provide insurance information or identification. Participating pharmacies work with their local public health department or within a collaborative practice agreement to refer any patients for confirmatory testing. The testing data over the last four years is as follows:

If you are interested in participating or would like to learn more, please contact Kellie Staiert, IPA’s Lead Project Manager, at kstaiert@iarx.org.

VACCINE HESITANCY: WHAT IT IS, WHAT CAUSES IT, AND WHAT TO DO ABOUT IT

AUTHORS

John Rovers, PharmD, MIPH, CPH Drake University College of Pharmacy & Health Sciences Des Moines, Iowa

Deborah H. Thompson, MPA President, DHT Consulting & Training Urbandale, Iowa

There are no conflicts of interest to report for either author.

ABSTRACT

Although vaccine hesitancy is not new, immunizing pharmacists are increasingly confronted by patients who vary from vaccine hesitant to loudly and angrily anti-vaccine. In this paper, we discuss what vaccine hesitancy is and why patients may present with negative attitudes towards vaccines. Using Haidt’s Moral Foundations Theory, we then discuss six principles of how people make moral decisions, including decisions about vaccines. Pharmacists who can identify which moral principle causes a patient to be vaccine hesitant can focus their patient education specifically on that principle, rather than providing general vaccine information which is unlikely to change a patient’s mind.

Although pharmacists have served as vaccinators for many years, the recent COVID pandemic and the essential role that pharmacists have played in vaccinating their communities has put pharmacists face to face with patients whose opinions about vaccines are negative.1 Even death threats to vaccinating pharmacists are not unheard of.2

As disquieting as the current anti-vaccine environment may be, it is important to note that such attitudes are not new. A smallpox outbreak in 1721 Boston may have been the first example of anti-vaccine sentiment in the United States.3 The Reverend Cotton Mather understood disease to be caused by sin and cured by prayer and devotion. But he also believed there were times that scientific enhancements, like the recent experiments in variolation by Jenner, were religiously permissible. Disagreements were so vigorous that someone threw a (defective) bomb through Mather’s window with the note, “Cotton Mather, you dog, dam you! I’ll inoculate you with this; with a pox to you.’’ 4

Clearly, pharmacists are having to deal with those whose objections to vaccines are closely held and hard to counter. In this article, we will provide an overview of what vaccine hesitancy is, some of its root causes, and how pharmacists can best speak with their vaccine hesitant patients.

VACCINE HESITANT VS ANTI-VACCINE

Accepting or rejecting vaccines appears to occur on a continuum.5 People may accept some vaccines under some circumstances while simultaneously rejecting other vaccines under other circumstances. It is important to make the distinction between those who are genuinely anti-vaccine and those who are vaccine hesitant. The former

are typically opposed to all vaccines, under all circumstances, and are estimated as no more than 5-10% of the general population.6 They often receive vaccine information from sources that have become known as “The Disinformation Dozen” which is a collection of typically very well-funded groups and individuals who are engaged fulltime in promulgating incorrect or misleading information about vaccines.7 Vaccine promotion efforts among the truly anti-vaccine population are probably not productive.

Pharmacists’ efforts are better directed towards the vaccine hesitant who may be more amenable to discussing the both the benefits and the risks of vaccines. According to the World Health Organization (WHO), vaccine hesitancy is “the reluctance or refusal to vaccinate despite the availability of vaccines.” WHO also counts vaccine hesitancy as one of the top ten threats to global health in the 21st Century.8

REASONS FOR VACCINE HESITANCY

Before reasons for vaccine hesitancy are reviewed, it is probably best to acknowledge the fact that much of the research in the hesitant was done in the parents of children eligible to be vaccinated. It is not always clear how well the models and explanations included below apply to adults, children, or both.

Theoretical Models for Vaccine Hesitancy

One model, developed by a WHO working group, explains vaccine hesitancy using three domains.5 Contextual influences include the socio-economic class an individual belongs to, the political environment (including vaccine mandates), religion, culture, gender, the opinions of others, opinions about the pharmaceutical industry, and geographic barriers to vaccination. Individual/social and group influences include beliefs that vaccines are not necessary or are harmful, beliefs about health and prevention, knowledge about vaccines, personal experiences with vaccines and trust in providers, perceived risks and benefits of vaccines, and prior experiences with vaccines. Vaccination specific influences include the vaccination schedule required, mode of administration, if the vaccine is new, the role of healthcare professionals, and costs.

A model developed by Dubé and colleagues place vaccine hesitancy on a spectrum.6 A person’s decision to be vaccinated depends on information from the media (including both traditional media and anti-vaccine sources), public health and vaccination policies (including safety monitoring), and the recommendations of professionals (including the provider’s training, communication skills, knowledge, and the vaccine status of the provider). In addition, a variety of historical, political and socio-cultural factors play a role in deciding to vaccinate or not. These include a person’s knowledge about vaccines, their past experiences, how important they believe vaccines are, how they process risk and who they trust, what they believe is normal behavior concerning vaccines, and finally, their religious and moral beliefs.

Explanations for Vaccine Hesitancy

A variety of less theoretical sources explain vaccine hesitancy more

directly. Hayden describes vaccine hesitancy as context specific, complex, and multidimensional.9 Salmon and colleagues explain vaccine hesitancy as a function of how people process risk.10 Perceived risk is higher when the choice to vaccinate is involuntary, when the risk of side effects is not under an individual’s control, when side effects are unpredictable, when the disease is an unusually dreaded one, and when the health problem is exotic. In addition, people may perceive a disease as a natural risk and prefer that to a manmade risk posed by a vaccine. Getting sick by getting a disease is an error of omission and preferable to getting sick due to the vaccine, which is an error of commission.

Lin and colleagues offer that general factors explaining vaccine hesitancy include the attributes of both the vaccine and the disease (safety, barriers to access, disease severity), characteristics of the healthcare provider (prefer younger female providers, pediatricians seen as more trustworthy, extensive provider clinical experience and knowledge of disease and vaccine, and if provider is vaccinated), patient characteristics (low socio-economic status, race, comorbidities), and system factors (vaccine guidelines, confidence in vaccine, clear official recommendations, source of information, practice setting.)11

Nagar and colleagues explored religious objections to vaccines and found that White Evangelicals, Black Protestants, and Hispanic Catholics were likely to be the most vaccine hesitant.12 Religious reasons given include vaccine misinformation (inclusion of fetal tissue in vaccines), conspiracy theories that nefarious actors seek to harm the virtuous, and experiences of prior racism in healthcare settings.

From the diversity of opinions provided above, it is clear there is no single, simple explanation for why some people are vaccine hesitant. That said, for those who prefer simple explanations, perhaps the most convincing one is that vaccines have been a victim of their own success. Vaccines have been so successful that many diseases of the last century are now so uncommon as to lead some people to believe that vaccines are no longer necessary.

WHAT TO DO ABOUT VACCINE HESITANCY

Moral Foundations Theory (MFT) may also offer insight into vaccine hesitancy as well as provide the pharmacist with tools to discuss vaccines with their hesitant patients.13 MFT is a psychological theory that seeks to explain why the morals of people differ but still share some fundamental characteristics. It was first outlined by moral psychologist Jonathan Haidt. The theory proposes that each one of us comes equipped with ‘intuitive ethics.’ This innate capacity causes flashes of approval or disapproval towards certain ideas, behaviors, and images that trigger reactions, including vaccines.

Haidt’s research suggests that people have gut reactions. These gut reactions are a physical connection to our conditioned morals and values. Haidt offers that gut reactions come first in our thought processes and that reasoning comes second. The reasoning that follows works to rationalize the intuitive reaction in a supportive way to make it one’s “truth.” It is similar to confirmation bias and the method of searching for and accepting information that confirms already formed beliefs and disregards information to the contrary. Haidt uses a metaphor called “the Elephant and the Rider” to describe this internal process. Most people believe that the rational rider is in charge of making deliberate moral decisions. Instead, it is the elephant acting instinctively who usually decides what will happen. The massive elephant in the analogy represents the power of this gut reaction. It outweighs and will easily

overpower the small rider. Only occasionally can the rational rider convince the “gut” reaction of the elephant to pursue a different path.

As the human mind moves into this defensive “gut” position, it becomes very difficult to use reason to convince someone of another viewpoint. It explains why facts and data about vaccines will nearly always fail to compel change in perspective. Indeed, when faced with “the facts,” people may actually double down on their deeply held, if misguided, beliefs. However, research also shows that morals and values can evolve and can be influenced over time and by speaking directly to one’s morals and values.

Haidt and his colleagues offer six different moral foundations categories that have evolved over the course of human development in response to individual or group survival needs. These moral foundations are:

• Care versus Harm

• Fairness versus Cheating

• Loyalty versus Betrayal

• Sanctity versus Degradation

• Authority versus Subversion

• Liberty versus Oppression

These foundations are old, primal and held deeply within the human psyche. Each foundation can cause both positive and negative reactions in a person. Not every foundation is triggered on every topic, although vaccines offer enough controversy to provide consideration of each category. Finally, when a moral foundation is triggered, it may be more intensely triggered for some people compared to others. Below, we will discuss how each of these moral foundations can be used in discussing vaccines with patients.

It has been observed that Republicans (who are presumably more conservative) are more likely to espouse anti-vaccine opinions than Democrats (who are presumably more liberal).14 This is important when discussing vaccines with patients since conservatives have been found to be motivated by all six moral foundations, while liberals are motivated by only three—care, fairness and liberty. When discussing vaccines with the vaccine hesitant, it is helpful if the pharmacist can intuit exactly which moral foundations are causing the hesitancy so they can be addressed directly. And the only way to intuit which moral foundation is in play is for the pharmacist to listen closely and give careful consideration to the patient’s concerns. Listening before speaking is vital for pharmacists using MFT to address vaccine hesitancy.

The foundations included in Haidt’s MFT framework offer support for Dubé and colleagues’ findings.6 What follows is a brief explanation of each moral foundation and how it relates to vaccine hesitancy and the aforementioned reasons offered by Dubé and colleagues where appropriate.

1. Care vs. Harm: Compels us to care for vulnerable populations like children, the elderly and those with medical conditions. Prevention of negative experiences in these populations is important. Justice is pursued to punish those who cause harm to them. For vaccines, this the care/harm foundation drives questions like: will this harm my children, myself or my loved ones?

For those who are vaccine hesitant, this produces strong safety concerns for vaccines compared to the hypothetical risk of COVID. This

disconnect is produced by misinformation and disinformation widely shared on social media platforms that use algorithms to produce clicks on content created to trigger fear.

For those who are vaccine confident, this foundation provides relief that there is protection against the transmission of COVID which is the larger perceived threat compared to the vaccine. It also triggers anger toward those who spread disinformation.

2. Fairness vs. Cheating: This foundation recognizes that we live in societal conditions that offer opportunities for mutually beneficial cooperation. For example, covering a co-worker’s shift or job responsibilities if requested to, so that this reciprocity is granted when needed. “They would do it for me,” is a common explanation for these acts of assistance.

This makes people sensitive to signs of cheating and deception. Anger, contempt, and disgust are felt when a person is found to be a social loafer or “free rider.” It supports the belief that people should contribute to the group in some way if they are able to. When they do not, they could be excluded from any benefit gained by the group.

As it relates to vaccines, this foundation is clear and present in regulation. In consideration of laws and policies, debate is centered around whether it is fair to create different policies for those who choose not to vaccinate compared to those who say yes. The vaccine hesitant may focus on perceived unfairness of vaccine mandates. Vaccine confident health care workers may feel it is unfair to have care for critically ill unvaccinated patients.

3. Loyalty vs. Betrayal: Makes us sensitive to signs that another person is—or is not—a team player. People trust members of the same group over outsiders. When someone betrays the group, they are punished or ostracized from it. Groups form strong bonds using rituals and traditions. Group pride leads members to work hard to defend it and sometimes to the point of becoming irrational.

Vaccine hesitant people may worry that receiving a vaccine is counter to the beliefs of their identify groups (e.g., family, political identity, church congregation). If they are “outed” as vaccinated, this may cause some of their relationships to become tense, and people are generally averse to conflict. While it is irrational to put themselves in harm’s way by increasing the likelihood of becoming severely ill, their gut (the elephant) is telling them that it is more dangerous to be ostracized from their identity groups.

4. Sanctity vs. Degradation: Gives us the ability to endow ideas (e.g., liberty and justice), objects (e.g., crosses and flags), places (e.g., battlefields and monuments) and people (e.g., saints and celebrities) with infinite value. People are in awe of their greatness and in shock if they are degraded.

For vaccine hesitant people who are religious, this drives concerns about the use of fetal cells in vaccine development. This is a nuanced issue, but use of fetal cells in some vaccines is perceived as a violation of the sanctity of life in these cases.

Some vaccine hesitant people closely monitor what they put into their bodies and are concerned about vaccine ingredients as unnatural (i.e. the adage, “My body is a temple.”). Conversely, for some vaccine confident people, the sanctity of keeping the body free of disease is an

important reason to take vaccines. Vaccine confident people may also revere the scientific method used to develop vaccines and their demonstrated success in the reduction of illness. Science is held as sacred.

5. Authority vs. Subversion: Figures in society like police officers, judges, teachers, and healthcare professionals are provided with some authority to keep daily order in the population to avoid chaos. When disagreements occur, they play a mediating role. They hold this distinction because standards, often in the form of laws, determine what qualities and credentials must be held to have authority and when and where it may be exercised. The population is conditioned to be compliant to their requests, orders and rulings, and when they are treated with disrespect, the subversion triggers discomfort and anger from other members of society.

When it comes to vaccine hesitancy, people are doing their own research on the Internet and then sharing their findings without achieving standards of expertise. They are subverting the authority of experts who are trained and educated to avoid pitfalls like confirmation bias. Without this education and training, the elephant in Haidt’s analogy works hard to confirm what is already believed to be true instead of having the discipline and expertise for objective analysis of information. For vaccines, the resulting spread of disinformation has impacted vaccine confidence.

It is also critical to remember, however, that to be a trustworthy authority figure in society, you must be trustworthy. Trust has to be earned and fostered with consistency in order to be kept. In exchange for the status of being an authority figure in society, ethical behavior is demanded by the population and consequences for violations result in the permanent or temporary loss of authority.

6. Liberty vs. Oppression: This foundation is often in tension with the previously mentioned authority/subversion foundation. People are wary that others will abuse their power and are triggered by individuals or institutions that try to impose what is perceived as illegitimate restraints on liberty. In order for an authority figure to be able to enforce a policy, there has to be agreement that the policy is fair given that compliance by a majority of people is necessary.

This was demonstrated by the reactions people had to lock downs during the COVID pandemic. People felt their liberty was being unjustly threatened by illegitimate authority figures. There remains an ongoing debate on which authority figures should be making these decisions, if anyone at all, in the future. Should it be public health and healthcare professionals or elected leaders?

When a new regulation or policy is being pursued, it is critical to persuade those it would impact that it is worth giving up some amount of personal freedom because the benefit to the community is more important. It is also good practice to make the case that what is good for the community is good for the individual. For example, requirements for vaccinations for school-aged children are mandated because the spread of infectious diseases in the community causes disruption to the individual if family members become ill or they themselves become ill.

Table 1 summarizes each moral foundation, shows how it relates to vaccine hesitancy, and provides a tip for how pharmacists may change their message depending on the moral foundation underlying a patient’s hesitation.

Six Intuitive Moral Foundations

Moral Foundation How it Relates to Vaccine Hesitancy

1. Care/Harm

• Protect and care for vulnerable people

• Sensitive to suffering, distress

• Desire to punish those who cause harm

2. Fairness/Cheating

• Benefits of reciprocity

• Sensitive to cheating, cooperation, deception

• Vaccine hesitant – Strong safety concerns for vaccine compared to a hypothetical risk of COVID

• Vaccine confident – Protect against COVID and transmission

• Vaccine confident – Threatened by people spreading disinformation

Quick Tip: Hear out concerns. Reduce perceptions of vaccine risk and amplify risks of not getting vaccinated. Avoid using numbers or statistics when discussing risk.

• Vaccine hesitant may focus on perceived unfairness of vaccine mandates raising resistance

• Vaccine confident health care workers may have feelings of unfairness by having to care for critically ill unvaccinated patients

Quick Tip: Hear out concerns. We all give up something we would like to do to benefit others. E.g., no smoking areas, picking up dog waste, obey speed limits.

CONCLUSIONS

Although the truly anti-vaccine patient is probably unwilling to consider any discussion about the risks and benefits of vaccines, the vaccine hesitant are a diverse group whose resistance to immunization may stem from a variety of underlying causes. Pharmacists who can listen closely to the reasons for such hesitation can employ Haidt’s Moral Foundations Theory and start a discussion to alleviate the patient’s concerns. Simply countering patient misinformation with “facts” is unlikely to be effective. The pharmacist’s listening and communication skills are vital best care for vaccine hesitant patients.

References:

1. weareiowa.com. Rural Iowa pharmacist says there’s real vaccine hesitancy among 20-50-year-olds. Published online April 6, 2021. Accessed June 29, 2022.

2. Peiser J. Self-proclaimed ‘Vaccine Police’ tells Walmart pharmacists they ‘could be executed’ for administering shots. The Washington Post. https://www.washingtonpost. com/nation/2021/08/19/walmart-christopher-key-anti-vaccine/. Published August 19, 2021. Accessed June 29, 2022.

3. Buhr S. To Inoculate or Not to Inoculate?: The Debate and the Smallpox Epidemic of Boston in 1721. Constructing the Past. 2000;1(1):61-67. Accessed June 29, 2022. https://digitalcommons.iwu.edu/cgi/viewcontent.cgi?article=1071&context=constructing

4. Best M, Neuhauser D, Slavin L. “Cotton Mather, you dog, dam you! I’l inoculate you with this; with a pox to you”: Smallpox inoculation, Boston, 1721. Quality and Safety in Health Care. 2004;13(1):82-83.

5. Larson HJ, Jarrett C, Eckersberger E, Smith DMD, Paterson P. Understanding vaccine hesitancy around vaccines and vaccination from a global perspective: A systematic review of published literature, 2007-2012. Vaccine. 2014;32(19):2150-2159.

3. Loyalty/Betrayal

• Forming cohesive groups to fend off threats

• Sensitive to group pride, rage at traitors

4. Authority/Subversion

• Authority figures maintain moral order

• Sensitive to obedience, deference, rank, and status

• Reverence for “good” leaders

5. Sanctity/Degradation

• Triggers feelings of disgust and awe

• Infinite value placed on ideas, people, places and objects and preventing their degradation

6. Liberty/Oppression

• Tension with authority foundation

• Sensitive to signs of self-aggrandizement, tyranny

• Triggers feelings of oppression, righteousness

• Vaccine hesitant may be concerned that receiving a vaccine would cause tension with groups that provide identity (e.g., church, social groups, political groups)

Quick Tip: Hear out concerns. Remind them of HIPAA requirements and patient privacy laws.

• People are exposed to information from authority figures in their identity groups which carry significant weight and may fall prey to confirmation bias, disinformation, and may not have the skills to evaluate information critically.

Quick Tip: Hear out concerns. Pharmacists are among the most trusted providers. Be trustworthy and transparent about what you know/don’t know to build your credibility.

• May voice concerns about vaccines and fetal tissues

• Concerns about vaccine ingredients as unnatural

Quick Tip: Hear out concerns. The Children’s Hospital of Philadelphia is a great resource on this topic of fetal cells: www. chop.edu/centers-programs/vaccine-education-center/vaccine-ingredients/fetal-tissues

• Creates push back about feeling “forced” either socially or by policy to receive a vaccine.

Quick Tip: Hear out concerns. Point out what freedoms are lost from illness and lasting side effects (e.g., where you go, who you see, how you earn a living).

6. Dubé E, Laberge C, Guay M, Bramadat P, Roy R, Bettinger J. Vaccine hesitancy: An overview. Human Vaccines and Immunotherapeutics. 2013;9(8):1763-1773.

7. Bond S. Just 12 People Are Behind Most Vaccine Hoaxes On Social Media, Research Shows. National Public Radio. Published May 14, 2021. Accessed June 29, 2022. https://www.npr.org/2021/05/13/996570855/disinformation-dozen-test-facebooks-twitters-ability-to-curb-vaccine-hoaxes

8. World Health Organization Newsroom. Ten Threats to Global Health in 2019. Ten Threats to Global Health in 2019. Published 2019. Accessed June 29, 2022. https:// www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019

9. Hayden J. Introduction to Health Behavior Theory. Jones & Bartlett; 2009.

10. Salmon DA, Dudley MZ, Glanz JM, Omer SB. Vaccine hesitancy: Causes, consequences, and a call to action. Vaccine. 2015;33:D66-D71.

11. Lin C, Mullen J, Smith D, Kotarba M, Kaplan SJ, Tu P. Healthcare providers’ vaccine perceptions, hesitancy, and recommendation to patients: A systematic review. Vaccines (Basel). 2021;9(7).

12. Nagar S, Ashaye T. A Shot of Faith—Analyzing Vaccine Hesitancy in Certain Religious Communities in the United States. American Journal of Health Promotion Published online January 2, 2022:089011712110695.

13. Haidt J. The Righteous Mind: Why Good People Are Divided by Politics and Religion. Pantheon Books; 2012.

14. Motta M. Republicans, Not Democrats, Are More Likely to Endorse Anti-Vaccine Misinformation. American Politics Research. 2021;49(5):428-438.

STUDENT SPOTLIGHTS: IPA ADVISORY COMMITTEE

Emily Weyenberg is a second-year student pharmacist at the University of Iowa College of Pharmacy and member of IPA’s Student Pharmacist Advisory Committee. She grew up in a small town outside of Green Bay, Wisconsin and completed her Bachelor of Arts in Biology at the University of Minnesota – Twin Cities. Now in Iowa City, Emily has enjoyed “hopping” her way around the Midwest.

In addition to her involvement with the Iowa Pharmacy Association (IPA), Emily spends her time involved with various school organizations, including the Admissions Committee and Graduate and Professional Student Governments’ Interprofessional and Governmental Committees. She also serves as the Co-Vice President of Professional Development for the University of Iowa Student Society of Health-System Pharmacists, President-Elect of Phi Lambda Sigma Leadership Society, Special Events Coordinator for the Pharmacy Student Ambassador Network, and Chief Curriculum Officer for the University of Iowa Healthcare Business Leadership Program.

Most recently, Emily was elected as the APhA Midyear Regional Meeting Coordinator for Region 5. In her words, these organizations have provided many opportunities to expand her network and facilitate an environment of growth.

Outside of school, Emily has worked as a pharmacy intern at CVS Pharmacy for the past three years. Working as an intern allows her to apply the knowledge and clinical skills she has learned in school and better understand the inner-workings of a community pharmacy. Emily is passionate about advocating for the profession of pharmacy, staying active within the college, leadership development, and providing opportunities for other students to grow.

When asked why she chose to pursue a career in pharmacy, Emily said it is because pharmacy is an ever-growing field. Pharmacists are an integral part of the healthcare team, she says, and it is rewarding to be able to help patients understand their medications. Currently, she is interested in pharmacy policy, pharmacy administration, and association management. In her free time, Emily enjoys going to the gym, spending time with friends, and learning to golf. ■

Originally from Plainfield, Illinois, Paula Ornelas is a second-year student pharmacist at Drake University College of Pharmacy & Health Sciences. She chose to pursue a career in pharmacy as she found herself seemingly surrounded by various health professionals from a young age.

According to Paula, she felt as though her mother was always sick, and it was not until later in life that she learned how a poor blood transfusion meant to help treat leukemia would come back to bite in the form of Hepatitis C. Paula was fascinated by the clinical trial her mother took part in for the treatment of her Hepatitis C, and she feels forever grateful her mother was willing to take this chance for a new start in life. While it was a difficult time for her family, it sparked Paula’s interest and passion to provide life-saving interventions and care to others.

Due to her personal background as well as professional background in a community pharmacy, Paula has interest in pursuing any career that will allow her to have long-term relationships with her patients. She finds the work is more meaningful when she knows her patients, not only for the medications they take but for the people they are when they step foot outside of the pharmacy. Additionally, as a Mexican American, Paula feels a strong devotion to diminishing health disparities for all who face language barriers and differences in cultural beliefs as it relates to healthcare.

When she is not in a lecture hall, studying in the library or working, Paula can be found in the campus gym, as she is a member of the weightlifting club. Additionally, Paula is a proud member of Lambda Kappa Sigma professional pharmacy fraternity and IPA’s Student Pharmacist Advisory Committee. ■

PharmD Class of 2025

Emily Weyenberg

The University of Iowa College of Pharmacy

PharmD Class of 2025

Paula Ornelas

Drake University College of Pharmacy & Health Sciences

PHARMACIST AND FAMILY

MEDICINE COLLABORATION FOR PRE-VISIT PLANNING FOR SHARED PATIENTS RECEIVING CHRONIC CARE MANAGEMENT SERVICES

AUTHORS

James D. Hoehns, PharmD, BCPS, FCCP1,2

Matthew Witry, PharmD, PhD1

Madison McDonald, PharmD3,4

Sarah Kadura, PharmD5,6

Emily O’Brien, PharmD, BCACP6,7

Robert Nichols, PharmD, BCPS4

Joe Greenwood, PharmD, MBA4

Jamie Snyder, LPN6,9

Raemi Chavez, PharmD, MPH1,8

Adam Froyum-Roise, MD, MPH, FAAFP6,9

The authors declare no potential conflicts of interest

1 University of Iowa College of Pharmacy, Iowa City, IA, USA

2 MercyOne Northeast Iowa Family Medicine Residency & Research, Waterloo, IA, USA

3 AdventHealth East Orlando, Orlando, FL, USA

4 Greenwood Pharmacy, Waterloo, IA, USA

5 University of Iowa Hospital & Clinics, Iowa City, IA, USA

6 Northeast Iowa Family Medicine Residency, Waterloo, IA, USA

7 UCHealth-Northern Colorado, Fort Collins, CO, USA

8 Hy-Vee Pharmacy (1825), Vinton, IA, USA

9 UnityPoint Central Iowa Residency Program-Waterloo Track, Prairie Parkway Residency Clinic, Cedar Falls, IA, USA

ABSTRACT

Background: Pre-visit planning entails completing necessary tasks prior to clinic appointments. Community pharmacists (CPs) have unique knowledge about patients’ medication use but do not routinely provide drug therapy reviews before clinic visits. Objectives: (1) Create and implement a business partnership between a CP and family medicine clinic (FMC) for CP provision of pre-visit medication reviews, and (2) describe the billing experience for shared patients in the FMC chronic care management (CCM) program. Methods: A prospective 8-month study in one community pharmacy and FMC in Iowa. Eligible patients were enrolled in the clinic CCM program and received their prescriptions at the community pharmacy. CPs were granted access to the clinic electronic health record (EHR), performed medication reviews, and recorded drug therapy recommendations (DTRs) in the clinic EHR. FMC physicians reviewed CP DTRs before the patient encounter. Time tracking software in the EHR recorded CP and FMC time performing CCM services. CCM revenue was prorated between parties. FMC physicians completed a survey about their experience. Results: Overall, there were 129 CP reviews performed for 95 patients. These reviews resulted in 169 DTRs and 76% were accepted by the physician. There were 71 CCM claims billed and CCM revenue was $3596 ($1796 FMC, $1800 CP). More than 90% of physicians (N = 11) indicated they reviewed CP DTRs before the patient encounter and agreed they were helpful to their practice. Conclusion: CPs completed pre-visit medication reviews and made accepted medication therapy recommendations.

CCM billing provided a mechanism for CPs to receive revenue for their services.

Keywords

pre-visit planning, chronic care management, patient-centered medical home, community pharmacy

BACKGROUND

Medication optimization has been defined as “a patient-centered, collaborative approach to managing medication therapy that is applied consistently and holistically across care settings to improve patient care and reduce overall costs”.1 There are compelling financial and quality of care reasons for improving the use of medications. It has been estimated that the annual cost in the United States of drug-related morbidity and mortality resulting from nonoptimized medication therapy in 2016 exceeded $528 billion and resulted in 276,000 deaths.2 The patient-centered medical home (PCMH) model of primary care has significant potential to improve health care value and patient care. A core principle of the PCMH is a team-based approach to care.3,4 Pre-visit planning is a key component of PCMH guidelines.5

Pre-visit planning is a proactive approach to organizing care that shifts tasks like lab tests, identifying “care gaps” such as immunizations or prevention screenings, pre-visit checklists, and medication review before the appointment so the care team members can focus on patient needs and engaging in patient-centered decision-making during the appointment.6-8 With pre-visit planning, providers have the information they need at the time of the visit to provide evidence-based care.

Community pharmacists (CP) are well suited to complete pre-visit medication reviews for primary care-based teams. In addition to their professional drug therapy knowledge, they have familiarity with the patient, medication adherence, prescription costs and copays. However, there are several barriers to CP providing such services. These include a lack of structures to facilitate patient information sharing, inadequate access to patient electronic health records, and a lack of adequate compensation methods for care team members.9

Chronic care management (CCM) is a reimbursable service for Medicare beneficiaries in the community setting which includes comprehensive care management and other activities.10 While only Qualified Health Professionals (QHPs) (ie, physicians, nurse practitioners, physician assistants) are eligible to bill for CCM services, pharmacists can create business partnerships with QHPs to provide CCM services. We and others have reported on successful pharmacist provision of CCM care.11-13 Pre-visit planning activities can be billed as chronic care management within CCM arrangements.

There have been a small number of reports about pharmacists contrib-

uting to pre-visit planning including prior to appointments for diabetes and hypertension management.14,15 More work is needed to describe financially sustainable solutions to integrating pharmacists, including those working in the community setting, into the pre-visit planning process. The objectives of this study were to describe the drug therapy recommendations (DTRs) and billing experience of a community pharmacist-provided pre-visit planning service for a shared cohort of patients enrolled in the clinic CCM program.

METHODS

This was a single group prospective pilot intervention. Previsit medication reviews were performed by community pharmacists over 8 months from 8/1/2020 to 3/31/2021 at Greenwood Pharmacy. Greenwood Pharmacy is an independently owned community pharmacy in Waterloo, Iowa that serves 7100 patients. Northeast Iowa Family Practice Center (NEIFPC) is a family medicine clinic also located in Waterloo, Iowa. NEIFPC has 1332 Medicare patients enrolled in the CCM program; 153 of the 1332 patients have Greenwood Pharmacy as their primary pharmacy. This study was approved by the NEIFPC ethics committee as a quality improvement project in April 2020.

NEIFPC uses a web-based EHR for clinic documentation which also has supplemental software to aid in CCM provision and billing. This system has been utilized by the practice since 2017. NEIFPC granted EHR access to Greenwood Pharmacists and provided training. NEIFPC created an agreement with Greenwood Pharmacy to be an independent contractor to provide pre-visit medication reviews (a CCM-related service) for select NEIFPC patients. This allowed community pharmacists to review medical charts and document pre-visit drug therapy recommendations.

Patient Eligibility and Recruitment

To be eligible for the study, patients had to be enrolled in the CCM service at NEIFPC, received their maintenance prescriptions from Greenwood Pharmacy, and had Medicare as their primary insurance. The clinic provided a list of shared patients to Greenwood Pharmacy and eligible patients (N = 153) were informed by the clinic via a mailed letter that the community pharmacist would be providing the consented CCM service related to pre-visit medication reviews.

Pharmacist Intervention to Support Pre-Visit Planning

Each week, NEIFPC supplied Greenwood Pharmacy with a list (via the clinic EHR) of enrolled CCM patients who had a physician visit for chronic disease or adult health maintenance scheduled in clinic the following week. CPs reviewed pharmacy records and the clinic EHR for each patient. The CPs noted any discrepancies between the medication list in the clinic EHR and pharmacy dispensing records. CPs reviewed the pharmacy prescription profile for interactions, fill history, and adherence. Patients were contacted by telephone to resolve discrepancies; however, most reviews were conducted via record review. The CP would make edits in the clinic HER medication list as necessary.

Within 7 days before the patient’s scheduled clinic visit, the CPs were required to document their interventions in the clinic EHR with the use of a templated note for pre-visit planning. The template contained the following elements: a list of maintenance medications with “proportion of days covered” (PDC) < 80%, medication costs (total monthly co-pays for maintenance medications, total monthly adjudicated ingredient costs, and cost savings opportunities), pharmacist’s recommendations, drug therapy problem categories,16 and whether or not they agreed with each pharmacist recommendation. This templated

pharmacist note was located in the “exam prep” section of the EHR; it was the first documentation the physician would view when they opened the patient encounter in the EHR. The CP also recorded the same information in the patient’s care plan in the community pharmacy’s electronic record system.

CCM Billing

All CCM service documentation, including for pre-visit planning was recorded to the second through the EHR supplemental software’s time tracking capabilities. This level of tracking allowed delineation of the exact time contributions from each site. NEIFPC was responsible for submitting CCM billing to Medicare. Centers for Medicare & Medicaid Services (CMS) pays for care coordination services to Medicare beneficiaries who reside in the community setting that meet the following requirements: two or more chronic conditions expected to be at least 12 months, chronic conditions placed the patient at significant risk of death, decompensation, or decline, and a comprehensive care plan is established, implemented, revised, or monitored. CMS regulations state that billing should be done if the eligible patient was provided at least 20 minutes of non-face-to-face CCM time within a calendar month. When patients exceed the 20-minute limit, where no complex medical decision was made or there is no change in the care plan, a 99 490 code is billed. If it exceeded 60 minutes where a moderate to high complexity medical decision shall be made regarding the patient’s care plan, a 99 487 code is billed. Finally, the 99 489 code is billed when a 30-minute time interval is added after the initial 60 minutes.17

Medicare reimbursed NEIFPC for the CCM services, and then the clinic paid the community pharmacy a prorated amount of the monthly CCM services provided by the community pharmacists. Prorated amounts for each party were determined according to the number of CCM billing minutes each party contributed for a subject each month. There was also a processing fee from the software vendor for each billing code claim processed. Key components of the pre-visit planning service are outlined in Figure 1.

Data Collection

Demographic information obtained from the clinic EHR for study participants included age, sex category, common chronic diseases (from the problem list in the EHR), smoking status, and insurance. From the EHR we collected patient attendance at the scheduled clinic visit, and

Figure 1. Flow diagram for community pharmacist and family medicine physician collaboration for pre-visit planning.

pre-visit pharmacist recommendations. From the pharmacy records, we recorded chronic medications, monthly prescription copays, and adjudicated prescription ingredient costs.

For the study, the final, completed physician EHR encounter note with only the pharmacist recommendation was reviewed for analysis. Also, extracted was clinic physicians documentation of which of the CP recommendations they agreed with. These were verified by one of the study pharmacists (SK). Monthly data of CCM billing was extracted from the billing software linked to the clinic EHR.

Lastly, an anonymous 3-item electronic survey was sent to all 17 physicians and resident physicians involved with the pre-visit planning pilot. They were asked if they had seen a pharmacist-previsit planning note and responded with their 5-point agreement (strongly agree, agree, neutral, disagree, strongly disagree) to whether they had enough time to read the notes, and how helpful the notes were.

Data Analysis

Patient characteristics and patient visit data, were analyzed descriptively. Drug therapy problems identified were coded by one of the study authors (SK) and counted. Drug therapy recommendations and acceptance rates were calculated. The survey was analyzed descriptively. All data were entered into IBM SPSS (version 27) for analysis.

RESULTS

Among the 153 patients we recruited, 8 patients withdrew after receiving the informational letter. Of the 145 eligible subjects, 95 had at least one pre-visit pharmacist review during the 8-month study period. The mean age of the patients (N = 95) was 76.8 years; 57.9% were female (Table 1). The mean (SD) number of prescription medications was 6.3 (3.4).

Interventions Provided

Community pharmacists completed a total of 129 pre-visit medication reviews for 95 patients (Table 2). Community pharmacist pre-visit recommendations resulted in 169 patient-specific drug therapy recommendations and 76% of recommendations were accepted by the physician. Many of the drug therapy recommendations were for care gaps

related to immunizations. The five most common types of pharmacist drug therapy recommendations related to: needs additional therapy (N = 70), low medication adherence (N = 28), potential adverse event (N = 22), unnecessary drug (N = 7), and dose too high (N = 7).

Economic Evaluation

There were 71 CCM billing claims submitted for the 95 patients during the study period (Table 3). Total net (with subtraction of software vendor processing fee) CCM revenue was $3596. Proration of revenue based upon the time each party contributed to each claim resulted in approximately an equal revenue allocation between the community pharmacy ($1800) and the clinic ($1796). The type and frequency of CPT codes billed were: 99 490 (N = 61), G2058 (N = 13), 99 487 (N = 10), 99 489 (N = 5), and 99 439 (N = 3). Some patients had more than one CPT code billed per claim.

For comparison, we also calculated what each party would have received from CCM billing if they would have provided the service independently of each other, rather than with our shared CCM service. Independently, pharmacy and clinic revenue would have been $1269 and $1300, respectively. With shared CCM billing the actual realized amounts were $1800 (pharmacy) and $1796 (clinic). This represents increased CCM revenue of 42% (pharmacy) and 38% (clinic) for each party due to combining CCM activities with more claim thresholds being achieved.

Physician Experience

There were 12 (9 resident physicians, and 3 faculty physicians) surveys completed out of 17 invitations (70.1% response). Eleven of 12 affirmed they had reviewed a community pharmacist note in the EHR during the project time period. All respondents “agreed” or “strongly agreed” that they had adequate time to review the pharmacist recommendations in the prep note section prior to seeing the patient. Ten of 11 physicians “agreed” or “strongly agreed” that the pharmacist recommendations were helpful to their practice.

DISCUSSION

In this evaluation of a community pharmacist-provided previsit planning process, pharmacists provided pre-visit planning workups for 95

patients over 8 months with most patients either having 1 or 2 pre-visit notes during the study period. Pharmacists identified more than one drug therapy problem per patient which most often focused on vaccination needs (e.g., herpes zoster, pneumococcal, and influenza). Most recommendations were accepted by the physician. The service also was found to be a source of revenue for both the pharmacy and clinic, with pharmacists receiving $1800 in reimbursement for their pre-visit planning contributions.

Pharmacists were able to reach 66% (95 of 145) of shared patients for this effort, and this was likely aided by several facilitators. First, the community pharmacists were engaged by the clinic as part of the clinic “care team.” Key project structural elements included granting CPs access to the clinic EHR, creation of a pre-visit template to record the CP recommendations, advance sharing of scheduled patient clinic visits, and creation of a business agreement for CCM billing. Second, CPs had monthly in-person meetings with clinic pharmacists for the first five months to discuss any process issues or review difficult patient cases. The CPs and clinic pharmacists formed a partnership to

improve patient care. Guiding statements have been created to facilitate collaboration between CPs and clinic-based pharmacists to improve medication optimization.18

Like with other CCM and pharmacist workup interventions, community pharmacists were able to routinely identify drug therapy problems, and propose actionable recommendations with a high rate acknowledged and accepted by the physician.14,19,20 The templated CP note was located in the prep-note section of the clinic EHR which includes all previsit planning documentation. The clinic physicians’ response to the project was favorable. Greater than 90% of clinic physician respondents noted they reviewed pharmacist recommendations, had adequate time to review such before the patient visit, and found them helpful to their practice which supports the feasibility and acceptability of the CP pre-visit planning intervention.

Pre-visit medication review is only one part of all previsit planning components,6,7 and pharmacists are well suited to perform this task. Pharmacists commonly perform pre-visit planning tasks related to

medication-use optimization. While the term pre-visit planning may not be used, pharmacists routinely perform such activities in various practice settings. For example, pediatric ambulatory clinical pharmacists in one health system used telemedicine during the COVID-19 pandemic to perform pre-visit planning and other patient care services.21 Pharmacists have also contributed to pre-visit planning to improve pneumococcal vaccination rates.22 It has been observed that most descriptions and evaluations of pre-visit planning are highly varied and it is difficult to ascertain which aspects of the process are most beneficial.23

Lastly, this pre-visit planning collaboration was found to be a financially viable approach for community pharmacists to partner with local clinics to provide chronic care medication management services to shared patients. For patients enrolled in a CCM program, CCM service and billing is one method for clinician and pharmacist compensation for pre-visit planning. As of January 2022, over 64.2 million people are enrolled in Medicare,24 and it is estimated that two-thirds of Medicare patients have two or more chronic conditions,25 which is a CCM requirement. Pharmacists who want to provide CCM services in collaboration with a qualified health professional must either be directly employed, independently contracted, or leased by that QHP or their practice to meet billing requirements.10 We utilized an independent contractor agreement for the pharmacists to provide previsit medication reviews. Based upon our previous experience with shared CCM billing11 which evaluated time contributions within each individual billing claim, we simplified revenue sharing with this current project and prorated CCM revenue according to total CCM minutes provided by each party for each submitted claim. The overall revenue result was the same. Shared CCM service revenue was greater for each entity (clinic $1796 and pharmacy $1800) compared to what each would have billed independently ($1300 and $1269, respectively).

This feasibility study has several limitations. It involved a single group design with no comparison group, and clinical endpoints were not evaluated. The frequency of pre-visit reviews by the CP was not structured; it was entirely dependent on the frequency of physician-patient visits as determined by the physician. As a result, only one-third of subjects had more than one pre-visit review by the pharmacist during the 8-month study period. Direct pharmacist-patient interaction was limited in our project. CPs did not contact patients via telephone routinely; direct patient contact was limited to clarifications with medication reconciliation. Most of the pharmacist review was done via record review. To measure physician acceptance of the pharmacist recommendations we recorded (yes/no) if the physician denoted agreement for each recommendation in the templated pharmacist prep-note. We did not investigate prospectively what physician action was taken following their noting acceptance of the pharmacist recommendation. It is possible some “accepted recommendations” are yet to be enacted, were modified, or not enacted. The greatest project challenge was ensuring the CPs had adequate allotted time to complete the previsit medication reviews. However, the study pharmacy employs multiple pharmacists, offers other clinically oriented services, and already had a strong working relationship with the partnering family medicine clinic. Pharmacies with other staffing models and with less experience providing clinical services likely would have different experiences. Providing the CPs access to the clinic EHR was instrumental for our project success.

CONCLUSION

This project successfully incorporated CPs within the ambulatory care team to provide medication reviews as part of pre-visit planning

services. CPs identified drug therapy problems, made appropriate drug therapy recommendations, and family medicine physicians found the reviews helpful to their practice. Providing this service to patients enrolled in the clinic CCM program provided a mechanism for CPs to receive payment for their service. Proration of shared CCM revenue between pharmacy and clinic resulted in increased CCM revenue for each entity beyond what they would have realized independently.

References:

1. Easter JC, DeWalt DA. The medication optimization value proposition: aligning teams and education to improve care. N C Med J. 2017;78(3):168-172.

2. Watanabe JH, McInnis T, Hirsch JD. Cost of prescription drug-related morbidity and mortality. Ann Pharmacother. 2018;52(9):829-837.

3. Patient-Centered Primary Care Collaborative. The Patient-Centered Medical Home: Integrating Comprehensive Medication Management to Optimize Patient Outcomes, Resource Guide. 2nd ed.; 2012. https://www.pcpcc.org/sites/default/files/media/medmanagement.pdf. Accessed May 4, 2022.

4. National Committee for Quality Assurance. Patient-centered Medical Home: Developing the Business Case from a Practice Perspective; 2019. https://www.ncqa.org/wp-content/ uploads/2019/06/06142019_WhitePaper_Milliman_BusinessCasePCMH.pdf. Accessed May 4, 2022.

5. National Committee for Quality Assurance. Introduction to PCMH: Foundational Concepts of the Medical Home; 2018. https://www.ncqa.org/wp-content/uploads/2018/09/20180913_ GRIP_PCMH_Training_Presentation.pdf. Accessed May 4, 2022.

6. Sinsky CA. Pre-visit planning. Chicago, IL: American Medical Association; 2019. https:// edhub.ama-assn.org/steps-forward/module/2702514. Accessed April 2, 2022.

7. Sinsky CA, Sinsky TA, Rajcevich E. Putting pre-visit planning into practice. Fam Pract Manag. 2015;22(6):34-38.

8. Gholamzadeh M, Abtahi H, Ghazisaeeidi M. Applied techniques for putting pre-visit planning in clinical practice to empower patient-centered care in the pandemic era: A systematic review and framework suggestion. BMC Health Serv Res. 2021;21(1):458. doi:10.1186/s12913-021-06456-7

9. Schottenfeld L, Petersen D, Peikes D, et al. Creating patient-centered team-based primary care. AHRQ Pub. No. 16-0002-EF. Rockville, MD: Agency for Healthcare Research and Quality; 2016.

10. American Pharmacists Association. Chronic Care Management (CCM): An Overview for Pharmacists; 2017. https://www.pharmacist.com/Portals/0/PDFS/Practice/CCM-An-Overviewfor-Pha rmacists-FINAL.pdf?ver=z1VjEDMg9Uk-1FEnMvX7Xg%3D%3D. Accessed April 17, 2022.

11. Hoehns JD,WitryM, Al-Khatib A, et al. Community pharmacist and family medicine clinic provision of chronic care management services for Medicare beneficiaries with uncontrolled hypertension. J Am Coll Clin Pharm. 2021;4:793-800. doi:10.1002/jac5.1224

12. Fixen DR, Linnebur SA, Parnes BL, et al. Development and economic evaluation of a pharmacist-provided chronic care in an ambulatory care geriatrics clinic. Am J Health Syst Pharm. 2018; 75(22):1805-1811.

13. Martin R, Tram K, Le L, et al. Financial performance and reimbursement of pharmacist-led chronic care management. Am J Health-Syst Pharm. 2020;77:1973-1979.

14. Jennings BT, Marx CM. Implementation of a pharmacist-managed diabetes program. Am J Health Syst Pharm. 2012; 69(22):1951-1953.

15. Snyder JM, Ahmed-Sarwar N, Gardiner C, et al. Community pharmacist collaboration with a primary care clinic to improve diabetes care. J Am Pharm Assoc. 2020;60(3):S84-S90.

16. Strand LM, Morley PC, Cipolle RJ, et al. Drug-related problems: Their structure and function. DICP. 1990;24(11): 1093-1097.

17. CMS. Chronic CareManagement Services; 2022. https://www.cms.gov/outreach-and-education/medicare-learning-networkmln/mlnproducts/downloads/chroniccaremanagement. pdf. Accessed May 4, 2022.

18. Collaboration between community pharmacy-based and clinic-based pharmacists to achieve medication optimization: Consensus guiding statements from ACCP, CPESN USA, and NCPA Innovation Center. J Am Coll Clin Pharm. 2019;2:447-448. doi:10.1002/ jac5.1157

19. Fitzpatrick RM, Witry MJ, Doucette WR, et al. Retrospective analysis of drug therapy problems identified with a telephonic appointment-based model of medication synchronization. Pharm Pract. 2019;17(2):1373. doi:10.18549/PharmPract.2019.2.1373

20. Milosavljevic A, Aspden T, Harrison J. Community pharmacist-led interventions and their impact on patients’ medication adherence and other health outcomes: A systematic review. Int J Pharm Pract. 2018;26:387-397.

21. Baron K, Herbst J, McNicol M, et al. Evaluation of a remote hybrid staffing model for ambulatory clinical pharmacists in a pediatric health system during the COVID-10 pandemic. Am J Health-Syst Pharm. 2022;79(11):852-859. doi:10.1093/ajhp/zxac022

22. Sivaraman V, Wise KA, Cotton W, et al. Previsit planning improves pneumococcal vaccination rates in childhood-onset SLE. Pediatrics. 2020;145(1):e20183141. doi:10.1542/ peds.2018-3141

23. Holdsworth LM, Park C, Asch SM, et al. Technology-enabled and artificial intelligence support for pre-visit planning in ambulatory care: Findings from an environmental scan. Ann Fam Med. 2021;19:419-426. doi:10.1370/afm.2716

24. Medicare monthly enrollment. Data.cms.gov. https://data.cms.gov/summary-statistics-on-beneficiary-enrollment/medicareand-medicaid-reports/medicare-monthly-enrollment. Accessed May 5, 2022.

25. Medicare Learning Network. Payment of Chronic Care Management Services under CY 2015 Medicare PFS. Woodlawn, MD: Centers for Medicare and Medicaid Services; 2015. https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2015-02-18CCM-Transcript.pdf. Accessed May 5, 2022.

Are you interested in becoming an important partner in helping IPA advance its legislative and regulatory agenda throughout the year? IPA is looking for Champion Advocates across the state of Iowa to build relationships with their elected officials. Help us designate a Champion Advocate in every House and Senate district!

WHAT DO CHAMPION ADVOCATES DO?

• Build relationships outside of the legislative session by hosting pharmacy visits with legislators and delivering PAC contributions when needed.

• Contact legislators during session to explain how pending legislation would affect their pharmacy practice.

• Relay personal experiences to help legislators understand the important roles that today’s pharmacists and pharmacy technicians play in enhancing the healthcare of Iowans.

• Stay informed with bill tracking/IPA’s legislative priorities and participate in bi-weekly update calls.

By Volunteering as a Champion Advocate: You would be kept up-to-date on the latest information relating to IPA’s advocacy agenda and would be ready to answer the call when IPA needs to make a grassroots push.

INTERESTED?

Contact Seth Brown, Director of Public Affairs, at sbrown@iarx.org or 515-270-0713.

He will help you identify your State Senator and Representative and get started with setting up a pharmacy visit.

2023 LEGISLATIVE PRIORITIES

MODERNIZE THE IOWA PHARMACY PRACTICE ACT

Since the Iowa Pharmacy Practice Act’s last complete update 30+ years ago, pharmacist education and training has transformed drastically. All pharmacists now graduate with a doctorate degree and training to perform clinical services in a wide variety of practice settings, as highlighted during the COVID-19 pandemic.

IPA supports modernizing the Iowa Pharmacy Practice Act to cut red tape, align with other healthcare practitioners in the state, increase professional autonomy, and match the evolving practice of pharmacists to improve patient access and outcomes.

PROTECT IOWA MEDICAID

Across the country, state Medicaid programs and Governors look to Iowa Medicaid’s prescription drug policies in managed care. Iowa Medicaid’s current model utilizes a state managed survey, which prevents the opacity prevalent in private sector PBM relationships.

IPA supports laws, regulations, and policies that ensure prescription drug reimbursement under Medicaid is sustainable, predictable, and transparent. This includes maintaining patient access by paying pharmacies at average acquisition cost, plus a cost of dispensing fee.

IPA supports continued funding under Medicaid for prescription drug reimbursement, as has been in place since 2012. The most recent survey in 2021 showed the COD increased from $10.38 to $10.97.

State Policy Positions

RESTRICTED DRUG DISTRIBUTION MODELS

Drug distribution models known as white bagging and brown bagging undermine hospitals’ patient safety protections and jeopardize patient care. IPA supports regulations that prohibit third-party mandated brown and white bagging, which interrupts safe chain of custody of medications and risks misuse by patients.

MAINTAIN THE INTEGRITY OF THE 340B PROGRAM

The 340B drug pricing program enables covered entities to stretch scarce federal resources as far as possible, reaching more eligible patients and providing more comprehensive services. Ensuring the 340B drug pricing program remains protected is essential to preserving access to care. IPA supports regulations to ensure the intent of the 340B program is not further eroded.

REGULATE PBMS TO ENSURE PATIENT ACCESS

Pharmacists are the most accessible member of the healthcare team with nearly 9 of every 10 Americans living within five miles of a pharmacy.

Pharmacies in Iowa continue to risk closure due to unfair and predatory PBM practices. The unanimous passage of PBM reform during the 2022 Legislative Session is an encouraging step in the regulation of nontransparent PBM practices in Iowa, and regulatory enforcement is the next step to ensure patient access to critical pharmacy services and prescription medications.

LEARN MORE: www.iarx.org/legresources

NON-MEDICAL SWITCHING

The practice of non-medical switching by PBMs and health plans compromises patient health, interferes with the patient-provider relationship, and increases overall healthcare costs. IPA opposes restrictions and barriers on pharmacists and other healthcare professionals that limit access to and prevent the optimization of healthcare services for patients.

PROFESSIONAL AUTONOMY

IPA recognizes the professional autonomy of pharmacists who have the authority and obligation to use their training, education, and experience to make clinical decisions for safe and effective patient care. IPA opposes legislation, regulation, or policies that limit the ability of pharmacists to exercise professional autonomy.

Continue learning about IPA’s advocacy efforts after Pharmacist Day on the Hill!

1 HOUR PHARMACY LAW CE PER SESSION

FREE with Pharmacist Day on the Hill registration for paid IPA members & FREE for all ENGAGED Pharmacist members! (Value $15/webinar)

AVAILABLE ON-DEMAND

PBM Regulation in Iowa and Beyond

Featuring:

Michael Murphy, PharmD, MBA, Advisor for State Government Affairs, APhA Andria Seip, Senior Policy Specialist, Iowa Insurance Division

FRIDAY, MARCH 24, 1:00-2:00 PM

First Funnel: Iowa Legislative Update

Featuring:

Matt Eide, IPA Lobbyist, Eide-Walton Lobbying and Government Relations

Kate Walton, IPA Lobbyist, Eide-Walton Lobbying and Government Relations

FRIDAY, APRIL 28, 1:00-2:00 PM

Pharmacy Practice Act Update

Featuring:

Seth Brown, JD, Director of Public Affairs, IPA

Brett Barker, PharmD, Senior Policy Advisor, IPA

For CPE details and more information, visit www.iarx.org/I2A_webinars .

BOARD OF PHARMACY UPDATE

REGULATORY REALIGNMENT

Among the many priorities stated in her 2023 Condition of the State address on January 10, Iowa Governor Kim Reynolds declared her intent to overhaul the administrative state in Iowa. This overhaul includes enacting a moratorium on rulemaking, instituting comprehensive cost-benefit reviews of all existing administrative rules, and realigning several regulatory agencies. One significant realignment transition announced prior to the Governor’s speech included the combining of the Iowa Department of Public Health (IDPH) and Human Services (DHS), to establish the new Department of Health and Human Services (DHHS).

During a stakeholder call following the Governor’s speech, Kelly Garcia, Director of the to-be consolidated IDPH, shared that health-related administrative boards in Iowa would no longer remain under the purview of the newly combined DHHS. This means the Iowa Board of Pharmacy, along with the Medical, Dental and Nursing Boards, will receive a new home in the Iowa Department of Inspections and Appeals (DIA).

DIA is more widely known to the public as regulators of the hospitality space (i.e., restaurants, gaming, and hotels); however, DIA currently conducts certain health-related regulatory actions, such as certifying nursing assistants and reviewing complaints against nursing homes. The responsibilities of the Board of Pharmacy range from regulating the distribution of controlled substances to licensing applicants to practice pharmacy. From a practical standpoint, the move to DIA aligns the Board of Pharmacy and other health boards with their licensing, registration, and inspection activities. These activities are extensive—regulating examination, renewal and reciprocity requirements, registering pharmacist-interns, pharmacy technicians and pharmacy support persons, and instituting disciplinary actions, hearings and appeals against licensee and registrants.

However, questions remain as to how the broader public health policy efforts which occur within DPH (now DHHS) might be affected. Until the text of the implementing bill is introduced by the legislature, uncertainties are expected to continue. IPA will continue to monitor the transition and provide updates as they become available.

If you have any questions or comments in the meantime, please contact Seth Brown at sbrown@iarx.org or Brett Barker at bbarker@iarx.org.

Each episode will focus on WHAT actions were taken by the Board of Pharmacy, WHY the BOP took the actions it did, and HOW BOP action will impact practice in Iowa.

2022 IPPAC & LDF DONORS

The Iowa Pharmacy Political Action Committee (IPPAC) is a fund used to strategically strengthen relationships with legislators who are supportive of pharmacy interests. The IPPAC is funded by contributions from individual pharmacists, technicians and student pharmacists, as well as member PACs of other organizations. This fund plays an important role in enhancing legislative action for the profession. Learn more at www.iarx.org/ippac

THANK YOU!

Maisaa Abudagga

Michael Andreski

Brett Barker

Emily Beckett

Nancy Bell

Sharon Cashman

Cheryl Clarke

Connie Connolly

Kyra Corbett

Jay Currie

William Drilling

IPA’s Legislative Defense Fund (LDF) consists of contributions from corporate sponsors. Since corporations are prohibited from contributing to candidates (and therefore, the IPPAC), these funds are used to pay for advocacy activities, which include IPA’s Pharmacist Day on the Hill, contracted lobbyists and external consultants, and IPPAC administration and fundraising costs. Learn more at www.iarx.org/ldf

THANK YOU!

Brent Bovy

Clayton Pharmacy Services

Daniel Pharmacy

Drilling Morningside Pharmacy

Meyer Pharmacy

NACDS

Sumpter Pharmacy

Valley Drug Store

Matt Eide

Dalton Fabian

Steve Firman

Emily Gajda

Kole Gallick

Brandon Gerleman

Jacqueline Gravert

Robert Greenwood

Betty Grinde

John Hamiel

Charles Hartig

Keaton Higgins

Jim Hoehns

Hy-Vee Employees’ PAC

Candace Jordan

Laura Knockel

Rick Knudson

Nicholas Lehman

Shane Madsen

Micaela Maeyaert

Edward Maier

Erik Maki

Gary Maly

Lisa Mascardo

Deanna McDanel

Randy McDonough

Kristin Meyer

Andrew Miesner

Wendy Mobley-Bukstein

Robert Nichols

Marilyn Osterhaus

Matt Osterhaus

Heather Ourth

Nathan Peterson

Wes Pilkington

Matt Pitlick

Lisa Ploehn

Diane Reist

Anne Roth

Cheri Schmit

Christie Schweitzer

Susan Shields

Angela Spannagel

CoraLynn Trewet

Kate Walton

Ryan Weber

PROPER VACCINE STORAGE

From IPA’s November 2022 Tech Tidbits

Influenza immunization season is upon us, and as many pharmacies are experiencing flu immunization taking place later than normal and an influx in COVID-19 boosters, it is important to review proper vaccine storage requirements and best practices, as well as the impact that improper handling and storage can have on patients.

Proper vaccine storage and handling is critical in preventing and eradicating vaccine-preventable diseases. Improper vaccine storage and handling can reduce vaccine potency, resulting in inadequate immune responses and poor protection against disease. Storage and handling errors can result in significant financial loss for the pharmacy, patient need for revaccination, and the development of mistrust and lack of confidence in the pharmacy team.

Vaccines must be properly stored from the time of manufacture through administration. Vaccine potency is reduced every time a vaccine has an improper exposure. Improper exposures include but are not limited to:

• Overexposure to heat, cold, or light.

• A refrigerated vaccine or liquid vaccine with an adjuvant can result in total loss of potency if a single freezing exposure (0° C [32° F] or colder) occurs.

Once potency is lost it cannot be restored. Since vaccine appearance is not a reliable indicator of proper storage requirements, it is imperative that all vaccines are stored according to the manufacturer’s specifications so an improper exposure in vaccine cold chain management does not occur.

Vaccine refrigerators should maintain temperatures between 2° C and 8° C (36° F and 46° F), and vaccine freezers should maintain temperatures between -50° C and -15° C (-58° F and +5° F). Ensure all vaccine storage units have properly closing doors, door seals that make contact all the way around, and are clean and away from anything that could cause a disturbance in airflow and over-heating of the vaccine storage unit.

Every vaccine storage unit must have a continuous temperature monitoring device (TMD), with temperatures being recorded at a minimum of twice daily (at the start and end of the workday). Temperature monitoring data should be kept for a minimum of three years, or longer depending on state and program requirements. Review temperature data to identify trends and/or recurring problems. Store vaccines in the original package with the packaging top closed until ready for administration to prevent potential potency reduction, reduce administration errors, and improve inventory management. The CDC’s “best storage practice” is to place vaccines in the center of the refrigerator and 2 to 3 inches away from refrigerator walls.

For additional tips, vaccine storage signage, temperature monitoring logs and vaccine cold chain management, visit the CDC’s website. Note: if a disruption in power to the refrigerator or vaccine cold chain management occurs, contact the pharmacist in charge and quarantine the vaccine in the refrigerator until further investigation and contact with the manufacturer has occurred.

References:

1. https://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf

2. https://www.immunize.org/guide/pdfs/vacc-adults-step3.pdf

NEWLY CERTIFIED IOWA PHARMACY TECHNICIANS

OCTOBER 1-DECEMBER 31,

Ryleigh Abbott

Samantha Anderson

Danae Barber

Lauren Bell

Sharon Boeding

Andrea Bohnsack

Parker Bramsen

Randi Brooks

Madelyn Bruns

Carrie Burt

Amy Cahill

Aaliyah Cathi

Megan Champlin

Karen Collier

Dennis Colwell

Angel Contreras-Varela

Laura Derby

2022

Congratulations to the following technicians!

ReJoana Duah

Rebecca Dunkel

Shelley DuVal

Dannette Fahrney

Tori Foote

Brenda Francis

Krystal Giebelstein

Madison Grasty

Cynthia Grimm

Dionte Hawks

Vonna Hayes

Kaysi Heims

Aaron Higgins

Kayla Holtgrewe

Dustin Hornberg

Amy Hurd

Katie Irwin

AnnaMaria Ivie

Lindsey James

Alitha Jellison

Parichat Kain

Heidi Kaufman

Katy Kephart

Samantha King

Lindsey Klennert

Alicia Long

Paulina Macias

Sierra McElfish-Argo

Mashall Meader

Dane Messersmith

Casey Mills

Shelby Olson

Mikayla Partlow

Onyx Phoenix

Lauren Playle

Bridget Podzemny

Rebekah Prochaska

Janet Ramirez

Kayla Reynolds

Miranda Rincon Gallegos

Jayda Runles

Brock Saunders

Faith Schultz

Suzanna Schurman

Amanda Seale

Molly Sickles

Riley Smith

Stephen Toothman

Jill Traylor

Rebecca Turpin

David Weidner

George White

Kaia Widitz

Kassidy Willis

Kathryn Wilson

Natalie Winchell

Alexa Winslow

Kaylen Witte

Vanessa Woelbe

Ashley Worthington

Paige Zynda

USE OF MOTIVATIONAL INTERVIEWING IN PATIENTS HESITANT TOWARDS CLINICAL SERVICES

From IPA’s December 2022 Tech Tidbits

Keeping up with the ever-changing clinical services that pharmacies provide can be overwhelming and confusing to patients. Patient hesitancy is very common, especially in today’s world with the vaccines and clinical services that pharmacies now provide to the public. Many times, pharmacy technicians are the first point of contact with patients, and perfecting motivational interviewing skills may be just what pharmacy technicians need to enhance clinical services and increase vaccination administration output.

Motivational interviewing is considered to be a “collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.”1 The overall objective of motivational interviewing is to elicit a behavioral change, whether that be receiving a vaccination, beginning nicotine replacement therapy, making lifestyle changes, or working through addiction. The purpose is to produce an elicit and intrinsic motivation within the patient.2 This means we want to produce a goal that fits within their boundaries, yet is also specific enough to meet the end goal.

When we use motivational interviewing with patients who have vaccination hesitancy, we want to begin by asking open-ended questions and meeting them where they are. Ask what their understanding of the vaccine or clinical service is, and what they feel the benefits and risks of receiving that vaccine or clinical service are. Make sure that you are staying curious and encouraging them along the way to make an educated behavior change that feels best for them.4 It is important when having these conversations with our patients that we make sure they feel heard and can share their own personal experiences or fears.1

A great way to approach this is through the listen and reflection model. Reflecting to the patient what you heard from their answer helps to instill trust between the patient and provider. Most of the time, the main reason as to why patients are hesitant is due to misinformation. We need to be sure that when we are asking these questions we have accurate information that we can relay answers back in an accurate and empathetic manner.4 Once you have determined what the patient’s end goal is, then work to positively affirm it through encouragement. If they say, “I want to protect _____ from getting _____ (disease),” remind them that this vaccine would help prevent that from happening. Reinforcement of positive behaviors that support the patient’s end goal is key to change. At the end of the motivational interview, summarize what the two of you have decided for the patient and why.1

Ultimately, motivational interviewing is an effective way to get patients to make behavioral changes when it comes to vaccinations and clinical services that are provided within the pharmacy. There is evidence that

motivational interviewing can improve clinical outcomes, as well as increase patients’ ability to make successful interventions that last.3 Creating open and thoughtful conversations with our patients, whether it be in person or through telehealth, allows for a closer patient-caregiver relationship and the potential to create behavioral patterns that withstand the test of time. As healthcare providers, our main goal should be to create a safe environment where we can educate our patients in a respectful manner and provide them with the services that they deserve.

Here is a step-by-step guide for Motivational Interviewing with Patients on Clinical Services:

• Ask open-ended questions that allow for the patient to give personal perspectives.

• Reflect on what you perceive from the patient’s answer and respond with accurate and educational information.

• Reaffirm the goals and decisions that patient is pushing towards.

• Summarize the steps that patient is willing to take in order to reach their ultimate goals.

References:

1. https://motivationalinterviewing.org

2. https://www.sciencedirect.com

3. https://onlinelibrary.wiley.com

4. IPA Goes Local 2022, "Rethinking Vaccine Communication: The Elephant in the Room"

TECHNICIAN SPOTLIGHT: LORI FOSTER, CPHT

Lori Foster did not originally choose pharmacy; she stumbled into it. Lori was between jobs, and her local community pharmacy in Marengo, Iowa was looking for a clerk. Upon employment, she began immersing herself in the profession. Lori was part of the first group of pharmacy technicians to be certified in the state of Iowa. (This was before PTCB was established!)

Lori states, “Our profession changes constantly.” She can attest to the constant changes in technology, innovation and professional representation. In her first community pharmacy role, Lori would place labels into claws of the platen of a manual typewriter. The original label was placed on the vial, while carbon copies were placed on the back of the prescription and into the patient’s paper profile, and third-party claims were submitted via mail. After some time, Lori transitioned to hospital pharmacy where she had one of the few workstations with a computer. As technology continues to advance and pharmacy practice becomes more digitized, every workstation has a networked computer.

According to Lori, the most rewarding part of being a pharmacy technician is knowing she is helping people. She also enjoys mentoring new and potential technicians. In her previous hospital pharmacy role, Lori created rapport with the physicians and was able to get to know them on a personal level. In her most recent position, she had many interactions with patients, both face-to-face and over the phone. In the early stages of the COVID-19 pandemic, she knew she was making an impact in patients’ lives, as many of them would express their appreciation and gratitude.

Lori is an active member of the Iowa Pharmacy Association (IPA) and American Society of Health-System Pharmacists (ASHP). She has also served on several committees, including IPA’s Pharmacy Technician Advisory Committee and an Iowa Board of Pharmacy task force. In 2006, Lori was honored with the IPA Pharmacy Technician of the Year Award, recognizing a technician in Iowa who has demonstrated outstanding involvement in the association and profession.

Lori is not only an asset to the pharmacy profession but to her family and community as well. Lori enjoys spending time with her siblings and their families, along with her special fella and his family. In her community, Lori is involved with the American Legion Auxiliary, Friends of the Marengo Public Library Foundation, and her lacemaking group. She formerly held a seat on the Marengo Public Library Board of Trustees, which was “very enlightening to severe the public in that role.”

When asked how IPA members can prepare for and direct change, Lori expressed that continuing education is more important than ever. “Information is accessible, and relevant information is prioritized.” Lori directs change by being an active member in IPA, which, in her words, “means a lot to her.” Lori suggests members join a committee, attend the Annual Meeting, and participate in Pharmacist Day on the Hill. Technicians have a voice, and every technician has a story to be told.

Thank you, Lori, for your service to the profession and your community! ■

Pharmacy Technician, Reutzel Pharmacy

Lori Foster, CPhT

Lori Foster and Mitch Meyers administering COVID-19 vaccines during a vaccine clinic in Cedar Rapids.

Reutzel Pharmacy staff posing for a photo in their masks.

THANK YOU IPAF DONORS

The Iowa Pharmacy Association Foundation sincerely thanks those members who make a contribution to the future of the profession by supporting the efforts of the Foundation…these contributions truly make a difference! The following list of contributors is for January 1–December 31, 2022.

PLATINUM ($1000+)

Bill Baker

Carl Chalstrom

Renae Chesnut

Connie and Chris Connolly

Jay and Ann Currie

Michele and Michael Evink

Steve Firman

Kate and Bob Gainer

Bob and Chery Greenwood

Tom Halterman

John Hamiel

Rick Knudson

Donald E. Letendre

Randy McDonough

Matt and Marilyn Osterhaus

Bob and Ann Osterhaus

Wes Pilkington

Lisa and Andy Ploehn

Al Shepley

Pamela Wiltfang

GOLD ($500-$999)

June Johnson

TJ Johnsrud

Julie Kuhle

Gary Milavetz and Mary Teresi

Jen Moulton

Darryl Nunes

Rachel Otting

Chuck and Janalyn Phillips

Matt and Jamie Pitlick

Anthony Pudlo

Nevin Radechel

Susan Shields

Sara and Terry Wiedenfeld

SILVER ($250-$499)

Bill Baer

Emily Beckett

Nancy Bell

Mike Brownlee

Sharon Cashman

Cheryl Clarke

Chris and Jen Clayton

Tom Greene

Charlie Hartig

Stephen Hopkins

Greg Hoyman

Tyson Ketelsen

Nic Lehman

Craig Logemann

Lyudmyla Lyasenko

Erik Maki

Deanna McDanel

Jim Miller

Mary Mosher

Heather Ourth

Angie Spannagel

Andy Stessman

John and Sarah Swegle

CoraLynn Trewet

Kate Waack

BRONZE ($100-$249)

Mike Andreski

Brett Barker

Ray Buser

Jordan and Jana Cohen

Jake Crimmins

Josh Davis

Ashley Dohrn

Bill Doucette

Matt Fleshner

Felix Gallagher

Jacqueline Gravert

Philip Greazel

Betty Grinde

Jill Guetersloh

Morgan Herring

Jim Hoehns

Terry Jacobsen

Sandra Johnson

Gene and Susan Lutz

Dana McDougall

Alex Mersch

Kristin Meyer

Jessica Nesheim

Rob Nichols

Phyllis Olson

Kaitlyn Pegump

Mike Pursel

Justin Rash

Diane and Jeff Reist

Kayla Sanders

SEPTEMBER 21, 2023

The Legacy Golf Club, Norwalk, IA

Doug Schara

Cheri Schmit

Bob Stessman

Heather Storey

Tom Truong

JP Webb

Dave Weetman

BUSINESS PARTNER CONTRIBUTORS

Cardinal Health

Drake University College of Pharmacy & Health Sciences

Dubuque Area Pharmacy Association

Greenwood Pharmacy & Compounding Center

Main at Locust Pharmacy

McKesson

MHCS

North Iowa Pharmacy, Inc.

NuCara Pharmacies

Osterhaus Pharmacy

University of Iowa

College of Pharmacy

STEP, CYCLE, SWING FOR STUDENT SCHOLARSHIPS

JULY 2023

Kick-off at IPA Annual Meeting!

PHARMACIST SPOTLIGHT: ASHLEY BREHME, PHARMD

Ashley Brehme started her journey into pharmacy when she was in high school. Her chemistry class did a section comparing acetaminophen and ibuprofen, and from there, she was hooked.

Originally from Manchester, Iowa, Ashley graduated from the University of Iowa College of Pharmacy in 2012 with her PharmD and a certificate in public health. While in school, she worked at Walgreens pharmacies and interned at Blakesley Drug over summer vacation. As graduation approached, Ashley reached out to the owners of Blakesley Drug and was hired as a pharmacist. Here, she quickly became a PIC, and after five years of working at Blakesley Drug, she bought the pharmacy and opened Brehme Drug.

For Ashley, community engagement is vital, as she lives and works in the same community. She is a part of a local volunteer community, the Manchester Planning & Zoning Commission, and is on the Manchester Enterprises Board. Additionally, during COVID-19, the Brehme pharmacy team went above and beyond what was expected. Not only were they integral in vaccinating their community by providing vaccinations to the local American Legion and using that space to hold large vaccination clinics, but they also made and donated hand sanitizer to local law enforcement and schools, showing how dedicated they were to keeping their communities safe. Additionally, they found a way to bring a little joy to their patients during the pandemic with events like “COVID Spirit Week,” that featured theme days like “COVID Hair Day,” and helped celebrate the Easter holiday with their T-rex mascot, T-Rx. In Ashley’s words, “Brehme Drug is going to great lengths to keep our community healthy and smiling!”

Brehme Drug’s motto is “fearless pharmacy,” and they are not afraid to innovate. As a member of CPESN and Flip the Pharmacy, Brehme Drug is currently implementing a Medication Synchronization program to better care for their patients. So far, they have over 350 patients in the program and are working to add more. In addition to this work, Ashley’s goal for Brehme Drug is to be a center for healthcare in Manchester. She wants to go beyond dispensing and is hoping to expand their immunization program, start a test and treat program, and launch patient education classes. This forethought has not gone unnoticed, as Brehme Drug was awarded Retail Management Solutions’ “Climb Ascender'' Award for going above and beyond in their community and being innovators of care.

Ashley has been an active member of the Iowa Pharmacy Association (IPA) over the years. Most recently, she took part in an IPA pharmacy visit, welcoming IPA staff to meet her pharmacy team and showcase all of the amazing things Brehme Drug is doing to fill the needs of the community. When looking towards the future, Ashley thinks pharmacists are in the prime position to make change in patient care. She encourages all pharmacists to share what they do, voice the obstacles they face, as well as the outcomes they achieve. Ashley wants all Iowans to know how impactful pharmacists can be as part of the care team.

Thank you, Ashley, for your commitment to advancing pharmacy practice and serving your community! ■

Owner & Pharmacist, Brehme Drug

Ashley Brehme, PharmD

“

“Brehme Drug is going to great lengths to keep our community healthy and smiling!”

Blakesley Drug

Brehme Drug

www.iarx.org/join_renew

MEMBER MILESTONES

WELCOME NEW IPA MEMBERS OCT. 1-DEC. 31, 2022

Perkins Aiyegbeni

Kristen Alford

Majid Ali

Hannah Barmore

Samantha Baumgartner

Joslin Bawek

Spencer Behning

Sophia Bell

Zachary Boten

Aaron Boyle

Dara Brandt

Kieler Brown

Zoe Bryant

Jennah Brygger

Gaige Buttler

Sarah Canfield

Kailey Casper

Erin Caylor

Morgan Christ

Jared Clement

Madelynn Clement

Jayden Cooper

Emma Creech

Roua Dabal

Nicole Dacus

Jenna Davey

Kristina Dibert

Eryka Dickey

Abby Ditsworth

Sara Dodge

Jamie Dugan

Stephanie Ekufu

Faith Fiedler

Julia Fischer

Allison Frale

Alexander Frank

Jayna Freeman

Hallie Frohn

Beca Gengler

Brandon Gibson

Allison Gieswein

Brandon Gillip

Lynsea Gordon

Noah Graalfs

Leann Greiner

Jenah Greiner

Anne Guthrie

Larry Hall

Chris Hallum

Kirre Hannan

Claire Horsfield

Brock Hunt

Holly Huynh

Christopher Ingram

Isabelle Johnson

Gregg Jones

Seungri Kang

Tobey Klungseth

Aurora Korfist

Leslie Lai

Nina Lanciloti

Delaney Lantz

Eesha Lawande

Sophia Lee

Olivia Lenz

Kevin Li

Stanley Liu

Mallory Loussaert

Lauren Lowry

Neanagit Malow

Madisyn Martin

Darlyn Mendoza

Karli Michael

Maxwell Monterastelli

Phoebe Moore

Dawson Mueggenberg

Alvin Nguyen

Nicholas Nielsen

Dean Oachs

Ochain Okey

Laura Peterson

Lucas Pitzen

Kaden Porter

Matthew Rafa

Benjamin Ragan

Kitri Reimer

Sabrina Renner

Conner Riley

Anna Roshek

Bomi Ryang

Sarah Schade

Natalie Schemmel

Megan Schreur

Sydney Sears

Mason Selk

Fatima Shah

Mukesh Shah

Madeline Sherwood

Avani Sheth

Mahaa Siddiqi

Autumn Smith

Alexandria Snell

Sydney Soeder

Anna Sprenger

Dat Tran

Hannah Tucker

Ellie Twedt

Carley Uhl

Emily Van Daele

Kaitlyn Wallace

Shaochen Wang

Tressa Weimerskirch

Natalie Wessel

Courtney White

Emily Woodhouse

Madeleine Wood-Smith

Madalynne Yenter

Ruoyi Zhang

MercyOne Northwood Pharmacy

Congratulations to Melissa Murer Corrigan, RPh, CAE, FAPhA, FASHP, who was named one of Pharmacy Podcast Network’s 50 Most Influential Leaders in Pharmacy!

Congratulations to Emmeline Paintsil, PharmD, MSLD, BCPS, who was awarded Drake University CPHS’ Young Alumni Achievement Award!

Best of luck to Logan Murry, PharmD, PhD, in his new role as Assistant Director of Continuing Pharmacy Education and Continuing Professional Development at ACPE!

Find additional details to these events and more at www.iarx.org. Click on “Calendar

Onnen Company has been serving our customers’ needs since 1964. Fourth generation owned and operated, we offer endless industry knowledge through dedicated sales reps, management and owners with well over 100 years combined experience. We have a knowledgeable, unparalleled, and dedicated customer service staff to help you through the order process. Thank you for trusting us to continue to serve your prescription packaging and pharmacy supply needs.

20

JANUARY:

Issues & Events That Have Shaped Iowa Pharmacy (Or Are Fun to Remember!)

The FDA issued an urgent Class I recall for injectable colchicine and other injectable pharmaceutical products distributed by Phyne Pharmaceuticals in Scottsdale, Arizona. These products were labeled as containing 0.5mg/mL but were found to contain 5mg/mL.

In addition, over 350 pharmacists, pharmacy technicians and student pharmacists attended the annual IPA Educational Expo, featuring nearly 40 different speakers and workshops.

FEBRUARY:

Wellmark and IPA hosted a conference to address the rising costs of drugs and look at ways to effectively manage medication use. The conference, “Maximizing the Value of Pharmaceuticals: New Strategies for Managing the Cost-Effective Use of Medication,” brought several key pharmacy leaders together.

MARCH:

The FDA approved Bimatoprost ophthalmic solution (Lumigan) and Travoprost ophthalmic solution (Travatan) for the treatment of elevated intraocular pressure, commonly associated with glaucoma.

MAY:

The National Cholesterol Education Program (NCEP) released new clinical practice guidelines on the prevention and management of high cholesterol in adults. These guidelines included more aggressive cholesterollowering recommendations and placed greater emphasis on addressing high triglycerides. They also introduced “Therapeutic Lifestyle Changes.”

During this month, the FDA also approved the use of the Twinrix vaccine, a combination of the hepatitis A and B vaccines, for individuals 18 years of age and older.

JULY:

The Iowa House of Representatives approved legislation mandating the use of standardized prescription identification cards. This legislation required third-party payers to issue cards that comply with guidelines established by the Director of Public Health.

Just eleven days later, President George W. Bush announced the implementation of a Medicare-endorsed prescription drug discount card program, designed to assist seniors in reducing their out-of-pocket drug costs. This program was intended as an interim measure until broader Medicare drug benefits could be established.

In 2001, several pharmacists were elected to positions in municipal government. Jerry Schwertfeger was re-elected as Mayor of Winterset (1994-2006), Tom Vlassis was re-elected to the Des Moines City Council (1988-2010), and Bob Greenwood (Waterloo) and Selma Mills (Anton) were elected to city council positions.

The Iowa Pharmacy Association Foundation is committed to the preservation of the rich heritage of pharmacy practice in Iowa. By honoring and remembering the past, we are reminded of the strong tradition we have to build upon for a prosperous future for the profession.

Jerry Schwertfeger

Tom Vlassis