Elements vol5 iss3 by Kellie Paxton

ELEMENTS TRANSITIONS GROW TRANSACTIONS How transitions of care can provide an untapped retail market

WORKPLACE FLU CLINICS Bartell Drugs helps area businesses fight the flu

Leading Pharmacy Bringing your pharmacy vision to life through effective leadership

VOL. 5 ISS. 3 | SEPT 2016 | PBAHEALTH.COM/ELEMENTS

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ELEMENTS

The business magazine for independent pharmacy

STAFF & CONTACTS Matthew Shamet – Publisher and Editorial Director Kirsten Hudson – Editor Kellie Paxton – Art Director Analisa Bregant – Contributing Writer Torrie Wright – Contributing Writer Paige Fisher – Graphic Designer INTERESTED IN ADVERTISING? elements@pbahealth.com

Contents Departments 5 NEWS:

24 MONEY:

Authorized to Prescribe A look at pharmacists’ role with opioid overdose reversal drugs. 6 TRENDS:

Mail Order Mishaps The dangers of narcotics, mail order and the 90-day supply. 29 OUTLOOK:

Transforming Technicians Insights into the expanding roles of pharmacy technicians—and what this means for independent pharmacies. 8 RETAIL:

Transitions Grow Transactions How transitions of care can provide an untapped retail market. 12 SOLUTIONS:

A Pharmacy Advocate How one devoted pharmacy owner fought to keep her pharmacy in network.

Sort it Out Help patients manage multiple medications and improve adherence with better packaging options. 34 NOTES:

Customized Bags Tailor your pharmacy’s prescription bags to bring in more business.

Feature: Leading Pharmacy

Bringing your pharmacy vision to life through effective leadership.

20 SPOTLIGHT:

Workplace Flu Clinics See how Bartell Drugs helps area businesses fight the flu.

ON THE WEB //

Find more strategies, tips and expert advice to improve your business at pbahealth.com/elements.

Do’s and Don’ts for Increasing Positive Online Reviews of Your Pharmacy

When potential patients are researching local pharmacies online, what do they see about your business? Read more at pbahealth.com/dos-and-donts-for-increasing-positive-online-reviews-of-your-pharmacy.

Elements magazine is published quarterly by PBA Health. Copyright© 2016 PBA Health. All rights reserved. Neither this publication nor any part of it may be reproduced without written permission by PBA Health.

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NEWS

Authorized to Prescribe A look at pharmacists’ role with opioid overdose reversal drugs Working to combat a national opioid epidemic in full force, states are increasingly authorizing pharmacists to prescribe opioid overdose reversal agents. “While some states have taken action to restrict access to prescription narcotics—prescription drug monitoring programs, limits on days supply that can be dispensed, encouragement of the use of abuse deterrent formulations—others are looking to increase access to life-saving opioid reversal agents,” said Krystalyn Weaver, Pharm.D., R.Ph., vice president of policy and operations at the National Alliance of State Pharmacy Associations (NASPA). A SOLUTION TO STAGGERING STATISTICS More than 28,000 individuals died from an opioid overdose in 2014, marking it as the highest year on record for prescription-abuse related deaths, according to statistics from the Centers for Disease Control and Prevention (CDC). Increasing national concern—and attention—has led to an upsurge in state regulations authorizing pharmacists to prescribe naloxone, an opioid overdose reversal drug. Previously administered only in a hospital setting, the opioid antagonist is now available for purchase over-thecounter in multiple states across the country. PHARMACISTS AS PRESCRIBERS Pharmacists now have the opportunity to play a pivotal role in the nation’s growing struggle with prescription drug addiction. “Pharmacists are in a key position to identify patients who are obtaining prescriptions from multiple prescribers or are at risk of overdose due to abuse, medication interactions or comorbidities,” Weaver said. “Some states have implemented policies that allow pharmacists to dispense naloxone to not only patients at risk of overdose, but also to their caregiver.” Independent community pharmacists in particular are vital in helping with the opioid epidemic.

Getting In-The-Know

Krystalyn Weaver, Pharm.D., R.Ph., vice president of policy and operations at the National Alliance of State Pharmacy Associations (NASPA), explains what pharmacists can do to prepare as more states authorize them to prescribe naloxone. Stay up-to-date on the products currently available on the market. Obtain professional liability insurance. Fully understand the risks and benefits of naloxone use to be able to identify and counsel the patients who need it. Utilize available resources, such as the Centers for Disease Control and Prevention (cdc.gov) and the Office of National Drug Control Policy (whitehouse.gov/ondcp).

They are trusted, accessible and knowledgeable health care providers, Weaver said. “Patients look to them for assistance with medication-related problems and health care questions. Because of this, pharmacists can be a great access point for people who need naloxone. By allowing pharmacists to prescribe and dispense naloxone to the community, you take down the barrier of having to see a second prescriber to first get the prescription. The more barriers we take down, the more likely that patients who need access will get it.” CHANGING THE INDUSTRY Weaver believes the trend in pharmacists’ prescribing authority will lead to other contributions to the health care system. “I see pharmacists as a great resource for making a variety of medications, especially those that are critical for public health goals, accessible to their communities,” she said. “More and more, policymakers are recognizing this opportunity as well.”

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TRENDS

Transforming Technicians By Analisa Bregant

Insights into the expanding roles of pharmacy technicians—and what this means for independent pharmacies Pharmacists aren’t the only ones with expanding job duties in the pharmacy. “The roles of the pharmacy technician are evolving and expanding concurrently with those of the pharmacist,” said Miriam A. Mobley Smith, Pharm.D., FASHP, director of strategic alliances at the Pharmacy Technician Certification Board (PTCB). With pharmacists clearing up their schedules to provide more clinical care services to patients, pharmacy technicians are stepping up to the plate and taking on more job duties. PHARMACY TECHS AND THE FUTURE Pharmacy technicians have always served a valuable role in the pharmacy setting, such as entering prescription information and preparing medications. But the career’s future is looking even brighter, Mobley Smith said. “In 2014, the U.S. Bureau of Labor Statistics predicted a nine percent growth in the job outlook for pharmacy technicians, which represented a faster growth average than all other occupations,” she said. “This was predicted due to an increased demand for prescription medications and related pharmacy services.” The duties of pharmacy technicians have already started advancing. Today, pharmacy techs support pharmacists in areas of medication reconciliation, medication therapy management, immunization delivery, indigent care programs, investigational drug programs, sterile

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and non-sterile compounding, pharmacist-managed chronic care clinics, tech-check-tech programs, pointof-care testing services, quality assurance and quality improvement initiatives, patient safety initiatives, informatics and health information technology and telepharmacy, among numerous other roles. And in some states, pharmacy technicians may even serve as members on pharmacy boards. THE EDUCATION DEBATE The education and licensure required to become a pharmacy technician vary state-by-state. And a lack of uniform knowledge, skills and competency-based preparation is a potential downside to pharmacy technicians taking on advanced duties in a pharmacy practice. Mobley Smith advises that independent community pharmacies require their pharmacy technicians to be subject to rigorous standards before assuming increased roles and responsibilities in the pharmacy.

TRENDS

“This will ensure they provide the highest quality health care to improve patient outcomes and protect the public’s health in the process,” she said. “Without uniform standards, many pharmacists have voiced concerns about technician quality, ability to delegate greater tasks and the potential impact on their license if errors occur that can be attributed to pharmacy technicians under their supervision.” TECHS OF THE TRADE Assigning pharmacy technicians to take on more roles can help increase the business of independent community pharmacy. “There are some estimates that the implementation of tech-check-tech initiatives may have a net effect of freeing greater than 20 percent of the pharmacist’s time, so that they can engage in advanced patient care roles and services,” Mobley Smith said. Delegating pharmacy technicians to gather patient data, schedule appointments, perform vital sign measurements or perform non-health related business tasks, such as marketing and front-end sales, can also free up the pharmacist’s time. Mobley Smith said pharmacy technicians can also play a valuable role in working with pharmacy automation systems and helping to resolve patient insurance issues. “Educated and skilled pharmacy technicians can be delegated many of the technical, non-clinically judgmental roles to allow the pharmacist to concentrate on those roles and responsibilities that require patientrelated clinical judgment,” she said. IN YOUR BUSINESS Inspire your own pharmacy technicians to expand their knowledge by requiring participation in professional development courses or joining organizations that will help them continue to learn new skills. “Pharmacy owners can also consider building in incentives to encourage technicians to expand their knowledge and expertise with an accompanying opportunity to work closely with pharmacists on the development of revenue-generating patient care services,” Mobley Smith said. “It’s important to

Technician Standards by State Regulations on the duties of pharmacy technicians vary widely by state. Here are a few key standards that differ. There are no uniform standards for technician education prior to employment. Some states require technicians to complete continuing professional education or to receive registration or licensure prior to beginning work in a pharmacy setting. Others do not. Some states require the completion of a background check. Others do not. Many states have instituted pharmacistto-technician ratios. This may vary based on the pharmacy practice’s setting and whether a technician is certified or not. Source: Pharmacy Technician Certification Board (PTCB)

recognize the value that the technician brings to the business and every pharmacy employee’s responsibility in ensuring the overall success of the business.” Advancing the pharmacy technician profession can influence the future of your business—and the future of the pharmacy profession. “As pharmacists, we need to take charge of our profession and envision what we want our future practice to be,” Mobley Smith said. “A better qualified pharmacy technician workforce will improve patient safety, provide greater consistency to enable the expansion of technician roles and responsibilities, give us greater confidence in the delegation of technical tasks to technicians, promote less turnover in technician positions, proactively address drug diversion prevention and advance the profession overall. We must strive to agree on where we are going, work together to get there, take action now and be steadfast on the journey.”

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RETAIL

Transitions Grow Transactions How transitions of care can provide an untapped retail market When patients are discharged from the hospital, they must transition to caring for themselves in a home setting, which can be difficult. It’s well known that independent community pharmacies can help these patients with their prescription needs, but if your pharmacy only focuses on prescriptions, you could be missing out on an opportunity in the front end. “Pharmacists are in an ideal position to become a liaison for these patients, as they’re one of the most trusted health care professionals,” said Dave Wendland, vice president, strategic relations and member of the owners group at Hamacher Research Group, a leading partner in category management, business strategy and marketing services focused on consumer health care at retail. “Most patients being discharged for acute conditions or chronic care situations are likely to require prescription medication, so aligning pharmacists with the role of managing both the regimen of Rx along with the complement of non-prescription products puts them in an empowered position,” he said. HOSPITAL READMISSIONS Readmitting patients to the hospital after a procedure costs the U.S. health care system more than $40 billion annually, according to a study by the Agency for Healthcare Research and Quality (AHRQ). And of that $40 billion, more than $4 billion is due to Medicare patients suffering from congestive heart failure, septicemia and pneumonia, and being readmitted to the hospital within the first 30 days of discharge. The magnitude of readmissions is scary and costly,

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Top 5 Reasons for Hospital Readmission 1. Congestive heart failure 2. Septicemia 3. Pneumonia 4. Bronchitis 5. Cardiac arrhythmia Source: Agency for Healthcare Research and Quality (AHRQ)

and pharmacists have an opportunity to help as the health care system continues to work toward reducing the number of hospital readmissions. “Pharmacists are in a unique position because they can be the educational resource or guidepost to the patient and the family caregiver, providing insight, knowledge, access and comfort to help ease the process,” Wendland said. It’s often not feasible for nurses, attending physicians or a hospital liaison to fully assist with a patient’s transition. Nurses and physicians are caring for a multitude of patients, and are unable to maintain relationships with patients after they leave the hospital in ways that pharmacists can, Wendland said. RETAIL OPPORTUNITY What independent community pharmacists haven’t yet recognized is how being that liaison for transitional patients provides a significant retail opportunity. “The pharmacy has the products and services that the patient is going to need,” Wendland said. “It can be very profitable for community pharmacies in particular, because of their ability to get close to the patient and have

RETAIL

that long-lasting relationship.” Pharmacies can provide non-prescription products that complement those prescriptions patients need and increase their bottom line at the same time. Retail products for transitional patients should cover the activities of daily living (ADLs) that patients in the recovery period or those living with a chronic condition need. These activities include mobility, feeding, toileting and bathing. “If pharmacists emphasize those areas of products and build a portfolio to care for patients being discharged, they can provide a holistic end-to-end solution for patients,” Wendland said. “This could give independent pharmacies another leg up on the competition.”

need states or with a color coordinated system based on need state. Another option is creating an inventory checklist based on condition. “If someone is being discharged, make a list of the items that individual should be aware of that you stock in your store. Create it in a bookmark size and include it in a discharge packet that you give to the patient,” Wendland said. You can also post these inventory checklists on your pharmacy’s website for added convenience. When patients, or caregivers, are searching for information on self-care after discharge, they can easily see how your pharmacy can help meet their needs.

PROMOTING TRANSITIONAL PRODUCTS AND SERVICES But how do pharmacists make patients and caregivers aware of everything they offer during these transitional periods? Wendland recommends taking a look at your store merchandising. This may require pharmacies to break away from the traditional approach to merchandising, and instead organize front-end products by transitional

EDUCATING TRANSITIONAL PATIENTS Besides stocking the products patients require, pharmacists also need to provide patients and their caregivers with proper education and counseling to ensure a smooth transition. “If someone is really interested in managing their condition effectively, that’s not an individual responsibility, it’s a team sport,” Wendland said.

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RETAIL

Retail Product Categories to Stock Dave Wendland, vice president, strategic relations and member of the owners group at Hamacher Research Group, points to four retail categories to address patients’ transitional needs: prevention, monitoring, recovery and management. Each category calls for certain products the pharmacy should carry based on patients’ transitional needs. Prevention: Avoid illness and maintain health Product categories: Vitamins, minerals, supplements, fitness support and wearables, skin care and protection, smoking cessation and general health products

By conducting educational sessions, pharmacists can let family members know how their lifestyle may need to change in order to support their loved ones, and what the pharmacy can offer to assist with the transition. It’s also important to examine a patient’s reason for discharge, identify his needs and make sure all pharmacy staff are prepared to act as resources. Wendland suggests pharmacists provide educational workshops or home visits as an additional benefit. “Think about what it would look like if a pharmacist went to an individual’s home, sat with them upon release from the hospital and said, ‘Here are some things you may encounter as you recover, here’s how we can service you, and here’s a 24-hour access number so if there’s anything you need in your transition, I’m available,’” he said. He also suggests inviting patients and caregivers into the pharmacy and conducting a tour. You can introduce them to everything the pharmacy has to offer and explain the products available in more detail. In addition to the tour, it’s important for pharmacists to let patients know about products outside of the pharmacy that they have access to. For example, while you may not have space for products, such as lift chairs, bed rails or grab bars in your store, let patients know that those items are available.

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Monitoring: Have a family history or pre-diagnosis Product categories: Diagnostic equipment, wearables for monitoring, weight management products and services and general health care products Recovery: Need for post-acute care Product categories: Hydration products, probiotics, supplements, wound care products and mobility products Management: Living with a chronic condition Product categories: Any products necessary to manage and monitor the condition and contribute to the patient’s well-being

Taking these extra steps is beneficial for patients because it gives them a clear picture of the products and services available to help them adjust. FUTURE OUTLOOK The retail opportunity for pharmacies created by transitions of care is an untouched market. And, according to Wendland, independent community pharmacies need to recognize this small window of opportunity before someone else owns the space. “Someone is going to recognize the tidal wave of opportunity,” he said. While there are currently pharmacists working with hospital systems regarding educating discharged patients, no one is providing an end-to-end solution for patients struggling with transitions of care, he said. Wendland suggests starting small by meeting with discharge nurses, reorganizing the pharmacy and making inventory checklists for patients’ conditions. “Don’t just think about how often you hear that question or find yourself in that place,” he said. “Innovate right now. Create a solution and start promoting it as a point of difference.”

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SOLUTIONS

A Pharmacy Advocate How one devoted pharmacy owner fought to keep her pharmacy in network Independent community pharmacies face tough competition and setbacks every day. But what happens when you take a stand? Can one person really make a difference? One business-savvy pharmacy owner did. When Mary Jasinski Caldwell, owner, vice president and general manager of City Pharmacy of Elkton, an independent community pharmacy located in Elkton, Md., discovered that her pharmacy would no longer be in-network for her patients enrolled in Maryland’s Medicaid program through United Healthcare, she took initiative and stood up for her business. Jasinski Caldwell talked with us about how she became an activist, and why it’s important to speak up for your patients and your independent community pharmacy. How did you find out about United Healthcare’s plan change? One of my customers came in at the beginning of March and told me she had received a letter stating she would no longer be able to come to my store after April 1. I looked at the letter and it did indeed say that City Pharmacy would no longer be in the plan’s network of pharmacies. The letter suggested she use K-Mart®, and it also named another independent that had just opened in the area. Why did you decide to challenge the plan’s change? I questioned the legality of the plan’s change.

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Contractually, I was supposed to have 60 days’ notice if there were to be a change in contract. What’s the first step you took to challenge this change? I immediately got on the phone and called my third party contracting provider, and they knew nothing about it. So, then I called the state of Maryland. The state of Maryland Medicaid program also informed me that they weren’t seeing any changes, so I then called OptumRx. After making numerous phone calls, I still wasn’t getting any answers. When did you finally get a clear answer of what was happening? After calling OptumRx, I was told that, yes, indeed, my pharmacy would no longer be included as a part of United Healthcare’s network. How did you take initiative to fight this change? I called everyone at the state level that I could think of. I called my patients. I sent out letters. I put information on social media urging patients to contact both the state and OptumRx. Because of everything I had put out to the public, the local newspaper contacted me and launched a full-blown story. A lot of people were upset, not only because they couldn’t come to my pharmacy, but there were other independents in the area that were going to be affected by this, too. I was then contacted by my state senator and state delegate, and I was asked if

SOLUTIONS

I would be interested in attending and speaking at a session with the Eastern Shore Contingency, United Health-

and complain. We have to be active, and there’s no one better than us to stand up for us.

care and the state regarding this issue. Did advocating for your pharmacy work out for you? After speaking at the contingency, I received a phone call from OptumRx. They told me I would need to fill out some paperwork and I would once again be one of their providers. My patients were very grateful. Many of them have come in here for years. They have a relationship with us, and they didn’t want to have to switch. I’m glad I was able to keep my patients here. What made you decide to take initiative and be an advocate? I’ve been an advocate for many years. I call myself a “pharmacy brat” because I’ve been involved in retail pharmacy ever since I can remember. I saw things back in the late 80s that gave me pause. I saw control of the business side of retail pharmacy starting to slip away, so I started getting involved at that point. Why is it important for those in independent pharmacy to take on an advocacy role? It’s the only way that we are going to see a change. And it’s the only way we are going to affect any change because no one knows our businesses and our circumstances better than we do. We cannot ring our hands

What advocacy advice do you have for independent pharmacy owners? You have to understand the issues. You have to be able to inform your customers about how this is going to affect them. Get to know your elected officials; they can be such an ally. Independents should also know and understand their state laws in regards to pharmacy benefit managers (PBMs), audits and everything of that nature. If you know the law, you can use that as a shield.

Mary Jasinski Caldwell is the owner, vice president and general manager of City Pharmacy of Elkton, an independent community pharmacy located in Elkton, Md. She graduated from Loyola University Maryland and Goldey-Beacom College with degrees in Business Administration and Accounting. She’s also a registered certified pharmacy technician (RCPhT).

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Leading Pharmacy Bringing your pharmacy vision to life through effective leadership By Torrie Wright

14 14

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How well can an independent community pharmacy run without effective leadership? Patrick Devereux, Pharm.D., a pharmacist (and soonto-be owner) at FMS Pharmacy in Bessemer, Ala., believes that the growth and sustainability of your business relies heavily on your abilities as a leader. “There is no way possible to gain fulfillment from this calling that we have unless you are surrounded by the right people, who can help do the things that need to get done to run a business,” Devereux said. “Unless you learn how to lead your pharmacy and develop a strong team, you will end up trying to do everything yourself, and eventually burn out.” Because the pharmacy industry is constantly evolving, as an independent community pharmacy owner or manager, you have to be willing to keep learning in order to lead your team and stay in the forefront. “With all these new opportunities and pharmacists being involved in patient care, if you’re not trying to learn and surrounding yourself with people willing to learn with you, then you’re not going to be able to move forward,” said Audrey Newton, Pharm.D., co-owner of Chad’s Payless Pharmacy and Singing River Healthcare, a primary care medical clinic, in Florence, Ala. Devereux acknowledged that pharmacy ownership isn’t for everyone, especially if you’re not comfortable working to be a good leader. “In order to be a successful pharmacy owner, you have to be deeply passionate about leading people, not just about the business and practicing pharmacy,” he said. BEING A TEAM LEADER Being a successful leader isn’t something you can do alone. You have to be willing to go outside of your comfort zone and learn from others, said Jake Galdo, Pharm.D., BCPS, CGP, assistant professor and director of the

community pharmacy residency program at the McWhorter School of Pharmacy at Samford University in Birmingham, Ala. And, being a pharmacy leader means nothing without the support of your team. “You can have a vision for your business and the future of your pharmacy, and have a really good grasp on that, but that doesn’t mean you’re going to have the buy-in from your colleagues or employees,” said Frances Cohenour, Pharm.D., coowner of Chad’s Payless Pharmacy and Singing River Healthcare in Florence, Ala. The ability to grow your business and achieve the goals you’ve set for your pharmacy stems from leading your team effectively. When your team believes in you and what you want to accomplish, they’ll work harder to make those dreams a reality. “It’s not only having the innovative vision, but the ability to share it and inspire others to buy into your vision,” Cohenour said. LEARNING TO BE A LEADER Most people aren’t born great leaders. There’s a lot of learning that goes into it. “Step one is acknowledging that you don’t know everything,” Devereux said. Newton shares a similar outlook. “So much of learning to be an effective leader is knowing that you don’t have all the answers all the time and that’s okay,” she said. “People want to know they can approach you with new ideas. It’s being open to those new ideas that’s difficult, and it’s a learning process.” Pharmacy school probably didn’t cover the skills needed to be an effective leader. But you have many resources at your disposal to learn effective leadership skills, such as looking to mentors and reading leadership books. “When I start a new leadership team, I have them read “Strengthsfinder” by Tom Rath,” Galdo said. “I

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Leadership Literature Check out these popular leadership books to help strengthen your leadership skills as an independent community pharmacy owner or manager.

“Strengthsfinder 2.0” by Tom Rath The new and improved version of the popular assessment is loaded with hundreds of strategies for applying your strengths. “Lean In” by Sheryl Sandberg Examines women’s progress in achieving leadership roles and offers solutions on how to lead a team involving both men and women. “Entreleadership” by Dave Ramsey Ramsey outlines his principles of leadership and how to achieve success by being an entrepreneur and a leader. “Good to Great” by Jim Collins Describes how companies transition from being average to great, and how some can fail to make the transition. “The Leadership Fables of Patrick Lencioni” by Patrick Lencioni Lencioni is the founder and president of The Table Group, a firm dedicated to helping leaders improve their organizations, and has authored multiple successful leadership fables including best-seller, “The Five Dysfunctions of a Team.”

have them identify where they excel, so we can build upon those strengths.” Understanding your team’s strengths is vital to your success as a leader, but you first have to learn what those strengths are and how they differ from your own. Galdo also suggested that independent community pharmacists join a buying group or other pharmacy services organization because these companies provide opportunities for pharmacy owners to attend conferences and events. And, you can use these events to build

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relationships with pharmacy leaders and to find mentors whose footsteps you’d like to follow. Cohenour said mentorship was essential to her own success. “We chose pharmacy because we’re scientists,” she said. “So often we’re placed in leadership roles and we’re not adequately prepared.” She stressed the importance of having strong mentors and taking their advice. You can also learn by looking at how other pharmacies lead their teams—even national chain pharmacies. It doesn’t hurt to do some research or gain some experience actually working in a chain pharmacy, Galdo said. “If you shadow and work a little bit in that realm and understand what they do well and what they don’t do well, you can do the good and ignore the bad,” he said. Use what you’ve learned from literature, your mentors and other pharmacies as a basis for forging your own path and finding a leadership style that works for your pharmacy. “Effective leaders need to be committed to finding avenues to grow themselves personally and professionally,” Devereux said. THE NECESSARY SKILLS The leadership skills you learn are invaluable, but there are also certain abilities and characteristics that make a good leader—and they might not be what you expect. Your willingness to fail and pick yourself up is important, Galdo said. As a leader, he chooses to focus on excelling in his strengths rather than building on his weaknesses, and he surrounds himself with team members whose strengths complement his own. Newton said pharmacy leaders need to have a thick skin. “You’ve got to believe in yourself and in what your abilities are, and have the faith of your own convictions to move forward,” she said. And, just because you choose to be a leader doesn’t mean you’re perfect. You have to continue to learn and grow, and you can’t let others knock you down. Cohenour encourages staying open minded to other people’s thoughts and opinions. She also advises stepping out of your comfort zone and away from the ‘Type A’ mentality. “You can’t just rely on the way you have always done things,” she said. “In a profession that changes so much and where there’s always new challenges, you’ve got to be ready and willing to take it head on.” LEADERSHIP STYLES Every leader has a unique style and it takes time to

find the leadership style that will work for you—and your business. Your team members also have different strengths and personalities, and you have to be able to effectively communicate with them based on—or despite of—those differences to get things done. Devereux describes his leadership style as asking his team members for input, but maintaining the ability to be extremely decisive and not letting pressure get to him. While for Galdo, it’s more about creating a family-oriented, team atmosphere where everyone feels comfortable. This helps him nurture relationships with his team members. “I love breaking bread with people,” Galdo said. “You can always have a great meeting over food.” Newton and Cohenour find that ensuring employees feel appreciated and that their ideas are valued works best in their pharmacy. “I get the most positive responses from staff and employees when I give them the autonomy to do things on their own,” Cohenour said. “People want to know their ideas are valued and that you’re not just there to delegate.” LEADING VS. MANAGING Just because you can manage your pharmacy, doesn’t mean you can lead it. There’s a big difference between being a leader and a manager, which some pharmacy owners fail to realize. In order to be an effective leader you have to first be an effective manager, but you can’t stop there. “Managing is just making sure the doors are open and the lights are on; leading comes down to casting the vision, figuring out how to get to where you want to be and surrounding yourself with the right people to do that,” Devereux said.

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Pharmacy managers are often put in charge of a team, and therefore assume they’re leaders. But according to Galdo, “a manager is someone who builds up the team, while a leader is the one the team follows.” Cohenour referred to leadership in terms of a team approach. Managing can be done on your own, while leadership indicates that you’re a team, you’re all on the same page and working together towards a common goal, she said. GETTING OTHERS ON BOARD Part of leading is inspiring others to embrace your ideas. Devereux suggests asking your team members for input, and actually valuing that input. It’s easy to get wrapped up in doing things the way you’ve always done them, but sometimes you just have to listen to others and accept that there may be a better way, he said. “You don’t know everything and are surrounded by people with different strengths who may have a different perspective,” he said. “Articulate the value proposition in doing it your way, and make sure that everyone is on board.” When introducing a new idea, Galdo looks to Dr. John Kotter, a Harvard Business School professor, New York Times best-selling author and well-known thought leader in the fields of business, leadership and change. Dr. Kotter founded the eight-step process for leading and accelerating change, which starts with creating a sense of urgency in order to get your team on board and institutionalize that change. “When you try to cast a new vision, ultimately you are leading change,” Galdo said. But there’s more to implementing a change than just getting your people on board. “Having a well-thought-out idea with a well-supported plan, and having the financials to back that up is essential,” Cohenour said. OVERCOMING OBSTACLES While getting others to accept your ideas is arguably the most difficult task for a leader, you have many other challenges to overcome. Galdo said he sees reprimanding and holding people accountable as the toughest part of leadership, although it’s one of the most important jobs a leader has to do. It’s never easy to tell others they’ve done something wrong or need to improve, but as a pharmacy owner you have to find a constructive way to communicate this to your team members, he said.

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According to Devereux, the most difficult part of being a leader is “finding the time to have face time, one-onone, with each of your key people.” He said that the reprimanding gets easier when the communication lines are open and comfortable, and you aren’t only meeting with employees when there’s a problem. You’re not only a leader, you’re also a boss. “It can be lonely and challenging being a leader, but also a boss and employer,” Cohenour said. Having to say “no” and enforcing hard concepts is more difficult than it looks, especially when you’re trying to please both your patients and your employees, she said. LEADING OUTSIDE THE PHARMACY Being an effective leader in pharmacy today means leading outside of your pharmacy, too. Newton said it’s important to step outside the pharmacy and show your patients that they can trust you because you’re doing good not only for them, but for the community as well. The community counts on your pharmacy. “It’s amazing how much independent pharmacy gives back to the community. Oftentimes our rural, independent pharmacies are the only small business in a town and are the lifeblood,” Galdo said. But Devereux cautions remaining balanced. “There’s a balance between running your business and being overly involved,” he said. Even if you don’t sit as a chair or a president for an organization, you’re still a leader when you are a successful independent pharmacy owner who others can look up to, Galdo said. Galdo seeks out pharmacy leaders who excel in patient care and in helping their community, and highlights their successes. He hopes that highlighting these industry leaders will motivate the entire profession to get better, as they’ll forge a path for others to follow. EVALUATING YOUR SUCCESS It’s beneficial to find a way to measure your success as a leader so that you know when to make improvements, and can ultimately keep working toward your pharmacy’s goals. Depending on your leadership style and the goals you’re trying to achieve, your way of evaluating success as a leader may differ from other pharmacy owners or managers.

8 Steps to Accelerate Change Dr. John Kotter, a Harvard Business School professor, New York Times best-selling author and well-known thought leader in the fields of business, leadership and change, founded the eight-step process for leading and accelerating change. This process is designed to help organizations, like your independent community pharmacy, develop the mindsets and skillsets necessary to lead change. 1. Create a sense of urgency. As a leader, you must describe an opportunity that will appeal to individuals’ heads and hearts and use this statement to raise a large, urgent army of volunteers.

4. Enlist a volunteer army. Large-scale change can only occur when very significant numbers of employees amass under a common opportunity and drive in the same direction. 5. Enable action by removing barriers. By removing barriers, such as inefficient processes or hierarchies, leaders provide the freedom necessary for employees to work across boundaries and create real change. 6. Generate short-term wins. Wins are the molecules of results. They must be collected, categorized, and communicated—early and often—to track progress and energize your volunteers to drive change.

2. Build a guiding coalition. A volunteer army needs a coalition of effective people—coming from its own ranks—to guide it, coordinate it and communicate its activities.

7. Sustain acceleration. Change leaders must adapt quickly in order to maintain their speed. Whether it’s a new way of finding talent or removing misaligned processes, they must determine what can be done— every day—to remain on the course towards the vision.

3. Form a strategic vision and initiatives. Strategic initiatives are retargeted and coordinated activities that, if designed and executed fast enough and well enough, will make your vision a reality.

8. Institute change. To ensure new behaviors are repeated over the long term, it’s important that you define and communicate the connections between these behaviors and the organization’s success. Source: Kotter International

Devereux attributes his success as a leader in his pharmacy to whether or not his team is growing and doing something better than they were before. “I may have coached that person to do something better, but they also may have seen what I was doing and are trying to model that,” he said. Devereux believes that your team will emulate the behavior you model, and you achieve success when you effectively communicate objectives to your team, and see those outcomes come to fruition.

Your ability to inspire other team members can also be a marker of success. Newton gauges her success as a leader by the number of students who decide to become pharmacists after working in her pharmacy. She believes she’s doing something right when students who don’t plan on being pharmacists really connect with her pharmacy’s mission and decide they want to be a part of that. “I feel pride and success when I can influence someone’s life in that way,” she said.

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SPOTLIGHT

Workplace Flu Clinics How Bartell Drugs helps area businesses fight the flu With flu season just around the corner, pharmacies need to start preparing, which includes considering offering influenza vaccination clinics—especially for local workplaces. The Centers for Disease Control and Prevention (CDC) reported that the preliminary overall influenza vaccine effectiveness was 59 percent for the 2015-2016 season. And, according to the 2013 Walgreens Flu Impact Report, the 2012-2013 flu season cost employers $30.4 billion and employees $8.5 billion nationally. The report found that employees missed, on average, three days of work during the flu season. The effect of the flu virus can be a hindrance to businesses, but independent community pharmacies can help. Bartell Drugs, a family-owned independent community pharmacy chain based in Seattle, offers workplace flu clinics every year to help local businesses keep their employees healthy. RECOGNIZING THE NEED Bartell Drugs began its workplace flu clinic program in 2006 after recognizing the need for a

more convenient flu vaccination option in the community. “Many people are so busy that rushing to get a shot after work isn’t on the forefront of their agenda,” said Christina Ree, clinical programs manager at Bartell Drugs. While the clinic’s main purpose is to prevent influenza and reduce sick days, it also serves as a reminder to the community that Bartell Drugs is more than just a place to pick up a prescription. “We are really positioning ourselves as their health care partner, and the added convenience we offer to our local community businesses is a benefit we are proud to offer,” Ree said. ORGANIZING THE CLINIC The process of organizing a workplace flu clinic is fairly simple for an employer. Employers need to give the pharmacy a general idea of how many employees will receive an immunization, how employees will be billed and provide a suitable room for the clinic to take place.

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Make it Successful Encourage employers to make the most of a workplace flu clinic with these top tips from the Centers for Disease Control and Prevention (CDC). Get senior management buy-in to support a flu vaccination clinic at the workplace Frame getting employees vaccinated against the flu as a business priority and create a goal aligned with this effort Identify a flu vaccination coordinator or team with defined roles and responsibilities Schedule the flu vaccination clinic to maximize employee participation Gauge need and demand among employees for flu vaccination Ask supervisors to allow employees to attend onsite flu vaccination clinics as part of their work day, without having to “go off of the clock” Set a goal to help show employees how their participation matters, and try to improve upon the percentage of employees vaccinated each year

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From the pharmacy’s perspective, it can be a bit more difficult. “Employee participation and allocation of convenient space on the worksite can sometimes be an issue,” Ree said. “Billing various insurance plans can also be a challenge.” The employer needs to provide an accurate representation of the allotted space and the number of participants in order for the pharmacy to supply proper staffing and complete immunizations in a timely manner. As far as the billing process goes, Ree said that Bartell Drugs encourages test claims to be done beforehand to ensure that all participants are aware of whether or not there will be a co-pay. If employees are unable to attend the clinic, employers may choose to hand out flu shot vouchers to be used at any of the 64 Bartell Drugs locations, so employees can still receive their vaccination. PROMOTING THE SERVICE As the flu season approaches, it’s important to let local businesses know that you provide workplace flu clinics. Bartell Drugs sends letters announcing the service to companies in the area, emails previous participants as a reminder to sign up again and includes the information in news releases. The CDC also recommends encouraging employers to assist with the promotion of clinics to increase employee participation. They can create posters and flyers, include the information in company communications and use social media channels to spread awareness. THE BOTTOM LINE Bartell Drugs credits the success of its workplace flu clinics to the convenience for employers. “They like that their employees don’t have to leave work to get preventative health care, and that there is no downtime or loss in work for the employees,” Ree said. From a profitability standpoint, Ree said it typically depends on the number of people getting vaccinated. “It is fairly profitable if we are doing clinics for 25 or more people in about two hours,” she said. Ree recommends independent community pharmacies consider offering workplace flu clinics in their communities because they build awareness for the services and preventative care that the pharmacies provide.

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Mail Order Mishaps The dangers of narcotics, mail order and the 90-day supply

Pharmacists know better than anyone that the wrong combinations can lead to negative results. And this doesn’t just apply to the wrong mixture of drugs. Negative consequences can happen when narcotics, mail order and 90-day supplies are combined. Michael Deninger, R.Ph., Ph.D, chief technology officer of Innovative Pharmacy Solutions, a consulting and software solutions company for pharmacies, and owner of Towncrest Pharmacy, an independent pharmacy located in Iowa City, Iowa, shared his take on the implications of narcotics, mail order and 90-day supplies. CONTRIBUTING TO THE EPIDEMIC Every day, 78 Americans die from an opioid overdose, according to statistics from the Centers for Disease Control and Prevention (CDC). With a national epidemic of opioid misuse, mail order pharmacies that provide 90-day supplies of narcotics are part of the problem, Deninger said. “Pharmacies are the gatekeepers for controlled substances,” he said. “Criminals know all the ins and outs, so they look for the weakest links. They look for the most fruitful areas to go after. In my opinion, despite

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what a mail order company can try and do to limit it, they’re a really easy mark.” Patients who suffer from acute or chronic pain rely on narcotics, but even chronic pain needs to be monitored regularly, Deninger said. “If you go to any pain management clinic and ask them if they’re dispensing 90-day supplies, they’re not. They want to evaluate that patient, make sure they understand the pain, what’s causing the pain and whether they’re having any problems.” LACK OF FACE TIME Independent community pharmacies thrive on personal counseling and getting to know every one of their patients. “With mail order, you have no idea who’s filling the prescription or who you’re talking to,” Deninger said. “It may not even be the same person week-to-week, month-to-month or even day-to-day. It may not even be a pharmacist.” Mail order pharmacies can’t offer the same communication as independents, so getting the medication delivered to the right patient can often be an issue. The mailman delivering the prescription may not know the person who the prescription needs to go to,

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What’s Fringe Prescribing? The other side of the narcotics epidemic begins with prescribing. Michael Deninger, R.Ph., Ph.D, of The Thriving Pharmacist blog, explains fringe prescribing as prescribing medications without close monitoring. It’s on the edge of legality, but technically a lawful form of narcotics prescribing practices.

so there’s a chance anyone can take the package—and he or she may not be the patient who ordered it. This is dangerous when narcotics are involved. Deninger also noted that mail order isn’t conducive to the level of monitoring some medications may require. Without a local presence, there is a missed opportunity to accurately counsel and more closely monitor a patient’s condition. Local pharmacies are better suited to effectively monitor medications, as they’re more accessible. “Having the patient at your counter is a large part of the opportunity, and mail order doesn’t have this,” Deninger said. “In my opinion, you’re undermining the profession of pharmacy and not getting the value of what independents have to offer patients,” he said. INDEPENDENTS AND THE 90-DAY SUPPLY Deninger isn’t a fan of 90-day supplies, but he believes local pharmacies are best suited for offering them to patients. “Independents can put a name to a face. We have a relationship with them, so we understand what’s actually going on,” he said. “A mail order place might call to ensure the patient wants the medication filled, but they oftentimes won’t even do that. They’ll just mail it out and get a signature to prove that it was ‘delivered.’ But they don’t

“A fringe prescription would be a doctor whose not really monitoring a patient’s pain well, prescribing large quantities and multiple medications that are therapeutically not appropriate, and basically just ignoring the fact that this patient is diverting some, if not all, of those medications,” Deninger said. “But the prescriptions are technically legal.”

know if the patient’s having side effects; they don’t know if the patient is actually in pain; and they don’t know if it’s acute or chronic. They’ve got very little information.” Having a local presence also means that independent pharmacies have a better idea of local prescribing habits. This allows them to pinpoint the doctors who are potential problems and who might be participating in fringe prescribing behaviors, legal narcotics prescribing that’s probably not fully compliant. “The reality is that without a local presence, a pharmacist can’t look the patient in the eye and determine if that patient actually needs that prescription,” Deninger said. THE MONEY OF MAIL ORDER Like any competitor, mail order pharmacies have the potential to hurt business for independent pharmacies. Mail order pharmacies offer cheaper alternatives for patients, as a 90-day bulk supply may be more affordable. And, “obviously when you take the business out of town it hurts the local economy,” Deninger said. “The problem isn’t so much one of economics, even though it’s there,” he said. “It’s one of providing the best possible care. With mail order, it’s very difficult to give your patients the best possible care.” Follow Michael Deninger for more pharmacy insights at thethrivingpharmacist.com.

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Sort it Out Help patients manage multiple medications and improve adherence with better packaging options

How you package prescriptions matters. When you use adherence packaging solutions that help you sort, organize, label and track patients’ medications, you can improve patients’ lives—especially those on complex drug therapies. One such medication synchronization and adherence packaging system is Medicine-OnTime, which offers standard and high capacity multi-dose blister cards that stand alone or work with a pharmacy automation system. “The package itself has never been the focal point,” said Peter Benjamin, director of business development at Medicine-On-Time, a compliance packaging and medication management company. “It’s always been about making it simple and easy for the patient.” “But the package is critically important when you talk about multiple medications being taken, or multiple doses at various times throughout the day. Having all of that medication in one package that’s labeled correctly, organized correctly, with the correct dose, at the right time and is color-coded by time of day, that’s a huge improvement from what has traditionally been offered through pharmacies.”

PACKAGING BENEFITS Independents are always looking for new ways to differentiate their businesses from competitors, improve patient care and grow their profits. And, adding nextlevel medication packaging solutions that also promote medication synchronization can accomplish all three. You can increase refills—even up to three or more refills per patient—with a medication synchronization and adherence packaging program like Medicine-On-Time. “Those two components lead to more refills per patient, which links directly to profitability and revenue for a pharmacy,” Benjamin said. Better medication packaging can also improve pharmacy workflow and procedures. Without a medication

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OUTLOOK

packaging system, you get what Benjamin calls “medication bingo.” “This is patients taking their prescription meds, spreading them out on a countertop, trying to figure out where to put the next dose for the next days or next weeks in pill organizers or bags, or even back into vials,” he said. “It’s very complex and it’s very disconcerting. It can be equally as challenging for their family members who are their caregivers, as well. That’s when we see incredible increases in misdoses, forgetting to take medication, running out of medication and failing to refill.” HELPING PATIENTS Not only does adherence packaging combined with medication synchronization simplify the prescription refilling process for your pharmacy, it can also improve patients’ lives, especially for individuals on complex medication regimens. Benjamin said that almost any individual can benefit from medication packaging services. Any patient on a multi-dose medication regimen, even if he just takes multiple vitamins a day, is an excellent candidate. Others who can benefit include elderly patients in assisted living facilities, professionals on-the-go looking for organization and convenience and even children going to summer camp (or camp nurses managing multiple medications.) “The missing piece of medication synchronization has always been the packaging,” Benjamin said. “This is a great

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opportunity for pharmacies to pursue advanced patient care.” Many patients likely don’t know that they can benefit from compliance packaging. Benjamin advises pharmacies to market and sell their unique medication packaging services. You can do this by creating marketing materials to distribute and share with patients and physicians. Other marketing opportunities include attending health fairs and working with hospitals post-discharge to aid in transitions-of-care. “There are a plethora of opportunities pharmacies have to market and sell this service,” Benjamin said. “The main point being that this will enhance and improve patient care.” PRODUCT DETAILS Medicine-On-Time helps pharmacies simplify medication regimens through its complete system, which includes compliance packaging, integrated software and an optional workstation. Its two compliance packaging lines include standard and high capacity multi-dose blister cards. The standard size can hold up to six medications, and the high capacity size can hold up to 12. The packaging keeps medications airtight and the labeling system on the calendar cards features all the information you need to know, such as product name, strength, quantity, physical description and a photo of each drug contained in the calendar card. “Both products have our perforated, detachable dose cups with patient-specific information and prescription history on the back of the dose cup,” Benjamin said. The detachable feature is key. “You don’t have to take an

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entire calendar with you over lunch, at night or on the weekend,” he said. “The dose is for that particular time period and they’re color-coded.” And if your pharmacy already uses an automation system or if you’re looking to add a pharmacy robot, Medicine-On-Time works with various automation vendors. “We’re not an automation company per se,” Benjamin said. “We’re in the medication adherence, compliance packaging and medication management business. But we do partner with select automation companies.” The company’s new laser labels also make the product stand out. “Our new laser labels feature color printing, drug images or pill pictures, and patient photos that combine with our new clear coat blisters to give our pharmacy customers the ability to package and deliver patient-specific, multi-dose blister cards efficiently, consistently and compliantly,” Benjamin said. But you need more than just compliance packaging for a comprehensive service. Medicine-On-Time includes a robust workflow system that integrates with more than 50 pharmacy management systems and can handle complex dose schedules. “It’s user-friendly and was developed with pharmacies in mind,” Benjamin said. “It may seem like a daunting task in the beginning to have a new software system, and all this packaging implemented in the pharmacy, but we have pharmacies up and running sometimes in a few days or even a week,” he said. THE COSTS OF COMPLIANCE Medicine-On-Time charges a monthly fee, which includes software, hardware components, training, installation and support. The consumables and additional supplies are purchased as needed. “The program pays for itself with as few as 15 patients,” Benjamin said. “After that it can be a significant vehicle for additional revenue and profit.” If you’re working on a limited budget, charging patients for packaging their prescriptions could mitigate some of the costs—and add perceived value. “It really is contingent upon the population that’s being served and not so much the reimbursement structure, but what the pharmacy is comfortable with charging or not,” Benjamin said. “I’ve had pharmacies that charge nothing because maybe they’re serving a

population that can’t afford even a nominal fee. I’ve had pharmacies charge anywhere from $5 to $35 a month for this service, or for the packaging or delivery fees. It really depends on the pharmacy, the population and what the acceptability of the charge would be for this type of enhanced service.” PACKAGING CAN IMPROVE ADHERENCE In today’s environment, where more of your reimbursement will be tied to performance measures such as adherence, it’s important to find ways to boost your patients’ adherence rates. Compliance packaging and medication synchronization not only offer convenience for pharmacists, they can also improve patients’ adherence. Adherence leads to better patient outcomes and lower health care costs, as demonstrated in a February 2011 study published in the The American Journal of Geriatric Pharmacotherapy, where nursing home admissions were reduced by 66 percent and hospitalizations and ER visits also saw significant reductions when utilizing the Medicine-On-Time program. “Medicine-On-Time is committed to improving patient quality of life through safe, accurate solutions to medication management,” Benjamin said.

By the Numbers Simplifying patients’ complex medication regimens doesn’t need to be difficult. And Medicine-On-Time, an industry pioneer in medication packaging systems, has the record to prove it. 250+ million – Prescriptions filled 33 – Years in the industry 400 – Pharmacies using Medicine-On-Time 96 – Average compliance rate percentage

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NOTES

Customized Bags Tailor your pharmacy’s prescription bags to bring in more business It’s not just what’s in the prescription bag that matters. How it looks matters, too. If you’re handing a generic prescription bag to patients, what does that say about your business? Custom prescription bags are a supplementary way to enhance your brand, increase your bottom line and market your other pharmacy services,” said Derek Jensen, vice president of sales at Rx Systems, a full-service provider of pharmacy packaging and supplies. “Promoting the pharmacy name and logo can attract new customers, plus it can help drive customers to the pharmacy’s website, which not only allows for easy refills, but also provides in-depth information regarding alternative services they may offer,” he said. GENERIC BAGS VERSUS CUSTOM Many pharmacies purchase generic prescription bags in bulk simply out of convenience. But just changing what’s on the front of your bag—to showcase your pharmacy—can make your business stand out to patients. Custom prescription bags offer multiple benefits for pharmacies. They promote your pharmacy’s name and brand, drive patients to your website and help attract new referrals due to an emphasis of the business’s logo, Jensen said. “Bags can also provide more information about other services the pharmacy offers, including vaccinations, durable medical equipment (DME), compounding, overthe-counter (OTC) products and medication therapy management (MTM),” he said.

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The Bag for You Rx Systems, a full-service provider of pharmacy packaging and supplies, offers a feature on its website (rxsystems.com) that lets you generate a custom prescription bag proof and submit it for a quote. Just insert the following information to find out how much your custom design will cost: • Pharmacy logo • Pharmacy name • Location • Phone and fax numbers • Website

MUST-HAVE FEATURES For a customized prescription bag to work to a pharmacy’s advantage, it needs to include several fundamental features. Jensen said the pharmacy’s logo, phone number and website should always go on a custom prescription bag. But don’t clutter the front of the bag with too much extra information, Jensen advises. Use the back of the bag to list alternate services. “This maximizes the real estate on the bag while getting a clear message to the customer,” he said. ADDITIONAL COSTS Independent community pharmacies run on tight budgets. But customizing your prescription bag doesn’t add significant costs compared to using a generic version, Jensen said. “The average pharmacy uses 25,000 bags per year,” he said. “Over a 12-month timeframe, they will only spend an extra $10 per month to upgrade from a generic stock bag to a custom format.” Streamlining your bag sizes can also help decrease costs. Many pharmacies use five to six different bag sizes when they only need three to four, Jensen said. “Most pharmacies can use one size bag (5”x 2”x10”) for 80 percent of their business,” he said. “We recommend customizing just one to two sizes to start, and using stock for the lower volume sizes.”

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