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Pharmacy Services in Community and Migrant Health Centers Studied

Nancy Tarleton Landis

A study of the scope of pharmaceutical services in community and migrant health centers—an integral part of the nation’s health safety net—has identified opportunities for greater pharmacist involvement in primary care.

Marvin D. Shepherd and colleagues at the University of Texas (UT) College of Pharmacy surveyed 1260 centers nationwide in 2000 (out of a total of 2500 centers) and released their findings (PDF) in January. The Bureau of Primary Health Care, Health Resources and Services Administration (HRSA), part of the federal Department of Health and Human Services, initiated the study to gain a better understanding of traditional services (dispensing medications, counseling patients, and managing the pharmacy) and clinical services offered through the centers.

The UT group was awarded a contract for the study in an application process conducted by the American Association of Colleges of Pharmacy. The study objectives included determining the extent of relationships between schools of pharmacy and the centers.

Shepherd said some of the centers have inhouse pharmacies, while others do no dispensing but are staffed by pharmacists who help with the patients’ drug problems. Another reason the bureau had difficulty quantifying its pharmacists’ activities is that a center may have satellite facilities that are open a few days each week and the pharmacists may move among the main center and the satellites.

The mail surveys were addressed to center directors, who were asked to give them to pharmacy personnel if the center had them. One hundred thirty-eight responses from pharmacists and 420 from medical or executive directors were received. About 40% of the respondents said their centers had an onsite pharmacy, and 28% had an onsite pharmacist. Follow-up telephone interviews with 15 providers of traditional pharmacy services and 5 providers of comprehensive pharmaceutical care services were conducted; the latter group was asked about overcoming barriers to such services.

The respondents were asked how often they provided various clinical services, the importance of each service, and their preparedness to provide the service. "Half of the time" to "often," respondents provided medications and counseled patients; collected, organized, and evaluated information; or referred patients to other health care professionals and services. "Sometimes" to "half of the time," respondents formulated a course of action; promoted public health; or monitored and managed patient outcomes. Providing traditional services and collecting, organizing, and evaluating information were more likely than the other services to be considered "very important" by the respondents. Respondents felt least prepared to formulate a course of action, promote public health, and monitor and manage patient outcomes.

"They’re all providing good quality traditional services and some of the more advanced services," Shepherd said. "Overall, I think they’re doing better than average" compared with community pharmacies, he said, but the health centers’ pharmacies have some problems not faced by most community pharmacies—most important being "the nationalities and the language barrier."

The researchers offered recommendations for improving services in the centers (box), as well as recommendations for collaboration between the centers and schools of pharmacy.

Recommendations for Delivering Pharmaceutical Care Services in Community and Migrant Health Centers

Provide pharmacists training to improve communication skills, such as skills in interviewing patients to collect medical and drug-related information, use of open-ended questions in patient counseling, and counseling on the use of self-monitoring devices

Provide pharmacists training in the provision of pharmaceutical care in the following areas: developing strategies for resolving drug-related problems, evaluating patient expectations for drug therapy, documenting medical and drug-related outcomes, establishing follow-up plans, and monitoring patient outcomes

Provide centers with funding to deliver a higher level of pharmaceutical care: Renovate pharmacies to create more space to operate and to provide private counseling, provide pharmacists better computer systems and better computer-system training to improve documentation of medical and drug-related information, and recruit and retain pharmacists and technicians, focusing recruitment efforts on staff who are bilingual and multilingual

Encourage interdisciplinary teamwork regarding patient care activities

Pharmacists with education and training beyond the bachelor’s degree, including disease-specific training, provide more advanced services, Shepherd said. Also, centers closely associated with pharmacy schools "deliver a higher standard of services."

The respondents indicated that about 15% of their patients do not get needed prescriptions filled because of access issues and about 20% do not receive comprehensive pharmacy services that result in optimal outcomes.

About 64% of the respondents described themselves as white. The findings showed that nonwhite respondents felt significantly more prepared to provide medications and counsel patients than white respondents. Nonwhite respondents attached greater importance than white respondents to promoting public health and were more likely to feel prepared to provide that service. "Perhaps the ethnic background of nonwhite pharmacists helped them feel more competent to counsel patients, many of whom were ethnic minority," the authors wrote.

Jimmy Mitchell, director of the Office of Pharmacy Affairs of the Bureau of Primary Health Care, said the differences in responses by race are important. "Minority pharmacists felt much more confident that they had the competencies to communicate educational services to their patients," he said, which points to the need to "raise the cultural competencies within pharmacy practice."

Mitchell said the recommendations of the UT researchers tie in well with the current mission of the bureau: to achieve 100% access to quality health care for underserved people and zero health disparity between minority and disadvantaged patients and the population as a whole. "We’re really convinced that increasing the availability of comprehensive pharmacy services will decrease health disparities," he said.

The Bush administration’s goal, said Mitchell, is to double the capacity of community health centers over the next four years, "so we see a significant expansion in opportunities to provide an increased level of access to affordable pharmacy services." He noted that HRSA has awarded 14 clinical pharmacy demonstration grants in the past year and that additional grants are being awarded in 2001. Recipients of the clinical pharmacy demonstration grants are required to work with colleges of pharmacy. Smaller "start-up" grants are available to help sites establish pharmacy services for the first time. Mitchell noted that disproportionate-share hospitals, academic medical centers, and city and county hospitals have opportunities to collaborate with the primary care centers applying for the HRSA grants.

The bureau hopes, said Mitchell, that additional colleges of pharmacy will establish relationships with the community and migrant health centers. "We’d like to see every Pharm.D. student have a rotation in a facility that serves the underserved." This, he said, would raise the level of practice, as well as provide outstanding opportunities for education in primary care services.