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8/21/2003

Pharmacists' Involvement With Vaccinations Leads to Preventive Health Care Role

Krysten A. Modrzejewski

Pharmacists in health systems involved with immunizations have used their practice settings to become advocates for immunization and increase their responsibilities in the public health realm.

Administering vaccines to patients and health care workers is enabling some health-system pharmacists to assume a prominent role in public health. Pharmacists have noticed that immunization needs were not being met and, through their advocacy, increased the numbers of patients and employees of health systems who have been vaccinated.

Colleagues first. Mike Grunske, clinical pharmacist with Aurora Health Care in Milwaukee, Wisconsin, started an immunization administration program as part of a collaborative practice protocol he developed five years ago as a pharmacy residency project.

"Initially, it started out very slow," he said. "In fact, the first year I concentrated mainly on just vaccinating employees." Aurora Health Care tries to vaccinate as many appropriate employees during the influenza season as possible, but often it is difficult to vaccinate everyone, Grunske said. He thought that having another person available to administer vaccines would make it easier for pharmacy employees to be vaccinated. His clinic is mobile, consisting of a tote that has everything necessary to administer the vaccine. "We go to our managers' meetings and get our management staff right there," Grunske said, noting that this approach has been successful.

The purpose of the pharmacist-run immunization clinic was not to take over the existing systems, he said, but to provide another resource for influenza vaccine. Although the original focus of Grunske's immunization clinic was pharmacy employees, the program has evolved to incorporate both patients and pharmacy staff. He also added the pneumococcal vaccine to the clinic a few years ago. He hopes to expand his clinic to include immunization against tetanus, hepatitis A, and hepatitis B.

Outpatients with chronic diseases. While Grunske intended for his clinic to primarily service pharmacy employees, Michele Faulkner, a clinical pharmacy specialist who works in a pharmacist-run diabetes management clinic at Creighton University Medical Center in Omaha, Nebraska, saw a new opportunity to help her patients.

"I was finding that a good number of our diabetic patients, even those who had been diabetic for many, many years, were deficient in immunizations or weren't sure whether or not they had ever had them," she said. She entered into a collaborative practice protocol with the head physician of the internal medicine clinic and now gives influenza and pneumococcal vaccinations as part of her weekly diabetes management clinic.

Since she started her collaborative practice, she said the physicians' perception of her as a pharmacist has changed. "They recognize me now as a resource for immunization information", she stated, "whereas before I don't think that would have been the case."

Quality assurance collaboration. Another health-system pharmacist saw an opportunity to increase her institution's vaccination rate. Jill Robke, a clinical specialist working in the pulmonary unit at St. Luke's Hospital in Kansas City, Missouri, has been part of a collaborative practice agreement with the head of her hospital's quality assurance department. One of the reasons the director wanted a protocol in place was to increase the pneumococcal and influenza vaccination rates for eligible patients and show the data to the Joint Commission on Accreditation of Healthcare Organizations and the Centers for Medicare & Medicaid Services (CMS).

The protocol held the pharmacists responsible for screening the patients and writing the orders for the vaccines. Members of the medical staff who did not want to participate in the protocol could decline, but very few did. Robke said that St. Luke's was able to increase its vaccination rate for patients with community-acquired pneumonia to about 90%, which is the recommendation of Healthy People 2010, a national health promotion and disease prevention initiative.

"This is one of our first steps in providing direct patient care through collaborative practice agreements," Robke said. The collaborative practice has generated a good working arrangement, she said, and is seen as a positive step for more collaborative practices in the future and direct patient care. She feels it is rewarding when patients realize pharmacists are involved in the care of their patients.

Advocacy. Although some pharmacists do not want to administer vaccines or are not allowed to do so by state law, there are other ways to increase vaccination rates. Melissa Blair, a clinical pharmacist who has been involved with vaccination programs at the Medical University of South Carolina in Charleston, said that being an advocate is just as important as giving the actual vaccine. "It doesn't mean that every pharmacist has to be an immunizer," she said. Even if you are telling patients what kind of vaccinations they need to get and why, "that role is almost as important as actually being able to provide those immunizations," Blair said.

Educational issues. An important factor to consider in predicting how these immunization practices will affect the future role of pharmacists and pharmacy in preventive health care is the curricula at pharmacy schools. The curriculum at Creighton University incorporates the American Pharmacists Association immunization program as an elective, which many students take. Michele Faulkner, one of the instructors of the course, hopes that the course will promote the awareness of the pharmacist in a preventive health role.

Legislative and economic issues. Legislative and economic concerns can be barriers for pharmacists who want to be involved with vaccine administration and advocacy. All of the pharmacists interviewed for this article used standing orders as the means to accomplish their vaccination goals. Currently, 39 states allow pharmacists to implement collaborative practices using standing orders, according to the ASHP government affairs division. The National Association of Chain Drug Stores reviewed state laws that regulate pharmacy practice and found laws specifically addressing immunizations and vaccinations in 19 states; in seven states, laws allow immunization administration "per protocol." According to an American Pharmacists Association survey of state pharmacy association executives, 36 states have pharmacists that actively administer immunizations.1

CMS issued a final rule encouraging the use of standing orders to facilitate influenza and pneumococcal vaccine administration.2 This rule authorizes licensed practitioners to vaccinate patients after appropriate assessment; however, this authorization is dependent on laws governing state pharmacy practice. Blair believes that, in order for pharmacy to progress with immunization advocacy and administration, legislation needs to support collaborative drug therapy and other arrangements to increase pharmacist participation.

Reimbursement is another concern. Blair indicated reimbursement is a factor to consider when a pharmacist tries to start or sustain an immunization program. It can be difficult to justify immunization services if reimbursement barely covers the cost of the vaccine.

According to the most recent ASHP survey on ambulatory care responsibilities, the percentage of organizations in which pharmacists routinely perform immunization screening decreased from 24% in 1999 to 19% in 2001. Administering vaccines as part of pharmacy practice also decreased from 11% in 1999 to 8% in 2001.3 Although no explanation was given to explain this decrease, reimbursement issues could have been a factor.

1. American Pharmacists Association. States where pharmacists have the authority to immunize patients. www.aphanet.org/pharmcare/immunofact.html (accessed 2003 Jul 31).

2. Centers for Medicare and Medicaid Services. Medicare and Medicaid programs; conditions of participation: immunization standards for hospitals, long-term care facilities, and home health agencies. Fed Regist. 2002; 67:61808-14.

3. Knapp KK, Blalock SJ, Black BL. ASHP survey of ambulatory care responsibilities of pharmacists in managed care and integrated health systems—2001. Am J Health-Syst Pharm. 2001; 58:2151-66.