Maximum Exposure
Did you know that the state of Minnesota has more shoreline than Florida, California, and Hawaii combined?1 How is this possible? In short, smaller bodies of water in larger numbers are geometrically more efficient at creating shorelines than large bodies of water; overall, they have more exposure to land. Systems need maximum exposure to the environment, which is the underlying reason that the average adult human has more than 850 square feet of surface area in their lungs to optimize gas transfer and the same reason our small intestine is so small in radius and carpeted with diverticula.2 According to mother nature, small and localized is a superior and more effective perfusion strategy than large and centralized.
What Does Community-Based Mean?
Similarly, community-based health systems are situated proximally to patient-residents, in smaller provider units spread out throughout geographic sectioning, layered with social, economic and political boundaries. Patient-residents, community organizations, and care team members are anchored with relationships and familiarity to their surroundings, much like local anglers maintain unique and often multigenerational knowledge about the fisheries of the surrounding lakes. Decision making is local and participatory, with shared efforts and outcomes.
In Minnesota, the locals collectively use and cherish each of the more than 14,000 navigable lakes and protect them, requiring variances and special permissions provided at the county level for anything that may impact those bodies of water. On any given day, there is a good probability that you run into a county commissioner at the grocery store, church, or gas station, and you are able to ask them a question and expect an honest, trusted response that contains important context native to that area. Community-based health care systems do the same, with care team members living in the same community in which they provide care, sharing school systems, values, and local customs with their patients and molding their practice(s) on locally derived objectives and norms. Because community-based health care professionals are typically woven into the fabric of their community, any health care conjecture or venue involving a community need or project commonly involves the presence of a local pharmacist and local primary care clinician alongside other community leaders—this is the essence of being community-based (Table 1).
Local Pharmacy COVID-19 Response and Community-Based Systems at Work
Community-based health care systems have been put to the test by recent strains, including the COVID-19 pandemic. Consider the most recent widespread system test thrust upon us less than 5 years ago—COVID response and mitigation. During that fateful March of 2020, when seemingly everything closed, community-based pharmacies stayed open and operational. Curbside delivery of prescriptions, immunization administrations in the parking lot and at home, pop-up point-of-care testing sites, and a host of other snap innovations were deployed within hours in response to the ever-growing pandemic. Local pharmacies could decide, based on the shared objectives and context of their respective communities, how to respond with amazing efficiency. Coordination across care team members, health departments, public officials, teachers, clergy, and, importantly, prescribers was most effective where trusted, local working relationships carried the day.
When the COVID-19 vaccine was approved and distribution ensued, both big ocean (sports arena) and small lake (community-based pharmacy) approaches were employed. In the Federal Retail Pharmacy Program, vaccines were initially distributed to pharmacies located in communities where patient-residents were less likely to access large, drive-up or drive-through vaccination and testing sites. Along with determining vaccine allotments to pharmacies, the Centers for Disease Control and Prevention (CDC) tracked which allotments were ultimately administered to which patient-residents in which zip codes. Community-based pharmacies such as those participating in the CPESN NC clinically integrated network of pharmacies are disproportionately located in zip codes with high socioeconomic vulnerability; they administered vaccines in large part (~67.9%)3 to patient-residents living in neighborhoods close to the pharmacy, whereas vaccines distributed to mass vaccination sites attracted patient-residents from many zip codes—often from afar. For the vaccine-enthusiastic, a trip 3 counties away to spend hours in a running car was sufficient. For households that were vaccine-apathetic, vaccine-hesitant, or lacked transportation, the “big ocean” approach likely failed. Community-based pharmacies were already open, trusted, and well positioned. Pharmacies proved to be the alveoli of vaccination, testing, and treatment, with more than 340 million service encounters provided during the first year and a half of COVID-19 response.3
Who are the Core Community-Based “Actors” in Every Community, and What is the Health Care “Play”?
Nearly every community in the country has a primary care clinician, a pharmacist in a community pharmacy, and emergency medical services that sit alongside schools and community-based organizations that provide education as well as religious and social support services. Primary care clinicians and community pharmacy providers share an important kinship and responsibility in being generalists, covering the waterfront at the interface of community and practice. Considered together, primary care encounters and pharmacy visits dwarf all other touchpoints with other health care providers.4,5 Additionally, both primary care clinicians and community pharmacists are required to take the long view, with empanelment often lasting for many years, decades, or generations. There is no luxury of selective scheduling for a narrow grouping of chief complaints or patient discharge after an acute episode of care. Community-based actors maintain patient-household relationships that are durable, accessible, and all-encompassing (Table 2).
A claims review for a broad sample of commercially insured adults aged 18 to 64 revealed that on average, adults go to the pharmacy 5 times per year while visiting any physician 3 times per year. However, for patients with 2 or more chronic conditions, these numbers increase to 17 pharmacy visits and 7 physician visits, with a ratio of nearly 2.5:1.5 For Medicare beneficiaries, the ratio of pharmacy visits to primary care physician visits is 13:7 overall, but larger in rural areas (14:5),6 emphasizing the importance of community pharmacy as a point of health care access, particularly in rural communities.
In a 2019 study of physician office visits, Americans made approximately 1 billion visits to clinicians, with just over 50% of them occurring in primary care. Not surprisingly, given their role as generalists, primary care clinicians prescribed, provided, or continued medications at a rate of 3.697 medications per office visit—the highest among all visit types.4 Additionally, another study conducted from 2008 to 2015 revealed that over time, primary care visits on average became several minutes longer and addressed more diagnoses, medications, and preventive services per visit.7
Changes in primary care visit length and intensity, combined with widespread primary care clinician shortages (92 out of 100 North Carolina counties are designated as primary care shortage areas),8 increases the importance of locally based pharmacists and other community-based care team members serving in roles that fulfill patient needs while simultaneously supporting the availability and efficiency of primary care delivery. Fortunately, from an access perspective, more than 90% of the US population lives within 5 miles of a community pharmacy.9
The Role of Pharmacy and Pharmacy Supports
Community pharmacies serve an important role in terms of providing products for self-care along with professional guidance and triage by the pharmacist. In situations of low accessibility and/or low affordability of health care services, having the opportunity for professionally guided self-care in each community is paramount. Community-based pharmacists can help patients navigate basic ailments like poison ivy exposure or the common cold, and they can also identify when patients require evaluation by a physician, whether emergent or not, for the treatment of chronic conditions. In terms of sheer volume of cost-effective triage services and supports, community pharmacies are indispensable to the health care system.
For patients who are loyal customers of one pharmacy, the pharmacist’s expertise can go further, helping patients select over-the-counter medications that do not conflict with their prescriptions or chronic conditions, monitoring adherence to prescription medications, providing education for self-monitoring of chronic disease, and ensuring proper preventive care in terms of vaccinations.
The average Medicare recipient fills more than 50 unique medications each year, prescribed by an average of 17 prescribers.10 The community pharmacist may be the only clinician on the health care team who is aware of all the prescriptions, over-the-counter medications, and herbals and supplements a patient is taking. This perspective allows for a unique role in care coordination, whereby the pharmacist can inform prescribers of other potentially conflicting or interacting medications the patient is taking and resolve drug-related problems before they occur. Similarly, the pharmacist can help evaluate potential side effects and help avoid a common scenario where patients take additional medications simply to combat the side effects of others.
For patients who take prescription medications, community pharmacies are a more frequent opportunity for regular follow-up than the primary care clinician, with prescription refills occurring at least 4 times annually, if not monthly for most chronic medications. Recent research has shown that chronically ill patients5 and Medicare beneficiaries6 see the pharmacist approximately 2–2.5 times more often than clinicians.
Beyond community pharmacies, federally qualified health centers (FQHCs) are great examples of accessible, community-based practices where pharmacists can serve in multiple roles, in close collaboration with clinic staff and clinicians. Established as “safety net” providers, FQHCs have often been a petri dish for community-based pharmacist-primary care clinician innovations, especially for at-risk populations. A study by Rodis and colleagues demonstrated that FQHC pharmacist involvement was able to impact disease state control, bringing around 60% of a study population of more than 1500 people with diabetes and around 80% of those with hypertension under better control than at baseline.11 Importantly, formal interviews with FQHC staff involved in the study outlined many contributing success factors that are hallmarks of community-based models, namely pharmacist access to the electronic health record, a collaborative care team with one or more medical clinicians, and referrals from clinicians for pharmacist services.11
A similar study of pharmacists at Minnesota-based FQHCs assessed the impact of pharmacists incorporating social determinants of health (SDOH) screening and referrals into an existing program for diabetes and blood pressure control.12 At baseline, patients with needs related to SDOH had worse disease state control than peers. Trends toward disease state improvement occurred when the pharmacist addressed SDOH needs.12
Other Examples and Demonstrations of Community-Based Pharmacy Support Systems
Cabarrus Family Medicine
What is old can be new again—and is more needed than ever. Cabarrus Family Medicine in Mt. Pleasant, North Carolina (Drs. Dobson, Rhodes and Tom Earnhardt, PA-C) and Moose Pharmacy (Whit Moose Sr.) provided community-based, coordinated care dating back over 40 years. The physicians relied on the pharmacist’s relationship with the patient as an early warning system for patients needing follow up, either when the patient presented in the pharmacy or when making an in-home medication delivery. When patients on multiple medications were discharged from the hospital, the pharmacist would often have figured out their new medication regimen and communicated that before their follow up appointment. If a patient was seen outside of regular hours and needed medicine, the pharmacist was available and willing to make sure the patient got their needed medications. This close relationship led to Cabarrus Family Medicine incorporating Moose Pharmacy into their Concord, North Carolina office location and establishing a formal pharmacist relationship in every future community primary care/residency office.
A Clinically Integrated Network of Community-Based Pharmacies
CPESN is a self-governed, clinically integrated network (CIN) of community-based pharmacies, each of which provides medication reconciliation, medication synchronization, adherence packaging, and hand delivery to local patient-residents often supported by a workforce member who serves a large portion of the patient population. Largely owner operated, CPESN’s ~3200 participating pharmacy locations cover 83% of the US population. CPESN’s back-office support services, contracting, and practice transformation efforts allow each pharmacy to “act big as a group but remain small and community-based” in the same manner that medical practices group together to create CINs and accountable care organizations (ACOs) with shared infrastructure.
Very few patients with multiple chronic diseases have optimized and coordinated drug regimens. Each patient with synchronization services gets a medication review prior to the patient’s pre-designated “sync date” to ask the patient about regimen changes the prior month, side effects, and outcomes of interest being achieved (or not), and resets the regimen prior to either home delivery or pickup. These scheduled care activities are documented in monthly pharmacy care plans and often shared with care team members and health plans. These services would not be possible in a centralized model, where relationships with the patient and the patient’s care team are superficial at best. CPESN estimates that more than 2 million patients are served in this fashion each month in more than 3000 pharmacies across the country, including nearly 300 in North Carolina alone.
Bringing Community-Based Pharmacy into the Medical Neighborhood
North Carolina became a pilot site for the CPESN concept in the mid-2010s, and the initial North Carolina-based community pharmacy network collaborated closely with primary care clinicians and care managers to support Medicaid beneficiaries taking multiple chronic medications. While those patients were a small proportion of the Medicaid population, the program’s development led to the illumination of a cacophony of unaddressed needs among at-risk Medicaid enrollees who lacked a “pharmacy home” that community-based pharmacies could help address, including hand delivery of medications (to the home or in some instances other locations) to address transportation barriers, or specialized packaging to improve adherence to complex medication regimens. In the model, community-based nurse and social work care managers made home visits or joined practice visits for complex patients, and as part of those sessions, screened for medication-related challenges that could be improved with community-based pharmacy services. Meanwhile, primary care clinicians collaborated with participating community-based pharmacies that were operating alongside care managers to ensure patient engagement and provided primary care clinicians with a clean medication list in advance of upcoming patient visits.
Conclusion
Community-based primary care and pharmacy clinicians have long been in a position to provide patient-centered care that is local (face-to-face), customized, collaborative, wholistic, and longitudinal, especially in rural and underserved communities. The increasing use of centralized services and the loss of community-based clinicians may lead to an even more disorganized and dysfunctional health care “system,” spurning even more suboptimal and ineffective medication use and non-use. Community-based pharmacies and primary care providers are team members who practice where their patients live, work, play, and pray; they have the context, the trust, and are in the best position to provide patient-centered care that optimizes medication use.
Acknowledgments
The authors have no interests to disclose.