Pharmacy Outreach to Underserved Areas-

Medication Assistance Program Development

Bruce Hancock, MS RPh

Carriann Richey-Smith, Pharm D

Background: Role of Pharmacists

• Pharmacists are sometimes considered the most accessible health care provider; however, federal designations of medically underserved areas do not consider the role of pharmacists.

• Previously documented research suggest that recruitment and retention of students to medically underserved communities is reflective on tuition reimbursement (such as in medicine), geographic and community characteristics as well as experiential learning.

• A 1994 study, by Scammon DL et al, suggests that physicians practicing in rural underserved areas were primarily motivated by personal values to make a difference and work in a challenging, stimulating and personally rewarding position.

This sessions objectives

• Determine methods to identify key areas to focus pharmacy involvement through outreach programs in designated areas throughout the State.

• Identify key strategies for involvement of students in selected sites based on needs noted by health care providers at the site.

• Implement medication access programs that will benefit the site and collect data to document interventions and outcomes.

WHY PHARMACY?

Background: Prescription Costs

• Prescription drug costs are an ever increasing financial burden for many patients

– According to the Congressional Budget Office, in

2010 over 50 million people in the U.S. were reported to be without health insurance

• Even more patients are without prescription coverage causing a significant limitation to accessing treatment

Background: Prescription Behavior • April 2008 survey from

the Kaiser Family Foundation

• Among those who reported these actions, many said their medical conditions worsened as a result Economic problems facing families. Kaiser Public Opinion Survey Brief. Kaiser Family Foundation, 2008. Available at http://www.kff.org/kaiserpolls/upload/7773.pdf.

Initial Experience/Research

• Past Participation in RUAH Grant

• Experience with faculty and students at underserved sites

• Early exposure of students to patients in need

• Limitations were providing a constant presence

• Relationship with IRHA initiatives

Initial Research

Student Researchers supported faculty in the following projects

• Survey of how community health centers meet the medication needs of their patients

• Survey of pharmacy students perceptions of medically underserved areas

• Survey of pharmacists perceptions of community health in HPSAs

• Survey of patients as select pharmacies regarding the role of their pharmacist

Initial Research

• Survey of Purdue and Butler Pharmacy Students530 students completed survey Butler: 256 (37.5% of eligible Butler students); Purdue: 274 (23.1% of eligible Purdue students)

Are you interested in serving as a resource for community health as a future pharmacist?

• Yes: 426 (80.4%) No: 9 (1.7%) Not sure: 95 (17.9%)

Underserved collaborations

• As part of the College’s strategic plan, key areas of the State were identified to focus our involvement with potential collaborators who were providing services to the underserved.

• Utilized maps of full county HPSAs and results from surveys of patients and pharmacists in that area

Establishing the partnerships

• Local meetings with– County Health Department– Pharmacist (s)– Other community leaders

• Review of staffing and ability of facility to support the needs of students

• Pharmacist interested in being a preceptor and promoting the public health role of pharmacy

• Locate fully furnished safe housing

Promoting the public health role of pharmacy• Pharmacists serve the whole patient not

just their medication needs

• Pharmacists help with lifestyle and behavior health considerations especially in areas with a shortage of other health care providers

• Pharmacists address concerns of patients regarding ability to pay

Role at sites

• Once sites were identified with worked with each site to decide on what key activities we would have Pharm.D. students assist with while doing rotations at the sites.

• A wide variety of key activities were identified through these discussions, with each site having unique, but at the same time, common needs.

• A consistent need was to review medication assistance program options and assist with the implementation of a selected program at the site.

WHY MANUFACTURE ASSISTANCE PROGRAMS?

Background: Assistance Programs• Manufacturer assistance programs

(MAPs) have evolved to provide medications to low income patients at little or no cost

• Many community health centers utilize MAPs

Need for the Study • Participation in MAPs has demonstrated

numerous benefits

– Improved access to needed medications– Improved health outcomes – Increased patient compliance– Decreased out-of-pocket expenses– Decreased ER visits and hospitalizations

Chauncey D, Mullins CD, Tran BV, et al. Medication access through patient assistance programs. Am J Health Syst Pharm 2006;63(13):1254-9.

Harmon GH, Lefante J, Roy W, et al. Outpatient medication assistance program in a rural setting. Am J Health-Syst Pharm. 2004; 61:603-7.

Trompeter JM, Havrda DE. Impact of Obtaining Medictions from Pharmaceutical Company Assistance Programs on Therapeutic Goals. Ann Pharmacother. 2009; 43:469-77.

Schoen MD, DiDomenico RJ, Connor S, et al. Impact of the cost of prescription drugs on clinical outcomes in indigent patients with heart disease. Pharmacotherapy. 2001; 21(12):1455–1463.

Need for the Study

• Lack of published literature demonstrating the tools and processes needed to implement a MAP enrollment service

Study Objectives

• The primary objective is development of a service for enrolling and maintaining eligible patients in MAPs at an underserved clinic

• A secondary objective is to quantify cost savings as it relates to the implemented MAPs

Methods – Data Source• Patients’ medical charts• RxAssist Plus© software program

• Feedback collected from clinic staff, pharmacy staff– Monthly feedback was elicited through

meetings or e-mail communication– Evaluation of MAP procedure steps– Positive/Negative experiences– Additions/Deletions to the MAP Guide

Methods – Inclusion Criteria• Patients with one of the following

diagnosis requiring treatment with a brand name medication – Type 2 Diabetes Mellitus, Asthma, Chronic

Obstructive Pulmonary Disease, Mental Health diagnosis

• Patients prescribed up to four brand name medications

• Patients who can not afford brand name medications without MAPs

Methods – Exclusion Criteria• Patients with active prescription drug

insurance

• Unable to meet financial requirements of a MAP

• Five or more medications requiring MAPs (alternative process available for these patients)

Intervention RxAssist Plus©

• Software program was purchased to help manage MAP applications at the clinic – Create patient records– Retrieve information on hundreds of

manufacturer programs– Print out completed MAP applications– Track participation, refills, and cost savings

Tools/Processes Developed

Patient Assistance Questionnaire

MAP Guide

Process to manage arrival, documentation, and dispensing of MAP medications

Tools

Patient Assistance Questionnaire

• Patient demographics

-Age, gender, race• Employment status • Household income• Medical/prescription insurance

Tools MAP Guide

• Developed for the most commonly prescribed medications on the clinics’ formulary

• Manufacturer contact information • Medications available for assistance • Patient eligibility information

– Financial requirements

• Physician licenses and signatures required• Quantity of medication dispensed • Refill and renewal information

Results Stepwise approach to identify patients 1.Does the patient meet inclusion criteria/not

meet exclusion criteria2.Prescriber indicated brand name

medication was therapeutically necessary3.Pharmacy staff would determine if there

were available MAPs utilizing RxAssist Plus© or the MAP Guide

Results

• Samples provided to patients if available while they wait on medications to arrive

• Drug inventory, record keeping and distribution was also managed by pharmacy staff

• Appropriate package labels, medication guides via Micromedex®, and counseling was also provided to patients

Results

• After six months of feedback, an RxAssist User Manual was created

• The manual was used to orientate new pharmacists, pharmacy students, and clinic staff to MAPs

• Listed detailed steps on how to enroll and maintain eligible patients in MAPs

Results

• Contents of RxAssist User Manual:– Selecting and enrolling patients in the MAP

service – Clinic’s procedure for submitting and tracking

MAP applications– Record-keeping and inventory requirements – How to utilize and run RxAssist Plus© reports

Results

Need to update with results across all states.

Limitations

• Consistency of staff to dedicate their time to the MAP process

• Inability to require volunteers to attend education/training on the new process

• Different prescribing practices• Software limitations especially with regard to

refills• Ability to maintain long-term pharmacy

connection

Conclusion

• Prescription drug costs are an ever increasing financial burden for many patients.

• Patient assistance programs can offset these rising drug costs by providing prescription medications to uninsured and underinsured patients.

• Enrolling and maintaining eligible patients in MAP can be a complex and overwhelming.

Future actions and areas of research • Creation of further educational training

sessions/materials for providers of clinic on manufacture assistance programs

• Effect of MAP enrollment on increased compliance of patients to medication therapy

• Effect of MAP enrollment status on improved therapeutic outcomes

Acknowledgements

The following students assisted in variety of research projects leading up to these initiatives

Kelli Salmon Betsy Ummel

Erin McCann Megan Schwegal

Tiffany Hall Nikki Javit

Courtney Seal Jessica Lamb

Josh Lorenz Janna Fett

Questions