Pharmacy schools are focused on providing accessible healthcare to underserved populations.
By Jane E. Rooney
How do most Americans receive healthcare? The answer used to be fairly straightforward: people would see a physician for checkups, go to the pharmacy for prescriptions and visit the hospital only in the event of an emergency or major procedure such as surgery. But increasingly, access to care across the United States is taking a different direction, with shifts in providers’ responsibilities and their roles in caring for patients not as clearly delineated as they once were. Particularly for patients in underserved communities—rural or urban areas, for instance—the pharmacist is often the most accessible provider.
A 2019 poll by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health found that one out of every four people living in rural areas said they couldn't get the healthcare they needed. As of December 2018, there were more than 7,000 areas in the U.S. with health professional shortages, nearly 60 percent of which were in rural areas. Since 2010, 113 rural hospitals across the country have closed. An article that appeared last year in The Conversation noted, “Each time a rural hospital closes, there are tragic consequences for the local community and surrounding counties. While the medical consequences are the most obvious, there is also loss of sales tax revenue, reduction in supporting businesses such as pharmacies and clinics. There are also fewer professionals, including doctors, nurses and pharmacists, and fewer students in local schools.”
Disparities in access often prevent patients in underserved communities from receiving needed care. “Pharmacies are less accessible and there are fewer in low-income and minority neighborhoods. Closures are more common in underserved urban areas,” noted Dr. Dima Qato, associate professor, Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago (UIC) College of Pharmacy, and current National Academy of Medicine Pharmacy Fellow. “In Chicago, you see that the number of pharmacies is growing but there are fewer available in low-income, predominately minority neighborhoods. Rural closures are also a challenge but many rural states have some policy in place to incentivize pharmacies to stay open. Those incentives don’t exist in urban areas. If we’re trying to address health disparities, we really have to think about pharmacy access in minority neighborhoods in large cities.”
Qato emphasized that conversations around improving access to care need to acknowledge that while pharmacists are accessible, we need to be doing more. “Even when the pharmacy is available it doesn’t mean the pharmacist is free,” she said. “We can’t just say most people live within a mile of a pharmacy—if the pharmacist isn’t available to help the patient and answer questions, they’re really not available. We have to think beyond pharmacy availability to pharmacist availability and awareness of what policies are in place in the state in terms of what pharmacists can and cannot do.”
Pharmacy schools are preparing future pharmacists to reach out to underserved communities with innovative programs focused on providing care in rural and urban areas to ensure that all populations have access to quality healthcare.
The goal is to develop a group of future healthcare professionals dedicated to caring for urban, underserved populations and who are committed to interprofessional teamwork and the value of each profession. Our curriculum also places strong emphasis on public health and primary care as a career pathway.
Dr. Devra Dang
Reaching Out to Rural Areas
In Perry County, Alabama, a predominately African-American community, the household income is roughly half the national average and rates of cardiovascular disease are alarmingly high. This spurred a former dean of the Samford University McWhorter School of Pharmacy to partner with Sowing Seeds of Hope, a nonprofit organization, to launch the Perry County Outreach program in 2006. “We work with patients on disease state management and helping them reduce the risk of heart attack or stroke, and the care we provide is absolutely free,” said Dr. Pilar Murphy, associate professor, Department of Pharmacy Practice, who—with help from her students—runs the Cardiovascular Risk Reduction Clinic (also known as the Hypertension Clinic). The rural clinical rotation, a five-week APPE for students in their senior year, allows them to practice ambulatory care in the hypertension clinic and in a rural health clinic.
“When patients come in the students work them up as if they were working in a doctor’s office,” Murphy explained. “They do a medication review with each patient, looking to see if they are at goal for their disease states, they weigh them, calculate their BMI, check blood pressure in each arm, talk to the patient. They review goals and where things are. If they find something they will notify the patient’s primary care physician and offer a recommendation if needed. We recently had a patient with uncontrolled blood pressure who also has diabetes. So the students are looking at guidelines and what they can do to help intervene and get the patient to goal. Or there may be a drug reaction the provider doesn’t know about and the student will recommend monitoring that.”
In the rural health clinic, a nurse debriefs students before they participate in the patient interview, talk with the provider about a care plan and counsel the patient about how to get the best benefit from their medication. “The students are on an interprofessional team when they are working at the rural health clinics,” Murphy noted.
She said a key element in student pharmacists’ training is learning to meet patients where they are. During the rotation orientation, “on the first day we go through the patient care process and also talk about health literacy to make sure they aren’t using language people can’t understand. We have some patients who are living on $785 a month. For most students that’s unfathomable. We talk about why people don’t make the choices we want them to make, and a lot of times that has to do with finances. [They practice talking to] a patient and interview me to realize the words they use, the questions they ask, and I help them learn how to reword and rephrase and make a measureable plan with the patient.”
With area hospitals closing, Murphy said patients in the community are definitely turning to pharmacists more often for care. “Affordable access is so hard. People are having to rely on pharmacists a lot more, not even just in rural areas,” she acknowledged. “Some of our patients don’t even think of the students as pharmacists, they think of them as doctors. It helps patients to see the breadth of knowledge our students have. Our students really get to help people and this work shows everything that a pharmacist can do.”
At the Appalachian College of Pharmacy, the Pharmacists in Community Service (PICS) program has been woven into the curriculum since 2005. It reflects the institution’s mission to give back to the community and instill in students the importance of volunteerism. PICS is a mandatory part of the Doctor of Pharmacy program and requires that all students complete 150 hours of community service over three years. “Opportunities to interact with patients are pretty numerous and diverse,” said Sharon Deel, coordinator of community outreach. “Students do blood pressure checks, blood glucose screening, we have a smoking cessation group…but they also have general volunteer hours. They may help coach a little league sport or work with after-school programs.”
Interactions with patients in the rural community “help students become more confident with their communication skills and knowledge base and increase their awareness of the challenges we face in a medically underserved area. It also teaches them how to educate patients about their diseases and associated therapy,” Deel said. With limited resources in the area, especially specialized medical services, “pharmacists play a vital role in providing MTM and screenings, so many patients seek their help with understanding their treatment program. This is especially true with hypertension and diabetes. We continue to educate the community on the role of chronic disease and the role the pharmacist can play in improving patient outcomes,” she added.
“Pharmacists are our nation’s most trusted healthcare professional and one of the most accessible providers here,” she continued. “They have trained in diverse patient care settings. They have a lot to offer patients trying to navigate these facets of our healthcare systems.” With local patients facing barriers such as low health literacy or financial and transportation limitations, Deel said the curriculum emphasizes communication skills. “We make sure students have an understanding of how to talk to patients about their disease in a way that’s easy for the patient to understand.”
Through reflective essays that students write upon completing PICS, Deel said it’s clear that they believe the program makes a positive impact in helping them understand the challenges that rural patients face. “Students enjoy working with patients one on one and it really increases their comfort level as well. Many students go back to their communities once they graduate to do wellness screenings or educate patients,” she noted. This desire to help underserved communities is what Dean Susan Mayhew said the college strives to emphasize: “If we create habits of volunteerism throughout their professional development, then hopefully it will become second nature to them once they become licensed pharmacists. Since we attract students from all over the United States and beyond, the impact of this unique program is felt locally, regionally and nationally.”
Combating Health Disparities in Cities
The University of Connecticut School of Pharmacy identified the need for an Urban Service Track (UST) in 2004. Knowing they wanted the program to be interprofessional, the founding faculty representing the pharmacy, medical, nursing and dental schools worked together to plan the curriculum that began with its first cohort of students in fall 2007. The curriculum has since expanded to include the UConn School of Social Work and the Quinnipiac University’s physician assistant program.
“As clinicians working in urban primary care clinics in Hartford, we were acutely aware of the many medical and psychosocial challenges that our patients face each year,” said Dr. Devra Dang, associate clinical professor at the School of Pharmacy and faculty advisor for students in the Urban Service Track curriculum. “Connecticut is typically described as a state of the ‘haves and have nots.’ We are consistently ranked in the top three richest states per capita in the U.S. and one of the healthiest by many measures. But if you look closer, our urban cities also have some of the highest rates of health disparities in the country. The capital, Hartford, is one of the poorest cities of its size and has one of the highest rates of pediatric asthma in the country, for example. The need to train future healthcare professionals who can provide comprehensive, compassionate medical and psychosocial care using a team approach, instead of the traditional silos structure at that time, was very clear to the founding faculty.”
Each year, UST Scholars and faculty run more than 60 community outreach events reaching several thousand of the state’s neediest citizens. “The activities are quite varied but center around health education on a large number of topics: basic health screenings, career awareness initiatives to children and teens from underserved populations and direct patient care experiences in their APPE year,” Dang noted. “All experiences are interprofessional. In recent years I have even reached out to professions outside of UST, for example the Audiology and Physical Therapy programs at UConn, and included them in some of our outreach activities. This broadens the students’ interprofessional exposure as well as helps us provide even better services in our outreach efforts.”
The curriculum includes learning retreats that focus on different vulnerable populations and the health and psychosocial needs of those groups. “The learning retreats include interactions with faculty, community clinicians and staff from social services organizations who are experts in working with that population, and also actual community members/patients from that population when available,” Dang explained. “In between learning retreats, students implement what they learn by running health-related community outreach programs for urban and underserved populations throughout Connecticut.” A newer outreach project called the Going Beyond Initiative brings health education and screening topics, in the form of health fairs, to populations that UST has not reached previously through regular channels of community outreach activities such as immigrant and refugee populations. “Working with these groups not only brings much needed health education to these populations but also definitely challenges the students’ communication and cultural sensitivity abilities, which is a good thing,” she said.
Affordable access is so hard. People are having to rely on pharmacists a lot more, not even just in rural areas. Some of our patients don’t even think of the students as pharmacists, they think of them as doctors. It helps patients to see the breadth of knowledge our students have.
Dr. Pilar Murphy
Dang hopes the UST curriculum helps students from all professions understand the contribution of pharmacists in the primary care setting. “The goal is to develop a group of future healthcare professionals dedicated to caring for urban, underserved populations and who are committed to interprofessional teamwork and the value of each profession. Our curriculum also places strong emphasis on public health and primary care as a career pathway.” Feedback indicates that the program is meeting these goals.
“I’ve had so many faculty and preceptors tell me over the years that they could always tell when they have an Urban Service Track Scholar on rotation because that student immediately knows how to interact with the team and with patients from underserved backgrounds even on the first day of the first APPE of the academic year,” she noted. “The students are comfortable being an assertive and active member of the team and are not afraid to take on ‘tough’ patients. This feedback comes not just from pharmacy preceptors but from those from medicine and the other professions as well.”
Ensuring that underserved populations have access to care from an interprofessional team is crucial. “We know that the complexity of healthcare means that it needs to be a team sport and that pharmacists are the medication experts on the team,” Dang pointed out. “Pharmacists are especially needed when working with underserved patient populations as they tend to have more medications and medical conditions, have greater health needs in general but are challenged by psychosocial barriers, and are more vulnerable to medication safety and efficacy concerns.”
Easier Access Across the Spectrum
UIC’s Qato said improving healthcare access begins with preparing student pharmacists to work with underserved populations. “Education needs to include training around barriers that affect medication use, whether it’s access or safety or MTM issues that are outside the clinical setting. It’s also thinking about what does a patient experience before they come to the pharmacy?” she said. “What can you do about adherence? What can we do within the health system to address impaired access to medication to patients affected by closures? It requires a discussion among multiple stakeholders. What are large retailers doing when a pharmacy closes? There should be more effort around outreach and awareness. We need to think creatively about these target populations.”
Qato does see telehealth/telepharmacy as one potential solution to addressing barriers that some populations face. “It could be pharmacy technicians and pharmacists working with technology to counsel patients in their homes,” she noted. “For those solutions to work, we need to consider the preferences of the local population, so it’s not a blanket solution. If you are trying to address access with a patient who is homebound, telepharmacy may or may not be helpful.” Appalachian College of Pharmacy’s Deel said they are considering telehealth options for uninsured patients. In addition, “access to mental healthcare is a huge challenge in this area and hopefully one we can explore and bring to table for the future with telehealth,” Deel said.
Pharmacists play a vital role in providing MTM and screenings, so many patients seek their help with understanding their treatment program. This is especially true with hypertension and diabetes. We continue to educate the community on the role of chronic disease and the role the pharmacist can play in improving patient outcomes.
“Pharmacies matter and have the potential to improve access but a lot needs to be done,” Qato said. “We need more integration within pharmacies and communities and patients they serve. It’s so fragmented. We’re good at developing policies but not always good at implementing them. There is no mandate in terms of pharmacy services or pharmacy care. We’re not always thinking at the systems level and I think we need to if we really want to have an impact.”
Pharmacy schools that underscore health disparities in urban and rural settings are on the right track, she said. “We need to be thinking about social determinants of health in our curriculum, and not just through one lecture. It’s important to engage student pharmacists in the process of care outside the clinic. We could use more public service projects that get students exposed to how people live and how that could affect their access and use of care.”
For Murphy, the Perry County APPE and work of student organizations imparts something that will be invaluable to future pharmacists in any healthcare setting: empathy. “It amazes me how much students change over those five weeks of really being able to put themselves in a person’s shoes,” she pointed out. “They are seeing how something like transportation can be a major issue. I hope when students leave that they carry that mindset forward. Will you still make time to say, ‘there may be a good coupon out there that can help you’ or similar types of questions.”
She said that in students’ written reflections on service-based learning at the end of the rotation, one sentiment continues to pop up. “They say, ‘it made me see what it looks like to be a really good pharmacist,’” Murphy noted. “I hope it helps them see there’s always opportunity for them to give back. Students continue to say that this rotation is one of the biggest learning experiences they have had because they are getting so much hands-on time with patients.”
Jane E. Rooney is managing editor of Academic Pharmacy Now.