Pharmacists: Pharmacists:
Access to Immunization ServicesAccess to Immunization Services
MitchelMitchel C. Rothholz, C. Rothholz, RPhRPh, MBA, MBA
American Pharmacists AssociationAmerican Pharmacists Association
Chief of StaffChief of Staff
American Pharmacists AssociationWashington, DC
Ø National professional society of pharmacists
Ø Represents the interests of pharmacists across
practice settings
Ø Improving medication use…Advancing
patient care
Ø 63,000 members and growingØ Largest and oldest organization in pharmacy
Ø Immunization Roles for Pharmacists
ØAdvocate
Ø Facilitate
Ø Immunize
Pharmacy’s Unique Pharmacy’s Unique
ContributionContribution
•• Access, proximity, extended hoursAccess, proximity, extended hours
•• Ability to narrowAbility to narrow--cast messages to elderly and cast messages to elderly and
high risk patientshigh risk patients
•• Public’s trust Public’s trust -- Gallop PollGallop Poll
•• Public’s enthusiastic acceptancePublic’s enthusiastic acceptance
Pharmacists’ Role inPharmacists’ Role in
Emergency Preparedness and ResponseEmergency Preparedness and Response
•• SurveillanceSurveillance
•• InformationInformation
•• Patient education and counselingPatient education and counseling
•• Distribution of pharmaceuticals and medical Distribution of pharmaceuticals and medical
suppliessupplies
•• Administration of vaccinesAdministration of vaccines
•• Evaluation / TriageEvaluation / Triage
•• Community planning and preparationCommunity planning and preparation
Developed by the JCPP Working Group on Emergency Preparedness & Response
APhA Focus for Adult ImmunizationAPhA Focus for Adult Immunization
•• EducateEducate the public about adult vaccinethe public about adult vaccine--preventable preventable
diseases and the value of immunizations;diseases and the value of immunizations;
•• Be Be accessibleaccessible to the public for immunization to the public for immunization
information and administration of vaccineinformation and administration of vaccine
•• Increase pharmacist Increase pharmacist knowledgeknowledge regarding adult regarding adult
immunizations, vaccine schedules and opportunities immunizations, vaccine schedules and opportunities
to improve public healthto improve public health
•• Maximize Maximize opportunitiesopportunities for pharmacists to remind or for pharmacists to remind or
encourage patients to be immunizedencourage patients to be immunized
But Immunization activities Across LifespanBut Immunization activities Across Lifespan
GUIDELINES FOR PHARMACYGUIDELINES FOR PHARMACY--BASED BASED
IMMUNIZATION ADVOCACYIMMUNIZATION ADVOCACY
•• Guideline 1 Guideline 1 -- Prevention Prevention
Pharmacists should protect their patients' health by being vacciPharmacists should protect their patients' health by being vaccine ne advocates. advocates.
•• Guideline 2 Guideline 2 -- Partnership Partnership
Pharmacists who administer immunizations do so in partnership wiPharmacists who administer immunizations do so in partnership with th their community. their community.
•• Guideline 3 Guideline 3 -- QualityQuality
Pharmacists must achieve and maintain competence to administer Pharmacists must achieve and maintain competence to administer immunizations. immunizations.
•• Guideline 4 Guideline 4 -- DocumentationDocumentation
Pharmacists should document immunizations fully and report cliniPharmacists should document immunizations fully and report clinically cally significant events appropriately. significant events appropriately.
•• Guideline 5 Guideline 5 -- EmpowermentEmpowerment
Pharmacists should educate patients about immunizations and respPharmacists should educate patients about immunizations and respect ect patients' rights. patients' rights.
Adopted by APhA, 1996
Education & TrainingEducation & Training
APhA Immunization ProgramAPhA Immunization Program
SelfSelf--Study (0.8CEU)Study (0.8CEU)
•• Primer on immunologyPrimer on immunology
•• Clinical disease reviewClinical disease review
•• Practice managementPractice management
•• Regulatory roadmapRegulatory roadmap
•• CDC resourcesCDC resources
Seminar (1.2 CEUs)Seminar (1.2 CEUs)
•• Recap of vaccines, antibodies, Recap of vaccines, antibodies,
diseases, microbesdiseases, microbes
•• ImplementationImplementation
•• Record keepingRecord keeping
•• Public health collaborationPublic health collaboration
•• Cases and practicumCases and practicum
CDC
Recognized
Also CPRP and OSHA Training
Barrier: Authority for Barrier: Authority for
Pharmacists to Administer Pharmacists to Administer
ImmunizationsImmunizations•• StatutoryStatutory
•• Regulations / Attorney General OpinionRegulations / Attorney General Opinion
•• No positionNo position
Limitations of AuthorityLimitations of Authority
•• Requirements Protocols / Standing Orders/ RxRequirements Protocols / Standing Orders/ Rx
•• AntigensAntigens
•• AgeAge
•49 states currently authorize pharmacists to administer immunizations•Over 40,000 pharmacists trained•Delivered over 2 million influenza vaccinations
Pharmacist Authority toPharmacist Authority to
Administer ImmunizationsAdminister Immunizations
0
5
10
15
20
25
30
35
40
45
50
States authorizing pharmacists
Before 1978
1979
1982
1987
1996
1999
2002
2004
2007
2008
Pharmacist Immunization AdministrationPharmacist Immunization Administration
Protocol / Standing Order Protocol / Standing Order vsvs RxRx
0
2
4
6
8
10
12
14
16
18
20
States authorizing
Protocol only
Protocol &/orStanding Order
Protocol &/orPrescription
Prescription only
Standing order orPrescription
Protocol, StandingOrder &/orPrescription
49 states, July 2008
Protocol Protocol
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
50.00%
Individual
Rx
Not
Required
Internal
Med
Family MD Corporate
MD
Health Dept
2006
2007
2008
2006 n=314 2007 n=272 2008 n=174
Health Department
Medical Directors can
play a major role…
Components of ProtocolComponents of Protocol
•• Identify individual who has delegated activityIdentify individual who has delegated activity
•• Identify pharmacist authorized to administer vaccineIdentify pharmacist authorized to administer vaccine
•• Types of vaccines pharmacist is authorized to Types of vaccines pharmacist is authorized to
administeradminister
•• Procedures, decision criteria or plan pharmacist Procedures, decision criteria or plan pharmacist
should follow, including when to refer patientshould follow, including when to refer patient
•• Procedure for emergency situationsProcedure for emergency situations
•• Record keeping and documentation proceduresRecord keeping and documentation procedures
Other Limits to Other Limits to
Pharmacist’s authorityPharmacist’s authority
•• Age RestrictionAge Restriction–– No restriction (17)No restriction (17)–– >> 18yo (22)18yo (22)–– >> 16 16 yoyo (1)(1)–– >> 14 14 yoyo (4)(4)–– Other (5)Other (5)
•• 10+ influenza,10+ influenza,>> 18 other18 other
•• >>12 influenza, No 12 influenza, No restriction for restriction for othersothers
•• > > 13yo13yo•• >> 19yo19yo•• > > 15yo influenza, 15yo influenza, >>
18 for others18 for others
•• AntigenAntigen–– Influenza only (3)Influenza only (3)–– Influenza / Influenza / PneumoPneumo (2)(2)–– Adult (1)Adult (1)–– No restrictions (33)No restrictions (33)–– Other (10)Other (10)
Authority could state: “vaccines
recommended by ACIP for targeted
patient population.”
What Immunization Services Do What Immunization Services Do
Pharmacies Provide to Patients?Pharmacies Provide to Patients?Pediatric Check All That ApplyCheck All That Apply
32.7%32.7%Refer patients to public health departmentsRefer patients to public health departments
63.9%63.9%Refer patients to physiciansRefer patients to physicians
18.0%18.0%Administer Immunizations by pharmacistsAdminister Immunizations by pharmacists
5.7%5.7%Facilitation of immunizations (host other providers)Facilitation of immunizations (host other providers)
44.2%44.2%EducationEducation
GraphGraphPercentagePercentageResultResult
Adolescent Check All ThatCheck All That ApplyApply
23.7%23.7%Refer patients to public health departmentsRefer patients to public health departments
40.9%40.9%Refer patients to physiciansRefer patients to physicians
50.8%50.8%Administer Immunizations by pharmacistsAdminister Immunizations by pharmacists
6.5%6.5%Facilitation of immunizations (host other providers)Facilitation of immunizations (host other providers)
45.0%45.0%EducationEducation
GraphGraphPercentagePercentageResultResult
2006, Responses represent 4,700 sites
What Immunization Services Do What Immunization Services Do
Pharmacies Provide to Patients?Pharmacies Provide to Patients?Adult >65 Years Old Check All That ApplyCheck All That Apply
17.2%17.2%Refer patients to public health departmentsRefer patients to public health departments
21.3%21.3%Refer patients to physiciansRefer patients to physicians
86.0%86.0%Administer Immunizations by pharmacistsAdminister Immunizations by pharmacists
18.0%18.0%Facilitation of immunizations (host other Facilitation of immunizations (host other
providers)providers)
55.7%55.7%EducationEducation
GraphGraphPercentagePercentageResultResult
2006, Responses represent 4,700 sites
Targeting Messages:Targeting Messages:Prescription VialPrescription Vial
Auxiliary LabelsAuxiliary Labels
2008v1-17
•• Need for influenza & Need for influenza & pneumococcalpneumococcal vaccines:vaccines:
–– Heart Disease Heart Disease DigoxinDigoxin, , warfarinwarfarin, nitrates, nitrates
–– Lung Disease Lung Disease TheophyllineTheophylline, , zafirlukastzafirlukast, ,
steroids, chronic inhaler use steroids, chronic inhaler use
–– Diabetes Diabetes Insulin, oral Insulin, oral hypoglycemicshypoglycemics
–– All All >> 65 65 y/oy/o Any or noneAny or none
•• Other vaccines?Other vaccines?
Comparison of Vaccination Rates When Comparison of Vaccination Rates When
Pharmacists Vaccinate the ElderlyPharmacists Vaccinate the Elderly
52
54
56
58
60
62
64
66
68
70
1995 1999
States that allow
Pharmacist
Immunizations
States that do not allow
Pharmacist Immunization
10.7%
Change
3.5%
Change
Steyer TE et al. Vaccine. 2004;22:1001-6.
Vacc
inati
on
Rate
s
Persons ≥≥65 y/o
Combined Participant Percent* Combined Participant Percent*
Flu, Foot and EyeFlu, Foot and Eye
0
10
20
30
40
50
60
70
80
90
Baseline Year 1 Year 2 Year 3
Flu Shot
Foot Exam
Eye Exam
Align the Incentives, Empower the Patient, Control the CostsSM
*As reported in the Patient Self-Management Program reports each year for 99 patients with baseline,1st , 2nd and 3rd year results
55%
70%
Access: Access:
Structure of PracticeStructure of Practice
0% 20% 40% 60% 80%
Clinic
Walk-in Limited
Walk-in Hourly
Walk-in Anytime
Appointment
2007
2006
2006 n=266 2007 n=363
DocumentationDocumentation
0.00% 20.00% 40.00% 60.00% 80.00%
Public Health
Patient's MD
Protocol MD
Pt Record Card
Rx Record Card
Copy of Consent
Maintained in Rx
2007
2006
2006 n= 261 2007 n=229
Access to
registries
limited to
pharmacists
CompensationCompensation
0.00% 20.00% 40.00% 60.00% 80.00% 100.00%
Patient
Medicare
Medicaid
Insurance
HMO
Employer
2007
2006
2006 n=257 2007 n=354
Please complete the following statement: Please complete the following statement:
"To expand influenza immunization "To expand influenza immunization
services in our practice we need..."services in our practice we need..."
–– Patient education regarding pharmacist Patient education regarding pharmacist education /training and service.education /training and service.
–– Patient education that the shot will not cause the Patient education that the shot will not cause the disease.disease.
–– A huge outbreak of the flu in our area.A huge outbreak of the flu in our area.–– Additional local physician support.Additional local physician support.–– Ability to bill for our services to insurance Ability to bill for our services to insurance
companies other than Medicare Part B.companies other than Medicare Part B.–– Staff members to understand importance of Staff members to understand importance of
getting vaccinations.getting vaccinations.–– State laws and regulations to be more State laws and regulations to be more
pharmacistpharmacist--friendly.friendly.
APhA, 2008 survey, 330 responses
representing 11,188 sites
Questions?Questions?
Mitchel C. Rothholz, RPh, MBAMitchel C. Rothholz, RPh, MBA
Chief of StaffChief of Staff
American Pharmacists AssociationAmerican Pharmacists Association
1100 15th Street NW, Suite 4001100 15th Street NW, Suite 400
Washington, DCWashington, DC 2000520005--17071707
202/429202/429--75497549
[email protected]@aphanet.org
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