A qualitative case study exploring the implementation of pharmacist care planning services in community pharmacies

SCIENCE AND PRACTICE Journal of the American Pharmacists Association xxx (2019) 1e9

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RESEARCH

A qualitative case study exploring the implementation of pharmacist care planning services in community pharmacies Christine A. Hughes, Rene R. Breault, Theresa J. Schindel* a r t i c l e i n f o

a b s t r a c t

Article history: Received 17 September 2019 Accepted 12 December 2019

Objectives: To describe the comprehensive annual care plan (CACP) process and to conceptualize how remunerated CACP services were implemented by community pharmacists. Design: A comparative, multiple case study approach with data comprising document review, observation, and semistructured interviews. Setting and participants: Pharmacists, pharmacy technicians and staff, and student pharmacists from 4 different community pharmacy sites in Alberta, Canada, including independent, franchise, and corporate chain pharmacies. In addition, patients and other health care providers were included in the interviews. Outcome measures: Constructivist grounded theory was used to understand how care planning services were implemented in the real-world context of community pharmacies and how pharmacists provided CACPs within their practice. Results: Between May 2016 and January 2018, a total of 77 interviews and 94 hours of observations were completed at the 4 pharmacy sites, and 61 documents were collected. The CACP service required adaptation of the workflow at each of the sites. However, pharmacists and other pharmacy staff recognized benefits of the service with respect to pharmacists’ role expansion. The overarching grounded theory concept was changing the status quo. The following 4 themes emerged representing how the service was implemented: engaging patients, professional development and learning from experience, creating a supportive environment, and building community connections. Conclusion: This study found that practice change or changing the status quo was needed to implement remunerated care planning services in community pharmacies. The results of this study may be of interest to community pharmacists, pharmacy managers, and policy makers who are implementing remunerated care planning services in other jurisdictions. Crown Copyright © 2019 Published by Elsevier Inc. on behalf of the American Pharmacists Association. All rights reserved.

Background In more recent years, health systems around the world are undergoing a paradigm shift in the management and delivery of health services with a focus on strengthening primary health care and the delivery of people-centered and integrated health services.1 Integrated, people-centered health services are aimed at empowering patients, enhancing

Disclosure: The authors declare no relevant conflicts of interest or financial relationships. Funding:Canadian Foundation for Pharmacy and the Alberta Pharmacists’ Association. Previous presentation: The results of this study have been reported at a poster presentation at the Canadian Pharmacy Education and Research

patient-provider relationships, and improving information sharing and collaboration among providers. Such an approach is needed to help address escalating costs associated with chronic conditions and preventable illnesses, lack of care coordination, and gaps in care. Owing to accessibility and changing roles, community pharmacies are ideally situated to be one of the first places that people go to for health care services. Patients often see their community pharmacist more

Conference in Edmonton, June 11-13, 2019, and at the Pharmacy Experience Pharmacie in Toronto, June 3-5, 2019. * Correspondence: Theresa J. Schindel, BSP, MCE, PhD, Associate Clinical Professor, Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, 2-35 Medical Sciences Building, 8613 - 114 Street, Edmonton, AB, Canada, T6G 2H1. E-mail address: [email protected] (T.J. Schindel).

https://doi.org/10.1016/j.japh.2019.12.007 1544-3191/Crown Copyright © 2019 Published by Elsevier Inc. on behalf of the American Pharmacists Association. All rights reserved.

SCIENCE AND PRACTICE C.A. Hughes et al. / Journal of the American Pharmacists Association xxx (2019) 1e9

Key Points Background:
In 2012, government compensation for pharmacist care planning services was implemented in Alberta, Canada.
Comprehensive annual care plans are prepared by pharmacists in collaboration with the patient and are documented and shared with other health professionals.
Limited research is available that has explored how remunerated care planning services are implemented in community pharmacies in the context of pharmacist expanded scope of practice. Findings:
The implementation of remunerated care planning services required changing the status quo at each of the sites and supported innovative care delivery models.
Future research is needed to evaluate implementation processes and patient-centered care quality indicators related to care planning. frequently than their family physician,2 and research indicates a willingness of community pharmacists to provide patient-centered services that contribute to primary health care delivery.3,4 In the Canadian province of Alberta, changes in pharmacists’ roles have been enabled by legislation to expand pharmacists’ scope of practice and, more recently, the regulation of pharmacy technicians. Community pharmacists can access patient information and laboratory results through a provincial electronic health record as well as order laboratory values, administer vaccines and drugs by injection, and prescribe medications.5 Although pharmacists can adapt medications, only those pharmacists who apply for and are granted additional prescribing authorization (APA) are able to prescribe independently. Incremental changes over the past decade or so have resulted in a supportive practice environment allowing pharmacists to contribute more to patient-centered services. Although remuneration has traditionally been a barrier to the implementation of new pharmacy services,6-9 in 2012 the Alberta government introduced the Compensation Plan for Pharmacy Services. The plan reflects pharmacists’ scope of practice in Alberta and is one of the most wide-ranging remuneration plans for pharmacy services in Canada.5,10 Comprehensive annual care plans (CACPs) for patients with specific chronic diseases and risk factors are covered by the compensation plan according to a fee-for-service model.11 To be eligible, patients must have 2 or more specified chronic conditions (i.e., hypertension, heart failure, angina, ischemic heart disease, diabetes, chronic obstructive pulmonary disease, asthma, or mental health disorder) or 1 of the specified chronic conditions and 1 risk factor (i.e., tobacco use, obesity, or drug or alcohol dependence). CACPs are prepared by pharmacists in collaboration with the patient and include the following components: gathering of patient information to complete patient assessments,

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conducting a best possible medication history (BPMH), identifying and responding to drug therapy problems, developing agreed upon goals of medication therapy, and developing a progress monitoring plan. The compensation plan does not require the use of a specific template for documentation. The components of CACP are harmonious with patient care processes outlined by national pharmacy organizations in the United States and Canada.12,13 In addition, follow-up assessments are covered by the compensation plan to foster and support long-term patient relationships. The fee for the completion of a CACP is $100, with a CACP-related follow-up assessment fee of $20 (Canadian). Up to 12 follow-up assessments are covered per patient per year.11 Care plans are documented and shared with other health professionals involved in patient care. In addition, the patient must sign that they have reviewed their CACP with the pharmacist and were provided a summary of the plan. Since 2012, the implementation of care planning services by pharmacists and the number of patients receiving CACPs have steadily increased.5 Several studies have evaluated experiences with the implementation of remunerated medication management services such as medication reviews in community pharmacies14-18; however, there is limited research exploring the implementation of remunerated comprehensive care planning services provided by community pharmacists, particularly in the context of pharmacist’s expanded scope of practice. Smith et al.19 interviewed community pharmacists in North Carolina who reported challenges while implementing a new integrated medication management service (comprising a comprehensive medication review, assessment, care plan, and follow-up) for high-risk patients. Pharmacists noted that the service was more intense and complex compared with medication therapy management services covered by Medicare Part D in the United States. Themes included inadequate staffing, time to focus on the service, and challenges navigating the Web-based application to document.19 In the United Kingdom, the evaluation of the Pharmacy Care Plan service found that pharmacists were positive about the service and were able to offer insights into overcoming issues regarding implementation,20 but understanding how this service was implemented was not a major focus of this research. The unique practice environment and compensation plan in Alberta provides an opportunity to better understand how remunerated care planning services are provided by community pharmacists. Objectives The overall objectives of this study were to explore how care planning services were implemented and to determine the perceived value of these services. The focus of this paper was to describe the care planning process and to conceptualize how remunerated CACP services were implemented by community pharmacists in Alberta. Methods Study design The methodology used for this study combined qualitative case study21,22 and constructivist grounded theory.23 This methodological approach was chosen for its systematic,

SCIENCE AND PRACTICE Implementing pharmacist care planning services

flexible, and comparative approaches to explore the experiences of implementing remunerated care planning services. It permitted an in-depth look at care planning services given the complexities of integrating this new service within different community pharmacy organizations.22,24 A comparative, multiple case study approach was used to understand how care planning services were implemented in the real-world context of community pharmacy practice, geography, and policies.21,22,24 The constructivist grounded theory approach addressed questions such as what is care planning process, what are pharmacists’ experiences, and how do pharmacists implement CACPs during their practice.23 Although the principles of grounded theory,23 specifically of inductive analysis that is data driven versus deductive analysis that is based on preconceived concepts, are useful in implementation-related research,25 authors recognize the relevance of intervention research that focuses on the application of research-based knowledge in practice associated with implementation science.26,27 Because this study did not involve an intervention, the grounded theory approach was useful to conceptualize a process model to explore actual practice experiences with the implementation of remunerated care planning services within the unique context of pharmacists’ expanded scope of practice. This research was approved by the University of Alberta Health Research Ethics Board (Pro00059814).

Data collection Details regarding the methods of data collection used in this study have been previously published28 and are briefly described here. Document review, observation, and interview data represented the 3 methods of data collection. Case-specific documents such as policies and procedures, care plan documentation templates, example care plans and follow-up progress notes, and summary of care plans sent to physicians were collected by research team members when visiting sites. Direct observation of the provision of patient care services and interactions of pharmacists with patients, pharmacy staff, and other health professionals permitted the study of care planning and patient follow-up in the “realworld” community pharmacy setting.21 During site visits, research team members observed individuals involved in care planning (pharmacists, pharmacy technicians or assistants, student pharmacists, and patients), recorded field notes, and created a narrative description.21 A standardized form was developed to guide the collection of observation data, documentation of the narrative descriptions of observations, and support reflexivity by the researchers. The length of observations varied depending on the interaction. For example, observations of CACP services with a new patient lasted approximately 30 minutes and interactions with pharmacy staff and other health professionals ranged from 2 to 15 minutes. The total hours of observation at each site ranged from 15.5 (site 4) to 28.5 hours (site 2).28 Semistructured interviews were conducted by research team members using a topic guide focused on open-ended questions. Data collected from documents and observation were initially analyzed and compared with interview data. At subsequent visits, questions arising from documents and observations were incorporated into the interview topic guide for each site. Interviews were conducted in person or

in some cases over the phone following the site visit and were approximately 30-60 minutes in length. All interviews were audio recorded and subsequently transcribed verbatim by a professional transcription service. Examples of the interview and observation guides can be found in Appendix 1. No specific theoretical framework was used to develop interview questions because the intention was to explore data that emerged. Recruitment A sample of 4 practice sites was purposefully selected on the basis of the following predefined criteria: pharmacy type (e.g., independent, franchise, or corporate), population size, engagement in CACP services, and the provision of other compensated services (e.g., pharmacist prescribing or administering drugs or vaccines by injection).21,23 The sites included in this study were selected by the research team, with input from Research Advisory Committee members, according to a list of all Alberta pharmacies provided by the Alberta College of Pharmacy and by cross-referencing this list with pharmacists who had APA and injections authorization. A member of the research team initially approached the pharmacy manager to determine the suitability of the pharmacies as potential sites and to provide information about the study and obtain written consent. Five sites were recruited in total; however, 1 site withdrew before the start of data collection as a result of staffing changes. Participants recruited for interviews during the on-site visits (pharmacists, pharmacy technicians, student pharmacists, staff, patients) were provided information about the study and completed written informed consent. Other health care providers including nurses, nurse practitioners, and physicians in the community were identified by the community pharmacists or patients and invited to participate, and written consent was obtained. As an incentive to participate, a $25 gift card was offered to patients and other health care providers (i.e., nurses). Physicians in Alberta are primarily paid as on a fee-for-service basis; therefore, a higher incentive ($100) was offered to encourage participation. Pharmacy staff members were not offered an incentive. Data analysis All transcripts were reviewed for accuracy by a research team member by comparing transcripts with audio recordings. Identifying information was removed during this process. The analysis of the data gathered through documents and observations collected at site visits and interviews followed the constructivist grounded theory approach.23 The guiding principles of the constructivist grounded theory approach included iteration, constant comparison, and theoretical sampling.23 The approach was iterative as data were analyzed simultaneously during the collection and comparison process. The analysis involved constant comparison of codes, categories, and themes. Coding involved interpreting and naming portions of data from documents, observations, and interviews with a label to categorize and summarize data.23,29 The initial step entailed line-by-line coding of each phrase or a portion of data from the various data sources (observation narratives, documents, and interviews) by 3

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Table 1 Overview of pharmacy sites Parameter Type of pharmacy Population size Pharmacists (with APA) Registered technicians Assistants

Site 1

Site 2

Site 3

Site 4

Independent 1000e29,999 3 (3) 1 3

Franchise > 100,000 3 (1) 0 3

Corporate 30,000e99,999 3 (1) 1 2

Independent > 100,000 5 (4) 2 6

Abbreviation used: APA, additional prescribing authorization.

1 research team member. This process ensured all sources of data were combined for analysis at the conclusion of each site visit. Codes were not predetermined; analysis was inductive and grounded in the data. All team members met regularly following each site visit to review and refine the categories and reach consensus on themes. Categories emerging from the data analysis for each site were compared among sites as data were collected; emerging categories were developed into themes. The interview topic guide was revised throughout the data analysis process to identify points of clarification and opportunities for theoretical sampling to further refine themes.28 The NVivo 12 software was used for storing data and for coding and analysis. Results The 4 sites included were 2 independent pharmacies, a franchise pharmacy, and a large corporate chain pharmacy that were located in small-to-large population centers (Table 1).30,31 Site 1 was located in a small population center that served rural communities within an approximate 60-mile radius. Site 2 was in the inner city of a large population center. Site 3 was located in a suburban, medium population center, and site 4 was located in a large population center and provided CACP services at the pharmacy as well as at off-site for patients living in care facilities that the pharmacy served and in family physician offices. Pharmacists at each of the 4 sites had authorization to administer injections; at least 1 pharmacist at each site had APA. All of the included sites completed 20 or fewer CACPs per month, with the exception of site 4, which completed more than 100 CACPs per month. Between May 2016 and January 2018, each site was visited by research team members 3 times to collect additional data to clarify the interpretation of document and observation data, to achieve theoretical sampling, and to capture whether implementation processes evolved over time; follow-up visits typically occurred at 6 and 12 months after the initial visit. A total of 77 interviews and 94 observation hours were completed, and 61 documents were collected (Table 2).

Overview of the CACP service Figure 1 captures how the CACP service was provided on the basis of data collected from the documents, observations, and interviews. The service was adapted and incorporated into the pharmacy workflow at each of the 4 sites. Pharmacists and other pharmacy staff noted benefits of the service in terms of expansion of the pharmacist’s role and improving patient care. However, the CACP service also added workload (time) for the pharmacists, which varied greatly depending on pharmacist expertise and documentation styles, system support for documentation, and patient complexity. Up to 4 hours were required in some cases to complete the CACP service (preparation, patient consultation, and postconsultation activities). The CACP service entailed the following with further explanation of similarities and differences between sites.

Eligible patients identified Patients eligible for a CACP were identified at the time they presented to the pharmacy for a service (e.g., new prescription or refill) or when requesting a service over the phone. In addition, 3 sites (1, 2 and 4) provided a CACP to eligible residents living in long-term care or institution-type settings where the pharmacy provided medication services. In addition, site 4 provided CACP services at a family physician’s office. Other pharmacy team members (e.g., pharmacy technicians and assistants) were involved to varying extents in identifying patients who may be eligible for a CACP and would communicate this to the pharmacist.

Patients recruited for CACP service Although some sites had passive recruitment (e.g., signs in the pharmacy advertising the service), patients were typically recruited at the pharmacy by staff. In some cases, the patient or another health care provider (e.g., nurse or physician) would request a CACP for a patient.

Table 2 Summary of observation hours and interviews Site

1 2 3 4 Total a

4

Observation h

24 28.5 26 15.5 94

Interviews with Pharmacista

Pharmacy techniciana staff

Physician

Nurse

Patient

Student pharmacist

8 4 4 6 22

4 4 2 3 13

2 2 d 2 6

2 d d 3 5

11 5 8 5 29

d d 2 d 2

Note: Pharmacists and some pharmacy technicians were interviewed more than once at different site visits.

SCIENCE AND PRACTICE Implementing pharmacist care planning services

Figure 1. Overview of comprehensive annual care plan service. Abbreviation used: CACP, comprehensive annual care plan.

Pharmacist preparation Pharmacists would prepare for patient consultations by gathering information including relevant laboratory values or medication dispensing history from the provincial electronic health record and by reviewing previous CACPs, if available. In addition, site 1 routinely requested physician care plans, and site 4 had access to the patient’s electronic medical record at sites they provided services at outside the pharmacy. Site 3 developed disease-based templates with goals of therapy, relevant information and questions to guide the assessment

(e.g., signs and symptoms and laboratory values), in addition to recommending treatment and monitoring parameters. Patient consultation Depending on the patient’s and pharmacist’s availabilities, CACP consultation would occur either during the same visit or an appointment was booked at another time. CACP consultation typically occurred in a private room located within the pharmacy or, in some cases, off-site. The consultations were conversational in style as the pharmacist gathered patients’

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Professional development and learning from experience

Building community connecons

Creang supporve environment

Engaging paents Paentcentered care

follow-up in person or over the phone either at 30 days or sooner if there was a more “urgent” need for follow-up. Changing the status quo The main grounded theory concept emerging from the data from all sources, changing the status quo, conceptualizes how pharmacists implement remunerated patient care services within the context of their sites. The following 4 themes highlight how the CACP service was implemented (Figure 2): (1) engaging patients, (2) professional development and learning from experience, (3) creating a supportive environment, and (4) building community connections. Each of these themes has been described in detail below. Data to support the themes, represented by quotes that combined data from all sources, can be found in Appendix 2. Engaging patients

Figure 2. Patient-centered care through comprehensive annual care plan service.

medical and social history, confirmed allergies, obtained vitals (e.g., blood pressure), and completed a BPMH. Patients’ main concerns and goals of therapy were discussed and agreed upon. Following the identification of any drug therapy problems, pharmacists would discuss recommended changes in drug therapy (if any) and provide additional patient education. Interventions as a result of the care plan varied from the pharmacist ordering additional laboratory tests (e.g., hemoglobin A1c or lipid panel) to initiating drug therapy (e.g., smoking cessation), stopping drug therapy, or providing recommendations to the patient’s physician. Patients signed a form indicating that the pharmacist completed the CACP and reviewed and discussed it with them. At the end of the consultation, all 4 sites provided the patient a medication list and, in some cases, offered the entire CACP document.

Following consultation Following patient consultation, some pharmacists would do additional research and look up information to complete the care plan. Three sites documented the care plan in an electronic template, whereas 1 site prepared handwritten care plans. In addition to scanning the care plan (or parts of it) into the pharmacy dispensing software, pharmacists would prepare additional documentation notes (summary) in certain software fields that facilitated information sharing among pharmacy team members and more efficient care at follow-up. Most sites sent a summary of the care plan, including problems identified and recommendations or interventions, to the patient’s physician as a part of an information package including a facsimile cover letter along with an updated summary of the patient’s medications. Some sites shared the full care plan with the physician as well. Patient follow-up occurred in person as well as over the phone. Some sites would primarily follow-up with the patient in person the next time the patient was at the pharmacy. Site 3 would schedule 6

An important aspect of implementing care planning services was engaging patients and building relationships to provide patient-centered care. As patients were often not aware of care planning services, pharmacists adjusted language when patients were recruited to help them understand what the service was about rather than using the formal names of services outlined in the compensation plan.5 In many cases, the CACP service was referred to as a “medication review.” Getting to know patients better through care planning services and follow-up encounters was essential for providing patient-centered counseling and support for managing chronic conditions, use of medications, and healthy lifestyles. Patients commented that pharmacists were more involved in their care and worked with them, in addition to their physicians, on their disease management goals. Many patients expressed being much more knowledgeable about their medical conditions and medications as a result of the CACP service. They appreciated the time the pharmacist spent with them explaining medication changes. In addition, patients described the encouragement and support provided by their pharmacist to reach their health goals, such as smoking cessation, as illustrated in the following quote: [The pharmacist is] very encouraging, he said “you’ve been smoking for over 40 years… you need to give yourself a break… so okay, you start over again”. So his encouragement actually is the reason why I went back for another prescription and actually finally beat it. And I’ve been a non-smoker for 27 months. (Site 3, Patient)

Professional development and learning from experience Professional development and learning played an important role in operationalizing CACP services, although the needs were specific to the pharmacist themselves. The CACP service represented a shift in pharmacists’ roles and pharmacists were motivated to further increase their knowledge and development of skills to better prepare them to assess chronic disease management and optimize drug therapy for the patient. In addition, pharmacists felt that obtaining APA was helpful for their practice. Learning took the form of traditional methods of

SCIENCE AND PRACTICE Implementing pharmacist care planning services

professional development such as continuing education courses, conferences, certifications, and even degree programs. I was starting to provide certainly a higher level of care… I did go and do my board certification specialty in pharmacotherapy which is an American designation… I wanted to be better at customized medication not for your age or for your demographic but for who you are as a person. So, that was a very intense course, but it has helped improve my practice. (Site 4, Pharmacist) Some pharmacists completed formal, accredited continuing pharmacy education offered by pharmacy advocacy organizations related to care planning or patient assessment. For site 1, the pharmacy owner took formalized training in leadership, as he or she viewed this would be beneficial for him or her as the compensation plan was being rolled out. Informal learning in practice, such as learning from peers or other health professionals and learning through experience, contributed to pharmacists being able to implement the CACP service. Learning from peers, as it relates to care planning, occurred both within and outside their own pharmacy practice setting. Pharmacists commented on the value of building knowledge and skills from everyday practice and the concept of “learning by doing” and application. CACP services were initially provided in areas the pharmacists were knowledgeable (e.g., diabetes, asthma, hypertension, and smoking cessation). As the pharmacists gained confidence, they identified their learning needs according to gaps in their knowledge and skills to add more areas of focus. Quality assurance processes were reported at site 4, which comprised supervisor audits of clinical work and documentation to ensure quality work and conciseness.

Creating a supportive environment Creating a supportive environment for providing the CACP service through organizational changes, teamwork, and the use of technology were noted at each of the sites. Several organizational changes were made to support the integration of care planning processes into existing work processes. These included shifting tasks from pharmacists to technicians, scheduling overlap time for pharmacists, and hiring and training administrative staff to support billing. Except for site 2, all sites had at least 1 registered technician and described shifting of more dispensing-related responsibility to the technician to allow pharmacists the time to provide care planning services. I think the fact that the technicians or assistants are doing all adjudication [of claims] now has really freed up the time that we spend with the patients, for sure. And it also has allowed us to continue to do more for follow-ups and initial care plans and continue to keep doing more of that, too. (Site 3, Pharmacy Manager) Technicians at some of the sites also helped with the preparation of care plan documentation by printing CACP templates and medication lists. During busy times of the day, additional pharmacist overlap was scheduled to allow

pharmacists time to focus on care planning or follow-up services. Site 1 introduced incentives for pharmacists and pharmacy technicians (scheduled clinical time and sharing a percentage of the compensation for the CACP service). In addition, physical changes such as use of the private consultation room to support care planning services were noted. For site 3, a policy guide was developed outlining the processes and steps in creating a care plan and where/how it should be documented. Technology played an important role in supporting the process for care planning. Software functions were used at all the sites to enable prompts that would flag eligible patients for CACPs in addition to prompting patient follow-ups and when annual care plan renewals were due. “And if we are following up with a patient…and I want them to have their creatinine checked in a week, right, we always schedule our follow-ups in [name of pharmacy software].” (Site 1, Pharmacist) Accessing laboratory results through the provincial electronic health record was used extensively by all sites to assist with care plan completion. Most sites had electronic templates for documenting care plans; however, pharmacists prepared separate summary notes within the dispensing software fields that were used to guide patient follow-up and share information among pharmacists at the site. Limitations of pharmacy dispensing software for patient care processes were frequently described, resulting in inefficiencies and duplication of work (documentation).

Building community connections Compensation for care planning services supported innovation in terms of care delivery models and building connections in the community. At several sites, the CACP service was delivered outside the pharmacy, including in the patient’s home, “on-site” at long-term care facilities, or at family physician’s offices creating stronger connections between the pharmacy and the community. This further increased the visibility of community pharmacists and opportunities for collaboration with other team members. “I am one of the mobile clinical pharmacists, so I go to different congregate living facilities, mostly seniors’ homes.” (Site 4, Pharmacist) The location of the CACP service influenced patient expectations and the time available for patient interaction, the type of collaboration with other health care providers, and how care plans were shared. Patient expectations of pharmacist services and time spent was different during home visits or when care planning services were provided outside the community pharmacy. Patients in these settings typically were not in a rush and had more time available to speak with the pharmacist. In addition, the pharmacist had dedicated time available to complete patient consultation. Although information sharing around care plans with physicians was primarily through facsimile, at site 4, there was an evidence of development of shared care plans when physicians and pharmacists were colocated. At site 1 (small population 7

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center), there was more information sharing over the phone or in person between pharmacists and other health care providers (in addition to faxing of information).

Discussion Using a comparative case study and the constructive grounded theory approach, this research explored experiences implementing remunerated care planning services at 4 different community pharmacy sites in Alberta, Canada. Despite differences in terms of organizational structure, location, resources, and collaborative relationships with other health care providers at each of the sites, the overall process for the CACP service was similar. Through the analysis of data collected from documents, observation, and interviews, this qualitative study provided an in-depth view of how the implementation of the CACP service involved changing the status quo, with themes of engaging patients, professional development and learning from experience, creating a supportive environment, and building community connections. It offers a conceptual model, an explanatory grounded theory, which can be tested in future research for implementing care plans in contexts of expanded scope of practice for pharmacists. These findings are in keeping with those of other qualitative research looking at the implementation of remunerated medication therapy management services.14,16,17 Human resource management including shifting tasks to technicians, software adaptations, and staff training in addition to targeted patient recruitment were reported by researchers evaluating the implementation of medication reviews in community pharmacies in Ontario.17 Similar to our results, pharmacy ownership type did not strongly affect the implementation strategies used; however, targets such as incentives for medication review services were described by these researchers, which were not commonly reported in this study. This may be owing to differences in study design because MacKeigan et al.17 interviewed pharmacy managers, owners, and corporate executives. Likewise, Pestka et al.14 found that staff training, pharmacist task distribution, and learning as you go were important factors in establishing and sustaining medication management programs in community pharmacies in Minnesota. Moreover, the importance of building relationships with patients and other primary care providers has been previously reported.14,18 Patton et al.18 conducted a qualitative ethnographic study of 4 community pharmacies in Ontario, Canada, and found that the ability of pharmacists to engage in the community and build relationships with patients and other care providers affected the delivery of quality medication reviews. In addition, the expectations of patients and health care providers in terms of the professional role of pharmacists affected the performance of medication reviews, whereas structural challenges such as information connectivity and linkages between community pharmacies and other components of the health care system were problematic across all pharmacies. Although all community pharmacists and other primary care providers in Alberta have access to patient information through a provincial electronic health record called Netcare, this system does not currently support 2-way communication of patient information between pharmacists 8

and physicians or other care providers. This study found that engaging patients, relationship building, and community connections were important in the delivery of the CACP service. At most sites, the CACP service was delivered outside the community pharmacy to eligible patients. Settings where information is shared more easily or where care plans can be viewed or developed collaboratively may reduce duplication of work and frustration with lag times in communication. Moreover, our findings, generated through a grounded theory approach, are consistent with a recent article by Dolovich et al.32 describing pharmacy in the 21st century. These authors identified principles that should guide the provision of care (patient focused, effective, safe, comprehensive, longitudinal, collaborative, accessible, and integrated) and identified 2 summary themes to transform pharmacy over the next 5-10 years: organizational change and better external relationships. Despite the range of implementation strategies, our data suggest that care planning services in Alberta are still evolving as pharmacists gain experience implementing the service and providing patient-centered care in their practices. A number of challenges remain. Patients were generally not aware of the service when first approached by the pharmacist and were identified for the service according to eligibility criteria outlined in the compensation plan. Patient self-referrals or referrals from other health care providers were not common. Simpler terminology in place of “care plan,” most commonly “medication review,” used to communicate the service and recruit patients obscures the fact that patients are engaged in a care plan service. Technology is required to fully support CACP process and mitigate inefficiencies leading to the duplication of work by other primary care providers involved in patients’ care. When patients are not provided with a full care plan or a summary of the discussed plan, realization of the outcomes of the care plan may not be achieved. Challenges with documenting and sharing information with existing systems persist. Quality assurance processes for CACP services are important for implementation; only 1 of the 4 sites in our study formally implemented these processes. It is important to note the strengths and limitations of this research. The use of a longitudinal case study method that included a comparison of multiple sites, several data collection methods, and different perspectives of study participants are the strengths of this research. Limitations include the relatively low number of CACPs performed at most sites, self-report of CACPs done each month, and the small number of physician interviews. There were challenges recruiting physicians to participate in this research and those who did participate likely had established relationships with pharmacists. The constructivist grounded theory approach produced a concept, changing the status quo, using an inductive, data-driven analysis approach. The results may have differed if a deductive analysis approach was used guided by an existing framework, such as the Consolidated Framework for Implementation Research.33 Finally, this study was conducted within the unique practice environment of Alberta and included 4 pharmacy sites. Compensated care planning services have been fairly recently introduced and are continuing to evolve; therefore, it is not possible to depict the entire range of experiences with CACP services. Future research is needed to simultaneously capture implementation processes and patient-centered care quality indicators related to care planning.

SCIENCE AND PRACTICE Implementing pharmacist care planning services

Conclusion 14.

Remunerated care planning services in Alberta reflect policy changes designed to support the expanded roles of pharmacists in primary care in addition to the focus on patient-centered care for individuals with chronic conditions. To implement this new service, changes in status quo were needed and a variety of strategies were used. Understanding how care planning services are implemented within realworld practice may be of interest to community pharmacists, pharmacy managers, and policy makers in other jurisdictions and to researchers who are seeking to test the grounded theory concept introduced by this research.

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Acknowledgments

19.

The authors would like to thank the study participants and pharmacies for participating in this work and Deborah Hicks, Amy Semaka, and Iryna Hurava for assisting with data collection.

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References 1. World Health Organization. WHO global strategy on people-centred and integrated health services. Interim Report. Available at: https://apps.who. int/iris/bitstream/handle/10665/155002/WHO_HIS_SDS_2015.6_eng.pdf? sequence¼1. Accessed September 6, 2019. 2. Tsuyuki RT, Beahm NP, Okada H, Al Hamarneh YN. Pharmacists as accessible primary health care providers: review of the evidence. Can Pharm J. 2018;151(1):4e5. 3. Grindrod KA, Marra CA, Colley L, Tsuyuki RT, Lynd LD. Pharmacists’ preferences for providing patient-centered services: a discrete choice experiment to guide health policy. Ann Pharmacother. 2010;44(10): 1554e1564. 4. Munger MA, Walsh M, Godin J, Feehan M. Pharmacist’s demand for optimal primary care service delivery in a community pharmacy: the OPTiPharm study. Ann Pharmacother. 2017;51(12):1069e1076. 5. Breault RR, Whissell JG, Hughes CA, Schindel TJ. Development and implementation of the compensation plan for pharmacy services in Alberta, Canada. J Am Pharm Assoc (2003). 2017;57(4):532e541. 6. Roberts AS, Benrimoj SI, Chen TF, Williams KA, Aslani P. Practice change in community pharmacy: quantification of facilitators. Ann Pharmacother. 2008;42(6):861e868. 7. Wang J, Hong SH, Meng S, Brown LM. Pharmacists’ acceptable levels of compensation for MTM services: a conjoint analysis. Res Social Adm Pharm. 2011;7(4):383e395. 8. Freeman C, Cottrell WN, Kyle G, Williams I, Nissen L. Integrating a pharmacist into the general practice environment: opinions of pharmacist’s, general practitioner’s, health care consumer’s, and practice manager’s. BMC Health Serv Res. 2012;12:229. 9. McMillan SS, Wheeler AJ, Sav A, et al. Community pharmacy in Australia: A health hub destination of the future. Res Social Adm Pharm. 2013;9(6): 863e875. 10. Breault RR, Schindel TJ, Whissell JG, Hughes CA. Updates to the compensation plan for pharmacy services in Alberta, Canada. J Am Pharm Assoc (2003). 2018;58(6):597e598. 11. Government of Alberta. Compensation plan for pharmacy services. Available at: https://open.alberta.ca/dataset/0e5f556a-2ac0-40a6-8 fbc-d46fb92b0ee1/resource/a6c00fcd-58db-4b45-b368-df999211173 9/download/mo-614-2018-pharmacycompensation.pdf. Accessed September 6, 2019. 12. Joint Commission of Pharmacy Practitioners. Pharmacists’ patient care process. Available at: https://jcpp.net/wp-content/uploads/2016/03/ PatientCareProcess-with-supporting-organizations.pdf. Accessed September 6, 2019. 13. National Association of Pharmacy Regulatory Authorities. Professional competencies for Canadian pharmacists at entry to practice (2014).

22.

23. 24.

25.

26. 27. 28.

29. 30.

31.

32.

33.

Available at: https://napra.ca/pharmacists/professional-competenciescanadian-pharmacists-entry-practice-2014. Accessed September 6, 2019. Pestka DL, Frail CK, Palombi LC, Von Hoff BA, Conway JM, Sorensen TD. Strategies and steps fostering the success of medication management services in community pharmacies. J Am Pharm Assoc (2003). 2016;56(5): 504.e1e512.e1. Roberts AS, Benrimoj SI, Chen TF, Williams KA, Hopp TR, Aslani P. Understanding practice change in community pharmacy: a qualitative study in Australia. Res Social Adm Pharm. 2005;1(4):546e564. ndez D, Benrimoj SI. Qualitative study on the Moullin JC, Sabater-Herna implementation of professional pharmacy services in Australian community pharmacies using framework analysis. BMC Health Serv Res. 2016;16:439. MacKeigan LD, Ijaz N, Bojarski EA, Dolovich L. Implementation of a reimbursed medication review program: corporate and pharmacy level strategies. Res Social Adm Pharm. 2017;13(5):947e958. Patton SJ, Miller FA, Abrahamyan L, Rac VE. Expanding the clinical role of community pharmacy: a qualitative ethnographic study of medication reviews in Ontario, Canada. Health Policy. 2018;122(3):256e262. Smith MG, Ferreri SP, Brown P, Wines K, Shea CM, Pfeiffenberger TM. Implementing an integrated care management program in community pharmacies: a focus on medication management services. J Am Pharm Assoc (2003). 2017;57(2):229.e1e235.e1. Twigg MJ, Wright D, Kirkdale CL, Desborough JA, Thornley T. The UK pharmacy care plan service: description, recruitment and initial views on a new community pharmacy intervention. PLoS One. 2017;12(4): e0174500. Yin RK. Applications of Case Study Research. Thousand Oaks, CA: Sage Publications Inc; 2011. Kaae S, Søndergaard B, Haugbølle LS, Traulsen JM. Development of a qualitative exploratory case study research method to explore sustained delivery of cognitive services. Pharm World Sci. 2010;32(1):36e42. Charmaz K. Constructing Grounded Theory: A Practical Guide through Qualitative Analysis. London, UK: Sage Publications Ltd; 2006. ttir AB, Traulsen JM. Multimethod research into policy changes Almarsdo in the pharmacy sector–the Nordic case. Res Social Adm Pharm. 2009;5(1):82e90. National Cancer Institute. Qualitative methods in implementation science. Available at: https://cancercontrol.cancer.gov/IS/docs/NCI-DCCPSImplementationScience-WhitePaper.pdf. Accessed November 24, 2019. Nilsen P. Making sense of implementation theories, models and frameworks. Implement Sci. 2015;10(1):53. Hamilton AB, Finley EP. Qualitative methods in implementation research: an introduction. Psychiatry Res. 2019;280:112516. Schindel TJ, Breault RR, Hughes CA. “It made a difference to me”: a comparative case study of community pharmacists’ care planning services in primary health care. Pharmacy. 2019;7(3):E90. Sutton J, Austin Z. Qualitative research: data collection, analysis and management. Can J Hosp Pharm. 2015;68(3):226e231. Perepelkin J, Dobson RT. Influence of ownership type on role orientation, role affinity, and role conflict among community pharmacy managers and owners in Canada. Res Social Adm Pharm. 2010;6(4): 280e292. Statistics Canada. Variant: population centre and rural area 2016 by province and territory. Available at: https://www23.statcan.gc.ca/imdb/ p3VD.pl?Function¼getVD&TVD¼340985&CVD¼314302&CPV¼48&CST¼ 01012016&CLV¼2&MLV¼4. Accessed November 26, 2019. Dolovich L, Austin Z, Waite N, et al. Pharmacy in the 21st century: enhancing the impact of the profession of pharmacy on people’s lives in the context of health care trends, evidence and policies. Can Pharm J. 2019;152(1):45e53. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4:50.

Christine A. Hughes, BScPharm, PharmD, Professor, Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada Rene R. Breault, BScPharm, PharmD, Associate Clinical Professor, Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada Theresa J. Schindel, BSP, MCE, PhD, Associate Clinical Professor, Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada

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SCIENCE AND PRACTICE C.A. Hughes et al. / Journal of the American Pharmacists Association xxx (2019) 1e9

Supplementary data

Appendix 1 Interview topic guide for semistructured interviews Interview participant

Discussion points

Pharmacist, pharmacy technician,
History with the pharmacy and staff
Description of patient care services
Experiences with care planning (CACP) services
Implementation of care planning services
Support provided/required to provide patient care services
Benefits/challenges associated with provision of patient care services
Changes, if any, to the professional role or activities of the pharmacy staff since the implementation of the Compensation Plan for Pharmacy Services
Learning and professional development related to provision of patient care services
Perceptions of the value of care planning (CACP) services Added for site visit 3:
Information sources used for care planning (CACP) services
Feedback received on care plans
Professional development and learning Patients
History with the pharmacy
Experiences with care planning (CACP) services
Perceptions of the value of care planning (CACP) services Added for site visit 3:
Care plan goals discussed
Action plan after a care plan has been developed Physicians, nurses
History of the practice
Experiences with the pharmacy
Experiences with care planning (CACP) services provided by pharmacists
Perceptions of the value of care planning (CACP) services Abbreviation used: CACP, comprehensive annual care plan.

Observation guide for comprehensive annual care plan services During the CACP service:
Pre-CACP activities
Pharmacist-staff interactions
Patient-staff interactions
Patient-pharmacist interactions
Patient involvement in CACP development
Information seeking and use
Documents/forms/tools used
“Take away” documentation provided to the patient
Physician (or other) communication
CACP documentation sharing and storing
Postepatient interaction activities
Time spent on the activity
Location of staff and changes over the course of CACP
Physical layout of the setting Following the CACP service:
How does the researcher feel about the day’s occurrences?
Did the researcher(s) have any apparent influence on the activities?
How do the observed actions compare with the findings from the document analysis? Do the key messages found there affect/influence/contradict the observations?
What changes to the observation process should be made for the next time? Abbreviation used: CACP, comprehensive annual care plan.

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SCIENCE AND PRACTICE Implementing pharmacist care planning services

Appendix 2 Sample of data representing how care planning was implemented Quote

Theme

I am one of the mobile clinical pharmacists, so I go to different congregate living facilities, mostly Building community connections seniors’ homes. [Pharmacists] deliver medicines, and I think they do full medication reviews and they’ll take blood Building community connections pressure and check on patients, see how they’re doing. [The pharmacist will] go to a home, he’ll do their CACP there, he’ll go to the lodge, CACP there. Building community connections

Source Site 4 (Pharmacist) Site 2 (Pharmacy assistant) Site 1 (Pharmacist) Site 1 (Pharmacist)

Creating a supportive environment If we are following up with a patient, let’s say I do a med review and I want them to have their creatinine checked in a week, right, we always schedule our follow-ups in [the [the pharmacy information system]. It is paperless for the most part but it’s not really set up perfectly for clinical services…that’s why we Creating a supporting environment Site 3 had to create a few little counseling notes and documenting things a certain way. (Pharmacist) Technology is a challenge. I love it, but it’s expensive, the good stuff’s really expensive. Creating a supportive environment Site 2 (Pharmacist) I have access to the Wifi here, so I can use that to connect to Netcare [electronic health record], and Creating a supportive environment Site 4 be able to access….some of our electronic resources that are physically at the pharmacy. (Pharmacist) I feel now that the services are involved in our work flow, like, theyre immersed, they’re part of Creating a supportive environment Site 1 (Pharmacist) it….And I have included it now into my work flow so that I keep caught up with it. It used to be a problem you’d get behind….And so the staff, the assistant and technician really help with stating on the prescription that this is a CACP patient and follow them up. I think the fact that the technicians or assistants are doing all adjudication now has really freed up Creating a supportive environment Site 3 (Pharmacist) the time that we spend with the patients, for sure. And it also has allowed us to continue to, continue to, you know, do more for follow-ups and initial care plans and continue to keep doing more of that, too, so. Days when [the pharmacy manager] has one of her other pharmacists in, she’ll come in for large Creating a supportive environment Site 2 (Pharmacy chunks of the day to do a lot of patient stuff and history stuff. assistant) I went to that care plan course….through [Alberta Pharmacists’ Association]. Professional development and Site 1 learning through experience (Pharmacist) Site 4 And I was starting to provide certainly a higher level of care…I did go and do my board certification Professional development and learning through experience (Pharmacist) specialty in pharmacotherapy which is an American designation…I wanted to be better at customized medication not for your age or for your demographic but for who you are as a person. So, that was a very intense course, but it has helped improve my practice. Site 1 I was not as learned in all the disease states for assessment, and that’s taken some working with my Professional development and (Pharmacist) colleagues, they help a lot with that. Having good references to go to, talking with the doctors, learning through experience ‘cause that took a long time, like, you have to know what to monitor, you have to know what the goals would be, you have to know what the treatment of choice would be with that. And 15 years ago we didn’t really follow that too well. Site 2 So, we knew it was coming… so we got together a couple of us [Pharmacist names] who are friends Professional development and (Pharmacist) and colleagues and created some documents to help us do this appropriately. So we've been using learning through experience those documents to try and do the assessments that are required. Site 1 (Patient) Rather than just taking your prescription and saying, well, this is what you need, this is what you Engaging patients need, give it to you, and you pay for it and go home. I found that pharmacists intermingle with you better now than they used to. They’re more involved, and is not just the process of selling, fixing up your prescription, selling it to you and goodbye, you know, in that aspect. Yes, I’m pleased with the service we get, that’s for sure. Engaging patients Site 4 (Patient) We go over my medication. And then she explains to me if she thinks it should be changed, she explains to me why, and, you know, why the change. She keeps track of how I’m doing on the medication that I am, you know, that I’m already on, right. But that’s about it. I mean, she’s verydshe’s a person that takes the time to explain stuff to you. So I really appreciate that, ‘cause there’s not much of that anymore. Site 3 (Patient) Well, my goals are to get my blood sugar down to an acceptable level because I’m Type 2 diabetes, Engaging patients and my blood sugar was way up in the 26 range. And with the help of [named pharmacist] and my family doctor, it is now down roughly about 6. At one time I was on quite a few [medications], and we kind of streamlined my medications so that Engaging patients Site 2 (Patient) the medication that I was taking was better for me. Site 3 (Patient) [The pharmacist is] very encouraging. He said no, [patient name], you’ve been smoking for over 40 Engaging patients years, come on, you know, you need to give yourself a break and, you know, so okay, you start over again. So his encouragement actually is the reason why I went back for another prescription and actually finally beat it. And I’ve been a non-smoker for 27 months.

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