- Email: [email protected]
Women's Health Education: An Opportunity for Community Pharmacy
Women's Health Education: An Opportunity for Community Pharmacy Before launching a new health program) the pharmacist should ascertain the particular needs of the target population. by Calvin H. Knovvlton, PhD, Orsula Voltis Thomas, PharmD, Stephanie A. Zarus, PharmD, and Marissa L. Buttaro
Learning Objectives
Introduction
Upon successful completion of this continuing education article, the pharmacist should be able to: • List the steps involved in establishing a women's CE Credit health education center in a community pharmacy. CE Credit To obtain two hours of contin• Explain the importance of uing education credit (0.2 conducting a focus group CEU) for completing "Wommeeting before establishing en's Health Education: An Opportunity for Community a pharmacy-based women's Phannacy," complete the health education center. assessment exercise and CE • Identify the components registration fonn and return it to APhA. Acertificate will be of a women's health educaawarded upon achieving a tion intervention objective. passing grade of 700/0 or better: • Describe an educational Pharmacists compl.e !ing this strategy for female patients article by February 1, 2000, who seek information about can receive credit. The hormone replacement theraPhannapy or osteoporosis prevention. ffi American ceutical Association is approved by the • Describe a key objective American Council on Pharof Healthy People 2000, maceutical Education as a which is to increase to at provider of continuing pharmaceutical education. least 90% the number of women counseled about the @ APhA provider number benefits and risks of hor\g) is: 202-OOO-97-013-H04. mone replacement therapy.
Women's health education provides a challenging new opportunity for pharmacists who wish to expand their scope of practice. This article presents step-by-step guidelines for planning, establishing, and evaluating a women's health education center in a community pharmacy.
ILC [
Vol. NS37, No.1
January/February 1997
Need for Pharmacy-Based VVomen's Health Education Women may see their pharmacist more frequently than they see any other health care provider. For a growing number of women who do not have health insurance, the pharmacist may be the only point of regular access to the health care system, for their family members' medications as well as their own. For these reasons, the community pharmacy is a logical place for women to obtain health information. Pharmacists need to devote greater attention to women's health issues for several reasons. 1 Patient compliance can be improved by education leading to proper use of medication and realistic expectations for therapy outcomes. Proper health education and drug therapy can help women prevent the complications of chronic diseases such as osteoporosis, diabetes, and heart disease. Several objectives of Healthy People 2000,
Journal of the American phannaceutical Association
"Women's Health Education: An Opportunity for Community Pharmacy" is part of the Dynamics of Phannaceutical Care: Enriching Patients' Health series for phannacists that appears in theJournal of the American Pharmaceutical Association. Developed by APhA, the series is edited by Janet P. Engle, PhannD, FAPhA, associate dean for academic affairs and clinical professor of phannacy practice, University ofDlinois at Oticago, and supported by an educational grant from Merck Human Health Division. The Dynamics of Phannaceutical Care: Enriching Patients' Health series was formerly known as the Value Added Services series.
an initiative published in 1992 by the U. S. Department of Health and Human Services (HHS) with the goal of improving national health, relate directly to women's health (see Table 1). 2 Current public interest in osteoporosis, breast cancer, weight-reduction medications, and new antidepressant drugs makes these areas particularly promising for a phannacy-based education program. Programs that build on the phannacist's customary areas of Table 1
Examples of Healthy People 2000 Objectives Relating to Women's Health • Increase to at least 900/0 the proportion of perimen<;>pausal women who have been counseled about the benefits and risks of estrogen replacement therapy (combined with progestin when appropriate). • Reduce unintended pregnancies to no more than 30% of pregnancies and increase the effectiveness with which family planning methods are used. • Increase to at least 450/0 the proportion of people with major depressive disorders who obtain treatment. • Reduce coronary heart disease deaths to no more than 100 per 100,000 people. • Increase clinical breast examinations and mammography every two years to at least 60% of women aged 50 and older. • Reduce the prevalence of overweight among people aged 20 and older to 20% or lower. • Reduce iron deficiency to less than 3% among children aged 1-4 and among women of childbearing age. Source: Reference 2.
JOunW of the American phannaceutical Association
expertise, and that have the potential to reduce morbidity, mortality, and health care costs, are logical starting points. For example, pharmacists have specialized knowledge of the medications used to prevent and treat osteoporosis, a disease ) that affects 50% of women over age 45 and 90% of women over age 75. 3 Fractures from osteoporosis are responsible for ' $7 to $10 billion in annual health care costs in the United States. 3 A pharmacy-based osteoporosis health education program can increase patients' awareness and knowledge of pre· vention and treatment of this disease. A phannacy-based program need not be limited to "tradi· tional" women's health areas (e.g., the reproductive cycle). Coronary heart disease (CHD), for example, is the leading cause of death among postmenopausal women. 4 Other rele· vant topics include compliance with hypertensive and antilipidemic regimens, -diet and lifestyle changes, and the 1 benefits and risks of hormone replacement therapy (HR1), \ Women who are considering having children may benefit from diabetes education.
Getting Started The steps involved in establishing a women's health educa· tion center are summarized in Table 2. Derived from a classic health education program planning model, these steps can be Table 2
How to Develop a PharmacyBased Health Education Program for Women • Identify the health education needs of women in your community. • Develop expertise in one or several women's health topics. .. Assess the activity and system changes needed to provide health education in your practice. • Create goals and objectives for your health education program. •
Design your program plan and interventions.
• Develop or obtain educational materials to supplement pharmacist counseling. •
Market your program.
•
Implement your program.
• Evaluate results and use findings to improve the quality of your health education program.
January/February 1997
Vol. NS37, No, 1
Figure 1
Health Education Program Planning and Implementation Tlmalina -'
January
February
March
May
April
~
J uy I
J une
August
s eptember
October November Decemj:>er
Assess needs Educate staff Conduct SWOT analysis
""l) lie<.
Hold focus group Identify needed resou rces ' ..
Re-engineer site
/'
!,
.~
':h,
'i'i
Train support personnel Develop mission statement Set goals and objectives !iI.l
lJ
~'
,ill
Design and print educational forms .
.
.i,.
':.'"
"
!!!
,~
~,
."
"
to
1;;
"1
M:
,~
.,,' I ~ ~.
~
Obtain lists of possible patients Implement health education services
e .':f,~'''':
,t
.,~.
~j
Q?j,
"
Develop educational curricula
Send letter to local physicians
I.".,,!,
'1;1
'to,
"l
Develop marketing materials
'"
,-','
i
I,
1ft'
". !
...
i
<'til!!,!""".
l\!,0
~?
t P~"
."If
i'
.1
'wt,
Monitor and evaluate services Refine program
;~.
II!:
Source: Focused Pharmaceutical Care: A Sourcebook on Establishing a Diabetes Practice. Washington, D.C.: American Pharmaceutical Association; in press. Developed by the Center for Pharmaceutical Care at Amherst, lumberton, N.J.
Needs of Your Target Population
readily translated into the actions needed to design and implement a phannacy-based education program. As your work proceeds, you will need a means of tracking progress and ensuring that project timelines are being met. Figure 1 shows a sample timeline. Note that several activities can be pursued concurrently.
The questions in Table 3 will help you better understand women's health issues in your community. The following subsections describe the needs assessment process. Primary Research
Needs Assessment As noted in Table 2, the ftrst step in program planning is to conduct a needs assessment. Windsor et al. 5 defme a needs assessment as the process by which the program planner identiftes and measures the gaps between what is and what oUght to be. A needs assessment can determine which topics are best suited to your patient population, who is affected by a particular health problem, what is being done about it, and What needs to be done about it. For best results, approach the needs assessment from the perspective of your target population and that of your practice.
VoL NS37, No.1
January/February 1997
The flfSt question is, "What issues need to be addressed?" A primary data search can help you identify the concerns of the women in your community. Methods of primary data collection include mailed questionnaires, target population surveys, community forums, opinion leader surveys, and focus groups. A research method may be quantitative, qualitative, or a combination thereof. For example, mailed questionnaires are often used to obtain quantitative data (e.g., "Seventy~ne percent of respondents stated that they would be interested in menopause management education,,). 6 Focus groups are a relatively inexpensive qualitative research method. Green and Kreuter defme focus groups as "informal sessions in which representatives of your target population are asked to discuss their thoughts on a speciftc topic or product.,,7 These group discussions reveal the perceptions of the target audience and the issues of importance
lID
journal of the American PbarmaceuticaI Association
Table 3
Planning a Health Education Center for Women: Needs Assessment Questions and Ansvvers Questions
Possible Answers
What issues need to be
Poor health outcomes of women who are at risk for osteoporosis, coronary heart disease, estrogen deficiency
addressed? Who is affected?
Patients, families, employers, physicians, the health care system
How aware is our target population of the issue we want to address?
Develop a questionnaire or brochure; consider a community awareness campaign
Who is interested in the issue?
Patients, families, employers, physicians, other health care providers, third-party payers
What organizations are already addressing the issue?
National research, community efforts, educational programs
How can our pharlJ1acy Identify gaps in existing activities by telephone help resolve the probletn? interviews and questionnaires; direct queries to those most affected WhatdoesourpharlJ1acy want to acconJplish?
Provide targeted health education to women in our practice that will result in improved health and quality of life
What resources are available to us?
Research educational program materials (e.g., government resources, pharmaceutical manufacturers, materials produced by private groups such as the American Heart Association and the American Cancer Society)
Who will bene'it frolJ1 ou~ program?
Female clients, the community, the health care system, pharmacy staff
Source: Reference 6.
to them, as well as the misconceptions that can be corrected through health education. Unlike surveys or questionnaires, focus groups permit a moderator to clarify responses and probe for further information. The interaction among participants fosters the discussion of ideas that may not arise during individual interviews. To be most productive, a focus group should comprise representatives of all segments of the target population, as well as stakeholders in the community (Table 4). Broad representation will not only provide the necessary qualitative information but serve as the first step in forming collaborative relationships within the community. 6 Finally, the focus group can provide a pool of potential members of an advisory committee to help you design, market, and evaluate your program. Focus groups do have limitations. Participants may be hesitant to discuss private issues in such a forum. Some participants may be influenced by those with strong personalities or by the moderator. For these reasons, an experienced modera-
journal of the American Pharmaceutical Association
tor is essential. Moreover, the fmdings of a focus group can· not necessarily be general· ized to a population as a whole. Nonetheless , most health program planners agree that the advantages of focus groups outweigh the disadvantages. If your program is inappro- ) priate and does not meet the needs of your pharmacy's tar· get patient population, it will likely falter or fail because of a lack of clients. Collecting data to better identify your ' target population is therefore essential. For example, if a women 's health education center is to focus on osteo· porosis , you should deter· mine the age range of the women your pharmacy serves. Demographic infor· mation about the surround· ing community may be found in a local library.
Practice Needs
T he second step of the needs assessment is to exam ine the structure and processes of your current practice, The purpose of this assess· ment is to determine whether you have the resources to meet the needs identified through your primary research. SWOT Analysis
Assessing practice needs entails examining the ~trengths, \ weaknesses, QPportunities, and threats related to establishing a women's health education center at your current practice site. Strengths and weaknesses are the personal and professional merits and deficiencies of your practice. Opportunities and threats are external forces that may affect your program, The process of examining each of these four factors is called a SWOT analysis (Table 5). A SWOT analysis requires you to examine existing health education programs in your community. Your state or county health department may be able to provide a list of established programs and initiatives. New Jersey, for example, publishes Countdown to a Healthy New Jersey 2000: Regional Efforts and Progress Toward the Year 2000 Objectives, which out-
January/February 1997
Vol. NS37, No.1
lines statewide health promotion and education programs. similar resources should be available in each state. It is important to formulate thoughtful and relevant questions to determine whether existing programs are meeting the needs of women in your pharmacy's service area. Does a local cancer center sponsor breast cancer screening and awareness programs? Does a local medical center have a childbirth education program? Do area obstetricians employ nurse educators? Do any community organizations sponsor , menopause management programs or women 's support groups?
Table 4
Stakeholders in Women's Health Education
Applying Results of the SWOT Analysis
After completi!lg the SWOT analysis, consider strategies for turning weaknesses into strengths and threats into opportunities. This will likely require changes in both external and internal operations. From the external perspective, establishing a women's health center can be a catalyst for the fonnation of strategic partnerships with other health care providers. For example, you may decide to collaborate with a local preferred provider organization or a physician's office. An alliance between primary care phYSiCians, obstetricians and gynecolOgists, and the local radiology center may be one way for a women's health center to promote awareness of bone densitometry testing and osteoporosis. An alliance may also facilitate negotiation with managed care organizations for reimbursement of cognitive services. Alterations in the pharmacy's physical environment are among the most obvious internal changes that may be needed. To provide an appropriate location for individual counseling, some pharmacists place a desk behind a partition in the corner of the pharmacy and designate a larger space for group learning sessions. For example, the Center for Pharma-
ceutical Care at Amherst, in Lumberton, New Jersey, uses a 6' x 10' room as the health education center. It includes a table and chairs, a bookcase of health education materials, a fue cabinet for patient records, and equipment for educational sessions (e.g., easel and flip-chart, overhead projector, screen). Regardless of its size, the patient education area should be clean, quiet, comfortable, and conducive to information exchange. 6 You may also want to devote a section of your pharmacr to literature on women's health. A carousel with health information brochures can be added to the section of the pharmacy Table 5
Example of SWOT Analysis Strengths
Threats
La rge female population in thei::: 45-year-old age range Established, achievable objectives for osteoporosis prevention
Positive feedback wheA proposed program is , discussed wit h Rhysicians Patient accessibility Interaction with local nursing school Rapport with area women's organizations
Media interest in women's health
Staff have not received training in women's health education in pharmacy school
Capacity for management of menopausal symptoms
No marketing background
Managed care
Vol. NS37, No. 1 January/February 1997
Women's education program already in place at local hospital Other health care professionals maintain health education programs for women Managed care
journal of the American Phannaceutical Association
devoted to over-the-counter products or sundry items for of midlife women: women. Brochures on nutrition, prenatal care , HRT, 1. Promote increased awareness and knowledge of issues menopause, and osteoporosis can trigger conversation and related to menopause management and osteoporosis. opportunities for patient assessment. 1 2. Improve the health status of women nearing or experiencYour phannacy will also need to develop new work flow ing menopause. processes. A system to track educational appointments and activities is very important. Although many phannacies use computers for scheduling activities, an appointment book Objectives will also suffice. The staff must know how to handle patients Objectives describe the steps needed to meet a goal. They who call to make appointments for health education. The per- are necessarily more specific than goals and must include a son's name, address, and phone number, as well as the type time frame or target date. Objectives must be measurable and of education requested, should be recorded. quantifiable, and should answer the questions who, what, . Staffing patterns may need some rearrangement. When why, when, and how much. 6 Objectives should be based on starting out, one afternoon a week may be reserved for health the infonnation garnered from the focus group meeting and education activities, with appointments booked in half-hour other primary research strategies and should reflect your p hiblocks. Additional phannacy staff may be needed to handle losophy of practice. dispensing services during this period. Health educators have defmed six levels of objectives: Professional and support staff should be prepared to dis- • Increased awareness. cuss the health education center with patients. When coun- • Increased knowledge. seling female patients, be proactive in asking how they are • Changes in attitudes. taking care of their own health and that of their families. 1 For • Changes in behavior. example, you might ask, "How are you coping with your • Risk reduction. mother's hip fracture? " or "How have you been feeling late- • Reductions in morbidity and mortality. 7 ly?" On the basis of these responses, you may infonn women The objectives that you select will depend on your level of of the services and programs that your phannacy offers. expertise and your pharmacy's resources. In other words, objectives should be realistic. For example, it would be unrealistic to expect an immediate reduction in morbidity and mortality among the target patient population. However, a Goals and Objectives phannacy-based program may be able to achieve measurable changes in patients' awareness, knowledge, attitudes, and behavior. Objectives should also be modest. It might be advisable to Writing a mission statement that reflects your phannacy's purpose or philosophy of practice can guide the process of begin by focusing on a single issue. Once the health educaestablishing goals for your women's health education cen- tion center becomes more widely recognized and your p roter. For example, the mission of the Amherst Health Educa- gram matures, it may be necessary to revise and expand your tion Center is to provide individualized treatment and educa- objectives. Table 6 lists sample objectives for a phannacytional plans based on patients ' lifestyle, needs, and based women's health education center. challenges; a place for encouragement, understanding, and answers to patients' questions; and education and care to make patients' lives better. Post the mission statement in your phannacy to educate your staff and patients about the Program Planning program. and Inlplementation Written goals and objectives for the program are essential. They provide motivation when implementation seems difficult, lend direction to your activities, and serve as a template Designing Interventions for evaluation. 6 The next step is to develop interventions that will enable you to reach your goals and objectives. Health education Goals interventions must be appropriate for the age, socioeconomic A goal is a broad defmition of what your women's health status, and knowledge level of your target population. Howeveducation program is designed to accomplish. Goals include a er, they may vary enonnously in content and intensity. For "who" and a "what.,,8 The following two goals could apply to example, some studies have shown that a single learning sesa women's health education center with a target population sion can precipitate behavior change; others indicate that sev-
JOumal of the American Pharmaceutical Association
January/February 1997 Vol. NS37, No.1
~
eral sessions may be required. 5 Health education interventions are often based on theoretical models developed by social and behavioral scientists to help explain factors that influence patient behavior. Theories provide a bridge between your goals and objectives and the program as implemented. 8
Theories of Behavioral Change Theories or models of behavioral change can be used as a guide for providing community pharmacy-based women's health education sessions. (These learning sessions may be group based, individualized, or a combination of both.) Three theories or models are commonly used to understand healthrelated behavior: the health belief model, the transtheoretical model, and social learning theory. Some models (e.g., the health belief model) deal with internal motivators that predict behavior. Others (e.g., socialleaming theory) outline the internal and external components related to behavior change. 5,9 The transtheoretical model is based on an analysis of a variety of psychotherapeutic approaches used to facilitate healthrelated behavior change, with commonalities among these approaches synthesized into a single framework. 10 Pharmacists using this model can gear their educational message to the patient's level of motivation. Tables 7 and 8 outline the stages of the transtheoretical model and corresponding educational strategies for the pharmaCist, respectively.6,10 The advantage of the transtheoretical model is that other psychosocial models can be used within it. For example, changing perceived susceptibility may be a goal in the precontemplation stage. Developing behavioral capacity, a social learning theory construct, would be an appropriate target for the action stage.
Translating Theory into Practice Importance of Communication Skills
Pharmacists need to understand how the dynamics of information exchange affect patient outcomes and adherence to the pharmaceutical care plan. Certain factors have been associated with improved quality of patient-provider interactions. An important factor in translating theory into practice is strong communication skills. Studies have shown that patient satisfaction is greatest when patients can explain problems in their own words, present their concerns early in the encounter, and express agreement with the provider's recommended treatment plan. 9 When providers respond to patient questions, health outcomes tend to be better. 9 Encourage patients to express their concerns eady in the learning session; Listen closely; ask questions to fill in the gaps. For example, if a woman inquires about HRT, determine her understanding of menopause and what she expects from
Vol. NS37, No.1
January/February 1997
Table 6
Pharmacy-Based Women's Health Education: Sanlple Program Objectives • During the first year of our program,each of our pharmacists will inform 10 female patients per week of our health education service. • One year after initiation of our program, 900/0 of women with prescriptions for alendronate (Fosamax), calcitonin (Calcimar, Miacalcin), or estrogen products will have been invited to schedule an individual health education session with a pharmacist. ~ After completing formal sessions with a health
education pharmacist, 90% of women considering or receiving estrogen or hormone replacement therapy (ERT/HRT) will demonstrate an understanding of the risks and benefits of their medication regimen to one of our pharmacists. • After completing formal sessions with a health education pharmacist, 900/0 of women receiving , ,a lendronate (Fosamax), calcitonin (Miacalin, Calcimar), HRT, or other treatment for osteoporosis will have an increased knowledge of how to prevent disease complications through appropriate diet and lifestyle. • After attending the group sessions on preventing osteoporosis, 80% of women will be aware of their personal risk for osteoporosis and of appropriate prevention and treatment options. • After attending educational sessions on midlife health, 80% of women will have increased knowledge of dietary and lifestyle measures to prevent ()steoporosis, of bone densitometry testing, and of · drug therapy options for preventing and treating osteoporosis.
medication, identify her concerns, and determine what additional information she or her physician may need.1 It is important to detennine the patient's educational or literacy level. Nontechnical language and short sentences facilitate leaming. 9 Provide the most important information first or last. Reinforce important concepts by repeating or reviewing them throughout the educational session, and check for comprehension by asking the patient to restate in her own words what she has learned. Finally, give the patient written information that she can refer to later. Convey empathy, warmth, and consideration. Ask openended, probing questions and clarify what the patient is requesting. For example, if the patient tells you that her grandmother had "bad bones," you might ask, "Did your grandmother break a hip, or did she have a curved back?" to ascertain whether the "bad bones" were a manifestation of osteoporosis or another medical problem. When the patient has many concerns, help her prioritize them.
journal of the American pharmaceutical Association
Table 7
Stages of the Transtheoretical Model Precontemplation • The patient has not thought about change. • The pharmacist provides information about risks and benefits, and increases patient's awareness about positive outcomes related to change.
Contemplation • The patient may feel there is a problem and is thinking about change. • The pharmacist supports patient concerns, identifies patient support systems, and clarifies misconceptions.
Action • The patient is working toward change or has begun new therapy. • The pharmacist reviews change expectations, provides technical information, and resets or refines goals.
Maintenance • The patient is practicing learned skills and needs to expand coping skills. • The pharmacist provides encouragement and support and develops a relapse plan.
Relapse • The patient has stopped adhering to plan or is practicing old behaviors.
sample learning objectives for a woman considering estro· gen replacement therapy (ERT)/HRT. The following case study demonstrates how to translate the information provided in this article into practical patient care. It shows how to prioritize patient requests, probe for further information, and use the transtheoretical model.
Case Profile
If, a 47-year-old special education teacher, comes to the pharmacy for a health • The pharmacist explains that relapse does not mean failure, examines • The pharmacist develops a care plan education session. From her and timeline for change and provides reasons for relapse, and identifies history, you can see that she positive reinforcement for a decision to strategies for coping with situations change. that lead to relapse. smokes, and that she may not be a candidate f or Termination ERT/HRT because of her • Behavior successfully changed. past history with migraine headaches. She states that Patient Assessnlent Worksheet last year she slipped on the ice and fractured her wrist. Her A worksheet designed for the educational session is a good physician described her injury as a Colles ' fracture. tool for patient assessment. Include all of the topics for which Although she completed a course of physical therapy, no information is required. The worksheet should be problem- one advised her to continue to exercise. II read in a popular specific or disease-state specific. Different worksheets may be magazine that Colles' fracture is often associated with needed for different health education topics. For example, if osteoporosis. The magazine advised women ofII's age who you have an individual education session with a woman con- have had fractures to have a bone-density test, increase sidering HRT, assess the following factors: 1 their calcium intake, lift weights, and stop smoking. II asks what a bone-denSity test is and whether a home • Age. diagnostic kit is available. She also asks whether nonpre· • Mother's age at menopause. scription antacid tablets are a satisfactory calcium supple• Reproductive organ surgical history. ment or whether she should take another medication to • Menstrual history and current cycle status. prevent fractures. • Menopausal symptoms. ]]'s concerns may be different from yours. You may feel • Family history of risks for osteoporosis, heart disease, cancer, hypertriglyceridemia, and stroke. that getting her to stop smoking is the most important priori· ty. However,]] appears to be more interested in "quick fIx" • Previous breast or endometrial cancer, liver disease. • Lifestyle and social habits (e.g. , exercise, smoking, alcohol methods to prevent osteoporosis. Therefore, your task is to ingestion). negotiate a plan that not only addresses prevention, but fIts • Diet (e.g., amount of calcium, vitamin D, carbonated bever- the patient's individual needs. Ask what she believes are the ages). three most important steps to take to prevent another frac• Underlying medical conditions (in particular, liver impair- ture. Agree that these are important issues, but provide your I own views. If quitting smoking is not one of her priorities and ment, thrombosis, hypertension, and gallbladder disease). • Chronic medication use (nonprescription and prescription). you designate this as a priority, she may feel that you are attacking her. Gently provide information about the risks of I • Bone denSity. smoking to move her toward contemplation, then focus onl • Lipid profile. her stated goals. Facilitating behavior change in areas where a • Anxiety/depression history. It may also be helpful to design a set of learning objectives patient is ready to take action is preferable to imposing goals. If]] lists starting a new medication for osteoporosis as ·her related to the topics in which you specialize. Figure 2 provides Preparation • The patient wants to make a change but has not taken action.
journal of the American Pharmaceutical Association
January/February 1997
Vol. NS37, No. 1
most important priority, probe further to determine why she feels this way. Make sure that she understands that a bone density test may be required before starting therapy. Ask her
what she expects from drug therapy. Ask her whether she feels that she will still need to reduce her risk factors if she is taking medication and whether she fmds adhering to a regular Table 8
Health Education Theories Health Behavior Theory
Major Components of Theory
Health Belie' Perceived Model (HBM) perceived perceived perceived perceived
susceptibility, seriousness, benefits, barriers, self-efficacy
Reciprocal determinism (i.e., behavior and environment are bidirectional) Environment Situation Behavior Capacity Expectations Expectancies Observational learning Reinforcements Self-Efficacy
Social Learning Theory
Applicability to a Pharmacy-Based Women's Health Program
Often works well when people have already experienced a health event (e.g., women who have had an osteoporotic fracture or are experiencing menopausal symptoms).
Sample Intervention
Target population: women with a history of osteoporotic fracture; women experiencing symptoms of menopause Program designed to: 1. Review the benefits of appropriate drug therapy, diet, and lifestyle. 2. Design personal strategies to overcome perceived barriers to adherence to pharmaceutical care plan. 3. Assess woman's perception of being able to follow the care plan (e.g., take medication as scheduled) and work towards changing perception to III can do this." Target population: Perimenopausal women
Includes interpersonal factors. Difficult to use. Can be useful for designing complex interProgram designed to: ventions (e.g., an educational 1. Provide positive environment by program to provide patients ' encouraging social support and with a variety of opportunities to learn, practice, and use skills relationships through group health educational sessions. related to osteoporosis 2. Review the health impact of prevention and treatment). osteoporosis and menopause. 3. Review preventive strategies (e.g., diet, exercise, lifestyle changes). 4. Discuss the benefits and risks of current prevention and treatment options, including bone densitometry testing, dietary and lifestyle changes, alendronate (Fosamax), calcitonin (Miacalcin, Calcimar) and ERT/HRT. 5. Provide observational learning through activities that promote healthy bone (e.g., grocery shopping with a nutritionist to help select high-calcium foods). 6. Teach skills needed to maintain a bone-hea Ithy" lifestyle. Target population: perimenopausal Works well for a wide range of women populations and health problems. Program designed to: May be useful for women who 1. Establish credibility with women and gain their trust. are considering preventive 2. Increase awareness among treatment for osteoporosis or perimenopausal women of issues HRT, or evaluating options for relating to menopause, osteoporosis, cardiac health. and heart disease prevention and treatment options. 3. Provide patients in the precontemplation stage with information about risk factors associated with health problem and pros and cons of variou~ pharmacologic and nonpharmacolog1c therapies. 4. Provide individual education to women in other stages of change. II
Transtheoretical Model
Vol. NS37, No.1
Precontemplation Contemplation Preparation Action Maintenance Relapse Termination
January/February 1997
journal of the American PharmaCeUtical Association
Figure 2
Learning Objective Worksheet for Peril11enopausal Women Considering ERT/HRT Date Completed
Date Revie""ed
Objective
Patient can explain in her own words the physiologic an d psychologic changes associated with menopause. Patient can list common menopausal symptoms (e.g., hot flushes, perspiration, palpitations, insomnia, vaginal itching or burning, vaginal dryness, changes in mood, changes in frequency of intercOurse, difficult or painful intercourse). Patient can outline nondrug measures to decrease menopausal symptoms. Patient can list the complications of osteoporosis. Patient can outline nondrug methods to reduce osteoporosis risk (e.g., increasing calcium intake, partaking in weight-bearing exercise, stopping smoking, eliminating environmental hazards that may cause a fall) Patient can list sources of calcium and describe a diet that would provide the recommended amount of calciu m for postmenopausa! women (1500 mg elemental calcium/day). Patient can recite concerns that she would like to bring t o her physician's attention. ;c'
'\
Patient can list potential side effects of therapy and how to deal with them (e.g., cyclic bleeding on cyclic HRT rna y be expected in some women; breakthrough bleeding should be reported to the physician). Patient can discuss the benefits of ERT/HRT to relieve menopausal symptoms, prevent osteoporosis, and, possibly, decrease cardiovascular risk.
pare the letter on your phannaC)' letterhead and include the fol. lowing infonnation: 6 • Patient's name and address. • History of case and your/ role (paragraph 1). • Findings and outcomes of your interventions (paragraph 2). • Recommendations and pharmaceutical care plan (para· graph 3). Document the assessment, care plan, learning objective work sheet, and physician letter in the patient chart. A patient chart selVes as a pennanent database used to keep the pertinent infor· mation about the client and her plan of care. Demographics, farm ly history, social history, medical history, prescription and over the counter medication records, insur·' ance coverage, and other infonm tion can also be maintained in the chart. The chart enables any health care provider to follow the course of a patient's educational sessions and related diet, lifestyle, and drug therapy intenrentions. I
Patient can describe the risks of ERT/HRT. On the basis of her personal and family history, patient can discuss relative and absolute contraindications to ERT/HRT.
Program Evaluation
ERT/HRT = Estrogen replacement therapy/hormone replacement therapy.
medication schedule difficult. Provide her with the information that she requested about calcium supplements. The patient should be given written information, which is available from a variety of sources. For example, the National Osteoporosis Foundation in Washington, D.C. [(202) 2232226], provides a catalog of multimedia educational materials. The Older Women's League, also in Washington, D.C. , is another source of women's health information [(202) 783-6686]. The individualized health education plan should be based on the results of the patient assessment and the patient's level of motivation and understanding. It is negotiated with the patient. Table 9 presents a sample pharmaceutical care plan. Communicate in writing the results of your educational session to the patient's physician. A common method of communication among health care practitioners is the referral letter. 6 Pre-
JOumal of the American Pharmaceutical Association
Periodic evaluation provides feedback that can be used to refme your program. Is your program reaching its target po~ ulation, being implemented as intended, and meeting W: objectives? There are four types of evaluation: formative , process, impact, and outcome. Process and formative evaluations are most applicable to pharmacy-based health education programs. In time, outcome evaluation may also be conducted. Outcome evaluation looks at long-term health outcomes such as quality of life and reductions in morbidity and mortality.s
Formative Evaluation Formative evaluation should be conducted early in the program's implementation phase. This type of evaluation assesses whether you are meeting the needs of the target population.I
January/February 1997
VoL NS37, No.1
Internal and external infonnation should be collected. 5 Internal information includes how pharmacy staff members believe the program is working. External infonnation refers to ), the perceptions and experiences of your target population. Data collection instruments include participant surveys, written questionnaires, and telephone interviews.
Process Evaluation Process evaluation is similar to quality assurance. 5 It can help determine whether your program is being implemented as intended. Process evaluation examines the structure and activities related to your service, and the findings can be used to drive any necessary modifications. Examine whether your staff is promoting the program as outlined in your marketing plan. Are the resources and space proving adequate? Data of interest may include the number of women who requested program infonnation or were referred to the center, reasons for referrals, and the number of women who participated in educational sessions.
Impact Evaluation Impact evaluation is the process by which you examine whether your program is meeting your predetermined knowledge, skill, or behavioral objectives. For example, if an objective was to refer 10 patients to their family physician for follow-up information about bone densitometry testing in a three-month period, did this occur? If you are targeting improved compliance with HRT regimens, were you successful? Data that can be used to determine program impact include pharmacy records and results of provider and participant surveys and pre- and post-tests. (pre-tests ask questions about a topic before the educational sessions. Post-tests ask \ similar questions after the session.)
Marketing Marketing is a planned attempt to influence the components of voluntary exchange. 8 In this case, you are exchanging the costs and benefits of targeted women's health education. The components that govern the exchange-called the "Five Ps" of marketing-are product, price, place, promotion, and people. The product you are marketing is personalized women's health education services. These services are a separate business unit. Pricing cognitive services is a new arena for pharmacists. When determining price, examine current third-party reimbursement for similar services and what competitors charge. Look at your fmancial needs: How much does it cost your practice to provide personnel and marketing support to health education?
Vol. NS37, No.1
January/February 1997
Marketing strategy requires you to position your service relative to others in the market. How will you differentiate your service? Where is the d~mand highest? Focus groups can help answer these types of questions. Using this infonnation, formulate your marketing message. Use a variety of tools to communicate your message, including letters, phone calls, brochures, and one-to-one meetings. The method should be suited to the audience; for example, a personal meeting with the director of health education of a local preferred provider organization may have more impact than a letter. The types of promotional activities you use will depend on your budget, the expertise of your staff, and your community. Methods that a.health education phannacy could use include:6 • Describing the program to individual local physicians. • Developing and disseminating marketing brochures. • Sending letters to patients receiving targeted medications. • Posting signs describing the program at the cash register.
Reimbursement for Cognitive Services Phannacists commonly cite lack of reimbursement as one of the barriers to providing patient education. Most patients Table 9
Sample Pharmaceutical Care Plan for a Postmenopausal Woman Concerned about Osteoporosis Goal To reduce patient's risk of osteoporosis Objectives 1. Educate patient about osteoporosis physiology and its relationship to calcium, vitamin 0, exercise and estrogen (use learning objective worksheets). 2. Ask patient to keep a dietary record for one week to assess current calcium consumption.
3.
Provide information to patient about bone densitometry testing.
4. Explain pharmacologic treatment options available for osteoporosis treatment and prevention. 5. Discuss what is meant by weight-bearing exercise. 6. Make an appointment with physician to discuss possibility of bone densitometry testing. 7. Role-play with the patient to ensure that the patient is able to express her concerns to the physician. 8. Request that patient return to the pharmacy in two weeks for follow-up education.
journal of the American Phannaceutical Association
are not accustomed to paying out of pocket for provider vis- Conclusion its, but this should not prevent you from moving forward with your education program. You may use several strategies to secure reimbursement. A women's health education center is an option for pharo First, during your focus group meeting, determine what macists who are seeking to develop a new revenue-prodUCing' people would be willing to pay. Ask, for example, "do you unit. It also provides an opportunity for personal and profes- ' think $30 is too much, too little, or just right to pay for a sional growth. Before establishing such a center, however, one-hour educational session with your pharmacist?" phannacists must reexamine the philosophy that guides theu Patients will pay for services that they feel will benefit them; practice; assess community needs; determine their practice'! for example, thousands of people pay for programs strengths and weaknesses, opportunities and threats; plan" designed to help them lose wei.ght. Before you can bill for their intervention; and market the program. Also, the pro your services, you must develop an invoice that states the gram must be periodically evaluated. type of education provided, the length of the session, the The educational focus of your center depends not only on rate, and the total payment due. the needs of your target population but also on your own lev· Explore options for third party reimbursement. Many insur- el of knowledge and comfort in providing patient infonnation ance companies are willing to pay pharmacists if they can and counseling. An investment in health education require! document appropriate outcomes. To secure reimbursement that you continually expand your own knowledge, skills, and from an insurance company, you must submit the following abilities. More than anything else, pharmacy-based health edu· cation requires well-articulated, patient-oriented goals and infonnation: • Patient and provider demographic information (e.g, patient objectives and the commitment and capability to meet them. name, address, phone, birth date, social security number). Calvin H Knowlton, PhD, is president; Orsula Voltis Thomas, • Letter of medical necessity from referring physician. • Related International Classification of Diseases (lCD)-9 PharmD, is director of disease state management and pharmaceu· tical care initiatives; Stephanie A. Zarus, PharmD, is vice presicodes (if available). dent, health education resources; and Marissa 1. Buttaro is a pharo • Invoice. macist and project manager, all at the Center for Pharmaceutical • Documentation of care provided and the outcome. Care at Amherst, Lumberton, NJ • Patient's signature. If the claim is rejected, you or the patient may call the insurer and speak to a case manager. Follow up these calls References with a letter that documents your conversation. 6 Another for Pharmaceutical Care at Amherst. Pharmacist's Guide to Man· option is to contact local health maintenance organizations 1. Center aging Menopause. Lumberton, N.J.: Center for Pharmaceutical Careal and preferred provider organizations about becoming a health Amherst; 1995. 2. Public Health Service. Healthy People 2000: National Health Promotion education provider in the planning stages and then follow up and Disease Prevention Objectives: Summary Report. Washington, DC: as the program is implemented. You may be able to establish US Department of Health and Human Services; USDHHS publication, PHS91-50123;1992. your phannacy as a site or secure recognition for your phar3. Melton LF, Riggs B. Epidemiology of age-related fractures. In: Avioli LV, macists as individual providers. ed. The Osteoporotic Syndrome. New York: Grune & Stratton Inc; 1987. A third strategy is to obtain a grant that would enable you 4. Kraynak MA. The women's health movement: political, social and medi· cal issues. Am Pharm. 1994;34:30-5. to provide health education for a limited period of time to a R, Baranowski T, Clark N, et al. Evaluation of Health Promotion, number of patients. Possible sources of grant money include 5. Windsor Health Education, and Disease Prevention Programs. 2nd ed. Mountain , local agencies, the phannaceutical industry, phannacy associView, Calif.: Mayfield Publishing Co; 1994. ations, and nonprofit charitable groups. A research grant may 6. Center for Pharmaceutical Care at Amherst. Focused PharmaceutiCEi, Care: A Sourcebook on Establishing a Diabetes Practice. Washington, provide the start-up funds needed to establish a strategic D.C.: American Pharmaceutical Association (in press). business unit. 7. Green LW, Kreuter MW. Health Promotion Planning: An Educational ana Environmental Approach. 2nd ed. Mountain View, Calif.: Mayfield Pu~ The United States Department of Health and Human Serlishing Co; 1991. vices provides Small Business Innovation Research (SBIR) 8. McKenzie JF, Jurs JL. Planning, Implementing and Evaluating Health Pier , motion Programs: A Primer. New York: Macmillan Publishing Co.; 1993. grants. l1 Call SBIR at (301) 206-9385 and ask for publication 9. Glanz K, Lewis FM, Rimer BK, eds. Health Behavior and Health Educanumber SBIR 96-2 and a grant application. The publication tion: Theory, Research, and Practice. San Francisco, Calif.: Jossey-BaSS includes telephone numbers of federal agencies that award Inc; 1990. health education grants. For example, the National Institute 10. Prochaska J, DiClemente C. Toward a comprehensive model of cha n9d In: Miller VR, Heather N, eds. Treating Addictive Behaviors: ProcesS of Aging supports research on interventions to maintain or Change. New York: Plenum Press; 1986. improve functioning to prevent disease or disability. Informa- 11. US Department of Health and Human Services (USDHHS). Omnibu1, solicitation of the National Institutes of Health, Centers for Disease Corr tion is also available through the National Institutes of Health trol and Prevention, and Food & Drug Administration for Small BusineSS Innovation Research grant applications. Bethesda, Md.: USDHHS; 1996. home page on the World Wide Web (http://www.nih.gov).
journal of the American Pharmaceutical Association
January/February 1997
Vol. NS37, No.1
Learning Objectives
Introduction
Upon successful completion of this continuing education article, the pharmacist should be able to: • List the steps involved in establishing a women's CE Credit health education center in a community pharmacy. CE Credit To obtain two hours of contin• Explain the importance of uing education credit (0.2 conducting a focus group CEU) for completing "Wommeeting before establishing en's Health Education: An Opportunity for Community a pharmacy-based women's Phannacy," complete the health education center. assessment exercise and CE • Identify the components registration fonn and return it to APhA. Acertificate will be of a women's health educaawarded upon achieving a tion intervention objective. passing grade of 700/0 or better: • Describe an educational Pharmacists compl.e !ing this strategy for female patients article by February 1, 2000, who seek information about can receive credit. The hormone replacement theraPhannapy or osteoporosis prevention. ffi American ceutical Association is approved by the • Describe a key objective American Council on Pharof Healthy People 2000, maceutical Education as a which is to increase to at provider of continuing pharmaceutical education. least 90% the number of women counseled about the @ APhA provider number benefits and risks of hor\g) is: 202-OOO-97-013-H04. mone replacement therapy.
Women's health education provides a challenging new opportunity for pharmacists who wish to expand their scope of practice. This article presents step-by-step guidelines for planning, establishing, and evaluating a women's health education center in a community pharmacy.
ILC [
Vol. NS37, No.1
January/February 1997
Need for Pharmacy-Based VVomen's Health Education Women may see their pharmacist more frequently than they see any other health care provider. For a growing number of women who do not have health insurance, the pharmacist may be the only point of regular access to the health care system, for their family members' medications as well as their own. For these reasons, the community pharmacy is a logical place for women to obtain health information. Pharmacists need to devote greater attention to women's health issues for several reasons. 1 Patient compliance can be improved by education leading to proper use of medication and realistic expectations for therapy outcomes. Proper health education and drug therapy can help women prevent the complications of chronic diseases such as osteoporosis, diabetes, and heart disease. Several objectives of Healthy People 2000,
Journal of the American phannaceutical Association
"Women's Health Education: An Opportunity for Community Pharmacy" is part of the Dynamics of Phannaceutical Care: Enriching Patients' Health series for phannacists that appears in theJournal of the American Pharmaceutical Association. Developed by APhA, the series is edited by Janet P. Engle, PhannD, FAPhA, associate dean for academic affairs and clinical professor of phannacy practice, University ofDlinois at Oticago, and supported by an educational grant from Merck Human Health Division. The Dynamics of Phannaceutical Care: Enriching Patients' Health series was formerly known as the Value Added Services series.
an initiative published in 1992 by the U. S. Department of Health and Human Services (HHS) with the goal of improving national health, relate directly to women's health (see Table 1). 2 Current public interest in osteoporosis, breast cancer, weight-reduction medications, and new antidepressant drugs makes these areas particularly promising for a phannacy-based education program. Programs that build on the phannacist's customary areas of Table 1
Examples of Healthy People 2000 Objectives Relating to Women's Health • Increase to at least 900/0 the proportion of perimen<;>pausal women who have been counseled about the benefits and risks of estrogen replacement therapy (combined with progestin when appropriate). • Reduce unintended pregnancies to no more than 30% of pregnancies and increase the effectiveness with which family planning methods are used. • Increase to at least 450/0 the proportion of people with major depressive disorders who obtain treatment. • Reduce coronary heart disease deaths to no more than 100 per 100,000 people. • Increase clinical breast examinations and mammography every two years to at least 60% of women aged 50 and older. • Reduce the prevalence of overweight among people aged 20 and older to 20% or lower. • Reduce iron deficiency to less than 3% among children aged 1-4 and among women of childbearing age. Source: Reference 2.
JOunW of the American phannaceutical Association
expertise, and that have the potential to reduce morbidity, mortality, and health care costs, are logical starting points. For example, pharmacists have specialized knowledge of the medications used to prevent and treat osteoporosis, a disease ) that affects 50% of women over age 45 and 90% of women over age 75. 3 Fractures from osteoporosis are responsible for ' $7 to $10 billion in annual health care costs in the United States. 3 A pharmacy-based osteoporosis health education program can increase patients' awareness and knowledge of pre· vention and treatment of this disease. A phannacy-based program need not be limited to "tradi· tional" women's health areas (e.g., the reproductive cycle). Coronary heart disease (CHD), for example, is the leading cause of death among postmenopausal women. 4 Other rele· vant topics include compliance with hypertensive and antilipidemic regimens, -diet and lifestyle changes, and the 1 benefits and risks of hormone replacement therapy (HR1), \ Women who are considering having children may benefit from diabetes education.
Getting Started The steps involved in establishing a women's health educa· tion center are summarized in Table 2. Derived from a classic health education program planning model, these steps can be Table 2
How to Develop a PharmacyBased Health Education Program for Women • Identify the health education needs of women in your community. • Develop expertise in one or several women's health topics. .. Assess the activity and system changes needed to provide health education in your practice. • Create goals and objectives for your health education program. •
Design your program plan and interventions.
• Develop or obtain educational materials to supplement pharmacist counseling. •
Market your program.
•
Implement your program.
• Evaluate results and use findings to improve the quality of your health education program.
January/February 1997
Vol. NS37, No, 1
Figure 1
Health Education Program Planning and Implementation Tlmalina -'
January
February
March
May
April
~
J uy I
J une
August
s eptember
October November Decemj:>er
Assess needs Educate staff Conduct SWOT analysis
""l) lie<.
Hold focus group Identify needed resou rces ' ..
Re-engineer site
/'
!,
.~
':h,
'i'i
Train support personnel Develop mission statement Set goals and objectives !iI.l
lJ
~'
,ill
Design and print educational forms .
.
.i,.
':.'"
"
!!!
,~
~,
."
"
to
1;;
"1
M:
,~
.,,' I ~ ~.
~
Obtain lists of possible patients Implement health education services
e .':f,~'''':
,t
.,~.
~j
Q?j,
"
Develop educational curricula
Send letter to local physicians
I.".,,!,
'1;1
'to,
"l
Develop marketing materials
'"
,-','
i
I,
1ft'
". !
...
i
<'til!!,!""".
l\!,0
~?
t P~"
."If
i'
.1
'wt,
Monitor and evaluate services Refine program
;~.
II!:
Source: Focused Pharmaceutical Care: A Sourcebook on Establishing a Diabetes Practice. Washington, D.C.: American Pharmaceutical Association; in press. Developed by the Center for Pharmaceutical Care at Amherst, lumberton, N.J.
Needs of Your Target Population
readily translated into the actions needed to design and implement a phannacy-based education program. As your work proceeds, you will need a means of tracking progress and ensuring that project timelines are being met. Figure 1 shows a sample timeline. Note that several activities can be pursued concurrently.
The questions in Table 3 will help you better understand women's health issues in your community. The following subsections describe the needs assessment process. Primary Research
Needs Assessment As noted in Table 2, the ftrst step in program planning is to conduct a needs assessment. Windsor et al. 5 defme a needs assessment as the process by which the program planner identiftes and measures the gaps between what is and what oUght to be. A needs assessment can determine which topics are best suited to your patient population, who is affected by a particular health problem, what is being done about it, and What needs to be done about it. For best results, approach the needs assessment from the perspective of your target population and that of your practice.
VoL NS37, No.1
January/February 1997
The flfSt question is, "What issues need to be addressed?" A primary data search can help you identify the concerns of the women in your community. Methods of primary data collection include mailed questionnaires, target population surveys, community forums, opinion leader surveys, and focus groups. A research method may be quantitative, qualitative, or a combination thereof. For example, mailed questionnaires are often used to obtain quantitative data (e.g., "Seventy~ne percent of respondents stated that they would be interested in menopause management education,,). 6 Focus groups are a relatively inexpensive qualitative research method. Green and Kreuter defme focus groups as "informal sessions in which representatives of your target population are asked to discuss their thoughts on a speciftc topic or product.,,7 These group discussions reveal the perceptions of the target audience and the issues of importance
lID
journal of the American PbarmaceuticaI Association
Table 3
Planning a Health Education Center for Women: Needs Assessment Questions and Ansvvers Questions
Possible Answers
What issues need to be
Poor health outcomes of women who are at risk for osteoporosis, coronary heart disease, estrogen deficiency
addressed? Who is affected?
Patients, families, employers, physicians, the health care system
How aware is our target population of the issue we want to address?
Develop a questionnaire or brochure; consider a community awareness campaign
Who is interested in the issue?
Patients, families, employers, physicians, other health care providers, third-party payers
What organizations are already addressing the issue?
National research, community efforts, educational programs
How can our pharlJ1acy Identify gaps in existing activities by telephone help resolve the probletn? interviews and questionnaires; direct queries to those most affected WhatdoesourpharlJ1acy want to acconJplish?
Provide targeted health education to women in our practice that will result in improved health and quality of life
What resources are available to us?
Research educational program materials (e.g., government resources, pharmaceutical manufacturers, materials produced by private groups such as the American Heart Association and the American Cancer Society)
Who will bene'it frolJ1 ou~ program?
Female clients, the community, the health care system, pharmacy staff
Source: Reference 6.
to them, as well as the misconceptions that can be corrected through health education. Unlike surveys or questionnaires, focus groups permit a moderator to clarify responses and probe for further information. The interaction among participants fosters the discussion of ideas that may not arise during individual interviews. To be most productive, a focus group should comprise representatives of all segments of the target population, as well as stakeholders in the community (Table 4). Broad representation will not only provide the necessary qualitative information but serve as the first step in forming collaborative relationships within the community. 6 Finally, the focus group can provide a pool of potential members of an advisory committee to help you design, market, and evaluate your program. Focus groups do have limitations. Participants may be hesitant to discuss private issues in such a forum. Some participants may be influenced by those with strong personalities or by the moderator. For these reasons, an experienced modera-
journal of the American Pharmaceutical Association
tor is essential. Moreover, the fmdings of a focus group can· not necessarily be general· ized to a population as a whole. Nonetheless , most health program planners agree that the advantages of focus groups outweigh the disadvantages. If your program is inappro- ) priate and does not meet the needs of your pharmacy's tar· get patient population, it will likely falter or fail because of a lack of clients. Collecting data to better identify your ' target population is therefore essential. For example, if a women 's health education center is to focus on osteo· porosis , you should deter· mine the age range of the women your pharmacy serves. Demographic infor· mation about the surround· ing community may be found in a local library.
Practice Needs
T he second step of the needs assessment is to exam ine the structure and processes of your current practice, The purpose of this assess· ment is to determine whether you have the resources to meet the needs identified through your primary research. SWOT Analysis
Assessing practice needs entails examining the ~trengths, \ weaknesses, QPportunities, and threats related to establishing a women's health education center at your current practice site. Strengths and weaknesses are the personal and professional merits and deficiencies of your practice. Opportunities and threats are external forces that may affect your program, The process of examining each of these four factors is called a SWOT analysis (Table 5). A SWOT analysis requires you to examine existing health education programs in your community. Your state or county health department may be able to provide a list of established programs and initiatives. New Jersey, for example, publishes Countdown to a Healthy New Jersey 2000: Regional Efforts and Progress Toward the Year 2000 Objectives, which out-
January/February 1997
Vol. NS37, No.1
lines statewide health promotion and education programs. similar resources should be available in each state. It is important to formulate thoughtful and relevant questions to determine whether existing programs are meeting the needs of women in your pharmacy's service area. Does a local cancer center sponsor breast cancer screening and awareness programs? Does a local medical center have a childbirth education program? Do area obstetricians employ nurse educators? Do any community organizations sponsor , menopause management programs or women 's support groups?
Table 4
Stakeholders in Women's Health Education
Applying Results of the SWOT Analysis
After completi!lg the SWOT analysis, consider strategies for turning weaknesses into strengths and threats into opportunities. This will likely require changes in both external and internal operations. From the external perspective, establishing a women's health center can be a catalyst for the fonnation of strategic partnerships with other health care providers. For example, you may decide to collaborate with a local preferred provider organization or a physician's office. An alliance between primary care phYSiCians, obstetricians and gynecolOgists, and the local radiology center may be one way for a women's health center to promote awareness of bone densitometry testing and osteoporosis. An alliance may also facilitate negotiation with managed care organizations for reimbursement of cognitive services. Alterations in the pharmacy's physical environment are among the most obvious internal changes that may be needed. To provide an appropriate location for individual counseling, some pharmacists place a desk behind a partition in the corner of the pharmacy and designate a larger space for group learning sessions. For example, the Center for Pharma-
ceutical Care at Amherst, in Lumberton, New Jersey, uses a 6' x 10' room as the health education center. It includes a table and chairs, a bookcase of health education materials, a fue cabinet for patient records, and equipment for educational sessions (e.g., easel and flip-chart, overhead projector, screen). Regardless of its size, the patient education area should be clean, quiet, comfortable, and conducive to information exchange. 6 You may also want to devote a section of your pharmacr to literature on women's health. A carousel with health information brochures can be added to the section of the pharmacy Table 5
Example of SWOT Analysis Strengths
Threats
La rge female population in thei::: 45-year-old age range Established, achievable objectives for osteoporosis prevention
Positive feedback wheA proposed program is , discussed wit h Rhysicians Patient accessibility Interaction with local nursing school Rapport with area women's organizations
Media interest in women's health
Staff have not received training in women's health education in pharmacy school
Capacity for management of menopausal symptoms
No marketing background
Managed care
Vol. NS37, No. 1 January/February 1997
Women's education program already in place at local hospital Other health care professionals maintain health education programs for women Managed care
journal of the American Phannaceutical Association
devoted to over-the-counter products or sundry items for of midlife women: women. Brochures on nutrition, prenatal care , HRT, 1. Promote increased awareness and knowledge of issues menopause, and osteoporosis can trigger conversation and related to menopause management and osteoporosis. opportunities for patient assessment. 1 2. Improve the health status of women nearing or experiencYour phannacy will also need to develop new work flow ing menopause. processes. A system to track educational appointments and activities is very important. Although many phannacies use computers for scheduling activities, an appointment book Objectives will also suffice. The staff must know how to handle patients Objectives describe the steps needed to meet a goal. They who call to make appointments for health education. The per- are necessarily more specific than goals and must include a son's name, address, and phone number, as well as the type time frame or target date. Objectives must be measurable and of education requested, should be recorded. quantifiable, and should answer the questions who, what, . Staffing patterns may need some rearrangement. When why, when, and how much. 6 Objectives should be based on starting out, one afternoon a week may be reserved for health the infonnation garnered from the focus group meeting and education activities, with appointments booked in half-hour other primary research strategies and should reflect your p hiblocks. Additional phannacy staff may be needed to handle losophy of practice. dispensing services during this period. Health educators have defmed six levels of objectives: Professional and support staff should be prepared to dis- • Increased awareness. cuss the health education center with patients. When coun- • Increased knowledge. seling female patients, be proactive in asking how they are • Changes in attitudes. taking care of their own health and that of their families. 1 For • Changes in behavior. example, you might ask, "How are you coping with your • Risk reduction. mother's hip fracture? " or "How have you been feeling late- • Reductions in morbidity and mortality. 7 ly?" On the basis of these responses, you may infonn women The objectives that you select will depend on your level of of the services and programs that your phannacy offers. expertise and your pharmacy's resources. In other words, objectives should be realistic. For example, it would be unrealistic to expect an immediate reduction in morbidity and mortality among the target patient population. However, a Goals and Objectives phannacy-based program may be able to achieve measurable changes in patients' awareness, knowledge, attitudes, and behavior. Objectives should also be modest. It might be advisable to Writing a mission statement that reflects your phannacy's purpose or philosophy of practice can guide the process of begin by focusing on a single issue. Once the health educaestablishing goals for your women's health education cen- tion center becomes more widely recognized and your p roter. For example, the mission of the Amherst Health Educa- gram matures, it may be necessary to revise and expand your tion Center is to provide individualized treatment and educa- objectives. Table 6 lists sample objectives for a phannacytional plans based on patients ' lifestyle, needs, and based women's health education center. challenges; a place for encouragement, understanding, and answers to patients' questions; and education and care to make patients' lives better. Post the mission statement in your phannacy to educate your staff and patients about the Program Planning program. and Inlplementation Written goals and objectives for the program are essential. They provide motivation when implementation seems difficult, lend direction to your activities, and serve as a template Designing Interventions for evaluation. 6 The next step is to develop interventions that will enable you to reach your goals and objectives. Health education Goals interventions must be appropriate for the age, socioeconomic A goal is a broad defmition of what your women's health status, and knowledge level of your target population. Howeveducation program is designed to accomplish. Goals include a er, they may vary enonnously in content and intensity. For "who" and a "what.,,8 The following two goals could apply to example, some studies have shown that a single learning sesa women's health education center with a target population sion can precipitate behavior change; others indicate that sev-
JOumal of the American Pharmaceutical Association
January/February 1997 Vol. NS37, No.1
~
eral sessions may be required. 5 Health education interventions are often based on theoretical models developed by social and behavioral scientists to help explain factors that influence patient behavior. Theories provide a bridge between your goals and objectives and the program as implemented. 8
Theories of Behavioral Change Theories or models of behavioral change can be used as a guide for providing community pharmacy-based women's health education sessions. (These learning sessions may be group based, individualized, or a combination of both.) Three theories or models are commonly used to understand healthrelated behavior: the health belief model, the transtheoretical model, and social learning theory. Some models (e.g., the health belief model) deal with internal motivators that predict behavior. Others (e.g., socialleaming theory) outline the internal and external components related to behavior change. 5,9 The transtheoretical model is based on an analysis of a variety of psychotherapeutic approaches used to facilitate healthrelated behavior change, with commonalities among these approaches synthesized into a single framework. 10 Pharmacists using this model can gear their educational message to the patient's level of motivation. Tables 7 and 8 outline the stages of the transtheoretical model and corresponding educational strategies for the pharmaCist, respectively.6,10 The advantage of the transtheoretical model is that other psychosocial models can be used within it. For example, changing perceived susceptibility may be a goal in the precontemplation stage. Developing behavioral capacity, a social learning theory construct, would be an appropriate target for the action stage.
Translating Theory into Practice Importance of Communication Skills
Pharmacists need to understand how the dynamics of information exchange affect patient outcomes and adherence to the pharmaceutical care plan. Certain factors have been associated with improved quality of patient-provider interactions. An important factor in translating theory into practice is strong communication skills. Studies have shown that patient satisfaction is greatest when patients can explain problems in their own words, present their concerns early in the encounter, and express agreement with the provider's recommended treatment plan. 9 When providers respond to patient questions, health outcomes tend to be better. 9 Encourage patients to express their concerns eady in the learning session; Listen closely; ask questions to fill in the gaps. For example, if a woman inquires about HRT, determine her understanding of menopause and what she expects from
Vol. NS37, No.1
January/February 1997
Table 6
Pharmacy-Based Women's Health Education: Sanlple Program Objectives • During the first year of our program,each of our pharmacists will inform 10 female patients per week of our health education service. • One year after initiation of our program, 900/0 of women with prescriptions for alendronate (Fosamax), calcitonin (Calcimar, Miacalcin), or estrogen products will have been invited to schedule an individual health education session with a pharmacist. ~ After completing formal sessions with a health
education pharmacist, 90% of women considering or receiving estrogen or hormone replacement therapy (ERT/HRT) will demonstrate an understanding of the risks and benefits of their medication regimen to one of our pharmacists. • After completing formal sessions with a health education pharmacist, 900/0 of women receiving , ,a lendronate (Fosamax), calcitonin (Miacalin, Calcimar), HRT, or other treatment for osteoporosis will have an increased knowledge of how to prevent disease complications through appropriate diet and lifestyle. • After attending the group sessions on preventing osteoporosis, 80% of women will be aware of their personal risk for osteoporosis and of appropriate prevention and treatment options. • After attending educational sessions on midlife health, 80% of women will have increased knowledge of dietary and lifestyle measures to prevent ()steoporosis, of bone densitometry testing, and of · drug therapy options for preventing and treating osteoporosis.
medication, identify her concerns, and determine what additional information she or her physician may need.1 It is important to detennine the patient's educational or literacy level. Nontechnical language and short sentences facilitate leaming. 9 Provide the most important information first or last. Reinforce important concepts by repeating or reviewing them throughout the educational session, and check for comprehension by asking the patient to restate in her own words what she has learned. Finally, give the patient written information that she can refer to later. Convey empathy, warmth, and consideration. Ask openended, probing questions and clarify what the patient is requesting. For example, if the patient tells you that her grandmother had "bad bones," you might ask, "Did your grandmother break a hip, or did she have a curved back?" to ascertain whether the "bad bones" were a manifestation of osteoporosis or another medical problem. When the patient has many concerns, help her prioritize them.
journal of the American pharmaceutical Association
Table 7
Stages of the Transtheoretical Model Precontemplation • The patient has not thought about change. • The pharmacist provides information about risks and benefits, and increases patient's awareness about positive outcomes related to change.
Contemplation • The patient may feel there is a problem and is thinking about change. • The pharmacist supports patient concerns, identifies patient support systems, and clarifies misconceptions.
Action • The patient is working toward change or has begun new therapy. • The pharmacist reviews change expectations, provides technical information, and resets or refines goals.
Maintenance • The patient is practicing learned skills and needs to expand coping skills. • The pharmacist provides encouragement and support and develops a relapse plan.
Relapse • The patient has stopped adhering to plan or is practicing old behaviors.
sample learning objectives for a woman considering estro· gen replacement therapy (ERT)/HRT. The following case study demonstrates how to translate the information provided in this article into practical patient care. It shows how to prioritize patient requests, probe for further information, and use the transtheoretical model.
Case Profile
If, a 47-year-old special education teacher, comes to the pharmacy for a health • The pharmacist explains that relapse does not mean failure, examines • The pharmacist develops a care plan education session. From her and timeline for change and provides reasons for relapse, and identifies history, you can see that she positive reinforcement for a decision to strategies for coping with situations change. that lead to relapse. smokes, and that she may not be a candidate f or Termination ERT/HRT because of her • Behavior successfully changed. past history with migraine headaches. She states that Patient Assessnlent Worksheet last year she slipped on the ice and fractured her wrist. Her A worksheet designed for the educational session is a good physician described her injury as a Colles ' fracture. tool for patient assessment. Include all of the topics for which Although she completed a course of physical therapy, no information is required. The worksheet should be problem- one advised her to continue to exercise. II read in a popular specific or disease-state specific. Different worksheets may be magazine that Colles' fracture is often associated with needed for different health education topics. For example, if osteoporosis. The magazine advised women ofII's age who you have an individual education session with a woman con- have had fractures to have a bone-density test, increase sidering HRT, assess the following factors: 1 their calcium intake, lift weights, and stop smoking. II asks what a bone-denSity test is and whether a home • Age. diagnostic kit is available. She also asks whether nonpre· • Mother's age at menopause. scription antacid tablets are a satisfactory calcium supple• Reproductive organ surgical history. ment or whether she should take another medication to • Menstrual history and current cycle status. prevent fractures. • Menopausal symptoms. ]]'s concerns may be different from yours. You may feel • Family history of risks for osteoporosis, heart disease, cancer, hypertriglyceridemia, and stroke. that getting her to stop smoking is the most important priori· ty. However,]] appears to be more interested in "quick fIx" • Previous breast or endometrial cancer, liver disease. • Lifestyle and social habits (e.g. , exercise, smoking, alcohol methods to prevent osteoporosis. Therefore, your task is to ingestion). negotiate a plan that not only addresses prevention, but fIts • Diet (e.g., amount of calcium, vitamin D, carbonated bever- the patient's individual needs. Ask what she believes are the ages). three most important steps to take to prevent another frac• Underlying medical conditions (in particular, liver impair- ture. Agree that these are important issues, but provide your I own views. If quitting smoking is not one of her priorities and ment, thrombosis, hypertension, and gallbladder disease). • Chronic medication use (nonprescription and prescription). you designate this as a priority, she may feel that you are attacking her. Gently provide information about the risks of I • Bone denSity. smoking to move her toward contemplation, then focus onl • Lipid profile. her stated goals. Facilitating behavior change in areas where a • Anxiety/depression history. It may also be helpful to design a set of learning objectives patient is ready to take action is preferable to imposing goals. If]] lists starting a new medication for osteoporosis as ·her related to the topics in which you specialize. Figure 2 provides Preparation • The patient wants to make a change but has not taken action.
journal of the American Pharmaceutical Association
January/February 1997
Vol. NS37, No. 1
most important priority, probe further to determine why she feels this way. Make sure that she understands that a bone density test may be required before starting therapy. Ask her
what she expects from drug therapy. Ask her whether she feels that she will still need to reduce her risk factors if she is taking medication and whether she fmds adhering to a regular Table 8
Health Education Theories Health Behavior Theory
Major Components of Theory
Health Belie' Perceived Model (HBM) perceived perceived perceived perceived
susceptibility, seriousness, benefits, barriers, self-efficacy
Reciprocal determinism (i.e., behavior and environment are bidirectional) Environment Situation Behavior Capacity Expectations Expectancies Observational learning Reinforcements Self-Efficacy
Social Learning Theory
Applicability to a Pharmacy-Based Women's Health Program
Often works well when people have already experienced a health event (e.g., women who have had an osteoporotic fracture or are experiencing menopausal symptoms).
Sample Intervention
Target population: women with a history of osteoporotic fracture; women experiencing symptoms of menopause Program designed to: 1. Review the benefits of appropriate drug therapy, diet, and lifestyle. 2. Design personal strategies to overcome perceived barriers to adherence to pharmaceutical care plan. 3. Assess woman's perception of being able to follow the care plan (e.g., take medication as scheduled) and work towards changing perception to III can do this." Target population: Perimenopausal women
Includes interpersonal factors. Difficult to use. Can be useful for designing complex interProgram designed to: ventions (e.g., an educational 1. Provide positive environment by program to provide patients ' encouraging social support and with a variety of opportunities to learn, practice, and use skills relationships through group health educational sessions. related to osteoporosis 2. Review the health impact of prevention and treatment). osteoporosis and menopause. 3. Review preventive strategies (e.g., diet, exercise, lifestyle changes). 4. Discuss the benefits and risks of current prevention and treatment options, including bone densitometry testing, dietary and lifestyle changes, alendronate (Fosamax), calcitonin (Miacalcin, Calcimar) and ERT/HRT. 5. Provide observational learning through activities that promote healthy bone (e.g., grocery shopping with a nutritionist to help select high-calcium foods). 6. Teach skills needed to maintain a bone-hea Ithy" lifestyle. Target population: perimenopausal Works well for a wide range of women populations and health problems. Program designed to: May be useful for women who 1. Establish credibility with women and gain their trust. are considering preventive 2. Increase awareness among treatment for osteoporosis or perimenopausal women of issues HRT, or evaluating options for relating to menopause, osteoporosis, cardiac health. and heart disease prevention and treatment options. 3. Provide patients in the precontemplation stage with information about risk factors associated with health problem and pros and cons of variou~ pharmacologic and nonpharmacolog1c therapies. 4. Provide individual education to women in other stages of change. II
Transtheoretical Model
Vol. NS37, No.1
Precontemplation Contemplation Preparation Action Maintenance Relapse Termination
January/February 1997
journal of the American PharmaCeUtical Association
Figure 2
Learning Objective Worksheet for Peril11enopausal Women Considering ERT/HRT Date Completed
Date Revie""ed
Objective
Patient can explain in her own words the physiologic an d psychologic changes associated with menopause. Patient can list common menopausal symptoms (e.g., hot flushes, perspiration, palpitations, insomnia, vaginal itching or burning, vaginal dryness, changes in mood, changes in frequency of intercOurse, difficult or painful intercourse). Patient can outline nondrug measures to decrease menopausal symptoms. Patient can list the complications of osteoporosis. Patient can outline nondrug methods to reduce osteoporosis risk (e.g., increasing calcium intake, partaking in weight-bearing exercise, stopping smoking, eliminating environmental hazards that may cause a fall) Patient can list sources of calcium and describe a diet that would provide the recommended amount of calciu m for postmenopausa! women (1500 mg elemental calcium/day). Patient can recite concerns that she would like to bring t o her physician's attention. ;c'
'\
Patient can list potential side effects of therapy and how to deal with them (e.g., cyclic bleeding on cyclic HRT rna y be expected in some women; breakthrough bleeding should be reported to the physician). Patient can discuss the benefits of ERT/HRT to relieve menopausal symptoms, prevent osteoporosis, and, possibly, decrease cardiovascular risk.
pare the letter on your phannaC)' letterhead and include the fol. lowing infonnation: 6 • Patient's name and address. • History of case and your/ role (paragraph 1). • Findings and outcomes of your interventions (paragraph 2). • Recommendations and pharmaceutical care plan (para· graph 3). Document the assessment, care plan, learning objective work sheet, and physician letter in the patient chart. A patient chart selVes as a pennanent database used to keep the pertinent infor· mation about the client and her plan of care. Demographics, farm ly history, social history, medical history, prescription and over the counter medication records, insur·' ance coverage, and other infonm tion can also be maintained in the chart. The chart enables any health care provider to follow the course of a patient's educational sessions and related diet, lifestyle, and drug therapy intenrentions. I
Patient can describe the risks of ERT/HRT. On the basis of her personal and family history, patient can discuss relative and absolute contraindications to ERT/HRT.
Program Evaluation
ERT/HRT = Estrogen replacement therapy/hormone replacement therapy.
medication schedule difficult. Provide her with the information that she requested about calcium supplements. The patient should be given written information, which is available from a variety of sources. For example, the National Osteoporosis Foundation in Washington, D.C. [(202) 2232226], provides a catalog of multimedia educational materials. The Older Women's League, also in Washington, D.C. , is another source of women's health information [(202) 783-6686]. The individualized health education plan should be based on the results of the patient assessment and the patient's level of motivation and understanding. It is negotiated with the patient. Table 9 presents a sample pharmaceutical care plan. Communicate in writing the results of your educational session to the patient's physician. A common method of communication among health care practitioners is the referral letter. 6 Pre-
JOumal of the American Pharmaceutical Association
Periodic evaluation provides feedback that can be used to refme your program. Is your program reaching its target po~ ulation, being implemented as intended, and meeting W: objectives? There are four types of evaluation: formative , process, impact, and outcome. Process and formative evaluations are most applicable to pharmacy-based health education programs. In time, outcome evaluation may also be conducted. Outcome evaluation looks at long-term health outcomes such as quality of life and reductions in morbidity and mortality.s
Formative Evaluation Formative evaluation should be conducted early in the program's implementation phase. This type of evaluation assesses whether you are meeting the needs of the target population.I
January/February 1997
VoL NS37, No.1
Internal and external infonnation should be collected. 5 Internal information includes how pharmacy staff members believe the program is working. External infonnation refers to ), the perceptions and experiences of your target population. Data collection instruments include participant surveys, written questionnaires, and telephone interviews.
Process Evaluation Process evaluation is similar to quality assurance. 5 It can help determine whether your program is being implemented as intended. Process evaluation examines the structure and activities related to your service, and the findings can be used to drive any necessary modifications. Examine whether your staff is promoting the program as outlined in your marketing plan. Are the resources and space proving adequate? Data of interest may include the number of women who requested program infonnation or were referred to the center, reasons for referrals, and the number of women who participated in educational sessions.
Impact Evaluation Impact evaluation is the process by which you examine whether your program is meeting your predetermined knowledge, skill, or behavioral objectives. For example, if an objective was to refer 10 patients to their family physician for follow-up information about bone densitometry testing in a three-month period, did this occur? If you are targeting improved compliance with HRT regimens, were you successful? Data that can be used to determine program impact include pharmacy records and results of provider and participant surveys and pre- and post-tests. (pre-tests ask questions about a topic before the educational sessions. Post-tests ask \ similar questions after the session.)
Marketing Marketing is a planned attempt to influence the components of voluntary exchange. 8 In this case, you are exchanging the costs and benefits of targeted women's health education. The components that govern the exchange-called the "Five Ps" of marketing-are product, price, place, promotion, and people. The product you are marketing is personalized women's health education services. These services are a separate business unit. Pricing cognitive services is a new arena for pharmacists. When determining price, examine current third-party reimbursement for similar services and what competitors charge. Look at your fmancial needs: How much does it cost your practice to provide personnel and marketing support to health education?
Vol. NS37, No.1
January/February 1997
Marketing strategy requires you to position your service relative to others in the market. How will you differentiate your service? Where is the d~mand highest? Focus groups can help answer these types of questions. Using this infonnation, formulate your marketing message. Use a variety of tools to communicate your message, including letters, phone calls, brochures, and one-to-one meetings. The method should be suited to the audience; for example, a personal meeting with the director of health education of a local preferred provider organization may have more impact than a letter. The types of promotional activities you use will depend on your budget, the expertise of your staff, and your community. Methods that a.health education phannacy could use include:6 • Describing the program to individual local physicians. • Developing and disseminating marketing brochures. • Sending letters to patients receiving targeted medications. • Posting signs describing the program at the cash register.
Reimbursement for Cognitive Services Phannacists commonly cite lack of reimbursement as one of the barriers to providing patient education. Most patients Table 9
Sample Pharmaceutical Care Plan for a Postmenopausal Woman Concerned about Osteoporosis Goal To reduce patient's risk of osteoporosis Objectives 1. Educate patient about osteoporosis physiology and its relationship to calcium, vitamin 0, exercise and estrogen (use learning objective worksheets). 2. Ask patient to keep a dietary record for one week to assess current calcium consumption.
3.
Provide information to patient about bone densitometry testing.
4. Explain pharmacologic treatment options available for osteoporosis treatment and prevention. 5. Discuss what is meant by weight-bearing exercise. 6. Make an appointment with physician to discuss possibility of bone densitometry testing. 7. Role-play with the patient to ensure that the patient is able to express her concerns to the physician. 8. Request that patient return to the pharmacy in two weeks for follow-up education.
journal of the American Phannaceutical Association
are not accustomed to paying out of pocket for provider vis- Conclusion its, but this should not prevent you from moving forward with your education program. You may use several strategies to secure reimbursement. A women's health education center is an option for pharo First, during your focus group meeting, determine what macists who are seeking to develop a new revenue-prodUCing' people would be willing to pay. Ask, for example, "do you unit. It also provides an opportunity for personal and profes- ' think $30 is too much, too little, or just right to pay for a sional growth. Before establishing such a center, however, one-hour educational session with your pharmacist?" phannacists must reexamine the philosophy that guides theu Patients will pay for services that they feel will benefit them; practice; assess community needs; determine their practice'! for example, thousands of people pay for programs strengths and weaknesses, opportunities and threats; plan" designed to help them lose wei.ght. Before you can bill for their intervention; and market the program. Also, the pro your services, you must develop an invoice that states the gram must be periodically evaluated. type of education provided, the length of the session, the The educational focus of your center depends not only on rate, and the total payment due. the needs of your target population but also on your own lev· Explore options for third party reimbursement. Many insur- el of knowledge and comfort in providing patient infonnation ance companies are willing to pay pharmacists if they can and counseling. An investment in health education require! document appropriate outcomes. To secure reimbursement that you continually expand your own knowledge, skills, and from an insurance company, you must submit the following abilities. More than anything else, pharmacy-based health edu· cation requires well-articulated, patient-oriented goals and infonnation: • Patient and provider demographic information (e.g, patient objectives and the commitment and capability to meet them. name, address, phone, birth date, social security number). Calvin H Knowlton, PhD, is president; Orsula Voltis Thomas, • Letter of medical necessity from referring physician. • Related International Classification of Diseases (lCD)-9 PharmD, is director of disease state management and pharmaceu· tical care initiatives; Stephanie A. Zarus, PharmD, is vice presicodes (if available). dent, health education resources; and Marissa 1. Buttaro is a pharo • Invoice. macist and project manager, all at the Center for Pharmaceutical • Documentation of care provided and the outcome. Care at Amherst, Lumberton, NJ • Patient's signature. If the claim is rejected, you or the patient may call the insurer and speak to a case manager. Follow up these calls References with a letter that documents your conversation. 6 Another for Pharmaceutical Care at Amherst. Pharmacist's Guide to Man· option is to contact local health maintenance organizations 1. Center aging Menopause. Lumberton, N.J.: Center for Pharmaceutical Careal and preferred provider organizations about becoming a health Amherst; 1995. 2. Public Health Service. Healthy People 2000: National Health Promotion education provider in the planning stages and then follow up and Disease Prevention Objectives: Summary Report. Washington, DC: as the program is implemented. You may be able to establish US Department of Health and Human Services; USDHHS publication, PHS91-50123;1992. your phannacy as a site or secure recognition for your phar3. Melton LF, Riggs B. Epidemiology of age-related fractures. In: Avioli LV, macists as individual providers. ed. The Osteoporotic Syndrome. New York: Grune & Stratton Inc; 1987. A third strategy is to obtain a grant that would enable you 4. Kraynak MA. The women's health movement: political, social and medi· cal issues. Am Pharm. 1994;34:30-5. to provide health education for a limited period of time to a R, Baranowski T, Clark N, et al. Evaluation of Health Promotion, number of patients. Possible sources of grant money include 5. Windsor Health Education, and Disease Prevention Programs. 2nd ed. Mountain , local agencies, the phannaceutical industry, phannacy associView, Calif.: Mayfield Publishing Co; 1994. ations, and nonprofit charitable groups. A research grant may 6. Center for Pharmaceutical Care at Amherst. Focused PharmaceutiCEi, Care: A Sourcebook on Establishing a Diabetes Practice. Washington, provide the start-up funds needed to establish a strategic D.C.: American Pharmaceutical Association (in press). business unit. 7. Green LW, Kreuter MW. Health Promotion Planning: An Educational ana Environmental Approach. 2nd ed. Mountain View, Calif.: Mayfield Pu~ The United States Department of Health and Human Serlishing Co; 1991. vices provides Small Business Innovation Research (SBIR) 8. McKenzie JF, Jurs JL. Planning, Implementing and Evaluating Health Pier , motion Programs: A Primer. New York: Macmillan Publishing Co.; 1993. grants. l1 Call SBIR at (301) 206-9385 and ask for publication 9. Glanz K, Lewis FM, Rimer BK, eds. Health Behavior and Health Educanumber SBIR 96-2 and a grant application. The publication tion: Theory, Research, and Practice. San Francisco, Calif.: Jossey-BaSS includes telephone numbers of federal agencies that award Inc; 1990. health education grants. For example, the National Institute 10. Prochaska J, DiClemente C. Toward a comprehensive model of cha n9d In: Miller VR, Heather N, eds. Treating Addictive Behaviors: ProcesS of Aging supports research on interventions to maintain or Change. New York: Plenum Press; 1986. improve functioning to prevent disease or disability. Informa- 11. US Department of Health and Human Services (USDHHS). Omnibu1, solicitation of the National Institutes of Health, Centers for Disease Corr tion is also available through the National Institutes of Health trol and Prevention, and Food & Drug Administration for Small BusineSS Innovation Research grant applications. Bethesda, Md.: USDHHS; 1996. home page on the World Wide Web (http://www.nih.gov).
journal of the American Pharmaceutical Association
January/February 1997
Vol. NS37, No.1