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THE TOPICS

The Time For Change Is Now
Dr Alison Roberts
It's time to welcome a changed model of pharmacy – as a pharmacist, you are now a primary healthcare provider, and your pharmacy, now a health destination. Alison Roberts uncovers what…

It's time to welcome a changed model of pharmacy – as a pharmacist, you are now a primary healthcare provider, and your pharmacy, now a health destination. Dr Alison Roberts uncovers what the Health Destination Study means for your pharmacy and the action that can be taken to better serve your community.

The Time For Change Is Now

PHARMACISTS ARE BEING URGED TO CHANGE THEIR PRACTICE, BUT MANY DO NOT HAVE A CLEAR PICTURE OF HOW THE NEW PRACTICE MODEL IS TO FIT INTO CURRENT REALITY.1

Whilst this statement was made more than a decade ago, its sentiment still holds today. Pharmacists in Australia are facing unprecedented levels of change, much of it imposed on them by the external environment, including PBS reforms and Community Pharmacy Agreements.

While some of these changes have undoubtedly created opportunities for the pharmacy sector to improve health outcomes for patients, successive Community Pharmacy Agreements have seen a lack of integration of programs into the regular operations of pharmacies. Aside from the innovative few, there has been no new practice model formed; for most it remains 'business as usual'.

The changing healthcare environment has resulted in renewed emphasis on more fully utilising the skills and knowledge that healthcare professionals possess to improve health outcomes for consumers.

This is particularly true of pharmacists who remain among the most trusted of all health professionals as well as being the most accessible.

None of this is of any use to consumers, however, if pharmacists and pharmacies are unable to make the necessary changes to their practice. The expectation that widespread delivery of professional programs would occur simply because there was evidence that the programs could be effective has been shown to be flawed. Pharmacy organisations charged with implementing professional programs have been forced to acknowledge the emerging evidence that programs or services that have been shown to have good outcomes for consumers do not automatically translate to being easy to implement in practice.2At the Pharmaceutical Society of Australia (PSA), this led to an acceptance that some commonly held beliefs and approaches to program delivery and dissemination may not be the most effective, and a genuine recognition that a new approach to developing understanding of the service business model was urgently needed.

A NEW MODEL OF PHARMACY

"... Services cannot just be added as the next 'retail category' ... Everything from philosophy of practice and vision, to customer service and staffing, will need to be built from the ground up ... A new approach, developing understanding of the service practice model, is urgently required."3

"FOR ME IT HAS DEFINITELY BEEN A LIFE CHANGER…I WAS ALWAYS IN THIS FRAME OF MIND THAT I WANTED TO DO MORE PROFESISONAL AND HEALTH-RELATED SERVICES WHEREVER I ENDED UP BEING WORKING, BUT THE TRIAL HAS FIVEN ME THE TOOLS TO BE ABLE TO REALLY KNOW WHAT I WANT AND HOW TO GO ABOUT GETTING THERE."

As a result, in 2012, PSA funded a small trial to investigate the feasibility of a changed model of pharmacy practice in which the pharmacist is repositioned as a primary healthcare provider and the pharmacy is positioned as a healthcare destination. The impetus for the trial came from discussions regarding sustainable models of community pharmacy practice that would weather reforms and embrace changes that increase the opportunity for pharmacists to be more involved as primary healthcare providers. In line with reforms to primary care in Australia and internationally 4,5 any changes would need to be consumer-focused, would need to capitalise on the expertise of pharmacists and be underpinned by an evidence-based approach to managing change.

This approach was already in operation at PSA, through the Practice Support Program, which is based on the use of a facilitator or coach to effect change and address implementation challenges. This method has been demonstrated to result in significant and – importantly – sustained improvements in practice organisation, processes and service delivery.6,7 Australian research too had shown that community pharmacies could benefit from coaching to provide targeted, on-site support to assist their preparation for change and to build the capacity to integrate new professional programs over time.8

The Health Destination Pharmacy trial was therefore introduced and used a mixed-methods, multiple-case study approach to explore several aspects of introducing a new model of pharmacy practice while the participating pharmacies continued – and adapted where necessary – their usual day-to-day operations. The trial was informed by previous research drawing on insights from outside of the pharmacy sector, including organisational change and flexibility, and the understanding that targeted education and practical assistance in the development of service models "is likely to positively improve the overall capacity of community pharmacy to make the transition to a business orientation for professional services delivery".9

THE TRIAL

A total of 14 pharmacies were selected for the Health Destination Pharmacy trial to ensure the broadest possible representation of pharmacy types, using geographic location, local location, pharmacy size, banner group affiliation, weekly average prescription numbers, full-time equivalent (FTE) pharmacists and other staff, and demographic characteristics.

The trial involved assisting pharmacies to make changes to their service model to achieve sustainable delivery of consumer-focused health services and enhance the pharmacy's image as a healthcare destination. The activities focused on building capacity and ensuring that all participating pharmacies could put in place the appropriate infrastructure and resources to be able to integrate new professional programs over time. These changes were centred on having a pharmacist engaging with all customers and enhanced delivery of professional services.

At the start of the trial, participating pharmacies were at different stages of change along the journey towards becoming a true 'health destination'. Some pharmacies had been considering change while others had made more concrete plans; some had made changes to their staffing or layout and had commenced delivering new services, but were doing so in a somewhat ad hoc manner or had found themselves unable to sustain their new practices.

Participants’ specific goals varied accordingly, but overall the trial group shared certain goals, established with the assistance of the PSA coach, and prompted by baseline demographic and workflow analyses. These included:

- Develop strategies to reduce the pharmacist's time in the dispensary and increase consumer engagement in the front of shop, guided by insights from an initial analysis of workflow efficiency and effectiveness.
- Focus health promotions and professional services to target areas of local need, using demographic data from a local area snapshot.
- Implement and/or increase delivery of professional pharmacy programs and services, particularly 5CPA PPIs and MedsChecks.
- Improve communication and relationships with local GPs and other health professionals.

Pharmacists in Australia are facing unprecedented levels of change, much of it imposed on them by the external environment, including PBS reforms and Community Pharmacy Agreements.

The coach worked with all pharmacy teams, developing specific goals and monitoring progress towards these goals at each of the visits. As expected, all pharmacies experienced some difficulties and barriers to progress throughout the trial period. Regardless of the challenges encountered, some pharmacies made significant practice changes while others made very minimal adjustments to their daily operations.

Key success factors to action change
Key success factors to action change

Pharmacies received four visits from the PSA Coach during the nine months of the trial, with participants reporting unequivocally that the coach's visits provided the driving force effecting practice change. "I don't think we actually would have got here in the complete or comprehensive way we’re at now. I think it would have been more ad hoc and non-sustainable."

"It's given us a little bit of direction as to what needs to happen moving forward… it would've taken a lot longer to figure out what had to happen and then to try and implement it... I would've been stumbling around, trying to fix things but without being able to put our finger on it."

THE WINS: PERSONAL AND BEYOND

Several participating pharmacists reported major personal changes as a result of their embracing the health destination approach and of having participated in the trial.

One of the owners reported, "I have actually noticed a change in both of the pharmacists in that they feel a lot more motivated to come to work and in customer engagement, and they make a lot more effort to involve themselves with the customers."

Another pharmacist said, "For me it has definitely been a life changer... I was always in this frame of mind that I wanted to do more professional and health related services wherever I ended up being or working, but the trial has given me the tools to be able to really know what I want and how to go about getting there."

Not only were the pharmacists satisfied, consumers also reported satisfaction with the image of participating pharmacies as healthcare destinations; and with the image of their pharmacist as a primary healthcare provider. A number of other consumer measures were also positive, with observed increases in prescription processing efficiency, reductions in waiting times and greater customer engagement in-store during dispensing.

The success of the trial hinged on the flexibility of the way each individual pharmacy's needs were approached, analysed and addressed. There was no one-size-fits-all philosophy and this ensured targeted solutions to meet the demographics of the area and the consumer needs of the pharmacies involved.

While a number of features common to the successful pharmacies were able to be identified, taking a look at individual pharmacies highlights the tailored approach to each location and pharmacy team (see case study, opposite).

The health destination pharmacy trial showed that it is feasible for pharmacies to adopt a changed model of pharmacy practice in which the pharmacist is repositioned as a primary healthcare provider and the pharmacy as a healthcare destination. The coach assisted pharmacies of different sizes, locations and staffing levels to increase pharmacist-consumer engagement, target health promotions and professional services to areas of local need, implement and/or increase delivery of professional pharmacy programs and services, and improve communication and relationships with local GPs and other health professionals. Further research is necessary to determine the sustainability of these changes long-term.

The Time For Change Is Now

References:
1. Holland, R.W. and C.M. Nimmo, Am J Health Syst Pharm, 1999. 56(17).
2. Schroeder, J.A. Integrating implementation science, practice and policy. 2011. National Implementation Research Network
3. Woods, P. Two Worlds Colliding Australian Journal of Pharmacy, 2011. 92:74 (July).
4. Australian Government. Primary healthcare reform in Australia - Report to support Australia’s first National Primary Healthcare Strategy. Publications Number: P3 -5480. Canberra, The Australian Capital Territory:, Department of Health and Ageing; 2009.
5. Barnes KA, Kroening-Roche JC, Comfort BW. The developing vision of primary care. N Engl J Med. 2012 September; 367(10): p. 891-893.
6. Parchman Ml, Noel PH, Culler SD, lanham HJ, leykum lK, Romero Rl, et al. A randomized trial of practice facilitation to improve the delivery of chronic illness care in primary care: initial and sustained effects. Implementation Science. 2013; 8(93).
7. Baskerville BN, liddy C, Hogg W. Systematic review and meta-analysis of practice facilitation within primary care settings. Annals of Family Medicine. 2012; 10.
8. Roberts AS, Benrimoj SI, Chen TF, Williams KA, Aslani P. Practice change in community pharmacy: Quantification of facilitators. Ann Pharmacother. 2008 June; 42(6): p.861-868
9. Benrimoj SI, Feletto E, and Wilson l. Building organisational flexibility to promote the implementation of primary care services in community pharmacy. Sydney, New South Wales, Australia: Australian Government, Department of Health and Ageing; 2010.