Pharmacists: Pharmacists:

Access to Immunization ServicesAccess to Immunization Services

MitchelMitchel C. Rothholz, C. Rothholz, RPhRPh, MBA, MBA

American Pharmacists AssociationAmerican Pharmacists Association

Chief of StaffChief of Staff

American Pharmacists AssociationWashington, DC

Ø National professional society of pharmacists

Ø Represents the interests of pharmacists across

practice settings

Ø Improving medication use…Advancing

patient care

Ø 63,000 members and growingØ Largest and oldest organization in pharmacy

Ø Immunization Roles for Pharmacists

ØAdvocate

Ø Facilitate

Ø Immunize

Pharmacy’s Unique Pharmacy’s Unique

ContributionContribution

•• Access, proximity, extended hoursAccess, proximity, extended hours

•• Ability to narrowAbility to narrow--cast messages to elderly and cast messages to elderly and

high risk patientshigh risk patients

•• Public’s trust Public’s trust -- Gallop PollGallop Poll

•• Public’s enthusiastic acceptancePublic’s enthusiastic acceptance

Pharmacists’ Role inPharmacists’ Role in

Emergency Preparedness and ResponseEmergency Preparedness and Response

•• SurveillanceSurveillance

•• InformationInformation

•• Patient education and counselingPatient education and counseling

•• Distribution of pharmaceuticals and medical Distribution of pharmaceuticals and medical

suppliessupplies

•• Administration of vaccinesAdministration of vaccines

•• Evaluation / TriageEvaluation / Triage

•• Community planning and preparationCommunity planning and preparation

Developed by the JCPP Working Group on Emergency Preparedness & Response

APhA Focus for Adult ImmunizationAPhA Focus for Adult Immunization

•• EducateEducate the public about adult vaccinethe public about adult vaccine--preventable preventable

diseases and the value of immunizations;diseases and the value of immunizations;

•• Be Be accessibleaccessible to the public for immunization to the public for immunization

information and administration of vaccineinformation and administration of vaccine

•• Increase pharmacist Increase pharmacist knowledgeknowledge regarding adult regarding adult

immunizations, vaccine schedules and opportunities immunizations, vaccine schedules and opportunities

to improve public healthto improve public health

•• Maximize Maximize opportunitiesopportunities for pharmacists to remind or for pharmacists to remind or

encourage patients to be immunizedencourage patients to be immunized

But Immunization activities Across LifespanBut Immunization activities Across Lifespan

GUIDELINES FOR PHARMACYGUIDELINES FOR PHARMACY--BASED BASED

IMMUNIZATION ADVOCACYIMMUNIZATION ADVOCACY

•• Guideline 1 Guideline 1 -- Prevention Prevention

Pharmacists should protect their patients' health by being vacciPharmacists should protect their patients' health by being vaccine ne advocates. advocates.

•• Guideline 2 Guideline 2 -- Partnership Partnership

Pharmacists who administer immunizations do so in partnership wiPharmacists who administer immunizations do so in partnership with th their community. their community.

•• Guideline 3 Guideline 3 -- QualityQuality

Pharmacists must achieve and maintain competence to administer Pharmacists must achieve and maintain competence to administer immunizations. immunizations.

•• Guideline 4 Guideline 4 -- DocumentationDocumentation

Pharmacists should document immunizations fully and report cliniPharmacists should document immunizations fully and report clinically cally significant events appropriately. significant events appropriately.

•• Guideline 5 Guideline 5 -- EmpowermentEmpowerment

Pharmacists should educate patients about immunizations and respPharmacists should educate patients about immunizations and respect ect patients' rights. patients' rights.

Adopted by APhA, 1996

Education & TrainingEducation & Training

APhA Immunization ProgramAPhA Immunization Program

SelfSelf--Study (0.8CEU)Study (0.8CEU)

•• Primer on immunologyPrimer on immunology

•• Clinical disease reviewClinical disease review

•• Practice managementPractice management

•• Regulatory roadmapRegulatory roadmap

•• CDC resourcesCDC resources

Seminar (1.2 CEUs)Seminar (1.2 CEUs)

•• Recap of vaccines, antibodies, Recap of vaccines, antibodies,

diseases, microbesdiseases, microbes

•• ImplementationImplementation

•• Record keepingRecord keeping

•• Public health collaborationPublic health collaboration

•• Cases and practicumCases and practicum

CDC

Recognized

Also CPRP and OSHA Training

Barrier: Authority for Barrier: Authority for

Pharmacists to Administer Pharmacists to Administer

ImmunizationsImmunizations•• StatutoryStatutory

•• Regulations / Attorney General OpinionRegulations / Attorney General Opinion

•• No positionNo position

Limitations of AuthorityLimitations of Authority

•• Requirements Protocols / Standing Orders/ RxRequirements Protocols / Standing Orders/ Rx

•• AntigensAntigens

•• AgeAge

•49 states currently authorize pharmacists to administer immunizations•Over 40,000 pharmacists trained•Delivered over 2 million influenza vaccinations

Pharmacist Authority toPharmacist Authority to

Administer ImmunizationsAdminister Immunizations

0

5

10

15

20

25

30

35

40

45

50

States authorizing pharmacists

Before 1978

1979

1982

1987

1996

1999

2002

2004

2007

2008

Pharmacist Immunization AdministrationPharmacist Immunization Administration

Protocol / Standing Order Protocol / Standing Order vsvs RxRx

0

2

4

6

8

10

12

14

16

18

20

States authorizing

Protocol only

Protocol &/orStanding Order

Protocol &/orPrescription

Prescription only

Standing order orPrescription

Protocol, StandingOrder &/orPrescription

49 states, July 2008

Protocol Protocol

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

50.00%

Individual

Rx

Not

Required

Internal

Med

Family MD Corporate

MD

Health Dept

2006

2007

2008

2006 n=314 2007 n=272 2008 n=174

Health Department

Medical Directors can

play a major role…

Components of ProtocolComponents of Protocol

•• Identify individual who has delegated activityIdentify individual who has delegated activity

•• Identify pharmacist authorized to administer vaccineIdentify pharmacist authorized to administer vaccine

•• Types of vaccines pharmacist is authorized to Types of vaccines pharmacist is authorized to

administeradminister

•• Procedures, decision criteria or plan pharmacist Procedures, decision criteria or plan pharmacist

should follow, including when to refer patientshould follow, including when to refer patient

•• Procedure for emergency situationsProcedure for emergency situations

•• Record keeping and documentation proceduresRecord keeping and documentation procedures

Other Limits to Other Limits to

Pharmacist’s authorityPharmacist’s authority

•• Age RestrictionAge Restriction–– No restriction (17)No restriction (17)–– >> 18yo (22)18yo (22)–– >> 16 16 yoyo (1)(1)–– >> 14 14 yoyo (4)(4)–– Other (5)Other (5)

•• 10+ influenza,10+ influenza,>> 18 other18 other

•• >>12 influenza, No 12 influenza, No restriction for restriction for othersothers

•• > > 13yo13yo•• >> 19yo19yo•• > > 15yo influenza, 15yo influenza, >>

18 for others18 for others

•• AntigenAntigen–– Influenza only (3)Influenza only (3)–– Influenza / Influenza / PneumoPneumo (2)(2)–– Adult (1)Adult (1)–– No restrictions (33)No restrictions (33)–– Other (10)Other (10)

Authority could state: “vaccines

recommended by ACIP for targeted

patient population.”

What Immunization Services Do What Immunization Services Do

Pharmacies Provide to Patients?Pharmacies Provide to Patients?Pediatric Check All That ApplyCheck All That Apply

32.7%32.7%Refer patients to public health departmentsRefer patients to public health departments

63.9%63.9%Refer patients to physiciansRefer patients to physicians

18.0%18.0%Administer Immunizations by pharmacistsAdminister Immunizations by pharmacists

5.7%5.7%Facilitation of immunizations (host other providers)Facilitation of immunizations (host other providers)

44.2%44.2%EducationEducation

GraphGraphPercentagePercentageResultResult

Adolescent Check All ThatCheck All That ApplyApply

23.7%23.7%Refer patients to public health departmentsRefer patients to public health departments

40.9%40.9%Refer patients to physiciansRefer patients to physicians

50.8%50.8%Administer Immunizations by pharmacistsAdminister Immunizations by pharmacists

6.5%6.5%Facilitation of immunizations (host other providers)Facilitation of immunizations (host other providers)

45.0%45.0%EducationEducation

GraphGraphPercentagePercentageResultResult

2006, Responses represent 4,700 sites

What Immunization Services Do What Immunization Services Do

Pharmacies Provide to Patients?Pharmacies Provide to Patients?Adult >65 Years Old Check All That ApplyCheck All That Apply

17.2%17.2%Refer patients to public health departmentsRefer patients to public health departments

21.3%21.3%Refer patients to physiciansRefer patients to physicians

86.0%86.0%Administer Immunizations by pharmacistsAdminister Immunizations by pharmacists

18.0%18.0%Facilitation of immunizations (host other Facilitation of immunizations (host other

providers)providers)

55.7%55.7%EducationEducation

GraphGraphPercentagePercentageResultResult

2006, Responses represent 4,700 sites

Targeting Messages:Targeting Messages:Prescription VialPrescription Vial

Auxiliary LabelsAuxiliary Labels

2008v1-17

•• Need for influenza & Need for influenza & pneumococcalpneumococcal vaccines:vaccines:

–– Heart Disease Heart Disease DigoxinDigoxin, , warfarinwarfarin, nitrates, nitrates

–– Lung Disease Lung Disease TheophyllineTheophylline, , zafirlukastzafirlukast, ,

steroids, chronic inhaler use steroids, chronic inhaler use

–– Diabetes Diabetes Insulin, oral Insulin, oral hypoglycemicshypoglycemics

–– All All >> 65 65 y/oy/o Any or noneAny or none

•• Other vaccines?Other vaccines?

Comparison of Vaccination Rates When Comparison of Vaccination Rates When

Pharmacists Vaccinate the ElderlyPharmacists Vaccinate the Elderly

52

54

56

58

60

62

64

66

68

70

1995 1999

States that allow

Pharmacist

Immunizations

States that do not allow

Pharmacist Immunization

10.7%

Change

3.5%

Change

Steyer TE et al. Vaccine. 2004;22:1001-6.

Vacc

inati

on

Rate

s

Persons ≥≥65 y/o

Combined Participant Percent* Combined Participant Percent*

Flu, Foot and EyeFlu, Foot and Eye

0

10

20

30

40

50

60

70

80

90

Baseline Year 1 Year 2 Year 3

Flu Shot

Foot Exam

Eye Exam

Align the Incentives, Empower the Patient, Control the CostsSM

*As reported in the Patient Self-Management Program reports each year for 99 patients with baseline,1st , 2nd and 3rd year results

55%

70%

Access: Access:

Structure of PracticeStructure of Practice

0% 20% 40% 60% 80%

Clinic

Walk-in Limited

Walk-in Hourly

Walk-in Anytime

Appointment

2007

2006

2006 n=266 2007 n=363

DocumentationDocumentation

0.00% 20.00% 40.00% 60.00% 80.00%

Public Health

Patient's MD

Protocol MD

Pt Record Card

Rx Record Card

Copy of Consent

Maintained in Rx

2007

2006

2006 n= 261 2007 n=229

Access to

registries

limited to

pharmacists

CompensationCompensation

0.00% 20.00% 40.00% 60.00% 80.00% 100.00%

Patient

Medicare

Medicaid

Insurance

HMO

Employer

2007

2006

2006 n=257 2007 n=354

Please complete the following statement: Please complete the following statement:

"To expand influenza immunization "To expand influenza immunization

services in our practice we need..."services in our practice we need..."

–– Patient education regarding pharmacist Patient education regarding pharmacist education /training and service.education /training and service.

–– Patient education that the shot will not cause the Patient education that the shot will not cause the disease.disease.

–– A huge outbreak of the flu in our area.A huge outbreak of the flu in our area.–– Additional local physician support.Additional local physician support.–– Ability to bill for our services to insurance Ability to bill for our services to insurance

companies other than Medicare Part B.companies other than Medicare Part B.–– Staff members to understand importance of Staff members to understand importance of

getting vaccinations.getting vaccinations.–– State laws and regulations to be more State laws and regulations to be more

pharmacistpharmacist--friendly.friendly.

APhA, 2008 survey, 330 responses

representing 11,188 sites

Questions?Questions?

Mitchel C. Rothholz, RPh, MBAMitchel C. Rothholz, RPh, MBA

Chief of StaffChief of Staff

American Pharmacists AssociationAmerican Pharmacists Association

1100 15th Street NW, Suite 4001100 15th Street NW, Suite 400

Washington, DCWashington, DC 2000520005--17071707

202/429202/429--75497549

mrothholz@aphanet.orgmrothholz@aphanet.org