The role of pharmacists is turning full circle. Once known as apothecaries, they were nearly as important a medical authority as the local physician in small communities. Just as people once relied on barbers for surgeries and dental work, apothecaries provided medical advice and both prescribed and dispensed prescriptions. Over time, however, these medical professionals were limited to filling and dispensing medications; 50 years ago, they could not even discuss drugs with patients.
This arrangement has undergone something of a reversal over the last few decades, and the pharmacist’s role is expanding into new directions. The demand for primary medical services is growing rapidly, and some, such as the U.S. Health Services and Resources Administration, predict a shortage of family practice physicians. Pharmacists stand ready to fill the gap and serve in areas that were once the domain of primary care physicians. Many pharmacies now host an array of primary clinical services, including disease management and vaccination.
Primary care is by no means the only beneficiary of the expanded role of pharmacists. Infectious disease practitioners rely on pharmacists to prepare and infuse antibiotics, while endocrinologists depend on the information pharmacists supply when working as diabetes case managers. Pain control specialists, oncologists, and other specialty practices network with pharmacists for a variety of reasons.
The increased reliance on pharmacists is not limited to physicians, either. The days of pharmacists standing behind windows and interacting with hospital staff via telephone have long passed. Quality hospitals have at least one pharmacist, and the American Society of Health-System Pharmacists states hospitals have about 12 pharmacists per 100 occupied beds. Pharmacists assigned to the emergency room are less common, but they have been proving their worth in the hospitals that do have them. This multipurpose role of the pharmacist carries over into hospice and home health services, as well.
Due to these changes, the number of pharmacists obtaining a doctoral degree has increased from 7,000 in 2001 to nearly 12,000 a decade later, according to the American Journal of Pharmaceutical Education.
Intravenous Drug Infusions
If a physician orders infusion drug therapy for a patient, that patient will likely need to go to an ambulatory care setting to receive it. Most patients (or their caregivers) cannot afford the supplies, compound and store the medications in a sterile environment, ensure the exact dosage at the necessary time, or flush the system. Furthermore, they may not know how to recognize and respond to adverse reactions. A pharmacist’s role here can be significant, whether she works in a hospital, retail pharmacy, or medical supply vending setting. According to the National Home Infusion Association, pharmacists provide a variety of services while working alongside registered nurses and other professionals. These services include:
- Conducting a full assessment of a patient’s mental, cognitive, psychosocial, and physical status
- Instituting a plan with clear goals and how they will be measured
- Monitoring drug dosages and interactions, as well as catheter incompatibilities
- Educating patients on how to store medications, maintain equipment, and respond to potential equipment complications and drug reactions, including emergency procedures
- Monitoring patient compliance
- Serving as a care manager by coordinating with and reporting to other providers on an ongoing basis
- Maintaining facilities to store, prepare, and dispose of infusion medications and supplies
- Developing performance measures to monitor outcomes
- Ensuring the ongoing education of appropriate staff
When educating patients on intravenous therapy, pharmacists might provide additional information such as alerting them about Medicare, which will pay for most intravenous drugs but will not cover home infusion therapy under the popular fee-for-service program.
Vaccination regulations vary by state, but all 50 permit pharmacists to administer them. PM360, an online magazine devoted to pharmacy marketing, reports that between 2007 and 2011, the number of pharmacists trained in vaccination increased from 40,000 to 150,000.
Seniors can take advantage of infectious disease inoculations against pneumonia, influenza, shingles (herpes zoster), tentatus, and hepatitis. However, vaccination rates among older adults remain low for a variety of reasons, including the fear that the vaccine itself might cause the disease. While influenza vaccines protected 65 percent of seniors during the 2013–14 flu season, the U.S. Centers for Disease Control and Prevention (CDC) reports that less than half of all adults are vaccinated against the disease.
A CDC report on noninfluenza vaccination highlights the seriousness of the problem. While roughly 60 percent of those over age 65 received the pneumococcal vaccine in 2012 and 55 percent were up to date on their tetanus, diphtheria, and pertussis (Tdap) vaccines, only 15 percent were vaccinated against hepatitis B and 20 percent against herpes zoster. Conveniently located pharmacies may improve these numbers, along with the encouragement of pharmacists who can discuss the benefits of vaccination with their senior clients.
In addition to inoculation, pharmacies sell and service durable medical equipment. Walkers, shower chairs, grabbers, sock pullers, and numerous other tools used to maintain daily activities can now be found at most corner drugstores. Some pharmacies also provide oxygen therapy by collaborating with respiratory therapists and prescribing physicians.
Disease Management and Counseling
Chronic diseases are among the most common and costly of health problems. The CDC estimates that half of Americans live with one chronic disease, while a quarter have two or more. And yet, many of these diseases are preventable. While some cases of chronic disease may be too far advanced to reverse, most can be slowed and their symptoms treated.
The dual role of pharmacists in limiting the impact of chronic disease puts them in an important position. In their traditional function of filling prescriptions, they can help seniors by explaining the effects of drugs and monitoring their impact. Alert pharmacists can also screen for drug interactions and dangerous side effects when conversing with seniors. For example, since some drugs may lead to complications such as dizziness, they might monitor those at risk for falling.
Pharmacists can also work with patients and their physicians to improve medication management. Polypharmacy is a leading contributor to poor medication management, which can result in various health complications. According to American Nurse Today, 57 percent of women and 44 percent of men over 65 take five or more medications weekly — and many take more. Seniors suffering from memory loss or sensory deprivation are at risk for accidental or missed dosages.
Pharmacists can assist seniors with home medication management in a number of ways. To reduce the overall number of pills that need to be managed, they can advise the ordering physician to change or eliminate certain medications. They can also share tips with patients on ways to improve compliance, such as the use of an automatic medication dispenser.
As a disease case manager, the pharmacist’s role is much more involved and direct. For instance, anticoagulation therapy sometimes requires close monitoring, and some pharmacists are trained to routinely check levels. They can also counsel and educate patients on this therapy, answer questions, and refer them to other healthcare professionals, such as dietitians, exercise therapists, and mental health therapists. They then transmit patient information to the physician treating the disease, who might use that information to order modifications.
Similar work is done when managing other diseases. For example, the role of a pharmacist might include:
- Assisting diabetes patients to keep the disease in check by monitoring blood sugar levels, ensuring compliance with blood sugar monitoring, and providing dietary information
- Working with pain management patients to ensure the effectiveness of narcotics and other drugs or therapies, along with keeping an eye out for signals of addiction and abuse
- Helping patients with smoking cessation programs, which might include drug therapy
- Helping those with hypertension reduce their risk for heart disease and stroke through medications and by encouraging healthy eating and exercise
As promising as these avenues for pharmacists may be to patients and to the delivery of healthcare overall, there are several hurdles to overcome, according to a 2010 Booz & Company report. Regulatory barriers, encouraged by physician groups, limit pharmacists to varying degrees. Structural factors — primarily involving reimbursement practices — do not encourage physician-pharmacist collaboration. There are technological constraints as well, especially patient record data sets that do not interface with providers’ electronic health record systems. And a “fear of alienating prescribing physicians” has caused some pharmacies to constrain themselves. Clinical transitions are expensive, and thus far the report says pharmacy-based clinical services are not profitable.
Expansion of the role of pharmacists into retail clinics to make healthcare more accessible and economical has yet to be fully measured. Still, PM360 indicates pharmacies seem to be overcoming their self-imposed restrictions since the number of retail clinics across the country is estimated to grow to 2,868 this year. Twenty-seven percent of adults report having accessed a retail clinic for some form of medical care; that percentage may grow as the number of retail clinics increases. Regardless of the setting, the goals to relieve pressure on physicians, make seniors safer for independent living, improve accessibility, aid caregivers, and initiate critically needed prevention measures make the pharmacist an important component of senior healthcare.
And, of course, there is still the traditional pharmacist role of filling prescriptions and counseling patients. Seniors often need reliable information about complicated and sometimes sensitive subjects. They want to know their apothecaries are watching out for them and to trust any drug interactions, medication errors, or potential complications will be avoided. In spite of new technology and the expanding roles of pharmacists, maintaining a personal connection is vital when performing these basic tasks.