Abstract
Purpose:
To investigate the prevalence and type of clinical pharmacy services offered within South Carolina Federally Qualified Health Centers (SC FQHCs) and identify existing implementation barriers.
Methods:
This study was a cross-sectional survey of pharmacists or Chief Medical Officers practicing in SC FQHCs. Organizations were identified utilizing the Health Resources and Services Administration (HRSA) database and were contacted to participate in a telephone survey. An electronic form was created in REDCap® software. Descriptive statistics were used to analyze and evaluate data.
Results:
Twenty-two SC FQHCs were eligible for the survey, with 16 (72.7%) participating. Of the respondents, 9 (56%) offered at least 1 service. The most common services offered were chronic disease state management, diabetes self-management education and support (DSMES), and tobacco cessation (43.8%, n = 7). The least common services offered were chronic care, Hepatitis C, and HIV management (18.9%, n = 3). The most common barriers to implementation were lack of personnel and provider interest (62.5%, n = 10). The least common barrier was a lack of pharmacist interest or time (25%, n = 4).
Conclusion:
Pharmacists offered at least 1 clinical service within most SC FQHCs. Barriers were identified that prevented expansion of services and further research is needed to overcome these.
Introduction
First established in 1965, Federally Qualified Health Centers (FQHCs) have a long history of providing for Americans who either live in medically underserved areas or cannot afford primary care services. 1 Recently, there has been an increased interest in how pharmacists operate within FQHCs and what their involvement in the clinical services offered to patients at these organizations entails. Pharmacists may independently manage chronic disease states such as hypertension and type II diabetes, oversee international normalized ratio (INR) testing for anticoagulation management, or conduct Medicare annual wellness visits (AWVs), among other services.2 -14 It is increasingly evident that pharmacists’ roles in FQHCs are expanding to include more clinical services, and those interventions have been successful at improving patient health outcomes. 15
Recently, a literary review was conducted by scholars at the Ohio State University College of Pharmacy and Oregon State University College of Pharmacy. 15 The team analyzed 54 manuscripts detailing clinical services within FQHCs across many states; however, there is a clear disparity in information regarding clinical services offered by pharmacists in Southeastern FQHCs. 15 With the varying scopes of practice that exist amongst states and the differences that exist between patient populations, it is important to delve into clinical services offered by pharmacists on a regional basis. An extensive review of the literature concluded that there is a lack of information regarding the type, prevalence, and impact of clinical services offered by pharmacists within South Carolina (SC) FQHCs, as well as a lack of identified barriers pharmacists have faced regarding service implementation. This study aimed to bridge the existing gap in information by surveying clinical pharmacists within SC FQHCs to determine the clinical services offered within their practice and acknowledge the barriers that may exist for implementation.
Methods
This cross-sectional survey of clinical pharmacists, pharmacists-in-charge (PICs), directors of pharmacies, and Chief Medical Officers (CMOs) was conducted to assess the variation in clinical pharmacy services offered within FQHCs in South Carolina. Organizations were identified utilizing the Health Resources and Services Administration (HRSA) database and were eligible for inclusion if the organization met the HRSA requirement for an FQHC at the time of inquiry (October 3, 2022) and had at least 1 site that provided primary health care services. To be deemed a Health Center Program Awardee, or to qualify for funding under Section 330 of the Public Health Service Act and be reimbursed through the Centers for Medicare and Medicaid Services (CMS), they must offer discounted drugs through HRSA’s 340B Drug Pricing Program and provide comprehensive services to an underserved area or population. 16 Organizations were excluded if they met the HRSA definition of an FQHC “Look-Alike” facility, a site consistent with the HRSA FQHC definition but does not receive government funding, or only operates as an administrative organization. 17 Contact information for each organization was collected from the HRSA online database if available; otherwise, contact information was identified using the organization’s website. If an email address was provided, the primary investigators extended an invitation to participate in a telephone survey via email. If no email address was provided, primary investigators called each FQHC to establish a point-of-contact for email correspondence. All organizational contacts received communication at least twice regarding invitation to participate in the survey, once by email and once by telephone (see Supplemental Appendix A for email language utilized). Organizational contacts were requested to schedule and complete the telephone survey from November 2022 to February 2023. An electronic data collection form was created in REDCap® software and used by investigators during telephone surveys (see Supplemental Appendix B for survey questions). All responses and data presented were de-identified to prevent bias. Upon survey completion, respondents were eligible to receive 1 of 6 available gift cards through a random drawing. Winners were selected through a random online generator and emailed to accept their virtual gift cards. The study was approved through the University of South Carolina Institutional Review Board.
The primary outcomes were to determine the prevalence of FQHCs in South Carolina that offer clinical pharmacy services and to identify the type of clinical pharmacy services offered at each organization. For the purposes of this study, investigators deemed “clinical pharmacy services” to be any duty that exceeds the common expectations of pharmacists to conduct medication reconciliations, medication therapy management (MTM) consults, and participation in the dispensing and processing of medication orders. Clinical pharmacy services identified in previously published literature were included in the REDCap® survey and presented as options to surveyed FQHC employees. To account for any additional services that the respondents deemed to be a clinical pharmacy service, an “other” category was included.
The secondary outcome was to describe barriers faced by FQHCs to implement clinical pharmacy services. Once the prevalence of clinical pharmacy services were identified at each organization, barriers that prevented implementation of services or barriers that were experienced during the implementation period were discussed. Based on the literature search and the clinical experience of this study’s investigators, a list of potential barriers was included in the study survey. Descriptive statistics were applied to the collated data. Continuous data were reported as the mean and standard deviation.
Results
Twenty-four HRSA Health Center Program awardees were identified in SC. One awardee was identified as an “FQHC Look-Alike” and 1 awardee operated only as an administrative facility. Therefore 22 organizations met the inclusion criteria of the study and were invited to participate in the survey. Of those that met the inclusion criteria, 16 FQHCs (72.7%) scheduled an interview with the investigators and completed the survey. Organizations were categorized as serving an urban or rural population according to the HRSA database. Ten organizations were deemed to serve an urban population and 6 serve a rural population. Among the SC FQHCs surveys, 7 FQHCs billed Medicaid/Children’s Health Insurance Program (CHIP) most frequently (43.75%), 4 FQHCs billed third-party insurance most frequently (25%), and the remaining 5 FQHCs surveyed provided much of their care to uninsured patients (31.25%). The majority of FQHCs had more than 1 site that delivered primary health care services (93.75%), with the mean number of sites being 7 (1-17). 18 See Table 1 for baseline characteristics.
FQHC Baseline Characteristics.
Abbreviations: M/C, Medicaid/Children’s Health Insurance Program; TP, third-party; UI, uninsured.
Of the 16 responding FQHCs, all had numerous clinical departments within their organizations. The most common clinical department offered to patients was family medicine (100%, n = 16) and the least common service offered was Ryan White HIV/AIDS services (62.5%, n = 10). Eight organizations had unique departments at their organization including optometry, podiatry, nutrition services, radiology and imaging, rheumatology, endocrinology, and pain management.
On-site pharmacies are common among SC FQHCs, with 15 organizations (93.75%) having at least 1 on-site pharmacy with an average of 3 pharmacy locations per organization. Of those with on-site pharmacies, all had access to patient electronic health records (EHR) and participated in the 340B Drug Pricing Program per HRSA requirements. The number of pharmacists employed at each organization varied greatly, with an average of 6.28 full-time employees (FTEs) across surveyed FQHCs at the time of data collection.
Though not considered a clinical service for the purpose of this study, medication therapy management (MTM) services were commonly offered by pharmacists within SC FQHCs. Fifteen organizations (93.75%) identified MTM as one of their provided services. However, the billing practices for this service varied; 6 organizations did not bill for MTM services at all, 6 organizations billed through the OutcomesMTM platform, 2 organizations billed for the service directly through the pharmacy, and 1 organization billed for MTM services through a third party.
Of the FQHCs surveyed, 11 (68.75%) offered at least 1 clinical pharmacy service. Four organizations (25%) offered only 1 clinical pharmacy service, and 7 organizations (43.75%) offered 3 or more. Five organizations (31.25%) did not offer any clinical pharmacy services. The most common clinical pharmacy services offered by SC FQHCs were diabetes self-management education and support (DSMES; 50%, n = 8) and Medicare annual wellness visits (AWV; 43.75%, n = 7). Chronic disease state management services were offered by pharmacists in 6 organizations (37.5%). Only 25% (n = 4) of surveyed FQHCs offer either INR/anticoagulation management or tobacco cessation services. Hepatitis C management and HIV management services were the least common services offered as they were offered at only 3 organizations (19%). See Table 2 for a summary of clinical pharmacy services offered at each site.
Clinical Services Offered by Pharmacists Within FQHCs.
The most common barrier to implementing clinical pharmacy services was a “lack of provider interest or time,” with 10 organizations (63%) indicating it was an issue. “Knowledge of where to start” was identified by 8 organizations (50%) as the second most common barrier. Billing issues, physical space limitations, and upfront costs were identified as the next most common barrier, with 7 organizations (43.75%) citing these as an issue in their practice. Lack of leadership support was an additional barrier experienced by 6 organizations (38%). Two organizations identified “other” barriers of “finding pharmacists with clinical experience” and “convincing patients of the value of pharmacists within a healthcare team.”
Six respondents spent time detailing the extent of the barriers present within their organization. When discussing the resistance of implementation from leadership, 1 respondent stated, “our leadership wants to see the dollar amount of these services, which is difficult to do until they are implemented.” Another respondent stated, “some providers do not understand all that a pharmacist can bring to the table” and “[leadership] needs to first feel more comfortable knowing the services will pay for themselves before implementing them.”
Discussion
Prior to this study, there was no published literature regarding the scope of pharmacists in SC FQHCs. This study sought to investigate the prevalence of clinical services offered by pharmacists throughout the state and discovered a variation in the services offered. The results of this study help us better understand how clinical pharmacists are used within FQHCs and how they contribute to patient care. Our study found FQHCs located in urban areas were more likely to offer a clinical pharmacy service, with an average of 2.9 services versus an average of 1 service within rural FQHCs. However, this number does not correlate with the number of patients the FQHC may serve. Therefore, the area in which a SC FQHC is located may be a determining factor in the availability of clinical pharmacy services. Another potential contributor to the number of services offered by pharmacists may be the number of FTE pharmacists within the organization. Organizations that employ greater than 5 FTEs offer an average of 2.9 clinical pharmacy services, while organizations that have less than 5 FTEs offer an average of 1.3 clinical pharmacy. As expected, the more pharmacists an FQHC can employ, the greater opportunities there are for implementation of clinical pharmacy services.
The clinical pharmacy services offered in South Carolina are comparable to those offered in other states according to published literature. 15 The most common services currently being offered are DSMES and Medicare AWVs. Many organizations reported that the clinical pharmacist serves as their FQHC’s primary diabetes educator, providing patient counseling, measuring medication adherence, and making treatment-related recommendations directly to providers. Six of the 7 FQHCs that reported clinical pharmacist involvement in AWVs allow their pharmacists to perform these visits independently. These visits take place between the pharmacist and the patient, serving as a review of medical and family history, current medication regimens, advanced care planning, and ensuring that patients are up to date on vaccinations and screenings. When these visits are performed by a pharmacist, the physicians have more time to focus on other patients’ acute problems. Although only 25% of SC FQHCs are performing anticoagulation management services, tobacco cessation services, or chronic disease state management services, these are important examples of how clinical pharmacists’ knowledge can be utilized for direct patient care. Pharmacists can measure INR values in their clinic and make warfarin dose change recommendations, they may participate in remote patient blood pressure monitoring and make antihypertensive recommendations based on patients’ average readings, or they could practice motivational interviewing while counseling on over-the-counter options for tobacco cessation. Though only 19% of pharmacists in SC FQHCs perform hepatitis C management, HIV management services, or respiratory disease state management, this is another important example of the impact a pharmacist can have on patient care. Pharmacists offering these services can ensure patients are receiving optimal therapy regimens and aid in any medication access-related issues, such as safety, efficacy, or accessibility.
The most common barrier to implementation found in our study was a lack of provider interest and limited personnel or time. Based on the available literature, this is a unique finding that may not be applicable to other states, or those in other practice areas within South Carolina. One organization reported that leadership support was their biggest set-back, however this could be resolved with greater provider support. However, a different organization reported that when their providers realized the depth of a clinical pharmacists’ contributions to physician workload, the providers gave their full support. This discovery has not been isolated to SC practice sites alone, as many studies have documented the advantages of team-based care models in clinic settings. A 2022 study analyzed the impact of an ambulatory care pharmacist on provider productivity. The authors concluded that when collaborating with pharmacists, providers were able to bill at a higher level suggesting an increase in productivity and an improvement in the patient care process. 19
One organization also noted that identifying correct billing codes was their biggest obstacle during implementation, but their clinical pharmacy services now “pay for themselves.” The cost-justification of a clinical pharmacist in ambulatory clinics has been well documented in literature. A 2014 study by Park et al determined that pharmacist-led Medicare AWVs were a feasible way to support a pharmacist position in physician offices. 19 Another study looking at the financial implications of pharmacist-led AWVs showed the potential for indirect revenue generation through recommendations for preventative services provided during these visits. 20 Once initial barriers are overcome, the benefit of implementing these services is easily understood to each member of the patient care team. The current lack of provider status, both on a state and federal level, continues to be a barrier as it prevents direct billing, reimbursement, and awareness of services a pharmacist can provide. 21
This study has several limitations. Contact information for clinical pharmacists, directors of pharmacy, and CMOs was not readily available at multiple SC FQHCs despite multiple attempts to establish contact. Six of the 22 SC FQHCs were unable to be reached or did not respond to our initial contact, which limits the ability to document all clinical pharmacy services taking place in SC FQHCs. Chronic disease state management was also not clearly defined. This term is all-encompassing and if defined more specifically, may have allowed more unique clinical pharmacy services to be identified. Additionally, the scope of this study included only the state of South Carolina, limiting the applicability of these findings to FQHCs located in other states.
Conclusions
Over 60% of SC FQHCs offered at least 1 clinical pharmacy service, with DSMES and Medicare AWVs being the most common. While the services themselves vary widely across the state, barriers to implementation of clinical pharmacy services are shared among many organizations. Even though lack of provider interest and limited personnel or time remain as the most prevalent barriers to further service implementation in SC, the more we can advocate for these services, the easier it will become to address these barriers. Future studies should evaluate clinical pharmacy services in FQHCs and how they directly impact patient care, provider workload, and the organization.
Supplemental Material
sj-pdf-1-jpc-10.1177_21501319241295952 – Supplemental material for Investigating the Prevalence and Types of Clinical Services Offered by Pharmacists in Federally Qualified Health Centers in South Carolina: A Qualitative, Cross-Sectional Survey
Supplemental material, sj-pdf-1-jpc-10.1177_21501319241295952 for Investigating the Prevalence and Types of Clinical Services Offered by Pharmacists in Federally Qualified Health Centers in South Carolina: A Qualitative, Cross-Sectional Survey by Brice Laney, Anna Rayfield, Reagan K. Barfield, Paul Brandon Bookstaver, Natalie Nelson, Kaitlyn Phillips and Carrington Royals in Journal of Primary Care & Community Health
Footnotes
Acknowledgements
Data presented in part at the American Pharmacist Association Annual Meeting and Exposition, March 24-27, 2023, Phoenix, AZ. Brice Laney has now earned his PharmD and is completing his PGY1 pharmacy residency at Monroe Carell Jr. Children’s Hospital at Vanderbilt University in Nashville, TN. Anna Rayfield, now Anna Cooke, has now earned her PharmD and is completing her PGY1 pharmacy residency at Prisma Health Richland—University of South Carolina in Columbia, SC. Kaitlyn Phillips, now Kaitlyn North, is now affiliated with East Tennessee State University Bill Gatton College of Pharmacy in Johnson City, TN.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The author(s) received funding from the South Carolina Center for Rural and Primary Healthcare grant.
Consent to Participate
This study received approval from the University of South Carolina Institutional Review Board. All data was de-identified and patient consent was not required.
Data Availability Statement
Data has not been shared to a public repository.
Supplemental Material
Supplemental material for this article is available online.
References
Supplementary Material
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