Aine Cryts

Cigarette smoking claims more than 480,000 American lives—approximately 1 in 5 of total US deaths—each year, according to the CDC. This makes smoking the leading cause of preventable disease, disability, and death in the United States.

Although the number of smokers continues to fall, about 13 of every 100 US adults were smoking cigarettes in 2020 (12.5% vs 20.9% in 2005). This means that approximately 30.8 million American adults smoke cigarettes,

 and more than 16 million are living with smoking- related conditions.

Joe Moose, PharmD, clinical pharmacist, co-owner of Moose Pharmacy in Mount Pleasant, North Carolina

According to Joe Moose, PharmD, a clinical pharmacist, co-owner of Mount Pleasant, North Carolina-based Moose Pharmacy, and director of strategy and luminary development with CPESN USA, smoking-cessation programs are an ideal way for independent pharmacists to collaborate with physician practices.

“What we don’t have in health care are good signals of failure,” said Moose. A primary care physician (PCP) can tell their patient to quit smoking, write prescriptions for nicotine patches and amlodipine to control their blood pressure, and ask the patient to buy a blood pressure cuff for monitoring purposes. But too often, the patient doesn’t act on their physician’s recommendations.

The PCP’s goals include controlling their patient’s blood pressure and starting them on a smoking-cessation program. But without access to the patient’s care plan, the pharmacist doesn’t know that the PCP wants their patient to start the program and monitor their blood pressure in the first place.

At Moose Pharmacy, prescriptions will pop up for smoking-cessation patches and amlodipine, but the patient may tell Moose they are not ready to quit smoking. The conversation could end right there, the patient becoming a statistic who joins the more than 16 million Americans living with smoking-related conditions. Or the pharmacist can seize the opportunity to partner with the PCP and ensure they have access to the patient’s care plan, said Moose. The challenge is getting paid for this work. The solution, according to Moose, is what he calls a neighborhood accountable care organization (ACO).

Embed Pharmacists in the Physician’s Practice

The immediate impact of the pharmacist’s lack of awareness of the patient’s care plan is that the patient may pick up their amlodipine but not start the smoking-cessation program or use the cuff to monitor their blood pressure at home, said Moose.

The remedy is to embed a pharmacist in the PCP’s office for 40 hours a week to learn about patients’ care plans and reinforce and support their efforts to quit smoking, manage their diabetes, or control their blood pressure, he added. This enables the pharmacist to meet with patients directly following their visits to the practice. Immediate benefits include the opportunity for the pharmacist to earn in real time about patients’ care plans, access the practice’s electronic health record, and receive a “warm hand-off” from the clinicians at the practice as an integrated part of the patient experience, Moose explained. These connections are initially made in person at the practice between the embedded pharmacist and the clinical team. And when patients receive a follow-up call from a pharmacy technician at Moose Pharmacy, the whole process feels seamless.

This same collaborative model can be applied in the treatment of other chronic conditions, such as diabetes and hypertension. It can also help the practice successfully achieve quality measures to ensure the practice gets its full value-based care payments, Moose added.

That’s where the neighborhood ACO model comes in, explained Moose. Creating a neighborhood ACO means that accountability for patients doesn’t just rest with the PCP while the pharmacist focuses only on dispensing medications and working with the pharmacy benefit manager. Instead, both physician and pharmacist are accountable for the same measures, which can include reducing blood pressure or getting patients to stop smoking, 2 goals of the value-based model, according to Moose.

What’s missing, though, is assurances that the pharmacist is paid in addition to the PCP’s practice. Moose kickstarts compensation conversations with the practice leader after collaborating on data mining to determine missed annual wellness visits for adult patients, chronic care management opportunities, remote patient monitoring opportunities, and the number of patients with diabetes whose glycated hemoglobin A1C levels are above 9, an indication their condition is being poorly treated.

The simple question Moose poses to practice leaders is this: “If [our pharmacists] complete these things and bring in half a million dollars in payments to the practice, is that worth making a $100,000 payment to Moose Pharmacy?”

But even if Moose is successful with this pitch and delivers on the value promised to the practice, he knows his pharmacists must continue to deliver value or he risks the practice choosing to hire a nurse to take on the same work at 70% of the cost.

Moose’s advice? “You have to be valuable...and help generate income.”

Jessica Gustin, PharmD, pharmacy manager at Gwinnett Drugs in Lawrenceville, Georgia

Jessica Gustin, PharmD, pharmacy manager at Gwinnett Drugs in Lawrenceville, Georgia, agreed it’s important for pharmacists to show their worth to physicians. Consultations with patients experiencing chronic pain is one area in which she has achieved success. Providing this service is important because many people pass judgment on individuals taking opioids for pain management when they may actually need them, said Gustin. She is also cofounder and chief operating officer of SynerGrx, based in Chamblee, Georgia, which facilitates collaboration between pharmacists and physicians.

After asking patients about their pain management challenges, Gustin can discuss the adverse effects of opioids, provide access to naloxone HCl (Narcan), and suggest patients participate in physical therapy.

Collaborate With Physicians on Diabetes Management

Eklavya Lalwani, PharmD, pharmacist-in-charge at Olden Pharmacy in Hamilton, New Jersey, said that pharmacists—with their 6 to 8 years of education in a pharmacy school program in addition to clinical knowledge and skills—are uniquely prepared to provide clinical services. Despite this education and experience, though, pharmacists are “extremely underutilized,” he said.

Eklavya Lalwani, PharmD, pharmacist-in-charge at Olden Pharmacy in Hamilton, New Jersey

Lalwani, who is also a preceptor for Fairleigh Dickinson University School of Pharmacy and Health Sciences, said a good way to start collaborating with physician practices is to focus more closely on patients with diabetes. For example, when a patient says their insulin is too expensive, the pharmacist can call the physician and suggest the patient switch to a less expensive biosimilar with a lower co-pay. Most of the time, the pharmacist is talking to the receptionist, a medical assistant, or a nurse in these conversations. Over time, these team members start to remember the pharmacist and look to them as an expert. Lalwani also steals a page from the pharmaceutical sales rep’s book by occasionally showing up for quick in-person meetings at practices.

The ever-present challenge, though, is getting paid for chronic condition management, Lalwani noted. The American Society of Health-System Pharmacists (ASHP) provides guidance to pharmacies on billing Medicare for diabetes self-management. First, the pharmacy needs to set up a diabetes self-management training/education program that has been accredited or recognized by the American Diabetes Association or Association of Diabetes Care & Education Specialists. The program can be run and managed by a registered dietician, nurse, or pharmacist.

For billing, the pharmacy must use the practice’s or pharmacy’s National Provider Identifier (NPI) rather than the pharmacist’s NPI. Payment can range from $15 per patient for a group-based diabetes self-management training education session to $51 for a 30-minute session for an individual patient, according to ASHP.

“Ultimately...the primary role of the pharmacist is ensuring that medications are utilized in the safest, most effective, most efficient manner,” said Tom Kalista, PharmD, a lecturer at the University of Rhode Island College of Pharmacy. “Facilitating communication is only going to enhance that.”

Tom Kalista, PharmD, lecturer at the University of Rhode Island College of Pharmacy

Frequently, the biggest pitfalls are difficulties that occur between prescribing and dispensing, he said. Reviewing drug use and insurance coverage and addressing questions about cost and dosing concerns can take weeks, which introduces delays in patients’ receiving therapy, Kalista explained. “Any delays have an impact in terms of long-term outcomes.”

Kalista recalled a time over the Christmas holidays when a family of 5 came to the pharmacy unsure if they all had COVID-19 or strep throat. As a result of the pharmacy’s collaboration with a local physician, the family was able to access a diagnosis and treatment within 25 minutes. In addition, they were advised against going to a New Year’s Eve party to avoid spreading the strep infection.

“Picking up the phone or walking into the physician’s office is probably the biggest hurdle to [collaboration] because all the parties have the same intention, [which is caring for patients],” Kalista said.

1. Current cigarette smoking among adults in the United States. CDC. Updated March 17, 2022. Accessed May 16, 2022. 

https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm

2. Cornelius ME, Loretan CG, Wang TW, Jamal A, Homa DM. Tobacco product use among adults – United States, 2020. 

. 2022;71(11):397-405. doi:10.15585/mmwr. mm7111a1

3. National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. The Health Consequences of Smoking—50 Years of Progress. CDC; 2014. Accessed May 16, 2022. 

https://www.ncbi.nlm.nih.gov/books/NBK179276/

4. FAQ: alternatives to “incident-to” billing for revenue generation in non-facility (physician-based) ambulatory clinics for pharmacists. American Society of Health-System Pharmacists. March 2019. Accessed May 16, 2022. 

https://www.ashp.org/-/media/assets/pharmacy-practice/resource-centers/ambulatory-care/alternatives-to-incident-to-billing-2019.pdf

Articles

As a pharmacist, embedding yourself in a primary care practice can have positive outcomes for both patients and your business.

Empowering Pharmacist-Physician Collaboration

Elizabeth Gooking Greenleaf blazed a trail as the first female pharmacist in the United States, opening a Boston apothecary shop in 1727—the only one helmed by a woman in the entirety of the New England colonies.

Since then, many thousands of women have joined the same ranks as Greenleaf. According to the US Bureau of Labor Statistics, 57.8% of all practicing pharmacists in 2020 were women,

 and data from that same year from the American Association of Colleges of Pharmacy showed that women made up 64.6% of the total number of pharmacy students enrolled in their first professional degree program.

 shares the story of 3 women making their own mark on the industry.

For Zarina Jalal, PharmD, community pharmacy runs in the family. Her earliest role model was her father, who owned Lincoln Pharmacy in Albany, New York, when she was growing up.

“I was always surrounded by pharmacy,” said Jalal, who is now supervising pharmacist at Lincoln Pharmacy, which has served the Albany community since 1935 and has been owned by her family since 1988. “I’m the youngest of 3 [siblings]. When my mom needed a break, she’d drop me off at the pharmacy,” she joked.

She remembers taking countless naps in her dad’s office at the pharmacy. Today, however, her days are spent managing the team of pharmacists and pharmacy technicians.

“I always loved coming to the pharmacy and seeing what my Dad did,” she said. “I didn’t like the hours; he was always at work. Growing up, he didn’t have a backup pharmacist—he was always running the entire show.”

Although that experience gave Jalal pause when pursuing a career
as a community pharmacist, she has relief help from the other pharmacists on her team. That help enabled her to spend a day recently serving as a luminary for the Community Pharmacy Enhanced Services Network (CPESN)—a clinically integrated, nationwide organization of local networks made up of individual community-based pharmacies working to empower community pharmacy practice—and helping with the Flip the Pharmacy initiative. This practice transformation initiative “aims to ‘flip’ community-based pharmacies away from point-in-time, prescription-level care processes and business models to longitudinal and patient-level care processes and business models through the use of hands-on coaching.”

That same day, Jalal also popped back into the pharmacy to give the pharmacist “a bit of a break,” coached a pharmacy technician on her team, and ended the day at a fundraiser for a local assemblyman who is also
a pharmacist.

Jalal is no stranger to advocating for community pharmacy. In October 2020, she wrote an opinion piece published in Albany’s 

 urging the New York Legislature to sign a bill regulating pharmacy benefit managers (PBMs).

“Like [then–New York Governor Andrew] Cuomo, I have followed in
my father’s footsteps to a profession where I proudly serve my community,” she wrote, referring to Cuomo’s father, Mario Cuomo, who served as New York governor from 1983 to 1994. “I also grew up in my father’s shadow and take great pride in upholding my father’s legacy. I want the same for my children. I want them to have the option of upholding the legacy of Lincoln Pharmacy and serving the community that has supported us for so many years.” 

New York Governor Kathy Hochul announced in January 2022 that
she had signed a bill requiring the licensure and registration of PBMs.

 “This landmark law creates the most comprehensive regulatory framework in the country for [PBMs], increasing transparency for consumers and shedding light on the cost of prescription drugs,” Hochul said in a news release. “Navigating costs associated with medications and insurance can be difficult, so I am proud to sign this legislation to make it that much easier.”

Looking back on her life and career so far, Jalal said she understands the “virtue of patience.”

“I’m someone who likes to see results for my actions—I want to see my results instantly,” she noted.“But you have to lay a foundation and do the groundwork. You won’t see the results immediately. It may be a year or two later.”

Michelle Farrell, PharmD, BCACP, grew up on a dairy farm in a small town in Wisconsin. She credits the now-retired Connie Kraus, PharmD, of University of Wisconsin Hospitals and Clinics in Madison, with inspiring her to become a pharmacist.

Today, Farrell is a pharmacist and owner of Boscobel Pharmacy in Boscobel, Wisconsin, and Center Pharmacy in Richland Center, Wisconsin. Within her practices, smoking cessation programs are one of her passions, she explained. Farrell’s mother, who was a smoker, passed away in 2006 due to lung cancer.

Farrell describes herself as a “strong tobacco-cessation advocate. ”That means she actively engages in conversations with patients to get them to quit smoking. That conversation might take place when a patient shows up at her pharmacy with a prescription to address bronchitis or for chronic obstructive pulmonary disease brought on by smoking.“ The copays and the drugs are adding up. The pill burden is adding up. They’re really amenable to accepting recommendations for change,” said Farrell, who’s a CPESN luminary for Wisconsin.

Her approach with patients is simple: Farrell asks, “Have you considered quitting smoking?” Often, the question prompts a longer conversation about the cost of quitting and the patient’s inability to tolerate smoking-cessation medication in the past, she explained. “That’s a great opportunity to have a conversation and immediately adjudicate a claim with their health insurer to see what’s covered and [to] get them set up for that ‘quit event,’” Farrell said.

Her advice for early-career pharmacists? “Be a sponge; soak in all the information around you,” she said. “Identify what you enjoy and what you don’t enjoy.”

Brooke Kulusich followed her older sister into the pharmacist profession.“I was very inspired by her journey,” she said. “I remember how much she studied and how hard she worked— the initial semesters that she was
in school and how hard they were. I really saw her persevere and grind through it.” 

Kulusich is a PharmD candidate at the University of Pittsburgh School of Pharmacy in Pennsylvania, graduating in 2022. She also serves as the 2021
to 2022 American Pharmacy Association–Academy of Student Pharmacists speaker of the house.

“We had quite a bit of illness in our family,” said Kulusich about her decision to go to pharmacy school. “I watched our grandparents get sick and be in the hospital, [and] I remember how my parents would struggle to play doctor or pharmacist. I wanted to play that role as a pharmacist and help families.”

Next up for Kulusich is a job at a management consulting firm in Chicago, where she’ll be “putting the white coat away.” Kulusich will work on a team that provides strategic business advice to health plans and biotechnology companies to help them improve their sales and marketing efforts.

As she prepares to embark on that journey, Kulusich has one piece of advice for her younger self: “Step outside your comfort zone. That’s where you’ll find the most growth and meaning.”

Eilders C. Celebrating women in pharmacy. Pharmacy Quality Solutions. October 12, 2021. Accessed April 6, 2022. 

https://www.pharmacyquality.com/2020/10/12/celebrating-women-in-pharmacy/#_ftn1

Labor force statistics from the current population survey. US Bureau of Labor Statistics. Updated January 20, 2022. Accessed April 6, 2022. 

Academic pharmacy’s vital statistics. American Association of Colleges of Pharmacy. Accessed April 6, 2022. 

https://www.aacp.org/article/academic-pharmacys-vital-statistics

What is Flip the Pharmacy? Flip the Pharmacy. Accessed April 7, 2022. 

Jalal Z. Sign bill to regulate pharmacy benefit managers. 

. October 6, 2020. Accessed April 6, 2022. 

https://www.timesunion.com/opinion/article/Sign-bill-to-regulate-pharmacy-benefit-managers-15626579.php

Governor Hochul signs landmark legislation bringing transparency and a comprehensive regulatory structure to otherwise unregulated pharmacy benefit managers. News release. Office of the Governor. January 2, 2022. Accessed April 6, 2022. 

https://www.governor.ny.gov/news/governor-hochul-signs-landmark-legislation-bringing-transparency-and-comprehensive-regulatory

Three pharmacists share their stories, challenges, and lessons learned.

Women in Pharmacy Make Their Mark on the Profession

In 2011, nearly half of the 6.1 million pregnancies—or 45%—in the United States were unintended.

 The highest rates of unintended pregnancy are among women with low incomes earning less than 200% of the federal poverty level, women aged 18 to 24 years, cohabitating women, and women of color.

Contraceptive access just is one area in which pharmacists can help women, said Veronica Vernon, PharmD, assistant professor of pharmacy practice at Butler University College of Pharmacy & Health Sciences in Indianapolis, Indiana. Access to a pharmacist can also help women who experience menstrual disorders, including menstrual pain, irregular periods, and heavy or unusual bleeding.

Access to care for women with menstrual disorders was particularly acute during the COVID-19 pandemic, noted Vernon, who is also a clinical pharmacy specialist in ambu- latory care for gynecology and primary care at Richard L. Roudebush Veterans Affairs Medical Center in Indianapolis. More women than men missed recommended preventive services, including yearly checkups and routine tests, and women with low incomes were more likely to have missed these preventive health services.

A variety of factors make care access challenging for women with lower incomes, including inconsistent transportation, lack of childcare, limited insurance coverage, and a work schedule that prevents them from going to medical appointments, according to a commentary published in Pharmacy.

“Equipping community pharmacies with specialized skills in family planning will increase their ability to meet patient and community needs and subsequently reduce barriers to access. Newly developed learning resources...are a bridge to successfully implementing practices [that] reduce stigma, increase patient satisfaction, and improve health outcomes,” wrote the authors, one of whom was Sally Rafie, PharmD, BCPS, APH, founder of Birth Control Pharmacist and a pharmacist specialist at University of California San Diego.

Because 91% of Americans live within 5 miles of a community pharmacy, pharmacists are in a unique position to fill these health care gaps.

 “[Pharmacies] can be a public health hub in their communities,” Vernon said.

Pharmacists also play a meaningful role in the inpatient environment. Kayla Popova, PharmD, a clinical pharmacist specialist in obstetrics and gynecology at Michigan Medicine in Ann Arbor, spends her days rounding with obstetrics specialists who see women with high-risk pregnancies. “It’s very important to have a pharmacist on the women’s service,” Popova said.“When a woman is pregnant, there are certain medications that can’t be taken. They’re not safe in the first trimester, [but] they may be safe in the second or third trimester.” And because of some women’s past medical history, taking birth control with a lot of estrogen isn’t an option because it can lead to thrombosis, added Popova, who is also an adjunct clinical instructor in pharmacy at University of Michigan.

Pharmacists face hurdles in providing access to contraception. Without a collaborative practice agreement, pharmacists can only prescribe con- traceptives in 20 states.

 Pharmacists, however, are aware that women experience challenges accessing birth control. “We’ve all received those panic[ed] phone calls,” Rafie said.

The pharmacist’s role is to serve as a resource to patients who need birth control, Rafie explained. That includes counseling and helping patients pick the contraception method that works best for them. And in states where pharmacists can prescribe contraception, that role includes writing a prescription. “This is a public health challenge,” she said.“It’s critically important that women have autonomy over their own bodies and their own health.”

Rafie, founder of the San Diego–based Pharmacists Clinic, provides contraception and other clinical services in a community pharmacy environment. Educating patients about the pharmacist’s ability to prescribe birth control is important as well.“ I definitely encourage pharmacists to make it very apparent that they’re offering this service,” she said. Education opportunities include sharing posts on social media, wearing buttons that promote the service, and using counter tents. Rafie also recommended providing a private or semiprivate space—or at least a sound barrier—to support women speaking with a pharmacist about birth control options.

Pain, psychological complaints, and tiredness are the most common symptoms associated with menstruation, and during menstruation, 1 in 3 women refrain from daily activities due to these symptoms.

 When a pharmacist sees a woman browsing the menstrual pain–relief section of the pharmacy, it’s a great opportunity to approach and ask questions, Vernon said. She recommends using this conversation starter: “You’re here looking for menstrual pain relief. What are your symptoms? How long has this been occurring?”

“You’re not going to have 20 [or] 30 minutes for this conversation,” Vernon said.“But you can have a 2-minute conversation with a patient to ask a few questions and determine if there’s something more going on than menstruation...such as overlooked endometriosis.” She also recommends using this opportunity to connect the woman with a gynecologist if she doesn’t already have one. Of course, this requires doing some research in advance to develop a list of obstetricians-gynecologists.

In her talk at a 2014 TEDxProvidence event, Alyson McGregor, MD, now the associate dean of faculty affairs and development at the University of South Carolina School of Medicine Greenville, discussed the mistake of merely focusing on reproduction when it comes to women’s health.

“Women’s health became synonymous with reproduction: breasts, ovaries, uterus, pregnancy,” McGregor said in her talk. “It’s this term we now refer to as ‘bikini medicine.’ And [it] stayed this way until... the 1980s, when the concept was challenged by the medical community and the public health policymakers, when they realized that by excluding women from all medical research studies, we actually did them a disservice—in that apart from reproductive issues, nothing was known about the unique needs of the female patient.”

Vernon agrees. Women’s health should also focus on tobacco-cessation management, cardiovascular health, and osteoporosis. And crucially, pharmacists must also be prepared to provide women’s health services to patients who aren’t cisgender women;

 transgender individuals require these services as well.

Immunizations, preventive care, medication management, and life- style changes are all services that pharmacists can provide.“Starting with immunization is a great way to focus on women’s health,” Vernon said. Pharmacists can ensure that all patients get their yearly flu vaccine and are up-to-date on human papillomavirus immunization as well, which prevents multiple types of cervical cancer in cisgender women and genital warts, anal cancers, and cancers of the mouth, throat, neck, and head in both women and men.

“Everything we look at in medicine is centered on a male lens,” Vernon said. Increasing awareness of these issues, in the pharmacy and beyond, is the first step to more equitable health care for everyone.

1. Unintended pregnancy in the United States. Guttmacher Institute. January 2019. Accessed April 18, 2022. 

https://www.guttmacher.org/sites/default/files/factsheet/fb-unintended-pregnancy-us.pdf

2. Period problems. Office on Women's Health. Updated March 16, 2018. Accessed April 18, 2022. 

https://www.womenshealth.gov/menstrual-cycle/period-problems

3. Frederiksen B, Ranji U, Salganicoff A, Long M. Women's experiences with health care during the COVID-19 pandemic: findings from the KFF women’s health survey. Kaiser Family Foundation. March 22, 2021. Accessed April 18, 2022. 

https://www.kff.org/womens-health-policy/issue-brief/womens-experiences-with-health-care-during-the-covid-19-pandemic-findings-from-the-kff-womens-health-survey

4. Pfaff A, Rafie S. Expanding pharmacy capacity for patient-centered reproductive health services. 

. 2020;8(4):236. doi:10.3390/pharmacy8040236

5. Face-to-face with community pharmacies. National Association of Chain Drug Stores. Accessed April 18, 2022. 

https://www.nacds.org/pdfs/about/rximpact-leavebehind.pdf

6. Pharmacist prescribing: hormonal contraceptives. National Alliance of State Pharmacy Associations. December 1, 2021. Accessed April 18, 2022. 

https://naspa.us/resource/contraceptives/

7. Schoep ME, Nieboer TE, van der Zanden M, Braat DDM, Nap AW. The impact of menstrual symptoms on everyday life: a survey among 42,879 women. 

2019;220(6):569.e1-569.e7. doi:10.1016/j.ajog.2019.02.048

Why medicine often has dangerous side effects for women

. TEDxProvidence. September 2014. Accessed April 18, 2022. 

https://www.ted.com/talks/alyson_mcgregor_why_medicine_often_has_dangerous_side_effects_for_women

9. American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice; American College of Obstetricians and Gynecologists’ Committee on Health Care for Underserved Women. 

Health care for transgender and gender diverse individuals: ACOG Committee Opinion, Number 823

2021;137(3):e75-e88. doi:10.1097/AOG.0000000000004294

10. HPV vaccine: who needs it, how it works. Mayo Clinic. September 18, 2021. Accessed April 18, 2022. 

https://www.mayoclinic.org/diseases-conditions/hpv-infection/in-depth/hpv-vaccine/art-20047292#

Pharmacists can improve quality of life for the women they care for by offering advice, education, and other point-of-care services.

Care at the Counter: Women's Health in the Pharmacy

Low pay, no opportunities for advancement and feeling disrespected at work: Those are the three top reasons American workers said “I quit” as part of the “Great Resignation,” according to a Pew survey conducted in March 2022. Other experts have referred to this wave of resignations, which rose to a 20-year high in November 2021, as the “Great Reshuffling,” indicating that these workers simply chose better jobs.

While health care providers more likely to stick around, your front desk staffer may have one foot out the door. Experts provide a wealth of advice to hire and retain employees—including offering salaries that compete with local retailers, conducting “stay interviews” and offering 4-day work weeks.

Chris Garofalo, MD, a physician in North Attleboro, Massachusetts, agrees that this is one of the most challenging hiring environments his practice has faced. “There are people who are looking for more flexibility. I know when I talk to my patients. Most people don’t want to go back to the office full time, but they don’t necessarily want to stay home full time.”

Still, one of the issues with a medical practice is that it’s difficult to have people working from home. “We need to take care of our patients in the office setting,” said Garofalo.

He addresses employees’ need for flexibility by letting them take a half a day if they’re sick or want to go to their child’s soccer game. “Most of the time we can accommodate that. They don’t necessarily need to take it as sick time. If someone needs to go, we will deal with it later.”

Hiring Strategies for Front Desk and Assistant Staff

Seeking candidates to fill front desk and assistant roles is never easy. According to Garofalo, online job boards can be hit or miss. “About 60% to 70% of the people who respond and make an appointment for an interview no-show the interview. Of the people who show up, 30% to 40% don’t have the medical assistant qualification, and we can’t train on the job,” he said.

Recently, Garofalo needed to hire a medical assistant at his practice so he posted the job opening on Everything North Attleboro, a community Facebook.

“My thought was this was more local,” he said. “It’s not just people who are going to apply generically to job postings. I put a more personal touch, and we got some really good responses. That’s how we hired our most recent medical assistant, who has 15 years of experience.”

Another option is to actively recruit employees who want to work as part-timers, according to Andy Swanson, CMPE, vice president of industry insights at Medical Group Management Association (MGMA). “Practices have gotten better at flexible staffing in the last 10 to 15 years,” he said.

Swanson expects that many of the people who recently left jobs will run out of money and need to pursue part-time work. At a medical practice, that could look like a 9 a.m.-to-2 p.m. shift 3 days a week for one front desk staffer, and another team member takes that shift the other two days.

“Not everyone wants full-time work.…Maybe they don’t want to stop driving for Uber or they want something while the kids are in preschool,” he said. Another benefit of this flexible staffing model: The practice can save money that it would have spent on health insurance and other benefits, added Swanson.

Hiring and Retention Strategies for Administrative Staff

The average hourly rate for a Target employee in Sunnyvale, California, is $21.80, while a Target employee in Washington, DC, earns $20.24 an hour, according to San Francisco-based Zippia, which tracks salary information for job seekers.

But understanding the local labor market is one area where health care practices fall short, said Swanson. “You’re competing with fast food services and retail. That means your pay has to be at or above [those workplaces], and you can’t pay the median rate of $18 an hour that MGMA says you should pay for your state or region. “

His advice to the practice’s human resources person: “You need to mind-shift and benchmark pay rates to your market, not just to the national average.”

Jennifer Brull, MD, FAAFP, a family medicine physician in Plainville, Kansas, doesn’t have to compete with Target’s hourly rate because the retailer is a two-hour drive from her practice. But she can offer her front desk staff some lifestyle benefits that are tough to beat: Minimal physical labor is required and the outpatient practice doesn’t require staff to work evening or weekend hours.

It’s just as important to create a work environment where employees want to stay. Many among Brull’s team have remained at the practice for 10 to 25 years. “We have a reputation for being a culturally good place [to work] where people care about you….If you need to be out for a family event, you can do that. You have health care coverage as a benefit. That’s how we try to make ourselves attractive as an employer.”

Hiring and Retention Strategies for Clinical Staff

In addition to hiring and retaining administrative staff, health care practices have to recruit and retain clinical providers. Twenty-eight percent of health care leaders reported losing a physician to an unexpected retirement, according to a March 2021 poll by MGMA. Meanwhile, the US Bureau of Labor Statistics projects 9% employment growth for RNs from 2020 to 2030; the fastest growth is expected for nurses in outpatient settings.

This is a real-world challenge for Brull, who has decided to leave her practice in November 2022 and hopes to hire 2 doctors before she leaves. She owns her practice and collaborates with a nearby practice; together they’re recruiting the new physicians.

In addition, a nurse practitioner is leaving the practice in June, so Brull needed to recruit another new clinician. In July, the practice will welcome a new physician assistant who is on course to graduate this spring.

Brull credits her practice’s work precepting physician assistants and nurse practitioners with creating “a pretty big pipeline” for the recent physician assistant hire. “They know who we are. They’re in our practice for a month or more, which is a great way to know if they like us and vice versa. That’s much better than an interview,” she said.

But the practices still need to recruit 2 physicians. Early on, she and her colleagues decided that one of the new physicians should specialize in family medicine with a focus on obstetrics. Besides that, one of the physicians—she’s “an amazing networker,” said Brull—is actively recruiting two new physicians.

She had to work with the nearby hospital to ensure an “income guarantee” for the new physicians and the recruitment process requires “getting us plugged into residency programs across the state,” said Brull.

There are two selling points she’s leaning into as her team recruits two new physicians: Plainville is a rural area with low crime and a good education system, and physicians who choose to practice in the area for four years can have their medical school tuition refunded.

“I grew up in this part of the state,” said Brull, who has practiced medicine in the Plainville area for 20 years. “I moved to the big city for 10 years for training and then I moved back. The only things I miss are the shopping and the food. Now there’s online shopping, which means I only miss the food. And my husband is a great cook.”

Tom Florence, executive vice president of recruiting at Merritt Hawkins, said the company’s recruiting business has seen “a tremendous uptick in demand.”

Typically, about 15% of physicians will move or change jobs each year, he explained, but that’s now “hovering in the 25% range.” Florence credits the pandemic with prompting physicians to reconsider what’s important to them. That could be a different location, a different practice setting, different work hours, or the need for flexibility, he said.

When Florence coaches hiring managers, he suggests that they start with a market analysis, much the same way a real estate agent does with a property that comes on the market.

“You want to make sure that the (physician) opportunity they’re providing is viable compared to other physician roles…which includes looking at compensation for a primary care doctor in Boston, for example. If we can’t find a candidate locally, that’s now a national search,” he said.

Beyond salary, flexibility for physicians is critical, according to Florence. “Anytime you can give them set hours or set schedules, they really appreciate that. Four-day work weeks—that’s an opportunity that stands out as well.”

Still, he encourages practices to retain physicians by consistently checking in to see how they’re doing. “Some companies do exit interviews. I encourage clients to do ‘stay interviews.’ ”

Stay interviews are meetings once or twice a quarter where physicians are engaged in a conversation with the lead physician who asks these questions:

Professional information services company Wolters Kluwer also offers advice on recruiting nurses, including the following tips:

Emphasize career advancement by offering new-graduate residency programs and transition-to-practice programs to attract new talent.

Focus on work-life balance, not just the job.

Compensate appropriately, realizing that tuition reimbursement and loan repayment programs are attractive perks.

Offer flexible schedules, which will may help with work-life balance.

Create “nurse ambassadors” who can connect emotionally with their peers in video testimonials.

Create a sense of community where nurses feel they have a voice.

Garofalo is candid about his practice’s inability to compete with larger practices or hospitals that can pay employees more. His strategy: Build and sustain a “kind culture.” For him that means letting an employee leave for the day if their child is sick and backing up an employee if a patient treats them rudely.

Building and sustaining a culture where employees want to work “starts at the top,” said Garofalo. “It starts with the owner and our practice manager. I think we have to model that kind of behavior….We are very protective of our employees. We certainly have had episodes where patients were getting very upset (at employees). We as doctors aren’t afraid to step into that, rather than just delegating it to our employees.”

“It’s important for employees to know we have their backs and we’re there to support them,” added Garofalo.

Here’s some language he has used with a patient who had treated a staffer poorly: “You don’t get to treat employees one way and me another way. You can’t be all ‘nicey nice’ with me (and rude to staff).”

Getting the workplace culture right seems to work as a retention tool, he said. “Over the past four years, we have had three people leave who came back. They got more money elsewhere but they came back here to get paid less. But we provide a better atmosphere for people.”

Successfully navigating conflict among employees also helps, advised Garofalo. His approach to building a “family-type” atmosphere at the practice is twofold. The practice is very careful to ensure the people it hires are a good fit and, he says: “We really try to keep drama to a minimum. We address it. We have our HR person who has no problem addressing it. We make sure that people understand what behaviors will and won’t be tolerated.”

MGMA’s Swanson advises practices to think long and hard about the employee value proposition. “That outlines a handful of key drivers in which employees find value, for example, pay, benefits, and vacation, in addition to the career benefit, learning and development, and flexibility with the ability to work from home,” he said.

It can be as simple as practice leaders asking this question: “What are we going to offer on a spectrum of value creators?”

“We’re either going to pay you more…or offer flexibility or better hours. What can we do…to really stand out for the majority of candidates?” Those are the questions every practice leader should be asking, said Swanson.

This article originally appeared on Medical Economics.

Practices can use these strategies to attract skilled workers to open positions. 

How to Hire Staff During the Great Resignation

“Where a person is born, where they live, worship, age, grow, and discover” are the elements that make up the social determinants of health (SDOH), said Erin Pauling, PharmD, BCACP, during her session at the American Pharmacists Association 2022 Annual Meeting & Exposition.

Pauling, assistant dean for academic affairs at New York’s Binghamton University School of Pharmacy and Pharmaceutical Sciences, was joined by Megan Coleman, PharmD, BCPS, CPP, associate professor at Wingate University School of Pharmacy in Wingate, North Carolina.

Together, they pointed to 6 elements of SDOH developed by Healthy People 2030, an initiative of the United States Department of Health and Human Services that sets data-driven national objectives to improve health and well-being over the next decade.

That’s about a person’s ability to read, or not.

This is the ability of a person to access healthcare. “We think about our patients…their healthcare is really visiting urgent care and emergency room departments. But access to healthcare also [considers], ‘Does a person have a PCP?’” she said. The difference is preventative care, instead of care that’s reactive.

 Included in this category is access to healthy foods, she explained, while asking these questions: “What does that environment look like? Are there grocery stores, are there markets…[what about] the restaurants that are available?”

“Are there bike paths on the roads? Are there sidewalks such that you would be able to walk and get physical activity? Are there parks available?” asked Pauling. The quality of home structures, such as apartments, is another consideration under environmental conditions; heating issues and mold are also potential concerns.

This includes the ability to vote, access community gardens, the prevalence of discrimination, and rates of incarceration.

Employment, housing stability, food insecurity, and poverty are issues of concern in this area.

“Diabetes is the seventh leading cause of death in the United States and immensely prevalent,” she said. Although 37.3 million adults in the United States have diabetes, 1 in 5 don’t know they have it.

But diabetes doesn’t affect all populations in the same way, Pauling explained, citing these statistics:

Eight percent of the homeless population in the United States has been diagnosed with diabetes.

Up to 25% of patients prescribed insulin report cost-related underuse. That means often stretching out the use of insulin in a given month.

80 million US adults–or more than 4% of the population–have difficulty understanding healthcare information and navigating the healthcare environment.

But diabetes-specific screening tools can help.

Pauling defined health literacy as a person’s ability to “obtain, process, and understand basic health information and services needed to make appropriate health decisions.” This is important to keep in mind when trying to avoid using medical jargon and using layperson language, she explained.

But there’s also health numeracy. That’s the ability to understand and apply numbers in the context of acts of daily living and with disease management, said Pauling, who added that diabetes management has many numbers associated with it.

Diabetes is full of clinical terminology, such as A1C, fasting blood glucose, and postprandial blood glucose, she explained. This is further complicated by the fact that a patient may need further customization for their care plan, depending on other comorbidities.

Nutrition, physical activity, and medication are always issues of concern, and they’re largely the responsibility of patients, who may get confused about when they should take their insulin. “There are a lot of areas where social determinants of health may impact patients with diabetes,” she said.

One in 5 American adults with diabetes don't know that they have the disease. 