Frieda Wiley, PharmD, BCGP, is a writer and pharmacist. 

Frieda Wiley, PharmD

The tentacles of racial and cultural health care disparities extend their reach deep into the fabric of American culture. The complexities are painfully entrenched throughout American identity: from where a person lives and their cultural identity to one’s complexion and economic standing. Sadly, a patient’s experience accessing and navigating the United States health care system also falls on this list, an unfortunate consequence of inherent bias borne from all too common effects of systemic racism and implicit biases. Although many factors contribute to the substandard experiences marginalized communities face in the health care setting, perhaps no reason bears greater weight than the basis on which the United States health care system was founded.

From health care access to medication use disparities, minority populations often bear the brunt of a system not weighted in their favor. While the problem isn’t new—the CDC published a Health Disparities and Inequalities Report in a 2013 issue of 

Morbidity and Mortality Weekly Report (MMWR)

—the COVID-19 pandemic threw many of the issues surrounding care equity into sharp relief.

Research throughout the pandemic has shown that some racial and ethnic minority groups are more likely, disproportionately so, to be negatively impacted by COVID-19.

 The reason is multifaceted: in some communities, racial and ethnic minorities were more likely to be working essential service jobs, increasing the risk of exposure to SARS-CoV-2. And because of systemic disparities in care access, many of these individuals were already living with conditions predisposed to experience worse COVID-19 outcomes.

Even after treatments like monoclonal antibodies became available, a 

 report found that of a total of nearly 6 million patients in PCORnet health care systems evaluated, “mean monthly [monoclonal antibody use] among all patients with positive SARS-CoV-2 test results” were lower among patients who were Black, Asian, Hispanic, or non-Hispanic compared with patients who were White.

Socioeconomic Factors Contribute to Care, Medication Disparities

Both race and socioeconomic standing play strong roles in dictating a person’s success. A person’s financial background, for example, can be an indicator of their overall health. In fact, personal wealth is so predictive of individual health outcomes and overall health that the scales remain drastically imbalanced and in favor of those with financial security.

“The US health care system was designed by and set up to care for White people, so of course, it does the best job caring for White people,” said Andrew Schmelz, PharmD, assistant professor of pharmacy practice at Butler University in Indianapolis.

“Because our health care system is structured around businesses and management of payment and profit, how much money someone has directly impacts how healthy they are,” Schmelz told 

. “This creates an environment where money, which…is controlled by social factors, plays an outsized role in determining health outcomes.

Historically, the United States health care system has focused on the biologic drivers of health, Schmelz explained. However, emerging data indicate that social determinants—which include access to clean water and healthy foods, the ability to afford medications, and adequate housing, among others—also affect overall health and well-being.

Chronic diseases tend to be more prevalent in Latino and Black communities as opposed to the White population.6 As a result, these communities are predisposed to use more medication. But despite these higher incidences of medication use, less access to medical care and greater financial constraints in these communities mean that many still struggle to achieve optimal rates of medication adherence. In fact, both groups are at least 50% more likely to have poorer adherence rates than the White population.

Three Tips to Tackle Health Care Disparities

A growing body of evidence indicates that Black patients face additional barriers in the form of discrimination and the effects of implicit bias by health care providers. In health care education settings, curriculum on race- and ethnicity-based health inequities can be limited,

 and compounded by biases that certain medications—for example, those used to treat pain—may work “better” or worse in patients based on race.

Language differences can further amplify medication use disparities. Such is the case for members of Latino and Asian communities who have language barriers when receiving care.

“[One] contributing factor to the low incidence of medication use [among] Latino and Asian communities is a lack of health literacy due to language barriers,” Donney John, PharmD, executive director of NOVA ScriptsCentral in Falls Church, Virginia, told 

Across the spectrum, members of non–English-speaking communities may not feel comfortable asking questions of their health care provider, concerned about appearing as if they are “questioning” or not respecting their provider’s knowledge and training, John explained. But sometimes, medication information is not translated into a language that patients can easily understand, leading to vital information being lost in translation.

John encourages pharmacists and other health care professionals to seek resources other than Google Translate. Although this tool can be beneficial in day-to-day life, instances of inaccurate translation of medication-related information have been noted.

Misunderstandings and patient engagement hesitancy owing to language barriers are not the only factors leading to disparity and inequality across the health care system. In some communities, individuals may prefer to turn to alternative healing practices, which could result in lower medication use. Once again, cultural idiosyncrasies make the situation more difficult to quantify.

“I would argue that non-Hispanic White [individuals] may also follow these practices and have some more common to their own culture—for example, doing “cleanses” to remove “toxins” from the GI tract,” Schmelz said. “Also, medication use for specific diseases (eg, drugs for opioid use disorder) has been historically stigmatized, and populations with higher incidence of these problems [are] disproportionately affected.”

The brutal murder of George Floyd by police in 2020 ignited widespread discussions around diversity, equity, and inclusion (DE&I), said Schmelz. Although encouraging, DE&I as a field isn’t new, and there is skepticism that this increased attention will result in any meaningful changes in how we train students or how we provide care.

Frank North, PharmD, MPA, president-elect of the National Pharmaceutical Association in Houston, shared some similar concerns regarding how meaningful changes look and whether they are effective.

“DE&I is [a] hot topic we see schools implementing, but is it done so in an effective way?” he asked. “Some institutions are wrapping their minds [around] the need for DE&I and the fact that communities of color have different experiences.”

These efforts are wide ranging. Some include steps to create narratives that change how the health industry discusses drug efficacy and disease prevalence, Schmelz said. Other efforts have involved research11 intothe impact of implicit biases—“attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner”11—on pharmacy education.

Cultural Competency: An Outdated Concept?

Education can help create awareness among providers about their own implicit biases while providing strategies to provide more culturally competent care. However, this isn’t a panacea for medication use disparities. According to John, cultural competence—defined as an ability to understand, appreciate, and interact with individuals from cultures different from one’s own

“All patients—regardless of gender or race—want to be provided with care that treats and engages them with respect,” he said. “Understanding the concept of cultural humility will go a long way for people to learn who to improve the health literacy for patients from different backgrounds so that they will be more responsive to medication therapies.

The narrative of cultural competency, while important, has 2 major limitations.

 First, it inadvertently introduces bias and stereotyping by implying that a person can collect information about group of people; and second, it creates the false notion that cultural competence is an area in which a person can become 100% proficient.

A growing body of evidence suggests that cultural competence is on its way to becoming an antiquated concept—perhaps rightfully so. Its origins date back to the ‘60s and ‘70s, an era marked by sociopolitical turbulence.

Cultural humility—a second-generation iteration of cultural competency—first emerged in 1998.13 The term acknowledges the fluidity of culture predomination while recognizing that understanding and honoring one’s culture is a lifelong process that commands reflection and introspection.

Empathy is another critical piece to solving the medication use disparity puzzle, especially when it comes to engaging the patient with practical action points.

“As a pharmacist, I don’t like to take medication myself, so I may not be as adherent to medication regimens if they are too cumbersome,” John admitted. “So, I try to put myself in the patient’s shoes and think [about whether] I could follow through on the recommendation that I am asking them to follow.”

CDC releases second health disparities & inequalities report—United States, 2013. CDC. Reviewed November 26, 2013. Accessed March 24, 2022. 

https://www.cdc.gov/minorityhealth/CHDIReport.html#anchor_1607954179

Risk of severe illness or death. CDC. Updated December 10, 2020. Accessed March 24, 2022. 

https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/racial-ethnic-disparities/disparities-illness.html

Wiltz JL, Feehan AK, Molinari NAM, et al. Racial and ethnic disparities in recipt of medications for treatment of COVID-19—United States, March 2020-August 2021. 

2022;71(3):96-102. Doi:10.15585/mmwr.mm7103e1

Lopez III L, Hart III LH, Katz MH. Racial and ethnic health disparities related to COVID-19. 

2021;325(8):719-720. Doi:10.1001/jama.2020.26443

Weida EB, Phojanajong P, Patel F, Chilton M. Financial health as a measurable social determinant of health. 

2020;15(5):e0233359. Doi:10.1371/journal.pone.0233359

Xie Z, St Clair P, Goldman DP, Joyce G. Racial and ethnic disparities in medication adherence among privately insured patients in the United States.

2019;14(2):e0212117. doi:10.1371/journal.pone.0212117

Weiner S. Medical schools overhaul curricula to fight inequities. American Association of Medical Colleges. May 25, 2021. Accessed March 24, 2022. 

https://www.aamc.org/news-insights/medical-schools-overhaul-curricula-fight-inequities

Lawrence E. What doctors aren’t always taught: How to spot racism in health care. KHN News. November 17, 2020. Accessed March 24, 2022. 

https://khn.org/news/racism-in-health-care-what-medical-schools-teach/

Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. 

2016;113(16):4296-4301. Doi:10.1073/pnas.1516047113

Prasad-Reddy L, Fina P, Kerner D, Daisy-Bell B. The impact of implicit biases in pharmacy education. 

DeAngelis T. In search of cultural competence. American Psychological Association. March 2015. Accessed March 24, 2022. 

https://www.apa.org/monitor/2015/03/cultural-competence

Khan S. Cultural humility vs cultural competence—and why providers need both. HealthCity. March 9, 2021. Accessed March 13, 2022. 

https://healthcity.bmc.org/policy-and-industry/cultural-humility-vs-cultural-competence-providers-need-both

Articles

Across the country, minority populations face significant disparities in medication use. It's time for that to change. 

Improving Health Care and Medication Access for Minority Populations

Estimates regarding the prevalence of people with autoimmune conditions range from as few as 24 million people to nearly 50 million people

Scientists have identified more than 80 autoimmune diseases, running
the gamut of conditions from type 1 diabetes and rheumatoid arthritis to scleroderma and multiple sclerosis. Despite their collective commonalities, many patients with autoimmune conditions—many of which fall under the umbrella of rare diseases—face access barriers, with health insurers and pharmacy benefit managers bearing the brunt of blame.

Although industry experts agree cost is a huge barrier to treatment, views on whether this is the greatest challenge faced by patients with autoimmune diseases vary and are sometimes in opposition. However, all agree that pharmacists can have a tremendous impact in helping patients access their medications.

For Denise Summers, PharmD, BCGP, CDCES, rare disease advocate and geriatric clinical pharmacist at Landmark Health in Boston, Massachusetts, the wounds caused by financial burdens cut much deeper than the pocketbook. “One of the greatest hurdles those with rare autoimmune conditions face is continuity of care,” Summers told 

Interruption of care is a topic Pam Cusick, senior vice president of Rare Patient Voice in Annapolis, Maryland, knows all too well both on a personal and profes- sional level. She shared the story of a situa-tion where a friend’s child with Crohn disease changed jobs, resulting in an insurance mix-up. The child needed an infusion but was denied treatment until her parents paid the $24,000 fee via credit card. “They got their money back, but it was a terrible experience,” Cusick said.

Cusick believes pharmacists are well positioned to help patients tackle this and other access-related issues. Pharmacists are often well versed in navigating the intricacies of the payer world. This experience allows them
to educate patients and their families about cost-saving measures. Pharma- cists can also leverage their rapport as highly influential and trustworthy health care professionals.“There is so much information out there, and they need a good resource they can trust,” Cusick said.

Engaging with a trustworthy health care provider can also help address the coverage gaps frequently exacerbated by racial, cultural, and ethnic divides. Summers pointed out that patients who are either un- or underinsured face the substantialrisk of failing treatment, as they often engage in behaviors such as reducing medication use due to costs. Nonelderly people of color, regardless of race or ethnicity, are less likely to have health insurance than White patients, according to a 2019 report conducted by the Kaiser Family Foundation.

“There is still mistrust of the medical community,” Cusick said. “There are cultural differences pharmacists should be aware of so they can meet people where they are and help patients feel comfortable.” The differences to which Cusick referred transcend medical mistrust owing to painful history of institutional racism plaguing communities of color. Cultural beliefs, creeds, and norms can also influence outcomes. In some cultures, having an illness such as an autoimmune disease or cancer may be seen as a weakness, meaning that people from those cultures may be less likely to seek medical help.

Cusick believes pharmacists can intervene in these kinds of cases, easing the patient’s anxiety and answering questions they might find uncomfortable otherwise.

 “The biggest hurdle patients with autoimmune conditions face is connecting with others who have had their lived experience,” Cusick said. “It can be very isolating.”

Autoimmune diseases. National Institute of Environmental Health Sciences. Reviewed July 9, 2021. Accessed February 3, 2022. 

https://www.niehs.nih.gov/health/topics/conditions/autoimmune/index.cfm

Leading autoimmune diseases undergo robust improvement in treatment by major pharma companies. Delve Insight blog. July 21, 2021. Accessed February 3, 2022. 

https://www.delveinsight.com/blog/leading-companies-in-autoimmune-diseases-market

Renfrow J. Study: payers, PBMs hinder drug access for autoimmune patients. 

. May 8, 2019. Accessed February 3, 2022. 

https://www.fiercehealthcare.com/payer/payers-pbms-restricting-drug-access-for-autoimmune-patients

Artiga S, Hill L, Orgera K, Damico A. Health coverage by race and ethnicity, 2010-2019. Kaiser Family Foundation. July 16, 2021. Accessed February 3, 2022. 

https://www.kff.org/racial-equity-and-health-policy/issue-brief/health-coverage-by-race-and-ethnicity/

Wiley F. Culturally competent care fights health disparities. 

®. February 2, 2021. Accessed February 3, 2022. 

https://www.drugtopics.com/view/culturally-competent-care-fights-health-disparities

Pharmacists are well positioned to address the care issues faced by patients living with autoimmune diseases.

Cost, Culture Affect Access to Autoimmune Disease Care

The long reach of the COVID-19 pandemic has engulfed every industry, including pharmacy. Although many industries have worked to adapt or survive, the variety of issues affected by the pandemic has triggered positive shifts in community pharmacy practice overall, according to Bri Morris, PharmD, senior director of program development at the National Community Pharmacists Association (NCPA) in Alexandria, Virginia.

Across the country, many pharmacists have long been waiting to practice closer to the top of their licenses. These emerging trends offer community pharmacists unprecedented opportunities to do exactly that. Here are some potential pharmacy trends to watch in 2022.

Expect to See an Uptick in Point-of-Care Services

Community pharmacies increased their point-of-care testing services during the pandemic—a feat that Morris says many pharmacists have “embraced…to meet their patients’ immediate needs.”

“Now that so many pharmacists have [obtained] their CLIA [Clinical Laboratory Improvement Amendments] certificates of waiver and introduced COVID-19 testing into their regular practice, there is an opportunity to branch into other acute infectious disease and chronic disease management,” Morris told Drug Topics®. “In many states, pharmacists are able to test and treat these patients for minor ailments as well.”

Immunization services have been trending in pharmacy for years, and the surge in recommended infectious diseases immunizations has only increased patient demand. Yet despite the apparent opportunity, providing these services remains a significant pain point for pharmacists on the front line, who often operate under the mounting pressure of meeting high prescription volumes with minimal staff support. Morris, though, is optimistic that recent technological interventions and logistic strategies have helped alleviate some of the pressure.

“Now community pharmacies have adopted scheduling platforms and designed a staffing workflow to integrate immunizations into pharmacy workflow,” she said. “Gaps still exist in routine immunizations for both adults and children, and community pharmacies can meet those gaps.” The numbers speak for themselves: As of November 9, 2021, community pharmacies and federal programs had administered and reported nearly 163 million doses of COVID-19 vaccines, according to data collected by the NCPA. This number does not include the data for vaccine doses administered and reported by state-administered programs.

The soaring demand for immunizations has expanded roles for pharmacy technicians. Much like the pharmacist’s role, that of pharmacy technicians’ has evolved over the years, and the concept of expanding the services that technicians provide is not new either.

 The COVID-19 pandemic led to the declaration of the Public Readiness and Preparedness (PREP) Act. Initially enacted by Congress on December 30, 2005, the PREP Act endows the secretary of the Department of Health & Human Services with the authority to declare the act whenever an emergent event poses a threat to public health.

In the pharmacy world, the PREP Act allows medical professionals to engage in the provision of services that may exceed their ordinary scope of services under usual circumstances, in an effort to address the shortage of responders and improve the availability of services and resources.

 On February 2, 2021, Acting Secretary of the Department of Health and Human Services Norris Cochran moved to amend the PREP Act declaration for the COVID-19 pandemic to define the list of individuals able to prescribe, dispense, and administer vaccines. The amendments culminated with one defining pharmacy technicians as “qualified persons” able to administer the seasonal influenza vaccine to adults in the state in which they are legally allowed to practice.

Secretary Xavier Becerra was responsible for the final amendment, which also grants pharmacist interns similar authority to administer seasonal influenza vaccines to the adult population. The act also allows pharmacy technicians to facilitate point-of care testing during the pandemic. Both pharmacy technician–provided immunizations and point-of-care services require pharmacist supervision. Morris anticipates that these services temporarily allowed by the PREP Act are the gateway for an entire suite of services that pharmacy can expect to fall under technician ownership.

“This expansion of scope combined with increased workforce demands brings about new roles for pharmacy technicians,” Morris said. “Medical billing specialist, immunization administrator, med sync [medication synchronization] lead, and community health worker are just a few of the titles we can expect technicians will have in the coming years.”

“With more than 10,000 Americans aging into Medicare daily, providing medical-at-home services to keep patients who might otherwise be in a nursing home in the familiarity of their homes is a patient care no-brainer, and many pharmacies are currently caring for these patients,” Morris explained. “Currently, the incentives and payment don’t match the effort.”

However, Morris anticipates that the historically poor reimbursement for the services that pharmacies provide will change with services that allow patients to age in place. For example, a new clinically integrated network focused on helping patients age in place, combined with advocacy efforts led by NCPA’s long term care division, helps pharmacies capitalize on potential business opportunities.

 NCPA has asked the Centers for Medicare & Medicaid Services (CMS) to formally “recognize medical at-home pharmacy services regardless of where the patient resides.” The Community Pharmacy Enhanced Services Networks (CPESN) USA started CPESN At-Home, a new network that contracts for enhanced services designed to address the needs of patients. Such patients would otherwise be candidates for a nursing facility, including those who are homebound, have trouble accessing a pharmacy, or require some level of caregiving assistance.

“You, as the pharmacist, are able to provide the same level of care that that same patient would receive in the nursing home, but you’d provide it at their home,” Morris said.

Improvements in a pharmacists’ longstanding battle for formal recognition by the US government and payors as health care providers continues, and with that comes the challenge not only of seeking compensation but also of gaining respect. However, a 2021 article by Deloitte, The Pharmacist of the Future,

suggests that a lack of the latter may prove advantageous from an accessibility standpoint.

“Pharmacists are not seen as authority figures the way that doctors are seen,” said an anonymous educator and research scientist who was quoted in the article.” [I]in a way, that’s probably sad, but what it means is that the pharmacist is more approachable than the doctor, and that can be really useful.”

The article’s authors also highlighted how pharmacists’ approachability, coupled with frequent patient contact, automatically enhances the opportunity to build trust. The patient-pharmacist rapport establishes a gateway into the patients’ worlds, with pharmacists able to form a bond that allows them to take a deep dive into their patients’ experiences and collect vital problem-solving information.

Being central figures in the health care equation uniquely allows pharmacists to identify additional resources for their patients and help them navigate the health care system. Watching these and other trends unfold over the past year suggests the consulting firm’s crystal ball is quite clear. Only time can tell how the industry will truly take shape.

As change continues to sweep the industry, we take a closer look at the trends that may be coming to a pharmacy near you.

2022 Pharmacy Trends

Diversity and inclusion remain a hot topic, but the embers that continue burning into the American conscience far transcend race and ethnicity. Like minority communities, the LGBTQ+ community also wrestles with its own struggles as another medically underserved population smoldering under the ashes, and pharmacists and other health care professionals who serve the LGBTQ+ community are working to establish methods to address these patients’ needs better.

“Historically, the barriers to care for LGBTQ+ individuals are complex and encompass many determinants,” said Tam Phan, PharmD, AAHIVP, assistant professor of clinical pharmacy and clinical pharmacist at the Jeffrey Goodman Special Care Clinic at the USC School of Pharmacy in Los Angeles, California.

The underlying barriers hindering access to health care in the LGBTQ+ community are numerous. Discriminatory practices such as patients having been refused care simply because they are LGBTQ+ and individuals lacking access to affordable health care due to uninsured status (as a result of family rejection, unemployment, and requiring services not covered by insurance) are a few examples.

The number of individuals identifying as LGBTQ+ is on the rise, having increased from 3.5% in 2012 to an estimated 4.5% in 2017 in the United States, with millennials (defined here as individuals born between 1980 and 1999) as contributing to the majority of the uptick, according to Gallup.

Not only do these statistics indicate a growing number of those who identify as LGBTQ+, but they also highlight an opportunity for health care professionals to ensure the provision of inclusive services for this patient population. Pharmacists play an important role in the health care system and can work to address the health disparities that exist for their LGBTQ+ patients.

The factors that compromise health outcomes in the LGBTQ+ community mirror those famously noted in communities of color and exacerbate health disparities by amplifying medical mistrust within the community. Examples include societal stigmas and discrimination.

The sources interviewed for this article did not reach a consensus regarding pinpointing the most significant barrier to creating a quality health care experience in the LGBTQ+ community. However, all cited the lack of awareness regarding population-specific health challenges and negative health care provider interactions as underlying contributors in preventing the LGBTQ+ patient from experiencing an equitable and quality health care experience.

“In a busy clinic or health setting, there will be many staff members who can interact with the patient—all of [whom] can either affirm or hinder the patient’s experience,” Phan said. “In many cases, problems can come from simple oversights or mistakes [from health care staff] who lack understanding—patients having reported hearing jokes or slurs and/or having received insensitive criticism about their appearance or behavior.”

Scott Nass, MD, MPA, a family physician based in Santa Rosa, California, noted that only in recent years has this started to change.

“In this context, we can’t ignore the fact that homosexuality and gender dysphoria were, for so many years, pathologized by organized health care,” he said. Only recently has so-called conversion therapy been widely condemned.”

Nass also serves as the president of Health Professionals Advancing LGBTQ Equality (GLMA) and noted that survey data indicate that more than half of lesbian, gay, and bisexual respondents and nearly 3 out of 4 (70%) of all transgender and gender-nonconforming individuals reported having experienced some degree of discrimination when using the health care system.

Another element amplifying the complexities of serving the LGBTQ+ lies in the community’s diversity, as it transcends many other cultural identifiers such as race, ethnicities, religious affiliation, and socioeconomic class.

These complexities include lack of access to quality health care, lower rates of health insurance coverage, failure to routinely and comprehensively include questions about sexual orientation and gender identity in health surveys and other data collection, and lack of consistent nondiscrimination protections for LGBTQ+ individuals in health care, workplace, housing, and other areas of everyday life.

Although HIV/AIDs is often associated with LGBTQ+ health, the community faces increased risks for many other conditions beyond this infectious disease. LGBTQ+ face greater risks for substance use, obesity, cancers, sexually transmitted diseases, and cardiovascular diseases than the general population.

In particular, those who are gender transitioning encounter compounded complexities and often find themselves at increased risks for some of these health challenges.

“This process often involves hormone replacement therapy that helps in physical transformations, such as the development of breasts, widening of hips, and growth of facial hair, etc,” explained Maria Perez, PharmD, AAHIVP, a clinical pharmacist at Gateway Apothecary in St. Louis, Missouri. “Although these are desirable developments, some patients may develop [adverse] effects such as obesity and cancers or overdose by adjusting their medications.”

Mental health conditions affecting the community deserve special attention, as the circumstances under which the LGBTQ+ population grows up often weigh on their mental, emotional, and psychological health throughout their lives. Children are more prone to bullying, isolation, rejection, depression, and suicide than the general population and are more likely to report suicidal ideations (30% vs 6%; 

 < .0001) and engage in self-harm (21% vs 6%; 

 < .0001) than their heterosexual and non-transgendered counterparts. In addition, LGBTQ+ patients may face societal ostracism, which also predisposes them to circumstances that threaten their health and livelihood early in life. For example, LGBTQ+ youth comprise 40% of all young individuals who experience homelessness.

Unfortunately, inadequate data collection contributes to the inequities affecting the medical treatment for those who identify as LGBTQ+. Many state and national surveys fail to include questions regarding sexual orientation and gender identity.

The health issues impacting the community affect all members—regardless of age. However, LGBTQ+ youth wrestle with their own set of challenges, including increased susceptibility to substance abuse, sexually transmitted diseases, cardiovascular disease, obesity, cancers, isolation, bullying, rejection, depression, anxiety, and suicide.

Establishing Best Practices for Inclusive Care

Despite the barriers hindering the provision of LGBTQ+-inclusive care, sources say there are several steps clinicians and their organizations can take to better serve the community.

For example, Perez’s institution encourages patients to self-identify. The practice allows patients to express how they want to be addressed by elucidating the pronouns they prefer.

Phan also recommends incorporating certain elements into the practice setting that members of the LGBTQ+ community often seek out as indicators that the care they receive will meet their needs. Pharmacists can assess their practice site for nondiscrimination policies. 

Assessment may include examining whether specific needs are met in the daily course of practice, including the following:

Does the practice site include gender-neutral bathrooms?

Are questions on the registration forms and electronic health records tailored to collect information for this demographic?

Is Your Pharmacy Inclusive of the Transgender and Gender-Diverse Community?

The American Pharmacists Association and Human Rights Campaign Foundation recently released a new guide for pharmacies on transgender and gender-diverse inclusion. The guide, which was released on International Transgender Day of Visibility on March 31, serves as an educational tool and resource for pharmacists and pharmacy staff on how to be inclusive to transgender, nonbinary, and gender-diverse patients.

According to the guide, the 6 qualities of a pharmacy that are inclusive of transgender, nonbinary, and gender-diverse individuals are:

To help address mental health concerns, Perez encourages her pharmacist colleagues to establish a rapport with patients by engaging them in conversation. The discussions might reveal mental or psychological challenges.

“The feelings of rejection, unacceptance, confusion, and loneliness are common in this patient population,” she said. And such feelings can lead to psychiatric illnesses such as depression and anxiety, among many others. “A simple conversation can open up a [larger] conversation,” she added. 

Perez recommends pharmacists ask their patients the following questions:

To determine whether patients warrant referral:

“Do you feel little interest in doing things?”

“Are you feeling down and hopeless?” (

a component of Patient Health Questionnaire-2, a screening tool for depression)

Nass and Phan agree that continuing education ranks among some of the most critical strategies organizations can implement to help ease clinician bias and improve patient trust by building a better rapport. For nearly 40 years, the GLMA has offered its 

. The conference is just one of the organization’s initiatives aimed at improving LGBTQ+ health, and its programming includes workshops and research presentations for pharmacists. Phan emphasizes that all health care professionals must take steps to improve their ability to serve the LGTBQ and that these efforts begin with introspection.

“I think it starts with a reflection and reassessment of individual practice and conduct and then [transitions] to reflect on practice policies applied to all workers,” he said.

He encourages pharmacists to educate themselves and their colleagues about LGBTQ+-inclusive care, such as terminology and various social and health disparities. Once this has been accomplished, clinicians can then devise a plan to address these topics in their practice settings. Phan also noted that customizing care for this patient population often requires interdisciplinary and external collaboration, engaging the LGBTQ community itself to learn about patients’ individual experiences and needs.

However, education, training, assessment, and exploration are only part of the work. Successful implementation and practice of such LGBTQ+-inclusive policies require cadence and an ongoing commitment. Institutions must periodically reevaluate their new politics to determine how the practice has changed and the degree of effectiveness.

Check out the following materials for more information on providing LGBTQ+-inclusive care:

Learning resources from the National LGBTQ+ Health Education Center: 

https://www.lgbtqiahealtheducation.org/resources/

Transgender and Gender Diverse Pharmacy Resource Guide

 from the Human Rights Campaign Foundation and American Pharmacists Association: 

https://www.thehrcfoundation.org/professional-resources/transgender-pharmacy-guide

Providing LGBTQ-Inclusive Care and Services at Your Pharmacy

 from the Human Rights Campaign Foundation: 

https://www.thehrcfoundation.org/professional-resources/providing-lgbtq-inclusive-care-and-services-at-your-pharmacy

Newport F. In US, estimate of LGBT population rises to 4.5%. Gallup. May 22, 2018. Accessed May 1, 2021. 

https://news.gallup.com/poll/234863/estimate-lgbt-population-rises.aspx

Hafeez H, Zeshan M, Tahir MA, Jahan N, Naveed S. Health care disparities among lesbian, gay, bisexual, and transgender youth: a literature review. 

. 2017;9(4):e1184. doi:10.7759/cureus.1184

Lesbian, gay, bisexual, and transgender health. HealthyPeople.gov. Updated October 8, 2020. Accessed April 30, 2021. 

https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health

Human Rights Campaign Foundation, American Pharmacists Association. 

Providing Inclusive Care and Services for the Transgender and Gender Diverse Community: A Pharmacy Resource Guide

https://hrc-prod-requests.s3-us-west-2.amazonaws.com/Transgender-Pharmacy-Resource-Guide.pdf?mtime=20210331072012&focal=none

Addressing the needs of LGBTQ+ patients requires insight, innovation, and introspection.

 Advancing LGBTQ+-Inclusive Care: How Pharmacists Can Better Support Patients

Stories about independent pharmacies not offering COVID-19 vaccines have flooded the local media in places like Philadelphia, Pennsylvania, and Colorado, but a different story is being told on the East and West coasts.

“Independent pharmacies and pharmacy owners can get the vaccine faster because it’s easier for them to communicate with county and city officials,” said Miguel Oseguera, CPhT, owner of Familia Farmacia in Modesto, California. “In fact, we get a lot of customers from chain pharmacies because they can’t get the vaccine there.”

Less than 2 weeks after having met with local government officials, Oseguera received his first batch of the COVID-19 vaccine. He believes the personal interaction helped increase his chances of getting the supply in his store.

Hossein Ejtemai, RPh, who owns Brookville Pharmacy and Wellness Center in Chevy Chase, Maryland, is still waiting for his first shipment, but he is ready to begin administering the vaccine as soon as it arrives. “I can vaccinate up to 500 patients a day if I get a vaccine,” he said.

Ejtemai has a plan that will allow him to immunize patients quickly and efficiently. His current strategy is to vaccinate 25 to 50 patients at the same time. His pharmacy has 2 rooms that can be used for the mass immunizations, where patients will be able to maintain a safe social distance. Each room will hold scheduled immunizations at least an hour apart.

Store owners offer tips for supplying and giving shots.

Independent Pharmacy’s Best Kept Secret in Administering COVID-19 Vaccines

Complementary and alternative medicine (CAM) has grown steadily over the last decade but surged in popularity in 2020—likely due to the coronavirus disease 2019 (COVID-19) pandemic.1 According to the results of a survey conducted by the Council for Responsible Nutrition, users cited overall immune support (57%) and health/wellness benefits (53%) as the most common reasons for increasing their supplement intake.1 With many individuals seeking additional ways to stay healthy, pharmacists are ideally positioned to help educate patients on the appropriate use of these products.

Despite the uptick in CAM use, misconceptions abound among health care professionals, including pharmacists. Two integrative pharmacists seek to dispel these myths and offer their colleagues tips to improve their ability to assist their patients in navigating complementary and integrative care.

"The biggest myth about CAM I keep hearing from medical professionals is that CAM and herbal products don't have evidence behind clinical use," said Marina Buksov, PharmD, health coach, nutritionist, and clinical herbalist based in Brooklyn, New York. "I think because of the lack of education, health care professionals and patients alike are wary of herbal medicine, and there's a general consensus that it's potentially dangerous to use—guilty until proven innocent."

For Hossein Ejtemai, RPh, owner of Brookville Pharmacy and Wellness Center in Chevy Chase, Maryland, the misconceptions surrounding CIM seem to be demographic- and geographic-based.

"People often think there's a [cultural] gap with CAM because people from overseas—especially from the Asian culture—are more likely to use supplements, natural products, and natural remedies," he said. "The younger generation in this country is also changing to CAM because of access to information [via the internet].”



Pharmacists Offer Key Counseling Points for CAM

To optimize their patients' experience with CAM, Ejtemai said pharmacists should seek training.

"Health care professionals are [generally] aware of CAM but most medical professionals, including pharmacists, lack sufficient training in CAM,” he said. "The 3 credits you get in pharmacy school is not enough to assist your patients."

Pharmacists looking to expand their knowledge can choose from numerous certifications, many that are available online and take 6 to 18 months to complete. "Get certified to better educate your patients," Ejtemai said. The Institute for Integrative Nutrition, Duke University, and The George Washington University are among the institutions that offer programs.

After developing their CAM skills, pharmacists should keep several key concepts front of mind when counseling patients on CAM. Most importantly, pharmacists should take the time to ensure patients understand when and how to use these products.

"Natural products have a place in both Eastern and Western medicine, but you have to keep in mind that natural products are generally better for prevention than treatment," Ejtemai explained. "You cannot treat a disease with natural products in the late stages."

Ensure patients understand that, unlike many conventional medicines that often show results in a few days or weeks, natural products can take several weeks to months to work.

Below are more recommendations for pharmacists seeking to educate their patients on CAM use.

Use trustworthy sources to conduct your research.

"It's important to look to reputable resources on topics that we don't have enough education on," Buksov said. She recommends Lexicomp, the Natural Medicines database, and 

 by Memorial Sloan Kettering Cancer Center.

Educate patients taking nutrient-depleting medications on the importance of supplementation.

For example, Ejtemai recommended counseling patients taking metformin on the importance of vitamin B12supplementation to potentially ward off diabetic neuropathy.

Alternative healing approaches and therapies become increasingly popular among consumers. 