Jill Sederstrom

An increasing number of pharmacists are now prescribing birth control, further expanding their role as public health service providers.

Lincoln Alexander, PharmD, residency program director in Portland, Oregon, for Albertsons Companies, has been prescribing birth control for just over 5 years and has received a positive response from his patients.

“Patients are highly appreciative of the service. Nowadays, [pharmacists prescribing birth control] seems like second nature to many, which is a testament to the effective rollout we have had here in Oregon,” said Alexander, who is also president-elect of Oregon State Pharmacy Association.

Oregon isn’t alone. Allie Jo Shipman, PharmD, MBA, director of state policy for the National Alliance of State Pharmacy Associations, said 13 states and the District of Columbia currently allow pharmacists to prescribe oral contraceptives independently.

“There are also 13 states with legislation pending this session that would allow for the same thing,” she said.

Although the prescriptive authority, age limits, and requirements for each state vary, the overall message is clear: Pharmacies in all practice settings are stepping up to the challenge.

In 2013, California became the first state to pass a bill allowing pharmacists to “furnish” contraception without a physician prescription. However, Oregon was the first state to implement independent pharmacist-prescribed contraception.

“We had a physician legislator, Dr [Knute] Buehler, who just decided this is an access issue for patients,” said Paige Clark, RPh, director of alumni relations and professional development at Oregon State University College of Pharmacy in Corvallis.

According to Shipman, state policies are typically structured using 1 of 3 types of prescriber authority: 

General prescriber authority, where the pharmacist is the prescriber of record

Statewide protocol, where the pharmacist serves as the prescriber of record but the overall protocol is developed and approved by a state pharmacy board

Under the last option, the state offers a statewide blanket prescription issued by a medical official in the department of health, who is often the chief medical officer. That official is considered the prescriber of record, but pharmacists are responsible for consulting and making clinical decisions.

Although some states have no age limits in place, Shipman said others only allow pharmacists to prescribe to those 18 years or older. Alternatively, they may allow prescribing to patients younger than 18 only if they have had a previous contraception prescription.

Capitalizing on a Need for Public Health Service Providers

A growing number of states are exploring options that go beyond collaborative practice agreements for birth control prescribing. The move follows a larger trend of enlisting pharmacists to provide public health services to patients for areas that don’t require a diagnosis.

“I think the pandemic has shown just how pharmacists have shined in
a time of a public health emergency where pharmacies have stayed open...when other providers have closed,” said Veronica Vernon, PharmD, an assistant professor of pharmacy practice at Butler University in Indianapolis, Indiana. “We have seen during the pandemic that access to contraception has been a significant concern.”

Pharmacists can bring their unique set of skills to address what Vernon referred to as “contraception deserts,” geographic regions where access to birth control prescribers might be limited. They can also save states significant money in public costs.

One study examined the policy’s impact on Oregon’s Medicaid program in the first 2 years since it went into effect in 2016. According to the results, published in 

, pharmacist prescription of contraception averted more than 50 unintended pregnancies and saved the state an estimated $1.6 million in public costs.

Pharmacist contraception prescription may come with big benefits, but it also brings its own set of challenges. Not least among these is ensuring that pharmacists are getting paid for their services.

“We want to remove barriers for patients and we can be a more cost-effective approach for patients when accessing contraception, but you want to make sure you are not giving away the service for free,” Vernon said.

Clark said that in Oregon the Medicaid system has put pharmacists in the provider lane, allowing them to use billing codes that are also available to physicians and physician assistants. However, to date, their adoption hasn’t been widespread because of the systems many pharmacies need to put into place in order to process medical billing.

“There are some hoops they have to jump through, and there are some connectivity issues,” she said.

Vernon said patient consultations and assessments can last up to 20 minutes or more. This makes it essential that pharmacists are paid not only for dispensing the medication but also for their time to properly assess the patient.

“If you are going to do this, make sure there is a payment pathway in place and that you are meeting with insurance companies in your state to talk about what this would look like...The states that have been most successful in pharmacists’ prescribing of contraception have ensured that there is a pathway for payment for pharmacists’ time,” she explained.

Vernon recommends having a designated space within the pharmacy to conduct patient assessments in community pharmacy settings.

She also stressed the need to evaluate the workflow within the pharmacy to manage day-to-day responsibilities and billing. It will most likely mean using technicians to their highest skill levels to increase overall efficiency.

“I think including them in your workflow so that the pharmacist can step away from checking prescriptions and counseling on other prescriptions to spend time with the patient...would be really helpful,” Vernon said.

For example, one pharmacy she talked with had tasked their lead technician with medical billing to streamline the workflow. Alexander echoed Vernon’s comments, saying one of the biggest challenges he has seen in practice is adapting the workflow.

“Time constraints with performing a contraceptive consultation with the patient can sometimes make this service a challenge to fit into the workflow, especially with the ongoing COVID-19 pandemic and vaccination efforts,” he said.

To accommodate all the workflow demands, Alexander said he has done his best to educate patients on the best time of day to come to the pharmacy for prescribing services, such as in the mornings when there is pharmacist overlap. However, he has also found that patients are generally “amenable [to] a short wait” if he clearly communicates to them the other demands going on at the time.

“It starts with treating each person that walks through our doors with courtesy, dignity, and respect,” he noted. He also stressed the importance of training pharmacy technicians, interns, and other associates on workflow procedures.

“Though these associates cannot make prescribing or consultation decisions, they are very helpful in onboarding the patient,” he said. He added that they can check IDs, gather insurance cards, or ask the patient to begin by filling out a self-screening questionnaire.

As an employee of the public state university in Oregon, Clark and her team were tasked with developing a thorough training program for pharmacists in the state and other areas. She recommends that pharmacists who assume the new role invest in an educational program, even if it isn’t specifically required in their state.

“We have a 4-hour course that literally [covers] the entire process from the beginning of that patient walking in the door all the way through all the safety guidelines,” she said. The course makes it very doable for frontline pharmacists to begin offering the service, she added.

When working with patients, Vernon said, most states require pharmacists to follow the CDC’s US Medical Eligibility Criteria (US MEC) for Contraceptive Use, 2016 and the US Selected Practice Recommendations For Contraceptive Use, 2016 to guide patient eligibility and selection.

Many states also require pharmacists to administer a patient questionnaire that can be a “great jumping off point” to begin a conversation with the patient, she continued.

“The best option is what the patient decides on, and so using a shared decision-making approach with the patient is really crucial,” she said. Having patient buy-in on the product will likely increase consistent adherence, she pointed out.

The last step is to find ways to successfully advertise the new services.

“It’s not if you build it, they will come, you also have to let patients know that you are doing this,” Vernon said.

1. Anderson L, Hartung DM, Middleton L, Rodriguez MI. Pharmacist provision of hormonal contraception in the Oregon Medicaid population. 

 2019;133(6):1231-1237. doi:10.1097/AOG.0000000000003286

Articles

Pharmacists’ Public Health Role Grows as Birth Control Prescribing Authority Expands 

Pharmacists across the country are seeing a milder flu season this year, thanks in part to the precautions put in place to prevent coronavirus disease 2019 (COVID-19), but many are also seeing increases in the number of flu vaccinations administered at their stores.

The COVID-19 pandemic has ushered in a greater focus on health and prevention efforts, which has led to fewer cases of the flu this season than in past years. “This flu season, we have seen lower incidences of flu compared to an average season, which may be due to our shift in behavior to reduce the spread of COVID-19,” said Tasha Polster, BSPharm, vice president of pharmacy quality, compliance and patient safety for Walgreens. “For example, more people are social distancing, wearing face masks, hand washing, and forgoing travel.”

According to the CDC, laboratory-confirmed cases of the flu remain “low at this time.”1 Additionally, reported deaths due to COVID-19 remain higher than for influenza, according to recent National Center for Health Statistics (NCHS) mortality surveillance data. For the data available on January 7, 2021, the NCHS reported that 14.5% of deaths occurring during the week ending January 2, 2021, were from pneumonia, influenza, and COVID-19 (PIC). However, of the 2150 PIC deaths reported in that week, 1496 had COVID-19 listed as an underlying or contributing cause of death, whereas only 2 listed influenza.

Rite Aid and CVS officials also reported decreased numbers in flu incidence this year among patients. “As a general trend, people are more aware of health and immunity than perhaps ever before, which fits into our purpose to become a neighborhood destination for whole being health, including traditional medicine like vaccinations and alternative remedies and supplements that may help boost immunity or reduce stress,” said Jocelyn Konrad, BSPharm, executive vice president and chief pharmacy officer for Rite Aid.

Moreover, the number of Americans receiving the flu vaccine is on the rise this season. The CDC led a push to encourage more individuals to get their vaccinations in order to avoid illness or hospitalizations that could tax an already overworked health care system.

“During the COVID-19 pandemic, reducing the overall burden of respiratory illnesses is important to protect vulnerable populations at risk for severe illness, the health care system, and other critical infrastructure,” the CDC said in its pandemic guidance released to the public.

The push—and greater concerns about health among Americans—resulted in a significant increase in the number of individuals who have received vaccinations to date. According to the CDC, by December 19, 2020, an estimated 46.9 million adult flu vaccinations had been administered in pharmacies, compared with 32.9 million at the same time in 2019, representing a 43% increase. An additional 28.9 million adult flu vaccinations were administered in physician medical offices.

Although last year 32.1 million turned to physicians’ offices to receive vaccinations—about the same number as those who went to a pharmacy setting in 2019—this year to date there has been a significant increase in those seeking immunizations at pharmacies rather than at their physicians’ offices (46.9 million vs 28.9 million, respectively).

These trends seem to match what pharmacists are seeing in stores. “This flu season we anticipate administering nearly 20 million vaccines, which is more than double last year, so the demand to be vaccinated has certainly increased,” said Ryan Rumbarger, BSPharm, senior vice president of retail 

Polster said Walgreens has seen “double-digit growth” in the number of flu vaccinations administered this year at its stores compared to this time last year

. The company has also seen seniors 65 or older—who are particularly at risk for COVID-19—getting flu vaccinations in higher numbers and earlier in the flu season than in past years.

“Our marketing mix is consistent with previous flu seasons; however, understanding the importance of flu shots amidst the COVID-19 pandemic, we wanted to ensure we reached our customers to raise broad awareness far earlier this flu season, and ramped up our flu messaging beginning in August,” Polster said. The organization continued its Flu Fighter campaign this year, emphasizing that getting a flu vaccination “not only helps protect you, but those you love—your crew,” she said.

Konrad said Rite Aid’s messaging focused on communicating the importance of getting a vaccination “as a way to prevent a possible ‘twindemic’ that some health care experts feared could result from the collision of flu season and the COVID-19 pandemic.”

To date, it appears that concern has failed to come to fruition, but flu season is not over, and experts and the CDC said the community needs to remain vigilant in the months ahead. “We’ve continued to remind people it’s never too late to get your flu shot,” Rumbarger said. “We’ve also increased access to flu shots for communities in need.”

Brian Caswell, RPh, National Community Pharmacists Association president and owner of Wolkar Drug in Baxter Springs, Kansas, said that although he hasn’t necessarily seen an increase in the number of flu vaccinations administered at his pharmacy this season, he has seen more interest from patients who may have declined vaccinations in past years.

“I have not talked to anyone who said that they are going to forgo their flu shot because of what’s going on, but I have talked to a few people who’ve said, ‘You know, I haven’t had a flu shot ever’ or ‘I haven’t had a flu shot in the last 2 years and with everything going on, I thought I better go ahead and get it this year,’ ” he said.

Although the COVID-19 pandemic appears to have motivated many Americans to seek out flu vaccinations, it has also presented challenges to pharmacies in terms of marketing and logistics. Caswell said his pharmacy was forced to close its lobby twice during the pandemic, and had to rely more heavily on communicating with patients through word of mouth and social media outlets like Facebook. It also switched to an appointment-based approach to vaccinations to minimize the number of individuals in the store at any given time.

“Moving over to an appointment model, I thought was going to be a problem. It hasn’t been a problem,” he said. “People were willing to do it, and I think they didn’t want to be hanging around a lobby with sick people, either.”

Caswell said he had expected the pharmacy’s home delivery services to rise during the pandemic, but was surprised to find the biggest growth was in drive-through use. “I think people still wanted to get out,” he said.

Rumbarger said CVS also amplified its digital experience within its mobile app and expanded home delivery options, like DoorDash and Instacart, to reach patients during the pandemic. “Before and during the pandemic we’ve deployed a diverse marketing strategy to meet people where they are—in our pharmacies, in the community, in the home or in the palm of their hand,” he said, adding that officials will continue to revise strategies based on patient feedback.

Konrad said Rite Aid’s marketing messages have focused on how the pharmacy chain is still able to serve patients amid the pandemic and the increased safety precautions in place. “We’ve worked hard to provide essential pharmacy services—including vaccinations—despite the need to socially distance and protect customers and associates from COVID-19 transmission,” she said. “From enhanced cleaning and sanitation protocols to [personal protective equipment] and social distancing, we’ve made sure our customers can safely visit their neighborhood Rite Aid, whether to get a flu shot, get tested for COVID-19, or pick up medications and immunity-boosting supplements.”

Polster said pharmacies are expecting the COVID-19 vaccine to be more broadly available toward the end of the flu season. There will likely be high demand for COVID-19 vaccinations, but even with help on the horizon, pharmacies will need to encourage patients to remain as healthy as possible.

“It’s going to take time for a COVID-19 vaccine to be available to the general population, so we encourage everyone to get vaccinated against the flu to avoid 2 respiratory illnesses circulating at the same time and reduce the burden on our strained health care system,” Polster said.

Flu season. CDC. Updated January 11, 2021. Accessed January 11, 2021. 

https://www.cdc.gov/flu/season/index.html

Interim guidance for routine and influenza immunization services during the COVID-19 pandemic. CDC. Reviewed October 20, 2020. Accessed January 11, 2021. 

https://www.cdc.gov/vaccines/pandemic-guidance/index.html

Weekly national flu vaccination dashboard. CDC. Reviewed January 6, 2021. Accessed January 11, 2021. https://www.cdc.gov/flu/fluvaxview/dashboard/vaccination-dashboard.html. 



Preventive efforts, renewed interest in vaccinations drive milder flu season. 

Pandemic Precautions Lead to Low Incidence of Flu

Results of a recent study showed that the Bacille Calmette-Guérin (BCG) vaccine can protect elderly adults against various respiratory infections—but it’s unclear what effect it could have on the coronavirus disease 2019 (COVID-19).

BCG is a vaccine for tuberculosis (TB). Although not widely used in the United States, the vaccine is often given to infants and small children in other countries where TB is common.

For the double-blind randomized clinical trial, which was a joint collaboration between Radboud University Medical Center and the National and Kapodistrian University of Athens, investigators examined the effect that the BCG vaccine had on elderly adults after they were discharged from the hospital.

The investigators assigned the 198 study participants to either receive a placebo or BCG vaccine as they were being discharged from the hospital and then followed the participants for 12 months to determine whether there were any new infections, according to the results of the ACTIVATE study published in 

Evangelos J. Giamarellos-Bourboulis, MD, PhD, co-coordinator of the study at the 4th Department of Internal Medicine at ATTIKON University Hospital, told 

® that the investigators discovered a “decrease of overall risk of new infection with the BCG vaccination” among those who received the vaccine.

According to the results, 42.3% of the elderly participants developed an infection in the placebo group, whereas only 25% developed an infection in the BCG group, according to 

 announcing the findings. Those in the treatment arm also took longer to develop their first infection—with an average of 16 weeks after vaccination—compared with 11 weeks in the placebo group.

“In addition to the clear effect of BCG vaccination on infections in general, the most important observation was that BCG could mainly protect against respiratory infections: BCG-vaccinated elderly people had 75% fewer respiratory infections than the elderly who received placebo,” Giamarellos-Bourboulis said in the release.

® that the types of respiratory infections included respiratory viruses and pneumonia.

Investigators reported no differences in adverse effects between the groups and determined the BCG vaccine was safe for elderly patients.

It’s also possible the vaccine could help protect the elderly against COVID-19, but that has not been fully studied. The study began before the coronavirus pandemic began and a low prevalence of COVID-19 among those in the study prevented the investigators from being able to draw any conclusions.

Giamarellos-Bourboulis said the next step in the research will be to “run trials with BCG vaccination to protect the elderly from COVID-19.”

Several studies are already underway to examine whether the BCG vaccine could also have a protective effect against COVID-19.

Giamarellos-Bourboulis EJ, Tsilika M, Moorlag S, et al. Activate: Randomized clinical trial of BCG vaccination against infection in the elderly. 

https://doi.org/10.1016/j.cell.2020.08.051

Elderly people protected against respiratory infections by BCG vaccine. News release. Radboud UMC; September 1, 2020. Accessed October 6, 2020. https://www.radboudumc.nl/en/nieuws/2020/elderly-people-protected-against-respiratory-infections-by-bcg-vaccine

The BCG vaccine decreased the overall risk of new respiratory infections in elderly adults, according to the study results. 

Study: BCG Vaccine Protects Elderly Against Respiratory Infections

Health care providers are getting creative and taking their immunization efforts on the road this year in an effort to increase influenza vaccinations.

Giant Food, a regional grocery chain in the greater Washington DC area, announced its pharmacy would be operating mobile clinics, manned by specially trained pharmacists, to make stops throughout the region in October, according to 

Pharmacists will use an Airstream vehicle to stop in key locations to provide influenza vaccines to interested families and individuals. Company officials said the grocery chain opted to take their immunization efforts on the road because of the high demand for the vaccine in light of coronavirus disease 2019 (COVID-19) pandemic.

“As we prepare for the possibility of the unprecedented convergence of COVID-19 and flu, getting your annual flu shot is more important than ever to help you, your family and your community stay healthy," said Paul Zvaleny, director of pharmacy operations at Giant Food.

As part of the effort, Giant also partnered with Gym Jonez, a popular certified fitness trainer in the area, to bring the mobile flu clinic to his outdoor workout classes to offer participants the flu vaccine.

“We are eager to make flu shots as accessible as possible for members of our communities and are hoping to continue to expand this program to more parts of the region to service people and communities who might not have easy access to a pharmacy,” Zvaleny said.

 “As pharmacists being the most accessible health care professionals, we need to ensure we expand that access to people and communities in need.”

Giant Food isn’t the only organization to bring the vaccines to its client base. In Virginia, the Carilion Clinic fixed up a new van to offer mobile health services.

“It was perfect timing for the vaccine season because our strategy this year was to be neighborhood-based,” community health workforce supervisor Cris Sheffield told 

 “We wanted to make it easy for people and go where people already are.”

In September, the van made a stop at a community center and offered free flu vaccinations to anyone over the age of 18. The health care clinic is planning to host free flu vaccination events 4 times a week through the end of October.

“My biggest hope for flu season is that [with] a lot of the precautions and the things we’ve been putting into place that people are listening," Sheffield told the outlet.

 "And that we will be able to keep it down and keep it pretty good so that we don’t complicate it with COVID and the pandemic we’re already dealing with.”

In Canada, Hamilton EMS Chief Mike Sanderson said Hamilton’s paramedic service hopes to vaccinate about 2400 people through mobile flu vaccine clinics this fall, according to 

. Sanderson said the immunization services are being offered at homeless shelters, social housing buildings, and senior centers throughout the city.

“With the risk of simultaneous cold and flu season, it’s even more important now to get people immunized against the flu as early as possible,” he said.

 everyone over 6 months old should get the flu vaccine, with some rare exceptions.

1. Giant Food Pharmacy Takes Flu Vaccinations On-The-Road with New Mobile Flu Clinics. News release. Giant Food; September 22, 2020. Accessed October 6, 2020. 

https://www.prnewswire.com/news-releases/giant-food-pharmacy-takes-flu-vaccinations-on-the-road-with-new-mobile-flu-clinics-301135518.html

2. Roshetko K. Free flu shot clinic launches Carilion mobile health outreach initiative. WDBJ. Published September 25, 2020. Accessed October 6, 2020. 

https://www.wdbj7.com/2020/09/25/free-flu-shot-clinic-launches-carilion-mobile-health-outreach-initiative/

3. Mann K. Paramedics hope to reach 6 times as many at-risk residents through mobile flu shot clinics. Global News. Published September 25, 2020. Accessed October 6, 2020. 

https://globalnews.ca/news/7359321/hamilton-mobile-flu-shot-clinics/

Some health care providers are taking their flu immunization efforts to the road this year. 