Ken Krizner

Individuals diagnosed with diabetes have to concern themselves about a variety of issues, like blood sugar level, diet, and a complex medication regiment. 

“A lot is required of a person diagnosed with diabetes in terms of what to do and not to do,” says Amy Carter, MA, RD, CDE, director of Outpatient Nutrition for Eskenazi Health in Indianapolis. “Knowing they will have to manage this chronic disease for the rest of their lives, often without education, support, or financial resources, significantly impacts a person’s self-care ability.”

While there are lifelong challenges, the good news is diabetes is manageable, Carter says. Patients can control their condition by making the right choices.

Here are some of the leading challenges that endocrinologists and educators see from their daily interactions with diabetes patients. 

“We have so many great medications available in our arsenal to treat diabetes,” says Patricia Luceri, DO, an endocrinologist with Jefferson Health in Marlton, New Jersey. “Unfortunately, they’re expensive. If the patient doesn’t have good insurance to cover the cost of the drug, then that drug is not an option. Even with insurance, there are copays, which could be high.

“Often, patients tell me they’ve had to choose between buying food or medication,” she adds. “Many times, they’re trying to stretch their medications by taking them every other day or taking a partial dose.”

“The actual percentage of people who receive the appropriate education about how to manage their diabetes is fractional-less than 10%,” Carter says. “Full diabetes education encompasses food, medicines, checking blood sugar, risk reduction, and other topics. Without education, it’s very challenging for people to understand what happens if they don’t take the appropriate steps.”

“Patients often don’t have access to the supplies they need to monitor their blood glucose levels,” says Ajaz Banka, MD, an endocrinologist with Beaumont Hospital in Michigan. “Testing supplies are expensive. But if patients don’t know their numbers, they don’t know what’s happening [to their health]. ”

“If patients don’t test their sugar, they can’t manage their diabetes,” Luceri says. “It can be cumbersome to test regularly and test in public. There have been many advances in recent years, so this is becoming less of a challenge. There are continuous glucose monitors available to monitor their sugar in real time without a finger stick. However, not every insurance company covers the monitors.”

“Diabetics are always on multiple medications, not just for their diabetes but also for high blood pressure and high cholesterol,” Luceri says. “It can be tough to remember when you’re taking that many medications, often at different times of the day. There is a class of medications that have a once-weekly injection, which can help with compliance. Some companies have programs that will send reminders to the patient to take their medications.”

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“Eating is a basic function and asking a patient not to eat a particular food is difficult,” Banka says. “Patients are asymptomatic. They don’t really care, because they don’t see the complications right away, though they could still happen in the future. Cultural and educational background plays a big role in diabetes management. If we can to get across to patients with education why managing diabetes is important, it will play a big role, long term, in their health.”

“It’s a difficult, long-term concern for people to incorporate diabetes management into their daily lives without feeling like it’s taking over,” Luceri says. “I discuss diet, exercise, and maintaining healthy eating habits with patients. But when they leave my office, it’s up to them to follow that advice.”

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Cost, education, self-monitoring, and more. 

Top Challenges in Managing Diabetes

Product-wise, they’re worlds apart. Yet a common bond exists between fast-food restaurants and pharmacies: Both are expected to place a premium on customer service. For that reason-as surprising as it might sound-when 

, BPharm, PD, and owner of iCare RX in Newport, AR, is seeking prospective new pharmacy technicians, he sees fast-food restaurants as fertile ground for his search.

“There is always someone in the restaurant running around like a chicken with its head cut off,” Shoffner says. “Those employees are doing more than anyone else. They’re the individuals I target. I ask them to consider a healthcare occupation.”

Not everyone jumps at the opportunity. Shoffner estimates that three or four out of ten fast-food employees he approaches show interest. But if employees show potential in the fast-food environment, they stand a better-than-good chance at succeeding as a pharmacy technician, he believes.

Once a person who shows potential is found, technician training is an absolute must. As pharmacies have evolved, so has technician training. With pharmacists doing more patient counseling than ever before, it is up to the technician to make sure the pharmacy itself is running efficiently and safely.

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“My pharmacy is clinically oriented, and our pharmacists are practitioners,” says 

, RPh, owner of Flower Mound Pharmacy in Flower Mound, TX. “I shift a lot of the day-to-day responsibilities to my technicians.”

Not only do technicians need to know the “soft skills” of customer service, they need to be proficient in data entry and possess clinical aptitude-the “hard skills” of the job, Song says. 

“Technicians need to be ‘technical’ because there is so much to work through in terms of prior authorizations, insurance rejections, and other issues,” he points out. “There is no manual, so a technician has to be able to think through these issues and come up with solutions. Critical-thinking and problem-solving skills are a must.”

Training is growing in importance because there is expected to be an increase in the need for technicians. According to the Bureau of Labor Statistics, nearly 450,000 pharmacy technicians will be needed in the United States by 2026. Training also reflects the broader changes in pharmacy. As pharmacists provide more patients with more clinical services, such as medication therapy, immunizations, medication reconciliation, and health screenings, technicians will shoulder a larger burden of the workflow.

“Even as we move toward the pharmacy becoming more of a primary healthcare destination, the traditional tasks will still continue,” says

, pharmacy content strategist for National Healthcareer Association (NHA). “Pharmacy technicians fill that void while pharmacists carry out clinical duties.”

There are numerous educational and training programsfor pharmacy technicians throughout the country, offered by colleges and universities, high schools, technical and vocational schools, allied health programs, career institutes, and training centers, as well as some sponsored by corporations and health systems.

The expansion of the role of the technician prompted the Pharmacy Technician Certification Board (PTCB) to change its eligibility requirements for the Certified Pharmacy Technician (CPhT) Program and update its Pharmacy Technician Certification Exam (PTCE). Beginning in 2020, PTCB will offer two eligibility pathways for technicians submitting certification applications-completion of a PTCB-recognized education/training program or equivalent work experience.

“Technicians are an integral part of the pharmacy team,” says 

, PharmD, BCACP, immediate past president of PTCP’s Certification Council and associate professor in the Department of Pharmaceutical Sciences at Ferris State University’s College of Pharmacy in Big Rapids, MI. “We believe the time is right to recognize and support the level of preparation that has become more standard in the field to advance medication safety and patient care.”

Students who complete a PTCB-recognized education/training program will be eligible to apply for and earn their CPhT credential. PTCB’s work experience alternative is for technicians who have completed 500 work hours and can attest to fulfilling specified knowledge requirements.

Aside from new eligibility requirements, PTCB recently granted more than 500 Compounded Sterile Preparation Technician (CSPT) certifications, the organization’s first advanced certification program, which was launched in December 2017.

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“Sterile compounding requires advanced knowledge, close attention, and skill proficiency to ensure patient safety,” Bright stresses. “This credential allows a pharmacy technician to mark their accomplishment and expertise in sterile compounding in a consistent way across the profession.” 

Once technicians are trained and working in the pharmacy, continuing education (CE) is a necessity to keep current with medication safety, new classes of medications, workplace performance and other responsibilities, says 

, PharmD, FAPhA, vice president of partnership development for PTCB. The organization requires technicians to take 20 hours of CE every two years to maintain national certification. One of the required hours is on medication safety and another hour is on pharmacy law. 

In addition to the CPhT and CSPT accreditations, PTCB recently announced the addition of five assessment-based certificate programs for advanced technician roles, and an Advanced Certified Pharmacy Technician (CPhT-Adv) credential. 

The five certificate programs under development are Technician Product Verification (Tech-Check-Tech), Medication History, Controlled Substance Diversion Prevention, Billing and Reimbursement, and Hazardous Drug Management. Candidates seeking to be a CPhT-Adv will be required to have earned at least four of the new certificates to be eligible.

PTCB’s program changes are based on data collected via a job task analysis survey of more than 40,000 respondents, as well as comments from technician employers, educators, state and national pharmacy associations, and state boards of pharmacy. 

The changes stemmed from input received at the 2017 Stakeholders Consensus Conference. That conference was instrumental because the American Society of Health-System Pharmacists (ASHP) and the Accreditation Council for Pharmacy Education (ACPE) revised their national standards for pharmacy technician education and training. 

The standards became effective for new programs at the beginning of 2019. Existing accredited pharmacy technician programs will be required to incorporate the new standards by Jan. 1, 2020.

The revised standards place additional emphasis on the educational outcomes expected of students and the methods used by training programs to assess competency. Competencies are defined to differentiate entry-level and advanced-level training, structural and process-related elements needed for program quality, and evidence-based outcome measures.

The number of standards has increased from six to 15. Each standard highlights the key elements that must be met to demonstrate compliance. The key elements model those in pharmacist education and training programs and emphasize collaboration with pharmacists and other healthcare personnel.

The reassessment was prompted by several factors, including changes in state laws that allow for expanded technician roles, responsibilities, and authority, says 

, BSPharm, director of program service for ASHP. 

“The preparation of medications is more extensive than ever before,” she notes. “There are more high-risk and dangerous medications to prepare–more than just a few years ago. Plus, new drugs are introduced all the time. The more technicians can be educated, the better.”

NHA’s new training product, PharmaSeer, exceeds ASHP’s revised standards. Sasser describes the product as a comprehensive approach to teaching individuals everything they need to know to practice as a technician. NHA markets its product primarily to employers and academic institutions such as community colleges and vocational programs. 

“We’re trying to take into account the marriage between didactic training and applying what is learned to hands-on tasks that go on behind the counter,” Sasser says. “We want to provide technicians with a baseline knowledge, so they can have confidence in the skills needed for the role.”

At a time when margins are tight, many pharmacies are transforming themselves into patient-centrered enterprises, where the pharmacist interacts with customers on a regular basis, almost assuming the role of primary care physician. 

In this environment, pharmacists remove themselves from the daily grind of filling prescriptions and fulfilling administrative tasks. Those responsibilities fall on the shoulders of a well-trained technician staff. 

At Flower Mound Pharmacy, pharmacists cannot enter data, adjudicate and fill prescriptions electronically, count, or manage inventory. “I don’t want my pharmacists to perform [those responsibilities],” Song maintains. “Pharmacists are there to address specific patient needs.

“To be patient-centric, it is critical that pharmacists have confidence in the ability of their technicians,” he stresses. “The modern pharmacy must operate with competent and forward-thinking technicians, especially when quality measures, outcomes, and value-based medicine are taken into consideration.”

iCare RX’s Shoffner says at one time, the role of the technician was simply to watch the pharmacist do the work. Today, pharmacists perform their responsibilities  and technicians do everything else.

With a population that continues to age and life expectancies continue to increase, the number of medications prescribed will continue to grow, and with it, more comorbidities. More high-quality counseling will be necessary to help patients avoid adverse outcomes.

“Pharmacists will be more involved as a provider, delivering more information to the patient,” ASHP’s Lifshin says. “We’ll continue to see technicians taking more responsibilities so pharmacists can provide that type of patient care.”

As a former community pharmacist, PTCB’s Chapman stresses she could not have met the demands of everyday work without the assistance of trained technicians.

“They’re an absolute necessity in all facets of the profession,” she points out. “As pharmacists, we can’t do what we do every day without technicians.”

Which is why technician training and education is so vital for public health, job stability, professional advancement and consistency throughout the industry.

Training programs reflect the changing practice of pharmacies.

Training Technicians for More Responsibility

In a competitive environment, it’s more important than ever for independent pharmacies to increase patient care and decrease costs. They cannot afford high overhead costs or inefficiencies behind the counter.

“Today, pharmacies have to be at the top of their game,” says Ryan Summers, PharmD, owner of Summers Pharmacy in Clinton, MO.

At the same time, patients expect more from their pharmacies. “Patients don’t just compare pharmacies to other pharmacies,” Summers says. “They compare us to nonpharmacy organizations that have a high level of customer satisfaction.”

One important way to improve customer service and staff efficiencies is to incorporate a workflow management process. The pharmacy will be more organized. Prescriptions will be filled by priority. Technicians and clerks will have a better sense of their individual responsibilities.

From the patient perspective, workflow management helps improve medication safety since there is an orderliness to filling prescriptions. The pharmacist, because he or she is less involved in the filling of prescriptions, has more time to counsel patients about their medications, which can lead to improved adherence and less side effects. 

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“Workflow management is important to both the pharmacy staff and patients,” says Stephen A. Brown, JD, PharmD, adjunct professor in the Department of Pharmaceutical, Social, and Administrative Sciences at Samford University in Birmingham, AL. “With the correct workflow management process, pharmacists and nonpharmacist personnel can operate at the top of their abilities. There is a sense of well-being among the staff.”

Many software programs are available to help independent retail pharmacies implement a workflow management system-each distinct in their own way. But they have a number of common traits:

Each system clearly orders and prioritizes the tasks at hand,  from the time the prescription comes into the pharmacy through to checkout. 

Employees, whether they are pharmacists, technicians, or clerks, know their individual responsibilities during their shifts. 

Prescriptions are prioritized so the pharmacist knows which ones to verify immediately and which can wait. 

There are checks and rechecks to ensure the proper medication is getting to the right patient. 

“The main objective of workflow management is to align the team,” says Ghada Abukuwaik, RPh, president and head pharmacist of CureMed Pharmacy in Clifton, NJ. Employees better understand what they’re doing and the tasks they are expected to perform. “It’s essential to running a successful pharmacy.”

A successful pharmacy breeds customer trust. “The last thing you want as a pharmacist is to have customers watching as the staff tries to locate their prescriptions,” says Michael Fapore, RPh, owner of The Medicine Shoppe in Somerset, PA. “Workflow builds patient confidence.”

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When Michael Fapore, RPh, decided to implement a new workflow management system in his pharmacy, The Medicine Shoppe, in Somerset, PA, he stressed patience with his staff. “I’m glad I did because we had some rough times at first,” he says.

Part of those rough times stemmed from the fact that his old software program could not support the improvements in the pharmacy’s workflow that Fapore wanted, despite assurances from the developer that it could.

“The day we opened, we had a mess,” Fapore says. “The system wouldn’t work as we wanted.”

Fapore and his staff were able to muddle through on a temporary fix for several months before he purchased a new software program that could accomplish everything he wanted.

Once the new system was implemented, Fapore began to see the changes in patient safety and staff efficiencies he had envisioned through workflow management. 

While it was a tough lesson, Fapore learned that there must be demonstrable proof that a software program can handle the type of workflow management system the pharmacist wants. 

“The first thing I would tell [pharmacists] is before they start, make sure their software can support the objectives,” he says. “Demand a demo to make sure it will work the way they want it to work. We did not do this, and it made it a lot tougher for us in the beginning.

“We found out the hard way that not all computer systems are set up to manage workflow,” Fapore maintains.

Patient safety was the No. 1 issue that prompted Fapore to implement a new workflow management system. 

In the old workflow system at his pharmacy, the pharmacist would enter all data into the computer, and the technicians would count, fill, and place the prescription at the end of the counter for the pharmacist to check. With a large amount of prescriptions coming in at any one time, Fapore wasn’t always sure at the end of the day that everything was done correctly. “It was hectic,” he says.

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In the new system, the process of filling prescriptions is broken down into various subsets. Technicians, working at their own workstations, know their individual responsibilities-entering prescription information, assembling the prescription or troubleshooting insurance questions.

There are several safety checks before the prescription gets to the pharmacist for a final check. For example, the technician filling the prescription identifies the medication by bar code. The system prevents the prescription from being filled if the incorrect bar code is scanned. 

When the medication gets to the pharmacist for the final check, its image appears on a computer screen, along with its drug utilization review data. “This is something the old system did not have,” Fapore notes. “It’s a big plus for patient safety.”

Repetitive mistakes are less common with the new workflow management system. That’s not to say mistakes are a thing of the past.

“We usually catch something every day, and although 99% are minor errors, we are able to correct them and educate our staff to reduce these errors in the future,” Fapore says.

When there is a mistake, Fapore can see where it occurs, and he can discuss the steps to take to avoid similar errors in the future with the responsible employee.

The new system gives Fapore peace of mind. “I want to be confident that all prescriptions are correct,” he says. “I know there is no guarantee we will be mistake-free. However, our new workflow management system gives us the best opportunity to safely deliver prescriptions to our patients.”

Independent pharmacies have to offer an array of services that appeal to the customer to remain competitive, says Summers, who opened Summers Pharmacy in 2013 after being employed at large retail chain. He has since added five more pharmacies through acquisition or openings

While offering more services sets independents apart, it creates challenges that can only be overcome with proper workflow management procedures, he points out.

“There are so much more that employees have to learn and be able to do in an independent pharmacy,” Summers notes. “To take care of patients today, there has to be more services such as multidose packaging and medication synchronization. Each service offered is another point where employees have to be trained and another point where something could go wrong.”

Workflow management makes other changes easier, he adds. “It’s much easier to add systems, services, and processes, as well as to make adjustments, when there is a workflow process. There is no worry that employees will feel stressed, overworked or overloaded when we add to our customer offerings.”

When Don Grove, RPh, was building his new store, J&D Pharmacy in Warsaw, MO, a decade ago, he experimented with workflow, even though he was unfamiliar with the concept. But he had a vision of how he wanted the pharmacy to operate. “I was mentally doing workflow,” he says.

He designed a system that includes inventory carousels, prescription bags that hang instead of being placed in bins, separate pharmacy and technician workstations, video counseling kiosks, and urgency color-coded transparent bundling bags. At the same time, the pharmacy was redesigned to reduce interruptions by patients and allow for more transparent interactions among employees.

Grove’s goal is to make it possible for one pharmacist to fill as many as 400 to 500 prescriptions a day.

As a result of the workflow management system, J&D Pharmacy achieved what Grove refers to as a “double oxymoron.” Not only was there an increase in volume, but also in accuracy and employee satisfaction. “It isn’t easy to achieve an increase in all three,” he stresses. 

Employee buy-in is critical. Without it, there isn’t much chance that workflow management, or any new system, will succeed. Buy-in might be the hardest part of implementing a workflow process, Summers says.

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While buy-in can be reached in different ways, with or without employee input, the workforce needs to be brought into the process at an early stage. Every employee should know why workflow management is important and its ultimate goals once implemented. 

Pharmacists will find that some employees will resist change for as long as possible. “Change is hard,” Summers says. “Employees have to be able to trust the process. Sometimes, that’s not the easiest thing.”

One aspect is that employees must come to terms with no longer being able to pick and choose the tasks hey perform. For a workflow management system to be successful, technicians and clerks should know all tasks and responsibilities. “They need to be able to step into someone else’s role without a loss of productivity,” Summers notes.

Regularly scheduled meetings with staff to discuss successes and where improvements can be made ensures that buy-in will continue long after implementation. 

“Our team preferred to be on the same page in terms of goals and productivity numbers,” Abukuwaik says. “They wanted to see our progress and discuss the next goals, and they wanted to know how they could raise their own productivity scores. The meetings gave our team members a sense of ownership in mastering workflow management.”

In the day-to-day work of the pharmacy, workflow management delivers improvements. 

“The system really helps with the relationship between the pharmacist and technicians and clerks,” Summers says. “Everyone knows what they’re supposed to do. It makes for a great workplace environment.”

Customer service is paramount. The traditional view of customer service is based on quick, reliable, and accurate service.

The customer has been to the doctor’s office, sometimes waiting for a long period of time before being seen. Or they have sick children, or they themselves are sick. Whatever the case, they don’t want to spend a lot of time in the pharmacy.

“Our main goal is to get them in and out as quickly as possible,” says Max Caldwell, PD, owner of Caldwell Pharmacy in Wynne, AR. “But in a high-volume store, pharmacists must utilize as much technology as they can to make that waiting time as short as possible.”

Workflow management allows independent pharmacists to extend customer service into the area of counseling. Because the pharmacy’s workflow is orderly, where technicians and clerks take care of their areas of responsibilities, pharmacists have the time to counsel patients.

“We have time to visit with our patients,” Caldwell says. “We can do whatever we can to take care of their needs for OTC and prescription products.”

In-depth counseling-more than just repeating label instructions-can mean better medication adherence, fewer side effects and improved safety, because patients will have a better idea of how to take their medications properly. There is also time for follow-up conversations to discuss any other medication issues.

“The pharmacist can counsel patients who haven’t started taking their medications because they’re afraid of the side effects, or point them in the right direction if there are side effects,” Summers says. This type of customer service not only can improve the health of the patient, it can create a patient-pharmacist relationship based on trust. “If we can meet the expectations that scripts are filled quickly but also provide high-quality counseling, then we have satisfied patients,” Samford’s Brown stresses. Patients will come back and grow to appreciate the role of pharmacists and staff in improving their health. 

“Workflow management is the key,” he adds. “It makes the dispensing quicker and frees up the pharmacist for quality patient interactions.”