Pharmacy workflow and tobacco-cessation programs

Lisa KroonKeys to vigorous tobacco-cessation programs in pharmacies include strong staff training, incorporation of the programs into the workflow, and documentation and feedback, said Lisa Kroon, PharmD, in a presentation made at the recent NACDS Total Store Expo in Denver. Kroon is a researcher who helped lead a trial for 20 Safeway stores in California.

In 2013, Kroon’s group conducted a study tracking implementation of cessation programs in the California pharmacies over 12 weeks. At week 1, pharmacies that had instituted the above elements had a much higher level of documentation of patients’ smoking status than those who did not, said Kroon, who is chair of the department of clinical pharmacy, University of California, San Francisco School of Pharmacy.

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“Ask-Advise-Refer”

Participating stores used the brief “Ask-Advise-Refer” counseling model (AAR), in which the patients are asked about tobacco use, and those who use tobacco are advised to quit and referred to other resources.

According to Safeway, “Pharmacists also assisted in the selection of appropriate smoking cessation medication therapy. When prescription therapy was deemed appropriate or if a prescription was necessary for over-the-counter nicotine replacement therapy insurance coverage, the patient’s primary care provider was contacted.”

In addition, pharmacists counseled patients on proper use of medications and provided follow-up care and referrals to other resources, including telephone quit lines.

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The study

Stores were randomized into two groups of 10 each. In one group, the pharmacy personnel were given only written educational materials and operational procedures. In the other group, they were also given four hours of live training and active monitoring and coaching by the pharmacy management, including weekly measures of how well they were doing.

At 12 weeks, the stores where staff received written materials showed about a 22% weekly cumulative percentage of computer profiles documenting patient smoking status. Those stores given more extensive training and monitoring were at about 44% documentation.

Likely reasons that documentation was not made in some encounters include staff’s lack of time, window pickups for prescriptions sent electronically, 90-day Rxs filled early in the study and not captured later, and staff failure to follow procedures or discomfort with asking questions, said Robin Corelli, PharmD, UCSF Professor of Clinical Pharmacy and a co-investigator on the project.

The study showed the feasibility of the AAR model, used in brief interventions made by the pharmacy team, said Kroon, adding that the difference in the two sets of stores shows that “pharmacy leadership support is a key factor in the success of the program.”

“The pharmacy management actually provided active monitoring. The stores got weekly metrics of how they were doing,” she says.

Systematic approaches

Kroon emphasized the importance of incorporating tobacco cessation into the workflow, with staff asking patients about tobacco use just as they ask about allergies or insurance. Safeway, she said, found a way to document tobacco use in its software, a sensible addition because it also enables pharmacists to assess for significant medication and smoking interactions.

Looking at the study’s basics, Robin Mermelstein, PhD, president of the Society for Research on Nicotine and Tobacco, said that “building in more systematic approaches to help pharmacy staff ask about tobacco use and advise smokers to quit is an excellent way to help reduce smoking.”

Although there is no direct reimbursement for tobacco-cessation programs in pharmacies now, Kroon noted that sale of nicotine-replacement products may offset the costs of such programs, particularly for a pharmacy chain.

Last fall Safeway said it would incorporate the Ask-Advise-Refer model in all of its pharmacies.

CVS, which has its own smoking-cessation effort, says that its pharmacists have counseled over 260,000 patients about cessation and “filled nearly 600,000 nicotine replacement therapy (NRT) prescriptions.”

Kathryn Foxhall is a healthcare journalist based in the Washington, D.C., area.