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In 1997, the city of Asheville, North Carolina was the site of a groundbreaking study to measure the outcome of community-based pharmaceutical care services (PCS) on diabetes patients. A combination of patient education and pharmaceutical care was offered to city employees with chronic health conditions over a five-year period.
Published in the Journal of the American Pharmaceutical Association, the results of The Asheville Project highlighted benefits for both patients and employers. Patients experienced improved A1c (glycosylated hemoglobin or blood sugar) levels while employers saved on mean total direct medical costs. Researchers also documented fewer sick days among participants and higher levels of satisfaction with pharmaceutical services.
Successful healthcare innovations like the Asheville Project have laid the groundwork for a new initiative, Flip the Pharmacy (FtP), whose goal is to take innovative community-based pharmacy to scale. Key players include founding partner CPESNⓇ (Community Pharmacy Enhanced Services Networks) and founding sponsor Community Pharmacy Foundation, along with a host of collaborators from industry and academia, including the ACT pharmacy collaborative. Participating pharmacies span the nation, and the full program impact aims to influence over 5,000 pharmacy locations over five years.
What is FtP?
With an overburdened healthcare system and rising rates of chronic illness, Ftp is a nationwide community pharmacy practice model that aims to transform the industry by taking it from point-in-time and product-level to longitudinal and patient-level. The new model would shift pharmaceutical practice from moment-in-time transactions based on filling prescriptions to providing patient-care over time through a two-year pharmacist coaching program.
The premise of FtP is that the thousands of innovations in community-based pharmacy practice like the Asheville Project, while important, were “one-in-a-row” and thus did not have a widespread impact on the field. In shifting the focus to scaling and implementation, FtP aims to bring this innovative community-based pharmacy model to the masses with sustainable and far-reaching effects on practice and policy.
The delivery of the program, as the name suggests, is based on the educational concept of flipping the classroom. In the educational model, students are exposed to new material outside of class and are supported by teachers and peers in assimilating that knowledge using higher-level cognitive skills (such as application, analysis, evaluation, and creation) during class.
The model was adapted by the Robert Wood Johnson Foundation for healthcare settings and the resulting flip the clinic was chosen as the basis for FtP along with current community-based pharmacy innovations.
Anne Marie Kondic, PharmD is the Executive Director of the Community Pharmacy Foundation (CPF)—the founding partner of Flip the Pharmacy. CPF is an independent organization funded by a class-action pharmaceutical lawsuit settlement in Chicago in the late 90s. It operates on the guiding principle of “investing in the innovative edge” of community pharmacy practice.
In October 2020, Kondic and colleagues published the origins of the Flip the Pharmacy implementation model in the journal Innovations in Pharmacy. Citing escalating healthcare costs, an aging population with chronic illness, healthcare provider burnout, and a projected shortage of primary care physicians within the next 12 years, Kondic and her team highlight the need for scalable solutions to alleviate medical practice burdens. Revealing that community-based pharmacist practitioners (CPPs) are an eager and untapped resource, the team demonstrates that accessibility alone makes the case for FtP strong with 82 percent of Americans living within five miles of a community pharmacy.
Speaking with Kondic on December 2nd, she provided background on the inception of FtP. At a CPF strategic plan meeting in February of 2019, the transformation of pharmacy workflow was discussed. Board members specifically pointed out the need to shift from the heavily dispensary-focused model of pharmacy practice to one that includes time for patient care. Kondic shared that several events simply aligned at the right time to allow FtP to come into being.
One of those events was the partnership of the Community Pharmacy Foundation (CPF) and CPESNⓇ (Community Pharmacy Enhanced Services Networks), which funded the operation of the program. Another was the leadership of Troy Trygstad, who had the operational experience and vision needed to structure the FtP program, get it up and running, and assemble the team.
By August 2019, the CPF board had determined and awarded the funding, the participating teams and pharmacies in cohort 1 were formed, and the FtP program was launched in October of that year.
How Flipping the Pharmacy Works
In order to effectively flip the pharmacy to scale, several moving parts need to be coordinated and aligned. Kondic shared, “Scalable pharmacy practice transformation requires changes to workflow, care processes, and business modeling in repeatable, consistent and achievable increments.”
This entails coordinated collaboration between all FtP constituents: participating pharmacies and pharmacists, practice transformation teams, and practice transformation coaches. The curriculum of transformation comes in the form of change packages, which provide a roadmap of prescribed changes in logical steps with data-supported feedback and support.
Implementation of the program has been spearheaded by Randy McDonough, consultant and co-owner of Towncrest Pharmacies, and Cody Clifton, director of practice transformation for CPESNⓇ. In this role, McDonough and Clifton conduct monthly webinars to share drafts of the content of the coming month’s change package with practice transformation team leaders; organize a second monthly webinar for team leaders and coaches; and then release the final draft of the change package to coaches to use in training the pharmacists.
These monthly touch-points serve to educate, train, and allow for discussion and sharing of best practices for the monthly topic focus.
Change packages have been created for Covid-19, opioids, and hypertension. Future packages will address immunizations, diabetes, and the social determinants of health. Each change package addresses the specific area of health concern with regard to workflow innovation/patient-care process and eCare plan documentation within six domains.
The domains involved in FtP practice transformation include:
- Domain #1: Leveraging the Appointment-Based Model
- Domain #2: Improving Patient Follow-Up and Monitoring
- Domain #3: Developing Roles for Non-Pharmacist Support Staff
- Domain #4: Optimizing the Use of Technology and electronic Care Plans
- Domain #5: Establishing Working Relationships with Other Care Team Members
- Domain #6: Developing the Business Model and Expressing Value
Becoming a Participating Pharmacy
The benefit of becoming an FtP participating pharmacy is that pharmacies receive funding by CPF and collaborating sponsors, as well as training by CPESNⓇ and collaborating partners; however, all change packages are freely accessible and can be downloaded from the FtP website for use by any interested pharmacy to use on their own.
Participating pharmacies are of a wide variety. Kondic explained that:
A community pharmacy is basically a storefront pharmacy open to the public. This includes your grocery store pharmacy, large pharmacy chains like Walgreens, CVS, Rite Aid, and Walmart, in addition to your mom-and-pop, family-owned drug stores … [But] that’s not to say that FtP isn’t open to pharmacies housed in hospitals and other ambulatory care settings.
The following criteria were used to select the pharmacies participating in the first cohort I of the FtP program:
- Lean programs that engage other partners (in-kind) and sponsors (cash) to increase program (participating pharmacies) capacity
- Pharmacies able to do data sharing using eCare plans to document their work with patients
- CPESN Participating Network Pharmacies
Additional information including eligibility requirements and scoring criteria are available on the FtP website.
The Impact of FtP
One of the most significant impacts Kondic has seen thus far is the effect the FtP program has had on the pharmacists’ relationship to their practice/work. She shared that the experience has been re-energizing for many of those involved.
Globally from the pharmacists, the pharmacies, and the teams, there’s energy to practice again. For the past several years, it’s been very downward … it’s [been] all about the prescriptions … It’s just been very mechanicalized.
A pharmacist herself, Kondic explained that,
This is why I went to school … caring for patients. That’s what it was about for me. It wasn’t about putting medicines into a bottle. It was about engaging with the patients.
Participating pharmacists have also had some great opportunities to make an impact on patient-care. Kondic explained that in one success story, a pharmacist was able to identify a patient with undiagnosed hypertension, and got the patient to talk to their provider to receive the needed care. She explained,
[If] that blood pressure wasn’t taken [at the pharmacy] that case would have gone by the wayside. Who knows what the outcome would have been down the road, but it allowed the opportunity to identify a problem, take the intervention, and create an ongoing relationship to help manage that patient-care.
Perhaps most significantly, Kondic reported that, “This program has brought the emphasis of patient-care to the forefront.”
The operating team is currently analyzing the data for Year 1 to provide evidence to support the anecdotal and descriptive successes they’ve seen thus far, however, preliminary results of FtP cohort 1 can be found here, and coaching enhancement objectives can be found here.
The Enduring Challenges of FtP
Access is a huge issue in healthcare—and especially so during a pandemic. FtP had already launched and was underway when the Covid-19 pandemic hit the U.S. In response, the FtP team began writing change packages in direct response to this public healthcare emergency immediately.
Kondic explained that while getting in to see a family doctor or specialist has not been possible at times during the pandemic, pharmacies are open and have been throughout. Hence the necessity of moving FtP forward in response to what is happening in the healthcare landscape in real time.
FtP released four Covid-19 change packages between March 24 and May 15, 2020 upon request by the leadership team. Because this happened so fast, and there were practices already happening, this changed how the packages were developed and released. The pandemic called for more practical applied tools as opposed to the academic nature of the other change packages. However, Kondic clarified that “this was always the premise: that it’s flexible and nimble.”
As mentioned above, CPF is the founding sponsor of FtP and a long-term partner; however, CPF is not the primary funder. Additional funding comes from sponsors, partners, and financial and in-kind contributors. Kondic shared,
Initial funding provided by CPF will support the program through three years. We are currently seeking additional financial sponsors to maintain and expand the program going forward.
The majority of FtP funding is in fact spent on the pharmacy teams and coach/educator role. In order to gain large-scale acceptance and implementation, the FtP model will be needing further financial sponsorship to support the sustainability of the program for the full five years and beyond. The demand is so great that pharmacies have had to be turned away—a significant indicator of both the need and desire on the part of community pharmacies and pharmacists for this change in practice.
On a final note, Kondic shared,
We know it’s happening. We hear stories. That’s why pharmacists are a highly trusted profession, but the pharmacy has been more [about] distribution as opposed to the care documentation, and that’s what this program is intending to do: to enhance, to document all of that good stuff that’s been happening.
Cevia Yellin is a freelance writer based in Eugene, Oregon. She studied English and French literature as an undergraduate. After serving two years as an AmeriCorps volunteer, she earned her master of arts in teaching English to speakers of other languages. Cevia’s travels and experiences working with students of diverse linguistic and cultural backgrounds have contributed to her interest in the forces that shape identity. She grew up on the edge of Philadelphia, where her mom still lives in her childhood home.