key: cord-0961604-o5zjtjb9
authors: Nardolillo, Joseph A.; Rosario, Natalie; Cheng, Vivian; Lobkovich, Alison M.
title: Initiating Primary Care Services when the World Is Paused: Lessons for Pharmacists in the Post–COVID-19 Era
date: 2022-04-19
journal: J Pharm Pract
DOI: 10.1177/08971900221087934
sha: 90eee98aad72d0f1aeeb14d3dd10735536e2ce1a
doc_id: 961604
cord_uid: o5zjtjb9

The COVID-19 pandemic impacted primary care and required pharmacists to adapt when implementing primary care services. Many lessons learned through this process are applicable in the post-pandemic era. First, primary care pharmacists must prepare for an ever-changing role and communicate with stakeholders to align with shifting institutional priorities. Additionally, designing a workflow given limited staffing and in-person communication require flexibility for scheduling and referral processes. Proactive outreach and communication via virtual platforms may be used to build trust in place of in-office interactions with providers. Lastly, fostering relationships with patients is essential to the success of the service and often requires creation of patient-centered goals to account for personal barriers. Many pandemic obstacles are transient; however, telehealth, virtual communication, and the subsequent lessons learned in adaptability, creativity, and flexibility when building a clinic practice are everlasting.

Prior to the COVID-19 pandemic, pharmacists within primary care demonstrated the ability to increase access to care and improve patient outcomes. [1] [2] [3] The pandemic decreased access and utilization of primary care, resulting in fewer patient interactions, assessments and evaluations of chronic disease states, medication prescribing rates, and preventive care measures. 4, 5 While established practices transitioned to telehealth, there is minimal published data or commentary regarding the implementation of new primary care pharmacy services during the COVID-19 pandemic. 6, 7 The authors of this commentary implemented four individual practices at the height of the pandemic (Table 1) . Each required modifications from traditional primary care best practices. This commentary describes how the authors adapted to this new environment and addresses lessons learned that may apply beyond the global health crisis.

To align with health system priorities, strategic planning with key players such as administrators and providers is a best practice and driver of success when initiating new services. 8, 9 While it was still prudent to conduct formal planning strategies (e.g., SWOT analysis) during the COVID-19 pandemic, primary care pharmacists recognized the potential shifts in feasibility and institutional priorities. 9 This author group began their roles after the initial wave of COVID-19 when telehealth was widely utilized. Integration into the patient care team required flexible and mindful planning with administrators, providers, and staff given the landscape. For example, stakeholders within one system desired to outreach patients with heart failure to optimize medication therapy; however, barriers to in-person physical assessment and lab monitoring limited the feasibility of this new service. Instead, priorities shifted to management of diabetes and hypertension with easier home-based monitoring. Many patients with diabetes and hypertension had concurrent heart failure; therefore, we continued to develop heart failure workflows and protocols to advance toward the original system goal. Additionally, less traditional roles for primary care pharmacists emerged such as administering COVID-19 vaccinations, staffing inpatient surges, and providing COVID-19-related education.

Pharmacists are well-positioned to fill a multitude of everchanging roles via virtual, in-person, and telephonic platforms. As we better understand the long-term effects of COVID-19 (e.g., respiratory conditions and anticoagulation), a deep understanding of therapeutics and appropriate medication utilization is crucial. Co-management of these potentially chronic conditions may fall under the purview of a primary care pharmacist. 10 Pharmacists should continue to maintain open dialogue, meet with stakeholders, and be prepared for shifting healthcare priorities as the pandemic evolves.

A structured workflow focused on referrals, scheduling, and lab monitoring procedures is critical to the success of a primary care service. Establishment of new pharmacy services amidst a pandemic may require temporary or altered workflows that may shift to more efficient strategies at the culmination of this public health emergency.

Some clinics did not have a formal referral process in place. Under traditional circumstances, the lack of referral processes could be replaced by curbside consults; however, curbside consults were less frequent due to social distancing and limited in-person staff. Early action was needed to mitigate these inefficiencies and potential missed opportunities for patients who may have benefitted from a referral to a pharmacist. We presented the service models at virtual provider meetings and clinic huddles to explain the service, referral eligibility, and basic workflow procedures since not all primary care providers (PCPs) had experience working with a clinical pharmacist. For example, when the pharmacist recognized low referral rates, they reviewed medical records, utilized informatics tools, and outreached PCPs to identify candidates who may benefit from a primary care pharmacist visit. This early detection of low uptake of the pharmacist-led service and swift intervention can continue to be applied post-pandemic for those implementing new pharmacist-led services.

At the authors' practice sites, COVID-19 exacerbated staffing shortages due to staff being redistributed to alternative roles (e.g., COVID-19 testing and temperature checks). Some primary care pharmacists encountered workflow bottlenecks given the limited support staff. Being flexible and having workflow conversations early maximized the pharmacists' clinical skills and time. For those establishing a new primary care service, tracking the time spent on administrative tasks may provide evidence to stakeholders that pharmacists' time could be better utilized conducting clinical visits that contribute to quality measures. This may help negotiate the need for redistribution of staff's responsibilities to assist with scheduling appointments. Additionally, lessons learned included the need for patience regarding stretched resources during these transitional times. Lab monitoring plays an integral part in drug therapy management by primary care pharmacists. However, this was disrupted by COVID-19 and required workflow adjustments for telephonic and telehealth visits. Fear of coronavirus exposure resulted in reduced patient willingness for follow-up blood work. For critical lab monitoring (e.g., warfarin management), the pharmacists stressed the importance of having labs checked the day prior to the appointment. Future directions related to lab monitoring involves pharmacists synchronizing lab appointments for convenience to the patients and aligning lab visits with previously scheduled in-person appointments.

Early and frequent assessments of these services were imperative to create a successful practice when the number of primary care visits were decreased. 5 These reflections and early action allowed opportunities to discover roadblocks, inefficiencies, and areas for education. This helped us more quickly establish our services despite the complications of a global pandemic. The lessons learned about workflow can continue to be applied post-pandemic to initiate new pharmacist-led primary care services.

Proactive communication with providers and staff sets the groundwork for creating an efficient exchange for service uptake. Traditionally, pharmacists relied heavily upon key trust-building activities with providers and staff such as inperson discussions, drug information questions, and "rounding" to foster relationships and expand services. 11 Due to social distancing and remote work, a more unique and thoughtful approach to engage team members was required.

The authors designed creative visual handouts describing the role of the clinical pharmacist to bring awareness to the service and convey professional skills and qualifications. Pharmacists contributed to staff meetings by presenting clinical pearls and performance measures. This served as essential relationship-building activities. The authors emphasized charting documentation to establish trust when other channels of communication were limited. 11 This provided insight into pharmacists' clinical decision-making skills and allowed for indirect communication with providers.

The extended period of non-face-to-face interactions with the clinic team made accessibility and communication critical to ensure adequate follow-up. Open dialogue regarding preferred communication methods was essential. 11 Modalities utilized to reach providers included electronic health record messages, phones, and other HIPAA-compliant applications. Additionally, the authors recommend obtaining access to a health-system contact list and preferred virtual communication platform for easier connection with the team whether they are in-clinic or remote.

The COVID-19 pandemic has changed work environments and interactions with colleagues who continue to serve patients virtually. This limited in-person engagement may require continued use of virtual communication strategies. As new members of an interprofessional team, pharmacists must be ready and willing to seek out, create, and modify those traditional relationship-building activities to foster trust and promote confidence.

Prior to the COVID-19 pandemic, high levels of patient satisfaction were demonstrated with pharmacist-led care across various practices. [12] [13] [14] [15] [16] As we transition to postpandemic life, pharmacists must be cognizant of the longterm impact the pandemic had on patients' ability or willingness to engage in care. Economic implications due to decreased work hours, layoffs, and subsequent loss of insurance led to barriers in core social needs such as housing, transportation, and food. 17 As a result, clinical pharmacists may play a greater role in connecting patients to resources beyond medications.

The authors engaged interdisciplinary care management teams to address various social and medical needs. During patient interviews, we asked more questions related to copays and healthy food access while also enrolling patients in medication cost-savings programs. These steps helped connect patients to resources and fostered patient-pharmacist relationships.

As health systems and patients embrace telehealth longterm, clinical pharmacists may require creative approaches to build patient relationships virtually. 6 Examples include going the extra mile to bring healthcare to patients via remote monitoring, telehealth appointments, and patient education related to new technologies. Additional strategies include spending more time getting to know patients during visits, coordinating lab monitoring and follow-up visits together, and being empathetic to difficult socioeconomic situations.

With the rise of mental health conditions related to the pandemic, patients may have other priorities or feel overwhelmed, limiting their willingness to engage with a new provider. 18 Now more than ever, it is crucial to engage in shared decision-making discussions with patients. For example, the authors relaxed the timeframe to achieve clinical goals (e.g., hemoglobin A1c), reduced the frequency of lab monitoring, and prescribed lower-cost medications. While these strategies may have delayed achieving clinical outcomes, this strengthened patients' trust and engagement in care. These approaches to patient-centered care will remain essential for maintaining patient-pharmacist relationships beyond the pandemic.

The COVID-19 pandemic has presented once-in-a-lifetime challenges to primary care pharmacists. While face masks and social distancing are hopefully temporary obstacles, the lessons learned in adaptability, creativity, and flexibility when building a clinic practice will endure.

Nardolillo JA, Rosario N, Cheng V, and Lobkovich AM all contributed to the conceptualization, writing-original draft, and writing-review and editing of this commentary.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Joseph A. Nardolillo  https://orcid.org/0000-0002-5914-126 Natalie Rosario  https://orcid.org/0000-0002-9965-0956 Vivian Cheng  https://orcid.org/0000-0002-3914-6424 Alison M. Lobkovich  https://orcid.org/0000-0003-1303-8457