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BACKGROUND

Few professions have experienced change as significant as that experienced by pharmacy in the last two decades. Today’s pharmacist continues to be responsible for the safe distribution of drugs; however, there is an increasing recognition by society of the pharmacist’s advanced training and expertise and that including pharmacists on care delivery teams has the potential to improve health outcomes. ¹ For many years, professional pharmacy organizations have emphasized the importance of having pharmacists engaged in ensuring appropriate medication therapy outcomes for all patients. They have also adopted a profession-wide consensus vision for the profession that emphasizes the critical importance of pharmacists as vital members of a health care team, providing both preventive health and interventional health services (Table 1).²

In order for pharmacists to fully engage in team-based, patient-centered care, it is essential that pharmacy technicians take on proactive and expanded roles within pharmacy practice. The American Society of Health-Systems Pharmacists (ASHP) identifies the need for increased training and expanded roles for pharmacy technicians.³ Further, the American Pharmacists Association (APhA) House of Delegates has adopted a policy that supports advanced education and training for technicians. This training would result in certified pharmacy technicians taking on expanded roles to free up pharmacist time to engage in direct patient care activities.⁴ The Pharmacy Technician Certification Board (PTCB) has adopted a new requirement which will become effective in 2020, requiring that all technicians seeking initial certification must have completed an accredited technician education program.⁵ This change, more than any other, is an acknowledgement by the professionals serving as technicians that their role is rapidly evolving. Perhaps among the most prominent nondispensing services that pharmacists provide are immunizations and medication therapy management. In this lesson, we will explore the expanding role of pharmacy technicians to support pharmacy’s professional engagement in these direct patient care initiatives.³

MEDICATION THERAPY MANAGEMENT

Medication therapy management, or MTM, is terminology that originated with the Medicare Modernization Act of 2003. While the Act did not specifically define all aspects of MTM, it did spur a national conversation about what this shift in the role of the pharmacist might mean to the health care system and to society. The profession did agree upon a professional definition of MTM (Table 2), which has been widely accepted by pharmacy and the broader health care system.⁶ However, despite this wide adoption, the acceptance of MTM services by payers has been slow to evolve. Further, while the hope was that MTM services and other nondispensing activities would predominate in community practice, the provision of these services has not developed as quickly nor as routinely from pharmacy to pharmacy as the profession may have hoped.⁷ This inconsistency in the provision of services has left room for improvement. APhA recently published an APhA Practice Perspectives Report, which suggests that while there are an increasing number of pharmacists engaged in MTM, continued inconsistent payment for the service and transitional development of business models and workflow may represent significant obstacles to greater implementation of MTM services into practice.⁸ Pharmacy technicians can assist pharmacists tremendously in this process.⁸

In order to fully examine the opportunities for pharmacy technicians to assist with MTM services, one must first recognize the core elements that constitute an MTM service. The Core Elements of an MTM Service in Community Pharmacy Practice are summarized in Table 3.⁹ Some people may assume that MTM is as simple as performing a drug utilization review or counseling a patient on the appropriate use of a medication. While these individual services are important, MTM is intended to represent a more comprehensive approach to patient care and the medication use process. MTM interventions can range from relatively straightforward to highly time consuming and intense, as illustrated in Table 3. A complete MTM service that follows the core elements format requires time. This is where the pharmacy technician enters the equation as a critical partner of this service. APhA provides comprehensive resources for establishing MTM services within a practice that the pharmacy technician may find useful (http://www.pharmacist.com/mtm).

The first step pharmacy technicians should undertake is to assist with analyzing and optimizing the workflow of the pharmacy. Pharmacy technicians can assist pharmacists by identifying processes and procedures within the individual practice that might be modified, or potentially even eliminated, in order to free up time for the pharmacist. For example, pharmacists may not need to be involved with prescription intake, product preparation, or communication management activities. Technicians can take on these roles in the pharmacy, and utilize technology to the greatest extent that is financially and physically possible. Pharmacists have reported in past surveys conducted by APhA (see APhA’s Patient Care Resource Library at https://www.pharmacist.com/resources/patient-care) that inadequate time and staff support is at least one of the reasons why they are unable to fully engage in MTM services with their patients. ⁸ Thus, a detailed analysis of the dispensing workflow cannot only establish further efficiencies, but can also free up valuable pharmacist time to provide the service.

Secondly, once MTM services are established, pharmacy technicians can take on critical functions, as state law allows, in promoting the availability of the service to existing patients. Many patients may not be aware that there are services beyond prescription drugs available at the pharmacy. Table 4 lists examples of patient prompts that could help the pharmacy technician to promote the availability of MTM services. These services may generate new revenue for the pharmacy in addition to improving the health and well-being of the community. This is especially important given the downward reimbursement pressures on prescription drugs.⁸

Patients identified for MTM services will likely need to schedule their appointments when the pharmacist is able to completely break away from the dispensing process because he or she will need to have uninterrupted time to focus on the patient, especially if the appointment is in person. For this reason, the pharmacy will need to establish an appointment scheduling process—an activity that pharmacy technicians can provide.³ Pharmacists will need to determine the approximate length of time for each appointment and the specific hours that should be set aside for MTM services. When scheduling an MTM service, it is important to know that the pharmacist will need to set aside time to review the patients’ medications and medical history prior to the appointment in addition to providing the appointment itself.⁹

Following the face-to-face meeting with the patient, the pharmacist will need time to document the encounter and make recommendations regarding the patient’s therapy to other health care providers. Depending on the availability of technology (ie, electronic documentation systems) and the complexity of the patient case, documentation may only take a few minutes or could become quite extensive. The technician can work with the pharmacist to maximize scheduling efficiency and to optimize the appointments available to patients. Pharmacy technicians can also establish a system for MTM appointment reminders intended for patients. For instance, they may consider contacting patients 1 to 2 days prior to the appointment to verify the date and time of the MTM service. This may help reduce the rate of no-shows for scheduled appointments.³

A related service that has supported providing MTM is the appointment-based model (ABM). The ABM is a patient-focused care model that can improve patients’ medication adherence, build efficiency into pharmacy workflow, and manage potential issues before the patient arrives at the pharmacy to pick up their multiple medications. The core components of the ABM include medication synchronization (med sync), a pre-appointment call 3 to 7 days before prescription refills are due, and a designated appointment day. The ABM can be implemented in any community-based pharmacy setting that dispenses medications and provides a platform on which patient care services can be expanded.¹⁰ Med sync or the ABM has been adopted by most national and regional chain community pharmacies and many independent community pharmacies. Download this resource to learn why pharmacists are implementing the ABM: https://www.pharmacist.com/sites/default/files/files/APhA_Benefits%20of_Medication_Synchronization_ABM.pdf

IMMUNIZATIONS: PROTECTING THE PUBLIC’S HEALTH

According to the World Health Organization (WHO), vaccines are one of the greatest, most cost-effective public health interventions in global society.¹¹ However, despite the availability of safe and effective vaccines to prevent a number of health conditions (Table 5),¹² many patients remain under- or unimmunized.¹³ A number of factors have been offered that may contribute to low immunization rates among adults. The Immunization Action Coalition and Centers for Disease Control and Prevention (CDC) have numerous resources available through their websites (www.immunize.org and www.cdc.gov/vaccines) to address these factors. The CDC Advisory Committee on Immunization Practices (ACIP) is the group largely responsible for making national recommendations for the use of vaccines in the United States.¹³ These recommendations influence health policy, form the basis for payment of vaccines by public and private payers, and are used as quality metrics by accrediting bodies and third party plans to articulate to consumers the quality of care being provided within a hospital, practice, and/or pharmacy.¹³ For pharmacists, ACIP recommendations are generally the guidelines under which immunization protocols are written. A physician-pharmacist protocol allows the pharmacist to independently immunize patients in the pharmacy. In most states, a vaccine requires a prescription from an authorized prescriber. The majority of states recognize the public health value of having pharmacists engage in immunization practice and have determined that standing orders or protocols between a physician and pharmacist are sufficient for meeting the requirement of a prescription, thus negating the need for individual prescriptions for each patient receiving a vaccine from a pharmacist.¹⁴ While all 50 states allow pharmacists to immunize, some states require prescriptions for certain vaccines while other states limit the vaccines that may be administered by a pharmacist.¹⁴ It is important to check with your state board of pharmacy to determine what is permitted in your state. In 2017, Idaho became the first state to allow pharmacy technicians to administer vaccines.¹⁵ For an Idaho technician to administer a vaccine, he or she must hold a national certification from the Pharmacy Technician Certification Board or National Health Career Association. In addition, the certified technician must “successfully complete a course on appropriate vaccine administration techniques by an Accreditation Council for Pharmacy Education (ACPE)-accredited provider” and hold a current certification in basic life support.

Pharmacy technicians can perform important supportive functions in the other states that will enable the pharmacist to provide this important public health intervention.

First, technicians can ensure that vaccines are stored and handled properly. It is critical that vaccines are put in the refrigerator or freezer (as appropriate) as soon as they arrive from the manufacturer or wholesaler. Improper vaccine storage will lead to the vaccine being unsafe for administration and ineffective against the disease it is indicated to prevent.¹² This process of ensuring vaccine storage from manufacturer to patient administration is often referred to by the CDC as the “Vaccine Cold Chain,” which references the analogy that, like a chain, storage is only as good as the weakest link.¹² If any part of the process from shipping through the provider breaks down, vaccine efficacy can be compromised. To assist health care professionals in storing and handling vaccines properly, the CDC strongly urges all health care providers and support personnel to review its recently updated toolkit and training module on vaccine storage and handling located at https://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/index.html. These recommendations cover wide ranging topics such as how to maintain vaccine temperature during power outages, selecting and utilizing an appropriate refrigeration or freezer unit for vaccine storage, appropriate placement of vaccines within the storage unit, temperature monitoring, and transportation standards for vaccines administered off-site (such as at an employer worksite or senior center).

The second critical role of the pharmacy technician is to ensure safe and effective vaccine dose preparation. Many vaccines come in single-use syringes, while others are available in multiple-dose vials, which require doses to be “drawn up” or prepared prior to administration. There is the potential for error in the preparation of vaccine doses. Many manufacturers use a similar naming system for their vaccines, which can potentially lead to errors in preparing the wrong vaccine.¹⁶ Table 6 identifies potential vaccine errors as well as suggestions for how pharmacy technicians and pharmacists can reduce the risk of vaccine errors.

Pharmacy technicians may also be involved in preparing doses and may assist the pharmacist at the time he or she is vaccinating a patient. According to federal Occupational Safety and Health Administration (OSHA) laws and regulations, as well as some state requirements, any individual with potential bloodborne pathogen exposure through the handling of used needles or syringes must be offered immunization against Hepatitis B without cost to the employee.¹⁷ For example, if a technician is asked to seal and remove a sharps container that has been filled with used needles/syringes, they may be exposed to bloodborne pathogens and would need to receive a 3 dose series of Hepatitis B vaccine.¹⁷ Pharmacy technicians should discuss this issue with employers prior to engaging in any immunization-related activities.

Patient advocacy for vaccines is critical for a successful pharmacy-based vaccination program. There is significant misinformation regarding vaccines and their effects. For example, there is a myth that the influenza vaccine can cause the flu. In fact, the injectable influenza vaccine is produced using a killed virus antigen; thus, it is not possible to contract influenza from the vaccine.¹⁸ Since the influenza vaccine is traditionally administered around the same time flu season begins and because the vaccine can take up to 2 weeks to elicit an immune response in the human body, patients who have already been exposed to the flu prior to receiving the vaccine may still contract the illness.¹² In addition, many viruses that are not influenza, but cause similar symptoms, may also be circulating during flu season. The flu shot is only designed to prevent infection from select strains of influenza.¹² There are a number of reliable resources available to assist health care providers in dispelling myths associated with vaccines. Health care providers can refer patients to the CDC’s website for links to online resources of credible vaccine information (http://www.cdc.gov/vaccines/vac-gen/evalwebs.htm). Researchers have found that strong, positive messages from providers, who are well-equipped to accurately address patient concerns about vaccines, are able to positively influence the patient’s decision to receive an immunization, even if the patient previously had negative attitudes about vaccines.¹⁹

Pharmacy technicians should talk to their pharmacists about how they can best help in providing positive messages to patients regarding their need for immunizations. Pharmacy technicians may also be able to assist the pharmacist in identifying patients who are in greatest need for immunizations. For example, the CDC now recommends that all patients aged 6 months and older should receive an influenza vaccine, and all patients aged 65 years and older should receive a pneumococcal conjugate vaccine, followed 12 months later by a pneumococcal polysaccharide vaccine.^20,21 These age-based recommendations offer a tremendous opportunity for pharmacy technicians to prompt pharmacists and patients about the need for vaccination.

Documenting a patient’s immunization status is the last, but certainly not least, important step in the process of providing vaccines in a pharmacy. While vaccines will be documented within the pharmacy’s dispensing system as a part of the prescription dispensing and billing processes, this documentation is inadequate to meet the current standards of practice for immunization set forth by public health agencies and the CDC.¹² All 50 states now have immunization information systems (IIS), or registries, for documenting immunization events. All states’ registries were initially created for seamless documentation of pediatric vaccinations; however, many states have now expanded these registries to permit the documentation of adult immunizations as well.¹² Unfortunately, adult vaccine providers (including pharmacists) are not routinely utilizing these state-based systems for documentation. The result is an incomplete immunization record keeping system for adults, with physicians, hospitals, nursing homes, pharmacies, and other health care facilities each unable to accurately identify the vaccines a patient may have already received. Pharmacy technicians should assist pharmacists in ensuring that their existing dispensing system can communicate electronically and seamlessly with the state’s IIS so that vaccine administration is documented correctly. This should be an automated process, but may require some persistence in working with a state’s IIS coordinator (typically located within the state department of health) to set up the process. A listing of state IIS coordinator contacts is found at the following website: http://www.cdc.gov/vaccines/programs/iis/contacts-locate-records.html. Additionally, pharmacy technicians can assist pharmacists by performing immunization record checks prior to the pharmacist administering a vaccine to the patient. The pharmacist can then review this information to reduce the risk of unnecessary doses of vaccines, as well as to identify additional vaccines that the patient may need to receive.

BILLING AND REIMBURSEMENT SUPPORT

Whether MTM or immunizations, these nondispensing activities require a unique way of billing and reimbursement from third-party insurance companies. MTM may be paid for by the pharmacy benefits management (PBM) company or by the patient’s major medical plan.²² Some patients, in particular Medicare Part D beneficiaries, may have an MTM benefit that is coordinated through a subcontract with an MTM company (eg, Mirixa, Outcomes Pharmaceuticals, PharmMD Solutions). For many patients, MTM is not covered by their insurance plan and may require out-of-pocket payment. Unfortunately, there is currently not a standard process among the various MTM companies, PBMs, and major medical insurance companies for the billing of MTM services.²² The MTM service companies typically mandate billing and documentation through proprietary, Internet-based software. Some PBMs allow for MTM billing through the dispensing software and billing program using unique coding. Most major medical plans that compensate pharmacists or pharmacies for MTM utilize Current Procedural Terminology (CPT) billing codes and require electronic billing of claims in a traditional fee-for-service model.²² Newer payment models are evolving as a result of the implementation of the Affordable Care Act. Pharmacy technicians should stay current with the opportunities for billing for pharmacist-provided MTM services. The APhA’s Billing Primer: A Pharmacist’s Guide to Outpatient Fee-for-Service Billing is an excellent resource.²² Pharmacy technicians should also work with their pharmacist to determine the breadth of opportunities related to the compensation for MTM services that may be available in your local area.

It is important for the pharmacy technician to have a strong understanding of the pharmacist’s usual charge for provision of MTM services to a patient. The “usual and customary charge” for any product or service is the fee the pharmacy or pharmacist would charge a patient paying out-of-pocket for the service. Federal laws and regulations prohibit providers, including pharmacists and pharmacies, from charging federal programs such as Medicare any amount greater than usual and customary charge for the service.²² Pharmacy technicians may need to become proficient in checking benefit coverage for patients to determine if coverage of MTM is provided and under which portion of their insurance benefits payment is possible. In the event that a patient must pay out-of-pocket for the pharmacist-provided MTM service, consider supplying him or her with a superbill, which is an itemized receipt detailing the services provided and the charges incurred.²⁴

For billing and reimbursement of vaccines, each vaccine product (sometimes manufacturer specific) has a unique CPT code that must be used to bill the vaccine to a major medical plan or to Medicare Part B.²³ This is different from the process typically used to bill vaccines to Medicare Part D, which utilizes the vaccine’s NDC number as the driver for billing.²³ To find a vaccine’s specific CPT code, simply consult the package insert for the respective vaccine. Manufacturers typically include the CPT coding information in the last section of the package labeling, near the end of the insert. The information can also be garnered from the CDC’s website. Pharmacies should also bill for the administration of the vaccine. This is a separately compensable service from the vaccine product itself.²³ Again, for vaccines billed through PBMs (eg, Medicare Part D claims), check with your software vendor to determine the appropriate field in which to document the administration service.

SUMMARY

Pharmacy is undergoing significant changes in its practice model in order to free up time for the pharmacist to engage in direct patient care, nondispensing activities. Pharmacy technicians are critical to the success of these programs. Pharmacy technicians must take on greater responsibility within the pharmacy practice, specifically the dispensing process. There are also significant and important supportive functions for the pharmacy technician related to immunization and MTM services. Technicians should work with pharmacists to determine how they can work together to improve patient care and advance the profession.

REFERENCES

1. The Expanding Role of Pharmacists in a Transformed Health Care System. National Governors Association. September 2015. NGA website. https://jcpp.net/wp-content/uploads/2015/09/NGA-TheExpandingRoleOfPharmacists.pdf. Accessed December 31, 2018.
2. Joint Commission of Pharmacy Practitioners Vision (JCPP). JCPP website. https://jcpp.net/resourcecat/jcpp-vision-for-pharmacists-practice/. Accessed January 1, 2019.
3. Myers CE. Opportunities and challenges related to pharmacy technicians in supporting optimal pharmacy practice models in health systems. Am J Health-Syst Pharm. 2011; 68:1128-1136.
4. American Pharmacists Association (APhA) policy manual: policies adopted by the 2014 APhA House of Delegates. APhA website. http://www.pharmacist.com/policy-manual. Accessed January 1, 2019.
5. Pharmacy Technician Certification Board (PTCB) 2015 Progress Report: setting the standard, advancing patient care. PTCB website. https://www.ptcb.org/docs/default-source/Annual-Progress-Report/2015-ptcb-progress-report-page-by-page-format997089F9BAD7.pdf?sfvrsn=8. Accessed January 1, 2019.
6. Bluml BM. Definition of medication therapy management: development of profession wide consensus. J Am Pharm Assoc. 2005;45:566-572.
7. Viswanathan M, Kahwati LC, Golin CE, et al. Medical therapy management interventions in outpatient settings: a systematic review and meta-analysis. JAMA Intern Med. 2015;175(1):76-87.
8. American Pharmacists Association (APhA). APhA Practice Perspectives Report: The Next Transition in Community-Based Pharmacy Practice. Washington, DC: American Pharmacists Association; September 2018. https://www.pharmacist.com/sites/default/files/files/APhA%20Practice%20Perspectives%20Report%20-%20The%20Next%20Transition%20in%20Community-based%20Pharmacy%20Practice%20-%20BOT%20Approved%20-%20September%202018_0.pdf. Accessed January 1, 2019.
9. American Pharmacists Association, National Association of Chain Drug Stores Foundation. Medication Therapy Management in Pharmacy Practice: Core Elements of an MTM Service Model— Version 2.0. Washington, DC: American Pharmacists Association, National Association of Chain Drug Stores Foundation; 2008. http://www.pharmacist.com/sites/default/files/files/core_elements_of_an_mtm_practice.pdf. Accessed January 1, 2019.
10. The Appointment-Based Model. American Pharmacists Association. Pharmacist.com website. https://www.pharmacist.com/ABM. Accessed January 1, 2019.
11. Immunization. World Health Organization website. http://www.who.int/topics/immunization/en/. Accessed January 1, 2019.
12. Vaccines and preventable diseases. Centers for Disease Control and Prevention website. November 22, 2016. https://www.cdc.gov/vaccines/vpd/index.html. Accessed January 1, 2019.
13. Williams WW, Lu P, O’Halloran A, et al. Surveillance of Vaccination Coverage among Adult Populations — United States, 2015. MMWR Surveill Summ 2017;66(No. SS-11):1–28. DOI: http://dx.doi.org/10.15585/mmwr.ss6611a1. Accessed January 1, 2019.
14. Pharmacist administered vaccines. American Pharmacists Association website. https://www.pharmacist.com/sites/default/files/files/IZ_Authority_012018.pdf. Accessed January 1, 2019.
15. Adams, AJ. Advancing technician practice: deliberations of a regulatory board. Res Social Adm Pharm. 2018;14:1-5. doi:10.1016/j.sapharm.2017.02.008.
16. Recommendations for practitioners and manufacturers to address system-based causes of vaccine errors. Institute for Safe Medication Practices website. https://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=74. Accessed January 1, 2019.
17.  Occupational Safety and Health Administration. OSHA Fact Sheet: Hepatitis B Vaccination Protection. Washington, DC: Occupational Safety and Health Administration website; 2011. https://www.osha.gov/OshDoc/data_BloodborneFacts/bbfact05.pdf. Accessed January 1, 2019.
18. Finding credible vaccine information. Centers for Disease Control and Prevention website. July 12, 2018. http://www.cdc.gov/vaccines/vac-gen/evalwebs.htm. Accessed January 1, 2019.
19.  Nichol KL, Mac Donald R, Hauge M. Factors associated with influenza and pneumococcal vaccination behavior among high-risk adults. J Gen Intern Med. 1996; 11(11):673-677.
20.  Grohskopf LA, Olsen SJ, Sokolow LZ et al. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP)—United States, 2014–15 influenza season. Morb Mortal Wkly Rep. 2014; 63(32):691-697.
21. Tomczyk S, Bennett NM, Stoecker C. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among adults aged ≥65 years: recommendations of the Advisory Committee on Immunization Practices (ACIP). Morb Mortal Wkly Rep. 2014; 63(37):822-825.
22. American Pharmacists Association. Billing Primer: A Pharmacist’s Guide to Outpatient Fee-for-Service Billing. Washington, DC: American Pharmacists Association; February 2018. 
23. Hogue, MD, Bluml B. The Pharmacist’s Guide to Compensation for MTM Services. Washington, DC: American Pharmacists Association; 2009.
24.  Hogue MD, McDonough RA, Bennett MA, et al; APhA Academy of Pharmacy Practice and Management Medication Therapy Management Task Force. Development of a medication therapy management superbill for ambulatory care/community pharmacy practice. J Am Pharm Assoc (2003). 2009; 49(2):232-236.

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