Business Opportunities for Community Pharmacy In Rural Health

Rural Hospitals
A December 2005 report by the Upper Midwest Rural Health Research indicated that 46% of rural hospitals surveyed reported having a pharmacist on site less  than 40 hours per week, and 17% shared a pharmacist with another hospital.[1]  The vast majority (88%) of hospitals rely on a staff pharmacist on call as their primary means of afterhours pharmacist consultation. Community pharmacies have the potential to not only provide assistance with traditional pharmacy procurement and safety, additional clinical services focused on formulary management and medication therapy management could greatly assist rural hospitals in managing costs and improving quality of care.

Patient-Centered Primary Care Medical Homes
The Patient-Centered Primary Medical Home model for health service delivery is predicated on the assumption that and integrated and collaborative system of care will reduce costs and improve quality of care.  Further, the medical home concept promotes evidence-based practices, enhanced coordination of care, greater safety, and more complete and effective use of the specialized knowledge and skills of those professionals working as part of the medical home patient care team.  The imperative for optimal medication use outcomes, quality and safety clearly supports the need for pharmacist integration. A white paper jointly prepared by the national pharmacy organizations offers supportive evidence.[2]  The Patient Centered Primary Care Collaborative website[3] maintains a listing of all demonstration by State along with participating providers, purchasers and other partners that community pharmacists can utilize to identify potential contacts to explore opportunities for collaboration.

Accountable Care Organizations
The accountable care organization (ACO) has become an increasingly advocated model for health care reform that typically centers on multi-specialty group practices that are bunched around local hospitals as an “extended hospital medical staff”.  In general there are  three essential characteristics of ACOs:
   -  The ability to provide, and manage with patients, the continuum of care across different institutional  
       settings, including ambulatory and inpatient hospital care and possibly post acute care;
   -  The capability of prospectively planning budgets and resource needs; and
   -  Sufficient size to support comprehensive, valid, and reliable performance measurement.

In exchange for investing in this reformed health care provider structure, the ACO members will  share in the savings that results from their cooperation and coordination. Much like medical homes, pharmacists can play a key role in guaranteeing an ACO’s success by ensuring appropriate medication use, reducing adverse drug events, preventing hospitalizations and helping patients manage chronic conditions.  Community pharmacists in rural areas must pro-actively reach out to hospitals and providers and demonstrate why and how their services can support the goals of existing or planned ACO’s.  In November 2010, the National Association of Chain Drugs Stores submitted comments to the NCQA supporting the need for pharmacist inclusion in ACO criteria.[4]

340B Drug Pricing Program
Two major developments in the 340B drug pricing program offers expanded opportunity for community pharmacies to partner with a covered-entity to provide pharmacy services under a contract pharmacy arrangement.  In April 2010 new guidelines allow a covered-entity to utilize multiple contract pharmacies.  In addition, the Affordable Care Act signed into law by President Obama expanded 340B program participation to critical access hospitals, sole community hospitals and rural referral centers that are typically located in rural areas.  Again, community pharmacists must first locate a covered-entity, fully understand the requirements and be prepared to make the necessary business operation changes to expand their existing practices.

HRSA Patient Safety and Clinical Pharmacy Services Collaborative
In 2009 HRSA announced a significant strategy to improve patient safety and the quality of care of care delivered by HRSA grantees and 340B participating entities.  The Collaborative central premise is based on the recognition that clinical pharmacy services represent a significant strategy to achieve high quality care.  Consequently, the Patient Safety and Clinical Pharmacy Services Collaborative (PSPC) has been enrolling hundreds of teams comprised of community based providers and partners (including community pharmacies) to implement and track the impact of clinical pharmacy services.  The PSPC offers an opportunity for community pharmacies to strengthen relationships and develop partnerships to work collaboratively towards improving medication use.  The PSPC web site[5] offers extensive information about the collaborative.  Community pharmacies are well positioned to proactively seek out HRSA grantees to explore potential opportunity to become part of and contribute to existing or future teams.