mph 612 capstone report

ASK THE PHARMACIST 1

Ask the Pharmacist- an Innovative Program Advancing Access, Awareness,

Wellness, and Prevention

Creighton University Master of Public Health Capstone Project MPH 612 August, 2016 Steven Banjoff

Ask the Pharmacist 1

Ask the Pharmacist- an Innovative Program Advancing Access, Awareness, Wellness, and

Prevention

Steven C. Banjoff

Creighton University Master of Public Health Capstone Project

MPH 612 07/25/2016

Author Note

This report would not be possible without the generous support and contributions of the

Ease@Work and The Centers for Families and Children staff whose vision and dedication

created an innovative and empowering Wellness Program. I was proud to play a role in planning

and advancing such an innovative strategy to improve health. Ease@Work is the profit earning

arm and represent 5% of the non-profit Centers for Families and Children income, or as they are

affectionately known, “The Centers”. My work on the Ask the Pharmacist booth, online, and

telephonic project was as an unpaid intern with no prior affiliation with either entity and as a

practicum requirement of Creighton University. My involvement with the project is designed to

give “real-world” experience as a health practitioner and no conflict of interest or financial

incentive exists.

Abstract


Employee Assistance Programs (EAP’s) are often overlooked opportunities to reduce

stress, increase awareness, and improve wellness. The Ask the Pharmacist booth and

online/telephonic wellness program developed with The Centers for Families and Children

pharmacist team and The Centers subsidiary, Ease@Work Wellness division as an innovative

approach to increasing access, awareness, and empowerment. Building upon a successful

Ease@Work health fair program, the use of a focus group of wellness division staff from various

clients indicated a desire for additional expertise at their health fairs. Adding opportunity for

participants to consult with a health expert like a Pharmacist to improve the health fair

experience was the result of several brainstorming sessions. It provides the platform to unite the

broad range of patient centered services that represent Medication Therapy Management (MTM)

practiced by the Center’s pharmacy and Ease@Work’s holistic philosophy of wellness into a

powerful new tool for addressing health strategies, awareness, screening, and outcomes.

The goal, to improve employee’s awareness of their health risks, ameliorate medication

error, promote prevention, and empower employees to take control of their own wellness

program. This is accomplished by providing expert guidance on a wide range of topics initiated

by the employee’s concerns, issues, or questions through collaboration with one of the more

accessible, yet overlooked members of a healthcare team, the Pharmacist. Allowing the

employee to direct the conversation not only allows for individual and relevant advice, it also

allows for the better understanding of issues, wants, and needs facing the employees served by

the EAP.

Increasing assessment abilities of existing programs as well as provide motivations for

new programs are an additional benefit. Detailed and sanitized information gathered from past

and ongoing Ask the Pharmacist booth events provide the justification program expansion, as


well as areas in which it can help to improve the wellness of the workforce. While, it may be too

early to tell what impact this program may have on wellness, initial data indicate possibilities for

lower healthcare costs, raising access to preventative measures, and empowering individuals

with control of their wellness needs and approaches.

Who are the Centers and Ease@Work?

The Centers for Families and Children (the Centers) is the fourteenth largest nonprofit in

Northeast Ohio, while also being one of the oldest and largest non-profit human services

organizations in the area (the Centers, 2016). It is the result of three well-respected human

service agencies; Center for Families and Children, West Side Ecumenical Ministry and El

Barrio joining forces in 2011 to provide a greater community impact. Their mission is the belief

“lasting, positive change begins with access to opportunity” (Berger & Smith, 2016, p. 3).

Currently, The Centers serve more than 25,000 people a year, connecting them with the right

opportunities, relationships, and resources to build better futures by making a difference in

someone’s life today (the Centers, 2016). The core offerings include Early Learning, Health and

Wellness, Workforce Development, Family Services, and an Employee Assistance Program

(EAP) Ease@Work. The Board of Directors is comprised of 48 community leaders from private,

public and nonprofit organizations, with an Associate Board containing emerging leaders

committed to building a brighter future with various community partners and volunteers (Berger

& Smith, 2016).

Overall, the Centers has a budget of approximately $54 million and employs 550

employees of which 50% work in Health and Wellness, 32% work in Early Learning, 13%

Administrative Support, 1% in family services, and 3% are with Ease@Work (Berger & Smith,

2016). The vast majority of the Centers revenue is generated from governmental reimbursement


for services (61%), government grants (16%) Lead Agency Funding for Head Start (9%), and

Charitable Contributions (7%), while Ease@Work, the only direct income generator at the

Centers, currently contributes 5% to the agency revenue. Ease@Work embodies the Centers’

mission of making a difference by providing opportunities, and is one of the first Employee

Assistance Programs in Northeast Ohio, first serving clients in 1979, and has continually evolved

to fit ever-changing needs of their clients. Ease@Work takes pride in providing solution based

behavioral health services that benefit both the employee and employer and their comprehensive

menu of services is impressive (Ease, 2012).

Ease@Work has grown from its humble beginnings as a substance abuse and workplace

compliance resource to assisting in a broad range of issues from anxiety, depression, smoking

cessation, and nutritional/ fitness coaching to workplace stress, parenting concerns, legal

difficulties, financial issues, and eldercare issues. The diverse blend of offerings available to

employees and their dependents completely shattered my illusion Employee Assistance

Programs were the equivalent of being sent to “the principal’s office”, and were, in reality, an

underutilized, overlooked resource that represents a cost-effective investment into wellbeing.

Wellness Manager (and boss/mentor through the duration of the internship), Stephanie Patek,

assured me my preconceived notion regarding EAPs was not unique and was a regular

misconception they were confronted with. Remarkably, even employees of the Centers were

unclear of the diverse array of assistance to a healthier, more balanced life available to them and

their dependents.

The recommendation to contact Stephanie and investigate a possible internship within the

Wellness division of Ease@Work came from a good friend and fellow Master of Public Health

student who previously interned for her. Initially hesitant due to my ill-conceived assumptions


concerning EPAs, Stephanie’s infectious “can-do” attitude, energy, and dedication to promoting

wellness through diverse cultural/belief sensitive approaches quickly put my concerns to rest.

Having the opportunity to take part in developing and launching a new participant-centered

wellness program as a respected and valued team member was a prospect that I couldn’t refuse.

The Ask the Pharmacist Program- Origins, Intent, and Justification

The Ask the Pharmacist project was initiated as a response from various Wellness

Managers using Ease@Work as their company’s Employment Assistance Program (EAP) desire

to improve the impact of Health Fairs. These events normally included informational booths

such as services the EAP offered, nutritional, physical activity information, and at times could

also include healthy cooking demonstrations, stress management techniques, and massage.

These managers were seeking strategies that would raise awareness, encourage prevention, and

add additional expertise to the health fair events they were hosting for their employees. Through

several brainstorming sessions between Ease’s Wellness Manager Stephanie Patek, the Center’s

Resident Pharmacists Ryan Bender, Lauren Miller, as well as other members of the Ease@Work

and pharmacy staff, Ask the Pharmacist was born. The program reflected the Medication

Therapy Management (MTM) training of the Center’s pharmacists with the Ease@Work mission

of improving health by increasing capability and access. MTM is much more than managing

medications, its philosophy aims to bring a group of services that optimize therapeutic outcomes

for individual patients (American Pharmacists Association, 2016). The MTM philosophy was

then captured in the mold of other Ease@Work Ask programs that utilize trained experts offering

a personalized approach to wellness that takes the time to understand the culture of the

organization, as well as the individual, to provide a sustainable wellness plan that strengthens

both.


The Ask the Pharmacist program attempts to fulfill the added proficiency and greater

awareness needs revealed by focus groups conducted amongst current clients. It brings access to

the expertise of respected and trusted healthcare professionals (Simone, 2013) through physical

and remote formats. The first format is in person, at the health fair event, which includes an

available consultation with two pharmacists to provide information on specific and general

topics. These topics could be detailed and as a result of health conditions and number of

medications individuals are on, or merely general inquiry or safe cost saving strategies through

the use of over-the-counter or generic medications. It provides an avenue for detailed

discussions of medications being taken, drug interaction, proper storage, and optimal conditions

for when and how to take the medications. This is extremely important when one considers

approximately 80% of all medical treatments involve medication and medication error represents

a possible $100 to as high as $289-billion-dollar expense to the U.S. healthcare system and

optimal medication adherence is essential to chronic disease management (CDC, 2014).

The in-person option also includes flu-shot immunizations and Biometric Screening

stations that provide; BMI or body fat measurement, blood pressure measurement, blood glucose

level, fasting and non-fasting total cholesterol, high density lipoprotein, and triglycerides screens

(both finger stick blood tests). Screenings increase access to health risk assessments that can

play a significant role in various stages of prevention (American College of Occupational and

Environmental Medicine, 2013), while immunizations assist in ameliorating the spread of

contagious disease, hospitalization, and death (Centers for Disease Control and Prevention,

2016). The presence of the pharmacists, (usually placed in an out of the way area as possible),

allows the employee semi-private access to have answers to any questions the screening may

have brought about. Engaging the employees in this fashion provides the potential to catch


health threatening conditions such as high blood pressure, risk for diabetes, heart disease, or

other chronic ailment at a much earlier stage. The pharmacists also serve as a reminder that the

screening does not represent a diagnosis but only an assessment of risk factors. Though on a few

occasions individuals were advised to go to the emergency room or to contact their primary care

physician as soon as possible as a result of the screenings or consultation with the pharmacist.

Providing influencers and motivators in the form of pharmacists who adhere to a MTM

philosophical approach furnishes individuals the access to tools and relevant information to assist

in the battle to change behavioral conditioning. Offering an opportunity to broaden the sense of

wellness beyond the physical and into the psychological, emotional, and social wellbeing needed

to understand the underlying causes that impact physical health. On more than one occasion

during my time observing these events the sense of relief felt by individuals was quite apparent.

They left the booth with a greater sense of awareness and empowerment, while feeling

appreciative a professional caregiver took the time to explain things in a manner in which they

could understand and accomplish.

Whether it was confirming that side-effects were a result of medication, elimination of

dangerous drug interaction possibilities, alternative treatment methods, confirmation they were

on a proven treatment method, simply having a better understanding of the purpose of the

medication they were on, or a simple inquiry on the effectiveness and safety of supplements,

they were able to take away information and strategies on something that was important to them.

The Ask the Pharmacist Program introduces individuals to the concept pharmacists can play a

role beyond that of a prescription filler. The pharmacist can provide access to preventative

services, optimize disease state management, provide greater access to care for those individuals

coping with chronic disease, and improve medication adherence (CDC, 2014). Additionally,


there is a growing recognition that supplements are loosely regulated (Richter, 2015) despite the

fact dietary supplements have grown into a $30 billion plus industry in which over half the adult

population uses, at times with fatal results (Docherty, 2016). Poor regulation has left little

control on the supplemental industry’s capacity to market their product without proof of

effectiveness or safety (Skerret, 2012). The ability to consult with an expert in medicinal

chemical compounds, their uses and effects could be an invaluable resource when one is

determining the safety, efficacy, legitimacy, possible dangerous side-effects and drug

interactions one could encounter, or simply not wasting valuable resources for a product that

lacks effectiveness.

The importance of privacy with health information can never be overlooked (Nass, Levit,

& Gostin, 2009) not only is it an ethical imperative but encompasses personal autonomy,

individuality, respect, and dignity that encompass ethical treatment. While data from screenings

and information gathered through the discussions with the pharmacists are treated carefully,

securely, and with the utmost consideration for HIPAA, providing a more private access to the

pharmacist was still a need that needed to be addressed. It was thought that those who may feel

hesitant about approaching the booth due to privacy, self-consciousness, feelings of intimidation

or other factor could be tackled by adding an internet and telephonic component to Ask the

Pharmacist. This would allow the individual the freedom and to have their questions or concerns

addressed at their convenience and with an additional layer of privacy not available at the health

fair event. The question is first initiated over a secure server with a twenty-four-hour response

time window.

Upon receipt, the question is evaluated for type of response warranted within the 24hr

window. Basic requests will be answered via email communication, and there will be no limit to


these types of consultations. A request is considered advanced if the individual is on three or

more medications, are experiencing at least one active disease state, or is on an active return to

work plan. Advanced requests will trigger an up to forty-five-minute telephonic consultation

that includes a comprehensive medication review. Advanced requests will also include a twenty-

minute follow-up consultation for adherence monitoring with an allowance of three sessions per

issue per year. Data entry and reporting will be completed within days of the initial request to

allow for aggregate reporting for employer, and internally to capture a picture of needs, wants,

and issues facing employees. The program has the necessary appeals process, participatory, and

contingent design that complies with ACA health promotion guidelines for qualifying financial

incentives (Pollitz & Rae, 2016).

ACA incentives are not the only potential cost savings the program provides. While

there is scant information on EAP’s offering a comprehensive MTM philosophy based program,

there have been clinical studies. A study from Minnesota using data from a six clinical settings

revealed MTM lowered healthcare costs from $11,965 to $8,197 per person, 637 drug

intervention problems were resolved among the 285 intervention patients, and biometric

screening numbers were improved in the intervention group as well (Issets, et al., 2008). A

Walgreen’s study also showed that patients do a better job with medical adherence and overall

healthcare costs decrease when a pharmacist is used as an intervention technique (Lowery,

2015).

Methods

As previously stated, the need for this program first originated through focus groups, and

has continued to rely upon them throughout its development. Development occurred with the

use of Social Cognitive Theory to behavioral change as a guiding principle. This principle


operates on three main factors that affect the likelihood of changing behavior self-efficacy, goals,

and outcome expectancy (U. S. Department of Health and Human Services, National Cancer

Institute, 2005). The program is rooted in the patient centered care coordination approach. Care

coordination is the key strategy to potentially improve effectiveness, safety, and efficiency that if

delivered to the right people can improve outcomes for individuals, providers, and payers (U.S.

Dept. of Health and Human Services, 2016). The use of a multi-level ecological approach helps

to identify intervention points and levels of influence for health related conditions and behaviors

(USDHHS, 2005). This patient-centered philosophy had already created successful Ask the

Expert programs that served as a template.

The ability to build upon already successful initiatives led the direction of this project,

and proved to be an invaluable starting point for how the program was envisioned. It was also

critical that the program met and exceeded ACA guidelines for workplace Wellness Programs

and continue the tradition of offering a comprehensive wellness program, a distinction only 13%

of programs can claim (Pollitz & Rae, 2016). The collaborate effort between all relevant

stakeholders closely mirrors the principles of the Community Based Participatory Research

(CBPR). It strives to recognize the community it serves as a unit of identity, that is built on

strengths and resources within that community (Minkler & Wallerstein, 2008). It is designed to

promote co-learning and capacity building and integrates and achieves a balance research and

action for the mutual benefit of all partners and is developed through a cyclical and iterative

process (Minkler & Wallerstein, 2008).

While information is shared among all stakeholders, it does not reach the level required

for a true CBPR, though the program is assessed and designed with issues and input that are a

primary concern of our clients. This is quite likely due to the nature of this service being offered


as a paid for service meant to not only improve health outcomes and lower costs for employers

who participate, but also as a means to generate a profit for Ease@Work (and ultimately the

Centers). While all legal disclaimers and privacy rights are rigidly adhered to there is a missing

acknowledgement and information sharing (it is prohibited for Ease to contact individuals of the

employers directly) that could have the potential to make this project even more effective.

Despite this fact, this project would not be possible without the collaborative effort of multiple

stakeholders with a focus of mutual respect and dignity that embodies a CBPR program.

Data gathered from Ask the Pharmacist events is analyzed through an observational,

cross sectional spreadsheet of qualitative and quantitative variables. This spreadsheet was a

compilation of information initially gathered to generate individual aggregate reports for the

client that procured the service. This report has been generated since the beginning of the phase

one in person portion of the program, and each occurring event is entered into the spreadsheet in

a timely manner. Because this spreadsheet was designed to capture as much data as possible,

different pivot tables can be used to examine relationships between different data points. Before

the compilation of this spreadsheet took place, the data for the project was spread over several

different individualized reports that made it difficult to understand what exactly was taking place

within the project.

The information on the spreadsheet includes type of issue being experienced by the

individual, number of medications they took, expected results, and recommendations made by

the pharmacist. While this method is not the best for making inferences, it is an excellent

method for descriptive purposes, and developing problem statements (Gordis, 2014). Research

through internet Pub-Med and other databases revealed this program was unique and the only

research available involved outpatient/inpatient MTM programs, with little indication that other


EAPs were attempting to integrate these principles within the wellness programs they offered.

Creating a descriptive tool was my attempt to help clarify the issues being presented and the

solutions that were being offered, and may have been the largest contribution I made to the

project. It is hoped this spreadsheet will serve as a tool to improve the focus of the program,

inform other programs, and inspire more rigid studies such as a Case Control or Cohort that

could provide a greater insight into the benefits, relationships, and efficacy a program like Ask

the Pharmacist offers.

Work Plan, Application, and Final Product

The unique position Ease@Work has within the Centers is perhaps the most crucial

element of the project. The collaborative effort between Ease and the pharmacy most likely

would not have been possible without this unifying connection. The project also benefitted from

the existing infrastructure, programs, and expertise present within the organization. While

funding and time are always an issue with any program, the Ask the Pharmacist program is in a

position where it has stable resources and personnel to ensure continuity of the program. The

needed legal, technical, marketing, and administrative hierarchy were already in place, from its

inception, drastically improving development time and start up expenses. While staffing is far

from optimal, the use of interns and volunteers along with a pharmacy residency program help to

overcome this personnel shortfall. Ease@Work’s long history of being a trusted partner in a

wellness program with dedication to bringing innovative solutions have provided solid footing

for this program, as well as serving as a benchmark to expected standards.

As of now, the only active portion of the project is in the form of the in person Ask the

Pharmacy booth, biometric screening, and flu shot (seasonal) option. This service has been

operational for nearly a year and has been building data for further analysis during this time.


Pricing for this option, mirrors those of other Ask the Expert programs, and thus far has been

well received by the clients that have taken advantage of the service. Several focus groups and

the Q&A session following a presentation to the North East Ohio Healthy Business Council have

left positive feedback on the potential of this program to benefit all stakeholders that employ its

use. At this time final adjustments of the online and telephonic version of the program. Pricing

and need of the internet/telephone option remains a sticking point between entities within

Ease@Work. The solution may be to create tiers such as “gold” “silver” and “bronze” packages

to enable clients to choose the most suitable program for their company’s budget. At this time

the overall internet/telephone protocol is set and only small details remain to be ironed out. This

is being accomplished with additional field research, and finalizing pricing for each package, and

launch date of this portion of the program is set for early Fall.

Resulting information from this project can be used in a variety of ways. The

information can assist employers in understanding the issues that are facing their most valuable

resource, their employees. The information also assists Ease@Work by directing their focus on

issues that are most pressing to their clients which enables them to develop programs and

strategies to meet these issues in a holistic manner. The research has already revealed that 76%

of the clients who used this service were on at least one medication, and 27% were on three or

more medications. The amelioration of medication error, improve medication adherence, and

assist in optimizing medication use are just a few examples this program has already begun to

accomplish its goal of improving health. The program represents access to preventative

strategies and screenings that may not normally take place if not for the convenience in accessing

these services Ask the Pharmacist provides. The dissemination of results in the form of client

reports as well as the observational compilation of this data will be pivotal for the development,


growth, and effectiveness of this program. The descriptive picture this data provides can serve

as inspiration for new programs and studies that have the potential to better understand the

efficacy, approach, and role EAPs play in improving health and controlling health care costs.

Conclusion

Bringing one of the more accessible and visible but overlooked members of a healthcare

team out of the stereotype of merely the person who fills medication needs and directly involves

them with a wellness strategy has the potential to positively influence health on a number of

levels. Having an additional expert to help raise awareness, model, encourage, and partner in

strategy has the capability to benefit the individual, the company, and the health provider. It is

no secret health costs and negative outcomes are still a concern even after the passage of the

ACA. Preventative measures are a key strategy in reigning in control of these costs, both

monetarily and impact on quality of life. Instilling commitment to health, and behavioral change

requires access to influencers, motivators, and trusted information. This program attempts to

broaden the focus of a wellness strategy through a patient centered program that views wellness

as a result of the interaction between the physical, emotional, and social environment.

The difficulty of this program is the inability for Ease@Work to directly market the

program to the employees. The promotion for the program (excluding the promotion to sell the

program to the Wellness Manager) is the responsibility to whomever is administering the

company’s Wellness Program. This hard truth was ironically bore out by a situation I

experienced with an associate. My associate was having difficulty at work with other personnel

to the point she was mentally distressed. I asked if she knew if her company had an EAP, and

informed her if they did there was a good chance she would have access to the brief counseling

she desired. It turned out that indeed they used to have an EAP, and ironically it was


Ease@Work, but the company had just discontinued their service due to lack of use. The

problem was, neither my associate, or others at her place of employment were not aware they

had access to comprehensive resources that provided assistance to an extensive variety of needs.

Proving, you can have the most effective program based on the best current evidence available

and if people are not aware of its existence it helps no one.

It is my hope the program continues to grow, and the descriptive information being

gained continues to be recorded and serve as a launching pad for further more rigidly controlled

studies, as well as raise awareness of the greatest concerns facing the employees that it serves. I

would like to see an improvement to the method that the information is initially gathered. The

largest concern being additional informed consent is not given at the information booth where

the data is gathered. While, disclosure is made within the paperwork of the event, and all legal

requirements and protection of the data is met, an additional disclosure is needed in my opinion.

The booth participant is not told verbally the information he/she are giving is being used as a

research tool. While I was successful including additional disclosure for the internet/telephonic

portion of the program explaining how this information may be used, it was determined no

additional disclosure beyond those included on procurement of the service is given was needed

for the live events. The information is also recorded after the participant leaves, which lends an

“air of secrecy” and provides the possibility for recording errors to occur. While for-profit

endeavors are more hesitant of sharing information and being completely transparent, changing

this method of information gathering may have the potential for strengthening the reliability of

the data gathered.


References

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Centers for Disease Control and Prevention. (2016, May 25). Key Facts About Seasonal Flu Vaccine. Retrieved from CDC web site, date accessed 7/30/16: http://www.cdc.gov/flu/protect/keyfacts.htm

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Lowery, M. (2015, November 3). Walgreens study: Pharmacist interventions improve med adherence, lower healthcare costs . Drug Topics Voice of the Pharmacist, pp. 1-2.

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Pollitz, K., & Rae, M. (2016, May 19). Workplace Wellness Programs Characteristics and Requirements. Retrieved from Henry J Kaiser Family Foundation: http://kff.org/private-insurance/issue-brief/workplace-wellness-programs-characteristics-and-requirements/

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Skerret, P. (2012, February 2). FDA needs stronger rules to ensure the safety of dietary supplements. Retrieved from Harvard Health Publications, Harard Medical School: http://www.health.harvard.edu/blog/fda-needs-stronger-rules-to-ensure-the-safety-of-dietary-supplements-201202024182

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8/1/2016: http://www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/index.html

Appendix A

The size of the file makes it impossible to include the spreadsheet within this report,

please double click on the icon to review the spreadsheet created for Ask the Pharmacist.

mph 612 capstone report

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