Pharmacy Times
Hello, I'm Luke Halpern from Pharmacy Times, and you're listening to Pharmacy Focus. The Pharmacy Times Pharmacy Focus podcast provides the latest industry news and information, thought leader insights, clinical updates, patient counseling tools, and innovative solutions for the everyday practice and business of pharmacy. Community pharmacies are among the most accessible points of care in the country, which makes them a promising place to help people quit smoking. A new qualitative study out of UC Davis Health looked at seven independent California pharmacies that trained pharmacy technicians and clerks as community health workers, expanding their role into tobacco treatment and beyond. The researchers explored what made it work and what got in the way. Joining me are two of the people behind that work: Cindy Valencia, director of CA Quits at UC Davis Health, and Robin Corelli, professor of clinical pharmacy at the University of California, San Francisco. So, Robin, Cindy, thank you both so much for being here today. Before we get into the questions, would you mind each just briefly introducing yourself? We can start with Robin.

Robin Corelli
Yes. Good morning. My name is Robin Corelli. I'm a faculty member in the UCSF School of Pharmacy. Worked on a wonderful research project with Cynthia Valencia and Dr. Eliza Tong on this initiative for really engaging pharmacy technicians and pharmacy teams in tobacco cessation and California community pharmacies.

Cindy Valencia
Hi, good morning, everyone. My name is Cindy Valencia. I'm a public health researcher at UC Davis and first author on this paper.

Pharmacy Times
Excellent. Thank you both for being here today. So this study looked at seven independent pharmacies throughout California that trained technicians and quirks as community health workers, Cindy, you've been at the center of that work through CA Quifs. What problem were you trying to solve by training pharmacy technicians as community health workers?

Cindy Valencia
The overall goal is to increase access to tobacco treatment. I think when most people think about tobacco treatment, they think about the doctor's office. But many medical members also interact with local community pharmacies, and perhaps you know even more frequently than they interact with other parts of the healthcare system. So we really saw an opportunity to build on that with pharmacy technicians who already have trusted relationships with their patient and are often helping them navigate different health needs. So in our study, as you mentioned, seven pharmacies that had previously trained pharmacy technicians and clerks as CHWs expanded this model to include tobacco treatment. Our qualitative study explores the barriers and facilitators for integrating CHW services, and by training technicians as community health workers, they gained additional tools and structure to help identify barriers and connect people who want to quit tobacco with tobacco treatment and resources. So really, we were building on trusted relationships that already existed in their communities. It

Pharmacy Times
sounds like a really intuitive way to really involve the community pharmacist and improve outcome for patients who are struggling with this. So, Robin, one thing that the research emphasizes is how accessible pharmacies are. Most people live within a few miles of one, and you could walk in without an appointment. And you've studied the pharmacist role in cessation for years. Why are community pharmacies and their technicians so well positioned to reach people who want to quit?

Robin Corelli
Well, that I mean, we've been saying this for years. That because you just quoted the the data that most Americans and most Americans live within five miles of a community pharmacy, so this is absolutely the most accessible place to get healthcare. There, you don't need as you said you don't need an appointment. The hours that most pharma many pharmacies are 24-hour operations, not all open in evenings and weekends. So again, you have a situation where the pharmacy is one of the most accessible healthcare service areas, and we've got highly trained individuals. The entry-level degree in the United States is a Doctor of Pharmacy. These are people that are highly trained, and that alongside the pharmacists are the technicians. Which, honestly, in my opinion, in community pharmacy, the technicians we call them a secret sauce. These are the individuals who are the front line. They're the ones filling the. You know, when patients come in, the first, really, the point of first contact, they often, more often, reflect the community they serve. They speak the language. They have the lived experience. So these individuals have incredible relationships with the patients served in community pharmacies. So this is just honestly a no-brainer to add to their skill set, their knowledge of medications, their knowledge of insurance, their knowledge of the communities. But now you're adding in some of the non-drug elements. How do you help people navigate food insecurity? How do you navigate transportation issues? Things that are also so pivotal to health, and will make our interventions related to health so much stronger. So yeah, this is-I mean, this is the technicians having this skill set is going to be a game changer, in my opinion, in community pharmacy.

Pharmacy Times
Absolutely, and you talked about so many of the little aspects that are so often underrecognized in pharmacist-led care, like knowing the language, like being able to arrange travel plans for patients to get to a pharmacy. There's so many underappreciated facets that community pharmacists are uniquely capable of of helping patients with. So I couldn't have said it better myself. There, and

Robin Corelli
and can I just add that I would say that there are many times where a technician from the community is far more effective in promoting behavior change than a trained pharmacist in many cases, because they're a trusted person that actually knows this person knows what we're going through. So again, I don't want to minimize the pharmacist's role, of course, but I think in tandem, this makes for a great team.

Pharmacy Times
Yeah, of course, and just as you know, pharmacies are a very busy place. It's it's really incredible to be able to utilize pharmacy technicians in this manner because they can really help fill in a lot of the gaps that pharmacists might have to. You know, they might get pulled away to help with the patient, help with specific prescriptions, things like that. So it's a really great idea here, and and this was for either of you something that was really notable in the findings. A lot of staff said that this wasn't really new work. One pharmacist put it as they'd been doing this for years and just never had a title or a way to bill for it. So you could start with either of you, and both of you can jump in on this. Could you unpack that idea that the community health worker model mostly formalizes what pharmacy teams were already doing? Yeah,

Robin Corelli
I I think many of this, a lot of these services that community health workers, some of our technicians are. I mean, they are so knowledgeable. They're they're knowledgeable about the needs of the community, and they've been navigating without this type of work. But now this formalizes, and I think this really expands and operationalizes. These are areas now. You have training. You actually have resources that you can be plugged into, and you're operating from from a from a perspective of actually know that you this is a covered benefit. We can make arrangements for this. Were you aware of this? So some I think that's what it this this will do is to increase the the the mass availability of these services versus isolated and sporadic where someone might have been aware of something. This is where you can. Did you were you aware you can get transportation? Were you aware that we can help with food? Actually, getting access to good quality food. Now it'll be it's they have a whole menu of opportunities, a whole menu of services that can be provided to patients, and part of an interaction in a healthcare setting.

Pharmacy Times
Yeah, absolutely.

Cindy Valencia
I'm not a pharmacist, and I thought that was surprising. I was I was surprised to hear it described in such a natural. This is a natural fit, as as Robin to quote Robin, a no brainer, which was incredibly exciting because they were already helping patients navigate benefits, medication issues, finding connections with community resources, so it's really interesting to to see that it aligns almost perfectly, almost fits like a glove, and that CHW training just gave additional structure right to that work. That it provides additional skills in the framework for something that was already doing, and especially excited about Medi-Cal CHW benefit, which is incredibly important to sustain this this work.

Pharmacy Times
Yeah, and that's a great transition to my next question for you, Cindy. Because a big piece of what makes this sustainable is that Medi-Cal now reimburses for community health worker services with a pharmacist able to supervise, and and that funding pathway is fairly new, so why does that reimbursement piece matter so much for keeping these programs alive?

Cindy Valencia
Sustainability. So I come from a public health background prior to to getting my PhD, and have seen so many amazing programs come and go because they're grant funded. And so, I think the Medi-Cal benefit really, you know, integrates that sustainability for many Medi-Cal members. The barriers to quitting aren't just clinical, as Robin mentioned earlier. So, someone may be dealing with transportation issues, food insecurity, financial stress, housing instability, and just having a really difficult time navigating the healthcare system, so bridge that with the community pharmacist pharmacy setting who already has these trusted relationships who can now bill and sustain these benefits within the community setting. It's it's incredible. So what we have to understand is that you know for pharmacies to do this work, it takes staff time. It takes staff time to train. It takes staff time to build the workflow, to build that confidence, and so billing is an incredible, incredibly important part for sustainability and for us to continue this work long term. MediCal, you know, essentially could create the pathway to to sustain the service,

Pharmacy Times
and sustainability is just such a huge part of it because you could run a pilot once and have it be a success, but if you don't have the foundation, as it works, foundation to keep that up, it it would be meaningless in the long term. So this would definitely sustainability is a huge part of it. But it wasn't all smooth though across nearly every pharmacy billing and credentialing, like we talked about, came up as the hardest part, and some described three to six month delays just to get set up. So this could be for either of you. What did those barriers actually look like on the ground? And Robin, I'm curious about the pharmacist supervision side of things.

Robin Corelli
Yeah, one of the things I wanted to mention too about the sustainability piece, and Cynthia talked about this. Lots of pilots with some seed funding and everything looks great until. But you have to create models that individuals in the pharmacies, the pharmacy teams, can see this as something that that can live beyond a grant. And I would say that these projects are doing that. Where it's being successful is these are one of the key things about this. These are independently owned pharmacies, community pharmacies, where the pharmacist makes the decision. So we can create models of sustainability in this group, and we're starting to see that where where you can see that I can implement a service, and that's the beauty of working with independent pharmacies. They can decide we're going to do this tomorrow or in two weeks.

Pharmacy Times
Yeah,

Robin Corelli
there's not a lot of corporate layers or other things that are going on. So some of this is what we're seeing right now is unique to the independent pharmacy setting, but so much innovation-that's where the innovation occurs-is in these settings, and we're hoping that this will translate into sustainable models in our larger, which is largely the face of pharmacy, and at least in California, is mostly chain pharmacies. But one thing to keep in mind with the reimbursement piece of this and why this is so critical is that pharmacies are losing money on some prescriptions? You know, the the reimbursement for prescriptions is often below the cost that for the pharmacist to obtain the medication. So these types of services tacking on billing for the actual cognitive providing care, whether it be with a pharmacy technician who's trained as a community health worker or a pharmacist, so these are really really important models for sustainability. But the credentialing, what was the problem with the billing and credentialing, and that continues to be a major problem in pharmacy, partially because pharmacists aren't used to medical billing; they're used to submitting a claim, boom, and having it, you know, adjudicated right away, and the payments received. You know, with medical billing, it goes into the box. You submit a claim, and then you wait. Of course, medical, you know, physicians, dentists, other healthcare providers are very used to submitting, you know, a bill, and we get paid later on. But for pharmacists, it's a new process, and they need to follow up. But what makes it very difficult for pharmacy is that if you submit a claim, often the payers are saying, "Oh, well, that's that's a pharmacy claim. You have the wrong department. So the billing for the act for the other services, these community health worker services or pharmacy services, is often it's you the teams and this is something we found in this study and it's nothing new that pharmacy teams are spending an inordinate amount of time triaging with the the payers to get paid for the non-medicine related care, which and a pharmacist can dispense medication much quicker than it would be to actually screen patients, or as the technicians are doing, providing extensive service. So that really does need to be compensated, as any other healthcare provider would. So again, that. That's that's one piece. Let me keep going because the other part of this is pharmacy software is really not set up for this. It's set up for processing claims, pharmacists and dispensing medications. So we need solid software that is actually doing a lot of this. That you have good documentation, but also tracking what happened to that claim from three months ago that we still haven't heard about. So those are systems that are going to be barriers in terms of the billing, and then the credentialing is a whole other piece of information that pharmacists are not used to being credentialed. That they have to go through a health plan and show that they have the skills to be able to do this, and each health plan has a different credentialing procedure.

Cindy Valencia
You touched on many aspects, especially the credentialing piece, which is incredibly important to get to get started. Three to six months, a year, more than a year-that's not acceptable. And you alluded to, you know, each health plan having a different process, and so even that there's a challenge in that. But I will say that I'm grateful to have heard of some health plans that had a built-in champion that had someone that they could call and help them navigate all of the nuances and you know establishing this new CHW service. So I'll end on a positive note that that it is possible, and really want to encourage health plans to help smooth the administrative pathway so that community pharmacies can partner, can be a better partner in helping improve health and community health throughout California.

Robin Corelli
Yeah, let me. Can I piggyback on that too? Because yeah, I was pretty much Debbie Downer during that, but I do want to say that the champion in the health plan is critical, and I and I don't know if I can call out a specific individual, but I'd like to, Dr. Stanley Young from Partnership Health Plan, which is one of the large, you know, his service area partnership health plan services most of rural North North California Northern California, and his I mean he comes from community pharmacy. His roots are there, so he knows the value of the technician, knows the value of the pharmacist in community settings, and he has really helped pharmacists navigate this. So really, he has sort of a best practices that we could be replicating across the state to do this because it can be done, and it's just that support was actually pivotal to the success of this initiative.

Pharmacy Times
Yeah, and there will always, you know, be obstacles to when you're initiating new things, especially in a pharmacy setting. But there was obviously, I'm glad Cindy added added that positive note to transition us because there were countless positives that came out of it. And despite those hurdles, the pharmacies did get up and running, and the study found that most of them started small with a single service like blood pressure checks or tobacco cessation before expanding. So we can start with Cindy on this question, and then move to Robin if she has anything to add. How did pharmacies actually get started, and why did that one service at a time approach seem to work.

Cindy Valencia
I think the goal. What I heard in in the interviews is that they were trying to start with one service and iron out the workflow, make sure it works, and it was really important in in order to build that staff confidence and to just make it easy. and And I think you know, starting smaller, growing from there is is important because if you take on too much, and then maybe you know it doesn't work, or it's not as easy to implement. So I think it just made it more manageable, given you know the busy pharmacy team setting and setting up workflow that you can then adapt for other services. And I'll let Robin speak to the pharmacy workflow too.

Robin Corelli
Yeah, and I think one of the other things to keep in mind: this particular study was was funded by the University of California Tobacco Related Disease Research Program, partially some of the backstory on this. So, obviously, our focus is on tobacco. That's I'm a tobacco researcher myself, so that's my interest. But what we're finding is that when you start with one, get confidence. People have to. People can do something, and one of the things pharmacists have done a lot of service implementation, and they can do things for three months, but sustaining it is key. And so, having this embedded as part of this is what we do. We ask everybody about their tobacco use, not just because we're doing a project, but it's because we should be screening for drug interactions with tobacco smoke in the first place. So adding in create a starting with one where people feel confident, and then you can start to layer clinical services into those. For example, pharmacists are extremely comfortable right now with giving immunizations. That is, I mean, that's just in fact most influenza, most COVID vaccines are given in pharmacies. But that's a ripe opportunity when you have someone you can be screening for other services. So, for example, with smoking. Somebody who's smoking should be offered other, you know, another vaccine. They should be offered the pneumococcal vaccine because they're at risk for serious disease caused by pneumococcal infection. So you can see how that logically layers into that. In fact, we've actually studied that as well. That pharmacy teams are finding, yeah, I can layer this in. I'm already doing this anyway, and I can add another service. So starting with one embedding, and I would say more entrenched is immunizations, but we're really working with tobacco cessation because it's another one that honestly pharmacists should be asking about smoking because of the clinically significant drug interactions, and then when you identify somebody, the prevalence of smoking in California is pretty low. You know, less than 10% but it's higher in some of our rural areas. So you can see you might not be overwhelming with something that's less than 10% overwhelming the staff. Like we can do this. You can document that, and then of course, you're offering the service. And if someone's not ready to quit at that time, you're planting the seed. No problem, if and when you're ready. Our pharmacists, our technicians were trained to help you with this. We would love to do that.

Pharmacy Times
Absolutely. And you talked about how pharmacy staff they know how to do so many different things already. And like technicians themselves, they already know the medications. They know chronic disease, of which addiction is a chronic disease, and they know the pharmacy workflow. And the community health worker piece adds things like social needs, screening, care navigation, and follow up. Robin, you've looked closely at what these technicians are capable of. How does CHW training expand what a technician can do beyond dispensing and counseling? I know you talked a little bit about it in your prior answer, but expand as you feel this bit.

Robin Corelli
I I don't know if I'm going to add too much other than the fact that this brings a unique skill set to our technicians, right? That they own this, and I think that gives them more confidence in adopting new services. And our pharmacists, well, pharmacists could be trained in this. They're not generally opting to be trained because they recognize that the pharmacy technicians can really take that and run with it. So I think it adds a whole other career ladder for our farm community pharmacy technicians to actually expand, and I suspect we might start seeing some of these technicians go go into pharmacy school with some of this newfound confidence.

Pharmacy Times
That'd be great, right?

Robin Corelli
UC San Francisco, our program. We have a program. It's the Farm Tech to Farm D program. There's a lot of individuals that they have excellent pharmacists. So how identify those? So again, I think that will be something else that will come out of this. But clearly, the other aspect of this is having the community pharmacy. It's really elevating the practice of community pharmacy that it's seen as a healthcare, you know, even more as a unique healthcare setting because of these other and very important skill sets that are important to health that are actually independent of drugs, but honestly, equally important.

Pharmacy Times
Yeah, absolutely agree there, and in the research, it points to two significant things that really accelerated adoption of this program: seeing peer pharmacy succeed, and having a champion inside the health plan who could help navigate the process. This is open to either of you. Cindy, you could provide a response first if you'd like. What role did those peer networks and health plan champions play in getting others on board?

Cindy Valencia
As we mentioned earlier, there was a specific plan and individual within partnership health plan that really helped establish a pilot that provided the financial support for pharmacy technicians to attend the training, staff time really gave them support to build the infrastructure. Right, not only did they help support the infrastructure, but they also were there hand in hand along the way to make sure that they could get support as along the implementation for any questions. One thing we heard from others is that they didn't have that. They didn't know who to call. They'd call and wouldn't get their answers, questions to their answers. And so it's just incredibly important to have that health plan champion and to invest in setting up that initial infrastructure for community pharmacies. The other piece is that, as you mentioned. This peer support. There's so much excitement when someone submitted a claim and got paid because then it made it real, right? While our study shows various themes and quotes, I think when they heard from each other that someone got paid, it really ignited and continued the momentum, right? To to keep keep at this CHW service integration keep at this model and see it through. So I think that that's just another niche I feel of the community pharmacy setting in that they there's this innate collaboration within to support each other. It's non competitive, and then they're they're there to support share forms and just a text away, even sometimes.

Pharmacy Times
Yeah, absolutely, Robin. Anything?

Robin Corelli
Another component of that peer, and one of the things that that strikes me is so pharmacies. Well, you might think they're in competition and business competition. I think pharmacists are highly collaborative, and they do share. As Cynthia mentioned, there would be a conversation as part of this grant. We actually had varied weekly, biweekly. Sometimes it was monthly, depending on the state of the project, where there was actually a Zoom call similar to what we're having right now, and I have to give credit to Dr. Mike Ahata, who is a faculty member and community pharmacist at Western University College of Pharmacy, for sort of navigating these and just I don't like weekly focus groups, support groups almost with this, where pharmacists where the pharmacists would get together, and we invited the tech champions as well. So it was a highly inclusive, and many of these individuals were community health workers to share best practices. And as Cynthia said, they would learn. Well, this is a form that I used, and they would share the form. This is a workflow that we use that was really successful. This is how I opened the conversation. I mean, one of the things that was very challenging and always has been for pharmacy personnel is how do you identify someone who's smoking? Someone's not going to say that they are. You have to ask. So how do you ask that question? Oh, I'm afraid they're going to think I'm prying. So the technicians would help each other. Well, this is how I ask it. I include it as part of my usual updating of information, and you know what? No one ever balked at that. So it was debunking some of the myths that people had about integrating this type of service. So I would say that the highly collaborative nature and just the fact that you know it's the the cliche a rising tide floats all boats. We really do need all pharmacies to be providing this level of service, chain pharmacies, independent pharmacies, so that it's just expected that we hope these types of services and community health worker ones. I'm hoping will be the next Vista are similar to how immunizations really are. You just expect that a pharmacy will provide that.

Pharmacy Times
Absolutely, and just to help wrap things up, this will be to both of you that these were seven early adopter pharmacies, and the authors careful to say that represents a real limitation. These are motivated sites with pilot support behind them, so what do you think has to change for this model to scale beyond that early group? We

Cindy Valencia
need to simplify implementation. We touched on the credentialing process, the documentation, billing, and that really, you know, sits with the payer. It sits with the health plan, and I think there's an opportunity there to make it straightforward and easy. You have willing and incredible partners in community pharmacies that are already doing this work, and this will continue to to sustain the efforts that they're already doing. So let's make it let's make it easy easy for them. Let's continue to leverage the trusted relationships that they have and ensure sustainability.

Robin Corelli
Yeah, I, I, I mean, I really can't add much more beyond that because that really is the summary. But I, the other thing we might add is we are seeing this. There's, this is no question. The pharmacies participating in this pilot were the early adopters. They were the ones that were going to take, you know, try something new, build new systems, and we're working now with the second level of adopters. And I would say we have some traction, and we need to work more. And and with I think if they have where it's where there's very clear, my investment will translate into more billing opportunities, more revenue generation, more sustainable clinical patient care services. So that's where this where we do really need the payers to adopt this and to reimburse just as they would for an immunization or prescription for these types of services. So I think that's going to be key. But once you start building it where it is, you're going to start seeing more pharmacies take this on, and hopefully, hopefully, we really do need the chain pharmacies to adopt these as well, and not see the pharmacy as a loss leader in a in another business enterprise. But that that is the pivotal focus of the services that are provided.

Pharmacy Times
Yeah, of course. I'm really excited to see where the program grows from here. It's it's super helpful to patient outcomes and just improving care across the board. So, thank you both for being here today. Is there anything else that either of you would like to add before we finish up this Insightful conversation.

Robin Corelli
I do think another thing we haven't really touched on is sort of the is the concept of some of this has to do has to be mandated, right? It has to be mandated through some of the legislative activities that are going on. And there's a number, you know, the the fact that pharmacists were taking on its expanded scope of practice was back. This isn't new. This goes back, you know, a dozen years, giving pharmacists advanced or enhanced authority for public health initiatives, immunizations, HIV, PEP, and PrEP, tobacco cessation, those types of services. But there was no payment tied to it, so there has to be another law to man. You know, there was another law that you had to have payment for this, but then the managed care organizations were not paying for it. So now there's another law saying now you have to do this. So I think those that our legislators do need to pick to actually help with this and to pass these types of legislation to make sure that we have our systems that actually, while they may be there may be a law to to allow for them, but there has to be a sustainable law, and and our payers have to follow the laws and actually reimburse providers for their services. Oh, that's I would say that's another thing that we that needs to be part of this puzzle, sadly, but it is an essential part.

Pharmacy Times
Absolutely. Well, that was all great. Thank you both so much for this this and great conversation. I loved hearing your insights, and I'm really looking forward to seeing where this program goes from here. So, Robin, Cindy, thank you both very much for being here, and thank you for listening to this episode of Pharmacy Focus. And we'll see you in the next episode.

Robin Corelli
Thanks for holding it, Luke. This was a really an important topic, and we're glad to see Pharmacy Practice News cover this.

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