Pharmacists’ Role in Expanding Healthcare Equity

US Pharm. 2024;49(8):41-45.

ABSTRACT: As the demand on the healthcare system increases, health disparities have also become more apparent. The differences in the quality of care, healthcare access, and clinical outcomes experienced by historically marginalized communities are alarming. It is critical to find solutions to address the barriers that they experience and create equitable healthcare. Pharmacists are equipped with the knowledge and skills that could help bridge gaps in health equity. Studies demonstrate that pharmacists have a positive influence on healthcare access, clinical outcomes, and patient satisfaction through the delivery of a variety of services. Unfortunately, not all of these services are universally available, and not all services may be appropriate for the communities that they serve. Therefore, it is crucial to identify pharmacy services and strategies that best meet the needs of the community. It is also important to know the barriers to implementation to determine the feasibility of the services and to guide their successful development and execution.

Pressure on the healthcare system creates challenges in access, leading to major public health issues and increasing direct and indirect costs.^1-3 Disparities can be seen throughout healthcare, and they historically impact marginalized communities, including people with disabilities, racial and ethnic minorities, people who experience homelessness, or individuals who have lower income.^4-6 For example, contraceptives were less likely to be dispensed to racial minorities, women aged between 38 and 49 years, and people with Medicaid insurance.⁷ Chronic disease or having at least one cardiovascular risk factor is more prevalent in non–Hispanic white, African American, and Hispanic communities.^4,8,9 These disparities, among many others, can increase morbidity and mortality in these communities.⁴

Chronic diseases are also more common in individuals living in rural and underserved communities, where more people are underinsured and have lower income.¹⁰ They also tend to have fewer available providers and fewer low-cost healthcare resources. Such inequities in healthcare result in inadequate care, which not only worsens the disease burden and healthcare outcomes but also results in the expenditure of hundreds of billions of dollars on avoidable costs.^3,11,12 This means that there is a dire need to pool healthcare resources, identify the causes of disparities, and find solutions to mitigate them.⁵ Pharmacist involvement in addressing health disparities could be of value. Pharmacy services have evolved from solely dispensing medications to a more person-centered care model by combining clinical practice and consideration for patients’ personal experiences, goals, beliefs, culture, and preferences.^13,14 This approach not only expands healthcare services to communities that may not have had access before, but it also creates more opportunities for pharmacists to improve public health.^13-15

Candidates for Improving Health Inequity

Pharmacies can serve as resources for the community and play a role in improving health equity.^11,15 Pharmacists are seen as trusted and essential members of the healthcare team.¹¹ In fact, patients are more likely to visit their pharmacy than their primary care provider (PCP) or the emergency department.^11,16 Pharmacies potentially have more convenient locations and extended hours, making pharmacists not only one of the largest groups of healthcare providers but also one of the most accessible resources.^{1,11,13,17-20} Pharmacists are often the first line of healthcare for patients, and they carry a wealth of resources and knowledge to properly provide patient education on medical and nonmedical issues.^11,20 They help find cost-effective therapies for patients and provide preventive care services.¹¹ They also perform patient counseling and optimize medication therapies that can improve patients’ quality of life, healthcare outcomes, and drug or disease knowledge while decreasing health-service utilization.^2,20 If pharmacist services and skills can be fostered, supported, and universally available and combined with improving cultural competency, pharmacists can contribute to a healthier future for all populations through the services they provide.^17,21

Candidates for Improving Health Inequity

The positive impact of pharmacy services on healthcare access is not a new concept. During the COVID-19 pandemic, nonessential businesses were halted, but pharmacies continued to offer healthcare services and acted as an extension of many healthcare providers hindered by limited availability.^16,22,23 They vaccinated people experiencing social vulnerability; provided drive-through, home delivery, and 24-hour services; and branched out to perform COVID-19 testing. Pharmacists are also more geographically dispersed compared with PCPs.²⁴

Patients found access to pharmacists easier than to  their own providers out of convenience and shorter waiting times.^1,13,18 In a systematic review including the United States, United Kingdom, Canada, and New Zealand, patients waited one-third of the time to see a pharmacist compared with a physician specialist. More patients were seen by a pharmacist within 7 days of a referral, and pharmacists tended to provide services outside of typical physician operating hours.¹ Patients also spent more time with their pharmacist than their physician, were offered more communication modalities, and felt that their pharmacist’s service fee was acceptable or lower than that of their physicians.¹ Additionally, enhanced pharmacy services for patients with chronic illnesses can improve adherence and positively influence clinical outcomes, quality of life, and other health measures.^8,9,25,26  

Pharmacists should adopt a person-centered care model to improve health equity.¹⁴ Pharmacists have the capability to identify the types of services that will meet the social and medical needs of their communities, coordinate healthcare delivery and interprofessional communication, and tailor pharmacy services, programs, and resources to meet patients’ healthcare goals.^11,13 Pharmacies can help determine unmet needs in the community and work with community leaders and healthcare organizations to create or reallocate resources and change policies to address them.^4,14,17

Carrying out a person-centered care model, however, extends beyond clinical services and coordination of care. Being aware of unconscious biases and ensuring cultural competency of the pharmacy staff minimizes health disparities.^4,5,13 Increasing cultural competency can better equip staff members to communicate with and understand patients.^21,23,27 Providing regular education on diversity, equity, and inclusion (DEI), social determinants of health and unconscious bias, and education on stigmatized diseases or populations is crucial.^17,23 Continuing education and lists of resources can be found through the Pharmacist’s Learning Assistance Network and the American Association of Colleges of Pharmacy, which can be used to train workplace personnel.²⁸ Lastly, incorporating DEI during pharmacy students’ clinical rotations can equip them early in their career with how to identify, address, and navigate through unconscious biases and health inequities in real time, ultimately creating the foundation to provide culturally competent care in their future.^12,15,17,21

All of these measures, combined with the regular evaluation of practices and policies for areas of growth and improvement, generate the comprehensive framework and mindset necessary to ensure that the medical and nonmedical needs of the community are met.

Pharmacists Managing Chronic Diseases

If they are given infrastructure, resources, and cultural competence training, pharmacists are the perfect candidates for evaluating social determinants of health and advocating for health equity. In fact, offering a variety of pharmacy services and strategies that are specific to patients’ needs can help improve healthcare access, cohesive and comprehensive care, and healthcare outcomes.

Pharmacists can collaborate with other healthcare sectors and professionals to comanage chronic diseases.^15,17 The value of pharmacists’ skills and services has been supported by physicians, particularly in conducting medication therapy management, medication reconciliation, and disease-focused management of diabetes, hypertension, and pain.² Patients also expressed satisfaction with their care and felt listened to, received appropriate explanations, and felt respected without experiencing significant differences in adverse reactions.²⁹

Pharmacist involvement in diabetes care, for example, helped decrease hemoglobin A1C levels and blood pressure when compared with no pharmacist involvement.^3,6 Positive effects on weight and cholesterol were also seen with pharmacist involvement.²⁶ In addition, pharmacists can review vital signs and laboratory values, schedule follow-up visits to monitor a patient’s progress, and provide patient education on diabetes and other chronic conditions.³ Having pharmacists conducting these patient visits can decrease the workload of the PCP. Pharmacists can further optimize the management of chronic conditions by encouraging medication adherence and preventive care.^9,26

Lastly, by addressing patients’ knowledge gaps and screening for chronic conditions, such as hyperlipidemia, hypertension, and diabetes, pharmacists may also decrease their disease burden, the burden on the healthcare system, and health disparities.^30,31 Therefore, pharmacists can serve alongside other healthcare professionals in managing chronic conditions by optimizing therapies, providing the appropriate education, assessing for barriers to therapies, improving medication adherence, and supporting patient safety.^11,29,31

Expanding Point-of-Care Services

Along similar lines, pharmacists have the capacity to provide more point-of-care (POC) testing.^16,31 Many pharmacies already host wellness days that include POC during health screenings for diabetes, hypertension, and hyperlipidemia. Expanding services beyond these tests can aid in public health initiatives in the prevention, detection, and treatment of a variety of infectious diseases.^11,19 Benefits of these services include decreasing inappropriate anti-infective use, decreasing infectious disease transmission, and detecting infectious diseases sooner.¹⁹ In fact, there are data to suggest that pharmacists already improve the prevention and management of infectious diseases such as influenza, herpes zoster, and streptococcal pharyngitis.¹⁹ The COVID-19 pandemic also paved the way for pharmacists to become key providers in testing for COVID-19.³² There are other POC tests that pharmacists could provide, such as those for hemoglobin A1C, international normalized ratio, HIV, and sexually transmitted infections.^16,19,33 If pharmacists could conduct more POC testing, then underserved communities, those who do not have a PCP, and those with limited transportation could still access these resources.^11,19

Increasing Preventive Services

Another way that pharmacists could alleviate gaps in care and barriers to healthcare access is by providing preventive care services that are not related to chronic conditions. As vaccine providers, pharmacists can bring immunizations to areas where there is inadequate coverage.²⁴ In one study, pharmacists used shared patient data to identify culturally specific individuals with Medicaid insurance who did not receive the COVID-19 vaccine, conduct targeted outreach activities, coordinate vaccine delivery to pharmacies, decrease vaccine hesitancy, and offer onsite vaccine clinics.³³ As a result, vaccination rates increased by approximately 50%.³³ Other studies also noted that there was an increase in vaccinations in patients who otherwise would not be immunized and that increases in the number of vaccines administered were linked to pharmacist involvement in the immunization process.^18,23,34

Increased vaccination rates can be attributed to pharmacists designing vaccination programs, using active outreach strategies to increase patient awareness, and generating a welcoming and culturally sensitive environment by adjusting education methods based on a patient’s level of understanding, addressing barriers to obtaining vaccines, or debunking vaccination myths.^18,34 One example is the onsite vaccine clinic, which minimizes time away from work and overcomes transportation barriers.²⁸ Another strategy that increases vaccination rates involves increasing vaccine awareness and addressing vaccine hesitancy by pharmacists partnering with facilities or organizations located in areas experiencing low immunization levels and underserved communities and with trusted community and government leaders and other healthcare professionals.²³

Pharmacists’ role in preventive care and health screenings, however, is not limited to vaccinations. Pharmacists can screen for cancer, osteoporosis, and sexually transmitted infections, and they can offer smoking-cessation opportunities.¹⁸ Programs for colorectal and breast cancer screening can target patients with low income or without insurance.⁴ One such program provided universal screening and treatment of colorectal cancer, which removed disparities in screening and disease incidence and decreased disease in African Americans from 70% to 49%, nearly eliminating disparities in mortality.⁴

Pharmacists can also address modifiable risk factors for cancer, such as tobacco use.³⁵ One study found that rural communities did not experience a decline in tobacco use that was seen in other populations, and they had fewer physician and healthcare resources and access.³⁵ Pharmacists, in collaboration with other healthcare providers, could conduct telehealth visits and prescribe smoking-cessation therapies.^18,35 Such positive impact in preventive-care services and risk-factor management supports prescriptive authority for pharmacists to prescribe other therapies, such as those for HIV prevention, contraception, and opioid use disorder.^11,18,36 In fact, patients may feel less stigma going to a pharmacy while also having better access, lower costs, counseling and education, and accommodations for clinic visits.³⁶ Through these services, pharmacists can increase healthcare access and reduce the impact of provider shortages.

Utilizing Telehealth and Technology

Pharmacists may also provide services through telehealth and use other technologies to expand access to care. Texting can be used to improve medication adherence by sending initial reminders for prescription refills, creating an opportunity to identify barriers to medication adherence, and providing patient counseling with follow-up phone calls.³⁷ Multiple languages can be built into the texting programs, too.³³ Technology can improve healthcare access through the use of wearable technology and telehealth visits, where pharmacists can obtain and assess patient data and conduct a clinic visit remotely.^29,38 These services can also be supported by using credible mobile applications to track patient progress, improve medication adherence, and provide virtual educational resources.³⁸ Telehealth and the use of other technology can expedite education and accurate health information delivery to the public, especially for patients who have difficulty accessing transportation, face geographical barriers, or have mobility issues.^11,23 Pharmacists will need to ensure technology literacy since it is important for the success of these services.

Barriers to Implementing Pharmacy Services

It is evident that there are numerous ways that pharmacists can become more involved in addressing health disparities; however, considering the barriers to overcome is crucial to successfully implementing these services. In some cases, the scope of practice can be a limitation. Therefore, advocating for changes in legislation to allow for expanded pharmacy services and pharmacists provider status can remove pharmacists’ practice limitations.^11,19,23,39 The other challenge is the lack of reimbursement, which remains a deterrent for starting new services.^{11,18,22,23,26,36} Recognizing pharmacy services and receiving funding from various government programs are imperative to the expansion of clinical pharmacy services, ultimately benefiting the community and empowering its members to be advocates for their own healthcare.^4,13 Funding could come from sponsorships through payers, health systems, public entities, and the private sector to start, maintain, or scale-up services.⁴

Other types of resource limitations are pharmacy-specific. New service implementation can be limited by insufficient pharmacy staff, time, training, physical space, patient data access, and workflow procedures.^{13,19,33,36,39} In addition, adding more to an already busy workflow can worsen wait times and decrease available bandwidth for walk-in appointments.³⁶ Some of these limitations can be addressed by the use of pharmacy technicians and students for nonclinical activities, such as medication dispensing.³⁹ Technicians can identify financial resources, proactively advertise preventive care, and conduct final product verification for certain subsets of pharmaceuticals.^11,39 Pharmacy students can also perform some clinical duties under the supervision of a practicing pharmacist that can free up time.^18,23,37 Even nonclinical staff can help with other administrative and nonclinical duties.¹³ Limited training in clinical services and cultural sensitivity, however, can contribute to staff hesitancy in adopting a new service.^19,36,37 It is important to ensure appropriate and thorough training. Increasing awareness of unconscious bias and providing instruction and coaching in delivering culturally sensitive care will better prepare the pharmacy staff to deliver new services.^17,23

Lastly, there is a concern that services may not be used. Sufficient demand for a service is therefore needed to ensure sustainability.¹³ Investigating the needs and demands of the community and targeting advertisements toward individuals who would benefit the most can increase utilization of the new service.^12,13,17

Conclusion

Pharmacists have demonstrated a positive impact on healthcare outcomes through nondispensing functions, and their services have a role in trying to mitigate health disparities. Through their clinical knowledge and skills, they could provide and grow services in chronic disease management, POC testing, preventive care, and telehealth. These services would not only bring relief to provider shortages but also extend access to underserved populations. Coupling these skill sets with cultural competency by accounting for the whole patient can improve healthcare equity as well. At the same time, awareness of the barriers to implementation of these services can help guide the appropriate steps to creating or expanding services to address health disparities.

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