Perceived Roles of Independent Community Pharmacists and Pharmacy Technicians in Patient Referrals to Community Resources: A Study from the Medication Safety Research Network of Indiana (Rx-SafeNet)

Abstract

Introduction:

Referrals to community resources represent one element of the Chronic Care Model, however, little is known about the perceived role of community pharmacy staff in referring patients to community resources.

Objectives:

The objective of this study was to describe community pharmacists’, community pharmacy technicians’, and patients’ perceptions of pharmacist referrals to community resources.

Methods:

Semi-structured interviews were conducted with community pharmacists, pharmacy technicians, and patients from community pharmacies that are members of the Medication Safety Research Network of Indiana (Rx-SafeNet). Qualitative analysis was conducted to identify emergent themes.

Results:

A total of 37 participants, including six community pharmacists, one pharmacy student completing an advanced pharmacy practice experience, 15 community pharmacy technicians, and 15 patients across four independently-owned community pharmacies were interviewed. Themes included: 1) Need to build on a foundation of strong patient-community pharmacist relationships to clearly define the pharmacist’s role in referrals, 2) Need to improve familiarity with community resources, 3) Need to clearly delineate and support the role for pharmacy technicians in making referrals, and 4) Need to follow-up on referrals.

Conclusion:

To enhance community pharmacy staff provision of referrals to community resources, interventions are needed to improve patient and pharmacist familiarity with available resources, patients’ perception of the pharmacist’s role outside of prescription fulfillment, and follow-up on referrals. Moreover, pharmacy technician education and training could be expanded to optimize their role in supporting community pharmacists in making referrals.

Approximately half of all adults in the United States have at least one chronic condition, and one fourth have two or more chronic conditions.¹ The Chronic Care Model (CCM) was developed to detail the proactive provision of optimal care for patients with chronic diseases in a primary care setting.² Self-management support and linkage of patients to community health resources are CCM elements.^2–3 Patients’ self-management skills are enhanced by resources and services that teach them to follow medication regimens, guide them in positive behavioral changes, and provide support for them.⁴

Pharmacists have long been perceived as some of the most trusted health care professionals.⁵ Social capital can be defined as “the support and trust generated from the structure of social relationships that can be used to facilitate action.”⁶ Residents of communities with higher levels of social capital tend to engage in healthier behaviors and feel emotionally and physically healthier.⁷ An increase in social capital correspondingly supports the overarching Healthy People 2020 goal of “creating social and physical environments that promote good health for all”, and supports care delivery in alignment with CCM elements.^2,8

Considering their accessibility and trusted role as community health care professionals, the community pharmacist is in a unique and advantageous position to forge relationships with patients, including the systematic provision of referrals, which positively impact patients’ health. Moreover, as pharmacists expand their roles in patient care and health promotion, they are becoming increasingly recognized as sources of health information; often, pharmacies serve as informal community health access points with pharmacy staff being the initial point of care for many patients.⁹ However, recent work examining medication therapy management (MTM) delivery through application of the CCM found that referrals to community health resources as part of MTM are uncommon due to pharmacist and staff reported lack of familiarity with resources available, and the perception that these referrals are not a part of MTM.¹⁰ It is unknown how these findings are similar or different when community pharmacists are providing care outside of MTM. A recent review of partnerships between community pharmacists and community organizations identified and described a limited number of examples of such relationships, but the experiences of pharmacy staff and patients was not described.¹¹ More work is needed to elicit pharmacy staff and patient experiences with community pharmacy staff referrals to these resources and considerations for how referrals can be optimized. Therefore, the objective of this study was to describe community pharmacists’, community pharmacy technicians’, and patients’ perceptions of pharmacist referrals to community health resources.

Methods

Overview of Study Design

This was a descriptive, cross-sectional, qualitative investigation of community pharmacists’, community pharmacy technicians’, and patients’ perceptions of pharmacist referrals to community health resources. Individual, semi-structured interviews were used for data collection and resulting transcripts were analyzed to identify themes.

Participant Recruitment

To recruit potential participants, we collaborated with the Medication Safety Research Network of Indiana (Rx-SafeNet), a practice-based research network currently comprised of approximately 140 community pharmacy locations in Indiana.¹² Following routine Network procedures, information about the study was conveyed to member pharmacies to seek volunteers willing to participate. From each willing pharmacy, individual community pharmacists and pharmacy technicians were recruited through email and during face-to-face visits to the pharmacies. A convenience sample of adult patients were recruited face-to-face by the investigators at the participating pharmacies. All participants were offered a $25 gift card for participation.

Data Collection

Interview guides (Appendices A–C) were designed by investigators and informed by our experiences in community pharmacy practice to elicit information from community pharmacists, community pharmacy technicians, and patients about community pharmacist referrals to community resources. For the purposes of this study, we defined community resources as any program or activity that could potentially impact the health of patients, as well as their access to care. Interviews were conducted by two individuals; one experienced in qualitative research and the other, a trained pharmacy student. Interviews were completed either face-to-face or over the telephone based on the preference of the interviewee. Face-to-face interviews were conducted in a private location at the participating Rx-SafeNet pharmacies. Interviews were audio-recorded with permission from participants. Audio recordings were transcribed verbatim by a professional transcription agency. This study was approved by the Purdue University Institutional Review Board.

Data Analysis

Demographic data were analyzed using IBM SPSS Statistics software v. 24 (IBM, Armonk, NY). Descriptive statistics were computed to characterize the study sample. Interview transcripts were coded and analyzed by two trained pharmacy students using an open-coding approach to qualitative thematic analysis. A codebook was created to track code definitions and coding decisions, with more specific and descriptive sub-codes accompanying broader main codes. MAXQDA v. 10 (VERBI, Berlin, German), a qualitative data analysis software program, was used to systematically organize, code, and evaluate data. Cross-tabulation analyses were conducted in MAXQDA to determine whether emergent themes differed across pharmacy location (i.e., urban vs rural) and participant type. Member checking was not performed.

Results

Participant Demographics

The four pharmacies participating in this study were all independently owned and located throughout the state of Indiana, including three in rural locations and one in an urban location. Across these pharmacies, we interviewed a total of 37 participants, including six community pharmacists, one pharmacy student completing an advanced pharmacy practice experience (APPE), 15 community pharmacy technicians, and 15 patients (Table 1). The duration of each interview ranged from approximately ten minutes to one hour. In the analysis, the APPE student was included in the group of pharmacists. On average, patient participants reported taking a total of 7.1 medications, and utilized two community pharmacies and two prescribers over the past year. Technician participants had an average of 4.4 years of experience as a technician, and 26.7% reported some post-secondary education. All pharmacists reported involvement in MTM and compounding services. Pharmacist participants reported practicing for an average of 27.1 years.

Table 1.

Participant Characteristics

	Demographic	Characteristic	Pharmacists† N=7		Technicians N=15	Patients N=15
ALL PARTICIPANTS	Age Mean (SD)			49.9 (14.5)	36.3 (15.0)	55.7 (12.5)
	Sex n (%)	Male		4 (57.1)	----------	5 (33.3)
		Female		3 (42.9)	15 (100)	10 (66.7)
	Ethnicity n (%)	Non-Hispanic		7 (100.0)	15 (100.0)	15 (100.0)
	Race n (%)	Caucasian/White‡		7 (100.0)	12 (80.0)	14 (93.3)
PHARMACISTS	Education n (%)	Bachelor of Pharmacy		4 (57.1)	----------	----------
		Pharm.D.		2 (28.6)	----------	----------
		Both Bachelor of Pharmacy and Pharm.D.		1 (14.3)	----------	----------
	Certifications & Certificates n (%)	CDE		2 (28.6)	----------	----------
		APhA Pharmacist & Patient-Centered Diabetes Care Certificate		2 (28.6)	----------	----------
		APhA Pharmacy-Based Lipid Management Certificate		5 (71.4)	----------	----------
		APhA Immunization Certificate		7 (100.0)	----------	----------
		APhA MTM Certificate		1 (14.3)
		Other certificate§		1 (14.3)	----------	----------
	Experience Mean (SD)	Years licensed as RPh		27.1 (14.3)	----------	----------
	Employment Mean (SD)	Years employed at pharmacy		3.4 (4.9)
	Additional Services Offered at Pharmacy n (%)	DSM/education programs		2 (28.6)	----------	----------
		Immunizations		5 (71.4)	----------	----------
		MTM – CMR		7 (100.0)	----------	----------
		Compounding		7 (100.0)	----------	----------
		DME		2 (28.6)	----------	----------
		Wellness screenings/PoC testing		4 (57.1)	----------	----------
		Other services¶		6 (85.7)	----------	----------
	Number of Rx Filled at Pharmacy (weekly) n (%)	< 500		4 (57.1)	----------	----------
		500–1000		3 (42.9)	----------	----------
	Environment n (%)	Live and work in the same area		2 (28.6)	----------	----------
	Community Activities n (%)	Participate in at least one community activity‖		6 (85.7)	----------	----------
TECHNICIANS	Education n (%)	Associates degree		----------	2 (13.3)	----------
		Other degree*		----------	2 (13.3)	----------
		None		----------	11 (73.3)	----------
	Certification	Technician-in-training		----------	1 (6.7)
		State certified technician		----------	13 (86.7)
		Certified pharmacy technician		----------	5 (33.3)
	Experience Mean (SD)	Years working as technician		----------	4.4 (5.7)	----------
	Employment Mean (SD)	Years employed at pharmacy		----------	2.5 (2.2)	----------
	Environment n (%)	Live and work in the same area		----------	5 (33.3)	----------
	Community Activities n (%)	Participate in at least one community activity**		----------	11 (73.3)	----------
PATIENTS	Education n (%)	High school/GED		----------	----------	6 (40.0)
		Some college/trade school		----------	----------	6 (40.0)
		Bachelor’s degree		----------	----------	2 (13.3)
		Graduate/professional school		----------	----------	1 (6.7)
	Marital Status n (%)	Single		----------	----------	2 (13.3)
		Married		----------	----------	10 (66.7)
		Separated/divorced		----------	----------	2 (13.3)
		Widowed		----------	----------	1 (6.7)
	Prescription Insurance n (%)	Private		----------	----------	8 (53.3)
		Medicare and/or Medicaid		----------	----------	4 (26.7)
		None		----------	----------	3 (20.0)
	Medications Mean (SD)	Number of medications***		----------	----------	7.1 (4.9)
	Prescriber Use (over the past year) Mean (SD)	Number of prescribers		----------	----------	2.1 (1.6)
	Pharmacy Use Mean (SD)	Number of pharmacies		----------	----------	1.5 (0.7)
	Community Activities	Participate in at least one community activity****		----------	----------	12 (80.0)

APhA = American Pharmacists Association; CDE = Certified Diabetes Educator; CMR = Comprehensive Medication Reviews; DME = Durable Medical Equipment; DSM = Disease State Management; GED = General Educational Development; MTM = Medication Therapy Management; Pharm.D. = Doctor of Pharmacy; PoC = Point-of-Care; Rx = prescriptions; PTO = Parent Teacher Organization RPh = Registered Pharmacist.

^†Includes one student pharmacist.

^‡Other races: African American/Black and/or more than one race.

^§Other certificate: Anticoagulation.

^¶Other services included diabetic supplies, consults (nutritional/hormonal), delivery services and Nursing home assistance.

^‖Top two activities: Religious organizations, volunteer events.

^*Other degrees reported included “Registered Nurse”, “Certified Nursing Assistant Certificate”.

^**Top three activities: Community social and sporting events, school organizations (e.g., PTO), and religious organization.

^***Medications included prescriptions, over-the-counter, herbal, and vitamins.

^****Top three activities: Religious organization, volunteer events, and community social/sporting events.

Emergent Themes

Perspectives differed across participant roles but not by pharmacy location. Data saturation was presumed to have been reached given the consistent themes that emerged from the data. Emergent themes can be grouped into four opportunities to enhance provision of referrals by community pharmacists, and these are described below.

Need to Build on a Foundation of Strong Patient-Community Pharmacist Relationships to Clearly Define the Pharmacist’s Role in Referrals

Patients reported strong satisfaction with pharmacists and placed significant value on pharmacist-patient interactions. One patient participant expressed an appreciation for pharmacists as, “true compassion and willingness to listen…you come in, and you converse. You don’t just walk in and get your medicine and walk out.”

Patient participants expressed a general awareness of the pharmacist’s responsibilities, but had limited awareness of the pharmacist’s role in referring patients to community resources. Participants reported that pharmacists are utilized to answer questions and could likely play a role in referring patients; however, this role remained largely undefined. For example, when asked what role pharmacists should play in connecting patients to community resources, one patient responded, “Gosh, I don’t know. I think they should…it would be nice if they did when people ask…”

Need to Improve Familiarity with Community Resources

When asked about their familiarity with community resources, patients lacked confidence in their awareness of resources but often mentioned free health clinics, local charities, physicians, or the internet. Patients felt that improved promotion of community resources would best be supported by more available written information for patients, greater stakeholder awareness of existing resources, and more opportunities to raise awareness, such as through screenings and informational booths. These comments were echoed by technicians.

Pharmacists noted limitations in patient knowledge and awareness of community resources. As one pharmacist stated, “If you look at all the chronic disease states, lifestyle is the first cure and I don’t feel like most people have enough knowledge to be successful in making those lifestyle changes.” Pharmacists also reported unfamiliarity with available resources, as well as time constraints and lack of input from patients regarding their specific needs. Often, pharmacists referred patients to a provider or service that he or she was previously familiar with. One pharmacist stated, “In this community, it probably boils down to the tail end of relationships that I have already established with the medical community. I spend a lot of time with diabetes and therefore know the endocrinologists here in town, most of them personally…I would direct people there.”

Need to Clearly Delineate and Support the Role for Pharmacy Technicians in Making Referrals

Many participants felt that the pharmacy technician was underutilized in pharmacy services. The extent of the technician role in the pharmacy is based on training, experience, self-motivation, the individual’s comfort level, and pharmacist delegation of responsibilities. The technician role was largely focused on prescription fulfillment tasks rather than interacting with patients. In some cases, the more a pharmacist trusts a particular technician, the more likely he or she will empower that technician to take on additional roles with greater depth of patient interaction.

When faced with a question, technicians most often defer to the pharmacist due to either a lack of training or a fear of overstepping their role. As one technician stated, “Well, I don’t really know that technicians … are utilized as much as they should be. But then again, I guess it depends on…the education that they’ve had and how comfortable they are with… making a referral.” Currently, the technician role in referrals is very limited; one patient wondered if technician referrals would be “overstepping a doctor’s part.” A pharmacist stated, “[Being a good technician] …comes down to training and experience. There’s no reason why a technician can’t refer patients or know about services or certainly even discuss them with a fellow pharmacist.”

Need to Follow-Up on Referrals

Most pharmacy staff reported not knowing the impact of their referrals. However, despite no consistent mechanism for feedback, patient responses to referrals were generally positive from both the technicians’ and pharmacists’ perspectives. One technician stated, “We do follow up with certain things, but [referrals are] not one of them. But that, that is something that we should probably consider.” A pharmacist from a different pharmacy noted that follow-up may be contingent upon a pre-existing relationship with patients, stating, “You know, if I feel necessary, I will [follow up]…And I can’t say I do a lot. Percentage, I don’t know what it would be. I’m sure a small percentage… it depends on how well I know them.”

Discussion

We found that patient interviewees placed significant value on the interactions they had with pharmacy staff, which demonstrates the social capital potential for community pharmacies.¹⁶⁻⁸ Moreover, our findings indicate that an informal framework for connecting patients to community resources exists in the community pharmacy setting already; however, clear role delineation is needed to advance this into a more formalized process. The patients we interviewed were largely unable to define the pharmacist’s role beyond prescription fulfillment which aligns with what has been reported previously in the literature.¹³ This is concerning given the ongoing evolution of the pharmacist’s role and the important role of referrals in the pharmacists’ patient care process (PPCP).¹⁴ Patient perspectives of the pharmacist role needs to be expanded beyond the traditional function in filling prescriptions to promote a larger pharmacist role in all steps of the patient care process, including the provision of patient referrals.

We also noted opportunities to improve patient awareness and utilization of available community resources, however, limited familiarity with available resources was not unique to patients. Pharmacists noted their own lack of familiarity with resources as a barrier to referral provision. There is a clear need for pharmacists and pharmacy technicians to increase their familiarity with resources available for their patients. This could be accomplished through curricular enhancements, including shared curricula such as the Rx for Change program developed for tobacco cessation,¹⁵ continuing education programs, and/or training provided by community pharmacy employers. In addition, while strong, positive pharmacist-patient relationships were evident, more consistent follow-up on referrals is needed to maximize the role of pharmacy staff in increasing patient access to community services and optimizing care delivery in alignment with the CCM and the PCPP. Most pharmacy staff reported not knowing the impact of their recommendations; this lack of feedback signifies an important opportunity for evaluating and improving recommendations made to patients. These findings echo a recent study examining MTM delivery through application of the CCM. That study found that referrals to community resources during MTM delivery was limited, partly due to a lack of pharmacist familiarity with available resources, and that follow up MTM consultations were less common.¹⁰

As pharmacist roles have expanded into direct patient care services, optimizing the utilization of pharmacy technicians and other support staff has been a commonly cited consideration.¹⁶ Available literature demonstrates the positive impact on patient care and safety when incorporating community pharmacy technicians into more direct patient care processes, ^17–20 and a recent white paper outlines “best practices” for engaging these personnel in ways which support pharmacist provision of patient care services.²¹ Examples of these best practices include ensuring appropriate certification and training of support staff and incorporating support staff into appropriate parts of the PCPP. With regards to the latter, the white paper notes, “…support personnel can also assist with scheduling and communicating referrals to other health care providers.”²¹ Our findings demonstrate a need to clearly define roles for pharmacy technicians in referrals and provision of associated training. This recommendation is consistent with Hudmon and colleagues’ work demonstrating success with two models (academic detailing and mailed materials) for engaging community pharmacy staff (both pharmacists and pharmacy technicians) in promoting referrals to a tobacco quitline.²² Clear roles and training for community pharmacists and pharmacy technicians in making quitline referrals were developed, with pharmacy technicians positioned to refer interested patients to pharmacists and the quitline for counseling.²³ Future research should define specific roles and examine educational strategies and other interventions to enhance the ability of the community pharmacy staff to systematically provide referrals to other types of resources.

Although this study provides insights on stakeholder perceptions of community pharmacist referrals to community resources, these perceptions may not be transferable across all pharmacy settings. For example, all four participating pharmacies are independently-owned pharmacies, which account for only 35% of community pharmacies across the United States.²³ Pharmacy personnel and patients at chain pharmacy locations may have differing perspectives about pharmacist referrals. In addition, participants were identified through a convenience sample, which likely represents those most inclined to voice their opinions and may be different than those who chose not to participate. Pilot testing of interview guides was limited and only conducted for patient interview guides. Moreover, while guides were informed by our community pharmacy experiences, we did not apply a theoretical model (such as the CCM) in the development of interview guides. Finally, while we identified repeating themes, it is possible that additional themes could have been identified had we recruited more pharmacies and interviewed more participants.

Conclusion

The perspectives identified in this study reflect the changing landscape of community pharmacy. Connecting patients to available resources in their communities allows for greater self-management and care that more closely aligns with the CCM. Patients, pharmacists, and pharmacy technicians responded positively to exploring the roles that pharmacy staff members play in connecting patients to health resources, but challenges in role definition, patient education, personnel training, and post-referral follow-up were highlighted.

Appendix A –. Interview Guide for Patients

Part I: Demographic Information

1. How many prescribed medications do you take? (include ALL unique medications, i.e., those that you do not take every day) ________________________________________________

   ___________________________________________________________________________

2. How many over-the-counter (OTC) medications do you take?

   (include ALL unique medications, i.e., those that you do not take every day)

   ___________________________________________________________________________

   __________________________________________________________________________

3. How many herbal medications do you take? (include ALL unique medications, i.e., those that you do not take every day) ________________________________________________

   ___________________________________________________________________________

4. How many vitamins do you take? (include ALL unique medications, i.e., those that you do not take every day) ________________________________________________

   How often do you take each medication? _________________________________________

   ___________________________________________________________________________

5. How many different people have written you prescriptions over the past year? _________

6. How many pharmacies do you use? _________

7. Types of pharmacies used- check all that apply:

   • ₶
     Chain retail (e.g. CVS, Walgreens, Rite Aid)₁
   • ₶
     Chain mass merchant (e.g. Target, Walmart)₁
   • ₶
     Chain grocery store (e.g. Kroger, Marsh)₁
   • ₶
     Independent retail pharmacy (fewer than four locations)₁
   • ₶
     Clinic based pharmacy₁
   • ₶
     Compounding-only pharmacy₁
   • ₶
     Mail order₁
   • ₶
     Internet₁
   • ₶
     Outpatient hospital pharmacy₁
   • ₶
     Veterans Affairs (VA)₁
   • ₶
     Other₁: __________
8. Of the pharmacies that you use, which pharmacy provides you with the majority of your pharmacy services? ____________

   • ₶
     Chain retail (e.g. CVS, Walgreens, Rite Aid)₁
   • ₶
     Chain mass merchant (e.g. Target, Walmart)₂
   • ₶
     Chain grocery store (e.g. Kroger, Marsh)₃
   • ₶
     Independent retail pharmacy (fewer than four locations)₄
   • ₶
     Clinic based pharmacy₅
   • ₶
     Compounding-only pharmacy₆
   • ₶
     Mail order₇
   • ₶
     Internet₈
   • ₶
     Outpatient hospital pharmacy₉
   • ₶
     Veterans Affairs (VA)₁₀
   • ₶
     Other₁₁: __________
   • ₶
     Both chain retail and compounding pharmacies₁₂
9. Participation in community activities-check all that apply:

   • ₶
     Community social and sporting events, e.g. festival, basketball game₁
   • ₶
     Fitness centers, e.g. YMCA, local gym₁
   • ₶
     Public office₁
   • ₶
     Religious organization₁
   • ₶
     School organizations, e.g. PTO₁
   • ₶
     Volunteer events/ benefits/ fundraisers₁
   • ₶
     Other₁: ________________
   • ₶
     None₁

10. Age: ______

11. Sex:

    • ₶
      Male₁
    • ₶
      Female₂
12. Ethnicity:

    • ₶
      Hispanic or Latino₁
    • ₶
      Non-Hispanic or Latino₂
13. Race:

    • ₶
      African-American/Black₁
    • ₶
      American Indian/Alaska Native₂
    • ₶
      Asian₃
    • ₶
      Caucasian/White₄
    • ₶
      Native Hawaiian/Other Pacific Islander₅
    • ₶
      More than one race₆
14. Preferred language

    • ₶
      English₁
    • ₶
      Spanish₂
    • ₶
      Other₃: __________
15. Marital status:

    • ₶
      Single₁
    • ₶
      Married₂
    • ₶
      Separated/Divorced₃
    • ₶
      Widowed₄
16. Living arrangements-check all that apply:

    • ₶
      Living alone₁
    • ₶
      Living with roommate₁
    • ₶
      Living with partner/spouse₁
    • ₶
      Living with children₁
    • ₶
      Living with parents and/or other family members₁
    • ₶
      Other₁: ____________
17. County of residence:

    • ₶
      Adams County₁
    • ₶
      Allen County₂
    • ₶
      Bartholomew County₃
    • ₶
      Benton County₄
    • ₶
      Blackford County₅
    • ₶
      Boone County₆
    • ₶
      Brown County₇
    • ₶
      Carroll County₈
    • ₶
      Cass County₉
    • ₶
      Clark County₁₀
    • ₶
      Clay County₁₁
    • ₶
      Clinton County₁₂
    • ₶
      Crawford County₁₃
    • ₶
      Daviess County₁₄
    • ₶
      Dearborn County₁₅
    • ₶
      Decatur County₁₆
    • ₶
      DeKalb County₁₇
    • ₶
      Delaware County₁₈
    • ₶
      Dubois County₁₉
    • ₶
      Elkhart County₂₀
    • ₶
      Fayette County₂₁
    • ₶
      Floyd County₂₂
    • ₶
      Fountain County₂₃
    • ₶
      Franklin County₂₄
    • ₶
      Fulton County₂₅
    • ₶
      Gibson County₂₆
    • ₶
      Grant County₂₇
    • ₶
      Greene County₂₈
    • ₶
      Hamilton County₂₉
    • ₶
      Hancock County₃₀
    • ₶
      Harrison County₃₁
    • ₶
      Hendricks County₃₂
    • ₶
      Henry County₃₃
    • ₶
      Howard County₃₄
    • ₶
      Huntington County₃₅
    • ₶
      Jackson County₃₆
    • ₶
      Jasper County₃₇
    • ₶
      Jay County₃₈
    • ₶
      Jefferson County₃₉
    • ₶
      Jennings County₄₀
    • ₶
      Johnson County₄₁
    • ₶
      Knox County₄₂
    • ₶
      Kosciusko County₄₃
    • ₶
      LaGrange County₄₄
    • ₶
      Lake County₄₅
    • ₶
      LaPorte County₄₆
    • ₶
      Lawrence County₄₇
    • ₶
      Madison County₄₈
    • ₶
      Marion County₄₉
    • ₶
      Marshall County₅₀
    • ₶
      Martin County₅₁
    • ₶
      Miami County₅₂
    • ₶
      Monroe County₅₃
    • ₶
      Montgomery County₅₄
    • ₶
      Morgan County₅₅
    • ₶
      Newton County₅₆
    • ₶
      Noble County₅₇
    • ₶
      Ohio County₅₈
    • ₶
      Orange County₅₉
    • ₶
      Owen County₆₀
    • ₶
      Parke County₆₁
    • ₶
      Perry County₆₂
    • ₶
      Pike County₆₃
    • ₶
      Porter County₆₄
    • ₶
      Posey County₆₅
    • ₶
      Pulaski County₆₆
    • ₶
      Putnam County₆₇
    • ₶
      Randolph County₆₈
    • ₶
      Ripley County₆₉
    • ₶
      Rush County₇₀
    • ₶
      Scott County₇₁
    • ₶
      Shelby County₇₂
    • ₶
      Spencer County₇₃
    • ₶
      St. Joseph County₇₄
    • ₶
      Starke County₇₅
    • ₶
      Steuben County₇₆
    • ₶
      Sullivan County₇₇
    • ₶
      Switzerland County₇₈
    • ₶
      Tippecanoe County₇₉
    • ₶
      Tipton County₈₀
    • ₶
      Union County₈₁
    • ₶
      Vanderburgh County₈₂
    • ₶
      Vermillion County₈₃
    • ₶
      Vigo County₈₄
    • ₶
      Wabash County₈₅
    • ₶
      Warren County₈₆
    • ₶
      Warrick County₈₇
    • ₶
      Washington County₈₈
    • ₶
      Wayne County₈₉
    • ₶
      Wells County₉₀
    • ₶
      White County₉₁
    • ₶
      Whitley County₉₂
18. Highest level of education completed:

    • ₶
      Grade/Middle School₁
    • ₶
      High School (12th grade) or G.E.D.₂
    • ₶
      Some College/Community College/Technical/Trade School₃
    • ₶
      College (Bachelors)₄
    • ₶
      Graduate (e.g. M.S., PhD)/ Professional School (e.g. MD, DDS, PharmD)₅
19. How would you describe your household income?

    • ₶
      Comfortable₁
    • ₶
      Just enough to make ends meet₂
    • ₶
      Do not have enough to make ends meet₃
20. Insurance carrier:

    • ₶
      Private Insurance₁
    • ₶
      Medicare₂
    • ₶
      Medicaid₃
    • ₶
      Dual Eligibility: Medicare and Medicaid₄
    • ₶
      Other₅: _____________
    • ₶
      None₆
21. Does your insurance carrier cover prescriptions?

    • ₶
      No₁
    • ₶
      Yes₂
      • ○
        If so, to what extent are you covered?
        • ■
          For example, is your plan based on a tiered copay? Do you have a spend-down, quantity limitations, etc.?
        • ■
          Response:_______________________________________________

Part II: Interview Questions

	Main Question	Follow-Up	Probes
Begin with general questions
	Tell me about your pharmacist. What does he/she do other than dispense medications?	Do they do any of the following? –answer questions –counsel on medications –vaccinate –education classes	What else?
	How would you describe your satisfaction with your relationship with your pharmacist?	–What makes you say that? –How would you describe your comfort level? –Can you give me an example of a positive interaction with your pharmacist? –Negative interaction? –How can your pharmacist improve this relationship?
	When you have questions about anything relating to your health, where do you go or who do you talk to in order to obtain more information? –e.g. library, internet, health food store, friend, family, physician, nurse, pharmacist, etc.	*If haven’t had questions, where would you recommend a friend or neighbor go? –To what extent would you recommend that your friend contact your pharmacist? Explain. *What types of questions did you ask them?
Now, I want to transition and talk about health resources for people in your community. *Define community-based resource	Tell me about the community-based resources that are available in your community.	In terms of these health resources, what needs are not being met in your community?	Community-based resources would include any program or activity that could potentially impact the health of patients, e.g. low-cost clinics, senior activity centers, child care, etc.
	Describe your use of these resources.	–If have not used: Describe a friend or family member’s use of community-based resources. –If have used: Have you personally requested information about such resources from your pharmacist or technician? –Explain
	In your experience, how are community pharmacists and technicians currently involved in recommending community-based health resources to patients?	With this in mind, what role do you believe they should play in recommending such resources?	For example, this could pertain to providing information about medical conditions, support groups, child care, social activities, etc.
Finally	In your opinion, is there anything else that pharmacists could do to improve the health of people throughout your community?

Appendix B –. Interview Guide for Technicians

Part I: Demographic Information

1. Technician degree received (check all that apply):

   • ₶
     Pharmacy technician-in-training₁
   • ₶
     State certified technician₁
   • ₶
     Certified pharmacy technician (CPhT)₁
2. Additional specialized training-Check all that apply:

   • ₶
     NPTA Compounding Certification₁
   • ₶
     NPTA Chemo Certification₁
   • ₶
     NPTA Sterile Products Certification₁
   • ₶
     Other₁: _______________
   • ₶
     None₁
3. Additional Degree Completed- Check all that apply:

   • ₶
     Associates₁
   • ₶
     Bachelors₁
   • ₶
     Masters₁
   • ₶
     PhD₁
   • ₶
     Other_{1:_________________}
   • ₶
     None₁

4. How long participant has been a technician: ____________

5. How would you describe your pharmacy site of employment:

   • ₶
     Chain retail (e.g. CVS, Walgreens, Rite Aid)₁
   • ₶
     Chain mass merchant (e.g. Target, Walmart)₂
   • ₶
     Chain grocery store (e.g. Kroger, Marsh)₃
   • ₶
     Independent retail pharmacy (fewer than four locations)₄
   • ₶
     Clinic based pharmacy₅
   • ₶
     Hospital outpatient pharmacy₆
   • ₶
     Compounding-only pharmacy₇
   • ₶
     Other specialty pharmacy₈
     • ○
       Describe:_____________________
6. County where currently employedAdams County₁

   • ₶
     Allen County₂
   • ₶
     Bartholomew County₃
   • ₶
     Benton County₄
   • ₶
     Blackford County₅
   • ₶
     Boone County₆
   • ₶
     Brown County₇
   • ₶
     Carroll County₈
   • ₶
     Cass County₉
   • ₶
     Clark County₁₀
   • ₶
     Clay County₁₁
   • ₶
     Clinton County₁₂
   • ₶
     Crawford County₁₃
   • ₶
     Daviess County₁₄
   • ₶
     Dearborn County₁₅
   • ₶
     Decatur County₁₆
   • ₶
     DeKalb County₁₇
   • ₶
     Delaware County₁₈
   • ₶
     Dubois County₁₉
   • ₶
     Elkhart County₂₀
   • ₶
     Fayette County₂₁
   • ₶
     Floyd County₂₂
   • ₶
     Fountain County₂₃
   • ₶
     Franklin County₂₄
   • ₶
     Fulton County₂₅
   • ₶
     Gibson County₂₆
   • ₶
     Grant County₂₇
   • ₶
     Greene County₂₈
   • ₶
     Hamilton County₂₉
   • ₶
     Hancock County₃₀
   • ₶
     Harrison County₃₁
   • ₶
     Hendricks County₃₂
   • ₶
     Henry County₃₃
   • ₶
     Howard County₃₄
   • ₶
     Huntington County₃₅
   • ₶
     Jackson County₃₆
   • ₶
     Jasper County₃₇
   • ₶
     Jay County₃₈
   • ₶
     Jefferson County₃₉
   • ₶
     Jennings County₄₀
   • ₶
     Johnson County₄₁
   • ₶
     Knox County₄₂
   • ₶
     Kosciusko County₄₃
   • ₶
     LaGrange County₄₄
   • ₶
     Lake County₄₅
   • ₶
     LaPorte County₄₆
   • ₶
     Lawrence County₄₇
   • ₶
     Madison County₄₈
   • ₶
     Marion County₄₉
   • ₶
     Marshall County₅₀
   • ₶
     Martin County₅₁
   • ₶
     Miami County₅₂
   • ₶
     Monroe County₅₃
   • ₶
     Montgomery County₅₄
   • ₶
     Morgan County₅₅
   • ₶
     Newton County₅₆
   • ₶
     Noble County₅₇
   • ₶
     Ohio County₅₈
   • ₶
     Orange County₅₉
   • ₶
     Owen County₆₀
   • ₶
     Parke County₆₁
   • ₶
     Perry County₆₂
   • ₶
     Pike County₆₃
   • ₶
     Porter County₆₄
   • ₶
     Posey County₆₅
   • ₶
     Pulaski County₆₆
   • ₶
     Putnam County₆₇
   • ₶
     Randolph County₆₈
   • ₶
     Ripley County₆₉
   • ₶
     Rush County₇₀
   • ₶
     Scott County₇₁
   • ₶
     Shelby County₇₂
   • ₶
     Spencer County₇₃
   • ₶
     St. Joseph County₇₄
   • ₶
     Starke County₇₅
   • ₶
     Steuben County₇₆
   • ₶
     Sullivan County₇₇
   • ₶
     Switzerland County₇₈
   • ₶
     Tippecanoe County₇₉
   • ₶
     Tipton County₈₀
   • ₶
     Union County₈₁
   • ₶
     Vanderburgh County₈₂
   • ₶
     Vermillion County₈₃
   • ₶
     Vigo County₈₄
   • ₶
     Wabash County₈₅
   • ₶
     Warren County₈₆
   • ₶
     Warrick County₈₇
   • ₶
     Washington County₈₈
   • ₶
     Wayne County₈₉
   • ₶
     Wells County₉₀
   • ₶
     White County₉₁
   • ₶
     Whitley County₉₂
7. Position held within pharmacy where currently employed:

   • ₶
     Lead pharmacy technician₁
   • ₶
     Pharmacy technician₂
   • ₶
     Pharmacy technician-in-training₃
   • ₶
     Other₄: ___________

8. How long have you been employed by this pharmacy? _____________

9. Approximate number of prescriptions filled at pharmacy per week:

   • ₶<500₁
   • ₶500–1000₂
   • ₶1001–2500₃
   • ₶>2500₄
10. Additional services offered at pharmacy where currently employed-Check all that apply:

    • ₶
      Disease state management/education programs₁
    • ₶
      Immunizations₁
    • ₶
      Medication Therapy Management (MTM--Comprehensive Medication Reviews)₁
    • ₶
      Compounding₁
    • ₶
      Mastectomy products/fittings₁
    • ₶
      Durable Medical Equipment (DME)₁
    • ₶
      Health and wellness screenings/ point-of-care testing₁
    • ₶
      Other₁: _________________________
11. Do you reside in the same community that your pharmacy is located?

    • ₶
      Yes₁
    • ₶
      No₂

12. If yes, how many years have you resided in this location: _____________year(s).

13. Participation in community activities-check all that apply:

    • ₶
      Community social and sporting events, e.g. festival, baseball game₁
    • ₶
      Fitness centers, e.g. YMCA, local gym₁
    • ₶
      Public office₁
    • ₶
      Religious organization₁
    • ₶
      School organizations, e.g. PTO₁
    • ₶
      Volunteer events/ benefits/ fundraisers₁
    • ₶
      Other₁: ________________
    • ₶
      None₁

14. Age: ______

15. Sex:

    • ₶
      Male₁
    • ₶
      Female₂
16. Ethnicity:

    • ₶
      Hispanic or Latino₁
    • ₶
      Non-Hispanic or Latino₂
17. Race:

    • ₶
      African-American/Black₁
    • ₶
      American Indian/Alaska Native₂
    • ₶
      Asian₃
    • ₶
      Caucasian/White₄
    • ₶
      Native Hawaiian/Other Pacific Islander₅
    • ₶
      More than one race₆

Part II: Interview Questions

	Main Question	Follow-Up	Probes
Begin with general questions
	How would you describe your patient population?		–Socioeconomic status –Racial/ethnic diversity –Religious diversity
	How would you describe your satisfaction with your role in the community?	Why? What do you think needs to be addressed?
	How would you describe your level of involvement with this community?		Does your level of involvement differ inside the pharmacy vs. your time spent outside of the pharmacy?
	In a typical week, how often do you assist patients with referrals, answering questions, giving additional information, etc.?	Who typically initiates the conversation? For example, does the patient come to you requesting your assistance? Do you offer such information in certain situations?
Now, I want to transition and talk about health resources for people in your community. *Define community-based resource	Please describe your familiarity with community-based resources available in your community.	Think about your patient population. What needs of your patients are currently not being met? What community-based resources would you refer such patients to if they were available in your community?	Community-based resources would include any program or activity that could potentially impact the health of your patients, as well as access to care.
	What role do community pharmacists and technicians currently play in the recommendation of community-based resources to patients?	What role do you think pharmacists should play? What role do you think technicians should play? In your opinion, what would it take for this to happen?
	What are examples of community-based resources that you have recommended to your patients?	In general, how have your patients responded to your promotion of community-based resources? Overall, how have your recommendations affected patient health outcomes? To what extent do you typically follow-up with these individuals? In what way?	–support groups –home care services –Meals-on-Wheels –etc.
Now, I want to transition and talk about these resources and how they relate specifically to the geriatric population.	In your community, what resources would you recommend to your geriatric patients?	What specifically do you do to assist your geriatric patients? What can technicians do, as a whole, to better serve the elderly? Pharmacists?	–easy off lids –mobility issues –fill weekly pill organizer
	What needs of your geriatric patients are currently not being met?	What health resources would you refer such patients to if they were available in your community?
Finally	What suggestions do you have for ways that the pharmacy profession can become more involved in promotion of community programs?

Appendix C –. Interview Guide for Pharmacists

Part I: Demographic Information

1. Pharmacy degree received:

   • ₶
     B.S.₁
   • ₶
     PharmD₂
   • ₶
     BS and PharmD₃
2. Additional education/degree completed-check all that apply:

   • ₶
     PGY-1 residency₁
   • ₶
     PGY-2 residency₁
   • ₶
     Fellowship₁
   • ₶
     PhD₁
   • ₶
     Masters₁
   • ₶
     Other_{1:_________________}
   • ₶
     None₁
3. Certifications obtained (check all that apply):

   • ₶
     Board Certified Pharmacotherapy Specialist (BCPS)₁
   • ₶
     Board Certified Ambulatory Care Pharmacist (BCACP)₁
   • ₶
     Certified Diabetes Educator (CDE)₁
   • ₶
     Certified Geriatrics Pharmacist (CGP)₁
   • ₶
     APhA Pharmacist and Patient-Centered Diabetes Care Certificate₁
   • ₶
     APhA Pharmacy-Based Lipid Management Certificate₁
   • ₶
     APhA Immunization Certificate₁
   • ₶
     APhA Medication Therapy Management Certificate₁
   • ₶
     Other₁: ______________________________________
   • ₶
     None₁

4. How many years licensed as a pharmacist: ____________

5. How would you describe your pharmacy site of employment:

   • ₶
     Chain retail (e.g. CVS, Walgreens, Rite Aid)₁
   • ₶
     Chain mass merchant (e.g. Target, Walmart)₂
   • ₶
     Chain grocery store (e.g. Kroger, Marsh)₃
   • ₶
     Independent retail pharmacy (fewer than four locations)₄
   • ₶
     Clinic based pharmacy₅
   • ₶
     Hospital outpatient pharmacy₆
   • ₶
     Compounding-only pharmacy₇
   • ₶
     Other specialty pharmacy₈
     • ○
       Describe:_____________________
6. County where currently employed:

   • ₶
     Adams County₁
   • ₶
     Allen County₂
   • ₶
     Bartholomew County₃
   • ₶
     Benton County₄
   • ₶
     Blackford County₅
   • ₶
     Boone County₆
   • ₶
     Brown County₇
   • ₶
     Carroll County₈
   • ₶
     Cass County₉
   • ₶
     Clark County₁₀
   • ₶
     Clay County₁₁
   • ₶
     Clinton County₁₂
   • ₶
     Crawford County₁₃
   • ₶
     Daviess County₁₄
   • ₶
     Dearborn County₁₅
   • ₶
     Decatur County₁₆
   • ₶
     DeKalb County₁₇
   • ₶
     Delaware County₁₈
   • ₶
     Dubois County₁₉
   • ₶
     Elkhart County₂₀
   • ₶
     Fayette County₂₁
   • ₶
     Floyd County₂₂
   • ₶
     Fountain County₂₃
   • ₶
     Franklin County₂₄
   • ₶
     Fulton County₂₅
   • ₶
     Gibson County₂₆
   • ₶
     Grant County₂₇
   • ₶
     Greene County₂₈
   • ₶
     Hamilton County₂₉
   • ₶
     Hancock County₃₀
   • ₶
     Harrison County₃₁
   • ₶
     Hendricks County₃₂
   • ₶
     Henry County₃₃
   • ₶
     Howard County₃₄
   • ₶
     Huntington County₃₅
   • ₶
     Jackson County₃₆
   • ₶
     Jasper County₃₇
   • ₶
     Jay County₃₈
   • ₶
     Jefferson County₃₉
   • ₶
     Jennings County₄₀
   • ₶
     Johnson County₄₁
   • ₶
     Knox County₄₂
   • ₶
     Kosciusko County₄₃
   • ₶
     LaGrange County₄₄
   • ₶
     Lake County₄₅
   • ₶
     LaPorte County₄₆
   • ₶
     Lawrence County₄₇
   • ₶
     Madison County₄₈
   • ₶
     Marion County₄₉
   • ₶
     Marshall County₅₀
   • ₶
     Martin County₅₁
   • ₶
     Miami County₅₂
   • ₶
     Monroe County₅₃
   • ₶
     Montgomery County₅₄
   • ₶
     Morgan County₅₅
   • ₶
     Newton County₅₆
   • ₶
     Noble County₅₇
   • ₶
     Ohio County₅₈
   • ₶
     Orange County₅₉
   • ₶
     Owen County₆₀
   • ₶
     Parke County₆₁
   • ₶
     Perry County₆₂
   • ₶
     Pike County₆₃
   • ₶
     Porter County₆₄
   • ₶
     Posey County₆₅
   • ₶
     Pulaski County₆₆
   • ₶
     Putnam County₆₇
   • ₶
     Randolph County₆₈
   • ₶
     Ripley County₆₉
   • ₶
     Rush County₇₀
   • ₶
     Scott County₇₁
   • ₶
     Shelby County₇₂
   • ₶
     Spencer County₇₃
   • ₶
     St. Joseph County₇₄
   • ₶
     Starke County₇₅
   • ₶
     Steuben County₇₆
   • ₶
     Sullivan County₇₇
   • ₶
     Switzerland County₇₈
   • ₶
     Tippecanoe County₇₉
   • ₶
     Tipton County₈₀
   • ₶
     Union County₈₁
   • ₶
     Vanderburgh County₈₂
   • ₶
     Vermillion County₈₃
   • ₶
     Vigo County₈₄
   • ₶
     Wabash County₈₅
   • ₶
     Warren County₈₆
   • ₶
     Warrick County₈₇
   • ₶
     Washington County₈₈
   • ₶
     Wayne County₈₉
   • ₶
     Wells County₉₀
   • ₶
     White County₉₁
   • ₶
     Whitley County92
7. Position held within pharmacy where currently employed:

   • ₶
     Pharmacy manager and/or owner₁
   • ₶
     Full-time staff pharmacist₂
   • ₶
     Part-time staff pharmacist₃
   • ₶
     Floater/ temporary staff pharmacist₄

8. How long have you been employed by this pharmacy? _________

9. Approximate number of prescriptions filled at pharmacy per week:

   • ₶<500₁
   • ₶500–1000₂
   • ₶1001–2500₃
   • ₶>2500₄
10. Additional services offered at pharmacy where currently employed-Check all that apply:

    • ₶
      Disease state management/education programs₁
    • ₶
      Immunizations₁
    • ₶
      Medication Therapy Management (MTM--Comprehensive Medication Reviews)₁
    • ₶
      Compounding₁
    • ₶
      Mastectomy products/fittings₁
    • ₶
      Durable Medical Equipment (DME)₁
    • ₶
      Health and wellness screenings/ point-of-care testing₁
    • ₶
      Other₁: _________________________
11. Do you reside in the same community that your pharmacy is located?

    • ₶
      Yes₁
    • ₶
      No₂

12. If yes, how many years have you resided in this location: _____________year(s).

13. Participation in community activities-check all that apply:

    • ₶
      Community social and sporting events, e.g. festival, baseball game₁
    • ₶
      Fitness centers, e.g. YMCA, local gym₁
    • ₶
      Public office₁
    • ₶
      Religious organization₁
    • ₶
      School organizations, e.g. PTO₁
    • ₶
      Volunteer events/ benefits/ fundraisers₁
    • ₶
      Other₁: ________________
    • ₶
      None₁

14. Age: ______

15. Sex:

    • ₶
      Male₁
    • ₶
      Female₂
16. Ethnicity:

    • ₶
      Hispanic or Latino₁
    • ₶
      Non-Hispanic or Latino₂
17. Race:

    • ₶
      African-American/Black₁
    • ₶
      American Indian/Alaska Native₂
    • ₶
      Asian₃
    • ₶
      Caucasian/White₄
    • ₶
      Native Hawaiian/Other Pacific Islander₅
    • ₶
      More than one race₆

Part II: Interview Questions

	Main Question	Follow-Up	Probes
Begin with general questions
	How would you describe your patient population?		–Socioeconomic status –Racial/ethnic diversity –Religious diversity
	How would you describe your satisfaction with your role in the community?	Why? What do you think needs to be addressed?
	How would you describe your level of involvement with this community?		Does your level of involvement differ inside the pharmacy versus your time spent outside of the pharmacy?
	In a typical week, how often do you assist patients with referrals, answering questions, giving additional information, etc.?	Who typically initiates the conversation? For example, does the patient come to you requesting your assistance? Do you offer such information during medication consultations?
Now, I want to transition and talk about health resources for people in your community. *Define community-based resource	Please describe your familiarity with community-based resources available in your community.	Think about your patient population. What needs of your patients are currently not being met? What community-based resources would you refer such patients to if they were available in your community?	Community-based resources would include any program or activity that could potentially impact the health of your patients, as well as access to care.
	What role do community pharmacists and technicians currently play in the recommendation of community-based resources to patients?	What role do you think pharmacists should play? What role do you think technicians should play? In your opinion, what would it take for this to happen?
	What are examples of community-based resources that you have recommended to your patients?	In general, how have your patients responded to your promotion of community-based resources? Overall, how have your recommendations affected patient health outcomes? To what extent do you typically follow-up with these individuals? In what way?	–support groups –home care services –Meals-on-Wheels –etc.
Now, I want to transition and talk about these resources and how they relate specifically to the geriatric population.	In your community, what resources would you recommend to your geriatric patients?	What specifically do you do to assist your geriatric patients? What can pharmacists do, as a whole, to better serve the elderly? Technicians?
	What needs of your geriatric patients are currently not being met?	What health resources would you refer such patients to if they were available in your community?
Finally	What suggestions do you have for ways that the pharmacy profession can become more involved in promotion of community programs?