Making it happen: Strategies to incorporate vaccinations into community pharmacy practice

Community pharmacists face a number of competing priorities each day. Nonprescription drug consultations, prescription dispensing and counselling (especially given the increasing complexity of third-party billing and recent drug shortages!), collaboration with other health professionals, medication reviews . . . each of these add up to a heavy workload and understandable challenges with adding vaccination services into the mix. Indeed, inadequate time and staffing to provide these services have been frequently cited as key barriers encountered by pharmacists worldwide when considering the implementation or expansion of vaccination services they offer.^1-3

This article presents strategies for starting, expanding or optimizing vaccination services in community pharmacy practice. Recognizing varying scopes of practice provincially, at least 1 practising pharmacist from each of the 9 Canadian provinces that authorize injection administration by pharmacists⁴ contributed to this article.

Identifying patients who may benefit from vaccination

Many patients present to the pharmacy requesting a specific vaccination; however, lack of awareness of the need for a vaccine is a common reason for patients to not receive it.⁵ The pharmacists interviewed provided a number of strategies to improve overall vaccination awareness and the identification of under- or unimmunized patients. While “passive” techniques such as signage, pamphlets and bag stuffers have been tried by a number of pharmacists, many commented that these have had marginal success rates and that the time and cost involved in designing and disseminating these resources can be better invested in engagement. As stated by 1 pharmacist, “Adults only learn when it applies to them,” and this necessary level of personalization is not achievable from generic printed and passive resources.

It is well recognized that pharmacists have the advantage of frequent contact with their patients. Each of these contacts provides an opportunity to screen for vaccination needs with greater efficiency than dedicated clinic days or campaigns. Reporting functions in the dispensary software can be used to place a pop-up reminder on profiles for all patients meeting a particular criterion, such as age or use of a medication that may indicate a higher risk of complications from a vaccine-preventable condition (e.g., an inhaler as a marker for asthma or chronic obstructive pulmonary disease as a trigger to ask about influenza vaccination status). This pop-up increases the chances that vaccination status is asked at the next prescription drop-off or pick-up and that the patient’s personal risk factor(s) are discussed.

Pharmacists also commented on the ease at which they have “piggy-backed” vaccination screening to other services. For example, asking about and documenting vaccination status in conjunction with medication reviews, asking about pneumococcal and shingles vaccination status for those aged ≥50 years on the patient consent form for influenza vaccination and inquiring about travel vaccination status when patients are picking up antibiotics for travellers’ diarrhea or purchasing sunscreen are successful strategies to identify under- or unimmunized patients with little additional time or resource investment required.

Improving efficiency of the vaccination process

Optimizing the efficiency of the vaccination process within the pharmacy’s workflow can offer many benefits: minimized disruption from walk-in requests for vaccination, reduced wait times for patients and greater cost-effectiveness of the service for the pharmacy. Key to optimizing efficiency is using pharmacy assistants and technicians as much as possible. Order entry, billing and inventory are perhaps the most obvious steps to delegate; however, this has been successfully expanded to also include the information-gathering and consent process, postinjection monitoring and sending notifications of vaccination to other health care professionals. For example, patients can self-complete the patient history and consent form with the assistant or technician checking it for completeness or requesting additional details (requiring the pharmacist to simply review it for precautions or contraindications) and the assistant or technician can also manage patients under observation for postinjection reactions and only refer those reporting any symptoms to the pharmacist for assessment. Having consent forms and information sheets for each vaccine within the scope of the pharmacist to administer preprinted and readily available also improves efficiency, versus printing them on demand. Finally, the scheduling of appointments was found to be a facilitator, particularly for patients likely to require additional time, such as those requiring a travel consultation, needing multiple injections or having a history of anxiety or fainting from injections.

Recognizing that appointment-based vaccinations are easier to plan for from the pharmacy’s perspective but that the convenience of walk-in service is valued by patients, most pharmacists interviewed employed a blended model—scheduling appointments whenever possible but also accommodating walk-ins as required to reduce any barriers to vaccination. Patients initially hesitant to schedule appointments were reminded that if an appointment is made, every effort will be made for the pharmacist to see them at their appointment time, whereas walk-ins are processed in the same queue as all prescriptions awaiting dispensing. This reduction in potential wait time was often valued by patients more than the convenience of being able to come in without an appointment.

One pharmacist stressed the importance of ensuring that all pharmacy staff subscribe to the belief that they are always “open for business” when it comes to vaccinations and to never turn someone away during busy times but rather make the expectation of a wait time clear for the patient upfront. Particularly at the start of the influenza season, the investment in additional overlap, allowing a dedicated pharmacist for clinic days, has been found to be well worth it in terms of reducing the disruption of vaccinations on pharmacy workflow and wait times. Finally, 1 pharmacist recommends taking appointments as soon as patients start asking when the vaccine will be available, as it is generally much easier to get a patient to book an appointment before the vaccine is released compared to afterwards, when people expect it to be available to them immediately.

Discussing injection administration fees with patients

All pharmacists consulted charge an administration fee to provide vaccinations not currently reimbursed by their provincial government, generally $15 to $20, although some include injections for travel vaccines within the fee charged if they receive a travel consultation from the pharmacy. When discussing with patients the reason for the fee, the following approaches have been successfully used:

• Educating the patient that while physicians and nurses may be paid for these services, the government does not currently reimburse pharmacists for it. Even though their physician or nurse is not charging them directly, they are being paid for it through tax dollars and not doing it for “free.” This can be an opportunity to engage patients to advocate for pharmacist reimbursement for these services to their government representative.

• Provide the patient with a receipt that also indicates the injection fee charged as a separate item, as these expenses are eligible for income tax deductions or reimbursement through health spending accounts.

• Provide options. For a fee, they can receive the injection immediately. Alternatively, they can make an appointment with another care provider, travel to the appointment and likely have a wait in the waiting room. Many patients will value their time at more than the fee charged.

• Don’t feel guilty about asking to be paid for your care. One pharmacist reminds readers that when charging for a professional service, “you are selling health, not a product.”

Pharmacists have reported that remuneration received for injection services, particularly government-funded injections, is too low to offset costs. Subsequently, they are hesitant to promote or expand these services.² A number of pharmacists consulted agreed that this may be the case for some vaccines but that pharmacists also need to consider the additional benefits of offering the service, such as over-the-counter sales for related conditions (e.g., cough and cold products during influenza season, sunscreen for travellers), drawing in new patients to your pharmacy and enhanced loyalty for future services if they have a positive experience with the vaccination. Spending the equivalent time required to give a vaccination to dispensing may be immediately more profitable, but long term, 1 pharmacist stated that vaccinations “give value in other ways.” Furthermore, 1 pharmacist also commented on the positive impact on the perception of our profession that offering vaccinations and other public health services can have, by “taking away some of the retailer stereotype that plagues pharmacists.”

Facilitating multiple-dose vaccine series and boosters

Administering a single vaccine at the pharmacy has become a regular part of most pharmacies’ workflows. However, how do we ensure that patients requiring multiple injections to complete a series receive them? Most pharmacists reported using the follow-up function in their dispensary software to prompt them when next doses are due (or auto-fill the prescription) and follow that up with a call to the patient. In the event that patients cannot be contacted, a pop-up note is placed on their file to ensure this is discussed at their next visit to the pharmacy. When possible, book an appointment for injection of the next dose during the current visit and provide the patient with an appointment card documenting this as well as a reminder call 48 hours before the appointment. One pharmacist uses a similar approach based on the expiry date of epinephrine autoinjectors dispensed, so that patients are reminded when their current pen needs replacement.

Minimizing patient anxiety and finding other opportunities to promote vaccinations

Administering vaccinations in a busy community pharmacy setting can present additional challenges when patients have anxiety about receiving injections. Here are some strategies other pharmacists have used to make this experience as smooth as possible:

• Never prepare a vaccine in front of the patient. Only use the injection room for the injection itself. Talk about something else to take their mind off the injection or consider playing a relaxing video on a loop on a computer for patients to watch.

• Sometimes, parents will insist that you vaccinate their child who is clearly anxious or screaming. One pharmacist reported that she will not vaccinate children under this circumstance as it only promotes more anxiety around receiving needles and instead will ask the parent to try other techniques such as distraction to allow this acute moment of anxiety to taper off before trying again.

• Other strategies for vaccinating children include having a candy jar for children to treat themselves from during the injection or toys that the children can play with as an additional distraction. Allow children to decide which arm they want to receive the injection in and don’t lie to them by saying it won’t hurt, but rather that it will feel like a small pinch that will go away very quickly and the needle is important to keep them from getting sick.

• One pharmacist uses humour to help relieve anxiety by telling patients, “We have the best needles around. They cost more, so don’t tell my boss!”

Finally, pharmacists encourage readers to look for and act upon all opportunities to promote yourself as an immunizer/injector and health care professional. Examples of identifying and acting upon opportunities that presented themselves to further enhance the pharmacist’s role include the following:

• One pharmacist shared how his ability to inject nonvaccine drug products within his scope of practice facilitated access to care for a patient with severe migraines. This patient was prescribed intramuscular meperidine but was unable to self-administer it. Wait times at a physicians’ office or emergency room were not an option for her, so the pharmacist made himself available to inject it for her when she had a severe migraine.

• Another pharmacist in a province allowing off-site influenza vaccinations coupled a clinic day at a long-term care facility with a 15-minute presentation for staff and family members on the benefits and safety of influenza vaccination. Not only were the long-term care residents vaccinated, but a number of staff and caregivers were as well, and informal discussions with these individuals identified other drug therapy problems that the pharmacist was able to address. Many of these patients subsequently became regular patients of this pharmacy after this outreach effort.

The bottom line

A common theme expressed by all of these pharmacists was the importance of viewing pharmacist-administered vaccinations through a public health service lens, rather than a product lens. In doing so, pharmacy staff can be encouraged to offer this service to all eligible patients and minimize barriers to access, patients can see value in paying for the ability to receive this care and pharmacies can value the downstream impact of offering vaccination services on future loyalty and new patient recruitment.■