Implementation of Primary Care Clinical Pharmacy Services for Adults Experiencing Homelessness

Implementation of Primary Care Clinical Pharmacy Services for Adults Experiencing Homelessness
Anna Insley, PharmD., Welia Health

Background: Homeless individuals experience proportionately higher rates of mental illness, substance abuse, diabetes, hypertension, and HIV than the general population. By the same token, several barriers stand in their way to access care, including food scarcity and limited healthcare resources. Additionally, they may have lower health literacy and competing health concerns. If they are able to gain access to care, these patients can experience social stigma, uncompassionate healthcare, and misconceptions about their homelessness that decrease their quality of care. These negative experiences can decrease their willingness to seek medical care in the future. The addition of a pharmacist on interdisciplinary teams taking care of these patients can improve access, provide more opportunities for patient education, and potentially improve health outcomes. This article set out to bridge the gap in literature regarding pharmacist-led clinical services for the homeless population.

Objective: To evaluate the type and frequency of the interventions made by the pharmacist at a clinic caring for patients experiencing homelessness, to describe the patients receiving the novel service, and assess the clinical outcomes related to primary care disease states, such as diabetes, hypertension, obesity and tobacco use disorder.

Practice Description: This was a pilot service provided by a postgraduate year 2 (PGY-2) ambulatory care resident pharmacist located at Pedigo Clinic within Eskenazi Health in Marion County, IN. Pedigo Clinic was established to provide care to patients experiencing homelessness and a clinical pharmacist had not previously been a member of the interdisciplinary care team. Prior to the study, pharmacists in this health system had an existing collaborative practice agreement (CPA) for cardiovascular risk reduction (CVRR) clinics to manage diabetes, hypertension, dyslipidemia, smoking cessation and vaccines. During the pilot period, the PGY-2 ambulatory care resident pharmacist attended the Pedigo Clinic one half-day each week to provide CVRR service under a CPA through referrals by the physician to patients noted to be experiencing homelessness. Additionally, the resident pharmacist consulted with the clinic staff regarding specific patients.

Practice Innovations: The pharmacist was able to address several aspects of patient care within the Pedigo Clinic. They helped patients with insurance coverage issues, provided bus passes to and from the clinic, monthly medication refills, and provided medication vouchers for copayments backed by health system funding. They helped store patient-specific medications for those unable to store refrigerated medications or where the patient possessing their medications posed a safety risk. They subsequently administered patient-specific medications at the clinic or dispensed smaller quantities to avoid any safety issues. Additionally, they tried to coordinate care on the same day as other visits.

Results: The service was piloted for 6 months, from September 2019 to March 2020. The resident pharmacist documented patient encounters in the electronic medical record and then retrospectively reviewed this convenience sample to collect data. Review included any patient with an appointment or consultation the pharmacist participated in. Twenty-eight patient encounters were completed for fourteen unique patients with a total of one hundred and twenty four interventions. Eighty-six percent of the patients were men, with ages ranging from 33 to 64 years old. Comprehensive medication review comprised 82.1% of the interventions, followed by patient education (75%), medication regimen optimization (64.3%), tobacco cessation (64.3%), coverage/cost inquiry (39.3%), and vaccination screening (28.6%). Evaluation of clinical outcomes at baseline and each subsequent visit happened for six patients that were seen more than one time. There were no statistically significant changes in clinical outcomes, given that this was a small convenience sample over a limited time period and therefore may not have been adequately powered to detect any meaningful differences in clinical outcomes.

Clinical Impact: The researchers found that pharmacists can have a positive impact on patient care for the homeless population. The pharmacist spent the most time optimizing patients’ medication regimens, as well as educating patients about disease states, goals of care, medication use, and adherence. Through extrapolation from previous data, they found a potential cost savings of an average of $160.58 per patient encounter translating to an approximate savings of nearly $321,000 annually.

Reference:

  1. Albertson S, Murray T, Triboletti J, Pence L, Gonzalvo J, Walroth T, Rodgers J, Crane L, Sidle J. Implementation of primary care clinical pharmacy services for adults experiencing homelessness. J Am Pharm Assoc. doi 10.1016/j.japh.2020.10.012