key: cord-270784-cmhtpxz7 authors: Thorakkattil, Shabeer A.; Nemr, Habib S.; Al-Ghamdi, Fuad H.; Jabbour, Rita J.; Al-Qaaneh, Ayman M. title: Structural and operational redesigning of patient-centered ambulatory care pharmacy services and its effectiveness during the COVID-19 pandemic date: 2020-06-23 journal: Res Social Adm Pharm DOI: 10.1016/j.sapharm.2020.06.017 sha: doc_id: 270784 cord_uid: cmhtpxz7 BACKGROUND: The newly emerged coronavirus pandemic (COVID-19) has collapsed the entire global health care system. Due to these settings, a lot of strategic changes are adopted by healthcare facilities to ensure continuity in patient-centered services. OBJECTIVE: This study aims to evaluate the effectiveness of structural and operational changes made in ambulatory care pharmacy services during the COVID-19 pandemic. METHODS: A retrospective comparative study was conducted to evaluate the impact and effectiveness of patient-centered interventions and consequent access to medication management care within Johns Hopkins Aramco Health Care ambulatory care pharmacy services during the COVID-19 pandemic by comparing patient-centered key performance indicators before and during COVID-19 pandemic for a total of 4 months. RESULTS: As a result of the structural and operational changes made in patient-centered ambulatory care pharmacy services during the COVID-19 pandemic, a 48% prescriptions requests and 90% prescriptions fills are increased through online health portal application. A three-fold increase in the pharmacy call center utilization resulted in around 10% abandoned calls. In the number of physical visits to ambulatory care pharmacies, a 37% reduction was also noted. The decrease in staff schedule efficiency and an increase in average prescription waiting time were also noticed. The prescription collection through remote area pick up locations, and medication home delivery services were successful during COVID-19 pandemic as supported by statistical data. CONCLUSION: The access to ambulatory care pharmacy services during COVID-19 pandemic has been successfully maintained via medication home delivery, remote area pickup locations, pharmacy call-center consultations and refill requests, online health portal application services, and other measures, while reducing the number of physical visits to the JHAH hospital/clinic to ensure compliance with infection control and prevention measures. The newly emerged coronavirus disease pandemic has led to the collapse of the entire global health care system by infecting, as of June 6, 2020, more than 6.8 million people, with almost 400,000 deaths. 1 for Disease Prevention and Control (Weqaya) has highlighted that specific patient populations are at higher risk for developing COVID-19; these populations include the elderly and patients with diabetes, heart disease, immunodeficiency conditions, and lung disease. 4 Other susceptible populations include pregnant and breastfeeding women, homeless individuals, and racial and ethnic minority groups. A wide range of symptoms is associated with COVID-19, from mild to severe. The most prominent symptoms of COVID-19 are cough, shortness of breath, fever, chills, muscle ache, sore throat, headache, and a loss of taste or smell. Symptoms may develop in 2 days to 2 weeks after exposure to the virus, although some reports suggest that the incubation period may last up to 24 days. 5 Restrictive measures including a curfew, area lockdown, physical distancing, case detection via proactive testing, isolation, contact tracing, and quarantine have been adopted by the governments worldwide to limit the spread of the disease. 6, 7 The COVID-19 pandemic has imposed a massive strain and challenges on the normal functioning of health care institutions worldwide. Special populations such as patients with chronic diseases are being affected due to social distancing and lockdowns to limit and contain the spread of the disease. They are unable to access healthcare facilities for routine care and medication management. The management of chronic conditions and the promotion of medication adherence during this pandemic is a burden on already strained health systems. To provide support for the World Health Organization's call to maintain essential services during the pandemic to limit non-COVID disease burden on healthcare systems is a challenging responsibility for each healthcare institution. 8 The well-being of both patients and health care workers is the cornerstone of every well-functioning health care institution. JHAH offers to its beneficiaries an online health portal, MyChart TM , which offers easy access to various services such as booking appointments, looking up test results, and requesting medication refills. 19 MyChart TM enables eligible beneficiaries and their family members to electronically request and arrange for medication refill dispensing from all pharmacy pickup locations to ensure access to care. JHAH also provides call-center pharmacy services through an interactive voice response system. This service allows patients to discuss their medication management requests with pharmacist operators who can counsel patients and to request and arrange medication refill dispensing. In addition to its 23 physical pickup locations, JHAH ambulatory care pharmacies manage pharmacy-operated clinics such as medication management clinics and anticoagulation clinics. The medication management clinic is a patient-centered, outcome-oriented interdependent practice managed by pharmacists that requires the pharmacist to work in collaboration with other healthcare providers and the patient, so as to ensure appropriate medication therapy and medication order extension under a collaborative agreement. The anticoagulation clinic is a patient-centered, outcome-oriented interdependent practice managed by pharmacists where the pharmacist reviews the oral anticoagulant medication profile and parameters, and provides instant International Normalized Ratio (INR) testing, dispensing, and appropriate counseling to ensure optimal therapy. To complement the person-centered interventions, both patient satisfaction and staff engagement data are collected electronically, measured, and benchmarked against regional providers by Press Ganey TM in collaboration with the JHAH Service Excellence group since August 2016. 20 Person-and patient-centered interventions applied within JHAH ambulatory care pharmacy services due to COVID-19 pandemic include the following: (I) General pharmacy infection control and prevention measures, (II) access to medication management care measures, (III) business continuity and staffing measures, and (IV) medication automation-related measures. • Nurses screen all patients, patients' family members, and JHAH staff upon entry into the pharmacy and before accessing any patient waiting areas. This infection prevention screening consists of the application of hand sanitizer; answering of questions related to travel history; temperature measurement; and a verbal assessment for symptoms, including cough, shortness of breath, and fever. 21 • In the patient waiting areas in the pharmacy, all chairs have been relocated to ensure proper physical distancing, easy-access hand sanitizer dispensers have been installed, and area TV screens have been modified to display hand hygiene videos. 22 • At the pharmacy dispensing counter, only one chair has been maintained per station, with a proper physical distancing from the counter and a floor marking. 23 All pharmacy staff are mandated to wear surgical masks along with face shields. 24 • All pharmacy staff are mandated to complete three online COVID-19-related courses via the JHAH electronic learning portal. 25 • Electronic communication methods are being used to advise and encourage all eligible patients to visit the JHAH pharmacy remote pickup location nearest to their work or residence to avoid unnecessary visits to the JHAH hospital and clinic buildings. 26 • In addition to the existing 23 JHAH ambulatory pharmacies and remote pickup locations, and to accommodate government-imposed lockdowns in specific areas, 27 JHAH has added three new temporary pickup locations within areas with a lockdown. All new three locations have been equipped with remote-access laptops to ensure access to electronic health care records, verification, and dispensing for eligible patients in the area who are unable to exit or enter the lockdown area. Patients' medication orders and refill requests made electronically and by calling the pharmacy call center are managed daily from the hospital ambulatory care pharmacy and shipped daily in a vehicle with police clearance to enter and exit the lockdown area. • JHAH enables eligible patients to request refills of existing medications electronically via the MyChart TM application or by calling the centralized pharmacy call center. In both cases, patients can select any of the 26 pickup locations (including the new 3 temporary locations). 19 • MyChart TM application access is available to JHAH's eligible patients, and requests for refills of existing medication orders or communication requests to clinicians can be made around the clock. The centralized pharmacy call center is accessible on weekdays during regular working hours. 19 • A new anticoagulation pharmacist-operated clinic has also been established in lockdown areas. In this center, the pharmacist reviews the oral anticoagulant medication profile and parameters, provides instant INR testing, dispensing, and appropriate counseling to ensure optimal therapy for patients affected by the lockdown. • On April 20, 2020, JHAH ambulatory care pharmacy services launched a pilot home delivery process to cater to cancer patients or patients aged above 60 years for due medication refills via a third-party courier provider. Requests received via the centralized pharmacy call center on business weekdays are delivered on the next working business day. • All new services, locations, and operational hours are advertised via SMS services, the JHAH website, and JHAH social media pages. • Pharmacy management actions are integrated with daily, JHAH institutional planning. Strategies for staffing, alternate care sites, re-assignment, and stocking of critical medications have been established in line with the directives of the JHAH management and COVID response team. • Pharmacy management monitors key performance indicators of core operations daily to adjust plans as necessary. • Pharmacy employees with medical conditions specified by the JHAH human resources department and Saudi MOH guidelines have been temporarily released from work under a "special medical leave." • Pharmacy operations are limited to core activities. Non-urgent meetings, committee sessions, educational activities, business assignments, and non-urgent audits have been postponed or conducted via teleconference. • Adequate supplies of essential pharmaceuticals as identified by the JHAH supply chain policy are monitored daily and ensured under the pharmaceutical supply unit operations. Committee have been considered for out-of-stock critical medications for which no therapeutic equivalents are available. • Staff schedule rotations are applied. • Pharmacists have been relocated to maximize the capacity of the centralized pharmacy call center. The number of agents has been increased from one full-time agent plus 2 backup agents to 6 full-time agents plus 2 backup agents. • The staff are encouraged to use the JHAH-established emotional-support helpline operated by mental health specialists. 28 • Utilizing JHAH's electronic healthcare host system for outpatient medication management (Epic Willow Ambulatory ®), an electronic banner and a report have been created to help users identify patients who have been confirmed or suspected to have COVID-19. • A report for medication "Due Refill" prescriptions has been electronically built to anticipate and reduce refill medication visits and identify candidates for the medication home delivery service. • An electronic best practice advisory alert has been created for ambulatory prescribing of chloroquine and hydroxychloroquine paired with the diagnosis to prevent off-label use. • New workflow and virtual build have been developed for the home delivery service and the three new pickup locations within JHAH's electronic healthcare host system for outpatient medication management (Epic® Willow Ambulatory). A retrospective, comparative study was conducted to evaluate the effectiveness of patient and person-centered interventions, and consequent access to medication management care during the COVID-19 pandemic by comparing data before and during the pandemic for a total period of four months at Johns Hopkins Aramco Health Care (JHAH) (two months before the pandemic -January and February 2020, and two months during the pandemic -March and April 2020). Although the number of working days did not exactly match the data before and during the COVID-19 pandemic, the comparison was made on two months of accumulated data before and during the COVID-19 pandemic, because the number of working hours was equal at both times due to reduced working hours in the lockdown period. The following data were collected and retrieved electronically from electronic healthcare records (Epic) and the Cisco TM call center dashboard (for two months before the pandemic -January and February 2020, and two months during the pandemic -March and April 2020). • Total number of patient calls to the centralized pharmacy call center to request refills, including the number of handled calls and percentage of abandoned calls. Results and discussion To assess the impact of critical operational changes in ambulatory care pharmacy services during the COVID 19 pandemic at JHAH, four months of data were retrieved electronically and compared during (March and April) and before (January and February) the COVID-19 pandemic with respect to certain patient-centered parameters. Comparison of Patient-centered parameters before and during COVID-19 workload in academic health center community pharmacies before and after implementation of a central call center. 30 In the current study, the effectiveness of pharmacy call center services before and during the COVID-19 pandemic was compared. Through the pharmacy call center, additional patient-centered services like patient counseling, medication renewal requests, and medication pick up requests through geographically distributed remote pick up locations were provided. These interventions led to a reduction in the number of physical visits to the JHAH hospital/clinics for medication-related purposes during the COVID-19 pandemic. The When the Saudi Arabian government imposed complete lockdown in a specific area that Figure 3 ). This patient-centered intervention ensured continuity of medication management and care of the eligible patients within the quarantined zones. The JHAH ambulatory care pharmacy services launched on April 20, 2020 as a pilot home delivery service (via a third-party courier) for cancer patients or patients above 60 years of age with medication refills. Requests received via the centralized pharmacy call center on business weekdays (Sunday to Thursday from 0700 h to 1600 h) were delivered the next business day. Between April 20 and May 14, 1,829 prescriptions were delivered to 349 geriatric and cancer patients. The number of patients that utilized home delivery services for medication, and the resulted number of prescriptions weekly is presented in Figure 4 . The success and patient feedback for this service are grounds for its future expansion. Remote area prescriptions pick up service data Week -1 Week -2 Week -3 Week -4 COVID-19 cases statistics Saudi Arabia Ministry of Health. News about coronavirus Saudi Arabia Ministry of Health. 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