Introduction

There are many different definitions for the term “rural.” The US Census does not define the term and instead delineates rural as any population, housing or territory not located within an urban area – essentially “whatever is not urban is considered rural.”¹ Since there is no widely agreed upon definition, the qualifications for rural healthcare funding opportunities may vary greatly depending on the definition that is used and may lead to disparate health conditions.²

There are many barriers for rural residents to maintain their health. Food deserts, defined as areas lacking access to affordable produce (fruits, vegetables), grains, and low-fat dairy products, is a prevalent issue and is common in rural areas. Consumers may be unable to access healthy foods because they are geographically isolated from a supermarket or do not have transportation; even if there is a grocery store nearby, the food products may not be affordable.³ Additionally, there is often a lack of facilities to support maintenance of health through exercise. Rural residents likely have less access to gyms/workout facilities or access to them is hindered by transportation issues. If there are opportunities, they are likely at the local community center and depend on resources such as money and workers to keep the program going.

Rural residents may have time constraints, transportation issues or other barriers that restrict their ability to obtain consistent healthcare. Access to medical facilities/specialists often involve traveling many miles and hours. Not only do patients often struggle to access healthcare and services in their communities, there is also a known shortage of healthcare professionals and especially specialists. Most residents have a limited number of healthcare workers that are taking care of a large population area. As such, specialist duties often fall on primary care providers. In some cases, there may not be an MD/DO in a rural clinic, and care may be consolidated to a nurse practitioner or physician assistant, depending on state law for independent practice. In other cases, the pharmacist may be the sole healthcare provider in a rural town with residents depending on their local pharmacist to assist in their care and coordination of services.^4,5

Finally, rural patients are more likely to be older, lack insurance, experience socioeconomic barriers, and have lower levels of health literacy; these factors culminate in in higher rates of chronic diseases. Similarly, they are at increased risk for geographic isolation, limited job opportunities and have increased rates of health risk behaviors.  These sets of barriers result in multiple barriers for optimal health for rural residents and provide health care workers with increased challenges when trying to manage the health of these patients.^6,7 Given these challenges there is a great public health need for patients who live in rural areas and was that pharmacists can be involved in helping the medically underserved in rural areas.

Case

CC: “My wife said I need that new shot for shingles even though I already had a shingles shot before.”

Patient: SM is a 68-year-old Caucasian male farmer (74 in, 285lbs). He is semi-retired but still helps his son farm the land that has been in his family for generations. He is busy farming during spring, summer and fall. Winter is a slower time for him, but due to cold winters full of snow, it is sometimes difficult for him to get to town. SM grew up eating meals of meat and potatoes the kinds of meals he says “sticks to your ribs.” His wife enjoys gardening, cooking and baking and a meal is never complete without dessert! She uses her garden produce for side dishes during the summer and early fall. Meal times are often sporadic during planting and harvest time. His wife has tried cooking healthy for him, but he admits to sneaking to the local cafe for a caramel roll or other treats to satisfy his sweet tooth. After funding was cut for the senior exercise program, they bought a treadmill and stationary bike a few years ago but he prefers exercise activities that are more social like they used to have at the Senior Center in town.

PMH: T2DM; hypertension; dyslipidemia; obesity

FH:

• Father: died at 88 from heart attack, history of T2DM, hypertension, dyslipidemia, osteoarthritis
• Mother: died at age 95 from a CVA, history of hypertension and osteoporosis

SH:

• 20 pack-year history of smoking (quit 26 years ago)
• Drinks one to two 12-oz beers on the weekend
• Exercise mainly is farm and yard work activities

Medications:

• Metformin 1000 mg by mouth twice daily
• 70/30 insulin 54 units in the AM and 27 units in the PM
• Lisinopril/HCTZ 20/25 mg once daily by mouth
• Acetaminophen 650 mg every 6 hours as needed for pain
• Refuses statin due to fear of muscle pain

Vitals:

• BP 122/84 mm Hg (sitting; repeat 120/86 mm Hg)
• HR 76 bpm (regular)
• RR 16/min
• Temperature 37°C

Labs:

• Basic metabolic panel:
• Na 138 mEq/L
• Cl 102 mEq/L
• K 4.1 mEq/L
• CO₂ 26 mEq/L
• SCr 0.9 mg/dL
• BUN 14 mg/dL
• Glucose 312 mg/dL
• Other electrolytes:
• Mg 2.3 mEq/L
• Phos 3.7 mg/dL
• Ca 9.1 mg/dL
• Cholesterol:
• Total 244 mg/dL
• LDL 151 mg/dL
• HDL 36 mg/dL
• TC/HDL ratio 6.7
• Trig 225 mg/dL
• Liver function tests:
• AST 26 IU/L
• ALT 29 IU/L
• Total bilirubin 0.5 mg/dL
• Albumin 3.7 g/dL
• Alkaline phosphatase 62 IU/L
• Blood counts:
• Hct 46%
• WBC 9.0 × 10³/mm³
• Platelets 220 × 10³/mm³
• HgA1c 11.0%

Vaccinations: Up to date except for Shingrix

SDH: SM completed high school, is able to read and write at an 8th grade level and speaks English as his first language. His income at this stage of his life consists of a social security check that is supplemented with limited seasonal income from his part time work on his farm. The farm doesn’t have any debt but requires workers to help SM complete all the harvesting.

He lives on farmstead with his wife. Son and family live just down the road and can help, though very busy with their own children. SM does drive and has access to a car but doesn’t like to drive at night anymore due to declining sight. He has a high deductible insurance plan.

Additional context: Most of your pharmacy patients are similar to SM. Because prevalence is so high in the community, you already hold a quarterly class for the community about diabetes management including tips on eating smart, to information on self-monitoring of blood glucose plus information on different medications.

Case questions

1. What are challenges facing both providers and patients in rural settings?

Some challenges facing providers: lack of resources and specialty care, difficulty staffing

Some challenges facing patients: food deserts, limited public transportation, workforce shortages, lack of exercise facilities, limited access to healthcare providers

2. What should be included in a needs assessment for a new rural clinical pharmacy service, such as chronic disease management?

Target an outcome such as better access and improved control for diabetic patients. Collect and analyze data, such as how many patients with uncontrolled diabetes do you see. Identify stakeholders including patients, providers willing to participate in a collaborative practice agreement, the pharmacy and medical boards, and others you may work with. Consider the engagement of your partners, your subject matter expertise and needs, technology support needed, financial resources, other staffing, training and other important components. How will you market your service? How will you stay up to date on training and knowledge of the subject, in this case diabetes? Do you need to train other employees, if so, how? What is the financial investment? What will be the return on investment? Do you need additional technology capabilities? Identify barriers and potential ways to overcome them.

3. How should the pharmacist RK engage SM and the rest of the community in the pharmacy service?

Discuss the benefits with patients and their support system members. SM may be willing to try without much convincing or it may take some persuasion from his wife after hearing benefits of the program from the pharmacist. Pharmacist RK already holds a quarterly class covering diabetes topics; this service could be discussed at those classes. Other marketing strategies could be used as well including but not limited to flyers, radio and print ads, and word of mouth. Other healthcare providers, churches, community centers, health department, insurers and food pantries are all possible partners in pharmacy services. In small communities, a success story or two will be shared with others and more people may be willing to engage in the service.

4. What interventions and recommendations would you make to help SM control his disease states (pharmacological and non-pharmacological)?

• >Increase insulin dosing. How much to increase by depends on how aggressive you want to be and what patient is willing to do. Consider increasing insulin by 2 units at each dose. Encourage blood glucose testing a few times a day depending on cost. Although difficult as a farmer, try for consistent meal times when possible and always carry a sugar source in case of hypoglycemia.
• Consider ordering microalbumin creatinine ratio lab test.
• Re-consider statin medication. Offer low dosing to start with and consider statin medications less likely to cause myopathy. Due to high deductible plan, generic option would be best.
• Assess use of acetaminophen. Consider decreasing dose so as to not exceed 3000 mg per day.
• Make dietary modifications. Start with small changes and gradually build to larger changes. Make sure they are sustainable. Asses for access to food and cost barriers to making dietary changes.
• Encourage exercise most days of the week and to avoid long sedentary periods throughout the day.
• Continue to stay up to date on vaccinations. Obtain Shingrix vaccination when available from pharmacy and schedule complete series.
• Have diabetic foot and eye exams performed yearly.
• Maintain dental visits about every 6 months.
• Screen for depression (PHQ).

5. What suggestions do you have for SM to exercise and improve his diet especially during the winter and times of limited transportation?

• >Walking is good exercise and can be done around the house or the yard, perhaps with his wife, son or a close neighbor
• A small set of hand weights or even soup cans can be used for resistance training, either standing up or sitting down in a chair
• If access to the internet, many videos are available online with simple exercise routines
• Since SM’s wife enjoys gardening, consider freezing and canning garden vegetables for use all year long; or buying canned or frozen vegetables with longer shelf lives to keep during the winter.
• Consider baking, steaming or air frying as alternatives to using oil for cooking
• Since SM has a sweet tooth, consider baking using fat alternatives such as greek yogurt or applesauce
• While SM likes his potatoes, could rotate having similar carbohydrates such as cauliflower, parsnips, turnips and rutabagas for a variety of nutrients
• Since SM likes to have meat with every meal, aim for lean meats and could consider meat substitutes made from tofu, beans, mushrooms and other plant-based products

Author Commentary

It is not uncommon that pharmacists are the only healthcare professional in a small town or rural area. Pharmacists in rural areas face different challenges when attempting to care for their patient population. By expanding services, pharmacists can help provide more comprehensive care for their patients in addition to potentially expanding their business model. In some states, pharmacists can identify patients at need for vaccinations and administer the vaccinations to the patient. Pharmacists can also impact other preventive, screening and monitoring services such as blood pressure checks, glucose and HgA1c point of care testing, testing lipids, DEXA scans, INR, HIV and Hepatitis C screening, and spirometry testing. Pharmacists can even participate in diagnostic testing such as influenza and Strep A with appropriate waivers. Through collaborative practice agreements (CPAs), pharmacists can prescribe medications for both chronic and certain acute disease states allowing for efficient and effective care for patients, especially in the rural setting. Some pharmacies offer weight management services. Although not applicable for the patient in this case, pharmacists in some states are able to prescribe contraceptives which play an integral role in public health.

CPAs authorizing pharmacists to prescribe vary by state. Some have limited authority while others approve pharmacists to prescribe medications to address a handful of conditions. Under specific conditions that may include protocols, inclusion and exclusion criteria, and need for referrals, pharmacists in some states can write for treatment of many medications, disease states and conditions including but not limited to: cold sores, seasonal influenza treatment and prophylaxis, strep throat (Group A streptococcal pharyngitis), uncomplicated urinary tract infections, statins for patients with diabetes, epinephrine auto-injectors, dietary fluoride supplements, contraceptives, vaccines and opioid antagonists. Many pharmacists work under a CPA for anticoagulation to manage that specific population of patients.

Specifically related to patients with diabetes, as in this case, pharmacists can partner with providers to manage patients’ needs (or a multitude of other disease states) through a CPA. Pharmacists can provide both pharmacological and non-pharmacological intervention strategies. Pharmacists can also assist in providing diabetic shoes and performing diabetic foot exams. Pharmacists can also become certified pump trainers (CPT) to help manage patients who have insulin pumps. Additionally, pharmacists can work to help their community residents prevent diabetes and other conditions. For example, pharmacists can participate in the National Diabetes Prevention Program and pursue diabetes certification. If supported by law, pharmacists can be creative in the way they offer services to their patients and expand beyond the duty of dispensing medications.^8-12

Patient Approaches and Opportunities

It is important to remember that it takes time to develop trust for managing chronic disease. It involves trust between the provider and pharmacist but also between the pharmacist and patient. Often in rural towns, providers and pharmacists have a close relationship and managing patients together can be seamless. However, in other situations, providers can feel like pharmacists are ‘stepping on their toes.’ Providers in rural settings are often overworked managing the care of the community and welcome help from pharmacists willing to manage chronic diseases. For patients, many times the pharmacist is their first line “go-to” person for healthcare so it makes sense for the pharmacist to manage chronic disease. In other cases, some patients might feel that it is only the provider’s job to do so. In either case, providing education on the training and ability of the pharmacist along with earning trust can go a long way in expanding pharmacy services to improve patient care and outcomes. The pharmacist should demonstrate to patients and providers alike that the service provided is valuable and beneficial to all parties. While many ideas might seem like good ones, and while patient care is at the forefront, ultimately healthcare is a business and services need to be sustainable.

By collaborating with the provider and including the patient in the process, the pharmacist can provide patient centered care in the rural setting. American College of Clinical Pharmacy (ACCP) developed a white paper that addresses developing ambulatory pharmacy services. Personal interests, professional knowledge, and patient/customer needs should be merged. A market assessment should be performed and the ACCP white paper provides resources to assist pharmacists in carrying out steps and weighing factors involved for a market assessment including: what is the current state of the proposed service, what is the current standard of care, what current and future developments may affect the service, identifying factors in customer decision making, customer needs to be addressed, timing of the service. The white paper includes a plethora of other useful information and the authors encourage readers to examine the document.¹³