Report of the 2013-2014 AACP Standing Committee on Advocacy: Improving Advocacy through the Use of Implementation Science Concepts and Frameworks

Selection and Development of AACP public policy priorities: A sustainable approach for advocacy

Academic experts continue to rank high among policy makers, including congressional staff as sources of trustworthy information.¹ AACP efforts to educate policy makers about issues of importance to academic pharmacy are therefore enhanced when they are developed using the content expertise of our members. The 2013-2014 standing committee on Advocacy continued the process developed by the 2012-2013 committee: “The creation of issue-specific workgroups is a strategy to improve AACP’s capacity to proactively engage in public policy development and implementation. The expertise of each workgroup assists AACP in the development of strategies to enhance communications to and from AACP members on priority issues. The list of priority issues was established through AACP leaders and staff input and in alignment with the AACP policy framework. The rationale for such action is to:

• • ensure that AACP advocacy is aligned with organizational priorities;

• • engage more AACP members in the identification and articulation of AACP public policy positions;

• • increase AACP member awareness of AACP organizational activity related to public policy development and implementation; and

• • provide AACP members and staff with evidence-based policy/issue briefs to support effective organizational, institutional, professional, and individual advocacy. “

Participation in the priority-issue workgroups was solicited from the AACP membership in a series of emails and to the attendees of the 2013 AACP annual meeting. AACP members with content expertise relevant to the priority issues were asked to submit their interest to AACP staff.

President Piascik asked the advocacy committee to consider three priority issues: community engagement; scholarship of community engagement; and wellness and health promotion. The following rationale for including these three issue areas was shared by President Piascik with the committee.

Community Engagement

“In the 1980’s, a community engagement movement began to emerge in higher education, asserting that a goal of the American university should be to restore its original purpose, that of preparing graduates for a life of involved and committed citizenship.”² The current atmosphere of greater accountability in higher education includes calls for an engaged university. For health professions schools there are many opportunities in health care reform and funding available from agencies such as the Patient Centered Outcomes Research Institute (PCORI). Academic pharmacy schools and faculty are perfectly poised to participate meaningfully in this effort and have done so for many years. Community engaged service is a valuable contributor to addressing critical public health issues. “While an area of emphasis for many universities or schools of pharmacy, many pharmacists are also actively engaged in this work. This may be via initiatives emanating from their practice or through collaborations with community-based organizations with service missions with which they hold a personal affinity.” The public and policymakers need to be educated to the value of pharmacists, in academic settings as well as community-based practice, in contributing to the health of our citizens via community engagement.

Scholarship of Community Engagement

Community-engaged scholarship is “teaching, discovery, integration, application and engagement that involves the faculty member in a mutually beneficial partnership with the community and has the following characteristics: clear goals, adequate preparation, appropriate methods, significant results, effective presentation, reflective critique, rigor and peer-review.”³ In other words, it goes beyond merely providing service to the community, but also involves addressing public health issues in a scholarly manner. This also requires sharing the results obtained via publishing and presenting the results. The ability to engage with the community in this manner is unique to higher education. The public and policymakers need to be educated to the value of academic pharmacy’s community-engaged scholarship and the need for continued/expanded funding to these efforts that may improve the health of citizens.

Wellness and Health Promotion

According to Giberson et al., “chronic diseases are the leading causes of death and disability in the United States. Chronic diseases currently affect 45 percent of the population (133 million Americans), account for 81 percent of all hospital admissions, 91 percent of all prescriptions filled, 76 percent of physician visits, and continues to grow at dramatic rates. These numbers are daunting. Quality medical care for people with chronic conditions requires a new orientation toward prevention of multiple chronic disease conditions, and provision of ongoing care and care management to maintain their health status and functioning.”⁴ Community pharmacists are well positioned to provide preventive care including health screenings, immunizations, and lifestyle modifications. Contemporary curricula prepare pharmacists to work effectively with patients in wellness and health promotion efforts. Given the focus on these topics in health care reform, the public and policymakers need to be educated to the value of pharmacists in providing these services in a convenient, cost-effective manner.

Chair Bell indentified and contacted a leader for each of the three workgroups. As was expected of the 2012-2013 workgroup leads this year’s leaders were asked to ensure their capacity to:

• • Serve as an issue expert for the workgroup;

• • Directly communicate with the Advocacy Committee Chair and staff liaison to ensure the workgroup stays on and completes tasks according to timelines and deadlines;

• • Participate in monthly conference calls with other workgroup leads to present workgroup progress, identify challenges and present recommended solutions;

• • Provide input and accept responsibility for the workgroup’s work;

• • Establish a schedule for the workgroups consideration, production and completion of its work; and

• • Contribute to the success of the workgroup including the completion of required documents prior to the final deadline.

Individual workgroup members were contacted to verify the interest they had expressed earlier and commit to:

• • Serving as an issue expert for the workgroup;

• • Directly communicating with the workgroup leader to ensure the workgroup stays on and completes tasks according to timelines and deadlines;

• • Providing input and accepting responsibility for the workgroup’s work;

• • Providing input into the establishment of the schedule for the workgroups consideration, production and completion of its work; and

• • Contributing to the success of the workgroup including the completion of required documents prior to the final deadline.

Members of the advocacy committee served as leads for one of the three workgroups. Chair Bell, the AACP staff liaison and the workgroup leads met face-to-face in October, 2013 during the meeting of AACP standing committees. The committee discussed the technical aspects of the report and workgroup deliverables as well as the basic constructs of implementation science that would ground and influence their work. The Advocacy Committee also met with the members of the Research and Graduate Education Committee to discuss common aspects of each committee’s work.

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After an organizing webinar that provided general directions for all the workgroups, each of the workgroups met via conference call, usually on a monthly basis. Workgroup leads met via conference calls, usually monthly, to discuss their workgroup progress with the Chair. All workgroup members were invited to participate in a webinar in which the Advocacy Committee members (Chair and workgroup leads) described the workgroup expectations, deliverables, process and timeline.

Considering the need to continually improve AACP advocacy tools and resources and their utility to AACP members, stakeholder and policymakers, Chair Bell focused the committee and workgroups on the following anticipated outcomes of their work:

• • Describe the current strengths of the academy in regard to development and use of effective, evidence-based interventions;

• • Describe alignment of those strengths with public policy initiatives;

• • Describe areas of needed improvement in regard to the utility of and evidence associated with specific interventions- thus establishing a research agenda to improve areas where we are not as strong; and

• • Support AACP staff development of advocacy materials that can support members in their advocacy efforts as necessary.

Implementation science concepts as a unifying framework for member engagement to support AACP advocacy activities

The United States spends billions of dollars annually in the pursuit of new knowledge across a wide range of disciplines. The National Institutes of Health, the premier agency for biomedical research, funds nearly $30 billion of competitive research grants annually. The National Science Foundation funds nearly $7 billion of research annually that includes competitive grants for social, behavioral and economic science research. The evidence generated from this research informs the development of evidence-based and science-based services and programs such as guidelines from the US Preventive Services Task Force, the Community Preventive Services Task Force and clinical and community-based prevention programs developed at the Centers for Disease Control and Prevention.

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In an era of constrained resources at the federal and state level, it becomes challenging to seek additional funding to support new knowledge development when current knowledge is used ineffectively or inefficiently. Policy makers challenge advocates by asking: ‘How do we maximize the use of current knowledge so that our needs for new knowledge can be better defined and targeted?’ Another challenge is: ‘How can we improve the diffusion of current knowledge in the form of evidence-based interventions across communities, populations and individuals?’ An approach to addressing these challenges is through a process improvement framework known as implementation science.

Federal interest in implementation science

Improving the application of evidence-based interventions (EBI) is becoming a priority of federal agencies. In a brief published by the US Department of Health and Human Services (HHS) Assistant Secretary for Planning and Evaluation the need for improving not only the use of EBIs, but more fully articulating the program components that are critical for that intervention reaching the intended outcome are highlighted.⁸ Similar interest in improving the efficient and effective use of new knowledge is reflected in the activities of specific federal agencies within HHS such as the National Institutes of Health and the Centers for Disease Control and Prevention.^9,10,11

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Determining institutional ability to implement interventions

Defining Context

Interventions alone are not sufficient to increase their effective and efficient use. The intervention must match the needs and expectations of the organization. Therefore an institution must define the context in which the intervention matches those needs and expectations. The compelling reason or context must be well articulated by the organization as it provides the vision and starting point for successful implementation. For each of the three priority issues, President Piascik presented a compelling reason - defined the context- for the installation of those issues within academic pharmacy.

Even when the context is well described and valid, other elements may come into play that must be identified and resolved so successful implementation can proceed. One framework for identifying these elements is the Hexagon Tool. This tool consists of six elements- capacity, need, fit, resources, evidence, readiness- that an organization can use to evaluate whether the selected intervention can successfully be implemented by the organization. Should the organization be unable to meet any of the six elements it might be appropriate to consider 1) how the organization can leverage resources to meet the element or 2) whether there are other interventions that the organization can successfully implement.¹²

Defining Core Intervention Components

A critical element of the effective implementation of evidence-based interventions is the complete description of all the elements essential for reaching the expected outcome. These essential elements are referred to as core components or core elements. While there may be components that are amenable to adaptation to local situations it is likely that the identified core components of an intervention must be present and must be sequenced in a consistent manner to reach the expected outcome.

Critical gaps exist in communicating the essential elements or core components necessary for successful intervention implementation. One gap is the lack of clear articulation of the critical- components that must be in place and how these components must be sequenced so that the intervention’s expected outcome is achieved. Currently, published articles and reports provide evidence of impact (expected outcome) but little knowledge about how that outcome was achieved and which activities were most important in that achievement. There is evidence that something works, but not enough evidence about what makes it work.

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Describing core components for each of the three priority areas

Community Engagement

Table 1 depicts the core components deemed necessary in any successful community engagement program. The components were derived by the workgroup from the following sources:

• 1. Criteria from the Carnegie Foundation for the Advancement of Teaching designation for community engagement^19,20

• 2. Principles of partnerships adopted by Community-Campus Partnerships for Health (CCPH)²¹

• 3. Interviews conducted by members of the 2013-2014 AACP Advocacy Workgroup on Community Engagement with seven colleges/schools of pharmacy

• 4. Review of application packets submitted by winners of the American Association of Colleges of Pharmacy Lawrence C. Weaver Transformative Community Service Award

The key component to any successful community engagement program is a sustained culture of community-engaged service throughout an institution and/or organization (Table 1). Indicators of commitment to service include: 1) alignment of service activities with the mission statement of an institution and profession-specific program; 2) visible support by the upper levels of administration including the president, provost and deans; and 3) recognition and celebration of commitment and dedication to serving the community. A pervasive culture of service requires three core components for sustainability: 1) mechanisms that facilitate engagement; 2) sufficient level of personnel support; and 3) strong partnerships between communities and the university and/or pharmacy program. Specific criteria for each of these three core components are listed in Table 1. Success of a community engagement program requires appropriate assessment of service activities, including level of engagement and impact on communities, teaching, learning, and scholarship.²² Existing programs require periodic assessment to ensure relevancy of activities in relation to community need and quality improvement.²³

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Scholarship of Community Engagement

As outlined by AACP President Peggy Piascik when establishing the workgroup on the Scholarship of community Engagement and as outlined on the Community Campus Partnership for Health website, the characteristics of community engaged scholarship (CES) are: clear goals, adequate preparation, appropriate methods, significant results, effective presentation, reflective critique, rigor and peer review.

After a thorough review of the literature and best practices, the workgroup agreed these characteristics align well with the six standards of scholarly work outlined by Charles Glassick, et al.²⁴ The workgroup proposes that the six standards of scholarly work- clear goals, adequate preparation, appropriate methods, significant results, effective presentation, reflective critique- as the core components of CES.

Clear Goals –establish the need for the research by engaging the community. The scholar should assist in the identification of the gaps in the community that would drive this research? A community health needs assessment, focus groups or community advisory boards may help in identifying goals.

Adequate preparation –Building partnerships with the community may take a significant amount of time to build trust, which is critical to carrying out the research.

Appropriate methods – Community members are key to the design of methods specific for the community which may include cultural or social determinants that may impact the expected outcomes. The scholar should work to power the study for significance.

Significant results – Will the results impact the health of the community or provide a change in behavior? The results may be used to change policy on a local, regional or national level.

Effective presentation – The results of the research must be shared with the community to maintain trust and communication. The results must also be published in a peer-reviewed journal which may include a research journal less familiar to faculty in an academic pharmacy institution.

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Reflective critique – Limitations of the research must be identified and shared with the community. The scholar should state whether the results inform the need for additional research.

Wellness and Prevention

Public health programs succeed and survive if organizations and coalitions address 6 key areas (“Frieden’s six elements”)²⁵ :

• 1. Innovation to develop the evidence base for action:

Pharmacists-delivered medication therapy management (MTM) in collaboration with other primary care providers combined with innovations related to enhancing efficiencies in the healthcare system (e.g., information technology and reimbursement) as well as the public health system (e.g., health and wellness education) can improve and revolutionize both individual and population health especially in chronic diseases.

• 2. A technical package of a limited number of high-priority, evidence-based interventions that together will have a major impact:

Positive clinical evidence of medication therapy management (MTM) with respect to Patient-Centered Medical Home (PCMH) and Employer-based Pharmacist/Ambulist (EBPA) have been demonstrated and supports pharmacists in various interprofessional and collaborative team-based care roles.^26,27 Significant improvements in therapeutic and safety outcomes, such as hemoglobin A1c, LDL cholesterol, blood pressure, and adverse drug events, further supports the effectiveness of pharmacist in team-based patient care.²⁸ Thus, the technical package involves specific activities related to MTM delivered thorough PCMH and EBPA.

• 3. Effective performance management, especially through rigorous, real-time monitoring, evaluation, and program improvement:

Valid and reliable metric in economic analysis and pharmacoeconomics (e.g., return on investment, cost-effectiveness analysis and cost-benefit analysis) will be implemented to monitor, evaluate, and continuously improve activities related to MTM, PCMH and EBPA. In addition, operations management technique, such as Lean Six Sigma and total quality improvement (TQM) tools, will be employed.

• 4. Partnerships and coalitions with public- and private-sector organizations:

Partnerships and coalition-building with the private sector as well all levels of the public sector (local, state, and federal) will drive the importance of pharmacist-delivered MTM, enhance pharmacists role in collaborative team-based care, as well as demonstrate the public health importance of pharmacists in many health and wellness activities.²⁹ Specific partnerships to establish include the American Public Health Association and HealthyPeople 2020.

• 5. Communication of accurate and timely information to the health care community, decision makers, and the public to effect behavior change and engage civil society:

The socio-ecological model along with other media and advocacy tools will help frame the communication of information.³⁰

• 1. Public policy: Public opinion process and policy changes can change the incentives for certain behaviors.

• 2. Community: Social marketing and community organizing can change community norms on behavior.

• 3. Organizations: Behavior can be influenced through organizational change and social marketing strategies.

• 4. Interpersonal: Family, friends, and peers provide role models, social identity, and support.

• 5. Individual: Knowledge is necessary but not sufficient to produce most behavioral changes.

• 6. Political commitment to obtain resources and support for effective action. AACP and key stakeholders will develop the political commitment to obtain resources and support for effective action.

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Identification of advocacy action points

Successful intervention development and implementing that intervention with fidelity generally proceed in regular order. A need is identified for the development of an intervention that addresses a particular issue of public interest and for which a socially acceptable outcome is desired. Evidence is gathered that a particular approach or intervention leads to that desired outcome. The intervention is tested to determine the sequencing of actions that lead to that outcome. If successful, the intervention becomes part of a guideline or program component focused on the target of the intervention.

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Likewise, implementation of the intervention is a similarly sequenced process. Individuals and organizations explore the potential use of an intervention within a context they collectively describe. The intervention is installed and support structures, including ongoing evaluation, are put into place. A period of initial implementation is initiated with providers and recipients prepared to deliver and receive the intervention. Organizational structure may change as rapid-cycle quality improvement approaches provide an ongoing stream of information.

As implementation of the intervention is evaluated for fidelity in its delivery and whether the expected outcome is reached, data drives the increased use of the intervention across the organization. Each stage of intervention development and intervention implementation provides for the identification of advocacy action points. Identifying both successes and challenges to intervention development and implementation allows advocates to describe the need for a particular activity that must be supported or overcome for the intervention to be effectively implemented. Advocacy tools and resources are more efficiently developed and more effective since they are based on the success or challenges associated with the implementation of specific interventions. These resources can be shared with policy makers formally through issue briefs and white papers or informally during personal discussions. The following examples provide a context for identifying the advocacy action points of intervention development and their successful implementation:

STAGES OF INTERVENTION DEVELOPMENT

Use of an existing evidence-based intervention developed by a federal agency:

• • Advocacy opportunity- support the agency’s continued development of interventions

  Example-Use of team-based care to improve blood pressure control guidelines recommended by Community Preventive Services Task Force http://www.thecommunityguide.org/cvd/teambasedcare.html

Interventions being developed by a federal agency that benefit from academic input:

• • Advocacy opportunity- support academic institutions knowledge and skills to improve federal intervention development

  Example- Pharmacy faculty review high blood pressure protocols to determine best fit with Million Hearts criteria http://millionhearts.hhs.gov/Docs/MH_Protocol_Implementation.pdf

Interventions being developed by academia based on recommendations of federal agency reports, research agendas (fill gaps, better data, increase population impact, support interdisciplinary research platforms, etc.):

• • Advocacy opportunity- support continued engagement of academia through grants provided through federal agency

  Example- Pharmacy faculty participation in a broad array of federal grant supported activities that improve health, education, etc. (See in particular Faculty News in any edition of Academic Pharmacy Now http://www.aacp.org/news/academicpharmnow/Pages/default.aspx

STAGES OF INTERVENTION IMPLEMENTATION

Exploring implementation of evidence-based intervention into institution/practice:

• • Advocacy opportunity- support academic translation of federally developed/supported interventions into practice

  Example- Integration of community partners into research agenda development of faculty participating in NIH supported Clinical and Translational Science Awards programs http://www.ncats.nih.gov/research/cts/cts.html

Installing the intervention into an institution/practice:

• • Advocacy opportunity- support institutional and faculty development for consistent use of intervention

  Example- Integration of Team-STEPPS as an interprofessional education strategy http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/index.html

Initial implementation of intervention into institution/practice:

• • Advocacy opportunity- continued support for institutional and faculty development for consistent use of intervention

  Example- Curriculum mapping based on 2013 CAPE Outcomes to improve education quality http://www.aacp.org/resources/education/cape/Open%20Access%20Documents/CAPEoutcomes2013.pdf

Intervention is fully implemented into the institution/practice:

• • Advocacy opportunity- commitment to continuous quality improvement based on use of effective evidence-based intervention needs recognition and support to maintain sustainability

  Example- Use of rapid-cycle quality improvement strategy [Plan, Do, Study, Act] to improve patient safety in community health centers through the integration of a team-based approach to comprehensive pharmacy services. http://www.hrsa.gov/communitiesofpractice/ataglance/patientsafety.pdf

Tools such as the Hexagon Tool, allow organizations to determine what challenges, if any, might limit the organizations ability to successfully implement an intervention. The Hexagon Tool also provides organizations such as AACP to identify advocacy action points. The 2014 Advocacy Committee sought to identify advocacy action points regarding organizational ability to implement all three of the priority issues: community engagement; scholarship of community engagement; and wellness and prevention. A survey developed by the committee and administered through Survey Monkey was sent to the CEO Deans, Advocacy Committee and workgroup members and the Research and Graduate Affairs Committee to help in the identification of advocacy action points related to the six elements of the Hexagon Tool: capacity; relevance; need; fit; resources; and evidence.

Community Engagement

Table 2 is a summary of findings from key informant interviews and review of applications to the Lawrence C. Weaver Transformative Community Engagement Award (AACP), Student Community Engaged Service Award (AACP), and profiles of recent recipients of the American Pharmacist Association (APhA) Pinnacle Awards. Recognizing the limitations of their methodology the workgroup suggests that a sustained culture of community-engaged service is a primary driver of successful community engagement programs. Facilitating mechanisms found consistently across successful programs include organizational support of a central infrastructure, curricular engagement and active student organizations. Sufficient human resources that encompass faculty, students, residents, preceptors and other volunteers are essential to any successful program. Most programs also reported the importance of interprofessional collaborations as another key success factor. Institutions with dedicated staff support identify this human resource as extremely helpful in coordinating programmatic activities.

Successful programs build on the strengths and diversity of their community partners so that engagement activities are in response to community needs and concerns, and community partners have a voice in the development of activities. Commitment of faculty and their institutions is demonstrated when faculty actively participate in community meetings/coalitions and work collaboratively to find ways of sustaining activities and partnerships. Measuring the impact of activities at varying levels can lead to sustainability and continued relevancy of any community engagement program.

Through their interviews and application reviews the workgroup identified a number of barriers to successful community engagement. Lack of recognition for service activities in promotion and tenure policies is noted as a barrier to sustained engagement efforts despite faculty desire to serve. Lack of opportunities for skills-development may actually be a barrier, but the inconsistent finding may be due to the fact that no specific question was asked during the interviews about whether skills-training is provided for students, faculty, preceptors and other volunteers. From the survey the workgroup identified the lack of consistent financial support, including fundraising, as a major barrier to successful community engagement. The input leads the members of the workgroup to infer that greater support and guidance on measuring and evaluating the impact of community engagement among colleges and schools of pharmacy is needed to improve the likelihood of program sustainability and to collectively record the impact of academic pharmacy involvement in service.

The Hexagon Tool was applied in analyzing the current state of readiness for community engagement among colleges/schools of pharmacy in the United States. Findings from the workgroup support results from the national survey. A majority of colleges/schools of pharmacy agree on the following:

• • NEED: There is a need for my college of school of pharmacy to implement initiatives in community engagement. [93% agree/strongly agree]

• • FIT: There is alignment between the values/priorities of my college or school of pharmacy and the values/priorities of my community to implement initiatives in community engagement. [91% agree/strong agree]

• • EVIDENCE: There is sufficient evidence to support the commitment of my college and school of pharmacy to the implementation of an initiative in community engagement. [92% agree/strongly agree]

Discrepancies were noted for the following categories:

• • RESOURCES: My college or school of pharmacy has sufficient resources to support implementation of an initiative in community engagement. Resources may include curricula, technology, faculty and administrative support, faculty development, etc. [65% agree/strongly agree vs. 35% disagree/strongly disagree]

• • READINESS: My college or school of pharmacy has identified the core components necessary to implement initiatives in community engagement. [69% agree/strongly agree vs. 31% disagree/strongly disagree]

• • CAPACITY: There is sufficient qualified faculty/staff within my college or school of pharmacy to implement and sustain initiatives in community engagement. [58% agree/strongly agree vs. 42% disagree/strongly disagree]

Scholarship of Community Engagement

Community-engaged scholarship (CES) is the collaboration of academicians and community partners who use their skills and expertise to solve societal problems in order to generate, disseminate and apply new knowledge. What makes community engagement “scholarly” is that it combines the principles of community engagement and accepted standards of scholarship to impact future outcomes. The research is subject to peer review and should be replicable based on similar circumstances.

Using the Hexagon Tool as a tool to assess the ability of the colleges and schools of pharmacy to implement CES, a survey was prepared to collect data based on the six elements of the Hexagon Tool. The survey was sent to the CEO Deans of Colleges and Schools of pharmacy as well as members of the Advocacy Committee and respective workgroups- community engagement, scholarship of community engagement, and wellness and prevention. Questions 13-23 pertained to the scholarship of community engagement.

• • There were 80 responses to the questions (34 from public institutions and 46 from private institutions). Ninety seven percent of public institutions and 96% of private institutions agreed that all academic pharmacy institutions have a responsibility to improve health at the community’s interface with the practice of pharmacy though scholarship.

• • Ninety-four percent of respondents from public and 95% of respondents from private schools indicated that there is a need for their college or school to implement initiatives to promote CES.

• • Seventy-six percent of respondents from public institutions and 84% of respondents from private schools indicated that there is an alignment between the values/priorities of their college and the values/priorities of the community to implement initiatives to promote CES.

• • With respect to resources, 44% of respondents from public institutions and 35% of respondents from private schools say they lack sufficient resources to support the implementation of initiatives to promote CES.

• • Although over 90% of all respondents replied that there is a need to implement initiatives to promote CES, 20% of respondents from public and 22% of respondents from private schools said there is not sufficient evidence to support commitment of their colleges to the implementation these initiatives.

• • Twenty-one percent of respondents from public and 45% of respondents from private schools said that the school has identified the core components necessary to implement initiatives to promote CES.

• • Thirty-five percent of respondents from public and 45% of respondents from private institutions say they lack sufficient qualified faculty/staff to implement and sustain initiatives in promoting CES.

When asked about the strategies necessary to build a program of CES, respondents from the public institutions indicated the acquisition of extramural funding resources (41%) as the number one need with the development of one or more faculty positions focused on CES as second at 26%. Respondents from private institutions indicated the development of new partnerships with external organizations interested in collaborating on projects of CES as the number one strategy at 26%. However, extramural funding resources were the second strategy at 23% along with more faculty positions focused on CES (23%). The development of the necessary skills required to participate in CES was third at 12%. Overwhelmingly, the greatest barrier to CES identified by respondents of both public and private institutions was a scarcity of resources followed by the lack of capability.

Gelman, Jordan and Seifer in their action agenda identified why the scholarship of community engagement is important to higher education and the current challenges related to this type of scholarship.³² There is an increasing expectation that universities must play a key role in addressing the problems of our communities. The scholarship of community engagement helps meet that expectation as it prepares students and faculty for democratic citizenship through their involvement with community-informed decision making. The scholarship of community engagement provides the knowledge base practitioners, policymakers, community leaders and the public can use to shape legislation, rules and regulations. It is the impression of the workgroup that the scholarship of community engagement will continue to become more valuable to our communities given the continued complexity of challenges in our communities in a time of declining fiscal resources.

Academic pharmacy is and must be a key player in the scholarship of community engagement given the focus of our practice in community and institutional- based pharmacy. The profession has evolved from its traditional dispensing role to an enhanced scope of practice involving specialty pharmacies, innovative new drug delivery systems, immunizations, medication therapy management and collaborative drug therapy management. With each of these areas, there are new questions being raised related to interprofessional patient-centered care involving pharmacists practicing in our communities. Many of the answers to these questions will involve collaboration between faculty and students and community stakeholders.

Based on the survey results, the academy must advocate for the resources (fiscal as well as human) necessary to implement CES. Institutional leaders must recognize that research that involves the community can be “scholarly” and meet the criteria necessary for peer review in the tenure process. Finally members of the Academy must recognize that there is sufficient evidence to support the need for CES and the impact that it may have on the overall health of the community or policies that impact their health.

Wellness and Prevention

The pharmacist's role is expanding beyond the traditional product-oriented functions of dispensing and distributing medicines and health supplies. The pharmacist's services of today include more patient-oriented, administrative and public health functions. There are many functions in public health that can benefit from pharmacists' unique expertise that may include pharmacotherapy, access to care, and prevention services. Apart from dispensing medicine, pharmacists are an accessible resource for health and medication information. The pharmacist's centralized placement in the community and their clinical expertise are invaluable. The reexamination and integration of public health practice into pharmacological training and pharmaceutical care is essential. The encouragement of cross-training will also maximize resources and aid in addressing the work force needs within the fields of pharmacy and public health.³³

The movement towards wellness and prevention is an overarching intent of the Patient Protection and Affordable Care Act (PPACA) and provides an opportunity for both academic and professional pharmacy to shine. Coupling this intent with Medicare payment for these services establishes opportunities for pharmacist-delivered wellness and prevention services. Academic pharmacy should care about this issue because all pharmacists must possess the ability to effectively educate communities and patients to ensure optimal patient and public health outcomes.

Pharmacists are arguably the most accessible of all healthcare professionals and have the potential to significantly impact the health of individuals and populations in more ways than dispensing medications or providing information concerning medications. Regardless of the setting, pharmacists possess the opportunity to counsel patients concerning their disease management, polypharmacy, medication adherence, and important lifestyle modifications. The Centers for Disease Control and Prevention (CDC) reports the following impacts on our health: 50% lifestyles, 20% immediate environment, 20% genetics, and 10% health care delivery or access. Pharmacists can impact the 50% lifestyle factor through education, proper use of medications for prevention, immunizations, smoking cessation, etc.

The workgroup selected medication management therapy as an intervention to evaluate the utility of the six elements of the Hexagon Tool as an effective tool for identifying advocacy action points. Medication therapy management (MTM) that incorporates the characteristics listed above that impact health and has been proven to improve chronic disease management and patient outcomes. It is thus imperative that didactic and laboratory training in pharmacy school and post-graduate education develops and implements a curriculum optimizing MTM knowledge and skills. With patient-centered medical homes (PCMH) becoming the next frontiers of care to manage chronic diseases, educational and practice policy need to be developed that includes pharmacist as key member of the interprofessional and collaborative team-based care. The need for and effectiveness of pharmacists in interprofessional and collaborative team-based care roles have been envisioned and supported in the literature.^{26,27,28,29,34} Pharmacists belonging to PCMH teams will also be called upon to track and manage care, provide self-care education to patients, and track patient progress in managing their health. These activities are not only critical to promoting health and wellness but also for pharmacists to enhance the visibility, value, and importance of pharmacy and pharmacist in individual and population-level outcomes through education, research and service.

The academy’s ability to effectively implement interventions should be guided by the recommendations that are based on the framework/model (Figure 1) and selecting key interventions (See Table 1 in complete workgroup report, Appendix B) that can be implemented now but have long-term effects. Thus, curricular/educational-level interventions, which are low-hanging fruit, may be easier to implement while having great potential to revolutionize pharmacy practice. The higher-hanging fruit may have greater potential and impact overall in advancing pharmacy but a combination of prudent, elite, and innovative strategies by key pharmacy stakeholders is essential. From the survey the workgroup drew the following conclusions related to wellness and prevention:

• • A majority of respondents agree or strongly agree that their school needs to implement initiatives in Wellness and Health Promotion activities.

• • A majority of respondents agree or strongly agree that their school values and priorities are in line with the values and priorities of their community to implement initiatives in Wellness and Health Promotion activities.

• • About half of respondents agree or strongly agree that their school has sufficient resources to support implementation initiatives in Wellness and Health Promotion activities. The other half disagrees or strongly disagrees.

• • A majority of respondents agree or strongly agree that there is sufficient evidence to support the commitment of their college or school to implement initiatives in Wellness and Health Promotion activities.

• • A majority of respondents agree or strongly agree that their school has identified the core components necessary to implement initiatives in Wellness and Health Promotion activities.

• • About half of respondents agree or strongly agree that there is sufficient qualified faculty and staff to implement and sustain initiatives in Wellness and Health Promotion activities. The other half disagrees or strongly disagrees.

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Figure 1.

Framework for defining and developing interventions: A model for pharmacy to enhance individual and population health and wellness promotion.

The results of the survey provide some of the evidence necessary to identify advocacy action points to promote health and wellness activities provided by pharmacists. These advocacy action points may be able to enhance the visibility, value, and importance of pharmacy and pharmacist in individual and population-level outcomes through education, research and service.