The Report of the 2016-2017 Advocacy Standing Committee

Community Engagement

Community engagement is recognized as a cornerstone of successful advocacy strategies. Advocates recognize that increasing the number and diversity of engaged individuals and organizations is critical to gaining traction around an issue. AACP acknowledges the importance of community engagement through the annual Weaver Transformational Community Engagement Award. Other health professions education organizations also recognize exemplary community engagement.¹ The Carnegie Foundation supports community engagement, as an important component of a strong university, college or school, through its classification of community engagement campuses and provides the following definition:

“Community engagement describes collaboration between institutions of higher education and their larger communities (local, regional/state, national, global) for the mutually beneficial exchange of knowledge and resources in a context of partnership and reciprocity.

The purpose of community engagement is the partnership of college and university knowledge and resources with those of the public and private sectors to enrich scholarship, research, and creative activity; enhance curriculum, teaching and learning; prepare educated, engaged citizens; strengthen democratic values and civic responsibility; address critical societal issues; and contribute to the public good.”²

Community engagement is important for the professional development of students and career development of faculty. In support of these activities, the policy statements of AACP include two statements that recognize the importance of community engagement within academic pharmacy:AACP supports efforts to develop and maintain strong, mutually beneficial community-campus partnerships that demonstrate and recognize the value of education and science scholarship and innovative practice models that improve the quality of individual and community health outcomes.³AACP will support member schools and colleges in their efforts to develop pharmacy professionals committed to their communities and all the populations they serve, by facilitating opportunities for the development and maintenance of strong community-campus partnerships. ⁴

Student engagement with community partners is celebrated by AACP through the Student Community Engaged Service Award, which highlights exemplary co-curricular activities at our member institutions. These co-curricular activities are now important elements of the accreditation standards set forth by the Accreditation Council for Pharmacy Education (ACPE).^5,6 In regard to the research aspect of faculty development, engaging patients and communities in health services research as well as clinical trials is increasingly important, with some grant applications requiring clear community engagement strategies. ⁷

Yet, communities engaged with academic partners in activities that are focused on improving health equity and social justice may benefit the most through the increased opportunities for impact on and sustainable solutions to community-identified needs. As stated in a white paper written in advance of the 15^th annual meeting of Community-Campus Partnerships for Health (CCPH), “Attending to equity and justice issues through partnerships means pursuing policy, practice and systems level changes that will support the health of our communities. The specific changes needed depend on the focus of the partnership and could include, policies, practices and systems at federal, state, regional and local levels as well as at those of corporations, organizations and institutions.” ⁸ The benefit and potential impact of community engagement in identifying, describing, developing and implementing systems change makes knowing how to engage more important than ever. As the CCPH white paper states, the opportunity for change can be local, statewide, national, or global.

So what drives the influence of community engagement in addressing public policy challenges? Patient engagement can influence health outcomes and yet access to care remains a challenge for many in our communities. By any estimate, the number of health care professionals with a traditional focus on the provision of primary care will lag for the next decade.⁹ The access to care issue is unlikely to abate if patients maintain access to traditional primary care delivery systems and are not included in discussions of how to increase access through new care delivery models.

The Patient Protection and Affordable Care Act of 2010 (ACA) (PL 111-148)¹⁰ included provisions to increase individual access to healthcare insurance. This valuable tool to improving individual and population health outcomes resulted in a significant decrease in the number of uninsured individuals. The U.S. Department of Health and Human Services estimates that 20 million individuals have enrolled in a health insurance plan as of early 2016.¹¹ A challenge for the newly insured is access to care, especially primary care providers, since access to insurance does not always translate into access to care. Those that gain access to primary care face a system in transition from fee-for-service to value-based payments. This transition carries with it both opportunities and threats for patients, creating a strong rationale for community-campus partnerships that can guide the systems change to best meet the needs of patients.

The ACA, by mandating access to preventive services, also heightened the public’s awareness of the value of wellness and prevention. The Centers for Disease Control and Prevention (CDC) report that as of 2012 more than half of the U.S. adult population had at least one chronic illness.¹² Chronic illness creates a significant burden on a health care delivery system that traditionally rewards acute care through both professional education and provider payments. The individual behaviors related to this large chronically ill cohort are readily listed, yet a clear path to changing the trajectory of chronic illness will take significant community engagement to untangle the contributing social determinants of health.

The unique position and accessibility of pharmacists provides an opportunity to help patients, other providers and communities make the best use of the ACA provisions related to insurance access, primary care and wellness and prevention. The alignment of the educational outcomes and accreditation standards related to the Doctor of Pharmacy degree support this opportunity.^6,13 Even as the opportunities increase for pharmacy practice in a transforming healthcare system we face challenges that may be overcome by engaging communities, in its broadest sense, to generate interest in pharmacy as a career. Communities, and the patients, caregivers, providers and policymakers they include, are essential to reversing the current trend of decreasing numbers of applicants to colleges and schools of pharmacy. As the number one priority in AACP’s newly created strategic plan, enriching the pipeline will require extensive community engagement. One key priority is to clearly communicate the importance of pharmacists to community stakeholders. This is recognized as AACP’s second priority, creating a new public image of the pharmacist.¹⁴

Strategic Priority 1: Enriching the Applicant Pipeline

AACP will partner with stakeholders to increase the Pharm.D. applicant pipeline to ensure there will be an appropriate number and quality of pharmacists to meet society’s needs.”

Strategic Priority 2: Creating a New Portrait of Pharmacists and Pharmacy Careers

AACP, in collaboration with stakeholders, will raise the profile of pharmacy as an essential health care profession. We will achieve recognition for pharmacists as trusted and highly accessible healthcare professionals in both traditional and new settings. And we will increase awareness of the quality and scientific rigor of pharmacy education and training.

Establishing the professional identity as a valuable member within the community in general and health care system specifically benefits from community service and engagement. As already mentioned, AACP, through its Student Engaged Community Service Award, recognizes the benefits of community engagement to the professional identity of student pharmacists. The benefits of student participation in community-based co-curricular activities are reflected in the 2016 accreditation standards.

Standard 3: Approach to Practice and Care

The program imparts to the graduate the knowledge, skills, abilities, behaviors, and attitudes necessary to solve problems; educate, advocate, and collaborate, working with a broad range of people; recognize social determinants of health; and effectively communicate verbally and nonverbally.

Standard 4: Personal and Professional Development

The program imparts to the graduate the knowledge, skills, abilities, behaviors, and attitudes necessary to demonstrate self-awareness, leadership, innovation and entrepreneurship, and professionalism.

Applying the Core Components of Community Engagement

The primary interest of the committee is that the information presented in this report be meaningful and able to be implemented by the reader. To that end, the report presents the core components of community engagement developed by the 2013-2014 advocacy committee and applies them to activities that are currently of interest and importance to academic pharmacy. The activities presented here in the report align with the AACP’s 2016 strategic plan, and represent a range of activities including those that engage communities within your institutions (interprofessional education), at the state level (opioid harm reduction, scope of practice) and nationally (pipeline development). The committee anticipates that a reader should be able to gain confidence in how to effectively use the core components of community engagement to effectively establish and sustain partnerships that result in mutually beneficial outcomes.

As described by the 2013-2014 AACP standing committee on advocacy, the core components for successful community engagement programs are: Culture of community engaged service, facilitating mechanisms, sufficient human resources, strong partnerships, and, impact of community engaged service (Table 1). While the core components are listed, the sequencing of the components-which should be done first, second, etc. so the anticipated outcome is attained- was not part of the 2013-2014 advocacy committee report in which the core components were presented. The report authors and in particular AACP staff, would appreciate learning from you about how you sequenced the core components, since this is an important aspect of consistent implementation that leads to an intended outcome.

To better, describe the how of community engagement, the committee reviewed the winning portfolios of the Weaver Transformational Community Engaged Service Award for alignment of activities with the community engagement core components. Established in 2009, the Lawrence C. Weaver Transformative Community Service Award was created to highlight colleges and schools of pharmacy who demonstrate a major institutional commitment to addressing unmet community needs through education, research, and practice. Institutions interested in being considered for the Weaver award are asked to demonstrate their commitment to transformative community service as it relates to their academic mission and vision. Specifically, prospective institutions are advised that the Weaver award selection committee is interested in programs with direct links to their research endeavors and the education of student pharmacists, residents and other postgraduate trainees.

Weaver award winners, while required to respond to the award criteria, are not asked to explain how the criteria are applied or how the criteria are sequenced. This aspect of how the criteria or core components are sequenced is essential for helping an individual or organization remain confident that implementing the core components with fidelity will lead to the expected outcome. What keeps an individual or organization from implementing the core components, with fidelity, can be described through many frameworks, with the Hexagon Tool being the framework of choice recommended and tested by past AACP Advocacy Committees.¹⁵

Because of its connection to strategic priority #2 of the AACP strategic plan, pipeline programs in Weaver award winner institutions provide an example of what activities are effective in raising awareness of careers in pharmacy among students, parents, community organizations and policy makers. The following example from the University of Arizona describes their long-standing, successful pipeline programs. Further examination of how these programs are developed, especially the sequencing of the core components of community engagement, could be an important follow-up to the benefit of our academy.

How Do The Core Components Work?

To offer the reader with an some answers to the questions of: “How do we do it?, How does it work?,” the committee aligns the core components for successful community engagement programs with the core features of programs who have been recognized with the winners of the Lawrence J. Weaver Community Engaged Service Award. To allow for visualization of this alignment the key features of 2016 Lawrence J. Weaver transformational community engagement award winner (Table 2), University of Arizona College of Pharmacy’s pipeline development programs with the core components of community engagement. These components (culture, facilitating mechanisms, sufficient human resources, strong partnerships, and impact to the community) allow you to assess where you are in relation to the components of successful community engagement and identify potential areas for growth or further development. One essential area to focus on is the impact your program has on the community and how you can best measure and document this impact in a meaningful way. This is an area that the University of Arizona has been able to measure and document consistently over the years which has directly led to their ability to sustain a strong community engagement program for greater than a decade.

Scope of Practice

Scope of practice expansion has re-emerged as an issue that stimulates advocacy efforts. This concept is often thought of as a pharmacy practice concern. However, it is equally, if not more, relevant to pharmacy academia because pharmacy academia is where future pharmacists develop their conceptualization of contemporary practice. The most recent resurgence of pharmacy scope of practice expansions started in California with 2013 Senate Bill 493,¹⁶ which designated pharmacists as healthcare providers, created an advanced practice licensure category, and broadened the authority of pharmacists in areas such as contraception, tobacco cessation, and travel medicine. Colleges and schools of pharmacy contributed extensively to the advocacy efforts for this legislation.

On a national level, H.R. 592/S. 109^17-18 would recognize pharmacists as providers for designated underserved populations. H.R. 592/S. 109 also assigns compensation for provided services. Table 3 evaluates the core components of community engaged service and suggests how schools and colleges of pharmacy may support these components.

Pharmacists and the Opioid Epidemic

The landscape for pain treatment in the United States changed in 1999, when standards enforced by The Joint Commission were updated to encourage pain assessment as the “Fifth Vital Sign.” Over the following decade, both opioid prescribing and opioid overdose deaths quadrupled.¹⁹ From 2000 to 2010, opioid overdose was the fastest growing cause of death in the United States. ²⁰ Drug overdose surpassed motor vehicle crash as the leading cause of injury death in 2009 and has continued to rise each year since.²¹ In 2014, opioids were implicated in 61% of all drug overdose deaths killing 28,647 Americans.²² Forty states have passed legislation recognizing pharmacists as frontline providers for overdose prevention efforts by allowing standing orders for naloxone dispensation.²³ Unfortunately, many pharmacists are not well prepared to play this essential role in opioid harm reduction efforts due to a lack of specific training in overdose prevention.

The pharmacist community has taken thoughtful steps to prevent opioid misuse, including the development of tamper-resistant opioid formulations and implementation of prescription drug monitoring programs. These supply-side interventions do seem to have had a modest effect, with overdose deaths from prescription opioids stabilizing from 2009 to 2013. The overall public health impact of these policies remains dubious, as overdose deaths from heroin skyrocketed almost three-fold in that same timeframe.²⁴

Harm reduction organizations have been working for decades to expand access to naloxone, the drug of choice for reversing acute opioid overdose. From 1996 to 2010, these programs distributed naloxone to over 53,000 individuals and received reports of more than 10,000 lives saved.²⁵ Despite this impressive data, prescribers and pharmacists have been slow to take an active role in increasing naloxone prescribing and dispensing to persons at risk for opioid overdose. A recent survey of primary care providers found that 33% recalled receiving education about the use of take-home naloxone and only 8% had ever prescribed it.²⁶

Operation Naloxone

In March 2015, Texas enacted SB 1462²⁷ to combat opioid overdoses. This legislation increases access to naloxone and removes barriers to its use. A key provision is the allowance for pharmacists to enter into standing orders with physicians and dispense naloxone at their discretion. The Texas Pharmacy Association has a standing order available online that can be obtained by completing a one hour continuing education program developed by faculty from The University of Texas at Austin College of Pharmacy. Several retail pharmacy chains have their own standing orders, although naloxone availability is dependent on the individual store and pharmacist.

Operation Naloxone is a local program devoted to combatting the opioid overdose epidemic in Texas. Launched in the fall of 2016 by faculty and students from The University of Texas College of Pharmacy, in collaboration with the School of Social Work and Texas Overdose Naloxone Initiative, the program has garnered local media attention for its innovative community training sessions. Specific objectives for this first phase of Operation Naloxone included the following: prepare student pharmacists to lead overdose prevention trainings in the community, and assess the impact of engaging in service learning on knowledge retention and harm reduction attitudes.

Student pharmacists at The University of Texas at Austin College of Pharmacy were invited to participate in overdose prevention training via social media and email. Clinical faculty led a ninety-minute train-the-trainer session covering opioid overdose epidemiology and the role of naloxone. Attendees completed a post-training assessment. Student directors scheduled community outreach events in college student housing cooperatives that were identified as common sites for recreational drug use. Student pharmacists engaged in each outreach event for two hours. The first hour included a team huddle to review training materials. The second hour included the workshop for college students. These community training sessions were student-led with third-year student pharmacists planning events, scheduling preceptors, and presenting to the college student audience in a large group lecture format. Student pharmacists from all years would then lead small group discussions and answer questions posed by their smaller audience. The preceptor circulated to verify information and answer questions out of the scope of the student pharmacists’ knowledge.

Simultaneously, the faculty leaders successfully collaborated with UT administration to get naloxone rescue kits stocked in residence halls and provided overdose response training to residential assistants. They also secured a donation of naloxone to supply the UT Police Department and completed an overdose training series for more than 100 officers. Operation Naloxone hopes to reach out further and expand to include social work, nursing, and medical students at outreach events, and faculty leaders will be developing continuing education programs for health professionals thanks to a grant from the Texas Health and Human Services Commission. Training materials from this program are publicly available at OperationNaloxone.org for those who are interested in replicating or adapting the intervention.

Tools for Successful Community Engagement

As outlined in Table 1, the Core Components for Successful Community Engagement Programs identifies “Strong Partnerships” as one of the key areas for successful community engagement programs. One strategy to enhance the elements of Strong Partnerships is through collaboration with local Department of Health and Human Services (DHHS) Offices through Memorandum of Understanding (MOU) agreements. Working directly with DHHS offices allows needs of the community to be identified, the community voice to be heard, mutual planning between universities and community organizations, commitment to the partnership, and mutual benefit for both parties through increased opportunities for students and enhanced care in the community for vulnerable patients. An excerpt from an example MOU between a regional higher education center and a local DHHS can be found in Appendix A. This example illustrates the multitude of areas where strategic community partnerships can benefit all stakeholder through prescribed community engagement areas.

Interprofessional Education

A complementary component referenced in the Core Components is interprofessional collaborations. Interprofessional collaborations among students, faculty, providers and the community are important for a number of reasons as it pertains to student learning and skill development as a member of the healthcare team, but also as another mechanism of community engagement. Interprofessional teams can provide enhanced access to care, especially in areas where primary care providers are scarce, as well as for vulnerable, underserved patients in the community.

The Interprofessional Education Collaborative (IPEC) was created in 2011 as part of a vision to achieve safe, high quality, accessible, patient-centered care and further, developed the “Core Competencies for Interprofessional Collaborative Practice” to guide health professions curricular development as it pertains to team care.²⁸ The competencies are organized into four topic areas of values and ethics, roles and responsibilities, interprofessional communication, and teams and teamwork. Each of the topic areas contains desired principles with a focus on community/population oriented and patient/family centered care. The competencies were updated in 2016 in part to integrate community and population health to a stronger degree.²⁹

Further, The National Center for Interprofessional Practice and Education (https://nexusipe.org) was formed in October 2012 through a cooperative agreement with the United States Department of Health and Human Services, Health Resources and Services Administration with additional funding through the Josiah Macy Jr. Foundation, the Robert Wood Johnson Foundation, the Gordon and Betty Moore Foundation and the University of Minnesota. The National Center for Interprofessional Practice and Education provides leadership and resources “to guide the nation on the use of interprofessional education and collaborative practice as a way to enhance the experience of health care, improve population health and reduce the overall cost of care.” The National Center has developed and launched two facilitators guides to (a) discuss components of the health care system and environment that must be present to provide optimal patient and community care (“Amina in the Nexus” https://nexusipe.org/engaging/learning-system/amina-nexus-0) and (b) promote and enhance discussions around a new case delivery model in the community that allows incorporation of student learning in teams (“Carl in the Nexus”). Both Amina and Carl in the Nexus include a variety of resources for use including background literature, links to videos describing Amina’s and Carl’s cases and care, and suggested instructions for facilitating small and large group discussions around community engagement through interprofessional education and practice. This material can be useful in discussions with students, faculty, providers, and administrators at both academic and healthcare institutions.

Policy Statement: AACP encourages colleges and schools of pharmacy to have an office or designated person(s) to focus specifically on community engagement. (Policy statement was adopted by the 2017 AACP House of Delegates)

Recommendation: Core components of community engagement, as presented in the 2013-2014 Advocacy Committee, should be an explicit part of the Weaver Award criteria.

Suggestion: The community engagement champion must work with an assessment representative to utilize data for program and quality improvement.