Breathing new life into rural respiratory care

Graduate student Sara Hernandez pilots a pharmacist-led program to improve COPD care and outcomes in rural Wisconsin

By Susan Smith

A map of chronic obstructive pulmonary disease (COPD) in Wisconsin shows that the disease burden is the highest in rural counties in northwestern, central, and southwestern parts of the state.

Unfortunately, COPD patients in these areas often live far from health systems that offer specialty care for chronic lung diseases. Sara Hernandez, Health Services Research in Pharmacy graduate student at the University of Wisconsin-Madison School of Pharmacy, has been studying the ways that pharmacists may be able to improve care in rural Wisconsin communities that may lack respiratory therapists and pulmonologists.

"COPD is not one specific disease - rather, it's a group of diseases defined by permanent and progressive lung damage, usually caused by long-term cigarette smoking,'' says Hernandez, a member of the Ford Research Group, led by School of Pharmacy Associate Professor James Ford, whose work focuses on implementation science and health services research.

"Pharmacists play a unique role in these rural communities; they're often one of the only health care providers in town."
-Sara Hernandez

With support from a Baldwin Wisconsin Idea Seed Grant, Hernandez is leveraging pharmacist expertise to create a COPD management program for rural patients. She will then pilot its implementation in small town pharmacies in Burnett, Grant, and Richland counties - all of which have higher than average COPD emergency department visits, per data from the Wisconsin Department of Health Services.

"Pharmacists play a unique role in these rural communities; they're often one of the only health care providers in town," she says. "And the social interaction and trust they've built with these patients is important."

Pharmacist-led resources

The work, part of her doctoral dissertation, builds on her master's research, in which she surveyed 34 rural Wisconsin pharmacists and did in-depth interviews with eight of them about their current COPD management care, and how it could be improved. That research was done in conjunction with the Pharmacy Society of Wisconsin.

"We asked them: 'In a perfect world, what would a COPD service look like?'" she says, "And, 'What barriers are preventing you from delivering it?'"

The surveyed pharmacists said they were already doing small interventions, but were interested in something more comprehensive and structured that covered the recommendations for COPD care. They also said including a follow-up visit was important.

The result is a framework for COPD management and a package of resources Hernandez is creating that includes a workflow, recommendations to overcome barriers to delivering the care, and strategies for reimbursement.

On the patient side, pharmacists suggested a number of topics they thought would benefit their patients with COPD.

The first was a comprehensive medication review with a focus on medication and treatment adherence, exploring barriers to care and whether affordability was hurting adherence. Pharmacists could offer co-pay cards or help the patients switch to a medication that their insurance would cover.

The second topic was vaccinations. Because of their underlying lung disease, it is critical that these patients be up-to-date on vaccinations for respiratory disease, including COVID-19, RSV, flu, and pneumonia.

Another topic was an assessment of the patient's inhaler technique. Hernandez says the intervention includes a "teach-back method" for improving inhaler technique.

"This is the time when the pharmacist can identify if the device itself is an issue and whether the patient would benefit from a different type of inhaler," Hernandez says.

And then there's a plan for how to tackle the elephant in the room: how to talk to COPD patients about quitting smoking.

"The pharmacists described it as harder to bring up," Hernandez says, "so making it part of a private appointment, away from the pharmacy counter, makes it easier to discuss."

"At the end, we hope to take all we learned to modify the package to make it an even more effective tool, and then launch it on a larger scale."
-Sara Hernandez

The plan includes education on how to talk about smoking cessation, including motivational interviewing techniques that can help identify barriers to patients' attempts to quit smoking.

"If they learn that the patients are interested in quitting, pharmacists can help with medications and strategies and connect them to support groups and smoking cessation hotlines," she says. "The goal is to support them through the steps to quitting."

Improving outcomes

The pilot phase, expected to begin in September, will last about six months. As part of the pilot, Hernandez will observe and document patient-pharmacist interactions during appointments and then will follow up with interviews with patients and pharmacists.

Finally, she will integrate qualitative data from observations, interviews, and documentation with quantitative data, such as patient outcomes and surveys, to understand the public health impact of the implementation package.

"At the end, we hope to take all we learned to modify the package to make it an even more effective tool, and then launch it on a larger scale," Hernandez says.