Complexity of patient encounters within a clinically integrated community pharmacy network Medicaid payer program

Background: Community pharmacists frequently care for patients with complex medical and social needs; however, specific evidence on pharmacist perceptions of what makes a patient encounter complex has not been clearly characterized. There is a need to better understand specific factors that contribute to patient encounter complexity and demonstrate how pharmacists in community settings care for these individuals. Objectives: The objectives of this programmatic case study were to: (1) elucidate factors that contributed to patient encounter complexity as a part of a Medicaid Managed Care Organization comprehensive medication management payer program in community pharmacies and (2) curate a series of patient case vignettes that provide evidence of pharmacists care for patients with complex medical and social needs within community pharmacies. Methods: This qualitative programmatic case study utilized data from semi-structured interviews with community pharmacists who provided comprehensive medication management services to Medicaid patients in Pennsylvania. Pharmacists described their most complex patient encounter. Interviews were transcribed and independently coded by 2 investigators. The coded texts were grouped into categories, and a cross-case inductive thematic analysis was performed to identify complexity factors. Results: Thirty pharmacists provided 48 patient case vignettes and 3 complexity factors emerged: (1) care coordination; (2) behavioral health support; and (3) social determinants of health. Representative patient case vignettes were selected to illustrate these factors. Conclusion: Pharmacists, who participated in a community pharmacy Medicaid Managed Care Organization payer program, provided care to patients with complex health needs. In addition to medication-related problems, specific factors that increased pharmacist perception of encounter complexity were care coordination with other health care providers, behavioral health support, and addressing social determinants of health. (c) 2024 American Pharmacists Association (R). Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).