Author ORCID Identifier
0009-0009-7136-6273
Defense Date
2025
Document Type
Dissertation
Degree Name
Doctor of Philosophy
Department
Pharmaceutical Sciences
First Advisor
Teresa Salgado
Abstract
Background: The United States faces a significant healthcare provider shortage, with projections indicating a deficit of 124,000 physicians by 2034, disproportionately impacting underserved communities. Community-based pharmacists, with their clinical training, widespread geographic distribution, and extended accessibility, represent an underutilized resource for expanding healthcare access. Virginia has taken legislative steps to expand pharmacist prescriptive authority through statewide protocols since 2020 and mandated Medicaid payment for pharmacist services in 2023. Despite these progressive policies, utilization remains limited, with only 24% of Virginia pharmacists reporting use of at least one statewide protocol, and pharmacist registration as Medicaid providers remain extremely low. The disconnect between policy authorization and practical implementation highlights critical gaps in understanding the complex factors that influence healthcare innovation adoption. Therefore, this dissertation aimed to systematically examine barriers to expanded pharmacist services in Virginia and develop evidence-based solutions to address identified implementation challenges.
Methods: A sequential, mixed-methods approach was employed across three interconnected aims. For Aims 1 and 2, semi-structured interviews were conducted with 16 Virginia community-based pharmacists between November 2024 and May 2025, guided by the Consolidated Framework for Implementation Research (CFIR) 2.0. Interviews explored contextual factors affecting implementation of statewide protocols (Aim 1) and Medicaid provider enrollment and billing (Aim 2). Data were analyzed using two-phase inductive and deductive coding, with themes mapped to CFIR domains and constructs. Each construct was rated for valence (direction of influence) and strength (magnitude of influence) on implementation outcomes. For Aim 3, a comprehensive Medicaid provider enrollment toolkit was developed using human-centered design principles guided by the design thinking framework. The development process included stakeholder engagement (n=7), prototype development with expert review (n=9), pilot testing with pharmacy residents (n=3), and final refinement based on iterative feedback. Pilot participants completed surveys assessing toolkit usability, perceived utility, and areas for improvement using 5-point Likert scales and open-ended questions.
Results: For Aim 1, statewide protocol implementation was facilitated by clear relative advantage in improving patient access and strong alignment with pharmacists' professional mission. Key barriers included resource limitations, particularly staffing and time constraints, complexity, and structural characteristics including physical space and workflow integration challenges. Notable differences emerged between pharmacy settings, with independent pharmacists reporting greater implementation autonomy compared to chain pharmacists who faced corporate constraints. Rural pharmacists emerged as innovators when protocols addressed critical healthcare access gaps despite facing unique challenges.
For Aim 2, Medicaid billing implementation faced substantial obstacles across all CFIR domains. The innovation domain revealed procedural complexity, high implementation costs, and poor system design as major barriers, despite recognition of potential financial benefits. Inner setting barriers included inadequate technical infrastructure, insufficient organizational resources, and significant knowledge deficits regarding credentialing and billing procedures. Individual-level factors highlighted pharmacists' lack of opportunity for implementation due to competing priorities and unfamiliarity with medical billing processes. Implementation processes were consistently problematic across planning, strategy development, execution, and evaluation phases, indicating that Medicaid billing remains in the innovator stage of adoption.
For Aim 3, the human-centered design process successfully translated identified barriers into a 35-page toolkit addressing procedural complexity, information accessibility, and implementation support needs. All three pilot participants rated the toolkit positively across all evaluation dimensions, with all reporting they were "extremely likely" to recommend it to other pharmacists. Most importantly, all participants successfully completed DMAS provider enrollment within six weeks using the toolkit as their primary guide. However, complete enrollment data including MCO credentialing completion and billing activity were not available at the time of analysis.
Conclusions: Legislative authorization alone is insufficient to drive widespread implementation of expanded pharmacist services. Statewide protocols show promises for expanding healthcare access but require targeted interventions addressing resource constraints, workflow integration challenges, and tailored support for different pharmacy settings. Medicaid billing implementation faces even more substantial barriers, particularly around procedural complexity, knowledge deficits, and inadequate infrastructure. The user-centered toolkit developed through human-centered design principles demonstrates initial promise in addressing enrollment barriers, though broader evaluation is needed. Implementation strategies must address multiple levels simultaneously: individual (education and training), organizational (resources and workflow support), and system (streamlined credentialing processes and technical infrastructure). Future research should evaluate the effectiveness of specific implementation strategies, conduct longitudinal follow-up to assess sustained adoption, and examine whether increased pharmacist participation translates into improved healthcare access for vulnerable populations. This work provides a model for systematically examining healthcare innovation implementation and developing practical, evidence-based solutions to bridge the gap between policy intention and real-world practice.
Rights
© The Author
Is Part Of
VCU University Archives
Is Part Of
VCU Theses and Dissertations
Date of Submission
12-3-2025