**1. Introduction**

According to the Centers for Disease Control and Prevention (CDC), one in four adults suffer from at least two or more chronic diseases such as diabetes, dyslipidemia, and hypertension [1]. The World Health Organization (WHO) found that only 50% of patients, on average, in developed countries with chronic diseases are adherent to their medications [2]. Medication nonadherence in patients with chronic conditions escalates direct health care costs nearly \$100–\$300 billion dollars each year [3]. Medication synchronization is a program proven to increase adherence, reduce emergency department visits and reduce hospitalizations for these patients [4,5]. Community pharmacies have incorporated medication synchronization into their workflow to improve quality of care and medication adherence. Medication synchronization is the alignment of a patient's medication refills to a single date each month. Other features can be added in conjunction, such as comprehensive medication reviews (CMRs) and delivery [6,7].

The Appointment Based Model (ABM), one type of medication synchronization, is a patient care model where patients have one or two appointed days per month to pick up all medications [7]. The pharmacist performs additional patient care services, such as a comprehensive medication review (CMR), on that day to evaluate therapy and answer any questions or concerns from the patient [8]. Approximately 20,000 community pharmacies have implemented this service in the United States, and it is predicted to expand [9]. The medication synchronization component of ABM may be implemented by personnel at the patient's pharmacy, or via a call center that identifies appropriate patients to enroll and places medication orders into pharmacy workflow. These programs allow pharmacies to clarify medication regimens, for stakeholders to enable optimization of medications while improving predictability of workflow and workload [6–9].

Successful process implementation requires buy-in from all members of the healthcare team [10]. Given the demands on pharmacist time, new service implementation in community pharmacy is frequently met with barriers [11–13]. While pharmacists deliver the clinical components of ABM, pharmacy technicians have a vital role in the implementation process for this service. The exploration of the pharmacy technician perspectives is crucial to understand how to overcome the hurdles facing ABM and medication adherence. There is limited research on roles, responsibilities, and challenges faced by pharmacy technicians in ABM implementation. The objective of this study was to qualitatively explore the role of pharmacy technicians in the implementation of an appointment-based medication synchronization program.

#### **2. Materials and Methods**

#### *2.1. Recruitment and Participants*

Pharmacy technicians working one regional division of a large community pharmacy chain in either Mississippi or Tennessee were recruited. A purposeful sampling approach was used to recruit participants, whereby key informants were selected based on their exposure to ABM implementation, rather than selected randomly. The researchers were provided with a list of pharmacies from which subjects could be contacted, and researchers subsequently contacted and consented participants via telephone. Participants were stratified based on their pharmacy's type of ABM used (in-store technician call model or an off-site call center model) and ABM performance (as defined by internal pharmacy measures of ABM implementation) within the supermarket chain pharmacy's division. Participants had no prior experience with ABM prior to the study. This study was approved by the Institutional Review Board at the researchers' university. All subjects gave their informed consent for inclusion before they participated in the study. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of the University of Tennessee Health Science Center (18-05758-XM).

#### *2.2. Data Collection*

One member of the research team, with training in qualitative research, conducted 6 in-depth, semi-structured interviews from January to April 2018. Interviews lasted approximately 60 minutes and were conducted either via telephone or in person at the workplace. To best understand individual technician perspectives about ABM implementation, semi-structured interviews were chosen as compared to other methods, such as focus groups, which have the potential to obtain a consensus. [14].

A semi-structured interview guide was developed (Table 1) based on the Consolidated Framework for Implementation Research (CFIR) [10]. The interview guide was pilot tested with technicians at the same supermarket chain in a different division. CFIR consists of 37 constructs developed to synthesize a unified typology of implementation and dissemination theories and frameworks. The interview guide included questions categorized within four CFIR domains: (1) process (i.e., champion, engaging, innovation participants; (2) inner setting (i.e., relative priority, readiness for implementation, access to knowledge and information; (3) outer setting (i.e., needs and resources of those served by the organization); and (4) intervention characteristics (i.e., adaptability). A verbal consent statement was gathered prior to conducting the interview. The interviews were audiotaped and transcribed in their original format. Field notes were made during the interviews and added to the transcripts.

#### **Table 1.** Interview guide.

#### **Section 1: Participant Demographics**


10. What are some of the barriers, if any, your pharmacy has faced when implementing medication synchronization?

• [PROBE] How has your pharmacy worked to overcome these barriers?

### **Section 6: Champion**

11. Does your store have a designated champion for the medication synchronization program?

**Section 7: Intervention Participants**

12. Tell me an example of how you are informing patients about this program?

• [PROBE] What promotional materials, if any, do you use to communicate the availability of this program?

• [PROBE] How do you select which patients to promote this program to?

## *2.3. Data Analysis*

Using the CFIR codebook, two members of the research team (CR and DC) analyzed thematic content [10]. The initial session consisted of both researchers identifying preliminary codes and subthemes and resolving differences through active discussion. Afterwards, the researchers independently translated the remaining transcripts and met for a second session to identify any further emerging codes or subthemes that surfaced. Transcripts were analyzed using NVivo12 (QSR International Pty Ltd., 2018). Consistent themes observed were mapped to the constructs of the CFIR. The Consolidated Criteria for Reporting Qualitative Studies checklist was used to guide the reporting of qualitative methods and findings [15].
