**1. Introduction**

In response to value-based paymen<sup>t</sup> structures, community pharmacies recognize the expansion of pharmacy technicians' roles for achieving optimal patient care [1]. Both medication dispensing support and clinical service support have been adopted by pharmacy technicians [2]. Technicians' roles have expanded to include taking and transferring prescriptions and "tech-check-tech" duties with no statistically significant differences detected in the accuracy or error-detection rates between pharmacists and technicians [3]. Advanced roles, such as, immunization administration have also emerged in some states to include technicians, further encouraging the advancement of their roles [1]. The evolution of technician roles better positions pharmacy technicians to support and free up pharmacists to focus on providing patient care services [4].

Medication nonadherence is estimated to account for nearly \$300 billion of the annual healthcare cost in the United States [5]. In an effort to improve adherence and reduce unnecessary spending, medication synchronization (Med Sync) programs have been adopted by community pharmacies [6]. Studies show medication adherence improves when patients are enrolled in a Med Sync program; however, considerable variability in the implementation of this service exists between community pharmacies [7–11]. Med Sync, as described by the American Pharmacists' Association (APhA) in their white paper, is designed to improve consumers' adherence to medications and build efficiencies in pharmacy operations. The white paper establishes how community pharmacies can integrate the Appointment Based Model (ABM) Med Sync into pharmacy workflow and business models [12]. The 10 steps outlined in the white paper were summarized in a systematic review of the Med Sync process conducted by Patti and colleagues [12,13]. The systematic review revealed 5 core components: (1) pharmacy sta ff identifying and enrolling patients, (2) pharmacy sta ff reviewing and assessing medication, (3) pharmacy sta ff working with patients to synchronize medication refills, (4) pharmacy sta ff contacting patients or designated care providers to identify medications for fill, and (5) patients meeting with pharmacy sta ff for pick up or delivery of medication [13]. The white paper and the systematic review demonstrate key roles that must take place to perform Med Sync services, ye<sup>t</sup> neither document mentions which pharmacy sta ff members should perform these services.

Across the country, community pharmacies have implemented Med Sync to promote medication adherence and improve patient outcomes. The National Community Pharmacists Association (NCPA) *Digest* reports 79% of independent pharmacies currently o ffer Med Sync to combat nonadherence [14]. Researchers identified several pharmacies in North Carolina who dispense more than fifty percent of their prescriptions as part of a Med Sync program. To explore how these community pharmacies operate Med Sync, a qualitative study was undertaken with the aim to reveal strategies that incorporate technicians' roles into Med Sync. Determination of these roles and responsibilities will provide insight into specific pharmacy operations employing technicians for successfully operating a Med Sync program.

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

The research team consisted of two pharmacists, one pharmacy student, and a qualitative research methodologist. The study reported here is a part of a larger multi-phase project examining adoption of Med Sync programs in community pharmacies. For the purposes of the study reported here, the data that focuses on the role of pharmacy technicians is highlighted. This observational study utilized a semi-structured interview guide with the initial goal of identifying the barriers and facilitators to adoption and explored community pharmacies practical solutions to ensure successful adoption of Med Sync services. Purposeful sampling was used to identify North Carolina community pharmacies with greater than 50% of their prescriptions in a Med Sync program and the leads of the Med Sync program were invited to participate in an interview. Interviews were conducted by three members of the research team via Zoom Client for Meetings [computer program] Version 4.6.7. (Zoom Video Communications Inc., San Jose, CA, USA). The semi-structured interview guide focused on all aspects of adoption of Med Sync. Each interview lasted approximately 60 min and were transcribed verbatim.

The analysis of interview data used an inductive approach to coding, and codes were derived from the data in order to reflect participants' perspective [15,16]. As a group, the team read and discussed participant responses and through these discussions created codes and corresponding definitions. Memos were written during and after each coding session to capture the analytic process and any themes or patterns that were emerging in the data [15,16]. Preliminary analysis revealed heavy involvement of non-pharmacist sta ff, leading the research team to further investigate the roles and tasks of technicians in Med Sync. After initial coding, cluster analysis was used to focus on the data that emphasized the roles of and tasks completed by technicians [15,16]. This process involved creating a summary matrix of the data and reviewing the data iteratively to identify key ideas expressed by participants regarding the role and tasks of technicians in the Med Sync program. At least two members of the research team analyzed the qualitative data at a given time and agreed on the application of codes and the identified themes. A third researcher, a pharmacist, verified all themes. This study (IRB# 19-1832) was determined to be exempt by the university's IRB.

## **3. Results**

Twelve community pharmacies met the inclusion criteria of having greater than 50% of their prescriptions in a Med Sync program and were invited to participate in the study. Seven pharmacies responded and agreed to be interviewed, Table 1 displays their demographic characteristics. The recruitment email requested to interview an individual who was the primary leader of the Med Sync program at the pharmacy. Six pharmacists and one pharmacy technician were interviewed.


**Table 1.** Participating Community Pharmacy Characteristics.

Analysis of the seven community pharmacies revealed technicians' support of Med Sync through various roles and tasks. Participants described technicians' roles in identifying patients for marketing and enrollment, reviewing patients' medications list to establish a plan for synchronization, choosing alignment dates based on patient preference, contacting patients in preparation for dispensing, and lastly, engaging in pickup or delivery of medications.

Program leaders from each store described varying levels of technician involvement in all aspects of the Med Sync Program. Each pharmacy recounted technician responsibilities in at least three of the tasks mentioned above. One pharmacy acknowledged technician involvement in all Med Sync tasks, and another pharmacy had a technician involved in four. All pharmacies detailed involvement in both documentation of patient information as part of the Med Sync process and preparation and packaging of prescriptions. Two pharmacies discussed technician involvement in addressing additional interventions, such as, delivery. Six of the seven pharmacies described technician assistance with patient enrollment.

Tasks mentioned in the marketing and enrollment of Med Sync patients included identifying nonadherent patients via performance information managemen<sup>t</sup> systems and communicating with new and frequent patients during face to face and telephonic encounters. For instance, one participant shared they have technicians "*run a report of everybody who is less than 80% adherent*" as a way to target patients for enrollment in Med Sync. Patient assessments and medication review tasks included technicians identifying low, medium, and high-risk patients for medication nonadherence based on medication burden and prior incidence with adherence. One participant, a pharmacist, when asked to "Walk me through how you synchronize your prescriptions once they are enrolled", responded, "*That's probably a better question for the techs.*" In addition, technicians also documented patient information, such as, counting refills and patient's "at home stock". For example, one participant stated that technicians "*tally up how many pills of each medication we need to give to the [patient]* ... *and short fill whatever needs to be short filled to get [the patient] lined up*." Technicians interacted with patients to set synchronization dates that accommodated finances, transportation and other patient limiting preferences. One participant noted their technicians set sync dates based upon patient preference, "*we leave it up to the individual [patient]* ... *they tell us when [they] want it, what day or what week and we kind of go from there*." During the preparation of the medications for dispensing, technicians conducted routine patient interviews and packaging of prescriptions using multi-dose packaging systems. Lastly, technicians were either present for pickup or addressed additional services, such as, delivery when necessary.

Additional corresponding participant quotes capturing technician roles, responsibilities, and tasks are matched with the identified 5 major themes in Table 2.


