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So now we're gonna be talking about the pharmacy encounter, you know, how to bridge those mixed messages and, and be confident and equitable in co-administration, and this is so critical because patients obviously need the protection from vaccines. As a clinician who works in the cardiovascular disease space, it's very clear how important vaccination is in reducing cardiovascular risk, and so really getting everyone to be engaged and encouraged on this from a pharmacy's perspective is, is really critical. So why the pharmacy door matters. You know, over the years, pharmacists have become prolific and important from a public health standpoint in terms of vaccinations, and pharmacists have become really the trusted immunizeers. They're walk-in, they have extended hours, no visitor fees, they're convenient. They're uniquely placed throughout the community or outside the realms of primary care, and we, we see in the data pharmacists are likely to have a higher odds of vaccination after pharmacist-led intervention, and we know that there are tons of doses delivered. You know, about 150, 115,000 contacts in one statewide outreach program, for example. So it is a very effective process, and it really does allow for access and equitability. You can reach people who you may not have been able to, low-income or uninsured adults because they don't need an appointment. They don't have to have. Uh, kind of an established arrangement to do this. You, patients who can't really get around, may, may be able to come there from a rural or limited transport perspective, because often pharmacies are kind of a central hub in the community, or homebound or older adults can visit mobile clinics or the area of the pharmacy, and working adults with, you know, who are busy during the day can get their vaccines on the evening or the weekend. So we're gonna kind of walk through this whole concept through a case study. We have Mrs. Jones, she's 67 years old. She's a type 2 diabetic and COPD, so very high risk, and obviously the patients we think about who should be getting vaccinations, and mainly uses a busy chain or community pharmacy near her apartment for refills, and the vaccine in play that she hasn't had, she hasn't gotten her flu vaccine or the influent this season, it's due. She's updated on her COVID-19 vaccine or was, but now is overdue. She's never had a pneumococcal vaccine, which is super critical for patients with diabetes or COPD, and she's not had or been offered a recumbentant zoster vaccine. And, you know, all four, if you can recall, can be administered safely based on the current evidences at the same time. And then she has two messages in one day, just conveniently her primary care physician, the clinician briefly mentions vaccines, but defers the specific to the pharmacy and really no clear plan or messaging. And at home, she is on her device scrolling around and social media posts warns that too many shots at once overload the immune system and that pharmacists push vaccines for profit or things related to that nature. And at the pharmacy, the tech also kind of engages in this faulty behavior and says you can get them together, but some doctors don't like that, and the pharmacist is also rushed and really only consists of the flu. So you see all sorts of missed opportunities and we're gonna walk through these today. And so the result through the 4 new vaccines are missed during the single touch point, when in reality, they all could have been given at the same time. So, we're going to do some interactive audience polling. So which factors most directly drove the miscomministration opportunities for Mrs. Jones once in the pharmacy? A, Social media misinformation about too many shots went uncountered before her visit. B, noracive workflow checked, flagged pneumococcal COVID-19 and zoster were also due. See, the pharmacy's teched hedge. Some doctors don't like it and comments reinforced out, or D, the PCP's vague hand off to the pharmacy that left Mrs. Jones without an unfilled plan. So we're going to allow you guys to answer these questions at this time. So now that we've seen the results, let's go through this guided discussion. Why did this happen? As you can see statistically in what the data suggests, only 18% of pharmacies proactively scheduled the pneumococcal vaccine for eligible adults, and often this is the vaccine that people tend to forget or gloss over or not think about, and most wait for the patient with a prescription to prompt action. But when you think about these situations with Ms. Jones, and you put the pharmacy level pressures together along with the patient level of confusion, you get. Hey, a reactive workflow versus a proactive workflow. So vaccines are administered when asked, and not necessarily that they're flagging or noting patients need to be doing this. Clearly across healthcare providers, social media, and with the patient, there's missed messaging in the tech as well, you know, hedge comments from the staff continues to reinforce his doubts or feed into social media narratives or other narratives. With the PCP or media, there's documentation gaps, so vaccines are inconsistently entered into information systems, leaving the PCP uncertain what is given. So sometimes it just happens because no one knows what's going on. The patient can't describe to you what vaccines they've had, and then there's access inequity and reliance on a single pharmacy plus transport barriers means one or more missed visits equals many weeks of delay. So let's talk about barrier one missed messages on co-administration. You can get them together, but some doctors don't like that. That's what the tech said at the pharmacy counter. And when, when this looks like in practice is when you get this hedge non-committed counseling that lets the patients expand upon their doubt about co-administration and and and and continues to have this narrative persist, and they survived when really the encounter can be resolved. So. What is the system, uh, vulnerability here is really you can see between the staff there's inconsistent messaging that contradicts national guidance, and the patient interprets this as uncertainty or ambiguity, has a reason to space vaccine and miss follow-ups. So what is the pharmacist moves really is to speak with one voice. Co-administration is safe and it's effective, getting your staff trained to say these things, providing constant. Medication related to the concept, you know, mild short-lived reactions, no loss of immune response across flu, COVID-19, RSV, pneumococcal, Tdap, and zoster. So I think it's worth putting an educational campaign together and always consistently having that messaging with your pharmacy staff. Theory too is misinformation from non-clinical sources, and this is obviously something that has grown since the pandemic and continues to be a piece of the narrative with social media. So you read online the patient that too many shots once at once can overload your immune system. You know, after they've done their doom scrolling or whatever that may be, and what this looks like in practice is the patient arrives pre-formed with pre-formed myths from a social media platform, sometimes more recent and emotionally charged than any clinical message they've seen, because there's a lot of people that are engaged in this on social media. And so the, the vulnerability here is scare tactics, and we just don't know responses seem to backfire. And without proactive breed debunking and understanding what misinformation out there and trying to combat that misinformation. You really got to work to fill that silence and and drive away the delay from the standpoint. So what's the pharmacists move is really prebunk and reframe, acknowledge their concern, always be empathetic, and then highlight scientific consensus in plain language and pre-warn patients that misleading content is circulating. Explain what the evidence actually shows, and use your opportunity to be the expert to show this. Barrier 3 is a reactive-only pharmacy workflow. She came in for her flu shot, so I gave her the flu shot. The rush pharmacist said. You know, just kind of thinking of that as the quick and easy and not doing the screening, and what this looks like in practice is there's really no systematic immunization status check at the dispensing window. Pneumococcal, COVID-19, and zoster sometimes are silently missed in some instances and the patient is in front of the team. You know, only 18% of pharmacies try to proactively schedule vaccines or the pneumococcal vaccine in specific and without prompts or standing orders, single vaccine intent looks, uh, locks into the counter just doing the single vaccine. The pharmacists move, you really need to screen at every counter, use age, chronic conditions, understand the evidence, what the guidelines suggest, use registry checks at a refill or every vaccine visit, trigger standing orders if able or alert, and eligible adults are offer all due vaccines, not just the one they ask for, and make sure that it's proactively and prolifically documented. And then the last is the barrier equity access and gaps. So I'll just wait and check with my doctor before getting the others. Transport limited patient has a differential. And so what this looks like in practice, you know, in low income, rural or disabled or homebound adults often have a single accessible touch point, and the delay often in the pharmacy becomes a month-long gap. And so these are system vulnerabilities that exist. You have a vulnerability by age and clinician risk is well targeted, and then you have socioeconomic and geographic vulnerability is consistently under targeted in pharmacy outreach. And so, Really the key is, is because they're in the pharmacy and you have a chance to capture them, bring the vaccines to where the patients are. So do it in your clinic, offer, uh, same day catch-up clinics, go out and do outreach at housing sites, do community events, go to community centers for home visits. It's a great way to really get your pharmacy out there and promote it, but also outreach to the patients and pair with coverage coverage navigation, so cost is never the deciding factor in doing this process. So what would have prevented it? Some workflow adjustment, you know, the three-step pharmacy vaccination check, you know, embedding in the check, dispensing, counseling, you know, beyond the covering of the single vaccine, but really do some screening works, alerts, uh, know that data and outcomes and what you're looking for, full age, chronic conditions, other history into the dispensing window, generate a daily list of the patients that are due for flu, pneumococcal zoster, or COVID-19. Some community pharmacies already do this and do provide alerts or to ask those questions. And then offer, use a presumptive consensus-based script. You're due for these, we can give them together with you today. Have you had them?