This case builds on elements of project management (PM) – specifically project initiation – including the development of a project charter and stakeholder analysis.
The case was developed from secondary sources as well as first-hand knowledge of the project by one of the authors. This author was on faculty at a private university in the southeastern USA, teaching numerous courses in the pharmacy curriculum while also serving as the Community Practice Residency Director for community pharmacies around the state. While connecting with these organizations, additional revenue requirements and complementary services were frequent topics of attention, leading to a grant to assist pharmacies in building out such services. Through this grant, the author engaged in consultations with community pharmacies around the state, including the pharmacy highlighted via this case. Pseudonyms have been used for the business, and all individuals associated with it, to maintain anonymity. Secondary sources used for additional research include industry reports and related websites.
Richard has owned and operated a community pharmacy, Our Family Farmacy (OFF), for years. A changing industry climate has forced Richard to diversify the products and services he provides. In addition to the distribution of medicine and front-end sales of consumer goods, Richard is seeking to expand into a larger spectrum of healthcare services. After researching several different types of services, and after dealing with related personal family circumstances, Richard decided that OFF should begin their expansion by offering depression screening services. He turned initiation of the project over to his pharmacy intern, Caitlin.
Complexity academic level
This compact case is geared toward undergraduate- and graduate-level students taking courses in general management and, more specifically, PM. This case might also be used by students with a career focus in the healthcare sector, and could of particular interest for students in a pharmacy program. Classroom application should encompass discussions on the project initiation process group, particularly with the processes regarding the project charter deliverable and the identification and assessment of project stakeholders.
CitationMazzei, M.J. and Galdo, J.A. (2019), "A case of the blues: depression screenings in a community pharmacy", The CASE Journal, Vol. 16 No. 1, pp. 34-50. https://doi.org/10.1108/TCJ-04-2019-0040 Download as .RIS
Publisher: Emerald Publishing Limited
“We are simply not making enough money dispensing prescriptions,” thought Richard. “We need to find another way to diversify revenues and better serve our community.”
Richard was the pharmacist-in-charge and owner of a small, independent pharmacy in rural Alabama. After graduating pharmacy school and gaining experience at an established chain, Richard started his own community pharmacy, Our Family Farmacy (OFF). Through diligence, discipline and an entrepreneurial spirit, Richard built the operation to nearly $2m in annual revenues, but challenges were mounting.
While medications remained a cornerstone of the overall healthcare industry, accounting for $450bn of the $3.2 trillion (14 percent) total cost of healthcare in the USA, they have not been enough to sustain most community pharmacies. Competition and updated regulations have deemed these businesses unsustainable solely through medication distribution. Over a number of years, Richard had expanded OFF’s services beyond pharmaceuticals by offering consumer goods. However, the non-prescription business (e.g. candles, toothpaste and over-the-counter medications) only accounted for 5 percent of total sales. Richard needed additional ways to stimulate revenue.
New legislation kept expanding pharmacists’ scope of practice toward clinical services, allowing for the delivery of more robust healthcare provisions. A clinical service is anything outside of producing a product (i.e. filling/dispensing a prescription), including, but not limited to: delivery services and home visits, administering immunizations, checking blood pressure or other vital signs, hospice care, health screenings, long-term care services and medication management. Following this trend, Richard reached out to his professional state pharmacy association to learn more about the variety of other services pharmacies may provide.
Of all the options, Richard was immediately drawn to health screenings, specifically one targeting depression. Richard’s son had battled depression in college, so he was familiar with the struggle of those experiencing it. Additionally, one of Richard’s colleagues in the pharmacy association had recently shared a story of preventing a patient from committing suicide and aiding in his recovery (see Video 1), further reinforcing the potential impact. Richard felt he could champion treatment in his small town and help overcome the stigma associated with depression, while beginning the process of expanding into additional services.
Depression is a leading cause of disability in persons age 15 years and older, and the leading cause of disability among adults in high-income countries. Depression dramatically impacts quality of life, and is often associated with increased mortality due to suicide. Patients with serious mental illness have a shorter life expectancy by 25 years. The economic burden in the USA is estimated at $22.8bn on treatment in 2009 and another $23bn on lost productivity in 2011 (National Association of State Mental Health Program Directors Council, 2006).
An estimated 18.5 percent of Americans experience a mental illness in a given year, and 6.9 percent suffer from depression (National Institute of Mental Health, 2017a, b). Without screening, only 50 percent are actually diagnosed (Mitchell et al., 2009). Despite the assessment being brief and requiring no invasive tests, only about 4 percent of eligible patients actually receive a depression screening (Akincigil and Matthews, 2017).
Initiating change at OFF
With his family background, a determination to better serve customers, and an eye toward improving his bottom line, Richard felt offering depression screenings was an appropriate first step in innovating OFF’s services. He reached out to peers for clinical services policy and procedures examples (see Exhibit 3) to better understand how other medical providers would support the screening (e.g. treatment plans and medications) and how reimbursement processes were to take place. Additional steps were still necessary to identify appropriate local healthcare providers rendering follow-up care.
Though he had concerns with how his employees might accept this change, he was confident they would see the value once established. There would be little impact to the clerks handling the day-to-day operations of the front end of the business. OFF’s pharmacists would need to learn the screening protocols, and the pharmacy technicians would also need to connect patients with referrals and handle necessary paperwork. While this would require a few new procedures, the benefit to customers struggling with depression could be life-saving.
After his initial research, Richard created a business case document and benefits management plan (Exhibits 4 and 5). He assigned oversight for the project to an intern, Caitlin. Caitlin was pursuing a joint doctor of pharmacy and MBA, and was doing a final clinical rotation with OFF to complete her pharmacy education. Upon graduation, her goal was to gain additional experience in the field before opening a community pharmacy in her hometown, just as Richard did. Richard had been mentoring Caitlin for eight weeks, training her on the pharmaceutical, operational and financial aspects of the industry.
“With your business training, I’d like you to plan the project to expand the clinical health services of OFF to include depression screenings,” Richard told Caitlin. He allocated $2,000 to launch the screening program and expected to have the project completed within eight weeks, when Caitlin’s rotation at OFF concluded. He predicted two weeks were necessary to conduct additional research and planning, and hoped to have employee training complete two weeks prior to the official launch of screening services. To begin documenting the project, he asked Caitlin to produce a project charter and stakeholder analysis.
Video 1. Depression screenings in community pharmacy impact
Independent community pharmacies represent $80bn in the healthcare marketplace and employ over 250,000 people. The majority of community pharmacies are located in rural areas. For example, Alabama, where OFF is located, has 569 independent pharmacies. These pharmacies account for over $2bn in sales each year, filling over 33m prescriptions. In Alabama alone, the additional economic activity generated from independent community pharmacies exceeds $1.8bn each year (National Community Pharmacists Association, 2018).
There are a variety of screening forms, the most common being the Patient Health Questionnaire Two (PHQ-2). The PHQ-2 screening (Exhibit 1) is used to identify depressive symptoms within the immediately preceding two weeks; if an individual is positive, then the Patient Health Questionnaire Nine (PHQ-9) is administered (Exhibit 2).
Akincigil, A. and Matthews, E.B. (2017), “National rates and patterns of depression screening in primary care: results from 2012 and 2013”, Psychiatric Services, Vol. 68 No. 7, pp. 660-6.
Kroenke, K., Spitzer, R.L and Williams, J.B. (2001), “The PHQ-9: validity of a brief depression severity measure”, Journal of General Internal Medicine, Vol. 16 No. 9, pp. 606-13.
Kroenke, K., Spitzer, R.L. and Williams, J.B. (2003), “The Patient Health Questionnaire-2: validity of a two-item depression screener”, Medical Care, Vol. 41 No. 11, pp. 1284-92.
Mitchell, A.J., Vaze, A. and Rao, S. (2009), “Clinical diagnosis of depression in primary care: a meta-analysis”, Lancet, Vol. 374 No. 9690, pp. 609-19.
National Association of State Mental Health Program Directors Council (2006), “Morbidity and mortality in people with serious mental illness”, available at: www.nasmhpd.org/docs/publications/MDCdocs/Mortality% (accessed December 31, 2018).
National Community Pharmacists Association (2018), “Alabama independent pharmacy fact sheet”, available at: www.ncpa.co/pdf/state/Alabama.pdf (accessed December 31, 2018).
National Institute of Mental Health (2017a), “Mental illness”, available at: www.nimh.nih.gov/health/statistics/mental-illness.shtml (accessed December 31, 2018).
National Institute of Mental Health (2017b), “Major depression”, available at: www.nimh.nih.gov/health/statistics/major-depression.shtml (accessed December 31, 2018).
Stakeholder analysis – stakeholder register
|Richard (owner of OFF)||High||High||High||Immediate action||Needs to be kept in communication in all aspects|
|OFF pharmacists||High||Moderate||High||Immediate action||Needs to understand need for new services, how/when they will be rolled out and how they will be equipped to perform them|
|OFF pharmacy technicians||High||Moderate||Low||Need to understand role and project timeframe||Keep informed|
|OFF cashiers/clerks||Low||Low||Low||Need to understand role and project timeframe||Keep informed|
|Current clients of OFF||High||Moderate||Moderate||Increasing.||Communication of new services offered|
|Prospective clients of OFF||Moderate||Moderate||Moderate||Increasing.||External marketing to reach new potential audience|
|OFF project manager (intern)||High||Moderate||High||Immediate action|
|Deliver project deliverables on time and on budget||Must conduct research, plan and manage the project|
|Rendering providers (healthcare professionals referred by OFF)||High||Moderate||Moderate||Increasing||Must conduct research to identify high-quality, local providers and establish ongoing communication for/coordination of patient care|
Note: Make a list of potential shareholders, identifying their interest, knowledge level and level of influence (utilizing H-M-L or a simple metric-based scale), as well as adding anticipated expectation from that stakeholder and an engagement plan
Exhibit 1. Patient Health Questionnaire Two (PHQ-2) Screening
Exhibit 2. Patient Health Questionnaire Nine (PHQ-9) Screening
Exhibit 3. Example of Clinical Services Policy and Procedure Guide
Exhibit 4. Business case document
Depression screenings at Our Family Farmacy
Expand clinical health services at Our Family Farmacy (OFF) by offering deliberate and unscheduled depression screenings during hours of operation.
Taking on this project would allow OFF the opportunity to expand healthcare service offerings to the citizens of the local community. Other pharmacies in the area do not currently offer such a service (specifically with regard to depression screening), giving OFF a potential competitive advantage on this service. Expanding into health screenings will also create additional revenues for OFF. At a price of $15 per screening, and assuming an estimate of four screenings per week initially, this would generate an estimated $3,120 annually in revenue ($15 per screening × 4 × 52 weeks) in year 1. Each depression screening should take approximately 5 min to complete, at a rate of $60/hour for a Registered Pharmacist.
By diversifying our services through screenings, OFF pharmacists and technicians increase their knowledge base and the care they provide, improving the business’ reputation and the overall health and wellbeing of those in the community.
Depression screenings would be an initial project to expand healthcare services at OFF. Other health screenings added in the future might include (but not be limited to) blood pressure, bone density, cholesterol and glucose screenings. Additional diversified healthcare provisional services for future consideration at OFF might include immunizations, weight management and wound care.
With very little overhead and – more importantly – the ability to potentially save lives in our community, it is within our means and best interest to begin conducting depression screenings at OFF.
Exhibit 5. Benefits management plan
Depression screenings at Our Family Farmacy
It expands clinical health services at Our Family Farmacy (OFF) by offering deliberate and unscheduled depression screenings during hours of operation.
Depression screenings offer the potential to save lives of the many in our community undoubtedly struggling with depression. While affordable and non-invasive to our customers, depression screenings also provide an additional source of revenue to OFF.
Depression is one of the most common mental health disorders in the USA. Offering these services provides an opportunity to increase awareness of mental health issues and meets OFF’s long-standing objective to provide the best in healthcare services to the local community.
OFF’s goal is to screen an average of four individuals per week the first year, anticipating additional growth in subsequent years. With an estimated $3,120 annually in revenue ($15 per screening × 4 × 52 weeks) in year 1, preliminary projections would be enough to cover OFF’s initial $2,000 investment and the ongoing operating costs.
Customers are willing to engage in depression screenings. OFF pharmacists and technicians are open and willing to the additional educational requirements and responsibilities of providing depression screenings.
Possible risks include cultural insensitivities regarding mental health and the potential lack of clinical follow-up and/or insufficient support from other healthcare providers.
This case was written, in part, to honor the life of a former student and friend to many, Avery Joseph White. If you or someone you know needs help, please contact the National Suicide Prevention Lifeline at 1-800-273-8255
Disclaimer. This case is intended to be used as the basis for class discussion rather than to illustrate either effective or ineffective handling of a management situation. The case was compiled from published sources.
About the authors
Matthew J. Mazzei is based at the Department of Entrepreneurship, Management, and Marketing, Samford University, Birmingham, Alabama, USA.
John A. Galdo is based at Performance Measurement, Pharmacy Quality Alliance, Alexandria, Virginia, USA.