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To learn how pharmacy staff can prepare for the 2020-2021 influenza season and discuss the changes that pharmacy staff may be anticipating, Pharmacy Times spoke with David P. Zgarrick, PhD, FAPhA, professor in the Department of Pharmacy and Health Systems Sciences in the School of Pharmacy at Northeastern University’s Bouvé College of Health Sciences in Boston, Massachusetts, and Shane Desselle, PhD, RPh, FAPhA, professor of social & behavioral pharmacy at Touro University California in Vallejo, California.

Pharmacy Times: How can pharmacy staff start to prepare for the upcoming influenza in the summer, and what might be different this year (2020)?

Zgarrick: We are going into a very unique influenza season this coming year. Everyone has COVID-19 on their minds; but, it is important to remember that we are still going to have a 2020-2021 flu season. The flu is still going to be out there, and it needs to be something that people are concerned about. Thousands of individuals die of the flu every year, and just because we arefocusing on COVID-19 right now does not mean that the influenza virus is going to go away. If anything, there will be an added challenge to help patients realize they still need their annual regular influenza vaccine.

Of course, there is the anticipation of the need for vaccines and supplies using pharmacy data, which is used to anticipate the number of [people] who may request vaccines, the total amount per vaccine type, and supplies that are needed. In addition, there [should] be consideration of the marketing activities…to encourage patients to receive vaccinations and when these activities will launch. Some of that planning already starts at the end of the previous flu season, but [as summer begins], we are starting to move into that full-court press to prepare for the fall. Decisions are being made regarding the aforementioned questions right now [in July].

Pharmacy Times: What advice would you give pharmacy staff on how they can ensure they are effectively commu- nicating the importance of the influenza vaccine at this time?
Zgarrick: It goes back to leveraging the fact that pharmacists are the most accessible health care professionals. In light of COVID-19, more patients are coming into the pharmacy with questions. This provides an opportunity for the phar- macist to get the message out that influenza [remains] an illness of concern, and patients should be prepared for the 2020-2021 influenza season. Pharmacists can ensure they are having those conversations with patients, and they need to be having those conversations now, to be ready for when the time comes to really start the push toward flu season—which, honestly, in many places starts in August. This brings up the question of when pharmacists should typically start thinking about influenza vaccines. As the new [seasonal] influenza vaccine becomes available, the message will quickly turn to reminding patients, “It isn’t too early to get your influenza vaccine” or “Don’t wait for a COVID-19 vaccine to get your influenza vaccine.” Pharmacy staff are increasingly getting into this mindset that immunizations are a year-round activity rather than seasonal.

Pharmacy Times: How can pharmacists help to flatten the curve?
Zgarrick: [As frontline health care providers] we recognize the importance of educating people about health and what they can do to protect not only their health, but that of those they love. [There is much talk about] social distancing and all the things we did to flatten the curve with COVID-19 and getting an influenza vaccine should also be thought of as another form of flattening that curve. The recommended actions to stay healthier overall are going to help not only individual patients, but also the health care system. This is certainly a message that pharmacists can put out there: We all play a part in keeping not just ourselves healthy, but also our communities, and getting an influenza vaccine is a really important component. Just like social distancing was an important part of lowering the COVID-19 curve, getting your immunization and keeping yourself healthy is also going to play a role moving forward.

Pharmacy Times: Should pharmacy staff expect a percentage increase in influenza vaccinations in fall 2020?
Zgarrick: That is a really good question, and I think the answer is still unknown. On one hand, there may be an uptick in people requesting immunizations because they are more tuned into their health as a result of COVID-19. [Many people] recognize that the healthier they are, the better their chances of effectively dealing with COVID-19 should they become infected. That is certainly a message I would want to get out there as a health leader and health professional.

On the other hand, demand for immunizations could be challenged because many people are unemployed right now and may have depended on their employment-based insurance for healthcare. Many people may not have the resources to be able to pur- chase a vaccine or immunization as they have had in previous years. Or, patients may be so tuned in to focus on COVID-19 only that they do not pay attention to other aspects of their health that require attention.¹

Pharmacy Times: How can pharmacy staff prepare in case there is an influx of people demanding vaccines, in terms of routing patients, having extra personal protective equipment, designated areas to vaccinate, etc?

Zgarrick: This is a good point. Pharmacies have already had to change their ways [because of COVID-19] and are already focused on appropriate use of personal protective equipment (PPE). However, pharmacies also are tasked with emphasizing [to the public] that it will still be safe to go to a pharmacy. And, when administering an influenza vaccine, pharmacists will take certain precautions to not only protect themselves but also to protect patients from any undue exposure to COVID-19—or anything else for that matter.

How to effectively communicate that it is safe to travel to a pharmacy to receive a vaccine is a challenge. On one hand, people could latch onto the message that it is important to stay healthy through this [current health crisis], and pharmacies could receive more influenza vaccine business as a result. On the other hand, patients could be worried about the risk of exposure to COVID-19 [and stay away from the pharmacy].

Many pharmacies have already transitioned some daily tasks to be performed through telemedicine, telepharmacy, and online orders. Reminding patients that if they do not have to go to the pharmacy [to pick up their medications] is important, but receiving vaccines is still a task that requires an in-person visit. The message we will have to get out is that: you can still come to the pharmacy to get your influenza vaccine, it’s more important than ever that you do, and we can do it safely.

Pharmacy Times: What can a pharmacy technician do if they are faced with a customer who is unwilling to adhere to recommended safety precautions (ie, wear a mask)?
Desselle: That relates back to communication. Each situation is somewhat different, yet they all share things in common; for example, patients might be recalcitrant [when it comes to] quitting smoking or not taking their medications properly. These are all potential barriers to effective treatment: If you do not take your medication or quit smoking, ultimately, you are not going to achieve the expected therapeutic outcomes.

There is no communication [strategy] that works 100% of the time, and there always will be some communication failures. If a patient is going to be belligerent, they will not necessarily open up to you, and you might not find the underlying reason for that belligerence. If a patient comes into the pharmacy and is not wearing a mask, there could be some political aspects involved, but although we might be quick to assume so, that may not be the reason at all (ie, the patient may have simply forgotten their mask at home). We will not always be able to talk a patient down if they are angry, belligerent, or bellicose, but utilizing empathy, asking open-ended questions, and providing rationale [can help]. If patients are allowed to express themselves and air their concerns, oftentimes, they will calm down.

It is important to remember that even after using empathy and asking open-ended questions, you might not get the result that you are looking for right then and there, and think the conversation was a failure. That’s the big mistake people make. They think, “I tried this communication strategy and it didn’t work because the patient left without doing what I wanted them to do, and they still left [angry].” However, if you were able to encourage the patient to talk things out, you probably planted a seed [in their minds] and at some point, maybe next time they come into the pharmacy, you will have success. Maybe at home or on the way there, they may reflect on the conversation: “The technician made a good point, and although I did not get my vaccinations today or I did not bring my mask today, I am going to think about this [situation] a little bit more.”

Communication is an ongoing, longitudinal process, and it may take several encounters for it to be successful.

Pharmacy Times®: In light of COVID-19, if more people request vaccinations, there will be more responsibilities on the pharmacist. As such, the role of pharmacy technicians may be evolving, and some tasks may be delegated. How can the pharmacy as a whole help to prepare technicians for a potential increase in their responsibilities?

Zgarrick: That has been a big issue. At the onset of the COVID-19 crisis, a number of states put forward emergency orders [to increase technician responsibilities].² In many cases, these will ultimately transition into permanent orders, thereby enabling pharmacy technicians to do more and enabling pharmacists to delegate more activities. Pharmacists are still ultimately responsible for what happens in their pharmacies, regardless of how tasks might be delegated and completed, especially as there is more ability now to do that with the technicians. Nevertheless, something incumbent upon pharmacists at this time is the need to recognize [that] we still need to educate and train our technicians. Just because the laws and regulations have changed, that does not necessarily mean it is acceptable to delegate [new tasks and/or responsibilities] to pharmacy technicians without training. Instead, we need to prepare them to be able to perform these new roles. Pharmacies need to take that step back and say, “Let’s train our technicians. Let’s make sure they are prepared to be able to do these things.” This includes going so far as considering compensation, to ensure technicians are effectively and appropriately compensated for what that they are doing, because their work is very much in demand right now.

Desselle: In the past couple of years, we’ve seen quite an [array] of diverse roles for technicians evolve, but even more so moving forward.^3,4 In the states where technicians can administer vaccinations, I don’t necessarily see much difference [than in states where] they cannot. Obviously, that is an added task technicians can do, but when you look at the whole process of vaccinations, there is an entire gambit of responsibilities that technicians can take up. There are also administrative components, such as keeping track of vaccinations that were provided. Additionally, there are a number of supply chain issues for vaccinations, so technicians can make sure to keep monitoring the amount of supply and work with pharmacists to not only anticipate the supply needs in the future, but also maintain contact with distributers of the vaccine to ensure vaccine lots are not expired. Even beyond the supply chain, technicians can work with pharmacists to help with administrative tasks, such as ensuring that vaccinations have been recorded into the patient’s medical record.

Given that they are on the proverbial front lines, technicians can also focus on communication with patients. In states where they do not [administer vaccinations], technicians are not prohibited from speaking to patients about vaccination. They can use motivational interviewing techniques to speak with patients and encourage them to receive the vaccinations.⁵ Although many patients come to the pharmacy who are willing to be vaccinated, they might have friends, family, and so forth who are not [or] who have doubts about it. These patients [may] want to know some tips and strategies to use when talking to the other individuals in their life to convince them to not only get vaccinated, but to do so here at this pharmacy. Technicians can elicit information about the patients themselves, as well as about the patient’s caregivers, family, and social support network to discover the patient’s logic behind wanting to get vaccinated [and where]. The technician can collect this information, record it, and share everything with the pharmacist.

In addition to coordinating the gathering of vaccination-related information from patients, technicians can also help with scheduling. For example, some pharmacies might use a first-come-first-served model for their vaccinations, whereas some might use an appointment-based structure, and some might use a hybrid of those 2 [arrangements]. The technician can help the pharmacist design an implementation strategy for vaccinations. For example, a pharmacy without an appointment-based system still might consider instituting such a system for patients who would prefer having a scheduled time rather than wait in a line. The technician can help by using that strategy and setting up appointments as needed, even though the pharmacy’s primary system is not appointment based.

This is an exciting time for the growth and advancement of the technician as a profession. Technician roles and responsibilities are evolving and continually changing and growing to meet different needs.

Pharmacy Times: Are roles for pharmacy technicians going to change in light of COVID-19?
Desselle: Unquestionably, and we have already seen [it] in a few states. Some states call it a suspension of rules, others call it an expansion of scope, some are calling it temporary. Some [states] are not necessarily labeling it as temporary, but under the current situation, boards of pharmacy are allowing different scopes of practice for technicians.^6,7 As with anything else, when an organization, a person, or an entity tries something out and it works, then it is likely to stay.

Pharmacy Times: What are some examples of how the scope of work for pharmacy technicians could be changing?
Desselle: There are specific things, but I might consider it in more of a generalist manner. For example, in Idaho—which is one of the more progressive states in terms of boards of pharmacy—regarding technician “deregulation,” what that state did was to say, “Rather than write a definitive list of what technicians can do, let’s just state what they can’t do.”⁸ Then, everything else is up to the pharmacist in terms of delegating. As a result of COVID-19—and certainly not solely due to COVID-19—certain things will speed up, [particularly] pharmacists having greater delegatory authority. Therefore, this change will not necessarily start with the technician, but rather with the pharmacist: An empowered pharmacist is the one who has greater delegatory authority.

Boards of pharmacy are going to leave more and more dis- cretion up to the pharmacist regarding what technicians can do, as opposed to [the Board] delineating all the [tasks]. With the advent of COVID-19 and the associated drug shortages, supply chain issues, and increased demand on pharmacy staff to help patients who are having difficulty navigating the health care system, or who are confused and/or frustrated, states are looking to one another to learn from the success of what’s happening in locations that have already expanded technicians’ scope of practice (ie, being able to immunize), to learn how to follow suit. Centralization is key here. Within certain limits and parameters that can be defined, it will be more up to the pharmacists and their organization to expand the technicians’ scope of practice.

Pharmacy Times®: What can pharmacy technicians do now to prepare themselves for this potential increase in responsibilities?
Desselle: Among the first things that technicians can do is to be proactive and talk to pharmacists. Most, if not all, technicians are aware that the landscape is changing. They know their duties and responsibilities are being expanded and that changes are coming. This [change] manifests in a great opportunity for technicians. Just as any employee should approach their supervisor or employer in saying, “In light of these changes that are coming, let me offer my services. Let me offer you what I would like to do in the future.” I think this is something more technicians should be doing—being proactive and talking to the pharmacist on their own behalf and having the pharmacist even talk to their supervisor, if need be, about the roles technicians can take on.

A technician can say, “My understanding is that beginning this fall, we are going to be able to do this and that. Let me speak on behalf of at least myself to say that I am very interested in doing that. Let me put my name in the hat as someone who wants this. Can you provide me with any suggestions on any education and training that I might need to better prepare myself?” Then, based on the response they receive, at least to some degree, technicians can seek out more education and training, and not just in the technical sense. For example, when it comes to immunization, technicians can take any number of nationally accredited courses on vaccinations or immunizations.

[I should mention,] however, there are also the issues of time management and stress management: How will [technicians] handle these new roles? How will they take on the stress of these now roles? How will they manage their time to effectively incorporate these new roles perhaps into the roles that they are already doing?⁹ Technicians may be asked to perform even more tasks. Oftentimes, people volunteer their services, but the employer or supervisor may say, “Great, but we’re not taking away these other responsibilities. They’re going to be added to what you are doing, and maybe later on, we might think about relieving you of some of your current duties, but first you’re going to have to do both.” With this in mind, there are issues of stress management, time management, organization, organizational skills, etc, that need to be considered.

We are beginning to see mentorship programs for pharma- cists in some of the professional organizations. For example, in California in the Sacramento Valley chapter of the California Pharmacists Association, there is a mentoring program that actually includes technicians.¹⁰ Technicians seeking to receive encouragement and aid with stress management may want to seek out mentorship for guidance, education, and training not just in the technical aspects, but in more humanistic aspects as well.

Pharmacy Times®: Would this additional training be provided onsite, online, or a mix of both, and how can pharmacies incorporate this training into their busy workflow?
Zgarrick: Likely a mix of both. [Additional training] is cer- tainly in the nature of the work of a pharmacy technician, and onsite training is key for tasks that are very specific to a particular pharmacy. Although there are online [training] options, much of what needs to be done requires hands-on, in-person training. That is the role of pharmacists and pharmacies to train technicians to do tasks such as intake interviews and to be more involved in the process of immunizations, or, especially now, to have pharmacies transition into places where COVID-19 testing occurs. And although the pharmacist may be the one who is doing [the actions of] swabbing and handling the sample, there is a role for the pharmacy technician in this process as well, such as taking the initial intake and other tasks. Ultimately, it comes down to the pharmacist and the pharmacy providing that technician with the training they need…to effectively do the things they are being asked to do.

This is where pharmacists have to recognize that [larger] pharmacies often have people with more expertise in some areas or topic than others and there is an entire staff of people whose job it is to help enable pharmacies to effectively provide immunizations and ensure there is a team of individuals with that expertise. It is essentially their job to educate technicians on what they need to do in order to help make these things happen. This is probably abit more of a challenge for an independent pharmacy where the staff have to figure out how to do that on their own. Nevertheless, [when it comes to training,] it can help to tap into the expertise of a relatively small number of trained staff who are expected to have skills in these areas, rather than simply telling every single pharmacist that they have to [personally] train their own technicians to do everything.

Desselle: Pharmacy Times recently published several articles on communication strategies, motivational interviewing, and the like.¹¹ Effective communication is the first area where technicians might seek additional education and training. Many people are under the false assumption that communication is easy, given that we communicate every day and we begin speaking between the ages of 1 and 2. Many people think communication means just people talking, but it is much more than that. Effective communication involves eliciting a feeling of mutual understanding. By being empathetic and using more advanced communication strategies, it becomes easier to learn from the patient any necessary [personal] history, disease history, and vaccination history.

Pharmacy Times: What else can pharmacy staff do to keep themselves and their patients safe during the upcoming 2020-2021 influenza season?
Zgarrick: One action would be to help people understand that flattening the curve is not just about social distancing and what we are doing specifically for COVID-19. Instead, it is about the actions we are taking to keep ourselves healthy and getting an influenza vaccine is very much part of that. Every time a patient comes into the pharmacy to get a prescription filled for something else, pharmacists have a role in getting the message out about how it is more important than ever to consider an influenza vaccine, and all their recommended vaccinations for that matter. The visit can become a point of interaction where you the pharmacist (or technician) can ask the patient whether they received an influenza vaccine this year, and remind the patient that staying healthy is going to increase the chances of being able to protect themselves and others.

Having that personal conversation is going to be especially important this year because patients are going to have questions about the influenza vaccine and COVID-19. [The conversation] needs to be about prompting the patient to get the influenza vaccine not only to stay protected themselves, but also to keep their family protected as well. And, we know COVID-19 is still out there and that we are going to be dealing with it for some time into the future. Although our natural inclination is to focus on COVID-19, we cannot lose sight of other illnesses as well.

Pharmacy staff are in the same boat as any essential worker or anyone who has to be in a store and exposed to people to providea service. Some pharmacies are providing PPE and other resources to their personnel, whereas others are redesigning how patients interact with staff.^12,13

Desselle: Come fall 2020, obviously, we are going to have a flu season. Many [public health experts] are predicting that we will have another wave of COVID-19 [infections], so individuals will have symptoms.¹⁴ Patients are going to be worried and overly anxious—more anxious than they were before. For example, some patients who [only] have cold-like symptoms [may] think they do not have the flu at all, and those with influ- enza might think that they have COVID-19. On the other hand, patients who have COVID-19 might think they have something else, such as influenza or just a bad cough. This increased uncertainty may lead to an added need for the coordination of administering vaccines. Communication will be the key in determining whether patients are infected with the influenza virus, and effective triage will be necessary to prepare for the potential increase in patient load at the pharmacy.

Technicians are in a tough spot. It is challenging because they cannot always procure PPE on their own. Again, communication is the key. If technicians feel unsafe or unprotected, they can [speak up] if the pharmacist has not already done so, by approaching the pharmacist and saying, “Flu season is coming up, [and] we are going to have patients [coming into the pharmacy] with allergic rhinitis, cold, flu, and COVID-19, etc. We will not necessarily know ‘who’s who’ and ‘what’s what’ right at the very beginning when they present themselves. What should we be doing to protect ourselves?” Pharmacies should be proactive and already have a plan.

Pharmacy Times: Is there anything that pharmacy staff might not be thinking about to prepare for this upcoming flu season?

Zgarrick: [As pharmacy staff,] we think a lot about equipment supplies and resources; however, an areas of focus that does not come into the conversation as often is it could is the costs of taking these additional prevention measures, especially at the pharmacy level. There are real financial costs [associated with] having to buy PPE to keep pharmacy staff and customers safe. Because PPE and other supplies meant to keep a pharmacy’s staff and patients safe are not something we are “selling to our patients” like a prescription or an OTC product, it does not generate revenue. PPE isn’t free; it is a pure cost and somehow, pharmacies need to figure out a way to incorporate it into the everyday costs of doing business and evaluate the impact.

There are also costs associated with additional marketing. To get the message out [to the public] that we want to keep people healthy and safe, it takes resources, which cost time and money. It is an investment most pharmacies should want to make because it brings in business, but they need to make that investment first.

One thing I have not heard or seen is pharmacies having an honest conversation with their clientele or patients and helping them understand that there are costs involved with the extra steps being taken to keep everyone safe. We need to get that same message out to our patients and pharmacies as well. For community pharmacies in particular, in many cases they will need to increase their price points on items because that is really the only way they can generate the revenue to be able to cover these extra costs. A big challenge is that much of the revenue pharmacies generate from prescriptions is based on contracts they have with pharmacy benefit managers and other third-party payers. In the short term, that limits the ability of a pharmacy to recoup any extra costs associated with the PPE and other supplies needed to keep pharmacy personnel and patients safe. Long term, pharmacies may look to renegotiate these contracts because they can make the argument that their costs are going up as a result of what is needed to keep patients, clients, and our personnel safe.

Desselle: The employer has an enormous role. The organizational culture of the employer is a primary driver behind the extent to which pharmacists will implement services and the success of those services. With that in mind, it all goes back to communication. Employers need to effectively communicate [with their staff]. They need to reconcile the difference between where they are now and what their company’s mission statement and goals are because there is likely to be a gap. They need to effectively communicate with pharmacy staff and pharmacy organizations and help facilitate education for the staff. There is a considerable amount of free education available from credible sources. Employers can identify sets of documents from both the professional and lay literature, the sources that are freely available online like Pharmacy Times, as well as peer-reviewed sources. For example, employers can create a repository on the company website or the company intranet where employees can find articles on promoting communication skills and various resources on time management. These actions can be accomplished with very little cost, but with maximum results to improve communication and the support provided to pharmacist staff with the goal of elevating the level of practice for everyone.

Pharmacy Times: Do you envision that because costs may be increasing, there will be an increase in the number of programs offered for low-income patients to be able to afford an influenza vaccine (or their medications)?​​​​​​​

Zgarrick: It’s challenging. Not every customer in a pharmacy is fortunate enough to be able to afford higher costs; however, they still need the services that a pharmacy provides. [The solutions] can come from different sources. Some unemployed patients may be able to [look to] their state Medicaid program, as well as other charitable and public assistance programs that provide influenza and immunization coverage.

On the other hand, we are likely to be dealing with more people in the future who have to pay for their health care themselves. We [have to] help our patients understand what options they have in these situations. Pharmacists do such a good job with this because they understand the costs of medications and vaccines. A pharmacist is a great resource for helping a patient find options so that they can more effectively make those choices; ultimately, it is the patient’s choice what care they receive, how much care they receive, and [to some extent] what they pay for it.

Pharmacy Times: How can pharmacy staff stay positive during this time?
Zgarrick: One of the positive takeaways [of this challenging time] is that pharmacies and pharmacy staff have been put front and center in ways they haven’t been before. Furthermore, whether it be policy makers at the government level, or among individual patients, there is a realization that pharmacies are an essential business in our communities. This has been a positive thing for pharmacies and pharmacists to relish this role—it’s what we do and what we want to do. We want to be there for people to be able to help them get the most out of their medica- tions and [learn] how to live the healthiest life possible. There is recognition that pharmacy staff are providing vitally important services, and will continue to do so.

REFERENCES

1. Hellmann, J. The next COVID-19 challenge: Convincing people to get flu shots. The Hill. Published June 11, 2020. Accessed June 24, 2020. https://thehill. com/policy/healthcare/502166-the-next-covid-19-challenge-convincing-people- to-get-their-flu-shots
2. ​​​​​​​Han E and Zgarrick D. Pharmacy technicians affected by state regulator actions to address COVID-19 crisis. Pharmacy Times®. Published April 6, 2020. Accessed June 10, 2020. https://www.pharmacytimes.com/news/pharmacy-technicians-affected-by-state-regulator-actions-to-address-covid-19-crisis
3. Pharmacists advancing healthcare. Pharmacy technician career overview. Accessed June 11, 2020. https://www.ashp.org/Pharmacy-Technician/About- Pharmacy-Technicians/Pharmacy-Technician-Career-Overview?loginreturnUrl= SSOCheckOnly#:~:text=Pharmacy%20technicians%20are%20critical%20mem- bers,%2C%20clinics%2C%20and%20community%20pharmacies
4. Guidance for pharmacies: guidance for pharmacists and pharmacy technicians in community pharmacies during the COVID-19 response. Reviewed May 28, 2020. Accessed June 11, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ pharmacies.html
5. Simko L. Guide to discussing influenza vaccine with patients. Pharmacy Times®. Published July 20, 2019. Accessed June 10, 2020. https://www.pharma- cytimes.com/publications/supplements/2019/july2019/guide-to-discussing-influenza-vaccine-with-patients
6. McKeirnan K, Desselle SP. Changes in practice scope of pharmacy technicians needed to address community needs during COVID-19 outbreak. Pharmacy Times®. Published April 16, 2020. Accessed June 11, 2020. https://www.pharma- cytimes.com/news/changes-in-practice-scope-of-pharmacy-technicians-needed- to-address-community-needs-during-covid-19-outbreak
7. National Alliance of State Pharmacy Associations. COVID-19: information from the states. Published June 9, 2020. Accessed June 11, 2020. https://naspa.us/ resource/covid-19-information-from-the-states/
8. IDAPA 27 – Idaho Board of Pharmacy: notice of omnibus rulemaking – adoption of temporary rule. Docket NO. 27-0101-2000F. Published March 20, 2020. Accessed June 10, 2020. https://bop.idaho.gov/wp-content/uploads/ sites/99/2020/04/2020-Temporary-Rules-%E2%80%93-Omnibus-Rulemaking.pdf
9. Johnson HE, Boils CB. Resident wellness: time management and stress reduction. The CPNP Perspective. Published January 28, 2020. Accessed June 12, 2020. https://cpnp.org/perspective/2020/01/427501
10. California Society of Health-Systems Pharmacists. Mentorship program. Accessed June 12, 2020. https://www.cshp.org/members/group_content_view. asp?group=158582&id=712022&hhSearchTerms=%22mentorship+and+pro- gram%22
11. Saclolo A, Desselle SP. Motivational interviewing: effective communication is important for technicians. Pharmacy Times®. Published May 19, 2020. Accessed June 12, 2020. https://www.pharmacytimes.com/news/motivational-interview- ing-effective-communication-is-important-for-technicians
12. Here is PPE guidance for pharmacists participating in COVID-19 testing. U.S. Pharmacist. Published April 22, 2020. Accessed June 10, 2020. https://www. uspharmacist.com/article/here-is-ppe-guidance-for-pharmacists-participating-in- covid19-testing
13. Wells J. How the pandemic could fundamentally alter store layouts. Grocery Dive. Published June 8, 2020. Accessed June 10, 2020. https://www. grocerydive.com/news/how-the-pandemic-could-fundamentally-alter-store-lay- outs/579372/?MessageRunDetailID=1953622677&PostID=15867430
14. Sun LH. CDC director warns second wave of coronavirus is likely to be even more devastating. The Washington Post. Published April 21, 2020. Accessed May 5, 2020. https://www.washingtonpost.com/health/2020/04/21/coronavirus-second- wave-cdcdirector/

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“She’s worked hard on her game year-round,” Duxbury coach Bob Sullivan said. “She’s very supportive of her teammates and is just a wonderful young lady baller.”

Fitzpatrick, who is often the smallest person on the court at 5’2, has used her lack of size to her advantage to outthink and outmaneuver opponents. She said if anything, her height has helped her work harder and fueled her to where she is now.

Following a strong career with the Dragons, punctuated by a terrific season as a senior captain this winter, the 2020 DHS graduate has found a home on the Western New England hoops team. She knows she’s never a finished product, and she’s eager to keep working on her skills while looking to carve out some playing time for the Golden Bears, who finished this past season 21-6.

“Caeliana is a player that hustles,” fellow senior captain Sophie Thompson said. “Her commitment to the game of basketball and work ethic has always made her a pleasure to play with. I look forward to watching her at the next level.”

Hustling has always been a key part of Fitzpatrick’s game. When she latched onto the AAU circuit in fifth grade, she knew she’d have to do the little things on the court to complement her skills as a playmaker and defensive stopper.

Competing and training year-round – she’s played 17 seasons of AAU ball in total now – helped her get ready for high school basketball. She contributed on the freshman team right away, helped out with junior varsity and practiced with varsity, then she made varsity as a sophomore. Sullivan knew he could count on her to help out in every facet of the game.

“She’s fearless,” he said. “She’s willing to go to the hoop against the bigs and knock down a 3 when open.”

As her career progressed, she became more and more comfortable on the court. She considers the Dragons’ Senior Night win over defending Division 2 South champion Pembroke to be the most gratifying victory of her high school career. 

“I felt like we were underdogs in that one,” Fitzpatrick said, “but we came out with the win. It was special for Sophie and me.”

Fitzpatrick, who garnered the Patriot League Sportsmanship Award as a senior, always knew she wanted to play in college. There was a brief moment during her junior year when she considered not doing so, but eventually she decided she was too passionate about the sport to give it up.

Once she toured WNE, she was infatuated with the campus, the coach and the welcoming members of the team. It had everything she was looking for, and she decided in late October that it was the right place for her.

Life as a hooper has been tricky during the pandemic. The hoop in her driveway is somewhat bent and broken, so Fitpatrick focused predominantly on ball-handling, running and strength training during that time.

Eventually, she managed to find her way into some gyms, and she’s been playing outside as well now that courts are open. WNE sent her a packet to follow that instructs her to take 100 free throws a day and count how many she makes, attempt shots from inside and out, complete footwork drills, work on dribbling exercises and more.

Fitzpatrick loves a challenge, and she’s excited for the next one. She’s had plenty of success as a 5’2 basketball player in the past, and she sees no reason to stop striving for the same excellence now.

“Honestly, a lot of people have told me I’m really little and that they don’t see me as a basketball player,” Fitzpatrick said. “You just kind of work with what you’ve got and don’t give up, as cheesy as that sounds. You have to work hard and work on everything you can improve on.”

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Dive Brief:

• Mall owner CBL & Associates is prepping a Chapter 11 bankruptcy filing, Bloomberg reports, citing people familiar with the matter. A CBL spokesperson declined to comment to Retail Dive on the report.

• On July 15, the company and certain lenders entered into a forbearance agreement, rescuing it from the consequences of a missed $18.6 million interest payment due June 15, according to a filing with the Securities and Exchange Commission. Another forbearance agreement, formed after CBL skipped an $11.8 million payment due June 1, was extended. Both periods end Wednesday.

• A bankruptcy filing would make CBL the first major mall owner to succumb to the woes besetting shopping centers, which have intensified during the pandemic.

Dive Insight:

Malls have watched footfall decline for years as shoppers gravitate to the internet, especially for undifferentiated products, and to retailers like off-price stores found in off-mall locations. All that has been exacerbated by the pandemic, first because stores and malls were locked down, and now because most shoppers remain wary of them.

“The convenience of online shopping has made it ubiquitous that has led to structural foot traffic declines over the past decade in U.S. malls,” Retail Metrics President Ken Perkins said in emailed comments regarding the most recent monthly retail sales report. “The health [threats] posed by shopping [indoors] has only accelerated consumer spending patterns toward this channel.”

The situation has been most stark at centers like those run by CBL, which feature the kind of mid-priced goods increasingly out of reach of their middle class consumer target. Stores run by apparel conglomerate Ascena, itself reportedly on the brink of bankruptcy, are among CBL’s top tenants, Bloomberg noted.

It doesn’t help that many retailers have withheld at least portions of their rent. Simon Property Group and Brookfield have taken the likes of Gap to court over unpaid rent. Nordstrom has warned its landlords not to expect full rent payments for the rest of the year.

In May, CBL said it had collected about 27% of April rents and that it expected May rent collections would be in the range of 25% to 30%. “While, in general, under the leases, CBL believes that the tenants have a clear contractual obligation to pay rent, CBL is working with tenants that may require rent deferral or relief,” the company said at the time. “These tenant discussions are ongoing and at this time, CBL is unable to estimate the outcome of these discussions, the impact of these relief packages or the ultimate recoverability of any amounts deferred.”

That has taken its toll. In May, CBL said its first quarter net loss more than doubled year over year to $133.9 million, from $50.2 million in the year-ago period. The company, based in Chattanooga, Tennessee, owns and manages 108 properties totaling 68.2 million square feet across 26 states.

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The Marathon Classic won’t be played in front of fans, after all.

The Toledo Blade, the tournament’s hometown newspaper, first reported the news Thursday morning, with the LPGA and the Marathon Classic confirming.

“I applaud Marathon Petroleum, Dana and the entire tournament team for working so hard to protect the health and safety of everyone involved in their event and the northwest Ohio community,” LPGA commissioner Mike Whan said. “This was a difficult decision as fans have always been a big part of the Marathon LPGA Classic presented by Dana.”

The decision came after consultations with local health and state officials.

The news also came in the wake of Ohio Gov. Mike DeWine’s stern warning to his state in a televised address Wednesday evening. The governor lifted public gathering restrictions last month, paving the way for fans to attend amid the coronavirus pandemic, but he warned Wednesday that COVID-19’s threat is growing dangerously in the state.

“Today, more Ohioans are getting sick than at any previous point in this pandemic,” DeWine said. “This is a worrisome, disturbing reversal of our progress … Ohio is sliding. We are sliding down a very dangerous path.

“We must act, and we must act now.”

At the beginning of the pandemic, DeWine said it took Ohio 20 days to reach 1,500 total COVID-19 cases.

“Last week, we saw over 1,500 cases in a single day,” he said.

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The LPGA faces a daunting return with or without fans after being in pause mode for five months.

The Marathon Classic is the second of back-to-back weeks in the LPGA’s planned restart, with both to be played in the Toledo area. The Drive On Championship is scheduled July 31-Aug. 2 at Inverness Club, with Marathon scheduled the week after, at Highland Meadows Golf Club in Sylvania.

The LPGA’s restart was slated to begin almost two months after the PGA Tour made its return, to allow the women’s tour, with its more limited resources, time to watch how other sports were re-opening and to get their testing protocols in order.

Of course, there was also the hope that extra time would see the pandemic slow or ease.

Instead, the LPGA finds itself ramping up plans for its return amid a growing fire, with a record number of COVID-19 cases reported in the United States this week, with increases reported in 41 states.

The tour released its new COVID-19 testing plan and operational protocols to media on Wednesday, laying out a map to navigate players, caddies and staff through a schedule that is more ambitious than what the PGA Tour is attempting.

How so?

The LPGA showed a willingness to pursue its reopening with both fans and pro-ams, ultimately leaving the final decision at the Marathon Classic to the title sponsor and local health officials. While the tournament won’t open its gates to fans, it will stage two pro-ams.

The PGA Tour has not played in front of fans in the six events it has staged in its return, nor has it staged any pro-ams. The men announced earlier this week that they won’t open their gates to spectators for the rest of this wraparound season, nor will they host any pro-ams.

The LPGA pro-ams are planned with amateurs required to follow LPGA protocols, including COVID-19 testing, with special pro-am rules in place for social distancing.

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Current LPGA tournament schedule

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For community-focused events like Marathon, fans, pro-ams and corporate hospitality are more integral to the tournament’s purpose and bottom line than they are to PGA Tour events.

“If we can’t figure out how to play pro-ams, the LPGA is going to have some challenges in ‘20 and beyond,” Whan said.

There’s growing excitement over the LPGA’s reopening in the player ranks, but some trepidation, too.

“We’re excited about getting back and playing,” Whan said. “We’ve waited long enough. We’ve got plenty of athletes that are itching to compete. I know we probably have athletes, too, who aren’t itching as much to compete … But we are trying to make sure that we’ve built all the resources that they would need.”

Whan knows this plan comes with risk that some players don’t want to assume.

“It is strange to get started in a time in which we know we’re going to have positive [COVID-19] results, no matter what we build,” Whan said.

Whan has built a safety valve for players uneasy about returning amid the pandemic. He did so by merging this year’s priority rankings with next year’s, so players who aren’t comfortable competing this season will know their status will be protected going into next year.

“I want to make sure what happens in 2020 is that my athletes and my caddies make their own personal decisions about when, where and how much they play,” Whan said.

How do you balance health and safety against economic realities?

Whan is trying to answer that question as heavily as any sports organization’s leader with its imminent restart.

“It’s been a lot of work to finalize our back-to-play protocols,” LPGA chief tour operations officer Heather Daly-Donofrio said. “Everything is rooted in health and safety, first and foremost, and nothing surprising in our plan, versus other professional sports leagues. We’ve consulted with just about everybody, I feel.”

That includes the CDC, the Federal Coronavirus Task Force, the PGA Tour, the European Tour and other professional sports leagues.

Still, Whan acknowledges the inevitability of players and caddies testing positive, and the possibility somebody could get sick in a foreign country.

After those Ohio events, the LPGA will head to Europe for back-to-back weeks in Scotland, with a charter flight planned to take players and caddies from Toledo to Edinburgh, for the Aberdeen Standard Investment Ladies Scottish Open and the AIG Women’s British Open.

If an LPGA player or caddie gets sick there, the tour’s new protocols would require they quarantine for 10 days in that country. An LPGA or tournament staff member would be assigned to assist any player or caddie in quarantine on the road. Whan’s particularly concerned about the possibility players and caddies get sick far from home and loved ones.

“If that doesn’t wear on you, then you’re not human,” Whan said.

The LPGA is making its plans with a budget that is a fraction of what other male sports leagues enjoy. If a PGA Tour player gets sick, there’s a stipend of up to $75,000 coming their way to help. If an LPGA pro gets sick, there’s $5,000 to help.

It’s one of the stark contrasts in the difference between the men’s and women’s games.

“It’s not the first huge difference you’ve seen between the PGA Tour and the LPGA,” Whan said. “I’m not proud of that, but it’s just a reality in terms of the resources.”

The LPGA has canceled 13 events so far this year, with the Buick Shanghai in China likely to be confirmed as the 14^th. There are 17 events left on the schedule, not counting Shanghai.

“I fully believe we’ll lose another event or two or three along the way,” Whan said. “I couldn’t really tell you which ones, but it would probably be naïve of me to think we are just going to roll through our season and roll through different countries and be able to play exactly as we have slated, but I’m excited about what we have.”

The LPGA began this year as robust as it’s ever been financially, with record prize money to be played for and a healthy cash reserve. It was a testament to Whan’s abilities, after inheriting a tour that many veteran LPGA players believed was on the verge of collapse when he took over in 2010.

Every event canceled this year affects that reserve, as do the increased costs of these new COVID-19 protocols.

“I’m not a guy who loses money, it’s just not in me,” said Whan, whose tour hasn’t lost money in any of his 10 years at the helm. “We took a tough shot. COVID-19 is going to definitely rattle us in 2020, but we are not searching for funding, and we could live through a 2021 COVID, if ’21 becomes like ’20 …

“We are not threatened. We are not dangerously low. It’s just tough to see a figure in red at the bottom of a spread sheet. It’s just not who we are as a team.”

Whan has said several times that he won’t make decisions about 2020 that threaten the long-term future of the tour.

Of course, there’s no guarantee the 2021 season won’t begin still amid the pandemic.

Dr. Bruce Thomas, the LPGA’s medical director, is teamed with Daly-Donofrio in overseeing the execution of the tour’s COVID-19 protocols. Medical staff will attend or be on call at every event.

Here are the basics of the LPGA protocols:

• Within seven days of arriving at a tournament, players, caddies and staff will be required to take an at-home COVID-19 saliva test.

• Upon arriving at the tournament site, players, caddies and staff will take another COVID-19 saliva test. While awaiting results, they will be allowed to use the grounds to practice. Upon receipt of a negative result, they will be allowed clubhouse access. Vault and Rutgers Lab have been partnered to run test results.

• Players, caddies and staff will complete daily healthcare questionnaires and submit to daily thermal temperature screenings.

• If anyone presents with a high temperature or begins displaying symptoms consistent with COVID-19, they’ll consult with an on-site tournament physician.

• If there is a positive test, the person will be immediately isolated and withdrawn from the tournament. Also, if a player or caddies tests positive, a stipend will be awarded as assistance. According to tour sources, it’s $5,000 if the player tests positive at a tournament site. LPGA or tournament staff member will be assigned to assist the player or caddie during any quarantine required.

• In order for a player to return to competition, the LPGA will follow CDC guidelines, which currently includes quarantining for a minimum of 10 days and returning two negative tests.

• With asymptomatic cases, the tour will determine next steps on a case-by-case basis, in consultation with the medical director.

• At a tournament site, 6-feet social distancing is encouraged.

• No handshakes, hugs, high fives, fist bumps, etc.

• Face coverings must be used while indoors at a tournament site, or outside the ropes, if social distancing is an issue (i.e. shuttle carts, scoring area).

• Hand washing and sanitizing is encouraged as often as possible.

• Symptom monitoring will be done by Healthy Roster; with symptoms/fever reported to LPGA.

• Cambia Health Solutions (masks), Global Rescue (medical advisory support), Theraworx Protect (hygiene protection), WHOOP (respiratory monitoring), NEC (biometric, technology solutions), Meijer and Kimberly Clark (PPE support) are partners supporting protocols.

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Please join the College Woman’s Club of Westfield in an extraordinary Zoom series: College Prep in the COVID Landscape. 

This series focuses on various topics regarding college admission and attendance, including how to best navigate the admissions process, standardized testing and obtaining financial aid. The online series will be moderated by Independent Education Consultant, Susana MacLean, principal of MacLean College Counseling.  The series will feature guest speakers, a PowerPoint presentation relevant to the topic, and a questions and answer chat room. 

The July 22 event will cover preparing your Freshman for college. Speakers include attorney Rafael Betancourt, of Triarsi, Betancourt, Wukovits & Dugan, LLC (https://www.tbwdlaw.com/), who will discuss Power of Attorney, Guardianship, HIPAA and other legal matters pertaining to sending your adult child away from home. A panel of ‘expert’ parents will discuss preparation from self-defense classes to Twin XL sheets and bed bug mattress covers.    

Registration for the event is free. You can register online at https://bit.ly/PreppingForCollege. Confirmation of registration will include the details for access to the specific Zoom event.

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NEW YORK – In this accelerated run-up to opening day, Gerrit Cole has one more tune-up before the Yankees’ July 23 meeting with the Washington Nationals.

For now, Cole is due to stay on his fifth day according to manager Aaron Boone.

That would put Cole in another simulated setting on Friday instead of pitching Saturday against the Mets at Citi Field, the first of three Yankees exhibition games.

The current plan is to provide Cole an extra day of rest heading into opening day at Washington, however, “that’s something we’ll also keep a little bit fluid,” Boone said.

“We’ll see how I bounce back in the next 24-48 hours,’’ said Cole, who tossed 84 pitches in Sunday afternoon’s intrasquad game at Yankee Stadium.

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Over 5.2 scoreless innings, Cole gave up four hits – including a double by Mike Tauchman – and one walk, with nine strikeouts.

“I was kind of tired in the sixth (inning),’’ said Cole, pleased at his fastball command. “It was good to push the limits a bit, especially being (a) hot (afternoon). It was a fun challenge.’’

“I thought he was even a little sharper this time out,” said Boone, compared to Cole’s initial intrasquad appearance. “I thought he was really impressive.”

Ordinarily, Cole would continue to push those limits in his next outing, but “I’m going to have those conversations’’ with Boone and pitching coach Matt Blake.

Cole gave up soft singles to Tauchman (check-swing) and Matt Duffy. His outing ended with an infield hit by Miguel Andujar.

Paired again with catcher Gary Sanchez, “I thought we were on the same page a lot today,’’ Cole said. “The few times we weren’t, we discussed it between innings.’’

Cole added praise for Sanchez’s good targets and sharp pitching sequences.

“He knows the other squad better than I do,’’ said Cole, who pitched with Sean Barber calling balls and strikes. It’s the first time the Yanks had MLB umpires during their intrasquad games. 

Story continues below gallery

Judge, Tanaka updates 

A day after being scratched from the intrasquad lineup due to a stiff neck, Aaron Judge was still receiving treatment and sat out Sunday’s game.

“We feel like he’s been able to get a lot of work in, a lot of at-bats to this point, so (we) just thought it was better to not push it,’’ said Boone, adding that Judge’s neck was improved “but still pretty stiff.’’

With no intrasquad game scheduled for Monday, Judge might return to playing on Tuesday.

Eight days after being struck in the head by a liner, Masahiro Tanaka played catch again on Sunday, this time extending this throwing to 100 feet.

Tanaka ramped up his cardio work and is expected to continue that trend “as long as everything goes well,’’ said Boone. Tanaka remains in concussion protocol and is not yet scheduled to throw a bullpen.

Pete Caldera is the Yankees beat writer for NorthJersey.com. For unlimited access to all Yankees analysis, news, trades and more, please subscribe today and download our app.

Email: caldera@northjersey.com Twitter: @pcaldera 

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BRIDGEWATER, NJ – Interim Superintendent Thomas Ficarra released a message to parents Friday with an update on when plans will be released regarding the reopening of schools in September.

First, Ficarra reminded families that the deadline for responding to a survey on the reopening is Saturday, July 11. The survey can be found on the district’s website at brrsd.org.

This past week, Ficarra said, the central office administration met with principals, assistant principals and supervisors to outline the governor’s guidance and begin developing multiple scenarios for the reopening of each school building. Principals, he said, met as a collective group for a brainstorming session to discuss ideas and plans, and provide consistency throughout the schools.

On Thursday and Friday, principals contacted their Pandemic Response Teams, Ficarra said, to work on further developing their options and plans in preparation for presenting those options to the superintendent next week.

The district has said it expects to present the plans by the beginning of August.

Below is Ficarra’s statement in its entirety:

Dear Parents/Guardians,

The intent of this communication is to keep you informed concerning the ongoing process as the District plans for the reopening of schools in September.

As you know, we have sent out surveys for your consideration and many of you have already responded. Thank you!  Your input is critical to our planning and those results will be reviewed and utilized throughout our planning stages.  Please remember that the deadline for responding to the survey is Saturday, July 11, 2020.

This week, the Superintendent and the central office administration met with principals, assistant principals, and supervisors to outline the Governor’s guidance on The Road Back: Restart and Recovery Plan for Education. The discussion focused on paying careful attention to the plan while developing multiple scenarios for the reopening of each school building. 

Principals met as a collective group for a brainstorming session in order to discuss ideas, plans, and provide consistency throughout the schools.

On Thursday and Friday, Principals contacted their Pandemic Response Teams in an attempt to further develop their options for reopening and to prepare for presentations of those options to the Superintendent and Central Office Administrative Team early next week.  

In the latter part of next week, the Administrative Team will share the various options developed by the school teams with a District Team composed of representatives from school community stakeholder groups.  

After receiving input from the stakeholders, the Principals and central office administrators will reconvene to revise and refine the re-entry options. The process will be repeated until the district staff presents the final re-entry plan for Board approval no later than August 6, 2020.

Information for the minimum standards for reopening can be found in the letter sent from the Office of the Superintendent earlier in the week, or by clicking here to access it on the District website.

It is my plan to keep you apprised of the district’s progress on a weekly basis as we move forward with the plans to reopen in September as per the Governor’s Guidance.

Stay well,

Dr. Thomas Ficarra
Interim Superintendent of Schools

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A meeting is planned next week between regional and state high school sports officials and athletic directors “to discuss possible alternatives, like moving fall sports to the spring season and thinking outside the box in ways we haven’t before,” Franklin Regional Athletics Director Zach Kessler said.

Kessler called the challenges of prepping for fall sports amid the covid-19 pandemic are “an uphill battle,” but said he and his staff are working hard to give students the best opportunity possible to succeed.

“The reality is, social distancing in sports is almost impossible, except for maybe tennis and golf,” Kessler told school board members at a special meeting Thursday where the board and staff detailed reopening and health-and-safety plans for the 2020-21 school year. “But we have protocols in place. We’re screening the kids every day, we’re providing cleaning supplies to clean balls, bags and equipment.”

On June 22, cross-country, football, soccer and other fall sports teams began returning to train. Kessler said guidance from the state is dictating how programs are run.

“Has it been perfect? No,” he said. “But we’re making changes as necessary.”

School board member Gary English said athletics in particular were a concern when it comes to high-contact items like sports balls.

“You can’t clean off the ball between every play,” English said.

Board member Ed Mittereder said ensuring good hygiene prior to athletic workouts and practices “goes a long way toward making this a safe environment.

“You can’t live in fear,” Mittereder said. “You have to be cautious. But I think if you take every precaution you possibly can, the benefits are better than living in fear that the boogeyman might get you.”

Middle-school nurse Beth Frydrych said she has confidence in athletic staff.

“We have an excellent (training) team there,” she said. “We have a plan in place, and we have students who are out there getting good exercise, interacting, doing healthy activity. We have to look at the benefits of the whole program, and right now — with very judicious procedures in place — we have students, coaches, athletic trainers doing great work.”

Dr. William Jenkins, a member of the district’s back-to-school task force, said there are simply a lot of unknowns when it comes to sports.

“No one knows what the impact of those soft touches are in sports,” he said. “I think you’ll see programs do a variety of things. You’ll see some cancel, and all we can do is rely on what the best expertise is today, and be fluid enough to react if those recommendations change.”

Frydrych agreed.

“If we have to change things, we will,” she said. “But it’s not going without a cautious eye at every practice.”

Kessler said his current focus is working to bring back fall middle-school sports and operating off-season workouts for winter sports.

“We’re also working with the band on what their return to campus may look like,” he said.

Read the district’s reopening and health-and-safety plans, approved Thursday, at FRSDk12.org.

Patrick Varine is a Tribune-Review staff writer. You can contact Patrick at 724-850-2862, pvarine@triblive.com or via Twitter .

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