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Innovative
Pharmacy Practices
VOLUME II: PROFILES OF
PHARMACY PRACTICES
September 2008
Prepared for:
Moving Forward: Pharmacy Human Resources for the Future
Prepared by:
MarketView Research Inc.
Funded by the Government of Canada’s Foreign Credential Recognition Program
How to cite this document:
Management Committee, Moving Forward: Pharmacy Human Resources for the Future.
Innovative Pharmacy Practices Volume II: Profiles of Pharmacy Practices. Ottawa (ON).
Canadian Pharmacists Association; (2008)
Innovative Pharmacy Practices
VOLUME II: PROFILES OF PHARMACY PRACTICES
September 2008
Prepared for:
Moving Forward: Pharmacy Human Resources for the Future
Prepared by:
MarketView Research Inc.
The Moving Forward initiative is funded by the Government of Canada's Foreign Credential Recognition Program.
The opinions expressed in this publication are those of the author and do not necessarily reflect those of the Government of Canada.
ACKNOWLEDGEMENTS
The Moving Forward partners would like to express their appreciation to all the individuals whose
participation in this research contributed to its success. Moving Forward especially wishes to thank the
many people who kindly took the time to participate in interviews and completed practice documentation.
This research was conducted by the firm of MarketView Research Inc. and their associates, as well as
subject matter advisors Dr. Jim Blackburn and Dr. Barbara Wells. The research team was assisted by the
Moving Forward Management Committee (and their representative organizations), the Moving Forward
National Advisory Committee, a team of subject matter experts and other contributors. These individuals
include:
Management Committee
Kevin Hall, Moving Forward Co-Chair
Fred Martin, Moving Forward Co-Chair
Zubin Austin, Association of Faculties of Pharmacy
of Canada
Patty Brady, Human Resources and Social
Development Canada
Aline Johanns, New Brunswick Department of
Health
Nadine Lacasse, Sebastien Aubin et Nadine Lacasse
Pharmaciens
Manon Lambert, Ordre des pharmaciens du Québec
Lisa Little, Canadian Nurses Association
Janet Cooper, Canadian Pharmacists Association
Jonathan Mailman, Canadian Association of
Pharmacy Students and Interns
Tim Fleming, Canadian Association of Pharmacy
Technicians
Ron McKerrow, British Columbia Provincial Health
Services Authority
Dennis Gorecki, Association of Deans of Pharmacy
of Canada
Colleen Norris, Glebe Pharmasave Apothecary
Ray Joubert, National Association of Pharmacy
Regulatory Authorities
Noman Qureshi, International Pharmacy Graduate
Alumni Association
Paul Kuras, Canadian Pharmacists Association
Michèle Roussel, New Brunswick Department of
Health
Allan Malek, Canadian Association of Chain Drug
Stores
Linda Suveges, The Pharmacy Examining Board of
Canada
Bonnie Palmer, Shoppers Drug Mart
Chris Schillemore, Ontario College of Pharmacists
Brenda Schuster, Regina Qu’Appelle Health Region
Jane Wong, Canadian Healthcare Association
Ken Wou, Canadian Society of Hospital Pharmacists
Research Team
National Advisory Committee
Jim Blackburn, Blackburn & Associates Inc.
Sandra Aylward, Sobeys Pharmacy Group
Jeanette Bellerose, Arturus Solutions
Danuta Bertram, Winnipeg Regional Health
Authority
Heather Chew, Blueprint Communications
Paul Blanchard, New Brunswick Pharmacists
Association
Kelly Goulet-Louis, Blueprint Communications
Anne Marie Burns, Ottawa Hospital
Lynda Buske, Canadian Medical Association
Candace Fedoruk, MarketView Research Inc.
Barbara Wells, BA Wells Healthcare
Jean-François Bussières, Hôpital Sainte-Justine
Subject Matter Expert Advisors
Nicolas Caprio, Shoppers Drug Mart
Colleen Metge, University of Manitoba
Deborah Cohen, Canadian Institute for Health
Information
Barbara Gobis Ogle, Network Healthcare
Omolayo Famuyide, Canadian Association of
Pharmacy Students and Interns
Regis Vaillancourt, Children’s Hospital of Eastern
Ontario
Rock Folkman, Canadian Pharmacy Technician
Educators Association
Project Staff
Anne Marie Ford, Ford’s Apothecary
Michael Gaucher, Canadian Agency for Drugs and
Technologies in Health
Terri Schindel, University of Alberta
Kelly Hogan, Research Coordinator
Heather Mohr, Project Manager
GLOSSARY OF TERMS AND ABBREVIATIONS
ACH = Alberta Children’s Hospital
DOSA = Drugstore Outstanding Service Awards
AHPA = Arthritis Health Professions Association
DPIN = a province-wide prescription database
AMS = anticoagulation management service
DRP = drug-related problem
ARV = antiretroviral
DSM = disease state management
ASA = acetylsalicylic acid
DUE = drug use evaluation
BCB test = a lab test
DWH Hom = women’s health and homeopath
BMI = body mass index
BP = blood pressure
CAD = coronary artery disease
Cardiac EASE = Cardiac Ensuring Access and
Speedy Evaluation program
CCC = Canadian Cardiovascular Congress
CDM = chronic disease management
CF = Canadian Forces
CFPCN = Calgary Foothills Primary Care Network
CHA = capital health authority
CHAP = Cardiovascular Health Awareness Program
CHC = community health centre
CIVA = a patient-specific intravenous admixture
CKD = chronic kidney disease
CNAC = Canadian Network for Asthma Care
COPD = chronic obstructive pulmonary disease
CP = central production
CPP = clinical pharmacotherapy practitioner
CrCl = creatinine clearance
CRI = chronic renal insufficiency
CSHP = Canadian Society of Hospital Pharmacists
CV = cardiovascular
DHPh = homeopathic pharmacy diploma
DND = Department of National Defence
diploma
EAC = Early Arthritis Clinic
EPIC = Empowering Patients through Integrated
Care program
ESRD = end-stage renal disease
FHN = family health network
FHT = family health team
FM = family medicine
GHC = Group Health Centre
GI = gastrointestinal
GPA = Glebe Pharmasave Apothecary
HRT = hormone replacement therapy
ICES = Institute for Clinical Evaluation Services
ICU = intensive care unit
ID = infectious diseases
IMPACT = Integrating family Medicine and Pharmacy to Advance primary Care Therapeutics
INR = international normalized ratio
IV = intravenous
LDL = low-density lipoprotein cholesterol
LHIN = local health integration network
LTC = long-term care
MI = myocardial infarction
MHEC = Murphy’s Health Education Centre
MoHLTC = Ministry of Health and Long-Term Care
Innovative Pharmacy Practices Volume II
Moving Forward: Pharmacy Human Resources for the Future
GLOSSARY OF TERMS AND ABBREVIATIONS
MPhA = Manitoba Pharmaceutical Association
PD = peritoneal dialysis
MRP = Manitoba Renal Program
PDDC = Fraser Health Pharmacy Drug Distribution
MS = multiple sclerosis
MSDIF = Medical Services Delivery Innovation
Fund
MSP = Manitoba Society of Pharmacists
NAMS ME = North American Menopause Society
Centre
PDSA = Plan Do Study Act
PIPEDA = Personal Information Protection and
Electronic Documents Act
PMPRB = Patented Medicines Prices Review Board
Menopause Educator
PN = parenteral nutrition
NAMS MP = North American Menopause Society
RHO = renal health outreach
Menopause Practitioner
NCTRF = Newfoundland Cancer Treatment and
Research Foundation
NICU = neonatal intensive care unit
NIHB = Non-Insured Health Benefits
OHIP = Ontario Health Insurance Plan
OPT = outpatient parenteral therapy
OTC = over-the-counter
PASIC = Programme ambulatoire spécialisé en
insuffisance cardiaque
PC = personal computer
PCAP = Primary Care Asthma Program
PCCA = Professional Compounding Centers of
America
RN = registered nurse
RPh = registered pharmacist
RRT = renal replacement therapy
SAP = Health Canada’s Special Access Program
SRHC = Southlake Regional Health Centre
SSL VPN = Secure Sockets Layer Virtual Private
Network
TAP = The Arthritis Program
TIA = transient ischemic attack
TIPPS = Team for Individualizing Pharmacotherapy in Primary Care for Seniors
UAH = University of Alberta Hospital
WHIM = Women’s Health in Motion
PCP = patient care pharmacist program
© 2008 Canadian Pharmacists Association
TABLE OF CONTENTS
ACKNOWLEDGEMENTS
GLOSSARY OF TERMS AND ABBREVIATIONS
1.0
2.0
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1
Overview of Moving Forward: Pharmacy Human Resources for the Future . . . . . . . . . . . 1
1.2
Categories of Innovation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
COLLABORATIVE PRIMARY HEALTH CARE TEAMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2.1
Integrating family Medicine and Pharmacy to Advance primary Care
Therapeutics (IMPACT), Ontario . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2.2
Pharmacist Integration into the Hamilton Family Health Team, Hamilton ON . . . . . . . . . . 5
2.3
Passport to Health, Hamilton ON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2.4
Cardiovascular Health Awareness Program (CHAP), Ontario . . . . . . . . . . . . . . . . . . . . . 9
2.5
Mid-Main Community Health Centre, Vancouver BC . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.6
Counselling Seniors in a Community-based, Multi-disciplinary Health Care Team,
Toronto ON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.7
Disease State Management (DSM) Clinic, Burnaby BC . . . . . . . . . . . . . . . . . . . . . . . . . 16
2.8
First Nations Onsite Pharmacy Services, Wynyard SK . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.9
Clinical Pharmacist Services in Parkridge Long-Term Care Facility, Saskatoon SK . . . . . . . 20
2.10 Primary Care Pharmacy Practice in an Ambulatory Setting, Saskatoon SK . . . . . . . . . . . 22
2.11 Other Pharmacists on Primary Health Care Teams . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
3.0
EXPANDED PRESCRIBING AUTHORITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
3.1
Cardiac Ensuring Access and Speedy Evaluation (EASE) Program, Edmonton AB . . . . . . . . 34
3.2
Regina Renal Program, Regina SK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
3.3
Non-certified Clinical Assistant Program, Winnipeg MB . . . . . . . . . . . . . . . . . . . . . . . 39
3.4
Hyperlipidemia Clinic, Canadian Forces Health Services Centre, Ottawa ON . . . . . . . . . 41
3.5
Travel Medicine Service, Ottawa ON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
3.6
Critical Care Pharmacist, St. Boniface General Hospital, Winnipeg MB . . . . . . . . . . . . . 47
Innovative Pharmacy Practices Volume II
Moving Forward: Pharmacy Human Resources for the Future
TABLE OF CONTENTS
4.0
CHRONIC DISEASE MANAGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
4.1
Anticoagulation Management Service (AMS), Edmonton, AB . . . . . . . . . . . . . . . . . . . . 49
4.2
Anticoagulation Management Service (AMS) in a Rural Hospital, Athabasca AB . . . . . . . . 51
4.3
Warfarin Dosage Adjustments Through Anticoagulation Case Management
in Community Pharmacies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
4.4
Anticoagulation Management in a Family Practice, St John’s NL . . . . . . . . . . . . . . . . . 56
4.5
Cardiovascular Risk Reduction in a Family Practice, Fort Qu’Appelle SK . . . . . . . . . . . . 58
4.6
Pharmacist Involvement in a Lipid Clinic, Regina SK . . . . . . . . . . . . . . . . . . . . . . . . . 59
4.7
Clinical Pharmacy Services in an Outpatient HIV Clinic, Edmonton AB . . . . . . . . . . . . . . 61
4.8
Pharmacist in a Multi-site HIV Clinic, St. John’s NL . . . . . . . . . . . . . . . . . . . . . . . . . . 64
4.9
Collaborative Diabetes Education and Management, Wynyard SK . . . . . . . . . . . . . . . . . 66
4.10 Diabetes Education Program, Youville Centre, Winnipeg MB . . . . . . . . . . . . . . . . . . . . 68
4.11 Multidisciplinary Metabolic Syndrome Clinic, Ottawa ON . . . . . . . . . . . . . . . . . . . . . . 70
4.12 The Arthritis Program (TAP), Newmarket ON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
4.13 Asthma and COPD Education Services in a Community Pharmacy, Regina SK . . . . . . . . . . 77
4.14 Essex County Community Asthma Care Strategy, Windsor ON . . . . . . . . . . . . . . . . . . . 79
4.15 Manitoba Renal Program (MRP), Manitoba . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
4.16 Infectious Diseases Ambulatory Care Clinic, St John’s NL . . . . . . . . . . . . . . . . . . . . . . 83
4.17 Pharmacist-managed Drug Safety Clinic, Toronto ON . . . . . . . . . . . . . . . . . . . . . . . . . 85
5.0
6.0
HEALTH PROMOTION AND DISEASE PREVENTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
5.1
Pharmacist Consulting at a Geriatric Assessment Clinic, Edmonton AB . . . . . . . . . . . . . 87
5.2
Good Samaritan Seniors’ Clinic, Edmonton AB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
5.3
Chart-based Consultations on Coronary Patients, Leader SK . . . . . . . . . . . . . . . . . . . . 91
5.4
Heart Health Education Program, Espanola ON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
5.5
Patient Care Pharmacist Program, Western Canada . . . . . . . . . . . . . . . . . . . . . . . . . . 94
CONTINUITY OF CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
6.1
Community Medication Management Program, Fraser Valley BC . . . . . . . . . . . . . . . . . . 97
6.2
Programme ambulatoire spécialisé en insuffisance cardiaque (PASIC), Moncton NB . . . . . 99
6.3
Outpatient Parenteral Therapy (OPT), Kamloops BC . . . . . . . . . . . . . . . . . . . . . . . . 103
© 2008 Canadian Pharmacists Association
TABLE OF CONTENTS
7.0
8.0
6.4
Seamless Care Outcomes Assessment Project for Discharged Oncology Patients,
St. John’s NL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
6.5
Technicians and Pharmacists Partnering in Medication Reconciliation, Moncton NB . . . . 107
6.6
Medication Reconciliation — Admission to Discharge and Into the Community,
Fraser Health Authority BC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
6.7
Leila Pharmacy’s Health and Wellness Program: Home-based
Medication Reconciliation, Winnipeg MB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
CONSULTING AND COGNITIVE SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
7.1
Murphy’s Health Education Centre, Charlottetown PE . . . . . . . . . . . . . . . . . . . . . . . 116
7.2
Affinity for Women’s Health, Kitchener ON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
7.3
Promotion of Women’s Health, Saskatoon SK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
7.4
Private Pharmacist Consultations, Community Pharmacy, Keswick NB . . . . . . . . . . . . . 122
7.5
Orthomolecular Management System: Individual Patient Assessment
and Compounding, Ottawa ON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
ENABLERS OF INNOVATIVE PHARMACY PRACTICE — AUTOMATION, INFORMATION
AND COMMUNICATION TECHNOLOGY, AND PHARMACY TECHNICIANS . . . . . . . . . . . . . . . . 126
8.1
EMRxtra — Electronic Medical Records, Sault Ste. Marie ON . . . . . . . . . . . . . . . . . . . 126
8.2
International Pharmacy Services: Internet-based Dispensing, Winnipeg MB . . . . . . . . . 128
8.3
Decentralized Hospital Pharmacy Services, Brandon MB . . . . . . . . . . . . . . . . . . . . . . 130
8.4
Pharmacist Network: Tele-health, Network Health Care, British Columbia and Alberta . . 134
8.5
Pharmacy Clinical Program and Pharmacy Education/Mentoring, BC Interior . . . . . . . . 137
8.6
Central Production Pharmacy, Calgary AB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
8.7
Fraser Health Pharmacy Drug Distribution Centre, Langley BC . . . . . . . . . . . . . . . . . . 140
8.8
Enhanced Utilization of Pharmacy Technicians in a Community Pharmacy, Ottawa ON . . 143
Innovative Pharmacy Practices Volume II
Moving Forward: Pharmacy Human Resources for the Future
© 2008 Canadian Pharmacists Association
SECTION I — INTRODUCTION
1.0 INTRODUCTION
1.1 Overview of Moving Forward: Pharmacy Human
Resources for the Future
One of the most urgent crises facing Canada’s health care system today is the appropriate
management of health human resources — that is, ensuring that the right health care
providers with the right skills are available in the right place at the right time. Pharmacists
have been identified as a high priority health human resource with key roles to play in delivering health care both now and in the future.
Many challenges surround the pharmacy sector’s efforts to optimize the management of its
available human resources. Reports of difficulties in recruitment and retention are common.
The role of the pharmacist and of the pharmacy technician in the delivery of health care is
changing. International Pharmacy Graduates, a significant and growing workforce population, need to be better supported in their integration to professional practice in order to
maximize the contribution they can make. A failure to address these human resources challenges will compromise the ability of the pharmacy workforce to provide quality, patient
health outcomes focused care.
In order to understand the factors contributing to these human resource pressures and to
strategize potential solutions, eight leading national pharmacy organizations partnered together in 2005 to carry a human resources study of pharmacists and pharmacy technicians
now known as Moving Forward: Pharmacy Human Resources for the Future. Funded by
the Foreign Credential Recognition Program of Human Resources and Social Development
Canada and managed by the Canadian Pharmacists Association, Moving Forward is a
multi-pronged research program examining the factors contributing to pharmacy human
resources challenges in Canada, that will develop a series of pharmacy human resources
planning recommendations to ensure a strong pharmacy workforce prepared to meet the
future health care needs of Canadians.
The information contained in this report (Volumes I and II) comprises the results of Moving
Forward’s efforts to identify, document and analyze emerging innovative pharmacy
practices and models of pharmacy practice. Volume I provides an overview of the findings,
while Volume II contains detailed profiles documenting individuals, organizations or
institutions from across Canada that have introduced significant or singular innovations to
their pharmacy practices.
These profiles do not represent either a random selection or an exhaustive list of innovative
pharmacy practices. They were chosen to represent as many new configurations in as many
different settings as possible. The organizations profiled were identified through a fourmonth process of “snowball” sampling consisting of referrals to key informants, interviews
with these individuals, followed by more referrals and more interviews. Both community
and institutional programs are described; some are publicly funded, while others are being
offered in retail settings; some are short-term pilot projects while others have been in place
for a number of years.
Innovative Pharmacy Practices Volume II
Moving Forward: Pharmacy Human Resources for the Future
1
SECTION I — INTRODUCTION
The number of innovative pharmacies profiled could have been much larger than the
almost 60 included here. When there were a number of sites using similar innovative
practices, in most cases only one has been described.
1.2 Categories of Innovation
As practitioners were being identified and interviewed for this study, their innovations were
classified into seven categories of innovation:
1.
2.
3.
4.
5.
6.
7.
Collaborative primary health care teams
Expanded prescribing authority
Chronic disease management
Health promotion and disease prevention
Post-hospitalization continuity of care and medication reconciliation
Consulting and cognitive services
Enablers of innovative pharmacy practice — innovation automation, information and
communication technology, and pharmacy technicians
However, it quickly became evident that many locations had introduced more than one
innovation. For example, some primary care units, based on collaboration among
physicians, nurse practitioners and pharmacists, had also instituted electronic record
keeping to facilitate the flow of patient information. Hospitals that had centralized
dispensing functions had also delegated tasks to highly trained pharmacy technicians.
Initiatives to provide continuity of care from hospital to community were doing medication
reconciliation and home-based visits. In many locations, innovation in one area of a
practice led to rethinking or restructuring elsewhere in the practice.
2
© 2008 Canadian Pharmacists Association
SECTION 2 — COLLABORATIVE PRIMARY HEALTH CARE TEAMS
2.0 COLLABORATIVE PRIMARY HEALTH CARE TEAMS
2.1 Integrating family Medicine and Pharmacy to
Advance primary Care Therapeutics (IMPACT),
Ontario
Interviewees: Dr. Lisa Dolovich, principal investigator; Dr. Barb Farrell, co-principal
investigator; and Kelly Babcock, co-investigator; for the demonstration project.
Sponsoring organization: Funded by the Ontario Primary Health Care Transition Fund.
Other participating organizations: McMaster University, University of Ottawa, University
of Toronto
Location or setting: Seven family practice sites across Ontario: Beamsville Medical Centre
in Lincoln, Caroline Medical Group in Burlington, Claire-Stewart Medical Centre in Mount
Forest, Fairview Family Health Network in North York, Bruyère Family Medicine Centre in
Ottawa, Riverside Court Medical Centre in Ottawa, and the Stratford Family Health
Network.
Type of innovation: Pharmacists providing primary care in conjunction with multidisciplinary health teams in family practices.
Start date: February 2004
End date: 2006
Description of initiative: This demonstration project had pharmacists physically located
within various family medicine group practices. Together, the seven practices involved
approximately 70 physicians and 150,000 patients.
Role of pharmacist:
•
Conducts individual patient assessments, including conducting medication histories;
identifying problems; developing and monitoring care plans; communicating the plan
to the patient and interdisciplinary team;
•
On request, provides consultation to the family physician and other team members to
assist in the individual care of patients;
•
Provides educational presentations to team members and patients;
•
Communicates with hospital and community pharmacists and other team members to
ensure smooth transitions for medication-related care between care sites; and
•
Recommends improvements to the medication use process at the practice site (e.g.,
prescribing, handling of samples, administration of medications and documentation).
Purpose: To improve patient outcomes by optimizing drug therapy through a community
practice model that integrates pharmacists into family practices.
Innovative Pharmacy Practices Volume II
Moving Forward: Pharmacy Human Resources for the Future
3
SECTION 2 — COLLABORATIVE PRIMARY HEALTH CARE TEAMS
Human resources: Seven pharmacists (0.5 FTE each); 70 family physicians, receptionists,
nurses, nurse practitioners, social workers, dietitians.
Other resources required: Recruited pharmacists participated in a transitional training program, consisting of training plus mentorship, which supported their transition into primary
care practice. The three-day training program stressed skill-building in areas such as documentation and prioritization. Each new pharmacist was paired with another more experienced primary care pharmacist to serve as a mentor for the first year. Pharmacists were also
supported by the services of the Ontario Pharmacists’ Association Drug Information Centre.
Funding/pharmacist remuneration: Ontario Ministry of Health and Long-Term Care
provided project funding. The project has resulted in funding for the integration of pharmacists into primary health care teams across Ontario.
Benefits/advantages/impacts: The project produced a practical and transferable practice
model for integrating pharmacists into community family practice.
Challenges and strategies used to overcome challenges: Physical logistics (i.e., space
needed to have a pharmacist onsite), physicians’ lack of time to meet with pharmacists and
developing physician trust were challenges.
Feasibility:
Sustainable: With government funding.
Scaleable: Yes, is being rolled out in other locations.
Supported: Yes.
Consistent: Yes, due to training.
Evaluation: Pilot project ended in September 2006; expecting results of evaluation to be
published sometime in 2008. Results are based on clinical outcomes only; funding cuts did not
allow for completion of economic analysis that had been planned. The process of integration,
pharmacist service uptake, the usefulness of different referral strategies, and drug-related
patient outcomes are being evaluated. Processes of care (e.g., vascular risk monitoring and
drug therapy changes) and outcomes of care (e.g., vascular surrogate endpoints and
improvement in symptoms) will be assessed to evaluate the effects of pharmacist integration.
Academic documents:
•
Integrating family Medicine and Pharmacy to Advance primary Care Therapeutics
(IMPACT). CPJ July/August 2004. Vol.137, No.6.
CONTACT
Kelly Babcock
Director of Pharmacy, SCO Health Service
43 Bruyere St.
Ottawa, ON K1N 5C8
Tel.: (613) 562-4262 ext. 4028
Email: [email protected]
4
© 2008 Canadian Pharmacists Association
SECTION 2 — COLLABORATIVE PRIMARY HEALTH CARE TEAMS
Dr. Lisa Dolovich
Associate Director, Centre for Evaluation of Medicines,
St. Joseph’s Health Care
105 Main St East, Level P1
Hamilton, ON L8N 1G6
Tel.: (905) 522-1155 ext. 33968
Email: [email protected]
Dr. Barb Farrell
C.T. Lamont Centre, Élisabeth Bruyère Research Institute,
SCO Health Services
43 Bruyere St.
Ottawa, ON K1N 5C8
Tel.: (613) 562-0050 ext. 1315
Email: [email protected]
2.2 Pharmacist Integration into the Hamilton Family
Health Team, Hamilton ON
Interviewee: Dr. Anthony Gagnon, pharmacy program manager and clinical pharmacist,
Hamilton Family Health Team
Location or setting: Hamilton Health District
Type of innovation: Pharmacist in primary health care team environment
Start date: Pharmacists introduced to teams in 2006
Description of initiative: The Hamilton Family Health Team (FHT) includes 114
physicians, 80 nurses, 17 dietitians and seven pharmacists in 62 medical offices in
40 different buildings. The target population is patients with medication-related problems
who visit the family health clinics. Primary focus is patients with chronic disease who are
not effectively managing their condition.
Role of pharmacist: Pharmacists are in the physician’s offices one half day per week.
New patients are referred by physicians and usually have a one-hour appointment;
continuing patients have a 30-minute appointment. Pharmacist makes recommendations to
the physician who is usually available to implement the recommendations immediately
(located in the office). Pharmacist also provides drug information (discussion of drug
related problems) and academic detailing onsite to physicians and nurses. The project is
also in the process of providing an anticoagulation service, but due to the limited
pharmacist time in the location, this must be done in collaboration with others on the team.
Purpose: To provide primary care pharmacy services to physicians in their office settings,
and improve medication management to the patients identified with medication-related
problems in the physician clinics.
Innovative Pharmacy Practices Volume II
Moving Forward: Pharmacy Human Resources for the Future
5
SECTION 2 — COLLABORATIVE PRIMARY HEALTH CARE TEAMS
Human resources: Currently seven pharmacists (4.8 FTEs).
Other resources required: Most of the physician offices (68%) have electronic health
records for their patients.
Funding/pharmacist remuneration: Salaries funded from the FHT (through MoHLTC).
Benefits/advantages/impacts: Pharmacists have full access to patient charts and can
make informed recommendations that are tailored to each specific patient’s needs. By
being in the medical clinic, the physician has direct access to the pharmacist and is able to
see first-hand the capabilities of the pharmacist in medication management issues.
Challenges and strategies used to overcome challenges: Physicians traditionally are not
in the habit of referring their patients to pharmacists and do not realize the capabilities of
the pharmacist.
It takes time for the pharmacist to work into the system and have the physician realize the
capabilities of the pharmacist and begin to refer patients. Pharmacists need to determine
the most effective niche for getting into the system. There is an orientation system for
pharmacists in joining the health team pharmacists group. Pharmacists within the teams
meet weekly to share their experiences.
Feasibility:
Sustainable: As long as salaries paid by Ontario Ministry of Health and Long-Term Care
(MoHLTC), through FHTs.
Scaleable: System is expanding to include more pharmacists within the teams.
Supported: Pharmacist involvement in family health teams is fully supported by the Ontario
government.
Consistent: By way of weekly meetings of the pharmacists, seek to share experiences and
develop a consistent approach in the family health team.
Evaluation: The formal program is currently in its infancy, but evaluation will occur.
The Hamilton FHT has an individual designated to assist in the evaluation of each program.
The FHT tracks medication-related programs, number of visits, time to perform basic functions, and some other basic workload measurements, as requested by the Ontario MoHLTC.
Academic documents:
•
Presented an abstract at the Ontario Pharmacists Association meeting, September 2007
•
Family Physician Forum, Winnipeg, Manitoba, October 2007
CONTACT
Dr. J. Anthony Gagnon, PharmD, CDE, CAE, FASCP
10 George Street, 3rd floor
Hamilton, ON L8P 1C8
Tel.: (905) 667-4865
Email: [email protected]
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2.3 Passport to Health, Hamilton ON
Interviewee: Iris Krawchenko; pharmacist/manager, Dell Pharmacy; pharmacist and
co-founder of program
Sponsoring organization: Hamilton Family Health Team
Location or setting: Community pharmacies in Hamilton, ON
Start date: Piloted in 2005; officially launched as a program in Hamilton in April 2007
End date: Depends on results of evaluation underway
Description of initiative: Community pharmacists and physicians partner with patients to
monitor and encourage attainment of established health goals. Target population involves
patients with three or more cardiovascular risk factors (e.g., Type 2 diabetes, over 55 years
of age, high blood pressure) who are referred by physician team members.
Role of pharmacist: Once a patient has been identified by the physician as a possible
participant, the pharmacist and physician jointly meet with the patient to explain the
program. If the patient agrees to participate, a three-way consent form is signed to
formalize the patient-pharmacist-physician collaboration. The pharmacist then sets up a
series of monthly appointments with the patient.
At the first appointment, the pharmacist establishes baseline data (lab values, cumulative
patient profile, and medication history) and takes objective measurements, including the
patient’s blood pressure, weight and waist circumference. Goals are set and the
pharmacist’s recommendations regarding medication therapy are given to the physician
(e.g., adjusting current medication, discontinuing or adding medication), and
recommendations on lifestyle modification are given to the patient. The initial visit typically
takes about an hour. A MedsCheck is also conducted during this first interview.
At subsequent monthly meetings (usually lasting about 30 minutes), the patient’s progress
towards goals and lifestyle changes is monitored. A special software program is used to
track and monitor measurements and lab values, and help assess cardiovascular risk. The
pharmacist provides monthly reports back to the physician on patient progress, along with
pharmacist recommendations if warranted.
Medications are regularly reviewed by the pharmacist during these visits, and the patient is
asked to report on any vitamins, herbals or non-prescription drugs they may concurrently
be taking.
The results of these visits are recorded in the patient’s Passport to Health record, which
they must take to all physician or pharmacist appointments. This record is kept updated by
the pharmacist, who acts as the information gatekeeper, and results in a very up-to-date
medication and health indicator record.
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With respect to medication modifications initiated by physicians, the contract that is signed
on enrollment stipulates that the patient agrees to advise the pharmacist within 48 hours if
there is a change in medication.
Purpose: To capture best possible patient medication histories, therefore increasing patient
safety; to integrate community pharmacists into health teams in an organized manner,
enabling physicians and patients to utilize pharmacists’ skills; and to improve access to
health care for patients, through a collaborative protocol, with oversight by a family
physician.
Human resources: There are five pharmacist-physician teams, each consisting of one
pharmacist and one physician. The goal is for each team to have 10 patients enrolled in
the program, for a total of 50 patients. As of the end of 2007, there were approximately
35 enrolled patients.
Other resources required: Program utilizes the office facilities of the Hamilton Family
Health Team (FHT) for coordination of teams, billing, etc. In community pharmacies:
private consultation rooms, blood pressure machines, software, weight scale, measuring
tape, binders for each patient. The software used for the program is not currently linked to
that of the pharmacy.
Funding/pharmacist remuneration: The pilot was originally funded by an unrestricted
grant from Pfizer Canada. Now funding for pharmacist fees comes from the Ontario
Ministry of Health and Long-Term Care, included in FHT funding. Pharmacists are paid on
a capitation basis and it works out to approximately $62.50 per hour for pharmacist time.
Benefits/advantages/impacts: Patients are receiving an enhanced level of care, compared
with receiving health services from physicians and pharmacists in isolation. Program also
allows pharmacists to participate as a health care team member, while remaining in the
community pharmacy environment and building on existing relationships with their patients.
Challenges and strategies used to overcome challenges: Obtaining funding from the
FHT for community pharmacist participation was a challenge. Lobbying efforts took a great
deal of time and money (presenting to and educating administrators). Not all participating
pharmacists were accustomed to the program software.
Having a physician co-develop the program and help champion it was a huge help.
Some degree of orientation and training were required for participating pharmacists who
had not used the program software.
Feasibility:
Sustainable: Only with government funding.
Scaleable: Yes. Limiting factor is number of participating physicians and pharmacists. This
model could be used for many chronic diseases (e.g., osteoporosis, asthma).
Supported: Yes. To-date, recommendations made by pharmacists have all been accepted by
partnering physician.
Consistent: Yes, because it is based on developed protocols, and substantial educational
programs are offered to enrolled pharmacists prior to joining a team, to ensure that there is
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a consistent level of knowledge and skill. Also, participating pharmacists all use the same
software program to help with documentation and assessments.
Evaluation: A formal evaluation is expected to be finished in 2008. Specific success markers are being evaluated, as well as soft indicators such as satisfaction and uptake by physicians, pharmacists and patients. Evaluation results will be published. Positive feedback is
received on a regular basis from physicians and patients.
Communications/promotional material: To date, promotional and communication efforts have been directed at recruiting pharmacists and physicians into the program.
CONTACT
Iris Krawchenko
C/o Dell Pharmacy
1955 King St. E.
Hamilton, ON L8K 1W2
Tel.: (905) 549-9775
Email: [email protected]
2.4 Cardiovascular Health Awareness Program
(CHAP), Ontario
Interviewee: Dr. Lisa Dolovich, BScPhm, PharmD, MSc; research pharmacist
Sponsoring organization: Funded by Ontario Ministry of Health Promotion (Ontario
Stroke System) and the Canadian Stroke Network.
Other participating organizations: Department of Family Practice, University of British
Columbia; McMaster University; Elisabeth Bruyere Research Institute; The Team for
Individualizing Pharmacotherapy in Primary Care for Seniors (TIPPS); Institute for Clinical
Evaluation Services (ICES); Fig.P Software Incorporated
Location or setting: The program is carried out in pharmacies in 20 mid-size (population
from 10,000 to 60,000) communities in Ontario. Each of these communities has at least five
family physicians and at least two community pharmacies participating.
Type of innovation: Pharmacists are providing primary care in the community pharmacy
setting.
Start date: September 2006
Description of Initiative: CHAP is a community-based program aimed at improving the
detection, treatment and control of hypertension and improving cardiovascular health.
In general, patients aged 65 years and older are invited by their family physicians to attend
up to two cardiovascular/blood pressure assessment clinics set up in local community
pharmacies. These sessions are led primarily by volunteers, who are trained by public
health nurses to assist with measuring blood pressures (using an accurate blood pressure
[BP] monitoring device), and also help with completing cardiovascular risk factor checklists,
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provide educational materials and advice on available resources, at the local level.
Participants are provided with a copy of their cardiovascular risk profile and resources for
modifying risk factors.
Patients with high BP are triaged to pharmacist for assessment; assessment is documented
and forwarded to family physician. Target population is seniors 65 years of age and over,
identified by their physicians.
Role of pharmacist: Provides access to the community pharmacy as a facility for the sessions, and collaborates with local session coordinators and peer health educators regarding
the operation of the blood pressure clinic. Also conducts medication assessments (medication adherence, drug interactions, drug-induced hypertension) for select participants identified as having uncontrolled high blood pressure and using standardized documentation
forms, communicates the results to the participant’s family physician.
Knowledge and skills required by the pharmacist to participate include:
•
Knowledge of current Canadian guidelines related to hypertension management;
•
Able to conduct a medication history to identify simple drug-related problems;
•
Able to assess medication compliance and suggest solutions to improve compliance;
•
Knowledge of medications that can elevate blood pressure or interact with blood
pressure medications, and
•
Able to provide individualized patient counselling regarding blood pressure
medications.
Purpose: To offer a community-based and cost-effective means of improve detection,
treatment and control of hypertension.
Human resources: Volunteer peer health educators, volunteer pharmacists, local
coordinator, community health nurse, family physicians (integrate information from clinics
into their care).
Other resources required: Community pharmacy facilities (where assessment sessions
are offered) and various supports for pharmacists (information, clinical guidelines,
documentation forms).
Funding/pharmacist remuneration: Pharmacists’ time is contributed on a volunteer
basis.
Benefits/advantages/impacts: Offering BP assessments in familiar settings such as
community pharmacies can alleviate barriers to effective monitoring of BP (i.e., “white coat
syndrome”). On average, patients make two trips per month to a community pharmacy, so
this program offers convenience. The presence of a pharmacist, as a health professional,
adds significant value to the program.
Challenges and strategies used to overcome challenges: Sometimes, participants identified as having uncontrolled high blood pressure from assessments by peer educators were
not able to take the time to see the pharmacist. This was remedied by mentioning the need
for extra time in the information letters given to patients (i.e., plan to possibly stay an extra
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30 minutes after assessment is done) and also making appointments at a later time after
the clinics. The pharmacist may be too busy in dispensary to see the participant for postassessment meeting. This is sometimes alleviated by scheduling some pharmacist overlap
in shifts.
There were instances when the peer educators would call the family physician on the
participant’s request and behalf, to schedule an appointment before they met with the
pharmacist. This was resolved by explaining to the peer educators the reasons why it is
important for the participant to meet with the pharmacist first, before the physician
(i.e., identify causes for uncontrolled BP and make recommendations for physician).
Feasibility:
Sustainable: With government funding for volunteer training and administration/
coordination of program
Scaleable: Yes
Consistent: Yes, through use of documentation and communication forms, well-established
protocols, and training.
Evaluation: A randomized controlled trial has been conducted comparing 20 intervention
communities to 19 control communities. Results will be available in 2008-2009. Two hundred and fourteen family physicians invited patients who attended 1265 sessions, in 129
pharmacies; 15,889 older adults participated.
Academic documents:
•
Chambers LW, Kaczorowski J, Dolovich L, et al. A community-based program for
cardiovascular health awareness. Canadian Journal of Public Health 2005:96(4):29498.
•
Kaczorowski J, Chambers LW, Karwalajtys T, et al. Cardiovascular Health Awareness
Program (CHAP): a community cluster-randomized trial among elderly Canadians.
Submitted to Preventive Medicine. In press.
•
Karwalajtys T, Kaczorowski J, Chambers LW, et al. A randomized trial of mail vs.
telephone invitation to a community-based cardiovascular health awareness program
for older family practice patients. [ISRCTN61739603] BMC Family Practice 2005 6:35
DOI:10.1186/1471-2296-6-35.
•
Pora VV, Farrell B, Dolovich L, Kaczorowski J, Chambers L, on behalf of the CHAP
working group. Promoting cardiovascular health among older adults: a pilot study
with community pharmacists. CPJ 2005:138(7):50-55.
Communications/promotional material:
•
Invitation letters (prepared by CHAP staff), signed by physicians are sent out to
qualified patients (i.e., matching the target population)
•
Tickets for assessment sessions are issued by family physicians to appropriate patients
as they visit the physician’s office, along with a schedule of the sessions.
•
Advertisements in local newspapers, newsletters, physician offices and public
buildings
•
Website: www.chapprogram.ca
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CONTACT
Lisa Dolovich
c/o Centre for Evaluation of Medicines,
St. Joseph’s Health Care
105 Main St East, Level P1
Hamilton, ON L8N 1G6
Tel.: (905) 522-1155 ext. 33968
Fax: (905) 528-7386
Email: [email protected]
2.5 Mid-Main Community Health Centre, Vancouver BC
Interviewee: Susan Troesch, clinical pharmacist, Mid-Main Community Health Centre,
Vancouver, BC
Sponsoring organization: Vancouver Coastal Health Authority
Location or setting: Mid-Main Community Health Centre, Vancouver BC
Type of innovation: Pharmacist on a primary care team that also focuses on chronic
disease management.
Start date: 1998
Description of initiative: An interdisciplinary team of health care professionals, including
a pharmacist, provides primary care in a non-profit community health centre. All team
members have access and input into the electronic medical records for each patient. There
is also a dental clinic onsite. The target population is patients visiting the Vancouver
Mid-Main Community Health Centre.
Role of pharmacist: Pharmacist’s duties have grown from answering drug information questions and seeing some clients after their physician appointments, to managing the smoking cessation program, providing diabetes and asthma education, performing shared-care with other team
members for home-bound elderly clients, and supervising the warfarin monitoring program. In
addition, the pharmacist authorizes prescription refills and some dosage adjustments using a delegated protocol from physicians. Pharmacist has been certified as a diabetes educator.
The latest addition was a support group for women with metabolic syndrome named
Women Health in Motion (WHIM). The goal is to support the development of
self-management skills through weekly group educational sessions, lifestyle and
peer-supported discussions regarding self-care.
Purpose: To provide optimum pharmacy care, within the integrated team approach, to
patients visiting the clinic.
Human resources: Professional personnel include 4.0 FTE for physicians (six physicians
share), a nurse practitioner, chronic disease coordinator (is also a dietitian), 0.75 FTE
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pharmacist at the Mid-Main Community Health Centre. The same pharmacist now spends
0.2 FTE at a second clinic.
Funding/pharmacist remuneration: Initially, the physicians in the clinic agreed to
accept a change from fee-for-service to salaried positions to accommodate funding for the
pharmacist role. Funding comes from the Vancouver Coastal Health Authority.
Benefits/advantages/impacts: The pharmacist’s one-on-one meetings with patients and
the group sessions make the patients sufficiently knowledgeable about their disease,
prevention, and medication management to make an impact on their health (i.e., supports
improved self-management).
Challenges and strategies used to overcome challenges: It took some time for the
pharmacist and physicians to become familiar with each other’s skill sets, and then to
brainstorm about the best ways to use the pharmacist’s particular skills on the team.
The government still does not provide funding for pharmacists to be a component of
primary care teams.
Pharmacists in primary care practice need to be onsite at least two half days per week to
really build relationships with other team members and have time to focus on projects.
Providing physicians and other team members with the experience of having a pharmacist
as a member of the interdisciplinary primary care team is one strategy to overcome
challenges. Physician advocacy for the pharmacist role in primary care is an important
determinant for future success. Initially the pharmacist volunteered her time to demonstrate
her effectiveness. Within one year the Mid-Main team negotiated alternative funding that
allowed funds to support her salary on a part-time basis.
Feasibility:
Sustainable: Pharmacist has been part of the Mid-Main Community Health Centre team for
nine years.
Scaleable: The value of a pharmacist on the team continues to be demonstrated, and she is
now scaled up to 28 hours per week. In addition, similar services are now provided for
two half-days at another primary care clinic.
Supported: Outstanding support from the clinic team members, both financially and through
their work with her. However, the government still does not directly support clinical
pharmacy services to primary care teams in BC.
Consistent: Once each pharmacist service is developed, it is consistently provided and
innovation continues.
Evaluation: There have been patient outcome evaluations for the clinic patients over the
years. The findings were very favourable for the team. Patient and clinic staff feedback has
been most positive and this has led to continuing expansion of the part-time appointment.
Academic documents:
•
Article in CPJ Collaborative Care Supplement Jan/Feb 2007;140(1): S8, S10.
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CONTACT
Susan Troesch
Mid-Main Community Health Centre
Vancouver, BC
Tel.: (604) 618-9783
Email: [email protected]
2.6 Counselling Seniors in a Community-based,
Multi-disciplinary Health Care Team, Toronto ON
Interviewee: Lalitha Raman-Wilms, BSc (Phm), PharmD, FCSHP, project leader, curriculum
renewal; Director, Division of Pharmacy Practice; Associate Professor, Leslie Dan Faculty of
Pharmacy; pharmacist team member, providing primary care to geriatric population.
Sponsoring organization: Ontario Ministry of Health and Long-Term Care
Location or setting: Community Health Centre (CHC), with a focus on youth with
disabilities (ages 13 to 24) and on seniors. The Centre will normally accept patients from
the local community.
Start date: October 1994
Description of initiative: Team-based approach to providing patient care. The clinic
operated by the CHC is but one component; other services offered by the Centre include
health promotion and social health (e.g., teen parents, stress counselling). The pharmacist’s
practice is focused on geriatric patients.
Role of pharmacist: Patients are referred to the pharmacist from health care professionals
both inside and outside the CHC. Patients can also self-refer.
The pharmacist works with the patients to find out their health or treatment goals and then
develops a care plan to achieve these goals. She also provides patient education (on both
an individual and group basis) to help patients understand their conditions and therapy.
Consults with the patient’s physician, then makes recommendations on drug therapy,
identifies drug-related problems and follows-up with the patient. Observations, findings
and recommendations are documented in the patient’s chart along with those of physicians,
nurses and other health care professionals at the Centre. She works closely with the
patients to implement the care plan and monitors their progress.
Dr. Raman-Wilms may also refer a patient to another health care professional for a general
health assessment if warranted.
Home visits for frail seniors are done by the pharmacist and other team members and are
reported to be valuable, as they sometimes provide a different perspective on the patient’s
life than what may be presented at the clinic.
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In Dr. Raman-Wilms’ opinion, the most important qualification for a pharmacist in this
setting is experience in providing direct patient care. The provision of direct patient care by
pharmacists practising in hospitals is not the same as that in the CHC. In the CHC setting,
the pharmacist must know how to approach clients, make them comfortable being interviewed, and earn their trust. As an example, she said that instead of focusing on the list of
medications that the patient is on when she first interviews them, she instead asks them
what their concerns are (focusing on the person rather than the drugs).
Purpose: To work with individual patients to optimize their drug therapy.
Human resources: 0.2 FTE for pharmacist, 3.0 FTE physicians, 1.0 FTE nurse practitioner.
Two nurses, one nurse practitioner, a dietitian, chiropodist, occupational therapist and
counsellors also provide services on a part-time basis. The Centre also has an executive
director, clinical coordinator, and receptionists.
Other resources required: Offices.
Funding/pharmacist remuneration: Centre physicians and nurses are compensated by
the Ontario government on a salary basis. Currently, pharmacist compensation if provided
through a purchase of services fund administered by the Centre. At this time, Ontario CHC
funding does not include salaried positions for pharmacists.
Benefits/advantages/impacts: Practising in a team with other health care professionals
offers many benefits to both patients and the pharmacist.
Challenges and strategies used to overcome challenges: Building a patient base
was a challenge at first. Since patients did not understand the value that pharmacists
could offer, there was a reluctance to make appointments with the pharmacist. This was
resolved through education sessions for seniors. The first such session attracted about
25 participants. A scheduled 30-minute question-and-answer period lasted over two hours
as participants were very interested in their medications, what questions they should ask of
their community pharmacists and other pharmacy-related issues. This led to an interest in
the pharmacist’s role at the CHC, and the pharmacist’s initial patient base. Now the client
base has expanded largely by word-of-mouth.
Liaison with some physicians external to the CHC is an ongoing challenge.
Dr. Raman-Wilms often needs to contact her clients’ physicians regarding
medication-related issues, and these calls are not always appreciated. The fact that a
pharmacist is intervening and/or that the patient is seeing another health professional
sometimes causes a negative response. To prevent this, Dr. Raman-Wilms adjusted her
approach so that she empowers the physician to make the decision about who should
contact the patient regarding any medication adjustments required due to her
recommendations. She offers the physicians the choice of speaking to the patient
themselves, or having her do it.
Feasibility:
Sustainable: Yes, with government funding for pharmacist position (rather than having the
pharmacist compensation come from a fund for miscellaneous services).
Scaleable: Services could be expanded if more funding were available; would need to be
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based where population is large enough to support an appropriate client base.
Supported: Yes.
Consistent: Yes. Pharmacist uses a step-wise, pharmaceutical care approach to identify and
resolve drug-related problems.
Evaluation: When the CHC first opened in 1992, an evaluation of the effect of a pharmacist’s services on health outcomes was conducted. This led to the decision to have a pharmacist join the CHC team.
Dr. Raman-Wilms routinely receives letters of gratitude and support from her CHC clients.
She also receives positive feedback from physicians (team members, and external) for her
services and, she receives referrals from external physicians.
Dr. Raman-Wilms credits the success of the team approach at the Centre in part to its
structure. Unlike Family Health Teams, which tend to be hierarchal and led by a physician,
the Community Health Centre structure is flatter, and the health professionals report
indirectly through the executive director or clinical coordinator.
CONTACT
Dr. Lalitha Raman-Wilms
Director, Division of Pharmacy Practice
Associate Professor, Leslie Dan Faculty of Pharmacy
University of Toronto
Toronto, ON
Tel.: (416) 978-0616
Fax: (416) 978-8511
Email: [email protected]
2.7 Disease State Management (DSM) Clinic, Burnaby BC
Interviewee: Leela John, BSc, BScPharm, ACPR, PharmD, assistant professor and clinical
coordinator, PharmD program, Faculty of Pharmaceutical Sciences, University of British Columbia; project director
Sponsoring organization: Cobalt Pharmaceuticals Inc.
Location or setting: Save-On-Foods Pharmacy, Burnaby, BC
Start date: January 2005
End date: 2008
Description of initiative: The pharmacists provide one-hour consultations for the target
population on medication management issues pertaining to that patient. These are
pharmacists from UBC, doctor of pharmacy students and community pharmacy residents.
The Save-On-Foods staff pharmacists do not provide this type of consultation yet. Patients
with chronic diseases are eligible to take part in this clinic if they are currently taking five
or more prescription medications, have questions about their drug therapy, are having
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difficulties taking their medications (i.e., non-adherence or adverse effects) or have recently
been discharged from a hospital.
Role of pharmacist: One of the objectives of the Disease State Management (DSM)
program is to educate community pharmacists about the management of chronic diseases
to enable treatment of complex patients with conditions such as hypertension,
dyslipidemia, heart failure, diabetes, asthma, chronic obstructive pulmonary disease,
anticoagulation, osteoarthritis, rheumatoid arthritis, osteoporosis and post-myocardial
infarction.
The average time spent with each patient is one hour for an initial interview, one to two
hours to compile information about complex drug-related problems, one hour for followup and counselling and an additional hour if changes to therapy are made.
The pharmacist providing care to these patients requires specialized knowledge about
chronic disease states to identify and resolve drug-related problems and provide drug
information. Work experience in a variety of settings including hospital pharmacy is an
asset, as this helps the pharmacist understand various diagnostic and laboratory tests that
the patient has undergone.
Purpose: The mission of this program is, “To be a unique pharmacy service in Canada
providing individualized medication counselling and management of drug therapies and
outcomes for patients with specific chronic diseases.” It is the first program of its kind
within a community pharmacy setting in Canada. Its objectives are to improve therapeutic,
humanistic and economic outcomes for patients with chronic diseases, and provide
developing pharmacists (PharmD students and community pharmacy residents) an
awareness of an advanced community practice model and increased exposure to
pharmacists’ roles beyond dispensing medications. A future goal of the program is the
education of community pharmacists at this pharmacy so that they can provide the service.
Human resources: Currently one part-time pharmacist (0.4 FTE). Eleven pharmacy students/residents have completed four-week unpaid rotations at the DSM clinic.
Other resources required: Private area for patient consultation.
Funding/pharmacist remuneration: Grant from Cobalt Pharmaceuticals, support from
Save-On-Foods.
Benefits/advantages/impacts: The PharmD students, community pharmacy residents and
pharmacist have counselled approximately 150 patients since inception of the program
two-and-a-half years ago. Presentations to seniors groups and the general public on the
topics of diabetes, anticoagulation, and dyslipidemia have resulted in positive feedback and
increased patient knowledge of these chronic diseases.
Challenges and strategies used to overcome challenges: Currently, pharmacists in
community settings do not have access to the patient’s medical chart or laboratory test
results. One of the major problems is recruitment of patients for the program. Having a
pharmacist on site five days a week or an administrative assistant would allow recruiting of
more patients. Inadequate space for privacy and patient confidentiality is a barrier to the
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provision of optimal pharmaceutical care. Large-scale academic detailing and continuous
follow-up is not possible due to time constraints.
Physicians and other health care professionals may not be aware of the expanded role of a
clinical pharmacist, since contact with other disciplines is limited in the current program.
Community resources available in the local area are difficult to identify. Sufficient patients
may not be willing or able to pay for the pharmacists’ wages and overhead costs of the
service.
Once recruitment strategies have been optimized, the next phase will include education of
the community pharmacists. Modules have been written to train community pharmacists on
diabetes, dyslipidemia, hypertension, asthma and osteoporosis. Other modules available for
further training include heart failure management, anticoagulation, osteoarthritis,
rheumatoid arthritis and post-myocardial infarction management. Training of community
pharmacists will allow them to provide a complex level of patient care on a larger scale
than that provided by one pharmacist and students.
A small survey of 10 patients attending two clinics for the Disease State Management
program reveals that seven of these 10 patients are willing to pay an average of $45 for
pharmacist consultation services. The remaining three patients did not specify if they would
be willing to pay for these consultation services.
Feasibility:
Sustainable: Depends on availability of continued funding beyond 2008. More pharmacists,
an administrative assistant and a research assistant would be needed in order to continue
this project.
Scaleable: Training of community pharmacists will allow them to provide a complex level
of patient care on a larger scale than that provided by one pharmacist alone.
Supported: In its current form, the pharmacy manager supports the project, but does not
have the ability to give the pharmacists or technicians time to help recruit patients.
Consistent: The care provided by the students, residents and supervising pharmacist is
consistent and follows a protocol.
Evaluation: A formal evaluation has not been undertaken at this time, but is planned in
the future. Patients have expressed their appreciation for the knowledge gained through
pharmacist consultation. Patients’ perception of this particular pharmacy has been
enhanced, and developing pharmacists have gained awareness of an advanced community
practice model.
CONTACT
Leela John
Tel.: (604) 827-3682
Email: [email protected]
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2.8 First Nations Onsite Pharmacy Services, Wynyard SK
Interviewee: Kendra Townsend, partner/owner, Townsend’s Drugs, Wynyard, SK
Sponsoring organization: Townsend’s Drugs
Location or setting: Day Star, Kawacatoose, George Gordon and Muskowekwan First
Nations (40 km to 80 km from Townsend Pharmacy)
Type of innovation: Provision of medications, counselling and education to First Nations
individuals, outside of the community pharmacy.
Start date: 1996
Description of initiative: First Nations patients on reserve who require patient focused
pharmacy services is the target population. They provide weekly on-reserve dispensing and
counselling in collaboration with a physician. These Tuesday night clinics are held at the
Kawacatoose Health Centre and are attended by approximately 30 patients. Each
prescription filled is complimented by a private consultation with a pharmacist.
The pharmacists also provide onsite education on the Day Star, Kawacatoose, George
Gordon and Muskowekwan First Nations reserves. Many of the educational sessions are
focused on diabetes. They have given didactic presentations, held Blood Sugar Bingos,
done one-on-one medication reviews and used the Conversation Map™ program as part
of our education service. Much time is spent pursuing coverage for specialty items such as
dressing supplies, wound care items and incontinence products that are require extra effort
and time via accessing the Non-Insured Health Benefits (NIHB) formulary, the NIHB Prior
Approval processes and the Medical Supplies and Equipment division of NIHB .
Role of pharmacist: Health education, medication counselling, dispensing
Purpose: As transportation to local retail pharmacies can often be a challenge to First
Nation individuals, this on-reserve service enables many patients receive timely and
accessible health care. Pharmacist works collaboratively with the home care nurses and
physicians to provide the best care possible to those with specific needs.
Human resources: 0.8 FTE pharmacist.
Other resources required: Have support of physician, home care nurses, public health
nurses, medical secretary, delivery person, etc.
Funding /pharmacist remuneration: Primary funding through professional fee from
NIHB, but also receive some support from the bands’ Diabetes Support funds.
Benefits/advantages/impacts: This program delivers on-site services (medications,
diabetic supplies and education) to patients who, due to location and circumstances, do
not have access to these services. It builds rapport and trust to groups of marginalized
people who lack access to these services.
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Challenges and strategies used to overcome challenges: These reserves are 40 km to
80 km from the pharmacy, so the pharmacist’s distance to travel is a challenge. The patients
are not restricted to a specific pharmacy, so access to patient medication records have been
a problem in the past. The team approach has been very effective in overcoming the
challenges.
Feasibility:
Sustainable: Yes, in operation for nine years.
Scaleable: There are other similar programs across Canada, and they are an appropriate
approach to dealing with this sub-population of Canadians.
Supported: Yes, by the local physician, public health nurses.
Evaluation: No formal evaluation has been conducted. Patient feedback has been very
positive and the home care program has been very supportive of this initiative.
CONTACT
Debra Townsend
Townsend Drugs
Wynyard, SK
Email: [email protected]
2.9 Clinical Pharmacist Services in Parkridge
Long-Term Care Facility, Saskatoon SK
Interviewee: Sandy Knezacek, clinical pharmacist
Sponsoring organization: Saskatoon Health Region
Location or setting: Parkridge Long-Term Care Facility
Type of innovation: Health region funding for purely clinical pharmacy services is unique
in the province.
Start date: March 1988
Description of initiative: The onsite pharmacist practises clinical pharmacy, but does no
dispensing. Her duties include:
•
Pharmacy rounds with physicians and nurses;
•
Attending all interdisciplinary resident care conferences;
•
Performing quarterly medication reviews for all residents;
•
Conducting drug use review: antipsychotics, gravol, prn hypnotic use on dementia
ward;
•
Chairing Medication Safety Team; and
•
Teaching residents and staff.
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She initiated and is a member of the palliative care team, and is also a member of the
infection control committee and long-term care (LTC) accreditation team.
The facility has 240 residents ranging in age from preschool to more than 100 years of age.
It is a heavy care facility, with many residents requiring specialized care. The facility is
organized into six “neighbourhoods” according to care needs.
Role of pharmacist: Clinical pharmacy only, since the facility out-sources technical duties
(medication dispensing) to a local pharmacy. Residents’ prescriptions and other medication
are all delivered to the facility. The on-site pharmacist is responsible for all cognitive and
non-technical services related to medication at this facility.
Purpose: Promote safe and effective medication therapy for all residents
Human resources: 0.6 FTE pharmacist.
Funding/pharmacist remuneration: Provided by the Saskatoon Health Region.
Benefits/advantages/impacts: Pharmacist is full member of interdisciplinary team; review
of medication is ongoing and in the forefront of resident care. Lots of issues can be solved
before they happen because of participation of pharmacist, who is present when issues are
discussed at time of medication ordering.
Challenges and strategies used to overcome challenges: Lack of time to do everything.
Prioritization is important; activities that benefit patients come first, then staff, then
administration.
Feasibility:
Sustainable: Yes, as long as health region is willing to fund.
Scaleable: Yes.
Supported: Yes.
Consistent: Yes.
Evaluation: No formal evaluation has been done. Pharmacist reports that medical and
nursing staffs are highly supportive of the value that is provided.
CONTACT
Parkridge Centre
110 Gropper Cres.
Saskatoon, SK
Tel.: (306) 655-3857
Email: [email protected]
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2.10 Primary Care Pharmacy Practice in an
Ambulatory Setting, Saskatoon SK
Interviewee: Shannan Neubauer, PharmD, consultant pharmacist in an ambulatory primary
care setting.
Sponsoring organization: College of Pharmacy & Nutrition, University of Saskatchewan
Location or setting: Lakeside Medical Clinic, Saskatoon, SK
Type of innovation: Pharmacist practising in a primary care setting (salaried pharmacist
with fee-for-service physicians). It was unusual for Saskatchewan-based practices to receive
support for pharmacists, nurse practitioners, dietitians, etc., when physicians were not
salary-based.
Start date: 1998
End date: May 2005
Description of initiative: Pharmacist-provided primary health care services in an
ambulatory setting for approximately 22,000 patients, as well as walk-in health care service.
Typically, patients referred by physicians were:
•
On eight or more medications;
•
Experiencing drug reactions, interactions or other adverse drug events; and/or
•
Patients with diabetes mellitus (Type 2), cardiovascular disease, hypertension,
metabolic syndrome, asthma, or in peri-menopause.
Role of pharmacist: Pharmacist saw patients by appointment for services including
patient education, monitoring for potential drug interactions (used clinic’s software program
and patient’s electronic record) and a consultation service (review patient charts, meet with
patients, make recommendations on drug therapy). As the physicians became more
knowledgeable about Dr. Neubauer’s ability, she was authorized to prescribe
independently (faxing prescriptions directly to the pharmacy).
Purpose: The physician-partners of the clinic supported involvement of a pharmacist, as a
way to increase time with patients and still provide quality care. Goals were to ensure that
drug therapy was appropriate (to begin with), to improve health benefits and utilization of
drug therapy for clinic patients.
Human resources: 0.3 FTE pharmacist; 16 to 17 FTE physicians.
Other resources required:
•
Software to create in-house electronic health records (Clinicare) by linking radiology
reports, lab reports, dictated notes, and patient records;
•
Internet access and pharmacy references (online and text);
•
Patient education materials (disease models, print, video), and
•
Office and administrative assistance for booking appointments.
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Funding/pharmacist remuneration: Position was funded by the College of Pharmacy &
Nutrition, University of Saskatchewan.
Challenges and strategies used to overcome challenges: Practising on a part-time basis
made patient follow-up (so important in primary care) difficult. To compensate for this,
Dr. Neubauer routinely worked many more out-of-clinic hours than were funded.
Pharmacist interacted with the clinic physicians as much as possible to build rapport.
Frequently attended medical conferences with physicians, read the same medical journals,
to gain the confidence of the medical team.
Feasibility:
Sustainable: Not without funding from the university or different funding model. Provincial
health system does not fund pharmacists on a fee-for-service basis, like physicians.
Scaleable: Not determined.
Supported: Yes, physicians and patients were all very receptive. Time in clinic was limited
by the level of funding not demand.
Consistent: Yes, since only one pharmacist.
Evaluation: One type of consultation (peri-menopause) was evaluated in a randomized,
comparative trial (see citation below).
Academic documents:
•
Deschamps M, Taylor J, Neubauer SL, Whiting S. Impact of pharmacist consultation
versus a decision aid on decision making regarding hormone replacement therapy.
International Journal of Pharmacy Practice 2004;12: 21-28.
CONTACT
Email: [email protected]; [email protected]
2.11 Other Pharmacists on Primary Health Care Teams
Location or setting: All provinces (listed from west to east)
Type of innovation: Pharmacists in primary health care teams
Start date: Various
This section provides contact information for more than 40 pharmacists who self-identified
themselves as working in primary health care settings across the country. Where a
description of their practice was provided by the practitioner, it follows the contact
information. This is not a complete listing of all primary health care team pharmacists but it
is certainly a substantial sample.
Many of these pharmacists had just begun this type of practice in the summer and fall of
2007, when this study was conducted. Their numbers are expected to continue to increase.
For example, as of September 19, 2007, the Ontario Ministry of Health and Long-Term
Care reported that they had approved 63.75 pharmacist FTEs within family health teams in
Ontario, and 27.7 pharmacist FTEs had been hired.
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BC.1
Amy Huang
Director, Downtown East-side Vancouver Clinic
Vancouver Coastal Health Authority
AB.1
Melissa Dechaine
Clinical Pharmacist, St. Albert & Sturgeon Primary Care Network
St. Albert, AB
Tel.: (780) 419-2214 ext. 229
Team consists of 1.5 FTE pharmacists, three mental health coordinators, a dietitian, two
chronic disease management (CDM) nurses, a lactation consultant, an IM/IT tech, business
manager and executive assistant. Team serves 40 physicians working out of seven
community clinics. Uses a centralized model; all work out of a clinic not attached to any of
the physician clinics. Starting to request more time at the doctor's offices as referrals
increase when they interact with the physicians. Current pharmacist began working with
team in April 2007 and reports that after almost six months is still working at building
relationships with the physicians and getting them more familiar with referring.
Her role is:
•
Conduct structured medication reviews with geriatrician’s patients, help to coordinate
med changes with the community pharmacies;
•
Review patient charts in three different clinics, recommend patients who are good
candidates for medication reviews. It would more efficient if the physicians did this,
but working on changing previous practices;
•
Receive referrals from physicians for structured medication reviews and drug info
questions;
•
Work with CDM nurse on diabetes patients and help to adjust insulin for new insulin
start patients;
•
Receive referrals from within the team for complex patients/mental health issues; and
•
Take training to offer smoking cessation program. (The physicians are highly in favour
of this.)
AB.2
Kaye Andrews
Calgary Rural Primary Care Network
Tel.: (403) 336-1784
Email: [email protected]
AB.3
Patricia Jacobsen
Rocky Mountain House, AB
Email: [email protected]
AB.4
Christal Lacombe, BScPharm.
High River Pharmacist
Calgary Rural Primary Care Network
Tel.: (403) 603-8799
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1.0 FTE pharmacist works closely with CDM nurse, home care and 23 family physicians in
High River. Duties include: doing medication reviews with nurse for diabetics and residents
at a local seniors lodge, and developing/providing support to home care for the medication
administration program at the lodge.
Transitioning to the Calgary Foothills Primary Care Network (CFPCN) where there will be
3.0 FTE pharmacists in total.
AB.5
Florrie MacDougall, BScPharm
Box 968, 1222 Bev McLachlin Drive
Chinook Health Primary Care Network
Pincher Creek, AB T0K 1W0
Tel.: (403) 627-1221
Fax: (403) 627-1226
Email: [email protected]
Daily clinical practice includes:
•
Ordering appropriate lab work initially on starting a new medication and continuing
as appropriate;
•
Applying clinical best practice guidelines to chronic disease treatments and advising
on changes suggested in drug management that come from updates of these
guidelines (chronic diseases include hypertension, asthma, chronic obstructive
pulmonary disease [COPD], geriatrics, diabetes, pain, arthritis, lipid management,
osteoporosis prevention/management, women's wellness);
•
Providing patient education for all new anticoagulation patients, and anticoagulation
management of difficult patients;
•
Providing drug information regarding side effects, suggestions of different drugs to try,
making sense of warnings about drugs;
•
Researching other possible drug treatments when there is treatment failure;
•
Gathering information and filling out applications for special authorization of
medications through provincial or national (i.e., Non-Insured Health Benefits) plans;
•
Accessing emergency supplies of drugs from drug companies for financially strapped
individuals until their own drug coverage is available;
•
Teaching patients drug information separately from any disease education;
•
Reviewing medications currently being used; assessing safety/appropriateness for
individual patients with respect to the whole person; assessing drug compliance;
resolving related issues; getting medications discontinued when therapy is no longer
indicated;
•
Advising on smoking cessation;
•
Teaching blood glucose monitoring;
•
Updating medical records with current drug information, participating in medication
reconciliation at the clinic level;
•
Assessing/educating patients (and physicians) about safety, interactions of herbals,
over-the-counter (OTC) medications, other non-drug treatments; and
•
Suggesting antibiotic therapy, drug therapy for individual patients.
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PCN pharmacist is also the hospital pharmacist in the Pincher Creek hospital to which the
clinic is attached so works very closely with physicians. The pharmacist has extra training
in asthma and COPD (educator), geriatric pharmacy, anticoagulation, diabetes, etc.
AB.6
Leanna St.Onge
Rocky Mountain House, AB
Email: [email protected]
SK.1
Leah Butt
Pharmacist, Leader Pharmacy
Leader, SK
Tel.: (306) 628-3744
Email: [email protected]
New pharmacy graduate. Town of 700 residents with one pharmacy, a hospital, two
physicians, one registered nurse practitioner. Mornings in the dispensary and most
afternoons works out of local medical clinic. The pharmacist is readily accessible to the
physicians/nurse practitioner who can utilize pharmaceutical knowledge. The pharmacist is
working with the nurse practitioner to identify coronary artery disease (CAD) patients who
are not at target blood pressure and not receiving adequate pharmacotherapy, and hopes to
expand project to include other patient categories as well as to become involved in patient
counselling sessions.
SK.2
Charity Evans
Graduate Student, College of Pharmacy & Nutrition
University of Saskatchewan
Saskatoon, SK S7N 5C9
Email: [email protected]
Pharmacist involvement of about 0.5 FTE in cardiovascular (CV) risk assessment, at a large
fee-for-service practice. The biggest goal when designing this program was to make it
generalisable. All of the activities performed by the pharmacist were designed to be
extremely simple so that any pharmacist could do them (advanced degree or formal
specialization not required).
Patients were referred by their physicians, who gave them information on the program
(brochure) and a consent form. Pharmacist contacted these patients within a week to
arrange a time to meet. All patients received the same initial information at the first
meeting: individual CV risk assessment (Framingham risk score) and basic information on
risk reduction strategies. At the end of this visit, patients were randomized into either the
intervention or usual care group.
Those in the follow-up group received pharmacist contact at a minimum of every eight
weeks (mail, email, phone or in person). In a lot of cases it was simply an informational
letter (e.g., a letter explaining the low-density lipoprotein [LDL] cholesterol goal has been
lowered, a letter reminding people to remain physically active over the Christmas season,
etc.). In other cases it was to relay lab values, and in some cases patients have contacted
the pharmacist with questions. The goal of the follow-up is to reinforce and remind
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patients basically to keep CV risk reduction constantly in the back of their minds — rather
than bombard patients with more educational information. Patients were only contacted for
a specific reason, so as not to appear paternalistic (many of the letters are about issues
currently in the media).
The primary outcome was a change in the Framingham risk score, and they also plan to
look at long term medication adherence rates (two years after the observation phase
concluded in December 2007). Received very positive (informal) feedback from physicians
and patients so far.
SK.3
Derek Jorgenson, BSP, PharmD.
Clinical Coordinator, Saskatoon Health Region Pharmacy Dept.
Clinical Pharmacist, West Winds Primary Health Centre
3311 Fairlight Drive
Saskatoon, SK S7M 3Y5
Tel.: (306) 655-4270
Fax: (306) 655-4894
Email: [email protected]
West Winds is a primary health centre run by the health region and the University of
Saskatchewan. It houses the academic family medicine program and many other health
region run primary health programs.
ON.1 Anjali Banerjee
STAR FHT (Stratford and Tavistock) (IMPACT site)
0.2 FTE
ON.2 Rashna Batliwalla
Riverside Court Medical Clinic
Ottawa, ON
(IMPACT site)
ON.3 Catherine Bednarski
Hamilton Family Health Team (see detailed description in Section 2.2)
ON.4 Cynthia Berry
Algonquin FHT, Geriatric Assessment Unit
29 Silverwood Drive
Huntsville, ON P1H 1N1
Tel.: (705) 789-6764
A geriatric assessment team with predominantly dementia patients in the region with the
highest density of seniors in Ontario (Muskokas/Algonquin area); 0.25 FTE of pharmacist
involvement.
ON.5 Janie Bowles-Jordan
0.2 FTE with Hamilton Family Health Team; 0.4FTE with North Hamilton CHC
(see detailed description in Section 2.2)
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ON.6 Robin Brown
Claire-Stewart Medical Clinic
525 Dublin Street
Mount Forest, ON N0G 2L3
(IMPACT site)
ON.7 Colleen Cameron, PharmD, RPh
Clinical Pharmacist, New Vision Family Health Team
421 Greenbrook Drive
Kitchener, ON N2M 4K1
Tel.: (519) 578-3510 ext 408
The pharmacist is 0.5 FTE at the FHT, and 0.5 FTE in the intensive care unit (ICU) at Grand
River Hospital, the hospital providing care for oncology, surgery, dialysis, paediatrics,
women's health and critical care. This creates opportunities to bridge acute care and
primary care. The hospital has created a formal partnership with the family health team
(FHT), which has allowed her a view of health care issues “on both sides of the health care
fence.” She plans to address improved patient care at points of transition within the health
care system.
Much of her day is spent seeing patients for hypertension, diabetes and dyslipidemia
(most of which were initiated by the Heart and Stroke Hypertension Management
Initiative). Additionally, a heart failure clinic similar to the one running at St. Mary's
Hospital is starting and she will be very involved.
ON.8 Karen Cameron, Christine Papoushek, and Debbie Kwan
Toronto Western Hospital Family Health Team
Toronto Western Hospital has three pharmacists on the team. Within the clinic the
pharmacists are responsible for dose adjustments as per a medical directive as well as:
•
Warfarin maintenance dose adjustment;
•
Participation in chronic disease management and comprehensive patient care;
•
Assessment and management of medication–related phone calls by the pharmacist;
•
Medication reviews for new, elderly patients (>65); and
•
Group education classes for the Diabetes Education Centre and Seniors Wellness
Clinic.
ON.9 Sylvia Chan
West Carleton Family Health Team
Carp, ON
Email: [email protected]
A 0.5 FTE pharmacist in clinic with eight physicians, three nurse practitioners, a dietitian,
health educator and a mental health professional. The clinic is located 30 minutes from
downtown Ottawa.
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ON.10 Tom Dolanjski
Professional Pharmacy Services
East End Family Health Team
497 Rea N.
Timmins, ON P4N 5A7
Tel.: (705) 363-8582
ON.11 Bernard Fitzgerald
Pharmacist
Kingston Family Health Team
ON.13 Lynn Halliday
Espanola, ON
Email: [email protected]
(See detailed description in Section 5.4)
Works as the hospital consultant, a member of the FHT and as a retail pharmacist. At the
FHT, the pharmacist works quite closely with a registered nurse (RN) in program
development. The programs put in place to date are multidisciplinary and are mostly
designed to screen for risk factors or to educate on different diseases or conditions.
The 10 programs developed so far cover: COPD, falls prevention, asthma, diabetes,
hypertension, pain management, heart health, smoking cessation and arthritis.
Perhaps the most innovative pharmacy role is found in the Heart Health Education
program. Patients are flagged and referred at reception if they are older than 50, male, have
increased abdominal weight, have diabetes, hypertension or smoke. These patients are sent
to the pharmacist to do the initial cardiovascular risk assessment. She establishes their risk
level and modifiable risk factors and redirects them to the appropriate health care professional to deal with their specific risk factors (e.g., dietitian for hyperlipidemia, abdominal
circumference, hypertensive diet or the social worker for stress management, or diabetic
educator for diabetes or nurse for smoking cessation). They are educated on their risk
factors and given an action plan. She then follows up with them monthly to monitor
progress. At the end of six months they redo their lab work and reassess their risk level.
If they have not met target levels then they are re-directed back to their primary care
physician with a letter outlining what has been done. At the one-year mark they reassess
again to watch for medication compliance (where applicable) and progress.
ON.14 Roland Halil, BSc.(Hon), BScPharm., ACPR, Pharm
Bruyere & Primrose Academic Family Health Teams
75 Bruyere St., Ottawa, ON K1N 5C8
35 Primrose Ave., Ottawa, ON K1R 0A1
(IMPACT site)
One FTE involves a combination of academic teaching, drug information and academic
detailing, and clinical services that include complete medication assessments, patient
education, evaluation of drug interactions, assessment of adherence, drug optimization and
more. Policy development and representation of pharmacist and allied health concerns in
committees has also become an important function of the pharmacist in this role as the
FHT expands.
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ON.15 Darlene Higgins
Prince Edward Family Health Team
Picton, ON
ON.16 Shelly House
Pharmacist, Caroline Family Health Team (IMPACT site)
Burlington, ON
Tel.: (905) 632-8007 ext. 107
ON.17 Natalie Jonasson
Elisabeth Bruyere Health Centre
(IMPACT site)
ON.19 Lisa Kwok, BScPhm, PharmD.
North York Family Health Team (Academic FHT)
310-240 Duncan Mills
Toronto, ON
1 FTE so far, but looking to hire another 1 FTE for Year 1
Practice is being set up from the ground up. It will involve medication assessments, patient
counselling, and some academic detailing. There will also be teaching of medical residents,
pharmacy and PharmD students. The pharmacist has seen many diabetic patients over the
first year, and worked with one physician to develop a draft medical directive that would
allow the registered pharmacist (RPh) to adjust medications doses and order relevant blood
tests. This is still in the preliminary stages.
ON.20 Jennifer Lake, PharmD.
840 Coxwell Ave., Suite 105
South East Toronto Family Health Team
Toronto ON M4C 5T2
Tel.: (416) 469-6580 ext. 3052
Email: [email protected]
South East Toronto Family Health Team has three sites, two clinics and a community
practice site. The pharmacist practices at the two clinics, but has only practised there for
12 weeks. The current initiatives are on warfarin dosing, medication assessment, diabetes
management.
ON.21 Lisa McCarthy
Stonechurch Family Health Centre
ON.22 Jeff Nagge, ACPR, PharmD.
Clinical Pharmacist, Centre for Family Medicine
Clinical Assistant Professor, School of Pharmacy, University of Waterloo
25 Joseph Street
Kitchener, ON
Tel.: (519) 578-2100 ext. 251
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FHT has 11 family physicians and approximately 18,000 patients spread across three
satellite locations. Currently only 1.0 FTE pharmacist is employed, but the FHT has applied
for another 2.0 FTE. Physicians are very open to collaborative arrangements with
pharmacists.
About 75% of the pharmacist’s practice is focused on primary and secondary prevention of
cardiovascular events; because of the prevalence of risk factors in the primary care setting,
and because pharmacist’s background is cardiology. The pharmacist focuses time on
patients with non-routine drug-related issues (e.g., resistant hypertension versus
initial/second-line therapy) and has run an anticoagulation clinic for all patients receiving
warfarin therapy in the FHT for the past 1.5 years with a point-of-care international
normalized ratio (INR) device. The pharmacist practices under a very flexible medical
directive that allows him to change doses of warfarin and administer vitamin K when
necessary. He has been able to avoid at least three emergency room visits in the past year
by administering vitamin K on the spot. A manuscript is in progress documenting an
improvement in the time in the therapeutic range of our patients from 54% when the
physicians were dosing, to 82% when done by pharmacist. He works with complete
support of the physicians, who have endorsed plans to start up heart failure, hypertension,
dyslipidemia and smoking cessation clinics.
ON.24 Laura Park-Wyllie
St. Michael’s Hospital
Department of Family & Community Medicine (0.4 FTE)
St. Michael’s Hospital is a tertiary care hospital and the clinic has approximately 20 family
physicians. Practice is referral-based and focuses on medication optimization/
pharmaceutical care for patients with diabetes, hyperlipidemia or hypertension, and any
other drug-related problems (DRPs) that are identified. A program evaluation of
pharmacist’s impact in this setting is underway.
ON.25 Nita Patel
Beamsville Medical Centre
ON.26 Joanne Polkiewicz
Stratford Family Health Network
ON.27 John Stanczyk
Delhi Community Health Centre
ON.28 Douglas Stewart, BSc, BScPhm, RPh, CAE
Clinical Pharmacist
Haliburton Highlands Family Health Team
Tel.: (705) 457-1212 ext. 248
Fax: (705) 457-3955
Email: [email protected]
Website: www.hhfht.com
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ON.29 Ginette Thibeault, BScPhm, RPh, CAE
Blue Sky Family Health Team
#403-111 Main Street West
North Bay, ON P1B 2T6
Tel.: (705) 475-0500
Fax: (705) 475-0571
Email: [email protected]
The 1.0 FTE position for a pharmacist at this FHT is partly filled. Pharmacist has practised
there since October 2006, providing medication reviews on complex cases, patients with
multiple medications and those with diabetes (mainly by referral). Also worked one day
per week directly in a physician's office, spending the morning see clients for medication
reviews and the afternoon doing multidisciplinary case reviews with the physician and his
staff (very innovative practice environment). The pharmacist also offered education on
diabetes and asthma/COPD, and recently implemented the Primary Care Asthma Program
(PCAP), so now does asthma/COPD education and follow-up on clients with the
respiratory therapist. The pharmacist implemented a CDM program for diabetes and will
begin participating in the Heart and Stroke Hypertension Management Initiative. The FHT is
still fairly young and still evolving, so the physicians' use of pharmacist clinical services is
gradually increasing.
ON.30 Cynthia Way, BScPharm.
Pharmacist, Family Health Team
The Ottawa Hospital Academic Family Health Team
Ottawa, ON K1Y 4K7
Tel.: (613) 798-5555 ext. 19635
Pager: (613) 274-8861
Email: [email protected]
Two sites split 1.0 FTE 60/40. Clinical practice is mostly referral based, and primarily
consists of complicated elderly patients with multiple medical problems. The pharmacist
also sees those with uncontrolled diabetes, dyslipidemia and/or hypertension. She teaches
pharmacy and family medicine residents and does a fair bit of drug information. Planning is
underway to implement a screening tool to identify patients who would benefit from a
pharmacist assessment, as well as beginning automatic referral of discharged patients to
pharmacist for a medication review.
QC.1
32
Marie-Claude Vanier, BPharm, MSc
Professeure agrégée de clinique, Faculté de pharmacie, Université de Montréal
Clinicienne, Chaire Aventis en soins ambulatoires, GMF-UMF Cité de la Santé de
Laval
Faculté de pharmacie, Université de Montréal
C.P. 6128 succursale Centre-ville
Montréal, QC H3C 3J7
Université: (514) 343-6111 poste 5065
Fax: (514) 343-6120
Clinique de médecine familiale: (450) 668-1010 poste 2720
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Between October 2001 and November 2004 there was 0.5 FTE, then 1.0 FTE in November
2004. The pharmacist offers a consultation service to which patients can be referred by a
physician or a nurse. The pharmacist is actively involved in shared care for anticoagulation,
chronic pain, diabetes and hypertensive patients, and can adjust medication dose and order
lab tests for these patients. The pharmacist also routinely manages patients' phone calls to
the clinic for problems directly related to their medication. She is involved in case
discussions with family medicine (FM) residents, interdisciplinary meetings,
multidisciplinary discussion pre- and post-homecare visits by FM residents. On occasion,
the pharmacist will visit the patient at home if an important medication problem has been
identified by the treating physician or the nurse.
Teaches family medicine residents and supervises fourth year pharmacy students' clerkship
and pharmacy residents' clerkship, at the clinic. The clinic also receives nursing students
and is considered an advanced model of interdisciplinary care by the family medicine
department of the Faculty of Medicine (Université de Montréal).
NB.1
Andrew Brillant, BSP
Pharmacist, St. Joseph’s Community Health Centre
Tel.: (506) 632-5774
NS.1
Glen Cox
Pharmacy Manager, Eskasoni Pharmacy
Eskasoni, NS
Tel.: (902) 379-2255
Onsite in a primary care clinic with three family physicians in Eskasoni, NS, a First Nation
community in Cape Breton. Pharmacists advise the physicians on formulary issues, adverse
drug events, new drug news, alternatives to therapy, and provide education for the
physicians a well as other health care providers (i.e., nurses, dietitians). They are also
involved in a number of adherence programs for patients. Because it is a First Nations
community, the NIHB formulary is used and if a prescribed treatment is not covered, the
physician is advised and changes are discussed.
NS.2
Anne Marie Whelan, PharmD.
College of Pharmacy, Dalhousie University
Dalhousie Family Medicine
Halifax, NS
Current practice consists of a consulting service addressing patient specific therapy
management issues, conducting patient interviews, providing patient education and drug
information with 0.2 FTE.
NF.1
Lisa Bishop
Asst Professor, Memorial University of Newfoundland
Tel.: (777) 8627-3443
Email: [email protected]
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3.0 EXPANDED PRESCRIBING AUTHORITY
3.1 Cardiac Ensuring Access and Speedy Evaluation
(EASE) Program, Edmonton AB
Interviewees: Glen J. Pearson, Sheri Koshman, clinical pharmacotherapy practitioners
(PharmD) team members
Sponsoring organization: Capital Health and University of Alberta Hospital
Other participating organizations: Medical Services Delivery Innovation Fund (MSDIF),
sponsored by Alberta Health and Wellness, and the Alberta Medical Association
Location or setting: Cardiac referral clinic, University of Alberta Hospital, Edmonton
Start date: 2003
Description of initiative: Target population is non-emergent patients requiring cardiac
consultation. Cardiac EASE provides an ambulatory practice for pharmacists through its
extended scope of practice, including physical assessment, and collaborative practice
opportunity with cardiologists, pharmacists, and nurse-practitioners. It highlights the ability
of pharmacists to provide comprehensive patient assessments, interpretation and
integration of diagnostic and clinical laboratory information, with the implementation of the
treatment and follow-up plans.
Role of pharmacist: Clinical pharmacotherapy practitioners (PharmD) have been
members of the health care team since the establishment of the clinic. The pharmacists’
primary clinical responsibilities are in the assessment of patients. When patients are referred
to the clinic, there is a central intake and a triage process that schedules patients according
to their risk. Diagnostic tests are arranged prior to and around the same time as their clinic
visit to facilitate availability of results for assessment in clinic. When patients arrive to be
seen in clinic they are initially seen by either a clinical pharmacotherapy practitioner (CPP)
or nurse practitioner. CPP responsibilities in clinic are parallel to those of the nurse
practitioner. During the initial assessment, a complete history is taken and a physical exam
is performed. The physical exam performed includes blood pressure and heart rate
measurement, assessment of pulses, a precordial exam, pulmonary auscultation and
assessment of fluid status. Laboratory values and diagnostic tests are also reviewed and
integrated into the overall patient review.
At the end of the assessment, the pharmacist provides a plan for treatment, and reviews the
details of the patient case and their findings with a cardiologist. Upon discussion of the case,
the pharmacist and cardiologist then return to the patient and review the results of diagnostic
tests, prognosis and the patient-specific treatment plan. The cardiologist then exits the room
to dictate the consult letter and the pharmacist closes with the patient to answer any
questions, review any further follow-up required and provide additional therapeutic
information as needed. The pharmacists see a wide variety of cardiac patients, since the clinic
is a general cardiology referral program; however, the most common patients seen are those
with chest pain, arrhythmias and dyspnea requiring assessment.
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Purpose: The clinic was designed to improve access and efficiency of tertiary cardiology
consultative services for non-emergent referrals by establishing a single point of entry and
utilizing multidisciplinary team approach with a unique set of knowledge and skills.
Cardiac EASE provides extends the role of the self-directed CPP and exemplifies the
potential for expanding the scope of practice for pharmacists within the health care team.
Human resources: The clinic currently has a 0.5 FTE pharmacist position.
Funding/pharmacist remuneration: The Cardiac EASE program began via an investigatorinitiated $1 million grant for a 3-year pilot project funded by the Medical Services Delivery
Innovation Fund (MSDIF) sponsored by Alberta Health and Wellness and the Alberta Medical
Association (Dr. Stephen Archer [MD] and Dr. Tammy Bungard [PharmD]). Due to program
success, funding of the CPPs is now provided by Capital Health.
Benefits/advantages/impacts: This practice exemplifies the ability of pharmacists to be
proactive, front line clinicians that perform activities ranging from assessment to
interpretation of results in light of appropriate pharmacotherapy.
Future directions of the clinic:
•
Integrate the clinical pharmacotherapy practitioner in the triage process and the
follow-up of patients, and
•
Other opportunities for clinical expansion, such as pharmacist-lead cardiovascular risk
reduction clinics, which will be enabled by recent prescriptive authority changes in
Alberta.
Challenges and strategies used to overcome challenges: Increasing volume of referrals
within fixed resources of program impacts efficiency/wait times.
Feasibility:
Sustainable: Following the trial period, funding for the program is now under the operating
funds of Capital Health.
Scaleable: Currently looking at increasing the triage function as well as the possibility of a
satellite or spin off clinics in other locations within the province.
Supported: Yes.
Consistent: Reliable, consistent, well-trained pharmacists provide services on an ongoing basis.
Evaluation: A report on the three-year grant is in the process of being written. The
evaluation component was a system evaluation rather than outcome based; namely
focusing on wait lists and access to cardiology consultation. This is consistent with the
purpose of the program from inception. Feedback from patients and clinic staff and
referring physicians and other health professionals has been very positive.
Academic documents:
•
Results paper — in preparation
•
Design paper — to be submitted
•
Poster presentations by Dr. Koshman at the Banff Canadian Society of Hospital
Pharmacists (CSHP) conference and Canadian Pharmacists Association conference in
2005
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•
•
•
•
Presentation by Dr. Pearson at Tripartite Conference (physicians, registered nurses,
pharmacists) 2007
Interim results poster at CSHP AGM 2007 — Dr. Tammy Bungard (published)
Interim results poster at Canadian Cardiovascular Congress 2007 — platform
presentation
CSHP Practice Spotlight (in press)
CONTACT
Sheri Koshman, BScPharm, PharmD, ACPR
Assistant Professor, Division of Cardiology, University of Alberta
Clinical Pharmacotherapy Practitioner, Regional Pharmacy Services
Capital Health
Email: [email protected]
Glen J. Pearson, BSc, BScPhm, PharmD, FCSHP
Associate Professor, Division of Cardiology, University of Alberta
Co-Director, Cardiac Transplant Clinic
Director of Research, Cardiovascular Risk Reduction Clinic
Edmonton, AB
Email: [email protected]
3.2 Regina Renal Program, Regina SK
Interviewees: Linda Gross, BSP; Jennifer Dyck, BSP, ACPR; staff pharmacists
Sponsoring organization: Regina Qu’Appelle Health Region
Other participating organizations: Risk management (Health Region), nephrologists,
College of Physicians and Surgeons, Canadian Medical Protective Agency, Saskatchewan
College of Pharmacists, Saskatchewan Transplant Program
Location or setting: Regina General Hospital
Type of innovation: Pharmacists expanded scope of practice that has evolved to include
prescribing. The transplant position is an example of ambulatory care clinic practice
without regular in-person physician contact.
Start date: 2003
Description of initiative: In 2003, due to exponential growth of the renal program and a
limited number of nephrologists serving southern Saskatchewan, a pharmacist became
involved in direct patient care, especially in anemia management.
There is no transplant physician in the Regina area. Until 2005, a pharmacist from
Saskatoon travelled to Regina twice monthly for follow-up clinics with renal transplant
patients from southern Saskatchewan. With the growing renal transplant patient population,
the need for additional pharmacist involvement was identified.
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The pharmacists’ scope of practice has been expanded to include a formalized process for
renal anemia management. The prescribing agreement gives the pharmacist responsibility
for prescribing of erythropoietin, intravenous and oral iron, folic acid, etc., as well as
ordering and evaluating tests for anemia management.
A part-time pharmacist was included in the renal transplant program in 2005 and was able
to establish a scope of practice within the transplant structure similar to that of the
Saskatoon office. Currently the anemia management prescribing agreement does not extend
to the transplant program. The pharmacist in the transplant program is also available for
consult on non-renal transplant issues. Target population is renal (pre-dialysis and dialysis)
and transplant patients in the renal program at the Regina General Hospital.
Role of pharmacist: The development of this unique prescribing agreement has led to
pharmacist involvement in drug management of chronic renal insufficiency (CRI),
peritoneal dialysis and hemo-dialysis patients.
In the CRI clinic, the pharmacist reviews the drug therapy of each patient (close to 800
patients), paying close attention to renal protection, anemia management, and
cardiovascular protection of these patients. Blood work is regularly reviewed for electrolyte
disturbances, and recommendations made. When drug related problems arise that are
unrelated to kidney disease, the patient's family physician may be contacted with a
recommendation.
In the hemo-dialysis and peritoneal dialysis (PD) areas, the focus is on anemia management
and blood pressure control. Pharmacists play a key role in medication management. In
cases where hypertension or cardiovascular protection therapy is recommended by the
pharmacist, the pharmacist writes the drug order on the chart, including dose, etc., which is
reviewed by the physician and initialed.
In order to be included within the prescribing agreement, pharmacists must successfully
complete a training and education and certification process. Four training modules were
developed (for erythropoietin, iron, adjuvant therapy and erythropoietin resistant situations)
by the core group of pharmacists.
The transplant pharmacist is responsible for ongoing post-transplant (ambulatory) care of
approximately 90 renal transplant patients in the southern half of the province. This
involves review of routine blood work and monitoring medication therapy. Monitoring
focuses on immuno-suppression, renal function, anemia, cardiovascular concerns, diabetes
and osteoporosis.
Purpose: To develop a collaborative prescribing agreement including the prescribing of
erythropoietin, intravenous and oral iron, folic acid, etc., and the right to order and
interpret any tests for evaluation of anemia related to chronic kidney disease (CKD).
The goal of the transplant pharmacist was initially to provide ongoing follow-up care to
post renal transplant patients (in-patient and out-patient). This has expanded to include
non-renal transplant in-patients on a request/consult basis.
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Human resources: Renal unit — initially 2 pharmacist FTEs, currently 5 FTEs.
Transplant unit — currently 0.5 pharmacist FTE.
Funding/pharmacist remuneration: From the operating budget of the Regina Health
Region.
Benefits/advantages/impacts:
•
Closer monitoring of renal disease progression and anemia management enabling
quicker intervention and thus, better patient care;
•
Dug therapy more custom tailored to patients;
•
Builds strong relationship with patients; they are better informed about their drug
therapy;
•
Reduction of nephrologists’ workload, enabling more patients to be seen;
•
The pharmacist working group;
•
Team based approach has built strong relationships among physicians, nurses,
dietitians, and social workers, which benefits the patient;
•
Specialization allows pharmacists to focus learning in one specified area, greater job
satisfaction; and
•
Autonomy to establish practice roles and adapt practice to identified patient needs.
Challenges and strategies used to overcome challenges: Challenges included finding
time to complete necessary training modules; limited time for on the job training, due to
other hospital events; staff buy-in; limited experience of participants in developing
formalized learning modules. There was no formal training process for transplant
pharmacist. Current pharmacist self-trained in this area with minimal shadowing of practice
in Saskatoon. There are also limited professional continuing education events due to highly
specialized nature of practice area.
Strategies involved regular meetings scheduled amongst participants to discuss progress of
modules, but did not begin early enough. Some time was allotted to work on training
modules. The pharmacist educator mentored participants in development of the learning
modules. A transplant pharmacists’ network was established via the Canadian Society of
Hospital Pharmacists (CSHP), to identify resources. Not all the challenges were overcome
(staff buy-in)
Feasibility:
Sustainable: During the three years of the program, the number of FTEs has increased from
two to five.
Scaleable: Desired benchmark of 250 patients/FTE pharmacist (not validated).
Supported: Co-supported by Regina Qu’Appelle Health Region and third party
(Ortho-Biotech).
Consistent: Three to five pharmacists work in the program on a daily basis. Consistent
training program and certification ensures consistency.
Evaluation: Until February 2007, formal review of anemia management data, to determine
effectiveness in meeting anemia targets. Due to costs of maintaining this method of
evaluation has been terminated. Semi-annual informal meetings with the nephrologists as a
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means of quality assurance. During these meetings, discuss changes to current guidelines,
and current trends in anemia management via journal club format.
Pharmacy students collect annual data on key monitoring areas for use of transplant
pharmacist. To date, have not developed measures to identify impact of pharmacist.
Academic documents:
•
Publication of outcomes pending. The group has presented at various conferences at
both the national and regional level.
CONTACT
CRI Clinic
Tel.: (306) 766-3396
Main Pharmacy
Tel.: (306) 766-4354 (2)
Transplant Clinic
Tel.: (306) 766-3493
Email: [email protected]
3.3 Non-certified Clinical Assistant Program,
Winnipeg MB
Interviewee: Dr. Mike Namaka, clinical assistant (pharmacist)
Sponsoring organizations: College of Physicians and Surgeons of Manitoba, and
Manitoba Pharmaceutical Association
Other participating organizations: Faculty of Pharmacy, University of Manitoba
Location or setting: Winnipeg Health Sciences Centre, Multiple Sclerosis Clinic
Type of innovation: Broadening the role of the pharmacist within the health system
Start date: May 2006
Description of initiative: Dr. Namaka has been recognized as a non-certified clinical
assistant under the supervision of Dr. Andrew Gomori, MD, at the Multiple Sclerosis (MS)
Clinic. All MS patients seen at the MS clinic receive professional health care services from
an MS interdisciplinary team of specialists that include: a neurologist, MS clinical pharmacist
practitioner, clinical nurse specialist, nurse clinician, clinical dietitian, social worker,
occupational therapist and physiotherapist. Approximately 40 ambulatory MS patients are
seen per week. This extrapolates to an annual patient load of about 2080. The patient
population is derived primarily from Manitoba and Northwestern Ontario.
Role of pharmacist: Dr. Namaka is actively engaged in the diagnosis and symptomatic
management of the disease in a shared basis with the neurologist. In this capacity, he is
able to order the appropriate diagnostic tests, initiate referrals, and prescribe the necessary
medications.
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Purpose: The purpose of this program is to provide patient services delegating appropriate
functions to interdisciplinary team members, under the supervision of the physician team
leader. Goals include contributing to reducing the neurologist time for the diagnostic
assessment significantly and thereby reduce the wait times for patients to be assessed, and
an overall improvement in services provided to multiple sclerosis patients.
Human resources: Two days per week (0.4 FTE).
Funding/pharmacist remuneration: Currently working on reimbursement for cognitive
services with the Registrar of Manitoba Pharmaceutical Association (MPhA) and Manitoba
Society of Pharmacists (MSP).
Benefits/advantages/impacts: Dr. Namaka has established a new career option with an
expanded role for pharmacists as a contributing member of the health team.
Increasing the pharmacists’ role has resulted in reducing the neurologist’s time for
diagnostic assessment, monitoring and addressing symptomatic management issues of
multiple sclerosis patients.
Challenges and strategies used to overcome challenges: In being the first pharmacist
in North America to take on this role, there were significant hurdles to go through during
the application process, including: proving his credentials to begin the process; writing the
formal examination; preparing a detailed job description; and, after certification, proceeding
through the levels of competency.
Perhaps the biggest challenge was to obtain liability insurance for a role that has never
been insured for pharmacists.
Dr. Namaka began working within the clinic in April 2001 and at that time, he brought both
a clinical experience (10 years clinical pharmacist in a hospital) and a scientific background
as a neuroscientist. Therefore, prior to receiving certification, he had three years experience
working with the neurologists and other health professionals in the clinic.
It was also significant that his success in meeting the qualifications was now identified in
the new pharmacy legislation (Bill 41), which describes the extended role of the
pharmacist.
It was very difficult to obtain liability insurance and as a last resort, Dr Namaka personally
purchased Alternative Risk Services insurance to cover his clinical assistant role as an
individual. The MSP played an instrumental role in securing liability coverage for this new
professional designation. Now that this position has been identified in the new pharmacy
legislation, it will be possible to include it in the pharmacy liability insurance program.
Feasibility:
Sustainable: This position is now formalized in legislation through the College of
Physicians and Surgeons and the MPhA.
Scaleable: Dr. Namaka currently has a graduate student who is in the process of proceeding
towards a clinical assistant role once she has completed her PhD. This sets the pattern for
future training of expanded roles for pharmacists.
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Supported: During this process, Dr. Namaka had the full support of the Faculty of
Pharmacy, Neurology Department at the Health Sciences Centre, the College of Physicians
and Surgeons of Manitoba, the Manitoba Pharmaceutical Association and the MSP.
Consistent: The job description for the role is very important in providing a consistent role
for this position.
Evaluation: It is too early in the development to be formally evaluated. Dr. Namaka’s role
has been well evaluated by the patients and the clinic staff and he has contributed to
reducing the neurologist’s time in patient assessment and monitoring.
Academic documents:
Namaka, M., Breaking new ground: the role of the clinical assistant. Can J Hosp Pharm
2007;60(S1:41-42).
CONTACT
Dr. Michael P. Namaka
Associate Professor, Faculty of Pharmacy, University of Manitoba
Winnipeg, MB
Tel.: (204) 055-8380
Email: [email protected]
3.4 Hyperlipidemia Clinic, Canadian Forces Health
Services Centre, Ottawa ON
Interviewee: Dr. Maria Gutschi, BScPhm, PharmD, Director, Hyperlipidemia Clinic
Sponsoring organization: Department of National Defence (DND)
Location or setting: Family Practice Clinic, Canadian Forces Health Services Centre,
Type of innovation: pharmacist providing primary health care and management of
chronic disease.
Start date: January 2000
Description of initiative: The family practice clinic has an onsite lab, x-ray services, and a
small outpatient department. Physicians at the clinic are salaried employees.
Cholesterol management services are provided to patients referred by family physicians and
nurse practitioners. These tend to be the more complex cases, for instance, those patients
not meeting primary goals, with comorbid conditions, or that the primary care provider
requires assistance in managing. Referring practitioner explains the risks/benefits to each
patient and obtains the patient’s consent prior to referral to the lipid clinic service.
Current patients are described as those who have been reluctant to start therapy, are high
risk for cardiovascular disease, or who have significant compliance issues. Currently serving
military personnel for mainly primary prevention.
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Role of pharmacist: Pharmacist interviews referred patients, checks blood pressure,
orders cholesterol blood work, and reviews patient drug and medical history. Makes
recommendations on drug therapy, and is able to adjust doses under hyperlipidemia
protocols (developed from evidence-based guidelines). Counsels and monitors individual
patients, and follows up with the referring physician. The pharmacist sees one to three
patients per week.
Purpose: It was recognized in 1996 that only about 40% of Canadian Forces (CF)
personnel being treated for high cholesterol levels were meeting their treatment targets.
Given that lipid clinics have been shown to improve attainment of treatment goals and
adherence with drug therapy, pharmacist-based lipid clinics were incorporated into existing
ambulatory care family medicine clinics.
Goals include:
•
Improve adherence to cholesterol drug therapy;
•
Identify, manage, and treat patients with dyslipidemias to treatment goals;
•
Identify and report adverse drug reactions, and provide alternative
therapies/recommendations for management; and
•
Provide expert resource to family physicians, thus decreasing the need to refer
patients to specialists.
Human resources: 0.10 FTE pharmacists.
Other resources required: Office and appointment booking provided by the family
practice clinic.
Pharmacists have delegated authority from the Surgeon General to adjust doses of lipidlowering drugs, substitute drugs within a class of agents, order lab work, provide lifestyle
counselling and refer patients to dietitians and other specialists, to attain or achieve lipid
control. Initiation of a new medication, switch to a different drug class, or addition of a
second lipid-lowering agent requires physician approval. This special authority was
necessary for some activities outside of the usual scope of pharmacy practice in ambulatory
settings.
Funding/pharmacist remuneration: Will be covered by DND, but at the moment this
service is being covered by the Patented Medicines Prices Review Board (PMPRB) (awaiting
Memorandum of Understanding with DND).
Benefits/advantages/impacts:
•
Frees primary care physician to coordinate care;
•
Allows in-depth teaching and risk assessment by practitioner;
•
Helps patient to better understand risk of cardiovascular disease and strategies to
manage risk; and
•
Identifies and addresses patient concerns regarding drug therapy, and places these in
context of overall cardiovascular health.
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Challenges and strategies used to overcome challenges: It is crucial to have the
respect and support of physicians, in order to get referrals — this takes patience,
perseverance, and confidence. With turnover of physicians, it can take one to two years to
earn the trust and support of staff. Once a working relationship has been clearly
established, more complex cases are referred and additional responsibilities are accrued to
the pharmacist.
Necessary to learn skills that are not normally taught to or learned by pharmacists:
•
Write good-quality consult notes that provide additional information, using dictation
system;
•
Function as a clinician, independent from the pharmacy team;
•
Be prepared for psycho-social issues to deal with sub-optimal inter-personal dynamics
with patients that may arise during interviews;
•
Be able to recognize when continued involvement is not longer necessary or
desirable;
•
Learn outpatient medical office procedures, such as how lab tests are ordered,
processed, and interpreted;
•
Identify and refer other medical problems as necessary, especially if emergent
(i.e., triage function);
•
Learn a physician role (pharmacist becomes the primary health care worker
responsible for dyslipidemia management for the patient);
•
Identify when not to treat, even if requested by family physician;
•
Learn the art of referral and to be considered the dyslipidemia specialist — know the
limits with regard to scope of practice;
•
Need to be a team player;
•
Inform referring physician of treatment plan, and explain face-to-face if possible;
•
Learn to work and make recommendations independently, without support from other
health care providers, and
•
Inform physician of other findings/medical issues as they arise.
Referring physicians expect pharmacists to be ahead of the curve with respect to
knowledge related to drug therapy, so it is imperative that pharmacists keep up-to-date on
new drugs and emerging therapeutic approaches.
Most pharmacists are accustomed to counselling and advising, but follow-up, as required
by this model, is not as common.
Feasibility:
Sustainable: Service has been provided for seven years thus far; now considered standard
requirement for base.
Scaleable: Very scaleable for dyslipidemias; dependent on knowledge and enthusiasm of
pharmacist. Maybe less scaleable for incidental medical issues such as diabetes or
hypertension, which play a role in dyslipidemia.
Supported: Supported by the base surgeon (i.e., medical team leader), which is essential for
continuation. Also solidly supported by individual DND physicians, since pharmacist offers
a value-added service.
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Consistent: Service must be consistent and reliable. Consults must be clear and actionable
for the times the pharmacist is not physically present. Pharmacist must be available for
advice/recommendations even if not physically present.
Evaluation: No cost-benefit analysis has been done. However, improved clinical outcomes
have been documented (reference below). Support expressed by physicians in making
referrals.
Academic documents:
•
Vaillancourt R, Gutschi LM, Ma J, Sinclair S, Beechinor D. Pharmacist-Managed Lipid
Clinics: Development and Implementation in the Canadian Forces, Canadian Journal
of Hospital Pharmacy, February 2003, Vol 56, No 1.
•
Yearly academic presentations to family physicians.
CONTACT
Maria Gutschi
c/o Patented Medicines Prices Review Board,
Box L40, 333 Laurier Ave. W., Suite 1400
Ottawa, ON K1P 1C1
Tel: (613) 952-3301
Fax: (613) 952-7626
Email: [email protected], [email protected]
3.5 Travel Medicine Service, Ottawa ON
Interviewee: Brian Stowe, owner, Prescription Shop, Carleton University campus, Ottawa, ON
Sponsoring organization: The Prescription Shop
Other participating organizations: Carleton University Health Services
Location or setting: Carleton University, Ottawa, ON
Type of innovation: Expanded role for the pharmacist through delegation protocol;
Specialized pharmacy travel service and protocol for delegation of prescribing of
medications to prevent travel-related diseases
Start date: 2002
Description of initiative: Initially, the pharmacists provided a consultation interview and
a written assessment regarding travel medicine needs (vaccination, Rx, and self-care based
on the patient’s destination and health status). The patient would take the assessment to a
physician for authorization of the recommended prescriptions.
Within months of starting the service, Brian Stowe and Mark Kearney wrote the first
examination for the International Society of Travel Medicine’s accreditation program, which
is open to physicians and other health professionals. Both now have a Certificate in Travel
Health from that organization.
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In the first few years of operation, the pharmacists invested time in communicating their
program to the University Health Services team, who then became increasingly comfortable
with the level of expertise that the pharmacists were providing. Once the campus health
service experienced the benefits of having an expert travel health consultancy in the
building, the demand for service expanded. In the spring of 2005 a protocol was developed
under which the director of health services delegated the authority to prescribe the
medication to the designated pharmacists.
Patients complete the travel clinic patient information questionnaire, then make an
appointment for an assessment and consultation with the certified pharmacist. Pharmacists
complete a travel medication care plan that includes the client information, their itinerary,
medical history and other information; a therapeutic plan, monitoring plan, prescription, and
documentation of counselling information. Targets the population of students, faculty and staff
at Carleton University (20,000 students and 4000 staff) who plan to travel internationally.
Purpose: The purpose initially was the development of an enhanced travel service for
students and staff that would represent an expanded role for pharmacists within their
practice. The service was previously provided in a less structured format within the clinic
by a part-time registered nurse. As demand and complexity of travel health issues increased
the service was deemed inadequate and discontinued. It was agreed that the pharmacy
would take on this specialized service.
It is in the best interest of a patient contemplating international travel to be assessed for
potential health risks associated with a given itinerary and to receive appropriate
medications and counselling to mitigate these health risks. Pharmacists with an expertise in
the field of travel medicine have the knowledge and medication expertise to assess a
patient, provide appropriate counselling and recommend appropriate medications for this
purpose.
Human resources: Two certified pharmacists.
Other resources required: Both pharmacists are members of the International Society for
Travel Medicine and access to services such as the chat room is very useful for being
updated on latest information regarding travel medicine.
Two software applications are used that facilitate the assessment and consultation process.
The travel software, Tropimed, provides maps showing endemic areas for specific diseases.
Mark developed a specialized software tool that allows input of the client’s basic
information regarding travel location, etc., and then the system generates the best option
for the medication/vaccine to be used given the local situation regarding drug resistance
and particular endemic diseases.
Patient pamphlets have been made available explaining the hazards of foreign travel and
specific diseases that may be prevalent in the specific area of travel.
Funding/pharmacist remuneration: The service is financed by a patient consultation fee
of $40. The Ontario government health plan does not cover travel clinic visits to physicians,
so patients pay a fee if they visit a physician for this service.
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Benefits/advantages/impacts: Patients are receiving a superior service compared to
previous system. Patient perception of what the pharmacist’s role and expertise has been
greatly enhanced. Pharmacists have professional satisfaction in providing this service.
Challenges and strategies used to overcome challenges: Originally there was a concern
from the physicians in the clinic regarding the broadened role of the pharmacist.
Remuneration for services provided was another challenge. The system is dependant on the
physician countersigning the prescription and the physician’s liability covers the situation.
Patient demand for specific medications that may not be appropriate is challenging, as is
access to specific products. An example is the Japanese encephalitis vaccine that the
company has refused to supply. It is in short supply and they will only provide it to travel
clinics with which they have an established agreement.
The concept of a collaborative approach requires quite a bit of communication so that
everyone understands what the pharmacist is doing and any confusion can be resolved.
Pharmacists explained they were not diagnosing; they were providing an assessment based
on the destination and their knowledge of medications and vaccines desirable for travel to
that location.
Visits to physician’s office for travel clinic consultation also required patient payment, so
establishing a fee for this service was not an additional or new expense for the patient.
The service provides patient options — if they wish to take the antibiotic, the pharmacist
explains how it works, what it is for, the benefits of therapy, and so on. It is up to the
patient to determine if they wish to have the prescription filled.
Feasibility:
Sustainable: Yes, based on a fee for service and not dependent on any grants or other
means to support the service.
Scaleable: Yes, this type of service can be established in other locations.
Supported: Yes, patients appreciate the service; physicians and the medical clinic support
the high quality service.
Consistent: Yes, the pharmacy service being provided is based on established protocols, so
the system is standardized.
Evaluation: Patient surveys have indicated a very positive response to the services
provided. They are planning a data review of more than 600 patients to determine
outcomes. The service has been positively received by patients, the medical clinic staff and
physicians.
Communications/promotional material: Pamphlets describing the service are available
in the medical clinic, physicians’ offices and at the travel agency on campus.
CONTACT
Brian Stowe
The Prescription Shop, Carleton University
Ottawa, ON
Email: [email protected]
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3.6 Critical Care Pharmacist, St. Boniface General
Hospital, Winnipeg MB
Interviewee: Dr. Robert Ariano, PharmD, BCPS, FCCM, critical care clinical pharmacist
Sponsoring organization: St. Boniface General Hospital
Location or setting: Cardiac and medical-surgery intensive care units, St. Boniface
Hospital — a 600-bed hospital.
Start date: 1988
Description of initiative: Pharmacist participates in medical rounds for both the cardiac
intensive care and the medical-surgical intensive care unit and makes recommendations on
drug therapy. Targets critical care patients.
Role of pharmacist: Attends rounds and oversees patient drug therapy as part of the
critical care team. Other team members include attending physician, charge nurse, bedside
nurse, dietitian, respiratory therapist, physiotherapist, and 3 - 4 medical residents/fellows.
Dr. Ariano is authorized to order certain medications and laboratory tests (e.g., amino
glycosides/vancomycin blood levels) in order to optimize drug efficacy and avert drug
toxicity. He does medication reconciliation on intake and discharge, and makes
recommendations on patient specific drug therapy to the medical team.
One particularly unique contribution Dr. Ariano makes to the critical care team is through
the use of drug pharmacokinetics as a marker of a patient’s health status. The changing
renal clearance of many monitored drugs in the intensive care unit (ICU) is used as a
surrogate marker of that patient’s kidney function; and this change is documented in the
patient’s chart. The ability of a patient to absorb the analgesic, acetaminophen, as assessed
by blood levels, is used as a surrogate marker of gastrointestinal function in the critically ill.
A not uncommon problem in the ICU is deciding whether medications can be given into
the stomach or through a small bowel feeding tube. This computerized analysis of
acetaminophen absorption provides a first step to address this problem.
Purpose: Enhanced patient care, by utilizing pharmacist’s specialized knowledge and
skills.
Human resources: Pharmacist 1.0 FTE.
Other resources required: Pharmacokinetic modeling computer programs.
Funding/pharmacist remuneration: St. Boniface General Hospital. Dr. Ariano has a
cross-appointment as a clinical associate professor with the University of Manitoba Faculties
of Pharmacy, and Medicine; however, he is salaried by the hospital.
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Challenges and strategies used to overcome challenges: Gaining the support of
physicians can be a bit of a struggle, to prove competence to medical residents/fellows,
particularly when they first join the team. Highly dependent on where they trained; i.e., in
a pharmacist-absent environment. Gaining support of physicians takes perseverance.
Dr. Ariano provides them with formalized teaching sessions on ICU drugs. Critical care
patients usually have multiple, complex health issues that must be addressed. Clinical
challenges of critically ill patients require constant learning and updating of knowledge
base. Also, patient numbers are constantly stretched to the limit.
Feasibility:
Sustainable: As long as hospital continues to fund the position.
Scaleable: Estimate that it would be difficult for a hospital smaller than 300 beds to justify a
dedicated ICU pharmacist position (in terms of economics and maintaining a skill set).
Supported: Yes, by physicians.
Consistent: Yes, because he is the sole pharmacist member of these critical care teams.
Evaluation: No formal evaluation. Critical care nurses and physicians routinely ask the
pharmacist to look at patient issues to determine if an abnormal reaction or new
development is drug-related. To the critical nurses, the services provided by the pharmacist
are invaluable and highly supported.
CONTACT
Dr. Robert Ariano
St. Boniface General Hospital
Winnipeg, MB
Tel.: (204) 237-2050
Fax: (204) 235-1476
Email: [email protected]
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4.0 CHRONIC DISEASE MANAGEMENT
4.1 Anticoagulation Management Service (AMS),
Edmonton, AB
Interviewee: Dr. Tammy Bungard, BSP, PharmD, AMS Director
Sponsoring organization: Program pilot sponsored by the Alberta Health and Wellness
Health Innovation Fund. Full, ongoing funding by Capital Health (regional health authority)
began in 2005.
Other participating organizations: University of Alberta, Division of Cardiology,
Department of Medicine; Regional Pharmacy Services, Capital Health.
Location or setting: University of Alberta Hospital (core clinic, with satellite operations in
other areas of Alberta).
Type of innovation: This program involves expanded authority for pharmacists
(prescribing, ordering lab work), primary health care, continuity of care, cognitive services
outside the pharmacy, and chronic disease management.
Start date: Program pilot, 2001; established program, January 2005.
Description of initiative: Pharmacist-managed ambulatory anticoagulation therapy.
Targets patients receiving anticoagulation therapy who present complex cases. Currently,
the AMS actively manages more than 600 patients. In addition, all patients with mechanical
valves implanted at the University of Alberta Hospital (UAH) are automatically referred to
the AMS program.
Role of pharmacist: Patients meeting the enrollment criteria have an initial face-to-face
meeting at the AMS clinic. During this initial meeting, the pharmacist:
•
Explains his/her role in patient’s care;
•
Collects information, compiling a good medication history so that a comprehensive
assessment can be made; and
•
Delivers one-on-one patient education.
Referring physicians are required to sign a referral form, which stipulates that they are
transferring the care of the patient to the AMS team, who are practising in accordance with
established policies and procedures.
From here on, the pharmacist takes responsibility for managing the patient’s
anticoagulation therapy — which includes adjusting anticoagulant drug dosages, and
ordering lab work. Patients have laboratory work done at any collection site in the Capital
Health Region, with lab results sent back to AMS.
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Follow-up meetings are normally conducted by telephone. Frequency of these follow-up
interactions can vary from three to four times per week to once every four weeks,
depending on needs of patient. The pharmacists also follow-up with patients who are
discharged from hospital (and in such cases the pharmacist would also follow-up with the
hospital ward for medication reconciliation).
Through an on-call rotation system, pharmacists are available 24 hours a day, seven days a
week, to address issues that arise, such as aberrant blood work, etc.
In an effort to optimize the AMS’s fixed resources, a study using is underway to determine
if patients on anticoagulation therapy can adequately self-monitor after a six-month term in
the AMS program. Currently, patients registered in the AMS program are cared for on an
ongoing, permanent basis, and if the study ultimately shows that patient outcomes are not
compromised with self-management after six months in the program, this will result in
considerable savings. This study will involve the home use of portable handheld devices
that patients can use to measure international normalized ratios (INRs). Dr. Bungard reports
that while these devices are quite common in Europe, their use in this study would be
unique in North America.
Human resources: 1.0 PTE director, 2.1 FTE pharmacists, 1.4 FTE administrative
assistance. The AMS program also retains three “medical directors” — a cardiologist, a
hematologist, and an internist — who are available on an ad hoc basis for consultation.
Benefits/advantages/impacts: This program has been proven to improve the health of
patients on anticoagulation therapy (increased time in INR range), and to reduce the rate of
thromboembolic complications.
Challenges and strategies used to overcome challenges: Obtaining buy-in from key
stakeholders would be the biggest challenge to initiate a program of this type. Establishing
personal and professional credibility within such a setting would be necessary to
implement such a program, which would require considerable time. Many of the typical
start-up challenges were mitigated by the training of the pharmacist (post-doctoral
fellowship in anticoagulation at the UAH), which enabled her to establish relationships with
physicians, key hospital personnel, and regional health officials.
At the time of creation (2001) the scope of practice for a pharmacist was legislated to be
linked to dispensing, hence using cognitive skills not linked to the distribution of a drug
fell outside of the scope of practice. This was problematic for some community pharmacists
in that there was a concern from a liability perspective. Further, there is no consistent
system or schedule in place for billing for this service or any pharmacist-delivered cognitive
service, making it challenging for these clinics to endure the test of time in the community.
Feasibility:
Sustainable: Yes, through provincial funding.
Scaleable: Yes, the UAH AMS is the core clinic, operating within a network of satellite
clinics (e.g., see following profile of Aspen Regional Health Authority).
However, it should be noted that not all of the satellite AMS clinics established through the
initial Alberta Health and Wellness Health Innovation Fund pilot have been successful —
only those sponsored by a regional health authority or within an institution survived. The
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satellite clinics set up in community pharmacies were not successful due to lack of
infrastructure and adequate funding.
Supported: Yes, is running at full capacity through referrals from physicians.
Consistent: Yes, due to extensive training of pharmacists, and general policies and
procedures.
Evaluation: Underwent formal evaluation process during pilot stage, which led to full
funding. A number of patient and physician satisfaction surveys have been done, with very
high scores.
Academic documents:
•
Bungard TJ, Archer SL, Hamilton P, Ritchie B, Tymchak W, Tsuyuki RT. Bringing the
benefits of anticoagulation management services to the community. Can Pharm J
2006; 139(2); 58-64.
CONTACT
Dr. Tammy Bungard
Assistant Professor, Division of Cardiology
Department of Medicine, University of Alberta
Edmonton, AB
Email: [email protected]
4.2 Anticoagulation Management Service (AMS) in a
Rural Hospital, Athabasca AB
Interviewee: Cindy Jones, Pharmacy Supervisor, Athabasca Health Care Centre;
Coordinator, Anticoagulation Management Service (AMS)
Sponsoring organization: Aspen Regional Health Authority.
Location or setting: Athabasca Health Care Centre
Type of innovation: Program involves a broadened role for pharmacists.
Start date: Pilot project January 2003 to October 2004. Ongoing.
Description of initiative: The Athabasca Health Care Centre is a small, rural hospital
(26 acute, 23 LTC beds), providing 24-hour emergency services, as well as acute, palliative,
and long-term care.
Anticoagulation clinics are a standard of care in the US, but relatively uncommon in
Canada, other than in larger urban centres. AMS clinics may provide ambulatory care to
out-patients, but are rarely integrated as one service including acute and long-term care
hospitalized patients.
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This service began in January 2003 as a pilot project/satellite of the University of Alberta
Hospital’s core AMS clinic, in Edmonton. In October 2004, the Regional Health Authority
began funding a 0.3 FTE pharmacist position to continue the service. This was expanded so
that a full time pharmacist position could be posted. (0.6 FTE AMS, 0.4 FTE hospital staff).
After 1-½ years of recruitment for an additional pharmacist, the position was officially filled
in July 2007.
AMS is a pharmacist-managed service for patients requiring anticoagulation therapy. Physician
referral is required for patients to enrol in this program. AMS monitors and maintains the
patient’s clotting factors within a narrow range, to treat and prevent blood clots. This can only
be measured by a blood test known as an international normalized ratio (INR).
The target group started as local residents, but any patient residing in the very large area
served by the Aspen Health Region may be referred. In particular, new warfarin starts and
patients whose anticoagulation therapies are difficult to manage may be referred from
outlying communities. Currently, the AMS has enrolled over 200 patients, and presently
oversees anticoagulation therapy for approximately 125 ambulatory patients, four to six
long-term care patients, and one to six acute care patients. Essentially, anyone initiated on
anticoagulation therapy is referred for AMS.
Role of pharmacist: Complete management of anticoagulation therapy. Pharmacist
initially interviews patients one-to-one for approximately an hour, to assess the patient,
review medication history, and provide education. INR lab tests are ordered, and the
warfarin dosage is adjusted with follow-up assessments by telephone. For remote patients,
the initial interview is via a Telehealth link to another health care facility.
The AMS provides anticoagulation information to other health care professionals, including
physicians and nursing staff. It is not uncommon for physicians to call the pharmacist for
advice on anticoagulation therapy.
This service was initially introduced for in-patients and long-term care patients. It was
problematic for nursing staff to follow-up afternoon INR results with physicians busy in the
office, and often there were significant delays in obtaining warfarin orders. Now the
pharmacist receives the lab results and can promptly order or adjust dosages. The
opportunity to expand this service to ambulatory care was enthusiastically endorsed by the
physicians due to the lack of time available to do the necessary follow-up on ambulatory
care INRs. It was not uncommon for patients to have to make appointments with their
family physicians to obtain their INR results. Often INR results were not communicated
unless out of range. With the specialty training received from the University of Alberta core
clinic, the pharmacist routinely follows-up up with every patient, regardless of whether
they are in or out of range.
Purpose: Better control of patient’s INR range, with a decrease in thrombosis and bleeding
rates. Provide anticoagulation expertise for patients and other health care professionals.
Human resources: 1 FTE pharmacist; pharmacy technician support on an ad hoc basis.
Other resources required: Pharmacists with baccalaureate degrees need additional
training; the University of Alberta offers an AMS course.
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Funding/pharmacist remuneration: Aspen Regional Health Authority.
Benefits/advantages/impacts: Because of pharmacists’ ability to order and monitor lab
results, it is immediately apparent if there is a problem. Medication changes, lifestyle
changes and alcohol often contribute to changes in INRs. Often poor patient compliance is
a problem, so AMS pharmacists can easily liaise directly with Home Care services and
community pharmacists to resolve these issues. There is improved continuity of care as one
centre provides anticoagulation services for patients whether in the home, or when
hospitalized.
Challenges and strategies used to overcome challenges: Because of the special
knowledge required, it is difficult to attain coverage for AMS pharmacist vacations and
illnesses. Also, AMS pharmacists are frequently on-call after hours, without compensation,
to ensure coverage.
One strategy is to provide pharmacists with extra training for AMS work. Also, direct patient
care enhances job satisfaction.
Feasibility:
Sustainable: Service is funded by Regional Health Service.
Scaleable: This location demonstrates that such a service can be offered by small health
care centres.
Supported: Yes, by local physicians who refer and call for advice.
Consistent: Yes, pharmacists adhere to recognized standards of practice for prescribing and
adjusting warfarin doses, and the operation is based on one originally established at the
University of Alberta Hospital in Edmonton.
Evaluation: A formal evaluation of pharmacist-led AMS clinics at the University of Alberta
Hospital was conducted by Dr. Tammy Bungard, and the positive results of this study
(patient health outcomes and service satisfaction) provided the rationale for setting up this
particular service. This study has not yet been formally published. There is US literature on
the cost-benefits of pharmacist-run AMS clinics. Tremendous buy-in from physicians and
nursing staff because of the added value, and therefore it has enhanced professional
relationships. The pharmacist reports that the pharmacist-managed AMS service has also
received positive feedback from the lab technicians — because of the close monitoring of
warfarin patients and better compliance, blood work is being done less frequently which
reduces scar tissue build-up.
CONTACT
Cindy Jones
Athabasca Health Care Centre
3100-48 Ave.
Athabasca, AB T9S 1M9
Tel.: (780) 675-6025
Email: [email protected]
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4.3 Warfarin Dosage Adjustments Through
Anticoagulation Case Management in Community
Pharmacies
Interviewee: Respondent (the initiator and director) and the organization represented wish
to remain anonymous since the project is at a pilot stage and takes place in a competitive
retail environment.
Sponsoring organization: Community pharmacy chain
Location or setting: Large Canadian metropolitan area
Type of innovation: Model based on delivery of services and not dispensing of a product.
The focus is on patient’s therapy, not on medication. The relationship with the treating
physician is changed. Instead of simply giving a prescription to be filled by the pharmacist,
the physician gives the pharmacist the mandate to adjust medication and follow up on the
patient’s condition and therapy. The physician is kept informed of the pharmacist’s
decisions but is no longer the case manager for the treatment of the patient. Point of care
testing is using technology for which the pharmacists need to be trained. Nurses and
technical assistants can also be trained to perform these tests.
Start date: Conception started May 2006. Infrastructure started to be put in place in January
2007. The start of a one-year pilot project planned for late 2007.
Description of initiative: Consultation services and testing services; dosage adjustments of
anticoagulant warfarin in retail pharmacies. Targets patients (outpatients) requiring
anticoagulation therapy.
Role of pharmacist: Close follow-up of patients; regular in-pharmacy INR testing and
dosage adjustments; other cognitive services such as education about optimal use of
warfarin, drug and drug-food interactions.
There is a support system in place for the pharmacists, nurses and technical assistants to
ensure continuous access to expert information and assistance. The goal is to have front
line and second line professional health services available at all times. The strategic details
of this system cannot be revealed at the time of reporting.
Purpose: There are many goals involved:
•
Provide assistance and the infrastructure necessary to community pharmacists who
provide expert case management of patients requiring anticoagulation therapy;
•
Broaden the pharmacist role;
•
Lessen burden on physicians and health system; and
•
Provide more timely and practical services to patients needing anticoagulation therapy.
Financial objective: The objective is to manage three cases per pharmacy the first year
and to go up to 50 at the end of the second year. This is what would be needed for the
project to be financially sustainable.
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Clinical objective: Optimize warfarin therapy. At the present time, physicians may not
prescribe warfarin because they do not have the resources necessary to follow up and
adjust the medication. They will advise the patient to take aspirin, although warfarin is
twice as effective as a blood thinner. However, because of its potency, it requires a much
tighter monitoring. It is estimated that only 60% of patients who could benefit from warfarin
are prescribed the medication due to lack of appropriate resources for monitoring and
adjusting the medication.
Societal objective: Reduce resources devoted simpler cases to allow to testing laboratories
and anticoagulotherapy clinics to focus on more difficult cases.
Human resources: 1.5 FTE managing the project, including 1 FTE working on strategic
development. There are 70 pharmacies; objective is to have a minimum of two pharmacists
per pharmacy at all times. There are 165 pharmacists trained to offer services and 23 more
in training; 33 of the pharmacists will offer INR testing.
Other resources required: 65 technical assistants trained specifically to perform INR
testing in the 33 pharmacies that offer it. They follow specialized training but no
certification is required. Some pharmacists may also choose to hire the services of a
registered nurse.
Funding/pharmacist remuneration: Seed money provided by sponsor for conception,
market research, infrastructure, training, etc. Patient has to pay for consultations and tests
as these kinds of services are not covered under current Canadian health system.
Benefits/advantages/impacts: It should unburden the current medical system by freeing
up laboratories and clinics of these relatively simpler cases. More patients will be able to
benefit from this more effective therapy. It is more practical for patients: instead of five
points of interaction with medical professionals, the patient would now require only three
when dealing with a pharmacy that provides point of care testing and only four when
dealing with a pharmacy that does not provide point of care testing. The time intervals will
also be much shorter. The consultation process will be more thorough. Pharmacists have
the pharmacological knowledge to adjust the medication as well as to inform and educate
patients.
Challenges and strategies used to overcome challenges: Patients must pay consultation
fees and testing fees. If these services were provided by a physician, they would be
covered under the patient’s provincial medical services. But because they are provided by a
pharmacist, they are not covered. Patients can decide to be tested in a hospital so that the
cost will be covered. However, the timeframe will then be much longer. Alternatively they
can have the testing done at one of the 33 affiliated pharmacies. The timeframe will then
be much shorter, but they have to pay for the testing themselves.
Marketing research has shown that only two to three patients out of 10 requiring
anticoagulotherapy would be willing to pay for these services. To be sustainable, there
would need to be at least 40 to 50 patients per pharmacy. Pharmacists need to purchase
the technology necessary to perform INR testing. Not all pharmacists involved in the pilot
project are in a position to offer INR testing at their pharmacy. Pharmacists require
additional training. There has to be a separate consultation room in each pharmacy. This,
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however, has been a minor challenge. Most pharmacies involved in the pilot project could
already accommodate this requirement as investments of that type started 10 years ago for
this chain of pharmacies.
Negotiation with government to demonstrate the need for such intervention so that the
services (consultation and testing) would be covered by the provincial health budget as
they would be if they were performed by a physician. Lobbying with private health
insurances to accept to cover these services. Information campaign with physicians to direct
more patients to these services. A support system has been put into place for pharmacists
offering both professional and emotional support.
4.4 Anticoagulation Management in a Family
Practice, St John’s NL
Interviewee: Dr. Stephanie Young, Assistant Professor and Primary Health Care
Pharmacist, School of Pharmacy, Memorial University of Newfoundland.
Sponsoring organizations: Memorial University, School of Pharmacy; grants from
Shoppers Drug Mart and pharmaceutical industry for evaluation. Initial two-year grant for
one FTE pharmacist has been restructured to one FTE for one year and up to five years
part-time.
Location or setting: Family Medicine Clinic, St. John’s, NL
Type of innovation: Pharmacist practice in medication management of anticoagulation
services in a primary care clinic; electronic medical records
Start date: 2005
Description of initiative: This project is the first instance of a pharmacist providing
services in a primary health care clinic in Newfoundland. The five physicians at the clinic
refer patients who they determine require medication management. The clinic developed
an electronic record system in December, 2006 and the referral is sent through the patient’s
medical record.
In addition, in 2006, a pharmacist-run collaborative anticoagulation management program
was developed for the clinic. Targets patients within the clinic population that require
medication management.
Role of pharmacist: Once a patient is referred, the pharmacist reviews the patient
information and then schedules an interview, usually at the patient’s home. The interview
usually requires about one hour. The pharmacist prepares recommendations to the
physician, as well as following up with the patient if required.
A policy/procedure protocol was developed for warfarin patients and the day-to-day
activities of this program are managed by the pharmacist, primarily by telephone and
through access to the electronic medical record. Utilizing laboratory results and based on
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the protocol, the pharmacist assesses the INR, asks patients appropriate questions to assess
response and side effects, etc. and then makes dosage adjustments and schedules the next
INR. New patients are seen face-to-face to review educational material (warfarin booklet
and pamphlet describing the service, other material as appropriate). The INR results and
the management plan are entered directly into the electronic chart and this can be done
from off-site.
More than 80 patients were assessed during the first eight months of the service.
Purpose: The initial purpose of the project was to establish contemporary pharmacy
services in a primary care setting. The goal was to demonstrate that primary care pharmacy
services can make a positive impact on patient outcomes within a primary care team
practice.
Human resources: 1 FTE pharmacist.
Funding/pharmacist remuneration: During the initial year of the project, the full-time
pharmacist was funded from the primary care grant through the School of Pharmacy.
Benefits/advantages/impacts: The clinic patients’ medication problems are being
identified and actions taken to improve medication therapy. Physicians and patients are
recognizing the role pharmacists can play within the primary health care team.
Challenges and strategies used to overcome challenges: Getting physicians to act on
the recommendations made by the pharmacist was a challenge. They tended to look at the
pharmacist’s evaluation of the patient in a similar vein to other referrals — as the end of
the process. In the case of pharmacist recommendations, this is the beginning of a process
to improve medication management. Pharmacist’s time constraints and obtaining stable
financial support for the program continues to be a challenge.
Steps are being taken to make physicians aware of the expectations regarding pharmacist
recommendations and to enhance communication around these referrals.
The School is seeking opportunities to provide stable financial commitment for the 1 FTE.
Feasibility
Sustainable: Financial sustainability continues to be a source of concern.
Scaleable: Due to the success of this program, another pharmacist has been established in a
primary care clinic in St. John, with the support of a School of Pharmacy faculty member.
Supported: The program has received very positive support from the physicians and other
health professional in the clinic as well as the patients.
Consistent: protocols have been developed and followed so the service is provided
consistently.
Evaluation: A summer student collected data on the interventions and conducted patient
and physician satisfaction surveys from the first year of the project. Feedback from the
surveys was very positive concerning the services being provided, both the general primary
care pharmacy services as well as the anticoagulation management.
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In examination of the intervention recommendations, the situation noted in the
“Challenges” section was identified, and strategies are being developed to improve
follow-up. The response from patients and the clinic physicians has been positive.
Communications/promotional material: Pamphlets on the anticoagulation service as
well as warfarin pamphlets have been produced.
CONTACT
Dr. Stephanie Young
300 Prince Phillip Drive,
St. John's, NL A1B 3V6
Tel.: (709) 777-8833
Fax: (709) 777-8870
Email: [email protected]
4.5 Cardiovascular Risk Reduction in a Family
Practice, Fort Qu’Appelle SK
Interviewee: Janet Bradshaw, staff pharmacist, Pharmasave # 412, Fort Qu’Appelle
Sponsoring organizations: Astra Zeneca and Merck Frosst
Location or setting: Fort Qu’Appelle Medical Clinic
Type of innovation: Community pharmacist functioning in a primary care clinic to
determine the impact of a pharmacist-managed, cardiovascular risk-reduction program in a
family medicine practice.
Start date: 2004
End date: 2006 (approximately 18 months)
Description of initiative: Patients were given an initial assessment, the rationale for
appropriate management of risk factors, a lifestyle assessment and recommendations, target
setting, and education regarding pharmacotherapy and adherence. The pharmacist also
made therapy and monitoring recommendations to the physicians.
Role of pharmacist: Patients were identified by the pharmacist or by direct physician
referral if they had a documented chart diagnosis of at least one of:
•
Diabetes;
•
Dyslipidemia or hypertension;
•
An objective clinical parameter for diabetes, dyslipidemia, or hypertension above the
recommended target; or
•
Being a current smoker.
Purpose: This project assessed the impact of a pharmacist-managed cardiovascular riskreduction program in a family medicine clinic.
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Human resources: One pharmacist.
Funding/pharmacist remuneration: Grant from pharmaceutical industry.
Benefits/advantages/impacts: Fifty-two patients were enrolled in the program over an
18-month period; 81% had hyperlipidemia, 35 % had diabetes and 44% had metabolic
syndrome.
The provision of these services by the co-located pharmacist appears to have contributed to
the reduction of dyslipidemia among patients with cardiovascular disease risk factors.
Emphasis was placed on education of the patient with regard to lifestyle modification:
dietary changes, physical activity, and smoking cessation.
Challenges and strategies used to overcome challenges: Very difficult to obtain
funding to support this initiative and project had to be stopped for this reason.
To date have not been able to obtain source of funding to overcome the challenge.
Evaluation: Service not functioning long enough for formal evaluation. Mean changes in
objective clinical parameters for the group from baseline to three months were compared
via paired t-tests and were considered statistically significant (at p < 0.05).
Academic documents: Bradshaw J, Neubauer S, Karakochuk M, Impact of a pharmacistmanaged, cardiovascular risk-reduction program in a family medicine practice. Can Pharm
J 2005:138(5):34.
CONTACT
Janet Bradshaw
Fort Qu’Appelle Medical Centre
Fort Qu’Appelle, SK
Email: [email protected]
4.6 Pharmacist Involvement in a Lipid Clinic,
Regina SK
Interviewee: Dr. Bill Semchuk, Manager, Clinical Pharmacy Services
Sponsoring organization: Regina Qu'Appelle Health Region
Location or setting: Regina General Hospital, a tertiary care centre
Type of innovation: Collaborative care, chronic disease management
Start date: 1998
Description of initiative: A pharmacist-managed, outpatient lipid clinic for high-risk
vascular patients.
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Role of pharmacist:
•
Education — education is provided to each patient seen in the clinic and specific
emphasis is on informing the clinic physicians on the latest studies and journal articles
pertaining to care of high-risk vascular patients.
•
Medication optimization — utilizing the patient’s past experiences with specific
medication, specific recommendations are made to the physician and the patient. Also
monitor and correct any drug related problems that become apparent.
•
Home follow-up — each patient is encouraged to contact the clinic if they require
advice or have problems. This has been an extremely effective way of giving patients
options and keeping them involved in their therapy.
•
Smoking cessation and other lifestyle approaches are offered where appropriate.
Purpose: Improve medication-related outcomes and decrease risk of vascular events.
Human resources: 0.25 FTE.
Other resources required: 1 FTE dietitian.
Funding/pharmacist remuneration: Regina Health Authority.
Benefits/advantages/impacts: More medication focus, enhanced adherence, better
patient education with regard to medications.
Challenges and strategies used to overcome challenges: Evolving roles and securing
funding were challenges overcome by persistence.
Evaluation: Dr. Semchuk has been a principal investigator in two major studies of
outcomes of high-risk vascular patients and interventions made by pharmacists, although
these are broader evaluations than of just the Lipid Clinic. Informal evaluation is done
through tracking of patients achieving their goals, adherence assessment.
Academic documents:
Dr. Semchuk has made numerous presentations on the Lipid Clinic practice as well as
describing appropriate management of high-risk cardiovascular patients.
Semchuk B, Taylor J, Sulz L, et al. Pharmacist intervention in risk reduction study: High-risk
cardiac patients. Can Pharm J 2007;140 (1):32-7.
SMART Study — Saskatchewan Medication Assessment for Risk Reduction Target Therapies.
Patients admitted to hospital for acute ischemic event (ACS or CABG) randomized to
conventional care or Pharmacist Driven Medication Optimization Clinic for one year.
Pharmacists Intervene with patient, family MD to optimize risk reduction pharmacotherapy
and aid in adherence. The study results are currently being tabulated.
Communications/promotional material: Various promotional material and activities are
used for the lipid clinic.
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CONTACT
Dr. Bill Semchuk
Regina Qu'Appelle Health Region
1440-14th Ave.
Regina, SK S4P 0W5
Tel.: (306) 766-4010
Fax: (306) 766-3547
Email: [email protected]
4.7 Clinical Pharmacy Services in an Outpatient HIV
Clinic, Edmonton AB
Interviewee: Christine Hughes, Associate Professor, Faculty of Pharmacy & Pharmaceutical
Sciences, University of Alberta; pharmacist in HIV clinic
Sponsoring organization: Faculty of Pharmacy & Pharmaceutical Sciences, University of
Alberta
Location or setting: University of Alberta Hospital — Out-patient HIV Clinics
Type of innovation: Chronic disease management, continuity of care. Pharmacists are
integrated into health care team in terms of drug therapy and are recognized for their
expertise.
Start date: January 1998
Description of initiative: Patient-oriented pharmacy services are provided as part of a
multidisciplinary team to HIV infected patients in Northern Alberta. The team includes a
nurse specialist, a full and part-time nurse, social workers, a dietitian, several infectious
diseases (ID) physicians as well as ID specialty residents who work in the clinic. There are
also a psychologist, psychiatrist, and neurologist that work closely with the team and see
patients by referral. The psychologist and psychiatrist attend weekly meetings with the rest
of the HIV team to discuss patients who are having problems or provide relevant patient
updates. Targets HIV-infected patients from northern Alberta.
Role of pharmacist:
•
Recommends/selects drug therapy (antiretrovirals and medications used to treat
related conditions or adverse effects of antiretrovirals such as hyperlipidemia, sleeping
disorders, neuropathy/pain etc);
•
Identifies drug related problems;
•
Conducts patient counselling on HIV and non-HIV medications, patient interviews and
follow-up as required;
•
Provides/coordinates adherence tools such as dosettes, blister packing, beepers and
individualized medication schedules;
•
Monitors patient's therapy including lab work, drug interactions, side effect
management, adherence, efficacy of antiretroviral (ARV) regimen, use of
complementary medications (during clinic time);
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•
•
•
•
•
•
•
Conducts in-depth medication/allergy history including obtaining information from
other provinces;
Identifies patients with drug payment/reimbursement issues (refer to social work if
needed);
Coordinates obtaining medications for patients including compassionate supplies,
Health Canada’s Special Access Program (SAP) /investigational medications,
medications from other provinces, special authorizations;
Provides drug information to health care professionals, patients and patient caregivers
within hospital/community;
Provides consultations on HIV resistance, reports and recommends new therapy based
on resistance mutations;
Coordinates seamless care with community pharmacies, hospital pharmacies, and
other agencies or health care workers; and
Calls or writes prescriptions for HIV-related medications during clinic time (currently
written prescriptions are co-signed by physicians however with new legislation in
Alberta this will change).
The pharmacists have also been involved in protocol development including a regional HIV
perinatal protocol to prevent mother-to-child transmission.
Purpose: To provide optimum medication management to the HIV infected patients in
Northern Alberta, to improve patient outcomes by providing cost-effective therapy.
Human resources: Began with 0.4 FTE pharmacist (funded by University of Alberta’s
Faculty of Pharmacy, in an agreement with Capital Health). In 2002, a 0.5 FTE pharmacist
was hired for a second HIV clinic in the inner city. In 2006/2007 funding was secured for
another 2 FTE pharmacists between the two sites.
Other resources required: Office space, computer support, etc., is provided by the
program.
Funding/pharmacist remuneration: Except for coordinator 0.4 FTE, the pharmacist
positions are funded through Province Wide Services (provincial program which funds the
high cost drugs such as antiretrovirals as well as program delivery staff). Support from
physicians and other allied health workers, growing complexity of patients, and importance
of adherence/appropriate prescribing led to a strong application to increase funding for
new pharmacist hires.
Benefits/advantages/impacts: HIV treatment’s major focus is medication management, so
having the pharmacist on the team has a definite impact on patient care.
Challenges and strategies used to overcome challenges: Challenges range from
maintaining communication with team members and between clinics and the very diverse
patient population, to provision of seamless care between community and institution when
hospitalized and subsequent return to home, and time management.
Team has a private computer server that permits good interaction among team members
regarding particular patient situations and assists with overall communication. Team
pharmacists have specific meetings to go over various issues. There are bi-annual full team
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meetings. Special awareness of issues in dealing with HIV patients is needed and requires
mentoring of new pharmacists to the area.
Effective liaison among the clinic, the institutional in-patient pharmacy and other
pharmacies that service these patients. Pharmacists in the program work together to share
the load, exchange ideas to make system more efficient, etc.
Feasibility
Sustainable: Recognized and funded by the Province Wide Services program. As previously
noted, support from physicians, complexity of patients and importance of
adherence/appropriate prescribing strengthened application to increase funding for new
pharmacist hires.
Scaleable: Similar programs with pharmacists on the HIV team are spread across Canada at
the major HIV centres including Regina, Calgary, Vancouver, several in Ontario, Halifax and
St. John’s (the role of the pharmacists may be slightly different among these sites mostly
due to the amount of pharmacist time).
Supported: Excellent support for the pharmacists on the team as demonstrated by the
demand for increased pharmacy services.
Consistent: Through protocol development, frequent interaction, and yearly meetings of
pharmacists in HIV programs across Canada (about 20 pharmacists), there is consistency in
services provided. HIV patients are a diverse group, so individual approaches are still
necessary.
Evaluation: Evaluations are usually done looking at the entire HIV service, of which
pharmacy is a part. Receive good feedback from both patients and clinic team. Reviewing
data on drug-related problems that have been identified and managed.
Academic documents:
Shah S, Hughes CA. Seamless pharmaceutical care in HIV-infected patients. CPJ 2003; 136:
28-31.
Tailor SAN, Foisy MM, Tseng A, et al. for The Canadian Collaborative HIV/AIDS Pharmacy
Network. The role of the pharmacist caring for persons living with HIV/AIDS: a Canadian
position paper. Canadian Journal of Hospital Pharmacy 2000;53(2):92-103.
CONTACT
Outpatient HIV Clinic
University of Alberta Hospital
Edmonton, AB
Tel.: (780) 492-5903
Email: [email protected]
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4.8 Pharmacist in a Multi-site HIV Clinic,
St. John’s NL
Interviewee: Dr. Debbie Kelly, Associate Professor, School of Pharmacy, Memorial
University of Newfoundland; pharmacist in HIV clinic
Sponsoring organization: School of Pharmacy, Memorial University of Newfoundland
Location or setting: St. Clare’s Mercy Hospital, Eastern Health
Type of innovation: Medication management for chronic disease (HIV patients)
Start date: 1999
Description of initiative: The HIV Clinic is responsible for the management of
approximately 120 HIV patients throughout the province. Satellite clinics are held when the
team visits Conception Bay (bi-monthly) and Cornerbrook (two to three times per year).
Role of pharmacist: Pharmacist sees patients to assess effectiveness, tolerability,
adherence to their medication, and works with the patient and team to achieve these goals.
Also monitors for drug interactions and makes recommendations accordingly to manage
them. When regimens are failing, the pharmacist reviews resistance test results/antiretroviral
drug history and makes recommendations for new regimens. The pharmacist is responsible
for cardiovascular and renal risk evaluations, as well as other non-HIV medication-related
issues.
Dr. Kelly is also the HIV team liaison with the government prescription drug program,
facilitating special authorization drug approvals, and reviewing criteria for anti-retroviral
therapy. Works with appropriate individuals within Eastern Health to set and revise
occupational post-exposure prophylaxis guidelines for the institution.
Purpose: To provide optimum therapy for HIV patients and maintenance of health.
Human resources: 0.2 FTE.
Funding/pharmacist remuneration: Eastern Health provides a stipend to support the
pharmacist’s time spent at the HIV Clinic.
Benefits/advantages/impacts: Patients are better informed to adhere to their medication
regimen. There is continuity or seamless care as Dr. Kelly follows up with local pharmacies
regarding the medication needs of each patient, as required. Potential drug interactions and
adverse reactions are screened on a routine basis. Patients receive support and
encouragement to participate in health-related decisions, and to adhere to their medication
therapy.
Challenges and strategies used to overcome challenges: Lack of a physical home base
for the clinic is a challenge. It is held in a general outpatient clinic that is also used by
other specialty clinics during the week. Therefore patient charts are maintained in a nursing
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office and brought to the clinic weekly. Access to the patient charts is difficult when the
clinic is not being held.
There has been a continuing change in the clinic staff (physicians, nurse, and social
worker) over the past two years. The pharmacist has been the only continuing professional
staff during this time. During two long-duration absences there has been no clinical
pharmacist coverage for the clinic.
The pharmacist maintains her own copy of notes for follow-up on each patient, so notes
can be referred to when patient contacts her. However, it is still difficult to get access to
patient charts for other type of information. Currently working on development of a
database on a secure server.
Team corresponds via email and phone between clinic days to ensure timely follow up on
critical patient issues. Dr. Kelly has acted in a consulting role during her extended absences
to address special clinic issues on an as-needed basis.
Feasibility
Sustainable/Supported: Has been in operation for eight years and is funded through Eastern
Health. One difficulty with the stipend arrangement is that it does not vary to account for
increasing time spent at the clinic.
Scaleable: Pharmacist involvement in these clinics is now seen in most provinces.
Consistent: A Canadian HIV Pharmacist Network that brings the pharmacists together to
exchange ideas has been established. The Network has published a position statement on
the role of the pharmacist in caring for patients with HIV infection.
Evaluation: During the first few years of the program workload statistics were maintained
in the development stage. Receives many letters and notes from patients expressing strong
support for the program.
Communications/promotional material: The Conception Bay North AIDS Interest
Group has published a self-help manual that includes a section on the HIV team through
Eastern Health. It highlights the services and support network available through the clinic
to all patients and families living with HIV.
CONTACT
Dr. Deborah Kelly
Associate Professor, School of Pharmacy,
Memorial University of Newfoundland
Email: [email protected]
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4.9 Collaborative Diabetes Education and
Management, Wynyard SK
Interviewee: Kendra Townsend, project manager
Sponsoring organization: Townsend’s Drugs
Other participating organizations: Lifescan, Saskatoon Health Region, Community Grant
Location or setting: Wynyard Community Health Centre
Type of innovation: Chronic disease management, cognitive services outside the
pharmacy. Community pharmacist has broadened scope of practice within an
interdisciplinary health care team; practising in public setting.
Start date: Spring 2005
Description of initiative: Over the years, a large deficiency was identified in this area in
the delivery of educational services to those with diabetes, pre-diabetes or metabolic
syndrome. The community is on the boundary of three regional health authorities and
access to formalized education services has been extremely limited.
Two community pharmacists received a $25,000 grant from the Primary Health Services
Branch of Saskatchewan Health for the project entitled Primary Care Intervention and
Education in Diabetes: A pharmacist coordinated comparison of usual care versus
collaborative primary care in affecting diabetes control and quality of life. This project
demonstrated the positive impacts a pharmacist can have on diabetes management and
outcomes in a collaborative primary care setting. Participating pharmacists completed the
Certified Diabetes Educator Examination in May of 2006.
A formalized diabetes education and consultation program is now held at the Community
Health Centre in Wynyard. The collaborative team members on the project include all local
physicians (salaried and fee-for-service), the primary health care nurse, all of the local
pharmacists, the home care nurse, the public health nurse, the manager of the Wynyard
Community Health Centre and the region’s dietitian. Targeted towards patients with
diabetes, pre-diabetes or metabolic syndrome.
Role of pharmacist: Both physician referrals and self-referrals are accepted by Community
Health Centre for individual consultations with a pharmacist one day per week. Many
clients have multiple follow-up visits to the service. Pharmacists also do insulin and
diabetes teaching for inpatients at the local hospital.
Purpose: To show that pharmacists can have significant impact on management and
outcomes of those with diabetes.
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During the first year of the project, 50 to 100 patients are expected to access the
consultative service. Expected benefits include:
•
Increased understanding of diabetes, treatment and risk reduction/prevention;
•
Improvement in HgA1C;
•
Improvement in patient self-management;
•
Decreased hypoglycemic events and diabetes-related emergency room visits/hospital
admissions;
•
Identification and resolution of drug-related problems;
•
Improvements in therapeutic outcomes for risk-related parameters such as blood
pressure and lipids; and
•
Increased access/referral to appropriate health care partners for assessment or
treatment (ophthalmologist, foot care specialist, public health nurse, dietitian).
Human resources: 0.4 FTE pharmacist.
Other resources required: Educational supplies, office space rental, support staff for
clinic, (from Wynyard Community Health Centre), professional fees (from Townsend’s
Drugs).
Funding/pharmacist remuneration: Through project grant from Saskatchewan Health
Benefits/advantages/impacts: From the initial pilot study, the trends noted in the data
indicated that patients in the intervention arm achieved lower fasting blood glucose, lower
HbA1c, lower diastolic blood pressure, and improved diabetes empowerment scores
(statistically significant) at six months when compared to baseline. The usual care (nonintervention arm) group had increases in fasting blood glucose, HbA1c, systolic and
diastolic blood pressure and low-density lipoprotein (LDL) cholesterol (statistically
significant) and had lower diabetes empowerment scores after six months when compared
to baseline. An average of four drug-related problems (DRPs) were found in each of the
patients enrolled in the intervention arm compared to only five DRPs found in the entire
usual care group. Recommendations made to physicians and/or patients regarding
medication or lifestyle changes were accepted 83% of the time.
It is expected that the above benefits will continue in the patients who are referred to the
service.
Challenges and strategies used to overcome challenges: The primary challenge was to
obtain funding.
Pharmacists endeavoured to keep all parties informed of their project and intent for this
enhanced service. Sought financial support from a variety of sources and plan to collect
formal evaluation data to support longevity of the service. It is hoped that long-term
permanent funding will be obtained through the Saskatoon Health Region, or the Primary
Health Services Branch of Saskatchewan Health.
Feasibility
Sustainable: Will depend on permanent financial support for the program.
Scaleable: Desire to have this model program adopted by other health authorities in
Saskatchewan.
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Supported: Excellent support from health professionals within the clinic and also
throughout the region.
Consistent: Services are provided on a consistent basis.
Evaluation: Data collection for formal evaluation is underway. Data will compare baseline
to post-education/intervention on parameters such as HgA1C, blood pressure control, lipid
levels, number of hypoglycemic events/diabetes-related emergency or hospital visits,
referrals to other health care professionals. Have received very positive feedback from
patients and health care professionals in the area, including the First Nations bands.
Academic documents:
•
Jade Rosin featured as CPhA Diabetes Educator Award in 2007.
•
Featured abstract — CPJ January/February 2007
Communications/promotional material: Sent personal letters to physicians in the area,
including referral form. Submitted news release to local weekly newspaper describing the
service.
CONTACT
Debra Townsend
Townsend’s Drugs
Wynyard, SK
Email: [email protected]
4.10 Diabetes Education Program, Youville Centre,
Winnipeg MB
Interviewee: Dinah Santos, pharmacist team member at Youville Centre Community
Health Resource, St. Vital
Sponsoring organization: Safeway Pharmacy
Location or setting: Youville Centre, St. Vital, 6-845 Dakota Street, Winnipeg
Type of innovation: Collaborative design (nurse, pharmacist, and dietitian) of Living Well
with Type 2 Diabetes Education Program, based on the Canadian Diabetes Association
Standards for Diabetes Education.
Start date: September 2002 (pharmacist on maternity leave until October 2007)
Description of initiative: Youville Centre is a community-based, accessible health
resource for the communities of St. Vital and St. Boniface. It provides a mix of services,
ranging from health care and wellness education, to counselling and support; encouraging
people to become involved in the management of their own health concerns, helping them
identify activities and programs that are of most benefit to them. Staff includes dietitians,
community health nurses, counsellors, nurse practitioner and certified diabetes and asthma
educators. Targets diabetics and families, either self or physician-referred.
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Role of pharmacist: Pharmacist is a certified diabetes educator, employed by Canada
Safeway, who donates eight hours per week to deliver diabetes education services at
Youville Centre. Pharmacist assists with the development of diabetes presentations, does
case-management, case-conferencing, corresponds with physicians and other team
members (nurses, dietitians, counsellors) and follow-ups with clients as necessary. Also
available to provide drug-related information to the Centre’s nurses and dietitians.
The diabetes self-management education program is based on the principles of adult
learning and stages of change. Participants attend five weekly sessions in a group setting.
The topics include: diabetes basics, nutrition, medications and blood testing, safety and foot
care, long-term complications/managing stress.
Each series is case-managed by either a nurse or pharmacist who assesses the health status
of each client, provides diabetes education, clinical support, community resources and
corresponds with physician as necessary.
Purpose: To improve the health status and decrease the risk for diabetes related
complications in adults with Type 2 diabetes.
Human resources: 0.2 FTE pharmacist.
Funding/pharmacist remuneration: Safeway Pharmacy.
Benefits/advantages/impacts: Pharmacist expertise contributes to the Enhanced Diabetes
Health Team and other Youville Centre programming. There is continuity of care for
diabetes clients requiring follow-up by pharmacist, and increased human resources to meet
the demand of diabetes epidemic.
Challenges and strategies used to overcome challenges: The pharmacist is not always
available to meet with the Diabetes Health Team because the time available is limited to
one day each week. Strategies used by members of the team include: email, and telephone
to communicate or case-conference with other members of the Diabetes Health Team at
Youville Centre.
Feasibility
Sustainable/Supported: Only with continued support from Safeway.
Scaleable: Could be expanded with funding, established protocol, documentation and
certification of the pharmacist.
Consistent: The Youville Centre is an accredited centre and has policies and procedures that
are followed by the pharmacist.
Evaluation: Youville Centre measures outcomes for the entire program, but no study of
specific impact/value of the pharmacist. Great, positive feedback from clients and
colleagues.
Communications/promotional material: Social marketing through regional office of
Canadian Diabetes Association. Youville Centre and diabetes programs are well known by
local health professionals and community members, often promoted through word of
mouth.
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CONTACT
Dinah Santos
Canada Safeway Pharmacy
1345 Waverley
Winnipeg, MB R2C 0A1
Email: [email protected]
4.11 Multidisciplinary Metabolic Syndrome Clinic,
Ottawa ON
Interviewee: Alan Gervais, Drug Use Evaluation Pharmacist, Department of National
Defence, Ottawa; pharmacist member of multidisciplinary team
Sponsoring organization: Carling Metabolic Syndrome Clinic (private clinic)
Location or setting: Small office clinic in a medical building, neighbouring physician
offices, laboratory services, and a community pharmacy. Clinic operates one day per week.
Type of innovation: Broadening role of pharmacist (review of patient data to make
recommendations on medications, lifestyle); cognitive services outside the pharmacy;
chronic disease management; health promotion and disease prevention.
Start date: January 2004
Description of initiative: Specialized individual consultation and group education for
patients diagnosed with metabolic syndrome, from an interdisciplinary team of health
professionals (endocrinologist, registered nurse, registered dietitian, and pharmacist).
Targets patients identified as having metabolic syndrome are referred to the clinic by their
family physician or specialist. Self-referrals are not permitted.
Role of pharmacist: After the patient has met with the nurse and dietitian, the pharmacist
reviews each of their consults and develops an individualized plan.
In many cases patients are given a trial of diet and exercise before medication is added. A
patient may do very well with lifestyle changes and the pharmacist may recommend to the
endocrinologist that the patient’s medication should be either discontinued or that the dose
should be lowered. If additional medication is required, the pharmacist discusses this
initially with the patient, and then subsequently with the patient and endocrinologist.
Patients are provided with individual and group education sessions. The first session lasts
about two hours, of which 45 minutes to one hour is spent with the pharmacist. Subsequent
visits are about one-and-a-half hours, of which 20 minutes is with the pharmacist.
Patients visit the clinic every month and blood work is done at the initial screening visit
and at the three- and six-month marks. Treatment plan is for a six-month period, and is
reviewed at the end of the term. Patients have the option of re-enrolling into the program
for another six-month session.
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In addition to patient treatment, the pharmacist and endocrinologist conduct research on
drug-related aspects of metabolic syndrome.
Purpose: The clinic was established primarily due to shortage of family physicians, which
makes it difficult for them to treat and follow-up complex conditions like metabolic
syndrome. The endocrinologist, Dr. Telner, was receiving referrals from family physicians
and realized that these patients required a multidisciplinary approach to the management of
the metabolic syndrome. There was no place to refer these patients to, and as a result he
set up the metabolic syndrome clinic, to improve long-term prospects for metabolic
syndrome patients; hopefully to prevent them from developing Type 2 diabetes,
cardiovascular disease, and other related health problems.
Human resources: 0.2 FTE of each of a pharmacist, endocrinologist, nurse, dietitian, and
receptionist. A statistician is used on an ad hoc basis.
In order to decrease operating costs and to decrease the number of health care
professionals that patients would have to see, the clinic may exclude the nurse from the
team. Her duties will be delegated to the dietitian, pharmacist and endocrinologist.
Other resources required: Office space, website (not mandatory).
Funding/pharmacist remuneration:
•
Canadian Forces — provide for the pharmacist’s weekly participation (to maintain
competency) at no cost. The clinic also provides a training site for DND’s military and
civilian pharmacists and students.
•
Pharmaceutical industry — approximately 12 pharmaceutical companies provide
financial support for the operation of the clinic (through unrestricted grants).
•
Ontario Health Insurance Plan (OHIP) — endocrinologist’s time is billed in the normal
manner.
•
Patient fees — patients pay an enrollment fee of $300 for the six-month program. This
represents about 10% to 20% of the costs of operating the clinic, and was
implemented primarily to ensure patient commitment. In the past, the program was
provided free to patients, however patients would not attend all of their sessions and
would not call to cancel their appointments.
Benefits/advantages/impacts: Each patient is provided with a sufficient amount of time to
address all of their health care needs related to the metabolic syndrome. This enables them to
receive significantly more attention than what would be available in the public health care
system (average family physician visit is six to seven minutes), and allows close monitoring
and follow-up, which is critical for this patient group. Education plays a major role.
The clinic is a teaching site for medical residents, civilian pharmacists, military pharmacists,
military pharmacy students and, civilian pharmacy students. It is also a training site for the
PHM 459 Specialty Practice Visit course associated with the University of Toronto. Other
health care professionals have requested rotations through the clinic (public health nurse,
etc.).
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Challenges strategies used to overcome challenges: It is a challenge to get referrals from
family physicians — many are reluctant to seek external assistance in managing their
patients’ health. Significant resources are required to measure long-term outcomes (i.e.,
years of follow-up).
Team routinely gives presentations to physician groups to promote the clinic and increase
referrals. Funding has just been received for a pilot study with 50 patients referred to the
clinic by their community pharmacists (rather than family physicians). Symptoms for
possible metabolic syndrome are often obvious to pharmacists (large waste circumference,
with high blood pressure), so that community pharmacists are in a perfect position to triage
metabolic syndrome patients. Pharmacists are able to determine if patients have high BP by
either their medication profile or by asking patients to measure their BP at the pharmacy
while they are waiting for their prescription to be filled.
Feasibility
Sustainable: As long as pharmaceutical companies continue to support it. Overtures made
to the provincial government for funding have not been successful.
Scaleable: The pharmacist is interested in expanding this program locally.
Their experience has enabled them to regularly modify their program to make it as
economical as possible. The long-term goal would be to implement similar programs across
Canada. Pending the results of the pilot, a pharmacist triage version could be expanded to
other disease states. Pharmacist notes that, “Patient profiles are a wealth of information”.
For example, pharmacists can identify patients with coronary artery disease (CAD) (use of
nitrates) or patients with diabetes (oral hypoglycemic agents or insulin) and ask them if
they are taking acetylasalicylic acid (ASA).
Supported: Possible due to small but very committed team of health care professionals.
Support of local family physicians/pharmacists is necessary to generate referrals.
Consistent: Yes, credible treatment guidelines/protocols are used, and there is good
communication among the small team.
Evaluation: Formal evaluation results will be published in the January/February 2008
edition of Canadian Pharmacists Journal. Preliminary review of patient data at 6-month
point shows a statistically significant difference from baseline data. Results were presented
at the Canadian Diabetes Association Conference in 2005, and at Endocrinology Division
rounds at the Ottawa Hospital.
The pharmacist has seen encouraging results among patients who have stayed in the
program for at least four months — reduced body mass index (BMI), waist circumference,
systolic blood pressure, diastolic blood pressure, blood glucose, low-density lipoprotein
(LDL) cholesterol and triglycerides, etc.
Patient satisfaction surveys have been very favourable. In addition, pharmacist intervention
and counselling about the concomitant use of herbal remedies (generally discouraged due
to the risks of adverse drug reactions at worst and at best, lack of efficacy) has resulted in
an estimated average saving of $240 per year per patient. This work has been published
(see publication below). In 2006, the pharmacist won a Drugstore Outstanding Service
Award (DOSA) award for this work.
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Academic documents:
•
Co-developed with Dr. Jean-Pierre Després: a lecture kit for pharmacists on the topic
of Metabolic Syndrome in 2006.
•
Gervais A. A heavy weight to carry. Pharmacy Practice 2006; 22(9); 39
•
Gervais A, Telner A. Metabolic rebuttal. Can Pharm J 2005;138(8).
•
Gervais A Treatment of Metabolic Syndrome (ask your pharmacist) CPJ March 2005;
138(2): 50.
•
Gervais A, Crotty K, Telner A. Natural Health Products and Metabolic Syndrome. Can
Pharm J 2005; 138:26-27
•
Gervais A, Crotty K, Telner A. The use of natural health products in patients with
metabolic syndrome [abstract]. Canadian Journal of Diabetes 2005; 29(3): 318.
•
Telner AH, Gervais AA. Challenges associated with the implementation of a
multidisciplinary clinic to treat the metabolic syndrome [abstract]. Canadian Journal of
Diabetes 2005; 29(3): 317.
•
Telner AH, Gervais AA, Amos SS. Outcomes of a multidisciplinary approach to the
management of the metabolic syndrome [abstract]. Canadian Journal of Diabetes
2005;29(3):318.
•
Telner AH, McClelland LS, Cameron AK and Gervais A. Initial characteristics of
patients referred to a multidisciplinary metabolic syndrome clinic [abstract] Canadian
Journal of Diabetes. 2006;30(3):309.
Communications/promotional material: Team has produced a brochure to give to
patients, and as well as a website (www.metabolicclinic.com).
CONTACT
Alan Gervais
Carling Metabolic Syndrome Clinic
3029 Carling Avenue, Suite 105
Ottawa, ON K2B 8E8
Tel.: (613) 828-7399
Fax: (613) 828-9013
4.12 The Arthritis Program (TAP), Newmarket ON
Interviewees: Marie Craig and Carolyn Bornstein; additional information provided by Ieva
Fraser OT, manager, chronic disease; pharmacists, The Arthritis Program (TAP), Southlake
Regional Health Centre, Newmarket, ON
Sponsoring organization: Ministry of Health and Long-Term Care (MoHLTC), since 1991
Other participating organizations: TAP has partnered with:
•
Pharmaceutical industry — unrestricted grants to pilot new programs targeting
osteoarthritis, osteoporosis;
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•
•
•
Change Foundation and University of Toronto for the Early Arthritis Clinic (EAC)
Project;
Arthritis Society to write early issues of the Consumer Guide to Arthritis Medications
and the quarterly “Ask a pharmacist” column; and
Arthritis Health Professions Association (AHPA).
Location or setting: Onsite at Southlake Regional Health Centre (SRHC) 1991-2001. Offsite
at the Tannery Mall 2001–present.
Type of innovation: A chronic disease management program, in operation for 20 years,
integrating pharmacists and other health care professionals.
Start date: Pharmacist was hired in 1991 by the MoHLTC-funded Arthritis Program
(separate from the SRHC pharmacy department staffing budget).
Description of initiative: In 1983, a pharmacist was added to an existing innovative
rheumatoid arthritis care team that was providing in-patient coverage at the York County
Hospital. By 1986, 50% of the patients were receiving care as outpatients. In 1991, a
submission entitled Chronic Disease Management for Ontario Using Arthritis as the Model
received funding.
The program’s goal is to improve the quality of life for arthritis patients and keep them
from needing hospital admission. Patients with the diagnosis of Inflammatory Arthritis are
seen individually and then placed in a three-week education program combined with a
rheumatology clinic. There are also formalized patient education programs for
osteoarthritis, fibromyalgia and osteoporosis. The educational programs cover every aspect
of the disease process so as to affect behavioural change in the patient and successful selfmanagement of their disease.
Unlike most ambulatory care clinics where the physician indicates when the patient is to be
seen again, triage is done by other health professionals after treatment and/or assessment.
Medical intervention is only required for patients with disease change, for medication
reviews, side effect challenges, etc.
The program has five individual treatment and consultation rooms, one large
classroom/exercise space, one small group room, and a staff room, chart room, central
receptionist/clerk and waiting room space. At present, the team consists of a program
coordinator, three rheumatologists, 1.5 FTE pharmacists, 1.5 FTE occupational therapists,
1.5 FTE physical therapists, 1 FTE kinesiologist/rehabilitation assistant, 0.3 FTE social
worker and group education by a registered dietitian.
Currently 99% of patients are seen as outpatients. Targets patients with any type of
musculoskeletal disease. There are more than 2000 referrals a year, prioritized by diagnosis.
The program offers group treatment and education; individual counselling; product interrelationship research; development of educational materials (e.g., medication info, herbal
remedies); community speaker/presentations; rheumatology clinics, partnering with
rheumatologists.
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Role of pharmacist: The pharmacist brings to the team the role of a scientist with the
understanding of the science of medicines and their utilization by the body.
The pharmacist provides medication sessions for the patient education programs and oneon-one patient medication consultations. Makes medication recommendations to the
rheumatologists and works closely with other team members. Patient education includes
instruction in the self-injection of methotrexate for the treatment of inflammatory arthritis.
Takes phone inquiries from previous and current patients for medication information and
medication related problems.
The pharmacist sees more than 200 patients per month either in the group/individual or
Clinic format. The pharmacist is also on the alert to any blocks to care the patient may
have, such as fear of medication, misinformation, cost of the medications, and those
“wowed” by the “science” quoted in dietary supplement advertisements.
The pharmacist may act as a medication mediator when the physician’s choice of
medication is at odds with the patient’s preference, or when there are complexities due to
co-morbidities. Teaching patients how to be their own advocate is an important component
of self-management of their disease.
Purpose: to provide timely access to care, reduce the disability that can accompany
musculoskeletal diseases, increase the success of long term self-management, increase
patient satisfaction through a holistic approach to care.
Other goals are:
•
Minimal pathology impact;
•
Health status;
•
Patient and staff satisfaction;
•
Seamless transition from inpatient care to outpatient/clinic service delivery system;
•
Utilized to full scope of practice;
•
Medication counselling — increase in medication adherence/compliance and decrease
in pathology impact;
•
Inter-relationship of scopes of practice increases efficiencies and effectiveness within
the system; and
•
Medication education to improve safety and effectiveness of arthritis treatment, reduce
hospital admissions and utilization of the emergency department.
Human resources: 1.5 FTE pharmacists divided into three roles: scientist, educator,
medication counsellor.
Other resources required: Computers for charting, communication and online tools.
Internet access is essential for pharmacists providing medication counselling. Palm Pilot
(PDA) and access to University of Toronto library resources are assets.
Funding/pharmacist remuneration: Ontario Ministry of Health and Long-Term Care.
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Challenges and strategies used to overcome challenges: Initially there was little
guidance from the literature or other practitioners for a pharmacist role in an
interdisciplinary team, and as a scientist and educator. Patient medication education
materials were often lacking and had to be developed.
A strategy used was to follow principles of interdisciplinary patient care and charting:
•
A written response is required to each physician who refers a patient;
•
One chart per patient and all disciplines work together in the same area; and
•
Any care concerns that need to be addressed by another member of the
interdisciplinary team member are identified during one to one session and the team
member facilitates the appointment.
Typically there are 30 to 40 telephone calls from patients (to pharmacist) per month.
The support of team and patient interactions and support for professional competency help.
Feasibility
Sustainable: The program has proven its sustainability over twenty years.
Scaleable: The hospital is utilizing the TAP model as it organizes five new chronic disease
management clinics: geriatrics, stroke and transient ischemic attack (TIA), wound
management, anticoagulation, metabolic medical follow-up and gastrointestinal (GI),
A pharmacist has been included in all clinic models.
Supported: Strong, enthusiastic medical coordinator support. Funded through regular
provincial health care funding.
Consistent: Extensive guidelines to ensure consistency of care.
Evaluation: Patient satisfaction questionnaires and clinical outcome measurements indicate
that patient needs are being met and their quality of life is improving. Workload Statistics
indicate constant growth in all areas in an efficient manner.
Recognized for Excellence of Care; received an Ontario Hospital Association Change
Foundation Grant for the Development of a Pre-Diagnostic Early RA Clinic, November 2003.
External workload versus internal budgeting process used as productivity indicators.
Academic documents:
The Arthritis Program: Evolution to Trans-Disciplinary Care & Pre-Diagnostic Clinics Central
LHIN: Chronic Disease Management and Prevention Think Tank Day — Ieva Fraser OT,
Manager of Chronic Disease Programs including TAP July 10/06.
Communications/promotional material: Consumer Guide to Arthritis Medications
developed with the Arthritis Society
CONTACT
Marie Craig
The Arthritis Program (TAP)
Tannery Mall
Newmarket, ON
Tel.: (905) 895-4521 ext. 2404
Email: [email protected]
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4.13 Asthma and COPD Education Services in a
Community Pharmacy, Regina SK
Interviewee: Pat Smith, Clinic Pharmacist, Safeway Regina
Sponsoring organization: Canada Safeway
Other participating organizations: Lung Association of Saskatchewan (since 2006)
Location or setting: In community pharmacy as well as seven physician offices in Regina
and two physician offices in Fort Qu’Appelle (covering more than 40 physicians).
Type of innovation: Health team approach to providing clinical pharmacy services in
respiratory health within physician’s offices and in the pharmacy.
Start date: 2000, but has expanded significantly over the years.
Description of initiative: One-on-one asthma and chronic obstructive pulmonary disease
(COPD) education sessions, free of charge, by pharmacist who is a certified asthma
educator and COPD educator. The patient can self-refer or be physician referred. The
education session takes approximately one hour. Family members are encouraged to attend
with the patient.
These services are provided both in the pharmacy (education room) and in physician’s
clinics, if identified by a physician. Each patient is seen individually, spirometry is
performed if indicated and education is provided. Education for each patient is unique and
may encompass topics such as: medications, inhaler technique, basic pathophysiology and
environmental control.
Using care flow sheets, the pharmacists are able to give the doctor pertinent information
and a history of the condition. At the end of the session, the details and findings are
discussed with the physician and changes or reinforcement take place at this time. An
action plan is written for each patient. When necessary they will bring the patient back in
one month for follow-up.
Each clinic has one designated day per month to allow pre-booking by the physicians as
they see their patients during the month. Targets asthma and COPD patients coming to
pharmacy or physicians’ offices.
Purpose: The basis of chronic disease management is education. With proper education
patient can better manage their disease (in this case asthma and/or COPD).
Short-term goal is to increase the patient’s confidence in their ability to control their
disease. Other expected outcomes: better compliance with medication use, fewer hospital
emergency room/walk-in clinic visits, decreased morbidity, decreased mortality.
Other resources required: Literature, patient education material from Lung Association,
Safeway or drug companies
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Funding/pharmacist remuneration: Safeway and Lung Association (through donations).
Benefits/advantages/impacts: Helps patient better manage a chronic disease, and
improves patient quality of life.
Challenges and strategies used to overcome challenges: It has been a challenge to
gain the trust and acceptance of the physician. Availability of space in the physician’s office
is another issue.
Strategies employed:
•
Obtained national certification as asthma educators and COPD educators (national
certification exam is Nov 2007);
•
Worked very hard over many years to gain the trust of the physicians. Pharmacists
have made it a point to be present at as many CE with physicians as possible and to
be visible in the medical community;
•
Positive patient outcomes, better disease control and increased patient QOL have
reinforced the pharmacists’ position as a part of the health team;
•
Worked in affiliation with the Lung Association of Saskatchewan doing public
awareness forum and education sessions; and
•
Education and spirometry testing are done in education room at the pharmacy, to
overcome the lack of space in the physicians’ offices. Results are faxed to the
physician’s office and confer with him/her via telephone.
Feasibility
Sustainable: The program has been in operation since 2000.
Scaleable: Now partnered with the Lung Association to extend the program.
Supported: Program is supported by patients, the Lung Association, Safeway and the physicians.
Consistent: Have developed a consistent approach to educating patients and are certified
asthma and COPD educators.
Evaluation: Data is being collected and the program will be evaluated in the future.
Program has received very positive support from patients and health team practitioners in
this area of practice. Patients say their confidence in their ability to control their disease has
increased.
Academic documents:
•
Pharmacy Practice, June 2002
•
New Pharmacist, Spring 2006, p. 33
Communications/promotional material: Pamphlets noting service provided.
CONTACT
Pat Smith
Safeway Pharmacy
Regina, SK
Tel.: (306) 586-5145
Email: [email protected]
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4.14 Essex County Community Asthma Care Strategy,
Windsor ON
Interviewee: Dorothy Pardalis, staff pharmacist and Certified Asthma Educator, McGaffey
Pharmacy
Sponsoring organizations: Created as a pilot project in October 2002 by Dr. Christopher
Licskai, a former Windsor-based respirologist, with support from unrestricted educational
grants from the pharmaceutical industry. Then funded by the Primary Health care
Transition Fund from October 2004 to July 2006. Currently funded by Ontario Ministry of
Health and Long-Term Care.
Other participating organizations: Essex County Pharmacists Association, University of
Windsor- WEDnet (created electronic assessment tools and collects/stores data for
evaluation purposes), Asthma Research Group Incorporated, Hotel Dieu Grace Hospital,
DaimlerChrysler, St. Joseph’s Health Care (London, ON), Leamington District Memorial
Hospital, Ontario Lung Association.
Location or setting: Family physicians’ offices in Windsor and Essex County, ON.
Type of innovation: Broadening role (pharmacists are assessing, educating, utilizing
spirometers, and making recommendations to physicians); cognitive services outside the
pharmacy (takes place in physician offices); chronic disease management (asthma).
Start date: October 2002
End date: Funding must be renewed on a yearly basis. No signs to-date that funding will
not be available.
Description of initiative: Patients meet with pharmacist educator in their physician’s
office for an extensive 90-minute assessment that includes a spirometry reading, inhaler
technique training, and individualized education. Patient education component includes:
•
General understanding of asthma;
•
Understanding of environmental triggers and avoidance;
•
Understanding the role of medication in control;
•
Recognition of symptoms and acceptable asthma control;
•
Self-monitoring of symptoms;
•
Device skills for inhaled medications; and
•
Understanding and confidence to adjust medication as recommended.
Pharmacist makes treatment and lifestyle recommendations to the physician, and helps the
patient create their own action plan for controlling their asthma. A report for the physician
added to the patient’s chart for review at future visits. A follow-up appointment is held with
the pharmacist one to three months after the initial meeting.
Targets patients identified as having asthma whose control could be improved.
Identification may be done through family physician’s office staff audit of their patient
records (“look-back” program) and subsequent referral by the family physician, or by
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referrals from walk-in clinics (for patients without their own family physician), emergency
departments, or employers.
Purpose: Created to meet a perceived need in the community and to prevent asthma
patients from falling through the cracks. Goals are to identify individuals with asthma and
initiate early treatment, improve patient outcomes, and support resource utilization, to
develop a community model for multidisciplinary chronic disease management that would
ultimately reduce health care utilization, asthma exacerbations, absenteeism and to improve
lung function.
Human resources: Five pharmacist-educators, six respiratory therapists, and a registered
nurse, who participate as needed/scheduled by the coordinator. Pharmacist educators are
booked online, according to their availability. Dorothy completed the asthma educator
course offered by the Michener Institute, and holds Certified Asthma Educator designation
from the Canadian Network for Asthma Care (CNAC).
Other resources required: Laptop, a portable spirometer with report printing capability
and other equipment. Pharmacists are linked via an electronic forum to share information
and experiences, and for consultation.
Funding/pharmacist remuneration: Since July 2006, all funding has been from the
Ontario Ministry of Health and Long-Term Care (MoHLTC), Primary Care Asthma Program
(PCAP) as one of 14 initiatives included in a province-wide Ontario Asthma Plan of Action.
This funding is granted on a yearly basis.
Benefits/advantages/impacts: See evaluation below for clinical outcomes. Also, program
provides a great deal of professional satisfaction to pharmacist-educators.
Challenges and strategies used to overcome challenges: Program accessibility for
patients has been the biggest challenge — there have been cases where the patient hears
about the program and wants to participate, but their family physician is reluctant to refer
(i.e., to another health care professional).
Continued promotion by the program coordinator, and outreach to family physicians to
promote and explain the program.
Feasibility
Sustainable: Yes, as long as provincial funding is available.
Scaleable: Could be a model for other disease state intervention programs (e.g., diabetes).
Supported: To date 850 new patients have enrolled in this program, with 563 returning for
follow-up assessment. Positive feedback from participating physicians and patients.
Consistent: Yes, through use of electronic software tool that standardizes the intervention,
also through objective measurement of lung function.
Evaluation: Evaluation is ongoing. Encrypted patient data is downloaded (from portable
laptops /assessment tools) to a secure central resource database for analysis and
measurement of efficacy. To-date the (unofficial) results reflect an over 50% improvement
in symptom control, decrease in emergency department and urgent health care utilization,
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and a doubling of the number of patients in control. May see an increase in prescription
drug usage, but this is countered by decrease in primary health care costs and absenteeism.
Note that this is preliminary data only.
There is a solid roster of physicians participating/referring, along with two walk-in clinics.
Positive feedback has been received from physicians and patients.
Academic documents:
•
2005 Commitment to Care Award-winner. Pharmacy Practice, November 2005. Vol. 21,
No.11.
•
Disease Management, June 2002
•
Preliminary evaluation results will be presented at an upcoming conference.
Communications/promotional material: Brochures about the program are distributed
through community pharmacies. Pharmacists also promote through presentations and
meetings with employers, physician groups. The Ontario Lung Association will also connect
Windsor-based patients to this program.
CONTACT
Dorothy Pardalis
McGaffey Pharmacy
3955 Tecumseh Rd. E.
Windsor, ON N8W 1J5
Tel.: (519) 945-2121
Email: [email protected]
4.15 Manitoba Renal Program (MRP), Manitoba
Interviewee: Lavern Vercaigne, Associate Professor, Faculty of Pharmacy, University of
Manitoba, and pharmacist team member.
Sponsoring organization: Manitoba Renal Program (MRP)
Other participating organizations: Winnipeg Regional Health Authority, Pharmacy
Services.
Location or setting: Winnipeg, Brandon, and 12 local dialysis centres
Type of innovation: Province-wide interdisciplinary teams providing extensive clinical
pharmacy services to individuals with chronic kidney disease.
Start date: 1998
Description of initiative: An interdisciplinary team of health care professionals
(physicians, nurses, dietitians, social workers, pharmacists, renal technologists, occupational
therapists, dialysis care technicians, aboriginal liaison and spiritual care providers) work
together to promote a holistic approach to care for people living with kidney disease, their
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families, and their communities. The teams provide ongoing care of patients with renal
disease and their families to maintain or enhance quality of life, including end of life
management, and to assist in adaptation to chronic illness. This is achieved as close to the
person’s home community as possible. Targets individuals with chronic kidney disease in
Manitoba.
Role of pharmacist: Renal pharmacists are involved in all areas of renal patient care
including:
•
Renal health clinics;
•
Local centres’ dialysis units;
•
Hemodialysis; and
•
Peritoneal dialysis.
The
•
•
•
•
•
•
•
•
renal pharmacist role includes:
Performing medication histories and reviews;
Assessing medication appropriateness and identifying drug-related problems;
Making recommendations to solve and prevent drug related problems;
Participating in interdisciplinary rounds;
Participating in hospital discharges and coordinating transfer of information back to
the local dialysis units;
Providing medication education and drug information to patients and staff;
Improving patient medication compliance; and
Designing and conducting research.
There are two coordinating pharmacists in the provincial program. The team of 14
pharmacists meets monthly by video and voice conferencing to provide updates and
discuss issues that have arisen.
Purpose: The MRP develops and provides two broad elements along the continuum of
care of renal disease:
•
Renal Replacement Therapy (RRT) used to improve or maintain a high quality of life
for individuals with end-stage renal disease (ESRD) through the provision of dialysis
for both acute and chronic kidney disease.
•
Renal Health Outreach (RHO) responsible for renal health promotion, disease
prevention and management through education and non-dialysis clinical care.
Human resources: 9.5 FTEs.
Funding/pharmacist remuneration: From MRP and the Winnipeg Regional Authority.
Benefits/advantages/impacts: Renal patients benefit from the expertise of the renal
pharmacists, improving their quality of life. The local practitioners have quick access to
expertise for dealing with these patients.
Challenges and strategies used to overcome challenges: Pharmacists feel pressure to
effectively provide pharmaceutical care for the 1000 dialysis patients and more than 3000
renal health clinic patients that are part of the MRP. Challenged to be accountable for the
drug budget for high-cost pharmaceuticals within the MRP; erythropoietic therapies are the
subject of many of research projects and cost containment initiatives. Monthly video and
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telephone conferences are held with each unit to update everyone on new developments
and to share experiences and therapeutic solutions to problems.
Feasibility
Sustainable: Program is well accepted and has been in operation with permanent funding
since 1998.
Scaleable: Covers the entire province of Manitoba.
Supported: Government provides stable funding for the program.
Consistent: Activities within the renal units are coordinated with constant collaboration.
Evaluation: Services are documented and evaluated from a quality performance basis (i.e.,
accreditation process).
Academic documents:
•
deRocquigny B, “Electronic database facilitates pharmacist-assisted anemia
management for renal patients.” Canadian Society for Hospital Pharmacists Western
Canadian Banff Seminar Conference Proceedings March 4, 2005.
•
Raymond C, Dyck J. Impact of a pharmacist at a renal health clinic. Can J Hosp Pharm
2004; 57(Suppl. 2):29.
•
Riley K, Martin J, Wazny LD. Impact of pharmacist intervention on osteoporosis
treatment after fragility fracture. Can Pharm J 2005;138(1):37-43.
•
Riley KD, Wazny LD. Assessment of a fax document for transfer of medication
information to family physicians and community pharmacists caring for hemodialysis
outpatients. CANNT J Jan-Mar 2006;16(1):24-8.
•
Vercaigne L, Wazny L, Raymond C, Skwarchuk D, Bernstein K. Funding of clinical
pharmacy services in the Manitoba Renal Program. CANNT J 2007;17(3). CANNT
Annual Meeting, Winnipeg, Manitoba (Oct. 25-28, 2007).
Communications/promotional material: www.manitobarenalprogram.ca
CONTACT
Lavern Vercaigne
Tel.: (204) 474-6043
Email: [email protected]
4.16 Infectious Diseases Ambulatory Care Clinic,
St. John’s NL
Interviewee: Dr. John Hawboldt, BSP, ACPR, PharmD, Assistant Professor in Clinical
Pharmacy, School of Pharmacy, Memorial University. Secondary appointments at the
Faculty of Medicine and the Eastern Health Department of Pharmacy. Pharmacotherapy
specialist at an ambulatory care clinic.
Sponsoring organization: Memorial University of Newfoundland
Location or setting: Hospital, St. John’s, NL
Start date: Spring 2006
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Description of initiative: Direct care services to infectious disease patients. The
pharmacist provides both primary care and post-institutional care. The pharmacist’s
consultation would involve meeting with the patient about the prescription written by the
physician; an explanation of any interaction with other medication if applicable; a call to
the patient’s community pharmacy to let them know about the course of the treatment
when necessary and provide answers to their questions. There may be two or three followup visits needed for some patients.
Pharmacist also works with the physician at the Clinic; discusses therapies that would be
efficient for each patient. Facilitates funding or application for funding for the therapy, if
required. This may involve literature searches in order to provide the rationale for the
pharmacotherapy. The pharmacist sees 10 to 14 patients per week. Targets patients with
infectious diseases, whether self-referred, in-patients or post-institutional patients.
Purpose: The goal is to provide more effective direct pharmaceutical care to patients. This
extended pharmaceutical service would be difficult to offer in a community setting, since
this type of consultation would not be billable.
Human resources: One pharmacist (about 0.4 FTE, including a half day for the clinic),
and one physician (part of his clinical practice functions).
Funding/pharmacist remuneration: No additional funding is required. Since these
services are provided within an institutional setting, the pharmacist’s remuneration is part of
his salary.
Benefits/advantages/impacts: Patient receives more enhanced care. By the pharmacist
adding these services, it makes the service more effective for the patient at a minimal
increase in cost or often at a decrease in cost.
This clinic demonstrates that even in a highly specialized field like infectious diseases there
is a role for pharmacy and that the pharmacist can improve patient’s outcome.
Challenges and strategies used to overcome challenges: The main challenge is other
health care professionals not really understanding what the pharmacist’s role could be. The
pharmacist basically has to slowly and cautiously educate other health professionals. It
requires persistence and strong will.
Evaluation: There is no formal evaluation planned.
CONTACT
John Hawboldt
Assistant Professor
School of Pharmacy
Memorial University of Newfoundland
Tel.: (709) 777-8777
Fax: (709) 777-7044
Email: [email protected]
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4.17 Pharmacist-managed Drug Safety Clinic,
Toronto ON
Interviewee: Sandra Knowles, BScPhm, manager, clinical pharmacist
Location or setting: Sunnybrook Health Sciences Centre, Toronto, ON
Start date: Dedicated pharmacist position added to Drug Safety Clinic in 1992.
Description of initiative: Evaluation, confirmation and treatment of drug allergies.
Patients are referred to the clinic from various communities in Ontario, and by Telehealth.
The clinic books approximately 30 new patients per week, and 75% to 80% of these return
for testing. In total, about 50 patients are treated weekly.
Role of pharmacist: Develops allergy testing (skin and patch) and desensitization
protocols. Pharmacist’s role includes:
•
Interviewing patients, reviewing information provided by physician;
•
Reviewing patients’ chart and possibly records from other hospitals to determine
causality;
•
Confirming possibility of drug allergy(ies), recommending drug(s) for which to be
challenged-tested;
•
Conducting double-blind challenge tests when appropriate (suspected multiple drug
allergies);
•
Conducting comprehensive literature searches to determine which drugs the patient
must avoid for serious drug reactions (e.g., with hepatotoxicity);
•
Educating the patient;
•
Following patient on a weekly basis until desensitization is complete;
•
Educating pharmacy students, pharmacy residents, and medical residents and fellows;
and
•
Writing up of various patient cases for publication.
Clinic physicians are responsible for the initial consultation with the patient and are
available when testing is occurring (in case of reactions).
Human resources: Approximately 0.6 FTE pharmacist; 1.0 FTE administrative assistant;
part-time nurse; four part-time physicians.
Other resources required: Office facilities, testing solutions and devices.
Funding/pharmacist remuneration: Prior to 1992, the Drug Safety Clinic was staffed on
a temporary basis by the Drug Information Pharmacists. In 1996, Sunnybrook received core
funding from GSK to formally set up the clinic, and to develop a financial plan. Funding
was made available for a part-time position at the Drug Safety Clinic.
OHIP payments to physicians providing services at the clinic are used to cover
compensation to the nurse and administrative assistant, in addition to the billing physicians.
The pharmacist’s compensation is covered by the Sunnybrook Pharmacy Department.
Patients are not charged for testing.
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Benefits/advantages/impacts: Improved patient care at the individual patient level and
global levels.
Challenges and strategies used to overcome challenges: Lack of time (funding) to set
up all the patient programs needed is the biggest challenge. Acceptance and support by the
medical community has never been an issue.
Feasibility
Sustainable: Through physicians’ billings to the Ontario Health Insurance Program (OHIP)
Scaleable: Very difficult for smaller institutions to establish an ongoing allergy clinic, for
financial reasons. Even with the high volume of patients visiting the Sunnybrook clinic, it is
just breaking even.
Supported: Yes
Consistent: Yes, due to the establishment of testing protocols and the fact that there is only
one pharmacist.
Evaluation: No formal evaluation, but an informal one as evidenced by the clinic’s
increasing number of referrals.
Communications/promotional materials: Professional presentations to let Sunnybrook
and other health care professionals know about the existence of the drug safety clinic.
CONTACT
Sandra Knowles
Sunnybrook Health Sciences Centre,
Drug Safety Clinic
Email: [email protected]
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5.0 HEALTH PROMOTION AND DISEASE PREVENTION
5.1 Phamacist Consulting at a Geriatric Assessment
Clinic, Edmonton AB
Interviewee: Dr. Cheryl Sadowski, Associate Professor, Faculty of Pharmacy &
Pharmaceutical Sciences.
Sponsoring organizations: University of Alberta and Capital Health Authority
Location or setting: Geriatric Assessment Clinic, part of a seniors’ clinic in Edmonton.
Type of innovation: Pharmacist is providing cognitive services (identifying and resolving
drug-related problems) outside the pharmacy.
Start date: January 2003; prior to that, the assessment team had been operating with nurses
and physicians only.
Description of initiative: Pharmaceutical consulting services as part of a multi-disciplinary
team in an assessment clinic. This model differs from the more commonly found clinics,
which focus on interventions and/or primary care. Geriatric population: patients 65 years of
age and older are eligible. In practice, most patients are between 70 and 80 years of age.
Role of pharmacist: Pharmacist meets with each patient referred (for 30 minutes, on
average), completes a medication history, and then assesses for drug-related problems. For
example, for a referred patient with a history of falls, would consider whether or not the
patient’s drug therapy may be contributing and review.
Any team members who have also assessed the patient then meet to discuss the respective
assessments and summarize them back to the patient and/or their family, and to the
referring physician.
Some follow-up may also be done, particularly if the patient changes medication regimens
or starts a new drug, due to the recommendations of the team. Once follow-up is
completed, the patient is discharged from the program. Team pharmacist also estimates that
she liaises with the patient’s community pharmacist in over half of referred cases. This is
done when intervention by the patient’s community pharmacist is judged to be warranted
for better care (e.g., review inhaler technique, provide compliance packaging).
In other words, team members each conduct independent assessments of the patient, meet
to discuss and summarize, forward the recommendations, then discharge the patient from
the program – the clinic does not provide treatment.
The assessment team normally completes two to five assessments per day, depending on
complexity.
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Purpose: Clinic is not a primary care clinic, but referral-based. As with any specialty, the
health care providers at the clinic do not take over the care of the patient. Instead, they do
a comprehensive assessment, provide the assessment to the primary care physician, and
provide support to that physician in terms of guidance on implementation. The goal is to
provide better patient care for geriatric patients with complex medical needs.
Human resources: 0.4 FTE pharmacist time.
Funding/pharmacist enumeration: Pharmacist has a University of Alberta crossappointment to the Capital Health Authority (CHA). The pharmacist is employed full-time
by the University of Alberta, with 0.4 FTE of her time spent on a service exchange with
CHA to work at the assessment clinic.
Benefits/advantages/impacts: The team environment provides a richer working
environment for pharmacists. The comprehensive assessment process allows the pharmacist
time and resources to conduct a thorough review. The clinic is an excellent teaching
environment, allowing students or trainees the time to complete assessments, interact with
patients and families/caregivers, and work side-by-side with team members.
Challenges and strategies used to overcome challenges: Generally, family physicians
will refer the more medically complex cases to the geriatric assessment clinic. There can be
some challenges with working as a team for health professionals without previous relevant
experience. However providing care for patients with more complex health issues normally
requires a team approach and health professionals practising in geriatrics are accustomed to
this dynamic.
Working in a team with other health professionals makes it necessary for the pharmacist
(and all others) to be prepared to defend their recommendations to team members. This
may present a challenge to some people.
Pharmacists undertaking this type of practice should have additional specialized education
(e.g., certified geriatric specialist), but not necessarily a PharmD. Experience in geriatrics,
and access to mentors are also important resources.
Difficult to conduct annual performance reviews due to the number of stakeholders and
clinic members involved.
Patient and caregiver feedback is often difficult to obtain as many of the patients suffer
with dementia and cannot complete a questionnaire or provide accurate feedback.
Feasibility
Sustainable: With continued funding and availability of pharmacists with experience and/or
additional training in geriatrics, this program will continue.
Scaleable: Further evaluation would be required to determine.
Supported: Medical community support is shown by mandatory referrals from family
physicians. CHA provides financial support for the pharmacist who handles a small number
of complex, time-consuming cases.
Consistent: Service is currently provided by a single pharmacist; therefore, there is
consistency. A process to ensure consistency between new pharmacists that may enter the
program has not yet been developed.
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Evaluation: No formal evaluation has been done. As with any geriatric health program,
evaluation would be a challenge because it would be difficult to identify markers of
success and to quantify or measure since it not a disease-specific clinic. Success is
measured by patient quality of life. Informal evaluation through support from referring
physicians, clinic staff, and administrators.
Communications/promotional material: Assessment service is promoted to family
physicians with in-hospital patients and those ready for discharge. It is also listed as an
available service to regional physician networks.
CONTACT
Dr. Cheryl Sadowski
University of Alberta
Edmonton, AB T6G 2N8
Tel.: (780) 492-5078
Email: [email protected]
5.2 Good Samaritan Seniors’ Clinic, Edmonton AB
Interviewee: Kathy James Fairbairn, pharmacist providing clinical pharmacy services in
project
Sponsoring organization: Good Samaritan Society
Location or setting: Medical clinic located in a neighbourhood mall.
Type of innovation: Pharmacy primary care services to seniors.
Start date: 2004
Description of initiative: Pharmacy services provided in a medical clinic that includes five
family physicians with advanced training in care of the elderly. A geriatrician oversees the
clinic but the day-to-day management is handled by an advance practice nurse. Additional
members of the team include a nurse practitioner, two licensed practical nurses and a
physiotherapist. Targets complex, vulnerable seniors who live in the community. A good
portion of the clinic clients are homebound and require the team to provide assessment in
their home. Many clients also receive home care or are in a supportive living environment
such as assisted living.
Role of pharmacist: Pharmacist services are provided for 1.5 days per week. The
pharmacist’s work is varied but most clinic days include a home visit, medication
assessments, investigation of a medication-related issue, teaching clients about medications,
chronic disease management and providing drug information and updates to staff.
Referrals are from clinic staff, home care professionals or directly from the client and
family. After an assessment is made, the pharmacist may make recommendations to alter,
initiate or stop therapy to the clinic physician and in some cases the patient’s own
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physician. The pharmacist also communicates with the patient’s pharmacist regarding any
changes in therapy as well as obtaining medication records of previous medications. In
addition to providing the patient with information on medication management issues, the
pharmacist encourages patients (and their support individuals) to develop lifestyle changes
that may improve health.
After the initial assessment, follow up calls or contacts are scheduled if required for
continued assessment or monitoring. The pharmacist also participates in teaching
opportunities to clients, families, and community groups in addition to the clinic staff.
Purpose: To encourage safe and effective medication use by the patients of the clinic. The
goal is to provide a multidisciplinary approach to improving the health of senior citizens
who are patients of the clinic.
Human resources: 0.33 FTE pharmacist.
Funding/pharmacist remuneration: The clinic receives primary care funding for the
physicians and the advanced practice nurses. Good Samaritan and the geriatrician
recognize the importance of the pharmacy and physiotherapy services to the clinic, so
these positions are funded by Good Samaritan.
Benefits/advantages/impacts: These advanced primary care pharmacy services enhance
the medication management of the seniors. Their medication needs are still provided by
their local community pharmacy.
Challenges and strategies used to overcome challenges: Since the government-funding
model in this case does not provide support for pharmacy services, there is a constant
challenge to demonstrate the value of pharmacy services to the clinic.
Maintaining good communication with the dispensing pharmacy for those patients, is a
challenge. The electronic medical record is not able to track specific pharmacy services
provided in a comprehensive manner.
Important to maintain an excellent relationship with clinic health professionals and ensure
they are aware of the benefits of pharmacy services provided and demonstrate the value of
the service to government and third party funders. Maintain frequent contact with the
dispensing community pharmacists to keep them in the loop. The pharmacist played a key
role in assisting with the development of the electronic medical record.
Feasibility
Sustainable: Program has been in operation for three years.
Scaleable: Good Samaritan is currently expanding the scope of the clinic by partnering with
an existing geriatric program in the region.
Supported: Pharmacy services has the strong support of the clinic health professionals and
the Good Samaritan Society.
Consistent: The service provided is primarily referral based, but the pharmacist also
conducts chart reviews to identify patients who may meet the criteria for this service.
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Evaluation: The clinic has a formal evaluation of all team members and a survey is now
being done to evaluate direct and indirect care. The service is greatly appreciated by the
clinic professional staff, and the Good Samaritan Society who provide the funding for the
position out of their operation funding.
Communications/promotional material: Kathy James Fairbairn is featured in the
September 2007 issue of Pharmacy Post.
CONTACT
GSS Seniors’ Clinic
Good Samaritan Society
Edmonton, AB
Tel.: (780) 486-3476 or (780) 910-1956
Email: [email protected]
5.3 Chart-based Consultations on Coronary Patients,
Leader SK
Interviewee: Leah Butt, BSP, staff pharmacist
Sponsoring organization: Stueck Pharmacy
Location or setting: Leader Medical Clinic
Type of innovation: Pharmacist is providing primary health care and cognitive services
outside the community pharmacy.
Start date: June 2007
Description of initiative: Pharmacist provides chart-based consultation service to
physicians and nurses at the Leader Medical Clinic. Targets coronary artery disease patients
with high blood pressure who are not receiving adequate pharmacotherapy
Role of pharmacist: Patients who fit the criteria are flagged by the physician and/or nurse
practitioner. The pharmacist conducts medication and chart reviews to check for blood
pressure and cholesterol levels, and prescribed medications. Referring to treatment
guidelines, she makes pharmacotherapy recommendations (e.g., change dosage of current
medication(s), initiate new drug) in the patient’s chart that the physician or nurse
practitioner can enact at the patient’s next appointment. This intervention is chart-based,
and does not involve meetings between pharmacist and patient. The pharmacist is able to
review approximately five patient charts per visit.
Purpose: In addition to the expected patient health benefits, this consultation service was
launched to enhance relationships with other health care professionals, and to let them
know what pharmacists are capable of doing. Goal is achieving enhanced patient care
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through initiating a positive working relationship with local physicians and nurses, and
identifying potential and/or actual drug-related problems.
Human resources: The pharmacist currently provides pharmacy services to the Medical
Clinic approximately two afternoons per week. The pharmacist and her employer, Stueck
Pharmacy, would like this time to increase, but it is currently limited to this level due to
pharmacy staffing pressures. A replacement is needed to fill in at the pharmacy while the
consulting pharmacist is at the clinic.
Other resources required: Office space is provided in the medical centre.
Funding/pharmacist remuneration: Stueck’s Pharmacy.
Benefits/advantages/impacts: While not yet proven, it is expected that the pharmacist’s
recommendations will result in improved patient outcomes.
Challenges and strategies used to overcome challenges: When this consultation service
was first initiated, the pharmacist’s recommendations were immediately enacted. This
caused some patients to be concerned (i.e., “I just saw my physician a month ago, why is
my prescription being changed now?”) so a new process was adopted. The pharmacist’s
recommendations are noted in the patient’s chart so that the physician can review them
with the patient at the next visit, before initiating any changes.
Time is also a challenge, since the pharmacist also has responsibilities as a dispensing
pharmacist at the community pharmacy.
Feasibility
Sustainable: As long as Stueck’s Pharmacy views this as a worthwhile endeavour.
Scaleable: Yes.
Supported: Yes. All recommendations have been accepted and initiated by the physician.
Consistent: Yes. Recommendations are in accordance with accepted guidelines and are
made by the same pharmacist.
Evaluation: No overall cost-benefit evaluation has been done and it is not likely that one
will be. The pharmacist has kept track of the recommendations made, and is planning to
review patient outcomes as a result of these recommendations.
CONTACT
Stueck’s Pharmacy
116-1st Ave. W.
Leader, SK
Tel.: (306) 628-3744
Email: [email protected] or
[email protected]
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5.4 Heart Health Education Program, Espanola ON
Interviewee: Lynn Halliday, staff pharmacist; Robinson’s Pharmasave, program coordinator
Sponsoring organization: The Ontario Ministry of Health and Long-Term Care (MoHLTC)
funds the Espanola and area Local Health Integration Network (LHIN), which in turn
operates the Espanola Family Health Team (FHT) (a collaboration of non-physician allied
health care professionals).
Location or setting: Family Health Team office, consisting of examination and
consultation rooms, and a reception area. Each health care professional involved with the
FHT has his or her own office.
Start date: July 2007.
Description of initiative: The Espanola FHT is unique in that it is not managed by a
physician. In physician-run collaborations the allied health professionals may be in
“physician assistant” roles. Because this FHT is not physician-centric, each health
professional is able to fully contribute their particular expertise. Innovative approaches to
enhancing the health and care of patients are encouraged. Targets patients identified as
being at risk for heart disease. Patients can self-refer or be referred by their family
physician to the FHT for assessment and enrollment in the program. Patients are flagged if
they are older than 50 years of age, male, have increased abdominal weight, have diabetes,
hypertension, or smoke. Patients are assessed, provided with action plans to reduce risk,
and monitored.
Role of pharmacist: Pharmacist serves as the lead, triage position in the family health
team for this program. The pharmacist pre-screens; conducts an initial cardiovascular risk
assessment (establishing their risk level and modifiable risk factors), then directs them to
the appropriate health care professional (e.g., a dietitian for hyperlipidemia/abdominal
circumference/hypertensive diet; a social worker for stress management; a diabetic
educator for diabetes; or a nurse for smoking cessation).
The pharmacist will also conduct medication reviews if requested by the nurse
practitioners, and provide drug information/education services for the other team members,
as part of the Heart Health program and on a general basis.
Patients are educated on their risk factors and given action plans by the various health care
professionals they see. The FHT sends a report on the assessment and action plan to the
patient’s physician (if they have one) and if not, just to the patient. In some cases, patients
without a physician are instructed to take the report to the local emergency department
where they can see a physician (e.g., “Patient has been screened, and here are the risk
factors…”).
The pharmacist follows up with patients every six months to monitor progress.
At the end of the six-month period, the patient’s lab work is repeated and their risk level is
reassessed. If they have not met target levels they are referred back to their primary care
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physician with a letter outlining what had been done. At the one-year mark, they are again
re-assessed for medication compliance (if applicable) and progress.
During the course of a typical day, the pharmacist sees 10 or 11 patients.
Purpose: The FHT was established to increase patient access to quality, cost-effective
primary care.
Human resources: 1 FTE pharmacist, also 1 FTE for dietitian, diabetes educator, social
worker; 2 FTE nurse practitioner, registered nurse; 1 FTE receptionist.
Funding/pharmacist remuneration: Ontario Ministry of Health and Long-Term Care.
Challenges and strategies used to overcome challenges: Working through the start-up
dynamics of operating in a multi-disciplinary team can be challenging.
Feasibility
Sustainable: Yes, funded by the provincial government.
Evaluation: No formal evaluation has been done yet, however data is collected by the
Ontario government on who is being treated (statistical data). Many other FHTs are
associated with larger teaching hospitals throughout Ontario, with access to research staff.
The Espanola FHT does not have this capability. The FHT is collecting some qualitative
data on some of the programs offered.
Communications/promotional material: The Espanola FHT funds a weekly article in
the local newspaper, highlighting the programs offered by the FHT.
CONTACT
Lynn Halliday
Robinson’s Pharmasave
119 Tudhope St.
Espanola, ON P5E 1S6
Email: [email protected]
5.5 Patient Care Pharmacist Program,
Western Canada
Interviewee: Shan Khoo, Manager, Pharmacy Managed Care, London Drugs
Location or setting: London Drugs community pharmacies and community locations
Type of innovation: Expanded role for pharmacists, pharmacist time specifically allotted
for patient consultation
Start date: 1997
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Description of initiative: Pharmacists provide patient education and conduct disease state
clinic days in local London Drug community pharmacies. Pharmacists with a particular
interest in clinical care are recruited from among existing staff and provided with
specialized training and continuing education. The Patient Care Pharmacist (PCP) program
is offered by London Drugs on an annual basis, and each year focuses on one particular
disease state (asthma will be the featured subject in 2008). The course is four to five days in
length and covers communication and presentation skills, how to collect specimens,
equipment training, as well as updates on disease states. Self-study modules are also
produced.
PCP
•
•
•
•
•
•
training/clinics and patient education/service programs offered to-date include:
Diabetes (three separate modules);
Sun awareness;
Osteoporosis – patients are provided with T-scores for possible presentation to
physician, along with advice on how to strengthen bones;
Smoking cessation;
Flu clinics – nurses are hired to administer flu shots; and
Heart health.
Program pharmacists may also become certified asthma or diabetes educators.
Anticoagulation Program – An additional program that includes in-store monitoring of INR
levels has been in place for approximately seven years. Patients can have venous puncture
performed in a counselling room and pharmacists obtain INR level. Under pre-established
agreements, the pharmacist can adjust the patient’s coumadin dosage based on these test
results. This program requires extra pharmacist training and certification, and is based on
physician referral of patients. Targets patients who are customers of London Drugs across
western Canada.
Role of pharmacist: After completing the training program, the PCP is then assigned a
number of London Drug pharmacies where they are responsible for conducting an average
of eight to nine clinics per year. The PCP also maintains a community practice based out of
a specific London Drugs pharmacy. The PCP spends 20% to 30% of their time on these
functions.
Family physicians are kept in the loop; test results and recommendations are provided by
the PCP to the physician if requested by the patient.
Purpose: This program was initiated by London Drugs to demonstrate that pharmacists are
an important part of the health care team.
Human resources: Currently, 32 community pharmacists (London Drug employees) are
enrolled in the program.
Other resources required: Testing equipment such as cholestic, spirometer, ultra-violet
sun camera.
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Funding/pharmacist remuneration: Until recently, patients were not charged for the
anticoagulation monitoring services. London Drugs collected data on the benefits of these
services and presented it to the provincial government with the goal of initiating the
development of a reimbursement model; however, this was not successful.
Patients pay a fee for a one-to-one consultation with the PCP regarding the other disease
states.
Benefits/advantages/impacts: London Drugs sees the consultations as an opportunity for
relationship building with patients. Since the inception of this program, participating
pharmacists report that they perceive patients to be more trusting and apt to consult with
them on health matters. The clinics are increasingly popular, with invitations extended by
local employers for clinics to be held at work sites for the convenience of employees.
Physicians sometimes refer patients to the PCP in place of more expensive testing
(e.g., osteo screening). Other patients may not have a regular family doctor for ongoing
monitoring (e.g., for diabetes).
Challenges and strategies used to overcome challenges: Making pharmacists available
for the program, due to staff shortages.
Feasibility
Sustainable: Yes, if the company is committed to absorbing the costs. London Drugs has
been offering its program for more than 10 years.
Scaleable: Yes, the program has been increased from 15 to 32 participating pharmacists.
Supported: Yes. The clinics are in demand; treatment recommendations provided to family
physicians are reported to be generally well received and accepted. Patients report that the
testing services offered by PCPs are more convenient than going to a lab.
Consistent: Yes, due to the training program and protocols established, as well as the
relatively small number of PCPs offering these services at multiple locations.
Communications/promotional material: The program is promoted on their website
(londondrugs.com), in the newspaper and in stores. Pharmacists have access to an intranet
site.
CONTACT
Shan Khoo
Manager, Pharmacy Managed Care
London Drugs
Tel.: (604) 448-4028
Email: [email protected]
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6.0 CONTINUITY OF CARE
6.1 Community Medication Management Program,
Fraser Valley BC
Interviewee: Dr. Adil Virani, Assistant Professor, Faculty of Pharmaceutical Sciences, UBC;
project’s regional manager.
Sponsoring organization: Fraser Health Authority
Location or setting: This program is located within four regions in the Fraser Health
Authority: Burnaby, White Rock, Surrey and Abbottsford/Mission.
Start date: April 2005.
Description of initiative: This medication management service involves pharmacists
identifying patients recently discharged from hospital who are at high risk for a medicationrelated problem, and performing a home visit medication review, with a goal of minimizing
hospital readmission.
This is one component of total community pharmacy focused services. Fraser Health also
has three other community programs: two pharmacists working with renal patients, two
pharmacists with mental health patients and three in palliative care.
Pharmacists do home visits to review an individual’s entire medication profile, including
prescription drugs, over-the-counter products, and herbal agents. If desired by the
individual, the pharmacist will remove outdated or unused medications no longer needed.
Once the pharmacist has completed an assessment of the medications the individual is
taking, recommendations are made to the primary care physician. The pharmacist may
introduce compliance aids, such as blister packs, if needed. A pharmacist may also list all
the medications being taken. This list can be used if the person is admitted to hospital or
when seen by their doctor. If needed, a pharmacist may make a second visit or follow up
by phone/email.
During the first year, 483 seniors received a home visit; there were 681 home visits during
which pharmacists made 1685 recommendations for medication regimen changes, with
1244 being accepted. The pharmacists provided medication education during 605 visits,
cleared medication cabinets during 190 visits, recommended a compliance aid during 260
visits and requested laboratory testing after 126 visits. During 244 visits, the pharmacists
performed a non-pharmacological intervention such as checking blood pressure or blood
glucose, requesting special authority for medicines, reporting an adverse drug event, or
referring the patient to another health care professional.
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Targets people at high risk for a medication related problems. Individuals must meet
several of the following criteria:
•
65 years of age and older;
•
Discharged from hospital with at least six regularly scheduled medicines and may be
at risk for drug interactions;
•
Taking medications that have a narrow therapeutic index;
•
With kidney or liver failure and requiring careful medication titration;
•
Those living independently with little support; and/or
•
Those suffering from confusion or dementia and taking several medications.
The pharmacists also see patients referred from other sources, such as home health, in each
of their communities and from the elder health program.
Once a person who may benefit from a home visit is identified, a pharmacist may call with
preliminary questions to assess whether a home visit is required. The pharmacist will also
try to identify the medications being taken by searching the PharmNet and hospital records.
The pharmacist then prioritizes which individuals receive a home visit based on those at
highest risk for a medication-related problem.
Purpose: In addition to helping seniors better understand the medications they are taking,
it has been shown that medication management programs, when used with those at high
risk, have the potential to decrease the number of emergency room visits, the number of
hospital visits and shorten the length of stay in hospital if a senior is readmitted.
Human resources: One pharmacist is located in each of the four designated regions and
their primary responsibility is to this program.
Funding/pharmacist remuneration: Operating funds from the BC government. Grant
funding received to support the evaluation component.
Benefits/advantages/impacts: Pharmacist recommendations had an acceptance rate of
74%. Preliminary data analysis at 30, 90 and 180 days after pharmacist visits, has shown
reduced hospitalization rates and a cost savings.
Challenges and strategies used to overcome challenges: The biggest challenge for the
program is the amount of time it takes to deal with each patient. Arranging the visit, travel
time to the widely dispersed homes, and then the visit itself, all take an extensive amount
of time.
The program provides services to approximately 10% of the eligible discharged patients.
Approximately 70% indicate that they do not wish to participate in the service. As the
service becomes better known, there appears to be some improvement in this statistic.
Time component is difficult to manage, but procedures to streamline the process are being
considered. Promotion of the program is being increased to improve target populations
understanding of the purpose of the program.
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Feasibility
Sustainable: Medication management program results will be used for the planning of an
expansion of the program to other Fraser Health Authority communities.
Scaleable: They are hoping to expand the program in the future to other areas of the
Health Authority.
Supported: Currently the Heath Authority’s operating budget is supporting the program.
Consistent: There is a structured process for the operation of the program (prioritizing
target group, medication home visits, etc.).
Evaluation: Further evaluation of the economic and humanistic outcomes is planned.
Preliminary data analysis at 30, 90 and 180 days after pharmacist visits have shown reduced
hospitalization rates and a cost savings.
Communications/promotional material: Have a brochure that is being updated. Also
have a “911 file” which is left in the home and is available to emergency personnel should
the patient require emergency attention. This file contains a listing of all medications that
the patient is currently receiving.
CONTACT
Adil Varani
Regional Pharmacy Manager
Fraser Health Authority
Tel.: (604) 455-1328 ext. 741297
Cell.: (604) 613-2549
Fax : (604) 455-1315
Email: [email protected]
6.2 Programme ambulatoire spécialisé en
insuffisance cardiaque (PASIC), Moncton NB
Interviewé : Luc Jalbert, BPharm, MSc, pharmacien clinicien spécialiste en cardiologie;
Hôpital Dr. Georges-L-Dumont, Moncton; Clinicien associé à l’Université de Montréal;
Professeur associé au département de pharmacologie de l’Université de Sherbrooke;
Professeur chargé de cours à l’Université de Moncton; pharmacien attitré à ce programme.
Commanditaire : Des fonds privés de démarrage ont été fournis par des compagnies
pharmaceutiques.
Autres organisations impliquées : Autorités de l’hôpital, l’Ordre des pharmaciens du NB,
et le Collège des médecins du NB.
Endroit : Hôpital régional Dr. Georges-L-Dumont, Moncton NB.
Type d’innovation : Ce type de projet n’est pas nouveau en soit. Des modèles semblables
existent au Québec depuis un certain temps, plus spécifiquement dans des hôpitaux de
Montréal. Ces modèles préexistants ont été modifiés et adaptés à la réalité du NB.
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Date du début du projet : Décembre 2006; par contre le projet était en développement
pendant 2 ans avant de voir le jour. Il a fallu mener des études légales et des évaluations
de besoins. Aucun changement législatif n’a été requis puisqu’il s’agit d’une délégation
d’acte du cardiologue au pharmacien et non pas d’un changement de fonctions du
pharmacien.
Description de l’initiative : Suivi très rapproché des patients en insuffisance cardiaque
après une hospitalisation. Une visite à la semaine ou aux deux semaines est nécessaire
après l’hospitalisation. Si tout va bien, la visite peut durer une vingtaine de minutes. Le
pharmacien clinicien peut aussi juger bon de faire voir le patient par un cardiologue; donc
un petit nombre de visites peut s’étendre d’une heure à une heure et demie.
Il s’agit de patients externes, la plupart sont recrutés de l’hôpital régional, mais le
programme s’adresse à toutes les régions du NB. Un des pré-requis est que le patient soit
suivi par un cardiologue de l’hôpital. Déjà une cinquantaine de patients dans le
programme, mais d’autres sont en attente.
Les statistiques démontrent que le taux d’hospitalisation de patients en insuffisance
cardiaque doublera au Canada d’ici l’an 2025. Il s’agit donc d’une population en croissance
rapide.
Rôle du pharmacien : L’insuffisance cardiaque se traite essentiellement avec des
médicaments et le traitement est assez complexe. Il y a au moins une douzaine de
médicaments qui sont souvent mal tolérés. Il faut commencer avec de très petites doses et
augmenter lentement. Pour qu’un patient soit traité de façon optimale, cela peut prendre
jusqu’à 25 à 30 visites au bureau du médecin. Les médecins n’ont pas le temps et les
ressources pour rencontrer ces patients afin d’optimiser la pharmacothérapie. C’est la
fonction que le pharmacien assume dans ce projet. Les patients sont rencontrés aux deux
semaines par le pharmacien qui a reçu une délégation de la part du cardiologue pour
ajuster les doses. Cette délégation de droit n’est applicable qu’à l’intérieur de ce projet.
C’est le nom du cardiologue qui apparaît sur la prescription même si le droit d’ajuster la
dose a été délégué au pharmacien clinicien.
Raison d’être : L’insuffisance cardiaque est le deuxième diagnostique le plus important au
Canada pour l’utilisation des lits d’hôpitaux. La moitié de ceux qui sont hospitalisés pour
insuffisance cardiaque seront ré-hospitalisés en deçà d’un an.
De plus, ce sont des patients dont la qualité de vie est très amoindrie.
L’élément déclencheur a en fait été un des cardiologues de l’hôpital qui n’était pas satisfait
du manque d’optimisation des traitements post-institutionnels de ces patients.
Objectifs : Un suivi très rapproché de la médication après une hospitalisation permet
d’augmenter l’intervalle entre les hospitalisations — donc de réduire le nombre
d’hospitalisations — ainsi que d’améliorer significativement la qualité de vie du patient.
Ressources humaines :
•
Quatre cardiologues participent au projet (fait partie de leurs multiples fonctions à
l’hôpital).
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•
•
•
Un pharmacien avec une grande expérience clinique, dont 5 ans spécifiquement en
cardiologie (1/2 temps au programme et reste du temps en clinique de soins
coronariens).
Un infirmière d’expérience en cardiologie qui s’occupe de la logistique des rendezvous, suivis et tests des patients (temps plein).
Un diététiste (0.3 ETP).
Autres ressources requises :
•
Au besoin : travailleur social, ergothérapeute, physiothérapeute, psychologue.
•
Éventuellement, on prévoit d’assigner des techniciens directement au projet, mais ce
n’est pas le cas présentement.
•
Un système informatique, développé par un cardiologue de Montréal, a été fourni à
l’équipe pour supporter le programme.
Fonds pour le projet et pour la rémunération du (des) pharmacien(s) :
•
Il y a eu des fonds de démarrage pour ce projet, principalement de sources privées
telles que des compagnies pharmaceutiques.
•
Les fonds de démarrage ont servi entre autre à la rémunération du pharmacien et de
l’infirmière. Le but est que la Régie verra le bien–fondé de ce programme et acceptera
de le subventionner à l’intérieur du système de santé.
Avantages/impacts :
•
Diminution du nombre d’hospitalisations et diminution des coûts pour le système de
santé.
•
Augmentation de la qualité de vie des patients.
•
Valorisation de la profession pour le pharmacien.
Défis/difficultés et stratégies utilisées pour relever les défis :
•
Il existe déjà une pénurie de pharmaciens donc il a été difficile au début de
convaincre les autorités de l’hôpital d’accepter de consacrer du temps d’un
pharmacien clinicien expérimenté à ce projet.
•
Il y a plusieurs patients en attente et un manque de ressources pour accepter plus de
patients de cette population grandissante.
•
Un des défis majeurs est le manque de locaux pour les consultations. Si ce n’était du
manque de locaux, le programme aurait pu débuter en avril 2006 plutôt qu’en
décembre.
•
Puisqu’il s’agit d’un hôpital régional, le trajet peut être un peu long pour certains
patients en dehors de Moncton.
Le but est d’augmenter le nombre d’équivalent temps plein de pharmaciens/pharmaciennes
et d’infirmiers/infirmières licenciés dans le programme. Il faut toutefois procéder
prudemment parce que les fonctions requièrent une grande expérience en soins
coronariens.
Il a fallu démontrer les avantages de ce programme sur les coûts pour le système de santé
et démontrer que ce programme contribue à diminuer les demandes sur les ressources
professionnelles plutôt que de les augmenter.
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L’équipe essaie d’accommoder autant que possible les patients qui viennent de plus loin en
espaçant un peu les visites. Le degré de liberté est quand même assez restreint si on veut
que le suivi soit un succès.
Faisabilité :
Durabilité : Le programme peut durer et même prendre de l’ampleur si on peut trouver les
ressources nécessaires. L’alternative (c.-à-d. le retour au statu quo) est moins durable
puisque le nombre de patients en insuffisance cardiaque continuera d’augmenter. Ce
programme ambulatoire s’inscrit très bien à l’intérieur de la vision de la Régie de prévenir
des hospitalisations.
Flexibilité : Pour l’instant, ce programme n’est appliqué qu’aux cas d’insuffisance cardiaque
mais il n’y a pas de raison qu’il ne puisse pas être appliqué à d’autres soins de maladies
chroniques au NB.
Soutient : Le projet est soutenu par les cardiologues, les autorités de l’hôpital, l’Ordre des
pharmaciens du NB, le Collège des médecins du NB et la Régie régionale de la santé
Beauséjour.
Cohérence/uniformité : Le pharmacien clinicien et l’infirmière licenciée attitrés au
programme actuel ont tous les deux reçus une formation d’appoint pour parfaire leurs
expertises dans le domaine des soins aux patients en insuffisance cardiaque. Un protocole
de formation est en développement pour former plus de personnel. La formation vise
principalement à palier au manque de connaissances en évaluation et diagnostique de la
formation du pharmacien. Un protocole de formation est aussi en développement pour des
infirmiers/ières.
Il y aura des examens écrits et pratiques pour les pharmaciens/iennes et les infirmiers/ières.
Évaluation : Des études d’impact économique ont été faites ailleurs pour des programmes
semblables et ont servies de base à la justification de ce programme. Les effets sur la
qualité de vie des patients inscrits au programme et sur la diminution de leur besoin d’être
hospitalisés sont faciles à voir.
Documents académiques :
•
Le modèle est basé sur un projet semblable mené au Québec et documenté dans un
journal académique. Le projet de Moncton a été adapté aux besoins et réalités du
Nouveau Brunswick.
•
P. Martineau, M. Frenette, L. Blais, C. Sauvé. Multidisciplinary outpatient congestive
heart failure clinic: Impact on hospital admissions and emergency room visits.
Canadian Journal of Cardiology. 2004;20(12):1205-11.
COORDONNÉES
Régie régionale de la santé Beauséjour,
330 Avenue Université
Moncton, NB E1C 2Z3
Tél. : (506) 862-4200
Courriel : [email protected]
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6.3 Outpatient Parenteral Therapy (OPT),
Kamloops BC
Interviewee: Ayesha Hassan, one of two pharmacists on the Outpatient Parenteral Therapy
(OPT) team.
Sponsoring organizations: Royal Inland Hospital; Kamloops Home & Community Care.
Location or setting: Pharmacy in the Royal Inland Hospital, a 285-bed, acute care hospital
located in Kamloops, BC.
Start date: November 2006
Description of initiative: Home intravenous (IV) programs are not new. For 10 years
prior to implementing the OPT program, the hospital had been discharging patients on IV
therapy. However, there was no formal program or criteria, and no resources committed to
assisting/transitioning these patients. The number of patients on IV therapy grew to the
extent that it was becoming increasingly difficult to ensure continuity of care in such an ad
hoc manner. A decision was made to formalize the program and provide funding so that it
could be set up properly.
The initiative uses a multidisciplinary team approach to transition patients through existing
inpatient and community-based outpatient parenteral therapy programs. Targets patients, 12
years of age or older, who require parenteral therapy and are medically stable. Their
medication regime must be suitable for outpatient delivery. Patient and/or caregiver must
understand and consent to program, be able and willing to adhere to treatment regime, and
be located in a suitable outpatient environment (e.g., safety, cleanliness, storage are
considerations), with a telephone. Participants must be referred by physician or nurse
coordinator.
Younger clients or special populations can be accommodated if adequate planning and
support can be established.
Depending on the ability of the patient and/or caregiver, nursing support may also be
provided through this program.
Role of pharmacist: The pharmacist serves as the glue for this program. The pharmacist:
•
admits patients into OPT, based on admission criteria and informs OPT team;
•
advises OPT team on:
• suitability of venous access based on properties of medication and length of
therapy;
• venue requirements for initial outpatient and subsequent doses of medication,
based on pharmacist-conducted allergy assessment;
• most cost-effective medication and dosing regimes, according to evidence-based
literature, best practices and available data;
• selection of ambulatory infusion devices;
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•
•
•
•
Coordinates monitoring of required lab tests, assists with their evaluation and resulting
adjustment of doses;
Analyzes and reports any adverse drug reactions;
Ensures timely delivery of medication and supplies to clients. Programs and verifies
pumps, and trains patients on use; and
Collects data to validate development and measurement of outcome measures.
Purpose: To facilitate advanced outpatient parenteral therapy for inpatients, to allow for
early discharge. This is done by standardizing parenteral therapy, supporting patients, and
appropriately utilizing acute, residential and community resources.
Human resources: 1.0 FTE pharmacist (two pharmacists share one full-time position);
emergency room physicians, family physicians, and specialists, nurse patient coordinator,
nurse clinician, IV therapy, laboratory services, direct care nursing staff.
Funding/pharmacist remuneration: Hospital employer.
Benefits/advantages/impacts: Better patient care, responsible utilization of health care
resources, and an interdisciplinary collaborative model of sharing patient responsibilities.
Challenges and strategies used to overcome challenges: It was difficult for
stakeholders to understand that goal was not just cost saving, but also to improve patient
care (i.e., may incur costs, but very beneficial to patients). Some health professionals
needed to be convinced that the previous system was not necessarily based on best
practices, and that certain roles would need to be redefined (e.g., no longer Emergency
Department staff transferring responsibility to family physicians after initial visit, as had
been the case prior to implementation of the OPT program). Sometimes communication
was challenging due to the number of health professionals involved with a patient or
caregiver.
To overcome these challenges, the pharmacist reviewed prescribing data (for ER physicians
prescribing IV therapy to outpatients) and presented statistics to staff. There was a
significant increase in support for the program once ER physicians saw the benefits of a
dedicated program.
To improve communication, a “traveling chart” (which stays with the patient) was
developed. It includes patient information, contact numbers, instructions on how to selfadminister medications, progress notes (from all involved health care professionals as well
as the patient themselves), and digital photos if required (e.g., wounds).
Pharmacists take a major role in directing therapy, and keeping patients, physicians and
nurses informed.
Feasibility
Sustainable: Through hospital and community home care funding.
Scaleable: Yes, now in process of expanding to serve other areas in the Thompson Cariboo
Shushwap region. Plan to eventually implement throughout Interior Health Region.
Supported: Yes. Over the 2006-2007 year, 477 patients were enrolled in the program, and it
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is growing. Supported by local family physicians as well (who will facilitate same day
appointments if referred by OPT program).
Consistent: Yes, through establishment of program practice standards and protocols,
incorporated into the Hospital Parenteral Therapy Manual (which is being adopted by
Interior Health as an approved model).
Evaluation: Formal evaluation showed that the program saved 4200 bed-days between
May 2006 and May 2007. Now starting a formal survey of patients for feedback. Their sister
hospital, Kelowna General, has just received Innovation Funds from the BC government to
implement a program which will be modeled after this one at Royal Inland.
Communications/promotional material: Presentations to raise awareness were done for
staff throughout the hospital, when this program was initiated.
CONTACT
Ayesha Hassan
Tel.: (250) 314-2444
Cell: (250) 318-0158
Email: [email protected] or [email protected]
6.4 Seamless Care Outcomes Assessment Project for
Discharged Oncology Patients, St. John’s NL
Interviewee: Dr. Scott Edwards, PharmD, Clinical Pharmacy Specialist, Newfoundland
Cancer Treatment and Research Foundation (NCTRF), Primary Investigator/clinical
specialist/coordinator
Sponsoring organization: Newfoundland Cancer Treatment and Research Foundation
(NCTRF)
Location or setting: Dr. H. Bliss Murphy Cancer Centre and regional cancer
centres/clinics.
Start date: July 2005
End date: 2007. Data dissemination expected in 2008
Description of initiative: Randomized controlled research project to measure clinical,
economic, and humanistic outcomes possible in oncology pharmacy practice. Two hundred
medical oncology patients enrolled in the study were receiving intravenous (IV)
chemotherapy from the cancer clinic in St. John’s or one of the regional cancer centres
throughout NL.
Patients accepted for this study must keep diaries (on a daily basis for recording adverse
reactions; a weekly basis for quality of life assessments; and a monthly basis for
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productivity assessments), and participate in follow-up consultations. They must also
provide consent for the clinical pharmacist to release information to other health care
professionals as described below.
Role of pharmacist: The clinical pharmacist meets patients prior to discharge from the
Bliss Murphy Cancer Centre, conducts a full medication history, then verifies the history
with the patient’s community pharmacist.
The clinical pharmacist then re-calculates the patient’s chemotherapy doses (if warranted),
checks drug interactions against the patient’s established drug regimen, confirms dosages
with established protocols, and verifies lab results. The clinical pharmacist then counsels
the patient on optimal treatment and the management of any potential side effects, and
provides printed information materials.
A report outlining current medications, medication history, monitoring parameters, possible
adverse drug reactions, and laboratory/diagnostic results, is sent to the patient’s family
physician. A similar report, with detailed information on the chemotherapy regimen,
medication preparation and administration, and specific drug-related issues is also sent to
the oncology nurse and hospital pharmacist at the regional clinic.
Throughout the study, the oncology pharmacist provides toxicity assessments to all
intervention patients after each chemotherapy treatment. The oncology pharmacist follow
up is designed to identify and resolve any drug related problems the chemotherapy patient
may be experiencing.
Purpose: To compare the outcomes of cancer patients whose illness is managed using
current practices versus an improved intervention strategy. Patients in the new program are
subject to greater attention to ensure optimal administration of cancer treatments by their
hospital pharmacist and other members of their health care team.
Intended to improve standard of care for cancer patients in NL by ensuring on-going
therapy without interruption when one pharmacist hands over responsibility for a patient’s
care to another.
Human resources: 3.0 FTE pharmacists to provide service, direct research.
Other resources required: Office space, tablet personal computer (PC), Epidemiologist
for protocol development and data dissemination.
Funding/pharmacist remuneration: Grant from Pfizer Canada ($100,000).
Benefits/advantages/impacts: In addition to improved patient care and optimal
treatment, this study is expected to result in financial benefits to the health care system;
proactively discussing potential side effects of cancer treatments with the patient should
result in fewer physician and emergency room visits.
Challenges and strategies used to overcome challenges: The biggest challenges were
human resources, and educating and engaging staff throughout the province.
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Tablet PCs were utilized to obtain information at the point of care to maximize clinical
pharmacist time. An electronic database was created to record all patient data needed for
the study.
Feasibility
Sustainable: Hope that the results of the study will lead to government funding of more
oncology pharmacy positions.
Scaleable: Unknown.
Supported: Yes.
Consistent: Yes, due to protocols.
Evaluation: Results expected to be released in 2008.
Communications/promotional material:
•
Conducted educational sessions for all health care professionals at the Murphy Cancer
Centre
•
CEO of the Centre gave a press conference to announce the seamless care study
•
Patients are given informational materials about the study
CONTACT
Dr. H. Bliss Murphy Cancer Centre
St. John’s, NL A1B 3V6
Tel.: (709) 777-8521
Fax: (709) 753-927
Email: [email protected]
6.5 Technicians and Pharmacists Partnering in
Medication Reconciliation, Moncton NB
Interviewee: Lauza Saulnier, Chief of Pharmacy Services
Sponsoring organization: South-East Regional Health Authority, Moncton, NB
Location or setting: Moncton Hospital, Moncton, New Brunswick
Start date:
•
1996 – Medication Reconciliation at admission
•
2000 – Seamless Care Research Project; pharmacy technicians join pharmacist on
discharge program
•
2004 – enhanced program with technicians joining admission team
•
2006 – pharmacy technician works with nurse on discharge team
Description of initiative: The Medication Reconciliation Project rolled out in steps, with
the introduction of medication reconciliation at admission in 1996, the Seamless Care
Research Project in 2000, and technicians included to assist the pharmacist with medication
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reconciliation at admission in 2004. The role of the technician continues to expand to assist
the nurse with medication reconciliation at discharge and assist the pharmacist with patient
care activities. The implementation plan included piloting in patient-care areas, assessing
for improvements, developing tools and standardizing the process, implementing training
programs for technicians and other team members, making improvements and then
spreading the service to other areas.
Medication reconciliation activities:
At admission the pharmacist:
•
Gathers patient’s medications;
•
Documents list of medications on form;
•
Identifies medications and verify usability;
•
Checks compliance information (quantity, refills);
•
Identifies patient’s community pharmacy and obtain medication history information;
•
Records patient’s weight and height to check creatinine clearance (CrCl); and
•
Determines if patient has any medication allergies.
At discharge:
•
Involve a pharmacist/technician team on several patient care unitsveral patient care
units;
•
Technician conducts medication reconciliation at discharge with a nurse when
pharmacist is not available;
•
Meets with clinical resource registered nurse to identify patients that require a best
possible medication discharge plan or identify patients at rounds (includes those with
a significant number of medication changes, those with known or suspected poor
compliance and those on complex medication regimens);
•
Technician prepares medication calendar using Seamless Solutions software;
•
Technician double checks the best possible medication discharge plan with pharmacist
or registered nurse;
•
Technician documents the activities in the electronic medical record; and
•
Pharmacist or nurse counsels patient using medication calendar.
Patients deemed at high risk for drug events as determined by standardized criteria are
referred to program.
Role of pharmacist: The pharmacist is in a supervisory role in the activities performed by
the technician.
Purpose: To develop a medication reconciliation program utilizing pharmacy technicians,
to minimize patient harm from unintended medication discrepancies. The role of the
pharmacy technician supports the delivery of clinical pharmacy services including
medication reconciliation from admission to discharge. Delegating appropriate duties to
technicians then frees up pharmacist resources to utilize their professional skills.
Human resources: 2 FTE pharmacy technicians in family practice/geriatrics program;
1 FTE pharmacy technician in emergency services.
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Other resources required: Appropriate computer support; space requirements for
pharmacist/technician team in patient care unit.
Funding/pharmacist remuneration: At the initiation of the program an additional 2.4
FTE pharmacist positions were approved by the provincial government. The program is
funded through operating funds for the health authority.
Benefits/advantages/impacts: The program is aimed at preventing adverse drug events
and it provides a continuity of care between settings. The physicians find that discrepancies
are identified and reconciled in a timely manner and it supports the multidisciplinary team
process. The Health Authority finds that it supports patient safety goals and required
organizational practices of the accreditation standards.
Benefits of technician involvement with the program:
•
Technicians are in innovative roles, which increases job satisfaction;
•
Increased interest in pharmacist/technician teams in other patient care areas;
•
Services are provided to more patients; and
•
Reduced physician, nurse and pharmacist time at admission and discharge.
Challenges and strategies used to overcome challenges: Providing consistency in
coverage (e.g., when an individual is on vacation or sick) is a challenge. It is a very busy
work environment, so the technician must be able to adapt to changing priorities/ multiple
demands for service.
Strategies for a successful multidisciplinary team:
•
Standardized process;
•
Training program – computer system software, orientation to the patient care area and
the medication reconciliation process;
•
Skills, knowledge and ability of experienced technicians – good interpersonal and
communication sills are required; and
•
Shared responsibility – require people that are accountable for their responsibilities
and take ownership of the process.
Feasibility
Sustainable: System has been sustained and enhanced over 11 years.
Scaleable: The utilization of the pharmacy technicians has developed over a seven-year
period. When moving into a new area, the approach is to provide service on a temporary
basis with internal funding support and once the advantage of the role of technicians is
seen, then the business case is supported.
Supported: Each unit is responsible for providing funding for the service provided by the
pharmacy, so a collaborative approach between Pharmacy Services and Program is
required.
Consistent: Process is designed to be consistent.
Evaluation: In development, a comparative assessment was done. The study found a 93%
reduction in omissions and inconsistencies. Two audits were completed. The audit of
December 2005 to May 2006, found that 83 patients received a best possible medication
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discharge plan, and 58% of these patients were on 11 to 20 medications. The second audit,
conducted May to July 2007, examined 24 patients in family practice. The average number
of medications was 11.7 and there were no discrepancies observed in the seamless care
program.
Academic documents:
•
Levesque J, White M. Presentation to Safer Health Care Now! Conference. Montréal,
QC, March 2007.
•
Nickerson A. Moving the Dots on Patient Safety Medication Reconciliation.
Presentation to Safer Health care Now! Third Session for the National Learning Series.
NS, May 2006.
•
Nickerson A. Medication Reconciliation. Presentation to Annual General Meeting of the
Canadian Society of Hospital Pharmacists. Ottawa, ON, August 2005.
•
Nickerson A. Outcome Analysis of a Pharmacist Directed Seamless Care Service.
Presentation to Professional Practice Conference Canadian Society Hospital
Pharmacists. Toronto, ON, 2002.
•
Nickerson A. Seamless Care. A Pharmacist’s Guide to Continuous Care Programs.
Published by Canadian Pharmacists Association Chapter 5: Hospital Pharmacist’s
Perspective, 2003.
•
Nickerson A, MacKinnon NJ, Roberts N, Saulnier L. Drug-Therapy Problems,
Inconsistencies and Omissions Identified During a Medication Reconciliation and
Seamless Care Service. Health Care Quarterly 2005;8:65-72.
•
Nickerson A, White M, Post A. Presentation to Provincial Pharmacy Technician
Conference, Saint John, NB, June 2007.
•
Saulnier L, White M. Technicians and Pharmacists Partnering for Successful Medication
Reconciliation. Presentation to CSHP Annual General Meeting. Regina, SK, August 14,
2007.
•
Saulnier L, White M. Presentation to National Teleconference on Safer Health Care
Now!. September 12, 2007.
CONTACT
Lauza Saulnier
Chief of Pharmacy Services
South-East Regional Health Authority
Moncton, NB
Tel.: (506) 857-5342
Email: [email protected]
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6.6 Medication Reconciliation — Admission to
Discharge and Into the Community, Fraser Health
Authority BC
Interviewee: Janice Munroe, Medication Safety Coordinator, Fraser Health Authority
Location or setting: Initially, Peace Arch Hospital in White Rock (pilot site). On roll-out,
13 sites as well as Mental Health & Addictions, Residential Care and Home Health.
Type of innovation: The program will reconfigure the professional practice of nurses,
physicians and pharmacists to improve patient safety.
Start date: February 2006
Description of initiative: The program is envisioned to follow the patient all the way
through the health system, from the hospital to community care, including the home
environment. Communication with the next care provider is an important component of the
system. The program will extend to other organizations that may be assuming care for the
patient, including Mental Health & Addictions, Residential Care, Home Health and the
Provincial Renal Program. Although it is anticipated that it will be some time before the
Medication Reconciliation Program reaches extensively outside of acute care, linkages with
these groups have been established. Medication management pharmacists visit select
patients in their home to reconcile medications. The best approach is identified through
process mapping.
Target is all residents in the Fraser Health Authority (approximately 1.5 million) who are
admitted to hospital.
Role of pharmacist: Consultation on admission, medication reconciliation in client’s home
(in select areas), discharge from hospital and communication to next care provider.
Purpose: To reduce preventable drug-related adverse events that can result in disability or
death. Reducing these drug-related adverse events will improve patient’s quality of life and
reduce expense incurred by the health care system.
Human resources: The goal is to develop tools and processes that do not require
additional human resources. Any new workload to be offset through improved efficiencies
and/or elimination of redundancies.
Other resources required: Software program to facilitate discharge communication to the
next care provider.
Funding/pharmacist remuneration: One-time funding to support development of tools
and processes.
Benefits/advantages/impacts: Improved patient care, reduced health care costs,
improved availability of hospital beds as a result of decreased length of hospital stay.
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Challenges and strategies used to overcome challenges: Without monetary
compensation, it has been difficult to engage physicians. With any practice change a
resistance to change has been seen across all disciplines. Potential for overall increase in
workload has resulted in resistance.
Visible and active support of senior leadership in the Health Authority and at the pilot site
has been instrumental in overcoming resistance to change. A physician champion to
facilitate physician engagement was critical to success. Engaging frontline staff in the
development and testing process (Plan Do Study Act [PDSA] cycles) directly demonstrated
the impact of their work and the value associated with their recommendations.
Feasibility
Sustainable: Sustainability is a component of the day-to-day operations.
Scaleable: Pilot project is being developed to enhance patient safety by following the
patient all the way through the system.
Supported: Fraser Health Authority Executive support.
Consistent: Developing a consistent medication reconciliation system throughout the Health
Authority is the purpose and mandate.
Evaluation: During the pilot project monthly audits were conducted to ensure
effectiveness of the changes that were made. Since going live throughout the pilot site,
these audits have been conducted weekly and with expanded measures. Weekly walkarounds to all patient care units at the pilot site has resulted in informal feedback from
frontline staff.
CONTACT
Fraser Health Medication Safety Coordinator
Support Services Facility
8521-198A St.
Langley, BC V2Y 0A1
Tel.: (604) 455-1328 ext. 741406
Fax: (604) 455-1315
Email: [email protected]
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6.7 Leila Pharmacy’s Health and Wellness Program:
Home-based Medication Reconciliation,
Winnipeg MB
Interviewee: Susan Selby, staff pharmacist, Leila Pharmacy, one of a number of
pharmacists involved in the home visit program.
Location or setting: Program is based in a community pharmacy, however pharmacist
services are provided in the patients’ homes (can also be independent living or assisted
living residences).
Type of innovation: Home visits to patients that can support continuity of care (after
discharge from health care facility). Cognitive services are provided outside of the
pharmacy (in patients’ homes). Medication reconciliation is provided.
Start date: 1999
Description of initiative: Pharmacist meets with patients enrolled in the program in their
homes on a regular basis to deliver prescriptions (i.e., exchange dosettes, bubble packaging
or other compliance packaging), counsel on new prescriptions or other medications,
monitor compliance, and provide advice on relevant disease states (asthma, diabetes,
dementia, hypertension, hyperlipidemia, osteoporosis).
A few clients are visited by a pharmacist every week, but most are visited on a less
frequent basis. In addition, in situations in which the client’s medications are handled by a
caregiver (e.g., supervised housing for the mentally ill), the pharmacist would typically
communicate with the caregivers and physicians.
Bubble or dosette packaging is promoted as part of the program (more than 80% of the
prescriptions dispensed are in bubble packaging).
Main target is seniors who are living independently – this comprises approximately 95% of
the program participants. Disabled patients and those with psychiatric disorders make up
the remaining 5% of program participants. The program is offered at no charge to the
patient, and the pharmacist reports that it is often family members who approach the
pharmacy for this service.
Role of pharmacist: In addition to visiting the enrolled seniors in their homes and
providing the services listed above, pharmacists keep in close contact with patient family
members to discuss their progress.
A new patient to the program will be visited by a pharmacist to set up and organize a
compliance package, review all medications they are using (including non-prescription
drugs, vitamins, inhalers, patches, etc.), identify any problems they may be having, ensure
everything they are taking is correct by verifying with the physician(s), and organizing
delivery and payment systems. This initial visit normally takes 30 to 60 minutes, and is
repeated when the patient’s first medication is delivered.
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Subsequent visits would be less frequent and usually of shorter duration unless the client is
having problems are needs a specific service (e.g., learning how to use a blood glucose
meter). A hospital discharge with several medication changes would also warrant a
pharmacist’s visit.
In addition, some follow-up can be done by telephone and there is a significant amount of
telephone or fax communication to the patient’s family and physician.
Many program patients also have home care services. In many cases, it is the home care
worker who dispenses the medications from the bubble or other compliance package.
Home care services policy prohibits home care workers from administering medications
from vials; however they are allowed to punch open blister packaging into a container, for
the patient. Accordingly, the pharmacist will work with home care workers and other
caregivers to help ensure that medication is taken accurately.
Purpose: Leila Pharmacy is independently owned and operated. This program was
initiated in response to what the owner perceived as an unfilled need in the community.
Provides a service that, together with other social services (e.g., home care), allows seniors
to live independently longer.
Human resources: 4.0 FTE pharmacists and 5.0 FTE pharmacy technicians are involved in
the operation of this program.
Other resources required: The entire community pharmacy is geared to offer this service.
Over 80% of the premises is configured for dispensing and re-packaging, with only one
aisle of over-the-counter medications/other.
Funding/pharmacist remuneration: It is funded solely by dispensing fees. About 40% of
clients have their medications dispensed on a weekly basis, another 40% bi-weekly, and
the remainder on four-week schedule.
Benefits/advantages/impacts: The pharmacist reported that while the benefits of the
program cannot be quantified, it is obvious that participants are benefiting. She said that
it is not uncommon, on an initial home visit, to see “drawers full of expired medications”
and the patient’s prescriptions in general disarray. The pharmacist will dispose of expired
and unused medications, and generally bring some order to medication administration.
Sometimes, the pharmacist can be helpful in referring patients in need to other social
agencies (e.g., Home Care) or facilitating other services through liaison with family
members.
Feasibility
Sustainable: There has been no formal assessment of economic viability done; however the
business is thriving. Start-up costs for a new client are very high in terms of the pharmacist
and technician time investments. It takes several months before these start-up costs are
recovered through dispensing fees.
Scaleable: Yes, would need staff resources and equipment.
Supported: Excellent feedback from participants, families and caregivers.
Consistent: Pharmacists all offer same basic service, but delivery would vary depending on
patient, circumstances and pharmacist’s professional judgment.
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Evaluation: Nothing formal, but positive feedback from clients, client family members, and
other caregivers.
Communications/promotional material: Article in Pharmacy Post a number of years
ago; website
CONTACT
Susan Selby
Leila Pharmacy
628 Leila Avenue
Winnipeg, MB R2V 3N7
Tel.: (204) 334-4248
Email: [email protected]
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7.0 CONSULTING AND COGNITIVE SERVICES
7.1 Murphy’s Health Education Centre,
Charlottetown PE
Interviewee: Ryan Murphy, Director, Pharmacy Development, Murphy’s Pharmacies,
Charlottetown, PEI
Sponsoring organization: Murphy’s Pharmacies
Other participating organizations: Works with many disease-based and non-profit
organizations in promoting health and illness prevention.
Location or setting: Community pharmacy.
Type of innovation: A community pharmacy innovation including a stand-alone health
education centre, with a multi-disciplinary health team, providing programs for health
education and illness prevention.
Start date: January 2005
Description of initiative: Murphy’s Health Education Centre (MHEC) was opened in
January 2005 to provide health promotion, health education and illness prevention services
to pharmacy patients. Pharmacists from six Murphy’s Pharmacies locations can book
appointments for individual medication consultations for patients. Additional services
offered at MHEC include health seminars, dietary consultations, weight management
programs, bone density screening, certified foot care, cholesterol testing and heart health
assessments, comprehensive health assessments, 24-hour blood pressure monitoring, and
INR monitoring. MHEC offers heart health and diabetes care clinics on a regular basis.
MHEC has private offices for consultation and health-related testing, a full kitchen for
healthy eating initiatives, a large seminar room, a drug information library, as well as a
library of patient education literature on most medications and health conditions.
Role of pharmacist: to work with other health professionals in providing expanded health
care services and programs.
Purpose: Murphy’s Pharmacies believes in health promotion, health education and illness
prevention. These programs are directed to the entire population of Prince Edward Island.
Human resources: There are 26 pharmacists within Murphy’s Pharmacies organization,
including nine added in 2007. The patient care facility is operated by pharmacists and
staffed by a multidisciplinary team including pharmacy technicians, pharmacists, registered
nurses, a certified foot care specialist, registered dietitian, and a dedicated receptionist.
Other resources required: Electronic data processing system, space for the health
education centre and several medical centres.
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Benefits/advantages/impacts: MHEC provides ongoing multidisciplinary health services
and programs for existing patients, the community and the province.
Challenges and strategies used to overcome challenges: The most difficult challenge is
to obtain third-party funding for pharmacy services not related to traditional medication
dispensing.
Feasibility
Sustainable: The program has been in operation since 2005. The program has been funded
by the retail operations of the pharmacy company; there has been no external funding
received.
Scaleable: Only if a viable funding model is available.
Supported: This innovative pharmacy service has been strongly supported by the patients
and the public.
Evaluation: No formal evaluation done to date. Public support has been very positive for
the program. It has been recognized as an excellent teaching site for health professional
students.
Communications/promotional material:
•
Extensive promotion through television, radio, and print media, directed at health
education and illness prevention. Have supported several health promotion campaigns
via radio, television, the Yellow Pages, and through public education.
•
Health Matters is a live one-hour television show aired twice weekly on the
community channel, in partnership with the Queen Elizabeth Hospital Foundation to
provide health education to the province.
•
Also partnered with a local radio station to air a 12-Week Wellness Challenge. Each
week the announcers were given a new health challenge by the Wellness Team,
which consisted of pharmacists, nurses and a dietitian. Comprehensive health
assessments, including various clinical measures and health questions, were conducted
at baseline and again at 12 weeks to determine winners. Listeners got on-air progress
reports and healthy living tips.
•
Have conducted similar programs in the community, including a 12-week Healthy
Choices Program for 30 participants, in partnership with the provincial government.
•
Also commits health professionals and resources to several school education programs
focusing on good health, including elementary, junior and senior high schools, and
the University of Prince Edward Island.
CONTACT
Ryan Murphy
Tel.: (902) 566-4660
Email: [email protected]
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7.2 Affinity for Women’s Health, Kitchener ON
Interviewee: Carole Beveridge, consultant pharmacist, owner/manager
Location or setting: Community health clinic
Start date: 2007
Description of initiative: Affinity for Women’s Health is a health care clinic designed to
support and promote women’s health through a variety of modalities and services, including:
•
Hormone health program;
•
Naturopathic medicine;
•
Massage therapy, reiki;
•
Far infrared sauna;
•
Bioelectrical impedance analysis;
•
Body composition and hormone balancing;
•
Holistic aesthetics;
•
Healthy breast program;
•
Live blood cell analysis
•
Infrared thermography clinics; and
•
Seminars and workshops on health issues including: fertility, healthy pregnancy,
perimenopause, menopause, healthy aging, bone health, and breast health.
Role of pharmacist: The pharmacist functions as a member of a multidisciplinary health
team. The pharmacist’s primary role in the clinic is disease prevention, through the
identification and treatment recommendations for horomonal imbalances that might relate
to health issues such as insulin resistance, abdominal obesity, hypertension and lipid
disturbances.
As part of the clinic’s hormone health program, the pharmacist completes a patient assessment including personal health history; lifestyle, symptom and risk factors; and hormone
level testing. The pharmacist uses the information from the client’s completed history form,
laboratory test results, and initial interview to determine the approach that should be taken
to promote health for that client. Recommendations for treatment may include lifestyle
change counseling, or hormonal and/or nutritional support. Clients are referred to other
health care professionals if required.
The pharmacist:
•
is certified by the North American Menopause Society as a Menopause Educator
(NAMS ME) and Practitioner (NAMS MP);
•
has completed the certification program in Breast Cancer Prevention developed by
Dr. Sat Dharam Kaur;
•
is a Registered Nutritional Consultant;
•
holds diplomas in Homeopathic Pharmacy (DHPh), Women's Health & Homeopathy
(DWH Hom), and Bach Flower Remedies; and
•
is a member of Professional Compounding Centers of America (PCCA).
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Purpose: To support and encourage women in making positive choices for their health.
Offers a combination of complementary and alternative medical therapies as well as healthfocused classes and educational seminars. For women of all ages who wish to enhance
their well-being.
The goal is to have women clients understand what signs and symptoms mean as their health
progresses, what they can do prevention-wise to improve their health. The program seeks to
make the health system more approachable and to serve as a conduit between the medical
health system and the complementary and alternative medicine (CAM) health system.
Human resources: Total staff includes three FTE and three part-time; one pharmacist.
Other resources required: The various health services within the program all require
specific equipment/resources. The program is located in a 2700 sq. ft. facility.
Funding/pharmacist remuneration: Funding is obtained on a fee-for-service from the
clients who utilize the program’s services.
Benefits/advantages/impacts: The practice aims at primary prevention of disease and the
promotion of a healthy lifestyle for women. One of the objectives is to help menopausal
women withdraw from hormonal preparations and offer other modalities to treat hormonal
imbalance.
Challenges and strategies used to overcome challenges: This is a new and innovative
program and the biggest challenge is to develop a sustainable client base for the program.
Seeking support from the physicians in the area is an ongoing challenge. The pharmacist is
currently enrolled in a Doctor of Homeopathy program to enhance her capabilities to
broaden services provided.
Feasibility
Sustainable/scaleable/supported/consistent: Due to the newness of the program, it is
difficult to assess at this time.
Communications/promotional material: The program has a website www.affinityforhealth.ca, and also produces a newsletter about women’s health issues.
CONTACT
Affinity for Health
558 Belmont Avenue W.
Kitchener, ON
Email: [email protected]
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7.3 Promotion of Women’s Health, Saskatoon SK
Interviewee: Brenda Dobni, owner/pharmacist
Sponsoring organization: Medical Arts Pharmacy
Location or setting: Community pharmacy
Type of innovation: Pharmacist is promoting healthy lifestyle and improving health
through a variety of steps related to both pharmaceutical and non-pharmaceutical
approaches.
Start date: November 2003
Description of initiative: In-depth consultations are provided to individual patients on
issues related to women’s health (e.g., menopause, perimenopause). These consultations
include a review of current medications, nutrition and lifestyle features, and the provision
of nutritional/supplement recommendations and medication options. Consultations are by
appointment. Referrals have come from a variety of sources including other patients, family
physicians, health food stores, physiotherapists, massage therapists and even a local
obstetrician/gynecologist.
Medical Arts Pharmacy has advanced compounding capability (e.g., laminar flow hood,
electronic mortar and pestle, ointment mill) to prepare formulations not commercially
available, and also offers a specialty compounding service.
Role of pharmacist: During the patient consultation appointments, pharmacist will:
•
Ask about the patient’s health goals, and determine why she is seeking assistance with
achieving them;
•
Assess the patient’s health and lifestyle (e.g., level of exercise, eating habits, sleep
patterns, nutritional supplements, current medications) and treatments tried in the
past; and
•
Devise with patient’s input, a plan of action: recommendations for achievable changes
to be made to improve health (e.g., eating a nutritious breakfast, 1-minute walks
throughout the day for stress release), and (where applicable), hormone therapy.
Purpose: To help educate women with gender-related health issues on how to achieve
their own balance and optimal wellness in life through diet, exercise, stress reduction,
nutritional supplementation, bioidentical hormones and if necessary, medication.
Human resources: 2.0 FTE pharmacists, 3.0 FTE pharmacy technicians, 0.5 FTE clerk, plus
occasional assistance from local pharmacy student.
Other resources required: Membership in, and special training from Professional
Compounding Centres of America (PCCA). The pharmacist attends two to four specialty
compounding training sessions per year, and technicians attend at least one on an annual
basis.
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Funding/pharmacist remuneration: Patients pay $60 to $90 per hour of consultation.
Benefits/advantages/impacts: Promotion of a healthy lifestyle for women.
Challenges and strategies used for overcoming challenges: Keeping up with the latest
developments in women’s health and specialty compounding is a challenge, as well as
obtaining formulae for compounds with patents pending. With the advent of the internet
and increased consumer awareness of promising new remedies, pharmacists face new
pressures to keep up with the information their patients are getting.
Hiring high-quality staff is essential to offer this consultation service.
Feasibility
Sustainable: Yes; services are revenue generating and more than offset investments needed
to offer them.
Scaleable: Yes.
Supported: Business is increasing through word-of-mouth from clients who have already
seen improvements to their health. Area physicians recognize and support this consultation
service as evidenced through referrals and also because they will, on occasion, call the
pharmacist for recommendations.
Consistent: Yes, since only the lead pharmacist is currently providing this service.
Evaluation: No formal evaluation done to-date. Informal evaluation on a case-by-case
basis. Since each patient’s needs are so unique, their feedback regarding what was
discussed and planned is reviewed.
Communications/promotional material: Promoted by word of mouth; service is not
formally advertised. This pharmacist is also featured in Pharmacy Practice’s Ask the Expert
column, offering advice to pharmacists on specific compounding problems.
CONTACT
Brenda Dobni
Medical Arts Pharmacy
Saskatoon, SK
Tel.: (306) 652-5252
Email: [email protected]
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7.4 Private Pharmacist Consultations, Community
Pharmacy, Keswick NB
Interviewee: Jeannie Collins Beaudin, community pharmacy co-owner and lead clinical
pharmacist
Sponsoring organization: Keswick Pharmacy
Location or setting: Two special counselling rooms within a community pharmacy
Type of innovation: Health promotion, chronic disease management, primary health care
Start date: 1997
Description of initiative: Private one-on-one consultations with pharmacist on a variety
of disease states. Mainly menopause/hormones issues, but also does consultations for
Restless Legs Syndrome, post-myocardial infarction (MI) care (including cholesterol
management), pain management, and general medication reviews. Recently started to do
lipid panel screening, cardiac risk assessment, and screening for UV damage to skin.
Consultations are booked for one day per week.
Role of pharmacist: Using a worksheet (to keep approach consistent and to guide
interview), pharmacist interviews patient, probing for information about symptoms relevant
to the offered disease state and lifestyle. Pharmacist then prepares a detailed report for the
patient – explaining the symptoms through provision of background information (“What’s
happening to cause these symptoms”) and makes recommendations on therapy (drugs as
well as nutrition, exercise, stress, etc where applicable) with rationale. Information is
divided under the headings: symptoms, recommendations, and discussion (rationale).
One copy of the report (usually one to two pages in length) goes to the patient, the other
to the patient’s physician. Report is accompanied by abstracts of the studies that support
the recommendations.
A second pharmacist has developed a special expertise in pain management. Nonprescription adjunctive drug therapy is sometimes recommended (muscle relaxants,
anti-inflammatories, nutritional supplements).
Purpose: This consultation program was initiated in response to patient demand for
individual attention and specific drug-related needs that could not be met in the course of
the more traditional community pharmacy practice. Targets community pharmacy clients
looking for in-depth information on specific disease states, including causes and treatment
options. Mainly self-referred, some physician-referred.
Patients commonly referred by physicians if they have expressed an interest in pursuing
natural hormone therapy or have failed to achieve symptom relief with standard therapy.
A local endocrinologist recently referred a gender-transitioned patient because of high
hormone requirements.
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Human resources: 0.4 FTE pharmacist devoted to consultations; second-year pharmacy
student (summer).
Other resources required:
•
Private consultation room (designated especially for this, rather than patient
counselling in conjunction with regular pharmacy business);
•
Software for pharmacy consultation business;
•
Internet access to conduct searches (recommends Google Scholar™ search); and
•
Equipment for cholesterol blood testing, skin damage assessment (ultraviolet camera)
on a lease basis through some banner programs.
Funding/pharmacist remuneration: Received start-up funding assistance through a
banner program (special funds for pharmacists wanting to move into patient consultation
practices).
Patients pay Keswick Pharmacy for these consultations. Some patients are reimbursed for
these through health benefit plans, other aren’t. Fees can be claimed as an income tax
deduction.
Benefits/advantages/impacts: Service provides more therapy options for patients, and
allows the pharmacist to devote the time needed to interview, research, and make
treatment recommendations.
Challenges and strategies used to overcome challenges: Was challenging at first to get
acceptance from local physicians, but countered this by providing them with significant
amounts of scientific data to support pharmacist’s recommendations. Having evidence to
support the pharmacist’s recommendations is key for physician support, as is the provision
of a copy of the report to the patient, for customer satisfaction.
Feasibility
Sustainable: Yes, patient pays.
Scaleable: Yes, but in relation to patient demand and availability of pharmacists to replace
the consulting pharamcist while she works on the consultations.
Supported: Yes, by clients who have received a consultation, as well as local physicians.
Credibility with local physicians illustrated by invitation to present at grand rounds at a
local hospital.
Consistent: Yes, through use of a worksheet.
Evaluation: No formal evaluation, but positive feedback from clients, referrals from
physicians.
Communications/promotional material: Have computer-generated brochures which
describe the service and provide contact information. These are distributed by e-mail, and
at pharmacy. A great deal of promotion is by word-of-mouth.
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CONTACT
Jeannie Collins Beaudin
Keswick Pharmacy
10 Yerxa Lane
Keswick, NB E6L 0A1
Email: [email protected]
Website: www.keswickpharmacy.com
7.5 Orthomolecular Management System: Individual
Patient Assessment and Compounding,
Ottawa ON
Interviewee: Kent MacLeod, CEO, NutriChem
Sponsoring organization: NutriChem
Location or setting: Community, compounding pharmacy
Type of innovation: Holistic approach to disease management.
Start date: 1981
Description of initiative: NutriChem has one of North America’s largest compounding
pharmacy centres. The company compounds individual prescriptions that are designed to
provide the specific ingredients that each individual requires.
Kent MacLeod is a specialist in women’s health issues and specializes in the impact of
nutrition on the biochemistry of individual disease states. He works with physicians,
naturopaths and a body chemistry-balancing consultant to ensure patients receive the best
combination of conventional and natural treatments for disease management. The
diagnostic approach includes assessment of organic acid markers, urinary peptides,
antioxidants, amino acids, oxidative stress and iron analysis and essential fatty acids.
Role of pharmacist: Pharmacist works with the biochemist to design a specific
formulation for each patient. Bio-identical hormone replacement therapy (HRT) can be
compounded in the needed strength and dosage form and administered via the most
appropriate route to meet each individual’s needs. The precise components of each
person’s therapy are determined after laboratory testing (BCB test), medical history and
determination of symptoms. Close monitoring and patient follow up is an important
component of the service.
Purpose: To ensure that patients receive the best combination of conventional and natural
treatments for disease management, and tohelp the general public achieve balance of body
chemistry in respect to optimal function and disease prevention and alleviation.
Human resources: Three pharmacists and approximately 10 technicians.
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Other resources required: 8000 sq. ft. facility, including a laboratory with analytical
equipment, compounding area, office space and a small retail outlet.
Funding/pharmacist remuneration: This is a fee-for-service operation.
Benefits/advantages/impacts: The company designs supplements to meet each patient’s
specific nutritional and metabolic needs. Blood and urine testing can be done onsite to
identify potential nutrient deficiencies, metabolic abnormalities, and oxidative stress. From
the results of this testing, a nutritional formula is created and custom compounded
specifically for the patient.
Challenges and strategies used to overcome challenges: Marketing challenge: patients
don’t understand why the health care system won’t pay for these services or why their own
physician doesn’t provide this service.
Developing appropriate marketing approaches, communicating with the patient regarding
the outcomes to be expected, and referring to the outcomes of other patients all help
overcome challenges.
Feasibility
Sustainable: Has been in operation since 1981.
Supported: Patients fees support operation.
Consistent: Consistent approach to the service provided
Evaluation: Cost of formal evaluation is a problem for this type of service. Patient
outcomes are tracked for in-house purposes.
Communications/promotional material: www.nutrichem.com
•
NutriChem Pharmacy has been featured on CBC Television’s The Health Show, on
ABC Television’s Day One, in books such as Prescription for Nutritional Healing, and
mentioned in patient support groups and websites. In 2003 Kent MacLeod published
his first book, thoroughly detailing metabolic and health issues in people diagnosed as
having Down syndrome.
CONTACT
Kent MacLeod, CEO
NutriChem Medical Centre
1305 Richmond Rd.
Ottawa, ON K2B 7Y4
Tel.: (613) 820-6755
Email: www.nutrichem.com
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8.0 ENABLERS OF INNOVATIVE PHARMACY PRACTICE —
AUTOMATION, INFORMATION AND
COMMUNICATION TECHNOLOGY, AND PHARMACY
TECHNICIANS
8.1 EMRxtra — Electronic Medical Records,
Sault Ste. Marie ON
Interviewee: Sunny Loo, Director, IT & eHealth, Ontario Pharmacists Association (OPA)
project lead
Sponsoring organization: Group Health Centre (GHC), Sault Ste. Marie, ON.
Other participating organizations: OPA; APOTEX Canada; Canada Health Infoway.
Location or setting: Primary Health Care Team
Type of innovation: Information and Communication Technology
Start date: August 2006
End date: April 2008
Description of initiative: The Group Health Centre (GHC) in Sault Ste. Marie provides
collaborative primary health care by a team of physicians, nurse practitioners,
physiotherapists, chiropodists, dietitians, optometrists and others. (The pharmacist,
however, has not yet been fully integrated into the team.) The EMRxtra program builds
upon the GHC’s current electronic health information platform, which is considered a
model for primary care across Canada.
EMRxtra will expand the continuum of care to the community pharmacists in a secure and
confidential manner, through electronic systems. Pharmacists will be able to collaborate
with the health care provider team and resolve drug related issues for patients more
efficiently. Currently the system has been implemented and is functioning in 21 out of the
24 pharmacies with the others being in the process of being connected.
Additional technology tools such as the iPharmacist (by APOTEX) will be made available to
support pharmacists in their provision of professional services to EMRxtra patients. The
GHC serves 60,000 people in Sault Ste. Marie.
Role of pharmacist: Pharmacists will have access to patients’ diagnosis, medications, and
lab results through a secure electronic gateway. To begin, patients enrolled in the
cardiovascular disease programs will give their permission to pharmacists to access their
electronic medical records. Pharmacists will help with disease management by making
recommendations to the patient regarding lipid levels, etc., and discuss dosage adjustment
with the physician.
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Purpose: Through this program, pharmacists will be able to collaborate with the health
care provider team and resolve drug related issues for their patients more effectively and
efficiently. The program has the following goals:
•
Integrate community pharmacists into a collaborative primary care team to enhance
collaboration, system efficiency and patient safety.
•
Create a sustainable model and significant infrastructure (e.g., IT and pharmacist’s
incentives) for collaboration between pharmacists and the GHC team.
•
Create program modules that enhance GHC programs and projects, with a focus on
medication adherence.
•
Demonstrate the role of community pharmacists in managing chronic diseases for
patients through a readily available electronic infrastructure.
Human resources: 24 pharmacies with 50 to 60 pharmacists.
Other resources required: Pharmacist web portal (Pharmacist Gateway) to provide
professional resources and tools supporting pharmacists, and as second level of secure
access to the electronic medical records. iPharmacist gives mobile access to professional
resources and tools through a PDA. It enables pharmacists to counsel their patients
anywhere within their work environment, without being tied to the desk.
Funding/pharmacist remuneration: This program has received funding from Canada
Health Infoway, an independent not for profit organization, supported by the federal
government. Infoway invests in projects across Canada to implement and use compatible
health information systems, which support a safer and more efficient health care system.
Fees for pharmacists providing professional services are sponsored by APOTEX Canada.
Benefits/advantages/impacts: Pharmacists will be more engaged in the care process with
access to clinical information for their patients, and will be able to provide enhanced
professional services.
Challenges and strategies used to overcome challenges: There have been a number of
challenges encountered:
•
There was a need to develop a web-based version of the electronic medical records
application to accommodate a Secure Sockets Layer Virtual Private Network (SSL VPN)
methodology for secure connection between GHC and pharmacies. SSL VPN
methodology was selected as it has least impact on existing pharmacy practice
management systems and therefore avoided software development for pharmacies;
•
It was necessary to involve the IT department at both pharmacies and GHC to deal
with restricted firewall access;
•
In order to comply with strict Personal Information Protection and Electronic
Documents Act (PIPEDA) requirements and to ensure patient confidentiality, several
levels of secure access were needed;
•
Different levels of network capacity at participating pharmacies impacted overall
access speed and quality of access by pharmacists; and
•
Change management – the need for pharmacists to adjust to new technologies and
processes inherent with the EMRxtra program. This is the first time many of the
pharmacists have access to electronic medical records.
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Some things that helped were:
•
Close involvement of electronic medical records software providers and various IT
departments from GHC and pharmacies;
•
User group meetings with pharmacists;
•
Training sessions; and
•
Mentorship program with local champions.
Feasibility
Sustainable: The system is being developed as a pilot project with the goal that it will be a
self-sustaining system to enhance patient care and health professional interaction.
Scaleable: This system could serve as a model for implementation in other parts of Ontario.
OPA has been approached by a number of family health teams regarding implementation
of a similar system.
Supported: Canada Health Infoway is very supportive of having this project be a pilot for
implementation in other areas across Canada.
Evaluation: The Courtyard Group is performing a formal evaluation of the project.
Feedback from patients and Group Health has been most supportive.
Academic documents:
•
The EMRxtra program has been featured in a number of pharmacy publications
including the Canadian Pharmacy Journal.
CONTACT
Sunny Loo
375 University Ave., #800
Toronto, ON M5G 2J5
Tel.: (416) 441-0788 ext. 4258
Fax: (416) 441-0791
Email: [email protected]
8.2 International Pharmacy Services: Internet-based
Dispensing, Winnipeg MB
Interviewee: Kris Thorkelson, Pharmacist and Owner, Canada Drugs.com
Location or setting: CanadaDrugs.com operates from a 9000 sq. ft. pharmacy and
distribution centre and 15,000 sq. ft. office for the call centre and management.
Type of innovation: Provision of pharmacy services through the internet with potential to
serve patients on a worldwide basis.
Start date: 2001
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Description of initiative: Pharmacy dispensing and delivery services are provided to
anyone who wishes to obtain medications from Canada Drugs.com, using the Internet:
•
More than 2700 prescription and over-the-counter products, vitamins and mineral
supplements;
•
Full selection of diabetic test strips, lancets, and glucometers;
•
Averaging over 500 prescriptions per day in Canada and many more outside of
Canada;
•
Pharmacists available, toll-free, during standard pharmacy hours;
•
Three health care professionals review each order at a different stage, and every
prescription is co-signed by a Canadian physician before being shipped;
•
Ordering and price reference available online or toll-free; and
•
Billing doesn’t occur until package is shipped.
Role of pharmacist: A pharmacist reviews each prescription, and contacts the patient’s
physician for verification if there are concerns about order accuracy or possible reactions.
Patient medication histories are obtained via telephone and e-mail and are verified by a
pharmacist. Patient counselling is provided via telephone and patient information sheets
are included with each prescription.
Three pharmacists review every prescription at different stages throughout the processing
of each order. Pharmacists are assigned a specific function (i.e., patient counselling,
therapeutic screening, confirmation of prescription order, approval of final prescriptions).
Purpose: This company is licensed by the Manitoba Pharmaceutical Association to practice
international prescription services from its base in Manitoba.
Human resources: Pharmacy technicians participate in the order filling process with a
tech-pre-check system. Pharmacists perform the final check on all activities.
Other resources required: Extensive facility and operation of large call centre, Canada
Post and other distribution services.
Funding/pharmacist remuneration: It is a fee-for-service pharmacy.
Benefits/advantages/impacts: Provides clients from any location with option of ordering
their medications without leaving their homes.
Challenges and strategies used to overcome challenges: The biggest challenge is the
provision of pharmacy services without the face-to-face interaction with the patient. The
patient has to be relied upon to provide the medication history and medication profile. It
should be noted that this challenge also occurs in many situations in the traditional
community pharmacy practice.
The system has been designed to provide effective electronic and telephone
communication with the patient or the patient’s agent to offset the drawback of lack of
face-to-face patient contact.
Feasibility
Sustainable: Canada Drugs has been in operation since 2001.
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Evaluation: None.
CONTACT
Canada Drugs
10 Terracon Place
Winnipeg, MB R2J 4G7
Tel.: 1 800 CAN-DRUG (226-3784)
Website: www.canadadrugs.com
8.3 Decentralized Hospital Pharmacy Services,
Brandon MB
Interviewee: Jane Lamont, Pharmacy Manager, Brandon Regional Health Authority,
Brandon, MB
Sponsoring organization: Brandon Regional Health Authority and Manitoba Department
of Health
Location or setting: 320-bed regional hospital.
Type of innovation: Utilization of automated systems and pharmacy technicians to free up
the pharmacists to provide patient-centred pharmacy services on a full-time basis to all
patients within the facility.
Start date: 2000
Description of initiative: In the late 1990s the Clinical Services Redevelopment Project at
the Brandon Regional Health Centre included funding automation in the distribution
module, pharmacy staffing to support it, and new pharmacy space. Despite a drop in
pharmacist staffing in 2000 (to four), the implementation of new technology was continued
in order to allow development of an innovative clinical role for the existing pharmacists.
(Aside from the main goal of providing good quality patient care.)
PYXIS cabinets were implemented for servicing the entire hospital, with the exception of
the neonatal ward. A pilot “tech-check-tech” was implemented to increase the technicians’
role in maintaining PYXIS. With distributive functions being automated within the
pharmacy department, attention was turned to greater involvement of pharmacists in direct
patient care. In 2001, the Centricity Module Fax Connect system was implemented, along
with relocation of pharmacists within the medical program, intensive care unit (ICU) and
long-term care (LTC). By 2003, the distribution centre was in new space, staffed primarily
by technicians, and staff had expanded to the current 12 full-time-equivalent pharmacists in
the decentralized model.
Pharmacists are assigned responsibility for specific program/departments of the hospital
and have offices within that area. Medication orders are scanned and transmitted as
electronic images from the nursing unit to the decentralized pharmacist’s offices,
eliminating paper orders. The pharmacist enters and verifies the order. All pharmacists have
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access to Internet based drug information and DPIN (the province-wide prescription
database for entire population).
Approval of the order through Centricity allows the nurse to obtain the appropriate
medication from the Pyxis Machine. The Pyxis system can handle almost all orders with a
ward stock of less than ten items, supplemented with patient-specific medications sent from
the pharmacy (e.g., inhalers, eye drops, creams).
In the central pharmacy, the pre-packing and preparation of the medications for the Pyxis
system is done by pharmacy technicians with a pharmacist in charge of the “tech check
tech” filling system. Technicians use bar-coding technology to verify medications in the
picking and refill process. The Pyxis system provides electronic records for controlled
substances and monitors expiry dates.
Role of pharmacist: Each decentralized pharmacist provides clinical services to their
assigned program, attending rounds, doing patient counselling, nursing education,
medication reviews, and develops practice guidelines for the pharmacy manual.
Psychiatry program – The pharmacist services acute adults; the geriatric assessment unit,
the child and adolescent treatment centre; and community mental health. Outpatients are
seen in a community setting once weekly (e.g., for Clozapine monitoring).
Renal program – The pharmacist looks after hemodialysis and pre-renal patients, interviews
them, does medication checks and medication reviews, follows the patient into the
community and partners with the community pharmacists to provide best medication
therapy. Renal patients admitted to acute care are more closely monitored by this
pharmacist especially at admission, transfer and discharge transition points.
Long-term care/palliation – The pharmacist is involved in rounds, family conferences, pain
recommendations, medication reviews for LTC patients, and has developed a discharge
program to facilitate the communication to the retail provider/personal care home
regarding medication at time of discharge.
Medicine program – two pharmacists in these areas also do discharge counselling, antibiotic
utilization review, investigational trials as well as the traditional pharmacy clinical roles.
One “Clinics Pharmacist” is involved in regional non-acute programs e.g., ambulatory heart,
respiratory, prehabilitation (optimizing patients for orthopedic surgery) and pain clinics.
The pharmacist does medication reviews, group teaching (both on site and by “Telehealth”
to remote sites), and services the Preoperative Assessment Clinic.
ICU/emergency – The pharmacist performs the traditional clinical role within the ICU unit
rounding daily with the multi-disciplinary team, educational, protocol development etc. The
pharmacist works in a consultative manner for the emergency department. This pharmacist
assists with the development of adult intravenous (IV) administration guidelines.
Rehabilitation – One pharmacist in this inpatient ward does specific medication assessment
rounds, patient counselling, is heavily involved in family conferencing and has a
specialization in tube feed assessment and medication issues.
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Pediatrics/maternity – One pharmacist provides services to both programs including a small
Neonatal Intensive Care Unit (NICU), is also responsible for the regional Respiratory
Syncytial Virus immunization program. The pharmacist has also developed pediatric
intravenous administration guidelines for the pharmacy manual.
Surgery – Serves the surgery inpatient units as well as OR, recovery, endoscopy and other
units. Home medication verification is a large part of the role in the surgical area.
Sterile services/chemotherapy – One pharmacist has developed a specialty in this area, but
all 12 pharmacists rotate through distribution in sterile services and four pharmacists rotate
through distribution of chemotherapy. Decentralized pharmacists in close proximity cover
other programs while the pharmacists rotate.
Medication reconciliation – Implementation of medication reconciliation on admission
began in June 2007.
Purpose: This project was initiated to develop an innovative hospital pharmacy service that
provides patient centred services to inpatient and ambulatory patients of the hospital.
Human resources: The 320-bed hospital has had as few as four pharmacists, but this has
grown to 12, including the project director, as the program has evolved. Other staff
includes an administrative assistant/secretary, technician manager, four FTE systems
technicians to maintain computer systems, interfaces, upgrades, system projects, etc., and
seven FTE pharmacy technicians for the PYXIS system.
Benefits/advantages/impacts: At the time of beginning the program, there was a massive
deficiency in pharmacists in Manitoba particularly the Brandon area due to the Internet
pharmacy hiring pharmacists in Minnedosa (small community 30 miles away). Developing
this system allowed pharmacists to be relieved of the drug distribution system and
broadened their role which was very attractive to potential hires. The pharmacist staff has
been expanded from four to 12.5 in three years.
Pharmacists are highly valued in the hospital for their expertise by administration, health
professionals and the patients. Patients are receiving better quality medication care, and this
program frees up pharmacist for clinical pharmacy duties.
Challenges and strategies used to overcome challenges:
Challenges included:
•
Obtaining the operating funds for the lease agreement with PYXIS.
•
The Centricity system frequently requires upgrades, so capital funding is required to
support the computer system upgrades.
•
Obtaining motivated pharmacists when there is staff turnover in an environment of
shortage.
•
Providing education for new pharmacists and maintaining and upgrading their
competency for the positions.
•
Since the pharmacists are spread out, maintaining communication with them all as
part of the department so they have a feeling of being on the team.
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Strategies were:
•
Continue to seek funding from management and the government to support and
upgrade the systems.
•
Developed good education and orientation modules for new staff.
•
Encourage continuing education programs by self education, special programs, bring
in speakers, participating in audio and video conferencing, provide educational
allowance, requirements for pharmacists to provide education session to colleagues at
meetings.
•
Now developing standards of practice that applies to all pharmacists in addition to
standards that apply to their specific area of practice.
Feasibility
Sustainable/scaleable/supported/consistent: The project director now judges the program is
sustainable. The lease agreement for PYXIS has been incorporated in the operational
budget. Staffing numbers are all permanent positions and pharmacist FTE is now
incorporated within health plans for new projects (e.g., new radiation/ expanded
chemotherapy program). The biggest challenge to sustainability is the availability of
pharmacists in Brandon; funding for four FTE pharmacists to develop a central intravenous
admixture program was lost when candidates could not be found to fill the positions.
Evaluation: No formal evaluation except through the performance evaluation feedback
done by program managers on pharmacists. Patient surveys consistently show positive
results in the pharmacy area if a pharmacist has been in contact. Program has received
very positive feedback from both nurses and physicians.
During 2006-2007, only 5% of the reported clinical interventions by pharmacists were
rejected by physicians, which demonstrates their acceptance of the pharmacists’ role.
Pharmacists reported 1395 drug info requests from health care professionals, 185 clinical
consults, 469 requests from nursing/physicians to provide patient counselling, and 1500
phone calls to physicians. These demonstrate that pharmacists are being utilized by their
colleagues and integrated well into the team.
CONTACT
Jane Lamont
Brandon Regional Health Authority
Tel.: (204) 578 4231
Email: [email protected]
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8.4 Pharmacist Network: Telehealth, Network Health
Care, British Columbia and Alberta
Interviewee: Barbara Gobis Ogle, Vice President, Clinical Services
Sponsoring organization: Network Health Care
Other participating organizations: Subcontracts for services provided by pharmacists
within community pharmacies; a large number of chain store pharmacies and individual
pharmacies participate in these contracts.
Location or setting: British Columbia and Alberta.
Type of innovation: This Pharmacist Network provides an innovative model of resource
utilization in delivering pharmacy innovative services. This is an innovative model of
chronic disease management.
Start date: 2003
Description of initiative: The Pharmacist Network was created, implemented and
continues to be contracted by the Ministry of Health in British Columbia to provide
program oversight to the BC NurseLine Pharmacist Service. This service is delivered
through a special network of community pharmacists providing medication information
services to BC NurseLine callers during evening and overnight hours when local
community pharmacists are not accessible. The service has handled over 40,000 calls and
has exceeded service level requirements since the first day of service in 2003.
Empowering Patients through Integrated Care (EPIC) is a second network of pharmacists
that provides medication management and self management support to people with
diabetes or congestive heart failure. This demonstration project was funded by the MultiJurisdictional Subcommittee on Telehealth and the BC Ministry of Health, in collaboration
with Fraser Health, Northern Health and the BC NurseLine from 2004 to 2006. Experience
from the EPIC project is being used by Health Lines Services BC to model future programs
such as Chronic Disease Management, Seamless Medication Care and Medication
Management. These services will utilize the Pharmacist Network and will be provided by
specially trained pharmacists working in community pharmacies throughout British
Columbia.
Contract recently awarded to build a medication information and advice service for callers
in the Edmonton area (Region 6) of Alberta. This service will give Alberta-based community
pharmacists their first opportunity to participate in a Pharmacist Network initiative and set
the stage for the implementation of future medication management services.
Generally aimed at government programs or third party payers.
Role of pharmacist: Pharmacist is contracted to provide the specific services within the
contract.
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Purpose: Network Health Care specializes in creating new innovative services and in
integrating and operationalizing these services into community pharmacy practice. Rather
than hiring pharmacists to work within these systems directly, the organization contracts
with the employers to have pharmacists within their organization provide specific services
within the project. The goal is a telephone service delivery platform that balances both
pharmacist availability and patient demand. It uses and supports community pharmacist
practice:
•
Increasing the capacity to deliver services to a larger geographic area without
compromising existing pharmacist services within a local community;
•
Providing program management to ensure service quality, consistency and patient
access to care across all participating pharmacies;
•
Leveraging the experience and expertise that a community pharmacist has and
maintains by working in a front-line practice setting;
•
Creating practice opportunities for community pharmacists to fully utilize their clinical
training, and
•
Optimizing human resources by providing clinical opportunities in their community
workplace and avoiding the current trend of requiring the pharmacist to move to
another clinical practice setting.
Other resources required: Administrative organization.
Funding /pharmacist remuneration: The Pharmacist Network provides funding as a
subcontract to pharmacy operations as a component of the service fee charged to the third
party or government program.
Benefits/advantages/impacts: This is a community pharmacy service model that has the
following advantages:
•
Services are scalable to meet demand;
•
Pharmacists remain in the community;
•
A comprehensive quality management system is built into front-line service delivery;
•
Clinical services are guideline and best practices based and can be quickly and
seamlessly integrated into practice;
•
Skill transference ensures that all patients receive the highest possible standard of care;
•
Costs are minimized by having no idle resources;
•
Services can be provided via Telehealth or in-person depending on the needs of the
patient and the proximity of a qualified pharmacist;
•
Provides an ideal platform for facilitating pharmacy practice change; and
•
Allows pharmacists and pharmacies a highly flexible and step-wise approach to
implementing a clinical practice.
The
•
•
•
advantages of having a pharmacist network include:
Uses a sophisticated quality management framework to ensure high quality care;
Uses clinical specialists to mentor pharmacists to ensure high quality clinical service;
Pharmacists gain experience working collaboratively within a multidisciplinary service,
and supporting primary care teams;
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•
•
•
•
•
Provides chronic disease management (CDM) and self-management support services;
Utilizes both hospital and community pharmacists;
Developer of innovative pharmacy case management and documentation software for
recording service episodes, tracking patient care over time and enabling collection of
population-based real-world clinical outcomes data;
Utilizes a layered referral system that recognizes the competitive aspect of pharmacy
and provides a right of first refusal opportunity based on existing patient preference;
and
Eliminates administrative overhead and allows the pharmacist to stay focused on
providing high quality clinical care.
Feasibility
Sustainable/scaleable/supported/consistent: In the implementation of the program, it has
been built on the assumption that this approach provides a program that should be
sustainable, scaleable, and consistent because of the administrative framework.
Evaluation: EPIC collected data from April 2005 to September 2006. The findings included:
•
Pharmacist telehealth medication and self management support works for most
patients;
•
Patients were significantly satisfied with EPIC;
•
Partnership with CDM programs improved physician engagement and information
exchange; and
•
Relationships and workflow changes would be optimized with longer time frames.
The Pharmacist Network programs have been well received by the government of British
Columbia, the pharmacists and the patients.
Academic documents:
•
The Tablet. Published by the British Columbia Pharmacists Association. April/May
2006, p10-11
CONTACT
Barb Gobis Ogle
Network Health Care,
445-5600 Parkwood Way,
Richmond, BC V6V 2M2
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8.5 Pharmacy Clinical Program and Pharmacy
Education/Mentoring, BC Interior
Interviewee: Dr. Dawn Dalen, Regional Pharmacy Practice Coordinator; Interior Health
Authority, Kelowna, BC
Sponsoring organization: Interior Health Authority, BC
Location or setting: Located in Kelowna, BC, and serving a large geographical area: from
the US border up to the Williams Lake area and from the Alberta border all the way to
Hope west of Kelowna.
Type of innovation: The provision of support and education programs remotely via electronic means.
Start date: June 2005
Description of initiative: The provision of education/mentoring and clinical support to
pharmacists and other clinical staff to ensure consistency in standards for clinical pharmacy
services. This program targets clinical staff (and their patients) in acute and/or long-term
care within the BC Interior Health Authority. This health authority covers a very large geographic region, with many remote locations. Sites include nine acute care facilities that have
pharmacists, 35 emergency departments, and a number of long-term care facilities.
The clinical support and education and mentoring delivered to pharmacists and other clinical staff (nurses and physicians) serving the region uses information technologies and other
web-based tools. For example, distance education usually takes place online using tools
like Microsoft Live Meeting and Powerpoint, as well as video conferencing because of geographic spread. In addition some of the pharmacists are also involved in innovative electronic practices; there are areas in Interior Health where full dispensing is done by
videoconferencing. A pharmacy technician at the site will contact the pharmacist, and the
pharmacist will counsel the technician and/or the patient via videoconference.
Role of pharmacist: Clinical practice, mentoring and education to staff.
Purpose: To ensure that all pharmacists feel supported in their growth and development,
not just those in teaching hospitals, but also those in small community hospitals.
Human resources: Four individuals invest part of their time to this initiative: one director
of pharmacy; one regional clinical manager, and two pharmacy practice coordinators. All
four are full-time equivalents, but also have other functions to fulfill.
There are professional practice leaders, who are site managers at each location. They are
responsible for assisting the clinical coordinators/manager with implementing programs,
courses, etc. At the regional office, there is a formulary manager and a medication safety
manager, in addition to the director and clinical manager, as well as pharmacy IT support
people.
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Other resources required: Video-conferencing equipment at all the sites. Each
pharmacist has a Palm Pilot. Regional staff members also need cell phones and/or
smartphones (e.g., Palm Treos). Many of the sites are also equipped with laptops for
meeting and presentation purposes.
Funding/pharmacist remuneration: From the province, through the Health Authority.
Benefits/advantages/impacts: The program extends specialized knowledge and support
to pharmacists and health professionals beyond the walls of a teaching facility to more rural
areas; helps them develop some of those resources and helps them feel supported in their
roles.
Challenges and strategies used to overcome challenges: Finding enough qualified
pharmacists to service all the rural areas is the major challenge. There was resistance to
change from some pharmacists and other health professionals, and there were legal barriers
to overcome to provide services remotely via videoconferencing. Finding enough qualified
pharmacists in the region, especially in remote areas, remains a challenge.
One tool was the extensive use of information technology (e.g., videoconferencing) in the
delivery of courses, support to pharmacists and even pharmacy services to patients. To
help increase buy-in from pharmacists in each location, participants tried to make sure that
local pharmacy managers understood what was being done. Ensure that everyone is
communicating the same message. Being in touch with the College of Pharmacists was
necessary to ensure that all the standards were being met. The result has been changes to
some of the standards to allow adequate health care to all the patients in the region.
Feasibility
Sustainable: Yes, because the status quo itself is not sustainable. It is not realistic to have
someone with a Doctorate of Pharmacy at every site in Canada, and this model does not
require that.
Scaleable: It is scaleable, but this is the major challenge. The limitation comes from the
availability of the human resources with adequate hospital training and clinical experience
in various settings.
Supported: Some physicians support the initiative and others may see it as impinging on
their territory. Upper management is very supportive. They like the idea of standardization
and delivery to all, as well as the mentoring for people that are outside the teaching
facilities. However, on the ground level, it takes a long time to see the results that upper
management wants to attain.
Consistent: The standardization and consistency of the delivery of the program is a work in
progress. It is improving.
Evaluation: Initially, there was a needs assessment with all of the pharmacy staff to
establish priorities. There is also an annual staff survey to help improve the process.
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CONTACT
Dr. Dawn Dalen
KGH-Pharmacy Services
2268 Pandosy St.
Kelowna, BC V1Y 1T2
Tel.: (250) 862-4300 ext. 7446
Email: [email protected]
8.6 Central Production Pharmacy, Calgary AB
Interviewee: Bruce McKenzie, Regional Operations Manager, Central Production
Pharmacy, Calgary Health Region
Sponsoring organization: Calgary Health Region
Location or setting : 1119-55 Ave. NE, Calgary, AB T2E 6W1. The facility is in a light
industrial area complex warehouse that was converted into the drug distribution facility and
state-of-the-art sterile production facility with contemporary large volume packaging
equipment and automated data system.
Type of innovation: Centralization of sterile and non-sterile medication preparation and
delivery to several institutions.
Start date: November 2002
Description of initiative: This was the first centralized system in Canada and possibly in
North America that combines inventory, drug ordering, oral unit dose and intravenous (IV)
preparation in one facility.
The Central Production Pharmacy serves all four acute care unit-dose hospitals in Calgary.
It plays a larger role for the three adult sites than for the Alberta Children’s Hospital (ACH).
The adult sites each maintain “immediate care” pharmacies that deal with most physician
orders and are responsible for sending all interim doses (unit dose and IV admixture) for
new orders. All orders from all sites are entered into the Centricity pharmacy system
(formerly BDM). Having one common database for all patient orders makes the Central
Production functions possible.
What Central Production (CP) does for the sites:
•
CP does all of the purchasing of inventory for the acute sites in Calgary. Each site
orders whatever inventory they may need from CP to keep on their shelves. This
inventory is kept on hand for urgent unit needs or interim dose issues. Their actual
inventory is greatly reduced from what a hospital normally keeps on hand.
•
All oral medication stock is unit dosed before being sent to the sites.
•
CP provides stock of all commonly used IV admixture doses to be used for interim
doses. Each site (adult sites mainly) keeps a standard number of doses of these
common intravenous (IV) admixtures and orders replacement stock as required.
•
CP prepares all of the patient specific 24 hour unit dose runs for the three adult sites.
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•
•
•
•
CP prepares all patient-specific IV admixture (CIVA) runs each day for the three adult
sites (two runs a day for each site – 12 hours worth per run).
CP prepares all patient specific parenteral nutrition (PN) solutions for all sites in
Calgary daily. PN orders are the only physician orders seen at CP. The CP pharmacists
process these orders each day. CP gathers and fills all unit specific ward stocks for the
four sites. The site technicians check the ward stocks and enter unit specific orders
into the pharmacy system. A requisition prints at CP for filling. The site assistants then
go up to the units to put the stock away.
CP purchases all narcotics for use in the region. All oral solids are packaged into
count cards, however nothing is done on a unit-specific basis for the sites. CP stocks
site pharmacy vaults so the site staff can stock the nursing units as required.
CP compounds about 20 of the more commonly used oral liquid and topical
preparations. The sites can order these compounded items as required to keep on
hand as stock.
Role of pharmacist: As a result of the new Alberta College of Pharmacy regulations (April
2007), the four pharmacists in the central facility are required to be on site for indirect
supervision (onsite and readily available). They do daily spot audits of checked products,
process the region’s daily parenteral nutrition orders as well as numerous special projects.
Technicians are responsible for all sterile production and all checking (tech-check-tech).
Assistants do only non-patient specific activities like unit dose packaging, operating the
automated unit dose dispensing machines, narcotic control, ward stock gathering, shipping
and receiving etc. CP dispenses 10,000 to 12,000 oral unit doses, 2000 IV admixtures and 60
PN solutions per day. The central facility services about 2200 hospital beds.
Purpose: This central production pharmacy was developed as an efficient system of
medication distribution in unit dose packaging to the acute care facilities in the Calgary
Health Region. One of the main goals was to use CP to facilitate conversion of the Foothills
Hospital to unit dose almost two years ago. It had been a very traditional ward stock
hospital prior to opening of CP. The pharmacy was physically too small to take on unit
dose independently. Foothills Hospital was able to successfully convert to unit dose by
having CP prepare their 24-hour unit dose fills as well as their CIVA and PN production.
Human resources: one operations manager (pharmacist), one systems and inventory
manager (pharmacist), four staff pharmacists, two technical managers, 35 technicians and
24 assistants.
Other resources required:
•
Unit dose – PacMed (McKesson) automated packaging machine for patient specific
unit dose runs; Twin Cadet oral solid packager for non-PacMed unit dosing.
•
PN – Baxa automated PN compounder.
•
CIVA – Healthmark (PharmAssist) pumps for large volume reconstitution and minibag
preparation.
•
GE Centricity – Pharmacy information system for patient order database, ward stock
maintenance, inventory purchasing, drug use evaluation (DUE), etc.
•
Eclipsys Sunrise Clinical Manager – Patient care information system (electronic patient
chart). Physicians enter all patient orders into this system.
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Funding/pharmacist remuneration: The funding is through operating funds for the
pharmacy services in the Calgary Health Region.
Benefits/advantages/impacts: The centralization of services provides economies of scale
for purchasing, packaging and delivery services.
Challenges and strategies used to overcome challenges: Workload challenges exist for
staffing – currently difficult to recruit assistants (must have completed a four-month
Southern Alberta Institute of Technology course). There are also delivery difficulties.
The program is currently trying to increase the assistant wage scale to attract more
employees to these jobs. It now has two dedicated pharmacy delivery trucks to handle
most daily runs to the various hospital sites, seven days per week. This will decrease
reliance on contracted private courier companies.
Feasibility
Sustainable: During the time is has been in operation, it has demonstrated that it is a
sustainable system.
Scaleable: The Central Production Pharmacy has seen visitors from all over North America
visit the facility with the intention of adopting a similar system.
Supported: The system is supported from permanent operating funds as a component of the
pharmacy services provided to the region.
Consistent: Very specific protocols have been developed for all components of the system
as well as for each type of personnel operating within the system.
Evaluation: No formal evaluation, but there is continuous quality monitoring; process
validation, certification and recertification of all staff involved in drug handling processes as
well as daily pharmacist spot audits to ensure the accuracy of the system.
CONTACT
Bruce McKenzie
Tel.: (403) 943-9603
Email: [email protected]
8.7 Fraser Health Pharmacy Drug Distribution Centre,
Langley BC
Interviewee: Linda Morris, Regional Pharmacy Manager, Support Services, Fraser Health
Sponsoring organization: Fraser Health Authority
Location or setting: Langley, BC
Type of innovation: Centralization of production for 12 individual site pharmacies at one
custom-built facility.
Start date: June 2006
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Description of initiative: Centralized distribution to 12 facilities within Fraser Health
Authority, covering 2000 acute care beds and 2000 residential beds with unit dose
packaged oral solids, batch and patient-specific; standardized intravenous solutions, batch
and patient specific; and purchasing.
The Fraser Health Pharmacy Drug Distribution Centre (PDDC) is a 16,000 sq. ft. facility
attached to the Fraser Health Materials Management Centre, so the delivery system is
shared. The facility is open from 6 a.m. to 6 p.m. seven days per week and has access to
two to three delivery times to each site per day.
All medication orders are processed in the local institutions and the MEDITECH system
then generates the patient-specific refill list and labels at the Drug Distribution Centre.
Patient doses and batches are delivered to the pharmacy in each location and then
distributed to the patient areas. Targets acute and extended care patient populations.
Role of pharmacist: There are no pharmacists as part of the distribution system, but there
are pharmacists located in offices above the facility for advice and direction. Pharmacists
develop the standardized procedures that are based on a “tech-check-tech” system.
Purpose: Certain repetitive production functions can be performed more safely and cost
effectively in a custom-designed centralized facility utilising pharmacy technicians.
Goals are to improve quality and hence safety of medications, provide efficiencies with
pharmacy and provide unit volume and space for applicable automation.
Human resources: Currently there are 20 FTE pharmacy technicians with a phasing
process to 40 FTEs when fully implemented.
Other resources required: New facility and the equipment on site includes:
•
Two automated packagers with batch and patient specific functionality (McKesson
PacMed);
•
Unit dose liquid packager (Fluidose);
•
Unit dose solid packager (Euclid Cadet); and
•
Five repeater pumps used for intravenous (IV) preparation (Healthmark).
They are considering automated inventory storage systems, additional packaging
equipment, parenteral nutrition pump and IV robot.
Funding/pharmacist remuneration: This service is financed by the Fraser Health
Authority under the operating budget of the pharmacy service.
Challenges and strategies used to overcome challenges: Requires consistency of
practice across region. There are significant logistic/distribution issues. Ongoing resource
funding is another challenge. In the region, MEDITECH has three different databases and it
is difficult to have them integrated into one system.
To address these issues, there is ongoing practice development with Pharmacy
Management Team, incorporation of contingency plans to address transportation issues,
business case submission for improvements to the drug distribution systems that would also
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provide additional staff and capital funding for PDDC. The program is also piloting a
system of creating patient specific medications at one 200-bed residential site. If successful,
plan to scale it up to cover the residential beds in the region.
Feasibility
Sustainable: Has been developed as an ongoing operation.
Scaleable: It services 12 facilities in Fraser Valley.
Supported: Supported from operating budget.
Consistent: Have extensive protocols and certification process to standardize procedures.
Evaluation: Ongoing statistical analysis of services and costs. Continual feed back from
“customers” (i.e., site pharmacy managers). There is extensive quality assurance for both
the product and the certification of the pharmacy technicians as well as environmental
quality assurance. They follow the USP 797 recommendations and are close to meeting the
requirements.
CONTACT
Linda Morris
Regional Pharmacy Manager
Tel.: (604) 455-1328 ext. 741298#
Email: [email protected]
8.8 Enhanced Utilization of Pharmacy Technicians in a
Community Pharmacy, Ottawa ON
Interviewee: Amanda Blazevic, staff pharmacist
Sponsoring organization: The Glebe Pharmasave Apothecary (GPA)
Other participating organizations: Suppliers provide on-site training and lunch and
learn sessions for technicians, and other outside training resources, e.g., Professional
Compounding Centers of America (PCCA).
Location or setting: A community pharmacy in a downtown urban area
Type of innovation: Delegation of duties/use of pharmacy technicians
Start date: 1984
Description of initiative: Technicians at GPA are described as having “an advanced level
of competency and delegated tasks.” Because of the significant amount of money and time
invested in technician training, management feels comfortable putting “a huge amount of
responsibility and trust in our technicians.”
While GPA pharmacy technicians receive training in most departments, they also each have
as assigned specialty, based on their own interest and experience, as well as the technical
support needs identified by staff pharmacists.
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Technician specialties include:
•
Dosette set-up;
•
Compliance packaging assessments;
•
Non-sterile compounding;
•
Sterile IV compounding;
•
Blood pressure monitoring and blood glucose monitoring patient training;
•
Compression stocking fittings; and
•
Identification of patients who may be candidates for the Ontario government
sponsored MedsCheck program, and booking appointments with the pharmacists for
program consultations.
Training is supervised and coordinated by the dispensary operations manager/senior
technician, who encourages technician staff to take workshops and participate in lunch and
learn sessions. GPA also sponsors more formal training of technicians, through enrollment
in special off-site training courses and programs (e.g., sterile compounding workshop in
Houston, Texas).
Efforts to train and utilize pharmacy technicians have been increased in the past year or so,
due to impending regulation of technicians in Ontario and other indications that this is
“where [pharmacy] practice is going.” While most have been trained on-the-job, two
technicians also recently completed a certification program.
Role of pharmacist: The advanced use of technicians enables the pharmacists to
concentrate on their professional, cognitive role – dealing with therapeutics and providing
pharmaceutical care. Protocols are in place that require pharmacists to check and sign-off
on some of the technician-led activities (e.g., compounding, dosette loading), however time
spend is minimal compared to having the pharmacist carry out these activities him or
herself.
Purpose: To increase efficiency of pharmacy’s operation and to offer a heightened level of
customer service. Empowering technicians at GPA frees up the pharmacists to care of
patients. With the pharmacists’ extensive knowledge in therapeutics, they are best used in
direct patient care versus the technical side of pharmacy.
GPA expects to have improved patient care with this system; more pharmacist time with
patients, answering their questions, helping them select non-prescription drug items,
catching drug interactions, etc. The pharmacy also aims to have the pharmacists and
technician employees “love their jobs”, keeping them busy with new tasks and challenges.
Human resources: GPA employs seven full-time technicians in total (including the
coordinator), four full-time pharmacists, and a part-time pharmacist assigned to the sterile
IV lab.
Other resources required: Financial resources for recruitment and training of technicians.
Funding/pharmacist remuneration: All provided by GPA.
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Benefits/advantages/impacts: Great resource for pharmacists (particularly given a climate
of pharmacist shortages). There is increased job satisfaction for both pharmacists and
technicians (able to focus on their respective areas of interest/education). It gives room for
learning and expansion on roles.
Challenges and strategies used to overcome challenges: There are high costs
(financial, time, energy) needed to properly train the technicians. Having specially trained
employees can cause problems for vacation and sick leaves. Need to constantly work on
communication and scheduling. GPA departments are spread out over three floors ( i.e., to
accommodate compounding, packaging and other technician-led services) which makes
communication between staff sometimes challenging.
Properly trained and motivated technicians have been effective in promoting the services
that the GPA offers, which has resulted in increased business – more than offsetting the
training and recruitment costs. GPA is conducting some cross-training of technicians to fill
gaps during vacation or other temporary leaves of absence. Pharmacists and technicians
meet every Monday to talk about challenges and successes from the week before.
Feasibility
Sustainable: Is supported by increased business revenues.
Scaleable: To a point; requires diversity of service offerings and volume.
Supported: By staff, management and owner.
Consistent: Through implementation of standard operating procedures.
Evaluation: No formal evaluation has been carried out. Informal evaluation criteria include:
job satisfaction of pharmacists and technicians, ease of recruiting pharmacists, and a
“booming” business with an ever-expanding customer base.
Communications/promotional material: Owner promotes this pharmacy’s operation
and philosophy. Many public presentations to various groups in the community.
CONTACT
Amanda Blazevic
The Glebe Pharmasave Apothecary
778 Bank St.
Ottawa, ON K1S 3V6
Tel.: (613) 234-8587
Fax: (613) 236-0393
Email: [email protected]
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ASSOCIATION OF DEANS OF PHARMACY OF CANADA
(ADPC)
ASSOCIATION OF FACULTIES OF PHARMACY OF CANADA
(AFPC)
CANADIAN ASSOCIATION OF CHAIN DRUG STORES
(CACDS)
CANADIAN ASSOCIATION OF PHARMACY TECHNICIANS
(CAPT)
CANADIAN PHARMACISTS ASSOCIATION
(CPhA)
CANADIAN SOCIETY OF HOSPITAL PHARMACISTS
(CSHP)
NATIONAL ASSOCIATION OF PHARMACY REGULATORY AUTHORITIES
(NAPRA)
THE PHARMACY EXAMINING BOARD OF CANADA
(PEBC)
OFFICE OF THE SECRETARIAT
1785 ALTA VISTA DRIVE, OTTAWA ON K1G 3Y6
TEL.: 613-523-7877 • FAX: 613-523-0445
www.pharmacyhr.ca
[email protected]
Funded by the Government of Canada’s Foreign Credential Recognition Program