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]

6

© 2008 Canadian Pharmacists Association 7

SECTION 2 — COLLABORATIVE PRIMARY HEALTH CARE TEAMS

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.

8 Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

7

SECTION 2 — COLLABORATIVE PRIMARY HEALTH CARE TEAMS

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

8

© 2008 Canadian Pharmacists Association 9

SECTION 2 — COLLABORATIVE PRIMARY HEALTH CARE TEAMS

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, 10 Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

9

SECTION 2 — COLLABORATIVE PRIMARY HEALTH CARE TEAMS

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 10

© 2008 Canadian Pharmacists Association 11

SECTION 2 — COLLABORATIVE PRIMARY HEALTH CARE TEAMS

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

12 Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

11

SECTION 2 — COLLABORATIVE PRIMARY HEALTH CARE TEAMS

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

12

© 2008 Canadian Pharmacists Association 13

SECTION 2 — COLLABORATIVE PRIMARY HEALTH CARE TEAMS

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.

14 Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

13

SECTION 2 — COLLABORATIVE PRIMARY HEALTH CARE TEAMS

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.

14

© 2008 Canadian Pharmacists Association 15

SECTION 2 — COLLABORATIVE PRIMARY HEALTH CARE TEAMS

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

16 Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

15

SECTION 2 — COLLABORATIVE PRIMARY HEALTH CARE TEAMS

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 16

© 2008 Canadian Pharmacists Association 17

SECTION 2 — COLLABORATIVE PRIMARY HEALTH CARE TEAMS

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

18 Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

17

SECTION 2 — COLLABORATIVE PRIMARY HEALTH CARE TEAMS

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]

18

© 2008 Canadian Pharmacists Association 19

SECTION 2 — COLLABORATIVE PRIMARY HEALTH CARE TEAMS

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.

20 Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

19

SECTION 2 — COLLABORATIVE PRIMARY HEALTH CARE TEAMS

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.

20

© 2008 Canadian Pharmacists Association

SECTION 2 — COLLABORATIVE PRIMARY HEALTH CARE TEAMS

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]

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

21

SECTION 2 — COLLABORATIVE PRIMARY HEALTH CARE TEAMS

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. 22

© 2008 Canadian Pharmacists Association

SECTION 2 — COLLABORATIVE PRIMARY HEALTH CARE TEAMS

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. Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

23

SECTION 2 — COLLABORATIVE PRIMARY HEALTH CARE TEAMS

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

24

© 2008 Canadian Pharmacists Association

SECTION 2 — COLLABORATIVE PRIMARY HEALTH CARE TEAMS

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.

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

25

SECTION 2 — COLLABORATIVE PRIMARY HEALTH CARE TEAMS

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

26

© 2008 Canadian Pharmacists Association

SECTION 2 — COLLABORATIVE PRIMARY HEALTH CARE TEAMS

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)

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

27

SECTION 2 — COLLABORATIVE PRIMARY HEALTH CARE TEAMS

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.

28

© 2008 Canadian Pharmacists Association

SECTION 2 — COLLABORATIVE PRIMARY HEALTH CARE TEAMS

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.

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

29

SECTION 2 — COLLABORATIVE PRIMARY HEALTH CARE TEAMS

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

30

© 2008 Canadian Pharmacists Association 31

SECTION 2 — COLLABORATIVE PRIMARY HEALTH CARE TEAMS

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

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

31

SECTION 2 — COLLABORATIVE PRIMARY HEALTH CARE TEAMS

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

© 2008 Canadian Pharmacists Association

SECTION 2 — COLLABORATIVE PRIMARY HEALTH CARE TEAMS

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]

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

33

SECTION 3 — EXPANDED PRESCRIBING AUTHORITY

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. 34

© 2008 Canadian Pharmacists Association

SECTION 3 — EXPANDED PRESCRIBING AUTHORITY

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

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

35

SECTION 3 — EXPANDED PRESCRIBING AUTHORITY

• • • •

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. 36

© 2008 Canadian Pharmacists Association

SECTION 3 — EXPANDED PRESCRIBING AUTHORITY

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.

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

37

SECTION 3 — EXPANDED PRESCRIBING AUTHORITY

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

38

© 2008 Canadian Pharmacists Association

SECTION 3 — EXPANDED PRESCRIBING AUTHORITY

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. Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

39

SECTION 3 — EXPANDED PRESCRIBING AUTHORITY

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.

40

© 2008 Canadian Pharmacists Association

SECTION 3 — EXPANDED PRESCRIBING AUTHORITY

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.

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

41

SECTION 3 — EXPANDED PRESCRIBING AUTHORITY

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.

42

© 2008 Canadian Pharmacists Association

SECTION 3 — EXPANDED PRESCRIBING AUTHORITY

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.

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

43

SECTION 3 — EXPANDED PRESCRIBING AUTHORITY

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. 44

© 2008 Canadian Pharmacists Association

SECTION 3 — EXPANDED PRESCRIBING AUTHORITY

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.

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

45

SECTION 3 — EXPANDED PRESCRIBING AUTHORITY

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]

46

© 2008 Canadian Pharmacists Association

SECTION 3 — EXPANDED PRESCRIBING AUTHORITY

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.

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

47

SECTION 3 — EXPANDED PRESCRIBING AUTHORITY

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]

48

© 2008 Canadian Pharmacists Association

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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.

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

49

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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

50

© 2008 Canadian Pharmacists Association

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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.

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

51

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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.

52

© 2008 Canadian Pharmacists Association

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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]

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

53

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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. 54

© 2008 Canadian Pharmacists Association

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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,

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

55

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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 56

© 2008 Canadian Pharmacists Association

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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.

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

57

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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. 58

© 2008 Canadian Pharmacists Association

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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. Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

59

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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.

60

© 2008 Canadian Pharmacists Association

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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); Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

61

SECTION 4 — CHRONIC DISEASE MANAGEMENT

• • •

• • • •

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

62

© 2008 Canadian Pharmacists Association

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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]

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

63

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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 64

© 2008 Canadian Pharmacists Association

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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]

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

65

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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.

66

© 2008 Canadian Pharmacists Association

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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.

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

67

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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. 68

© 2008 Canadian Pharmacists Association

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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.

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

69

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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. 70

© 2008 Canadian Pharmacists Association

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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.).

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

71

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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.

72

© 2008 Canadian Pharmacists Association

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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;

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

73

SECTION 4 — CHRONIC DISEASE MANAGEMENT

• • •

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.

74

© 2008 Canadian Pharmacists Association

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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.

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

75

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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]

76

© 2008 Canadian Pharmacists Association

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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 Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

77

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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]

78

© 2008 Canadian Pharmacists Association

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

79

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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,

80

© 2008 Canadian Pharmacists Association

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

81

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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

82

© 2008 Canadian Pharmacists Association

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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 Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

83

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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]

84

© 2008 Canadian Pharmacists Association

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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. Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

85

SECTION 4 — CHRONIC DISEASE MANAGEMENT

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]

86

© 2008 Canadian Pharmacists Association

SECTION 5 — HEALTH PROMOTION AND DISEASE PREVENTION

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.

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

87

SECTION 5 — HEALTH PROMOTION AND DISEASE PREVENTION

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. 88

© 2008 Canadian Pharmacists Association

SECTION 5 — HEALTH PROMOTION AND DISEASE PREVENTION

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

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

89

SECTION 5 — HEALTH PROMOTION AND DISEASE PREVENTION

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.

90

© 2008 Canadian Pharmacists Association

SECTION 5 — HEALTH PROMOTION AND DISEASE PREVENTION

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

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

91

SECTION 5 — HEALTH PROMOTION AND DISEASE PREVENTION

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]

92

© 2008 Canadian Pharmacists Association

SECTION 5 — HEALTH PROMOTION AND DISEASE PREVENTION

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

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

93

SECTION 5 — HEALTH PROMOTION AND DISEASE PREVENTION

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

94

© 2008 Canadian Pharmacists Association

SECTION 5 — HEALTH PROMOTION AND DISEASE PREVENTION

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.

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

95

SECTION 5 — HEALTH PROMOTION AND DISEASE PREVENTION

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]

96

© 2008 Canadian Pharmacists Association

SECTION 6 — CONTINUITY OF CARE

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.

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

97

SECTION 6 — CONTINUITY OF CARE

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.

98

© 2008 Canadian Pharmacists Association

SECTION 6 — CONTINUITY OF CARE

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.

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

99

SECTION 6 — CONTINUITY OF CARE

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).

100

© 2008 Canadian Pharmacists Association

SECTION 6 — CONTINUITY OF CARE

•

• •

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.

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

101

SECTION 6 — CONTINUITY OF CARE

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]

102

© 2008 Canadian Pharmacists Association

SECTION 6 — CONTINUITY OF CARE

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;

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

103

SECTION 6 — CONTINUITY OF CARE

• • • •

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

104

© 2008 Canadian Pharmacists Association

SECTION 6 — CONTINUITY OF CARE

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

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

105

SECTION 6 — CONTINUITY OF CARE

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.

106

© 2008 Canadian Pharmacists Association

SECTION 6 — CONTINUITY OF CARE

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

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

107

SECTION 6 — CONTINUITY OF CARE

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. 108

© 2008 Canadian Pharmacists Association

SECTION 6 — CONTINUITY OF CARE

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

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

109

SECTION 6 — CONTINUITY OF CARE

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]

110

© 2008 Canadian Pharmacists Association

SECTION 6 — CONTINUITY OF CARE

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.

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

111

SECTION 6 — CONTINUITY OF CARE

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]

112

© 2008 Canadian Pharmacists Association

SECTION 6 — CONTINUITY OF CARE

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.

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

113

SECTION 6 — CONTINUITY OF CARE

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.

114

© 2008 Canadian Pharmacists Association

SECTION 6 — CONTINUITY OF CARE

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]

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

115

SECTION 7 — CONSULTING AND COGNITIVE SERVICES

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.

116

© 2008 Canadian Pharmacists Association

SECTION 7 — CONSULTING AND COGNITIVE SERVICES

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]

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

117

SECTION 7 — CONSULTING AND COGNITIVE SERVICES

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). 118

© 2008 Canadian Pharmacists Association

SECTION 7 — CONSULTING AND COGNITIVE SERVICES

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]

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

119

SECTION 7 — CONSULTING AND COGNITIVE SERVICES

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.

120

© 2008 Canadian Pharmacists Association

SECTION 7 — CONSULTING AND COGNITIVE SERVICES

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]

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

121

SECTION 7 — CONSULTING AND COGNITIVE SERVICES

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.

122

© 2008 Canadian Pharmacists Association

SECTION 7 — CONSULTING AND COGNITIVE SERVICES

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.

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

123

SECTION 7 — CONSULTING AND COGNITIVE SERVICES

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.

124

© 2008 Canadian Pharmacists Association

SECTION 7 — CONSULTING AND COGNITIVE SERVICES

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

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

125

SECTION 8 — ENABLERS OF INNOVATIVE PHARMACY PRACTICE

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. 126

© 2008 Canadian Pharmacists Association

SECTION 8 — ENABLERS OF INNOVATIVE PHARMACY PRACTICE

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.

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

127

SECTION 8 — ENABLERS OF INNOVATIVE PHARMACY PRACTICE

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

128

© 2008 Canadian Pharmacists Association

SECTION 8 — ENABLERS OF INNOVATIVE PHARMACY PRACTICE

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. Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

129

SECTION 8 — ENABLERS OF INNOVATIVE PHARMACY PRACTICE

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 130

© 2008 Canadian Pharmacists Association

SECTION 8 — ENABLERS OF INNOVATIVE PHARMACY PRACTICE

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.

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

131

SECTION 8 — ENABLERS OF INNOVATIVE PHARMACY PRACTICE

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.

132

© 2008 Canadian Pharmacists Association

SECTION 8 — ENABLERS OF INNOVATIVE PHARMACY PRACTICE

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]

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

133

SECTION 8 — ENABLERS OF INNOVATIVE PHARMACY PRACTICE

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.

134

© 2008 Canadian Pharmacists Association

SECTION 8 — ENABLERS OF INNOVATIVE PHARMACY PRACTICE

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;

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

135

SECTION 8 — ENABLERS OF INNOVATIVE PHARMACY PRACTICE

• • •

•

•

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

136

© 2008 Canadian Pharmacists Association

SECTION 8 — ENABLERS OF INNOVATIVE PHARMACY PRACTICE

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.

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

137

SECTION 8 — ENABLERS OF INNOVATIVE PHARMACY PRACTICE

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.

138

© 2008 Canadian Pharmacists Association

SECTION 8 — ENABLERS OF INNOVATIVE PHARMACY PRACTICE

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.

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

139

SECTION 8 — ENABLERS OF INNOVATIVE PHARMACY PRACTICE

• •

•

•

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. 140

© 2008 Canadian Pharmacists Association

SECTION 8 — ENABLERS OF INNOVATIVE PHARMACY PRACTICE

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 Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

141

SECTION 8 — ENABLERS OF INNOVATIVE PHARMACY PRACTICE

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

142

© 2008 Canadian Pharmacists Association

SECTION 8 — ENABLERS OF INNOVATIVE PHARMACY PRACTICE

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. Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

143

SECTION 8 — ENABLERS OF INNOVATIVE PHARMACY PRACTICE

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.

144

© 2008 Canadian Pharmacists Association

SECTION 8 — ENABLERS OF INNOVATIVE PHARMACY PRACTICE

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]

Innovative Pharmacy Practices Volume II Moving Forward: Pharmacy Human Resources for the Future

145

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