Canadian Forces Health ServicesServices de santé des Forces canadiennes Physicians Assistants and Pharmacists: Working Together Lieutenant Commander Joe

Canadian Forces Health Services

Services de santé des Forces canadiennes

Physicians Assistants and Pharmacists: Working Together

Lieutenant Commander Joe Dagenais B.Eng BSP PharmD CD



Learning Objectives

1. Describe the factors that lead to Pharmacist scope of practise changes in Canada.

2. Outline the various changes in Pharmacist scope of practise.

3. Describe the pharmacy principle of Pharmaceutical Care.

4. Identify practise areas/ issues where collaboration between Physician Assistants and Pharmacists may occur.



Current Canadian Health Care System

Problems:1.Accessibility (disadvantaged populations)2.Care outside of business hours3.Wait times4.Non-optimized health promotion including patient involvement and self-management5.Appropriate use of health care providers and resources6.Chronic care management7.Mental health care8.Elderly and end-of-life care9.Questionable fiscal effectiveness and sustainability

Canadian Academy of Health Sciences, 2014



Collaborative Care

• Multiple health workers from different professional backgrounds provide comprehensive services by working with patients, their families, caregivers and communities to deliver the highest quality of care across settings. (WHO)– collaborative care models ensure (based on the needs of the patient):

• the right professional;

• the right setting; and

• at the right time. (CAHS 2014)



Relationship: Models of Care and Scope of Practice




Barriers to Collaborative Practice




Without Clear SoP

• Role confusion, competition among various HCPs, workplace tension, lack of trust, decreased professional identity, under/ over utilization of HCPs.

• Difficult for employers to optimize existing HR and assemble appropriate skill mix due to unclear understanding of education and the translation of knowledge into actual practice.

Health Council of Canada, 2005

Understanding a Pharmacist’s SOP



Ontario Pharmacy Act 1991 (2009)

Scope of Practice of pharmacy is:

a)the custody, compounding, dispensing and prescribing of drugs;

b)the provision of health care aids and devices;

c)the provision of information and education related to the use of anything mentioned in clauses (a) and (b); and

d)the promotion of health, prevention and treatment of disease, disorders and dysfunctions through monitoring and management of medication therapy.



Pharmacist Controlled Act

1. Dispensing, selling or compounding a drug or supervising the part of a pharmacy where drugs are kept.

2. Administering, by injection or inhalation, a substance specified in the regulations.

3. Prescribing a drug specified in the regulations.

4. Performing a procedure on tissue below the dermis.

Ontario Regulation 302/12



Pharmacist SOP By Province

Canadian Pharmacists Association

UNDERSTANDING HOW PHARMACISTS THINK



Pharmacy Education• Anatomy, physiology, pathophysiology, pharmacology, medicinal

chemistry, toxicology, pharmacokinetics– CV, psychiatry, oncology, pain, endocrinology, neurology,

gastroenterology, bone/ joint, infectious disease, hematology, immunology/ transplant, dermatology, ENT…

• Patient assessment• Critical appraisal, communication, self-directed learning, group

processes• Healthcare systems• Nutrition• Laboratory analysis• Pharmacoepidemiology• Practical Experience (Hospital/ Community)

College of Pharmacy University of Alberta



Pharmaceutical Care

“Pharmaceutical care is a patient-centered practice in which the practitioner assumes responsibility for a patient’s drug-related needs and is held accountable for this commitment”

-Requires: - the patient’s cooperation and coordination with the patient’s other

health care providers.

- rational decision-making process (Pharmacotherapy Workup)- Identify drug therapy problems (current or potential)- Develop care plan/ recommendations- Follow-up evaluation

Cipolle RJ, Strand LM, Morley PC. Pharmaceutical Care Practice: the clinician’s guide.



Drug Therapy Problem

“…are undesirable events or risks experienced by the patient that involve or are suspected to involve drug therapy and that inhibit or delay him/ her from achieving the desired goals of therapy.”

1.Unnecessary drug therapy

2.Needs additional drug therapy

3.Ineffective drug

4.Dosage too low

5.Dosage too high

6.Adverse drug reaction (drug/drug, drug/food, drug/test)

7.Non-adherence




Pharmacotherapy Workup

Two questions:

1.Is the patient’s problem caused by drug therapy?

2.Can the patient’s problem be treated with drug therapy?

– Indication– Effectiveness– Safety– Adherence





Indication:

Indication Drug Product Dosage regimen Outcomes





Indication:

Indication Drug Product Dosage regimen Outcomes

Effectiveness

Safety




Pharmcotherapy Workup

Effectiveness

Indication Drug Product Dosage regimen

Abnormal Lab Values

Signs & Symptoms

Labs

Effectiveness

Outcomes

Clinical

Goals of Therapy





Safety:

Indication Drug Product

Adverse Drug Reaction

Toxicity

Dosage regimen

Abnormal Lab Values

Signs & Symptoms

Labs

Effectiveness

Outcomes

Safety

Labs Clinical

Clinical

Goals of Therapy





Adherence:

“…someone who is not able or willing to take an appropriate, effective, and safe medication as intended”

The patient:

- does not understand instructions

- prefers not to take medication

- forgets

- too expensive

- cannot swallow or self-administer




Drug Therapy Problem

1. Unnecessary drug therapy

2. Needs additional drug therapy

3. Ineffective drug

4. Dosage too low

5. Dosage too high

6. Adverse drug reaction

7. Non-adherence

Recommendations to other healthcare providers


Indication

Adherence

Safety

Effectiveness

EXAMPLES OF WHERE WE CAN WORK TOGETHER

Hospital or Outpatient Practices



Collaborative Practice Examples

• Medication reviews• Medication consults• Diabetes clinics• Travel medicine• Chronic Care• Adherence issues• Smoking cessation • Academic Detailing



Medication Reviews/ Consults

• 65 yrs or older: >5 or more medications: – 13% private households– 53% healthcare institutions

• 87% of pharmacist recommendations accepted • Reviews:

– Present and past therapies• drug, dose, frequency, duration, efficacy/ side effects

– Patient’s expectations from drug therapy– Recommendations provided

• Deliverable: consult note

Health Reports, Vol. 20, no. 1, March 2009 • Statistics Canada



Travel Medicine

• Collaborative practice– Physician– PA– NP– RN– Pharmacist

• Preventative medication– Immunizations– Anti-malaria medications– Information/ Education

• With/ without collaborative prescribing agreement



Immunization nurse will contact you to book appointment.

Present for booked appointment with immunization nurse in office 4054 of Bldg S80 clinic (bring your immunization book). Necessary vaccines will be administered, and prescriptions (e.g. antimalarials) provided to present to pharmacy to be filled.

For personal travel, immunization nurse will provide you with traveler health advice

If necessary, book appointment with your doctor.

See CDU clerk: QL 6A Med Tech, PA or MO can confirm medical fitness for deployment.

For deployment, you will meet with PMED for:

• Mission specific brief • Force Health Protection Recommendations• Clothing dip if required

If you take chronic medications, ensure you obtain a prescription to bring to pharmacy to fill a deployment supply of your medications

Complete appropriate form for Personal Travel or Deployment Travel. Attach form in email to: +Travel Medicine@CF H Svcs C (A) Halifax



Chronic Care

• Diabetes– A1C (-2.1% vs -0.9%, P = .03)

• HTN– SBP (-9.3 mm Hg)

• CV– LDL ~0.44 mmol/l reduction

• INR (physician vs pharmacist)- 71% vs 81% of visits- 65% vs 73% time in therapeutic range



Diabetes Clinic

• Collaborative Practice:– Sponsoring physician– Nurse/ PA– Dietician– Pharmacist

• Certified Diabetes Educator

• Interpret lab tests

• Provide recommendations on initiating and altering DM drug therapy

• Advances in DM drug therapy

• With/ without collaborative prescribing agreement (delegated acts)



Adherence

• Financial– Drug plan assistance– Cheaper drug or dose – De-prescribing– Dispensing fees

• Frequency• Formulation (taste, size)• Patient education



Smoking Cessation

• Pharmacist: RR 0.77 compared to advice to quit • Behavioral counseling• Medication education/ Prescribing

– NRT– Bupropion– Varenicline

• Prescribing• Follow-up



Conclusions

• Pharmacists are more than simply dispensers.

• Evidence shows our involvement in collaborative teams leads to improved patient care.



Questions?



References• Nelson S, Turnbull J, Bainbridge L, et al. (2014) Optimizing Scopes of Practice: New Models for a New Health

Care System. Canadian Academy of Health Sciences. Ottawa, Ontario. • Baranek PM. (2005) A Review of Scopes of Practice of Health Professions in Canada: A Balancing Act. Health

Council of Canada. Toronto. Ontario.• Cipolle RJ, Strand LM, Morley PC. Pharmaceutical Care Practice: the clinician’s guide. 2004• Maxwell-Alleyne A, Farber A. Pharmacists’ Expanded Scope of Practice: Professional obligations for physicians

and pharmacists working collaboratively. Ontario Medical Review. Apr 2013; 17-19.• Tannenbaum C, Tsuyuki T. The Expanding Scope of Pharmacists’ practice: implications for physicians. CMAJ

2013; • Young S, Bishop L, et al. Comparison of pharmacist managed anticoagulation with usual medical care in a family

medicine clinic. BMC Family Practice 2011, 12:88• Garton L, Crosby J. A retrospective assessment comparing pharmacist-managed anticoagulation clinic with

physician management using international normalized ratio stability. J Thromb Thrombolysis (2011) 32:426–430• Kennedy A, Chen H, et al. Improving Population Managemet through Pharmacist-Primary Care Integration: A Pilot

Study.• Carter B, Rogers M, et al. The potency of team-based care interventions for hypertention: A meta-analysis. Arch

Intern Med. 2009;169(19):1748-1755• Santschi V, Chiolero A, et al. Impact of Pharmacist Care in the Management of Cardiovascular Disease Risk

Factors.Arch Intern Med. 2011; 171(16):1441-1453.• Choe HM, Mitrovich S, et al. Proactive case management by a clinical pharmacist: a randomized controlled trial.

Am J Manag Care. 2005;11:253-260

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Canadian Forces Health ServicesServices de santé des Forces canadiennes Physicians Assistants and Pharmacists: Working Together Lieutenant Commander Joe