Innovative_Pharmacy_Practices_Volume_II_final.pdf

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)

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.

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.

ACKNOWLEDGEMENTSThe 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 themany 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 theMoving Forward Management Committee (and their representative organizations), the Moving Forward National Advisory Committee, a team of subject matter experts and other contributors. These individualsinclude:

Management CommitteeKevin Hall, Moving Forward Co-Chair

Fred Martin, Moving Forward Co-Chair

Zubin Austin, Association of Faculties of Pharmacyof Canada

Patty Brady, Human Resources and Social Development Canada

Janet Cooper, Canadian Pharmacists Association

Tim Fleming, Canadian Association of PharmacyTechnicians

Dennis Gorecki, Association of Deans of Pharmacyof Canada

Ray Joubert, National Association of PharmacyRegulatory Authorities

Paul Kuras, Canadian Pharmacists Association

Allan Malek, Canadian Association of Chain DrugStores

Linda Suveges, The Pharmacy Examining Board ofCanada

Ken Wou, Canadian Society of Hospital Pharmacists

National Advisory Committee Sandra Aylward, Sobeys Pharmacy Group

Danuta Bertram, Winnipeg Regional Health Authority

Paul Blanchard, New Brunswick Pharmacists Association

Anne Marie Burns, Ottawa Hospital

Lynda Buske, Canadian Medical Association

Jean-François Bussières, Hôpital Sainte-Justine

Nicolas Caprio, Shoppers Drug Mart

Deborah Cohen, Canadian Institute for Health Information

Omolayo Famuyide, Canadian Association of Pharmacy Students and Interns

Rock Folkman, Canadian Pharmacy Technician Educators Association

Anne Marie Ford, Ford’s Apothecary

Michael Gaucher, Canadian Agency for Drugs andTechnologies in Health

Aline Johanns, New Brunswick Department ofHealth

Nadine Lacasse, Sebastien Aubin et Nadine LacassePharmaciens

Manon Lambert, Ordre des pharmaciens du Québec

Lisa Little, Canadian Nurses Association

Jonathan Mailman, Canadian Association of Pharmacy Students and Interns

Ron McKerrow, British Columbia Provincial HealthServices Authority

Colleen Norris, Glebe Pharmasave Apothecary

Bonnie Palmer, Shoppers Drug Mart

Noman Qureshi, International Pharmacy GraduateAlumni Association

Michèle Roussel, New Brunswick Department ofHealth

Chris Schillemore, Ontario College of Pharmacists

Brenda Schuster, Regina Qu’Appelle Health Region

Jane Wong, Canadian Healthcare Association

Research TeamJim Blackburn, Blackburn & Associates Inc.

Jeanette Bellerose, Arturus Solutions

Heather Chew, Blueprint Communications

Candace Fedoruk, MarketView Research Inc.

Kelly Goulet-Louis, Blueprint Communications

Barbara Wells, BA Wells Healthcare

Subject Matter Expert AdvisorsColleen Metge, University of Manitoba

Barbara Gobis Ogle, Network Healthcare

Terri Schindel, University of Alberta

Regis Vaillancourt, Children’s Hospital of EasternOntario

Project StaffKelly Hogan, Research Coordinator

Heather Mohr, Project Manager

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

GLOSSARY OF TERMS AND ABBREVIATIONS

ACH = Alberta Children’s Hospital

AHPA = Arthritis Health Professions Association

AMS = anticoagulation management service

ARV = antiretroviral

ASA = acetylsalicylic acid

BCB test = a lab test

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

DOSA = Drugstore Outstanding Service Awards

DPIN = a province-wide prescription database

DRP = drug-related problem

DSM = disease state management

DUE = drug use evaluation

DWH Hom = women’s health and homeopath

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 Phar-

macy 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

© 2008 Canadian Pharmacists Association

MPhA = Manitoba Pharmaceutical Association

MRP = Manitoba Renal Program

MS = multiple sclerosis

MSDIF = Medical Services Delivery Innovation

Fund

MSP = Manitoba Society of Pharmacists

NAMS ME = North American Menopause Society

Menopause Educator

NAMS MP = North American Menopause Society

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

PCP = patient care pharmacist program

PD = peritoneal dialysis

PDDC = Fraser Health Pharmacy Drug Distribution

Centre

PDSA = Plan Do Study Act

PIPEDA = Personal Information Protection and

Electronic Documents Act

PMPRB = Patented Medicines Prices Review Board

PN = parenteral nutrition

RHO = renal health outreach

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 Pharmacother-

apy in Primary Care for Seniors

UAH = University of Alberta Hospital

WHIM = Women’s Health in Motion


ACKNOWLEDGEMENTS


1.0 INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.1 Overview of Moving Forward: Pharmacy Human Resources for the Future . . . . . . . . . . . 1

1.2 Categories of Innovation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

2.0 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 IIMoving 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 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

6.0 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

TABLE OF CONTENTS

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

7.0 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

8.0 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


TABLE OF CONTENTS


SECTION I — INTRODUCTION


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1.0 INTRODUCTION

1.1 Overview of Moving Forward: Pharmacy HumanResources for the Future

One of the most urgent crises facing Canada’s health care system today is the appropriatemanagement of health human resources — that is, ensuring that the right health careproviders with the right skills are available in the right place at the right time. Pharmacistshave been identified as a high priority health human resource with key roles to play in de-livering health care both now and in the future.

Many challenges surround the pharmacy sector’s efforts to optimize the management of itsavailable 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 ischanging. International Pharmacy Graduates, a significant and growing workforce popula-tion, need to be better supported in their integration to professional practice in order tomaximize the contribution they can make. A failure to address these human resources chal-lenges will compromise the ability of the pharmacy workforce to provide quality, patienthealth outcomes focused care.

In order to understand the factors contributing to these human resource pressures and tostrategize potential solutions, eight leading national pharmacy organizations partnered to-gether in 2005 to carry a human resources study of pharmacists and pharmacy techniciansnow known as Moving Forward: Pharmacy Human Resources for the Future. Funded bythe Foreign Credential Recognition Program of Human Resources and Social DevelopmentCanada 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 resourcesplanning recommendations to ensure a strong pharmacy workforce prepared to meet thefuture health care needs of Canadians.

The information contained in this report (Volumes I and II) comprises the results of MovingForward’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 totheir pharmacy practices.

These profiles do not represent either a random selection or an exhaustive list of innovativepharmacy practices. They were chosen to represent as many new configurations in as manydifferent settings as possible. The organizations profiled were identified through a four-month process of “snowball” sampling consisting of referrals to key informants, interviewswith these individuals, followed by more referrals and more interviews. Both communityand institutional programs are described; some are publicly funded, while others are beingoffered in retail settings; some are short-term pilot projects while others have been in placefor a number of years.

SECTION I — INTRODUCTION

© 2008 Canadian Pharmacists Association2

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 InnovationAs practitioners were being identified and interviewed for this study, their innovations wereclassified into seven categories of innovation:

1. Collaborative primary health care teams2. Expanded prescribing authority3. Chronic disease management4. Health promotion and disease prevention5. Post-hospitalization continuity of care and medication reconciliation6. Consulting and cognitive services 7. 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 medicationreconciliation and home-based visits. In many locations, innovation in one area of a practice led to rethinking or restructuring elsewhere in the practice.

SECTION 2 — COLLABORATIVE PRIMARY HEALTH CARE TEAMS


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2.0 COLLABORATIVE PRIMARY HEALTH CARE TEAMS

2.1 Integrating family Medicine and Pharmacy toAdvance 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, Universityof Toronto

Location or setting: Seven family practice sites across Ontario: Beamsville Medical Centrein Lincoln, Caroline Medical Group in Burlington, Claire-Stewart Medical Centre in Mount Forest, Fairview Family Health Network in North York, Bruyère Family Medicine Centre inOttawa, Riverside Court Medical Centre in Ottawa, and the Stratford Family Health Network.

Type of innovation: Pharmacists providing primary care in conjunction with multi-disciplinary health teams in family practices.

Start date: February 2004

End date: 2006

Description of initiative: This demonstration project had pharmacists physically locatedwithin 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 planto the patient and interdisciplinary team;

• On request, provides consultation to the family physician and other team members toassist in the individual care of patients;

• Provides educational presentations to team members and patients;

• Communicates with hospital and community pharmacists and other team members toensure 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 communitypractice model that integrates pharmacists into family practices.



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 pro-gram, consisting of training plus mentorship, which supported their transition into primarycare practice. The three-day training program stressed skill-building in areas such as docu-mentation and prioritization. Each new pharmacist was paired with another more experi-enced primary care pharmacist to serve as a mentor for the first year. Pharmacists were alsosupported by the services of the Ontario Pharmacists’ Association Drug Information Centre.

Funding/pharmacist remuneration: Ontario Ministry of Health and Long-Term Careprovided project funding. The project has resulted in funding for the integration of pharma-cists into primary health care teams across Ontario.

Benefits/advantages/impacts: The project produced a practical and transferable practicemodel for integrating pharmacists into community family practice.

Challenges and strategies used to overcome challenges: Physical logistics (i.e., spaceneeded to have a pharmacist onsite), physicians’ lack of time to meet with pharmacists anddeveloping 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 notallow 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 anddrug 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.

CONTACTKelly BabcockDirector of Pharmacy, SCO Health Service43 Bruyere St. Ottawa, ON K1N 5C8Tel.: (613) 562-4262 ext. 4028Email: [email protected]



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Dr. Lisa DolovichAssociate Director, Centre for Evaluation of Medicines, St. Joseph’s Health Care 105 Main St East, Level P1 Hamilton, ON L8N 1G6Tel.: (905) 522-1155 ext. 33968 Email: [email protected]

Dr. Barb FarrellC.T. Lamont Centre, Élisabeth Bruyère Research Institute,SCO Health Services43 Bruyere St. Ottawa, ON K1N 5C8Tel.: (613) 562-0050 ext. 1315Email: [email protected]

2.2 Pharmacist Integration into the Hamilton FamilyHealth 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 problemswho visit the family health clinics. Primary focus is patients with chronic disease who arenot 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 tothe 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 isalso 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-relatedproblems in the physician clinics.


© 2008 Canadian Pharmacists Association6 7

Human resources: Currently seven pharmacists (4.8 FTEs).

Other resources required: Most of the physician offices (68%) have electronic healthrecords for their patients.

Funding/pharmacist remuneration: Salaries funded from the FHT (through MoHLTC).

Benefits/advantages/impacts: Pharmacists have full access to patient charts and canmake informed recommendations that are tailored to each specific patient’s needs. Bybeing in the medical clinic, the physician has direct access to the pharmacist and is able tosee first-hand the capabilities of the pharmacist in medication management issues.

Challenges and strategies used to overcome challenges: Physicians traditionally are notin the habit of referring their patients to pharmacists and do not realize the capabilities ofthe pharmacist.

It takes time for the pharmacist to work into the system and have the physician realize thecapabilities of the pharmacist and begin to refer patients. Pharmacists need to determinethe 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 teamsmeet 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 Ontariogovernment.Consistent: By way of weekly meetings of the pharmacists, seek to share experiences anddevelop 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 func-tions, 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

CONTACTDr. J. Anthony Gagnon, PharmD, CDE, CAE, FASCP 10 George Street, 3rd floor Hamilton, ON L8P 1C8 Tel.: (905) 667-4865 Email: [email protected]



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2.3 Passport to Health, Hamilton ONInterviewee: 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 tomonitor and encourage attainment of established health goals. Target population involvespatients with three or more cardiovascular risk factors (e.g., Type 2 diabetes, over 55 yearsof 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, cumulativepatient profile, and medication history) and takes objective measurements, including thepatient’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 typicallytakes about an hour. A MedsCheck is also conducted during this first interview.

At subsequent monthly meetings (usually lasting about 30 minutes), the patient’s progresstowards goals and lifestyle changes is monitored. A special software program is used totrack and monitor measurements and lab values, and help assess cardiovascular risk. Thepharmacist provides monthly reports back to the physician on patient progress, along withpharmacist recommendations if warranted.

Medications are regularly reviewed by the pharmacist during these visits, and the patient isasked to report on any vitamins, herbals or non-prescription drugs they may concurrentlybe taking.

The results of these visits are recorded in the patient’s Passport to Health record, whichthey must take to all physician or pharmacist appointments. This record is kept updated bythe pharmacist, who acts as the information gatekeeper, and results in a very up-to-datemedication and health indicator record.



With respect to medication modifications initiated by physicians, the contract that is signedon enrollment stipulates that the patient agrees to advise the pharmacist within 48 hours ifthere is a change in medication.

Purpose: To capture best possible patient medication histories, therefore increasing patientsafety; to integrate community pharmacists into health teams in an organized manner, enabling physicians and patients to utilize pharmacists’ skills; and to improve access tohealth care for patients, through a collaborative protocol, with oversight by a family physician.

Human resources: There are five pharmacist-physician teams, each consisting of onepharmacist 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 FamilyHealth Team (FHT) for coordination of teams, billing, etc. In community pharmacies: private consultation rooms, blood pressure machines, software, weight scale, measuringtape, binders for each patient. The software used for the program is not currently linked tothat of the pharmacy.

Funding/pharmacist remuneration: The pilot was originally funded by an unrestrictedgrant 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 ona 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, comparedwith receiving health services from physicians and pharmacists in isolation. Program alsoallows pharmacists to participate as a health care team member, while remaining in thecommunity pharmacy environment and building on existing relationships with their patients.

Challenges and strategies used to overcome challenges: Obtaining funding from theFHT for community pharmacist participation was a challenge. Lobbying efforts took a greatdeal of time and money (presenting to and educating administrators). Not all participatingpharmacists 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 whohad not used the program software.

Feasibility:Sustainable: Only with government funding.Scaleable: Yes. Limiting factor is number of participating physicians and pharmacists. Thismodel could be used for many chronic diseases (e.g., osteoporosis, asthma). Supported: Yes. To-date, recommendations made by pharmacists have all been accepted bypartnering physician. Consistent: Yes, because it is based on developed protocols, and substantial educationalprograms are offered to enrolled pharmacists prior to joining a team, to ensure that there is



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a consistent level of knowledge and skill. Also, participating pharmacists all use the samesoftware program to help with documentation and assessments.

Evaluation: A formal evaluation is expected to be finished in 2008. Specific success mark-ers are being evaluated, as well as soft indicators such as satisfaction and uptake by physi-cians, pharmacists and patients. Evaluation results will be published. Positive feedback isreceived on a regular basis from physicians and patients.

Communications/promotional material: To date, promotional and communication ef-forts have been directed at recruiting pharmacists and physicians into the program.

CONTACT Iris KrawchenkoC/o Dell Pharmacy 1955 King St. E. Hamilton, ON L8K 1W2 Tel.: (905) 549-9775Email: [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 (OntarioStroke System) and the Canadian Stroke Network.

Other participating organizations: Department of Family Practice, University of BritishColumbia; McMaster University; Elisabeth Bruyere Research Institute; The Team for Individualizing Pharmacotherapy in Primary Care for Seniors (TIPPS); Institute for ClinicalEvaluation Services (ICES); Fig.P Software Incorporated

Location or setting: The program is carried out in pharmacies in 20 mid-size (populationfrom 10,000 to 60,000) communities in Ontario. Each of these communities has at least fivefamily physicians and at least two community pharmacies participating.

Type of innovation: Pharmacists are providing primary care in the community pharmacysetting.

Start date: September 2006

Description of Initiative: CHAP is a community-based program aimed at improving thedetection, treatment and control of hypertension and improving cardiovascular health. In general, patients aged 65 years and older are invited by their family physicians to attendup to two cardiovascular/blood pressure assessment clinics set up in local community pharmacies. These sessions are led primarily by volunteers, who are trained by publichealth nurses to assist with measuring blood pressures (using an accurate blood pressure[BP] monitoring device), and also help with completing cardiovascular risk factor checklists,



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 formodifying risk factors.

Patients with high BP are triaged to pharmacist for assessment; assessment is documentedand 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 ses-sions, and collaborates with local session coordinators and peer health educators regardingthe operation of the blood pressure clinic. Also conducts medication assessments (medica-tion adherence, drug interactions, drug-induced hypertension) for select participants identi-fied as having uncontrolled high blood pressure and using standardized documentationforms, 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 bloodpressure medications, and

• Able to provide individualized patient counselling regarding blood pressuremedications.

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 clinicsinto 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 volunteerbasis.

Benefits/advantages/impacts: Offering BP assessments in familiar settings such as community pharmacies can alleviate barriers to effective monitoring of BP (i.e., “white coatsyndrome”). On average, patients make two trips per month to a community pharmacy, sothis 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 identi-fied as having uncontrolled high blood pressure from assessments by peer educators werenot able to take the time to see the pharmacist. This was remedied by mentioning the needfor extra time in the information letters given to patients (i.e., plan to possibly stay an extra


30 minutes after assessment is done) and also making appointments at a later time afterthe clinics. The pharmacist may be too busy in dispensary to see the participant for post-assessment meeting. This is sometimes alleviated by scheduling some pharmacist overlapin 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 thepharmacist. 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 programScaleable: YesConsistent: Yes, through use of documentation and communication forms, well-establishedprotocols, and training.

Evaluation: A randomized controlled trial has been conducted comparing 20 interventioncommunities to 19 control communities. Results will be available in 2008-2009. Two hun-dred and fourteen family physicians invited patients who attended 1265 sessions, in 129pharmacies; 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):294-98.

• 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 programfor older family practice patients. [ISRCTN61739603] BMC Family Practice 2005 6:35DOI:10.1186/1471-2296-6-35.

• Pora VV, Farrell B, Dolovich L, Kaczorowski J, Chambers L, on behalf of the CHAPworking group. Promoting cardiovascular health among older adults: a pilot studywith community pharmacists. CPJ 2005:138(7):50-55.

Communications/promotional material:

• Invitation letters (prepared by CHAP staff), signed by physicians are sent out toqualified patients (i.e., matching the target population)

• Tickets for assessment sessions are issued by family physicians to appropriate patientsas they visit the physician’s office, along with a schedule of the sessions.

• Advertisements in local newspapers, newsletters, physician offices and publicbuildings

• Website: www.chapprogram.ca


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CONTACT Lisa Dolovichc/o Centre for Evaluation of Medicines, St. Joseph’s Health Care105 Main St East, Level P1 Hamilton, ON L8N 1G6Tel.: (905) 522-1155 ext. 33968 Fax: (905) 528-7386 Email: [email protected]

2.5 Mid-Main Community Health Centre, Vancouver BCInterviewee: 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, includinga pharmacist, provides primary care in a non-profit community health centre. All teammembers have access and input into the electronic medical records for each patient. Thereis 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 ques-tions and seeing some clients after their physician appointments, to managing the smoking cessa-tion program, providing diabetes and asthma education, performing shared-care with other teammembers for home-bound elderly clients, and supervising the warfarin monitoring program. Inaddition, the pharmacist authorizes prescription refills and some dosage adjustments using a del-egated protocol from physicians. Pharmacist has been certified as a diabetes educator.

The latest addition was a support group for women with metabolic syndrome namedWomen 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 physiciansshare), a nurse practitioner, chronic disease coordinator (is also a dietitian), 0.75 FTE



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pharmacist at the Mid-Main Community Health Centre. The same pharmacist now spends0.2 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 thepharmacist role. Funding comes from the Vancouver Coastal Health Authority.

Benefits/advantages/impacts: The pharmacist’s one-on-one meetings with patients andthe group sessions make the patients sufficiently knowledgeable about their disease, prevention, and medication management to make an impact on their health (i.e., supportsimproved 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 toreally 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 pharmacistas 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 demonstrateher 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 fornine years.Scaleable: The value of a pharmacist on the team continues to be demonstrated, and she isnow scaled up to 28 hours per week. In addition, similar services are now provided fortwo half-days at another primary care clinic. Supported: Outstanding support from the clinic team members, both financially and throughtheir 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 theyears. The findings were very favourable for the team. Patient and clinic staff feedback hasbeen 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.



CONTACTSusan TroeschMid-Main Community Health Centre Vancouver, BCTel.: (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, curriculumrenewal; Director, Division of Pharmacy Practice; Associate Professor, Leslie Dan Faculty ofPharmacy; 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 fromthe 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 includehealth promotion and social health (e.g., teen parents, stress counselling). The pharmacist’spractice is focused on geriatric patients.

Role of pharmacist: Patients are referred to the pharmacist from health care professionalsboth 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 thendevelops a care plan to achieve these goals. She also provides patient education (on bothan 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, findingsand 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 generalhealth assessment if warranted.

Home visits for frail seniors are done by the pharmacist and other team members and arereported to be valuable, as they sometimes provide a different perspective on the patient’slife than what may be presented at the clinic.



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In Dr. Raman-Wilms’ opinion, the most important qualification for a pharmacist in this setting is experience in providing direct patient care. The provision of direct patient care bypharmacists 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 inter-viewed, and earn their trust. As an example, she said that instead of focusing on the list ofmedications that the patient is on when she first interviews them, she instead asks themwhat 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 andcounsellors 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 bythe Ontario government on a salary basis. Currently, pharmacist compensation if providedthrough a purchase of services fund administered by the Centre. At this time, Ontario CHCfunding does not include salaried positions for pharmacists.

Benefits/advantages/impacts: Practising in a team with other health care professionalsoffers 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 hoursas participants were very interested in their medications, what questions they should ask oftheir community pharmacists and other pharmacy-related issues. This led to an interest inthe pharmacist’s role at the CHC, and the pharmacist’s initial patient base. Now the clientbase 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 professionalsometimes 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 thepharmacist compensation come from a fund for miscellaneous services).Scaleable: Services could be expanded if more funding were available; would need to be



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 andresolve drug-related problems.

Evaluation: When the CHC first opened in 1992, an evaluation of the effect of a pharma-cist’s services on health outcomes was conducted. This led to the decision to have a phar-macist 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 herservices 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-WilmsDirector, Division of Pharmacy PracticeAssociate Professor, Leslie Dan Faculty of Pharmacy University of TorontoToronto, ON Tel.: (416) 978-0616Fax: (416) 978-8511Email: [email protected]

2.7 Disease State Management (DSM) Clinic, Burnaby BCInterviewee: Leela John, BSc, BScPharm, ACPR, PharmD, assistant professor and clinicalcoordinator, PharmD program, Faculty of Pharmaceutical Sciences, University of British Co-lumbia; 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 targetpopulation 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. Patientswith chronic diseases are eligible to take part in this clinic if they are currently taking fiveor more prescription medications, have questions about their drug therapy, are having



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difficulties taking their medications (i.e., non-adherence or adverse effects) or have recentlybeen 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 diseasesto 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 twohours to compile information about complex drug-related problems, one hour for follow-up and counselling and an additional hour if changes to therapy are made.

The pharmacist providing care to these patients requires specialized knowledge aboutchronic disease states to identify and resolve drug-related problems and provide drug information. Work experience in a variety of settings including hospital pharmacy is anasset, as this helps the pharmacist understand various diagnostic and laboratory tests thatthe 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 andoutcomes for patients with specific chronic diseases.” It is the first program of its kindwithin 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 stu-dents/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 fromSave-On-Foods.

Benefits/advantages/impacts: The PharmD students, community pharmacy residents andpharmacist have counselled approximately 150 patients since inception of the programtwo-and-a-half years ago. Presentations to seniors groups and the general public on thetopics of diabetes, anticoagulation, and dyslipidemia have resulted in positive feedback andincreased 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 apharmacist on site five days a week or an administrative assistant would allow recruiting ofmore patients. Inadequate space for privacy and patient confidentiality is a barrier to the



provision of optimal pharmaceutical care. Large-scale academic detailing and continuousfollow-up is not possible due to time constraints.

Physicians and other health care professionals may not be aware of the expanded role of aclinical pharmacist, since contact with other disciplines is limited in the current program.Community resources available in the local area are difficult to identify. Sufficient patientsmay not be willing or able to pay for the pharmacists’ wages and overhead costs of theservice.

Once recruitment strategies have been optimized, the next phase will include education ofthe community pharmacists. Modules have been written to train community pharmacists ondiabetes, dyslipidemia, hypertension, asthma and osteoporosis. Other modules available forfurther training include heart failure management, anticoagulation, osteoarthritis, rheumatoid arthritis and post-myocardial infarction management. Training of communitypharmacists will allow them to provide a complex level of patient care on a larger scalethan 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 forpharmacist consultation services. The remaining three patients did not specify if they wouldbe 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 continuethis project.Scaleable: Training of community pharmacists will allow them to provide a complex levelof 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 nothave 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 inthe future. Patients have expressed their appreciation for the knowledge gained throughpharmacist consultation. Patients’ perception of this particular pharmacy has been enhanced, and developing pharmacists have gained awareness of an advanced communitypractice model.

CONTACTLeela JohnTel.: (604) 827-3682 Email: [email protected]

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2.8 First Nations Onsite Pharmacy Services, Wynyard SK

Interviewee: Kendra Townsend, partner/owner, Townsend’s Drugs, Wynyard, SK

Sponsoring organization: Townsend’s Drugs

Location or setting: Day Star, Kawacatoose, George Gordon and Muskowekwan First Nations (40 km to 80 km from Townsend Pharmacy)

Type of innovation: Provision of medications, counselling and education to First Nationsindividuals, outside of the community pharmacy.

Start date: 1996

Description of initiative: First Nations patients on reserve who require patient focusedpharmacy services is the target population. They provide weekly on-reserve dispensing andcounselling in collaboration with a physician. These Tuesday night clinics are held at theKawacatoose 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 partof 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 effortand time via accessing the Non-Insured Health Benefits (NIHB) formulary, the NIHB PriorApproval 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 andphysicians 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 healthnurses, medical secretary, delivery person, etc.

Funding /pharmacist remuneration: Primary funding through professional fee fromNIHB, 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, donot have access to these services. It builds rapport and trust to groups of marginalized people who lack access to these services.

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Challenges and strategies used to overcome challenges: These reserves are 40 km to80 km from the pharmacy, so the pharmacist’s distance to travel is a challenge. The patientsare not restricted to a specific pharmacy, so access to patient medication records have beena 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 verypositive and the home care program has been very supportive of this initiative.

CONTACT Debra TownsendTownsend DrugsWynyard, SKEmail: [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 uniquein the province.

Start date: March 1988

Description of initiative: The onsite pharmacist practises clinical pharmacy, but does nodispensing. 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 dementiaward;

• Chairing Medication Safety Team; and

• Teaching residents and staff.



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She initiated and is a member of the palliative care team, and is also a member of the infection control committee and long-term care (LTC) accreditation team.

The facility has 240 residents ranging in age from preschool to more than 100 years of age.It is a heavy care facility, with many residents requiring specialized care. The facility is organized into six “neighbourhoods” according to care needs.

Role of pharmacist: Clinical pharmacy only, since the facility out-sources technical duties(medication dispensing) to a local pharmacy. Residents’ prescriptions and other medicationare all delivered to the facility. The on-site pharmacist is responsible for all cognitive andnon-technical services related to medication at this facility.

Purpose: Promote safe and effective medication therapy for all residents


Funding/pharmacist remuneration: Provided by the Saskatoon Health Region.

Benefits/advantages/impacts: Pharmacist is full member of interdisciplinary team; reviewof medication is ongoing and in the forefront of resident care. Lots of issues can be solvedbefore they happen because of participation of pharmacist, who is present when issues arediscussed 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 andnursing staffs are highly supportive of the value that is provided.

CONTACT Parkridge Centre110 Gropper Cres. Saskatoon, SK Tel.: (306) 655-3857 Email: [email protected]



2.10 Primary Care Pharmacy Practice in an Ambulatory Setting, Saskatoon SK

Interviewee: Shannan Neubauer, PharmD, consultant pharmacist in an ambulatory primarycare 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 pharmacistwith fee-for-service physicians). It was unusual for Saskatchewan-based practices to receivesupport for pharmacists, nurse practitioners, dietitians, etc., when physicians were notsalary-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 programand patient’s electronic record) and a consultation service (review patient charts, meet withpatients, 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 away to increase time with patients and still provide quality care. Goals were to ensure thatdrug therapy was appropriate (to begin with), to improve health benefits and utilization ofdrug 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 radiologyreports, lab reports, dictated notes, and patient records;

• Internet access and pharmacy references (online and text);

• Patient education materials (disease models, print, video), and

• Office and administrative assistance for booking appointments.



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Funding/pharmacist remuneration: Position was funded by the College of Pharmacy & Nutrition, University of Saskatchewan.

Challenges and strategies used to overcome challenges: Practising on a part-time basismade 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. Provincialhealth 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 limitedby 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-identifiedthemselves 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 itis certainly a substantial sample.

Many of these pharmacists had just begun this type of practice in the summer and fall of2007, 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 inOntario, and 27.7 pharmacist FTEs had been hired.



BC.1 Amy HuangDirector, Downtown East-side Vancouver ClinicVancouver 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, twochronic disease management (CDM) nurses, a lactation consultant, an IM/IT tech, businessmanager 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 ofthe 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 withteam 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 coordinatemed changes with the community pharmacies;

• Review patient charts in three different clinics, recommend patients who are goodcandidates 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 infoquestions;

• Work with CDM nurse on diabetes patients and help to adjust insulin for new insulinstart 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 favourof this.)

AB.2 Kaye AndrewsCalgary Rural Primary Care NetworkTel.: (403) 336-1784Email: [email protected]

AB.3 Patricia JacobsenRocky Mountain House, AB Email: [email protected]

AB.4 Christal Lacombe, BScPharm.High River PharmacistCalgary Rural Primary Care NetworkTel.: (403) 603-8799



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1.0 FTE pharmacist works closely with CDM nurse, home care and 23 family physicians inHigh River. Duties include: doing medication reviews with nurse for diabetics and residentsat a local seniors lodge, and developing/providing support to home care for the medicationadministration program at the lodge.

Transitioning to the Calgary Foothills Primary Care Network (CFPCN) where there will be3.0 FTE pharmacists in total.

AB.5 Florrie MacDougall, BScPharmBox 968, 1222 Bev McLachlin DriveChinook Health Primary Care NetworkPincher Creek, AB T0K 1W0Tel.: (403) 627-1221 Fax: (403) 627-1226Email: [email protected]

Daily clinical practice includes:

• Ordering appropriate lab work initially on starting a new medication and continuingas appropriate;

• Applying clinical best practice guidelines to chronic disease treatments and advisingon changes suggested in drug management that come from updates of theseguidelines (chronic diseases include hypertension, asthma, chronic obstructivepulmonary disease [COPD], geriatrics, diabetes, pain, arthritis, lipid management,osteoporosis prevention/management, women's wellness);

• Providing patient education for all new anticoagulation patients, and anticoagulationmanagement 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 ofmedications through provincial or national (i.e., Non-Insured Health Benefits) plans;

• Accessing emergency supplies of drugs from drug companies for financially strappedindividuals until their own drug coverage is available;

• Teaching patients drug information separately from any disease education;

• Reviewing medications currently being used; assessing safety/appropriateness forindividual patients with respect to the whole person; assessing drug compliance;resolving related issues; getting medications discontinued when therapy is no longerindicated;

• Advising on smoking cessation;

• Teaching blood glucose monitoring;

• Updating medical records with current drug information, participating in medicationreconciliation 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.



PCN pharmacist is also the hospital pharmacist in the Pincher Creek hospital to which theclinic is attached so works very closely with physicians. The pharmacist has extra trainingin asthma and COPD (educator), geriatric pharmacy, anticoagulation, diabetes, etc.

AB.6 Leanna St.Onge Rocky Mountain House, ABEmail: [email protected]

SK.1 Leah ButtPharmacist, Leader PharmacyLeader, SKTel.: (306) 628-3744Email: [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 thephysicians/nurse practitioner who can utilize pharmaceutical knowledge. The pharmacist isworking with the nurse practitioner to identify coronary artery disease (CAD) patients whoare not at target blood pressure and not receiving adequate pharmacotherapy, and hopes toexpand project to include other patient categories as well as to become involved in patientcounselling sessions.

SK.2 Charity EvansGraduate Student, College of Pharmacy & NutritionUniversity of SaskatchewanSaskatoon, SK S7N 5C9Email: [email protected]

Pharmacist involvement of about 0.5 FTE in cardiovascular (CV) risk assessment, at a largefee-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 toarrange 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 onrisk reduction strategies. At the end of this visit, patients were randomized into either theintervention or usual care group.

Those in the follow-up group received pharmacist contact at a minimum of every eightweeks (mail, email, phone or in person). In a lot of cases it was simply an informationalletter (e.g., a letter explaining the low-density lipoprotein [LDL] cholesterol goal has beenlowered, 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 contactedthe pharmacist with questions. The goal of the follow-up is to reinforce and remind



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patients basically to keep CV risk reduction constantly in the back of their minds — ratherthan bombard patients with more educational information. Patients were only contacted fora 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 tolook at long term medication adherence rates (two years after the observation phase concluded in December 2007). Received very positive (informal) feedback from physiciansand patients so far.

SK.3 Derek Jorgenson, BSP, PharmD.Clinical Coordinator, Saskatoon Health Region Pharmacy Dept.Clinical Pharmacist, West Winds Primary Health Centre3311 Fairlight DriveSaskatoon, SK S7M 3Y5Tel.: (306) 655-4270Fax: (306) 655-4894Email: [email protected]

West Winds is a primary health centre run by the health region and the University ofSaskatchewan. It houses the academic family medicine program and many other health region run primary health programs.

ON.1 Anjali BanerjeeSTAR FHT (Stratford and Tavistock) (IMPACT site)0.2 FTE

ON.2 Rashna BatliwallaRiverside Court Medical ClinicOttawa, ON(IMPACT site)

ON.3 Catherine BednarskiHamilton Family Health Team (see detailed description in Section 2.2)

ON.4 Cynthia BerryAlgonquin FHT, Geriatric Assessment Unit29 Silverwood DriveHuntsville, ON P1H 1N1Tel.: (705) 789-6764

A geriatric assessment team with predominantly dementia patients in the region with thehighest density of seniors in Ontario (Muskokas/Algonquin area); 0.25 FTE of pharmacistinvolvement.

ON.5 Janie Bowles-Jordan0.2 FTE with Hamilton Family Health Team; 0.4FTE with North Hamilton CHC (see detailed description in Section 2.2)



ON.6 Robin BrownClaire-Stewart Medical Clinic525 Dublin StreetMount Forest, ON N0G 2L3(IMPACT site)

ON.7 Colleen Cameron, PharmD, RPhClinical Pharmacist, New Vision Family Health Team421 Greenbrook DriveKitchener, ON N2M 4K1Tel.: (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 GrandRiver 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 carefence.” She plans to address improved patient care at points of transition within the healthcare 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 WellnessClinic.

ON.9 Sylvia ChanWest Carleton Family Health TeamCarp, ONEmail: [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 fromdowntown Ottawa.


ON.10 Tom DolanjskiProfessional Pharmacy ServicesEast End Family Health Team497 Rea N.Timmins, ON P4N 5A7Tel.: (705) 363-8582

ON.11 Bernard FitzgeraldPharmacistKingston Family Health Team

ON.13 Lynn HallidayEspanola, ONEmail: [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 theFHT, 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, haveincreased abdominal weight, have diabetes, hypertension or smoke. These patients are sentto the pharmacist to do the initial cardiovascular risk assessment. She establishes their risklevel and modifiable risk factors and redirects them to the appropriate health care profes-sional to deal with their specific risk factors (e.g., dietitian for hyperlipidemia, abdominalcircumference, hypertensive diet or the social worker for stress management, or diabeticeducator 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 monitorprogress. 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 reassessagain to watch for medication compliance (where applicable) and progress.

ON.14 Roland Halil, BSc.(Hon), BScPharm., ACPR, PharmBruyere & Primrose Academic Family Health Teams75 Bruyere St., Ottawa, ON K1N 5C835 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 andmore. Policy development and representation of pharmacist and allied health concerns incommittees has also become an important function of the pharmacist in this role as theFHT expands.


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ON.15 Darlene HigginsPrince Edward Family Health TeamPicton, ON

ON.16 Shelly HousePharmacist, Caroline Family Health Team (IMPACT site)Burlington, ONTel.: (905) 632-8007 ext. 107

ON.17 Natalie JonassonElisabeth 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, patientcounselling, and some academic detailing. There will also be teaching of medical residents,pharmacy and PharmD students. The pharmacist has seen many diabetic patients over thefirst year, and worked with one physician to develop a draft medical directive that wouldallow the registered pharmacist (RPh) to adjust medications doses and order relevant bloodtests. This is still in the preliminary stages.

ON.20 Jennifer Lake, PharmD.840 Coxwell Ave., Suite 105South East Toronto Family Health TeamToronto ON M4C 5T2Tel.: (416) 469-6580 ext. 3052Email: [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, diabetesmanagement.

ON.21 Lisa McCarthyStonechurch Family Health Centre

ON.22 Jeff Nagge, ACPR, PharmD.Clinical Pharmacist, Centre for Family MedicineClinical Assistant Professor, School of Pharmacy, University of Waterloo25 Joseph StreetKitchener, ONTel.: (519) 578-2100 ext. 251



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FHT has 11 family physicians and approximately 18,000 patients spread across three satellite locations. Currently only 1.0 FTE pharmacist is employed, but the FHT has appliedfor 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 ofcardiovascular 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 receivingwarfarin 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 yearby 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-WyllieSt. 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 familyphysicians. Practice is referral-based and focuses on medication optimization/ pharmaceutical care for patients with diabetes, hyperlipidemia or hypertension, and anyother drug-related problems (DRPs) that are identified. A program evaluation of pharmacist’s impact in this setting is underway.

ON.25 Nita PatelBeamsville Medical Centre

ON.26 Joanne PolkiewiczStratford Family Health Network

ON.27 John StanczykDelhi Community Health Centre

ON.28 Douglas Stewart, BSc, BScPhm, RPh, CAEClinical PharmacistHaliburton Highlands Family Health TeamTel.: (705) 457-1212 ext. 248Fax: (705) 457-3955Email: [email protected]: www.hhfht.com



ON.29 Ginette Thibeault, BScPhm, RPh, CAEBlue Sky Family Health Team#403-111 Main Street WestNorth Bay, ON P1B 2T6Tel.: (705) 475-0500Fax: (705) 475-0571Email: [email protected]

The 1.0 FTE position for a pharmacist at this FHT is partly filled. Pharmacist has practisedthere since October 2006, providing medication reviews on complex cases, patients withmultiple medications and those with diabetes (mainly by referral). Also worked one dayper week directly in a physician's office, spending the morning see clients for medicationreviews and the afternoon doing multidisciplinary case reviews with the physician and hisstaff (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 willbegin participating in the Heart and Stroke Hypertension Management Initiative. The FHT isstill fairly young and still evolving, so the physicians' use of pharmacist clinical services isgradually increasing.

ON.30 Cynthia Way, BScPharm.Pharmacist, Family Health TeamThe Ottawa Hospital Academic Family Health TeamOttawa, ON K1Y 4K7Tel.: (613) 798-5555 ext. 19635Pager: (613) 274-8861Email: [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 pharmacistalso sees those with uncontrolled diabetes, dyslipidemia and/or hypertension. She teachespharmacy and family medicine residents and does a fair bit of drug information. Planning isunderway to implement a screening tool to identify patients who would benefit from apharmacist assessment, as well as beginning automatic referral of discharged patients topharmacist for a medication review.

QC.1 Marie-Claude Vanier, BPharm, MScProfesseure agrégée de clinique, Faculté de pharmacie, Université de MontréalClinicienne, Chaire Aventis en soins ambulatoires, GMF-UMF Cité de la Santé deLaval Faculté de pharmacie, Université de MontréalC.P. 6128 succursale Centre-villeMontréal, QC H3C 3J7Université: (514) 343-6111 poste 5065 Fax: (514) 343-6120Clinique de médecine familiale: (450) 668-1010 poste 2720



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Between October 2001 and November 2004 there was 0.5 FTE, then 1.0 FTE in November2004. The pharmacist offers a consultation service to which patients can be referred by aphysician 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 orderlab tests for these patients. The pharmacist also routinely manages patients' phone calls tothe 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 beenidentified by the treating physician or the nurse.

Teaches family medicine residents and supervises fourth year pharmacy students' clerkshipand pharmacy residents' clerkship, at the clinic. The clinic also receives nursing studentsand 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, BSPPharmacist, St. Joseph’s Community Health CentreTel.: (506) 632-5774

NS.1 Glen CoxPharmacy Manager, Eskasoni Pharmacy Eskasoni, NSTel.: (902) 379-2255

Onsite in a primary care clinic with three family physicians in Eskasoni, NS, a First Nationcommunity in Cape Breton. Pharmacists advise the physicians on formulary issues, adversedrug 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, thephysician is advised and changes are discussed.

NS.2 Anne Marie Whelan, PharmD.College of Pharmacy, Dalhousie UniversityDalhousie Family Medicine Halifax, NS

Current practice consists of a consulting service addressing patient specific therapy management issues, conducting patient interviews, providing patient education and druginformation with 0.2 FTE.

NF.1 Lisa BishopAsst Professor, Memorial University of NewfoundlandTel.: (777) 8627-3443Email: [email protected]

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 cardiacconsultation. Cardiac EASE provides an ambulatory practice for pharmacists through itsextended scope of practice, including physical assessment, and collaborative practiceopportunity with cardiologists, pharmacists, and nurse-practitioners. It highlights the abilityof pharmacists to provide comprehensive patient assessments, interpretation andintegration of diagnostic and clinical laboratory information, with the implementation of thetreatment and follow-up plans.

Role of pharmacist: Clinical pharmacotherapy practitioners (PharmD) have beenmembers 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 referredto the clinic, there is a central intake and a triage process that schedules patients accordingto their risk. Diagnostic tests are arranged prior to and around the same time as their clinicvisit to facilitate availability of results for assessment in clinic. When patients arrive to beseen 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 nursepractitioner. During the initial assessment, a complete history is taken and a physical examis performed. The physical exam performed includes blood pressure and heart ratemeasurement, assessment of pulses, a precordial exam, pulmonary auscultation andassessment of fluid status. Laboratory values and diagnostic tests are also reviewed andintegrated into the overall patient review.

At the end of the assessment, the pharmacist provides a plan for treatment, and reviews thedetails 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 diagnostictests, prognosis and the patient-specific treatment plan. The cardiologist then exits the roomto dictate the consult letter and the pharmacist closes with the patient to answer anyquestions, review any further follow-up required and provide additional therapeuticinformation as needed. The pharmacists see a wide variety of cardiac patients, since the clinicis a general cardiology referral program; however, the most common patients seen are thosewith chest pain, arrhythmias and dyspnea requiring assessment.



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Purpose: The clinic was designed to improve access and efficiency of tertiary cardiologyconsultative services for non-emergent referrals by establishing a single point of entry andutilizing multidisciplinary team approach with a unique set of knowledge and skills.Cardiac EASE provides extends the role of the self-directed CPP and exemplifies thepotential 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 investigator-initiated $1 million grant for a 3-year pilot project funded by the Medical Services DeliveryInnovation Fund (MSDIF) sponsored by Alberta Health and Wellness and the Alberta MedicalAssociation (Dr. Stephen Archer [MD] and Dr. Tammy Bungard [PharmD]). Due to programsuccess, funding of the CPPs is now provided by Capital Health.

Benefits/advantages/impacts: This practice exemplifies the ability of pharmacists to beproactive, front line clinicians that perform activities ranging from assessment tointerpretation of results in light of appropriate pharmacotherapy.

Future directions of the clinic:

• Integrate the clinical pharmacotherapy practitioner in the triage process and thefollow-up of patients, and

• Other opportunities for clinical expansion, such as pharmacist-lead cardiovascular riskreduction clinics, which will be enabled by recent prescriptive authority changes inAlberta.

Challenges and strategies used to overcome challenges: Increasing volume of referralswithin fixed resources of program impacts efficiency/wait times.

Feasibility:Sustainable: Following the trial period, funding for the program is now under the operatingfunds of Capital Health.Scaleable: Currently looking at increasing the triage function as well as the possibility of asatellite 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. Theevaluation component was a system evaluation rather than outcome based; namelyfocusing on wait lists and access to cardiology consultation. This is consistent with thepurpose of the program from inception. Feedback from patients and clinic staff andreferring 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 HospitalPharmacists (CSHP) conference and Canadian Pharmacists Association conference in2005



• 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 — platformpresentation

• CSHP Practice Spotlight (in press)

CONTACTSheri Koshman, BScPharm, PharmD, ACPRAssistant Professor, Division of Cardiology, University of AlbertaClinical Pharmacotherapy Practitioner, Regional Pharmacy Services Capital HealthEmail: [email protected]

Glen J. Pearson, BSc, BScPhm, PharmD, FCSHPAssociate Professor, Division of Cardiology, University of AlbertaCo-Director, Cardiac Transplant ClinicDirector of Research, Cardiovascular Risk Reduction ClinicEdmonton, ABEmail: [email protected]

3.2 Regina Renal Program, Regina SKInterviewees: 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, SaskatchewanCollege of Pharmacists, Saskatchewan Transplant Program

Location or setting: Regina General Hospital

Type of innovation: Pharmacists expanded scope of practice that has evolved to includeprescribing. The transplant position is an example of ambulatory care clinic practicewithout regular in-person physician contact.

Start date: 2003

Description of initiative: In 2003, due to exponential growth of the renal program and alimited number of nephrologists serving southern Saskatchewan, a pharmacist becameinvolved in direct patient care, especially in anemia management.

There is no transplant physician in the Regina area. Until 2005, a pharmacist fromSaskatoon travelled to Regina twice monthly for follow-up clinics with renal transplantpatients from southern Saskatchewan. With the growing renal transplant patient population,the need for additional pharmacist involvement was identified.



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The pharmacists’ scope of practice has been expanded to include a formalized process forrenal anemia management. The prescribing agreement gives the pharmacist responsibilityfor prescribing of erythropoietin, intravenous and oral iron, folic acid, etc., as well asordering and evaluating tests for anemia management.

A part-time pharmacist was included in the renal transplant program in 2005 and was ableto establish a scope of practice within the transplant structure similar to that of theSaskatoon office. Currently the anemia management prescribing agreement does not extendto the transplant program. The pharmacist in the transplant program is also available forconsult 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 topharmacist 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 800patients), paying close attention to renal protection, anemia management, andcardiovascular protection of these patients. Blood work is regularly reviewed for electrolytedisturbances, and recommendations made. When drug related problems arise that areunrelated to kidney disease, the patient's family physician may be contacted with arecommendation.

In the hemo-dialysis and peritoneal dialysis (PD) areas, the focus is on anemia managementand blood pressure control. Pharmacists play a key role in medication management. Incases where hypertension or cardiovascular protection therapy is recommended by thepharmacist, the pharmacist writes the drug order on the chart, including dose, etc., which isreviewed by the physician and initialed.

In order to be included within the prescribing agreement, pharmacists must successfullycomplete a training and education and certification process. Four training modules weredeveloped (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 ofapproximately 90 renal transplant patients in the southern half of the province. Thisinvolves review of routine blood work and monitoring medication therapy. Monitoringfocuses on immuno-suppression, renal function, anemia, cardiovascular concerns, diabetesand osteoporosis.

Purpose: To develop a collaborative prescribing agreement including the prescribing oferythropoietin, intravenous and oral iron, folic acid, etc., and the right to order andinterpret 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 topost renal transplant patients (in-patient and out-patient). This has expanded to includenon-renal transplant in-patients on a request/consult basis.



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 HealthRegion.

Benefits/advantages/impacts:

• Closer monitoring of renal disease progression and anemia management enablingquicker intervention and thus, better patient care;

• Dug therapy more custom tailored to patients;

• Builds strong relationship with patients; they are better informed about their drugtherapy;

• 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 jobsatisfaction; and

• Autonomy to establish practice roles and adapt practice to identified patient needs.

Challenges and strategies used to overcome challenges: Challenges included findingtime to complete necessary training modules; limited time for on the job training, due toother hospital events; staff buy-in; limited experience of participants in developingformalized learning modules. There was no formal training process for transplantpharmacist. Current pharmacist self-trained in this area with minimal shadowing of practicein Saskatoon. There are also limited professional continuing education events due to highlyspecialized nature of practice area.

Strategies involved regular meetings scheduled amongst participants to discuss progress ofmodules, but did not begin early enough. Some time was allotted to work on trainingmodules. The pharmacist educator mentored participants in development of the learningmodules. A transplant pharmacists’ network was established via the Canadian Society ofHospital 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 fromtwo 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. Consistenttraining program and certification ensures consistency.

Evaluation: Until February 2007, formal review of anemia management data, to determineeffectiveness in meeting anemia targets. Due to costs of maintaining this method ofevaluation has been terminated. Semi-annual informal meetings with the nephrologists as a



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means of quality assurance. During these meetings, discuss changes to current guidelines,and current trends in anemia management via journal club format.

Pharmacy students collect annual data on key monitoring areas for use of transplantpharmacist. 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) 766-3493Email: [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, andManitoba 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 clinicalassistant 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 froman MS interdisciplinary team of specialists that include: a neurologist, MS clinical pharmacistpractitioner, clinical nurse specialist, nurse clinician, clinical dietitian, social worker,occupational therapist and physiotherapist. Approximately 40 ambulatory MS patients areseen per week. This extrapolates to an annual patient load of about 2080. The patientpopulation is derived primarily from Manitoba and Northwestern Ontario.

Role of pharmacist: Dr. Namaka is actively engaged in the diagnosis and symptomaticmanagement of the disease in a shared basis with the neurologist. In this capacity, he isable to order the appropriate diagnostic tests, initiate referrals, and prescribe the necessarymedications.



Purpose: The purpose of this program is to provide patient services delegating appropriatefunctions to interdisciplinary team members, under the supervision of the physician teamleader. Goals include contributing to reducing the neurologist time for the diagnosticassessment significantly and thereby reduce the wait times for patients to be assessed, andan 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 cognitiveservices with the Registrar of Manitoba Pharmaceutical Association (MPhA) and ManitobaSociety of Pharmacists (MSP).

Benefits/advantages/impacts: Dr. Namaka has established a new career option with anexpanded role for pharmacists as a contributing member of the health team.

Increasing the pharmacists’ role has resulted in reducing the neurologist’s time fordiagnostic assessment, monitoring and addressing symptomatic management issues ofmultiple sclerosis patients.

Challenges and strategies used to overcome challenges: In being the first pharmacistin North America to take on this role, there were significant hurdles to go through duringthe application process, including: proving his credentials to begin the process; writing theformal examination; preparing a detailed job description; and, after certification, proceedingthrough the levels of competency.

Perhaps the biggest challenge was to obtain liability insurance for a role that has neverbeen insured for pharmacists.

Dr. Namaka began working within the clinic in April 2001 and at that time, he brought botha clinical experience (10 years clinical pharmacist in a hospital) and a scientific backgroundas a neuroscientist. Therefore, prior to receiving certification, he had three years experienceworking with the neurologists and other health professionals in the clinic.

It was also significant that his success in meeting the qualifications was now identified inthe new pharmacy legislation (Bill 41), which describes the extended role of thepharmacist.

It was very difficult to obtain liability insurance and as a last resort, Dr Namaka personallypurchased Alternative Risk Services insurance to cover his clinical assistant role as anindividual. The MSP played an instrumental role in securing liability coverage for this newprofessional designation. Now that this position has been identified in the new pharmacylegislation, 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 ofPhysicians and Surgeons and the MPhA.Scaleable: Dr. Namaka currently has a graduate student who is in the process of proceedingtowards a clinical assistant role once she has completed her PhD. This sets the pattern forfuture training of expanded roles for pharmacists.



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Supported: During this process, Dr. Namaka had the full support of the Faculty ofPharmacy, Neurology Department at the Health Sciences Centre, the College of Physiciansand Surgeons of Manitoba, the Manitoba Pharmaceutical Association and the MSP.Consistent: The job description for the role is very important in providing a consistent rolefor this position.

Evaluation: It is too early in the development to be formally evaluated. Dr. Namaka’s rolehas been well evaluated by the patients and the clinic staff and he has contributed toreducing 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 Pharm2007;60(S1:41-42).

CONTACTDr. Michael P. NamakaAssociate Professor, Faculty of Pharmacy, University of ManitobaWinnipeg, MBTel.: (204) 055-8380Email: [email protected]

3.4 Hyperlipidemia Clinic, Canadian Forces HealthServices 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 ofchronic disease.


Description of initiative: The family practice clinic has an onsite lab, x-ray services, and asmall outpatient department. Physicians at the clinic are salaried employees.

Cholesterol management services are provided to patients referred by family physicians andnurse practitioners. These tend to be the more complex cases, for instance, those patientsnot meeting primary goals, with comorbid conditions, or that the primary care providerrequires assistance in managing. Referring practitioner explains the risks/benefits to eachpatient 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 highrisk for cardiovascular disease, or who have significant compliance issues. Currently servingmilitary personnel for mainly primary prevention.



Role of pharmacist: Pharmacist interviews referred patients, checks blood pressure,orders cholesterol blood work, and reviews patient drug and medical history. Makesrecommendations on drug therapy, and is able to adjust doses under hyperlipidemiaprotocols (developed from evidence-based guidelines). Counsels and monitors individualpatients, and follows up with the referring physician. The pharmacist sees one to threepatients 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 andadherence with drug therapy, pharmacist-based lipid clinics were incorporated into existingambulatory 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 alternativetherapies/recommendations for management; and

• Provide expert resource to family physicians, thus decreasing the need to referpatients to specialists.

Human resources: 0.10 FTE pharmacists.

Other resources required: Office and appointment booking provided by the familypractice clinic.

Pharmacists have delegated authority from the Surgeon General to adjust doses of lipid-lowering drugs, substitute drugs within a class of agents, order lab work, provide lifestylecounselling and refer patients to dietitians and other specialists, to attain or achieve lipidcontrol. Initiation of a new medication, switch to a different drug class, or addition of asecond lipid-lowering agent requires physician approval. This special authority wasnecessary for some activities outside of the usual scope of pharmacy practice in ambulatorysettings.

Funding/pharmacist remuneration: Will be covered by DND, but at the moment thisservice is being covered by the Patented Medicines Prices Review Board (PMPRB) (awaitingMemorandum 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 tomanage risk; and

• Identifies and addresses patient concerns regarding drug therapy, and places these incontext of overall cardiovascular health.



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Challenges and strategies used to overcome challenges: It is crucial to have therespect 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 toearn the trust and support of staff. Once a working relationship has been clearlyestablished, more complex cases are referred and additional responsibilities are accrued tothe 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 dictationsystem;

• Function as a clinician, independent from the pharmacy team;

• Be prepared for psycho-social issues to deal with sub-optimal inter-personal dynamicswith patients that may arise during interviews;

• Be able to recognize when continued involvement is not longer necessary ordesirable;

• 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 workerresponsible 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 thelimits 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 otherhealth 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 toknowledge related to drug therapy, so it is imperative that pharmacists keep up-to-date onnew drugs and emerging therapeutic approaches.

Most pharmacists are accustomed to counselling and advising, but follow-up, as requiredby this model, is not as common.

Feasibility:Sustainable: Service has been provided for seven years thus far; now considered standardrequirement for base.Scaleable: Very scaleable for dyslipidemias; dependent on knowledge and enthusiasm ofpharmacist. Maybe less scaleable for incidental medical issues such as diabetes orhypertension, which play a role in dyslipidemia.Supported: Supported by the base surgeon (i.e., medical team leader), which is essential forcontinuation. Also solidly supported by individual DND physicians, since pharmacist offersa value-added service.



Consistent: Service must be consistent and reliable. Consults must be clear and actionablefor the times the pharmacist is not physically present. Pharmacist must be available foradvice/recommendations even if not physically present.

Evaluation: No cost-benefit analysis has been done. However, improved clinical outcomeshave been documented (reference below). Support expressed by physicians in makingreferrals.

Academic documents:• Vaillancourt R, Gutschi LM, Ma J, Sinclair S, Beechinor D. Pharmacist-Managed Lipid

Clinics: Development and Implementation in the Canadian Forces, Canadian Journalof Hospital Pharmacy, February 2003, Vol 56, No 1.

• Yearly academic presentations to family physicians.

CONTACT Maria Gutschic/o Patented Medicines Prices Review Board, Box L40, 333 Laurier Ave. W., Suite 1400 Ottawa, ON K1P 1C1Tel: (613) 952-3301 Fax: (613) 952-7626Email: [email protected], [email protected]

3.5 Travel Medicine Service, Ottawa ONInterviewee: 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 ofmedications to prevent travel-related diseases

Start date: 2002

Description of initiative: Initially, the pharmacists provided a consultation interview anda written assessment regarding travel medicine needs (vaccination, Rx, and self-care basedon the patient’s destination and health status). The patient would take the assessment to aphysician for authorization of the recommended prescriptions.

Within months of starting the service, Brian Stowe and Mark Kearney wrote the firstexamination for the International Society of Travel Medicine’s accreditation program, whichis open to physicians and other health professionals. Both now have a Certificate in TravelHealth from that organization.



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In the first few years of operation, the pharmacists invested time in communicating theirprogram to the University Health Services team, who then became increasingly comfortablewith the level of expertise that the pharmacists were providing. Once the campus healthservice experienced the benefits of having an expert travel health consultancy in thebuilding, the demand for service expanded. In the spring of 2005 a protocol was developedunder which the director of health services delegated the authority to prescribe themedication to the designated pharmacists.

Patients complete the travel clinic patient information questionnaire, then make anappointment for an assessment and consultation with the certified pharmacist. Pharmacistscomplete a travel medication care plan that includes the client information, their itinerary,medical history and other information; a therapeutic plan, monitoring plan, prescription, anddocumentation of counselling information. Targets the population of students, faculty and staffat 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 forstudents and staff that would represent an expanded role for pharmacists within theirpractice. The service was previously provided in a less structured format within the clinicby a part-time registered nurse. As demand and complexity of travel health issues increasedthe service was deemed inadequate and discontinued. It was agreed that the pharmacywould take on this specialized service.

It is in the best interest of a patient contemplating international travel to be assessed forpotential health risks associated with a given itinerary and to receive appropriatemedications and counselling to mitigate these health risks. Pharmacists with an expertise inthe field of travel medicine have the knowledge and medication expertise to assess apatient, provide appropriate counselling and recommend appropriate medications for thispurpose.

Human resources: Two certified pharmacists.

Other resources required: Both pharmacists are members of the International Society forTravel Medicine and access to services such as the chat room is very useful for beingupdated 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 basicinformation regarding travel location, etc., and then the system generates the best optionfor the medication/vaccine to be used given the local situation regarding drug resistanceand particular endemic diseases.

Patient pamphlets have been made available explaining the hazards of foreign travel andspecific diseases that may be prevalent in the specific area of travel.

Funding/pharmacist remuneration: The service is financed by a patient consultation feeof $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.



Benefits/advantages/impacts: Patients are receiving a superior service compared toprevious system. Patient perception of what the pharmacist’s role and expertise has beengreatly enhanced. Pharmacists have professional satisfaction in providing this service.

Challenges and strategies used to overcome challenges: Originally there was a concernfrom the physicians in the clinic regarding the broadened role of the pharmacist.

Remuneration for services provided was another challenge. The system is dependant on thephysician countersigning the prescription and the physician’s liability covers the situation.Patient demand for specific medications that may not be appropriate is challenging, as isaccess to specific products. An example is the Japanese encephalitis vaccine that thecompany has refused to supply. It is in short supply and they will only provide it to travelclinics with which they have an established agreement.

The concept of a collaborative approach requires quite a bit of communication so thateveryone understands what the pharmacist is doing and any confusion can be resolved.Pharmacists explained they were not diagnosing; they were providing an assessment basedon the destination and their knowledge of medications and vaccines desirable for travel tothat location.

Visits to physician’s office for travel clinic consultation also required patient payment, soestablishing 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 pharmacistexplains how it works, what it is for, the benefits of therapy, and so on. It is up to thepatient 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 othermeans 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 supportthe high quality service.Consistent: Yes, the pharmacy service being provided is based on established protocols, sothe system is standardized.

Evaluation: Patient surveys have indicated a very positive response to the servicesprovided. They are planning a data review of more than 600 patients to determineoutcomes. The service has been positively received by patients, the medical clinic staff andphysicians.

Communications/promotional material: Pamphlets describing the service are availablein the medical clinic, physicians’ offices and at the travel agency on campus.

CONTACTBrian StoweThe Prescription Shop, Carleton UniversityOttawa, ONEmail: [email protected]



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3.6 Critical Care Pharmacist, St. Boniface GeneralHospital, 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. BonifaceHospital — a 600-bed hospital.

Start date: 1988

Description of initiative: Pharmacist participates in medical rounds for both the cardiacintensive care and the medical-surgical intensive care unit and makes recommendations ondrug therapy. Targets critical care patients.

Role of pharmacist: Attends rounds and oversees patient drug therapy as part of thecritical care team. Other team members include attending physician, charge nurse, bedsidenurse, dietitian, respiratory therapist, physiotherapist, and 3 - 4 medical residents/fellows.

Dr. Ariano is authorized to order certain medications and laboratory tests (e.g., aminoglycosides/vancomycin blood levels) in order to optimize drug efficacy and avert drugtoxicity. He does medication reconciliation on intake and discharge, and makesrecommendations on patient specific drug therapy to the medical team.

One particularly unique contribution Dr. Ariano makes to the critical care team is throughthe use of drug pharmacokinetics as a marker of a patient’s health status. The changingrenal clearance of many monitored drugs in the intensive care unit (ICU) is used as asurrogate marker of that patient’s kidney function; and this change is documented in thepatient’s chart. The ability of a patient to absorb the analgesic, acetaminophen, as assessedby 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 intothe stomach or through a small bowel feeding tube. This computerized analysis ofacetaminophen absorption provides a first step to address this problem.

Purpose: Enhanced patient care, by utilizing pharmacist’s specialized knowledge andskills.

Human resources: Pharmacist 1.0 FTE.

Other resources required: Pharmacokinetic modeling computer programs.

Funding/pharmacist remuneration: St. Boniface General Hospital. Dr. Ariano has across-appointment as a clinical associate professor with the University of Manitoba Facultiesof Pharmacy, and Medicine; however, he is salaried by the hospital.



Challenges and strategies used to overcome challenges: Gaining the support ofphysicians 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., ina pharmacist-absent environment. Gaining support of physicians takes perseverance. Dr. Ariano provides them with formalized teaching sessions on ICU drugs. Critical carepatients usually have multiple, complex health issues that must be addressed. Clinicalchallenges of critically ill patients require constant learning and updating of knowledgebase. 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 adedicated 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 thepharmacist to look at patient issues to determine if an abnormal reaction or newdevelopment is drug-related. To the critical nurses, the services provided by the pharmacistare invaluable and highly supported.

CONTACT Dr. Robert ArianoSt. Boniface General Hospital Winnipeg, MBTel.: (204) 237-2050Fax: (204) 235-1476Email: [email protected]

SECTION 4 — CHRONIC DISEASE MANAGEMENT


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4.0 CHRONIC DISEASE MANAGEMENT

4.1 Anticoagulation Management Service (AMS),Edmonton, AB

Interviewee: Dr. Tammy Bungard, BSP, PharmD, AMS Director

Sponsoring organization: Program pilot sponsored by the Alberta Health and WellnessHealth 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 inother areas of Alberta).

Type of innovation: This program involves expanded authority for pharmacists(prescribing, ordering lab work), primary health care, continuity of care, cognitive servicesoutside 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 mechanicalvalves implanted at the University of Alberta Hospital (UAH) are automatically referred tothe AMS program.

Role of pharmacist: Patients meeting the enrollment criteria have an initial face-to-facemeeting 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 comprehensiveassessment can be made; and

• Delivers one-on-one patient education.

Referring physicians are required to sign a referral form, which stipulates that they aretransferring the care of the patient to the AMS team, who are practising in accordance withestablished policies and procedures.

From here on, the pharmacist takes responsibility for managing the patient’santicoagulation therapy — which includes adjusting anticoagulant drug dosages, andordering lab work. Patients have laboratory work done at any collection site in the CapitalHealth Region, with lab results sent back to AMS.



Follow-up meetings are normally conducted by telephone. Frequency of these follow-upinteractions 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 aredischarged from hospital (and in such cases the pharmacist would also follow-up with thehospital ward for medication reconciliation).

Through an on-call rotation system, pharmacists are available 24 hours a day, seven days aweek, 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 determineif patients on anticoagulation therapy can adequately self-monitor after a six-month term inthe AMS program. Currently, patients registered in the AMS program are cared for on anongoing, permanent basis, and if the study ultimately shows that patient outcomes are notcompromised with self-management after six months in the program, this will result inconsiderable savings. This study will involve the home use of portable handheld devicesthat patients can use to measure international normalized ratios (INRs). Dr. Bungard reportsthat while these devices are quite common in Europe, their use in this study would beunique in North America.

Human resources: 1.0 PTE director, 2.1 FTE pharmacists, 1.4 FTE administrativeassistance. The AMS program also retains three “medical directors” — a cardiologist, ahematologist, 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 ofpatients on anticoagulation therapy (increased time in INR range), and to reduce the rate ofthromboembolic complications.

Challenges and strategies used to overcome challenges: Obtaining buy-in from keystakeholders would be the biggest challenge to initiate a program of this type. Establishingpersonal and professional credibility within such a setting would be necessary toimplement such a program, which would require considerable time. Many of the typicalstart-up challenges were mitigated by the training of the pharmacist (post-doctoralfellowship in anticoagulation at the UAH), which enabled her to establish relationships withphysicians, key hospital personnel, and regional health officials.

At the time of creation (2001) the scope of practice for a pharmacist was legislated to belinked to dispensing, hence using cognitive skills not linked to the distribution of a drugfell outside of the scope of practice. This was problematic for some community pharmacistsin that there was a concern from a liability perspective. Further, there is no consistentsystem or schedule in place for billing for this service or any pharmacist-delivered cognitiveservice, 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 satelliteclinics (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 theinitial Alberta Health and Wellness Health Innovation Fund pilot have been successful —only those sponsored by a regional health authority or within an institution survived. The



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satellite clinics set up in community pharmacies were not successful due to lack ofinfrastructure 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 andprocedures.

Evaluation: Underwent formal evaluation process during pilot stage, which led to fullfunding. A number of patient and physician satisfaction surveys have been done, with veryhigh 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 J2006; 139(2); 58-64.

CONTACT Dr. Tammy Bungard Assistant Professor, Division of Cardiology Department of Medicine, University of Alberta Edmonton, ABEmail: [email protected]

4.2 Anticoagulation Management Service (AMS) in aRural 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 inCanada, other than in larger urban centres. AMS clinics may provide ambulatory care toout-patients, but are rarely integrated as one service including acute and long-term carehospitalized patients.



This service began in January 2003 as a pilot project/satellite of the University of AlbertaHospital’s core AMS clinic, in Edmonton. In October 2004, the Regional Health Authoritybegan funding a 0.3 FTE pharmacist position to continue the service. This was expanded sothat 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 filledin July 2007.

AMS is a pharmacist-managed service for patients requiring anticoagulation therapy. Physicianreferral is required for patients to enrol in this program. AMS monitors and maintains thepatient’s clotting factors within a narrow range, to treat and prevent blood clots. This can onlybe 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 areaserved by the Aspen Health Region may be referred. In particular, new warfarin starts andpatients whose anticoagulation therapies are difficult to manage may be referred fromoutlying communities. Currently, the AMS has enrolled over 200 patients, and presentlyoversees anticoagulation therapy for approximately 125 ambulatory patients, four to sixlong-term care patients, and one to six acute care patients. Essentially, anyone initiated onanticoagulation therapy is referred for AMS.

Role of pharmacist: Complete management of anticoagulation therapy. Pharmacistinitially 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 thewarfarin 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, includingphysicians and nursing staff. It is not uncommon for physicians to call the pharmacist foradvice on anticoagulation therapy.

This service was initially introduced for in-patients and long-term care patients. It wasproblematic for nursing staff to follow-up afternoon INR results with physicians busy in theoffice, and often there were significant delays in obtaining warfarin orders. Now thepharmacist receives the lab results and can promptly order or adjust dosages. Theopportunity to expand this service to ambulatory care was enthusiastically endorsed by thephysicians due to the lack of time available to do the necessary follow-up on ambulatorycare INRs. It was not uncommon for patients to have to make appointments with theirfamily physicians to obtain their INR results. Often INR results were not communicatedunless out of range. With the specialty training received from the University of Alberta coreclinic, the pharmacist routinely follows-up up with every patient, regardless of whetherthey are in or out of range.

Purpose: Better control of patient’s INR range, with a decrease in thrombosis and bleedingrates. 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 additionaltraining; the University of Alberta offers an AMS course.



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Funding/pharmacist remuneration: Aspen Regional Health Authority.

Benefits/advantages/impacts: Because of pharmacists’ ability to order and monitor labresults, it is immediately apparent if there is a problem. Medication changes, lifestylechanges and alcohol often contribute to changes in INRs. Often poor patient compliance isa problem, so AMS pharmacists can easily liaise directly with Home Care services andcommunity pharmacists to resolve these issues. There is improved continuity of care as onecentre provides anticoagulation services for patients whether in the home, or whenhospitalized.

Challenges and strategies used to overcome challenges: Because of the specialknowledge required, it is difficult to attain coverage for AMS pharmacist vacations andillnesses. 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 patientcare 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 healthcare centres. Supported: Yes, by local physicians who refer and call for advice.Consistent: Yes, pharmacists adhere to recognized standards of practice for prescribing andadjusting warfarin doses, and the operation is based on one originally established at theUniversity of Alberta Hospital in Edmonton.

Evaluation: A formal evaluation of pharmacist-led AMS clinics at the University of AlbertaHospital 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 thisparticular service. This study has not yet been formally published. There is US literature onthe cost-benefits of pharmacist-run AMS clinics. Tremendous buy-in from physicians andnursing staff because of the added value, and therefore it has enhanced professionalrelationships. The pharmacist reports that the pharmacist-managed AMS service has alsoreceived positive feedback from the lab technicians — because of the close monitoring ofwarfarin patients and better compliance, blood work is being done less frequently whichreduces scar tissue build-up.

CONTACTCindy JonesAthabasca Health Care Centre 3100-48 Ave. Athabasca, AB T9S 1M9 Tel.: (780) 675-6025 Email: [email protected]



4.3 Warfarin Dosage Adjustments ThroughAnticoagulation Case Management in CommunityPharmacies

Interviewee: Respondent (the initiator and director) and the organization represented wishto remain anonymous since the project is at a pilot stage and takes place in a competitiveretail 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 treatingphysician 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 thepatient’s condition and therapy. The physician is kept informed of the pharmacist’sdecisions but is no longer the case manager for the treatment of the patient. Point of caretesting is using technology for which the pharmacists need to be trained. Nurses andtechnical assistants can also be trained to perform these tests.

Start date: Conception started May 2006. Infrastructure started to be put in place in January2007. The start of a one-year pilot project planned for late 2007.

Description of initiative: Consultation services and testing services; dosage adjustments ofanticoagulant warfarin in retail pharmacies. Targets patients (outpatients) requiringanticoagulation therapy.

Role of pharmacist: Close follow-up of patients; regular in-pharmacy INR testing anddosage adjustments; other cognitive services such as education about optimal use ofwarfarin, drug and drug-food interactions.

There is a support system in place for the pharmacists, nurses and technical assistants toensure continuous access to expert information and assistance. The goal is to have frontline and second line professional health services available at all times. The strategic detailsof 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 whoprovide 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 yearand to go up to 50 at the end of the second year. This is what would be needed for theproject to be financially sustainable.



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Clinical objective: Optimize warfarin therapy. At the present time, physicians may notprescribe warfarin because they do not have the resources necessary to follow up andadjust the medication. They will advise the patient to take aspirin, although warfarin istwice as effective as a blood thinner. However, because of its potency, it requires a muchtighter monitoring. It is estimated that only 60% of patients who could benefit from warfarinare prescribed the medication due to lack of appropriate resources for monitoring andadjusting the medication.

Societal objective: Reduce resources devoted simpler cases to allow to testing laboratoriesand anticoagulotherapy clinics to focus on more difficult cases.

Human resources: 1.5 FTE managing the project, including 1 FTE working on strategicdevelopment. There are 70 pharmacies; objective is to have a minimum of two pharmacistsper pharmacy at all times. There are 165 pharmacists trained to offer services and 23 morein training; 33 of the pharmacists will offer INR testing.

Other resources required: 65 technical assistants trained specifically to perform INRtesting in the 33 pharmacies that offer it. They follow specialized training but nocertification is required. Some pharmacists may also choose to hire the services of aregistered nurse.

Funding/pharmacist remuneration: Seed money provided by sponsor for conception,market research, infrastructure, training, etc. Patient has to pay for consultations and testsas these kinds of services are not covered under current Canadian health system.

Benefits/advantages/impacts: It should unburden the current medical system by freeingup laboratories and clinics of these relatively simpler cases. More patients will be able tobenefit from this more effective therapy. It is more practical for patients: instead of fivepoints of interaction with medical professionals, the patient would now require only threewhen dealing with a pharmacy that provides point of care testing and only four whendealing with a pharmacy that does not provide point of care testing. The time intervals willalso be much shorter. The consultation process will be more thorough. Pharmacists havethe pharmacological knowledge to adjust the medication as well as to inform and educatepatients.

Challenges and strategies used to overcome challenges: Patients must pay consultationfees and testing fees. If these services were provided by a physician, they would becovered under the patient’s provincial medical services. But because they are provided by apharmacist, they are not covered. Patients can decide to be tested in a hospital so that thecost will be covered. However, the timeframe will then be much longer. Alternatively theycan have the testing done at one of the 33 affiliated pharmacies. The timeframe will thenbe much shorter, but they have to pay for the testing themselves.

Marketing research has shown that only two to three patients out of 10 requiringanticoagulotherapy would be willing to pay for these services. To be sustainable, therewould need to be at least 40 to 50 patients per pharmacy. Pharmacists need to purchasethe technology necessary to perform INR testing. Not all pharmacists involved in the pilotproject are in a position to offer INR testing at their pharmacy. Pharmacists requireadditional training. There has to be a separate consultation room in each pharmacy. This,


however, has been a minor challenge. Most pharmacies involved in the pilot project couldalready accommodate this requirement as investments of that type started 10 years ago forthis chain of pharmacies.

Negotiation with government to demonstrate the need for such intervention so that theservices (consultation and testing) would be covered by the provincial health budget asthey would be if they were performed by a physician. Lobbying with private healthinsurances to accept to cover these services. Information campaign with physicians to directmore patients to these services. A support system has been put into place for pharmacistsoffering both professional and emotional support.

4.4 Anticoagulation Management in a FamilyPractice, St John’s NL

Interviewee: Dr. Stephanie Young, Assistant Professor and Primary Health CarePharmacist, School of Pharmacy, Memorial University of Newfoundland.

Sponsoring organizations: Memorial University, School of Pharmacy; grants fromShoppers Drug Mart and pharmaceutical industry for evaluation. Initial two-year grant forone FTE pharmacist has been restructured to one FTE for one year and up to five yearspart-time.

Location or setting: Family Medicine Clinic, St. John’s, NL

Type of innovation: Pharmacist practice in medication management of anticoagulationservices in a primary care clinic; electronic medical records

Start date: 2005

Description of initiative: This project is the first instance of a pharmacist providingservices in a primary health care clinic in Newfoundland. The five physicians at the clinicrefer patients who they determine require medication management. The clinic developedan electronic record system in December, 2006 and the referral is sent through the patient’smedical record.

In addition, in 2006, a pharmacist-run collaborative anticoagulation management programwas developed for the clinic. Targets patients within the clinic population that requiremedication management.

Role of pharmacist: Once a patient is referred, the pharmacist reviews the patientinformation and then schedules an interview, usually at the patient’s home. The interviewusually requires about one hour. The pharmacist prepares recommendations to thephysician, as well as following up with the patient if required.

A policy/procedure protocol was developed for warfarin patients and the day-to-dayactivities of this program are managed by the pharmacist, primarily by telephone andthrough access to the electronic medical record. Utilizing laboratory results and based on




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the protocol, the pharmacist assesses the INR, asks patients appropriate questions to assessresponse and side effects, etc. and then makes dosage adjustments and schedules the nextINR. New patients are seen face-to-face to review educational material (warfarin bookletand pamphlet describing the service, other material as appropriate). The INR results andthe management plan are entered directly into the electronic chart and this can be donefrom 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 pharmacyservices in a primary care setting. The goal was to demonstrate that primary care pharmacyservices can make a positive impact on patient outcomes within a primary care teampractice.

Human resources: 1 FTE pharmacist.

Funding/pharmacist remuneration: During the initial year of the project, the full-timepharmacist was funded from the primary care grant through the School of Pharmacy.

Benefits/advantages/impacts: The clinic patients’ medication problems are beingidentified and actions taken to improve medication therapy. Physicians and patients arerecognizing the role pharmacists can play within the primary health care team.

Challenges and strategies used to overcome challenges: Getting physicians to act onthe recommendations made by the pharmacist was a challenge. They tended to look at thepharmacist’s evaluation of the patient in a similar vein to other referrals — as the end ofthe process. In the case of pharmacist recommendations, this is the beginning of a processto improve medication management. Pharmacist’s time constraints and obtaining stablefinancial support for the program continues to be a challenge.

Steps are being taken to make physicians aware of the expectations regarding pharmacistrecommendations and to enhance communication around these referrals.

The School is seeking opportunities to provide stable financial commitment for the 1 FTE.

FeasibilitySustainable: Financial sustainability continues to be a source of concern. Scaleable: Due to the success of this program, another pharmacist has been established in aprimary 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 otherhealth professional in the clinic as well as the patients.Consistent: protocols have been developed and followed so the service is providedconsistently.

Evaluation: A summer student collected data on the interventions and conducted patientand physician satisfaction surveys from the first year of the project. Feedback from thesurveys was very positive concerning the services being provided, both the general primarycare pharmacy services as well as the anticoagulation management.



In examination of the intervention recommendations, the situation noted in the“Challenges” section was identified, and strategies are being developed to improvefollow-up. The response from patients and the clinic physicians has been positive.

Communications/promotional material: Pamphlets on the anticoagulation service aswell as warfarin pamphlets have been produced.

CONTACTDr. Stephanie Young 300 Prince Phillip Drive, St. John's, NL A1B 3V6Tel.: (709) 777-8833 Fax: (709) 777-8870Email: [email protected]

4.5 Cardiovascular Risk Reduction in a FamilyPractice, 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 todetermine the impact of a pharmacist-managed, cardiovascular risk-reduction program in afamily medicine practice.

Start date: 2004

End date: 2006 (approximately 18 months)

Description of initiative: Patients were given an initial assessment, the rationale forappropriate management of risk factors, a lifestyle assessment and recommendations, targetsetting, and education regarding pharmacotherapy and adherence. The pharmacist alsomade therapy and monitoring recommendations to the physicians.

Role of pharmacist: Patients were identified by the pharmacist or by direct physicianreferral 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 risk-reduction program in a family medicine clinic.



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Human resources: One pharmacist.

Funding/pharmacist remuneration: Grant from pharmaceutical industry.

Benefits/advantages/impacts: Fifty-two patients were enrolled in the program over an18-month period; 81% had hyperlipidemia, 35 % had diabetes and 44% had metabolicsyndrome.

The provision of these services by the co-located pharmacist appears to have contributed tothe 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 obtainfunding 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 inobjective clinical parameters for the group from baseline to three months were comparedvia paired t-tests and were considered statistically significant (at p < 0.05).

Academic documents: Bradshaw J, Neubauer S, Karakochuk M, Impact of a pharmacist-managed, cardiovascular risk-reduction program in a family medicine practice. Can PharmJ 2005:138(5):34.

CONTACTJanet BradshawFort Qu’Appelle Medical CentreFort Qu’Appelle, SKEmail: [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-riskvascular patients.



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 articlespertaining to care of high-risk vascular patients.

• Medication optimization — utilizing the patient’s past experiences with specificmedication, specific recommendations are made to the physician and the patient. Alsomonitor and correct any drug related problems that become apparent.

• Home follow-up — each patient is encouraged to contact the clinic if they requireadvice or have problems. This has been an extremely effective way of giving patientsoptions 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, betterpatient education with regard to medications.

Challenges and strategies used to overcome challenges: Evolving roles and securingfunding were challenges overcome by persistence.

Evaluation: Dr. Semchuk has been a principal investigator in two major studies ofoutcomes of high-risk vascular patients and interventions made by pharmacists, althoughthese are broader evaluations than of just the Lipid Clinic. Informal evaluation is donethrough tracking of patients achieving their goals, adherence assessment.

Academic documents:Dr. Semchuk has made numerous presentations on the Lipid Clinic practice as well asdescribing appropriate management of high-risk cardiovascular patients.

Semchuk B, Taylor J, Sulz L, et al. Pharmacist intervention in risk reduction study: High-riskcardiac 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 toconventional care or Pharmacist Driven Medication Optimization Clinic for one year.Pharmacists Intervene with patient, family MD to optimize risk reduction pharmacotherapyand aid in adherence. The study results are currently being tabulated.

Communications/promotional material: Various promotional material and activities areused for the lipid clinic.


CONTACTDr. Bill SemchukRegina Qu'Appelle Health Region 1440-14th Ave. Regina, SK S4P 0W5Tel.: (306) 766-4010 Fax: (306) 766-3547Email: [email protected]

4.7 Clinical Pharmacy Services in an Outpatient HIVClinic, Edmonton AB

Interviewee: Christine Hughes, Associate Professor, Faculty of Pharmacy & PharmaceuticalSciences, University of Alberta; pharmacist in HIV clinic

Sponsoring organization: Faculty of Pharmacy & Pharmaceutical Sciences, University ofAlberta

Location or setting: University of Alberta Hospital — Out-patient HIV Clinics

Type of innovation: Chronic disease management, continuity of care. Pharmacists areintegrated into health care team in terms of drug therapy and are recognized for theirexpertise.


Description of initiative: Patient-oriented pharmacy services are provided as part of amultidisciplinary team to HIV infected patients in Northern Alberta. The team includes anurse specialist, a full and part-time nurse, social workers, a dietitian, several infectiousdiseases (ID) physicians as well as ID specialty residents who work in the clinic. There arealso a psychologist, psychiatrist, and neurologist that work closely with the team and seepatients by referral. The psychologist and psychiatrist attend weekly meetings with the restof the HIV team to discuss patients who are having problems or provide relevant patientupdates. 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, sleepingdisorders, 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 ofcomplementary medications (during clinic time);


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• Conducts in-depth medication/allergy history including obtaining information fromother provinces;

• Identifies patients with drug payment/reimbursement issues (refer to social work ifneeded);

• 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 caregiverswithin hospital/community;

• Provides consultations on HIV resistance, reports and recommends new therapy basedon resistance mutations;

• Coordinates seamless care with community pharmacies, hospital pharmacies, andother agencies or health care workers; and

• Calls or writes prescriptions for HIV-related medications during clinic time (currentlywritten prescriptions are co-signed by physicians however with new legislation inAlberta this will change).

The pharmacists have also been involved in protocol development including a regional HIVperinatal protocol to prevent mother-to-child transmission.

Purpose: To provide optimum medication management to the HIV infected patients inNorthern Alberta, to improve patient outcomes by providing cost-effective therapy.

Human resources: Began with 0.4 FTE pharmacist (funded by University of Alberta’sFaculty of Pharmacy, in an agreement with Capital Health). In 2002, a 0.5 FTE pharmacistwas hired for a second HIV clinic in the inner city. In 2006/2007 funding was secured foranother 2 FTE pharmacists between the two sites.

Other resources required: Office space, computer support, etc., is provided by theprogram.

Funding/pharmacist remuneration: Except for coordinator 0.4 FTE, the pharmacistpositions are funded through Province Wide Services (provincial program which funds thehigh cost drugs such as antiretrovirals as well as program delivery staff). Support fromphysicians and other allied health workers, growing complexity of patients, and importanceof adherence/appropriate prescribing led to a strong application to increase funding fornew pharmacist hires.

Benefits/advantages/impacts: HIV treatment’s major focus is medication management, sohaving the pharmacist on the team has a definite impact on patient care.

Challenges and strategies used to overcome challenges: Challenges range frommaintaining communication with team members and between clinics and the very diversepatient population, to provision of seamless care between community and institution whenhospitalized and subsequent return to home, and time management.

Team has a private computer server that permits good interaction among team membersregarding particular patient situations and assists with overall communication. Teampharmacists have specific meetings to go over various issues. There are bi-annual full team




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meetings. Special awareness of issues in dealing with HIV patients is needed and requiresmentoring of new pharmacists to the area.

Effective liaison among the clinic, the institutional in-patient pharmacy and otherpharmacies that service these patients. Pharmacists in the program work together to sharethe load, exchange ideas to make system more efficient, etc.

FeasibilitySustainable: Recognized and funded by the Province Wide Services program. As previouslynoted, support from physicians, complexity of patients and importance ofadherence/appropriate prescribing strengthened application to increase funding for newpharmacist hires.Scaleable: Similar programs with pharmacists on the HIV team are spread across Canada atthe major HIV centres including Regina, Calgary, Vancouver, several in Ontario, Halifax andSt. John’s (the role of the pharmacists may be slightly different among these sites mostlydue to the amount of pharmacist time).Supported: Excellent support for the pharmacists on the team as demonstrated by thedemand for increased pharmacy services.Consistent: Through protocol development, frequent interaction, and yearly meetings ofpharmacists in HIV programs across Canada (about 20 pharmacists), there is consistency inservices provided. HIV patients are a diverse group, so individual approaches are stillnecessary.

Evaluation: Evaluations are usually done looking at the entire HIV service, of whichpharmacy is a part. Receive good feedback from both patients and clinic team. Reviewingdata 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 PharmacyNetwork. The role of the pharmacist caring for persons living with HIV/AIDS: a Canadianposition paper. Canadian Journal of Hospital Pharmacy 2000;53(2):92-103.

CONTACTOutpatient HIV ClinicUniversity of Alberta HospitalEdmonton, ABTel.: (780) 492-5903Email: [email protected]


4.8 Pharmacist in a Multi-site HIV Clinic, St. John’s NL

Interviewee: Dr. Debbie Kelly, Associate Professor, School of Pharmacy, MemorialUniversity 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 ofapproximately 120 HIV patients throughout the province. Satellite clinics are held when theteam 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 managethem. When regimens are failing, the pharmacist reviews resistance test results/antiretroviraldrug history and makes recommendations for new regimens. The pharmacist is responsiblefor cardiovascular and renal risk evaluations, as well as other non-HIV medication-relatedissues.

Dr. Kelly is also the HIV team liaison with the government prescription drug program,facilitating special authorization drug approvals, and reviewing criteria for anti-retroviraltherapy. Works with appropriate individuals within Eastern Health to set and reviseoccupational 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 thepharmacist’s time spent at the HIV Clinic.

Benefits/advantages/impacts: Patients are better informed to adhere to their medicationregimen. There is continuity or seamless care as Dr. Kelly follows up with local pharmaciesregarding the medication needs of each patient, as required. Potential drug interactions andadverse reactions are screened on a routine basis. Patients receive support andencouragement to participate in health-related decisions, and to adhere to their medicationtherapy.

Challenges and strategies used to overcome challenges: Lack of a physical home basefor the clinic is a challenge. It is held in a general outpatient clinic that is also used byother specialty clinics during the week. Therefore patient charts are maintained in a nursing



office and brought to the clinic weekly. Access to the patient charts is difficult when theclinic is not being held.

There has been a continuing change in the clinic staff (physicians, nurse, and socialworker) over the past two years. The pharmacist has been the only continuing professionalstaff during this time. During two long-duration absences there has been no clinicalpharmacist coverage for the clinic.

The pharmacist maintains her own copy of notes for follow-up on each patient, so notescan be referred to when patient contacts her. However, it is still difficult to get access topatient charts for other type of information. Currently working on development of adatabase on a secure server.

Team corresponds via email and phone between clinic days to ensure timely follow up oncritical patient issues. Dr. Kelly has acted in a consulting role during her extended absencesto address special clinic issues on an as-needed basis.

FeasibilitySustainable/Supported: Has been in operation for eight years and is funded through EasternHealth. One difficulty with the stipend arrangement is that it does not vary to account forincreasing 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 toexchange ideas has been established. The Network has published a position statement onthe role of the pharmacist in caring for patients with HIV infection.

Evaluation: During the first few years of the program workload statistics were maintainedin the development stage. Receives many letters and notes from patients expressing strongsupport for the program.

Communications/promotional material: The Conception Bay North AIDS InterestGroup has published a self-help manual that includes a section on the HIV team throughEastern Health. It highlights the services and support network available through the clinicto all patients and families living with HIV.

CONTACTDr. Deborah KellyAssociate Professor, School of Pharmacy, Memorial University of NewfoundlandEmail: [email protected]


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4.9 Collaborative Diabetes Education andManagement, 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 thepharmacy. Community pharmacist has broadened scope of practice within aninterdisciplinary 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 inthe delivery of educational services to those with diabetes, pre-diabetes or metabolicsyndrome. The community is on the boundary of three regional health authorities andaccess to formalized education services has been extremely limited.

Two community pharmacists received a $25,000 grant from the Primary Health ServicesBranch of Saskatchewan Health for the project entitled Primary Care Intervention andEducation in Diabetes: A pharmacist coordinated comparison of usual care versuscollaborative primary care in affecting diabetes control and quality of life. This projectdemonstrated the positive impacts a pharmacist can have on diabetes management andoutcomes in a collaborative primary care setting. Participating pharmacists completed theCertified Diabetes Educator Examination in May of 2006.

A formalized diabetes education and consultation program is now held at the CommunityHealth Centre in Wynyard. The collaborative team members on the project include all localphysicians (salaried and fee-for-service), the primary health care nurse, all of the localpharmacists, the home care nurse, the public health nurse, the manager of the WynyardCommunity Health Centre and the region’s dietitian. Targeted towards patients withdiabetes, pre-diabetes or metabolic syndrome.

Role of pharmacist: Both physician referrals and self-referrals are accepted by CommunityHealth Centre for individual consultations with a pharmacist one day per week. Manyclients have multiple follow-up visits to the service. Pharmacists also do insulin anddiabetes teaching for inpatients at the local hospital.

Purpose: To show that pharmacists can have significant impact on management andoutcomes of those with diabetes.


During the first year of the project, 50 to 100 patients are expected to access theconsultative 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).


Other resources required: Educational supplies, office space rental, support staff forclinic, (from Wynyard Community Health Centre), professional fees (from Townsend’sDrugs).

Funding/pharmacist remuneration: Through project grant from Saskatchewan Health

Benefits/advantages/impacts: From the initial pilot study, the trends noted in the dataindicated that patients in the intervention arm achieved lower fasting blood glucose, lowerHbA1c, lower diastolic blood pressure, and improved diabetes empowerment scores(statistically significant) at six months when compared to baseline. The usual care (non-intervention arm) group had increases in fasting blood glucose, HbA1c, systolic anddiastolic blood pressure and low-density lipoprotein (LDL) cholesterol (statisticallysignificant) and had lower diabetes empowerment scores after six months when comparedto baseline. An average of four drug-related problems (DRPs) were found in each of thepatients enrolled in the intervention arm compared to only five DRPs found in the entireusual care group. Recommendations made to physicians and/or patients regardingmedication 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 theservice.

Challenges and strategies used to overcome challenges: The primary challenge was toobtain funding.

Pharmacists endeavoured to keep all parties informed of their project and intent for thisenhanced service. Sought financial support from a variety of sources and plan to collectformal evaluation data to support longevity of the service. It is hoped that long-termpermanent funding will be obtained through the Saskatoon Health Region, or the PrimaryHealth Services Branch of Saskatchewan Health.

FeasibilitySustainable: Will depend on permanent financial support for the program.Scaleable: Desire to have this model program adopted by other health authorities inSaskatchewan.


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Supported: Excellent support from health professionals within the clinic and alsothroughout the region.Consistent: Services are provided on a consistent basis.

Evaluation: Data collection for formal evaluation is underway. Data will compare baselineto post-education/intervention on parameters such as HgA1C, blood pressure control, lipidlevels, number of hypoglycemic events/diabetes-related emergency or hospital visits,referrals to other health care professionals. Have received very positive feedback frompatients 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 theservice.

CONTACTDebra TownsendTownsend’s Drugs Wynyard, SKEmail: [email protected]

4.10 Diabetes Education Program, Youville Centre,Winnipeg MB

Interviewee: Dinah Santos, pharmacist team member at Youville Centre CommunityHealth 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 Wellwith Type 2 Diabetes Education Program, based on the Canadian Diabetes AssociationStandards for Diabetes Education.

Start date: September 2002 (pharmacist on maternity leave until October 2007)

Description of initiative: Youville Centre is a community-based, accessible healthresource 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; encouragingpeople to become involved in the management of their own health concerns, helping themidentify activities and programs that are of most benefit to them. Staff includes dietitians,community health nurses, counsellors, nurse practitioner and certified diabetes and asthmaeducators. Targets diabetics and families, either self or physician-referred.



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Role of pharmacist: Pharmacist is a certified diabetes educator, employed by CanadaSafeway, who donates eight hours per week to deliver diabetes education services atYouville Centre. Pharmacist assists with the development of diabetes presentations, doescase-management, case-conferencing, corresponds with physicians and other teammembers (nurses, dietitians, counsellors) and follow-ups with clients as necessary. Alsoavailable to provide drug-related information to the Centre’s nurses and dietitians.

The diabetes self-management education program is based on the principles of adultlearning 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 footcare, long-term complications/managing stress.

Each series is case-managed by either a nurse or pharmacist who assesses the health statusof each client, provides diabetes education, clinical support, community resources andcorresponds with physician as necessary.

Purpose: To improve the health status and decrease the risk for diabetes relatedcomplications in adults with Type 2 diabetes.


Funding/pharmacist remuneration: Safeway Pharmacy.

Benefits/advantages/impacts: Pharmacist expertise contributes to the Enhanced DiabetesHealth Team and other Youville Centre programming. There is continuity of care fordiabetes clients requiring follow-up by pharmacist, and increased human resources to meetthe demand of diabetes epidemic.

Challenges and strategies used to overcome challenges: The pharmacist is not alwaysavailable to meet with the Diabetes Health Team because the time available is limited toone day each week. Strategies used by members of the team include: email, and telephoneto communicate or case-conference with other members of the Diabetes Health Team atYouville Centre.

FeasibilitySustainable/Supported: Only with continued support from Safeway. Scaleable: Could be expanded with funding, established protocol, documentation andcertification of the pharmacist.Consistent: The Youville Centre is an accredited centre and has policies and procedures thatare followed by the pharmacist.

Evaluation: Youville Centre measures outcomes for the entire program, but no study ofspecific impact/value of the pharmacist. Great, positive feedback from clients andcolleagues.

Communications/promotional material: Social marketing through regional office ofCanadian Diabetes Association. Youville Centre and diabetes programs are well known bylocal health professionals and community members, often promoted through word ofmouth.



CONTACTDinah SantosCanada Safeway Pharmacy 1345 WaverleyWinnipeg, MB R2C 0A1 Email: [email protected]

4.11 Multidisciplinary Metabolic Syndrome Clinic,Ottawa ON

Interviewee: Alan Gervais, Drug Use Evaluation Pharmacist, Department of NationalDefence, 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 physicianoffices, laboratory services, and a community pharmacy. Clinic operates one day per week.

Type of innovation: Broadening role of pharmacist (review of patient data to makerecommendations on medications, lifestyle); cognitive services outside the pharmacy;chronic disease management; health promotion and disease prevention.


Description of initiative: Specialized individual consultation and group education forpatients diagnosed with metabolic syndrome, from an interdisciplinary team of healthprofessionals (endocrinologist, registered nurse, registered dietitian, and pharmacist).Targets patients identified as having metabolic syndrome are referred to the clinic by theirfamily physician or specialist. Self-referrals are not permitted.

Role of pharmacist: After the patient has met with the nurse and dietitian, the pharmacistreviews 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. Apatient may do very well with lifestyle changes and the pharmacist may recommend to theendocrinologist that the patient’s medication should be either discontinued or that the doseshould be lowered. If additional medication is required, the pharmacist discusses thisinitially with the patient, and then subsequently with the patient and endocrinologist.

Patients are provided with individual and group education sessions. The first session lastsabout two hours, of which 45 minutes to one hour is spent with the pharmacist. Subsequentvisits 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 visitand at the three- and six-month marks. Treatment plan is for a six-month period, and isreviewed at the end of the term. Patients have the option of re-enrolling into the programfor another six-month session.



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In addition to patient treatment, the pharmacist and endocrinologist conduct research ondrug-related aspects of metabolic syndrome.

Purpose: The clinic was established primarily due to shortage of family physicians, whichmakes it difficult for them to treat and follow-up complex conditions like metabolicsyndrome. The endocrinologist, Dr. Telner, was receiving referrals from family physiciansand realized that these patients required a multidisciplinary approach to the management ofthe metabolic syndrome. There was no place to refer these patients to, and as a result heset up the metabolic syndrome clinic, to improve long-term prospects for metabolicsyndrome 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, andreceptionist. A statistician is used on an ad hoc basis.

In order to decrease operating costs and to decrease the number of health careprofessionals that patients would have to see, the clinic may exclude the nurse from theteam. 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 andcivilian pharmacists and students.

• Pharmaceutical industry — approximately 12 pharmaceutical companies providefinancial support for the operation of the clinic (through unrestricted grants).

• Ontario Health Insurance Plan (OHIP) — endocrinologist’s time is billed in the normalmanner.

• Patient fees — patients pay an enrollment fee of $300 for the six-month program. Thisrepresents about 10% to 20% of the costs of operating the clinic, and wasimplemented primarily to ensure patient commitment. In the past, the program wasprovided free to patients, however patients would not attend all of their sessions andwould not call to cancel their appointments.

Benefits/advantages/impacts: Each patient is provided with a sufficient amount of time toaddress all of their health care needs related to the metabolic syndrome. This enables them toreceive significantly more attention than what would be available in the public health caresystem (average family physician visit is six to seven minutes), and allows close monitoringand 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 thePHM 459 Specialty Practice Visit course associated with the University of Toronto. Otherhealth care professionals have requested rotations through the clinic (public health nurse,etc.).



Challenges strategies used to overcome challenges: It is a challenge to get referrals fromfamily physicians — many are reluctant to seek external assistance in managing theirpatients’ 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 increasereferrals. Funding has just been received for a pilot study with 50 patients referred to theclinic by their community pharmacists (rather than family physicians). Symptoms forpossible metabolic syndrome are often obvious to pharmacists (large waste circumference,with high blood pressure), so that community pharmacists are in a perfect position to triagemetabolic syndrome patients. Pharmacists are able to determine if patients have high BP byeither their medication profile or by asking patients to measure their BP at the pharmacywhile they are waiting for their prescription to be filled.

FeasibilitySustainable: As long as pharmaceutical companies continue to support it. Overtures madeto 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 aseconomical as possible. The long-term goal would be to implement similar programs acrossCanada. Pending the results of the pilot, a pharmacist triage version could be expanded toother disease states. Pharmacist notes that, “Patient profiles are a wealth of information”.For example, pharmacists can identify patients with coronary artery disease (CAD) (use ofnitrates) or patients with diabetes (oral hypoglycemic agents or insulin) and ask them ifthey 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 goodcommunication among the small team.

Evaluation: Formal evaluation results will be published in the January/February 2008edition of Canadian Pharmacists Journal. Preliminary review of patient data at 6-monthpoint shows a statistically significant difference from baseline data. Results were presentedat the Canadian Diabetes Association Conference in 2005, and at Endocrinology Divisionrounds at the Ottawa Hospital.

The pharmacist has seen encouraging results among patients who have stayed in theprogram 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 interventionand counselling about the concomitant use of herbal remedies (generally discouraged dueto the risks of adverse drug reactions at worst and at best, lack of efficacy) has resulted inan 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 ServiceAward (DOSA) award for this work.



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Academic documents:• Co-developed with Dr. Jean-Pierre Després: a lecture kit for pharmacists on the topic

of Metabolic Syndrome in 2006.• Gervais A. A heavy weight to carry. Pharmacy Practice 2006; 22(9); 39• Gervais A, Telner A. Metabolic rebuttal. Can Pharm J 2005;138(8).• Gervais A Treatment of Metabolic Syndrome (ask your pharmacist) CPJ March 2005;

138(2): 50.• Gervais A, Crotty K, Telner A. Natural Health Products and Metabolic Syndrome. Can

Pharm J 2005; 138:26-27• Gervais A, Crotty K, Telner A. The use of natural health products in patients with

metabolic syndrome [abstract]. Canadian Journal of Diabetes 2005; 29(3): 318.• Telner AH, Gervais AA. Challenges associated with the implementation of a

multidisciplinary clinic to treat the metabolic syndrome [abstract]. Canadian Journal ofDiabetes 2005; 29(3): 317.

• Telner AH, Gervais AA, Amos SS. Outcomes of a multidisciplinary approach to themanagement of the metabolic syndrome [abstract]. Canadian Journal of Diabetes2005;29(3):318.

• Telner AH, McClelland LS, Cameron AK and Gervais A. Initial characteristics ofpatients referred to a multidisciplinary metabolic syndrome clinic [abstract] CanadianJournal of Diabetes. 2006;30(3):309.

Communications/promotional material: Team has produced a brochure to give topatients, and as well as a website (www.metabolicclinic.com).

CONTACT Alan GervaisCarling Metabolic Syndrome Clinic3029 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 IevaFraser OT, manager, chronic disease; pharmacists, The Arthritis Program (TAP), SouthlakeRegional 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;


• 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 Medicationsand the quarterly “Ask a pharmacist” column; and

• Arthritis Health Professions Association (AHPA).

Location or setting: Onsite at Southlake Regional Health Centre (SRHC) 1991-2001. Offsiteat 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 innovativerheumatoid arthritis care team that was providing in-patient coverage at the York CountyHospital. By 1986, 50% of the patients were receiving care as outpatients. In 1991, asubmission entitled Chronic Disease Management for Ontario Using Arthritis as the Modelreceived funding.

The program’s goal is to improve the quality of life for arthritis patients and keep themfrom needing hospital admission. Patients with the diagnosis of Inflammatory Arthritis areseen individually and then placed in a three-week education program combined with arheumatology clinic. There are also formalized patient education programs forosteoarthritis, fibromyalgia and osteoporosis. The educational programs cover every aspectof the disease process so as to affect behavioural change in the patient and successful self-management of their disease.

Unlike most ambulatory care clinics where the physician indicates when the patient is to beseen again, triage is done by other health professionals after treatment and/or assessment.Medical intervention is only required for patients with disease change, for medicationreviews, side effect challenges, etc.

The program has five individual treatment and consultation rooms, one largeclassroom/exercise space, one small group room, and a staff room, chart room, centralreceptionist/clerk and waiting room space. At present, the team consists of a programcoordinator, three rheumatologists, 1.5 FTE pharmacists, 1.5 FTE occupational therapists,1.5 FTE physical therapists, 1 FTE kinesiologist/rehabilitation assistant, 0.3 FTE socialworker and group education by a registered dietitian.

Currently 99% of patients are seen as outpatients. Targets patients with any type ofmusculoskeletal disease. There are more than 2000 referrals a year, prioritized by diagnosis.

The program offers group treatment and education; individual counselling; product inter-relationship research; development of educational materials (e.g., medication info, herbalremedies); community speaker/presentations; rheumatology clinics, partnering withrheumatologists.




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Role of pharmacist: The pharmacist brings to the team the role of a scientist with theunderstanding of the science of medicines and their utilization by the body.

The pharmacist provides medication sessions for the patient education programs and one-on-one patient medication consultations. Makes medication recommendations to therheumatologists and works closely with other team members. Patient education includesinstruction in the self-injection of methotrexate for the treatment of inflammatory arthritis.Takes phone inquiries from previous and current patients for medication information andmedication related problems.

The pharmacist sees more than 200 patients per month either in the group/individual orClinic format. The pharmacist is also on the alert to any blocks to care the patient mayhave, 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 ofmedication is at odds with the patient’s preference, or when there are complexities due toco-morbidities. Teaching patients how to be their own advocate is an important componentof self-management of their disease.

Purpose: to provide timely access to care, reduce the disability that can accompanymusculoskeletal diseases, increase the success of long term self-management, increasepatient 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.



Challenges and strategies used to overcome challenges: Initially there was littleguidance from the literature or other practitioners for a pharmacist role in aninterdisciplinary team, and as a scientist and educator. Patient medication educationmaterials 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 teammember 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.

FeasibilitySustainable: The program has proven its sustainability over twenty years.Scaleable: The hospital is utilizing the TAP model as it organizes five new chronic diseasemanagement clinics: geriatrics, stroke and transient ischemic attack (TIA), woundmanagement, 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 regularprovincial health care funding.Consistent: Extensive guidelines to ensure consistency of care.

Evaluation: Patient satisfaction questionnaires and clinical outcome measurements indicatethat patient needs are being met and their quality of life is improving. Workload Statisticsindicate constant growth in all areas in an efficient manner.

Recognized for Excellence of Care; received an Ontario Hospital Association ChangeFoundation 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 CentralLHIN: 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 Medicationsdeveloped with the Arthritis Society

CONTACTMarie CraigThe Arthritis Program (TAP) Tannery MallNewmarket, ONTel.: (905) 895-4521 ext. 2404Email: [email protected]



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4.13 Asthma and COPD Education Services in aCommunity 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 Reginaand two physician offices in Fort Qu’Appelle (covering more than 40 physicians).

Type of innovation: Health team approach to providing clinical pharmacy services inrespiratory 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 asthmaeducator and COPD educator. The patient can self-refer or be physician referred. Theeducation session takes approximately one hour. Family members are encouraged to attendwith the patient.

These services are provided both in the pharmacy (education room) and in physician’sclinics, if identified by a physician. Each patient is seen individually, spirometry isperformed if indicated and education is provided. Education for each patient is unique andmay encompass topics such as: medications, inhaler technique, basic pathophysiology andenvironmental control.

Using care flow sheets, the pharmacists are able to give the doctor pertinent informationand a history of the condition. At the end of the session, the details and findings arediscussed with the physician and changes or reinforcement take place at this time. Anaction plan is written for each patient. When necessary they will bring the patient back inone month for follow-up.

Each clinic has one designated day per month to allow pre-booking by the physicians asthey see their patients during the month. Targets asthma and COPD patients coming topharmacy or physicians’ offices.

Purpose: The basis of chronic disease management is education. With proper educationpatient 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 theirdisease. Other expected outcomes: better compliance with medication use, fewer hospitalemergency room/walk-in clinic visits, decreased morbidity, decreased mortality.

Other resources required: Literature, patient education material from Lung Association,Safeway or drug companies



Funding/pharmacist remuneration: Safeway and Lung Association (through donations).

Benefits/advantages/impacts: Helps patient better manage a chronic disease, andimproves patient quality of life.

Challenges and strategies used to overcome challenges: It has been a challenge togain the trust and acceptance of the physician. Availability of space in the physician’s officeis 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 tobe visible in the medical community;

• Positive patient outcomes, better disease control and increased patient QOL havereinforced the pharmacists’ position as a part of the health team;

• Worked in affiliation with the Lung Association of Saskatchewan doing publicawareness forum and education sessions; and

• Education and spirometry testing are done in education room at the pharmacy, toovercome the lack of space in the physicians’ offices. Results are faxed to thephysician’s office and confer with him/her via telephone.

FeasibilitySustainable: 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 certifiedasthma 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 inthis area of practice. Patients say their confidence in their ability to control their disease hasincreased.

Academic documents:• Pharmacy Practice, June 2002 • New Pharmacist, Spring 2006, p. 33

Communications/promotional material: Pamphlets noting service provided.

CONTACTPat SmithSafeway Pharmacy Regina, SKTel.: (306) 586-5145 Email: [email protected]



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4.14 Essex County Community Asthma Care Strategy,Windsor ON

Interviewee: Dorothy Pardalis, staff pharmacist and Certified Asthma Educator, McGaffeyPharmacy

Sponsoring organizations: Created as a pilot project in October 2002 by Dr. ChristopherLicskai, a former Windsor-based respirologist, with support from unrestricted educationalgrants from the pharmaceutical industry. Then funded by the Primary Health careTransition Fund from October 2004 to July 2006. Currently funded by Ontario Ministry ofHealth and Long-Term Care.

Other participating organizations: Essex County Pharmacists Association, University ofWindsor- WEDnet (created electronic assessment tools and collects/stores data forevaluation purposes), Asthma Research Group Incorporated, Hotel Dieu Grace Hospital,DaimlerChrysler, St. Joseph’s Health Care (London, ON), Leamington District MemorialHospital, Ontario Lung Association.

Location or setting: Family physicians’ offices in Windsor and Essex County, ON.

Type of innovation: Broadening role (pharmacists are assessing, educating, utilizingspirometers, and making recommendations to physicians); cognitive services outside thepharmacy (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 willnot be available.

Description of initiative: Patients meet with pharmacist educator in their physician’soffice for an extensive 90-minute assessment that includes a spirometry reading, inhalertechnique 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 thepatient create their own action plan for controlling their asthma. A report for the physicianadded to the patient’s chart for review at future visits. A follow-up appointment is held withthe 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 patientrecords (“look-back” program) and subsequent referral by the family physician, or by



referrals from walk-in clinics (for patients without their own family physician), emergencydepartments, or employers.

Purpose: Created to meet a perceived need in the community and to prevent asthmapatients from falling through the cracks. Goals are to identify individuals with asthma andinitiate early treatment, improve patient outcomes, and support resource utilization, todevelop a community model for multidisciplinary chronic disease management that wouldultimately reduce health care utilization, asthma exacerbations, absenteeism and to improvelung function.

Human resources: Five pharmacist-educators, six respiratory therapists, and a registerednurse, who participate as needed/scheduled by the coordinator. Pharmacist educators arebooked online, according to their availability. Dorothy completed the asthma educatorcourse offered by the Michener Institute, and holds Certified Asthma Educator designationfrom the Canadian Network for Asthma Care (CNAC).

Other resources required: Laptop, a portable spirometer with report printing capabilityand other equipment. Pharmacists are linked via an electronic forum to share informationand experiences, and for consultation.

Funding/pharmacist remuneration: Since July 2006, all funding has been from theOntario 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, programprovides a great deal of professional satisfaction to pharmacist-educators.

Challenges and strategies used to overcome challenges: Program accessibility forpatients has been the biggest challenge — there have been cases where the patient hearsabout 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 topromote and explain the program.

FeasibilitySustainable: 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 forfollow-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 portablelaptops /assessment tools) to a secure central resource database for analysis andmeasurement of efficacy. To-date the (unofficial) results reflect an over 50% improvementin symptom control, decrease in emergency department and urgent health care utilization,



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and a doubling of the number of patients in control. May see an increase in prescriptiondrug 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 distributedthrough community pharmacies. Pharmacists also promote through presentations andmeetings with employers, physician groups. The Ontario Lung Association will also connectWindsor-based patients to this program.

CONTACTDorothy PardalisMcGaffey Pharmacy3955 Tecumseh Rd. E. Windsor, ON N8W 1J5 Tel.: (519) 945-2121Email: [email protected]

4.15 Manitoba Renal Program (MRP), Manitoba

Interviewee: Lavern Vercaigne, Associate Professor, Faculty of Pharmacy, University ofManitoba, and pharmacist team member.

Sponsoring organization: Manitoba Renal Program (MRP)

Other participating organizations: Winnipeg Regional Health Authority, PharmacyServices.

Location or setting: Winnipeg, Brandon, and 12 local dialysis centres

Type of innovation: Province-wide interdisciplinary teams providing extensive clinicalpharmacy 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, occupationaltherapists, dialysis care technicians, aboriginal liaison and spiritual care providers) worktogether to promote a holistic approach to care for people living with kidney disease, their


families, and their communities. The teams provide ongoing care of patients with renaldisease and their families to maintain or enhance quality of life, including end of lifemanagement, and to assist in adaptation to chronic illness. This is achieved as close to theperson’s home community as possible. Targets individuals with chronic kidney disease inManitoba.

Role of pharmacist: Renal pharmacists are involved in all areas of renal patient careincluding:• 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 14pharmacists meets monthly by video and voice conferencing to provide updates anddiscuss issues that have arisen.

Purpose: The MRP develops and provides two broad elements along the continuum ofcare 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 dialysisfor both acute and chronic kidney disease.

• Renal Health Outreach (RHO) responsible for renal health promotion, diseaseprevention 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 renalpharmacists, improving their quality of life. The local practitioners have quick access toexpertise for dealing with these patients.

Challenges and strategies used to overcome challenges: Pharmacists feel pressure toeffectively provide pharmaceutical care for the 1000 dialysis patients and more than 3000renal health clinic patients that are part of the MRP. Challenged to be accountable for thedrug budget for high-cost pharmaceuticals within the MRP; erythropoietic therapies are thesubject of many of research projects and cost containment initiatives. Monthly video and




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telephone conferences are held with each unit to update everyone on new developmentsand to share experiences and therapeutic solutions to problems.

FeasibilitySustainable: Program is well accepted and has been in operation with permanent fundingsince 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 WesternCanadian Banff Seminar Conference Proceedings March 4, 2005.

• Raymond C, Dyck J. Impact of a pharmacist at a renal health clinic. Can J Hosp Pharm2004; 57(Suppl. 2):29.

• Riley K, Martin J, Wazny LD. Impact of pharmacist intervention on osteoporosistreatment after fragility fracture. Can Pharm J 2005;138(1):37-43.

• Riley KD, Wazny LD. Assessment of a fax document for transfer of medicationinformation to family physicians and community pharmacists caring for hemodialysisoutpatients. CANNT J Jan-Mar 2006;16(1):24-8.

• Vercaigne L, Wazny L, Raymond C, Skwarchuk D, Bernstein K. Funding of clinicalpharmacy services in the Manitoba Renal Program. CANNT J 2007;17(3). CANNTAnnual Meeting, Winnipeg, Manitoba (Oct. 25-28, 2007).

Communications/promotional material: www.manitobarenalprogram.ca

CONTACTLavern VercaigneTel.: (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 ClinicalPharmacy, School of Pharmacy, Memorial University. Secondary appointments at theFaculty of Medicine and the Eastern Health Department of Pharmacy. Pharmacotherapyspecialist at an ambulatory care clinic.

Sponsoring organization: Memorial University of Newfoundland

Location or setting: Hospital, St. John’s, NL

Start date: Spring 2006



Description of initiative: Direct care services to infectious disease patients. Thepharmacist provides both primary care and post-institutional care. The pharmacist’sconsultation would involve meeting with the patient about the prescription written by thephysician; an explanation of any interaction with other medication if applicable; a call tothe patient’s community pharmacy to let them know about the course of the treatmentwhen necessary and provide answers to their questions. There may be two or three follow-up visits needed for some patients.

Pharmacist also works with the physician at the Clinic; discusses therapies that would beefficient for each patient. Facilitates funding or application for funding for the therapy, ifrequired. This may involve literature searches in order to provide the rationale for thepharmacotherapy. The pharmacist sees 10 to 14 patients per week. Targets patients withinfectious diseases, whether self-referred, in-patients or post-institutional patients.

Purpose: The goal is to provide more effective direct pharmaceutical care to patients. Thisextended pharmaceutical service would be difficult to offer in a community setting, sincethis 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 theseservices are provided within an institutional setting, the pharmacist’s remuneration is part ofhis salary.

Benefits/advantages/impacts: Patient receives more enhanced care. By the pharmacistadding these services, it makes the service more effective for the patient at a minimalincrease in cost or often at a decrease in cost.

This clinic demonstrates that even in a highly specialized field like infectious diseases thereis a role for pharmacy and that the pharmacist can improve patient’s outcome.

Challenges and strategies used to overcome challenges: The main challenge is otherhealth care professionals not really understanding what the pharmacist’s role could be. Thepharmacist basically has to slowly and cautiously educate other health professionals. Itrequires persistence and strong will.

Evaluation: There is no formal evaluation planned.

CONTACTJohn HawboldtAssistant ProfessorSchool of PharmacyMemorial University of NewfoundlandTel.: (709) 777-8777Fax: (709) 777-7044 Email: [email protected]



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4.17 Pharmacist-managed Drug Safety Clinic,Toronto ON

Interviewee: Sandra Knowles, BScPhm, manager, clinical pharmacist

Location or setting: Sunnybrook Health Sciences Centre, Toronto, ON

Start date: Dedicated pharmacist position added to Drug Safety Clinic in 1992.

Description of initiative: Evaluation, confirmation and treatment of drug allergies.Patients are referred to the clinic from various communities in Ontario, and by Telehealth.The clinic books approximately 30 new patients per week, and 75% to 80% of these returnfor testing. In total, about 50 patients are treated weekly.

Role of pharmacist: Develops allergy testing (skin and patch) and desensitizationprotocols. 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 areavailable 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 ona temporary basis by the Drug Information Pharmacists. In 1996, Sunnybrook received corefunding from GSK to formally set up the clinic, and to develop a financial plan. Fundingwas made available for a part-time position at the Drug Safety Clinic.

OHIP payments to physicians providing services at the clinic are used to covercompensation 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.


Benefits/advantages/impacts: Improved patient care at the individual patient level andglobal levels.

Challenges and strategies used to overcome challenges: Lack of time (funding) to setup all the patient programs needed is the biggest challenge. Acceptance and support by themedical community has never been an issue.

FeasibilitySustainable: Through physicians’ billings to the Ontario Health Insurance Program (OHIP)Scaleable: Very difficult for smaller institutions to establish an ongoing allergy clinic, forfinancial reasons. Even with the high volume of patients visiting the Sunnybrook clinic, it isjust breaking even. Supported: YesConsistent: Yes, due to the establishment of testing protocols and the fact that there is onlyone pharmacist.

Evaluation: No formal evaluation, but an informal one as evidenced by the clinic’sincreasing number of referrals.

Communications/promotional materials: Professional presentations to let Sunnybrookand other health care professionals know about the existence of the drug safety clinic.

CONTACTSandra KnowlesSunnybrook Health Sciences Centre, Drug Safety ClinicEmail: [email protected]


SECTION 5 — HEALTH PROMOTION AND DISEASE PREVENTION


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5.0 HEALTH PROMOTION AND DISEASE PREVENTION

5.1 Phamacist Consulting at a Geriatric AssessmentClinic, 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 resolvingdrug-related problems) outside the pharmacy.

Start date: January 2003; prior to that, the assessment team had been operating with nursesand physicians only.

Description of initiative: Pharmaceutical consulting services as part of a multi-disciplinaryteam 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 ofage 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, onaverage), completes a medication history, and then assesses for drug-related problems. Forexample, for a referred patient with a history of falls, would consider whether or not thepatient’s drug therapy may be contributing and review.

Any team members who have also assessed the patient then meet to discuss the respectiveassessments and summarize them back to the patient and/or their family, and to thereferring physician.

Some follow-up may also be done, particularly if the patient changes medication regimensor starts a new drug, due to the recommendations of the team. Once follow-up iscompleted, the patient is discharged from the program. Team pharmacist also estimates thatshe liaises with the patient’s community pharmacist in over half of referred cases. This isdone when intervention by the patient’s community pharmacist is judged to be warrantedfor better care (e.g., review inhaler technique, provide compliance packaging).

In other words, team members each conduct independent assessments of the patient, meetto discuss and summarize, forward the recommendations, then discharge the patient fromthe program – the clinic does not provide treatment.

The assessment team normally completes two to five assessments per day, depending oncomplexity.



Purpose: Clinic is not a primary care clinic, but referral-based. As with any specialty, thehealth care providers at the clinic do not take over the care of the patient. Instead, they doa comprehensive assessment, provide the assessment to the primary care physician, andprovide support to that physician in terms of guidance on implementation. The goal is toprovide 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 cross-appointment to the Capital Health Authority (CHA). The pharmacist is employed full-timeby the University of Alberta, with 0.4 FTE of her time spent on a service exchange withCHA to work at the assessment clinic.

Benefits/advantages/impacts: The team environment provides a richer workingenvironment for pharmacists. The comprehensive assessment process allows the pharmacisttime and resources to conduct a thorough review. The clinic is an excellent teachingenvironment, allowing students or trainees the time to complete assessments, interact withpatients and families/caregivers, and work side-by-side with team members.

Challenges and strategies used to overcome challenges: Generally, family physicianswill refer the more medically complex cases to the geriatric assessment clinic. There can besome challenges with working as a team for health professionals without previous relevantexperience. However providing care for patients with more complex health issues normallyrequires a team approach and health professionals practising in geriatrics are accustomed tothis 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. Thismay 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 andclinic members involved.

Patient and caregiver feedback is often difficult to obtain as many of the patients sufferwith dementia and cannot complete a questionnaire or provide accurate feedback.

FeasibilitySustainable: With continued funding and availability of pharmacists with experience and/oradditional 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 familyphysicians. CHA provides financial support for the pharmacist who handles a small numberof complex, time-consuming cases.Consistent: Service is currently provided by a single pharmacist; therefore, there isconsistency. A process to ensure consistency between new pharmacists that may enter theprogram has not yet been developed.


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 ofsuccess and to quantify or measure since it not a disease-specific clinic. Success ismeasured by patient quality of life. Informal evaluation through support from referringphysicians, clinic staff, and administrators.

Communications/promotional material: Assessment service is promoted to familyphysicians with in-hospital patients and those ready for discharge. It is also listed as anavailable service to regional physician networks.

CONTACT Dr. Cheryl SadowskiUniversity of Alberta Edmonton, AB T6G 2N8Tel.: (780) 492-5078 Email: [email protected]

5.2 Good Samaritan Seniors’ Clinic, Edmonton AB

Interviewee: Kathy James Fairbairn, pharmacist providing clinical pharmacy services inproject

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 fivefamily physicians with advanced training in care of the elderly. A geriatrician oversees theclinic but the day-to-day management is handled by an advance practice nurse. Additionalmembers of the team include a nurse practitioner, two licensed practical nurses and aphysiotherapist. Targets complex, vulnerable seniors who live in the community. A goodportion of the clinic clients are homebound and require the team to provide assessment intheir home. Many clients also receive home care or are in a supportive living environmentsuch as assisted living.

Role of pharmacist: Pharmacist services are provided for 1.5 days per week. Thepharmacist’s work is varied but most clinic days include a home visit, medicationassessments, 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 andfamily. After an assessment is made, the pharmacist may make recommendations to alter,initiate or stop therapy to the clinic physician and in some cases the patient’s own


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physician. The pharmacist also communicates with the patient’s pharmacist regarding anychanges in therapy as well as obtaining medication records of previous medications. Inaddition to providing the patient with information on medication management issues, thepharmacist encourages patients (and their support individuals) to develop lifestyle changesthat may improve health.

After the initial assessment, follow up calls or contacts are scheduled if required forcontinued assessment or monitoring. The pharmacist also participates in teachingopportunities 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. Thegoal is to provide a multidisciplinary approach to improving the health of senior citizenswho are patients of the clinic.


Funding/pharmacist remuneration: The clinic receives primary care funding for thephysicians and the advanced practice nurses. Good Samaritan and the geriatricianrecognize the importance of the pharmacy and physiotherapy services to the clinic, sothese positions are funded by Good Samaritan.

Benefits/advantages/impacts: These advanced primary care pharmacy services enhancethe medication management of the seniors. Their medication needs are still provided bytheir local community pharmacy.

Challenges and strategies used to overcome challenges: Since the government-fundingmodel in this case does not provide support for pharmacy services, there is a constantchallenge to demonstrate the value of pharmacy services to the clinic.

Maintaining good communication with the dispensing pharmacy for those patients, is achallenge. The electronic medical record is not able to track specific pharmacy servicesprovided in a comprehensive manner.

Important to maintain an excellent relationship with clinic health professionals and ensurethey are aware of the benefits of pharmacy services provided and demonstrate the value ofthe service to government and third party funders. Maintain frequent contact with thedispensing community pharmacists to keep them in the loop. The pharmacist played a keyrole in assisting with the development of the electronic medical record.

FeasibilitySustainable: Program has been in operation for three years.Scaleable: Good Samaritan is currently expanding the scope of the clinic by partnering withan existing geriatric program in the region.Supported: Pharmacy services has the strong support of the clinic health professionals andthe Good Samaritan Society.Consistent: The service provided is primarily referral based, but the pharmacist alsoconducts chart reviews to identify patients who may meet the criteria for this service.


Evaluation: The clinic has a formal evaluation of all team members and a survey is nowbeing done to evaluate direct and indirect care. The service is greatly appreciated by theclinic professional staff, and the Good Samaritan Society who provide the funding for theposition out of their operation funding.

Communications/promotional material: Kathy James Fairbairn is featured in theSeptember 2007 issue of Pharmacy Post.

CONTACTGSS Seniors’ Clinic Good Samaritan SocietyEdmonton, ABTel.: (780) 486-3476 or (780) 910-1956Email: [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 servicesoutside the community pharmacy.

Start date: June 2007

Description of initiative: Pharmacist provides chart-based consultation service tophysicians and nurses at the Leader Medical Clinic. Targets coronary artery disease patientswith high blood pressure who are not receiving adequate pharmacotherapy

Role of pharmacist: Patients who fit the criteria are flagged by the physician and/or nursepractitioner. The pharmacist conducts medication and chart reviews to check for bloodpressure and cholesterol levels, and prescribed medications. Referring to treatmentguidelines, she makes pharmacotherapy recommendations (e.g., change dosage of currentmedication(s), initiate new drug) in the patient’s chart that the physician or nursepractitioner 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 toreview approximately five patient charts per visit.

Purpose: In addition to the expected patient health benefits, this consultation service waslaunched to enhance relationships with other health care professionals, and to let themknow what pharmacists are capable of doing. Goal is achieving enhanced patient care


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through initiating a positive working relationship with local physicians and nurses, andidentifying potential and/or actual drug-related problems.

Human resources: The pharmacist currently provides pharmacy services to the MedicalClinic approximately two afternoons per week. The pharmacist and her employer, StueckPharmacy, would like this time to increase, but it is currently limited to this level due topharmacy staffing pressures. A replacement is needed to fill in at the pharmacy while theconsulting 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’srecommendations will result in improved patient outcomes.

Challenges and strategies used to overcome challenges: When this consultation servicewas first initiated, the pharmacist’s recommendations were immediately enacted. Thiscaused some patients to be concerned (i.e., “I just saw my physician a month ago, why ismy prescription being changed now?”) so a new process was adopted. The pharmacist’srecommendations are noted in the patient’s chart so that the physician can review themwith the patient at the next visit, before initiating any changes.

Time is also a challenge, since the pharmacist also has responsibilities as a dispensingpharmacist at the community pharmacy.

FeasibilitySustainable: 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 aremade by the same pharmacist.

Evaluation: No overall cost-benefit evaluation has been done and it is not likely that onewill be. The pharmacist has kept track of the recommendations made, and is planning toreview patient outcomes as a result of these recommendations.

CONTACTStueck’s Pharmacy 116-1st Ave. W. Leader, SK Tel.: (306) 628-3744 Email: [email protected] or [email protected]




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5.4 Heart Health Education Program, Espanola ON

Interviewee: Lynn Halliday, staff pharmacist; Robinson’s Pharmasave, program coordinator

Sponsoring organization: The Ontario Ministry of Health and Long-Term Care (MoHLTC)funds the Espanola and area Local Health Integration Network (LHIN), which in turnoperates the Espanola Family Health Team (FHT) (a collaboration of non-physician alliedhealth care professionals).

Location or setting: Family Health Team office, consisting of examination andconsultation rooms, and a reception area. Each health care professional involved with theFHT 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 aphysician. In physician-run collaborations the allied health professionals may be in“physician assistant” roles. Because this FHT is not physician-centric, each healthprofessional is able to fully contribute their particular expertise. Innovative approaches toenhancing the health and care of patients are encouraged. Targets patients identified asbeing at risk for heart disease. Patients can self-refer or be referred by their familyphysician to the FHT for assessment and enrollment in the program. Patients are flagged ifthey 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 healthteam for this program. The pharmacist pre-screens; conducts an initial cardiovascular riskassessment (establishing their risk level and modifiable risk factors), then directs them tothe appropriate health care professional (e.g., a dietitian for hyperlipidemia/abdominalcircumference/hypertensive diet; a social worker for stress management; a diabeticeducator for diabetes; or a nurse for smoking cessation).

The pharmacist will also conduct medication reviews if requested by the nursepractitioners, 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 careprofessionals they see. The FHT sends a report on the assessment and action plan to thepatient’s physician (if they have one) and if not, just to the patient. In some cases, patientswithout a physician are instructed to take the report to the local emergency departmentwhere they can see a physician (e.g., “Patient has been screened, and here are the riskfactors…”).

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 isreassessed. If they have not met target levels they are referred back to their primary care



physician with a letter outlining what had been done. At the one-year mark, they are againre-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-effectiveprimary care.

Human resources: 1 FTE pharmacist, also 1 FTE for dietitian, diabetes educator, socialworker; 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-updynamics of operating in a multi-disciplinary team can be challenging.

FeasibilitySustainable: Yes, funded by the provincial government.

Evaluation: No formal evaluation has been done yet, however data is collected by theOntario government on who is being treated (statistical data). Many other FHTs areassociated with larger teaching hospitals throughout Ontario, with access to research staff.The Espanola FHT does not have this capability. The FHT is collecting some qualitativedata on some of the programs offered.

Communications/promotional material: The Espanola FHT funds a weekly article inthe local newspaper, highlighting the programs offered by the FHT.

CONTACTLynn HallidayRobinson’s Pharmasave 119 Tudhope St.Espanola, ON P5E 1S6Email: [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 allottedfor patient consultation

Start date: 1997



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Description of initiative: Pharmacists provide patient education and conduct disease stateclinic days in local London Drug community pharmacies. Pharmacists with a particularinterest in clinical care are recruited from among existing staff and provided withspecialized training and continuing education. The Patient Care Pharmacist (PCP) programis offered by London Drugs on an annual basis, and each year focuses on one particulardisease state (asthma will be the featured subject in 2008). The course is four to five days inlength and covers communication and presentation skills, how to collect specimens,equipment training, as well as updates on disease states. Self-study modules are alsoproduced.

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 tophysician, 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 INRlevels has been in place for approximately seven years. Patients can have venous punctureperformed in a counselling room and pharmacists obtain INR level. Under pre-establishedagreements, the pharmacist can adjust the patient’s coumadin dosage based on these testresults. This program requires extra pharmacist training and certification, and is based onphysician referral of patients. Targets patients who are customers of London Drugs acrosswestern Canada.

Role of pharmacist: After completing the training program, the PCP is then assigned anumber of London Drug pharmacies where they are responsible for conducting an averageof eight to nine clinics per year. The PCP also maintains a community practice based out ofa specific London Drugs pharmacy. The PCP spends 20% to 30% of their time on thesefunctions.

Family physicians are kept in the loop; test results and recommendations are provided bythe PCP to the physician if requested by the patient.

Purpose: This program was initiated by London Drugs to demonstrate that pharmacists arean important part of the health care team.

Human resources: Currently, 32 community pharmacists (London Drug employees) areenrolled in the program.

Other resources required: Testing equipment such as cholestic, spirometer, ultra-violetsun camera.



Funding/pharmacist remuneration: Until recently, patients were not charged for theanticoagulation monitoring services. London Drugs collected data on the benefits of theseservices and presented it to the provincial government with the goal of initiating thedevelopment 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 diseasestates.

Benefits/advantages/impacts: London Drugs sees the consultations as an opportunity forrelationship building with patients. Since the inception of this program, participatingpharmacists report that they perceive patients to be more trusting and apt to consult withthem on health matters. The clinics are increasingly popular, with invitations extended bylocal 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 ongoingmonitoring (e.g., for diabetes).

Challenges and strategies used to overcome challenges: Making pharmacists availablefor the program, due to staff shortages.

FeasibilitySustainable: Yes, if the company is committed to absorbing the costs. London Drugs hasbeen 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 familyphysicians are reported to be generally well received and accepted. Patients report that thetesting 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 therelatively 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 intranetsite.

CONTACTShan KhooManager, Pharmacy Managed Care London DrugsTel.: (604) 448-4028Email: [email protected]

SECTION 6 — CONTINUITY OF CARE


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6.0 CONTINUITY OF CARE

6.1 Community Medication Management Program,Fraser Valley BC

Interviewee: Dr. Adil Virani, Assistant Professor, Faculty of Pharmaceutical Sciences, UBC;project’s regional manager.

Sponsoring organization: Fraser Health Authority

Location or setting: This program is located within four regions in the Fraser HealthAuthority: Burnaby, White Rock, Surrey and Abbottsford/Mission.

Start date: April 2005.

Description of initiative: This medication management service involves pharmacistsidentifying patients recently discharged from hospital who are at high risk for a medication-related problem, and performing a home visit medication review, with a goal of minimizinghospital readmission.

This is one component of total community pharmacy focused services. Fraser Health alsohas three other community programs: two pharmacists working with renal patients, twopharmacists with mental health patients and three in palliative care.

Pharmacists do home visits to review an individual’s entire medication profile, includingprescription drugs, over-the-counter products, and herbal agents. If desired by theindividual, the pharmacist will remove outdated or unused medications no longer needed.

Once the pharmacist has completed an assessment of the medications the individual istaking, recommendations are made to the primary care physician. The pharmacist mayintroduce compliance aids, such as blister packs, if needed. A pharmacist may also list allthe medications being taken. This list can be used if the person is admitted to hospital orwhen seen by their doctor. If needed, a pharmacist may make a second visit or follow upby phone/email.

During the first year, 483 seniors received a home visit; there were 681 home visits duringwhich pharmacists made 1685 recommendations for medication regimen changes, with1244 being accepted. The pharmacists provided medication education during 605 visits,cleared medication cabinets during 190 visits, recommended a compliance aid during 260visits and requested laboratory testing after 126 visits. During 244 visits, the pharmacistsperformed a non-pharmacological intervention such as checking blood pressure or bloodglucose, requesting special authority for medicines, reporting an adverse drug event, orreferring the patient to another health care professional.


Targets people at high risk for a medication related problems. Individuals must meetseveral of the following criteria:• 65 years of age and older;

• Discharged from hospital with at least six regularly scheduled medicines and may beat 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 eachof their communities and from the elder health program.

Once a person who may benefit from a home visit is identified, a pharmacist may call withpreliminary questions to assess whether a home visit is required. The pharmacist will alsotry 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 athighest 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 highrisk, have the potential to decrease the number of emergency room visits, the number ofhospital 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 andtheir primary responsibility is to this program.

Funding/pharmacist remuneration: Operating funds from the BC government. Grantfunding received to support the evaluation component.

Benefits/advantages/impacts: Pharmacist recommendations had an acceptance rate of74%. Preliminary data analysis at 30, 90 and 180 days after pharmacist visits, has shownreduced hospitalization rates and a cost savings.

Challenges and strategies used to overcome challenges: The biggest challenge for theprogram is the amount of time it takes to deal with each patient. Arranging the visit, traveltime to the widely dispersed homes, and then the visit itself, all take an extensive amountof 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 theservice 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 beingconsidered. Promotion of the program is being increased to improve target populationsunderstanding of the purpose of the program.




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FeasibilitySustainable: Medication management program results will be used for the planning of anexpansion of the program to other Fraser Health Authority communities.Scaleable: They are hoping to expand the program in the future to other areas of theHealth 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 (prioritizingtarget 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 reducedhospitalization rates and a cost savings.

Communications/promotional material: Have a brochure that is being updated. Alsohave a “911 file” which is left in the home and is available to emergency personnel shouldthe patient require emergency attention. This file contains a listing of all medications thatthe patient is currently receiving.

CONTACTAdil VaraniRegional Pharmacy ManagerFraser Health AuthorityTel.: (604) 455-1328 ext. 741297Cell.: (604) 613-2549 Fax : (604) 455-1315Email: [email protected]

6.2 Programme ambulatoire spécialisé eninsuffisance 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 compagniespharmaceutiques.

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 semblablesexistent au Québec depuis un certain temps, plus spécifiquement dans des hôpitaux deMontréal. Ces modèles préexistants ont été modifiés et adaptés à la réalité du NB.


Date du début du projet : Décembre 2006; par contre le projet était en développementpendant 2 ans avant de voir le jour. Il a fallu mener des études légales et des évaluationsde besoins. Aucun changement législatif n’a été requis puisqu’il s’agit d’une délégationd’acte du cardiologue au pharmacien et non pas d’un changement de fonctions dupharmacien.

Description de l’initiative : Suivi très rapproché des patients en insuffisance cardiaqueaprès une hospitalisation. Une visite à la semaine ou aux deux semaines est nécessaireaprès l’hospitalisation. Si tout va bien, la visite peut durer une vingtaine de minutes. Lepharmacien clinicien peut aussi juger bon de faire voir le patient par un cardiologue; doncun 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 leprogramme s’adresse à toutes les régions du NB. Un des pré-requis est que le patient soitsuivi par un cardiologue de l’hôpital. Déjà une cinquantaine de patients dans leprogramme, mais d’autres sont en attente.

Les statistiques démontrent que le taux d’hospitalisation de patients en insuffisancecardiaque doublera au Canada d’ici l’an 2025. Il s’agit donc d’une population en croissancerapide.

Rôle du pharmacien : L’insuffisance cardiaque se traite essentiellement avec desmédicaments et le traitement est assez complexe. Il y a au moins une douzaine demédicaments qui sont souvent mal tolérés. Il faut commencer avec de très petites doses etaugmenter lentement. Pour qu’un patient soit traité de façon optimale, cela peut prendrejusqu’à 25 à 30 visites au bureau du médecin. Les médecins n’ont pas le temps et lesressources pour rencontrer ces patients afin d’optimiser la pharmacothérapie. C’est lafonction que le pharmacien assume dans ce projet. Les patients sont rencontrés aux deuxsemaines par le pharmacien qui a reçu une délégation de la part du cardiologue pourajuster 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 ladose a été délégué au pharmacien clinicien.

Raison d’être : L’insuffisance cardiaque est le deuxième diagnostique le plus important auCanada pour l’utilisation des lits d’hôpitaux. La moitié de ceux qui sont hospitalisés pourinsuffisance 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 satisfaitdu manque d’optimisation des traitements post-institutionnels de ces patients.

Objectifs : Un suivi très rapproché de la médication après une hospitalisation permetd’augmenter l’intervalle entre les hospitalisations — donc de réduire le nombred’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).



• Un pharmacien avec une grande expérience clinique, dont 5 ans spécifiquement encardiologie (1/2 temps au programme et reste du temps en clinique de soinscoronariens).

• Un infirmière d’expérience en cardiologie qui s’occupe de la logistique des rendez-vous, 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 accepterade 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’unpharmacien clinicien expérimenté à ce projet.

• Il y a plusieurs patients en attente et un manque de ressources pour accepter plus depatients de cette population grandissante.

• Un des défis majeurs est le manque de locaux pour les consultations. Si ce n’était dumanque de locaux, le programme aurait pu débuter en avril 2006 plutôt qu’endécembre.

• Puisqu’il s’agit d’un hôpital régional, le trajet peut être un peu long pour certainspatients en dehors de Moncton.

Le but est d’augmenter le nombre d’équivalent temps plein de pharmaciens/pharmacienneset d’infirmiers/infirmières licenciés dans le programme. Il faut toutefois procéderprudemment parce que les fonctions requièrent une grande expérience en soinscoronariens.

Il a fallu démontrer les avantages de ce programme sur les coûts pour le système de santéet démontrer que ce programme contribue à diminuer les demandes sur les ressourcesprofessionnelles plutôt que de les augmenter.


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L’équipe essaie d’accommoder autant que possible les patients qui viennent de plus loin enespaçant un peu les visites. Le degré de liberté est quand même assez restreint si on veutque le suivi soit un succès.

Faisabilité : Durabilité : Le programme peut durer et même prendre de l’ampleur si on peut trouver lesressources nécessaires. L’alternative (c.-à-d. le retour au statu quo) est moins durablepuisque le nombre de patients en insuffisance cardiaque continuera d’augmenter. Ceprogramme ambulatoire s’inscrit très bien à l’intérieur de la vision de la Régie de prévenirdes hospitalisations.Flexibilité : Pour l’instant, ce programme n’est appliqué qu’aux cas d’insuffisance cardiaquemais il n’y a pas de raison qu’il ne puisse pas être appliqué à d’autres soins de maladieschroniques au NB.Soutient : Le projet est soutenu par les cardiologues, les autorités de l’hôpital, l’Ordre despharmaciens du NB, le Collège des médecins du NB et la Régie régionale de la santéBeauséjour.Cohérence/uniformité : Le pharmacien clinicien et l’infirmière licenciée attitrés auprogramme actuel ont tous les deux reçus une formation d’appoint pour parfaire leursexpertises dans le domaine des soins aux patients en insuffisance cardiaque. Un protocolede formation est en développement pour former plus de personnel. La formation viseprincipalement à palier au manque de connaissances en évaluation et diagnostique de laformation du pharmacien. Un protocole de formation est aussi en développement pour desinfirmiers/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 programmessemblables et ont servies de base à la justification de ce programme. Les effets sur laqualité de vie des patients inscrits au programme et sur la diminution de leur besoin d’êtrehospitalisés 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 duNouveau Brunswick.

• P. Martineau, M. Frenette, L. Blais, C. Sauvé. Multidisciplinary outpatient congestiveheart 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 UniversitéMoncton, NB E1C 2Z3 Tél. : (506) 862-4200Courriel : [email protected]




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6.3 Outpatient Parenteral Therapy (OPT),Kamloops BC

Interviewee: Ayesha Hassan, one of two pharmacists on the Outpatient Parenteral Therapy(OPT) team.

Sponsoring organizations: Royal Inland Hospital; Kamloops Home & Community Care.

Location or setting: Pharmacy in the Royal Inland Hospital, a 285-bed, acute care hospitallocated in Kamloops, BC.

Start date: November 2006

Description of initiative: Home intravenous (IV) programs are not new. For 10 yearsprior to implementing the OPT program, the hospital had been discharging patients on IVtherapy. However, there was no formal program or criteria, and no resources committed toassisting/transitioning these patients. The number of patients on IV therapy grew to theextent that it was becoming increasingly difficult to ensure continuity of care in such an adhoc manner. A decision was made to formalize the program and provide funding so that itcould be set up properly.

The initiative uses a multidisciplinary team approach to transition patients through existinginpatient and community-based outpatient parenteral therapy programs. Targets patients, 12years of age or older, who require parenteral therapy and are medically stable. Theirmedication regime must be suitable for outpatient delivery. Patient and/or caregiver mustunderstand and consent to program, be able and willing to adhere to treatment regime, andbe located in a suitable outpatient environment (e.g., safety, cleanliness, storage areconsiderations), with a telephone. Participants must be referred by physician or nursecoordinator.

Younger clients or special populations can be accommodated if adequate planning andsupport can be established.

Depending on the ability of the patient and/or caregiver, nursing support may also beprovided 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 oftherapy;

• 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-basedliterature, best practices and available data;

• selection of ambulatory infusion devices;


• Coordinates monitoring of required lab tests, assists with their evaluation and resultingadjustment of doses;

• Analyzes and reports any adverse drug reactions;

• Ensures timely delivery of medication and supplies to clients. Programs and verifiespumps, 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 forearly discharge. This is done by standardizing parenteral therapy, supporting patients, andappropriately 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 careresources, and an interdisciplinary collaborative model of sharing patient responsibilities.

Challenges and strategies used to overcome challenges: It was difficult forstakeholders to understand that goal was not just cost saving, but also to improve patientcare (i.e., may incur costs, but very beneficial to patients). Some health professionalsneeded to be convinced that the previous system was not necessarily based on bestpractices, and that certain roles would need to be redefined (e.g., no longer EmergencyDepartment staff transferring responsibility to family physicians after initial visit, as hadbeen the case prior to implementation of the OPT program). Sometimes communicationwas challenging due to the number of health professionals involved with a patient orcaregiver.

To overcome these challenges, the pharmacist reviewed prescribing data (for ER physiciansprescribing IV therapy to outpatients) and presented statistics to staff. There was asignificant increase in support for the program once ER physicians saw the benefits of adedicated program.

To improve communication, a “traveling chart” (which stays with the patient) wasdeveloped. It includes patient information, contact numbers, instructions on how to self-administer medications, progress notes (from all involved health care professionals as wellas the patient themselves), and digital photos if required (e.g., wounds).

Pharmacists take a major role in directing therapy, and keeping patients, physicians andnurses informed.

FeasibilitySustainable: Through hospital and community home care funding.Scaleable: Yes, now in process of expanding to serve other areas in the Thompson CaribooShushwap region. Plan to eventually implement throughout Interior Health Region.Supported: Yes. Over the 2006-2007 year, 477 patients were enrolled in the program, and it




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is growing. Supported by local family physicians as well (who will facilitate same dayappointments 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 byInterior Health as an approved model).

Evaluation: Formal evaluation showed that the program saved 4200 bed-days betweenMay 2006 and May 2007. Now starting a formal survey of patients for feedback. Their sisterhospital, Kelowna General, has just received Innovation Funds from the BC government toimplement a program which will be modeled after this one at Royal Inland.

Communications/promotional material: Presentations to raise awareness were done forstaff throughout the hospital, when this program was initiated.

CONTACTAyesha HassanTel.: (250) 314-2444 Cell: (250) 318-0158Email: [email protected] or [email protected]

6.4 Seamless Care Outcomes Assessment Project forDischarged Oncology Patients, St. John’s NL

Interviewee: Dr. Scott Edwards, PharmD, Clinical Pharmacy Specialist, NewfoundlandCancer Treatment and Research Foundation (NCTRF), Primary Investigator/clinicalspecialist/coordinator

Sponsoring organization: Newfoundland Cancer Treatment and Research Foundation(NCTRF)

Location or setting: Dr. H. Bliss Murphy Cancer Centre and regional cancercentres/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 hundredmedical 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 centresthroughout NL.

Patients accepted for this study must keep diaries (on a daily basis for recording adversereactions; a weekly basis for quality of life assessments; and a monthly basis for


productivity assessments), and participate in follow-up consultations. They must alsoprovide consent for the clinical pharmacist to release information to other health careprofessionals as described below.

Role of pharmacist: The clinical pharmacist meets patients prior to discharge from theBliss Murphy Cancer Centre, conducts a full medication history, then verifies the historywith 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 dosageswith established protocols, and verifies lab results. The clinical pharmacist then counselsthe patient on optimal treatment and the management of any potential side effects, andprovides printed information materials.

A report outlining current medications, medication history, monitoring parameters, possibleadverse drug reactions, and laboratory/diagnostic results, is sent to the patient’s familyphysician. A similar report, with detailed information on the chemotherapy regimen,medication preparation and administration, and specific drug-related issues is also sent tothe oncology nurse and hospital pharmacist at the regional clinic.

Throughout the study, the oncology pharmacist provides toxicity assessments to allintervention patients after each chemotherapy treatment. The oncology pharmacist followup is designed to identify and resolve any drug related problems the chemotherapy patientmay be experiencing.

Purpose: To compare the outcomes of cancer patients whose illness is managed usingcurrent practices versus an improved intervention strategy. Patients in the new program aresubject to greater attention to ensure optimal administration of cancer treatments by theirhospital pharmacist and other members of their health care team.

Intended to improve standard of care for cancer patients in NL by ensuring on-goingtherapy without interruption when one pharmacist hands over responsibility for a patient’scare to another.

Human resources: 3.0 FTE pharmacists to provide service, direct research.

Other resources required: Office space, tablet personal computer (PC), Epidemiologistfor protocol development and data dissemination.

Funding/pharmacist remuneration: Grant from Pfizer Canada ($100,000).

Benefits/advantages/impacts: In addition to improved patient care and optimaltreatment, 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 shouldresult in fewer physician and emergency room visits.

Challenges and strategies used to overcome challenges: The biggest challenges werehuman resources, and educating and engaging staff throughout the province.




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Tablet PCs were utilized to obtain information at the point of care to maximize clinicalpharmacist time. An electronic database was created to record all patient data needed forthe study.

FeasibilitySustainable: Hope that the results of the study will lead to government funding of moreoncology pharmacy positions.Scaleable: Unknown.Supported: Yes.Consistent: Yes, due to protocols.

Evaluation: Results expected to be released in 2008.


• Conducted educational sessions for all health care professionals at the Murphy CancerCentre

• CEO of the Centre gave a press conference to announce the seamless care study

• Patients are given informational materials about the study

CONTACTDr. H. Bliss Murphy Cancer Centre St. John’s, NL A1B 3V6Tel.: (709) 777-8521 Fax: (709) 753-927Email: [email protected]

6.5 Technicians and Pharmacists Partnering inMedication 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, withthe introduction of medication reconciliation at admission in 1996, the Seamless CareResearch Project in 2000, and technicians included to assist the pharmacist with medication



reconciliation at admission in 2004. The role of the technician continues to expand to assistthe nurse with medication reconciliation at discharge and assist the pharmacist with patientcare activities. The implementation plan included piloting in patient-care areas, assessingfor improvements, developing tools and standardizing the process, implementing trainingprograms for technicians and other team members, making improvements and thenspreading 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 whenpharmacist is not available;

• Meets with clinical resource registered nurse to identify patients that require a bestpossible medication discharge plan or identify patients at rounds (includes those witha significant number of medication changes, those with known or suspected poorcompliance and those on complex medication regimens);

• Technician prepares medication calendar using Seamless Solutions software;

• Technician double checks the best possible medication discharge plan with pharmacistor 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 arereferred to program.

Role of pharmacist: The pharmacist is in a supervisory role in the activities performed bythe technician.

Purpose: To develop a medication reconciliation program utilizing pharmacy technicians,to minimize patient harm from unintended medication discrepancies. The role of thepharmacy technician supports the delivery of clinical pharmacy services includingmedication reconciliation from admission to discharge. Delegating appropriate duties totechnicians 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.


Other resources required: Appropriate computer support; space requirements forpharmacist/technician team in patient care unit.

Funding/pharmacist remuneration: At the initiation of the program an additional 2.4FTE pharmacist positions were approved by the provincial government. The program isfunded through operating funds for the health authority.

Benefits/advantages/impacts: The program is aimed at preventing adverse drug eventsand it provides a continuity of care between settings. The physicians find that discrepanciesare identified and reconciled in a timely manner and it supports the multidisciplinary teamprocess. The Health Authority finds that it supports patient safety goals and requiredorganizational 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 incoverage (e.g., when an individual is on vacation or sick) is a challenge. It is a very busywork environment, so the technician must be able to adapt to changing priorities/ multipledemands for service.

Strategies for a successful multidisciplinary team:• Standardized process;

• Training program – computer system software, orientation to the patient care area andthe medication reconciliation process;

• Skills, knowledge and ability of experienced technicians – good interpersonal andcommunication sills are required; and

• Shared responsibility – require people that are accountable for their responsibilitiesand take ownership of the process.

FeasibilitySustainable: System has been sustained and enhanced over 11 years.Scaleable: The utilization of the pharmacy technicians has developed over a seven-yearperiod. When moving into a new area, the approach is to provide service on a temporarybasis with internal funding support and once the advantage of the role of technicians isseen, then the business case is supported.Supported: Each unit is responsible for providing funding for the service provided by thepharmacy, so a collaborative approach between Pharmacy Services and Program isrequired.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 ofDecember 2005 to May 2006, found that 83 patients received a best possible medication


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discharge plan, and 58% of these patients were on 11 to 20 medications. The second audit,conducted May to July 2007, examined 24 patients in family practice. The average numberof medications was 11.7 and there were no discrepancies observed in the seamless careprogram.

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 theCanadian 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 HospitalPharmacists. Toronto, ON, 2002.

• Nickerson A. Seamless Care. A Pharmacist’s Guide to Continuous Care Programs.Published by Canadian Pharmacists Association Chapter 5: Hospital Pharmacist’sPerspective, 2003.

• Nickerson A, MacKinnon NJ, Roberts N, Saulnier L. Drug-Therapy Problems,Inconsistencies and Omissions Identified During a Medication Reconciliation andSeamless Care Service. Health Care Quarterly 2005;8:65-72.

• Nickerson A, White M, Post A. Presentation to Provincial Pharmacy TechnicianConference, Saint John, NB, June 2007.

• Saulnier L, White M. Technicians and Pharmacists Partnering for Successful MedicationReconciliation. Presentation to CSHP Annual General Meeting. Regina, SK, August 14,2007.

• Saulnier L, White M. Presentation to National Teleconference on Safer Health CareNow!. September 12, 2007.

CONTACTLauza SaulnierChief of Pharmacy ServicesSouth-East Regional Health AuthorityMoncton, NBTel.: (506) 857-5342Email: [email protected]




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6.6 Medication Reconciliation — Admission toDischarge and Into the Community, Fraser HealthAuthority 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 waythrough the health system, from the hospital to community care, including the homeenvironment. Communication with the next care provider is an important component of thesystem. The program will extend to other organizations that may be assuming care for thepatient, including Mental Health & Addictions, Residential Care, Home Health and theProvincial Renal Program. Although it is anticipated that it will be some time before theMedication Reconciliation Program reaches extensively outside of acute care, linkages withthese groups have been established. Medication management pharmacists visit selectpatients in their home to reconcile medications. The best approach is identified throughprocess mapping.

Target is all residents in the Fraser Health Authority (approximately 1.5 million) who areadmitted 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 ordeath. Reducing these drug-related adverse events will improve patient’s quality of life andreduce expense incurred by the health care system.

Human resources: The goal is to develop tools and processes that do not requireadditional human resources. Any new workload to be offset through improved efficienciesand/or elimination of redundancies.

Other resources required: Software program to facilitate discharge communication to thenext care provider.

Funding/pharmacist remuneration: One-time funding to support development of toolsand 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.


Challenges and strategies used to overcome challenges: Without monetarycompensation, it has been difficult to engage physicians. With any practice change aresistance to change has been seen across all disciplines. Potential for overall increase inworkload has resulted in resistance.

Visible and active support of senior leadership in the Health Authority and at the pilot sitehas been instrumental in overcoming resistance to change. A physician champion tofacilitate physician engagement was critical to success. Engaging frontline staff in thedevelopment and testing process (Plan Do Study Act [PDSA] cycles) directly demonstratedthe impact of their work and the value associated with their recommendations.

FeasibilitySustainable: Sustainability is a component of the day-to-day operations.Scaleable: Pilot project is being developed to enhance patient safety by following thepatient all the way through the system.Supported: Fraser Health Authority Executive support.Consistent: Developing a consistent medication reconciliation system throughout the HealthAuthority is the purpose and mandate.

Evaluation: During the pilot project monthly audits were conducted to ensureeffectiveness of the changes that were made. Since going live throughout the pilot site,these audits have been conducted weekly and with expanded measures. Weekly walk-arounds to all patient care units at the pilot site has resulted in informal feedback fromfrontline staff.

CONTACTFraser Health Medication Safety CoordinatorSupport Services Facility8521-198A St.Langley, BC V2Y 0A1Tel.: (604) 455-1328 ext. 741406 Fax: (604) 455-1315Email: [email protected]




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6.7 Leila Pharmacy’s Health and Wellness Program:Home-based Medication Reconciliation,Winnipeg MB

Interviewee: Susan Selby, staff pharmacist, Leila Pharmacy, one of a number ofpharmacists involved in the home visit program.

Location or setting: Program is based in a community pharmacy, however pharmacistservices are provided in the patients’ homes (can also be independent living or assistedliving residences).

Type of innovation: Home visits to patients that can support continuity of care (afterdischarge from health care facility). Cognitive services are provided outside of thepharmacy (in patients’ homes). Medication reconciliation is provided.

Start date: 1999

Description of initiative: Pharmacist meets with patients enrolled in the program in theirhomes on a regular basis to deliver prescriptions (i.e., exchange dosettes, bubble packagingor 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 lessfrequent basis. In addition, in situations in which the client’s medications are handled by acaregiver (e.g., supervised housing for the mentally ill), the pharmacist would typicallycommunicate with the caregivers and physicians.

Bubble or dosette packaging is promoted as part of the program (more than 80% of theprescriptions dispensed are in bubble packaging).

Main target is seniors who are living independently – this comprises approximately 95% ofthe program participants. Disabled patients and those with psychiatric disorders make upthe remaining 5% of program participants. The program is offered at no charge to thepatient, and the pharmacist reports that it is often family members who approach thepharmacy for this service.

Role of pharmacist: In addition to visiting the enrolled seniors in their homes andproviding the services listed above, pharmacists keep in close contact with patient familymembers to discuss their progress.

A new patient to the program will be visited by a pharmacist to set up and organize acompliance package, review all medications they are using (including non-prescriptiondrugs, vitamins, inhalers, patches, etc.), identify any problems they may be having, ensureeverything they are taking is correct by verifying with the physician(s), and organizingdelivery and payment systems. This initial visit normally takes 30 to 60 minutes, and isrepeated when the patient’s first medication is delivered.



Subsequent visits would be less frequent and usually of shorter duration unless the client ishaving problems are needs a specific service (e.g., learning how to use a blood glucosemeter). A hospital discharge with several medication changes would also warrant apharmacist’s visit.

In addition, some follow-up can be done by telephone and there is a significant amount oftelephone 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 careworker who dispenses the medications from the bubble or other compliance package.Home care services policy prohibits home care workers from administering medicationsfrom vials; however they are allowed to punch open blister packaging into a container, forthe patient. Accordingly, the pharmacist will work with home care workers and othercaregivers to help ensure that medication is taken accurately.

Purpose: Leila Pharmacy is independently owned and operated. This program wasinitiated 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 seniorsto live independently longer.

Human resources: 4.0 FTE pharmacists and 5.0 FTE pharmacy technicians are involved inthe 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 oneaisle of over-the-counter medications/other.

Funding/pharmacist remuneration: It is funded solely by dispensing fees. About 40% ofclients have their medications dispensed on a weekly basis, another 40% bi-weekly, andthe remainder on four-week schedule.

Benefits/advantages/impacts: The pharmacist reported that while the benefits of theprogram cannot be quantified, it is obvious that participants are benefiting. She said thatit 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 expiredand unused medications, and generally bring some order to medication administration.Sometimes, the pharmacist can be helpful in referring patients in need to other socialagencies (e.g., Home Care) or facilitating other services through liaison with familymembers.

FeasibilitySustainable: There has been no formal assessment of economic viability done; however thebusiness is thriving. Start-up costs for a new client are very high in terms of the pharmacistand technician time investments. It takes several months before these start-up costs arerecovered 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 onpatient, circumstances and pharmacist’s professional judgment.


Evaluation: Nothing formal, but positive feedback from clients, client family members, andother caregivers.

Communications/promotional material: Article in Pharmacy Post a number of yearsago; website

CONTACTSusan SelbyLeila Pharmacy 628 Leila AvenueWinnipeg, MB R2V 3N7 Tel.: (204) 334-4248 Email: [email protected]


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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-profitorganizations in promoting health and illness prevention.

Location or setting: Community pharmacy.

Type of innovation: A community pharmacy innovation including a stand-alone healtheducation centre, with a multi-disciplinary health team, providing programs for healtheducation and illness prevention.


Description of initiative: Murphy’s Health Education Centre (MHEC) was opened inJanuary 2005 to provide health promotion, health education and illness prevention servicesto pharmacy patients. Pharmacists from six Murphy’s Pharmacies locations can bookappointments for individual medication consultations for patients. Additional servicesoffered at MHEC include health seminars, dietary consultations, weight managementprograms, bone density screening, certified foot care, cholesterol testing and heart healthassessments, comprehensive health assessments, 24-hour blood pressure monitoring, andINR 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 forhealthy eating initiatives, a large seminar room, a drug information library, as well as alibrary of patient education literature on most medications and health conditions.

Role of pharmacist: to work with other health professionals in providing expanded healthcare services and programs.

Purpose: Murphy’s Pharmacies believes in health promotion, health education and illnessprevention. 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 andstaffed by a multidisciplinary team including pharmacy technicians, pharmacists, registerednurses, a certified foot care specialist, registered dietitian, and a dedicated receptionist.

Other resources required: Electronic data processing system, space for the healtheducation centre and several medical centres.


Benefits/advantages/impacts: MHEC provides ongoing multidisciplinary health servicesand programs for existing patients, the community and the province.

Challenges and strategies used to overcome challenges: The most difficult challenge isto obtain third-party funding for pharmacy services not related to traditional medicationdispensing.

FeasibilitySustainable: The program has been in operation since 2005. The program has been fundedby the retail operations of the pharmacy company; there has been no external fundingreceived.Scaleable: Only if a viable funding model is available.Supported: This innovative pharmacy service has been strongly supported by the patientsand the public.

Evaluation: No formal evaluation done to date. Public support has been very positive forthe program. It has been recognized as an excellent teaching site for health professionalstudents.


• Extensive promotion through television, radio, and print media, directed at healtheducation and illness prevention. Have supported several health promotion campaignsvia radio, television, the Yellow Pages, and through public education.

• Health Matters is a live one-hour television show aired twice weekly on thecommunity channel, in partnership with the Queen Elizabeth Hospital Foundation toprovide health education to the province.

• Also partnered with a local radio station to air a 12-Week Wellness Challenge. Eachweek the announcers were given a new health challenge by the Wellness Team,which consisted of pharmacists, nurses and a dietitian. Comprehensive healthassessments, including various clinical measures and health questions, were conductedat baseline and again at 12 weeks to determine winners. Listeners got on-air progressreports and healthy living tips.

• Have conducted similar programs in the community, including a 12-week HealthyChoices Program for 30 participants, in partnership with the provincial government.

• Also commits health professionals and resources to several school education programsfocusing on good health, including elementary, junior and senior high schools, andthe University of Prince Edward Island.

CONTACTRyan MurphyTel.: (902) 566-4660Email: [email protected]


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7.2 Affinity for Women’s Health, Kitchener ON

Interviewee: Carole Beveridge, consultant pharmacist, owner/manager

Location or setting: Community health clinic

Start date: 2007

Description of initiative: Affinity for Women’s Health is a health care clinic designed tosupport 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 healthteam. The pharmacist’s primary role in the clinic is disease prevention, through the identification and treatment recommendations for horomonal imbalances that might relateto 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 assess-ment including personal health history; lifestyle, symptom and risk factors; and hormonelevel 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 takento promote health for that client. Recommendations for treatment may include lifestylechange counseling, or hormonal and/or nutritional support. Clients are referred to otherhealth 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 byDr. 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).


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 health-focused classes and educational seminars. For women of all ages who wish to enhancetheir well-being.

The goal is to have women clients understand what signs and symptoms mean as their healthprogresses, what they can do prevention-wise to improve their health. The program seeks tomake the health system more approachable and to serve as a conduit between the medicalhealth 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 theclients who utilize the program’s services.

Benefits/advantages/impacts: The practice aims at primary prevention of disease and thepromotion of a healthy lifestyle for women. One of the objectives is to help menopausalwomen withdraw from hormonal preparations and offer other modalities to treat hormonalimbalance.

Challenges and strategies used to overcome challenges: This is a new and innovativeprogram 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 iscurrently enrolled in a Doctor of Homeopathy program to enhance her capabilities tobroaden 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.affinity-forhealth.ca, and also produces a newsletter about women’s health issues.

CONTACTAffinity for Health558 Belmont Avenue W.Kitchener, ON Email: [email protected]


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7.3 Promotion of Women’s Health, Saskatoon SK

Interviewee: Brenda Dobni, owner/pharmacist

Sponsoring organization: Medical Arts Pharmacy

Location or setting: Community pharmacy

Type of innovation: Pharmacist is promoting healthy lifestyle and improving healththrough a variety of steps related to both pharmaceutical and non-pharmaceuticalapproaches.


Description of initiative: In-depth consultations are provided to individual patients onissues related to women’s health (e.g., menopause, perimenopause). These consultationsinclude a review of current medications, nutrition and lifestyle features, and the provisionof nutritional/supplement recommendations and medication options. Consultations are byappointment. Referrals have come from a variety of sources including other patients, familyphysicians, health food stores, physiotherapists, massage therapists and even a localobstetrician/gynecologist.

Medical Arts Pharmacy has advanced compounding capability (e.g., laminar flow hood,electronic mortar and pestle, ointment mill) to prepare formulations not commerciallyavailable, 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, sleeppatterns, nutritional supplements, current medications) and treatments tried in thepast; and

• Devise with patient’s input, a plan of action: recommendations for achievable changesto be made to improve health (e.g., eating a nutritious breakfast, 1-minute walksthroughout the day for stress release), and (where applicable), hormone therapy.

Purpose: To help educate women with gender-related health issues on how to achievetheir 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, plusoccasional assistance from local pharmacy student.

Other resources required: Membership in, and special training from ProfessionalCompounding Centres of America (PCCA). The pharmacist attends two to four specialtycompounding training sessions per year, and technicians attend at least one on an annualbasis.


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 latestdevelopments in women’s health and specialty compounding is a challenge, as well asobtaining formulae for compounds with patents pending. With the advent of the internetand increased consumer awareness of promising new remedies, pharmacists face newpressures to keep up with the information their patients are getting.

Hiring high-quality staff is essential to offer this consultation service.

FeasibilitySustainable: Yes; services are revenue generating and more than offset investments neededto offer them.Scaleable: Yes.Supported: Business is increasing through word-of-mouth from clients who have alreadyseen improvements to their health. Area physicians recognize and support this consultationservice as evidenced through referrals and also because they will, on occasion, call thepharmacist 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-casebasis. Since each patient’s needs are so unique, their feedback regarding what wasdiscussed and planned is reviewed.

Communications/promotional material: Promoted by word of mouth; service is notformally advertised. This pharmacist is also featured in Pharmacy Practice’s Ask the Expertcolumn, offering advice to pharmacists on specific compounding problems.

CONTACTBrenda DobniMedical Arts PharmacySaskatoon, SKTel.: (306) 652-5252Email: [email protected]


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7.4 Private Pharmacist Consultations, CommunityPharmacy, Keswick NB

Interviewee: Jeannie Collins Beaudin, community pharmacy co-owner and lead clinicalpharmacist

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 varietyof disease states. Mainly menopause/hormones issues, but also does consultations forRestless Legs Syndrome, post-myocardial infarction (MI) care (including cholesterolmanagement), pain management, and general medication reviews. Recently started to dolipid 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 guideinterview), pharmacist interviews patient, probing for information about symptoms relevantto the offered disease state and lifestyle. Pharmacist then prepares a detailed report for thepatient – explaining the symptoms through provision of background information (“What’shappening to cause these symptoms”) and makes recommendations on therapy (drugs aswell as nutrition, exercise, stress, etc where applicable) with rationale. Information isdivided 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 otherto the patient’s physician. Report is accompanied by abstracts of the studies that supportthe recommendations.

A second pharmacist has developed a special expertise in pain management. Non-prescription adjunctive drug therapy is sometimes recommended (muscle relaxants,anti-inflammatories, nutritional supplements).

Purpose: This consultation program was initiated in response to patient demand forindividual attention and specific drug-related needs that could not be met in the course ofthe more traditional community pharmacy practice. Targets community pharmacy clientslooking for in-depth information on specific disease states, including causes and treatmentoptions. Mainly self-referred, some physician-referred.

Patients commonly referred by physicians if they have expressed an interest in pursuingnatural hormone therapy or have failed to achieve symptom relief with standard therapy.A local endocrinologist recently referred a gender-transitioned patient because of highhormone requirements.


Human resources: 0.4 FTE pharmacist devoted to consultations; second-year pharmacystudent (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 abanner program (special funds for pharmacists wanting to move into patient consultationpractices).

Patients pay Keswick Pharmacy for these consultations. Some patients are reimbursed forthese through health benefit plans, other aren’t. Fees can be claimed as an income taxdeduction.

Benefits/advantages/impacts: Service provides more therapy options for patients, andallows the pharmacist to devote the time needed to interview, research, and maketreatment recommendations.

Challenges and strategies used to overcome challenges: Was challenging at first to getacceptance from local physicians, but countered this by providing them with significantamounts of scientific data to support pharmacist’s recommendations. Having evidence tosupport the pharmacist’s recommendations is key for physician support, as is the provisionof a copy of the report to the patient, for customer satisfaction.

FeasibilitySustainable: Yes, patient pays. Scaleable: Yes, but in relation to patient demand and availability of pharmacists to replacethe 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 alocal hospital. Consistent: Yes, through use of a worksheet.

Evaluation: No formal evaluation, but positive feedback from clients, referrals fromphysicians.

Communications/promotional material: Have computer-generated brochures whichdescribe the service and provide contact information. These are distributed by e-mail, andat pharmacy. A great deal of promotion is by word-of-mouth.


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CONTACTJeannie Collins Beaudin Keswick Pharmacy 10 Yerxa Lane Keswick, NB E6L 0A1 Email: [email protected]: www.keswickpharmacy.com

7.5 Orthomolecular Management System: IndividualPatient 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 compoundingpharmacy centres. The company compounds individual prescriptions that are designed toprovide the specific ingredients that each individual requires.

Kent MacLeod is a specialist in women’s health issues and specializes in the impact ofnutrition on the biochemistry of individual disease states. He works with physicians,naturopaths and a body chemistry-balancing consultant to ensure patients receive the bestcombination of conventional and natural treatments for disease management. Thediagnostic 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 specificformulation for each patient. Bio-identical hormone replacement therapy (HRT) can becompounded in the needed strength and dosage form and administered via the mostappropriate route to meet each individual’s needs. The precise components of eachperson’s therapy are determined after laboratory testing (BCB test), medical history anddetermination of symptoms. Close monitoring and patient follow up is an importantcomponent of the service.

Purpose: To ensure that patients receive the best combination of conventional and naturaltreatments for disease management, and tohelp the general public achieve balance of bodychemistry in respect to optimal function and disease prevention and alleviation.

Human resources: Three pharmacists and approximately 10 technicians.



Other resources required: 8000 sq. ft. facility, including a laboratory with analyticalequipment, 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’sspecific nutritional and metabolic needs. Blood and urine testing can be done onsite toidentify potential nutrient deficiencies, metabolic abnormalities, and oxidative stress. Fromthe results of this testing, a nutritional formula is created and custom compoundedspecifically for the patient.

Challenges and strategies used to overcome challenges: Marketing challenge: patientsdon’t understand why the health care system won’t pay for these services or why their ownphysician doesn’t provide this service.

Developing appropriate marketing approaches, communicating with the patient regardingthe outcomes to be expected, and referring to the outcomes of other patients all helpovercome challenges.

FeasibilitySustainable: 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. Patientoutcomes are tracked for in-house purposes.

Communications/promotional material: www.nutrichem.com

• NutriChem Pharmacy has been featured on CBC Television’s The Health Show, onABC Television’s Day One, in books such as Prescription for Nutritional Healing, andmentioned in patient support groups and websites. In 2003 Kent MacLeod publishedhis first book, thoroughly detailing metabolic and health issues in people diagnosed ashaving Down syndrome.

CONTACTKent MacLeod, CEONutriChem Medical Centre1305 Richmond Rd.Ottawa, ON K2B 7Y4Tel.: (613) 820-6755Email: www.nutrichem.com


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SECTION 8 — ENABLERS OF INNOVATIVE PHARMACY PRACTICE


8.0 ENABLERS OF INNOVATIVE PHARMACY PRACTICE —AUTOMATION, INFORMATION ANDCOMMUNICATION TECHNOLOGY, AND PHARMACYTECHNICIANS

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 providescollaborative 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 buildsupon the GHC’s current electronic health information platform, which is considered amodel for primary care across Canada.

EMRxtra will expand the continuum of care to the community pharmacists in a secure andconfidential manner, through electronic systems. Pharmacists will be able to collaboratewith the health care provider team and resolve drug related issues for patients moreefficiently. Currently the system has been implemented and is functioning in 21 out of the24 pharmacies with the others being in the process of being connected.

Additional technology tools such as the iPharmacist (by APOTEX) will be made available tosupport pharmacists in their provision of professional services to EMRxtra patients. TheGHC serves 60,000 people in Sault Ste. Marie.

Role of pharmacist: Pharmacists will have access to patients’ diagnosis, medications, andlab results through a secure electronic gateway. To begin, patients enrolled in thecardiovascular disease programs will give their permission to pharmacists to access theirelectronic medical records. Pharmacists will help with disease management by makingrecommendations to the patient regarding lipid levels, etc., and discuss dosage adjustmentwith the physician.


Purpose: Through this program, pharmacists will be able to collaborate with the healthcare provider team and resolve drug related issues for their patients more effectively andefficiently. 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’sincentives) for collaboration between pharmacists and the GHC team.

• Create program modules that enhance GHC programs and projects, with a focus onmedication adherence.

• Demonstrate the role of community pharmacists in managing chronic diseases forpatients through a readily available electronic infrastructure.

Human resources: 24 pharmacies with 50 to 60 pharmacists.

Other resources required: Pharmacist web portal (Pharmacist Gateway) to provideprofessional resources and tools supporting pharmacists, and as second level of secureaccess to the electronic medical records. iPharmacist gives mobile access to professionalresources and tools through a PDA. It enables pharmacists to counsel their patientsanywhere within their work environment, without being tied to the desk.

Funding/pharmacist remuneration: This program has received funding from CanadaHealth Infoway, an independent not for profit organization, supported by the federalgovernment. Infoway invests in projects across Canada to implement and use compatiblehealth 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 withaccess to clinical information for their patients, and will be able to provide enhancedprofessional services.

Challenges and strategies used to overcome challenges: There have been a number ofchallenges 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 VPNmethodology was selected as it has least impact on existing pharmacy practicemanagement systems and therefore avoided software development for pharmacies;

• It was necessary to involve the IT department at both pharmacies and GHC to dealwith restricted firewall access;

• In order to comply with strict Personal Information Protection and ElectronicDocuments Act (PIPEDA) requirements and to ensure patient confidentiality, severallevels of secure access were needed;

• Different levels of network capacity at participating pharmacies impacted overallaccess speed and quality of access by pharmacists; and

• Change management – the need for pharmacists to adjust to new technologies andprocesses inherent with the EMRxtra program. This is the first time many of thepharmacists have access to electronic medical records.


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Some things that helped were:• Close involvement of electronic medical records software providers and various IT

departments from GHC and pharmacies;

• User group meetings with pharmacists;

• Training sessions; and

• Mentorship program with local champions.

FeasibilitySustainable: The system is being developed as a pilot project with the goal that it will be aself-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 implementationof a similar system.Supported: Canada Health Infoway is very supportive of having this project be a pilot forimplementation 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.

CONTACTSunny Loo375 University Ave., #800 Toronto, ON M5G 2J5 Tel.: (416) 441-0788 ext. 4258 Fax: (416) 441-0791Email: [email protected]

8.2 International Pharmacy Services: Internet-basedDispensing, Winnipeg MB

Interviewee: Kris Thorkelson, Pharmacist and Owner, Canada Drugs.com

Location or setting: CanadaDrugs.com operates from a 9000 sq. ft. pharmacy anddistribution 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 toserve patients on a worldwide basis.

Start date: 2001



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Description of initiative: Pharmacy dispensing and delivery services are provided toanyone 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 ofCanada;

• Pharmacists available, toll-free, during standard pharmacy hours;

• Three health care professionals review each order at a different stage, and everyprescription 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’sphysician 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 apharmacist. Patient counselling is provided via telephone and patient information sheetsare included with each prescription.

Three pharmacists review every prescription at different stages throughout the processingof 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 practiceinternational prescription services from its base in Manitoba.

Human resources: Pharmacy technicians participate in the order filling process with atech-pre-check system. Pharmacists perform the final check on all activities.

Other resources required: Extensive facility and operation of large call centre, CanadaPost 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 orderingtheir medications without leaving their homes.

Challenges and strategies used to overcome challenges: The biggest challenge is theprovision of pharmacy services without the face-to-face interaction with the patient. Thepatient has to be relied upon to provide the medication history and medication profile. Itshould be noted that this challenge also occurs in many situations in the traditionalcommunity pharmacy practice.

The system has been designed to provide effective electronic and telephonecommunication with the patient or the patient’s agent to offset the drawback of lack offace-to-face patient contact.

FeasibilitySustainable: Canada Drugs has been in operation since 2001.


Evaluation: None.

CONTACTCanada Drugs10 Terracon Place Winnipeg, MB R2J 4G7Tel.: 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 Departmentof Health

Location or setting: 320-bed regional hospital.

Type of innovation: Utilization of automated systems and pharmacy technicians to free upthe pharmacists to provide patient-centred pharmacy services on a full-time basis to allpatients within the facility.

Start date: 2000

Description of initiative: In the late 1990s the Clinical Services Redevelopment Project atthe Brandon Regional Health Centre included funding automation in the distributionmodule, pharmacy staffing to support it, and new pharmacy space. Despite a drop inpharmacist staffing in 2000 (to four), the implementation of new technology was continuedin 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 ofthe neonatal ward. A pilot “tech-check-tech” was implemented to increase the technicians’role in maintaining PYXIS. With distributive functions being automated within thepharmacy department, attention was turned to greater involvement of pharmacists in directpatient care. In 2001, the Centricity Module Fax Connect system was implemented, alongwith relocation of pharmacists within the medical program, intensive care unit (ICU) andlong-term care (LTC). By 2003, the distribution centre was in new space, staffed primarilyby technicians, and staff had expanded to the current 12 full-time-equivalent pharmacists inthe decentralized model.

Pharmacists are assigned responsibility for specific program/departments of the hospitaland have offices within that area. Medication orders are scanned and transmitted aselectronic images from the nursing unit to the decentralized pharmacist’s offices,eliminating paper orders. The pharmacist enters and verifies the order. All pharmacists have




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access to Internet based drug information and DPIN (the province-wide prescriptiondatabase for entire population).

Approval of the order through Centricity allows the nurse to obtain the appropriatemedication from the Pyxis Machine. The Pyxis system can handle almost all orders with award stock of less than ten items, supplemented with patient-specific medications sent fromthe pharmacy (e.g., inhalers, eye drops, creams).

In the central pharmacy, the pre-packing and preparation of the medications for the Pyxissystem is done by pharmacy technicians with a pharmacist in charge of the “tech checktech” filling system. Technicians use bar-coding technology to verify medications in thepicking and refill process. The Pyxis system provides electronic records for controlledsubstances and monitors expiry dates.

Role of pharmacist: Each decentralized pharmacist provides clinical services to theirassigned 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 areseen in a community setting once weekly (e.g., for Clozapine monitoring).

Renal program – The pharmacist looks after hemodialysis and pre-renal patients, interviewsthem, does medication checks and medication reviews, follows the patient into thecommunity and partners with the community pharmacists to provide best medicationtherapy. Renal patients admitted to acute care are more closely monitored by thispharmacist especially at admission, transfer and discharge transition points.

Long-term care/palliation – The pharmacist is involved in rounds, family conferences, painrecommendations, medication reviews for LTC patients, and has developed a dischargeprogram to facilitate the communication to the retail provider/personal care homeregarding medication at time of discharge.

Medicine program – two pharmacists in these areas also do discharge counselling, antibioticutilization 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 unitrounding daily with the multi-disciplinary team, educational, protocol development etc. Thepharmacist works in a consultative manner for the emergency department. This pharmacistassists with the development of adult intravenous (IV) administration guidelines.

Rehabilitation – One pharmacist in this inpatient ward does specific medication assessmentrounds, patient counselling, is heavily involved in family conferencing and has aspecialization in tube feed assessment and medication issues.



Pediatrics/maternity – One pharmacist provides services to both programs including a smallNeonatal Intensive Care Unit (NICU), is also responsible for the regional RespiratorySyncytial Virus immunization program. The pharmacist has also developed pediatricintravenous administration guidelines for the pharmacy manual.

Surgery – Serves the surgery inpatient units as well as OR, recovery, endoscopy and otherunits. 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, butall 12 pharmacists rotate through distribution in sterile services and four pharmacists rotatethrough distribution of chemotherapy. Decentralized pharmacists in close proximity coverother programs while the pharmacists rotate.

Medication reconciliation – Implementation of medication reconciliation on admissionbegan in June 2007.

Purpose: This project was initiated to develop an innovative hospital pharmacy service thatprovides 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 hasgrown to 12, including the project director, as the program has evolved. Other staffincludes an administrative assistant/secretary, technician manager, four FTE systemstechnicians to maintain computer systems, interfaces, upgrades, system projects, etc., andseven FTE pharmacy technicians for the PYXIS system.

Benefits/advantages/impacts: At the time of beginning the program, there was a massivedeficiency in pharmacists in Manitoba particularly the Brandon area due to the Internetpharmacy hiring pharmacists in Minnedosa (small community 30 miles away). Developingthis system allowed pharmacists to be relieved of the drug distribution system andbroadened their role which was very attractive to potential hires. The pharmacist staff hasbeen expanded from four to 12.5 in three years.

Pharmacists are highly valued in the hospital for their expertise by administration, healthprofessionals and the patients. Patients are receiving better quality medication care, and thisprogram 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 tosupport the computer system upgrades.

• Obtaining motivated pharmacists when there is staff turnover in an environment ofshortage.

• Providing education for new pharmacists and maintaining and upgrading theircompetency for the positions.

• Since the pharmacists are spread out, maintaining communication with them all aspart of the department so they have a feeling of being on the team.


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, bringin speakers, participating in audio and video conferencing, provide educationalallowance, requirements for pharmacists to provide education session to colleagues atmeetings.

• Now developing standards of practice that applies to all pharmacists in addition tostandards that apply to their specific area of practice.

FeasibilitySustainable/scaleable/supported/consistent: The project director now judges the program issustainable. The lease agreement for PYXIS has been incorporated in the operationalbudget. Staffing numbers are all permanent positions and pharmacist FTE is nowincorporated within health plans for new projects (e.g., new radiation/ expandedchemotherapy program). The biggest challenge to sustainability is the availability ofpharmacists in Brandon; funding for four FTE pharmacists to develop a central intravenousadmixture program was lost when candidates could not be found to fill the positions.

Evaluation: No formal evaluation except through the performance evaluation feedbackdone by program managers on pharmacists. Patient surveys consistently show positiveresults in the pharmacy area if a pharmacist has been in contact. Program has receivedvery positive feedback from both nurses and physicians.

During 2006-2007, only 5% of the reported clinical interventions by pharmacists wererejected by physicians, which demonstrates their acceptance of the pharmacists’ role.

Pharmacists reported 1395 drug info requests from health care professionals, 185 clinicalconsults, 469 requests from nursing/physicians to provide patient counselling, and 1500phone calls to physicians. These demonstrate that pharmacists are being utilized by theircolleagues and integrated well into the team.

CONTACTJane LamontBrandon Regional Health AuthorityTel.: (204) 578 4231 Email: [email protected]


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8.4 Pharmacist Network: Telehealth, Network HealthCare, 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 pharmacistswithin community pharmacies; a large number of chain store pharmacies and individualpharmacies participate in these contracts.

Location or setting: British Columbia and Alberta.

Type of innovation: This Pharmacist Network provides an innovative model of resourceutilization in delivering pharmacy innovative services. This is an innovative model ofchronic disease management.

Start date: 2003

Description of initiative: The Pharmacist Network was created, implemented andcontinues to be contracted by the Ministry of Health in British Columbia to provideprogram oversight to the BC NurseLine Pharmacist Service. This service is deliveredthrough a special network of community pharmacists providing medication informationservices to BC NurseLine callers during evening and overnight hours when localcommunity pharmacists are not accessible. The service has handled over 40,000 calls andhas exceeded service level requirements since the first day of service in 2003.

Empowering Patients through Integrated Care (EPIC) is a second network of pharmaciststhat provides medication management and self management support to people withdiabetes or congestive heart failure. This demonstration project was funded by the Multi-Jurisdictional Subcommittee on Telehealth and the BC Ministry of Health, in collaborationwith Fraser Health, Northern Health and the BC NurseLine from 2004 to 2006. Experiencefrom the EPIC project is being used by Health Lines Services BC to model future programssuch as Chronic Disease Management, Seamless Medication Care and MedicationManagement. These services will utilize the Pharmacist Network and will be provided byspecially trained pharmacists working in community pharmacies throughout BritishColumbia.

Contract recently awarded to build a medication information and advice service for callersin the Edmonton area (Region 6) of Alberta. This service will give Alberta-based communitypharmacists their first opportunity to participate in a Pharmacist Network initiative and setthe 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 thecontract.



Purpose: Network Health Care specializes in creating new innovative services and inintegrating and operationalizing these services into community pharmacy practice. Ratherthan hiring pharmacists to work within these systems directly, the organization contractswith the employers to have pharmacists within their organization provide specific serviceswithin the project. The goal is a telephone service delivery platform that balances bothpharmacist availability and patient demand. It uses and supports community pharmacistpractice:• 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 patientaccess to care across all participating pharmacies;

• Leveraging the experience and expertise that a community pharmacist has andmaintains by working in a front-line practice setting;

• Creating practice opportunities for community pharmacists to fully utilize their clinicaltraining, and

• Optimizing human resources by providing clinical opportunities in their communityworkplace and avoiding the current trend of requiring the pharmacist to move toanother clinical practice setting.

Other resources required: Administrative organization.

Funding /pharmacist remuneration: The Pharmacist Network provides funding as asubcontract to pharmacy operations as a component of the service fee charged to the thirdparty or government program.

Benefits/advantages/impacts: This is a community pharmacy service model that has thefollowing 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 andseamlessly 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 thepatient 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 toimplementing a clinical practice.

The advantages of having a pharmacist network include:• Uses a sophisticated quality management framework to ensure high quality care;

• Uses clinical specialists to mentor pharmacists to ensure high quality clinical service;

• Pharmacists gain experience working collaboratively within a multidisciplinary service,and supporting primary care teams;


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• Provides chronic disease management (CDM) and self-management support services;

• Utilizes both hospital and community pharmacists;

• Developer of innovative pharmacy case management and documentation software forrecording service episodes, tracking patient care over time and enabling collection ofpopulation-based real-world clinical outcomes data;

• Utilizes a layered referral system that recognizes the competitive aspect of pharmacyand provides a right of first refusal opportunity based on existing patient preference;and

• Eliminates administrative overhead and allows the pharmacist to stay focused onproviding high quality clinical care.

FeasibilitySustainable/scaleable/supported/consistent: In the implementation of the program, it hasbeen built on the assumption that this approach provides a program that should besustainable, 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 mostpatients;

• Patients were significantly satisfied with EPIC;

• Partnership with CDM programs improved physician engagement and informationexchange; and

• Relationships and workflow changes would be optimized with longer time frames.

The Pharmacist Network programs have been well received by the government of BritishColumbia, the pharmacists and the patients.

Academic documents:• The Tablet. Published by the British Columbia Pharmacists Association. April/May

2006, p10-11

CONTACTBarb Gobis OgleNetwork Health Care, 445-5600 Parkwood Way, Richmond, BC V6V 2M2



8.5 Pharmacy Clinical Program and PharmacyEducation/Mentoring, BC Interior

Interviewee: Dr. Dawn Dalen, Regional Pharmacy Practice Coordinator; Interior HealthAuthority, Kelowna, BC

Sponsoring organization: Interior Health Authority, BC

Location or setting: Located in Kelowna, BC, and serving a large geographical area: fromthe US border up to the Williams Lake area and from the Alberta border all the way toHope west of Kelowna.

Type of innovation: The provision of support and education programs remotely via elec-tronic means.


Description of initiative: The provision of education/mentoring and clinical support topharmacists and other clinical staff to ensure consistency in standards for clinical pharmacyservices. This program targets clinical staff (and their patients) in acute and/or long-termcare within the BC Interior Health Authority. This health authority covers a very large geo-graphic region, with many remote locations. Sites include nine acute care facilities that havepharmacists, 35 emergency departments, and a number of long-term care facilities.

The clinical support and education and mentoring delivered to pharmacists and other clini-cal staff (nurses and physicians) serving the region uses information technologies and otherweb-based tools. For example, distance education usually takes place online using toolslike Microsoft Live Meeting and Powerpoint, as well as video conferencing because of geo-graphic spread. In addition some of the pharmacists are also involved in innovative elec-tronic practices; there are areas in Interior Health where full dispensing is done byvideoconferencing. A pharmacy technician at the site will contact the pharmacist, and thepharmacist 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 directorof pharmacy; one regional clinical manager, and two pharmacy practice coordinators. Allfour are full-time equivalents, but also have other functions to fulfill.

There are professional practice leaders, who are site managers at each location. They areresponsible for assisting the clinical coordinators/manager with implementing programs,courses, etc. At the regional office, there is a formulary manager and a medication safetymanager, in addition to the director and clinical manager, as well as pharmacy IT supportpeople.


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Other resources required: Video-conferencing equipment at all the sites. Eachpharmacist has a Palm Pilot. Regional staff members also need cell phones and/orsmartphones (e.g., Palm Treos). Many of the sites are also equipped with laptops formeeting and presentation purposes.

Funding/pharmacist remuneration: From the province, through the Health Authority.

Benefits/advantages/impacts: The program extends specialized knowledge and supportto pharmacists and health professionals beyond the walls of a teaching facility to more ruralareas; helps them develop some of those resources and helps them feel supported in theirroles.

Challenges and strategies used to overcome challenges: Finding enough qualifiedpharmacists to service all the rural areas is the major challenge. There was resistance tochange from some pharmacists and other health professionals, and there were legal barriersto overcome to provide services remotely via videoconferencing. Finding enough qualifiedpharmacists in the region, especially in remote areas, remains a challenge.

One tool was the extensive use of information technology (e.g., videoconferencing) in thedelivery of courses, support to pharmacists and even pharmacy services to patients. Tohelp increase buy-in from pharmacists in each location, participants tried to make sure thatlocal pharmacy managers understood what was being done. Ensure that everyone iscommunicating the same message. Being in touch with the College of Pharmacists wasnecessary to ensure that all the standards were being met. The result has been changes tosome of the standards to allow adequate health care to all the patients in the region.

FeasibilitySustainable: Yes, because the status quo itself is not sustainable. It is not realistic to havesomeone with a Doctorate of Pharmacy at every site in Canada, and this model does notrequire that. Scaleable: It is scaleable, but this is the major challenge. The limitation comes from theavailability of the human resources with adequate hospital training and clinical experiencein various settings. Supported: Some physicians support the initiative and others may see it as impinging ontheir territory. Upper management is very supportive. They like the idea of standardizationand delivery to all, as well as the mentoring for people that are outside the teachingfacilities. However, on the ground level, it takes a long time to see the results that uppermanagement wants to attain. Consistent: The standardization and consistency of the delivery of the program is a work inprogress. It is improving.

Evaluation: Initially, there was a needs assessment with all of the pharmacy staff toestablish priorities. There is also an annual staff survey to help improve the process.


CONTACTDr. Dawn DalenKGH-Pharmacy Services 2268 Pandosy St. Kelowna, BC V1Y 1T2 Tel.: (250) 862-4300 ext. 7446Email: [email protected]

8.6 Central Production Pharmacy, Calgary AB

Interviewee: Bruce McKenzie, Regional Operations Manager, Central ProductionPharmacy, Calgary Health Region

Sponsoring organization: Calgary Health Region

Location or setting : 1119-55 Ave. NE, Calgary, AB T2E 6W1. The facility is in a lightindustrial area complex warehouse that was converted into the drug distribution facility andstate-of-the-art sterile production facility with contemporary large volume packagingequipment and automated data system.

Type of innovation: Centralization of sterile and non-sterile medication preparation anddelivery to several institutions.


Description of initiative: This was the first centralized system in Canada and possibly inNorth 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 physicianorders and are responsible for sending all interim doses (unit dose and IV admixture) fornew 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 CentralProduction 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. Thisinventory is kept on hand for urgent unit needs or interim dose issues. Their actualinventory 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 interimdoses. Each site (adult sites mainly) keeps a standard number of doses of thesecommon intravenous (IV) admixtures and orders replacement stock as required.

• CP prepares all of the patient specific 24 hour unit dose runs for the three adult sites.


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• CP prepares all patient-specific IV admixture (CIVA) runs each day for the three adultsites (two runs a day for each site – 12 hours worth per run).

• CP prepares all patient specific parenteral nutrition (PN) solutions for all sites inCalgary daily. PN orders are the only physician orders seen at CP. The CP pharmacistsprocess these orders each day. CP gathers and fills all unit specific ward stocks for thefour sites. The site technicians check the ward stocks and enter unit specific ordersinto the pharmacy system. A requisition prints at CP for filling. The site assistants thengo up to the units to put the stock away.

• CP purchases all narcotics for use in the region. All oral solids are packaged intocount cards, however nothing is done on a unit-specific basis for the sites. CP stockssite 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 topicalpreparations. The sites can order these compounded items as required to keep onhand as stock.

Role of pharmacist: As a result of the new Alberta College of Pharmacy regulations (April2007), the four pharmacists in the central facility are required to be on site for indirectsupervision (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 theautomated unit dose dispensing machines, narcotic control, ward stock gathering, shippingand receiving etc. CP dispenses 10,000 to 12,000 oral unit doses, 2000 IV admixtures and 60PN solutions per day. The central facility services about 2200 hospital beds.

Purpose: This central production pharmacy was developed as an efficient system ofmedication distribution in unit dose packaging to the acute care facilities in the CalgaryHealth Region. One of the main goals was to use CP to facilitate conversion of the FoothillsHospital to unit dose almost two years ago. It had been a very traditional ward stockhospital prior to opening of CP. The pharmacy was physically too small to take on unitdose independently. Foothills Hospital was able to successfully convert to unit dose byhaving 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 inventorymanager (pharmacist), four staff pharmacists, two technical managers, 35 technicians and24 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 minibagpreparation.

• GE Centricity – Pharmacy information system for patient order database, ward stockmaintenance, inventory purchasing, drug use evaluation (DUE), etc.

• Eclipsys Sunrise Clinical Manager – Patient care information system (electronic patientchart). Physicians enter all patient orders into this system.



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Funding/pharmacist remuneration: The funding is through operating funds for thepharmacy services in the Calgary Health Region.

Benefits/advantages/impacts: The centralization of services provides economies of scalefor purchasing, packaging and delivery services.

Challenges and strategies used to overcome challenges: Workload challenges exist forstaffing – currently difficult to recruit assistants (must have completed a four-monthSouthern Alberta Institute of Technology course). There are also delivery difficulties.

The program is currently trying to increase the assistant wage scale to attract moreemployees to these jobs. It now has two dedicated pharmacy delivery trucks to handlemost daily runs to the various hospital sites, seven days per week. This will decreasereliance on contracted private courier companies.

FeasibilitySustainable: During the time is has been in operation, it has demonstrated that it is asustainable system.Scaleable: The Central Production Pharmacy has seen visitors from all over North Americavisit the facility with the intention of adopting a similar system.Supported: The system is supported from permanent operating funds as a component of thepharmacy services provided to the region.Consistent: Very specific protocols have been developed for all components of the systemas well as for each type of personnel operating within the system.

Evaluation: No formal evaluation, but there is continuous quality monitoring; processvalidation, certification and recertification of all staff involved in drug handling processes aswell as daily pharmacist spot audits to ensure the accuracy of the system.

CONTACTBruce McKenzieTel.: (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 onecustom-built facility.



Description of initiative: Centralized distribution to 12 facilities within Fraser HealthAuthority, covering 2000 acute care beds and 2000 residential beds with unit dosepackaged oral solids, batch and patient-specific; standardized intravenous solutions, batchand patient specific; and purchasing.

The Fraser Health Pharmacy Drug Distribution Centre (PDDC) is a 16,000 sq. ft. facilityattached to the Fraser Health Materials Management Centre, so the delivery system isshared. The facility is open from 6 a.m. to 6 p.m. seven days per week and has access totwo to three delivery times to each site per day.

All medication orders are processed in the local institutions and the MEDITECH systemthen 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 thendistributed 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 thereare pharmacists located in offices above the facility for advice and direction. Pharmacistsdevelop the standardized procedures that are based on a “tech-check-tech” system.

Purpose: Certain repetitive production functions can be performed more safely and costeffectively in a custom-designed centralized facility utilising pharmacy technicians.Goals are to improve quality and hence safety of medications, provide efficiencies withpharmacy and provide unit volume and space for applicable automation.

Human resources: Currently there are 20 FTE pharmacy technicians with a phasingprocess 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 packagingequipment, parenteral nutrition pump and IV robot.

Funding/pharmacist remuneration: This service is financed by the Fraser HealthAuthority under the operating budget of the pharmacy service.

Challenges and strategies used to overcome challenges: Requires consistency ofpractice across region. There are significant logistic/distribution issues. Ongoing resourcefunding is another challenge. In the region, MEDITECH has three different databases and itis difficult to have them integrated into one system.

To address these issues, there is ongoing practice development with PharmacyManagement Team, incorporation of contingency plans to address transportation issues,business case submission for improvements to the drug distribution systems that would also




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provide additional staff and capital funding for PDDC. The program is also piloting asystem 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.

FeasibilitySustainable: 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 boththe product and the certification of the pharmacy technicians as well as environmentalquality assurance. They follow the USP 797 recommendations and are close to meeting therequirements.

CONTACTLinda MorrisRegional Pharmacy ManagerTel.: (604) 455-1328 ext. 741298# Email: [email protected]

8.8 Enhanced Utilization of Pharmacy Technicians in aCommunity 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 andlearn sessions for technicians, and other outside training resources, e.g., ProfessionalCompounding 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 levelof competency and delegated tasks.” Because of the significant amount of money and timeinvested in technician training, management feels comfortable putting “a huge amount ofresponsibility and trust in our technicians.”

While GPA pharmacy technicians receive training in most departments, they also each haveas assigned specialty, based on their own interest and experience, as well as the technicalsupport needs identified by staff pharmacists.


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 governmentsponsored MedsCheck program, and booking appointments with the pharmacists forprogram consultations.

Training is supervised and coordinated by the dispensary operations manager/seniortechnician, who encourages technician staff to take workshops and participate in lunch andlearn sessions. GPA also sponsors more formal training of technicians, through enrollmentin special off-site training courses and programs (e.g., sterile compounding workshop inHouston, 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, twotechnicians also recently completed a certification program.

Role of pharmacist: The advanced use of technicians enables the pharmacists toconcentrate on their professional, cognitive role – dealing with therapeutics and providingpharmaceutical care. Protocols are in place that require pharmacists to check and sign-offon some of the technician-led activities (e.g., compounding, dosette loading), however timespend is minimal compared to having the pharmacist carry out these activities him orherself.

Purpose: To increase efficiency of pharmacy’s operation and to offer a heightened level ofcustomer service. Empowering technicians at GPA frees up the pharmacists to care ofpatients. With the pharmacists’ extensive knowledge in therapeutics, they are best used indirect patient care versus the technical side of pharmacy.

GPA expects to have improved patient care with this system; more pharmacist time withpatients, answering their questions, helping them select non-prescription drug items,catching drug interactions, etc. The pharmacy also aims to have the pharmacists andtechnician employees “love their jobs”, keeping them busy with new tasks and challenges.

Human resources: GPA employs seven full-time technicians in total (including thecoordinator), four full-time pharmacists, and a part-time pharmacist assigned to the sterileIV lab.

Other resources required: Financial resources for recruitment and training of technicians.

Funding/pharmacist remuneration: All provided by GPA.


Benefits/advantages/impacts: Great resource for pharmacists (particularly given a climateof pharmacist shortages). There is increased job satisfaction for both pharmacists andtechnicians (able to focus on their respective areas of interest/education). It gives room forlearning 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 trainedemployees can cause problems for vacation and sick leaves. Need to constantly work oncommunication and scheduling. GPA departments are spread out over three floors ( i.e., toaccommodate compounding, packaging and other technician-led services) which makescommunication between staff sometimes challenging.

Properly trained and motivated technicians have been effective in promoting the servicesthat the GPA offers, which has resulted in increased business – more than offsetting thetraining and recruitment costs. GPA is conducting some cross-training of technicians to fillgaps during vacation or other temporary leaves of absence. Pharmacists and techniciansmeet every Monday to talk about challenges and successes from the week before.

FeasibilitySustainable: 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 operationand philosophy. Many public presentations to various groups in the community.

CONTACTAmanda BlazevicThe Glebe Pharmasave Apothecary778 Bank St. Ottawa, ON K1S 3V6 Tel.: (613) 234-8587 Fax: (613) 236-0393 Email: [email protected]



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ASSOCIATION OF DEANS OF PHARMACY OF CANADA(ADPC)

ASSOCIATION OF FACULTIES OF PHARMACY OF CANADA(AFPC)

CANADIAN ASSOCIATION OF CHAIN DRUG STORES (CACDS)

CANADIAN ASSOCIATION OF PHARMACY TECHNICIANS (CAPT)

CANADIAN PHARMACISTS ASSOCIATION (CPhA)

CANADIAN SOCIETY OF HOSPITAL PHARMACISTS (CSHP)

NATIONAL ASSOCIATION OF PHARMACY REGULATORY AUTHORITIES (NAPRA)

THE PHARMACY EXAMINING BOARD OF CANADA (PEBC)

OFFICE OF THE SECRETARIAT

1785 ALTA VISTA DRIVE, OTTAWA ON K1G 3Y6TEL.: 613-523-7877 • FAX: [email protected]

Funded by the Government of Canada’s Foreign Credential Recognition Program