Physicians Assistants and Pharmacists Working Together Lieutenant Commander

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Physicians Assistants and Pharmacists: Working Together Lieutenant Commander Joe Dagenais B. Eng BSP Pharm.

Physicians Assistants and Pharmacists: Working Together Lieutenant Commander Joe Dagenais B. Eng BSP Pharm. D CD Canadian Forces Health Services de santé des Forces canadiennes

Learning Objectives 1. Describe the factors that lead to Pharmacist scope of practise changes

Learning Objectives 1. Describe the factors that lead to Pharmacist scope of practise changes in Canada. 2. Outline the various changes in Pharmacist scope of practise. 3. Describe the pharmacy principle of Pharmaceutical Care. 4. Identify practise areas/ issues where collaboration between Physician Assistants and Pharmacists may occur. Canadian Forces Health Services de santé des Forces canadiennes

Current Canadian Health Care System Problems: 1. Accessibility (disadvantaged populations) 2. Care outside of

Current Canadian Health Care System Problems: 1. Accessibility (disadvantaged populations) 2. Care outside of business hours 3. Wait times 4. Non-optimized health promotion including patient involvement and self-management 5. Appropriate use of health care providers and resources 6. Chronic care management 7. Mental health care 8. Elderly and end-of-life care 9. Questionable fiscal effectiveness and sustainability Canadian Academy of Health Sciences, 2014 Canadian Forces Health Services de santé des Forces canadiennes

Collaborative Care • Multiple health workers from different professional backgrounds provide comprehensive services by

Collaborative Care • Multiple health workers from different professional backgrounds provide comprehensive services by working with patients, their families, caregivers and communities to deliver the highest quality of care across settings. (WHO) – collaborative care models ensure (based on the needs of the patient): • the right professional; • the right setting; and • at the right time. (CAHS 2014) Canadian Forces Health Services de santé des Forces canadiennes

Relationship: Models of Care and Scope of Practice Canadian Academy of Health Sciences, 2014

Relationship: Models of Care and Scope of Practice Canadian Academy of Health Sciences, 2014 Canadian Forces Health Services de santé des Forces canadiennes

Barriers to Collaborative Practice Canadian Academy of Health Sciences, 2014 Canadian Forces Health Services

Barriers to Collaborative Practice Canadian Academy of Health Sciences, 2014 Canadian Forces Health Services de santé des Forces canadiennes

Without Clear So. P • Role confusion, competition among various HCPs, workplace tension, lack

Without Clear So. P • Role confusion, competition among various HCPs, workplace tension, lack of trust, decreased professional identity, under/ over utilization of HCPs. • Difficult for employers to optimize existing HR and assemble appropriate skill mix due to unclear understanding of education and the translation of knowledge into actual practice. Canadian Forces Health Services Health Council of Canada, 2005 Services de santé des Forces canadiennes

UNDERSTANDING A PHARMACIST’S SOP

UNDERSTANDING A PHARMACIST’S SOP

Ontario Pharmacy Act 1991 (2009) Scope of Practice of pharmacy is: a) the custody,

Ontario Pharmacy Act 1991 (2009) Scope of Practice of pharmacy is: a) the custody, compounding, dispensing and prescribing of drugs; b) the provision of health care aids and devices; c) the provision of information and education related to the use of anything mentioned in clauses (a) and (b); and d) the promotion of health, prevention and treatment of disease, disorders and dysfunctions through monitoring and management of medication therapy. Canadian Forces Health Services de santé des Forces canadiennes

Pharmacist Controlled Act 1. Dispensing, selling or compounding a drug or supervising the part

Pharmacist Controlled Act 1. Dispensing, selling or compounding a drug or supervising the part of a pharmacy where drugs are kept. 2. Administering, by injection or inhalation, a substance specified in the regulations. 3. Prescribing a drug specified in the regulations. 4. Performing a procedure on tissue below the dermis. Canadian Forces Health Services Ontario Regulation 302/12 Services de santé des Forces canadiennes

Pharmacist SOP By Province Canadian Forces Health Services de santé des Forces canadiennes Canadian

Pharmacist SOP By Province Canadian Forces Health Services de santé des Forces canadiennes Canadian Pharmacists Association

UNDERSTANDING HOW PHARMACISTS THINK

UNDERSTANDING HOW PHARMACISTS THINK

Pharmacy Education • Anatomy, physiology, pathophysiology, pharmacology, medicinal chemistry, toxicology, pharmacokinetics – CV, psychiatry,

Pharmacy Education • Anatomy, physiology, pathophysiology, pharmacology, medicinal chemistry, toxicology, pharmacokinetics – CV, psychiatry, oncology, pain, endocrinology, neurology, gastroenterology, bone/ joint, infectious disease, hematology, immunology/ transplant, dermatology, ENT… • Patient assessment • Critical appraisal, communication, self-directed learning, group processes • Healthcare systems • Nutrition • Laboratory analysis • Pharmacoepidemiology • Practical Experience (Hospital/ Community) Canadian Forces Health Services College of Pharmacy University of Alberta Services de santé des Forces canadiennes

Pharmaceutical Care “Pharmaceutical care is a patient-centered practice in which the practitioner assumes responsibility

Pharmaceutical Care “Pharmaceutical care is a patient-centered practice in which the practitioner assumes responsibility for a patient’s drug-related needs and is held accountable for this commitment” -Requires: - the patient’s cooperation and coordination with the patient’s other health care providers. - rational decision-making process (Pharmacotherapy Workup) - Identify drug therapy problems (current or potential) - Develop care plan/ recommendations - Follow-up evaluation Cipolle RJ, Strand LM, Morley PC. Pharmaceutical Care Practice: the clinician’s guide. Canadian Forces Health Services de santé des Forces canadiennes

Drug Therapy Problem “…are undesirable events or risks experienced by the patient that involve

Drug Therapy Problem “…are undesirable events or risks experienced by the patient that involve or are suspected to involve drug therapy and that inhibit or delay him/ her from achieving the desired goals of therapy. ” 1. Unnecessary drug therapy 2. Needs additional drug therapy 3. Ineffective drug 4. Dosage too low 5. Dosage too high 6. Adverse drug reaction (drug/drug, drug/food, drug/test) 7. Non-adherence Cipolle RJ, Strand LM, Morley PC. Pharmaceutical Care Practice: the clinician’s guide. Canadian Forces Health Services de santé des Forces canadiennes

Pharmacotherapy Workup Two questions: 1. Is the patient’s problem caused by drug therapy? 2.

Pharmacotherapy Workup Two questions: 1. Is the patient’s problem caused by drug therapy? 2. Can the patient’s problem be treated with drug therapy? – – Indication Effectiveness Safety Adherence Cipolle RJ, Strand LM, Morley PC. Pharmaceutical Care Practice: the clinician’s guide. Canadian Forces Health Services de santé des Forces canadiennes

Pharmacotherapy Workup Indication: Indication Drug Product Dosage regimen Outcomes Cipolle RJ, Strand LM, Morley

Pharmacotherapy Workup Indication: Indication Drug Product Dosage regimen Outcomes Cipolle RJ, Strand LM, Morley PC. Pharmaceutical Care Practice: the clinician’s guide. Canadian Forces Health Services de santé des Forces canadiennes

Pharmacotherapy Workup Indication: Effectiveness Indication Drug Product Dosage regimen Outcomes Safety Cipolle RJ, Strand

Pharmacotherapy Workup Indication: Effectiveness Indication Drug Product Dosage regimen Outcomes Safety Cipolle RJ, Strand LM, Morley PC. Pharmaceutical Care Practice: the clinician’s guide. Canadian Forces Health Services de santé des Forces canadiennes

Pharmcotherapy Workup Effectiveness Signs & Symptoms Abnormal Lab Values Labs Goals of Therapy Indication

Pharmcotherapy Workup Effectiveness Signs & Symptoms Abnormal Lab Values Labs Goals of Therapy Indication Drug Product Dosage regimen Clinical Effectiveness Outcomes Cipolle RJ, Strand LM, Morley PC. Pharmaceutical Care Practice: the clinician’s guide. Canadian Forces Health Services de santé des Forces canadiennes

Pharmacotherapy Workup Safety: Signs & Symptoms Abnormal Lab Values Labs Goals of Therapy Indication

Pharmacotherapy Workup Safety: Signs & Symptoms Abnormal Lab Values Labs Goals of Therapy Indication Drug Product Clinical Effectiveness Dosage regimen Outcomes Toxicity Safety Adverse Drug Reaction Labs Clinical Cipolle RJ, Strand LM, Morley PC. Pharmaceutical Care Practice: the clinician’s guide. Canadian Forces Health Services de santé des Forces canadiennes

Pharmacotherapy Workup Adherence: “…someone who is not able or willing to take an appropriate,

Pharmacotherapy Workup Adherence: “…someone who is not able or willing to take an appropriate, effective, and safe medication as intended” The patient: - does not understand instructions - prefers not to take medication - forgets - too expensive - cannot swallow or self-administer Cipolle RJ, Strand LM, Morley PC. Pharmaceutical Care Practice: the clinician’s guide. Canadian Forces Health Services de santé des Forces canadiennes

Drug Therapy Problem 1. 2. 3. 4. 5. 6. 7. Unnecessary drug therapy Indication

Drug Therapy Problem 1. 2. 3. 4. 5. 6. 7. Unnecessary drug therapy Indication Needs additional drug therapy Ineffective drug Effectiveness Dosage too low Dosage too high Safety Adverse drug reaction Non-adherence Adherence Ø Recommendations to other healthcare providers Cipolle RJ, Strand LM, Morley PC. Pharmaceutical Care Practice: the clinician’s guide. Canadian Forces Health Services de santé des Forces canadiennes

Hospital or Outpatient Practices EXAMPLES OF WHERE WE CAN WORK TOGETHER

Hospital or Outpatient Practices EXAMPLES OF WHERE WE CAN WORK TOGETHER

Collaborative Practice Examples • • Medication reviews Medication consults Diabetes clinics Travel medicine Chronic

Collaborative Practice Examples • • Medication reviews Medication consults Diabetes clinics Travel medicine Chronic Care Adherence issues Smoking cessation Academic Detailing Canadian Forces Health Services de santé des Forces canadiennes

Medication Reviews/ Consults • 65 yrs or older: >5 or more medications: – 13%

Medication Reviews/ Consults • 65 yrs or older: >5 or more medications: – 13% private households – 53% healthcare institutions • 87% of pharmacist recommendations accepted • Reviews: – Present and past therapies • drug, dose, frequency, duration, efficacy/ side effects – Patient’s expectations from drug therapy – Recommendations provided • Deliverable: consult note Canadian Forces Health Services de santé des 20, Forces Health Reports, Vol. no. canadiennes 1, March 2009 • Statistics Canada

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

Travel Medicine • Collaborative practice – – – Physician PA NP RN Pharmacist • Preventative medication – Immunizations – Anti-malaria medications – Information/ Education • With/ without collaborative prescribing agreement Canadian Forces Health Services de santé des Forces canadiennes

Complete appropriate form for Personal Travel or Deployment Travel. Attach form in email to:

Complete appropriate form for Personal Travel or Deployment Travel. Attach form in email to: +Travel Medicine@CF H Svcs C (A) Halifax Immunization nurse will contact you to book appointment. Present for booked appointment with immunization nurse in office 4054 of Bldg S 80 clinic (bring your immunization book). Necessary vaccines will be administered, and prescriptions (e. g. antimalarials) provided to present to pharmacy to be filled. For personal travel, immunization nurse will provide you with traveler health advice For deployment, you will meet with PMED for: • • • Mission specific brief Force Health Protection Recommendations Clothing dip if required See CDU clerk: QL 6 A Med Tech, PA or MO can confirm medical fitness for deployment. If necessary, book appointment with your doctor. If you take chronic medications, ensure you obtain a prescription to bring to pharmacy to fill a deployment supply of your medications Canadian Forces Health Services de santé des Forces canadiennes

Chronic Care • Diabetes – A 1 C (-2. 1% vs -0. 9%, P

Chronic Care • Diabetes – A 1 C (-2. 1% vs -0. 9%, P =. 03) • HTN – SBP (-9. 3 mm Hg) • CV – LDL ~0. 44 mmol/l reduction • INR (physician vs pharmacist) - 71% vs 81% of visits - 65% vs 73% time in therapeutic range Canadian Forces Health Services de santé des Forces canadiennes

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

Diabetes Clinic • Collaborative Practice: – – Sponsoring physician Nurse/ PA Dietician Pharmacist • • Certified Diabetes Educator Interpret lab tests Provide recommendations on initiating and altering DM drug therapy Advances in DM drug therapy • With/ without collaborative prescribing agreement (delegated acts) Canadian Forces Health Services de santé des Forces canadiennes

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

Adherence • Financial – – Drug plan assistance Cheaper drug or dose De-prescribing Dispensing fees • Frequency • Formulation (taste, size) • Patient education Canadian Forces Health Services de santé des Forces canadiennes

Smoking Cessation • Pharmacist: RR 0. 77 compared to advice to quit • Behavioral

Smoking Cessation • Pharmacist: RR 0. 77 compared to advice to quit • Behavioral counseling • Medication education/ Prescribing – NRT – Bupropion – Varenicline • Prescribing • Follow-up Canadian Forces Health Services de santé des Forces canadiennes

Conclusions • Pharmacists are more than simply dispensers. • Evidence shows our involvement in

Conclusions • Pharmacists are more than simply dispensers. • Evidence shows our involvement in collaborative teams leads to improved patient care. Canadian Forces Health Services de santé des Forces canadiennes

Questions? Canadian Forces Health Services de santé des Forces canadiennes

Questions? Canadian Forces Health Services de santé des Forces canadiennes

References • • • Nelson S, Turnbull J, Bainbridge L, et al. (2014) Optimizing

References • • • Nelson S, Turnbull J, Bainbridge L, et al. (2014) Optimizing Scopes of Practice: New Models for a New Health Care System. Canadian Academy of Health Sciences. Ottawa, Ontario. Baranek PM. (2005) A Review of Scopes of Practice of Health Professions in Canada: A Balancing Act. Health Council of Canada. Toronto. Ontario. Cipolle RJ, Strand LM, Morley PC. Pharmaceutical Care Practice: the clinician’s guide. 2004 Maxwell-Alleyne A, Farber A. Pharmacists’ Expanded Scope of Practice: Professional obligations for physicians and pharmacists working collaboratively. Ontario Medical Review. Apr 2013; 17 -19. Tannenbaum C, Tsuyuki T. The Expanding Scope of Pharmacists’ practice: implications for physicians. CMAJ 2013; Young S, Bishop L, et al. Comparison of pharmacist managed anticoagulation with usual medical care in a family medicine clinic. BMC Family Practice 2011, 12: 88 Garton L, Crosby J. A retrospective assessment comparing pharmacist-managed anticoagulation clinic with physician management using international normalized ratio stability. J Thrombolysis (2011) 32: 426– 430 Kennedy A, Chen H, et al. Improving Population Managemet through Pharmacist-Primary Care Integration: A Pilot Study. Carter B, Rogers M, et al. The potency of team-based care interventions for hypertention: A meta-analysis. Arch Intern Med. 2009; 169(19): 1748 -1755 Santschi V, Chiolero A, et al. Impact of Pharmacist Care in the Management of Cardiovascular Disease Risk Factors. Arch Intern Med. 2011; 171(16): 1441 -1453. Choe HM, Mitrovich S, et al. Proactive case management by a clinical pharmacist: a randomized controlled trial. Am J Manag Care. 2005; 11: 253 -260 Canadian Forces Health Services de santé des Forces canadiennes