Northern pharmacy practice: Lessons in collaboration, adaptation and reconciliation

Our flight departs from Wollaston Lake, Saskatchewan, located approximately 900km north of Saskatoon, on Treaty 10 Territory, and the homeland of the Hatchet Lake Denesculine Nation. This is my second trip to this community, and it was my distinct pleasure to share this experience as a preceptor for a 4th year PharmD candidate from the University of Saskatchewan. Flights have always been a time for writing and reflection for me, and this trip has culminated a powerful year of learning and growth as a Mètis pharmacist, serving the pharmacy needs of remote Indigenous communities in Saskatchewan. Pharmacies have been providing medication services and distribution to remote communities for decades, with a variety of distribution methods, service offerings, and partnerships with the Indigenous peoples who reside there. Some of these partnerships are formed as an invitation by community leaders, a services agreement based on collaboration, trust, reciprocity, and respect. Sadly, just as many are greatly lacking in these measures, with a distinct absence of standards regarding indigenous ways of knowing, but also standards of patient care. Regardless of the intentions of pharmacies that provide pharmacy care to Indigenous communities, there are service shortcomings experienced by these communities that fail to meet pharmacy's professional standards, ultimately resulting in inequitable health disparities. The reasons for these failings are multi-factorial, systemic and historically colonial in nature. It is not just access to medications that holds extensive barriers for these communities. All medical services and personnel, virtual/communication tools, affordable food, and even clean water, are broadly lacking throughout Northern communities across Canada. As an Indigenous healthcare professional, with sincere intentions to apply best standards of pharmaceutical care, the hurdles are numerous, all requiring innovation, dedication, collaboration, advocacy and funding. Even with mindful planning, there are extensive costs to pharmacies providing distribution. The airfare, gas, mileage, mailing, and shipping fees for prescriptions are rarely covered through non-insured health benefits. The “what is covered” becomes a very tangible and regularly communicated barrier for Indigenous patients, often a difficult narrative to develop a trusting relationship within. Ultimately, for pharmacies already living on the razor’s edge of staffing and sustainability within our funding models (a measure of our own systemic failings), doing Northern health the “right” way seems increasingly impossible. System barriers are significant There are significant systemic barriers in pharmacy practice that impact Northern Indigenous communities. Well intentioned regulatory barriers can be detrimental to the logistics of providing remote distribution, including standards for controlled medications, privacy compliance, and delivery of clinical services outside of the pharmacy space. Many communities are unable to construct spaces that meet satellite pharmacy schematic requirements, and regulated personnel who are able to travel on a standardized schedule have weather and other travelling disruptions working against them. Clinical shortcomings come primarily from communication barriers, including patients who have no active phone number, or whose first language is not English. How do you communicate vital information on new prescriptions to a patient who is unreachable or requires translation? How can you adequately ensure appropriate receipt of short-dated compounds, urgent medications, or controlled medicines to the receiving personnel? There are ongoing issues regarding who is responsible for ensuring timely reorders of vital medications, or, just as important, stopping the “auto fill” process for medications that are not being picked up. The inaccuracy of medical records on profiles like the Pharmacy Integration Program (PIP) can occur for many patients who are the recipients of remote distribution. How is a hospital to discern a patient’s medication reconciliation when they “look” compliant, but months of medication are still sitting on shelves at a health facility, never to be picked up. There is significant costs to these inefficacies, funds that could be redistributed to communities to support community healing efforts, and improve access to health foundations like food, safe spaces, and cultural events. This trip to the Hatchet Lake Health Centre was to assess our own pharmacy’s role and efficacy in this process, while sharing clinical and collaborative resources with the health centre and community. Ultimately, our team has applied our best intentions for serving Northern communities, with regular collaboration and reciprocity. We have hired Indigenous pharmacy professionals from the communities we serve, including Dene speaking individuals to facilitate the “tracking down” of patients, education during language barriers, and to create a safe space to access health information. This is one of three remote communities that I visit in person, which is my way of “showing up” in a literal sense, to assess medication stock, review problems with the health centre’s staff, and offer face-to-face services to community members. I have done continuous quality improvement and development for these incredible and worthy communities, but it requires nearly monthly adaptations to operating procedures, innovation with intentional collaboration, and sometimes, it still is not enough. My student and I met each morning this past week with the health centre’s nursing staff to discuss the inefficacies of medication access and collaborate on potential solutions. I would be remiss if I did not take the time to reflect on how inspiring these professionals are. This is a nursing staff that wakes up nearly every night on-call for an emergency: delivering babies, providing emergency services for traumatic wounds, psychiatric illness, overdoses and other critical care. During the day they are operating an entire health facility, dispensing and administering medications, providing acute and continuous medical care, and managing medications and medical supplies stock. They’re dealing with shortages just as much as pharmacy, and then turning around and handling a patient in acute psychosis. Somehow, beautifully, they still seem to laugh and connect with their patients and each other, learn and respect Indigenous ways of knowing, practice speaking Dene phrases, and collaborate with pharmacies, physicians, dentists, RCMP and pretty much any other provider that visits the community. Together, we spent the week designing a new set of collaborated solutions, all of which I will design and have our pharmacy enact. Some examples are as follows: Standardized bag stuffers that describe to patients about reordering their medication, and how to connect with the pharmacy staff Front end calls from the pharmacy about ALL prescriptions being shipped up (not just the new medications). We will collaborate with the health Centre administration staff who may be able to reach patients on our behalf via Facebook messenger to “contact the pharmacy” Notes for visiting prescribers that state “you have been prescribed medications for: ________, these medications will arrive in 1-2 days by flight from the pharmacy. Contact the pharmacy at (phone number) if they do not arrive SOPs for personnel who receive medications, including instructions if a patient has multiple packages already awaiting them, detailed storage requirements, and with shipping reports noting which patients should be contacted upon arrival. Today I am flying home with 3 boxes of medication for destruction. Many of which were unreachable patients, some were patients who were not aware they were receiving a new prescription, some were non-compliant or moved away, some returns are old doses or bubble packs that did not reflect new changes (and I shudder to think if both had been handed out), and others were compounded prescriptions whose BUD had expired. Some patients just didn’t want the medication, but when an order arrives and the indication is important (like depression), it seems prudent to send the prescription even if you cannot connect with the patient. As one Indigenous nurse at the health centre reflected with us this week, it is time for pharmacy to recognize the colonist structures that continue to shape poor medication management, our calls to reconciliation require us to recognize the history of the relationship between Indigenous patients and healthcare. Indigenous Peoples have been “told what to do” for so long that it is important to coach them into autonomy in their own health, and to provide them with the resources and safe spaces to be their own advocate. Needless to say, there is a lot to unpack, and it’s not just boxes of medications being shipped from somewhere down south. "Finally, I have a community" This year, through the vision and lived experiences of Dr. Jaris Swidrovich, Canada’s first Indigenous pharmacy professor, the Indigenous Pharmacy Professionals of Canada (IPPC) was born. Through the allyship and resources of the Canadian Pharmacist’s Association, was brought to life, and into the spotlight of pharmacy professionals, as an organization forming a community and voice for all pharmacy professionals with Indigenous Ancestry. Jaris and I now share the role of Co-chairs of the organization, and for the first time in two years of advocating for these communities within pharmacy systems, distribution systems, funding models, prescribers, and industry partners, representatives are requesting my input, instead of providing responses like “this is not their problem to solve.” Finally I have a community, one of collaboration built to reflect and respect the decision making and knowledge gathering of our ancestors, both to bolster and support my voiced concerns, but to share in the process of reconciling anti-Indigenous systems that exist in the pharmacy profession. I have always loved the North. My summers were spent on Lac la Ronge, Saskatchewan, fishing for lake trout along shorelines built of impressive Precambrian Shield rock. You can imagine how thrilled I was to have myself and my student invited out fishing for “lakers” by one of the local Health Centre staff during our trip this week. We cruised along at sunset, watching the sun turn into a dusky orange as it sank into distant forest fire smoke, lighting up willows growing on nearby rocky shores. My dad always pointed out willows on shorelines, reminding me that those willows indicate shallow water, a sign of changing landscape, and a warning that you might lose your boat’s prop to a rock if you approach too close. Willows are a long-standing source of medicine for Indigenous Peoples, and willow bark is the original source of aspirin (notably, drugs derived of traditional Indigenous medicines have not resulted in royalties or compensation to original knowledge keepers). Willows are a plant that adapts to changing water levels, growing along shorelines and in wetlands. I practice out of WillowGrove Pharmacy Prince Albert. I feel at home with that name, thinking back to my dad and to my ancestors who read shorelines and gathered medicines from the land, deciding that as willows adapt to changing landscapes, then my role in WillowGrove Pharmacy will be to adapt to the changing landscapes in healthcare. Pharmacy can be a tough and frustrating gig, but it is trips to community, visions of change, inspiration from the land and traditional practices, and the power of caring professionals like the nursing staff at the Hatchet Lake Health Centre that give me the courage to think “maybe I CAN make a difference”. If you’re an Indigenous Pharmacy professional and would like to join IPPC email indigenous@pharmacists.ca

Northern pharmacy practice: Lessons in collaboration, adaptation and reconciliation

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