Where do we go from here?

Pharmacy and healthcare as a whole are in a period of transformation,” says Dr. Danielle Paes, Chief Pharmacist Officer at the Canadian Pharmacists Association (CPhA). As community pharmacies add patient care services throughout the pandemic, they are solidifying their stake as healthcare hubs. But is it sustainable for the long term?

“Pharmacists have become the go-to healthcare provider for many patients, answering questions, providing vaccinations and screening services, all to combat the pandemic,” says Paes. “It’s important to remember that the role of the pharmacist has always been clinical, but now there is increased awareness, and public expectations have finally aligned with what we’ve been capable of offering for a long time. Our role in public health is being accessed and utilized in a variety of ways and at a greater volume.”

In the primary care space, one of the most significant changes triggered by the pandemic are the exemptions to Health Canada’s Controlled Drugs and Substances Act (CDSA). These exemptions enable pharmacists to extend/renew, transfer and adapt prescriptions for controlled drugs, as well as accept verbal orders for prescriptions and permit pharmacy staff to deliver prescriptions. While not all provinces and territories have been able to fully implement the exemptions, since they are subject to the scope of practice, laws and regulations of the jurisdiction, they have made a difference.

Just ask pharmacist Dr. Dimitri Kachenyuk of Primrose IDA Pharmacy in Edmonton, Alberta. Since graduating in 2018, he has worked primarily with individuals with substance-use disorders, doing outreach at many different types of facilities, such as halfway and supportive houses. When the pandemic hit, many of these vulnerable people had no place to isolate and COVID-19 isolation shelters were set up for them, he explains. The CDSA exemptions permitted pharmacy teams to service those patients on-site with significantly reduced barriers.

“The first and biggest difference that the CDSA exemptions made was in terms of transition of care where individuals may be coming in from a different city, different practitioner, different pharmacy, or even different province and are currently on opioid or controlled therapies,” says Kachenyuk. Pharmacists could simply request other pharmacies to transfer prescriptions, removing the need for new assessments—and lowering the risk of patients going into withdrawal, leaving the site and possibly infecting others with COVID-19.

The authority to renew prescriptions bolsters continuity of care and verbal orders make “a massive difference as well,” as physicians can treat patients faster and more conveniently, says Kachenyuk.

In their 2021 analysis of pharmacy’s implementation of the CDSA exemptions, researchers Sarah Lussier-Hoskyn and Brett Skinner of the Canadian Health Policy Institute concluded: “There is currently no evidence to suggest that there were any negative outcomes associated with the expanded scope of practice for pharmacists under the temporary exemptions of CDSA, while there is some evidence that the CDSA exemptions were associated with positive outcomes regarding access to opioid agonist therapies.”¹

Health Canada appears to agree with this conclusion: originally set to expire in October 2020, the exemptions were extended to September 30, 2021, and then again to September 30, 2026.

CPhA and other provincial and national advocacy associations are using the time to lobby to make the exemptions permanent. Associations are also pursuing the authority for pharmacists to make therapeutic substitutions of opioids and controlled substances, and the recognition of pharmacists as practitioners under the CDSA so that they can initiate opioid agonist therapy. “There is so much opportunity to build on the gains that we’ve made,” says Paes.

Provinces adding services and funding

Over the past two years, pharmacists have achieved a number of “wins” as services expand across the country, both in scope and in funding. Some are tied directly to the pandemic, while others were already in the works—though likely accelerated by the public health crisis.

Alberta, which already stood out as the jurisdiction with the broadest scope of practice for pharmacy, added a new billable service for assessments to screen and/or test for infectious disease. While the program was put in place with COVID-19 in mind, the stage is set to expand it to include other infectious diseases.

Nova Scotia’s scope of practice has expanded significantly in recent years. Most of the changes—such as the permanent authority for technicians to administer most influenza and other vaccines, and reimbursement for prescribing for urinary tract infections (UTIs) and contraception management—were already in the works prior to the pandemic, says Allison Bodnar, CEO of the Pharmacy Association of Nova Scotia (PANS). Other services, however, were propelled to completion more quickly by the pandemic. “We were scheduled to launch a fully funded renewal service on April 1, 2020, but we moved it up to March 18 to meet pandemic needs over that two-week period,” she says.

Most recently, the province rolled out the Community Pharmacist-led Anticoagulation Management Service (CPAMS) as a permanent, publicly funded service following a successful 2018-2019 pilot. Bodnar sees the opportunity to leverage similar types of services to help with other chronic disease states, such as diabetes. PANS has also launched pilot projects in hypertension management and deprescribing to demonstrate the value of expanding scope, funding, or both.

Currently, PANS is lobbying for the administration of all publicly funded vaccinations in pharmacies. “We have an agreement with government to expand adult publicly funded vaccines into pharmacy and are waiting to work through operational implementation issues,” Bodnar explains. “This was part of our 2019 agreement but COVID has delayed the work required to put it into place. We continue to advocate for inclusion of all publicly funded vaccines-not just adult.”

The other piece PANS is focusing on is the implementation of pharmacists’ authority to order lab tests. “We’ve had the legal authority to do this since 2014,” Bodnar explains. “We just need the operational authority to do it, so we’re working to get that implemented as quickly as possible.”

New Brunswick has also been on a fast track when it comes to pharmacy services. During the pandemic, the province introduced funding for assessing and prescribing for UTIs and for prescription renewals, both of which were already in the scope of practice. “We’ve seen a huge uptake of renewals at pharmacy,” says Jake Reid, Executive Director of the New Brunswick Pharmacists’ Association.

The province already has an extensive list of 35 minor ailments within its scope, having recently added contraception management, herpes zoster, and Lyme disease/tick bites. “We would like to see more of those minor ailments covered,” he says. “We are looking at those conditions that drive people the most towards our emergency rooms or towards their family doctors, where pharmacies could play a role to provide greater access to primary care and to offload those healthcare services from an overburdened system.”

The pandemic precipitated several changes to scope and funding in Ontario in a bid to increase capacity in the healthcare system. In addition to COVID-19 testing and administering vaccines, pharmacies became authorized to administer influenza vaccines outside of the pharmacy, run clinics in communities and underserviced areas, and administer the high-dose flu vaccine for older adults, says Angeline Ng, Vice-President, Professional Affairs, at the Ontario Pharmacists Association (OPA). As of July, a pharmacist, intern, pharmacy student or pharmacy technician can perform point-of-care testing to support the medication management of certain chronic diseases. Meanwhile, the long-awaited minor ailments prescribing program—starting with 13 ailments—comes into effect on January 1, 2023, with funding details to be announced.

OPA is also currently advocating for pharmacists to prescribe antivirals to treat COVID-19, and for authorization of pharmacy professionals to administer all publicly funded routine immunizations, notes Ng.

Last but not least, the pandemic fast-tracked pharmacists’ authority to provide services virtually, by phone or video. While some provinces already permitted this, all provinces made it happen within months of the start of the pandemic. All but three provinces also enabled pharmacies to bill for some or all of these virtual services.

A call for harmonization

The divergences in authorized services among jurisdictions have prompted growing calls for a national scope of practice. “Every patient deserves the same level of care,” says Paes.

In March this year, Geraldine Vance, CEO of the B.C. Pharmacy Association, presented the case to the Standing Committee on Health Canada’s Health Workforce for a National Scope of Practice, to “ensure all pharmacists are able to deliver care to their maximum level of expertise.” This would include prescribing rights.

She noted that in B.C., pharmacies are enabled to bring nurses and other immunizers on to their teams to help administer COVID-19 booster shots. “This model should be extended beyond the pandemic,” she urged. “We believe the federal government should target funding to provinces that would be used to improve and harmonize a standard scope of practice for pharmacists across the country. We recommend that this Committee create a forum of engagement with the Canadian Pharmacists Association and other provincial associations to develop a strategy to fully employ the expertise of community pharmacists.”

“Increased prescribing capacity of pharmacists across the country overall is something that I would love to see more of,” says Kachenyuk. “I think that would be a great expansion all across the nation that could potentially lower healthcare costs and provide more value from our services too.” He adds that the same thinking can be applied to pharmacy technicians as well, noting that despite Alberta’s wide scope of practice, pharmacy technicians are not yet authorized to administer injections.

A checklist for future growth

As COVID-19 starts to ease, pharmacists are keen not only to protect, but also to build on their hard-won gains.

“COVID has really opened the eyes of policymakers, so I think it presents a real opportunity for pharmacy across Canada to get where we should have been a decade or two ago in terms of our scope of practice,” says Bodnar. In a province where almost 100,000 people don’t have a family physician, she says it’s essential “to get to the point where we are at the table when any conversation about primary care happens because we’re recognized to be such an integral part of that.”

The implementation of pharmacy services calls for mutual trust, respect and collaboration between government and pharmacists, says OPA’s Ng. “Implementing these services requires so much careful planning and preparation, not only in the government piece, like developing the policies, but the guidance, the tools and the resources to support the services.”

Much more planning and support are required when adding services, echoes Dr. Mona Kwong, managing partner of Pharmasave Howe Street in Vancouver. “Pharmacists need to be at that table when scope work is being looked at.”

Kwong would also like to see fees for services linked to the clinician, rather than the pharmacy. In her additional role as clinical pharmacist at Vancouver’s first collaborative medical specialists’ clinic, Infinity Medical Specialists Clinic Inc., Kwong provides education and support in the areas of diabetes and hypertension, yet there is no public-funded mechanism to compensate a pharmacist working in conjunction with medical specialists in the community.

From his perspective on the front line, Kachenyuk is hoping to one day see more widespread adoption of physical assessments in pharmacies for simple ailments. He cites the example of a colleague who works at a clinic where the patient sees the pharmacist first for an assessment before seeing the physician.

“It would obviously require a bit more equipment and training, but…I see pharmacists as being the ultimate first point of contact of access to the healthcare system, and then a physician referral potentially afterwards if needed,” summarizes Kachenyuk. “What I see in the future is pharmacists being minimally involved in dispensing and shifting towards the clinical assessments almost exclusively, while the pharmacy technicians are more responsible for the dispensing. I think that COVID-19 has helped propel us further towards that, and we just need to continue.”

As health care is provincially mandated, CPhA is somewhat limited in its capacity to advocate at a federal level. However, as a way of supporting its members, the Association issued a national call to action. “This was a way to raise awareness, and the intention is that our associations at a provincial level can use this to ground some of their conversations and reference it,” explains Paes. The call to action asks for, among other requests: the removal of unnecessary administrative and regulatory burdens; resources to help pharmacy technicians and foreign-trained pharmacy professionals become licensed; enabling full scope of practice for pharmacists and pharmacy technicians; public funding for health services provided by pharmacists; and the integration of pharmacists/pharmacy groups into policy planning decisions that impact the profession.

“We need to re-think the way we deliver health care, all while ensuring that pharmacists have the support that they need to make this evolving role that we’ve seen over the past few years sustainable,” says Paes. “This includes the mental health and wellness of the profession, effective human health resource management and appropriate compensation for expanded services.” ■

Reference

1.Lussier-Hoskyn S, Skinner B. Pharmacy scope of practice and access to Opioid Agonist Therapies (OAT) in Canada after COVID-19. Canadian Health Policy

Reprinted with kind permission from CFP.