Adapting Prescriptions: Addressing perceived barriers to allow for more creative and effective patient care

The Tablet

While pharmacists have had the ability to adapt prescriptions in B.C. since 2008, PharmaCare statistics show us that the vast majority of adaptions are for renewals, with only a small percentage attributed to dose changes, formulation changes or therapeutic substitutions (see sidebar for full statistics). Similarly themed, medication reviews are most often identified as MR-S (standard), as opposed to the additional billing eligibility of MR-PC (pharmacist consult).

These statistics are perplexing to me, as I have completed countless medication reviews and adapted hundreds of prescriptions of all varieties, and yet can count on one hand how many of these reviews have not been eligible for the additional billing of an MR-PC. In my experience, it is incredibly rare to not find a drug therapy problem (DTP) that needs to be solved for my patients, which makes me question why would pharmacists not make use of these extra billable services? Over the last few years, I have spoken to many pharmacists who have self-identified barriers about adapting prescriptions. While I won’t review all the barriers here, I would like to call attention to the following statement listed several times in the College of Pharmacists of British Columbia “Orientation Guide to Medication Management (Adapting a Prescription).” The following blurb appears as a limitation on pharmacist practice for changing a dose or regimen of cancer, cardiovascular disease, asthma, seizures, psychiatric conditions, and therapeutic substitutions:

“Unless in practice settings such as hospital, long-term care facilities, or multi-disciplinary environments where collaborative relationships or appropriate protocols are established…”

Many pharmacists believe that this statement limits their ability to adapt prescriptions, beyond simple renewals for medications other than those used in psychiatry. Pharmacists have expressed concerns about lacking the credentials of other practitioners across Canada, such as prescribing pharmacists in Alberta, primary care pharmacists in Ontario or those with a PharmD, for example. The reality is that the College has not identified any separate tiers of pharmacists. There are no prescribing pharmacists in B.C., and we do not have many publicly funded primary care pharmacists working directly in physicians’ offices. Our College also has not defined any of the terms used in that statement. Where does that leave pharmacists? 

Following a two-year stint in B.C.’s Interior, where physicians were in short supply, I looked at that statement in the orientation guide and used it as an opportunity to widen my practice – and 

I think you can, too. Let’s break down the statement.

“Unless in practice settings such as hospital…” There are many pharmacists who work on the community or outreach side of things attached to or directly within hospitals.

  • “…long-term care facilities…” In my practice, we serviced two small  group homes that were classified as Plan B facilities.
  • “…multi-disciplinary environments…” I spent a few hours a week seeing patients at a First Nations Health Centre. I had a close, collaborative relationship with their registered nurses, program director and main physician.
  • “…where collaborative relationships…” This term is meant to describe multi-disciplinary environments consisting of more than one pharmacist and one physician. In addition to the First Nations Health Centre, a nearby office of four local physicians had maxed out their rosters and patients had a two-week wait to see their doctor. They also had a nurse and diabetes educator on staff. I met with them several times to establish a working understanding of how adapting prescriptions could lessen their paperwork burden.
  • “…appropriate protocols…” This is a vague statement and at first I was not sure what to make of it. At the time, I was finishing my PharmD from the University of Waterloo. All our staff pharmacists had completed CPhA’s ADAPT course and a Laboratory Monitoring course. Together as a team, our pharmacists individually had continuing education credits in COPD, asthma, anticoagulation and diabetes. Based on this, we stipulated that all pharmacists adapting prescriptions would have similar advanced training in order to work collaboratively with the nearby physicians and RNs.
  • It’s also important to note the College states that you need to satisfy describing collaborative relationships or explain appropriate protocols within the multi-disciplinary environment. You don’t need both.

I came up with agreements between the local physicians, the divisions of family practice representative, the staff and caretakers at our Plan B facilities, the nurses at the First Nations Health Centre and our staff pharmacists to add all this information to our Policy and Procedure Manual. Just like that, we 
had documented information proving that we were qualified and ready to adapt prescriptions within our scope of practice without limitations holding us back.

Can you do the same thing? Yes! It just takes some creativity. There are many different types of pharmacy practices in B.C. Do you work in a specialized compounding lab? Do you collaborate with a nurse practitioner? Do you service a long-term care home? Do you offer specialized immunization clinics? Do you have a certified diabetes or asthma educator on your team? If you can’t think of anything that would qualify in your practice, start reaching out to your local health organizations. You’ll be surprised who wants to work with you. Develop your own protocols and keep them updated in your Policy and Procedure Manual.
Greg Becotte is a Pharmacy Practice Support coordinator with the BC Pharmacy Association. For further support, information and guidance on adapting prescriptions, contact him at greg.becotte@bcpharmacy.ca.

References available upon request at info@bcpharmacy.ca.
 

PharmaCare Statistics in B.C.

Periodically, PharmaCare releases statistics on professional pharmacist activities in it bs newsletter. The most recent statistics from 2015/16 were shared in October 2016.

Medication Reviews in B.C.

  • 82.3% MR-S (Standard)
  • 8.7% MR-PC (Pharmacist Consult)
  • 9% MR-F (Follow Up)

Adapting Prescriptions in B.C.:

  • 72% for renewals (NL)
  • 7.3% for dose changes (NI)
  • 8.5% for formulation changes (NJ)
  • 9% for changing directions (NK)
  • 2.5% for therapeutic substitutions (NM)

This article is featured in The Tablet. The Tablet features pharmacy and industry news, profiles on B.C. pharmacists, information on research developments and new products.