Providing continuity of care in rural B.C.
Recently discharged from the hospital, a patient stumbled into the Lumby IDA Pharmacy. As pharmacist Judy Phillips sat him down, she discovered burns on his scalp from being electrocuted. Titanium plates in his skull from a motorcycle accident many years ago had transferred the current through his body.
Her patient had no family physician, and there was no doctor working that day in this small town of 1,700 people in the northern Okanagan Valley. There had been no follow up from the hospital. And on that hot summer day, he could have easily overheated.
Phillips gave him a dermal wound cleanser, Polysporin to apply to the burns and ibuprofen to help with the pain and inflammation. She also made sure he knew to stay hydrated and cool and that he could call her for anything at all.
“Here I am – with no tools except OTCs – to deal with a still critical individual,” Phillips recalls. “These are the types of things I’ve had to deal with because there was no other caregiver at the time but me.”
Like so many rural communities in B.C., Lumby is facing a health-care crisis. Lumby lost two doctors this past year and has only one practicing physician, who covers not only the village of Lumby, but serves the area east towards Nakusp, two and half hours away. The public health unit is only open Monday to Friday from 9 a.m. to 4 p.m. and the closest hospital is 30 minutes away. As Lumby’s only community pharmacy, Phillips and her team find themselves constantly dispensing emergency refills or helping patients get access to physicians or other health-care providers in Vernon.
“The pharmacy becomes a triage per se,” Phillips says. “Where else can the patients go? They come to us.”
As the first point of care in rural and remote communities, community pharmacies play a critical role for patients who have limited access
to physicians. This summer, the BC Pharmacy Association (BCPhA) made four recommendations to the B.C. government to help improve health care in rural, remote and isolated communities. One of these recommendations includes asking that pharmacists be able to prescribe for minor ailments in rural communities.
Minor ailments mean lab tests are not needed to diagnose the condition; that treating the condition as a minor ailment will not mask underlying more serious health conditions; that medical and medication histories can reliably differentiate more serious conditions; and that only minimal or short-term follow-up with the patient is necessary.
Phillips says her hands are often tied when a patient comes into the pharmacy, has no doctor and their prescription says “no refills.” She often finds herself issuing 14 days of an emergency supply, but that’s all she can do.
“Rural pharmacists need to be given the option to prescribe for disease states that the College deems appropriate,” Phillips says. These include common conditions like headaches, back pain, insect bites, diaper rash, cold sores, acne, athlete’s foot, heartburn or indigestion and nasal congestion. “We have the abilities, we have the knowledge base, but right now our hands are tied.”
What is rural?
In 2001, the Joint Standing Committee on Rural Issues (JSC) was established, with representation from both the provincial government and Doctors of BC, to develop strategies to look at the challenges associated with providing physician services to rural communities across the province. Through the JSC’s efforts, the Rural Practice Subsidiary Agreement (RSA) was established.
The agreement designates 183 rural communities in the province where practicing physicians are eligible to receive financial incentives. Eligibility for the RSA is determined by evaluating a community’s level of isolation, using criteria such as number of designated specialties within 70 km, number of general practitioners within 35 km, community size and distance from a major medical community. The communities are separated into four groupings from “A” to “D,” with “A” rankings receiving the highest level of incentives to attract and retain physicians.
In 2010, under the framework of the Pharmacy Services Agreement, the Province committed $1.6 million in an Enhanced Rural Incentive Program to enhance support to community-based pharmacy in rural B.C. Under the program, qualifying pharmacies receive a subsidy for each claim below a specific threshold
To qualify, pharmacies must apply for the program, and meet the following criteria: be the only pharmacy in the community; the next nearest pharmacy must be at least 25 km away; and the number of PharmaCare claims submitted by the pharmacy must not exceed 1,700 per month.
Pharmacies with lower monthly claim volumes receive a larger subsidy for each claim. No subsidy is paid if PharmaCare-paid claims for a particular month exceed 1,700. The subsidies, calculated and paid monthly, are based on a sliding scale with a minimum of $3 and a maximum of $10.50 per claim.
As part of its recommendations to government on rural health care, the BCPhA is asking the Ministry of Health to modernize and review this program. The Association recommends the 183 rural communities included as part of the RSA be adopted as part of the eligibility criteria for the community pharmacy rural incentive program. There should be alignment in location eligibility criteria for prescriber and pharmacist incentive programs.
Phillips agrees with the alignment of pharmacy rural incentive program to the RSA, but believes the RSA itself needs a review as well. Since May of this year, Judy has been working to lobby politicians, drafting letters and fundraising with the health society to see if they can change Lumby’s rural designation.
Because of its proximity to Vernon, Lumby is currently listed as a “D” community, which means physicians working there receive fewer incentives than the rest of those in the RSA.
“Salmon Arm is a city with a hospital but is declared more rural than us,” Phillips says. There’s word that new physicians have been recruited there because the salary is higher.
“Not only do we need to get a doctor here, but we need them to stay. Retention issues are huge. Lumby has been left out in the cold in terms of proper rural designation,” she says.
First point of contact
Recently, one of Phillips’ elderly patients, who is blind, called in the early afternoon in a panic. She had been watering her plants on her deck and a wasp had snuck inside her soda can and stung her when she took a sip of the cola. She had an anaphylactic reaction, but luckily had the pharmacy on speed-dial.
“I grabbed the EpiPen, and literally ran the four blocks to her house,” Phillips says. When she arrived, the woman was in distress so Phillips injected her with the EpiPen and called 911. The ambulance took more than half an hour to arrive.
“Had I not been there, she wouldn’t have survived."
In addition to Phillips, the pharmacy has two part-time pharmacists, one of whom focuses on blister packing and deliveries. When they deliver, Phillips and her team have been known to take out their patients’ garbage or bring along treats for their dogs. Phillips has even driven a patient who was suffering from shingles all the way to Vernon because she didn’t have a family physician in town and her partner refused to drive her the 30-minute trip to the hospital.
Even prior to the recent loss of two physicians, there were days where this rural area didn’t have any coverage because none of the doctors worked full-time. Phillips says patients struggled getting x-rays and lab results with locum physicians assisting for short periods of time.
“It’s very staggered and fragmented care,” she says of the state of rural health care
in B.C. Other remote communities with telepharmacies face an uncertain future, with the possibility that many may close due to impending regulatory changes that take effect on Jan. 1, 2017.
Phillips says community pharmacy in rural areas isn’t just about dispensing medications to patients.
“It goes so far beyond pharmaceuticals,” Phillips says. “It’s also such an incredible social impact that we’re making on the fibre of our small community.”