If not for community pharmacists, many Nova Scotians would have had nowhere to turn for their primary health care needs during the pandemic.
That’s one of the takeaways from a new research paper, ‘Community Pharmacists’ Expanding Role In Supporting Patients Before and During COVID-19: An Exploratory Qualitative Study.’
“I would say that we have proven our ability to be a really important part of the healthcare system during COVID, and that hopefully we can maintain that and have funding to maintain that,” one Halifax area pharmacist told the study’s authors.
“A lot of patients, and in particular unattached patients, would have been really left without anybody if they didn’t have their pharmacist during COVID.”
The study’s authors found the role played by Nova Scotia pharmacists in delivering primary care during the pandemic has highlighted an “urgent need” for funding, legislative, and structural changes that can help pharmacists better fill health care gaps.
This is especially true in rural areas where pre-existing challenges were exacerbated as a result of COVID-19.
“The [rural region], like we deal with a large shortage of family physicians … that’s always been challenging to try to get people the appropriate amount of care that they need,” one pharmacist from outside HRM told researchers.
“As pharmacists, we do as much as we can. But obviously there comes a point in time where they need to see a doctor.”
Currently under peer review with the International Journal of Clinical Pharmacy, the study’s goal was to explore the role of Nova Scotia’s community pharmacists in caring for patients before and during the pandemic. It also sought to identify “barriers and facilitators to optimizing patient access.”
The new research is part of the Canadian Institutes of Health Research-funded PUPPY study (shortened from ‘Problems Coordinating and Accessing Primary Care for Attached and Unattached Patients in a Pandemic Year’).
Interviews for the study were conducted earlier in the pandemic (between September 2020 and January 2021) and before the COVID-19 vaccine rollout.
Pharmacists ‘kept showing up’
“What just keeps coming back loud and clear to me from all the work we’ve been doing is that we’ve been overlooking the role they (pharmacists) have been playing and how important it is,” Dalhousie University College of Pharmacy professor, and the paper’s lead author, Jennifer Isenor said in an interview.
“When things got really bad, they just kept going and they kept showing up and they kept providing all that care and going above and beyond at all times.”
The research paper notes how pharmacists play an important role in primary care and access to care for both unattached patients (people without a primary health care provider) and attached (those who had one).
“Pharmacists aren’t often credited as being primary care providers. However they really of course are,” Isenor said.
“They’re often the first point of care and access for patients to the health care system. We really saw how that changed and emerged for both attached and unattached patients.”
The study also highlights the emergence during the pandemic of a group of patients referred to as semi-attached. These were people who had a family physician or nurse practitioner but were unable to access them in a timely manner, if at all.
Isenor said the role played by pharmacists for those semi-attached patients was “huge” and further increased the workload for community pharmacists.
“(Pharmacists) are able to do so much and provide so much for the public, for the health care system, they can take the strain off others,” Isenor said.
“But we don’t want to put more strain on them either, so having some infrastructure and funding in place would remove some of the strain.”
Some Nova Scotians ‘go years’ without family doctor
According to the most recent monthly reporting data from Nova Scotia Health (NSH), 85,856 Nova Scotians (8.6%) were on the ‘Need a Family Practice Registry’ as of March 1. In February, 7,476 people had added their names to the list.
“In NS, unattached patients can go years without having a regular family physician or nurse practitioner, creating barriers to accessing diagnostic testing and specialist care (e.g., endocrinologists) vital to preventative care and maintenance of existing health conditions,” the study notes.
Isenor said one of the many benefits offered by pharmacists is their accessibility, with 40% of Nova Scotians living within walking distance of a community pharmacy and 79% within a five-kilometre drive.
“This degree of accessibility, and the resulting frequency of pharmacy visits (14 times per year on average), provides pharmacists with multiple opportunities to address health issues among their patient population,” the study states.
“Most Canadians trust the care they receive from pharmacists and are open to visiting their pharmacist for healthcare services beyond filling a prescription.”
Despite having the legislated authority to order and interpret diagnostic tests, the paper’s authors highlight that funding and operational barriers prevent Nova Scotia’s pharmacists from providing those services. Isenor said it would be helpful, for example, if pharmacists could order follow-up lab tests to ensure a drug therapy is working without unintended consequences.
Some study participants also expressed the need to be able to refer patients to specialists for issues requiring further assessment. This was seen as especially important for those who rely on a pharmacist as their primary health care provider.
“These were felt to be good opportunities to provide care, especially for those unattached patients,” Isenor said.
‘I fear things are going undiagnosed’
Pharmacists who participated in the study also suggested they be allowed to provide other publicly funded immunizations beyond influenza and COVID-19. They also wanted to see mental health and addiction services such as the Bloom program made available in more pharmacies across the province.
They also pointed to Health Canada’s issuing of exemptions for prescribing controlled substances during the pandemic. This enabled pharmacists to extend and deliver prescriptions, transfer to other pharmacies, and accept verbal orders for extensions or refills.
They recommended these changes remain post-pandemic as they helped remove unnecessary barriers for patients.
‘We’re seeing people with chronic conditions who haven’t seen a physician in months, maybe a year, year and a half. You know, people getting sicker or people who are coming into us are much sicker than they were prior to all of this,” one pharmacist working outside of HRM told the study’s authors about the impacts of primary health care barriers on patient care during COVID-19.
“We’re kind of left with … a small toolbox of things that we can do for them. But people are getting sicker. And I fear things are going undiagnosed. And you can just see it in your patients, that they’re failing. So, yeah, there’s been a big impact.”
Another pharmacist identified as being from” outside the provincial capital” recalled the story of one patient they were used to seeing regularly who came in during those early months of the pandemic. The pharmacist looked at the patient and could tell she wasn’t feeling well.
And she said, “I am not well. Something is wrong. I don’t know what it is. I just…” You know, this was a lively, active, very, you know, tough woman… she said, “I had bloodwork done, but no one can read it because I don’t have a family doctor.”
Because I didn’t order the bloodwork, it’s technically out of my scope of practice to then go and look at the bloodwork. But I did anyway because what am I going to do?
Identified some issues and told her to go back to emergency and just kind of say… that someone needed to take a look at this. Which they did, and now have done follow-up things, and she may have cancer.
The study notes that unattached patients often receive “fractured” primary health care. They often have no choice but to seek care at different locations and from different providers who are unfamiliar with them and their medical history.
If pharmacists are able to provide additional services, it will improve health care access for those patients.
“Unattached patients have reported seeking care in walk-in clinics and emergency departments for referrals and bloodwork, but often having referrals not made or lost, resulting in delayed or missed diagnoses,” the report states.
“Pharmacists can close this care gap and lessen the demand for care within overcrowded walk-in clinics and emergency departments, especially outside the provincial capital. Community pharmacists are under-utilized PHC (primary health care) providers that are accessible and distributed throughout the province.”
Isenor said the words “unsung heroes” frequently run through her head when she thinks about community pharmacists and all they’ve done throughout the pandemic to provide care.
“We’ve been hearing that a lot about everybody, but I do think … pharmacists have been providing heroic efforts,” Isenor said.
“They haven’t been seeking credit, but they have been working their butts off just as much of the health care system has, and I hope lots of people go thank their pharmacists and pharmacy team and say, ‘I really appreciate what you’ve been doing.’”
Expanded scope of practice
Evidence supports the role of pharmacists in chronic disease management like high blood pressure, heart failure, diabetes, COPD and asthma, as well as the treatment of self-limiting conditions.
The study notes how the scope of pharmacist practice in Nova Scotia has expanded further in recent years. Community pharmacists can administer drugs by injection, assess and prescribe for minor ailments, contraception (including emergency contraception), uncomplicated urinary tract infections, and medications for smoking cessation.
They can also offer prescription adaptations and therapeutic substitutions, order and interpret lab tests needed to manage drug therapy (with access through the provincial electronic health record system, SHARE [Secure Health Access Record]) and prescribe renewals.
“We’ve never shown people the degree of work and expertise that our teams have,” Pharmacy Association of Nova Scotia (PANS) CEO Allison Bodnar said in an interview.
“So it comes as a real surprise to many people, and people continually underestimate the value and input that we have and that we are an integral part of the health care system.”
Describing the role played by pharmacists in maintaining the health system throughout the pandemic as “integral,” Bodnar said pharmacies were among the few health care facilities open in the early days of the pandemic.
“We were getting all sorts of different types of requests and different people relying on us to provide care that quite frankly we could have provided previously, but people were unaware or had alternatives,” Bodnar said.
Much like other health care providers, Bodnar said pharmacists are experiencing burnout and exhaustion. In a recent PANS workplace survey, 50% indicated they hadn’t previously worked regular overtime. Now, just 30% say they aren’t regularly putting in excess hours.
But despite the fatigue, she said the province’s pharmacists are proud of the work they’ve been doing.
“There’s this renewed sense that people are finally recognizing the value that pharmacy brings,” Bodnar said.
“Much of our scope of practice has been in place for a decade or more, but it hasn’t been publicly funded or it hasn’t been necessarily recognized.”
‘Real opportunity to rethink how we deliver care’
From providing care for attached, unattached and semi-attached patients to renewing medications and providing other assessments, the province’s pharmacists were — and still are — busy.
Bodnar reiterated how Nova Scotia pharmacies were a national leader in vaccine delivery, providing more COVID-19 vaccines through pharmacies on a per capita basis than anywhere else in Canada.
“They had that layered on top of all of the other services and expanded scope that they were providing while still dealing with the realities of COVID and infection control policies and practices,” she said.
Bodnar said COVID has opened the eyes of many policymakers and members of the general public who are increasingly recognizing pharmacists as an “incredibly well-trained, compassionate and effective” workforce that can help address some of the province’s health care system woes.
“We have a real opportunity to rethink how we deliver care in this province,” Bodnar said.
Much like pharmacists, she said other health care professionals — including nurses, nurse practitioners, and those working in emergency health — have scopes of practice that aren’t being maximized.
She said the opportunity to reshape the health care system could include rethinking who patients see for specific ailments.
“We’ve been very well trained in our health care system that we’re not allowed to go to a specialist without going through a triage through a family physician first,” Bodnar said.
“Why would we not want to create another layer where simple things like immunizations or renewals or other things aren’t handled by less expensive resources? Why don’t we put in another layer of triage?”