The pharmacist primary care clinic: The evolution of pharmacy practice?

A national trend has started—the “pharmacist primary care clinic.” We first reported on this in the Journal in early 2023, ¹ and since then, numerous corporate pharmacy chains and independent pharmacies have started to open “pharmacy clinics” across the country.

Pharmacists are primary care providers and always have been. The COVID-19 pandemic made pharmacists more visible and demonstrated our role as a trusted resource for health care. ¹ Pharmacists and pharmacy teams served their communities by adapting their roles and using their autonomy to provide a haven for ongoing health care. Our post-pandemic health care system continues to have many flaws—a shortage of family physicians, difficulties accessing timely primary care, a lack of chronic disease screening and management and a lack of health care resources in rural areas. Is the next step in the primary care evolution of pharmacy practice the pharmacist-led clinic?

What is a pharmacist primary care clinic?

There is no standard definition of a pharmacist primary care clinic. Any pharmacy clinic is required to follow the Standards of Practice for Pharmacists in their province. In addition, a pharmacy must differentiate their services from those of a “medical” (physician) clinic when advertising their services, so as not to mislead the public. Pharmacists must ensure they have the necessary competencies and take responsibility for the services they provide within their scope of practice. Pharmacists must continue to collaborate with other health professionals and refer patients to other health care providers when necessary. In addition, clinic rooms must be adjacent to the pharmacy dispensary. For consistency, we suggest that the term “pharmacist primary care clinic” be used, rather than other terms such as “pharmacist clinic” (we think that “primary care” needs to be in the name, since it will help with awareness of the public), “Pharmacy Walk-in Clinic” (since most also book appointments in advance, it’s not just for urgent care) and other similar designations.

For a pharmacist primary care clinic to be successful, there are certain components that should be in place:

1. Reception: A designated employee to book appointments, coordinate follow-up visits, complete necessary paperwork, maintain clinic supplies and clinic facilities.

2. Online booking system: The ability of patients to book appointments online, especially for walk-in services, can be helpful and is often incorporated with EMRs.

3. Private consultation rooms: One or more private consultation rooms with adequate space in the patient services area are recommended to conduct patient assessments. Ideally these rooms should be equipped with a sink, medical bed, blood pressure monitor, scale and stadiometer.

4. Electronic Medical Record (EMR): Traditional pharmacy dispensing software is not well suited to documenting clinical activities as per our Standards of Practice. Investing in an EMR will facilitate clinical documentation, ordering and receiving of labs and prescribing activities. This would also be important to evaluate the effectiveness of the service.

5. Adequate staffing: Pharmacists practising in the pharmacist primary care clinic cannot be responsible for dispensary duties at the same time. Separate staff to complete clinical and dispensing duties is a best practice to ensure the safe provision of pharmacy services.

Pharmacist primary care clinics across the country

Source: https://www.mapchart.net/canada.html.

Alberta: Pharmacists in Alberta have had the broadest scope of practice in Canada for the last decade. In June 2022, the first corporate pharmacist primary care clinic opened in Lethbridge, a city in southern Alberta with a population of ~100,000. ² This clinic is open 7 days per week and in the first 8 months of operation had 8300 patient visits. ² The main reasons for visits included acute infections, chronic disease management, mental health and dermatologic conditions. ² In addition, the clinic receives referrals from the local emergency department and pediatricians for non-urgent patient assessments. ² To date, about 60 corporate and independent pharmacist primary care clinics have opened across Alberta in urban and rural areas.

Saskatchewan: Saskatchewan pharmacists have been able to assess and prescribe for certain minor ailments since 2011. A Pharmacy Care Pilot Project started in fall 2023 in Swift Current. Through this pilot, a collaborative agreement between 1 pharmacy and 2 physician-led clinics allows pharmacists to manage chronic obstructive pulmonary disease, hypothyroidism, warfarin and mental health. ³

Ontario: In late summer 2023, pharmacist primary care clinics opened across Ontario using the newly expanded scope of pharmacists to assess and prescribe medications for some common ambulatory illnesses. ⁴

New Brunswick: In late summer 2023, 6 pharmacist primary care clinics opened across New Brunswick. ⁵ These clinics offer point-of-care testing and treatment for group A strep along with the management of diabetes, chronic obstructive pulmonary disease, asthma and cardiovascular disease. ⁵ Officials are hopeful that all 240 pharmacies in the province will eventually participate in this initiative. ⁵

Nova Scotia: In early 2023, the Pharmacy Association of Nova Scotia (PANS), in partnership with the Government of Nova Scotia and Nova Scotia Health, started a pilot program of 25 primary care pharmacy clinics at selected pharmacies in areas with the highest number of Nova Scotians without a family physician. ⁶ These pharmacist primary care clinics provide government-funded services to patients, including assessment and prescribing for group A strep, minor infections, chronic disease management, prescription renewals and vaccinations. ⁶

Advantages of pharmacist primary care clinics

Yes, pharmacists have always been primary care providers. Nevertheless, what pharmacist primary care clinics have done is provide an opportunity to build awareness of the scope of practice of pharmacists. The public is now learning what pharmacists can do, and that is a good thing. And these clinics are high profile—there is significant interest and investment from ministries of health because they provide greater access to primary care. What a great opportunity to change our profession for the better.

Pharmacist primary care clinics also allow pharmacists to practise to their full scope. They provide dedicated staff for the clinics, who are independent of the dispensary.

Community pharmacists are well positioned to relieve stress on the health care system, to keep patients out of emergency rooms and allow physicians and hospitals more time to treat acute conditions.

Challenges for pharmacist primary care clinics

Expanding pharmacy services will assist in addressing the challenges of our health care crisis. However, there are multiple challenges that need to be addressed.

First, the scope of pharmacy practice is limited in many jurisdictions, though this has expanded significantly in the last few years. Currently, all pharmacists across Canada can offer some degree of common ailments prescribing and have some level of prescribing authority; in the future we hope that this will be harmonized nationally.

Second, there is a lack of access to medical charts or provincial health records for pharmacists in many jurisdictions. To appropriately assess a patient for a common ailment, prescription renewal or for chronic disease management, patient records and lab results must be accessible.

Third, the funding models for these services has not kept up with the scope of practice for pharmacists. The owners of pharmacies offering pharmacist primary care clinics currently need to cover the cost of building necessary infrastructure, logistics and staffing to provide comprehensive patient assessment and prescribing practices. This is costly and may discourage pharmacy owners from adopting this new model. In addition, patients may have to pay out of pocket for clinical pharmacy services, such as point-of-care testing, where no public funding is available.

Fourth, some pharmacists may need to upgrade their physical assessment skills, which are needed to appropriately evaluate many common ailments and chronic diseases.

Finally, there are no guidelines or standards for pharmacist primary care services (although we would hope that most would likely follow already published primary care guidelines).

Future plans

Pharmacist primary care clinics have made the primary care role of pharmacists more visible to the public. This is a good thing for our profession. So is this an important step in our profession’s evolution as primary care providers? We would say yes!

There is much work to be done to develop care pathways, educate pharmacists and evaluate the outcomes of pharmacy clinics. In terms of evaluation, there are ongoing quantitative and qualitative research projects to analyze the first 8300 patient visits at the Lethbridge Pharmacist Primary Care Clinic. In addition, there are programs underway to develop care pathways for common conditions to facilitate the assessment, treatment, follow-up and collection of patient outcomes. These care pathways are evidence and guideline based, have input from specialist and family physicians, offer decision support, incorporate a documentation module and collect patient outcomes facilitating evaluation. It is anticipated that the PANS project will release an interim report shortly, which we all eagerly await (stay tuned to CPJ for updates).

This is a fast-moving area of pharmacy practice and an exciting one. Almost certainly, our descriptions of clinics above will be outdated by the time this editorial is published. We will continue to follow developments in this area—please contact us with updates by writing a letter to the editor. To be continued. . .■