Abstract
Background:
The Bloom Program was designed to enhance pharmacists’ care of people with lived experience of mental illness and addictions in Nova Scotia. The Program’s demonstration period was from September 2014 to December 2016 and included a qualitative evaluation of the patient experience.
Methods:
Patients were recruited for individual interviews through Bloom Program pharmacies. Interviews were transcribed verbatim and analyzed following Braun and Clarke’s 6-step approach for thematic analysis.
Results:
Ten patients were interviewed between May and June 2016. Ten themes were determined through data analysis and included medication management, accessing pharmacists in a new way, providing social support, bridging service gaps, providing interim care, reducing financial barriers, navigation and advocacy, holistic approaches, empowerment through knowledge and awareness and collaboration.
Discussion:
Pharmacists expectedly provided medication management activities to patients for both physical and mental health concerns in the Bloom Program. Many activities conducted with Bloom Program patients fell outside of dispensing roles and medication management. These activities, such as social support, triage, navigation and increasing access, which were highly valued by patients, are poorly measured and assessed in pharmacy practice research.
Conclusion:
Participants in the Bloom Program reported the significant contributions of pharmacists and pharmacy teams in their overall health and wellness. Future evaluations of interventions like the Bloom Program should include measurement of constructs valued by patients and also consider impacts on inequalities and inequities. Pharmacy practice researchers can benefit from other research and evaluation being conducted for primary care interventions.
Knowledge Into Practice.
Patient expectations of pharmacists are often defined by previous experiences in pharmacies, ranging from an engaged and proactive clinician role to a more passive and technical role.
The experiences shape patient expectations of pharmacy staff related to mental health and addictions services and support.
Patients experienced positive outcomes and valued Bloom Program pharmacy team services, many of which were not directly tied to medication management and included activities such as navigation and advocacy, collaboration, providing social support, education and bridging gaps in services.
Valued experiences that expand the patient’s perspective of the pharmacist’s role are achieved through their direct participation in pharmacy-based mental illness and addictions services.
Patient expectations are increased for both medication and non-medication-related services from participating the Bloom Program.
Mise En Pratique Des Connaissances.
Les attentes des patients envers les pharmaciens sont souvent définies par leurs expériences antérieures en pharmacie, allant d’un rôle de clinicien engagé et proactif à un rôle plus passif et technique.
Les expériences façonnent les attentes du patient envers le personnel de la pharmacie relativement aux services et au soutien en santé mentale et dans la lutte contre la toxicomanie.
Les patients ont obtenu des résultats positifs et ont apprécié les services de l’équipe de pharmacie du programme Bloom, dont beaucoup n’étaient pas directement liés à la gestion des médicaments et comprenaient des activités telles que la navigation et la défense des intérêts, la collaboration, l’apport d’un soutien social, l’éducation et le comblement des écarts dans les services.
Les expériences fructueuses qui élargissent la perspective du patient quant au rôle du pharmacien découlent de la participation directe de ce dernier aux services de lutte contre la maladie mentale et la toxicomanie dispensés en pharmacie.
Les attentes des patients envers les services liés ou non aux médicaments augmentent du fait de leur participation au programme Bloom.
Introduction
Pharmacists work with people with lived experience of mental illness and addictions to optimize medication management and other health issues. Recognizing the potential opportunities for pharmacists to play a more active role in community-based mental health care, the Bloom Program, also known as the Mental Health and Addictions Community Pharmacy Partnership Program of Nova Scotia, was designed, developed and implemented in 23 pharmacies across Nova Scotia.
Funded by the Nova Scotia Department of Health and Wellness Mental Illness and Addictions Strategy, the Bloom Program demonstration period was from September 2014 to December 2016. The project’s governance structure included a multistakeholder steering committee and an evaluation subcommittee. People were eligible for enrollment in the Bloom Program if they had at least 1 mental health medication-related issue and a self-identified mental health diagnosis. Enrolment could be initiated by referral (e.g., peer, health provider, self) or pharmacist invitation. Participant cap per pharmacy was 20 at any one time. Pharmacists prioritized patients with specific diagnoses for the program (i.e., psychosis, mood disorders [depression and bipolar disorder], anxiety disorders, obsessive-compulsive disorder and trauma- and stress-related disorders). The aim was for the program to enroll 70% or more participants with these higher priority diagnoses based on unmet health needs, common medication management issues and the pharmacist’s role in patient care. Pharmacists and Bloom Program enrollees worked together to determine the goals for the duration of a person’s enrolment, which was 6 months by default and could be extended when remediable new or ongoing issues existed that were within the pharmacist’s scope. During the initial stages of the program’s development, a mixed-methods evaluation framework was created with various sources of data collection, including surveys, interviews and a retrospective chart review. The outcomes of interest in the Bloom Program evaluation were both patient and process oriented. Clinical outcomes data were reported by clinicians and patients and were also systematically collected from charts. More information on the Bloom Program is available via Murphy et al.1 and the Bloom Program website (www.bloomprogram.ca). In this article, we report on the qualitative findings from semistructured interviews conducted with Bloom Program patients.
Methods
Patients were made aware of the opportunity to give feedback via interviews through the Bloom Program pharmacies. This occurred primarily through paper-based surveys that were distributed by these pharmacies or if patients took an online survey via the Bloom Program website. In the last section of the paper-based and online survey, there was a question as to whether the patient would like to be contacted to participate in an interview regarding the Bloom Program. Paper surveys were submitted back to the Bloom Program administration via a self-addressed stamped envelope. Participants were eligible for an interview if they had been or were actively enrolled in the Bloom Program, aged 18 years or older, able to converse in English and able to consent to the interview. Participants were paid $40 to participate in the interview. The Bloom Program administrator conducted the interviews, and all interviews were transcribed verbatim by a transcriptionist. We used thematic analysis to analyze the data using a 6-step approach, as outlined by Braun and Clarke.2 The data were analyzed by the team, with LMJ leading the analysis and DMG and ALM providing iterative feedback and comments on interpretation and findings. See Appendix 1, available at www.cpjournal.ca, for the interview guide.
Ethics
The Bloom Program was reviewed by the Dalhousie University Research Ethics Board and determined to be program evaluation, thus not requiring an ethics application. A consent procedure was conducted with all interviewees regarding the purpose of the interview and data usage following. A privacy impact assessment was completed and approved by the government of Nova Scotia in accordance with provincial privacy legislation.
Results
Participants
Ten patients were interviewed between May and June 2016, from 7 different Bloom Program pharmacies; 3 pharmacies were not identified.
Themes
Ten themes were determined through data analysis, including medication management, accessing pharmacists in a new way, providing social support, bridging service gaps, providing interim care, reducing financial barriers, navigation and advocacy, holistic approaches, empowerment through knowledge and awareness and collaboration. See Appendix 2, available at www.cpjournal.ca, for patient quotes that support these themes.
Medication management
Most patients said that participating in the Bloom Program helped them identify and address medication management issues, and the Bloom pharmacist was integral to the process. The goal of optimizing medications was the most frequently discussed issue, which was also noted in the retrospective chart evaluation.1 Other medication management activities included medication initiation, dose adjustments and medication withdrawals. Bloom pharmacists also supported patients in medication management outside of mental illness and addictions issues and, in some cases, helped patients to get basic medical tests done.
Accessing pharmacists in a new way
The convenience of pharmacy hours for participants in the Bloom Program facilitated access to mental health and addictions services provided by the pharmacist beyond what patients had regularly. Bloom Program patients were often able to schedule appointments during evening or weekend hours, and people were encouraged to visit the pharmacies or call if they had questions. Many patients acknowledged that the pharmacists explicitly and overtly stated that they would make themselves accessible to patients. Patients said this was important to them, and they appreciated the easy access. For some, easy access was particularly important because they did not feel comfortable going out in public. In most cases, the increased access was primarily to the lead Bloom pharmacist, whom patients would specifically seek out. In pharmacies that took a team approach to the Bloom Program versus a solo pharmacist offering the program, patients recognized they had access to the full complement of pharmacy staff who were aware of the Program’s objectives and who were involved in delivering the Program.
Several Bloom Program enrollees noted the change in how they interacted with their pharmacists. Prior to the Program, interactions were mainly in the context of picking up medications. Many patients said they were not previously aware of the extent of knowledge pharmacists had about psychotropic medications. Recognizing the depth of pharmacists’ knowledge encouraged a shift in thinking and how patients would access and use the pharmacists as health care professionals in the future. For many, this also resulted in increased feelings of comfort in speaking with their pharmacist about issues that they would not have otherwise discussed. Some patients were also generally unaware that pharmacists could provide them with the range of services, care and supports. Overall, patients consistently said their Bloom Program experience allowed them to see pharmacists as helpful, supportive and genuinely interested in their mental health and overall well-being.
Providing social support
Many patients accessing the Bloom Program discussed needing and wanting “someone to talk to.” Patients commented directly on this support as something separate from medication management, and the value they attributed to it was consistently high.
Bridging service gaps
Patients found value in the program because it addressed a gap in available mental health and addictions services in the local community. These services were perceived to be either nonexistent, which was the case in the smaller rural communities that had a Bloom pharmacy, or with an apparently lengthy waitlist. In some cases, patients said that the services that were available prior to the Bloom Program were difficult to access so they chose not to use them. Patients perceived that the Bloom Program increased access to care in rural communities, with over half (n = 13) of Bloom Program pharmacies operating in rural communities.
Providing interim care
Bloom Program pharmacists supported patients who were waiting to access other services. Some patients also perceived health care professionals such as psychiatrists or counsellors as inaccessible. Patients discussed the demand for mental health and addictions services as high and stated that the Bloom Program provided an interim level of support while waiting for, or in the absence of, more formal mental health and addictions counselling.
Reducing financial barriers
The Bloom Program, which was publicly funded, was accessible to patients who had a provincial health card. For some patients on a fixed or low monthly income, public coverage was an appealing part of the Program. It may have also increased access to mental health and addictions services because patient out-of-pocket spending was not required for participation.
Navigation and advocacy
Bloom pharmacists helped to increase efficiencies and facilitated connections within the health care system. Some patients described losing contact or experiencing challenges in their relationships with other health care professionals, including physicians. There was also some evidence that Bloom pharmacists were able to help some patients navigate the broader primary health system for other chronic conditions (e.g., diabetes). This included making recommendations for services or agencies and making appointments with physicians and other health care professionals. Some patients said they found this difficult to do on their own, in part because of the stigma surrounding mental health and addictions.
Holistic approaches
Some patients commented on the pharmacists encouraging and supporting the adoption of healthy behaviours, such as healthy diet and exercise, stress reduction and nonpharmacological techniques such as meditation and cognitive-behaviour therapy for sleep problems. This holistic approach was appreciated and viewed as being helpful by patients, with some achieving goals beyond their expectations.
Empowerment through knowledge and awareness
Increased patient knowledge and awareness of medications and health took several different forms. Some patients said that meeting with the pharmacist to talk about their medication helped them learn what their medications were for, how they worked, what common side effects they could expect and how to manage them. Some patients indicated that they learned important information about medication safety, and some said that they learned more about their particular mental illness and addiction(s).
Collaboration
Patients appreciated that health care providers have different but complementary roles to play. They seemed to understand the importance of health care provider collaboration and want to see more occur. Some patients initiated and encouraged discussions of the Bloom Program with other health care professionals (e.g., physicians, psychologists) that encouraged an increase in teamwork and collaboration.
Discussion
Bloom Program patients accessed pharmacists in new and more meaningful ways to experience improved holistic care approaches for their mental and physical health. Pharmacists were delivering medication management activities but importantly provided services highly valued by patients that included navigating the system, bridging gaps in services and providing interim care and being part of patients’ social support networks. Patients experienced a change in their relationships with and expectations of pharmacists. Our findings support a key phenomenon in pharmacy practice regarding the importance of nonmedication management activities. Not unexpectedly, patients in the Bloom Program perceived that pharmacists help to improve important outcomes described by others with lived experience of mental illness (e.g., adherence, relapses, decreasing numbers of prescribed medications, decreasing side effects).3
Similar to the findings of systematic reviews4-6 of community pharmacy−based services, interviewees in the Bloom Program had limited expectations of their pharmacists. Experiences in the Bloom Program changed expectations of the patient-pharmacist relationship. Pharmacists offered and engaged in many activities, including providing social support, health system navigation and solutions or interim measures to close gaps in the health care system. More than half of recorded activities undertaken by Bloom pharmacists were on nonmedication management activities.1 As per the definition of professional pharmacy services by Moullin et al.,7 these services fall under the umbrella of “other health care services” as a part of “professional pharmacy services.” These “other” activities performed by pharmacists are often poorly measured and evaluated in the current evidence base. Improving the characterization and measurement of these activities, many of which fall outside of dispensing, is needed given the present climate that demands providing value for money to payers and key stakeholders such as pharmacy owners. For example, social support, which was highly valued by Bloom Program patients and can often redirect time from core dispensing activities, is poorly defined, described and measured in pharmacy practice research, and this has been a longstanding issue.8
Typically, the impact of “nondispensing roles,” including health promotion activities, has focused on measures of patient satisfaction. Satisfaction is important but it is not the most appropriate measure to capture the impact of these activities, and to date, patient satisfaction has often been conducted with nonvalidated, ad hoc measures,9 not systematically. Other primary care researchers have stressed the importance of measuring the patient experience in primary care. In 2014, Laberge et al.10 reported on survey findings of the Quality and Costs of Primary Care Canada study and demonstrated that the most highly valued aspects of primary care from the patient’s perspective, with most important first, were 1) continuity and coordination, 2) communication and patient-centred care, 3) patient activation and 4) access. Some of these values are contained within Wong and Haggerty’s11 proposed 6 dimensions, each with subdimensions, of primary health care items that are important to measure from patients’ perspectives. These 6 dimensions include 1) access, 2) interpersonal communication, 3) continuity and coordination, 4) comprehensiveness of services, 5) trust and 6) patient-reported impacts of care. Significant challenges exist with measurement of these constructs, but research in this area continues to evolve.11 From a pharmacy practice perspective, there is limited research regarding the measurement of these constructs. Access, for example, is often oversimplified in pharmacy practice research with pharmacists cited as one of the “most accessible” health care professionals. Although many frameworks exist regarding access, according to Levesque et al.12 access is viewed “as the possibility to identify health care needs, to seek health care services, to reach the health care resources, to obtain or use health care services and to actually be offered services appropriate to the needs for care.” Further, they define 5 dimensions from the supply side of care, including approachability, acceptability, availability and accommodation, affordability and appropriateness. From the patient perspective, they define “abilities,” including the ability to perceive needs for care, seek, reach, pay and engage. Application of such frameworks would be beneficial in pharmacy practice research in the future to more fully characterize the breadth of pharmacists’ and pharmacy team members’ interventions. The Bloom Program improved several dimensions of access of participants. From our interview data, using the supply side factor of approachability as an example and based on the work of Richard et al.,13 the Bloom Program provided patients with more navigation and information, referral and triage to other services and proactive identification of health needs. From the demand side for patients, modelled after the work of Levesque et al.12 and Richard et al.,13 the Bloom Program enhanced the ability of clients to perceive (e.g., increased health and service literacy), to seek (e.g., through education and self-management coaching), to reach (e.g., pharmacies are in most communities in Nova Scotia14) and to pay (e.g., minimized out-of-pocket expenses). Given the complexity related to many of these constructs and with some constructs and their measurement less well established in the research literature, more work is required for pharmacy practice researchers to align with other stakeholders who are working to evaluate the patient experience in primary care.
Moving forward and based on the positive experiences of participants with lived experience of mental illness and addictions in the Bloom Program, it will be important to evaluate pharmacy practice interventions from a lens of reducing inequalities and inequities. A recently published systematic review protocol by Hillier-Brown et al.,15 regarding community pharmacy public health interventions’ effects on population health and health inequalities, highlights an important step in this direction. In their methods, PROGRESS-Plus criteria are used in which PROGRESS refers to place of residence, race/ethnicity/culture/language, occupation, gender/ sex, religion, education, socioeconomic status and social capital, and “Plus” is in reference to personal characteristics associated with discrimination (e.g., age, disability), features of relationships (e.g., excluded from school) and time-dependent relationships (e.g., leaving the hospital).15,16
Limitations
We did not interview patients from all Bloom Pharmacies and therefore cannot conclude that the themes developed in this analysis would be transferable to all patients in the program.
Conclusion
Participants in the Bloom Program reported significant contributions of pharmacists and pharmacy teams in their overall health and wellness through accessing pharmacists in new ways. Health system navigation, bridging service gaps and providing interim care, advocacy and integration of pharmacists into the patients’ social support systems were important activities that were valued by patients and occurred in addition to medication management. Future evaluations of interventions like the Bloom Program should include measurement of constructs valued by patients and also consider impacts on inequalities and inequities. Pharmacy practice researchers can benefit from other research and evaluation being conducted for primary care interventions.
Box 1. Benefits of Bloom Program pharmacists’ care from patients’ perspectives.
Navigation and triage
Advocacy
Social support
Collaboration
Empowerment
Supplementary Material
Acknowledgments
We would like to acknowledge the members of the Bloom Program Steering Committee and the Bloom Program Evaluation Subcommittee for their contributions throughout the Bloom Program demonstration project. We would like to express our appreciation to the Nova Scotia pharmacy teams that provided the Bloom Program and to the study patient participants who were interviewed and provided their perspectives on the Bloom Program.
Footnotes
Author Contributions:All authors were involved in revising the logic model for the Bloom Program, which included the qualitative interviews. LMJ led the qualitative analysis with ALM and DMG providing iterative review and feedback on the interpretation and findings. ALM drafted the manuscript and LMJ and DMG provided feedback, made critical revisions and approved the final version.
Financial acknowledgements:The Funding for the Bloom Program was received through the Mental Health and Addictions Strategy of Nova Scotia through the Department of Health and Wellness of Nova Scotia. The funding agency was not involved in the design, interpretation or writing of the manuscript.
Conflict of interest statement:The authors have no conflicts to declare.
ORCID iD:Andrea L. Murphy 
https://orcid.org/0000-0001-5093-6681
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