The journey begins: BC roadmap for pharmacist integration into team-based primary care

For the past 20 years, the profession of pharmacy has been changing to align pharmacist roles and scope with the growing needs of patients and society. Pharmacists today have the training, skills and abilities to meet these needs through the provision of comprehensive medication management, which includes patient assessment, identification and prioritization of drug therapy problems; collaborative care plans; and follow-up to resolve drug therapy problems and optimize drug therapy outcomes for patients.

The evidence is well established that patients taking drug therapy benefit when they receive care from a team of health care providers that includes a pharmacist.^1,2 Without pharmacists, patients receiving drug therapy are at increased risk of drug therapy problems and poor health outcomes.³ Patients want pharmacists on their health care team because they improve patient health outcomes and reduce health care costs.⁴

In addition to benefits to patients, there are clear health care system benefits to the full integration of pharmacists in patient care across all sectors of health care. At any given time, up to 23% of people taking drug therapy may experience an adverse drug event.^5-9 Using a cost-of-illness model, it is estimated that for every $1 spent on drug therapy, an additional $2 to $3 is needed to manage the consequences of drug therapy problems.³ In addition, patients in Canada are having difficulty accessing primary health care, and physicians are experiencing burnout.^10-12 Having a pharmacist on the primary health care team provides systematic benefits, as has been shown in other jurisdictions, including the United Kingdom, Unites States and Australia.^13-15

Pharmacists benefit when they are able to use their training and education and practise to their full scope.^16,17 Despite challenges, barriers and the slow pace, most pharmacists continue to believe that practice change is worth the effort, as it will result in improved patient health outcomes and increased personal job satisfaction.¹⁸ We agree with other pharmacy thought leaders that all pharmacists have a part to play, in their own way and in their own practice setting, to enable forward progress within our profession.¹⁹

In June 2018, the British Columbia (BC) government announced funding for the developmental phase of a new program, which will see an initial cohort of 50 pharmacists integrated into team-based primary care practices.² The integration of pharmacists is one part of a large and complex process within the BC health care system to enhance the way team-based primary care is delivered across the province. Work is ongoing to achieve increased pharmacist input in drug-therapy decision making for complex patients; reduced number and severity of drug-related problems in patients; reduced unnecessary and negative drug therapy consequences for patients; increased patient, family, caregiver, physician, pharmacist and health care team satisfaction; and increased information sharing and collaboration between pharmacists and other members of the patient care team.

This has far-reaching implications and is a tremendous opportunity for all pharmacists, not just the 50 new pharmacists, to be part of a significant practice change. Imagine yourself practising in a community pharmacy, having a pharmacist colleague share care plans for mutual patients and having a role in the success of those care plans. Imagine yourself practising in a local hospital and having a pharmacist counterpart on the primary health care team for transitional care on patient discharge.

This change will take time, and the full impact and benefits on all levels will require leadership and the collective will of all pharmacy stakeholders to place patient needs at the forefront of care delivery along the entire continuum of care.

Unfortunately, pharmacists are increasingly reporting burnout and change fatigue.^20,21 Pharmacists need support, understanding, effective change management approaches and leadership that respects the importance of pharmacist well-being in these changing times.²² Although we talk about change being difficult, in fact, change just happens. Change is an external event that takes place around us and with or without us. The hard part is the human transition—the inner psychological process that individual people go through as they internalize and come to terms with the new situation caused by the change.²³ We need to keep this human transition process top of mind as BC integrates pharmacists in team-based primary care.

Transition starts with the end of the current situation. Pharmacists recognize that the old ways need to change; however, the old ways are familiar. The end involves identifying what is over and being left behind and may include relationships, processes, team members or locations. This ending also means identifying what is being kept for the future.

The neutral zone is the in-between time when critical psychological realignments and repatterning take place in the brain. It is when pharmacists create new processes and learn new roles, but it does not feel comfortable yet. It is the seedbed of the new beginnings to come.

Transition ends with new beginnings, new understandings, new values and attitudes, a release of energy in a new direction and expression of a fresh identity. Well-managed transition allows pharmacists to establish new roles with an understanding of their purpose, the part they play and how to contribute and participate most effectively. With well-managed transition, pharmacists can be reoriented and renewed.

As preparations come together to integrate pharmacists in the broader BC team-based primary care strategy, the government has recognized that pharmacists need information, preparation and support as they transition into new roles. Building on existing work in other Canadian jurisdictions,^24,25 BC is taking a centralized approach and the UBC Faculty of Pharmaceutical Sciences (the Faculty) has been tapped to lead the operations, training and evaluation of the developmental phase for the 50 new pharmacists. Operational support includes dedicated medical office assistants, documentation software, patient scheduling, key messages, integrated quality assurance, integrated data collection for evaluation, shared clinical resources and a clinical community of practice. Training includes policies and procedures, clinical processes, documentation processes and collaborative care best practices in the BC context. Pharmacists across the care continuum will also have access to practice support so they can engage more fully in the care of mutual patients.

As a first step, a writing team from the Faculty has recently published “A White Paper on Team-Based Primary Health Care in British Columbia—Context and Opportunities for Pharmacists.”²⁶ Now available online, this document provides a comprehensive review of health care system changes, where pharmacists fit in, how pharmacists can optimize their readiness and practical front-line strategies to help pharmacists across all care settings be aware, prepared and successful within the team-based primary care strategy. This document also has wider application for pharmacists in other provinces and countries, as it lays out the foundations and a road map for pharmacist success, starting with mind-set. We invite pharmacists and health stakeholders to read this White Paper from the perspective of pharmacists in transition and identify how we collectively can support each other in moving forward together.

Ultimately, patients, pharmacists, other health care team members and society as a whole will benefit from having pharmacists healthy, prepared, supported and integrated in team-based primary care. ■