Tag: Highlights

Published in the Ontario Pharmacist magazine, Vol. 81, Issue 2, 2017, click here for the full article. By: Heather Hadden, BScPhm, ACPR, RPH and Suzanne Singh, BScPhm, ACPR, PharmD, RPH While patients typically encounter pharmacists at their local commu­nity pharmacy, or at the hospital if admitted with an acute ill­ness, it is increasingly important that patients have access to pharmacists at all major intersection points within the healthcare system. This can help mitigate risks that may result from fragmented care and ensure safe and effective medication use. Strong partnerships between pharmacists through the continuum of health ser­vices across Ontario can be leveraged to elevate our collective professional profile and make a difference. Pharmacists embedded within Ontario’s family health teams (FHTs) play an important role in today’s healthcare system and contribute to the enhance­ment of intraprofessional collaboration.

1. What are FHTs?

FHTs are interprofessional prac­tice sites that were created to expand access to comprehensive primary healthcare services across Ontario. Since 2005, 184 FHTs have been operationalized, with over 3 million Ontarians currently enrolled in FHTs over 200 com­munities within 14 Local Health Integration Networks (LHINs).¹ About 170 pharmacists are cur­rently employed as salaried FHT employees funded by the Ontario Ministry of Health and Long-Term Care.

2. What do FHT pharmacists do?

FHT pharmacists are typically engaged in four core activities:²

• Patient care – FHT pharmacists work with patients at all ages and stages of life. Patients may self-refer, or be referred for scheduled appointments (e.g., for compre­hensive medication reviews), or ad-hoc consultation as nec­essary. FHT pharmacists often lead programs that focus on high-alert medications (e.g., opioids, antithrombotics), chronic disease management (e.g., diabetes, hypertension, angina, heart failure, asthma, COPD, smoking cessation), or vulnerable patient populations at risk of adverse events (e.g., post-hospitalization discharge, elderly with multimorbidity and polypharmacy).
• Education – FHT pharmacists wear multiple hats as educators in their work with patients, family physicians and other clinicians or FHT staff, pharmacy students, and other health professional learners. FHT pharmacists advise on best practices on medication use and also increase awareness about the expanded scope of practice for pharmacists.
• Quality improvement and practice/ system-level projects – FHT pharmacists help determine processes to complete medication reconciliation and may be involved in quality improvement initiatives that help evaluate the impact of patient care services. FHT pharma­cists may also participate in FHT, LHIN, or other initiatives to help integrate FHT care with the rest of the healthcare system.
• System navigation – The key placement of FHT pharmacists embedded within the primary care team helps foster linkages in the healthcare system to promote effective and efficient resource utilization, with attention to optimizing medication use.

  FHT pharmacists report that working at a FHT practice is professionally rewarding.^3,4

3. How can FHT pharmacists partner with pharmacists working at com­munity and hospital practices to provide effective care?

FHT pharmacists are uniquely posi­tioned within an interprofessional primary care practice to support seamless transitions as patients tra­verse various sectors of the healthcare system. Given that a solo FHT pharmacist may be employed at a FHT with a large patient roster, it is essential to help coordinate pharmacist services so that the most vulnerable patients at highest risk for adverse events benefit from care coordination. This may be facilitated by intraprofessional collab­orative practice models. For example, the FHT pharmacist may refer patients to the community pharmacist for expanded scope activities, or the FHT pharmacist and community pharma­cist may adopt a shared-care approach to managing complex patients. Simi­larly, the hospital and FHT pharmacist may collaborate around discharge planning.

4. What is one key challenge that FHT pharmacists face today?

Unfortunately, the pharmacist position is not automatically included in the base funding for a FHT and so not all FHTs have a minimum 1.0 full-time equivalent pharmacist integrated in the team. We need to work on this. No family doctor working in a group practice would set up their practice without a nurse or an administrative professional; the same view should now apply to pharmacists. Pharmacists need to unapologeti­cally promote pharmacist integration into primary care teams such as FHTs. Having a pharmacist working within a FHT is helpful for all pharmacists in a given community, and as a profession we have a responsibility to continue to advocate for funding from the Minis­try of Health and Long-Term Care for pharmacists. It is important that we are capitalizing on the skills and knowl­edge of pharmacists to deliver safe and high-quality care wherever and whenever necessary.

5. How can you connect with a FHT pharmacist in your local community?

Each LHIN in Ontario has a FHT phar­macist liaison. Contact the authors to learn who the FHT pharmacist liaison is in your LHIN and to discuss collabo­rative opportunities. For more information, email Heather Hadden at heather.hadden@trillium­healthpartners.ca or Suzanne Singh at suzanne.singh@sinaihealthsystem.ca The authors would like to acknowledge the contributions of Lisa Dolovich, Chair of the Ontario Primary Care Team Pharmacists Working Group. References:

1. Rosser WW, Colwill JM, Kasperski J, Wilson L. Progress of Ontario’s Family Health Team model: a patient-centered medical home. Ann Fam Med 2011; 9(2):165-171.
2. Dolovich L. Ontario pharmacists prac­ticing in family health teams and the patient-centered medical home. Annals of Pharmacotherapy 2012:46(4):S33-9.
3. Farrell B, Pottie K, Haydt S, Kennie N, Sel­lors C, Dolovich L. Integrating into family practice: the experiences of pharmacists in Ontario, Canada. International Journal of Pharmacy Practice 2008;16:309-315.
4. Pottie K, Haydt S, Farrell B, Kennie K, Sellors C, Martin C, Dolovich L. Pharmacist’s identity development within multidisciplinary primary health care teams in Ontario; qualitative results from the IMPACT project. Research in Social and Administrative Pharmacy 2009;5:319-26.

Click here to access the article (PDF)

CTV News Article published July 19, 2017. Article in full pasted below. Sheryl Ubelacker, The Canadian Press TORONTO – A small proportion of Ontario doctors who treat people battling opioid addictions prescribe the majority of the medications used to treat the disorder, a study has found, raising concerns about the quality of patient care and access to therapy. Most of these physicians work in addiction treatment centres located in urban areas and see dozens of patients each day, say researchers, whose study was published Wednesday in the journal Drug & Alcohol Dependence. The top 10 per cent of methadone providers – 57 physicians – wrote prescriptions for 56 per cent of the total patient days of methadone dispensed, the study found. For buprenorphine, known by the brand name Suboxone, the 64 highest-volume providers were responsible for prescribing 61 per cent of the total days of the drug given to patients. This extreme clustering of services among a small group of physicians creates a vulnerable opioid maintenance therapy system, said senior author Tara Gomes, a scientist at St. Michael’s Hospital and the Institute for Clinical Evaluative Sciences (ICES) in Toronto. “It can be challenging to find physicians interested in treating this population, and any changes to this group of physicians may affect a large number of patients who are currently seeking treatment for their opioid addiction.” Gomes said little was known about prescribing patterns among doctors who provide opioid addiction treatment in Ontario, despite the growing number of people who have become dependent on such drugs as hydromorphone, oxycodone and heroin. Patients receiving this therapy are often prescribed a longer-acting but less euphoria-inducing opioid such as methadone or buprenorphine, which are taken under close medical supervision. Using ICES health-care data, Gomes’ team identified 893 doctors who provided methadone or Suboxone more than once in 2014 to people eligible for the Ontario Drug Benefit Program, stratifying them into low-, moderate- and high-volume prescribers. Most were family practitioners. On average, each high-volume methadone prescriber treated 435 patients who were eligible for coverage of the drug under the program over the one-year study period. The patients had an average of 43 office visits that year, 43 urine drug screens and 190 days of methadone treatment. Gomes said that translated into an office visit and urine drug test – given to detect the presence of non-treatment opioids like oxycodone – every four to five days. These high-volume methadone providers billed the Ontario Health Insurance Plan (OHIP) for a daily average of 97 patients, approximately half of whom engaged directly with the prescribing physician. On average, doctors billed $648,352 to OHIP for all services provided to methadone patients in 2014; almost 46 per cent of the payment was to cover the cost of urine drug tests. Patterns among high-volume buprenorphine prescribers were different, with doctors treating 64 patients with the drug in 2014 and billing 22 urine drug screens per patient. Patient volume was lower among these prescribers, with physicians billing an average for 51 patients daily, of whom six were treated with buprenorphine. Total OHIP billings were lower than for high-volume methadone providers due to a smaller patient population. But similar to methadone, almost 41 per cent of the total cost was due to urine drug tests. Gomes said the large number of patients seen by high-volume methadone prescribers raises concerns about the quality of care patients receive, particularly when coupled with frequent clinic visits for urine drug screens. While regular urine testing is considered beneficial in the first few months of treatment, there is no evidence that ongoing weekly clinic visits and urine drug screens are linked to reduced opioid abuse. “There’s such a high degree of burden on the individuals when they are seeking treatment for their opioid abuse disorder to have regular visits with their physician … (and) also having to go to the pharmacy every day for their daily dose,” Gomes said. Spending several hours a week travelling to and from clinics, waiting to see the doctor and providing urine samples may interfere with a patient’s ability to meet his or her family and work responsibilities, she added. “So you can imagine there’s a huge amount of burden on them in the system and if they have to come in every four or five days for a urine drug screen, that can lead to a lot of people leaving addiction programs because it’s just too much for them to take on.” Study co-author Dr. Mel Kahan, medical director of the substance use service at Women’s College Hospital in Toronto, said ideally patients trying to get off opioids who have been stabilized on either methadone or Suboxone should be looked after in primary-care settings, such as a community health centre or by a family health team. “They don’t need to be looked after in a specialized clinic, and the problem is that if all the patients are looked after in specialized clinics, then the clinics get jammed up. … And the quality of care would be better in a primary-care setting,” Kahan said Tuesday. Patients struggling with an opioid addiction should be able to access Suboxone, in particular, because it is safer than methadone, carrying little risk of overdose, he said. The medication also is easier for primary-care physicians to provide, as it requires no complex training or special licensing to prescribe, as is the case with methadone. Click here to access the CTV News article. Relevant Links

• Mentoring, Education, and Clinical Tools for Addiction: Primary Care-Hospital Integration (META:PHI) program

Published in Behavioral Sleep Medicine, May 2017 Abstract Objective/Background: Primary care is where many patients with insomnia first ask for professional help. Cognitive-behavioral therapy for insomnia (CBT-I) is the recommended treatment for chronic insomnia. Although CBT-I’s efficacy is well established, its effectiveness in real-life primary care has seldom been investigated. We examined the effectiveness of CBT-I as routinely delivered in a Canadian primary care setting. Participants: The patients were 70 women and 11 men (mean age = 57.0 years, SD = 12.3); 83% had medical comorbidity. Methods: For the first 81 patients who took the six-session group program we compared initial and postprogram sleep diaries, sleep medication use, Insomnia Severity Index (ISI), the Hospital Anxiety and Depression Scale (HADS), and visits to the family physician. Results: Sleep onset latency, wake after sleep onset, total sleep time, sleep efficiency, and ISI scores improved significantly (p < .001). Mood ratings also improved (p < .001). Use of sleep medication decreased (p < .001). Effect sizes were medium to large. Eighty-eight percent of patients no longer had clinically significant insomnia (ISI score ≤ 14) by the last session; 61% showed at least “moderate” improvement (ISI score reduction > 7). Wait-list data from 42 patients showed minimal sleep and mood improvements with the passage of time. Number of visits to the family physician six months postprogram decreased, although not significantly (p = .108). Conclusions: The CBT-I program was associated with improvement on all sleep and mood measures. Effect sizes were similar to, or larger than, those found in randomized controlled trials, demonstrating the real-world effectiveness of CBT-I in an interdisciplinary primary care setting. To continue reading, go to the article in Behavioral Sleep Medicine. Authors

• Dr. Judith R. Davidson, Kingston Family Health Team, Department of Psychology, Department of Oncology
• Samantha Dawson, MSc. (PhD Candidate Clinical Psychology), Department of Psychology, Queen’s University
• Adrijana Krsmanovic, MSc., Department of Psychology, Queen’s University

Relevant Links

• 2014 Bright Lights Award Winners – includes Dr. Davidson for her work using cognitive-behavioral therapy for insomnia
• 2014 Bright Lights Award Profile– Dr. Judith Davidson in Clinical innovations in comprehensive primary care (PDF)