B.C. government reviewing clinic model for community pharmacies

By Michael Mui
Communications Manager, BCPhA

B.C. government has been reviewing different models of pharmacy clinics across Canada with an interest to implementing primary care services at community pharmacies in the province. 

In February 2024, the BC Pharmacy Association presented a proposal to government to bring a “clinic model” of primary care to community pharmacies to help increase access to health care in underserved communities and for unattached patients with chronic conditions. Nova Scotia was the first province to implement such a model in community pharmacies, followed by New Brunswick and Alberta. 

In a presentation to attendees at BCPhA annual conference in May, Mitch Moneo, assistant deputy minister of the Pharmaceutical, Laboratory and Blood Services Division of the Ministry of Health, said his division has been collaborating with the BCPhA on the clinics proposal.

“We’re really interested in the implementation of the pharmacists’ clinic in British Columbia,” Moneo said. “It seems like the work that’s being done in Nova Scotia is also showing where there’s opportunities and also where there are gaps, and where those gaps can be shored up.”

Moneo said one of the first areas his division is examining is the ability for pharmacists to order lab tests, which will be enabled in B.C. in late August.

“There are other regulatory changes that we have to address around the ability for pharmacists to prescribe beyond medicines for minor ailments, so we really want to provide pharmacists with the authority to prescribe, to treat conditions, particularly for people with long-time chronic conditions,” he said.
 

In a presentation on upcoming pharmacy initiatives on July 25, Jonathan Lau, director of pharmaceutical care initiatives at the Ministry of Health, said the pharmacy clinic model is increasingly common in Canada. 

“Patients seem to like it a lot and even the pharmacists providing the service say they’re getting a lot of professional satisfaction,” he said. 

“We are trying to take the learnings from Nova Scotia and other provinces to refine our process. I think the final report when it comes to the Nova Scotia model is coming out in October, so we’ll be able to learn through the experience and adopt that into B.C.’s approach.”

Nova Scotia was the first to test the pharmacy primary care clinic model in 2022. Since then, 31 community pharmacies in that province offer primary care services. Each clinic has its own set of two examination rooms, dedicated pharmacist, plus an administrative staff who are solely focused on pharmacy clinic operations separately from the dispensary. 

In summer 2023, some pharmacies in Alberta began their own primary care clinics, and in September that same year, the New Brunswick College of Pharmacists and the provincial Department of Health launched their own 12-month pilot program.

Allison Bodnar, CEO of the Pharmacy Association of Nova Scotia, provided an update to pharmacy clinics in her province at the BCPhA conference in May. Services at the Nova Scotia clinics include assessments and prescribing for a range of minor ailments, medication reviews, injections and immunizations, plus chronic disease care for diabetes, lung disease, heart disease and anticoagulation management. 

Like other provinces, Nova Scotia has been experiencing a lack of access to health care services, with 15 per cent of the population without access to a family physician or nurse practitioner. Community pharmacy clinics were offered as a solution, and so far, Bodnar said, patients have embraced the new model with most pharmacy clinic locations operating at 90 per cent capacity or more.

“We often hear in pharmacy, ‘fill the gaps,’” Bodnar said. “We are not here to fill gaps. We are here to redefine how we deliver health care, because the system that was designed over 60 years ago when we weren’t as sick, when we didn’t have technology, when we didn’t have this scope, is not what we should be trying to fit into and fill gaps in.”
 

The Tablet spoke with three pharmacists operating pharmacy clinics in Nova Scotia to hear about their experiences. 

Carolyn Cox, pharmacy manager at Brookline Pharmasave in Bedford, N.S., said her pharmacy has been operating a clinic since January 2023. To create the additional space for a pharmacy clinic, her team leased the unit next door to their pharmacy, which itself is located inside a shopping plaza. 

“The space was just renovated and we have five clinic rooms in there, there’s a waiting area and a reception where we have our clinic administrator,” Cox said. “We mainly use two of the clinic rooms. In one room, we do strep throat assessments – and soon to have ear and sinus assessments, too – and in the other room we have our A1C machine and lipid machine, and that’s where we do our chronic disease type of appointments.” 

Her average clinic day is typically organized by appointments, each taking up to 30 minutes. To help split the workload, her staff team of three pharmacists share a schedule where each operate the clinic for a few days per week.

“Depending on the time of year, some of the work can be quite repetitive. For example, this year, we had a surge in strep throat appointments during the winter. There was one day where I did 28 appointments for strep throat. If I was doing that for five days a week, that would be difficult, in that it would be a lot of repetition, so we try to make sure that our team members have variety in their work,” Cox said. 

Cox said most patients have been very receptive to the new services, are relieved to finally have timely access to care, and are comforted by the clinic setting that reminds them of physicians’ offices. For many patients, their first introduction to the clinics is hearing about them through government advertising, being referred by another pharmacy, or being referred by other health providers such as from hospitals or physician offices. 

“I would say these pharmacy clinics look almost identical to a physician’s office … having that private consultation room space to have someone to talk to, to have someone go over their medical history, especially for chronic disease appointments, and just having someone to listen to them is very helpful in making them comfortable,” Cox said.

“The public loves our services. Anyone coming in for an appointment, we ask them do a survey and the satisfaction rate is in the 90 per cent range.”

Terry Higgins, associate owner of two Shoppers Drug Mart locations in Sydney, N.S., said he jumped at the opportunity to have one of his stores serve as a pharmacy primary care clinic when applications first opened. His store was among the first dozen selected in areas of Nova Scotia that were determined to lack access to primary care.

Apart from setting up his store to meet the physical requirements of having a clinic, Higgins and his staff also had to undergo about 40 hours of training before offering the new services, including training on ordering and interpretation of pertinent labs.   

“Scope is continuing to expand and evolve, so the learning is perpetual. Before I even opened our door, I had a lunch and learn with a group of physicians and nurse practitioners in a primary care clinic for unattached patients. The purpose was to provide clarity of what we can and can not do, and to discuss how we can work together to optimize efficient delivery of care. This open discussion was invaluable to set the stage for congenial collaboration,” Higgins said. 

“Their clinic was extremely busy and they were not taking new patients. We forged a strong relationship with them early on, with the goal of seeking clarity on what we can offer to reduce the burden on their practice, while improving care in our community in general.”

As a result of those initial discussions, the relationship between the pharmacy clinic and the physicians’ clinic has evolved into one where the pharmacy is referring complex cases, or cases where a patient’s condition becomes more serious, while the physicians refer chronic conditions, minor ailments, prescription renewals and the like to the pharmacy team. 

“We started as a 40-hour per week clinic and now we are operating 44 hours each week, typically at full capacity” he said. 

One thing that Higgins and his team had to be wary of was the potential mental fatigue of complex clinical work, which led his team to start arranging appointments to have more complex cases early in the day, and to spread these appointments throughout the week so they don’t all land on the same shift. 

“It was a little tip from our consultant from the Association. We did a reset to allow for a mix of more complex interactions with shorter, lighter interactions, such as strep assessments and injections,” Higgins said. 

To help his team become acclimatized to the clinical work, Higgins created a chat group among his pharmacists so lessons from each day’s clinic shift could be shared. His team also further leveraged relationships with physicians and specialists so they could ask for advice. Another important component was having a well-trained clinic administrator who can help smooth out the pharmacist’s workflow. 

“We call her the clinic administrator extraordinaire. Every day she comes in early and tees up the day for us. If our first appointment is a diabetes follow up, she will have the initial assessment sheet ready to go before the patient walks in through the door. I can check the notes that the previous pharmacist left, so I know right where we left off,” Higgins said.

Miranda Teasdale, pharmacist-owner of Teasdale Apothecary Co. in Antigonish, N.S., signed on as a pharmacy clinic in April 2023 when the province added 14 more pharmacy locations to the existing dozen at the time. 

Over the past year, her team has noticed that taking clinical work out of the dispensary has been a significant benefit.

“Where it gets tricky and what we’re trying to avoid is that if you have a pharmacist in the dispensary, they should ideally be focused on dispensing, counselling and phone calls,” Teasdale said. “It can get overwhelming and can become a recipe for staff burnout if you have a dispensing pharmacist also trying to help someone at the counter with a tick bite, or rash; it’s just a lot better for safety and workflow to separate those two services.”

Having practiced previously in Alberta, where qualified pharmacists were given prescribing authority in 2007, Teasdale said it’s not surprising other provinces have began expanding their scope and implementing pharmacy clinic models. 

“The health-care crisis is not going anywhere. In many places for a long time, pharmacists have not been able to practice to their full scope until very recently,” she said. “The clinic-based pharmacy is the best way to utilize the profession to our full scope in the most effective and safe way for our patients. It doesn’t surprise me that more provinces are jumping on board.”

Currently, the vast majority of pharmacy clinic appointments are pre-booked by patients at all three pharmacies The Tablet spoke with. Teasdale advised that pharmacists should still strive to accept walk-in patients whenever possible. 

“Because we are known as the most accessible health-care providers. But with all of these extra roles and extra scope that we are taking on, sometimes we’re unable to make that expectation a reality. For example, you would never walk into your doctor’s office and say I need someone to look at this immediately. You would make an appointment,” she said. 

“So setting that expectation with patients can be a little bit of a barrier at first. We are still accessible. What we try to do is book our appointments only two to three weeks in advance, and also reserve about 25 per cent of our appointments for same day bookings. That way we’re still able to take care of someone seeking urgent, same-day service.”

The Tablet also reached out to several pharmacy chains operating pharmacies in British Columbia to inquire about the local appetite for pharmacy clinics. 

Eric Lin, District Leader with Rexall, said his company has already been operating clinics in Ontario and Alberta, where pharmacists offer services such as minor ailments prescribing, chronic disease management, immunizations, point-of-care testing and more.

“Rexall is highly committed to being part of the solution to the current challenges in our health-care system. As an industry leader in patient care, Rexall aims to enhance access to health care by opening pharmacist-led walk-in clinics in British Columbia,” Lin said. 

However, he pointed to several factors that should be taken into consideration to support pharmacy teams if a decision is made to implement pharmacy clinics in B.C. 

These factors would include ensuring there is funding available to help pharmacies cover operational costs, such as hiring a dedicated pharmacist for the clinic, or costs involved in making structural changes to pharmacy sites to ensure pharmacy clinics have a dedicated space. 

Lin said decision-makers should be open to piloting and testing new health-care services or programs within clinics.

“This may include establishing partnerships with health technology vendors or virtual care teams to enable a more holistic care model based on the needs of each specific community, as well as patient feedback,” he said.

Lastly, Lin said that it would be important to have a process in place so clinic teams are able to collaborate seamlessly with other health-care providers involved in the patients’ care. 

“The clinic and pharmacy teams are extensions of the patient care journey,” Lin said. 

Along with ensuring proper reimbursement for services, the BC Pharmacy Association believes pharmacy clinics can't exist without adding additional scope of practice.

Brent Evans, General Manager, Medicine Shoppe Canada, shared lessons from his banner’s experience learned in the Nova Scotia pharmacy clinic project. 

“Based on our experience with the Nova Scotia Community Pharmacy Primary Care Pilot project, it is crucial to have effective administrative support, an efficient appointment booking system, and a clear distinction between core pharmacy services and clinic operations,” he said. “Starting with a smaller-scale implementation allows pharmacists to gradually adapt and build confidence in the new model, especially since many are already providing similar services.”

Evans said his pharmacy franchise is committed to advancing the role of pharmacist-led clinics due to the benefits this model offers for patient care and outcomes. He said many Medicine Shoppe locations are already equipped with private consultation rooms and were designed to facilitate expanded pharmacy services. 

“Our existing pharmacy infrastructure, combined with a focus on providing uninterrupted access to pharmacists, makes the expansion into primary care both practical and advantageous for our locations,” he said. “We couldn’t be more proud or confident in our ability to deliver positive patient outcomes to Canadians, including through support for pharmacist-led clinic space.”
 

Penny Lehoux, Manager of Pharmacy Managed Care at London Drugs, shared that their pharmacies across B.C. are planning for more expanded scope of practice roles for pharmacists. 

“To best execute these services, the pharmacists need training, support, a strong pharmacy team, and more time to interact with patients, less time filling prescriptions,” she said. “One way we are preparing is by adding multiple consultation rooms to our new or renovated stores. We are also utilizing advanced workflow technology and have expanded our central fill facility capacity to relieve some of the refill prescription volume.”

Lehoux said London Drugs is hiring clinical pharmacists across B.C. to focus on appointment-based pharmacy services like vaccinations, MACS assessments, medication reviews, disease management, point of care tests, patient support programs, and the expansion of London Drugs Travel Clinics. 

“Due to shortages across all health care professions, there is an endless supply of patients with unmet health care needs,” she said. “We want to help those patients conveniently access trusted health advice and pharmacy services when they need it, so they can feel empowered to maintain and improve their health.”

For those pharmacists who have worked decades in a dispensing model, being able to offer a wide range of clinical services has been exciting.

“A lot of our new graduates, they’re trained for exactly this type of work. This is my 30th year as a pharmacist. When I first heard of this opportunity, I jumped at it. I love pilot projects and I try to be involved in every one that comes along. The clinical work is so rewarding and it is nice to have a mix of work between the dispensary and the clinic,” said Higgins, the Shoppers Drug Mart pharmacist in Nova Scotia. 

“It’s been incredible,” said Teasdale, owner of the independent pharmacy. “The feedback we have received is nothing but positive. We’ve had folks who have previously sat in the emergency room for eight hours with their young kids for what they thought was a strep throat. Now, they can book an appointment with us, get their results back within six minutes, and we send them on their way with a prescription. As a pharmacist, this is a really rewarding role.”

Cox, the Pharmasave manager, echoed her colleagues.

“I love it. I really enjoy it. Especially when you see someone who has had a hard time accessing health care in the past, and now you’re developing a relationship with them and seeing that what you’re doing is making a difference, I get a lot of satisfaction from that.  

“I never thought I would be doing this. It really opens up a world of opportunities. This was not something on my radar when I started as a pharmacist 18 years ago, or even five years ago.”