Clinical Pearls: Hospital Pharmacy Practice in Rural Canada  

February 13, 2023
By Layne Liberty

This article is part of a series appearing in Interactions, our biweekly newsletter, written and researched by CSHP's students. We've created this series as a valuable learning activity for pharmacy students undertaking rotations at CSHP. Crafting these pieces not only helps students gain in-depth knowledge of specific conditions, treatments, and resources, it also helps them hone their skills in research, critical appraisal, evaluation, synthesis, and writing – all of which will serve them well in clinical practice. The Professional Practice Team works with the students to select hot topics that are of interest and utility to both the students and to you, the reader. We hope you enjoy this piece by one of our future colleagues! Let us know what you think: If you would like to provide any comments or constructive feedback for our students, please email us at practice@cshp.ca.
 

Background

Canadians who live in rural, remote, and northern communities have a higher burden of disease, higher mortality rates, and less access to healthcare services and providers compared to urban Canadians.1 One in every five Canadians lives in rural communities, which cover 98% of the country's land area.2 Many studies have looked into the differences between urban and rural health outcomes, and it has been discovered that patients with chronic diseases like heart failure, diabetes, and cancer are more vulnerable to urban-rural differences.3 These disparities for patients with chronic disease are often because specialized services, which are generally more readily available in urban settings, are a requirement to optimize health outcomes.4,5 The lack of specialty services in local communities leads to higher re-admission rates to rural hospitals.6

Rural Canadian populations experience several other challenges that restrict the availability and accessibility of typical medical services. For example, small rural areas sometimes have no hospital, and larger rural centres often only have hospitals with basic facilities. These hospitals face challenges in recruiting specialists, such as anesthesiologists, who could provide specialty surgery or obstetrics services.7 It is also common for small rural hospitals to close emergency departments on weekends or not provide 24-hour access to care.7 Consequently, patients do not seek out healthcare services as often due to reasons such as long wait times or distance to urban centres.7 Additional health disparities seen in these areas can be due to geographical barriers (e.g., inclement weather, mountainous terrain), difficulty in recruitment and retention of health care providers (HCP), healthcare avoidance (less health literacy and unfamiliarity with the healthcare system), and limited access to culturally and linguistically appropriate services.8 As a result, rural Canadians experience poorer health outcomes and have more unmet health care needs than urban Canadians.9 

Pharmacists play an integral role as part of the clinical health care team, and with the expanded scope of practice, their role will become even more essential. According to NAPRAs 2022 national statistics, there are approximately 44,031 licensed and actively practicing pharmacists in Canada, with 6,940 of those registrants being hospital pharmacists.10 However, according to the 2021 Canadian Institute for Health Informatics (CIHI) pharmacist workforce report, only about 3,402 (7.7%) of these pharmacists work in rural and remote areas of Canada (hospitals and communities).11 The majority of pharmacists (community and hospital) practice in urban areas which poses an issue of supply to rural areas of Canada.12 The CIHI (2020) published numbers of pharmacists per 100,000 population and the provinces with the lowest ratios were Ontario, British Columbia, Quebec, Nunavut and the Northwest territories.12 Although this does not directly describe the number of employment vacancies in rural Canada, it can indicate a low supply to these areas especially knowing that the majority of pharmacists practice in urban settings. Other provinces, such as Newfoundland and Labrador, have an equal number of pharmacists in both urban and rural areas.12 This equal distribution could be explained by Memorial University's pharmacy program requirement to reserve 75% of seats for in province applicants, which has potentially translated into the province having the highest pharmacist to 100,000 population ratio at 14312. Nationally, the average vacancy rate for hospital pharmacist positions was 8% in the 2020/2021 Canadian Society of Hospital Pharmacist (CSHP) Hospital Pharmacy in Canada Survey; however, this fairly low rate does not indicate that pharmacies had enough resources to meet patient pharmaceutical care.13 These rates may simply reflect insufficient funding for many hospitals, health authorities, and provinces to open the necessary number of positions.13 With many rural areas in Canada facing pharmacist vacancies, novel approaches should be considered, including introducing joint-effort clinical services (JECS), targeted recruitment for rural areas and the use of innovative technologies such as telepharmacy. 

Joint-effort clinical pharmacy services model 

In hospitals, pharmacist-led interventions have been shown to improve patient outcomes by decreasing lengths of stay, frequency of serious adverse events, and improving morbidity and mortality outcomes.14 In rural hospitals, pharmacy resources are most often lower than urban centres due to hospital size (more basic facilities and less need for specialized pharmacist roles) and geographical location (difficulties recruiting candidates). According to the 2020/2021 CSHP Hospital Pharmacy in Canada Survey, the most common clinical pharmacist practice model was reported to be "mainly clinical activities with limited distributive activities", with several hospitals reporting pharmacists working in multiple models (e.g., a pharmacist that provides clinical services to all wards of the hospital and one pharmacist that performs mainly distributive and verification activities).14 Depending on the province or territory of licensure, two-thirds of respondents reported working to their full scope of practice in the hospital.13 Many pharmacists want to provide patient-centered care in collaboration with other health care professionals, but some hospitals do not have the appropriate staffing resources. 

A joint-effort clinical service model (JECS) could help pharmacists not only practice within their full scope of practice, but also deal with the pharmacist shortage in rural areas.15 By utilizing trained clinical pharmacy technicians, this model increases the time pharmacists can devote to clinical pharmacy key performance indicators (cpKPI) (e.g., contributing to interprofessional patient care rounds, resolving drug therapy problems, patient education, and so on).15 Clinical pharmacy KPIs have been shown to reduce healthcare resource costs, improve patient health outcomes and also provide data for comparison strategies that progress the pharmacy profession by sharing and learning best practices.15 These cpKPIs are evidence-based and have real-world applications which can be used to demonstrate the importance of the profession and help fund additional clinical pharmacist positions in the healthcare system.16 Clinical pharmacy technicians are technicians who have been trained to perform organizational tasks such as triaging problems for the clinical pharmacist, collecting best-possible medication histories, alerting nurses to potential medication problems, and managing clinical operations.15 This collaborative clinical pharmacy service has been successfully implemented in American urban centres and could be beneficial for rural hospitals where clinical pharmacy services would not otherwise be possible.15 This model would also be useful in rural hospitals that lack an on-site pharmacist and instead rely on coverage from a remote regional pharmacist (technicians supervising dispensing locations under the supervision of a remote pharmacist is legal in British Columbia, Manitoba, and Ontario).17

The JECS model has been utilized at two small rural hospitals in British Columbia, both sites had one clinical pharmacy technician on site and a remote pharmacist who provided services virtually.15 Examples of the interventions that were considered appropriate for these technicians to be involved with included rational use of antibiotics, allergy clarifications (including distinguishing between allergy types and adverse drug reactions (ADR)) and medication reconciliation.15 This study focused on intervention’s related to rational antibiotic use, and the pharmacy technician's responsibilities included forwarding progress notes and clinical sheets to the pharmacist, determining patient weight, height, and antibiotic indication, and determining allergy status.15 The aim of the study was to determine if the JECS model would allow the pharmacist and pharmacy technician team to participate in more patient interventions.15 Examples of interventions by the team included assessing the choice of drug therapy or dose, drug interactions, adverse event reporting, and consulting with other HCPs.15 Another outcome measured was the difference in time (minutes) the pharmacist allocated during the pre-intervention phase compared to the time allocated when the JECS was implemented, both phases being 3 months in length.15 During the pre-intervention phase, there were 69 interventions made by the regional pharmacist, which rose to 115 completed by the JECS team.15 Furthermore, prior to JECS, regional pharmacists spent 5085 minutes fulfilling interventions and only 1751 minutes after implementation.15 This study demonstrates how this model can allow pharmacists to allocate more time to clinical services, rather than spending countless hours on organizational tasks that can be successfully completed by technicians. A notable limitation of this study is that these pharmacy technicians were highly skilled and had experience knowing which interventions needed pharmacist involvement and which could be dealt with locally. Even though there was no mention of issues with patient safety in this study, there is potential for technicians to miss important red flags requiring clinical knowledge such as cross-allergy of antibiotics, antibiotic indication and obtaining incomplete medication history. Additionally, clear documentation of a pharmacy technician’s role and responsibilities along with an understanding of a clinical pharmacist’s duties would be necessary before implementing this model. In an ideal world, this model could be employed in all rural areas; however, restrictions to be considered would be concerns from provincial regulatory organizations and differing provincial scopes of practice; criteria for technician training and certification; and the availability of pharmacy technicians in Canada. Nevertheless, technicians are skilled individuals that can help provide additional patient care, and the JECS is a novel idea that could aid in closing the rural healthcare gap. 

Retention and recruitment  

There is an immediate need for university pharmacy programs to graduate pharmacy students who have experience in and an appreciation for rural clinical practice. Recruiting and retaining pharmacists in rural areas of Canada can be exceptionally difficult due to the availability of accommodation, geographical location, professional isolation, infrastructure disparities, and personal aspects of living.8,18 Retention efforts may be even more important than recruitment efforts because they demonstrate the desirability of these communities to other HCPs considering rural locations.18 Global research into the rural pharmacy workforce has identified positive indicators and barriers to retention. In these studies, the criteria associated with a pharmacist continuing to practice in these communities was work variety (often rural hospital pharmacists are generalists leading to unique opportunities in all professional areas), trusting relationships with patients and health providers, and financial incentives.19 The barriers were identified as professional isolation, lack of access to professional development (educational training or conferences), lack of relief coverage, frequent on-call demands, and a lack of family opportunities.19-21 Locally, a random sample of 2,524 Canadian pharmacists working in rural and remote locations all over the country were asked to participate in a survey to determine how to predict rural pharmacists' intent to remain in their communities.18 In terms of retention predictors, the significant pharmacist attributes were younger age, being married and the presence of children at home.18 Additionally, 67% of pharmacists that intended to remain in rural practice stated they lived in a rural community for at least 2 years before university.18 Experience and social connections in rural areas prior to university would be a large driver for students to choose rural placements and subsequently accept job opportunities in these areas. Interestingly, the size of the community did not predict intent to remain, however the distance to a larger population centre (population >100,000) was a determining factor.18 The greater the distance, the lower the proportion of pharmacists who stated that they intended to remain in that community.18 Pharmacists also reported that positive social factors such as feeling a sense of camaraderie with others that have relocated for work and being a trusted and valued member of the multi-disciplinary team were strong determinants.22 Influences affecting a pharmacist's decision to remain in rural practice are multifaceted, with both personal and community traits playing an influential role, but this data can be useful to help determine how rural coverage can be improved. 

All Doctor of Pharmacy programs in Canada require experiential learning through practicums.23 However, currently, there are no minimum requirements for students to complete these in rural or underserved clinical settings. In Australia, researchers investigated the impact of practicum placement and curriculum, finding that rural practicums had a significantly greater impact on new pharmacists' decision to practice in rural areas than curriculum.21 Yet, curriculum is still valuable to create a foundation of knowledge for students, and ideas for course content could be to focus on cultural safety, social and geographical determinants of health, and healthcare issues specific to indigenous populations. Implementing a requirement for pharmacy students to complete one experiential education practicum in a rural area, expanding the amount and location of available rural residency seats, or reserving seats for rural applicants, could be methods to promote students filling these vacancies after graduation.  
 

Telepharmacy

Individuals living in remote areas are frequently considered to be underserved in terms of healthcare.24 Accessing services can be difficult due to financial constraints (expensive travel or lost work hours), transportation availability, or harsh weather.25 Over the last five years, the use of telehealth services in Canada has increased exponentially, particularly during the COVID-19 pandemic, which helped safely connect patients to health care providers.26 The benefits of clinical pharmacists utilizing telepharmacy to manage ambulatory care patients have been described in a systematic review investigating three clinical outcomes: clinical disease management, patient self-management, and adherence.27 Interventions made by pharmacists included pharmacist-led telephone clinics, post-discharge follow-up, medication counselling, and monitoring lab values and vital signs.27 Over half of the 34 studies reviewed described largely positive patient outcomes in clinical disease management, adherence, and patient self-management.27 The available technology used to provide telepharmacy services were telephone (predominantly) and video conferencing platforms such as Zoom, Microsoft Teams and Skype.26 In a survey of Canadian pharmacists asking their opinion on telepharmacy, the pharmacists felt it had augmented their practice, that they were able to communicate effectively and that they were comfortable making recommendations via these platforms.26

Other forms of delivery for telepharmacy services in Canada include the use of a robotic telepresence where the caregiver's physical presence is virtually extended via a mobile robotic platform with real-time audiovisual communication.28 A study done by Northwest Telepharmacy Solutions (NTS) looked at virtual pharmacist lead best possible medication discharge plan for patients admitted to a small rural hospital.28 The study found that 75% of patients felt their care was better using this platform and the pharmacist found that 78% of these patients had at least one unintentional discharge medication discrepancy that they were able to correct before discharge.28 This model shows that delivering virtual care in hospitals that may otherwise not have the resources to support pharmacist patient interactions, enhances patient satisfaction and ensures medication safety. NTS has also made it possible for many rural hospitals to offer 24/7 pharmacy services.29 During the day, the remote NTS pharmacist helps with order verification, allowing the on-site pharmacist to complete clinical tasks, and overnight the remote pharmacist is providing physician order review and clinical coverage.28 This system not only ensures medication safety and accuracy at all hours, it also allows for more pharmacist led clinical interventions and decreases the overall workload and stress for the on-site pharmacist.  

Even though technology is already a large part of pharmacy, it is important that all pharmacists feel comfortable utilizing these programs, which can be encouraged through exposure to telepharmacy in school, during conferences, and at the workplace. These services could be incorporated into pharmacy schools' course content to ensure digital literacy and promote student-led telepharmacy initiatives when they complete clinical practicums. Nation-wide implementation of telepharmacy services in Canada is still low.23 but with the expanding healthcare crisis and lack of coverage in rural areas, technology could be a means to fill the gap and improve health outcomes. 

Conclusion

Clinical pharmacy in rural communities provides pharmacists with unique opportunities to work closely in multidisciplinary teams and use their entire scope of practice. The use of the JECS model could be an innovative way to close the rural healthcare gap and allow rural hospital pharmacists to migrate towards a more clinical role by being able to allocate more time to cpKPIs. Additionally, more cross-sectional and qualitative studies of rural Canadian hospital pharmacists could aid in the visualization of urban versus rural vacancies and gather ideas on recruitment and retention. The patient demographic in a rural setting differs from one in an urban area, as patients tend to be older with more chronic medications, have lower levels of health literacy, and be members of an Indigenous community. Therefore, educating students on these health disparities and ensuring cultural safety is implemented in their practice will help students feel more equipped and confident to deliver a high level of patient-centered care. This exposure to rural practice through pharmacy curriculum could also encourage students from urban backgrounds to select rural practicum placements. Implementing a portion of seats reserved for students from rural and underserved areas could also ensure a steady flow of rural pharmacists. Finally, the use of telepharmacy services can streamline the patient follow-up process by eliminating common rural healthcare barriers like access to specialty services, public transportation, and financial constraints. Telepharmacy has been shown to improve chronic disease management, adherence, and health literacy in remote communities. It also allows rural hospitals to provide 24/7 pharmacy services which improves patient safety and decreases stress and risk of occupational burnout for the on-site pharmacist. Overall, rural practice presents an opportunity for pharmacists to expand their skills and experience unique areas of practice while developing close, trusting relationships with healthcare colleagues and patients. 

References

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  2. Innovation, Science and Economic Development Canada. Canada’s rural economic development strategy: progress report august 2021 [Internet]. Ottawa: Minister of the Office of Infrastructure of Canada; 2021 [cited 2023 Jan 9]. 15 p. Available from: https://ised-isde.canada.ca/site/rural/en/canadas-rural-economic-development-strategy-progress-report-august-2021 
  3. Gamble JM, Eurich DT, Ezekowitz JA, Kaul P, Quan H, McAlister FA. Patterns of care and outcomes differ for urban versus rural patients with newly diagnosed heart failure, even in a universal healthcare system. Circulation: Heart Failure [Internet]. 2011 [cited 2023 Jan 16];4(3):317-23. Available from: https://doi.org/10.1161/circheartfailure.110.959262 
  4. Ezekowitz JA. Impact of specialist follow-up in outpatients with congestive heart failure. Canadian Medical Association Journal [Internet]. 2005 [cited 2023 Jan 16];172(2):189-94. Available from: https://doi.org/10.1503/cmaj.1032017 
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  13. Canadian Society of Hospital Pharmacists. Hospital pharmacy in Canada survey report 2020/2021 [Internet]. Ottawa: [publisher unknown]; 2021 [cited 2023 Jan 10]. 136 p. Available from: https://www.cshp.ca/docs/pdfs/HPCS-2020-21-Qs-ENG.pdf 
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  16. Lo E, Rainkie D, Semchuk W. M. Gorman S. K, Toombs K, Slavik R. S, et al. Measurement of Clinical Pharmacy Key Performance Indicators to Focus and Improve Your Hospital Pharmacy Practice. The Canadian journal of hospital pharmacy [Internet]. 2016 [cited 2023 Jan 25];69(2), 149–155. Available from: https://doi.org/10.4212/cjhp.v69i2.1543 
  17. National Association of Pharmacy Regulatory Authorities. NAPRA [Internet]. Pharmacy technicians’ scope of practice in Canadian jurisdictions - NAPRA; 2021 Dec [cited 2023 Jan 13]. Available from: https://www.napra.ca/publication/pharmacy-technicians-scope-of-practice-in-canadian-jurisdictions/. 
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  23. Canadian Council for Accreditation of Pharmacy Programs. Annual report and directory of accredited programs 2021-2022 [Internet]. Toronto: [publisher unknown]; 2022 [cited 2023 Jan 16]. 39 p. Available from: https://ccapp.ca/wp-content/uploads/2022/09/2021-2022-Annual-Report-and-Directory-of-Accredited-Programs-1.pdf 
  24. Timony P, Houle SK, Gauthier A, Waite NM. Geographic distribution of Ontario pharmacists: A focus on rural and northern communities. Canadian Pharmacists Journal / Revue des Pharmaciens du Canada [Internet]. 2022[cited 2023 Jan 17]:171516352211154. Available from: https://doi.org/10.1177/17151635221115411 
  25. Goodridge D, Marciniuk D. Rural and remote care: Overcoming the challenges of distance. Chronic Respiratory Disease. 2016;13(2):192-203. Available from: doi:10.1177/1479972316633414 
  26. Park JY, Zed PJ, A De Vera M. Perspectives and experiences with telepharmacy among pharmacists in Canada: a cross-sectional survey. Pharmacy Practice [Internet]. 2022 [cited 2023 Jan 17];20(1):2609. Available from: https://doi.org/10.18549/pharmpract.2022.1.2609 
  27. Niznik JD, He H, Kane-Gill SL. Impact of clinical pharmacist services delivered via telemedicine in the outpatient or ambulatory care setting: a systematic review. Research in Social and Administrative Pharmacy [Internet]. 2018[cited 2023 Jan 17];14(8):707-17. Available from: https://doi.org/10.1016/j.sapharm.2017.10.011 
  28. Newman P, Dhaliwall S, Bains S, Polyakova O, McDonald K. Patient satisfaction with a pharmacist-led best possible medication discharge plan via tele-robot in a remote and rural community hospital. Canadian Journal of Rural Medicine [Internet]. 2021 [cited 2023 Feb 8];26(4):151-159. Available from: https://doi.org/10.4103/cjrm.cjrm_74_20 
  29. Dhaliwall S, Thompson J. Telepharmacy helps Ontario community hospital provide 24/7 services. Canadian Healthcare Technology. Nov/Dec 2013 [cited 2023 Feb 8];18(8): 6 Available from: https://www.canhealth.com/images/PDF/Canadian%20Healthcare%20Technology%202013-08.pdf 

     
     

     
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