Prescription-Related Services
The Case for Prescription-Related Services by Pharmacists
What are prescription-related services?
Advantage to plan member
- Providing medication on an incidental or emergency basis when the patient cannot contact the original prescriber and when the history of the patient is known.
- Faster access to renewals, changes to the dosage form, and provision of emergency supplies of medications in specific or unique situations
Advantage to employer
- Prescription drug therapy initiated sooner resulting in faster intervention and recovery
- Reduced workplace illness, absenteeism, and presenteeism (from relapses or delayed treatment)
Advantage to plan
- Potential for reduced drug plan cost (from earlier intervention, treatment and recovery)
- Greater adherence to prescribed treatment and medication resulting in cost avoidance from potential costly relapses or complications
Prescription-related services refer to a range of pharmacist-led services that can involve prescribing or taking away medication, ordering and interpreting lab tests, and vaccinating patients. While the authority to prescribe varies by province, since 2006 most provincial governments across Canada have expanded the prescribing rights of pharmacists as part of a strategy to better leverage the full scope of pharmacists’ expertise and improve health care services to patients.
Prescription-related services provided by pharmacists that are implemented or pending in most provinces now include:
- Emergency prescription refills
- Renew or extend prescriptions
- Adapt or change the existing prescription
- Initiate new prescriptions for specified conditions
How can pharmacists help?
The intent is not to bypass or circumvent traditional physician-prescribed prescriptions but rather to improve patients’ access to care by optimizing the role of pharmacists and decreasing the number of steps to obtain treatment. All decisions related to medication management, including prescribing are collaborative, patient-centred and focused on addressing the health care needs of the patient. Collaboration includes two-way communication with other health providers and documentation of any drug therapy decisions.
The changing scope of the pharmacists’ prescribing role across the country is illustrated here:
Case study example
Here’s how a medication review helped one man better understand and manage his treatment for a healthy outcome (names have been changed to protect privacy).
Mary, a young 24-year old woman living in Alberta with asthma experienced a severe reaction when exposed to grass pollen and mold over the course of a long-weekend. The exposures lead to classic asthma symptoms of wheezing, coughing, and shortness of breath.
Normally Mary relied on a Ventolin inhaler, as prescribed by her family doctor to relieve her symptoms. In this incident, Mary found her prescription had lapsed and she was unable to contact her doctor during the holiday weekend. Rather than waiting or traveling a considerable distance to the hospital emergency ward, Mary sought treatment from her pharmacist Rick Nielsen, BScPhm.
In Alberta, all pharmacists can adapt prescriptions and prescribe in an emergency. In this case, Rick renewed her prescription, substituting the brand name drug Ventolin with the generic drug Salbutamol, providing Mary with immediate breathing relief. Rick explained that the substitution was chemically identical but more cost effective.
He also helped Mary create an up-to-date asthma action plan and sent a summary of the intervention to the family physician with details on the prescription and substitution. “I was so thankful that Rick could renew my prescription so quickly,” comments Mary. “I was concerned I would have to go to emergency or take time from work on Tuesday morning to visit by doctor,” she adds.
In another example of the evolving pharmacist role, Rick took his team to several workplaces to provide a convenient “mobile flu clinic”1. In the past, employees would take time off work to wait in line at the local immunization clinic or visit their family doctor. “Employees appreciate the convenience of pharmacists immunizing,” Rick says. “It’s also a great way to educate people about how pharmacists can improve access to health care while providing immunizations safely and conveniently,” he adds.
The business case for plan sponsors
It is becoming clear that optimal health care will be realized through a collaborative approach between physicians, nurses and pharmacists. Research published in the April 2014 issue of CMAJ (Canadian Medical Association Journal) revealed that stroke patients managed by a pharmacist had a 12.5% improvement in blood pressure and low-density lipoprotein (LDL), or “bad” cholesterol levels when compared to a control group.2
The problem with traditional approaches to prescribing medication
- Employees must wait to see a physician to extend or modify existing prescriptions – delaying treatment
- When employees seek treatment from a family doctor they usually take time from work – leading to higher absenteeism and/or presenteeism
- Lack of readily available access to physician care – due to hours of operation or location – or not having access to a family doctor delays some employees from getting an emergency refill, renewing or extending a prescription – or getting a drug by injection
This study involved 279 participants and compared case management between nurses and pharmacists. Both nurses and pharmacists provided counselling to patients on smoking, diet, exercise, and other factors. However, pharmacists were also able to actively prescribe medications based on current Canadian guidelines and adjusted doses to achieve the best results for each patient.
While the study only covered a six-month period, the authors cautiously concluded, “Even greater improvements were seen among patients whose care was managed by a pharmacist case manager who was empowered to initiate and adjust medications to gain guideline-recommended targets.”
The value of an active and expanding pharmacist role was reinforced in a 2013 study by Dr. Cara Tannebaum, Faculties of Medicine and Pharmacy, Université de Montréal and Dr. Ross Tsuyuki, Faculty of Medicine and Dentistry, University of Alberta.3 The authors reported that more than 10% of emergency department visits in Canada result from drug-related problems.
Reducing inappropriate medications – medication with excessive risk and for which safer alternatives are available – is a challenging problem. “Pharmacists can help physicians keep abreast of changes in guidance to minimize drug-related risk and substitute inappropriate prescriptions,” they report. The authors also wrote, “The expanding scope of pharmacists’ practice offers many opportunities to improve patient care. Once established, collaborative care with pharmacists will likely yield tremendous benefits to both patients and physicians.”
Above all, this study clearly demonstrates how pharmacists can reduce emergency room visits that result from medication misuse. Increasing the sustainability of the health care system by keeping plan members healthy and in the workplace, benefits all stakeholders including private payers.
Prescription related services in action
Licensed pharmacists must follow regulations and meet certain criteria as stipulated by their provincial/territorial college in order to perform the following prescription related services.
Emergency Prescription Refills
A patient may present symptoms to a pharmacist for a known condition with a request for an emergency refill. In the absence of an existing prescription, but when there is an immediate need for drug therapy, a pharmacist is able to provide a prescription subject to provincial/territorial regulations.
If the patient is new to the pharmacy, the pharmacist:
- Develops a patient profile documenting medical history, drug profile and allergy status
- Dispenses a minimum amount of the requested drug to alleviate the patient’s immediate risk.
- Counsels the patient on the proper use of the medication, how it works, potential side-effects, and the importance of adherence
- Advises the patient to seek medical attention if symptoms worsen
Renew or Extend Prescriptions
A regular client may ask their pharmacist to renew a prescription for a known medical condition under certain circumstances. For example, the patient may be leaving for a trip, they are running low, and they don’t have time to visit their physician for a new prescription.
The pharmacist will review the patient profile – noting the dosage, frequency and results of treatment to date. Unless something unusual is discovered, the pharmacist typically:
Renews and dispenses a limited supply (maximum renewal supply ranges from 30 days to 6 months across Canada)
Documents the consultation
Advises the patient to see their physician upon return
Adapting or Change the Existing Prescription
In most provinces pharmacists can assess patients and adapt a prescription to change the dose, formulation or regimen of the prescription to enhance patient outcomes. Adaptations must be accompanied by proper and complete documentation on the original prescription (i.e. pharmacist name, signature, change made). Upon dispensing, the pharmacist provides counselling on proper storage and administration.
Formulation Change
A patient may complain of difficulties taking a prescribed medication. For example, they may have difficulty swallowing large capsules or the taste of a prescribed medication is unpleasant. In this case, after reviewing the patient profile and confirming the original prescription, the pharmacist may change the prescription to a liquid formulation and document the correct concentration and dose to be administered. Upon dispensing, the pharmacist provides counselling on proper storage and administration.
Incomplete Prescription
A pharmacist may notice that the medication strength for a given prescription is missing. The pharmacist will verify the patient’s profile and confirm that the treatment has been effective before re-issuing the prescription at the same strength. The pharmacist adapts the prescription by adding in the strength and documents accordingly on the prescription.
Dose Change
In some situations a patient with a known condition and prescription may not be achieving the treatment outcomes expected. Based on current practice guidelines, the pharmacist adapts the prescription by increasing or decreasing the dose. Subsequently, the pharmacist counsels the patient on the new dose and informs the patient to call if their presenting condition continues..
Initiate New Prescriptions for Specified Conditions
Initiating new prescriptions is a form of independent prescribing that has been adopted in many provinces. For example, a client may reveal a desire to quit smoking. The pharmacist may recommend scheduling an initial 30-minute consultation on smoking cessation. After ruling out contraindications (e.g. history of seizures and eating disorders), the pharmacist may also prescribe a 12-week treatment of bupropion. For any new prescription, the patient is counselled on the directions for use and the side effects of therapy.
In most if not all cases interventions by the pharmacist are documented in the patient profile and the primary care physician is notified of the emergency prescription via fax, usually within 24 hours.
In conclusion
Pharmacists have emerged as a proven and important part of the health care team in Canada. The ability to independently initiate, adapt (modify) and continue prescriptions ensures the fastest time to treatment and resolution of prescription issues resulting in lower employee absenteeism, presenteeism, and improvements in workforce productivity.
1. The ability for pharmacists to travel onsite to a workplace varies by province
2. CMAJ 2014. DOI:10.1503/cmaj.140053, Case management for blood pressure and lipid level control after minor stroke: PREVENTION randomized controlled trial
3. CMAJ 2013. DOI:10.1503/cmaj.121990, The expanding scope of pharmacists’ practice: implications for physicians
