Patient-Centered Care
Leadership in Medication Use & Safety
Sub-Domain: Practice-Focused; Organization-Focused; Profession-Focused
Implementation of the Wellness+ Appointment-Based Model in Canadian Community Pharmacies
Submitted by Annalise Mathers, B.Sc., M.P.H.
Case Overview
In current pharmacy practice, patients typically request prescription refills on an unaligned schedule, which can decrease adherence and pharmacy efficiency, simultaneously resulting in longer wait periods and reducing the time pharmacists have available to provide clinical services. As the aging population in Canada continues to grow and the burden of chronic diseases increases, both medication complexity and non-adherence among patients are likely to increase.
To improve adherence and reduce the need for a patient to make multiple visits to a pharmacy, the implementation of alternative pharmacy workflow models is gaining traction in pharmacies, particularly in the United States. One example of this is the Appointment-Based Model (ABM). ABM shifts workflow from reactive to proactive by synchronizing medication (i.e., “med sync”) refills allowing patients to pick up their months’ supply of medication(s) in one trip. In addition to med sync, ABM offers pharmacists the opportunity to provide clinical services regularly. The model was first created by California pharmacist John Sykora in 1995, and over the last decade, uptake of the ABM has grown significantly in the United States.
Research from the United States demonstrates that implementing the ABM may support improvements in medication adherence and refills, pharmacy operational efficiencies, clinical services, and patient satisfaction. Compared to the United States, implementation of the ABM in Canada has been very limited.
Whole Health Pharmacy Partners (WHPP) is a pharmacy banner of independent community pharmacies located across Canada with a predominant presence in the province of Ontario. In September 2017, select Whole Health locations implemented the ABM, called the Wellness+ ABM program. The Wellness+ ABM program has two key components:
- Medication Synchronization: aligns medication refills to enable patients to pick up all their medication at once at a predetermined interval. Synchronization provides patients the convenience of making fewer trips to the pharmacy and eliminating the need to call for refills.
- Appointment Consultation on Pick-up Day: an opportunity for patients to receive one-on-one counseling from the pharmacist and discuss topics such as, but not limited to, medication review and optimization, administration technique for inhalers, eye drops, ointments/creams and other topical medications, vaccination status, smoking cessation, blood pressure, blood sugar, cholesterol screening/monitoring, mental health screening, planned vacation time, allergies/sun protection, and health goals and needs.
All pharmacists and pharmacy staff involved in the program delivery were trained according to a protocol and manual developed by WHPP
Key Elements
The first element of success was having designated personnel focused on program development and implementation. Tools and resources were created to guide and manage program implementation at independent pharmacies, including program manuals, video tutorials, marketing tools, a synchronizer calculator, and enrollment and prescriber notification forms.
The second element of success consisted of a focus on improving patient-centered care. Patients were informed about the program and its potential benefits and given the option to enroll. The proactive nature of the workflow model frees up time for pharmacists to better monitor patient adherence and schedule regular in-person appointments to discuss health needs and goals.
Impact on Patient Outcomes
Data were obtained from a convenience sample of three independent pharmacies within the Whole Health banner in Ontario. A total of 131 patients were enrolled in the program between September 19, 2017, and December 18, 2018. We found that:
- The ABM resulted in patients visiting the pharmacy less often to obtain their dispensed prescriptions but that they had the same or more numbers of prescription refills. Patients had a significant reduction in the mean number of distinct refills dates (6.8 ± 3.8 six months pre-implementation of the ABM vs. 4.9 ± 3.1 six months post-implementation, p < 0.0001). This was accompanied by a significant increase in the mean number of refills (11.9 ± 6.6 six months pre-implementation vs. 13.3 ± 7.4 six months post-implementation, p = 0.02).
- Patients had high baseline adherence (i.e., over the 80% threshold for proportion of days covered that is defined in literature as optimal adherence) to antihypertensives, oral antihyperglycemics, and statins. The ABM program preserved the high adherence across all medication classes studied and demonstrated a significant increase in adherence to statin therapy both six months and 12 months after enrollment in the ABM program.
- Over half (56.5%) of patients received one or more MedsChecks on the day of or after enrollment in the ABM. During these MedsChecks, the most common type of drug therapy problems identified were patient needs additional drug therapy, therapeutic duplication, and adverse drug reaction.
In summary, the ABM program added value to patients by enabling patients to visit the pharmacy less often to pick up an average of more medications helped to maintain high adherence and increased adherence to statin medications and allowed pharmacists to provide more clinical services for patients.
Pharmacy and Pharmacist Roles
The ABM+ Wellness program was developed by pharmacists and the management team at Whole Health Pharmacy Partners head office. This program was implemented by independent pharmacies within the banner after thorough training regarding the Wellness+ program.
Pharmacists and pharmacy assistants were responsible for explaining the program and its potential benefits to patients, enrolling patients, and scheduling appointments. Pharmacists ensured that prescriptions were synchronized and ready for pick-up on the pre-determined appointment date and conducted the one-on-one clinical appointments with patients.
Lessons Learned
Winning elements were being able to provide more clinical service opportunities to address patient concerns and needs. Not only has this improved patient satisfaction, but it also helped to develop stronger patient-pharmacist relationships. Another winning element is the increased convenience for patients. Due to reduced wait times and proactive resolution of prescription-related problems, patients could pick up more medications with less frequent pharmacy visits.
A challenge is increasing program uptake. Community pharmacies are accustomed to using a traditional, reactive workflow model, and so adoption of a new model requires staff buy-in and key personnel to lead its implementation within each pharmacy location. This can be a challenge, especially with the under-staffing situations at numerous pharmacy locations across the province of Ontario.
Budget & Resource Allocation
This project was funded by the Canadian Foundation for Pharmacy. Training began in August 2017, and implementation of the program began in September 2017 at five independent pharmacies. Various tools and resources were created to guide and manage program implementation at independent pharmacies, including program manuals, video tutorials, marketing tools, a synchronizer calculator, and enrollment and prescriber notification forms.
Future Goals
We have had the opportunity to share our research findings through a variety of poster and oral presentations at the FIP World Congress of Pharmacy and Pharmaceutical Sciences 2020, the 2020 ASHP Midyear Clinical Meeting, the Trillium Primary Health Care Research Day Conference 2020, the North American Primary Care Research Group Annual Meeting 2020, and the Ontario Pharmacy Evidence Network (OPEN) Summit 2021.
We have an abstract that will be published on this work in the Canadian Pharmacists Journal. Finally, we plan to submit two research manuscripts to peer-reviewed, high-impact academic journals in the coming months.