Community pharmacists build relationships
Community pharmacy practice is characterized by patient-pharmacist relationships that have sometimes been built over years. You get to know your patients as people, and over many conversations (sometimes medication-related but more oftentimes not) you develop an understanding of what’s important to them. This relationship and the frequent opportunities for assessment, monitoring, and follow-up are important elements that support community pharmacists in playing a larger role in initiating and implementing deprescribing initiatives.
However, community pharmacy practice can be tough. As a pharmacist, you’re often struggling to keep up with workplace demands while also trying to keep up with evolving scopes of practice. Providing good clinical care can be challenging as community pharmacists often don’t have access to useful resources, such as electronic health records. Communicating with prescribers, typically located offsite, can also have its challenges.
With all of this already on their plate, how can community pharmacists better integrate deprescribing into their practices?
While I can’t speak for everyone, here are a few things that have worked in my practice:
1. This is a team effort
It is important that you and your pharmacy team members are on the same page and understand that you’re working towards the common goal of ensuring that a patient’s medications are working and not causing any harm. A challenge may be that some pharmacists might not feel like their knowledge is sufficient. Making colleagues aware of the many excellent resources available will support that knowledge development. You could also be creative and have a monthly theme, i.e. Benzodiazepine Deprescribing Month, not unlike Diabetes Month or Heart Health Month, to promote education and awareness in the pharmacy. Improving the confidence of all pharmacy team members by improving their knowledge will enable them to engage in these conversations with their patients.
2. Document, document, document
It’s true that community pharmacists don’t always have access to electronic health records and patients themselves are not always accurate history givers. This makes investigating the history of a drug very challenging. Pharmacists can partially address this issue by committing to thorough documentation practices at their own pharmacies. This includes documenting the reasons for stopping or starting each medication the patient is taking in the notes or comment section, depending on which software you are using.
3. Discharge medication reviews
Hospital discharges can be a very overwhelming and difficult time for patients. They are also a time when multiple medication changes can occur. It’s often recommended to provide a discharge medication review as soon as a patient has been discharged but there might be more value in waiting a day or two to go through the changes more thoroughly with them in person or by phone/virtually. Patients may be better able to explain why medications were prescribed and the intended duration and clear documentation will be helpful later when determining if a medication should be continued.
4. Medication review protocol
Consider creating a list of critical questions to ask when conducting a medication review so that potentially inappropriate medications can be identified. For example, this list could include questions aimed at assessing which medications may contribute to a patient’s risk of falls or assessing for appropriate use of a PPI. A list of questions can elevate a medication review from simply creating a list of medications to a more comprehensive clinical review. Also, lab values are often accessible to the patient online. Request that your patient brings in a copy so that you can better assess appropriate renal dosing, A1C, etc.
5. Patient education
Our responsibility as pharmacists is to provide patients with the information they need so that they can make the best medication-related decisions for themselves. Think about adding discussions around deprescribing into your practice through the interactions that you are already having. You can do this in many ways, for example through conversations at prescription drop-off or during medication reviews. If time is limited (and it often is) you can direct patients to websites so they can find information for themselves or provide patient handouts. These resources are best accompanied by an invitation to come back and talk to you about it.
There are examples of other pharmacies finding innovative ways to incorporate deprescribing into their practice such as those pharmacies that participated in the Catalyst Study in Ontario. At the bottom of this post are some resources that would be helpful to pharmacists interested in exploring deprescribing further.
I can honestly say that after working in community pharmacy for over 10 years, I still feel excited about the work that I do. Learning more about deprescribing and the potential impact it can have on a patient’s quality of life has created a new focus and renewed my motivation to provide good patient care and I’m happy to be joining the increasing number of health care providers who feel the same.
- Farrell B, Mangin D. Deprescribing Is an Essential Part of Good Prescribing. Am Fam Physician. 2019 Jan 1;99(1):7-9. PMID: 30600973. https://www.aafp.org/afp/2019/0101/p7.html
- Farrell B, Clarkin C, Conklin J, et al. Community pharmacists as catalysts for deprescribing: An exploratory study using quality improvement processes.Canadian Pharmacists Journal. 2020;153(1):37-45. doi:10.1177/1715163519882969 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6966265/
- Presentation to CFPC: Approaches to deprescribing for older people: what to stop, when and how by Dr. Barbara Farrell www.youtube.com/watch?v=0Gb7Zs4ndXU
- deprescribing.org and deprescribingnetwork.ca: patient and HCP resources