Primary healthcare (PHC) is the cornerstone of a robust healthcare system. PHC is essential to meeting the quadruple aim for health services: improved population health, improved patient experiences, healthcare team wellbeing, and cost savings. Patient access to a regular family physician or nurse practitioner is associated with better population health outcomes, lower costs of care, and reduced health disparities across socioeconomic status. PHC access challenges include patients who do not have a regular family physician or nurse practitioner but would like one (“unattached”) and patients who identify as having a family physician or nurse practitioner (“attached”) but experience long wait times to see them[3–5]. In 2019, 14.5% of Canadians over 12 years old were unattached, higher than other commonwealth countries.
On March 11, 2020, the World Health Organization declared a global pandemic from the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and the pandemic was referred to as COVID-19, (i.e., coronavirus disease 2019). Prior to the pandemic, the proportion of people in Nova Scotia (NS) aged 12 years and older who were registered on the provincial centralized waiting list for primary care, identifying themselves as in need of a primary care provider (i.e., unattached), was around 47,056 (5.1% of the provincial population). The number of people on the waitlist has increased substantially since. As of February 1st, 2022, 8.6% of the provincial population (~86,000 people) are registered on the waitlist indicating that the proportion of unattached patients has grown during the pandemic. Rates of unattachment are lowest in urban regions of the province (e.g., 6.1% in Central Zone, which contains the urban provincial capital) and highest in the Western and Northern Zones (14.5% and 14.8%, respectively). Both zones are entirely rural, where challenges with attachment and access are most pronounced[10,11].
When the supply of family physician/nurse practitioner-delivered PHC cannot meet patients’ needs, other PHC providers, such as community pharmacists, may fill gaps in care and serve as the PHC provider[12–15]. Community pharmacists are highly accessible healthcare professionals. This has been particularly noticeable during periods of the COVID-19 pandemic restrictions, during which even attached patients were often unable to visit their regular provider for routine care. Approximately 40% of Nova Scotians reside within walking distance of a community pharmacy and 79% within a 5 km drive. Community pharmacies across Canada often offer walk-in appointments and extended hours of operation. This degree of accessibility[18–20], and the resulting frequency of pharmacy visits (14 times per year on average), provides pharmacists with multiple opportunities to address health issues among their patient population. Most Canadians trust the care they receive from pharmacists and are open to visiting their pharmacist for healthcare services beyond filling a prescription.
Evidence supports a pharmacists’ role in chronic disease management (e.g., hypertension, heart failure, diabetes, COPD, asthma), treatment of self-limiting conditions[23–27], and meeting routine and specialized immunization needs of patients[28,29]. In addition, in NS, the scope of pharmacist practice expanded further in recent years. In NS, community pharmacists can administer drugs by injection; assess and prescribe for minor ailments, contraception, including emergency contraception, uncomplicated urinary tract infections, and medications for smoking cessation; offer prescription adaptations and therapeutic substitutions; order and interpret laboratory tests needed to manage drug therapy (with access through the provincial electronic health record system, SHARE [Secure Health Access Record]))[31,32]; and prescribe renewals[33,34].
The COVID-19 pandemic led to publicly funded pharmacist assessments for renewals becoming available to all Nova Scotians a couple of weeks earlier than planned (March 2020 instead of April 2020). In addition, federal exemptions from specific provisions of the Controlled Drugs and Substances Act and its regulations allowed pharmacists to extend, transfer, and receive verbal orders to extend or refill prescriptions for controlled substances to help address access issues caused by the pandemic.
While anecdotal evidence suggests pharmacists are using their scope of practice to assist in managing care for unattached patients, little is known about their specific activities or how the management of unattached patients impacts their practice. This study addresses gaps in the literature by describing community pharmacists’ roles in caring for unattached patients before and during the COVID-19 pandemic and identifying barriers and facilitators to optimizing patient access. Although some literature has examined the early stages of COVID-19[32–35], little is known about pharmacists' role in caring for unattached versus attached patients and others with issues accessing PHC before and during the pandemic.
This study was approved by the Nova Scotia Health Research Ethics Board (File #1025905; August 6, 2020).
1In Nova Scotia, Canada, legally pharmacists can order and interpret laboratory tests, but this practice remains to be operationalized from a health system perspective. The Pharmacy Act s. 32(2)(b) and the Pharmacist Extended Practice Regulations definitions authorize pharmacists to order, receive, conduct, or interpret tests needed to properly manage drug therapy. A position statement from the Nova Scotia College of Pharmacists clarifies the position of the College on what constitutes drug therapy management, and when testing would be consistent with the legislated requirement.