Charles Helm
Over the course of the past twelve months our community pharmacist Charissa Tonnesen and I have spent an hour together with each of 79 Tumbler Ridge seniors. Through the Shared Care program, which is a joint initiative of the Ministry of Health and Doctors of BC, the three South Peace communities (Dawson Creek, Chetwynd and Tumbler Ridge) had received funding to try to tackle the issue of ‘polypharmacy’, which is what happens when patients, particularly the elderly, end up on a multitude of medications. Many of these medications may have been prescribed initially for what seemed like good reasons, but over time they often tend to pile up and may have unintended side-effects or drug interactions. Polypharmacy is recognized internationally as a major health care problem, especially in seniors. We hoped to give eligible Tumbler Ridge seniors the tools they needed to be on the right amount of the right number of medications, and our goals included enhanced physical and emotional well-being, as well as cost savings.
To meet the criteria, people had to be 65 or older, and had to be on five or more medications. In Tumbler Ridge 85 people met the criteria. It turned out that five of these declined, and in one case we had a ‘no-show’. We met the remaining 79 seniors for medication assessments (the average number of medications was 10 per person) via Zoom or phone, and followed this up with a written summary to each patient and a letter with recommendations to the local physician of their choice.
We ended up making 226 such recommendations. More than three quarters of these were for medication discontinuation or reduction. In many cases we also tried to make things easier for patients in other ways, for example, changing from four-times-a-day dosing to daily or twice daily. On other occasions we were able to recommend a switch to lower-cost alternatives, or medications that were covered by drug plans. There was no change to patients for this service, and family members were encouraged to attend. People essentially ended up with a publicly-funded, hour-long session with a physician and pharmacist who were combining their skills to try to make them healthier and happier (and perhaps even wiser and a bit wealthier).
Bob Norman explained this eloquently: “My wife found this interview reassuring – the opportunity to discuss each and every one of her medications with a pharmacist-doctor team, to be able to talk about the risks and benefits of each drug, and to decide for herself whether or not she wanted to continue/discontinue/change/whatever with them. Not to mention the fact that this was a free hour-long personal interview with a pharmacist-doctor team. Just sit back and think about that for a bit… a free hour-long personal interview with a pharmacist-doctor team. Where else would you find that happening?”
Bob has touched on a few other important things. Our goal was to empower people, so that in cases where medication use might be useful, but was not essential, they understood the pros and cons and did not feel pressured. After all, what was right for one patient was not necessarily right for the next, yet there would only be right answers as long as Charissa and I did our jobs properly and provided the information in an understandable and supportive way.
Unexpectedly perhaps, in times when short physician appointments are often the norm, we found that we needed the full hour in order to get through everything to our satisfaction. From the patient perspective, they were free to ask anything that came to mind, from lifestyle questions to our feelings on Covid vaccinations (no prizes for guessing what our response was to that question).
Combining our skill-sets proved remarkably effective and Charissa and I both felt that our patients had benefited significantly from our collaboration, rather than speaking with us individually. “Inter-professional team” is a new buzzword in health care, and in putting this into practice in Tumbler Ridge we certainly saw the positive effects. (In Dawson Creek a nurse practitioner, Christy Demeter, was part of a similar team with wonderful results too.)
In the South Peace our team hosted ten educational webinars for our colleagues, and we had outstanding support from the Therapeutics Initiative at UBC, led by Dr Tom Perry (who has been to Tumbler Ridge a number of times for our medical conferences and to hike our trails). Our three communities in the South Peace each approached the problem of polypharmacy in their own way, and in each case successfully. We are one of three project teams in BC who have been asked to present on our work at a provincial workshop in late October, and we plan to publish on what we have achieved and to present this at both Canadian and international conferences. Rather remarkably, it appears that the Tumbler Ridge example may be unique and unprecedented.
However, this is more about people than statistics. Hearing about the immense gratitude of those whose lives we helped to make simpler and less symptomatic was meaningful beyond measure. In one example it was straightforward discontinuation of a medication which often causes confusion – the result was that patient and family could put aside their worries of impending dementia. How does one put a value on that? In another example someone who had struggled to perform the simplest activities of daily living due to medication-induced pain symptoms was ready after a few days to go out fly-fishing.
These were the rewarding ‘quick-fixes’. At other times, progress was slower but nonetheless steady. It is not easy coming off medications that one has been on for decades. In such cases, small steps are worthy of celebration. One patient in this situation wrote to us, and has given permission to be quoted here: “I was Lost! My memory was just about gone. I was confused and my balance was getting really bad. I wanted everything to stop, but I kept trying! Then my pharmacist called with help. I am not saying it was easy, but with help, understanding and encouragement to let them help you, this program works!”
None of this would have been possible were it not for the most wonderful pharmacy that we are privileged to have operating in Tumbler Ridge. Clearly, having people in town on fewer prescription medications is not good for a pharmacy’s financial bottom line. But a truly great pharmacist (in this case Charissa) sees beyond that, and wants only the best for her patients.
In summary I will say that in my medical career of forty years, this may have been the most fulfilling work I have ever been involved in. Thanks to Shared Care for the funding and for the confidence shown in us. Sometimes things are easier to achieve in remote, isolated communities than in the big city. I look forward to the next chapter, which is to proudly tell the world what we have achieved through the polypharmacy project in Tumbler Ridge and the South Peace.
Trent is the publisher of Tumbler RidgeLines.
