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Download The 6/25/2020 Our Practice: Issue 17, May 2020 Issue 17, May 2020 | View Online Visit our website Read past issues of Our Practice CORONAVIRUS (COVID-19) and UBC’s response: Information and FAQs here. FEATURE ARTICLE Pivoting to Virtual Care – What We Know Now BY: TIMOTHY LIM BSC(PHARM), ACPR, RPH e1.envoke.com/m/96eb22084d70e7a25cf58dab3b4f1ecc/m/3a1222889f6905a7ee85ebc306a5249e/?utm_medium=email&utm_campaign=Our-Practic… 1/6 6/25/2020 Our Practice: Issue 17, May 2020 Health care professionals across the country are demanding access to virtual care platforms and training so they can safely provide patient care, while maintaining physical distancing requirements. Pharmacists have not been spared from this new challenge, and as virtual care models rapidly begin to integrate into traditional workflows, we expect this will be a new normal within pharmacy practice. Since our opening in 2013, the Pharmacists Clinic has offered patients the option of in-person, telephone or telehealth appointments. This article describes our challenges, experience and learnings as we shifted entirely to virtual care in March 2020. Different logistic aspects need to be considered for virtual care: 1. Patient Consent: It is important to communicate the risk, limitations and benefits of a virtual appointment, then obtain and document consent before proceeding. This is especially important if another individual, like a student, is participating. Keep in mind that patients can be put-off by any surprises during a virtual appointment. Conversely, patients may invite a friend or family member to participate without letting you know beforehand. Decide in advance how you will handle these requests and what role this observer will play. 2. Confidentiality and Security: All of our devices are password protected and encrypted to safely store information. In addition, our electronic medical records are secured through a virtual private network (VPN). Appointments are offered through a secure telehealth platform and occur with the pharmacist, and ideally the patient, in a private room. 3. Connectivity: Prior to a telehealth appointment, we send patients detailed instructions on technology requirements, set up, and a link to access our telehealth system. The instructions contain screenshots and practical tips. Our medical office e1.envoke.com/m/96eb22084d70e7a25cf58dab3b4f1ecc/m/3a1222889f6905a7ee85ebc306a5249e/?utm_medium=email&utm_campaign=Our-Practic… 2/6 6/25/2020 Our Practice: Issue 17, May 2020 assistant is available prior to these appointments to help patients troubleshoot. 4. Contingency Planning: Technology is great when it works, however, unforeseen circumstances are also part of our reality. For example, patients in rural communities do not always have a reliable internet connection. When we suspect this issue, we avoid scheduling appointments during high-traffic times like lunchtime or late afternoon. If problems persist, we will either transition to a phone appointment or reschedule. 5. Policies and Procedures: The College of Pharmacists of BC provides guidance for telepharmacy services – a helpful starting point for telehealth. We carefully follow the Pharmacist Code of Ethics, HPA Bylaws and FIPPA. Processes are also in place in the event of a privacy breach, which we review and update annually. Additionally, we have found the following practical tips helpful in providing virtual care: 1. Preparation: We review a patient’s PharmaNet profile and any referral documents prior to appointments. Preparation is important in a virtual space so the pharmacist is ready to help direct a conversation if a patient has difficulty communicating their concerns. 2. Pace: It is important to remember that the pace of a virtual appointment may need to be slower than in-person appointments. Technology can be a barrier that prevents clinicians from picking up on non-verbal cues. Throughout the appointment, we suggest taking a moment to check comprehension and ask how the patient is doing. 3. Disclosure: The patient’s willingness to disclose information may differ virtually. Patients may disclose more information if they feel conformable, while others will share less or none at all. Follow-up appointments are important for establishing rapport and trust, which usually makes patients more comfortable to disclose additional information. 4. Interpersonal skills: As with in-person care, developed interpersonal skills such as listening and empathy are vital for building trust. Ideally, we try to have at least one in-person or virtual face-to-face appointment early on to establish some connection before transitioning to telephone appointments. 5. Sound: Using a headset and microphone optimizes your sound quality and frees up your hands to write notes. This also reduces the risk of others hearing personal information. We still have much to learn about virtual patient care, and will continue to share what we learn with our pharmacist colleagues so we can all contribute to the growing body of knowledge in this area. Our team acknowledges and gives thanks to all front-line workers who are tirelessly and selflessly working during the pandemic. We admire your commitment, compassion and professionalism. e1.envoke.com/m/96eb22084d70e7a25cf58dab3b4f1ecc/m/3a1222889f6905a7ee85ebc306a5249e/?utm_medium=email&utm_campaign=Our-Practic… 3/6 6/25/2020 Our Practice: Issue 17, May 2020 CASE STUDY Deprescribing – a painful or painless process? BY: SELENNE DORUS, BSC, ENTRY-TO-PRACTICE PHARMD CANDIDATE 2021 JAMIE YUEN, BSC(PHARM), RPH, BCGP Chronic neuropathic pain has a prevalence of ~5-33% in the community.1 The Canadian Pain Task Force reports that one in five Canadians lives with chronic pain (CP).2 However, the management of chronic pain often leads to polypharmacy, as patients commonly try multiple medications. Without careful assessment and diligent monitoring, many patients tend to stay on various treatments, even when benefit is lacking or side effects appear.3 Therefore, when pain is well managed, it is worth having a conversation with the patient regarding long term treatment goals and the opportunity for deprescribing or tapering. A 73 year-old Caucasian male self-referred to the Clinic in May of 2015 for chronic pain management. He experienced neuropathic pain secondary to a motor vehicle accident affecting his right leg, described as burning, shooting, cramping with electrical-type sensations. The constant pain ranged between 4/10 – 10/10 in severity. His past medical history includes previous myocardial infarction, type 2 diabetes, psoriatic arthritis, benign prostate hyperplasia, and hypothyroidism. Patient has no known drug allergies or intolerances. Social history is non-contributory. Following several appointments with a pharmacist, the patient was satisfied with the e1.envoke.com/m/96eb22084d70e7a25cf58dab3b4f1ecc/m/3a1222889f6905a7ee85ebc306a5249e/?utm_medium=email&utm_campaign=Our-Practic… 4/6 6/25/2020 Our Practice: Issue 17, May 2020 recommendations and treatment plan at the time and required no further follow-up. In November 2019, the patient underwent a spinal stimulator implant, which significantly reduced his overall pain by 90% and reinforced his desire to taper off morphine and other pain medications. The patient successfully self-tapered his morphine but needed guidance for the final steps of the taper. Therefore, he self- referred back to the Clinic, 3 years after the initial appointment, to discuss pain management and create a new deprescribing plan. His current medications include morphine ER 15mg daily, gabapentin 500mg twice daily, amitriptyline 25mg daily, topiramate 25mg twice daily, ASA 81mg daily, ramipril 5mg daily, rosuvastatin 10mg daily, bisoprolol 2.5mg daily, metformin 500mg twice daily, venlafaxine 150mg daily, tamsulosin 0.4mg daily, finasteride 5mg daily, levothyroxine 50mcg daily, and certolizumab 200mg SC every 2 weeks. The patient and pharmacist decided on the following taper schedule based off opioid tapering guidelines and patient preference4,5: • morphine 10mg ER HS x 2-4 weeks, then • morphine 7.5mg IR HS + 2.5mg IR PRN for breakthrough pain x 2-4 weeks, then • morphine 5mg IR HS x 2-4 weeks, then • morphine oral solution 4mg x 2-4 weeks, then • morphine oral solution 3mg x 2-4 weeks, then • morphine oral solution 2mg x 2-4 weeks, then • morphine oral solution 1mg x 2-4 weeks Key considerations when discussing the tapering plan included patient willingness, physician support, previous experiences, withdrawal management, ongoing follow- up and a plan to pause the taper as necessary. He was followed-up with regularly during the tapering process for support and potential withdrawal effect management. Flexibility in the tapering schedule was emphasized to provide the patient with options to taper when he felt stable. Ultimately, a conservative approach allowed the patient to successfully taper off morphine with no major flare ups or withdrawal. This initial success without a resurgence in pain presented an opportunity to taper off the other chronic neuropathic pain medications. After discussing with him, he decided to taper off gabapentin. He suspected it might be causing some cognitive side effects and was eager to stop if possible. After long term use of various medication cocktails for chronic pain, patients are often willing to sit down and re-evaluate the need for these therapies. Pharmacists have a key role in planning the deprescribing process and offering patient support. It is important for pharmacists to emphasize the need to taper
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