Pharmacy 08 00234 v3
Pharmacy 08 00234 v3
Pharmacy 08 00234 v3
Review
The Evolving Role and Impact of Integrating
Pharmacists into Primary Care Teams: Experience
from Ontario, Canada
Manmeet Khaira 1,2 , Annalise Mathers 1 , Nichelle Benny Gerard 1 and Lisa Dolovich 1,2,3, *
1 Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St, Toronto, ON M5S 3M2, Canada;
manmeet.khaira@hotmail.com (M.K.); annalise.mathers@utoronto.ca (A.M.);
nichelle.bennygerard@mail.utoronto.ca (N.B.G.)
2 School of Pharmacy, University of Waterloo, 10 Victoria St S, Kitchener, ON N2G 1C5, Canada
3 Department of Family Medicine, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
* Correspondence: lisa.dolovich@utoronto.ca; Tel.: +1-416-978-3188
Received: 31 October 2020; Accepted: 5 December 2020; Published: 7 December 2020
Abstract: The movement to integrate pharmacists into primary care team-based settings is growing
in countries such as Canada, the United States, the United Kingdom, and Australia. In the province
of Ontario in Canada, almost 200 pharmacists have positions within interdisciplinary primary care
team settings, including Family Health Teams and Community Health Centers. This article provides
a narrative review of the evolving roles of pharmacists working in primary care teams, with a focus
on evidence from Ontario, as well as drawing from other jurisdictions around the world. Pharmacists
within primary care teams are uniquely positioned to facilitate the expansion of the pharmacist’s
scope of practice, through a collaborative care model that leverages, integrates, and transforms the
medication expertise of pharmacists into a reliable asset and resource for physicians, as well as
improves the health outcomes for patients and optimizes healthcare utilization.
1. Introduction
Although pharmacists are the most accessible and visited healthcare professionals in the
world, the contributions that pharmacists make to interdisciplinary healthcare settings often remain
overlooked [1–3]. It is known that poor communication and connectivity between healthcare
professionals can fragment patient care, is a significant contributor to the development of drug-related
problems (DRPs), and results in poorer health outcomes and experiences [4–6]. Moreover, since most
prescribing of medications occurs in primary care, defined as a “whole-of-society approach to health
and well-being” that addresses the broader determinants of health [7], pharmacists have an integral
role in providing education and information about the appropriate and safe use of medications to
patients, as well as to other healthcare professionals [8]. Healthcare professionals who work within a
primary care team (PCT) have significantly improved communication and coordination, are optimally
placed to detect and resolve DRPs, and can improve the availability and efficiency of healthcare [9,10].
In the past two decades, the movement to include pharmacists as essential members of PCTs
has gained traction in a number of countries, including Canada [9,11,12], the United States [13–15],
the United Kingdom [16,17], Australia [18], Malaysia [19–21], and Brazil [22]. Pharmacists integrated
into interdisciplinary PCTs globally demonstrated their significant role in many direct patient care
activities, including medication management, identifying adverse or incorrect medication usage,
Table 1. Selected major activities performed by pharmacists in Family Health Teams (FHTs) in Ontario i .
In contrast to other pharmacy settings, pharmacists working in PCTs have additional roles that
emerge when working with other healthcare professionals [33]. For example, pharmacists working in
Ontario FHTs reported that their role was more strongly anchored in supporting healthcare professionals
to manage medication use, locally implement national health priorities, arrange access to funding
and health services, as well as design treatment pathways for patients [34]. The wider scope of a
pharmacist’s clinical duties in PCTs, which can include point of care anticoagulation monitoring in
specialty PCT clinics, and direct collaboration with other healthcare professionals was shown to result
in a longer acclimatization process for pharmacists in FHTs across Ontario, than for pharmacists in other
practice settings [35]. However, research in Canada and the United Kingdom suggests that pharmacists
working in primary care are well-positioned to build relationships with pharmacists working in
community and hospital settings and ultimately collaborate to provide patient care that is coordinated
across pharmacy settings. This might include monitoring of patients started on new medications,
patients transitioning between healthcare environments, and improved accuracy and continuity of
medication review assessments, and other healthcare information [36,37]. These intra-professional
relationships and roles are critical to facilitate improved patient care. In the United Kingdom, a pilot
project integrating nearly 1500 pharmacists into PCTs highlighted the additional roles of pharmacists
responding to hospital discharges and prescribing, which, unlike in many other countries, pharmacists
have the authority to do in the United Kingdom [38].
These findings are further supported by a randomized control trial in Malaysia for patients with diabetes,
hypertension, and hyperlipidemia, in which pharmacists were able to identify a medication issue in over
50% of patients [21]. Pharmacists were able to convey these issues to physicians, who implemented 87%
of the pharmacist’s recommendations [21]. Collectively, these findings demonstrate that pharmacists
in PCTs are able to identify and address medication discrepancies and DRPs, to improve medication
management, the provision of appropriate prescribing and simplifying patient’s medication regimens.
The impact of pharmacist-led interventions in PCTs for elderly patients also improved medication
adherence and reduced emergency room visits and hospitalizations due to DRPs [32], as well as
improved prescribing appropriateness [42] in Ontario and globally. These improvements are particularly
significant among polypharmacy patients [43]. Pharmacists in Ontario-based PCTs also showed
improvements for chronic condition management among patients on medications for diabetes [44]
and anticoagulation [35], which is also complemented by additional evidence from the province of
Alberta, Canada, for improvements in blood pressure and cholesterol [45]. These studies demonstrate
the pivotal and proactive role pharmacists play in optimizing patient care, when integrated into PCT
settings around the world.
the visibility and credibility for the role of pharmacists in PCTs [26]. Furthermore, the Pharmacy
Specialty Network (PSN) developed by the Canadian Society of Hospital Pharmacists and the Canadian
Pharmacists Association, enables pharmacists to share practice-based resources; develop, support,
and maintain networking opportunities for pharmacists; advocate for the role of pharmacists in
PCTs; and provide education and training to its members, including mentorship opportunities for
pharmacists new to PCT settings [63]. The development of Pharmacist Program Toolkits by the
IMPACT project (Integrating Family Medicine and Pharmacy to Advance Primary Care Therapeutics;
www.impactteam.info) provides guidance and strategies for PCTs to successfully integrate pharmacists
alongside other healthcare professionals. To provide additional resources for PCT pharmacists,
the Ontario Pharmacists Association developed a toolkit [64] that pharmacists can leverage to practice
to their full scope.
8. Conclusions
Pharmacists in Ontario are now formally funded by the public healthcare system to be members
of the interdisciplinary healthcare team. There is a growing evidence base that describes the role and
impact of Ontario-based PCT pharmacists, which is consistent with evidence emerging worldwide.
Pharmacists within PCTs are uniquely positioned to facilitate the expansion of the pharmacist’s scope
of practice through a collaborative care model that leverages, integrates, and transforms the medication
expertise of pharmacists into a reliable asset and resource for physicians. Further research in Ontario is
needed to quantify the effectiveness of PCT pharmacists on health outcomes, and the resulting impact
on healthcare service use and costs.
Author Contributions: Conceptualization, L.D. and M.K.; methodology, L.D. and M.K.; formal analysis, L.D.,
M.K., A.M., and N.B.G.; investigation, L.D., M.K., A.M., and N.B.G.; data curation, M.K., A.M., and N.B.G.;
writing—Original draft preparation, M.K.; writing—Review and editing, L.D., M.K., A.M., and N.B.G.; supervision,
L.D.; project administration, L.D.; funding acquisition, L.D. All authors have read and agreed to the published
version of the manuscript.
Funding: This research results from an Applied Health Research Question submitted by The Association of Family
Health Teams (AFHTO) to the Ontario Pharmacy Evidence Network (OPEN). OPEN was funded by a grant from
the Government of Ontario (grant #6674). The views expressed in this manuscript are those of the authors and do
not necessarily reflect those of the funder.
Acknowledgments: The authors would like to acknowledge the contributions of Divjyot Kochar who helped
with aspects of writing review and editing.
Conflicts of Interest: The authors declare no conflict of interest.
Pharmacy 2020, 8, 234 7 of 10
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