Patient perceptions and experiences receiving care from pharmacists in team-based primary care in British Columbia

Abstract

Background:

The University of British Columbia Faculty of Pharmaceutical Sciences led the 3-year implementation of the Pharmacists in Primary Care Network (PCN) Program in collaboration with regional health authorities and PCNs across British Columbia (BC). Primary care clinical pharmacists (PCCPs) were integrated into 47 PCNs from October 1, 2020 to September 30, 2023. Our study aimed to describe the experiences of patients after receiving care from a PCCP as a member of the interprofessional team in PCNs.

Methods:

This study was conducted as part of the program evaluation and was informed by qualitative description methodology to produce themes. Patients who had 2 or more appointments with a PCCP were randomly selected to participate, with representation stratified by health authority and PCN location.

Results:

We interviewed 39 patients who participated in 6 focus groups across 5 BC health authorities. Patients perceived positive changes in health management since working with PCCPs owing to their PCCP’s support with comprehensive medication reviews, patient education, and empowerment. Patients also appreciated their PCCP’s patient-centred approach, specialized knowledge, professionalism, and flexibility. Patients felt there was insufficient public awareness about the program and the PCCP role. Some patients also criticized having the family physician or nurse practitioner as the sole access point to the PCCP.

Interpretation and conclusion:

Patients’ experiences were overall positive after receiving care from a PCCP. Patients recommended promoting the program directly through social media, posters, newsletters, and billboards. In addition, self-referral and referrals from any health care provider within the PCN to PCCPs would enhance accessibility and optimize service uptake. Can Pharm J (Ott) 2025;158:xx-xx.

Knowledge into Practice

• Pharmacists are becoming more frequently integrated into primary care teams, both nationally and internationally, as one of the most accessible health care professionals.

• Reflecting on patient experiences receiving care from a primary care clinical pharmacist (PCCP) in British Columbia reveals the critical role pharmacists play in delivering patient-centred care which empowers patients to take control of their own health.

• System-level barriers such as limited public awareness of the Pharmacists in Primary Care Network Program and lack of patient self-referral to a PCCP should be addressed to enhance accessibility and service utilization by patients.

De la connaissance à la pratique

• Les pharmaciens sont de plus en plus fréquemment intégrés aux équipes de soins primaires, tant à l’échelle nationale qu’internationale, en tant que l’un des professionnels de la santé les plus accessibles.

• Une réflexion sur l’expérience des patients qui reçoivent des soins d’un pharmacien clinicien en soins primaires (PCCP) en Colombie-Britannique révèle le rôle essentiel que jouent les pharmaciens dans la prestation de soins axés sur le patient, ce qui permet à ce dernier de prendre en main sa propre santé.

• Les obstacles à l’échelle du système, tels que la faible sensibilisation du public au Pharmacists in Primary Care Network Program et le manque d’auto-orientation des patients vers un PCCP, doivent être résolus afin d’améliorer l’accessibilité et l’utilisation des services par les patients.

Introduction

The pharmacy profession has been in an evolving state of change to align pharmacist roles and scope with the needs of patients and society. Pharmacists have the training, skills, and abilities to meet these needs through the provision of comprehensive medication management to identify and resolve drug therapy problems and optimize health outcomes for patients. ¹ The benefits to patients who receive care from a team of health care providers, which includes a pharmacist, across all settings, are well-established.^2,3 The integration of pharmacists into team-based primary care teams across Canada has been supported by both pharmacists and family physicians.^4-6 The first integration of pharmacists into family health teams in primary care occurred in Ontario, where it continues to be the most established.^7,8 The integration in Ontario in the early 2000s of pharmacists into team-based primary care in other provinces has evolved with varying pace, approach, and models. ⁹ Outside Canada, pharmacists have been well-established into primary care practices, including in the United Kingdom, Ireland, and Australia.^10-12

In June 2018, the British Columbia (BC) government announced new funding for a program to integrate pharmacists into team-based primary care practices. ¹³ The integration of pharmacists is one part of a large and complex process within the BC health care system to enhance the way team-based primary care is delivered and to establish, for the first time in BC, a comprehensive team-based primary care model built around Primary Care Networks (PCNs). ¹⁴

The 3-year implementation of the Pharmacists in PCN Program (the program) was led by the Faculty of Pharmaceutical Sciences at the University of British Columbia between October 1, 2020 and September 30, 2023. ¹⁵ The program worked in collaboration with the BC Ministry of Health, regional health authorities, and PCNs to integrate primary care clinical pharmacists (PCCPs) as core members of the interprofessional team. Pharmacists provided expertise in drug therapy decision-making for complex patients and were expected to reduce the number of drug-related problems; reduce unnecessary and negative drug therapy consequences; increase patient, family, caregiver, physician, pharmacist, and health care team satisfaction; and enhance information sharing and collaboration between pharmacists and other members of the patient care team within PCN communities.^15,16 Patients were attached to their PCCP following a referral from a family physician or nurse practitioner. Initial appointments were scheduled for 60 minutes, and follow-up appointments were 30 minutes. Appointments took place in-person or using telehealth platforms. The first period of program implementation occurred during the COVID-19 pandemic, and as such, the types of appointments were dictated by provincial guidelines on how patients were permitted to access their primary health care team. Further details of the program, including governance, program team and resources, program structure and approach, as well as implementation outcomes, are described elsewhere. ¹⁶

A comprehensive mixed-methods evaluation was executed in parallel with program implementation. The evaluation was designed to broadly understand how the implementation processes and clinical care provided by the program affected user experiences (i.e., patients, pharmacists, physicians, nurse practitioners, health authority representatives, PCN administrators, PCN interprofessional team members, and community pharmacists) and quality of care when receiving care from a PCCP as a member of the interprofessional team in PCNs. More detailed perspectives and experiences of implementation, as well as the quality of care outcomes, will be published separately. ¹⁶

The objective of this article is to describe patients’ perceptions and experiences receiving care from a PCCP as a member of their interprofessional team in primary care.

Methods

The qualitative study design was informed by qualitative description (QD) methodology to evaluate patients’ experiences in the program.^17,18 Data collection took place in October and November 2023.

Setting and participants

Participants were selected through stratified random sampling with disproportionate allocation. ¹⁹ Patients with 2 or more appointments with PCCPs were recruited for focus group interviews. From the program’s electronic health record (OSCAR Rx v15.10 (07/19/2020), Colcamex Resources Inc., Vancouver, BC), patient records were pooled and organized by health authority and then further grouped by their PCN location. This stratification was conducted to ensure geographic representation across BC and the various regions within the health authorities. Each focus group was organized by the 5 health authorities in BC and aimed to have a minimum of 5 and a maximum of 10 participants. Due to varying numbers of eligible patients within each PCN location, fixed allocation percentages were defined for participant selection using the following criteria: (1) 100 patients or more (20% were randomly selected), (2) 50 to 99 patients (30% were randomly selected), (3) 20 to 49 patients (40% were randomly selected), (4) 6 to 19 patients (50% were randomly selected), and (5) ≤5 patients (100% were selected). Using this method of disproportional allocation, PCN locations with diverse eligible patient ranges were appropriately represented among their respective health authority-specific focus groups. The selected patients were sent an e-mail invitation to participate. All participants received a $40 gift card for their participation.

Data collection

The focus group interviews were held over Zoom for 2-hour sessions with the evaluation team members (A.N. or A.S.) acting as the interviewer and another as the note taker. An interview guide (Appendix 1, available online under Supplementary Materials) was used to facilitate the sessions and was informed by the evaluation framework. The domains explored included the care they received, the confidence they had in the PCCPs, challenges, and experiences receiving care from the PCCPs as well as from family physicians and community pharmacists. Consent was obtained from all participants, and all interviews were audiorecorded and transcribed verbatim by a third-party professional transcription company.

Data analysis

The analysis was informed by QD methodology, which is a generic qualitative methodology commonly used in research studies in health care^17,18 and “involves research designed to produce a low-inference description of a phenomenon.” ²⁰ Accordingly, we implemented content analysis and thematic analysis, which are the common analysis approaches used in research adopting QD methodology.^17,20-22 We developed a coding framework and embedded it within NVivo 12™ (Lumivero, Denver, CO, USA) as a supporting software. We revised the coding framework based on regular meetings and deliberations between research team members (A.N. and A.S.), while disagreements on coding were resolved via open dialogue and discussions. Analysis of interview data progressed from a descriptive level, using traditional content analysis and coding to try to capture meanings and obtain a “first feel” of what was going on in order to identify patterns and similarities inside and between interviews. Analysis then evolved to a more conceptual level by connecting and grouping the data into categories to inductively develop final themes. Furthermore, we prepared analytic memos in the form of descriptive notes and interpretative comments based on in-depth readings of the entire dataset for each focus group while considering how these data or sections of the dataset help to comprehend the overall picture. The triangulation strategy for enhancing the credibility of our data entailed having more than 1 researcher carry out the data analysis.

Results

We interviewed 39 patients who participated in 6 focus groups across 5 BC health authorities (Vancouver Island [18], Vancouver Coastal [8], Fraser [8], Interior [3], Northern [2]). The mean (standard deviation [SD]) age of the participants was 61.1 years (13.1), and 69.2% were female. The median (interquartile range) number of patient appointments with a PCCP was 6 (3–10). The patients’ experience with receiving care from a PCCP included 4 themes: (1) PCCP impact on patient health management, (2) patient confidence in PCCP support, (3) patient involvement in the decision-making of their care, and (4) patient awareness of the program and the PCCP’s role. Overall, patients found that the PCCPs supported their care provisions through a patient-centred care approach, specialized knowledge, professionalism, and flexibility.

PCCP impact on patient health management

When asked about the changes in health management since working with PCCPs, many patients shared the various ways that PCCPs improved the management of their medical conditions. Patients attributed the changes in their health to the PCCP’s support with patient education, comprehensive medication reviews, patient empowerment in care management, and consistent monitoring. Specifically, PCCPs provided medication management for chronic diseases, which included but were not limited to diabetes, cardiovascular, and kidney diseases.

“It has been exceptional in terms of getting me to a place (probably for A1C and weight) down to the point of meeting my needs but also seeing if I needed anything.” (Participant 4 in patient focus group 1)

“I originally met with the PCCP to go over my medications but also my doctor had asked if I wanted to try going on Ozempic for weight loss. I have been speaking with the PCCP at least every 2 weeks and he has been monitoring me, checking in with me, increasing my dosage very gradually. He knows all about the side effects. He can tell me up-to-date research because I am really interested. I always have lots of questions for him and so rather than just go to the Internet, I just wait until I am going to talk to him and ask all the questions. There is no way my doctor would have time for this. I would just be given a prescription and the pharmacist at the drug store would be too busy to answer my questions.” (Participant 7 in patient focus group 1)

In providing comprehensive medication reviews, PCCPs educated patients about their medications and supported adherence.

“I have an underlying autoimmune condition and a couple other conditions that make me a complex patient. Being able to access the primary care clinical pharmacist, they could spend a little bit more time with me than my family physician, could go through the medications that I was currently on, the medications that my doctor wanted to put me on, how those medications could potentially interact, provide me with some direction on the best times to take the medications, which ones I should and shouldn’t take together if I was on supplements. I was getting a more comprehensive overview of the medications used to treat my underlying medical conditions while keeping in mind my ability to become compliant.” (Participant 4 in patient focus group 4)

Patients felt well-supported as the PCCPs collaborated with them, their community pharmacist, and their family physician to provide individualized patient-centred care. They highly valued the ongoing support from PCCPs in their health management.

“I wanted to try a new drug to deal with my diabetes and my doctor was quite receptive and then referred me over to [PCCP name] to help me through that and he was absolutely marvelous. He introduced me to this drug very slowly and we talked every couple of weeks. A couple of other health issues came up during this introduction to the med and he very gently talked to me about other items that were going on with my health and that’s one thing I really enjoyed about it. He would work with my doctor along with my pharmacy as well. It was kind of a three-way thing going on here. I was very appreciative of his expertise and his patience because I had to phone him a couple of times outside of our scheduled calls because I was having some concerns and he dealt with it immediately.” (Participant 7 in patient focus group 2)

With the PCCP’s extensive knowledge base on drug–food interactions, many patients felt educated on new approaches to manage their health.

“I found him [PCCP] really thorough and asking a lot of questions and the more he was asking me, the more I was remembering. He focused a lot on what really helped me, the drug interactions that could occur, or the possibility of a syndrome. Not even necessarily other drug interactions but just how food could affect the medication you take or a different combinations of things. You would not think of it. That was really smart of him. Things to watch out for; it was new information for me but really interesting.” (Participant 5 in patient focus group 1)

Some patients shared their reluctance to advocate for their health in the current health care system. Those patients felt that the PCCP empowered them to communicate and collaborate with their family physician or nurse practitioner and other health care professionals to advocate for their health. PCCPs also supported some patients by providing choices that could alleviate the financial burdens they faced.

“One of the medications I was able to taper myself off was at the recommendation of the PCCP and she was like, ‘My recommendation would be this. I will put it in my report to the doctor. But if you feel confident that you can start to taper yourself off then do not wait for my report to go.’ I was like, ‘Okay, I’ll start following this plan.’ Then the next time I talked to my family physician, and we did my annual go through all the things meeting, I said, ‘Did you get the report from the PCCP?’” (Participant 4 in patient focus group 4)

Patient confidence in PCCP support

Through establishing a strong rapport and thoroughness in their strategies to support patients, the PCCPs instilled confidence in the patients through patient-centred care.

“I was very confident going in because I felt like the PCCP was one of the only persons that has actually taken the full story of everything from all the different problems I was experiencing and put it all into one. The actual research and time that she took to do that, and it was a very good two-way conversation. There was a lot of support there, so I felt confident in that, and it has been an ongoing process. I feel like she has a genuine care to herself, and she wants to see me reach my goals.” (Participant 3 in patient focus group 3)

With progress made in reaching patient health goals, patients shared their confidence in the care the PCCPs provide with evidence-based recommendations.

“I have been working with my PCCP for about a year now and I would say for me a hundred percent confidence based on the evidence and data behind what we have been able to achieve. I would say for me it is seeing the results and the evidence based on the direction he [PCCP] is taking me. At this point, I have no doubts with the level of care I am receiving because we are certainly moving in the right direction.” (Participant 8 in patient focus group 1)

Many patients emphasized the confidence and reassurance they felt from having a PCCP on their health care team owing to the PCCP’s extensive knowledge and skills to support patient health needs.

“I have never actually had anybody go over my medications, so her [PCCP] knowledge of what each medication did blew me away. She helped my nurse practitioner along with my medications so I could not be more confident in what was happening. I walked out of that going, ‘Okay, somebody is taking care of my meds.’ So, I am completely confident.” (Participant 8 in patient focus group 1)

Patient involvement in the decision-making of their care

Reflecting on the care patients received from PCCPs, many patients shared that they felt in control of making decisions about their health owing to the collaborative approach taken by PCCPs as they encouraged shared decision-making and invited discussions with patients.

“I definitely felt confident that I had a say in it. I would say that these were discussions we had and if anything, what was being proposed was a discussion where my PCCP would provide me with information, answer my questions, and then he would pose the course of treatment to see what I thought. I definitely felt like I had a say in it, and I felt well-informed based on the information that he would provide and some of the evidence and research that he was using to help inform my decision.” (Participant 4 in patient focus group 1)

Some patients recognized the active role they can play in decision-making and managing their own health by engaging in conversations with the PCCPs about their recommendations.

“Overall, it was a really good experience and I think it was a bit of a wake-up call in terms of knowing a little bit more and not just accepting. There is so much to take, just keep taking it. Put your head down and move forward. You need to be a more active participant in your own health care and also to have some guidance with it because we are not experts on this stuff. You get to talk with a learned person and ask some harder questions. It is a wonderful thing to help you out on your journey to wellness.” (Participant 5 in patient focus group 4)

A few patients compared experiences of their involvement in decision-making with PCCPs and their family physician. They found that PCCPs provided holistic patient-centred care that encouraged patient involvement, whereas there were many systemic challenges with their family physician that interfered with that process.

“With the PCCP, I definitely feel at least a little more in control or I have more of a say. There have been a couple of things the PCCP has really recommended strongly, and my GP said, ‘no.’ There is that frustration. In general, it has definitely helped me feel a tiny bit more in control, but the health care system is so broken.” (Participant 9 in patient focus group 1)

Patient awareness of the program and PCCP role

Some patients felt there was not enough knowledge and public awareness of the program across the province and what the PCCP role entails and therefore suggested measures directed toward enhancing PCCP role promotion and program awareness.

“Put it on social media, community pharmacy, physician’s office, all of the groups that you work with having some sort of representation of the program in those places. Have it as a poster. Speak to your family physician about access to [PCCP]. There needs to be a campaign and it needs to be on billboards. It needs to be outside, e-mailed, digital so you’re reaching everybody. Because everybody consumes their news and information in different ways, whether it’s paper or online. I think that’s obviously at a government level, communication and advertising and just general knowledge and awareness.” (Participant 4 in patient focus group 4)

In addition, patients shared criticism of having the family physicians or nurse practitioners as the sole access point to the program.

“For this specific program, until my family physician brought it up, I did not know it existed because I would have advocated for myself to work with a team given the complex nature of my chronic conditions. If you cannot advocate for yourself and your family physician is not advocating for you or does not know that the program exists, I would just say that was for me the biggest inhibitor was not knowing the program existed until my doctor brought it up.” (Participant 4 in patient focus group 4)

Discussion

Our study offers insights into patients’ perceptions and experiences receiving care from a PCCP within an evolving team-based primary care model in BC. The patient experience was overwhelmingly positive and in line with a patient-centred, comprehensive care approach offered by PCCPs, an important objective of the program. Patients perceived positive changes in managing their own health since working with PCCPs and felt improvements in their medical conditions. Changes were largely attributed to the PCCP’s support with comprehensive medication reviews, patient education, patient empowerment in care management, and consistent monitoring and follow-up. Patients also described developing a strong rapport with their PCCP and overall established high confidence in their care to help them achieve their personalized health goals. Patients felt in control of making decisions about their health owing to the collaborative nature of the relationship with their PCCP.

Findings from our study are supported by evidence from Australia ²³ and the United Kingdom, ²⁴ where researchers concluded that patients valued the input and had positive perceptions toward primary care pharmacists practising in physician’s offices. In these studies, patients were also extremely satisfied with pharmacist-led consultations and medication reviews owing to the pharmacist’s expertise, attitude, and knowledge. Kozminski et al. ²⁵ from the United States examined the acceptance and attitudes of patients with integrating pharmacists into family physicians’ offices/clinics that functioned as patient-centred primary care medical homes. Similar to our findings, patients reported feeling motivated and empowered to manage their own health and take their medications as prescribed. Patients specifically appreciated the proximity of having their physician and pharmacist practice within the same space (i.e., co-location) while working collaboratively to optimize patient care, an aspect that increased the patient’s trust. Furthermore, research from Ontario on the benefits of integrating pharmacists in interdisciplinary family health teams and community health centres concluded that patients appreciated the pharmacist role, especially in eliminating the unnecessary use of medications/deprescribing and optimization of drug regimens.^5,8

Despite all participants having the opportunity to receive care from a PCCP, patients were critical of the lack of public awareness of the program and the PCCP role and how their physician is the main access point to the program, leaving patients without a family physician or who are not aware of the program with the inability to access and receive care from a PCCP. This perspective was also highlighted in a study by Karampatakis et al. ²⁶ from the United Kingdom, where almost all patient participants underlined the importance of promoting the presence of pharmacists in general practice/PCNs to enhance patient awareness, access, and use of pharmacists’ expertise. Accordingly, as suggested by our patient participants, measures directed at increasing program awareness and promoting the PCCP role among citizens of BC are needed, including how the PCCP role differs from pharmacists working in other practice settings, such as the community or hospital. In addition, allowing patient self-referrals and removing the requirement of a physician or nurse practitioner would also improve patient access to PCCPs.

Among the limitations of this study is that only patients who were able to speak and comprehend in English were eligible to participate. Consequently, this limits the transferability of our findings to patients who can communicate and understand the English language. Another limitation is that patient participants were sharing their perspectives and reflecting on their experiences receiving longitudinal care from a primary care pharmacist working as a member of the PCN interprofessional team; therefore, findings from our study might not be necessarily transferable to other pharmacy practice settings such as community, hospital, and ambulatory, or different models. Despite this, all participants met the inclusion criteria and so had experiences and opinions relevant to the study objectives. Researcher bias is also a potential limitation since 1 of the 2 research team members involved in data collection and analysis (A.N.) is a pharmacist and has experience practising in the primary care setting. Consequently, they may have some degree of pre-existing bias that could have influenced the data analysis and interpretation of findings.

Conclusion

Patients’ positive experiences with receiving care from PCCPs are a reflection of the success of the integration of pharmacists in primary care team-based settings, in an effort to achieve the goal of optimizing the provision of patient-centred care. However, this goal is hindered by the lack of public awareness of the existence of pharmacists in primary care settings and having family physicians as the main access to PCCPs. Accordingly, patients recommended promoting the program more broadly and improving patient access through self-referral and referrals from any health care provider within the PCN to PCCPs. ■

Supplemental Material

sj-pdf-1-cph-10.1177_17151635251380295 – Supplemental material for Patient perceptions and experiences receiving care from pharmacists in team-based primary care in British Columbia

Supplemental material, sj-pdf-1-cph-10.1177_17151635251380295 for Patient perceptions and experiences receiving care from pharmacists in team-based primary care in British Columbia by Arwa Nemir, Anupama Salil, Anita I. Kapanen and Peter J. Zed in Canadian Pharmacists Journal / Revue des Pharmaciens du Canada