Community Pharmacists’ Expanding Roles In Supporting Patients Before And During COVID-19: An Exploratory Qualitative Study (preprint)

Background: Timely access and attachment to a primary healthcare provider is essential for population health outcomes. Patients without a family physician or nurse practitioner (“unattached”) or who cannot access their provider when needed may seek care from a community pharmacist. Community pharmacists are highly accessible in Canada and have a broad scope of practice. During the coronavirus disease 2019 (COVID-19) pandemic, community pharmacists took on additional roles. However, little is known about how community pharmacists managed the needs of unattached versus attached patients before and during the COVID-19 pandemic.Aim: To explore Nova Scotian community pharmacists’ roles in caring for patients before and during the COVID-19 pandemic and identifying barriers and facilitators to optimizing patient access.Method: Semi-structured interviews with community pharmacists across the province of Nova Scotia (Canada) were conducted. Data were analyzed using framework analysis.Results: Eleven community pharmacists were interviewed. Five key themes were noted: 1) rising pressure on pharmacists to meet unique health needs; 2) what pharmacists have to offer; 3) positioning pharmacists in the system; 4) pharmacist wellbeing; and 5) recommendations for practice post-pandemic.Conclusion: Before and during the pandemic, community pharmacists played a significant and increasing role in providing care to patients, especially unattached patients. With the growing number of unattached patients, it is vital community pharmacists are supported to provide additional services to care for the health needs of patients.

Emergency department utilization and hospitalizations for ambulatory care sensitive conditions among unattached people actively seeking a primary care provider during the COVID-19 pandemic: a retrospective cohort study (preprint)

Background: Primary care (PC) attachment improves healthcare access and prevention and management of chronic conditions. Yet, growing proportions of Canadians are unattached, signing-up on provincial waitlists. Understanding variations in healthcare utilization during COVID-19, and among potentially vulnerable unattached patients, is needed. This study compares emergency department (ED) utilization and hospitalization among those on and off a provincial PC waitlist, during the first two waves of COVID-19. Methods: Waitlist and administrative health data were linked to describe persons ever/never on the waitlist between January 1, 2017, and December 24, 2020. ED utilization and ambulatory care sensitive conditions (ACSC) hospitalization rates by current waitlist status were quantified from physician claims and hospitalization data. Relative differences during COVID-19 first and second waves were compared with the previous year. Results: During the study period, 100,867 Nova Scotians (10.1%) were on the waitlist. Those on the waitlist had higher ED utilization and ACSC hospitalizations. ED utilization was higher overall for individuals [≥]65 years and females; lowest during first two COVID-19 waves; and differed more by waitlist status for those <65 years. ED contacts and ACSC hospitalizations decreased during COVID-19 relative to the previous year, and for ED utilization this difference was more pronounced for those on the waitlist. Interpretation: Nova Scotians seeking PC attachment utilize hospital-based services more frequently than those not on the waitlist. Both groups had lower utilization during the COVID-19 pandemic than the year before. The degree to which forgone services produces downstream health burden remains to be seen.

COVID-19 – An Opportunity to Improve Access to Primary Care Through Organizational Innovations? (preprint)

Background: COVID-19 catalyzed a rapid and substantial reorganization of primary care, accelerating the spread of existing strategies and fostering a proliferation of innovations. Access to primary care is an essential component of a health care system, particularly during a pandemic. We describe organizational innovations aiming to improve access to primary care and related contextual changes, during the first year of the COVID-19 pandemic in two Canadian provinces, Quebec and Nova Scotia. Methods: We conducted a multiple case studies, based on 63 semi-structured interviews (n=33 in Quebec, n=30 in Nova Scotia) conducted between October 2020 and May 2021 and a review of related internal documents from both jurisdictions. We recruited a diverse range of provincial and regional stakeholders (e.g., policymakers, decision-makers, family physicians, nurses) involved in reorganizing primary care during COVID-19 using purposeful sampling (e.g., based on role, region). Interviews were transcribed verbatim and thematic analysis was conducted in NVivo12. Emerging results were discussed by team members to identify salient themes and organized into logic models. Results: We identified and analyzed six organizational innovations. Four of these - centralized public online booking systems, centralized access centers for unattached patients, and interim primary care clinics for unattached patients and community connector to health and social services for older adults – pre-dated COVID-19 but were accelerated by the pandemic context. The remaining two innovations were created to specifically address pandemic-related needs: COVID-19 hotlines and COVID dedicated primary healthcare clinics. Innovation spread and proliferation was influenced by several factors such as a strengthened sense of community amongst providers, decreased patient demand at the beginning of the first wave, renewed policy and provider interest in population-wide access (versus attachment of patients only), suspended performance targets (e.g., continuity ≥80%) in Quebec, in modality of care delivery, modified fee codes, and greater regional flexibility to implement tailored innovations. Conclusion: COVID-19 accelerated the uptake and creation of organizational innovations to potentially improve access to primary healthcare, removing, at least temporarily, certain longstanding barriers. Many stakeholders believed this reorganization would have positive impacts on access to primary care after COVID-19. Further studies should analyze the effectiveness and sustainability of innovations adapted, developed, and implemented during the COVID-19 pandemic.

The PUPPY Study – Protocol for a Longitudinal Mixed Methods Study Exploring Problems Coordinating and Accessing Primary Care for Attached and Unattached Patients Exacerbated During the COVID-19 Pandemic Year (preprint)

Background The COVID-19 pandemic significantly disrupted primary care in Canada, with many walk-in clinics and family practices initially closing or being perceived as inaccessible, pharmacies remaining open with restrictions on patient interactions, rapid uptake of virtual care, and reduced referrals for lab tests, diagnostics, and specialist care. The PUPPY Study (Problems Coordinating and Accessing Primary Care for Attached and Unattached Patients Exacerbated During the COVID-19 Pandemic Year) seeks to understand the impact of COVID-19 across the quadruple aim of primary care, with particular focus on the impacts on patients without attachment to a regular provider and those with chronic health conditions. Objective The PUPPY Study objective is to understand the impact of COVID-19 across the quadruple aim of primary care. Methods The PUPPY study builds on an existing research program exploring patients’ access and attachment to primary care, pivoted to adapt to the emerging COVID-19 context. We will undertake a longitudinal mixed methods study to understand critical gaps in primary care access and coordination, comparing data pre- and post-pandemic in three Canadian provinces (Quebec, Ontario, and Nova Scotia). Multiple data sources will be used including: a policy review; qualitative interviews with primary care policymakers, providers (i.e., family physicians, nurse practitioners, and pharmacists), and patients (N=120); and medication prescribing and healthcare billings. The findings will inform the strengthening of primary care during and beyond the COVID-19 pandemic. Results Funding was provided by the Canadian Institutes of Health Research COVID-19 Rapid Funding Opportunity Grant. Ethical approval to conduct this study was granted in Ontario (Queens Health Sciences & Affiliated Teaching Hospitals Research Ethics Board, file number 6028052; Western University Health Sciences Research Ethics Board, project 116591; University of Toronto Health Sciences Research Ethics Board, protocol number 40335), Québec (Centre intégré universitaire de santé et de services sociaux de l’Estrie, project number 2020-3446) and Nova Scotia (Nova Scotia Health Research Ethics Board, file number 1024979). Conclusions This is the first study of its kind exploring the impacts of COVID-19 on primary care systems, with particular focus on the issues of patient’s attachment and access to primary care. Through a multi-stakeholder, cross-jurisdictional approach, the PUPPY Study will generate findings and implications for future policy and practice.