Practice transition project sparks framework for team-based care

Chilliwack doc’s succession plan turns into success story for pharmacist collaboration

By Mari-Len De Guzman

What began as a succession planning project for Chilliwack family physician Dr. Cameron Ross has turned into a success story for patient-centred, team-based care — and a framework for ongoing collaboration between primary care providers and clinical pharmacists.

In anticipation of his pending retirement, Ross wanted to ensure a seamless transition for his patients as they are transferred to a new family doctor. As part of this effort, and with support from the FPSC Practice Support Program, Ross undertook a systematic medication review for a selected number of his patients who are on five or more medications.

“I was handing over my practice, and I was thinking of all the things that would make that transition better for my patients and for the new doctor,” Ross said. “One of the challenges is sometimes our medication lists are not accurate… so the prompt was to try to improve the continuity of care for all involved during the transition.”

Ross saw an opportunity to leverage the services of the Chilliwack Primary Care Network’s (PCN) clinical pharmacist Tamer Eid to help implement the project as a collaborator.

To start the pilot, Ross used the EMR dashboard to identify a cohort of 69 patients meeting the polypharmacy threshold. He then carefully triaged the list based on his deep knowledge of his panel. Patients with complex behavioral or mental health factors were kept under his direct review, while 30 to 35 patients deemed suitable for an independent clinical consultation were assigned to the clinical pharmacist.

Towards the end of the project, a key takeaway for Ross was the level of detail Eid provided in his review of the patients assigned to him. It’s a compelling proposition given the relentless time constraints family physicians face daily.

“Of particular value to me as a practitioner is the expertise applied from Tamer, and the ability to have some of this essential patient care done well by someone else, which in the long run should lead to increased provider capacity and improved patient outcomes,” Ross explained.

Time-saving teamwork

For Tamer Eid, the project highlighted how PCN clinical pharmacists can help alleviate the daily time crunch for family physicians, while enhancing patient-centred care.

For one, having full access to patient charts, lab results, specialist consults, and history within the clinic’s EMR allowed Eid to tailor his medication reviews to specific patients’ unique clinical profiles.

Ross recognized the value the clinical pharmacist has brought to the process in terms of time savings and the quality of patient review.

“He goes through all the charts and looks at all the consult notes and everything… he’s doing that heavy lifting, so I don’t have to go through years of notes,” Ross explained.

In addition to time efficiency outcomes, the impact on patient care was immediately evident. Eid’s deeper consultations with the patients provided space and time for them to ask questions and have a better understanding of their medication regimens.

“When you explain to the patient why they are taking this medication, what the goals are, in an easy-to-understand way, it changes their perspective completely,” Eid noted. “They feel heard, they feel listened to (and) that builds a huge amount of trust.”

Ross also noted that patient feedback had been generally positive, and they particularly appreciated the time Eid spent with them to go over their prescriptions.

“They found it very helpful to have someone sit down with them and go through their medications in detail,” Ross noted.

It also helped ease some of the patients’ anxiety about transitioning to a new family doctor after Ross’s retirement. “It gave them reassurance knowing that their medication list was being thoroughly cleaned up and organized as part of this transition.”

Eid said one of his takeaways from the project was the affirmation of the PCN clinical pharmacist’s role as a preliminary screen for complex medication profiles. Instead of the physician spending a significant amount of time reviewing each patient’s medication history, Eid was able to perform this exhaustive background work and summarize his findings into a concise report for Ross.

This pre-screening meant Ross could review Eid’s clinical findings and decide on treatment adjustments in minutes, without needing to manually go through years of medical records.

“When Tamer reviewed it, there was a very rigorous analysis,” Ross noted. “So my total time, aside from the time with the patient, would be as quick as three minutes and as long as five or 10 minutes to come up with very similar outcomes.”

Scaling for impact

As the project concluded, Ross and Eid both see the value of expanding this collaboration to other primary care practices across Chilliwack.

For Ross, the initiative provided a proven framework for physician succession planning, showing how PCN clinical pharmacists can help stabilize complex patient panels during practice transitions. He said he is recommending the pilot project be expanded and encouraged his colleagues at Crossroads Family Practice to consider implementing it and exploring a collaboration with the PCN clinical pharmacist.

For Eid, the pilot’s success highlights a broader opportunity to support more family physicians across the community. With the workflow framework established, he hopes more primary care providers in Chilliwack will leverage PCN clinical pharmacists as an allied health team member for complex medication management.

“I really hope that other physicians in Chilliwack see the value in this and feel comfortable reaching out,” Eid shared, emphasizing his eagerness to collaborate with more local clinics.

“My goal is to be a resource for them — to take that heavy medication review workload off their plates so they can focus on direct patient care.”