College of Dietitians of British Columbia Update: Inter-Professional Agreement - CDBC and College of Pharmacists of BC October 23, 2009

Background what RDs said… what is the issue? Dietitians Regulation pharmacists’ legislation the problem and a possible solution Current status of IPA signed Agreement Professional Practice Policy outcomes Next steps? Overview

Conversations on Health (2007) changes to health care system desired by the public… the need for collaborative practice… Provincial Government Throne Speech (2008) …changes needed for more efficient and effective health care delivery… Registrant liaison sessions (2008/09) enhance practice/expand scope identify barriers to practicing full scope Background

Masset Terrace Smithers Fort St. John Revelstoke Fernie Cranton Trail Chase/ Salmon Arm Oliver Penticton Merritt Port Hardy Campbell River Port Alberni Burnaby/ New West/ Surrey Chilliwack White Rock Langley/ Ridge Meadows Duncan Nanaimo Courtenay/Comox Powell River Sechelt

Aging population

Chronic disease

Inter-professional practice

1.Perceived barriers – public domain practices, misperceptions about role/scope of RD practice 2.Actual practice barriers – practice is within the RD role/scope of practice but a barrier exists with another health care professional’s legislation What RDs said…

What is the issue? Pharmacists and parenteral nutrition ingredients

Dietitians Regulation Restricted Activities: …a registrant who meets additional qualifications may… (b) design therapeutic diets if nutrition is administered through parenteral means (Note: CDBC interpretation: “design” includes “re- design” which is the same as “adjust”)

Pharmacists’ legislation Pharmacists may only dispense drugs on order from “authorized practitioners” – physicians, nurse practitioners, dentists, mid-wives, veterinarians

Pharmacists’ legislation Drug Schedules Act (2008) Schedule I - Prescription Schedule IA - Controlled Prescription Program Schedule II - Professional Service Area (eg. insulin, oral hypoglycemics) Schedule III - Professional Products Area Schedule IV - Prescription by Pharmacist Non-scheduled (eg. vitamins, minerals to a specified dose)

The problem In a parenteral formula: –vitamins/minerals that are normally unscheduled are considered Schedule I drugs –insulin and oral hypoglycemics that are normally Schedule II drugs are considered Schedule I drugs Schedule I drugs require a prescription from an “authorized practitioner” Dietitians are not “authorized practitioners” Therefore pharmacists cannot accept an RD’s “order” or request to adjust (re-design) a therapeutic diet

A possible solution… Develop an Inter-professional Agreement (IPA) between the CDBC and College of Pharmacists of BC (CPBC), with… limits and conditions that allow: –Pharmacists: to accept dietitians’ authority to relay the physician’s original order, –Physicians: to rely on the dietitian to send in the therapeutic diet ordered and monitor the patient’s response –Dietitians: to relay the physician’s order to the pharmacist without going back to the physician or requesting the assistance of another health care professional

Current status of the IPA Signed June 17, 2009 by CDBC & CPBC Registrars: The CDBC and CPBC agree that, 1)on the direct request of a Registered Dietitian, Pharmacists may dispense: oral vitamins and minerals (un-scheduled), or insulin (Schedule 2) AND 2)when a practitioner orders a RD to assess and design a nutritional or therapeutic care plan, the RD has the authority to request the Pharmacist to accept and dispense macronutrients, micronutrients, insulin and oral hypoglycemic agents when…

Current status of the IPA the RD’s authority is consistent with practice setting policies/protocols, the Pharmacist meets CPBC’s Professional Practice Policy, and the RD: has received an order from a practitioner for a nutritional or therapeutic care plan, complies with the CDBC’s Professional Practice Policy, and meets CDBC’s standards for professional judgment as outlined in the Code of Ethics and Standards for Practice.

Current status of IPA Examples of orders from practitioners: Parenteral feeding: TPN as per RD Diabetic client: Adjust insulin/ OH as per RD Iron deficiency: assess for supplements as per RD

Current status of IPA To note: Practices within RD role/scope of practice may always be defined or restricted by facility policies/protocols… … including a facility not allowing physicians, pharmacists and RDs to participate in this Agreement

CDBC’s Professional Practice Policy Appropriate Information Notification Documentation Limits and Conditions Informed Consent Consultation Competence

Outcomes Client outcomes: Increase clients’ timely access to therapeutic nutritional ingredients that optimize their ability to attain health Practice outcome: Removal of role/scope barrier for RDs Government outcome: From the 2008 Throne Speech… there’s a need “for more efficient and effective health care delivery”

Next steps? draft Inter-professional Agreement between the CDBC and CPBC CDBC committee review and feedback CDBC Board approval in principle CPBC official consultations signatures of both College Registrars acceptance from the government (or an amendment to the pharmacists’ legislation) common education materials developed by CDBC and CPBC and circulate to registrants of both Colleges as an approved change in practice (with limits and conditions) Liaison sessions to explain the Agreement and practice implications

Questions? Fern Hubbard, Registrar College of Dietitians of BC Phone: Toll free in BC: