College of Dietitians of British Columbia

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

2. Overview • 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?

3. Background • 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

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

5. Aging population

6. Chronic disease

7. Inter-professional practice

8. What RDs said… • Perceived barriers– public domain practices, misperceptions about role/scope of RD practice • Actual practice barriers– practice iswithin the RD role/scope of practice but abarrier existswith another health care professional’s legislation

9. What is the issue? Pharmacists and parenteral nutrition ingredients

10. 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”)

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

12. 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) www.bcpharmacists.org

13. 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

14. 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

15. 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 • 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…

16. 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.

17. 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

18. 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

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

20. 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”

21. 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

22. Questions? Fern Hubbard, Registrar College of Dietitians of BC Phone: 604.736.2016 Toll free in BC: 1.877.736.2016 info@collegeofdietitiansbc.org