Washington project goal: Increasing ECP access
A young woman who relies on a diaphragm for contraception goes out with her boyfriend Friday night and forgets to put the device in her purse. The next morning she worries about unintended pregnancy. She frantically calls her family practice physician, then realizes the office will be closed for a long holiday weekend. How can she get emergency contraceptive pills (ECPs) in that all-important 72-hour window?
If she is in Washington state, she may be in luck. An innovative pilot project is providing ECPs directly through pharmacist prescription. By calling a toll-free hotline, women can find the nearest participating pharmacy and obtain ECPs directly from the pharmacist there.
Increased access through pharmacist prescription does not mean ECPs will be offered over the counter (OTC), stresses Jane Hutchings, MPH, senior program officer for Program for Appropriate Technology in Health (PATH), an international nonprofit organization that works to improve health, especially that of women and children. The project is a collaboration among PATH, Washington State Pharmacists Associa- tion, University of Washington Department of Pharmacy, and Elgin DDB Needham advertising agency, all in Seattle, and is funded by the David and Lucile Packard Foundation in Los Altos, CA.
"It’s easy for people to think that through this project, emergency contraception is available without a prescription," she says. "It is not. It is just that the pharmacist is the person who’s writing the prescription. It is a big difference from OTC."
The project draws the ECP provider circle wide, using pharmacist prescriptive authority to increase the number of providers who can offer ECP access. This arrangement is better understood as collaborative drug therapy, says Don Downing, RPh, pharmaceutical care provider with the University of Washington, Washington State University in Pullman, and the Washington State Pharmacists Association.
Pharmacists in Washington do not have independent authority to write prescriptions, Downing says. They must obtain a collaborative agreement from a physician, nurse practitioner, nurse midwife, or clinical nurse specialist who has independent prescriptive authority. This agreement allows the pharmacist to write the prescription without the provider being present at the time of the transaction. These types of agreements were established in Washington more than 20 years ago. The collaborations allow state pharmacists to perform a range of services, many of which are more technically risky and complicated than the protocol involved in the ECP project, he observes.
Network, training in place
Pharmacists who are participating in the program have submitted a protocol that is co-signed by a physician or clinician with independent prescriptive authority to the state pharmacy association. Special training sessions have covered such issues as informed consent, contraceptive counseling, service to minors, and sexually transmitted disease referral, Hutchings says. Pharmacists receive a notebook with a list of referrals to clinics for ongoing contraceptive care and testing for sexually transmitted diseases, as well as sexual abuse reporting information. These referrals augment the relationship pharmacists already have with their collaborating independent prescriptive provider, she notes. Referrals are documented and tracked by pharmacists so health care providers maintain continuity of care, Downing says.
Names and locations of pharmacists are available through the national Emergency Contracep-tion Hotline (1-888-NOT-2-LATE) and World Wide Web site (http://opr.princeton.edu/ec/). A media campaign, including radio and print advertising, serves to heighten awareness about the project.
Once women locate a participating pharmacist, efforts are made to maintain confidentiality and ease any potential embarrassment, Downing says. "We train to make sure that the technicians or clerks who meet these people understand body language and confidentiality, so when a person comes in and says, I need to talk to a pharmacist about a problem I’m having,’ instead of just yelling back on a microphone, we’re trying to sensitize people to those kinds of needs."
Business-size cards with ECP information are available in the stores so consumers can hand them to a clerk or pharmacist as a silent signal for ECPs. Once interest is expressed in ECPs, women and pharmacists move to a more private area in the pharmacy so discussion can be held on the subject. Many pharmacies are remodeling to provide such counseling areas, he says. An intake form is filled out with demographic information and specific information on menstrual cycles and the date of the last unprotected intercourse. A bullet list of specific questions is asked in order to obtain informed consent.
If the criteria are met, a prescription is written and filled for ECPs and an anti-nausea medi-cine. Complete instructions and an anonymous evaluation survey are included in the package. According to pharmacists who are involved in the project, this entire level of service can be provided in 12 to 15 minutes, Downing says.
The collaboration among physicians, clinicians, and pharmacists is giving women a more complete circle of care, project coordinators say. One community clinic is including information about its collaborating pharmacy on its telephone answering message.
Providers are so enthusiastic about the program that they are calling to find pharmacists who are interested in participating in ECP collaborative agreements, Downing says. "Usually we are out there knocking on providers’ doors to get collaborators to agree to this. At this point, they are knocking on our door saying, We need you where are you?’"
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