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Table 2 Barriers and Enablers of MTM for Persons with SCI/D with Participant Quotes and Recommendations

From: “The strategies are the same, the problems may be different”: a qualitative study exploring the experiences of healthcare and service providers with medication therapy management for individuals with spinal cord injury/dysfunction

1. Patient self-management skills including knowledge of SCI/D-specific medications and information seeking behaviors
Maybe it’s the educational level of the person. If it’s really, really, rudimentary level then it’s a little bit – can be a little bit tough, you know, to reinforce certain ideas. (C08, Community Pharmacist)
…they want to know more and they want to be educated more, but sometimes where they get their education, their resources are not, are not appropriate sites. (C09, Community Pharmacist)
The longer the person has [the] injury, the more insight they have into their body and you have to give credit... I could say once they are, you know, more medically stable, you really need to listen to them and listen to how they want to live their life and how you can complement their life with the medication to control the spasms, to control the pain at the right time so that they can have a meaningful life. (C14, Occupational Therapist)
…one of the ways that individuals with spinal cord injury… cope with a primary care practitioner who may only have one or two people with spinal cord injury in their practice, is they become experts in the care of their own disease… individuals with spinal cord injury become very well-educated consumers for the most part and they understand their bodies better than anyone. (C28, Specialist Physician)
• Spend time with patient to:
 ◦ Share medication-related information
 ◦ Understand how the therapy will complement/ improve their lives
 ◦ Identify reliable sources of information
2. Provider knowledge and confidence with SCI/D secondary health complications and related medications
…because I’m not like primarily focused on the SCI patients, that I don’t really put like a—I don’t know that much about specifics that should be addressed. So, I probably don’t provide education that might be more specific or tailored to them just because I’m unaware of that information and where to find it. (C05, Community Pharmacist)
based on your experiences you know what other medications are commonly used in SCI so, yeah, you feel comfortable enough to kind of be like to the doctor maybe we can try this. (C18, Occupational Therapist)
…you know, recognizing that for the average primary care practitioner, they are going to have a very small number of these people and so, to expect that they, by themselves, can maintain a level of clinical expertise necessary or appropriate to the complexity or the specifics of the type of health problems and medication issues that spinal cord patient experience, I think that’s not reasonable. (C22, Family Physician)
• Access to guidelines, best practices, websites, or information sheets on common SCI/D-related medications
• Create SCI/D-specific continuing education courses
3. Relationships and trust between healthcare providers and patients/their caregivers
… I think it also comes down to their comfort level with the pharmacist that they are speaking with. I found that at times when they don’t know the pharmacist or they’re not familiar with the pharmacist, it might just be the medication and that’s it. Whereas if they’re comfortable, they can actually have the conversation with the pharmacist to explain how they’re doing. (C02, Community Pharmacist)
What I would like most is some sort of feedback mechanism about whether they’re taking their meds or not and why not. And I just – I can ask them but the answer to that question is always yes, I take them. You know. Nobody says I don’t. It’s always yes…they want me to like them. I don’t – I think they – they’re concerned about honesty. Just, you know… they don’t want to piss off their doctor… But I like when people tell me the truth. (C15, Family Physician)
Somebody with spinal cord injury, they might be on a medication that was prescribed to them by a specialist who they know they can only see once a year and they really just don’t want to mess with it because they don’t have confidence that whoever their regular is would have the same knowledge in terms of making changes. So, I think just the confidence of a person who can provide them with that information is valuable. (C19, Occupational Therapist)
• Create an inviting environment
• Ensure two-way communication
• Listen and understand patients' concerns
4. Interprofessional collaboration through multidisciplinary workplaces and through access to SCI/D specialists for clinical support
I rely on either the specialist provider and reach out to them if I’ve got questions or our local pharmacist who can also access other pharmacists, for instance, who might be in particular clinics where they are providing care to a lot of spinal cord patients. (C22, Family Physician)
…there has to be support in place in the either local community or regionally so that, for instance, the person can access timely medication support information that they would need. They understand enough about medications and interactions, what they don’t necessarily have is access to the specifics as they pertain to somebody with spinal cord injury. So, I think that’s the key thing. If they can be—the ideal is like—it works very well in our setting because of the onsite interdisciplinary team and we’re fortunate, again, because linked to the hospital and our office design allows the accommodation. (C22, Family Physician)
• Work in collaborative, multidisciplinary practices
• Access knowledgeable specialists
• Create an electronic record system that is shared with the patient's circle of care
5. Community pharmacist and physician funding models
Sometimes, you know, sometimes time is hard, you know, to talk to a patient or be with that patient or just, you know, that touch point. It takes time, I mean if you ask anybody, everybody will always tell you time… you wish you would have more time to follow up to make sure that people are doing things properly. (C09, Community Pharmacist)
Some physicians like to talk about one issue per visit, so we do have a barrier there with physicians of being able to say well, you know, if the transportation to the physician’s office is hugely time consuming and difficult and you have to arrange or pay for a cab or it takes you, you know, you have to book a week, you know, in advance, for the transportation, all those kinds of things. Then we would love to have an avenue to have multiple issues dealt with in one appointment, but in fairness to the physician, they can really only bill for one issue and one medication per visit. So, and they don’t have any financial ability to really cooperate with a patient with spinal cord injury needs. (CC01, Care Coordinator)
Yeah, I mean that’s probably a little bit more unique to our practice because we do – do some emailing and we do – do some videoconferencing, but that wouldn’t be typical of most practices. […] So, that is done officially I can follow-up on patients. It’s an easier sort of a thing. The problem is that you can’t bill for that though, so it’s not – it’s not conducive to most practices… (C23, Family Physician)
• Change billing models to allow for longer appointment times:
 ◦ Reimburse pharmacists for more patient care services
 ◦ Allow discussion of multiple issues during one physician appointment
 ◦ Account for technology supported consultations
5.1 Alternative appointment formats
I’m sort of more flexible on doing phone appointments (C15, Family Physician)
…we have support through PCVC (personal computer video conferencing) support that they don’t have to necessarily come in in-person or virtual visits… (C17, Family Physician)
Quite often what you would do is just, you’d book an afternoon which is just strictly home visits…I can do telephone follow up… and part of the reason for that is just cuz of the challenges for the person to be able to come to the office easily. (C22, Family Physician)
• Use technology supported consultations:
 ◦ Video-conferences
 ◦ Telephone
• Offer home visits
  1. Abbreviations: MTM Medication therapy management, SCI/D Spinal cord injury/dysfunction
  2. Barriers and enablers are set in bold