Post-discharge Home Medicines Reviews

in TCP

Dean Byrnes – Senior Pharmacist TCP

Gold Coast HHS

Overview

TCP Gold Coast HHS

Quality Use of Medicines and TCP

Post-discharge medication review model – Gold Coast HHS Patient identification

Review process / assessments

Snapshot of 43 clients Client impact

Client and Staff satisfaction

Service Delivery

IN HOUSE Administration (7)

Allied Health (32)

Nursing (9)

Operational staff (6)

Rehab Physician (0.5)

BROKERAGE Personal Care

Social Support

Domestic Assistance

Transportation

Equipment

Hotel Services

Additional AH and Nursing as

required

Medication management & TCP

TCP guidelines

“Control and administration of medications prescribed by medical practitioner, subject to legal restrictions on providing the medication”

“Appropriate medication management”

What exactly does this mean?

Is this what we want for our patients?

Open to interpretation! Medication management forms part of core services

Ongoing support of patient with medication management

Pain assessment and management plans (medication management plans)

Falls risk assessment and mitigation strategies (medications and falls)

TCP Gold Coast Prior to pharmacist service – nurse driven

Little / untimely access to specialist medication review services already available in the community Medicare funded Home Medicine Review Program

Referral to outpatient clinics with pharmacists attached

Focus on competency to administer medications

Less emphasis on other activities which achieve Quality Use of Medicines

Quality Use of Medicines

Central objective of Australia’s National

Medicines Policy

Selecting management options wisely

Considering suitable medicines if they are

deemed necessary

Using medicines safely and effectively

Home Medicine Reviews Medicare funded pharmacist / GP program available to Australian

residents Collaborative program between GPs, accredited pharmacists and

community pharmacy Referral to community pharmacy

Referral direct to an accredited pharmacist

In-home review by pharmacist

Generation of report for GP

Agreed medication management plan between GP and client

Assists individuals living at home to maximise the benefits of their medication regimen and prevent medication related problems Available to all Australia residents

TCP clients

Evidence – HMRs General evidence

High patient acceptability

GPs who use the service like it

High pharmacist workforce satisfaction

Often underutilised

Hepler et al – functions of the HMR1

Identify potential and actual drug related problems

Resolving drug related problems At time of review

Through liaison with prescribers

Preventing potential drug related problems

“Quality use of Medicines in the Community Implementation Trial” – University of SA and Adelaide2

Pharmacist identify a lot of drug related problems

GPs implement 42% of recommended changes to regimens Of these implementations 81% were resolved, well managed or improving

Improved pharmacist and GP collaboration to achieve QUM

1. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm 1990;

47:533-43

2. Beilby J et al. Quality use of medicines in the community implementation trial. Available at:

http://www.aro.gov.au/aro/researchEntryView.do;jsessionid=FOGPILDFLPEI?id=1535&type=keyword

What about TCP?

What are we doing? The traditional HMR model?

Post-discharge HMR model? Evidence?

Consultative advice

Surveillance

Rehabilitation towards self-management

Pain management

SOME OF THE ABOVE or ALL OF THE ABOVE?

Post-discharge medication reviews

Vrong et al – post-discharge models

Post-discharge HMRs by pharmacists best conducted

by at least 7-10 days after discharge

Enhance compliance

Improve knowledge

Identify problems

Role for patients initiated on warfarin2

Role for patients with heart failure3

1. Holland R et al. Does home based medication review keep older people out of hospital? – The HOMER RCT. BMJ

2005; ;330:293

2. Roughead E, Barratt J, Ramsey E, Pratt N, Ryan P, Peck R et al. Collaborative home medicines review delays time

to next hospitalization for warfarin associated bleeding in Australian war veterans. J Clin Pharm & Ther. 2011;36:27-

32

3. Ponniah A, Shakib S, Doecke C, Boyce M, Angley M. Post-discharge medication reviews for patients with heart

failure: a pilot study. Pharm World Sci. 2008;30:810-815.

HOMER trial1

Do home based reviews keep older people out of hospital?

Post-discharge model

RCT

Intervention – 2 home visits within 2-8 weeks of discharge Education focus

Remove out of date drugs

Inform GPs of ADRs and DIs

Inform community pharmacist if administration aid required

Results Higher rates of hospitalisations!

Did no significantly improve QOL or reduce deaths

1. Holland R et al. Does home based medication review keep older people out of hospital? – The HOMER RCT. BMJ

2005; ;330:293

Problems Timely access to HMR model

Studies suggest that HMR model relying on GP referral can take on average 18 days to secure

Evidence of impact suggests a review within 7-10 days

Do all patients need to be seen? Who benefits the most

Sustainability Funded by state government through TCP on the Gold Coast

Existing funding pool for clients Approximately $200 dollars per review

What is the dollar value that we know is paid vs the realistic service that needs to be provided to a client on TCP

Episodes of care, documentation time, liaison time, referrals to other services, case conferencing

Who is responsible for what? – where to the recommendations go? GP

Specialist Outpatients

Residential TCP patients under rehabilitation consultant

TCP Gold Coast HHS Project Objectives

Create a system for patient identification

Conduct reviews

Standardise activities and assessments

Capture data Pharmacist interventions

Prescriber recommendations

Staff satisfaction

Client satisfaction

Analyse data Process evaluation

Impact evaluation

Patient outcome measurements

Satisfaction

Identifying patients

Existing Medicare Australia criteria

All residential patients

Treated like a ward

Some additional criteria of importance

Criteria Meet 2 of the following criteria – see within 7-10 days of discharge

Currently taking five or more regular medicines

Taking more than 12 doses of medicine per day

Significant changes to their medicine regimen in the last three months, including recent discharge from hospital

Taking medicine with a narrow therapeutic index or required therapeutic monitoring

Taking medicines not prescribed by a doctor

Attending a number of different doctors, both general practitioners and specialists

Automatic referral – within 1-2 days of discharge Difficulty managing medications

Symptoms suggestive of ADR

Ongoing need for pain management input

Requires manipulation of oral doses

Requested by patient

Requested by ward pharmacist

Conducting the HMR

Ideally a post-discharge HMR should be done within 10 days of discharge from hospital.

Home Medicines Review Assessment at home

Medication History

Patient activities / counselling

GP/prescriber recommendations

Follow-up on recommendations

Sounds like an easy concept! Delivery can be much more difficult

Cognition of the patient following discharge can be impaired Post-surgical pain medications

General disorientation

Service overload results in overwhelmed patients

Even when a patient meets the criteria, there may not be a need for pharmacist intervention

Specialised input - pain management

GP collaboration can be difficult – establishing relationships and preferred method of communication is important

Assessments during HMR DRUGS

Drug Regimen unassisted grading scale

Conducted by pharmacist or nurse

Pre and post scores – show worth of interventions

TABS

Tool for adherence behaviour screening

STOPP

Screening tool of older persons’ potentially inappropriate prescriptions

FALLS

Medication and falls assessment with mitigation strategies

Findings – 43 patients Sex:

Male

Female

No. of patients

16

27

Average age of clients 78 years old (rounded)

Presentation types

Medical/Trauma

Neurology

Surgical (orthopaedic

No. of patients

19

2

22

Time spent with patients per presentation type

Medical/Trauma

Neurology

Surgical (orthopaedic)

All patients

Face to face

69.21 mins

55.43 mins

45.69 mins

56.17 mins

Other

51.84 mins

42.5 mins

46.82 mins

48.83 mins

Total time

121.1mins

100.9mins

92.5mins

105mins

What did the pharmacist do?

Hepler et al – functions of the HMR

Identify potential and actual drug related

problems

Resolving drug related problems

At time of review

Through liaison with prescribers

Preventing potential drug related problems

Pharmaceutical Society Interventions

“A process of identifying drug related problems and making a recommendation in an attempt to

solve the problem”

Solved at time of review within a pharmacist’s scope of practice Easy!!!!

Referred to a prescriber for consideration Easy???

Drug related problems Drug related problems

Drug selection – 22 interventions

Over or under dose – 5 interventions

Compliance – 23 interventions

Undertreated / Untreated – 39 interventions

Monitoring – 1 intervention

Not classifiable – 4 interventions

Drug Toxicity management – 15 interventions

Referred to prescriber 75 drug related problems

Mitigated by a pharmacist at the time of review 34 drug related problems

75

55

71

4 3 14

0

10

20

30

40

50

60

70

80N

um

be

r

Recommendation type

Prescriber Recommendations

So what?

Looks like a lot of work on paper

BUT…..

Does it have any value?

Realistically – what is the point? Health districts increasingly results driven

Prevent hospitalisations

Prevent costs to the system

Improve patient outcomes

Clinical questions

What impact do the patient/prescriber interventions have on patient care when compared to the literature?

Do interventions / prescriber recommendations made during home medicines reviews remain outstanding at the end of TCP?

Do interventions / patient recommendations made during home medicines reviews remain outstanding at the end of TCP?

Risk mitigation Society of Hospital Pharmacists Australia

Risk classification system for interventions made by pharmacists in hospital inpatients

Australian risk management principles

Elliott et al 2009 Adapted and validated the SHPA risk matrix

Geriatric ambulatory patients

Consequence (severities) Assume intervention not made – what is the likely scenario (NOT worst case

scenario)

Likelihoods Likelihood of consequence occurring within the next 12 months

Explored the differences in risk classifications between pharmacists and geriatricians

Risk matrix Insignificant Minor Moderate Major Catastrophic

Almost Certain NO RISK HIGH EXTREME EXTREME EXTREME

Likely NO RISK MODERATE HIGH EXTREME EXTREME

Possible NO RISK MODERATE MODERATE HIGH EXTREME

Low NO RISK LOW RISK

MODERATE HIGH HIGH

Rare NO RISK LOW RISK

LOW RISK

MODERATE HIGH

Staff Satisfaction 1. The level of pharmacy services is adequate to fulfil my needs and those of the

patients.

2. Having a pharmacist available in TCP improves the quality of care for my patients.

3. I frequently contact the pharmacist for medication-related questions about my patients.

4. The questions that I direct to the pharmacist in TCP about medications are answered completely.

5. The questions that I direct to the pharmacist in TCP about medications are answered in a timely manner.

6. The pharmacist is helpful in clarifying medication related issues.

7. The pharmacist explains things in words I can understand.

8. Overall, I am satisfied with the level of services that I receive from the pharmacist in TCP.

Ratings: 1 = strongly disagree 2 = disagree 3 = neutral 4 = agree 5 = strongly agree.

Pre and post comparison

46% Response Rate

0

1

2

3

4

5

6

1 2 3 4 5 6 7 8

Scor

e

Question No.

Average Staff Responses -comparison

Patient satisfaction – CSQ-8

Validated patient satisfaction survey for a service

Administered by Therapy Assistants and Pharmacist

Response rate of approximate 44%

Results: Clients liked the service

Clients liked what the service covered

Clients felt the service met their needs

Clients would recommend the services to other people

Clients would utilise such a service in the future

In a nutshell The post-discharge model

Adapts to the patient Sometimes traditional HMR type

Sometimes you review pain management / post-surgical medications

Sometimes you organise self-management services

The pharmacist activities Consistent – no matter what type of review is undertaken

Identifies drug related problems

Mitigates within scope of practice

Refers to appropriate clinicians with recommendations

Is there an impact Client satisfaction with services is high

Depending on the patient risk, GPs are highly collaborative

Teamwork is fostered through high staff satisfaction

Future Direction – Post-discharge HMR

Future directions – Evidence

HOMER TRIAL

“Failure is only the opportunity to begin again, this time more wisely.”

“Man cannot discover new oceans unless he has the courage to lose sight of the shore.”

Business rules are changing for direct hospital referrals to accredited pharmacists to perform post-discharge HMR

Quality and Sustainability

Long hard look at our own service

Confront the current climate

The reality of service provision and funding

Clinical pharmacist roles – who can provide what

services to patients in the community

Evolution of the TCP pharmacist role in our

district?

TCP Gold Coast Survey of services provided by community pharmacy in our district

Database

Refer as required

Continue with our data collection Use intervention data to shape practice in our district at a hospital level

Validate a tool which identifies risky patients in hospital Get people thinking about involving a pharmacist

Those who benefit most

Strengthen the referral evidence

Sustainable practice and being patient centred Involving patients’ long term practitioners

We are time limited – who will be there for the patient in the future

Investigating the readiness and willingness of other pharmacists in the district to take over the model of post-discharge HMR as the business rules change

Collaboration with Community Pharmacists and GPs MedsCheck / Diabetes MedsCheck

Referral into ongoing Home Medicines Review Program

TCP Gold Coast

Innovative practice Collaboration with short stay units

Targeting short stay units – these are often risky admissions to TCP

Improved communication of essential medication information – in and out of ED/Medical Assessment Units

Identifying frequent fliers to emergency departments due to medication management

Rotation of ward pharmacists into TCP – learning experience Improve hospital discharges

Evolution of the role Identifying patients in hospital who would benefit from HMR

Collecting intervention data to shape practice in the district Hospital level

Community level

Post-discharge referral pathways Creating new paths in the district

Strengthening ties created

Leading by example Replicating the model across other patient types

Providing clinical services where specialised advice is required Rehab of self-management

Post-surgical pain management

Osteoporosis treatment

Delirium and dementia – drug induced

Providing clinical services when timeliness is a necessity

Providing clinical services for clients who don’t have pre-existing pharmacist networks

Being a source of information for other pharmacist service providers

Take home messages

There is a very big role for pharmacists working in the TCP environment Staff pharmacist OR other pharmacists in the

community

There is a wealth of opportunity in many health districts Find out what your pharmacists do

Be ready for the changes to the program Direct referrals

Dean Byrnes BPharm MHlthSc AACPA MASCP

Senior Pharmacist – Transition Care Program GC HHS

dean_byrnes@health.qld.gov.au

(07) 5570 8579