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
(07) 5570 8579
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