Chronic Disease Management – Role of the Community Pharmacist

1. Chronic Disease Management – Role of the Community Pharmacist Andrew J. Burr

4. Chronic Disease Management People £ Those with multiple chronic conditions 33% 6% 22% Those with one chronic condition 31% 72% Those with no chronic condition 36% Costs associated with each segment Segments within the total population

5. AIM • Reshape care around the patient • Help to reduce risk • Set outcome goals for treatment • Create a Clinical Management Plan • Implement plan across health care team • Improve health and quality outcomes • Make better use of the skills and knowledge of the team

6. Scope of Medicine Management • Prescription review • Patient counselling • Patient education and self-care • Management of repeat prescribing • Services from within community pharmacy • Medication monitoring • Medication-history taking • Patient referral • Services across the 1*/2* interface • Prescriber-led CDM clinics • Services to residential/nursing homes • Domiciliary services

7. Risk Management - Archiving 3,313 Patients have at least 1 active prescription item not issued in last 12 months Practice total population 12,200 Patients A - M = 1,428 Patients 5,409 active repeat items 571 Patients no longer on repeat medication 3,011 items archived 857 Patients have active repeat prescription 2,398 items remain on active repeat 486 out of the 857 patients have justifiable pharmaceutical interventions Clinically significant pharmaceutical interventions = 957

8. 100 80 60 Hitting Target 40 Not Hitting Target 20 0 70 127 26 Primary Secondary Hyperlipidaemia NSFs- Management of CHD patients Pre Review Breakdown of Heart At Risk Groups (April 2001)

9. 120 100 80 Hitting target 60 Not hitting target 40 20 0 70 127 26 Primary Secondary Hyperlipidaemia NSFs - Management of CHD patients Post Review Breakdown of Heart At Risk Groups (August 2001)

10. 300 250 200 150 100 50 0 ADR Archive Drug interaction Drug withdrawal Optimisation of therapy Therapeutic drug monitoring Disease drug interaction Cost saving (brand or generic) Change form, dose, frequency NSFs - Management of CHD patients Medication Review Results Interventions beyond changes in statin medication Prescription items N = 1477

11. Improved Quality Outcomes • Effective use of skills • Formal patient care plans • Improved concordance and outcomes with medicines • Improved understanding and appreciation of how pharmacist can help achieve goals

12. Context of Medicine Management • Reshaping care around the patient • Improving and ensuring quality • Reducing Risk • Improving health • Making better use of the skills and knowledge of staff

13. Integration of Community Pharmacy

14. Community Pharmacy • Equity • Standards and accreditation • Skill mix • Supply v Outcome • Integration • Competencies • Access • Workload

17. + + Pharmacy Pharmacies & pharmacists with varying standards of premises, qualification and services to both GP’s and patients. Services A - F Pharmacy - + Services A - C No supporting remuneration model. Pharmacy + - A need for consistent and accurate results for the basis of clinical decisions. Services D - F GP/ PCT Pharmacy - - Service A Integration of Community Pharmacy

18. Service Accreditation & Standards set by Professional Bodies, sHAs & PCTs ALL pharmacies offer services A-Z. Patients gain equity of service as do GP’s. Pharmacy Services A - Z Pharmacy Patients Home Any pharmacy can provide a specific service by meeting the same standards. Nursing Home Services A - Z LPS Provider Services A - Z Pharmacy GP Surgery Centralised PCT management provides transactional audit as a basis for new payment systems Services A - Z Call Centre Pharmacy Consistent and accurate results with standard reports to all GP’s GP Services A - Z Equity - A Model for the Future

19. Chronic Disease Management – PPIs Confirm guidelines objectives and schedules Patient ID, Capture & Review Screen patients on existing therapy Audit Protocol Definition Define target patient criteria 1day / 35 target patients to review notes & implement ‘Step Down’ exercise PCT Board & Primary Care Development Board agree programme Practice decide and agree ‘Step Down’ changes Define action plan for target patients Medication changed accordingly Define patient communication plan

20. Chronic Disease Management - PPIs Communications Exercise Patient Follow up & Monitoring Issues reported - Patient booked Into practice based Nurse led GI Clinic Letter to patient advising changes 14 - 21 Days post receipt of new prescriptions conduct Patient Audit Practice audit collection of new prescriptions • Date Rx cashed • No. of tablets • left • Symptoms • Compliance • Side Effects Local PR campaign via local media • Audit:- • Medicines use • Patients response • to medication No issues reported Patient continues with new medication Community Pharmacists advised.

21. Chronic Disease Management - PPIs Patient Follow Up & Monitoring cont.. Patient Support Clinic bookings confirmed by letter Step Up maintenance to treatment dose All practices have a clinic Further follow up via call centre to next changes. 0845 number left if symptoms return Change medicine in line with programme Clinics will have PCP support Lifestyle and condition audit performed Discontinue new medicines / regime

22. Clinical Management Plan • Legal requirement • Patient specific • Agreed with Independent Prescriber • Arrangement endorsed by Patient • Sets out scope of SP activities • Referral criteria • Monitoring parameters • Demands a formal review • Time limited

23. Clinical Management Plan • Conditions to be treated Diabetic control Blood pressure Cholesterol CHD risk factors • Guidelines or protocols British Hypertension Society Local guidelines on diabetic care

24. Medicines prescribed in CMP • Statins • (upto Atorvastatin 80mg or equivalent) • Oral hypoglycaemics • alone or combination to maximum rec. dosage • Anti-hypertensive regime • Thiazide, ß-blocker, calcium-channel blocker or ACE-inhibitor (A2 alternative) alone or in combination to achieve BP target • Smoking cessation programme • Nicotine replacement therapy • Continuation of remaining repeat master • Maintenance of existing repeat master

25. Clinical Management Plan • Aim of treatment ADVICE: Diet, medicines, exercise BLOOD PRESSURE: BP >140/80 CHOLESTEROL: < 5.0 mmol/L DIABETES CONTROL: HbA1C < 7.0% EYE SCREENING FEET SCREENING GUARDIAN DRUGS: Aspirin, ACE-inhibitors • Frequency of review and monitoring • Quarterly monitoring with six monthly review

26. Formalised plan Framework to prescribing Timely monitoring Improved communication Shared record keeping Efficient use of healthcare team Time consuming Patient selection Limitations of plan Implementing CMPs – Pros and Cons

27. Nursing Homes – Medication Reviews Practice total population 10,800 4,121 Medication reviews in the last 15 months Patients OVER 75 = 919 Patients 782 patients on at least ONE active repeat items 1,507 reviews required per year Residential or Nursing care homes 123 patients 238 reviews required per year 40 hours of reviews required per year

28. Nursing Homes – SP role High demands on practice for visits TARGETTED GP VISITS High use of medicines and dressings CONTROL OF MEDICINE USAGE Routine monitoring omitted MEDICINES MONITORED Residential or Nursing care homes 123 patients High rate of hospital admissions REDUCED RE-ADMISSIONS No formalised framework for review FORMAL CMP FOR EACH RESIDENT Review = reauthorisation ASSESSMENT BEFORE ISSUE AND REVIEW

29. Key to Success • Work as part of the team to deliver real health outcomes by ensuring robust and effective mechanisms • Facilitate local decision making to underpin coherent strategic framework