EPIC – a Chronic Disease Management Initiative in BC

1. EPIC – a Chronic Disease Management Initiative in BC Barbara Ogle, BSc(Pharm), ACPR, MScPhm, RPh VP Clinical Services, Network Healthcare May 31, 2007

2. Network Healthcare • Network Healthcare • A health services company that supports the development & delivery of health care through sophisticated networks of clinical professionals. • Pharmacist Network • A service delivery arm of Network Healthcare that utilizes pharmacists to deliver care to patients.

3. CURRENT HEALTH SYSTEM • Health Care Organization • Concern about the bottom line • Incentives favor more frequent, shorter visits • No organized QI Community Resources & Policies No links to community agencies or resources • Self-Management Support • Not systematic • Didactic • ClinicalInformationSystems • Don’t know patient or their needs • System • Design • Reliance on short, unplanned visits • Decision • Support • No agreement on good care • Traditional referrals Uninformed, Passive Patient/ Caregivers Frustrating Problem-Centered Interactions Unprepared Practice Team Sub-optimal Functional and Clinical Outcomes

4. Chronic Disease Management in British Columbia • > 50% of BC health care budget goes to the 10% of people with chronic diseases • Ministry of Health’s response • Adopted the Expanded Chronic Care Model and Patient Self-Management • Used Primary Health Care Transition Funds for strategic initiatives focused on high-risk, high-cost CDM patients

5. Expanded Chronic Care Model

6. EPICEmpowering Patients through Integrative Care

7. Business Need • Expand the primary care team where gaps exist (pharmacist) • Increase system capacity to meet periodic needs of patients for more intense support • Increase access to timely support between appointments and where rural or individual barriers to service exist

8. Goal • To develop and evaluate the feasibility of a telehealth model for pharmacists to provide self-management and medication management support to people with diabetes or heart failure in collaboration with primary healthcare teams.

9. Objectives • Increase patient self-efficacy and self-management with medications • Improve attainment of desired drug therapy outcomes • Improve medication safety

10. Pharmacist Intervention • Community pharmacist as virtual member of health team • Provide telehealth coaching, information and self-management support for up to 6 weeks • Identify, prevent and/or manage potential and actual drug-related problems • Provide clinical decision support to the family physician and primary healthcare team • Facilitate transition to community resources (e.g., community pharmacist, local groups)

11. Project Details • Timeline • Planning 2004 • Pilot Testing 2005 • Data Collection 2005 – 2006 • Team • BC Ministry of Health • BC NurseLine • Pharmacist Network BC • University of Victoria – Centre on Aging • Fraser Health Authority • Northern Health Authority

12. Patient Findings (n = 201) • Learned self-management skills • Resolved drug-related problems • Became more engaged in their own care • Improved health status • Liked having telehealth in their own home, interpreters and flexible times • Regular follow-up kept patients focused

13. Physician Findings (n = 112) • Collaborative interactions observed • Electronic lab data accessed for some • Telehealth was economical, scalable, and sustainable • Follow-up extended beyond practice • Focus on patient self-management filled existing care gap

14. Other Research • Impact of medication therapy discontinuation on mortality after MI • Endpoints: use of aspirin, β blockers and statins at 1 month; mortality @ 12 months • >33% had stopped one or more medications • 12.1% had stopped all three • Poorer 1-year survival than those persisting 88.5% vs 97.7%, p<0.001 • Risk factors include age and education PM Ho et al. Arch Intern Med 2006;166:1842-1847.

15. Other Research Other Research • Drug-related hospitalizations in a tertiary care internal medicine service • n=565 adult patients admitted to hospital • Drug-related 24.1% (95% CI 20.6-27.8%) • Adverse drug reactions 35.3% • Improper drug selection 17.6% • Noncompliance 16.2% • Majority of cases were preventable • 72.1% (95% CI 63.7-79.4%) Samoy LJ et al. Pharmacotherapy 2006;26:1578-86.

16. Other Research • Effectiveness of telephone counselling by a pharmacist in reducing mortality in patients receiving polypharmacy • RCT, n=502 non-compliant pts • 6-8 telephone calls between visits • Polypharmacy = 5 or more medications • Endpoint: all-cause mortality in 2 years • ARR 6% (17% control vs 11% intervention) • RRR 41% (95% CI 0.35-0.97, p=0.039) • NNT to prevent 1 death = 16 JYF Wu. BMJ  2006;333:522, doi:10.1136/bmj.38905.447118.2F

17. Compared to… • Statin therapy • Based on 2003 Canadian guidelines • NNT to prevent 1 death due to CHD over 5 years for high risk* Canadians is 98 • Canadian statin market = $1.4B *10-year risk of CHD ≥ 20%, or history of CVD or diabetes with age > 30 yrs

18. Going Forward • BC • Alberta • Service Development • SAFERx (real world safety & effectiveness) • Seamless Medication Care • Chronic Disease Management (medication management and self-management support) • Medication Reviews and Assessments • Emergency Preparedness

19. The ‘Innovation’ Challenge

20. Contact Information Barbara Gobis Ogle, Vice President, Clinical Services Network Healthcare bogle@networkhealthcare.ca 604-231-3245