Doctors, Nurses ... and pharmacists - why this threesome works. - - PowerPoint PPT Presentation

Doctors, Nurses ... and pharmacists - why this threesome works.

Vanessa Brown Brendan Duck RNZCGP GPCME 2014

What is a clinical pharmacist?

Specialist Pharmacist Practitioner Post Graduate education and/or significant clinical experience Undertakes Medicine Review = Medicine Therapy Assessment (MTA) Provides medicine and clinical information services

What's different about a Clinical Pharmacist?

Focus on risk vs benefits for individual patients for each medicine Applying most recent evidence to specific patient medicine related problems Recommendations on how to implement treatment plan Unbiased assessment of emerging medicine evidence and guideline updates

Mrs F.J.

76yr female Her current issues:

• Tiredness, cramps + twitchy legs
• Constipation, renal function changes
• Falling regularly
• BP 120/58mmHg

Calc CrCl= 21.5mL/min

• HbA1c 37mmol/mol Cholesterol levels good
• Liver function good

Current meds

• Furosemide

80mg mane

• Amitrip

25mg nocte

• Ezetrol

10mg daily

• Aspirin

100mg daily

• Quinine

300mg BD

• Simvastatin

40mg nocte

• Omeprazole 20mg mane
• Cholecalciferol 1.25mg monthly

Recommendations

• Change simvastatin 40mg to atorvastatin

10mg

• Stop omeprazole
• Stop quinine

Follow-up

• Feeling much better no longer tired.

Birth of clinical pharmacist facilitation?

$1.06 million year on year increase in combined pharmaceutical budget

– CPB = community pharmaceuticals + pharmaceutical cancer treatments + vaccines (from 1 July 2013)

Not sustainable No ‘low hanging fruit’ ‘Unmet need’

Aging Population

Items Dispensed per Capita by Age

Comparison of dispensing rates by age group (items), January to December 2010

0.0 20000.0 40000.0 60000.0 80000.0 100000.0 120000.0 0-14 years 15-24 years 25-44 years 45-64 years 65-84 years 85+ years Total (all ages) Rate (crude) per 1000 population Haw ke's Bay New Zealand

Source: Pharmaceutical Claims Data Mart, Ministry of Health (Extracted: 22/4/2011). Note data subject to change over time.

Dr Info

The model

Clinical pharmacist facilitators (1.5 FTE) Focus on best practice – not cost To complement the population based clinical pharmacist facilitator (1.0 FTE) Proof-of-concept Funded by Hawke’s Bay DHB

– working out of Health Hawke’s Bay PHO – in specific practices (0.5 FTE x 3)

Aims

Interventions targeted at polypharmacy

– ≥ 65 years – would not disadvantage Māori, Pacific or NZDep 9/10

 Polypharmacy

– patient harm / ADRs

Improve chronic disease

• utcomes (CV risk, diabetes)

Fulton & Allen 2005

Practice Focuses

Patients >65 years residing in Age Related Residential Care (ARRC) facilities Patients who are over 65 years living independently in the community Practice - with high needs population (Māori, Pacific or NZDep 9/10)

The Practices

TE MATA PEAK PRACTICE GREENDALE FAMILY HEALTH CENTRE TOTARA HEALTH

Location Havelock North Taradale Hastings & Flaxmere Targeted population Patients 65 years and over, living in Age Related Residential Care Facility Patients, 65 years and over, living independently in the community Patients with high needs including Māori, Pacific and NZDep 9/10 Enrolled Population 9800 6000 11000 Target Population 175+ 1200 7029

Evolution of role

Relationship building Initially focus was on patients taking >10 meds Medicines rather than people Development of tools to generate referrals Quality activities Demand for services

Practice Nurse Quote “Resource for education of nurses, patients, GPs. Can't imagine not having CP here now as I probably access CP expertise daily…”

Totara Health

Individual vs Population Focus

–Individual reviews = large benefit for individuals ≠ large benefit for high needs population –Focus on population with chronic disease with poor outcomes –Smaller review of medicines treating chronic disease and recommendations to General Practitioner

Adherence

Number of risk factors for non- adherence per patient

32% 1 37% 2 22% 3 or more 9%

Mr T.J.

Male, 63 year old, Cook Island Māori Labels

– ‘Non-compliant’ – ‘Poor diabetes control due to religious beliefs’

Problem

– Poor understanding of medication – Strong beliefs in value of nutrition and ‘living off the land’

Mr T.J.

Type 2 diabetes Recent admission for heart failure Recent admission for cellulitis Cancellation of cataract surgery

– Poorly controlled hypertension and diabetes

HbA1c 123 mmol/mol BP 195/110 mmHg LDL 4.5 mmol/L

Mr T.J.

Intervention

– Improve understanding of medicines – Sustained adherence to medicines (BP, Lipid and Diabetes)

BP 120/70 mmHg HbA1c 56mmol/mol LDL 2.5 mmol/L No recent HF symptoms

– Teaching other about the benefits of medicines

Te Mata Peak Practice

Primarily Aged Related Residential Care Aims:

– Reduction in polypharmacy – Improve medicine safety

Medicine reconciliation on admission Medicine Therapy Assessment prior to 3/12 review Medicine quality initiatives

Digoxin administration and monitoring

Vitamin D Prescribing

Medicines and Falls Risk

ARC Registered Nurse – how has the CP helped?

“Education. Medication

• Reviews. Input into Best Practice
• projects. Liaison between GP

and facility when required”.

Greendale Family Health

Focused on ≥ 65 years living at home Medicine therapy assessments Co-ordination of multiple prescribers! Medicine reconciliation Clinical guidelines and standing orders

Tools used – Multi-Med Survey

Tools Used – S.I.M.P.L.E.

Linkages

• Health Hawke’s Bay
• Care cluster
• Home services
• District nurses
• Local specialists
• Hospital pharmacists
• Community pharmacist
• Allied health; OT, PT, dietitian, social worker

Medicine reconciliation

Update medical record 37% Required clarification 29% Required a medicine review as multiple issues 23% Other interventions 11%

– E.g. advice on syringe driver medicine doses medicine information queries Special Authority number follow up

Greendale: 1 December 2012 – 18 January 2013

Benefits to GP

High quality unbiased advice Different set of eyes/focus Collaborative decision making Source of information on constantly changing evidence and guidelines Availability of medicine information Coordination of multiple prescribers MOPS audits

Benefits to Practice

Collaboration to manage chronic disease Increased practice confidence in managing polypharmacy Contribution to quality improvement of the practice Review of medicine policies and standing

• rders

Cornerstone accreditation support

Benefits to patients

Patient centered approach Different focus, asks different questions Address medicine benefits vs harm Improved outcomes Reduced medicine complexity Coordination of multiple prescribers

GP Quote

“Initially I had no idea what a clinical pharmacist would do for our practice, now I don’t know how I could live without them.”

Cost reduction / avoidance

Category Cost $

p.a. or per event*

Number of events

Known / estimated*

Total DHB savings

Known / estimated*

• 1. Community

pharmaceuticals

¥$500,000

• 2. Falls

$0 to $47,000 64 $149,400

• 3. Reduction in BP §

*3 *$100,000

• 4. Delayed admission to

ARRC

$24,000 2 $48,000

• 5. ED transfer avoided

$450 *1 *$450 Total ~$800,000

¥ Hawke’s Bay CPB September 2012 to August 2013 § Reduction in sBP by 10mmHg (1 each renal failure, myocardial infarction, stroke)

Hawkes Bay Future Direction

Clinical Pharmacist Facilitators add value to general practice 1 FTE per 20,000 patients Ensure access to all areas within DHB At 1 July 2014, HBDHB is rolling out this service Hawke’s Bay wide (8 FTE)

We Can Help You

Evidence to support clinical pharmacist role Experience of implementation Hawke’s Bay team is happy to put together a proposal Contact:

• Billy Allan, Chief Pharmacist, HBDHB

William.Allan@hawkesbaydhb.govt.nz

• Di Vicary, Health Hawke’s Bay

pharmacist@healthhb.co.nz

Acknowledgments

Di Vicary, Clinical Pharmacist Facilitator Team Leader Billy Allan, Chief Pharmacist Hawke’s Bay DHB Health Hawke’s Bay Greendale Family Health Te Mata Peak Practice Totara Health

Any Questions?