Patients Support a Pharmacist-led Best Possible Medication - - PowerPoint PPT Presentation

Patients Support a Pharmacist-led Best Possible Medication Discharge Plan (BPMDP) via Tele- robot in a Remote and Rural Community Hospital

PAULA NEWMAN CADTH SYMPOSIUM APRIL 2019

Disclosure

I have the following relevant financial relationships to disclose:

 I am employed by Northwest Telepharmacy Solutions  I received research support from the Ontario Branch

Canadian Society of Hospital Pharmacists to conduct this study I do not have any actual or potential non-financial relationships to disclose

Outline

 Health care in rural & remote communities  Medication Reconciliation or MedRec  Videoconferencing

 Ontario Telemedicine Network (OTN),  Robotic Telepresence

 Our research

Remote and Rural Communities

 Fewer visits to primary care provider- decreased preventative

services and disease management

 Sparsely populated, northern Ontario presents challenges to the

health care system

 87% of Ontario land is populated by 6% of the population  Northern and rural hospitals struggle to recruit healthcare providers  Results in difficulty in providing the same level of care offered in

larger, urban centres

http://www.health.gov.on.ca/en/pro/programs/ecfa/action/primary/pri_telemedecine.aspx

Remote and rural residents

 People living in Northern Ontario, lag behind provincial averages in the

quality of health and healthcare

 Report poorer health, more chronic conditions, more likely to smoke,

increased morbidity and mortality from heart disease and diabetes.

 Life expectancy 2.9 years less, dying prematurely due to suicide, circulatory

disease and respiratory disease

 In young First Nations population 76% of men and 87% of women will

develop diabetes in their lifetime Highest burden of disease, worst quality of health, least access to health care

 To conduct medication counselling  To answer questions from patients and their families about their

medications prior to leaving hospital

 Formalize communication between the hospital pharmacist and the

community pharmacist and patient’s other health care providers

 Provide post-hospital follow-up and support  Provide discharge/transfer medication reconciliation

Remote and Rural Communities

Gap in healthcare includes access to a pharmacist

Medication Reconciliation in Hospital

 Reduces the risk of preventable medication-related adverse events  Pharmacists have demonstrated invaluable in the process:

 Improvement in health outcomes  Reduction in health care costs and utilization,  Reduction in mortality, 30 day re-admission, and ER visits  Significant ROI

E.A. Wright et al. / Journal of the American Pharmacists Association 59 (2019) 178e186The Journal of Rural Health 00 (2016) 1–8c 2016 National Rural Health Association

`A formal process in which healthcare providers work together with patients and care providers to ensure accurate and comprehensive medication information is communicated consistently across ALL transitions of care.’

Medication Reconciliation

MedRec

• n

Transfer

BPMH

HOSPITAL ADMISSION

*BPMDP

Despite Canada having a publicly funded universal healthcare system there is an inequality in healthcare access

Many small and rural hospitals do not have on-site pharmacists to support medication reconciliation upon hospital discharge

Medication Reconciliation in Hospital- BPMDP- Opportunity

 For pharmacists to review patient’s discharge medications:

 provide medication management at discharge  counsel patients and coach patients in disease prevention  Communicate with other health care providers and prescribers

 For patients and their caregivers to ask questions about their

medications

 Medication dosing changes, medications discontinued  New medications initiated in hospital

Provincial Telemedicine- Ontario Telemedicine Network (OTN)

 49% conducted in Northern Ontario  Has enabled increased access to healthcare

 Rural and remote, aboriginal, underserviced, official language minorities

 Significantly decreases travel (245 M km of travel since 2002):

 Time and cost ($ 25 million annually in northern travel) for patients and

providers

 Carbon footprint (67 M kg of pollutant load and > 27 M L of fuel saved)

 Facilitation of education and skills transfer for HCP

http://www.health.gov.on.ca/en/pro/programs/ecfa/action/primary/pri_telemedecine.aspx

Robotic Telepresence

 Care-giver’s physical presence virtually extended via a mobile robotic

platform with real-time audio-visual equipment

 Study in a remote Inuit northern community found deploying a remote

presence robot

 Feasible  had a high degree of satisfaction by patients and caregivers  Health care providers deemed it improved patient care, workload and job

satisfaction

Ivar M, Jong M, Keays-White D, Turner G. The Use of Remote Presence for Health Care Delivery in a Northern Inuit Community: a Feasibility Study. Int J Circumpolar Health 2013,72:21112

Lady Dunn Health Centre

 North shore of Lake Superior, ON  Population 4,300-



Dubreuville, Hawk Junction, Michipicoten First Nation, Michipicoten Township-Wawa, Missanabie and White River

 10 acute care, two respite and

16 long-term beds, 24 h ER

 1 remote pharmacist 8-4 M-F  1 community pharmacy  Nearest tertiary care hospital is 225 km

Study Objectives

Primary

 To assess how patients in a remote and rural community hospital, who are

at high risk for preventable adverse drug events, perceive a pharmacist- led real-time BPMDP utilizing telerobot technology Secondary

 To determine interview time requirements – prep, interview, discrepancy

resolution

 To describe unintentional discharge medication discrepancies (type, cause,

intervention)

 To describe facilitators, inefficiencies and barriers in completing interviews

Methodology



Patients were provided a letter of information BPMDP interview by the RN



Pharmacists created a BPMDP and documented:



all unintended discharge medication list discrepancies by class, type, cause and intervention



Inefficiencies, barriers and facilitators for conducting interviews.



Pharmacist conducted interview via telerobot



Provided patient counselling and health literature



Encouraged patients and caregivers to ask questions regarding their medications



Patients completed anonymous satisfaction survey via kiosk on a computer tablet or paper copy with RN assistance if required

TELEROBOT

Inclusion Criteria- Patients at High Risk of Adverse Drug Events

Eligibility Criteria  Age > 18 AND  Admitted to the hospital for >72 h AND  High risk for ADE, one of: > 5 medications for chronic conditions OR High risk medications OR Principle diagnosis, one of:  Cancer  COPD  Stroke  Heart failure  Diabetes  Depression, OR Prior unplanned hospitalization within the last 6 months

High Risk Medications

Categories:

• antiretrovirals,
• chemotherapeutic,
• ral hypoglycemic,
• immunosuppressant

agents,

• insulins, opioids,
• pediatric liquids,
• pregnancy category X

Drugs:

 Carbamazepine,  Heparin,  Metformin,  Methotrexate,  Propylthiouracil,  Warfarin

Study Flow Chart

Patients assessed for eligibility (n=202) Interviews completed (n=9)

Analysis

Eligible (n=47) Contacted (n=24) Satisfaction Surveys completed (n=8)

Allocation

Review completed interview (n=9) Completed Surveys (n=8) Excluded (n=23)  No longer eligible (n=9)  Logistic problem (n=5)  Language barrier (n=5)

Enrollment

Excluded (n=15)  Technical problems (n=6)

• Absence of internet (n=2)
• Connectivity to the robot (n=4)

 Declined to participate (n=6)  Language barrier (n=2)  Could not be reached (n=1)

Study Population

Characteristics Value Gender Males, % 55 Females, % 45 Age, years (median, IQR) 76 (7) Location Wawa, ON , % 100 Primary reason for hospitalization Cardiovascular, % 44 Respiratory,% 22 Musculoskeletal, % 11 Gastrointestinal, % 11 Other, % 11 Rate of eligible patient participation, % 37.5

Survey Responses

Negative 7% Undecided 13% POSITIVE 80% N=8

Becevic, Mirna; Clarke, Martina A; Alnijoumi, Mohammed M; Sohal, Harjyot S; Boren, Suzanne A; Kim, Min S; Mutrux, Rachel. "Robotic Telepresence in a Medical Intensive Care Unit—Clinicians’ Perceptions" Perspectives in Health Information Management (Summer, July 2015).

Discharge Medication List Discrepancies: Drug Category

14% 14% 43% 14% 14%

ANATOMICAL MAIN GROUP

Alimentary tract/metabolism Blood and blood forming organs Cardiovascular system Systemic hormonal (exclude insulin, sex hormones) Various

Rate=0.78

Claeys et al. Content Validity and Inter-Rater Reliability of an Instrument to Characterize Unintentional Medication Discrepancies Drugs Aging 2012; 29 (7): 577-591

Unintentional Discharge Medication List Discrepancy- TYPE

71% 14% 14%

TYPE OF UNINTENTIONAL MEDICATION DISCREPANCY

Omission Addition Other

Claeys et al. Content Validity and Inter-Rater Reliability of an Instrument to Characterize Unintentional Medication Discrepancies Drugs Aging 2012; 29 (7): 577-591

Unintentional Discharge Medication List Discrepancy - CAUSES

13% 88%

DISCREPANCY CAUSE(S)

Patient level Med system level

Claeys et al. Content Validity and Inter-Rater Reliability of an Instrument to Characterize Unintentional Medication Discrepancies Drugs Aging 2012; 29 (7): 577-591

Unintentional Discharge Medication List Discrepancy Causes - MED LEVEL

Rate=0.78

Claeys et al. Content Validity and Inter-Rater Reliability of an Instrument to Characterize Unintentional Medication Discrepancies Drugs Aging 2012; 29 (7): 577-591

14% 43% 14% 14% 14%

SYSTEM LEVEL CAUSE(S)

Conflicting information from different informational sources BPMH incomplete/inaccurate Rx error Administrative problems Other

Unintentional Discharge Medication List Discrepancies- Pharmacist Interventions

15% 25% 30% 30%

INTERVENTION(S) TO SOLVE THE UNINTENTIONAL MEDICATION DISCREPANCY

Healthcare professional level Patient level Medication level Other

Claeys et al. Content Validity and Inter-Rater Reliability of an Instrument to Characterize Unintentional Medication Discrepancies Drugs Aging 2012; 29 (7): 577-591

Unintentional Discharge Medication List Discrepancy-Pharmacist Intervention

50% 17% 33%

INTERVENTION, MEDICATION LEVEL

Drug changed (cancelled or started) Dose changed Other

Rate=0.67

Claeys et al. Content Validity and Inter-Rater Reliability of an Instrument to Characterize Unintentional Medication Discrepancies Drugs Aging 2012; 29 (7): 577-591

Unintentional Discharge Medication List Discrepancies-Pharmacist Interventions

67% 33%

HEALTH CARE PROFESSIONAL (HCP) LEVEL (Prescriber, Nurse, Pharmacist)

Requested information from HCP Intervention suggested to HCP

Rate=0.33

Claeys et al. Content Validity and Inter-Rater Reliability of an Instrument to Characterize Unintentional Medication Discrepancies Drugs Aging 2012; 29 (7): 577-591

Inefficiencies, Barriers and Facilitators

Inefficiencies

 Technical issues with the robot connectivity (Wi-Fi) and operation  Pharmacist assigned for robot interviews only (not hospital pharmacist) needed to frequently check for patient discharge list  Last minute notice of discharge and/or availability of discharge medication list  On site staff had difficulty turning on robot and computer tablet for survey, patient did not want to wait for interview

Barriers

 RN selection bias for patients for interviews  Not supported as a mandatory process prior to hospital discharge  Usual charge nurse not available to set up robot  On-site pharmacy software not working to view discharge script

Facilitators

 Hospital staff were supportive once interview time established  Hospital staff present during interview and to assist with robot if required

Conclusion

 Conducting BPMDP interviews via telerobot in a small, rural community

hospital is feasible and well accepted by patients

 Most high risk patients have a medication discrepancy upon hospital

discharge:

 Often a medication to for the management of CV disease  Usually by omission, due to an inaccurate BPMH on admission  Pharmacists are able to resolve these discrepancies by communicating with

both patients and their providers

 Program barriers, and inefficiencies have been identified to increase

recruitment and timely BPMDP interviews.

Next Steps

 Larger study

 Multi-centre

 Include larger hospitals in urban centres  Assess healthcare provider satisfaction  Include semi-qualitative post study interviews with health

care providers and patients

 Assess healthcare utilization  30 day ER visits and  30-day hospital re-admissions

Thank you for giving us the

• pportunity to share our research

Robot video