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 Highest burden of disease, worst quality of health, least access to health care  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

Remote and Rural Communities Gap in healthcare includes access to a pharmacist  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

Medication Reconciliation in Hospital `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 .’  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

Medication Reconciliation MedRec * BPMDP BPMH on Transfer HOSPITAL ADMISSION

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 High Risk Medications  Age > 18 AND  Admitted to the hospital for >72 h AND Categories:  antiretrovirals,  High risk for ADE, one of:  chemotherapeutic,  oral hypoglycemic, > 5 medications for chronic conditions OR  immunosuppressant agents, High risk medications OR  insulins, opioids,  pediatric liquids, Principle diagnosis, one of:  pregnancy category X  Cancer  COPD Drugs:  Stroke  Carbamazepine,  Heart failure  Heparin,  Diabetes  Metformin,  Depression, OR  Methotrexate,  Prior unplanned hospitalization within the Propylthiouracil, last 6 months  Warfarin

Study Flow Chart Patients assessed Enrollment for eligibility (n=202) Eligible (n=47) Excluded (n=23)  No longer eligible (n=9)  Logistic problem (n=5)  Language barrier (n=5) Excluded (n=15) Contacted (n=24)  Technical problems (n=6) o Absence of internet (n=2) o Connectivity to the robot (n=4)  Declined to participate (n=6) Allocation  Language barrier (n=2)  Could not be reached (n=1) Interviews completed Satisfaction Surveys completed (n=9) (n=8) Review completed interview Completed Surveys Analysis (n=9) (n=8)

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 Rate=0.78 ANATOMICAL MAIN GROUP Alimentary tract/metabolism 14% 14% Blood and blood forming organs 14% 14% Cardiovascular system Systemic hormonal (exclude insulin, sex hormones) 43% Various 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 TYPE OF UNINTENTIONAL MEDICATION DISCREPANCY Omission 14% 14% Addition Other 71% 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 DISCREPANCY CAUSE(S) 13% Patient level Med system level 88% Claeys et al. Content Validity and Inter-Rater Reliability of an Instrument to Characterize Unintentional Medication Discrepancies Drugs Aging 2012; 29 (7): 577-591