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Optimize Presentation

  1. 1. Optimize© -A Medicines AdherenceSolutionprovided byGreen Light Pharmacyin it’s Stepney branchcommissioned by Tower Hamlets PCT in2012 & now by NHS England
  2. 2. There is no impending pharmaceuticaldiscovery, surgical innovation orgovernmental policy change withgreater potential for improving thehealth of patients and efficiency of thehealth care system, than simplyincreasing the percentage of treatmentplans that patients (are able to) carryout as prescribed[Align Map www.alignmap.com ]
  3. 3. “Drugs don’t work in patients who don’t take them” C. Everett Koop M.D – Surgeon GeneralUSA 1982-89It is estimated that 50% of all prescribed medication is not used by patientsas intended by the prescriber [ Sackett D.L., Snow J.C. “The Magnitude of Compliance & Non-Compliance” In:Haynes R.B. et al (Eds) “Compliance in Health Care” Baltimore, John Hopkins University Press 1979; Nov 22]It has been estimated that between 20 and 50% of patients are notadherent to their medication regimeKripalani S, Yao X, Haynes RB. Interventions to Enhancemedication Adherence in Chronic Medical Conditions: A systemic Review. Archives of Internal medicine 2007; 167:540-550Improving medicine taking may have a far greater impact on clinicaloutcomes than an improvement in treatments Haynes R.B., Ackloo E., Sahota N., McDonald H.,Yao X. “Interventions for Enhancing Medication Adherence” Cochrane Database System Review 2008; (CD0000011)33-69% of all medicine related hospital admissions are due to poormedication adherenceOsterberg & Blaschke. New England Journal of Medicine 2005 Vol 353Only 4 to 21% of patients are receiving the optimum benefit from theirmedicines Garfield S, Barber N, Walley P, Willson A, Eliasson L. Quality of Medication Use in Primary Care - Mapping theProblems, Working to a Solution: A Systemic Review of the Literature. BMC Medicine 2009; 7:50
  4. 4. • To support independent living• To improve patient adherence with therapy by– Improving understanding– Identifying practical problems– Supporting the carer• To reduce wastage and thus make cost savings by decreasingthe local prescribing budget• To help people manage their medicines safely & appropriately• To decrease Preventable Medication Related HospitalAdmissions and thus make cost savings to the CCG’s HospitalAdmissions budget
  5. 5. The service focuses on improving,supporting & monitoringadherence (how people take theirmeds) not simply on the provisionof compliance devices (ie not justa blister pack, other solutions aswell)
  6. 6. Itsintentionalnon-compliance
  7. 7. Optimize© addresses:Unintentional noncompliance• Access (eg over / underscript request)• Physical issues (usinginhalers, readingEnglish)• Adherence solutions(Blister Packs ,Reminder Charts,prompts eg phone call,text, phone aps )Intentional non-compliance• Cognitive support• Meds Education Plan• Patient held medsrecord - their“MedicationPassport”• Condition EducationPlan• Adherence Record• Reward Plan• Relapse Plan
  8. 8. Optimize©:A MedicinesAdherence SolutionReferralAdherenceAssessment byAccreditedCPSupport Plan &Report (SPAR), carriedout by patient’s usual,localCP.(Compliance aids;cognitive support;use of MAR sheets;reminders/prompts)Discharge fromservice, butwith on-goingSupport PlanReview(initiallyat 3months,then every6 months)Evaluationof ReferralbyAccreditedCommunityPharmacist(CP)Patient referred to other health & socialcare services and/or contacted byaccredited pharmacist to discuss thereason for the referral and possiblesolutions.InappropriateReferralAppropriateReferralAdherence Evaluation by AccreditedCP (usually as a domiciliary visit)Adherence MUR Plus by AccreditedCPSupport PlanCommunicated to thepatient, as userfriendly (patient held)Medicines PassportPatient carrieson in the serviceAnnual Report &Evaluation of Serviceto Commissioner byService Provider
  9. 9. What’s the service?Adherence Assessment (AA)followed by a Support Planand Report (SPAR). Peoplerequiring ongoing support willbe referred onto OptimizeAdherence Support Service fortailor-made adherencesupport.Who can refer?Any CCG / LA approvedbodyWhich patients need theservice?Patients with long-termconditions who havedifficulty taking, orremembering to take, theirmedicines; complex andhigh need patients only.Who provides theservice? – Hub & Spokemodel• Assessments byAccreditedCommunityPharmacists (hub)• The patient’s presantlocal (Accredited)CommunityPharmacist (spoke)How will we link to otherservices (for referral and forreporting)?• Community nurses• GP practices•Multi-disciplinaryGroups•Social Care Organisations• Pharmacy network• Hospital discharge department• Pathway design (CCG,locality/network etc)What do we report?• Patient review• Info the GP requires.• Cost savings ofrecommendations• Summary of health outcomesfor patients in scheme• Patient satisfaction surveys• Assessment of data fromstakeholdersOptimize©: A MedicinesAdherence Solution
  10. 10. What we were not commissionedto provide – but on reflection wouldbe useful• IT platform• Training of Pharmacy Staff in otherpharmacies for roll out of service• Whole team training (GPs, Nurses, &other Health & Social CareProfessionals)
  11. 11. Optimize© Referral FormConfusion on taking medicationRemembering to take medication is a problem (eg evidence of missed doses)Assistance required to physically take medication (eg dexterity issues)Medications are not synchronised on prescription, requiring extra visits to the Dr / PharmacyDifficulty in maintaining supply of medication evident (eg stockpiling or running out of medication)Patient forgetting to request repeat prescriptionsHealth Literacy (eg difficulty understanding & reading medication labels / non-English literate, lack ofunderstanding of meds or medical condition)Prescribing Interval to be reassessed (eg patient is on 7 day prescriptions -might imply adherence issues)Patient has requested help in taking medicinesIntentional non-adherence (ie patient intentionally choosing to not take medication)High Risk Patient (eg onVirtualWard, Frequent HospitalAdmissions)
  12. 12. Optimize© Adherence Evaluation (Part 1)MMAS-8 Questions.Note for pharmacist - If repeating questionnaire after 6 month please preference each question with the phrase “since welast spoke …...”You are taking medication(s) for your condition. Individuals have identified several issues regarding their medication takingbehaviour and we are interested in your experiences. There is no right or wrong answer. Please answer each questionbased on your personal experience with your new medication.Do you sometimes forget to take your medicine(s)? Yes NoPeople sometimes miss taking their medications for reasons other than forgetting.Thinking over the past two weeks, were there any days when you did not take yourmedicine(s)?Yes NoHave you ever cut back or stopped taking your medication without telling yourdoctor because you felt worse when you took it?Yes NoWhen you travel or leave home, do you sometimes forget to bring along yourmedication?Yes NoDid you take your medicine(s) yesterday? Yes NoWhen you feel like your condition is under control, do you sometimes stop takingyour medicine?Yes NoTaking medicine everyday is a real inconvenience for some people. Do you ever feelhassled about sticking to your medicine treatment plan?Yes NoHow often do you have difficulty remembering to take all your medications? Never / RarelyOne in whileSometimesUsuallyAll the time
  13. 13. Optimize© Adherence Evaluation (Part 2)BMQ Questions.I would like to ask you about your PERSONAL VIEWS about the medicines prescribed for you.Note for pharmacist - If repeating questionnaire after 6 month please preference with the phrase “since we last spoke …...”Please indicate how much you agree or disagree with the following statements about yourmedicine by answering the following. There are no right or wrong answers. We areinterested in your personal views.Tick the appropriate box StronglyagreeAgree Uncertain Disagree Stronglydisagree1) My health, at present, depends on my medicine(s)2) Having to take my medicine(s) worries me3) Without my medicine(s) I would be very ill4) My life would be impossible without my medicine(s)5) I sometimes worry about long term effects of mymedicine(s)6) My medicine(s) are a mystery to me7) My health in the future will depend on my medicine(s)8) My medicine(s) disrupts my life9) I sometimes worry about becoming toodependent on my medicine(s)10) My medicine(s) protects me frombecoming worse
  14. 14. Optimize© Adherence MUR Plus (Page 1)Patient name & address Attach Patients PMR Bag Label Here DOB Total number ofmedicines being used bypatient:Ethnicity PrescribedGender OTC &complementarytherapiesPharmacist name: Date:Suggested questions Complete GLMAS Patient Evaluation Questionnaire Form with patient at start of interview Yes/No1. How are you getting on with your medicines?2. How do you take or use each of these medicines?3. Are you having any problems with any of yourmedicines, or concerns about taking or using them?Medicines not listed on the patient’s PMR Dosage Notes (include if OTC or prescribed. If prescribed from GP or Hosp etc)Consultation notesList ALL meds patient is on from GP / Hospital etc with prescribed dosages (can attach a copy of patients Repeat Request Form or PMR recordprint out). List actual dosages that the patient takes (can do this on the Repeat Form or PMR print our). List any significant side effects. Can usecodes from GL MUR referral sheet as “short codes”Group Q4 & Q5 by therapeutic areas4. Do you think they are working? Prompt: is thisdifferent from what you were expecting?5. Do you think you are getting any side effects orunexpected effects?6. People often miss taking doses of their medicines,for a wide range of reasons. Have you missed anydoses of your medicine, or changed when you take it?Prompt: when did you last miss a dose?7. Do you have anything else you would like to knowabout your medicines or is there anything you wouldlike me to go over again? Prompt: Are you happy withthe information you have on your medicines?
  15. 15. Optimize© Adherence MUR Plus (Page 2)Is a Compliance Aid being used now. Patients views of its usefulness.Prompt: How does the Compliance Aid help you ?Evidence of intentional non-compliance. Why is patient intentionally non-compliant?How does person order / collect prescriptions?. Which pharmacy do they use ?Do they remember to order medicines? What about PRNs & non MDS medicationIs there duplication of medication due to supply from different pharmacies (including hospital) ?How do medicines get delivered to the patient ?Is there evidence of stockpiling or running out of meds. (Check patients actual stock of meds: listexcess meds & quantities of patients stock)Does patient order all medicines together or at different times?Can person read all labels? Yes / NoCan thepersonreadEnglish ?Yes / No Can they open and close all containers? Yes / NoDexterity – able to push tablets out of blisters, pick up small tablets, halvetablets?Yes / NoCan theymeasureany liquidmedicines?Yes / NoInhalers / eye drops – check technique / able to administer correctly? Yes / NoAre they able to swallow their medicines? Yes / NoIs personaware oftime (day)and place?Yes / NoAssess if any of the following would be helpful (please circle)Hand written labels, Large print labels, Symbols / colour coding, Easy open lids, Large bottles, Pop blister meds into bottle, Halvetablets, Haleraid, Spacer , Eye drop dispenser, Different formulation, Measuring cup / oral syringe, OtherWhat systems do they use to remind them to take their medicines?Does someone help patient take their medicines? Who?Does this person prompt or actually administer?Is this person able to help patient with all doses on all days? (check weekends / evenings)Does person have a compliance aid already – what type/ who fills it?Who initiated the compliance aid in the first place ? (GP, Patient, Nurse, CP etc)What condition is the compliance aid in ? (clean, labelled, legible?)Adherence to ‘prn’ medicines, medicines unstable in compliance aid, inhalers, creams etc ?Note to Pharmacist - Remember to take medicines for disposal.Other issues (eg frequent attendance at Urgent Care Centre, A&E)
  16. 16. Optimize© Adherence MUR Plus (Page 3)Name Strength & Form ofmedicineApproximatequantityApproximate cost(based on present DTprice can be completedin the Pharmacy)Reason for disposal RIO scorePlease list medicines no longer required taken for disposalI agree to the above medication being removed for safe disposal by the pharmacistSignature of patient …………………………...…..…......... Signature of pharmacist ……….....................Date ……RIO scoring: 1 – no likelihood of preventing an emergency admission, 2 – possibly may prevent an emergency admission, 3– likely to prevent an emergency admission
  17. 17. Optimize© Adherence Assessment & Support Plan,including Patient’s Medication Passport (MedsUsage Issues)Actions required for MedicinesUsage Issue (Assessor to tick which were identified fromassessment):Improve the patient’s actual use of their medicines Improve the patient’s understanding of their medicines Improve the patient’s experience of taking their medicines Address any issues with any meds with inadequate dosage instructions (ie as directed) & PRNmeds with the prescriber Address side effects (patient reported or clinically identified) and drug interactions that mayaffect the patient’s adherence with the prescriber Recommendations from review of the clinical and cost effectiveness of drugs prescribed. Fromreview of the clinical and cost effectiveness of drugs prescribed itemise here potential costsavings. Include proposals for changing brands to generics (& vice versa) if appropriate; non-use/ under use of meds by patient (eg evidence from meds patient requested for disposal) Change existingAdherence Solution to a more suitable one Discus with prescriber altering the prescribing interval so patient does not run out / have excessmedication Improve the patient’s baseline understanding of their condition(s) Improve the patient’s interpretation of a healthy lifestyle Address intentional non-compliance issues Other -
  18. 18. Optimize© Adherence Assessment & Support Plan,including Patient’s Medication Passport (MedsAccess Issues)Actions required for Access Issue (Assessor to tickwhich were identified from assessment): Prescription ordering service Prescription Collection service Prescription Delivery Service Prescription Synchronisation Duplication of medication due to supply fromdifferent pharmacies (including hospital) Stockpiling (excess stock with patient. Reference-6 month ordering history from GP records orPharmacy PMR) Other -
  19. 19. Optimize© Adherence Assessment & Support Plan,including Patient’s Medication Passport (PhysicalIssues)Actions required for Physical Issue (Assessor totick which were identified from assessment): Use of aids including:o Hand written labels (ie written in a differentlanguage)o Large print labelso Symbols / colour codingo Easy open lids; Large bottleso Pop blister meds into bottleo Halve tabletso Haleraid; Haleraido Eye drop dispensero Eye drop dispensero Measuring cup / oral syringe
  20. 20. Optimize© Adherence Assessment & Support Plan,including Patient’s Medication Passport (AdherenceSolutions)Actions required for Adherence Solution Issue: (Assessor to tick which were identified from assessment) Simplify dosage regime (discus with prescriber) Support carers (formal or informal carers) re medicines oversight. This includes supply of meds & meds education(eg to enable identification of adverse effects) Link medication to daily routine with reminders & prompts Supply Medication Reminder Chart (MR Chart) (A list of all meds & when to take) (Use Medication ReminderChart specified in SLA) Supply MedicationAdministration Records chart (MAR)Chart (use MAR Chart specified in SLA).o Retain used MAR charts , use to make notes of patients on-going Adherence Provide a reminder mechanism for prompting medication adherence (eg phone calls, texting, e-mails, phone ap).o Specify reminder mechanism chosen here: Supply medication in multi-compartment compliance aido Analyse used Blister Packs & make notes of patients on-going Adherence Supply cogitative support: Educational Plan to increase patient/carer understanding of the underlying conditions Supply cogitative support: Educational Plan to increase patient/carer understanding how their medication works Supply cogitative support : Adherence Record Chart (AR Chart) (similar to a MAR but actually asks thepatient/carer to record the reason why a medication was missed or intentionally not taken)o Retain used Adherence Record Charts , use to make notes of patients on-going Adherence Supply cogitative support: Reward Plan.o Details of Reward Plan: Supply cogitative support Relapse Plano Details of Relapse Plan: If patient is not aware of time or place then the patient will need support from informal carer (family / friend , orformal carers (eg Social Care Support, Community Nurse support) for medication administration.o Details of Informal or Formal Support : Other -
  21. 21. Unused Meds, collected from just ONEpatient, prior to joining Optimize©service
  22. 22. Evaluation of DataDue end July 2013 (from 1st six months ofservice)Evaluation will be supported by UCL
  23. 23. Any Questions ?sanjay@greenlightpharmacy.comOptimize©Green Light Healthcare LtdJanuary 2012