The document summarizes three medication management programs:
1. The London Older Peoples Service Development Programme uses a specialist pharmacist assessment and care plan coordinated by a case manager to address older patients' medication access, compliance, and clinical issues.
2. Imperial College's My Medication Passport provides patients a consolidated list of their medications, allergies, and contacts to improve information sharing between care settings.
3. Optimize Adherence Service uses accredited community pharmacists to conduct adherence assessments, develop support plans, and provide ongoing reviews to both address unintentional non-compliance barriers and provide cognitive support to improve intentional medication taking.
4. London Older Peoples Service Development
Programme, Lelly Oboh, April 2003
Aim
ā¢ to promote independence among older
people, through the delivery of person-
centered, coordinated services
LOPSDP medicines management pilot
5. LOPSDP medicines management pilot
Patient Case Selection
Social services staff, Nurses,
Occupational therapists, etc
Initiate Single Assessment
Process (SAP)
4 questions about medicines
Social services or health staff
Continued Care
Case manager or care coordinator
(health or social service staff)
The Medicines Management Project
In-depth Medication Assessment &
Pharmaceutical Care Plan
Specialist Pharmacist
Provide Pharmaceutical Care Package
Community Pharmacist
Nurse GP Carer
London Older People
Program
Referral Pathway
Adapted from: Lelly Oboh, LOPSDP, The āMedicines Managementā Project, (January to July 2003)
6. Single Assessment Process (SAP)
4 questions about medicines
Area of Concern Single Assessment Process (SAP) Questions
Access issues
Q1. I need help getting a regular supply of my
medicines.
Compliance issues
Q2. Sometimes I do not take my medicines the way
that the doctor wants.
Day to day medicines
management issues
Q3. There are some medicines that I cannot get out of
their containers.
Clinical issues
Q4. Realistically, I think some of the medicines that I
take could work better.
7. In depth medicines assessment by
specialist pharmacist
Area of Concern Example Questions
Access issues Has you ever run out of medication?
Compliance issues
Do you need any help taking medication?
Do you use a compliance aid e.g. blister pack?
Day to day medicines
management issues
Can you use your inhaler properly?
Can you open and remove medicines from a blister
pack?
Clinical issues
Pharmacist assesses the safety and appropriateness of
medication.
8. Care Plan delivered and monitored by
community pharmacist
Patients name: DOB: Assessed by Date: Tel:
PHARMACEUTICAL NEEDS
IDENTIFIED
PLAN
ANTICIPATED OUTCOMES
AND ACTION
Access issues e.g. repeat
prescription collection
Patient does not run out
of medicines
Compliance and day-to-day
medicines management
issues
e.g. medication
provided in easy-open
bottles
Patient able to take
medicines
Clinical issues (Identify the
problem or risk involving
medication, including
failure to prescribe for an
condition)
e.g. liaise with GP /
diabetes specialist
nurse for blood glucose
monitoring
Good blood glucose
control and medication
used to get maximum
benefit for the patient
9. LOPSDP pilot - benefits
ā¢ ļ¢ number of hospital and GP attendances
ā¢ ļ¢ waiting times & speeded service delivery
ā¢ Developed joint training & multi-skilling
ā¢ Improved information & improved
processes
ā¢ Empowered front-line staff
LOPSDP pilot - benefits
10. LOPSDP medicines management pilot
Patient Case Selection
Social services
staff, Nurses, Occupational
therapists, etc
Initiate Single Assessment
Process (SAP)
4 questions about medicines
Social services or health staff
Continued Care
Case manager or care coordinator
(health or social service staff)
The Medicines Management Project
In-depth Medication Assessment &
Pharmaceutical Care Plan
Specialist Pharmacist
Provide Pharmaceutical Care Package
Community Pharmacist
Nurse GP Carer
London Older People
Program
Referral Pathway
Adapted from: Lelly Oboh, LOPSDP, The āMedicines Managementā Project, (January to July 2003)
11. LOPSDP pilot - considerations
ā¢ Sounds complicated: multiple professions and
referrals
ā¢ Role of care co-ordinator vital
ā¢ Communication pathways to be established
ā¢ Training staff to understand the 4 trigger
questions and carry out reviews
ā¢ Time constraints
ā¢ Backup plans for IT failure / lack of trained
staff
LOPSDP pilot - considerations
14. Imperial College - My Medication Passport
ā¢ Basic rules about medicines
ā¢ Contact details - Patient, GP and community
pharmacist
ā¢ List of allergies / medicines that canāt be taken
ā¢ List of medication aids
ā¢ Medicines reminder chart
ā¢ List of changes to medication and reasons
Imperial College - My Medication Passport
15. Imperial College - My Medication Passport
Benefits
ā¢ Concise list of patientsā medication
ā¢ Booklet or App (available on phone, computer)
ā¢ ļ¢ medication-related problems during transfer
of care e.g. allergies, interactions
ā¢ Adapt to include other information e.g.
contacts of diabetes specialist nurse, carer etc.
Imperial College - My Medication Passport
16. Imperial College - My Medication Passport
Considerations
ā¢ Too many pieces of paper / information e.g.
warfarin booklet, steroid card, insulin passport.
ā Can we place them all together?
ā¢ Will patients / healthcare staff use the passport?
ā¢ Cost of booklets and implementation
Imperial College - My Medication Passport
18. Optimize -
A Medicines Adherence
Solution
provided by
Green Light Pharmacy
in itās Stepney branch
commissioned byTower Hamlets PCT in
2012 & now by NHS England
19. There is no impending pharmaceutical
discovery, surgical innovation or
governmental policy change with greater
potential for improving the health of
patients and efficiency of the health care
system, than simply increasing the
percentage of treatment plans that
patients (are able to) carry out as
prescribed
[Align Map www.alignmap.com ]
20. āDrugs donāt work in patients who donāt take themā C. Everett Koop M.D ā Surgeon General
USA 1982-89
It is estimated that 50% of all prescribed medication is not used by patients
as intended by the prescriber [ Sackett D.L., Snow J.C. āThe Magnitude of Compliance & Non-Complianceā In:
Haynes R.B. et al (Eds) āCompliance in Health Careā Baltimore, John Hopkins University Press 1979; Nov 22]
It has been estimated that between 20 and 50% of patients are not
adherent to their medication regimeKripalani S, Yao X, Haynes RB. Interventions to Enhance
medication Adherence in Chronic Medical Conditions: A systemic Review. Archives of Internal medicine 2007; 167:540-550
Improving medicine taking may have a far greater impact on clinical
outcomes than an improvement in treatments Haynes R.B., Ackloo E., Sahota N., McDonald
H., Yao X. āInterventions for Enhancing Medication Adherenceā Cochrane Database System Review 2008; (CD0000011)
33-69% of all medicine related hospital admissions are due to poor
medication adherenceOsterberg & Blaschke. New England Journal of Medicine 2005 Vol 353
Only 4 to 21% of patients are receiving the optimum benefit from their
medicines Garfield S, Barber N, Walley P, Willson A, Eliasson L. Quality of Medication Use in Primary Care - Mapping the
Problems, Working to a Solution: A Systemic Review of the Literature. BMC Medicine 2009; 7:50
21. ā¢ To support independent living
ā¢ To improve patient adherence with therapy by
ā Improving understanding
ā Identifying practical problems
ā Supporting the carer
ā¢ To reduce wastage and thus make cost savings by decreasing
the local prescribing budget
ā¢ To help people manage their medicines safely & appropriately
ā¢ To decrease Preventable Medication Related Hospital
Admissions and thus make cost savings to the CCGās Hospital
Admissions budget
22. The service focuses on
improving, supporting & monitoring
adherence (how people take their
meds) not simply on the provision of
compliance devices (ie not just a
blister pack, other solutions as well)
25. Optimize addresses:
Unintentional non
compliance
ā Access (eg over / under
script request)
ā Physical issues (using
inhalers, reading
English)
ā Adherence solutions
(Blister Packs ,
Reminder Charts,
prompts eg phone call,
text, phone aps )
Intentional non-
compliance
ā Cognitive support
ā Meds Education Plan
ā Patient held meds
record - their
āMedication
Passportā
ā Condition Education
Plan
ā Adherence Record
ā Reward Plan
ā Relapse Plan
26. Optimize:A MedicinesAdherence
Solution
Referral
Adherence
Assessment by
AccreditedCP
Support Plan &
Report (SPAR), carried
out by patientās usual,
localCP.
(Compliance aids;
cognitive support;
use of MAR sheets;
reminders/prompts)
Discharge from
service, but
with on-going
Support Plan
Review
(initially
at 3
months, t
hen every
6 months)
Evaluation
of Referral
by
Accredited
Community
Pharmacist
(CP)
Patient referred to other health & social
care services and/or contacted by
accredited pharmacist to discuss the
reason for the referral and possible
solutions.
Inappropriate
Referral
Appropriate
Referral
Adherence Evaluation by Accredited
CP (usually as a domiciliary visit)
Adherence MUR Plus by AccreditedCP
Support Plan
Communicated to the
patient, as user
friendly (patient held)
Medicines Passport
Patient carries
on in the service
Annual Report &
Evaluation of Service
to Commissioner by
Service Provider
Systemwide Improvement of Services for Older People http://www.ihi.org/knowledge/Pages/ImprovementStories/SystemwideImprovementOfServicesForOlderPeople.aspx The aim of the two-year programme was to promote independence in the London community of older people, through the delivery of person-centered, coordinated services.The specific objectives were: To identify vulnerable older people at risk in the community, using a case finding or case management approach To initiate the single assessment process (a new government led multi-agency, multidisciplinary, whole person assessment system to reduce duplication and speed processes), wherever the person enters the system To deliver coordinated services in the community To gather systematically the views of older people and caregiverIn the next few slides I will discuss the medicines-related programme.
All health and social care professionals can carry out the single assessment process (SAP). In this there are 4 trigger questions about medication. I will explain these questions in the next slide. If the answer to any of the questions is yes, the patient is referred to a specialist pharmacist for a detailed medication review. The specialist pharmacist develops a pharmaceutical care plan which is then sent to the patientās local community pharmacist who then delivers and monitors the care plan. They may need to liaise with the patientās GP, nurse or carer and with the care co-ordinator.If the patient does require any health or social care then their case is sent to the care co-ordinator who then co-ordinates all the communication and health and social care for that patient.
These four trigger questions can be asked by anybody in health or social care. They can even be asked in hospital during an inpatient stay.The questions address the issue of accessing medicines, adherence or compliance, day to day issues with taking medicines and clinical issues.If the answer to any of the 4 questions is yes, the patient is referred to a specialist pharmacist for a review.
Upon receipt of a referral, the specialist pharmacist requests obtain a summary of patientās medication and health problems from the GP.The specialist pharmacist carries out a detailed review of the patients medicines.The key themes of this review are the same as the 4 trigger questions but there are detailed questions about each. In the assessment, the top three are similar to MUR but more detailed. The fourth, medication review, requires specialist clinical knowledge / training.Questions covered in Access IssuesGetting repeat prescriptions / Delivering medication to patientHas patient ever run out of medication?Compliance issuesDoes the patient need any help with taking medication?Does the patient currently have a compliance aid?Do you know/understand how to take the medicines?Day to day medication management issuesAny problems with swallowing tablets, reading labels, mobility, manual dexterityCan they instil eye drops or use inhalers properly?Clinical medication reviewConsider appropriateness of each medication (indication, dose, ADR, drug interaction, monitoring)Consider patientās medical conditions (untreated condition, drug use without indication)
The role of the community pharmacist is crucial here.The pharmacist will not only be delivering the care plan in a practical way but also monitoring this plan. In the programme follow-up was after 6 months but it can be more frequently.Monitoring and review are very important because they give patients and professionals a chance to understand what is working well and take steps to improve other aspects. This is especially important if the patientās condition has changed since the initial review with the specialist pharmacist.
This project has already shown some positive results with reduced hospital and GP attendances. The improved communication pathways have resulted in better flow of information between various agencies / professionals and therefore resulted in faster service for patients. Staff working directly with patients are able to help the patients immediately by making referrals rather than simply signposting patients to appropriate services.
A quick look at the programme again. There are several communication streams and multiple health professionals involved in the scheme.
The programmes sounds and looks very complication with multiple professionals and referral or communication pathways. It is important to get the communication pathways clear to prevent failure. Forms may be posted, faxed, emailed between agencies, but there should be feedback/acknowledgement mechanism in place too.The role of the care co-ordinator is vital as they are co-ordinating both the health and social care for the patient.Staff training is required to ensure these new roles can be fulfilled. So staff should be trained on how to ask the 4 trigger questions and refer.Pharmacists will need to be trained to develop care plans and packages. It is also important to understand the time required to performs these additional tasks and this will have resource implications. Such a system relies on complex communication and trained staff and most importantly the care co-ordinator. There should be plans in place for continued safe service during these systems failures.
Communication of medication changes across interfaces is a well recognised issue within the NHS. Whenever a patient transfers care settings there is a risk that information about their medicines is not transferred, or inaccurately transferred.My Medication Passport is a written record of a patient's medicines. My Medication Passport was launched on 17 April 2013 The medication passport is designed to help the patient and anyone involved in the patientās care to understand their current medication and changes to it and what the cannot take.It should be shown to the GP, pharmacist, dentist or any other healthcare professional involved in provision of care. It should be presented at outpatient appointments and at A&E attendances.The passport has been given to over 5000 patients across Imperial College Healthcare NHSĀ Trust with excellent feedback. The plan is now to make the passport available across the wider area of North West London and then potentially further afield.
It is designed to improve communication between patients, carers and healthcare professionals and maintain a record of changes made to the patient's medication. Features of the medication passport include:Relevant information about the patient andĀ his/her GPList of medicines that the patient cannot take and the reasons whyCompliance aids in useList of theĀ patient's current medicines List of changes to medicinesWhat are the aims?The passport aims are to help patients/carers have a complete record of their medicines as well as an understanding of the reasons for any changes being made to their medicines. It's designed to empower patients/carers to take control of their medication and help seamless transfer of medication information across healthcare interfaces.Passports are available in two formats:As a paper based bookletĀ As an app for iPhone or Android phones
It lists patientās medication as well as medication that the patient cannot take. Recent changes to medication are also documented so health professionals can get a brief medication history.Available as a booklet or App ā it is useful for patients of all ages, especially those who have and know how to use Smart Phones. Information is instantly accessible.Because all medication is listed clearly, it avoids problems during transfer e.g. when patients go to hospitals or see another health professionals. Health professionals can check the patientās medication list and prescribe new medicines that do not interact with the current medicines. During outpatient clinic appointments at the hospital, this is very important as the Drs donāt always have a list of the patientās regular medication when they see the patient.This booklet could also be adapted to include other information that is relevant to the patient e.g. the contact name and number of their specialist nurse, carers etc. and this will allow better communication between professionals without having to go to the GP each time.
A booklet just for medicines will increase the amount of medicines-related documents/paperwork that patients have to carry with them. Patients on warfarin have yellow anti-coagulation booklets, those on insulin have the insulin passport.It may be worth if we could have a booklet that had space to add these other documents.Will patients carry their booklets / passports. The App is a good idea and can be used if people have smart phones. We could wait to see what the response is from the Imperial project.Will healthcare staff use the booklet. At the moment, staff write in other patient records (e.g. medical notes) but on patient-held information. Staff training and commitment are also required. Also need to include hospital staff who may prescribe/change medication. They should be documenting their actions in the booklet too.There is a cost associated with these and the scheme should only be commissioned if there is significant commitment from all parties to use the booklet at all times.
