Post-discharge Home Medicines Reviews
in TCP
Dean Byrnes – Senior Pharmacist TCP
Gold Coast HHS
Overview
 TCP Gold Coast HHS
 Quality Use of Medicines and TCP
 Post-discharge medication review model – Gold
Coast HHS...
Service Delivery
IN HOUSE
 Administration (7)
 Allied Health (32)
 Nursing (9)
 Operational staff (6)
 Rehab Physicia...
Medication management & TCP
 TCP guidelines
 “Control and administration of medications
prescribed by medical practition...
Open to interpretation!
 Medication management forms part of core services
 Ongoing support of patient with medication m...
Quality Use of Medicines
 Central objective of Australia’s National
Medicines Policy
 Selecting management options wisel...
Home Medicine Reviews
 Medicare funded pharmacist / GP program available to Australian
residents
 Collaborative program ...
Evidence – HMRs
 General evidence
 High patient acceptability
 GPs who use the service like it
 High pharmacist workfo...
What about TCP?
 What are we doing?
 The traditional HMR model?
 Post-discharge HMR model?
 Evidence?
 Consultative a...
Post-discharge medication reviews
 Vrong et al – post-discharge models
 Post-discharge HMRs by pharmacists best conducte...
HOMER trial1
 Do home based reviews keep older people out of hospital?
 Post-discharge model
 RCT
 Intervention – 2 ho...
Problems
 Timely access to HMR model
 Studies suggest that HMR model relying on GP referral can take on average 18 days ...
TCP Gold Coast HHS
 Project Objectives
 Create a system for patient identification
 Conduct reviews
 Standardise activ...
Identifying patients
 Existing Medicare
Australia criteria
 All residential
patients
 Treated like a ward
 Some additi...
Criteria
 Meet 2 of the following criteria – see within 7-10 days of discharge
 Currently taking five or more regular me...
Conducting the HMR
 Ideally a post-discharge HMR should be done
within 10 days of discharge from hospital.
 Home Medicin...
Sounds like an easy concept!
 Delivery can be much more difficult
 Cognition of the patient following discharge can be i...
Assessments during HMR
 DRUGS
 Drug Regimen unassisted grading scale
 Conducted by pharmacist or nurse
 Pre and post s...
Findings – 43 patients
Sex:
 Male
 Female
No. of patients
 16
 27
Average age of clients 78 years old (rounded)
Presen...
What did the pharmacist do?
 Hepler et al – functions of the HMR
 Identify potential and actual drug related
problems
 ...
Pharmaceutical Society Interventions
“A process of identifying drug related problems
and making a recommendation in an att...
Drug related problems
 Drug related problems
 Drug selection – 22 interventions
 Over or under dose – 5 interventions
...
75
55
7
1
4 3 1
4
0
10
20
30
40
50
60
70
80Number
Recommendation type
PrescriberRecommendations
So what?
 Looks like a lot of work on paper
BUT…..
 Does it have any value?
 Realistically – what is the point?
 Healt...
Clinical questions
 What impact do the patient/prescriber
interventions have on patient care when
compared to the literat...
Risk mitigation
 Society of Hospital Pharmacists Australia
 Risk classification system for interventions made by pharmac...
Risk matrix
Insignificant Minor Moderate Major Catastrophic
Almost Certain NO RISK HIGH EXTREME EXTREME EXTREME
Likely NO ...
Staff Satisfaction
1. The level of pharmacy services is adequate to fulfil my needs and those of the
patients.
2. Having a...
Pre and post comparison
46% Response Rate
0
1
2
3
4
5
6
1 2 3 4 5 6 7 8
Score
Question No.
Average Staff Responses -
compa...
Patient satisfaction – CSQ-8
 Validated patient satisfaction survey for a service
 Administered by Therapy Assistants an...
In a nutshell
 The post-discharge model
 Adapts to the patient
 Sometimes traditional HMR type
 Sometimes you review p...
Future Direction – Post-discharge HMR
Future directions – Evidence
HOMER TRIAL
“Failure is only the opportunity to begin again, this time
more wisely.”
“Man can...
Quality and Sustainability
 Long hard look at our own service
 Confront the current climate
 The reality of service pro...
TCP Gold Coast
 Survey of services provided by community pharmacy in our district
 Database
 Refer as required
 Contin...
TCP Gold Coast
 Innovative practice
 Collaboration with short stay units
 Targeting short stay units – these are often ...
Evolution of the role
 Identifying patients in hospital who would benefit from HMR
 Collecting intervention data to shap...
Take home messages
 There is a very big role for pharmacists working
in the TCP environment
 Staff pharmacist OR other p...
Dean Byrnes
BPharm MHlthSc AACPA MASCP
Senior Pharmacist – Transition Care Program GC HHS
dean_byrnes@health.qld.gov.au
(0...
Dean Byrnes, Queensland Health - Pharmacist Led Home Medicines Review Model  in Transition Care Program
Dean Byrnes, Queensland Health - Pharmacist Led Home Medicines Review Model  in Transition Care Program
Dean Byrnes, Queensland Health - Pharmacist Led Home Medicines Review Model  in Transition Care Program
Dean Byrnes, Queensland Health - Pharmacist Led Home Medicines Review Model  in Transition Care Program
Dean Byrnes, Queensland Health - Pharmacist Led Home Medicines Review Model  in Transition Care Program
Dean Byrnes, Queensland Health - Pharmacist Led Home Medicines Review Model  in Transition Care Program
Dean Byrnes, Queensland Health - Pharmacist Led Home Medicines Review Model  in Transition Care Program
Dean Byrnes, Queensland Health - Pharmacist Led Home Medicines Review Model  in Transition Care Program
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Dean Byrnes, Queensland Health - Pharmacist Led Home Medicines Review Model in Transition Care Program

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Dean Byrnes, Senior Pharmacist, Transition Care Program,
Gold Coast Hospital & Health Service, Queensland Health delivered the presentation at the Transition Care: Improving Outcomes for Older People Conference 2013.

The Transition Care: Improving Outcomes for Older People Conference explores a combination of residential and community transition care programs. It also features industry professionals' experiences in transitional aged care, including the challenges and successes of their work.

For more information about the event, please visit: http://www.communitycareconferences.com.au/transitioncareconference13

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Dean Byrnes, Queensland Health - Pharmacist Led Home Medicines Review Model in Transition Care Program

  1. 1. Post-discharge Home Medicines Reviews in TCP Dean Byrnes – Senior Pharmacist TCP Gold Coast HHS
  2. 2. Overview  TCP Gold Coast HHS  Quality Use of Medicines and TCP  Post-discharge medication review model – Gold Coast HHS  Patient identification  Review process / assessments  Snapshot of 43 clients  Client impact  Client and Staff satisfaction
  3. 3. Service Delivery IN HOUSE  Administration (7)  Allied Health (32)  Nursing (9)  Operational staff (6)  Rehab Physician (0.5) BROKERAGE  Personal Care  Social Support  Domestic Assistance  Transportation  Equipment  Hotel Services  Additional AH and Nursing as required
  4. 4. Medication management & TCP  TCP guidelines  “Control and administration of medications prescribed by medical practitioner, subject to legal restrictions on providing the medication”  “Appropriate medication management” What exactly does this mean? Is this what we want for our patients?
  5. 5. Open to interpretation!  Medication management forms part of core services  Ongoing support of patient with medication management  Pain assessment and management plans (medication management plans)  Falls risk assessment and mitigation strategies (medications and falls)  TCP Gold Coast  Prior to pharmacist service – nurse driven  Little / untimely access to specialist medication review services already available in the community  Medicare funded Home Medicine Review Program  Referral to outpatient clinics with pharmacists attached  Focus on competency to administer medications  Less emphasis on other activities which achieve Quality Use of Medicines
  6. 6. Quality Use of Medicines  Central objective of Australia’s National Medicines Policy  Selecting management options wisely  Considering suitable medicines if they are deemed necessary  Using medicines safely and effectively
  7. 7. Home Medicine Reviews  Medicare funded pharmacist / GP program available to Australian residents  Collaborative program between GPs, accredited pharmacists and community pharmacy  Referral to community pharmacy  Referral direct to an accredited pharmacist  In-home review by pharmacist  Generation of report for GP  Agreed medication management plan between GP and client  Assists individuals living at home to maximise the benefits of their medication regimen and prevent medication related problems  Available to all Australia residents  TCP clients
  8. 8. Evidence – HMRs  General evidence  High patient acceptability  GPs who use the service like it  High pharmacist workforce satisfaction  Often underutilised  Hepler et al – functions of the HMR1  Identify potential and actual drug related problems  Resolving drug related problems  At time of review  Through liaison with prescribers  Preventing potential drug related problems  “Quality use of Medicines in the Community Implementation Trial” – University of SA and Adelaide2  Pharmacist identify a lot of drug related problems  GPs implement 42% of recommended changes to regimens  Of these implementations 81% were resolved, well managed or improving  Improved pharmacist and GP collaboration to achieve QUM 1. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm 1990; 47:533-43 2. Beilby J et al. Quality use of medicines in the community implementation trial. Available at: http://www.aro.gov.au/aro/researchEntryView.do;jsessionid=FOGPILDFLPEI?id=1535&type=keyword
  9. 9. What about TCP?  What are we doing?  The traditional HMR model?  Post-discharge HMR model?  Evidence?  Consultative advice  Surveillance  Rehabilitation towards self-management  Pain management SOME OF THE ABOVE or ALL OF THE ABOVE?
  10. 10. Post-discharge medication reviews  Vrong et al – post-discharge models  Post-discharge HMRs by pharmacists best conducted by at least 7-10 days after discharge  Enhance compliance  Improve knowledge  Identify problems  Role for patients initiated on warfarin2  Role for patients with heart failure3 1. Holland R et al. Does home based medication review keep older people out of hospital? – The HOMER RCT. BMJ 2005; ;330:293 2. Roughead E, Barratt J, Ramsey E, Pratt N, Ryan P, Peck R et al. Collaborative home medicines review delays time to next hospitalization for warfarin associated bleeding in Australian war veterans. J Clin Pharm & Ther. 2011;36:27- 32 3. Ponniah A, Shakib S, Doecke C, Boyce M, Angley M. Post-discharge medication reviews for patients with heart failure: a pilot study. Pharm World Sci. 2008;30:810-815.
  11. 11. HOMER trial1  Do home based reviews keep older people out of hospital?  Post-discharge model  RCT  Intervention – 2 home visits within 2-8 weeks of discharge  Education focus  Remove out of date drugs  Inform GPs of ADRs and DIs  Inform community pharmacist if administration aid required  Results  Higher rates of hospitalisations!  Did no significantly improve QOL or reduce deaths 1. Holland R et al. Does home based medication review keep older people out of hospital? – The HOMER RCT. BMJ 2005; ;330:293
  12. 12. Problems  Timely access to HMR model  Studies suggest that HMR model relying on GP referral can take on average 18 days to secure  Evidence of impact suggests a review within 7-10 days  Do all patients need to be seen?  Who benefits the most  Sustainability  Funded by state government through TCP on the Gold Coast  Existing funding pool for clients  Approximately $200 dollars per review  What is the dollar value that we know is paid vs the realistic service that needs to be provided to a client on TCP  Episodes of care, documentation time, liaison time, referrals to other services, case conferencing  Who is responsible for what? – where to the recommendations go?  GP  Specialist Outpatients  Residential TCP patients under rehabilitation consultant
  13. 13. TCP Gold Coast HHS  Project Objectives  Create a system for patient identification  Conduct reviews  Standardise activities and assessments  Capture data  Pharmacist interventions  Prescriber recommendations  Staff satisfaction  Client satisfaction  Analyse data  Process evaluation  Impact evaluation  Patient outcome measurements  Satisfaction
  14. 14. Identifying patients  Existing Medicare Australia criteria  All residential patients  Treated like a ward  Some additional criteria of importance
  15. 15. Criteria  Meet 2 of the following criteria – see within 7-10 days of discharge  Currently taking five or more regular medicines  Taking more than 12 doses of medicine per day  Significant changes to their medicine regimen in the last three months, including recent discharge from hospital  Taking medicine with a narrow therapeutic index or required therapeutic monitoring  Taking medicines not prescribed by a doctor  Attending a number of different doctors, both general practitioners and specialists  Automatic referral – within 1-2 days of discharge  Difficulty managing medications  Symptoms suggestive of ADR  Ongoing need for pain management input  Requires manipulation of oral doses  Requested by patient  Requested by ward pharmacist
  16. 16. Conducting the HMR  Ideally a post-discharge HMR should be done within 10 days of discharge from hospital.  Home Medicines Review  Assessment at home  Medication History  Patient activities / counselling  GP/prescriber recommendations  Follow-up on recommendations
  17. 17. Sounds like an easy concept!  Delivery can be much more difficult  Cognition of the patient following discharge can be impaired  Post-surgical pain medications  General disorientation  Service overload results in overwhelmed patients  Even when a patient meets the criteria, there may not be a need for pharmacist intervention  Specialised input - pain management  GP collaboration can be difficult – establishing relationships and preferred method of communication is important
  18. 18. Assessments during HMR  DRUGS  Drug Regimen unassisted grading scale  Conducted by pharmacist or nurse  Pre and post scores – show worth of interventions  TABS  Tool for adherence behaviour screening  STOPP  Screening tool of older persons’ potentially inappropriate prescriptions  FALLS  Medication and falls assessment with mitigation strategies
  19. 19. Findings – 43 patients Sex:  Male  Female No. of patients  16  27 Average age of clients 78 years old (rounded) Presentation types  Medical/Trauma  Neurology  Surgical (orthopaedic No. of patients  19  2  22 Time spent with patients per presentation type  Medical/Trauma  Neurology  Surgical (orthopaedic)  All patients Face to face  69.21 mins  55.43 mins  45.69 mins  56.17 mins Other  51.84 mins  42.5 mins  46.82 mins  48.83 mins Total time  121.1mins  100.9mins  92.5mins  105mins
  20. 20. What did the pharmacist do?  Hepler et al – functions of the HMR  Identify potential and actual drug related problems  Resolving drug related problems  At time of review  Through liaison with prescribers  Preventing potential drug related problems
  21. 21. Pharmaceutical Society Interventions “A process of identifying drug related problems and making a recommendation in an attempt to solve the problem”  Solved at time of review within a pharmacist’s scope of practice  Easy!!!!  Referred to a prescriber for consideration  Easy???
  22. 22. Drug related problems  Drug related problems  Drug selection – 22 interventions  Over or under dose – 5 interventions  Compliance – 23 interventions  Undertreated / Untreated – 39 interventions  Monitoring – 1 intervention  Not classifiable – 4 interventions  Drug Toxicity management – 15 interventions  Referred to prescriber  75 drug related problems  Mitigated by a pharmacist at the time of review  34 drug related problems
  23. 23. 75 55 7 1 4 3 1 4 0 10 20 30 40 50 60 70 80Number Recommendation type PrescriberRecommendations
  24. 24. So what?  Looks like a lot of work on paper BUT…..  Does it have any value?  Realistically – what is the point?  Health districts increasingly results driven  Prevent hospitalisations  Prevent costs to the system  Improve patient outcomes
  25. 25. Clinical questions  What impact do the patient/prescriber interventions have on patient care when compared to the literature?  Do interventions / prescriber recommendations made during home medicines reviews remain outstanding at the end of TCP?  Do interventions / patient recommendations made during home medicines reviews remain outstanding at the end of TCP?
  26. 26. Risk mitigation  Society of Hospital Pharmacists Australia  Risk classification system for interventions made by pharmacists in hospital inpatients  Australian risk management principles  Elliott et al 2009  Adapted and validated the SHPA risk matrix  Geriatric ambulatory patients  Consequence (severities)  Assume intervention not made – what is the likely scenario (NOT worst case scenario)  Likelihoods  Likelihood of consequence occurring within the next 12 months  Explored the differences in risk classifications between pharmacists and geriatricians
  27. 27. Risk matrix Insignificant Minor Moderate Major Catastrophic Almost Certain NO RISK HIGH EXTREME EXTREME EXTREME Likely NO RISK MODERATE HIGH EXTREME EXTREME Possible NO RISK MODERATE MODERATE HIGH EXTREME Low NO RISK LOW RISK MODERATE HIGH HIGH Rare NO RISK LOW RISK LOW RISK MODERATE HIGH
  28. 28. Staff Satisfaction 1. The level of pharmacy services is adequate to fulfil my needs and those of the patients. 2. Having a pharmacist available in TCP improves the quality of care for my patients. 3. I frequently contact the pharmacist for medication-related questions about my patients. 4. The questions that I direct to the pharmacist in TCP about medications are answered completely. 5. The questions that I direct to the pharmacist in TCP about medications are answered in a timely manner. 6. The pharmacist is helpful in clarifying medication related issues. 7. The pharmacist explains things in words I can understand. 8. Overall, I am satisfied with the level of services that I receive from the pharmacist in TCP. Ratings: 1 = strongly disagree 2 = disagree 3 = neutral 4 = agree 5 = strongly agree.
  29. 29. Pre and post comparison 46% Response Rate 0 1 2 3 4 5 6 1 2 3 4 5 6 7 8 Score Question No. Average Staff Responses - comparison
  30. 30. Patient satisfaction – CSQ-8  Validated patient satisfaction survey for a service  Administered by Therapy Assistants and Pharmacist  Response rate of approximate 44%  Results:  Clients liked the service  Clients liked what the service covered  Clients felt the service met their needs  Clients would recommend the services to other people  Clients would utilise such a service in the future
  31. 31. In a nutshell  The post-discharge model  Adapts to the patient  Sometimes traditional HMR type  Sometimes you review pain management / post-surgical medications  Sometimes you organise self-management services  The pharmacist activities  Consistent – no matter what type of review is undertaken  Identifies drug related problems  Mitigates within scope of practice  Refers to appropriate clinicians with recommendations  Is there an impact  Client satisfaction with services is high  Depending on the patient risk, GPs are highly collaborative  Teamwork is fostered through high staff satisfaction
  32. 32. Future Direction – Post-discharge HMR
  33. 33. Future directions – Evidence HOMER TRIAL “Failure is only the opportunity to begin again, this time more wisely.” “Man cannot discover new oceans unless he has the courage to lose sight of the shore.” Business rules are changing for direct hospital referrals to accredited pharmacists to perform post-discharge HMR
  34. 34. Quality and Sustainability  Long hard look at our own service  Confront the current climate  The reality of service provision and funding  Clinical pharmacist roles – who can provide what services to patients in the community  Evolution of the TCP pharmacist role in our district?
  35. 35. TCP Gold Coast  Survey of services provided by community pharmacy in our district  Database  Refer as required  Continue with our data collection  Use intervention data to shape practice in our district at a hospital level  Validate a tool which identifies risky patients in hospital  Get people thinking about involving a pharmacist  Those who benefit most  Strengthen the referral evidence  Sustainable practice and being patient centred  Involving patients’ long term practitioners  We are time limited – who will be there for the patient in the future  Investigating the readiness and willingness of other pharmacists in the district to take over the model of post-discharge HMR as the business rules change  Collaboration with Community Pharmacists and GPs  MedsCheck / Diabetes MedsCheck  Referral into ongoing Home Medicines Review Program
  36. 36. TCP Gold Coast  Innovative practice  Collaboration with short stay units  Targeting short stay units – these are often risky admissions to TCP  Improved communication of essential medication information – in and out of ED/Medical Assessment Units  Identifying frequent fliers to emergency departments due to medication management  Rotation of ward pharmacists into TCP – learning experience  Improve hospital discharges
  37. 37. Evolution of the role  Identifying patients in hospital who would benefit from HMR  Collecting intervention data to shape practice in the district  Hospital level  Community level  Post-discharge referral pathways  Creating new paths in the district  Strengthening ties created  Leading by example  Replicating the model across other patient types  Providing clinical services where specialised advice is required  Rehab of self-management  Post-surgical pain management  Osteoporosis treatment  Delirium and dementia – drug induced  Providing clinical services when timeliness is a necessity  Providing clinical services for clients who don’t have pre-existing pharmacist networks  Being a source of information for other pharmacist service providers
  38. 38. Take home messages  There is a very big role for pharmacists working in the TCP environment  Staff pharmacist OR other pharmacists in the community  There is a wealth of opportunity in many health districts  Find out what your pharmacists do  Be ready for the changes to the program  Direct referrals
  39. 39. Dean Byrnes BPharm MHlthSc AACPA MASCP Senior Pharmacist – Transition Care Program GC HHS dean_byrnes@health.qld.gov.au (07) 5570 8579

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