Chronic Disease Management – Role of the Community Pharmacist Andrew J. Burr

People 6% 22% 72% Segments within the total population Costs associated with each segment £ 36% 31% 33% Those with multiple chronic conditions Those with one chronic condition Those with no chronic condition Chronic Disease Management

AIM Reshape care around the patient Help to reduce risk Set outcome goals for treatment Create a Clinical Management Plan Implement plan across health care team Improve health and quality outcomes Make better use of the skills and knowledge of the team

Scope of Medicine Management Prescription review Patient counselling Patient education and self-care Management of repeat prescribing Services from within community pharmacy Medication monitoring Medication-history taking Patient referral Services across the 1*/2* interface Prescriber-led CDM clinics Services to residential/nursing homes Domiciliary services

Risk Management - Archiving 486 out of the 857 patients have justifiable pharmaceutical interventions 2,398 items remain on active repeat 571 Patients no longer on repeat medication 857 Patients have active repeat prescription Clinically significant pharmaceutical interventions = 957 Practice total population 12,200 3,313 Patients have at least 1 active prescription item not issued in last 12 months Patients A - M = 1,428 Patients 5,409 active repeat items 3,011 items archived

NSFs- Management of CHD patients Pre Review Breakdown of Heart At Risk Groups (April 2001) Primary 127 Secondary 26 Hyperlipidaemia Hitting Target Not Hitting Target

NSFs - Management of CHD patients Post Review Breakdown of Heart At Risk Groups (August 2001) Primary 127 Secondary 26 Hyperlipidaemia Hitting target Not hitting target

NSFs - Management of CHD patients Medication Review Results Interventions beyond changes in statin medication Prescription items N = Optimisation of therapy Cost saving (brand or generic) Archive Change form, dose, frequency Disease drug interaction Drug interaction ADR Drug withdrawal Therapeutic drug monitoring

Improved Quality Outcomes Effective use of skills Formal patient care plans Improved concordance and outcomes with medicines Improved understanding and appreciation of how pharmacist can help achieve goals

Context of Medicine Management Reshaping care around the patient Improving and ensuring quality Reducing Risk Improving health Making better use of the skills and knowledge of staff

Integration of Community Pharmacy

Community Pharmacy Equity Standards and accreditation Skill mix Supply v Outcome Integration Competencies Access Workload

Integration of Community Pharmacy Pharmacy Services A - F Services A - C Services D - F Service A GP/ PCT A need for consistent and accurate results for the basis of clinical decisions. Pharmacies & pharmacists with varying standards of premises, qualification and services to both GP’s and patients. No supporting remuneration model.

Equity - A Model for the Future Pharmacy Services A - Z LPS Provider Services A - Z Service Accreditation & Standards set by Professional Bodies, sHAs & PCTs GP Consistent and accurate results with standard reports to all GP’s Patients Home Nursing Home GP Surgery Call Centre Centralised PCT management provides transactional audit as a basis for new payment systems ALL pharmacies offer services A-Z. Patients gain equity of service as do GP’s. Any pharmacy can provide a specific service by meeting the same standards.

Audit Protocol Definition Define target patient criteria Define action plan for target patients Define patient communication plan Screen patients on existing therapy Confirm guidelines objectives and schedules Patient ID, Capture & Review 1day / 35 target patients to review notes & implement ‘Step Down’ exercise Practice decide and agree ‘Step Down’ changes Medication changed accordingly PCT Board & Primary Care Development Board agree programme Chronic Disease Management – PPIs

Patient Follow up & Monitoring Communications Exercise Letter to patient advising changes Practice audit collection of new prescriptions Community Pharmacists advised. Local PR campaign via local media Days post receipt of new prescriptions conduct Patient Audit Audit:- Medicines use Patients response to medication Date Rx cashed No. of tablets left Symptoms Compliance Side Effects Issues reported - Patient booked Into practice based Nurse led GI Clinic No issues reported Patient continues with new medication Chronic Disease Management - PPIs

Further follow up via call centre to next changes number left if symptoms return All practices have a clinic Clinics will have PCP support Lifestyle and condition audit performed Clinic bookings confirmed by letter Step Up maintenance to treatment dose Change medicine in line with programme Discontinue new medicines / regime Patient Follow Up & Monitoring cont..Patient Support Chronic Disease Management - PPIs

Clinical Management Plan Legal requirement Patient specific Agreed with Independent Prescriber Arrangement endorsed by Patient Sets out scope of SP activities Referral criteria Monitoring parameters Demands a formal review Time limited

Clinical Management Plan Conditions to be treated Diabetic control Blood pressure Cholesterol CHD risk factors Guidelines or protocols British Hypertension Society Local guidelines on diabetic care

Medicines prescribed in CMP Statins –(upto Atorvastatin 80mg or equivalent) Oral hypoglycaemics –alone or combination to maximum rec. dosage Anti-hypertensive regime –Thiazide, ß-blocker, calcium-channel blocker or ACE-inhibitor (A2 alternative) alone or in combination to achieve BP target Smoking cessation programme –Nicotine replacement therapy Continuation of remaining repeat master –Maintenance of existing repeat master

Clinical Management Plan Aim of treatment ADVICE: Diet, medicines, exercise BLOOD PRESSURE: BP >140/80 CHOLESTEROL: < 5.0 mmol/L DIABETES CONTROL: HbA 1C < 7.0% EYE SCREENING FEET SCREENING GUARDIAN DRUGS: Aspirin, ACE-inhibitors Frequency of review and monitoring –Quarterly monitoring with six monthly review

Implementing CMPs – Pros and Cons Formalised plan Framework to prescribing Timely monitoring Improved communication Shared record keeping Efficient use of healthcare team Time consuming Patient selection Limitations of plan

Nursing Homes – Medication Reviews Residential or Nursing care homes 123 patients Practice total population 10,800 4,121 Medication reviews in the last 15 months Patients OVER 75 = 919 Patients 782 patients on at least ONE active repeat items 1,507 reviews required per year 238 reviews required per year 40 hours of reviews required per year

Nursing Homes – SP role 123 patients Routine monitoring omitted Review = reauthorisation No formalised framework for review High use of medicines and dressings High rate of hospital admissions High demands on practice for visits Residential or Nursing care homes MEDICINES MONITORED FORMAL CMP FOR EACH RESIDENT ASSESSMENT BEFORE ISSUE AND REVIEW CONTROL OF MEDICINE USAGE REDUCED RE-ADMISSIONS TARGETTED GP VISITS

Key to Success Work as part of the team to deliver real health outcomes by ensuring robust and effective mechanisms Facilitate local decision making to underpin coherent strategic framework