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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 857patients have justifiable
pharmaceutical interventions
2,398 items remainon active repeat
571 Patients nolonger on repeat
medication
857 Patients haveactive repeat prescription
Clinically significantpharmaceutical
interventions= 957
Practice total population
12,200
3,313 Patients have at least 1 activeprescription item not issued in last
12 months
Patients A - M=
1,428 Patients
5,409 active repeatitems
3,011 itemsarchived
NSFs- Management of CHD patients
Pre Review Breakdown of Heart At Risk Groups (April 2001)
0
20
40
60
80
100
70
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)
0
20
40
60
80
100
120
70Primary
127Secondary
26Hyperlipidaemia
Hitting target
Not hitting target
NSFs - Management of CHD patients
Medication Review Results Interventions beyond changes in statin medication
Prescription items N = 1477
0
50
100
150
200
250
300
Optim
isatio
n of
ther
apy
Cost s
aving
(bra
nd o
r gen
eric)
Archiv
e
Chang
e fo
rm, d
ose,
freq
uenc
y
Diseas
e dr
ug in
tera
ction
Drug
inter
actio
n
ADR
Drug
withdr
awal
Thera
peut
ic dr
ug m
onito
ring
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
Pharmacy
Pharmacy
Pharmacy
+ +
- -
+ -
- +
Services A - F
Services A - C
Services D - F
Service A
GP/PCT
A need for consistent and accurate resultsfor the basis of clinical decisions.
Pharmacies & pharmacists with varying standards of premises, qualification and services to both GP’s andpatients.No supporting remuneration model.
Equity - A Model for the Future
Pharmacy
Pharmacy
Pharmacy
Pharmacy
Services A - Z
Services A - Z
Services A - Z
Services A - Z
LPS ProviderServices A - Z
Service Accreditation & Standardsset by Professional Bodies, sHAs & PCTs
GPConsistent and accurate
results with standard reports to all GP’s
Patients Home
Nursing Home
GP Surgery
Call CentreCentralised PCTmanagement 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 canprovide a specific service by meetingthe same standards.
Audit ProtocolDefinition
Define targetpatient criteria
Define action plan for target
patients
Define patient communication
plan
Screen patientson existing
therapy
Confirm guidelinesobjectives and schedules
Patient ID, Capture & Review
1day / 35 target patients to
review notes & implement
‘Step Down’exercise
Practice decideand agree ‘StepDown’ changes
Medicationchanged
accordingly
PCT Board &Primary CareDevelopmentBoard agreeprogramme
Chronic Disease Management – PPIs
Patient Follow up & Monitoring Communications
Exercise
Letter to patient advising
changes
Practice auditcollection of new
prescriptions
Community Pharmacists
advised.
Local PRcampaign via
local media
14 - 21 Days postreceipt of newprescriptions
conductPatient 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 reportedPatient continues
with new medication
Chronic Disease Management - PPIs
Further follow up via call centre tonext changes.
0845 number leftif symptoms return
All practiceshave a clinic
Clinics will havePCP support
Lifestyle andcondition audit
performed
Clinic bookings confirmed by
letter
Step Upmaintenance totreatment dose
Change medicinein line with programme
Discontinue newmedicines /
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: HbA1C < 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
10,8004,121 Medication reviews
in the last 15 months
Patients OVER 75=
919 Patients 782 patientson at least ONE
active repeatitems
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 useof medicines and dressings
High rate of hospital admissions
High demands on practice
for visits
Residential or
Nursing care homes
MEDICINESMONITORED
FORMAL CMP FOR EACH RESIDENT
ASSESSMENT BEFORE ISSUE AND REVIEW
CONTROL OF MEDICINE USAGE
REDUCEDRE-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