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Pharmaceutical Services DivisionMinistry of Health Malaysia
PROTOCOLMEDICATION THERAPY ADHERENCE CLINIC, WARD & HMR: NEUROLOGY (STROKE)
Pharmaceutical Services DivisionMinistry of Health Malaysia
Lot 36, Jalan Universiti46350 Petaling Jaya, Selangor.
Tel. : 03-78413320/3200 Faks : 03-79682222
www.pharmacy.gov.my
MEDICATION THERAPY ADHERENCE CLINIC,
WARD & HMR: NEUROLOGY (STROKE)
First Edition2013
Pharmaceutical Services DivisionMinistry of Health Malaysia
PROTOCOL
First Edition, 2013
Pharmaceutical Services Division
Ministry of Health, Malaysia
ALL RIGHTS RESERVED
No part of this publication may be reproduced, stored or transmitted in any form or by any means whether electronic, mechanical, photocopying, tape recording or
others without prior written permission from the Senior Director of Pharmaceutical Services, Ministry of Health, Malaysia.
Perpustakaan Negara Malaysia Cataloguing-in-Publication Data
ISBN: 978-967-5570-47-6
[ i ]
PREFACE
Stroke is a global health problem and is the second commonest cause of death. In Malaysia, it is the third largest cause of death after heart diseases and cancer. It
is considered to be the single most common cause of severe disability. The risk of having recurrent stroke is very high throughout the year if patient are not provided with a proper management. Hence, pharmacists play an important role in improving patient care, with regards to medication adherence, education and awareness of quality of life in order to convey
the best management to the patient.
This protocol is meant for pharmacists in Ministry of Health (MOH), who are involved in providing intensive stroke management. This protocol will ensure the standardisation of practice on the activity and documentations of practice and continuity of care towards stroke patients from ward, to medication therapy adherence clinic and home medication review.
I would like to thank the Neurology Task Force Group, Pharmaceutical Services Division, MOH for their contribution and commitment to the publication of this protocol.
DR. SALMAH BINTI BAHRIDIRECTOR OF PHARMACY PRACTICE AND DEVELOPMENTPHARMACEUTICAL SERVICES DIVISIONMINISTRY OF HEALTH, MALAYSIA
[ ii ]
ADVISORSDr. Salmah binti Bahri
Director of Pharmacy Practice DevelopmentPharmaceutical Services Division, MOH
EDITORSRosminah binti Mohd Din, Pharmaceutical Services Division, MOHNoraini binti Mohamad, Pharmaceutical Services Division, MOH
Eezmalina Sazza binti Shaharuzzaman, Pharmaceutical Services Division, MOH
EXTERNAL REVIEWERSDato’ Dr Hj. Md Hanip bin Rafia
Consultant Neurologist and Head of Department of NeurologyHospital Kuala Lumpur
Dr. Zariah binti Abdul AzizConsultant Neurologist
Hospital Sultanah Nur ZahirahDr. Looi Irene
Consultant NeurologistHospital Seberang JayaDr. Nor Aida binti MusaRehabilitation Physician
Hospital Sultanah Nur Zahirah
CONTRIBUTORSNorsima Nazifah binti Sidek
Hospital Sultanah Nur ZahirahCik Khor Seau Ting
Hospital Sultanah Bahiyah‘Arafah Nur Na’im binti Hamzah
Hospital Rehabilitasi Cheras
ACKNOWLEDGEMENTPharmaceutical Services Division would like to thank all who have in one way or
another supported and/or contributed towards the development of the protocol.
TABLE OF CONTENTS PAGE NUMBER
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[ iii ]
TABLE OF CONTENTS PAGE NUMBERA. Stroke Medication Therapy Adherence Clinic
(SMTAC) Protocol 1 • Introduction 1• Objectives 1• Scope Of Service 2• Location / Setting 2• Man Power Requirement 2• Appointment 2• Procedures 2• Others 5
B. Stroke Protocol for Ward Pharmacist 6• Introduction 6• Location / Setting 7
C. Home Medication Review (HMR) 8• Introduction 8• Scope Of Service 8• Man Power Requirement 8• Appointment 8• Procedures 10
References 10
Appendices
Workflow
• Appendix 1 : Stroke MTAC Pharmacy Workflow 12• Appendix 2 : Patient Consent Form 13• Appendix 3 : Patient Assessment Form 14• Appendix 4 : Patient’s Visit Form 15• Appendix 6 : Education Outline for Stroke Patient 21• Appendix 7 : Stroke Ward Pharmacy Workflow 22• Appendix 8 : Stroke Management Checklist 23• Appendix 9 : Stroke Education Checklist 24• Appendix 10 : Home Medication Review (HMR) 26
[ 1 ]
A. STROKE MEDICATION THERAPY ADHERENCE CLINIC (SMTAC)
INTRODUCTION
Stroke represents a major health concern for Malaysians, ranking as one of the top 10 reasons for hospitalisation and the third largest cause of death in Malaysia. It is considered to be the single most common cause of severe disability and an estimated 40,000 people in Malaysia suffer from stroke every year. The number of Malaysians suffering from stroke is increasing rapidly while most of the cases were preventable.
The morbidity burden for patients, families, and society is ponderous. Seventy percent of stroke patients who recovered keep themselves away from social activities and nearly 30% of survivors suffer permanent disabilities and needed assistance in coping with their daily activities. Stroke hits the health budget in the form of long and costly rehabilitation process.
Stroke is the most preventable of all life-threatening health problems. Modifying certain behaviors has been shown to decrease stroke incidence. Awareness of the risk factors of stroke and the ways to control them; recognizing the signs and symptoms of strokes which are necessity for prompt emergency stroke care can minimize the chance of getting stroke as well as the level of disability it cause.
Pharmacists as an integral part of the health care team can play a significant role in improving patient’s awareness and knowledge and are in a key position to track adherence to drug therapy. Pharmacist involvement can improve disease and disability prevention, leading to fewer physician visits, decrease the need for medical treatment, lower heath care costs and most important, improve patient’s quality of life.
Stroke Medication Therapy Adherence Clinic (SMTAC) is an ambulatory care service conducted by pharmacist in collaboration with physicians and other health care providers with the aim in improving patient’s compliance and knowledge with therapy.
OBJECTIVE
1. To maximize the benefits of medication and minimise the adverse effect and complications resulting from the medication.
2. To improve patient’s adherence towards medication and post stroke management.
[ 2 ]
3. To increase patient’s understanding towards their illness and medication through education, monitoring, and close follow up.
4. To enhance awareness on risk factors and prevention of recurrent stroke through education on healthy lifestyle and risk factor management by collaborating with other MTAC programs and other facilities .
5. To work together with neurologist, physicians and other healthcare providers in patient’s pharmacotherapy management.
SCOPE OF SERVICE
Patients who are managed in the Neurology/Stroke/Medical Clinic/Rehabilitation Clinic who are referred to SMTAC by health care professionals.
LOCATION / SETTING
The SMTAC service should operate in the clinic area during clinic days.
MAN POWER REQUIREMENT
At least 2 pharmacists should be assigned to SMTAC.
APPOINTMENT
Appointment should be scheduled by pharmacist. Number and frequency of visits for patients under SMTAC will be determined by the pharmacist conducting the MTAC and patient’s/caregiver’s capabilities. For continuity of service, patient shall be referred to HMR team or pharmacist at other MOH facility by using the CP4 form.
PROCEDURES
The procedures for SMTAC workflow and documentation are shown in Appendix 1, 2, 3, 4 and 5.
1. SELECTION OF PATIENT
1.1 Patient who has been diagnosed with stroke with the following criteria:
a. Newly diagnosed with stroke and initiated with medication.
b. Patient suspected of having non-adherence towards their medication.
[ 3 ]
c. Patient who have drug related problems and suspected adverse drug reactions.
d. Patient referred by healthcare providers, i.e. specialist, medical officers, pharmacist, speech therapist.
A consent form must be obtained from the patient as an agreement to enroll in SMTAC.
2. MISSED APPOINTMENT
Patient/caregiver will be contacted by phone for appointment to be rescheduled.
3. MODULE
3.1 FIRST VISIT
At the initial visit, the pharmacist will perform an initial assessment of the patient/caregiver. The initial assessment will entail:
3.1.1 Review of patient medical/medication history3.1.1.1 List of medication3.1.1.2 Method of administration
3.1.2 Conduct a baseline assessment3.1.2.1 Past medical/medication history3.1.2.2 Social/family history3.1.2.3 Diet/lifestyle3.1.2.4 Allergies (drug and food etc)3.1.2.5 Medication knowledge3.1.2.6 Medication adherence3.1.2.7 Any other drugs/supplement/herb intake
3.1.3 Determination of any medication related problem and issues3.1.3.1 Untreated conditions3.1.3.2 Drug use without indication3.1.3.3 Improper drug selection3.1.3.4 Sub therapeutic dosage3.1.3.5 Over dosage3.1.3.6 Adverse drug reactions (ADRs)3.1.3.7 Drug interactions3.1.3.8 Failure to receive medication
[ 4 ]
3.1.4 Pharmacist recommendation3.1.4.1 Discussion with neurologist or physician regarding patient’s
pharmacotherapy management or if any pharmaceutical care issue identified.
3.1.4.2 Proposed action plan or ultimate outcome as agreed by patient/caregiver.
3.1.4.3 Discussion with patient/caregiver on the pharmaceutical care plan based on the laboratory parameters.
3.1.5 Patient’s counseling and education• Stroke symptoms• Secondary prevention of stroke
o Stroke risk factoro Medication
Importance of drug adherence Indication of each drug
o Diet controlo Exerciseo Smoking cessation
• Target for BP, Glucose level, LDL and other related parameter• Medication indication, administration, storage, common side
effects etc• Rehabilitation intervention
o Promote stroke recoveryo Prevention of complications
3.2 FOLLOW UP
3.2.1 An appointment is given one to two months later to assess patient’s related issues (adherence, disease control, drug’s side effect and efficacy).
3.2.2 Scheduled appointments based on patients/caregiver timing preferences.
3.2.3 Pharmacotherapy management advice and stroke education provided and referral made to physician for any drug related issues.
[ 5 ]
4. OTHERS
4.1. SCOPE OF FUNCTION AND RESPONSIBILITIES OF PHARMACIST
4.1.1 Monitoring and Evaluation.
4.1.2 Pharmacotherapy management consultation.
4.1.3 Patient Education – refer Appendix 6.
4.1.4 Medication Dispensing• Medications shall be dispensed to the patient/caregiver
during part supply medication collection or during scheduled appointment.
4.1.5 Documentation• All relevant data to be recorded using the designated forms as
follows and kept in the patient’s profile. The documentation will contain the followings:o Patient demographic and medical/medication history.
During each visit, patient’s status will be updated in patient’s file such as any medication changed or added, medication adherence progress, any drug related issues, patient’s complaint, any intervention and action plan for each medical condition addressed.
4.2. QUALITY ASSURANCE/OUTCOME
4.2.1 This service shall be continuously assessed to ensure that patients are receiving optimal care.
4.2.2 Outcomes of SMTAC will include improvement in patient medication knowledge, controlled risk factor and reduce hospitalisation.
o Assessment of patient’s medication knowledge and adherence
o List of patient’s current medication.o Pharmaceutical care issues and pharmacist’s plans.
[ 6 ]
B. STROKE PROTOCOL FOR WARD PHARMACIST
INTRODUCTION
The pharmacist is involve in the care of acute stroke patient by collaborating with multidisciplinary team (Neurologist/Physician, Rehab Physician, Staff Nurse, Occupational Therapist, Physiotherapist, Speech Therapist, Dietician and Social Worker) in the management of patient, focusing on medication therapy.
The procedures for stroke protocol for ward pharmacist workflow are shown in Appendix 7.
In the ward, pharmacist should perform the following functions:
1. Involve in stroke round.
2. Patient medication history taking (CP1 and National Stroke Registry form).
3. Review patient‘s medication management and progress.
4. Assist in managing stroke patient in accordance with the following guidelines:
- To fill up Stroke Management Checklist (Refer Appendix 8).
Acute management
• Thrombolytic therapy for patient arriving within 4.5 hour for ischemic stroke.
• Antiplatelet within 48 hours of admission for ischemic stroke and Transient Ischemic Attack (TIA).
• Deep Vein Thrombosis (DVT) prophylaxis for patient with leg power of <3/5 (for ischemic stroke, to start immediately and for hemorrhagic stroke, after 72 hours of event).
• Hypertension management (refer to CPG Management of Ischemic Stroke 2012).
• Hyperglycemia management (refer to CPG Management of Ischemic Stroke 2012).
• Infection management (refer to CPG Management of Ischemic Stroke 2012).
[ 7 ]
Secondary prevention of stroke
• Antiplatelet upon discharge for ischemic stroke and TIA.
• Lipid lowering therapy upon discharge (for hemorrhagic stroke, must consider the risk of stroke recurrence).
• Anticoagulant for stroke patient with atrial fibrillation.
* Time of initiation will depend on the severity of the stroke.
• DVT prophylaxis for patient with leg power of <3/5 (if there is a need to continue).
• Risk factor control
* Hypertension (refer to CPG Management of Hypertension 3rd Edition 2008).
* Diabetes Mellitus (refer to CPG Management of Type 2 Diabetes Mellitus 4th Edition 2009).
* Atrial Fibrillation (refer to CPG on Management of Atrial Fibrillation 2012).
* Ischemic Heart Disease.
* Others.
5. Patient education (Refer Appendix 9)
• Stroke risk factor.
• Stroke symptoms.
• Secondary prevention of stroke.
• Medication.
* Importance of compliance.
* Indication and role of each drug.
• Diet control.
• Exercise.
• Smoking cessation.
• Target for BP, Glucose level, LDL and other related parameters.
LOCATION / SETTINGThis ward pharmacy service shall operate in the ward.
[ 8 ]
C. HOME MEDICATION REVIEW (HMR)
INTRODUCTION
HMR is a patient – focused process which advocates the optimal and quality of medication at the stroke patient’s home. It involves systematic assessment of the patient’s medication in order to identify and meet the medication - related needs as well as to identify, resolve and prevent drug related problems.
This service is a continuity of patient’s care from ward and MTAC to their home. It is a comprehensive activity which involves clarification of the indication for use and administration details of all prescription and non – prescription medicines, assessment of medication storage in the home and any drug related issues.
SCOPE OF SERVICES
This service is to be extended to stroke patient under Stroke Pharmacist Management. The stroke patient may be referred from hospital to nearest facility (i.e. health clinic) for this service by using CP4 form and Home Medication Review referral form (refer Home Medication Review Protocol 1st edition 2011).
MANPOWER REQUIREMENT
All HMR appointment should be conducted by a qualified pharmacist. The HMR pharmacist will accompany the multidisciplinary homecare team members (Homecare Nurses, Physiotherapist and Occupational Therapist) to conduct the HMR activity. However if the pharmacist are able to provide the service without a home care team, a minimum of two pharmacists are required.
APPOINTMENT
Appointments and frequency of visits for patients under the HMR program will be determined by the pharmacist who is conducting the HMR and in consultation with the referral pharmacist (if applicable).
PROCEDURES
The procedures for stroke HMR workflow and documentation are shown in Appendix 10.
[ 9 ]
1. SELECTION OF PATIENT
1.1 The criteria which may be used to determine the need of a patient’s recruitment to the Stroke HMR are as follows:
1.1.1 Refer by neurologist/physician, homecare nurse or selection by Ward/MTAC pharmacist.
1.1.2 Non or poor compliant patient.1.1.3 Geriatrics who are managing their own medication with no or
poor family support.1.1.4 Newly discharge patient with multiple concomitant problems.1.1.5 Patient on Nasogastric Tube.1.1.6 Patient suspected to have poor disease controlled such as poor
glucose control and poor blood pressure controlled despite on medication.
2. ACTIVITIES2.1 Assess patient and fill up the HMR form (refer to Home Medication
Review Protocol 1st edition 2011).2.2 Assess stroke management (Refer Appendix 9).
2.2.1 Aspirin and lipid lowering therapy.2.2.2 Indication to continue DVT prophylaxis (if applicable).2.2.3 Indication to start anti hypertension (if applicable).
2.4 Identify any pharmaceutical issues.2.4.1 Any drug related issues will be discussed with the neurologist/
physician during or after HMR.2.5 Check necessary parameters: Blood pressure, glucose level, INR (if
applicable).2.6 Any drug related issues will be discussed with physician during HMR or
after HMR.2.7 Assess storage of medication at home.2.8 Assure patient has the next appointment date with the doctor and
remind the patient to attend the clinic on the appointment date.2.9 Follow up visit will be held upon referring from stroke team or when
deemed appropriate by HMR pharmacist.
2.3 Assess patient’s knowledge and compliance by using any suitable assesment tools.
[ 10 ]
REFERENCES
1. CPG on the Management of Ischemic Stroke 2012.
2. Home Medication Review Protocol 1st edition 2011.
3. Venketasubramaniam N The epidemiology of stroke in ASEAN countries - A review. Neurol J SEA 1998; 3: 9-14.
4. Health Facts, 2009. Health Information Centre, Planning and Development Division, Ministry of Health.
5. S C Johnston, S Mendis, CD Mathers. Global variation in stroke burden and mortality: estimates from monitoring, surveillance and modeling. Lancet Neurol 2009; 8: 345-54.
APPENDICES
[ 12 ]
Appendix 1
STROKE MTAC PHARMACY WORKFLOW
Medical Assistant
Pharmacist
Neurologist/Physician
Pharmacist
Pharmacist
Pharmacist
Pharmacist
Registration
Vital sign and body weight check (if needed)
• Discuss on treatment optimization• Assess for any drug related issues if
patient is not seen earlier• Answer queries & provide information
• Explain regarding medication management changes (if any)
• Provide counseling and Education• Dispense medication
Pharmacist Assessment and Review
Review and Treatment
Screen prescription
Documentation
Yes
No
Patient comes for MTAC follow up and medication supply
Discuss with physician regarding the pharmaceutical
care issues identified
Problem or intervention
[ 13 ]
Appendix 2
PERAKUAN PENYERTAAN
Saya………………………………………………………………...(No.K/P: ....…………………………………….)
bersetuju menyertai program Stroke Medication Therapy Adherence Clinic (SMTAC)
atau Klinik Kepatuhan Terapi Ubat Strok yang dianjurkan oleh Jabatan Farmasi,
Hospital……………………………………………………………Saya juga berjanji akan memberikan
kerjasama sepenuhnya dengan menghadiri ke semua sesi kaunseling yang diadakan
oleh Pegawai Farmasi SMTAC dan aktiviti – aktiviti lain berkaitan dengannya yang
bertujuan membantu pengurusan penyakit strok saya/pesakit.
…....................................... (Tandatangan) Nama pesakit : No. K.P. :Tarikh :
Pegawai Farmasi yang bertugas,
…………………………………….(Tandatangan)Nama :Cop :Tarikh :
PATIENT CONSENT FORM
[ 14 ]
Appendix 3
Visit No: Date:
Patient Name:
NRIC: MRN:
Stroke Subtype:
Risk Factors:
Evaluation/Problem(s) & Action(s) Taken
No Issues (raised by patient/observed by pharmacist)
Action/Counseling
Pharmacist Signature & Stamp
PATIENT ASSESSMENT FORM
[ 15 ]
Appendix 4
PATIENT ID:NEUROLOGY (STROKE)
MEDICATION THERAPY ADHERENCE CLINIC (MTAC) PHARMACY DEPARTMENT,
.………………………………………………………………………………
Patient Name: Contact No.:
NRIC: Marital Status:
Address:Sex:
Male
Female
Caregiver’s Name: Relationship: Contact No.:
Social/Family History: Smoking Alcohol
Drug Abuse Pregnant
Stroke Subtype:
Concomitant Diseases:
Past Medication History:
No. Name of Drug(s) Date start Date stop
PATIENT’S VISIT FORM
[ 16 ]
LABORATORY PARAMATERS
Normal ValueDate
VITAL SIGNS
BP (mmHg)
PR 60-100 p/min
RR 12-18 b/min
CARDIAC ENZYMES
CK 24-195 u/l
LDH <247 u/l
AST <45 u/l
LIPID PROFILE
T. Chol <5.2 mmol/L
TG (mmol/L) 0.6 -2.3 mmol/L
LDL (mmol/L) <1.8 mmol/L
HDL (mmol/L) >1.7 mmol/L
RENAL PROFILE
Na 133-145 mmol/L
K 3.3-5.1 mmol/L
SrCreatinine 45-84 umol/L
CrCl 105-150 ml/min
[ 17 ]
LIVER PROFILE
Albumin 35-50mg/dL
ALP 30-120 u/l
ALT <34 u/l
COAGULATION PROFILE
PT 10.6-15.0 sec
APTT 26-42 sec
INR
OTHERS:
RBS 6-8 mmol/l
FBS 4-6mmol/L
HbA1c <6.5%
Uric Acid 180-420 µmol/L
[ 18 ]
Date / Visit Pharm Care Issues Pharmacist intervention Outcome Pharmacist’s sign
& stamp
[ 19 ]
ASSESSMENT ON PATIENT’S/CAREGIVER’S MEDICATION KNOWLEDGE
Date Medication Visit 1 Visit 2 Visit 3 Visit 4
D F I T D F I T D F I T D F I T
Score (%)
[ 20 ]
Date Medication Visit 5 Visit 6 Visit 7 Visit 8
D F I T D F I T D F I T D F I T
Score (%)
Appendix 6
EDUCATION OUTLINE FOR STROKE PATIENTFirst visit:
• Brief overview about stroke and stroke subtypes.
• Stroke risk factors.
• Stroke symptoms.
• Specific discussion on drugs as secondary prevention of stroke – indication, role of each drug and adverse effects.
* For ischemic stroke and transient ischemic attack (TIA) –anti platelet
* Lipid lowering therapy.
* Antihypertensive drug.
* Anticoagulant for cardio embolic stroke.
• Therapeutic goal for main parameter : blood pressure, glucose level, LDL and INR.
Second visit
• Education on risk factor (hypertension , diabetes mellitus, atrial fibrillation, ischemic heart disease, hyperlipidemia, smoking cessation (if applicable), alcohol consumption (if applicable) and etc.
Third visit
• Stroke complication and prevention.
Fourth visit
• Benefit of exercise.
• Basic nutrition and diet control.
Subsequent Visit
• How to maintain the therapeutic goal and long term plan.
• Revision on treatment goals.
• Specific drug counseling.
[ 21 ]
Appendix 7
STROKE WARD PHARMACY WORKFLOW
Stroke Round
End
Check case notes and complete patient medication history taking (CP1)
Review patient‘s medication management and progress (Appendix 8)
Patient education and bedside counseling (Appendix 9)
Follow up patient and review medication therapy
Discharge Counseling
Refer HMR teamHome Medication Review
Upon discharge
YES
NO
[ 22 ]
Appendix 8
STROKE MANAGEMENT CHECKLIST
Patient Name:MRN:
Please Tick During Admission
• Thrombolytic therapy for patient arrived within 4.5 hour for ischemic stroke
Antiplatelet within 48 hours of admission for ischemic stroke and TIA
In Ward
• Deep vein thrombosis (DVT) prophylaxis for patient with leg power of <3/5 (for ischemic stroke start immediately, for hemorrhagic stroke, after 72 hours of event)
• Lipid lowering therapy Stroke education checklist (refer appendix 8)
During Discharge
• Antiplatelet upon discharge for ischemic stroke and TIA• Lipid lowering therapy upon discharge (for hemorrhagic stroke, must
consider the risk of stroke recurrence)• Anticoagulant for stroke patient with atrial fibrillation
Time of initiation will depend on the severity of the stroke • DVT prophylaxis for patient with leg power of <3/5 (if there is a need
to continue)• ACEI for hypertension and stroke prevention
[ 23 ]
Appendix 9
STROKE EDUCATION CHECKLIST
Patient Name:MRN:
Stroke Please Tick
• What is Stroke• Stroke subtypes• Pathophysiology • Symptoms of stroke• Stroke risk factors
Secondary prevention
Medication
• Indication, role, dosage, administration, frequency, possible and common side effects, drug interaction (if applicable)
• Anti-platelet (for ischemic stroke and TIA) – GI upset, to take after meal
• Cholesterol-lowering agent, muscle pain (rhabdomyolysis)
o Must be taken before sleep
• ACEs inhibitor/ARBo Will be started after two week of stroke (for ischemic stroke).o Must go to nearest clinic for BP monitoring and drug initiation/
optimization.o ACE- cough.
• DVT prophylaxis (if applicable).
• Anti coagulant (if applicable).
• Importance of drug compliance.
Risk factor controlled – HPT, DM , Hyperlipidemia, AF, IHD etc
[ 24 ]
Monitoring parameter and target for all the parameter
• Blood pressure• Glucose level • LDL level • Other parameters related to risk factors
Life style modification
• Diet control• Smoking cessation• Stress management• Regular exercise
Rehabilitation
• Importance of adherence to rehabilitation plan• Stroke complication and prevention
o Aspiration Pneumoniao Urinary Tract Infectiono Bed Soreo Upper Gastro Intestinal Bleedingo Depressiono Recurrent Stroke
Closing
• Assess patient’s/caregiver’s understanding towards the disease and medication
• Provide patient with stroke booklet or relevant pamphlet• Provide contact information for any enquiries
[ 25 ]
Appendix 10
HOME MEDICATION REVIEW (HMR) WORKFLOW
Referred case or selection by pharmacist
Documentation
Visit Patient’s Home
Assess medication adherence and storage at home
Assess any pharmaceutical care issues
Discussion with physician
Discuss with caregiver on the management plan changes via
MTAC visit
CounselingUnsatisfied
Satisfied
YES
NO
[ 26 ]