Doctors, Nurses ... and pharmacists - why this threesome works. - PowerPoint PPT Presentation

Doctors, Nurses ... and pharmacists - why this threesome works. Vanessa Brown Brendan Duck RNZCGP GPCME 2014

What is a clinical pharmacist? Specialist Pharmacist Practitioner Post Graduate education and/or significant clinical experience Undertakes Medicine Review = Medicine Therapy Assessment (MTA) Provides medicine and clinical information services

What's different about a Clinical Pharmacist? Focus on risk vs benefits for individual patients for each medicine Applying most recent evidence to specific patient medicine related problems Recommendations on how to implement treatment plan Unbiased assessment of emerging medicine evidence and guideline updates

Mrs F.J. 76yr female Her current issues: • Tiredness, cramps + twitchy legs • Constipation, renal function changes • Falling regularly • BP 120/58mmHg Calc CrCl= 21.5mL/min • HbA 1c 37mmol/mol Cholesterol levels good • Liver function good

Current meds • Furosemide 80mg mane • Amitrip 25mg nocte • Ezetrol 10mg daily • Aspirin 100mg daily • Quinine 300mg BD • Simvastatin 40mg nocte • Omeprazole 20mg mane • Cholecalciferol 1.25mg monthly

Recommendations • Change simvastatin 40mg to atorvastatin 10mg • Stop omeprazole • Stop quinine Follow-up • Feeling much better no longer tired.

Birth of clinical pharmacist facilitation? $1.06 million year on year increase in combined pharmaceutical budget – CPB = community pharmaceuticals + pharmaceutical cancer treatments + vaccines (from 1 July 2013) Not sustainable Hawkes Bay pharmaceutical expenditure (12 month rolling totals) No ‘low hanging fruit’ Data source: Pharmac Drug expenditure report for DHB for year ending Sep-10 $36,500,000 $31,500,000 $26,500,000 $21,500,000 ‘Unmet need’ $16,500,000 $11,500,000 $6,500,000 $1,500,000 Feb-04 Jun-04 Oct-04 Dec-04 Feb-05 Jun-05 Oct-05 Dec-05 Feb-06 Jun-06 Oct-06 Dec-06 Feb-07 Jun-07 Oct-07 Dec-07 Feb-08 Jun-08 Oct-08 Dec-08 Feb-09 Jun-09 Oct-09 Dec-09 Feb-10 Jun-10 Apr-04 Aug-04 Apr-05 Aug-05 Apr-06 Aug-06 Apr-07 Aug-07 Apr-08 Aug-08 Apr-09 Aug-09 Apr-10 Aug-10 12 months to

Aging Population Items Dispensed per Capita by Age Comparison of dispensing rates by age group (items), January to December 2010 Rate (crude) per 1000 population 120000.0 100000.0 80000.0 60000.0 40000.0 20000.0 0.0 0-14 15-24 25-44 45-64 65-84 85+ years Total (all years years years years years ages) Haw ke's Bay New Zealand Source: Pharmaceutical Claims Data Mart, Ministry of Health (Extracted: 22/4/2011). Note data subject to change over time.

Dr Info

The model Clinical pharmacist facilitators (1.5 FTE) Focus on best practice – not cost To complement the population based clinical pharmacist facilitator (1.0 FTE) Proof-of-concept Funded by Hawke’s Bay DHB – working out of Health Hawke’s Bay PHO – in specific practices (0.5 FTE x 3)

Aims Interventions targeted at polypharmacy – ≥ 65 years – would not disadvantage M ā ori, Pacific or NZDep 9/10  Polypharmacy –  patient harm / ADRs Improve chronic disease outcomes (CV risk, diabetes) Fulton & Allen 2005

Practice Focuses Patients >65 years residing in Age Related Residential Care (ARRC) facilities Patients who are over 65 years living independently in the community Practice - with high needs population (Māori, Pacific or NZDep 9/10)

The Practices TE MATA PEAK GREENDALE TOTARA HEALTH PRACTICE FAMILY HEALTH CENTRE Location Havelock North Taradale Hastings & Flaxmere Targeted Patients 65 years Patients, 65 years Patients with high population and over, living in and over, living needs including Age Related independently in Māori, Pacific and Residential Care the community NZDep 9/10 Facility Enrolled Population 9800 6000 11000 Target Population 175+ 1200 7029

Evolution of role Relationship building Initially focus was on patients taking >10 meds  Medicines rather than people Development of tools to generate referrals Quality activities Demand for services

Practice Nurse Quote “Resource for education of nurses, patients, GPs. Can't imagine not having CP here now as I probably access CP expertise daily…”

Totara Health Individual vs Population Focus – Individual reviews = large benefit for individuals ≠ large benefit for high needs population – Focus on population with chronic disease with poor outcomes – Smaller review of medicines treating chronic disease and recommendations to General Practitioner

Adherence

Number of risk factors for non- adherence per patient 3 or more 0 9% 32% 2 22% 1 37%

Mr T.J. Male, 63 year old, Cook Island M ā ori Labels – ‘Non - compliant’ – ‘Poor diabetes control due to religious beliefs’ Problem – Poor understanding of medication – Strong beliefs in value of nutrition and ‘living off the land’

Mr T.J. Type 2 diabetes Recent admission for heart failure Recent admission for cellulitis Cancellation of cataract surgery – Poorly controlled hypertension and diabetes HbA 1c 123 mmol/mol BP 195/110 mmHg LDL 4.5 mmol/L

Mr T.J. Intervention – Improve understanding of medicines – Sustained adherence to medicines (BP, Lipid and Diabetes) BP 120/70 mmHg HbA 1c 56mmol/mol LDL 2.5 mmol/L No recent HF symptoms – Teaching other about the benefits of medicines

Te Mata Peak Practice Primarily Aged Related Residential Care Aims: – Reduction in polypharmacy – Improve medicine safety Medicine reconciliation on admission Medicine Therapy Assessment prior to 3/12 review Medicine quality initiatives

Digoxin administration and monitoring

Vitamin D Prescribing

Medicines and Falls Risk

ARC Registered Nurse – how has the CP helped? “Education. Medication Reviews. Input into Best Practice projects. Liaison between GP and facility when required”.

Greendale Family Health Focused on ≥ 65 years living at home Medicine therapy assessments Co-ordination of multiple prescribers! Medicine reconciliation Clinical guidelines and standing orders

Tools used – Multi-Med Survey

Tools Used – S.I.M.P.L.E.

Linkages • Health Hawke’s Bay • Care cluster • Home services • District nurses • Local specialists • Hospital pharmacists • Community pharmacist • Allied health; OT, PT, dietitian, social worker

Medicine reconciliation Update medical record 37% Required clarification 29% Required a medicine review as multiple issues 23% Other interventions 11% – E.g. advice on syringe driver medicine doses medicine information queries Special Authority number follow up Greendale: 1 December 2012 – 18 January 2013

Benefits to GP High quality unbiased advice Different set of eyes/focus Collaborative decision making Source of information on constantly changing evidence and guidelines Availability of medicine information Coordination of multiple prescribers MOPS audits

Benefits to Practice Collaboration to manage chronic disease Increased practice confidence in managing polypharmacy Contribution to quality improvement of the practice Review of medicine policies and standing orders Cornerstone accreditation support

Benefits to patients Patient centered approach Different focus, asks different questions Address medicine benefits vs harm Improved outcomes Reduced medicine complexity Coordination of multiple prescribers

GP Quote “Initially I had no idea what a clinical pharmacist would do for our practice, now I don’t know how I could live without them.”

Cost reduction / avoidance Category Cost $ Number of events Total DHB savings Known / estimated* p.a. or per event* Known / estimated* ¥ $ 500,000 1. Community pharmaceuticals $0 to $47,000 64 $149,400 2. Falls 3. Reduction in BP § *3 *$100,000 $24,000 2 $48,000 4. Delayed admission to ARRC $450 *1 *$450 5. ED transfer avoided Total ~$800,000 ¥ Hawke’s Bay CPB September 2012 to August 2013 § Reduction in sBP by 10mmHg (1 each renal failure, myocardial infarction, stroke)

Hawkes Bay Future Direction Clinical Pharmacist Facilitators add value to general practice 1 FTE per 20,000 patients Ensure access to all areas within DHB At 1 July 2014, HBDHB is rolling out this service Hawke’s Bay wide (8 FTE)

We Can Help You Evidence to support clinical pharmacist role Experience of implementation Hawke’s Bay team is happy to put together a proposal Contact: - Billy Allan, Chief Pharmacist, HBDHB William.Allan@hawkesbaydhb.govt.nz - Di Vicary, Health Hawke’s Bay pharmacist@healthhb.co.nz

Acknowledgments Di Vicary, Clinical Pharmacist Facilitator Team Leader Billy Allan, Chief Pharmacist Hawke’s Bay DHB Health Hawke’s Bay Greendale Family Health Te Mata Peak Practice Totara Health

Any Questions?