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