CLINICAL PHARMACY IN GENERAL PRACTICE

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CLINICAL PHARMACY IN GENERAL PRACTICE A REVIEW OF THE FIRST NINE MONTHS

Contents 1.

Executive summary

2

2.

Introduction

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Purpose of the review

4

Review questions

4

3.

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Background

Community pharmacy vs clinical pharmacy

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Role of the clinical pharmacist in the IFHC

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4.

8

Data Collection Methods

Shadowing the GP

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Clinical pharmacist’s paper notes

9

IFHC pilot evaluation

9

Case studies

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5.

Two week clinical pharmacist activity analysis

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Total activity time over two weeks

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Who initiated the activity?

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Summary of type of activity

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Category: Medicine review or reconciliation

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Category: Medication issues

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Category: Education and information

13

Category: Diabetes

13

Category: Tests or support

14

Category: Paperwork

14

Category: Smoking cessation

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ACKNOWLEDGEMENTS Thank you to Penny Clark, Clinical Pharmacist at NorthCare, for consenting to being shadowed for two weeks. Penny also provided the selection of case studies and answered many questions. We are also grateful to Dr Antony Raymont for his helpful advice on the review and for providing a summary of NorthCare staff feedback (section 8) from the contracted IFHC evaluation work before it was officially due. We also need to thank Sarah Farmer who is currently a pharmacy student at the University of Auckland. She was employed by Midland Community Pharmacy Group to be Penny’s ‘shadow’ and gathered the information used in the activity analysis section.

Midlands Health Network

6.

The clinical pharmacist’s impact on efficiency, quality and patient outcome

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Intervention classification and outcome significance

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Impacts on practice efficiency and quality – potential time saving and emergency department presentation/admission saves

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Summary

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7.

Medicine reconciliation post discharge analysis

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Method

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Discharge summary errors

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Practice level interventions

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Contacts arising from medicine reconciliations

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Clinical pharmacist specific interventions and referrals

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Medicine reconciliation summary

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8.

Results – feedback from the first NorthCare staff interviews

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Appendix 1: Selected timeline of IFHC implementation

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Appendix 2: Maps of NorthCare patient distribution

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Appendix 3: Activity analysis form

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Appendix 4: Analysis record categories and definitions

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Appendix 5: Detailed data tables related to two week activity analysis

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Appendix 6: Medicine reconciliation form

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AUTHORS Jenny West (Midlands Health Network), Janet Amey (Midlands Health Network), Cath Knapton (Midland Community Pharmacy Group), Sam Illing (Midlands Health Network – summer medical student).

SUGGESTED CITATION Midlands Health Network (2012). Clinical Pharmacy in General Practice: a review of the first nine months. Hamilton. Information in this report may be used freely provided the source is acknowledged.

Clinical Pharmacy in General Practice: A review of the first nine months

1

1. Executive summary In 2010, Midlands Health Network presented a business case to the Ministry of Health that identified a number of strategies to provide better, sooner, more convenient health care, including a strategy to develop integrated family health centres. The business case was accepted, a project was established, and a range of health professionals including doctors, nurses, pharmacists, and other allied staff, designed and developed a new model of care to not only address the key issues facing the sustainability of health sector, but to also place the patient at the centre of their health care journey. Five key strategies were developed including an expanded general practice team, improved access to services through a patient access centre, system initiated contacts to provide proactive health care, virtual consultations, and new strategies to streamline the patient experience. Three proof of concept sites in Hamilton were chosen for the initial launch of Midlands Health Network’s model of care – NorthCare Grandview Road, NorthCare Pukete Road and NorthCare Thomas Road. The first stage of the model of care went live in April 2011. Through the design and development stage, Midlands Health Network partnered with Midland Community Pharmacy Group to develop one particular component of the model of care – the extension of the general practice team to include an expert clinical pharmacist (CP). The CP role is designed to support the general practice team, have scheduled appointments with patients to manage and monitor their medications, provide specialist input into the patient’s care plan, and liaise with local and hospital pharmacies to make sure that medication-related information is transferred seamlessly. The CP is full-time and works across all three NorthCare sites during the week. Nine months after implementing the model of care at NorthCare, a review of the CP role was initiated to assess its impact on the day to day operation at the three NorthCare sites. The review focuses on the following operational questions: • What types of activities has the CP undertaken and what impact has this had on the three practices? • What effects do general practitioners (GPs) and practice nurses report the role of the CP has had on their daily work? Data for this review was gathered by three main sources: • Data from an ‘activity analysis’ of 10 days of the CP’s work. This was gathered by a pharmacy student shadowing the CP and classifying and timing all activities; • Data from medicine reconciliation post discharge forms; and • A summary of feedback from GPs and practice nurses regarding the impact the addition of the CP to the general practice team has had on their daily activity. The main impacts of the CP identified through this review are: • The CP has become a highly valued member of the general practice team; • The CP saves the GP time by undertaking specific tasks such as medicine reconciliation post discharge, an activity previously undertaken by GPs, now allowing them more face-to-face time with patients; • The general practice team has benefited from having expert pharmaceutical advice on hand. This has saved team members from having to do research and/or answer patient medication questions and enabled them to move onto other patient activities; • Paperwork is often identified as the bane of general practice. The CP has undertaken both clinical and nonclinical-related paperwork leaving other members of the team to undertake other activity; • The CP has potentially avoided emergency department presentation or admission for some patients, or re-admission post discharge due to timely identification of medication errors; • The CP has improved the quality of the service provided to patients enrolled at all three practice sites; there are specific examples of harm reduction through the outcomes of timely medicine reconciliation and clinical review;

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Midlands Health Network

• The CP has played an important role in the practice teams’ contribution to meeting health targets related to diabetes and smoking cessation; • The CP has an impact on practice performance as measured through the annual Midlands Health Network Quality Plan; • The CP has improved medication management for patients. There are specific examples of patients identified who had not been taking their medication regimes optimally – the CP has been able to remedy these – streamlining processes for patients and improving quality of life in some cases; • The CP has been available to undertake medication education for patients. This would previously have been done by GPs or practice nurses. The CP has been particularly useful in difficult cases or where patients have been non-compliant; • The CP has improved care for those patients with high needs through proactively focusing on auditing patient files where there has been frequent hospital admission, multiple medications or poor control of chronic conditions such as diabetes. In addition, auditing has ensured practice alignment with current best practice guidelines. At the commencement of the role the activities of the CP were left broad in scope. With the results of this review it is time for the extended general practice team, Midland Community Pharmacy Group and Midlands Health Network to decide how to configure the role moving forward in order to meet both patients’ needs and the practice’s workload. Figure 1 below shows the summary of impacts (as identified through this review) on individuals, groups and organisations affected by the introduction of the CP into the extended general practice team.

Figure 1: Summary of identified benefits of an extended practice team Midland Community Pharmacy Group and Midlands Health Network I mp roved standard o f pa perwor k for aud it purposes

Har m re du ction focus

I mp roved quality perfor mance

Pilot for e xtended general pra ctic e team s

Waikato Hospital clinicians, community pharmacists G reater attenti on given to hospi tal disc harg e summ aries

S av e GP t im e

General Practitioners and Practice Nurses Direct access t o pharma cy exp ertise in th e wo rkplac e

E xt ra tea m member w or ki ng t o m eet qual ity pe rformanc e targets

S av e prac tice nurse time

I ncrease GP billable hours

R educed non- clinical bureaucra tic work load

Whanau / Family

LTM dat aset up to date

I mp roved communic ation be tween prim ary & s econdary-bas ed h ea lth pr ofessi onals

I mp roved medicati on m an agem ent I ncreased s en se of teamw or k in pat ie nt car e

Fac ilitation wi th externa l a gencies across t he sector

I mp roved quali ty of li fe

I ncreased a cc ess to pharm acy ad vice & s ki lls

Patient T ai lored educatio n to me et need

B etter manage me nt of patien t chroni c cond itio ns

R ecognised pote ntial to reduce ED a dmis sion s and hosp it al readm ission s

Phone, ema il or F 2 F a vail abilit y

Only on n eeded m edication

Clinical Pharmacy in General Practice: A review of the first nine months

Optimisat ion of therapy

Optimisat ion of health do llars

A f acil itator for ‘tricky’ or diff ic ult cases

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2. Introduction In 2011, Midlands Health Network introduced a new model of primary health care at three integrated family health centre (IFHC) proof of concept sites in Hamilton. Elements of the new model of care began to be implemented from April 2011. The three NorthCare practices in Grandview Road, Pukete Road and Thomas Road have been developing and testing the new model of care approaches on behalf of the wider network (see Appendix 1 for an implementation timeline). The NorthCare sites had a combined total of 15,694 enrolled patients in September 2011 (see the two maps in Appendix 2). One key strategy of the IFHC model of care is the expanded general practice team. The first phase of this strategy commenced in April with the addition of a full-time clinical pharmacist (CP) to the team working across all three NorthCare sites.

Purpose of the review The addition of a full-time CP into the extended general practice team is a major development in primary care. In November 2011, NorthCare, Midlands Health Network and Midland Community Pharmacy Group decided that it was time to review the initiative thus far, realising that the role of the CP has developed considerably from its initial implementation. This review of the first nine months seeks to capture the impact of the CP’s work on the everyday operation at the three NorthCare sites, including the self reported impact on general practitioners and practice nurses. It is intended that this review be used to aid discussion on how the role of an expert CP resource can be further developed in the general practice setting. It is important to note that this review was not designed to collect all the required data to undertake a robust cost-benefit analysis of the role of a CP in general practice. However, the information presented should assist work in this area in the future.

Review questions The main review question was “what has been the impact of the implementation of a full-time CP on the day to day operational activity of the three NorthCare general practice sites”. To answer this, the review concentrated on the following: • What types of clinical and non-clinical activities has the CP undertaken and what impact has this had on the three practices? • What effects do general practitioners and practice nurses report the role of the CP has had on their daily work? In addition, the CP recorded a number of brief case studies of interest to show real life examples of the role. These case studies are anonymous and no patient identifying information is included.

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Midlands Health Network

CASE STUDY: RESISTANT HYPERTENSION AND ADVERSE EFFECTS Mrs B had persistent high blood pressure despite being on maximum doses of blood pressure medication. She has multiple long-term conditions. The CP identified NSAID use and substituted this for regular paracetamol. The timing of one blood pressure medication was changed. These changes resulted in a significant reduction in blood pressure ~20mmHg one month after review. The CP identified metformin adverse effects which were significantly affecting Mrs B’s quality of life. She is now able to tolerate metformin at a reduced dose and is most grateful for the review.

CASE STUDY: PATIENT QUERIED HIS NUMBER OF MEDICATIONS Mr M queried the number of medications he was on. He complained of constipation, tiredness, dizziness and nightmares. The CP identified he was not testing his blood glucose and advised him to test four times daily to identify any low blood glucose levels. The medications gliclazide, oxybutynin and amitriptyline were stopped. Low vitamin B12 levels were identified as a result of long-term metformin use and so B12 was started. The changes to his medication reduced the risk of hypoglycaemia, his dry mouth and nightmares were resolved, constipation and dizziness were reduced and Mr M felt more energetic and “much better”. In addition Vitamin D was recommended for fracture risk reduction and Nutraplus cream for dry skin.

CASE STUDY: DABIGITRAN DOSE CHANGED AS A RESULT OF CLINICAL AUDIT The CP undertook a clinical audit of Ms A’s oral anti coagulant use and found that dabigitran had been prescribed by a cardiology registrar. Due to Ms A’s reduced creatinine clearance and multiple co-morbidities the CP identified a lower dose would be appropriate to reduce the risk of drug accumulation and increased bleeding risk. The CP sought the cardiologist’s opinion. As a result the dabigitran dose was subsequently decreased, thus reducing the risk of bleeds. The CP also identified that Ms A was storing dabigitran incorrectly in a daily medicine organiser thereby compromising integrity of the capsule and affecting the dose. This was easily resolved.

CASE STUDY: GP REQUESTS MEDICINE RECONCILIATION Mr T’s doctor requested CP review as the long-term medicine list held at the diabetes renal clinic did not match that held by the practice. The CP contacted Mr T, his community pharmacy and the renal clinic. The clinic thought Mr T was adherent with his medications, however he was still taking aspirin, which should have been stopped when he started dabigitran one month prior. Taking both had increased his bleeding risk. He was also taking a double dose of inhibace plus tablets and had high potassium levels, possibly contributed to by high dose inhibace plus. He was on a low potassium diet for this. Mr T was also taking less gliclazide than prescribed, which was affecting his blood glucose control. Dabigitran education for Mr T was organised. A plan was made with the renal clinic regarding all medications. The renal clinic and the CP are now in contact if there are any changes to Mr T’s medications and his regular community pharmacy has been alerted to follow up with education, monitoring adherence and asked to contact the CP if they have any concerns.

Clinical Pharmacy in General Practice: A review of the first nine months

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3. Background Adverse clinical consequences and increased economic costs related to medication misuse, and medication-related problems such as non-adherence and suboptimal therapeutic outcomes, are widely recognised by clinicians, policy makers, and health care economists. In New Zealand, these issues are accompanied by a huge growth in the number and complexity of available prescription medications and a primary sector facing increased pressures on workforce capacity and capability. The Midland Community Pharmacy Group has worked with Midlands Health Network to begin addressing these issues through the development and implementation of the CP role within the IFHC model of care. The role of the CP in the primary health care setting was designed to provide solutions to clinical consequences and the economic costs of medicine misuse, medication-related problems, patient non-adherence and suboptimal therapeutic outcomes. It was envisaged the CP role would provide an additional avenue to coordinate and improve the care transition for patients as they moved from secondary care episodes back into primary care. The CP role at NorthCare was expected to allow GPs more time to spend with patients with complex conditions and co-morbidities.

CASE STUDY: ADVERSE EFFECT OF MEDICATION RESOLVED Mr F was referred from his GP with daily, moderately severe headaches affecting his quality of life which the GP thought could be medication-related. Immediate CP consult with the patient was possible. The CP recommended a trial of changing his isosorbide medication to night time, which resolved headaches completely and improved the patient’s quality of life. This action saved GP research time and avoided ongoing consults and tests for Mr F.

Community pharmacy vs clinical pharmacy It is important to clarify the difference between the role of the community pharmacist in drug distribution and safety and the CP as a drug therapy expert involved in the management of patient health and medications in collaboration with other health care professionals.

COMMUNITY PHARMACIST The community pharmacist’s primary focus is on proving professional care to patients, supported by safe and effective medication management and medication information. Services are provided based on the pharmacist’s assessment of patient situations with the objective of optimising patients’ health. Community pharmacists in the Midland region are also involved in implementating many additional health services such as: • Comprehensive warfarin counselling • Smoking cessation counselling • MUR – medicine use reviews • Free emergency contraception for under 25s • Flu vaccination campaigns • Waste management and DUMP (Dispose Unwanted Medicines Programme) • Medication counselling for patients initiated on medicines for mild to moderate depression.

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Midlands Health Network

CLINICAL PHARMACIST The discipline of clinical pharmacy requires an obligation to increase knowledge for the purpose of advancing health and quality of life. Focus is placed on both pharmacologic and nonpharmacologic strategies. 2 Clinical pharmacists assume responsibility and are accountable for managing medication therapy for patients acting in collaboration with other health care professionals. A CP is considered to be a drug therapy expert. This service helps to avoid prescribing errors. They must be briefed on a patient’s medical information in order to provide drug therapy recommendations to the health care provider.3

Role of the clinical pharmacist in the IFHC Midland Community Group Pharmacy used international research into roles in primary care to define the role of the CP as: • Medicine therapy assessments (targeted at complex patients); • The development, implementation, and monitoring of medication treatment plans, including medication reconciliation, education and adherence support; • Provision of best practice medicine-related education and support for all members of the extended general practice team to ensure consistency of messages; • Signposting/referral to other support services; • Access to the MedTech system to support and inform clinical service and decision-making functions as part of the core health team. This access includes the authority and responsibility to input information into patient records to facilitate enhanced team-based knowledge and information support for the respective clinical and decision-making responsibilities of the extended general practice team; • Contribution towards the development of outcome measures for assessing the clinical outcomes, safety, and costeffectiveness of medication use in the population being served by the IFHC; • Assisting with the development of effective tools and information technology to close the compliance loop; and • Development of training for the patient flow team around the role of medicines in therapeutic treatment. Initially the implementation of the model of care meant that the opportunities for the CP role to be fully utilised were reduced. For example, clinical meetings were mostly procedural model of care-based and not clinical-based, therefore the CP role was not able to be fully utilised in this setting for practice support, provision of best practice updates and education until several months post implementation. In addition, the daily PDCA (plan, do, check, act) meetings also took time from the planned CP activities.

2

www.ehow.com/info_7761792_clinical-pharmacy.html

3

www.ehow.com/info_7761792_clinical-pharmacy.html

Clinical Pharmacy in General Practice: A review of the first nine months

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4. Data collection methods This review has used a mixed methods approach to gather the information needed to answer the questions listed above. Accordingly, data for this review was gathered in four different ways:

Shadowing the GP Data regarding the CP role analysis was gathered by shadowing the CP for two weeks (10 working days) and recording and timing all daily activities. This was undertaken by a pharmacy student (nine days) contracted to Midland Community Pharmacy Group and a Midlands Health Network funded medical student (one day) using a form for each activity developed specifically for the review. The CP’s activities were recorded and analysed following headings (refer to Appendix 4 for detailed definitions): • Total activity time and daily activity average; • Source of interaction referring to the person, group or event that triggered the activity, such as CP, GP, patient or discharge summary (Dx); • Whether any face-to-face interaction(s) had resulted from a patient drop-in without appointment (walk-in), add-on to an existing PN or GP consultation, or booked CP appointment; • Type of interaction, such as brief advice, medicine advice to staff, medicine reconciliation, paperwork and tests or support given; • Where applicable clinical significance using the Midland Community Pharmacy Group intervention classification system: – Very significant intervention(s) that potentially averted emergency medical attention or serious harm. This included prevention of disability, impairment, damage or disruption in the patient’s body function/structure, physical activity or quality of life, prevention of birth defects, prevention of serious drug toxicity or major adverse events. – Significant intervention(s) that avert routine medical attention, either through the improvement in patient care and/or optimisation of therapy including decreasing length of hospital stays, risk of moderate or adverse symptoms, preventing the exacerbation of a condition. For example preventing high blood pressure or improving blood glucose control. – Minor intervention(s) resulting in minor improvement in patient care and/or optimisation of therapy that includes improvement in quality of life, mobility or comfort, or in symptoms usually left untreated or treated with non-prescription medicines. – Intervention that had no impact on the patient or their wellbeing. – Interventions harmful to the patient or may have had a harmful or negative impact on the patient’s wellbeing. • Non-clinical: efficiencies and improved quality; – Bureaucratic save: non-clinical and process focussed tasks that saved another practice team member time and consequently reduced workload; – Money save: tasks that did or had the potential to save the patient, the practice or the health system money; – Emergency department (ED) save: tasks that did or had the potential to save an emergency department admission; – Save GP time: clinical tasks that did or had the potential to save GP time; – Save practice nurse time: clinical tasks that did or had the potential to save GP time; – Quality: Tasks that directly contribute to the achievement of quality performance indicator targets. No patient identifying information was collected on the activity analysis forms. Completed forms were provided on a regular basis to the Midlands Health Network team by the pharmacy student. Data was entered into excel over the two-week period and analysed.

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Midlands Health Network

CP’s paper notes Data regarding medicine reconciliation post discharge was gathered from the CP’s paper notes. Patient identifiers were removed by Midland Community Pharmacy Group staff before the forms were supplied to Midlands Health Network staff doing this review. Data was entered into excel and analysed.

IFHC pilot evaluation Data regarding the impact the role of the CP has had on the work of GPs and practice nurses (self reported) was collected in November and December 2011 as part of a wider pilot evaluation of the IFHC implementation being undertaken on contract by the University of Waikato (funded by Midlands Health Network). Individual staff responses were not identifiable and all interviews notes were combined and written up prior to being supplied to Midlands Health Network staff. Only data from questions specifically related to the role of the CP were supplied.

Case studies Case studies were selected and provided to the Midlands Health Network team by the CP and no identifying patient information was included.

CASE STUDY: SUITABILITY OF MEDICATION QUERIED The CP received a query from the GP regarding dabigitran suitability as Mrs D had asked to try it. The CP advised it was not suitable due to Mrs D’s reduced renal function, advanced age, frailty and low weight, which would increase bleeding risk. Mrs D was very stable on warfarin. After talking with Mrs D she was happy to stay on warfarin.

CASE STUDY: CONTRAINDICATION IDENTIFIED – AVOIDED EMERGENCY DEPARTMENT ADMISSION Mrs X was discharged from hospital on NSAID for pain. Her medical history includes von Willebrand disease (bleeding disorder), congenital kidney problems and asthma. When undertaking a medicine reconciliation post discharge the CP identified increased bleeding risk, risk of renal impairment and risk of bronchospasm from Mrs X’s combination of medications and conditions. She had been previously advised by her Haematologist to avoid NSAID use. Mrs X had taken NSAID for four days since she left hospital as she did not realise it was a NSAID. Mrs X was educated regarding NSAID use and an alert put on her medical file.

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5. Two week clinical pharmacist activity analysis This section summarises the results of the two week shadowing of the CP and the categorisation and timing of all work during that period.

Total activity time over two weeks During the two week role analysis the CP completed a total of 457 activities over 84 hours (5,043 minutes). The average daily activity duration ranged from 7.9 to 13.3 minutes with an overall activity time average of 11 minutes. The average number of daily activities ranged from 34 to 55 and had an overall two week average of 46 tasks per day.

Who initiated the activity? The CP proactively initiated 38.4 per cent of her activities by: • Auditing patient files to ensure alignment with current national and international best practice guidelines, eg. changes to medicine dose recommendations or contradictions. • Identifying patients who need a medication review, specifically patients who: – Frequently present to hospital. – Are listed on the appointment book and have for example multiple medications or are attending a Diabetic Annual Review and have poor diabetes control. • Auditing quality clinical indicator codes on patient files (contributing to the annual Midlands Health Network Quality Plan). A significant amount, almost a quarter (105, 23.2 per cent) of activities, originated from DHB discharge summaries (Dx), an important task traditionally performed by GPs but often delayed due to time pressures. The NorthCare practice support team who fulfil the practices administrative functions triggered 46 (10.1 per cent) of the CPs activities, an average of five per day.

Table 1: Number and percentage of activities by source or initiator Current source

Daily source count average

Source %

CP

174

17

38.4

Discharge summary

105

11

23.2

GP

52

5

11.5

Practice support

46

5

10.1

Practice nurse

28

3

6.2

Patient

23

2

5.1

Pharmacy

7

1

1.5

PAC

3

0

0.7

Hospital diabetes nurse

1

0

0.2

Other

18

2

4.0

Grand Total

453

46

100

Source or initiator

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Midlands Health Network

Summary of type of activity Figure 2 shows the CP’s work aggregated into seven main categories for analysis. Activity types have been allocated to each category with the number of activities undertaken over the two week period and the average time each activity took.

Figure 2: Summary of CP time spent over the two week period ACTIVITY CATEGORY

Medicine Review or Reconciliation all % of 13.6 ity activ

Medication Issue of all 4.5% ity activ

Education and Information all % of 24.1 ity activ

ACTIVITY TYPE

Number undertaken

Average time per activity

Medicine Review

77 activities

29 minutes

Medicine Reconciliation

34 activities

35 minutes

Clinical medical review

1 activity

95 minutes

Drug interaction

10 activities

27 minutes

Recall

1 activity

95 minutes

Medication change

14 activities

44 minutes

Allergy

1 activity

2 minutes

ADR

11 activities

36 minutes

Advice to patients

53 activities

18 minutes

Advice to GPs & Nurses

93 activities

15 minutes

Counselling patients

40 activities

34 minutes

Warfarin education

3 activities

16 minutes

Other drug education

10 activities

28 minutes

Blood glucose meter

5 activities

48 minutes

Diabetes general

11 activities

40 minutes

CVRA

1 activity

25 minutes

Blood Pressure

3 activities

43 minutes

HbA1c

3 activities

62 minutes

Blister pack

3 activities

17 minutes

Labs organised

20 activities

28 minutes

Rx Issued

20 activities

29 minutes

Medication card

6 activities

34 minutes

Long term medicines

29 activities

36 minutes

General deskwork

350 activities

11 minutes

SC standalone

11 activities

10 minutes

SC combined

8 activities

24 minutes

Referred

5 activities

19 minutes

Diabetes of all 1.9% ity activ

Tests or Support of all 6.8% ity activ

Paperwork all % of 45.9 ity iv t c a

Smoking cessation of all 2.9% ity activ

Clinical Pharmacy in General Practice: A review of the first nine months

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5. Two week clinical pharmacist activity analysis continued Category: Medicine review or reconciliation ACTIVITY CATEGORY

Medicine Review or Reconciliation all % of 13.6 ity activ

Number undertaken

Average time per activity

Medicine Review

77 activities

29 minutes

Medicine Reconciliation

34 activities

35 minutes

Clinical medical review

1 activity

95 minutes

ACTIVITY TYPE

• The most time consuming activity, by activity average, involved the interventions of comprehensive clinical medicine review, medication reconciliation and medication change. Changing medication and recalling a patient to a screening appointment are not in themselves time consuming and records show they occurred alongside more time consuming interventions. • With having only one comprehensive clinical medicine review occurring during the two week period, it is difficult to accurately estimate the average duration of a CP medicine clinical review conducted at the NorthCare practices, although the CP’s previous work experience suggests a clinical medicine review takes between one and three hours. To ultimately improve patient outcomes and to save additional practice time, internal CP referral procedures and external marketing of CP services could be introduced with a view to increase the number being completed.

Category: Medication issues ACTIVITY CATEGORY

Medication Issue of all 4.5% ity iv t c a

Number undertaken

Average time per activity

Drug interaction

10 activities

27 minutes

Recall

1 activity

95 minutes

Medication change

14 activities

44 minutes

Allergy

1 activity

2 minutes

ADR

11 activities

36 minutes

ACTIVITY TYPE

• There were 11 activities to remedy adverse drug reactions (ADR) taking an average 36 minutes (range 10 to 90 minutes) involving either interaction between drugs or with a medical condition. The variance in activity duration involving ADR was high with a recorded range of 10 to 90 minutes. There was one activity involving an allergy able to be treated within two minutes. • There were 11 activities involving drug interactions taking an average 27 minutes to remedy.

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Category: Education and information ACTIVITY CATEGORY

Education and Information all % of 24.1 ity iv t c a

ACTIVITY TYPE

Number undertaken

Average time per activity

Advice to patients

53 activities

18 minutes

Advice to GPs & nurses

93 activities

15 minutes

Counselling patients

40 activities

34 minutes

Warfarin education

3 activities

16 minutes

Other drug education

10 activities

28 minutes

• A total of thirteen drug education sessions were held during the two weeks. • Because of the importance for self management and continual monitoring with anticoagulant therapies, anticoagulant subcategories warfarin, clexane, and dabigatran were included. • Three warfarin education sessions were conducted and took between 10 and 20 minutes (average 16 minutes). There where no clexane or dabigatran education sessions required, contrary to the numbers noted earlier in 2011 during which time dabigatran was launched onto the New Zealand pharmaceutical market. • 10 other drug education sessions took an average 28 minutes ranging from five to 57 minutes in length.

Category: Diabetes ACTIVITY CATEGORY

Number undertaken

Average time per activity

Blood glucose meter

5 activities

48 minutes

Diabetes general

11 activities

40 minutes

ACTIVITY TYPE

Diabetes of all 1.9% ity activ

• The categories Diabetes General, HbA1c and BG meter (blood glucose meter) involve the health management of, and education for, patients with either type one or two diabetes. The general diabetes practice level interventions involving medication advice and/or insulin adjustment averaged 40 minutes and ranged from seven to 95 minutes. • The wide range in time for activities involving diabetic patients reflects the varying levels of medication advice diabetics can require. This depends on their current level of blood glucose management and the complexity of their case. • Blood glucose management software enabling the download and reporting of blood glucose monitor data is available for NorthCare patients to print reports to assist with their diabetes and insulin management. During the two week task analysis the CP assisted with five blood glucose monitor downloads averaging 48 minutes and ranging from three to 95 minutes.

Clinical Pharmacy in General Practice: A review of the first nine months

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5. Two week clinical pharmacist activity analysis continued Category: Tests or support ACTIVITY CATEGORY

ACTIVITY TYPE

Tests or Support of all 6.8% ity iv t ac

Number undertaken

Average time per activity

CVRA

1 activity

25 minutes

Blood pressure

3 activities

43 minutes

HbA1c

3 activities

62 minutes

Blister pack

3 activities

17 minutes

Labs organised

20 activities

28 minutes

Rx issued

20 activities

29 minutes

Medication card

6 activities

34 minutes

• As a clinician in the therapeutic management of medications, the CP is qualified to take blood pressure measurements and carry out CVRA. • Most test or support activities included organising labs and issuing scripts.

Category: Paperwork ACTIVITY CATEGORY

Number undertaken

Average time per activity

Long term medicines

29 activities

36 minutes

General deskwork

350 activities

11 minutes

ACTIVITY TYPE

Paperwork all % of 45.9 ity iv t c a

• Over three quarters of activities (76.6 per cent, 350) had a paperwork component. • Paperwork included normal practice activities such as updating patient notes, amending long-term medication lists, and disease and smoking coding. • The CP updated 29 patients’ long-term medicines lists.

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Category: Smoking cessation ACTIVITY CATEGORY

Smoking cessation of all 2.9% ity iv act

ACTIVITY TYPE

Number undertaken

Average time per activity

SC standalone

11 activities

10 minutes

SC combined

8 activities

24 minutes

Referred - other provider

5 activities

19 minutes

• Most smoking cessation services provided by the CP were stand alone. • Time required for stand alone smoking cessation averaged 10 minutes. • It is expected that the provision of stand alone sessions will decrease over the next six months to a year as the GPs begin to refer more patients for clinical medical reviews.

CASE STUDY: ERRORS ON THE DISCHARGE SUMMARY FOR HIGH RISK MEDICINES A post discharge medicine reconciliation for Ms P identified that her amiodarone was missed off the list, her furosemide dose was incorrect and her antibiotics were not listed. Ms P had received varying oral instructions for furosemide from two different hospital doctors causing her some confusion. She had been instructed to weigh herself daily but had no scales at home. The CP organised medication counselling for Ms P, arranged labs and updated the long-term medicine list.

Clinical Pharmacy in General Practice: A review of the first nine months

15

6. The clinical pharmacist’s impact on efficiency, quality and patient outcome The CP proactively resolves issues and responds to events that can incur undue time, cost or patient harm, and require notable resource to remedy. CP activities were analysed to assess their impact on efficiency and quality, and the significance of intervention(s) on patient outcome.

Intervention classification and outcome significance To measure how the CP role impacts the clinical management of patients activities were analysed and, if applicable, classified using the Midland Community Pharmacy Group classification system (refer to Section 4 Methods). • Some 235 (51 per cent) out of the 457 recorded activities were classified. • Of the 235 activities; 11 per cent (26) were classified very significant as they had the potential to or actually averted either emergency medical attention, serious harm, or an adverse event. • 23 per cent (55) involved interventions classified as significant in that they averted routine medical attention by either the improvement of patient care, optimisation of therapy or by preventing the exacerbation of condition(s). • Approximately a third of classified activities 32 per cent (76) were minor. The categorisation title of ‘minor’ does not mean to say that the intervention was inconsequential or trivial, but that it resulted in minor improvements such as the optimisation of therapy to improve quality of life, mobility and comfort, or in symptoms. • A third (78) of activities classified had no direct patient impact. • There were no activities deemed harmful or negatively impacting a patient.

Table 2: Number and percentage of intervention classification by activity source or initiator Very significant

Significant

Minor

No. patient impact

Harmful to patient

Total classified

% of classified

CP

10

18

25

30

0

83

35.3

Discharge summary

6

13

15

30

0

64

27.2

GP

3

7

11

6

0

27

11.5

Hospital diabetes nurse

0

1

0

0

0

1

0.4

PAC

1

1

0

0

0

2

0.9

Community pharmacy

0

3

1

1

0

5

2.1

Practice nurse

3

4

5

5

0

17

7.2

Practice support

0

1

7

5

0

13

5.5

Patient

3

7

12

1

0

23

9.8

Total Classified

26

55

76

78

0

235

100.0

% of Classifed

11.1

23.4

32.3

33.2

0.0

100.0

-

% of Tasks

5.7

12.0

16.6

17.1

0.0

51.4

-

Activity source or initiator

16

Midlands Health Network

Impacts on practice efficiency and quality – potential time saving and emergency department presentation/admission saves The CP activities of reviewing discharge summaries (Dx) and medicine reconciliations (required upon discharge summary analysis) have traditionally been carried out by GPs and therefore provide a measurement of how the role impacts workforce efficiency through increasing GP billable hours. • In carrying out these two activities, the CP potentially saved 15.9 hours of GP time (averaging 8 hours per week). Of the total 15.9 hours, nine hours were spent reviewing Dx that required no further action, and 6.9 hours completing medicine reconciliations (MR) for patients discharged from hospital identified as having a medication discrepancy. It is important to note that while the CP spent an average nine hours reviewing Dx and 6.9 hours completing MRs, this review did not endeavour to measure the time it would have taken for GPs to complete the same activities. Table 3 provides the breakdown of time spent on these two activities over the 10-day period.

Table 3: Time spent on discharge summaries (Dx) reviewed and medicine reconciliations Discharge summary (Dx)

Time (minutes)

Time (hours)

540

9

Requiring medicine reconciliation

416.5

6.9

Total

956.5

15.9

Reviewed

It is important to note that the following saves and improvements report the number of hours the CP spent carrying out activities that contained elements of both actual and potential time and money saved. • In terms of total activity time, the CP is currently spending an average 5.9 hours per day carrying out activities with an element of GP time saving (including the time spent on Dx and MRs as noted in table 5 above), and 1.2 hours per day on activities with an element of practice nurse time savings (refer to Table 4).

Table 4: Number and time spent on activities with an element of time save and/or quality improvement

Activity number

Activity time (minutes)

Activity time (hours)

Activity time (hours) in average day

Bureaucratic save

116

1420.5

23.7

2.37

Money save

112

2001.5

33.4

3.34

Emergency department save (presentation or admission)

23

739.5

12.3

1.23

GP time save (including DX and MR)

281

3539

59.0

5.90

Practice nurse time save

44

720

12.0

1.20

Quality

53

720

12.0

1.20

Save or Quality Improvement

Note: A single activity may count in multiple categories so totals do not sum.

Clinical Pharmacy in General Practice: A review of the first nine months

17

6. The clinical pharmacist’s impact on efficiency, quality and patient outcome

continued

• The CP is reducing the non-clinical bureaucratic workload of other practice team members with an average 2.3 hours spent per day on activities with an element that saved another practice member from completing paperwork. Examples include organising prescriptions, coding smoking status or updating a patient’s long-term medication (LTM) or file notes. • Tasks that did or had the potential to save emergency department presentations/admissions and therefore the health system money averaged 1.2 hours per day (refer to Table 6). Tasks that directly saved or potentially saved either the patient, practice or health system money totalled 112 and concerned an average 3.3 hours CP hours per day. • Activities that directly saved or potentially saved either the patient, practice or health system money totalled 112 and concerned an average 3.3 hours CP hours per day. • In addition to saving time and money, the CP is also having a substantial impact on quality improvement. A total of 53 activities involved work towards achieving quality goals that have a financial incentive based on performance. Over the two weeks, a total of twelve hours or 1.2 hours per day were spent on tasks positively impacting the Midlands Health Network quality programme. The quality goals most impacted by CP work were Diabetes Annual Review (DARs), smoking status coding and smoking cessation. • To determine the actual freeing up of billable GP and PN hours for activities other than discharge review and medicine reconciliation, any future analysis should be designed to measure the specific activity elements that save GP and PN time.

CASE STUDY: THE IMPORTANCE OF AN UP-TO-DATE LONG-TERM MEDICINE (LTM) LIST Mr K’s wife requested a post discharge medicine reconciliation. The CP identified five discrepancies between the LTM list held at the practice and what Mr K was actually taking. Mr K had been to a specialist and his GP was unaware of medicine changes. Mr K had missed some medications when in respite care as the institution had checked off an out of date medication list faxed from the practice rather than what Mr K’s wife had packed in his medicine organiser. This had resulted in less well controlled parkinson’s disease. This had a huge impact on Mr K’s quality of life and control of his condition, which could potentially have resulted in hospital admission or further medication being inappropriately started or altered.

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Midlands Health Network

CASE STUDY: MULTIPLE MEDICINE CHANGES REQUIRES LIAISON WITH SECONDARY CARE A post discharge medicines reconciliation for Mrs Y identified six new medications, three medications stopped and one dose increase. Mrs Y had not used the recormon injection yet and did not know how to administer it. The CP liaised with the hospital dialysis unit for recormon injection to be kept and administered there and then followed up regarding the hypoglycaemic medication dose titration to optimise Mrs Y’s diabetes control. The practice long-term medicine list was updated and a helpful medication card provided to Mrs Y.

CASE STUDY: HOME VISIT IDENTIFIES ISSUES WITH MEDICATION REGIME Mr H’s wife organises his medications for him. The CP identified during the post discharge medicine reconciliation that she had not started giving Mr H his felodipine as she was worried about side effects – his blood pressure was subsequently 180/90mmHg. The CP identified that Mr H had also been taking only half the prescribed dose of dipyridamole for 12 months – resulting in an increased risk of stroke. Mr and Mrs H were confused regarding pantoprazole and somac (the same thing). His simvastatin was not being taken at the ideal time of the day. The CP promoted the use of compliance packs and liaised with Mr H’s community pharmacy to organise this. Mr H’s adherence to his medication regime is now good.

Summary • The CP is improving patient outcomes through optimising treatment and preventing the need for medical attention and/or serious harm. • Some 235 (51.4 per cent) activities undertaken by the CP since April 2011 were classified using a clinical intervention classification system developed by the Midland Community Pharmacy Group. Of the total 235 tasks: – 11.1 per cent (26) were classified very significant as it potentially or did avert emergency medical attention or serious harm, or adverse event. – 23.4 per cent (55) involved interventions classified as significant in that they averted routine medical attention by either the improvement of patient care, optimisation of therapy or prevention of the exacerbation of condition(s). – 32.3 per cent (76) were minor in that they resulted in minor improvements such as the optimisation of therapy to improve quality of life, mobility and comfort, or in symptoms. • Activities classified as having no direct patient impact totalled 78 (33.2 per cent). • There were no activities that categorised as dealing with events or interactions that were harmful or negatively impacting the patient. • During the two week period, the CP spent an average eight hours per week reviewing discharge summaries and 5.9 hours carrying out medicine reconciliations. These have traditionally been GP activities. • Over the two weeks, CP activities that did or had the potential to save emergency department presentation or hospital admission averaged 1.6 activities per day. • The CP carried out activities that contain an element of clinical and non-clinical time savings that free up GP and practice nurse hours. In addition, the CP saves money for either the health system or patients (25 per cent of tasks) and has a substantial impact on quality improvement (1.2 activity hours per day).

Clinical Pharmacy in General Practice: A review of the first nine months

19

7. Medicine reconciliation post discharge analysis Medicine reconciliation is an evidence-based process, which has been demonstrated to significantly reduce medication errors that occur at transition points of care (admission, transfer and discharge) by incomplete or insufficient documentation of medicine-related information. It involves three core steps: 1. Collecting the most accurate medicines list using at least two different information sources, the primary source being the patient; 2. Comparing the most accurate medicines list against the current medication chart and clinical notes for any documented changes to medicines; 3. Communicating any discrepancies to the prescriber to reconcile and action.

Method Between 21 April and 28 October 2011, the CP analysed 627 discharge summaries (Dx) sent to the practice from Waikato Hospital. The 627 reviewed by the CP represented those brought to her attention by practice support staff. It is now operational policy to alert the CP of Dx receipt, but during the period of analysis, this was not the case and it is unknown what percentage of Dx sent by DHBs the 627 represents. Dx analysed as having issues requiring further investigation had a full medicine reconciliation completed with results being recorded on a medicine reconciliation post discharge form (MR form). The MR form categorised reconciliations under the following event headings: 1. Whether completion took fewer or greater than 48 hours to complete from the time the practice received the Dx. 2. Contact(s) in the form of phone, face-to-face, or email required to complete the MR process. Contacts noted where those made with the patient, GP, pharmacy or other services involved in the case. More than one contact with a person or service provider and more than one type of contact were noted. 3. Where an error occurred on the Dx they were recorded under discharge summary interventions in one of the following categories: a. Medicine missing where the medicine was on the patient’s MedTech practice notes but missed off the patient’s hospital records for the duration of their stay in hospital and at point of discharge; b. Incorrect medicine doses listed on the Dx; c. Interactions between known medications on the Dx, or, over the counter (OTC) medications, or known medical conditions; d. Error on Dx summary including events where there were Dx double ups, the Dx had not been sent to the practice or the hospital had not completed one, the Dx was incomplete or contained a lack of information, and when Dx were received for patients not enrolled at the practice. These errors often required contact with the hospital ward or doctor, and for patients not enrolled at the practice contact with the correct practice. 4. Practice level interventions noted in response to medication Dx errors where: a. A medication was not listed on the long-term medication (LTM) section of the patient’s file, meaning the practice did not know the patient had been prescribed a medicine; b. The LTM needed updating, and whether medications were removed and/or added; c. A further prescription needed to be issued; d. A laboratory referral was required; e. Recall inputted meaning the patient required to be contacted to advise or remind them of a follow up or referral.

20

Midlands Health Network

5. Adherence and support services in the form of patient counselling, blister packs issued, or referral to health support services outside the practice, eg. diabetes clinic. 6. Referrals to pharmacy for: a. Medicine use review (MUR) where patients with adherence issue or whom require support can be treated and advised face-to-face by the MUR travelling pharmacist; b. Smoking cessation support and treatment; c. Warfarin counselling. Out of the total 627 discharge summaries (Dx) received by the NorthCare practice, a full medicine reconciliation post discharge was required for 214 (31 per cent). The Midlands Health Network team collated and analysed the data recorded on MR Forms using Microsoft Excel 2007.

Discharge summary errors Of the 214 medicine reconciliations required, there were a total of 87 medication errors. A significant number of incorrect doses were noted (27, 12.6 per cent) as were medications missing from the Dx that were listed on the MedTech patient notes, but missed off the hospital records (27, 13.6 per cent). Some 14 per cent (32) had a medication missing that had been listed on the general practice MedTech patient file prior to hospital admission, but had been missed off while in hospital and at discharge. Of those medications listed, 13 per cent (27) had an incorrect dose and 5 per cent (11) involved interactions with other prescribed medication or current conditions (refer to Table 5). There were 11 (5.1 per cent) interactions with medicines and/or known patient conditions that required extensive CP and practice involvement to remedy. Other errors requiring contact with the hospital to seek clarification totalled 12 (9.9 per cent). Measured against the total 627 discharge summaries analysed, five per cent of the discharge summaries had medication missing that had been listed on MedTech, four per cent had an incorrect dose, two per cent involved interactions, and three per cent other errors.

Table 5: Number and percentage of discharge summary error by type Number

% of MRs completed

% of Dx reviewed

Medication missing

32

13.6

5.1

Incorrect dose

27

12.6

4.3

Medication interaction

11

5.1

1.8

Error on Dx

17

9.9

2.7

Total

87





Error type

Clinical Pharmacy in General Practice: A review of the first nine months

21

7. Medicine reconciliation post discharge analysis continued Practice level interventions There were a total of 431 practice level interventions required in response to the 214 medicine reconciliations completed (refer to Table 6): • The long-term medication (LTM) database required updating for 66 per cent (141) • There were 20 per cent (51) that had a long-term medication recorded on the Dx that practices were unaware of the medication having been prescribed • The CP removed medications from the LTM for 29 per cent (62) of the MRs, and added medications to the LTM for 38 per cent (82) • Interventions in the form of a new prescription where required in nine per cent (19) of the MR’s, and lab referrals 16 per cent (35) • There were 19.2 per cent (41) patients requiring a recall of one or more of their medications. Measured against the 627 discharge summaries analysed: • 23 per cent required the LTM on MedTech to be updated • Eight per cent had a medication missing from the LTM, 10 per cent a medication removed and 13 per cent added • Scripts were issued from the practice in response to three per cent • Six per cent of patients required a lab referral • A total of seven per cent of patients had to be contacted to remind them of a referral or to arrange a follow up (recall inputted).

Table 6: Number and percentage of practice level intervention type required after MR Number

% of MRs completed

% of Dx reviewed

Med missing from long-term medication list (LTM)

51

19.6

8.1

LTM updated

141

65.9

22.5

Meds removed from LTM

62

29.0

9.9

Meds added from LTM

82

38.3

13.1

Rx printed

19

8.9

3.0

Lab referral

35

16.2

5.6

Recall inputted

41

19.2

6.5

431





Practice level intervention

Total

Note: Any single MR can have more than one action.

22

Midlands Health Network

Contacts arising from medicine reconciliations Some 89 per cent (191) of the MRs required contact with the patient and/or other health providers either via phone, email or face-to-face (refer to Table 7). The CP had to make contact with the GP to complete 57 per cent (122) of the MRs post discharge, and the community pharmacy to complete 54 per cent (116). Contacts with the hospital and other services were comparatively low, but still significant, at 13 per cent (27) and five per cent (11) respectively.

Table 7: Number and percentage MR requiring contact by type Contact Type

Contact

% of all MR contact

Patient

191

89.3

GP

122

57.0

Pharmacy

116

54.2

Hospital

27

12.6

Other services

11

5.1

Note: A single MR can have multiple contacts.

Table 8: Number and percentage MR requiring one contact or more than one contact by type One contact

% having one contact

Required more than one contact

% Requiring more than once contact

Patient

169

79.0

22

17.3

GP

120

56.1

2

1.6

Pharmacy

105

49.1

11

8.7

Hospital

22

10.3

5

3.9

Other services

11

5.1

0

0.0

Contact type

CASE STUDY: MEDICINE INTERACTION IDENTIFIED AND SOLVED In the process of undertaking a medicine reconciliation post discharge, the CP identified an interaction between tramadol that had been prescribed at emergency department and Ms J’s regular SSRI medication. Ms J said she had been fine, but on further discussion it was discovered she had been having mild seratogenic adverse effects (sweating), which she hadn’t realised could be medicine-related. Subsequent to her hospital visit, her dose of SSRI was increased. The CP advised her that the likelihood of a worse reaction was therefore increased and she should avoid tramadol while on the SSRI, take paracetamol instead, and ring back if an alternative pain relief was required.

Clinical Pharmacy in General Practice: A review of the first nine months

23

7. Medicine reconciliation post discharge analysis continued Clinical pharmacist specific interventions and referrals Support offered by the CP in response to MR findings (Table 9) was recorded into one or more of the following categories: patient counselling, blister packs, and/or referral to another support service. The most common support service was patient counselling, with 60 per cent (129) patients receiving counselling about medication or required lab test interventions.

Table 9: Number and percentage of MRs leading to interventions of support/referral for support Support Category

Number

%

Patient counselling

129

60.3

Blister packs

10

4.7

Referral to support service

10

4.7

Pharmacy medicine use review

3

1.4

Pharmacy smoking cessation

1

0.5

Pharmacy warfarin

3

1.4

156



Total

24

Midlands Health Network

Medicine reconciliation summary • All 627 discharge summaries (Dx) received by the CP were reviewed with 31 per cent (214) requiring further analysis and medicine reconciliation (MR). • Out of the 627 Dx reviewed, five per cent had medications missing, 4.3 per cent had incorrect doses listed, one per cent involved interactions with other medications or conditions, and 2.7 per cent required the CP to contact the hospital for clarification or forwarding to another practice. • There were a total of 87 medication errors in the 214 MRs. A significant number of incorrect doses were noted (27, 12 per cent) as were medications missing from the Dx that were listed on the MedTech patient notes, but missed off the hospital records (27, 13.6 per cent). There were 11 (five per cent) interactions with medicines and /or known patient conditions that required extensive CP and practice involvement to remedy. Other errors requiring contact with the hospital to seek clarification totalled 12 (9.9 per cent). • A total of 431 practice interventions were made in response to the 214 MRs. The most common intervention was the updating of the long-term medicines list in the patient MedTech notes (66 per cent MRs, 23 per cent Dx). Some 41 of the Dx required a patient be contacted to recall them to a practice appointment or follow up. • A significant number of contacts were required to complete the medicine reconciliations. Patients were contact for 89 per cent, GP for 57 per cent, the community pharmacy for 54 per cent and hospital 13 per cent. • Most CP specific interventions required were in the form of patient medication counselling (60 per cent).

CASE STUDY: AVOIDED TOXICITY AND POSSIBLE EMERGENCY DEPARTMENT ADMISSION WITH TIMELY MEDICINE RECONCILIATION Ms G’s mother had a discharge prescription for carbamazepine CR 300mg twice daily. She thought this was in addition to the carbamazepine CR 200mg twice daily already in the medico blister pack, whereas it was intended to be the total dose. Ms G was on leave from an institution in another location. Her mother was therefore going to get the prescription at a different pharmacy from the usual one and give it in addition to blister pack (resulting in a dose of 500mg twice daily and risked toxicity). The CP was able to intervene before the medication was dispensed and ensured Ms G’s mother understood the correct dose.

CASE STUDY: TIMELINESS OF MEDICINE RECONCILIATION AVOIDS DOSE ERROR ON PRESCRIPTION Mr Z’s metoprolol dose was reduced while he was in hospital. When doing the medicines reconciliation the CP noticed that Mr Z had ordered a repeat script for metoprolol after discharge, and it had been done for the original dose as the discharge summary had not been received at that stage. The CP was able to retrieve the script from reception before Mr Z picked it up – avoiding him taking a double dose. The CP arranged a new script with his GP and updated the practice long-term medicine list.

Clinical Pharmacy in General Practice: A review of the first nine months

25

8. Results – feedback from the first NorthCare staff interviews Midlands Health Network is in the process of formally evaluating the first stage of the IFHC development and implementation. The University of Waikato has been contracted to undertake the first stage of the longer-term evaluation – particularly looking at patient and staff assessments of the new model of care to date. The first results are not officially due until April 2012, but the contractor has made some information available early, as there were some concerns about the role of the CP collected in the process of interviewing NorthCare staff in November and December 2011. The following are summary points from NorthCare staff interviews (across the three sites): • The GPs were supportive of the role and collegial relationships were becoming more rewarding and productive as trust was built and both patients and staff knew what to expect. • Early in the role there had been some issues with access to resources, including mobile phones, office space, computer access and research materials. • Practice staff reported very positive views on the appointment of a CP. They suggested that the CP “was the best thing that had come out of the changes” and consistently used superlatives in connection with the CP (such as excellent and wonderful). • The CP was viewed as a “great fund of knowledge”, proactive, competent and thorough. • For clinicians, the CP provided up-to-the-minute information, saved them time by having the information at hand or by doing the necessary research, and this function was improved by the CPs accessibility. • The CP also saved GP and nurse time by explaining medication-related issues to patients. This was of particular value for people on complicated or dangerous regimes (eg. warfarin), for people who had difficulty understanding medication and for those reluctant to comply with medication regimes. • Medicine reconciliation after hospital discharge was thought to be particularly useful and examples of the detection of errors were given. One GP expressed less enthusiasm for the review of patients’ drug regime, feeling that he already had this optimised. • Some felt that the CP could do more population education. It was noted that the CP might not be self-funding and that fees for CP services were problematic. The question of patient payment for services had been discussed. It was recognised that some people would not have financial resources to pay; it was also important to be clear with patients when they would be expected to pay, and that this should be made clear before a consultation is arranged. The CP role and service has been universally welcomed by practice staff.

26

Midlands Health Network

CASE STUDY: POTENTIAL EMERGENCY DEPARTMENT ADMISSION AVOIDED The post discharge summary was received by the practice 11 days after Mr V’s thyroidectomy. It was discovered that Mr V was taking levothyroxine twice daily instead of once daily. His other medications are taken twice daily so he had assumed that the levothyroxine was too. The CP advised the hospital endocrinology team and Mr V’s dose was subsequently decreased and follow up labs done.

CASE STUDY: MULTIPLE DRUG INTERACTIONS – EMERGENCY DEPARTMENT AVOIDED Mr L’s discharge summary was received three weeks after discharge. The CP found three significant medication errors. The anticoagulant dabigitran was missing, inhibace was listed instead of inhibace plus, and the diltiazem dose and frequency were missing. The patient had fortunately been receiving the correct medications however, NSAIDs were also prescribed and he had been taking them for three weeks on a when required basis. Several potential serious interactions were identified. There was a potential bleeding risk due to the use of NSAID with an oral anticoagulant. In addition, the use of a NSAID, diuretic and ACE inhibitor together can increase the risk of acute renal impairment, and the effect on the kidney may also increase the effects of dabigitran, thereby increasing the bleeding risk. Mr L was recommended not to take the NSAID and anticoagulant education was provided. As paracetamol wasn’t sufficient for his pain management, an alternative was recommended. Brief smoking cessation advice was also provided.

CASE STUDY: MEDICATION INTERACTION AVOIDED Mrs F did not have her pain relief specified on the discharge summary. The CP suspected a NSAID and rang to check as Mrs F was on an ACE inhibitor and diuretic, had several long-term conditions, and had recently started new antihypertensive and iron supplements. Mrs F was advised to avoid the NSAID due to risk of renal impairment, increased blood pressure and increased bleeding risk with concurrent anaemia. A blood pressure check and new labs were organised. As all was well, Mrs F was able to get a new prescription without seeing the GP.

Clinical Pharmacy in General Practice: A review of the first nine months

27

Appendix 1: Selected timeline of IFHC implementation For those not familiar with IFHC developments at the NorthCare sites, the table below shows the significant milestones to date in terms of implementation in the proof of concept sites.

Table A: Timeline of selected major development points for the IFHCs Date

Detail

Mid 2009

Midlands Health Network CEO presents on new model of care to Primary HealthCare Ltd (PHCL) staff

June 2010

Seattle trip to Group Health (included GPs from NorthCare)

October – December 2010

Workshop 1: the model of care; Workshop 2: system initiated contacts; Workshop 3: contact management; Workshop 4: pre-consult consult

February 2011

Workshop 5: facility and information technology

28 March

Site blessing

29 March

Patient Access Centre (PAC) go live

1 April

Staff celebration dinner

4 April

NorthCare Thomas Road go live

11 April

NorthCare Pukete Road go live

11 April

Clinical pharmacist joins the general practice team working across all three sites

10 May

NorthCare Grandview Road go live

30 May

IFHC project team meeting “where to next for IFHC”

30 May

IFHC clinical governance group starts weekly meetings

2 June

Medical centre assistant training day Additional administration tasks shift to PAC including: • Administration support – end July (including ACC45 download, ACC45 checking, NHI lookup and SureMed progress report checking) • Immunisation recall letters – mid July • Cervical smear recall letters – end July • Three years not seen letters – August

July onwards

• Measles outbreak campaign – end August • Breast screening enrolment – September • HPV campaign – September • Credit control letters – mid October • HUHC process – October (still in pilot phase) • Credit control phone calls – mid November • Scanning/allocating – November (still in pilot phase)

28

16 August

Re-setting workshop

September

Clinical pharmacist with patient bookable appointments

18 October

Rounding begins

7 November

NorthCare Pukete Road facilities completed

December

Rooming implemented at NorthCare Pukete Road (facility constraints at Thomas Road and Grandview Road sites)

From February 2012

Fishing and pre-consult processes implemented in all three sites

Midlands Health Network

Appendix 2: Maps of NorthCare patient distribution Map 1: Distribution of enrolled population for NorthCare – Grandview Road

LEGEND NorthCare Grandview Road

Principal highway

Enrolled Patient

Hamilton city locality boundary

Arterial and minor roads

Clinical Pharmacy in General Practice: A review of the first nine months

29

Appendix 2: Maps of NorthCare patient distribution continued Map 2: Distribution of enrolled population for NorthCare – Pukete and Thomas Road

LEGEND NorthCare Grandview Road

Principal highway

Enrolled Patient

Hamilton city locality boundary

Arterial and minor roads

30

Midlands Health Network

Appendix 3: Activity analysis form Date:

Time:

Charge:

GP request Source of interaction

NHI:

Pt

Practice support

Pharmacy

Dx - 48h

Nurse request

CP initiated

Reason F2f info

F2f walk in

F2f add on

Brief advice

Med chg

Counselling

F2f bkd Smoking Referred

New Stop

Med advice staff

Combined

LTM updated

Med reconciliation

Stand alone

Clin med review

Education

Brief med review

Warfarin

Admin

Practic level interaction

Rx issued

BP

Labs organised

CVRA

Recall (circle) Im / Cerv / Flu / DARs / Br

Diabetes gen BG meter Clex

HbA1c

Dabigatran

Med card

ADR I_I DrugInteractN

Blister pack

Allergy

Other

Other Information T1 T2 T3 Strategies used

Referred to

GP

PN

Pcy

Other

Advice from

GP

PN

Pcy

Other

Intervention classification

Pt contacts

V. signif

Bureaucratic save

Signif

Money save

Minor

Save ED

No pt impact

Save GP time

Harmful to pt

Save nurse time

Phone-Ms

Email

Letter

Txt

Notes and comments

Clinical Pharmacy in General Practice: A review of the first nine months

31

Appendix 4: Analysis record categories and definitions The CP’s tasks were recorded and analysed under the following headings: 1. Date the task began, total time taken to complete task measured in minutes including follow up times on subsequent days, the amount of money charged for the task (if applicable), and NHI number for CP to refer to for follow up. The NHI number was not used for analysis purposes. 2. Source of interaction refers to the person, group or event that initiated the task. Sources listed were CP, GP, patient, practice nurse, discharge summary (Dx), Midland Community Pharmacy Group, the Midlands Health Network Health Intelligence Team (HIT) and the hospital diabetes nurse. 3. Reason for task initiation. 4. Whether any face-to-face interaction(s) with the patient had resulted from a patient drop-in without appointment (walk-in), add-on to an existing PN or GP consultation, or booked CP appointment. 5. Practice level interactions: a. Type of interaction: i.

Brief advice given to patient about medication(s)

ii.

Counselling that involves intensive advice about medication(s) and adherence

iii.

Medication advice to staff about a specific patient of medication(s)

iv.

Medicine reconciliation resulting from a Dx analysis

v.

A comprehensive clinical medicine review usually involving 1-3 hours research to improve patient outcomes and save practice time in the long-term

vi.

Brief medicine review being a shorter version of the comprehensive clinical medicine review that is a straight forward review of medication

vii. Administrative tasks that include checking lab test results, updating of patient notes on the patient database MedTech, sending and receipt of emails, registration with professional viii. Facilitating Rx issue ix.

Labs organised

x.

Medication change recommended by CP and signed off by GP

xi.

Long-term medication list updated on the patients MedTech file

xii. Recall of patient for immunisation (Im), cervical smear (Cerv), influenza vaccination (Flu), Diabetes Annual Review (DARs), and breast screening (Br) xiii. Adverse Drug Reaction (ADR) intervention xiv. Drug interaction where medication(s) is interacting, either with another medication or condition, to cause adverse or unintended side effects xv. Allergy to a drug leading to change of medication xvi. Smoking Cessation (SC): 1. Patient referred by CP to another party, eg. community pharmacy or practice nurse, for SC counselling 2. SC combined as part of another patient interaction 3. SC provided as a stand alone consultation and primary intervention xvii. Education in the form of warfarin, clexane and dabigatran information, general diabetes information including medication and lifestyle factors, and blood glucose meter data downloads for trend analysis.

32

Midlands Health Network

b. Tests or support: i.

Blood pressure

ii.

Cardiovascular Risk Assessment (CVRA)

iii.

HbA1c

iv.

Medication card containing all patient medications and dosage supplied to patient

v.

Blister pack provided

vi.

Blood glucose monitor – downloading a patients blood glucose tester data to graph trends for disease or insulin medication management

vii. Other diagnostic tests or items supplied or referred to the patients. c. Information or research of literature or patient case notes categorised as: i.

Tier One – task query that requires no research and took less than five minutes

ii.

Tier Two – took 5-20 minutes and/or research

iii.

Tier Three – complex medical query that required significant, eg. 30-120 minutes, research

iv.

Strategies used refers to research sources other than MedTech patient notes, such as literature search source, contact with pharmacy, specialist advice.

d. Other – referrals to services outside of the practice. 6. Referred to GP, PN, pharmacy and/or other. 7. Advice obtained from GP, PN, pharmacy and/or other to complete the task. 8. Intervention classification: a. Very significant intervention(s) that potentially averted emergency medical attention or that potentially averted emergency medical attention or serious harm. This included prevention of disability, impairment, damage or disruption in the patient’s body function/structure, physical activity or quality of life, prevention of birth defects, prevention of serious drug toxicity or major adverse event b. Significant intervention(s) that avert routine medical attention, either through the improvement in patient care and/or optimisation of therapy including decreasing length of hospital stays, risk of moderate or adverse symptoms, preventing the exacerbation of a condition. For example preventing high blood pressure or improving blood glucose control c. Minor intervention(s) resulting in minor improvement in patient care and/or optimisation of therapy that includes improvement in quality of life, mobility or comfort or in symptoms usually left untreated or treated with nonprescription medicines d. Intervention that had no impact on the patient or their wellbeing e. Interventions harmful to the patient or may have had a harmful or negative impact on the patient’s wellbeing. 9. Non-clinical interventions: a. Bureaucratic save: non-clinical and process focussed tasks that saved another practice team member time and consequently reduced workload, eg. organising a prescription, smoking status coding or updating a patient’s long-term medication list or file notes b. Money save: Tasks that did or had the potential to save the patient, the practice or the health system money c. Emergency department save: Tasks that did or had the potential to save and emergency department admission d. Save GP time: Clinical tasks that did or had the potential to save GP time, eg. providing information that meant the GP did not have to do their own research, or completed a task that would have otherwise be done by the GP e. Save practice nurse time: Clinical tasks that did or had the potential to save GP time, eg. providing information that meant the practice nurse (PN) did not have to do their own research, or completed a task that would have otherwise be done by the PN f. Quality: Tasks that directly contribute to the achievement of quality performance indicator targets.

Clinical Pharmacy in General Practice: A review of the first nine months

33

Appendix 5: Detailed data tables related to two week activity analysis Table B: Number, duration, and average duration of CP daily tasks Task count

Task duration (minutes)

Average task duration

Task duration (hours)

5/12/2011

38

443

11.7

7.38

6/12/2011

34

452

13.3

7.53

7/12/2011

51

540

10.6

9.00

8/12/2011

45

543

12.1

9.05

9/12/2011

55

436.5

7.9

7.28

12/12/2011

54

486

9.0

8.10

14/12/2011

42

493.5

11.8

8.23

15/12/2011

41

515

12.6

8.58

16/12/2011

51

609

11.9

10.15

20/12/2011

46

464.5

10.1

7.74

-

60

-

1.00

457

5042.5

11.0

84.04

Date

Travel to and from practices during the two weeks* Grand Total

* Time spent travelling between the three NorthCare practices has been calculated based on one single travel time recorded to and from each practice site multiplied by the number of times the CP travelled to and from the particular practice. As the act of travelling has no impact on clinical outcomes the number of trips taken has been omitted from the total task count, but because travel is required to fulfil the CP role within the three separate practices, it is included in the overall task duration total.

34

Midlands Health Network

Table C : Type of intervention by activity number and percentage, duration average and range ranked by highest to lowest activity number Task type

Number

% of tasks

Average time

Max. time

Min. time

Paperwork

350

76.6

11.2

110

0.5

Med advice to staff

93

20.4

14.5

90

1

Brief medicine review

77

16.8

28.9

110

3

Brief Pt advice

53

11.6

18.2

70

1

Counselling

40

8.8

33.9

95

10

Medicine reconciliation

34

7.4

34.5

110

12

LTM updated

29

6.3

35.7

4

95

Labs organised

20

4.4

28.2

90

3

Rx issued

20

4.4

28.5

95

1

Med change

14

3.1

44.4

5

95

Diabetes general

11

2.4

40.1

95

7

ADR

11

2.4

35.5

90

10

SC stand-alone

11

2.4

10.1

30

2

Other drug education

10

2.2

28.2

57

5

Drug interaction

10

2.2

26.9

90

2

SC combined

8

1.8

23.5

50

10

Med card

6

1.3

34.0

90

5

BG meter

5

1.1

48.0

95

3

SC referred

5

1.1

18.8

50

2

HbA1c

3

0.7

62.3

95

2

BP

3

0.7

43.0

95

4

Blister pack

3

0.7

17.3

19

15

Education warfarin

3

0.7

16.0

20

10

Other

2

0.4

15.5

17

14

Clinical medicine review

1

0.2

95.0

95

95

Recall

1

0.2

95.0

95

95

CVRA

1

0.2

25.0

25

25

Allergy

1

0.2

2.0

2

2

Clexane education

0

0.0

0.0

0

0

Dabigatran education

0

0.0

0.0

0

0

825

100.0

11.0

110

1

Total

Clinical Pharmacy in General Practice: A review of the first nine months

35

Appendix 5: Detailed data tables related to two week activity analysis continued Table D: Number and percentage of trigger for face-to-face add on, booked and walk in consultations f2f type

Add on

Booked

Walk in

Total

% of Total

CP

2

4

1

7

28

DX

1

3

-

4

16

GP

1

2

-

3

12

PN

-

1

-

1

4

Practice support

-

-

1

1

4

Patient

2

5

2

9

36

Pharmacy

-

-

-

-

-

PAC

-

-

-

-

-

Total

6

15

4

25

100

% of Total

24

60

16

100

100

Just under half (12, 48 per cent) of the face-to-face consults involved counselling, and 10 or 40 per cent a brief medical review. Almost all involved paperwork, usually in the form of updating patient notes and/or long-term medication list. Five (20 per cent) involved giving medical advice to staff upon request and six (24 per cent) were implicated as a result of a medicine reconciliation triggered after analysis of a discharge summary (Dx). Further analysis on a larger sample of face-to-face consultations could be done to validate these results. Non face-to-face contacts made with patients were mostly made by phone (97.7 per cent), either to have a conversation (71.1 per cent) or leave a message (26.6 per cent). One (0.8 per cent) email and two (1.6 per cent) letters were written.

Table E: Number and percentage of patient contacts by contact method Patient contact method

36

Number

Percentage

Phone conversation

91

71.1

Phone message

34

26.6

Email

1

0.8

Letter

2

1.6

Text

0

0.0

Total

128

100.0

Midlands Health Network

Appendix 6: Medicine reconciliation form Medicine Reconciliation Post Discharge DATE: # referred per day

# completed < 48h

# completed > 48h

PATIENT: Contacts

Time taken

Comments

Patient GP Pharmacy Hospital Other Services

Dx summary interventions Med missing (was on prior to admission but missed off while in hospital and at discharge) Incorrect dose Interaction Error on Dx summary

Practice level interventions Med missing from LTM (eg. started by specialist) LTM updated Meds removed Meds added Rx printed Lab referral Recall inputted

Adherence / Support Patient counselling Blister packs Referral to support service (eg. diabetes clinic)

Referral to pharmacy

MUR

SC

Warfarin

Total time taken

Clinical Pharmacy in General Practice: A review of the first nine months

37

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