Doctors, Nurses ... and
pharmacists - why this
threesome works.
Vanessa Brown
Brendan Duck
RNZCGP GPCME 2014
What is a clinical pharmacist?
Specialist Pharmacist Practitioner
Post Graduate education and/or significant
clinical experience
Undertakes Medicine Review = Medicine
Therapy Assessment (MTA)
Provides medicine and clinical information
services
What's different about a Clinical
Pharmacist?
Focus on risk vs benefits for individual patients
for each medicine
Applying most recent evidence to specific
patient medicine related problems
Recommendations on how to implement
treatment plan
Unbiased assessment of emerging medicine
evidence and guideline updates
Mrs F.J.
76yr female
Her current issues:
• Tiredness, cramps + twitchy legs
• Constipation, renal function changes
• Falling regularly
• BP 120/58mmHg Calc CrCl= 21.5mL/min
• HbA1c 37mmol/mol Cholesterol levels good
• Liver function good
Current meds
•
•
•
•
•
•
•
•
Furosemide 80mg mane
Amitrip
25mg nocte
Ezetrol
10mg daily
Aspirin
100mg daily
Quinine
300mg BD
Simvastatin 40mg nocte
Omeprazole 20mg mane
Cholecalciferol 1.25mg monthly
Recommendations
• Change simvastatin 40mg to atorvastatin
10mg
• Stop omeprazole
• Stop quinine
Follow-up
• Feeling much better no longer tired.
Birth of clinical pharmacist
facilitation?
$1.06 million year on year increase in
combined pharmaceutical budget
– CPB = community pharmaceuticals
+ pharmaceutical cancer treatments
+ vaccines (from 1 July 2013)
Haw kes Bay pharm aceutical expenditure (12 m onth rolling totals)
Data source: Pharmac Drug expenditure report for DHB for year ending Sep-10
$36,500,000
$31,500,000
$26,500,000
$21,500,000
$16,500,000
$11,500,000
$6,500,000
$1,500,000
Feb-04
Apr-04
Jun-04
Aug-04
Oct-04
Dec-04
Feb-05
Apr-05
Jun-05
Aug-05
Oct-05
Dec-05
Feb-06
Apr-06
Jun-06
Aug-06
Oct-06
Dec-06
Feb-07
Apr-07
Jun-07
Aug-07
Oct-07
Dec-07
Feb-08
Apr-08
Jun-08
Aug-08
Oct-08
Dec-08
Feb-09
Apr-09
Jun-09
Aug-09
Oct-09
Dec-09
Feb-10
Apr-10
Jun-10
Aug-10
Not sustainable
No ‘low hanging fruit’
‘Unmet need’
12 months to
Aging Population
Items Dispensed per Capita by Age
Rate (crude) per 1000 population
Comparison of dispensing rates by age group (items),
January to December 2010
120000.0
100000.0
80000.0
60000.0
40000.0
20000.0
0.0
0-14
years
15-24
years
25-44
years
45-64
years
Haw ke's Bay
65-84
years
85+ years Total (all
ages)
New Zealand
Source: Pharmaceutical Claims Data Mart, Ministry of Health (Extracted: 22/4/2011). Note data subject to
change over time.
Dr Info
The model
Clinical pharmacist facilitators (1.5 FTE)
Focus on best practice – not cost
To complement the population based clinical
pharmacist facilitator (1.0 FTE)
Proof-of-concept
Funded by Hawke’s Bay DHB
– working out of Health Hawke’s Bay PHO
– in specific practices (0.5 FTE x 3)
Aims
Interventions targeted at polypharmacy
– ≥ 65 years
– would not disadvantage Māori, Pacific or NZDep
9/10
 Polypharmacy
– patient harm / ADRs
Improve chronic disease
outcomes (CV risk, diabetes)
Fulton & Allen 2005
Practice Focuses
Patients >65 years residing in Age Related
Residential Care (ARRC) facilities
Patients who are over 65 years living
independently in the community
Practice - with high needs population (Māori,
Pacific or NZDep 9/10)
The Practices
TE MATA PEAK
PRACTICE
GREENDALE
FAMILY HEALTH
CENTRE
TOTARA HEALTH
Location
Havelock North
Taradale
Hastings &
Flaxmere
Targeted
population
Patients 65 years
and over, living in
Age Related
Residential Care
Facility
Patients, 65 years
and over, living
independently in
the community
Patients with high
needs including
Māori, Pacific and
NZDep 9/10
Enrolled Population 9800
6000
11000
Target Population
1200
7029
175+
Evolution of role
Relationship building
Initially focus was on patients taking >10 meds
Medicines rather than people
Development of tools to generate referrals
Quality activities
Demand for services
Practice Nurse Quote
“Resource for education of nurses,
patients, GPs. Can't imagine not
having CP here now as I probably
access CP expertise daily…”
Totara Health
Individual vs Population Focus
– Individual reviews = large benefit for
individuals ≠ large benefit for high needs
population
– Focus on population with chronic disease
with poor outcomes
– Smaller review of medicines treating
chronic disease and recommendations to
General Practitioner
Adherence
Number of risk factors for nonadherence per patient
2
22%
3 or more
9%
1
37%
0
32%
Mr T.J.
Male, 63 year old, Cook Island Māori
Labels
– ‘Non-compliant’
– ‘Poor diabetes control due to religious beliefs’
Problem
– Poor understanding of medication
– Strong beliefs in value of nutrition and ‘living off
the land’
Mr T.J.
Type 2 diabetes
Recent admission for heart failure
Recent admission for cellulitis
Cancellation of cataract surgery
– Poorly controlled hypertension and diabetes
HbA1c 123 mmol/mol
BP
195/110 mmHg
LDL
4.5 mmol/L
Mr T.J.
Intervention
– Improve understanding of medicines
– Sustained adherence to medicines (BP, Lipid and
Diabetes)
BP
120/70 mmHg
HbA1c 56mmol/mol
LDL
2.5 mmol/L
No recent HF symptoms
– Teaching other about the benefits of medicines
Te Mata Peak Practice
Primarily Aged Related Residential Care
Aims:
– Reduction in polypharmacy
– Improve medicine safety
Medicine reconciliation on admission
Medicine Therapy Assessment prior to 3/12
review
Medicine quality initiatives
Digoxin
administration
and
monitoring
Vitamin D
Prescribing
Medicines
and Falls
Risk
ARC Registered Nurse – how has the
CP helped?
“Education. Medication
Reviews. Input into Best Practice
projects. Liaison between GP
and facility when required”.
Greendale Family Health
Focused on ≥ 65 years living at home
Medicine therapy assessments
Co-ordination of multiple prescribers!
Medicine reconciliation
Clinical guidelines and standing orders
Tools used – Multi-Med Survey
Tools Used – S.I.M.P.L.E.
Linkages
•
•
•
•
•
•
•
•
Health Hawke’s Bay
Care cluster
Home services
District nurses
Local specialists
Hospital pharmacists
Community pharmacist
Allied health; OT, PT, dietitian, social worker
Medicine reconciliation
Update medical record
Required clarification
Required a medicine review
as multiple issues
Other interventions
37%
29%
23%
11%
– E.g. advice on syringe driver medicine doses
medicine information queries
Special Authority number follow up
Greendale: 1 December 2012 – 18 January 2013
Benefits to GP
High quality unbiased advice
Different set of eyes/focus
Collaborative decision making
Source of information on constantly changing
evidence and guidelines
Availability of medicine information
Coordination of multiple prescribers
MOPS audits
Benefits to Practice
Collaboration to manage chronic disease
Increased practice confidence in managing
polypharmacy
Contribution to quality improvement of the
practice
Review of medicine policies and standing
orders
Cornerstone accreditation support
Benefits to patients
Patient centered approach
Different focus, asks different questions
Address medicine benefits vs harm
Improved outcomes
Reduced medicine complexity
Coordination of multiple prescribers
GP Quote
“Initially I had no idea what
a clinical pharmacist would
do for our practice, now I
don’t know how I could live
without them.”
Cost reduction / avoidance
Category
1.
Community
pharmaceuticals
2.
Falls
3.
Reduction in BP §
Cost $
Number of events
Total DHB savings
p.a. or per event*
Known / estimated*
Known / estimated*
¥$500,000
$0 to $47,000
4.
Delayed admission to
ARRC
5.
ED transfer avoided
64
$149,400
*3
*$100,000
$24,000
2
$48,000
$450
*1
*$450
Total
~$800,000
Hawke’s Bay CPB September 2012 to August 2013
Reduction in sBP by 10mmHg (1 each renal failure, myocardial infarction, stroke)
¥
§
Hawkes Bay Future Direction
Clinical Pharmacist Facilitators add value to
general practice
1 FTE per 20,000 patients
Ensure access to all areas within DHB
At 1 July 2014, HBDHB is rolling out this
service Hawke’s Bay wide (8 FTE)
We Can Help You
Evidence to support clinical pharmacist role
Experience of implementation
Hawke’s Bay team is happy to put together a
proposal
Contact:
- Billy Allan, Chief Pharmacist, HBDHB
William.Allan@hawkesbaydhb.govt.nz
- Di Vicary, Health Hawke’s Bay
pharmacist@healthhb.co.nz
Acknowledgments
Di Vicary, Clinical Pharmacist Facilitator Team
Leader
Billy Allan, Chief Pharmacist
Hawke’s Bay DHB
Health Hawke’s Bay
Greendale Family Health
Te Mata Peak Practice
Totara Health
Any Questions?