reasons for than expected take up of service provision are investigated in chapter 7; links between MedsCheck and other 5CPA services are analysed in chapter 8; eligibility criteria and the number of patients who currently qualify for a service are discussed in chapter 9; the useful of the content within the Assessment Tool is reviewed in chapter 10; findings and recommendations for the roll-out are discussed in chapter 11; and indicators to monitor the success of the national roll-out are proposed in chapter 12.
Service provision per State and Territory from August/September 2011 to March 2012 The high volume of services provided by pharmacies in Tasmania was driven by a relatively high rate of claims per pharmacy (see 6.5). Rates of claims were also relatively high in NSW until January 2012, when pharmacies in Queensland and the ACT increased their claim rate. Services claimed per pharmacy Table 6.5 further supports the findings above that pharmacies in Tasmania were most likely to provide the MedsCheck and Diabetes MedsCheck services — with a rate of service provision more than proportional to the Tasmanian population share. As per Table 6.1, the representation of pharmacies providing MedsCheck services in Victoria and WA was low compared to the resident population whereas in Tasmania, proportional representation pharmacies providing MedsCheck services was high. Discussion with a Tasmanian Branch Committee member of the Guild suggested that relatively high rates of service provision by pharmacies in Tasmania may be driven by the smaller, close knit communities in which pharmacists know their customers and can identify those likely to benefit from a medicines review. Of the 844 claims recorded between August 2011 and March 2012, 695 claims were made for MedsCheck services and 149 claims for Diabetes MedsCheck services. Number and proportion of services by or Territory and the proportion of the Australian resident population residing in each State and Territory NSW VIC QLD SA WA TAS NT ACT Total Number of MedsCheck services (proportion of total) 228 (33%) 59 (8%) 137 (20%) 20 (3%) 10 (1%) 161 (23%) 5 (1%) 75 (11%) 695 Number of Diabetes MedsCheck services (proportion of total) 44 (30%) 6 (4%) 29 (19%) 1 (1%) 11 (7%) 47 (32%) 8 (5%) 3 (2%) 149 Proportion of Australian resident population* 32% 25% 20% 7% 10% 2% 1% 2% 100% *Data Source: ABS 2011, Australian Demographic Statistics, Jun 2011, Cat No 3101.0, http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/3101.0Jun%202011?OpenDocument, accessed 22 December 2011.
It took too long to install the software (6 responses). The pharmacy didn’t receive information about the program in general (6 responses). It was too difficult/complicated to install the software (6 responses). The pharmacy had trouble with the digital signature/submitting the SmartForm online (5 responses). Close to half the responses under these top ten reasons (48%) concerned an IT related issue. Of the 163 responses in total, 83 (51%) specifically related to IT issues, while other responses may or may not reflect IT issues (for example, the 30 responses where the pharmacist indicated that ‘the pharmacy was too busy or the program takes too long to set up and/ or implement’). Other reasons are provided in Table 7.7. Non-computer related reasons for not providing MedsCheck and Diabetes MedsCheck services under the pilot program Reason Number of responses The pharmacy was too busy/the program takes too long to set up/implement 30 Not enough staff/staff turnover too high 20 No computer/consultation area available 7 Didn’t receive enough/clear information about the program in general 6 Other 4 Difficult to recruit patients 4 Already providing several HMRs would preclude several customers from MedsCheck services 2 Moving stores/selling stores 2 Too much paperwork 2 Had trouble filling out forms 1 Confusing/incorrect information provided 1 Didn’t receive CD 1 Barriers to service provision — the point in the service delivery chain at which pharmacies stopped Pharmacists who had not provided a MedsCheck or Diabetes MedsCheck service (N=83) or did not know if pharmacy had provided either service (N=2) were asked where their pharmacy “is currently up to” in implementing service delivery processes, or at which point in the implementation process they “decided not to proceed”. The implementation process for successful service delivery was broken down into six steps and pharmacists’ progression through those steps was mapped. The six steps were: Step 1: Received the Pilot Resource CD with the MedsCheck program software; Step 2: Successfully located the pharmacy’s existing AUSkey/attained a new AUSkey;
Group 1 pharmacist interview INTRODUCTION AND SCREENING Good (…). My name is (…). I’m calling from the on behalf of the team evaluating the ‘MedsCheck and Diabetes MedsCheck’ pilot program. May I please speak to <PRIMARYNAME>? IF PRIMARY CONTACT UNAVAILABLE: Then may I please speak to <ALTERNATIVENAME>? IF PRIMARY AND ALTERNATIVE CONTACT BOTH NO LONGER WORKING THERE OR BOTH UNAVAILABLE FOR DURATION: Could I please speak to a pharmacist working today, who may be familiar with the MedsCheck and Diabetes MedsCheck program? IF NECESSARY: It’s the medicines management service, and diabetes medicines management service, currently being piloted by the Department of Health and Ageing under the Fifth Community Pharmacy Agreement. We believe your pharmacy registered to provide these services starting in August 2011. *(NAMED OR NOMINATED PERSON) We’re conducting a short survey on behalf of the Deloitte Access Economics team evaluating this pilot program for the Department of Health and Ageing. They would like to understand the reasons why some pharmacies, who registered to take part in the pilot, have not provided these services or not submitted forms to the Department for payment. Your participation in the interview will help to refine the MedsCheck and Diabetes MedsCheck program so it’s delivered more efficiently and effectively. IF REQUESTED: For technical advice, you can contact the 5CPA helpline on 1300 555 262. 1. Continue 2. to know how they were chosen (GOTO ASELECT) 3. Stop interview, make appointment (RECORD NAME AND ARRANGE CALL BACK) 4. Business refusal (ATTEMPT CONVERSION / RECORD REASON) (GOTO RR1) 5. Respondent refusal (ATTEMPT CONVERSION / RECORD REASON) (GOTO RR1) 6. Queried about how telephone number was obtained (DISPLAY ATELQ) 7. Denies pharmacy registered in MedsCheck pilot (CONFIRM / GOTO TERM1)
Overview of medication review programs Overview of medication review programs Program Country Target population Coordinating organisation and launch year Overview Location of service Time/cost Home Medicines Review (HMR) Australia No specific eligibility criteria however documented risk factors to help general practitioners and patients appropriately identify who may benefit. These include: 1) currently taking five or more regular medicines 2) taking more than 12 doses of medicine per day 3) with significant changes to medicine regimen in the last three months, including a Pharmacy Guild of Australia and the Department of Health and Ageing (DoHA) Launched in 2001. The main objective of HMRs are to achieve safe and effective use of medicines; improve the patient’s quality of life and health outcomes using best practice approaches that involve cooperation between the general practitioner, pharmacist, and other relevant health professionals; improve the patient’s and health professional’s knowledge and understanding about medicines; and facilitate cooperative working relationships between members of the health care team in the Home Fee for GP: 2011$A 148.90 Fee for pharmacist:2011$A 197.76 Expected to take 60 minutes
recent discharge from hospital 4) taking medicine with a narrow therapeutic index or requiring therapeutic monitoring 5) with symptoms suggestive of an adverse drug reaction 6)having difficulty managing their own medicines because of literacy or language difficulties 6) attending a number of different doctors, both general practitioners and specialists. The HMR is not available to of a hospital, day interests of patient health and wellbeing. General practitioners must refer patients who they deem appropriate to their preferred community pharmacy. The community pharmacist must then contact a HMR accredited pharmacist who will conduct the review. The HMR is a private consultation undertaken by HMR accredited pharmacists with patients in their home. The pharmacist assesses the patient’s use of medication in his/her environment and also reviews the medicine regime and storage practices. The pharmacist writes a
or a pharmacist’ documented decision due to 1) significant changes made to an existing medication profile or addition of new medications, 2) documented evidence of a patient’s or 3) a patient has changed their place of residence and changed pharmacies necessitating review of medications by the new pharmacist. Must be diagnosed with either type 1 or type 2 diabetes for a MedsCheck for Diabetes. The number of to the patient and one may be forwarded to the family physician. MedsCheck for Diabetes includes training on the use and disposal of diabetic supplies, education and advice on medication adjustments and a discussion on the impact of lifestyle changes. The MedsCheck Program for LTC home residents involves a pharmacist reviewing patient’s medicines once three months. An annual in-depth medication review which replaces one of the quarterly reviews is also conducted for residents with complex chronic conditions. The main objectives are promoting a MedsCheck at Home. The program is paid for by the Ontario Ministry of Health and Care.
medications is not a consideration and patients may be on no medication and still be eligible. MedsCheck for LTC Home Residents is for residents at licensed Long-Term Care Homes. MedsCheck at Home is for people taking three or more prescription medicines for a chronic condition and must not be able to visit the pharmacy in person due to a physical or mental health condition. healthier patient outcomes and better resident focused care, improving and optimizing drug therapy for residents, promoting interdisciplinary collaboration in patient care. The review will be of patient’s medicine selection, dosage, hours, allergies and drug and food interactions. Any possible drug related problems that require more in-depth analysis will be followed up in collaboration with the healthcare team, the carer and the patient. MedsCheck at Home is for patients who cannot visit their community pharmacy due to their physical or mental health condition. It is a in-home medicine
pharmacist means that the pharmacist is registered to provide pharmacy services directly to the public. Medication Management Project Medication Review Services. Canada British Columbia (B.C) Patients eligible for the BC Medication Management Project require only one medication in their PharmaNet record. Patients eligible for the Medication Review Service must be B.C. residents with a B.C Personal Health Number who have at seven different qualifying medications that have been entered into PharmNet within the last six months, have a clinical need for the service and give informed consent to British Columbia Pharmacy Association and Pharmaceutical Services Division of the British Colombia Ministry of Health The Medication Management Project was launched in September 2010 and will The Medication Management Project Currently offered in 120 pharmacies across B.C. In the Medication Management Project, the pharmacist reviews the patient’s medication history with the patient, identifies any medication management issues, sets patient-focused goals, implements solutions to address issues and meet goals, monitors effects and modifies solutions according to changes in patient needs, prevents further medication management issues, documents the service Community pharmacy The Medication Review Service can be carried out anywhere as long as it is provided in a suitable area that respects the patient’s to privacy and the patient is present i.e., it cannot be conducted by telephone or other electronic means The fee scheduled for the Medication Management Project is based on patient complexity. Fees are paid by both the BC Pharmacy Association and the BC Ministry of Health. Fees vary from 2011 $A 72.68 to 2011 $A 115.08 for the full work-up contact. Fees for follow-up contacts for the medication management project are also based on the number of medication management issues to resolve.
receive the service and if applicable, give written consent to sharing the information gathered with a patient representative. To receive a Medication Review Consultation, the patient must have already had the Standard service and had a Medication Management Issue identified during the service. To receive a Medication Review Follow-up, the patient must have received the Standard service or consultation and require follow-up due to a subsequent medication change. The fee for the Medication may be Review- run to January 2012. The Medication Management Review was launched in 2011. and communicates and collaborates with other members of the patients healthcare team. During the first consultation (the full work-up contact), the pharmacist prepares a Best Possible Medication History (BPMH). This service is available once every 6 months. Under the Medication Management Project, the patient can return for unlimited follow-ups within 6 months of their full work-up contact. The pharmacist on the patient’s progress based on an existing care plan and determines that no previously existing or new medication The Medication Review- Standard fee is 2011 $A 72.68 paid by PharmaCare which is administered by the British Columbia Ministry of Health. The Medication Review Consultation fee is 2011 $A 84.79 paid by PharmaCare. The Medication Review-Follow-Up fee is 2011 $A 18.17 paid by PharmaCare
conditions: 1) taking 3 or more medicines and/or 12 or more daily doses, 2) have multiple prescribers, 3) had a recent hospital admission, 4) are taking or about to commence taking a medicine with a high risk of adverse effects, 5) have a particular medicine related problem (adverse effect, poor adherence), 6) are experiencing or at risk of response to pharmacotherapy, 7) are non-adherent or unable to manage their medicines, 8) have literacy or language difficulties, Primary Care Trust (PCT) Launched in 2005 additional accreditation to provide the service. The MUR aims to improve the knowledge and use of medicines by “(a) establishing the patient’s actual use, understanding and experience of taking drugs; (b) identifying, discussing and resolving poor or ineffective use of drugs by the patient; (c) identifying side effects and drug interactions that may affect the patient’s adherence with instructions provided by a health care professional for taking of drugs; and (d) improving the clinical and cost effectiveness of drugs prescribed to patients thereby reducing the wastage of such drugs (National Health Service Act 1977, Pharmaceutical Services,(England), Amendment Directions, 2006.
dexterity problems, impaired sight or cognitive deficiencies that impact on their ability to manage their medicines, 9) are taking or about to commence a narrow therapeutic index medicine, 10) are taking or about to commence taking a medicine(s) suspected of being inappropriately used based on regional utilisation data (DH 2005 cited in Blenkinsopp et al. 2008). A copy of the report of the consultation with recommendations is given to the patient and must also be sent to the patient’s GP. Community pharmacies are remunerated per service provided by the NHS Annual maximum of 400 services per pharmacy (National Health Service Act 1977, Pharmaceutical Services,(England), Amendment Directions, 2006. Medicines Use Review and Adherence Support New Zealand Eligibility criteria may vary slightly depending on the District Health Board. However, New Zealand College of Pharmacists and Pharmacy Council of New Implementation is flexible and is determined by District Health Boards (DHBs) in line with available Unrestricted- can be in the patient’s home, in a private 56 minutes (Brandt et al. 2009). The median initial consultation time
(MUR) Services the criteria listed below covers most of the criteria for receiving a MUR and is taken from DHBNZ, 2007. People living independently in the community who fall into one or more of the following categories and have one or more chronic disease states: (a) Are taking three or more medicines and/or 12+ doses per day; (b) Have multiple prescribers; (c) Had a recent admission to hospital (especially if there Zealand and New Zealand Ministry of Health Launched in 2007. resources and local need. Hence it is not compulsory for a DHB to fund this service The MUR service aims to improve the patient’s understanding of their medicines and medical conditions, assist patients and their families to monitor and self-manage their medicines for chronic medical conditions, support patients to achieve better health outcomes and quality of life through improved understanding of safe and effective use of medicines and facilitate a cooperative working relationship between pharmacists and other members of the primary health care team. It is not a clinical review area in the pharmacy and via phone. was to be 57 minutes (Lee et al. 2009). Not nationally funded- schemes must be agreed with District Health Boards. In May 2008, 5 of 21 DHBs were funding MURs (Lee et al. 2009). The payment ranges between 2011 $A 101.10 to $A 150.09 for interviews to $A 181.11-$A 200.11 for four interviews (Lee et al. 2009).
had been a medicine change) e.g. within 4 weeks; (d) Are taking or about to commence taking medicine(s) with a high risk of adverse effects; (e) With a particular medicine related problem e.g. adverse reaction, (f) Experience or are at risk of experiencing sub-optimal response to pharmacotherapy; (g) Are non-adherent or unable to manage their medicines; (h) Have difficulty managing their medicines due to, for however, the pharmacist undertaking the MUR has an ethical responsibility to address inappropriate selection, prescribing or use of medicine if identified. The consultation is conducted by a pharmacist with the patient and intervention is largely at the patient level. The service often involves four quarterly consultations between the pharmacist and patient and the pharmacist must have access to the patient’s medication profile but not necessarily their clinical information. It must be conducted in a private area. It involves a review of and counselling about all current medicines, assessment of
example, literacy or language difficulties, dexterity problems, impaired sight, or cognitive deficiencies; (i) Take or are about to commence taking a narrow therapeutic index medicine &/or one requiring monitoring; &/ or (j) Take or are about to commence taking a medicine(s) suspected of being inappropriately used based on regional utilisation data. Patients are not eligible if they are currently participating in Medicines Therapy Assessment or Comprehensive medication adherence, counselling about appropriate management of medicines and current medical conditions, reporting of significant adverse medicine effects and removal of out of date medicines or those no longer required with the consent of the patient. A record of all current medications must be provided to the prescriber and to the patient unless practical circumstances deem that this would not be beneficial. The pharmacist may formally refer and report to other health professionals on issues beyond the pharmacist’s scope. The pharmacist may also liaise with prescribers, patients and community
Other evaluation findings on medicine review programs Evaluations performed on medication review programs Program Evaluated by Evaluation methodologies Findings including barriers & facilitators Home Medicines Review (HMR) Campbell Research and Consulting (2010) Campbell Research and Consulting (2008), Sanburg (2009), Urbis Keys Young (2005) Stakeholder consultation with the Guild, PSA, SHPA, AACP, and Medicare Australia (CR&C, 2010). Interviews with pharmacists (CR&C, 2010) On-line survey (26 questions) of pharmacists: 19% response rate of accredited pharmacists and 5% response rate of pharmacists (CR&C, 2010) Case studies with pharmacists (CR&C, 2010) Stakeholder consultation via interviews with GPs, Divisions of General Practice, Medical organisations, Pharmacists/pharmacist General Findings HMRs are not meeting a number of their objectives mainly because they are not reaching people most at risk of medication misadventure. In addition, health professionals have not reported an improvement in the understanding of their medications, nor has there been an improvement in co-operation within the healthcare team (CR&C, 2008). In the first 3.5 years of the program, around 74% of HMRs to date were provided to people aged over 65 years and around 62% of people receiving HMRs were women (UrbisJHD, 2005). Those in the greatest need of a HMR are the least likely to receive one. The greatest gap in access is amongst those most likely to benefit (CR&C, 2008): Certain patients post discharge from hospital. Indigenous consumers Culturally linguistically diverse consumers