supporting medicines adherence developing the pharmacist contribution
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Supporting medicines adherence:Developing the pharmacist contribution
Graham Davies | Professor of Clinical Pharmacy and TherapeuticsKing’s College London
Supporting medicines adherence: developing the pharmacists contribution
Professor Graham Davies,Institute of Pharmaceutical ScienceKing’s College London
Content
South London project – supporting patients with diabetes
Supporting community pharmacists to deliver adherence support
Key challenges to future care – the Southwark and Lambeth Integrated Care initiative
Summary
South London HIEC
Richmond174,400
Wandsworth269,300
Kingston150,000
Merton192,300
Sutton180,900
Croydon336,600
Bromley 335, 914
Lewisham284,746
Lambeth329,174
Southwark298,073
Greenwich262,145
.
Bexley233,33311
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58
717
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Bethlem
Bolingbroke Hospital
Epsom Hospital
Guy’s Hospital
King’s College Hospital
Kingston Hospital
Lambeth Hospital
Maudsley
Mayday Hospital
Oxleas
Queen Mary’s Hospital
Royal Marsden – Sutton Hospital
South London Healthcare
St Helier Hospital
St Thomas’ Hospital
Tolworth Hospital
University Hospital Lewisham
1 Greenwich University
2 King’s College London (The Strand)
3 King’s College London (Waterloo)
4 King’s College London (Guy’s)
5 King’s College London (St Thomas’)
6 King’s College London (Institute of Psychiatry)
7 Kingston University
8 Lambeth College
9 London Southbank University
10 St George’s University
Four key priorities:
• Mental health
• Diabetes• Stroke• Infection
Challenges – UK perspective
Estimated that there are 3.1 million people with diabetes in England. 800,000 of these are not diagnosed (1)
By 2020 an estimated 3.8 million adults, or 8.5% of the adult population, will have diabetes and by 2030 this is estimated to rise to 4.6 million or 9.5% (1)
The NHS in England spends more than £2.3 billion a year on inpatient care for people with diabetes. That’s 11% of NHS inpatient care expenditure (2). Length of hospital stay is 2-3 nights longer than those without diabetes.
Anti-diabetes medicines cost the NHS £725 million/year.
30 -50% of medicines prescribed for long-term illnesses not taken as directed For diabetes, we can estimate at least £200 million/year waste
(1) APHO Diabetes Prevalence Model, http://www.yhpho.org.uk/resource/view.aspx?RID=81090. Last updated 28/09/2010(2) NHS Diabetes report November 2011. www.diabetes.nhs.uk
0%
10%
20%
30%
40%
50%
60%
% o
bes
e
Schools - % Obese Southwark average London average England average
Schools
Reducing Unwarranted Variation
Fourfold variation in the rate of hospital admissions for diabetes in London PCTs
Fivefold variation in Y6 childhood obesity rates across primary schools in Southwark
Tenfold national variation in the % of type 2 diabetics receiving all 9 NICE key care processes
Threefold variation in uptake of structured education across South London with best at 29%
https://slondonhiec.org.uk/sites/default/files/SL_HIEC_Community_Pharmacy_&_Diabetes_Report_FINAL_authors.pdf
Key stakeholders from across south London invited to discuss how community pharmacists could be more specifically involved in supporting people with diabetes.
Participants included representatives from national diabetes organisations, patient representatives, academics, commissioners and healthcare professionals.
Themes identified
Supporting patients’ use of medicines Identifying concerns and facilitating goal setting
Screening for undiagnosed diabetes Risk assessment using trigger drugs
Supporting use of glucose meters and test strips
Communication skills to promote inter-professional working
Signposting eye and foot checks; access to support groups
and structured education (DESMOND)
Patient Perspective
“…I’ve been going to the same place for the past 3 years and they understand my history and if my medication has run out they will phone me to remind me.”
Patient 3
“...I ring up the pharmacist, supplies are getting a bit low, tell them what I want...he will ring the surgery and I will go in about 2 days later and it’s all waiting for me. He will do a delivery service for those who need it.”
Patient 14
Educational support
Raise awareness of common beliefs about illness and treatment held by patients
Enhance consultation skills Provide systematic approach Examples of good behaviours
Develop a proactive versus reactive approach
Focus for education intervention
Endorsed by the Royal Pharmaceutical Society
Key points
Increase awareness about adherence and challenges
Underpinned by evidence: Perceptions and Practicalities model1
Focus on consultation skills using validated framework (MRCF)2
Highlights patient-centred approach to better understand their medicine-taking behaviour
Demonstrates good consultation behaviours which can lead to behaviour change Motivational interviewing
1 Horne, R. & Weinman, J. (1999) Patients' beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illness. Journal of Psychosomatic Research, 47 (6), 555–567. 2 Abdel-Tawab R et al (2011). Development and validation of the Medication-Related Consultation Framework (MRCF). Patient Education and Counseling 83 (3): 451-457.
Interactive
Videos demonstrate different levels of effective practice
Work at your own pace
Reflect on your own practice
Techniques explained in full
Rating exercises to reflect on level of practice
Features & Benefits
Overview of PackagePRE-MODULE ASSESSMENT (Clinical Knowledge)
PART 1: Assessing and addressing adherence in diabetes
PART 2:
Identifying and consulting with non-adherent patients with diabetes
PART 3: Using consultation skills to identify and address patient non-adherence
in diabetes
POST-MODULE ASSESSMENT & REFLECTIVE EXERCISES
Low concerns
High concerns
High necessityLow necessity
Sceptical
AcceptingIndifferent
Ambivalent
Mann et al. (2009)
Integrating care – the adherence challenge
Many people had care for more than one Long Term Condition
The intensity of care for people with LTCs will increase with the growth in the older population
No of Conditions per patient
0 - 4
5 - 9
10 -
14
15 -
19
20 -
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25 -
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40 -
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50 -
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60 -
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65 -
69
70 -
74
75 -
79
80 -
8485
+0%
10%20%30%40%50%60%70%80%90%
100%
Morbidity (number of LTCs) by Age Group
012345678+
Age Groups (Years)
Pe
op
le (
%)
Key challenges
Co-morbidities with ageing Engagement of different health care
professionals Silo approaches
Poor transfer of information Lack of consistency in messages
Medicines adherence Not routinely assessed or documented Agreed plan or intervention not documented New Medicines Service and MUR a start
Southwark and Lambeth Integrated Care will deliver a bold and radical transformation across health and social care at scale.
Citizens will feel that their health is also their responsibility and will be supported in self management by building community assets, capabilities and skills.We will provide the right care in the right place, at the right time, reliably and proactively by the professional(s), peer support workers or volunteers most suitable to provide care.Ensure we are treating the whole person with integrated care centred around empowered individuals.
Ensure professionals are best able to deliver this new approach, ensure better professional lives for the staff we are working with.
This requires behaviour change by all professionals, citizens and communities.
1.
2.
3.
4.
5.
We need to shift the LTC care paradigm from people being
dependent recipients of care to
enabling and supporting people with LTCs to live
independently and optimally with their
condition.
Doing more of the same better will not be enough
Improving and integrating care for LTCs will not be sufficient – we need a new paradigm to supporting people with Long Term Conditions
Must do better:
• LTCs are under-diagnosed
• Too many people with LTCs die prematurely
• QOF scores for LTC management are well below London average in 7 of 17 LTC diagnoses
The ‘Scissors of Doom’ - Growing demand with less funding
• Population in S&L expected to grow by 18% in next 10 years
• Aging population
• People live longer with LTCs
• Funding for NHS, Public Health and Social Services is falling well behind growth in demand
Key behaviours and support
Undertaking healthy behaviours• Not smoking, Exercising, Healthy eating, Drinking
alcohol in moderation
Keeping home environment safe• Impaired mobility and physical ability to take care of all
activities of daily living• Cognitive decline with impaired ability to run a
household independently• Epilepsy with frequent seizures and risk of injury
Optimising medicines use• Taking medications as prescribed or knowing how to
take PRN medications
Detecting and addressing risks early• Detecting people at risk and stratification• Early effective interventions• Care management
Optimising Medicines Use for LTC
Scoping the key issues, problems and successes
Developed medication adherence screener Piloted in hepatitis C out-patient clinic Adoption by Thrombosis Centre (KCH) -
focus on transfer of warfarin patients to NOAC (time in range <50%)
CCG backing to use screener in GP cluster.
Results
Pilot in 40 patients – over 20% admitted to missed doses in week before clinicThe majority of patients (70%) had concerns about their medicines
Frequency (%)Possible side effects 23 (62)How the medicines may damage my body in the long term 9 (24)Taking too many medicines 9 (24)Whether the medicines will be of any help 4 (11)Whether their effectiveness will wear off over time 4 (11)
Conclusions
• Preliminary results suggest that the screener can be integrated into routine care to identify non-adherence
• Non-adherence appears to be associated with:• Low motivation (as conceptualised by the Modified
Morisky i.e. forgetfulness and carelessness)• Perceptual barriers (only took their medicine when
they felt the need)• Practical barriers (poor planning of medicine-taking
behaviour )• Used by MDT to target inform consultation during
clinic visit
Future
Capture medicines adherence data routinely and make available to: Aid provision of consistent messages Facilitate patient self-management
Training for all HCPs is key Opportunity within Lambeth and Southwark
to design and test a system for LTC which draws on expertise of pharmacists
Need to measure impact of approach on health care outcomes/utilisation/satisfaction
Introduction to a medicines-adherence in diabetes e-learning package
Professor Graham Davies,Institute of Pharmaceutical ScienceKing’s College London