Community Pharmacy Presentation for Hospital Pharmacists July 2015

Community Pharmacy Services Community Pharmacy medicines adherence services Designed for people who have problems adhering to their complex medicines regime. In community pharmacy, this medicines adherence service is known as the Community Pharmacy Long Term Conditions (LTC) Service. Community Pharmacy Anti- coagulation Management Service (CPAMS) CPAMS is a point of care International Normalised Ratio (INR) monitoring service provided by specially trained pharmacists working under standing orders from the patient’s GP.

Community Pharmacy Services Continued Core Services Core services are for those patients who are not covered by any other service. It is for those people who are: a) taking medicines regularly without any adherence problems or b) those people who only require a prescription occasionally. Core service is the service the majority of New Zealanders will receive.

Medicines Adherence Service In community pharmacy it is known as the Community Pharmacy Long Term Conditions (LTC) Service. A recognition that patients who have problems managing their medicines will not see the desired improvements in health. The pharmacist develops a Medicines Management Plan to support the patient in adhering to their medicines regimen. The LTC Service is not to be confused with a Medicines Use Review (MUR) Service (see later).

Medicines Adherence Service Potential patients are assessed by the community pharmacist against eligibility criteria. Including – Living at home (not in an ARC facility) – Adherence problems – Long-term condition – Mental health diagnosis – Infectious disease – Palliative care – High risk medicine – Polypharmacy (  5 medicines) – Hospital medical admissions

Medicines Adherence Service The patient will receive support to improve their medicines adherence 1.synchronising medicines 2.improving patient understanding / education 3.reminders to collect repeats (e.g. txt)

Medicines Adherence Service Patients registered for the Community Pharmacy LTC Service sign a consent and have regular contact with the pharmacy. If you have a patient that is having problems adhering to their medicines regime, you could ask them if they are on the LTC Service at their community pharmacy. – There is no national register of LTC patients – Best to ask the patient themselves or their community pharmacy – Perhaps also give the community pharmacist a ‘heads up’ about the patient’s adherence support requirements.

Medicines Adherence Service If a patient is not already registered, you could suggest they talk to their pharmacist about the service and whether they could be eligible. If a patient is already registered with a pharmacy for LTC – encourage the patient to get their discharge medicines from their LTC pharmacy. There is no cost for the patient attached to the Community Pharmacy LTC service itself. Patients in the Community Pharmacy LTC service are reassessed for eligibility at least annually.

Compliance (Blister) Packaging Pharmacists are not directly funded for compliance (blister) packaging – They are now funded at a service level – Patients may not automatically receive compliance packaging, or – they may be charged a fee (determined by each community pharmacy)

Dispensing Frequency Changes The term ‘close control’ is no longer valid on prescriptions. Patients who required close control in the past may now receive adherence support from the community pharmacist. The pharmacist determines the frequency of dispensing with the patient. – Pharmacist may ‘challenge’ the prescriber’s indicated dispensing frequency – a discussion is required

Medicines Usage Review (MUR) Is more comprehensive than the medicines adherence support provided under the Community Pharmacy LTC Service. Contracted for under a separate agreement. Not all DHBs have contracted for MUR. Not all community pharmacies provide MUR. (in those DHBs that do contract for MUR) Your DHB Pharmacy Portfolio Manager can supply a list of contracted MUR pharmacies.

LTC vs. MUR

CPAMS Community Pharmacy Anticoagulation Management Service Accredited community pharmacists. – College course INR measured using point-of-care testing. – CoaguCheck Warfarin dose adjusted with the aid of a decision support tool. Doses adjusted under Standing Orders agreed by the GP. Results and new warfarin dose fed back to the GP. The GP retains overall responsibility for the patient’s management.

CPAMS Contracted for specifically by each DHB. Not all community pharmacies provide CPAMS. A list of contracted CPAMS pharmacies is available on the CPAMS page of the CPS website or from your DHB Pharmacy Portfolio Manager. Your may want to liaise with the CPAMS community pharmacy and GP for INR monitoring on discharge.

Benefits for Patients Patients feel involved Immediate information and advice. The patient can view how they are tracking between the upper and lower therapeutic limits on the PC screen. Convenient and acceptable The test involves a simple finger prick sample of blood. The pharmacist is able to provide immediate care. A dosing calendar is given to the patient to take away. The patient can receive automatic ‘next test’ reminders. The patient can access their own results on the internet.

CPAMS Safety and Reliability Pharmacists in the CPAM Service are accredited. At least two pharmacists are trained at each site. Pharmacists are working under Standing Orders. The decision support software provides reassurance that decisions on the dose and timing of the next dose are based on the best evidence. Patients are asked safety questions each time they have a test (e.g. adverse events, new medicines, hospital admissions). The GP is immediately alerted to out-of-range results and can suggest an alternative dose or next test date. All sites undertake regular quality control calibration. When CoaguChek results are compared to standard laboratory testing there is an excellent correlation.

Methadone maintenance programme: co-dispensing medicines Under the previous Community Pharmacy service model, pharmacists were paid for each item dispensed at the same time as the regular dose of methadone. In many cases, the co-dispensed medicines do not need to be dispensed at the same time – as there is low risk by providing the medicine in larger amounts – E.g. vitamins or antihypertensives Methadone prescribers have been asked to consider which medicines do need to be co-prescribed with methadone as opposed to a regular monthly/three- monthly prescription.

Some Final Thoughts The changes that have taken place within community pharmacy are to ensure the patient is at the centre of their healthcare and pharmacists are empowered to support patients taking medicines. If you have questions or concerns about something within the scope of community pharmacy, the best first point of contact is your Pharmacy Portfolio Manager. If you have concerns about a patient and their need for support – discuss this with the patient’s community pharmacy – adherence support (LTC) or MUR support may be appropriate. There will be some situations where individual relationships can be built up with community pharmacies – for example if you only have one CPAMS provider in your area.