1. EPIC – a Chronic Disease Management Initiative in BC Barbara Ogle, BSc(Pharm), ACPR, MScPhm, RPh VP Clinical Services, Network Healthcare May 31, 2007 Barbara Ogle, BSc(Pharm), ACPR, MScPhm, RPh VP Clinical Services, Network Healthcare May 31, 2007

2. Network Healthcare  Network Healthcare A health services company that supports the development & delivery of health care through sophisticated networks of clinical professionals.  Pharmacist Network A service delivery arm of Network Healthcare that utilizes pharmacists to deliver care to patients.  Network Healthcare A health services company that supports the development & delivery of health care through sophisticated networks of clinical professionals.  Pharmacist Network A service delivery arm of Network Healthcare that utilizes pharmacists to deliver care to patients.

3. Uninformed, Passive Patient/ Caregivers Frustrating Problem-Centered Interactions Unprepared Practice Team System Design Reliance on short, unplanned visits Decision Support No agreement on good care Traditional referrals Clinical Information Systems Don’t know patient or their needs Self- Management Support Not systematic Didactic CURRENT HEALTH SYSTEM Resources & Policies No links to community agencies or resources Community Health Care Organization Concern about the bottom line Incentives favor more frequent, shorter visits No organized QI Sub-optimal Functional and Clinical Outcomes

4. Chronic Disease Management in British Columbia  > 50% of BC health care budget goes to the 10% of people with chronic diseases  Ministry of Health’s response Adopted the Expanded Chronic Care Model and Patient Self-Management Used Primary Health Care Transition Funds for strategic initiatives focused on high-risk, high-cost CDM patients  > 50% of BC health care budget goes to the 10% of people with chronic diseases  Ministry of Health’s response Adopted the Expanded Chronic Care Model and Patient Self-Management Used Primary Health Care Transition Funds for strategic initiatives focused on high-risk, high-cost CDM patients

5. Expanded Chronic Care Model

6. EPIC Empowering Patients through Integrative Care

7. Business Need  Expand the primary care team where gaps exist (pharmacist)  Increase system capacity to meet periodic needs of patients for more intense support  Increase access to timely support between appointments and where rural or individual barriers to service exist  Expand the primary care team where gaps exist (pharmacist)  Increase system capacity to meet periodic needs of patients for more intense support  Increase access to timely support between appointments and where rural or individual barriers to service exist

8. Goal  To develop and evaluate the feasibility of a telehealth model for pharmacists to provide self-management and medication management support to people with diabetes or heart failure in collaboration with primary healthcare teams.

9. Objectives  Increase patient self-efficacy and self- management with medications  Improve attainment of desired drug therapy outcomes  Improve medication safety  Increase patient self-efficacy and self- management with medications  Improve attainment of desired drug therapy outcomes  Improve medication safety

10. Pharmacist Intervention  Community pharmacist as virtual member of health team  Provide telehealth coaching, information and self- management support for up to 6 weeks  Identify, prevent and/or manage potential and actual drug-related problems  Provide clinical decision support to the family physician and primary healthcare team  Facilitate transition to community resources (e.g., community pharmacist, local groups)  Community pharmacist as virtual member of health team  Provide telehealth coaching, information and self- management support for up to 6 weeks  Identify, prevent and/or manage potential and actual drug-related problems  Provide clinical decision support to the family physician and primary healthcare team  Facilitate transition to community resources (e.g., community pharmacist, local groups)

11. Project Details  Timeline Planning 2004 Pilot Testing 2005 Data Collection 2005 – 2006  Team BC Ministry of Health BC NurseLine Pharmacist Network BC University of Victoria – Centre on Aging Fraser Health Authority Northern Health Authority  Timeline Planning 2004 Pilot Testing 2005 Data Collection 2005 – 2006  Team BC Ministry of Health BC NurseLine Pharmacist Network BC University of Victoria – Centre on Aging Fraser Health Authority Northern Health Authority

12. Patient Findings (n = 201)  Learned self-management skills  Resolved drug-related problems  Became more engaged in their own care  Improved health status  Liked having telehealth in their own home, interpreters and flexible times  Regular follow-up kept patients focused  Learned self-management skills  Resolved drug-related problems  Became more engaged in their own care  Improved health status  Liked having telehealth in their own home, interpreters and flexible times  Regular follow-up kept patients focused

13. Physician Findings (n = 112)  Collaborative interactions observed  Electronic lab data accessed for some  Telehealth was economical, scalable, and sustainable  Follow-up extended beyond practice Focus on patient self-management filled existing care gap  Collaborative interactions observed  Electronic lab data accessed for some  Telehealth was economical, scalable, and sustainable  Follow-up extended beyond practice Focus on patient self-management filled existing care gap

14. Other Research  Impact of medication therapy discontinuation on mortality after MI Endpoints: use of aspirin, β blockers and statins at 1 month; mortality @ 12 months >33% had stopped one or more medications 12.1% had stopped all three Poorer 1-year survival than those persisting 88.5% vs 97.7%, p<0.001 Risk factors include age and education  Impact of medication therapy discontinuation on mortality after MI Endpoints: use of aspirin, β blockers and statins at 1 month; mortality @ 12 months >33% had stopped one or more medications 12.1% had stopped all three Poorer 1-year survival than those persisting 88.5% vs 97.7%, p<0.001 Risk factors include age and education PM Ho et al. Arch Intern Med 2006;166:1842-1847.

15. Other Research  Drug-related hospitalizations in a tertiary care internal medicine service n=565 adult patients admitted to hospital Drug-related 24.1% (95% CI 20.6-27.8%) –Adverse drug reactions 35.3% –Improper drug selection 17.6% –Noncompliance 16.2% Majority of cases were preventable 72.1% (95% CI 63.7-79.4%)  Drug-related hospitalizations in a tertiary care internal medicine service n=565 adult patients admitted to hospital Drug-related 24.1% (95% CI 20.6-27.8%) –Adverse drug reactions 35.3% –Improper drug selection 17.6% –Noncompliance 16.2% Majority of cases were preventable 72.1% (95% CI 63.7-79.4%) Samoy LJ et al. Pharmacotherapy 2006;26:1578-86.

16. Other Research  Effectiveness of telephone counselling by a pharmacist in reducing mortality in patients receiving polypharmacy RCT, n=502 non-compliant pts 6-8 telephone calls between visits Polypharmacy = 5 or more medications Endpoint: all-cause mortality in 2 years ARR 6% (17% control vs 11% intervention) RRR 41% (95% CI 0.35-0.97, p=0.039) NNT to prevent 1 death = 16  Effectiveness of telephone counselling by a pharmacist in reducing mortality in patients receiving polypharmacy RCT, n=502 non-compliant pts 6-8 telephone calls between visits Polypharmacy = 5 or more medications Endpoint: all-cause mortality in 2 years ARR 6% (17% control vs 11% intervention) RRR 41% (95% CI 0.35-0.97, p=0.039) NNT to prevent 1 death = 16 JYF Wu. BMJ 2006;333:522, doi:10.1136/bmj.38905.447118.2F

17. Compared to…  Statin therapy Based on 2003 Canadian guidelines NNT to prevent 1 death due to CHD over 5 years for high risk* Canadians is 98 Canadian statin market = $1.4B  Statin therapy Based on 2003 Canadian guidelines NNT to prevent 1 death due to CHD over 5 years for high risk* Canadians is 98 Canadian statin market = $1.4B *10-year risk of CHD ≥ 20%, or history of CVD or diabetes with age > 30 yrs

18. Going Forward  BC  Alberta  Service Development SAFERx (real world safety & effectiveness) Seamless Medication Care Chronic Disease Management (medication management and self-management support) Medication Reviews and Assessments Emergency Preparedness  BC  Alberta  Service Development SAFERx (real world safety & effectiveness) Seamless Medication Care Chronic Disease Management (medication management and self-management support) Medication Reviews and Assessments Emergency Preparedness

19. The ‘Innovation’ Challenge

20. Contact Information Barbara Gobis Ogle, Vice President, Clinical Services Network Healthcare bogle@networkhealthcare.ca 604-231-3245 Barbara Gobis Ogle, Vice President, Clinical Services Network Healthcare bogle@networkhealthcare.ca 604-231-3245