Optimizing Your Medication Review Services

Optimizing Your Medication Review Services Facilitated by: Iris Krawchenko RPh, BScPhm Saturday November 30, 2013 Vancouver Convention Centre

Disclosure The author and presenter of this program has declared that she has no conflict of interest to disclose.

Learning Objectives After completion of this program, pharmacists will be better able to: Discuss the value of their expertise in providing Medication Review Services Review the importance of this patient service in the healthcare system List reimbursed Medication Review Services across Canada Review strategies to optimize the identification of patient enrolment opportunities (Top Ten Opportunities) Identify methods of maximizing patient uptake (Pharmacist/Technician/Patient Dialogue ) Implement strategies to optimize team integration into daily practice

Community Pharmacists Are: Knowledgeable health professionals Medication Experts Great resource for recommendations (lifestyle) Real-time providers of evidence based health information Accessible Hours of operation Geographical locations No appointment necessary Frequent contact time with patients Well respected Have relationships with community and HCP Ipsos Reid Polls Most trusted professional

Why do we need Medication Review Services? Identified Care Gap Polypharmacy is now the norm Multiple prescribers People using multiple pharmacies Medication Non-Adherence People self medicating with OTCs + Herbals Increased numbers of Medication Misadventures The value to patient care cannot be underestimated. It needs to be done!

Province Medication Review Service Fee Alberta Standard Medication Management Assessment (SMMA) SMMA Follow-Up Comprehensive Annual Care Plan (CACP) CACP Follow-Up $60 ($75 APA) $20 ( $25 APA) $100 ($125APA) $20 ($25 APA) British Columbia Saskatchewan Ontario Medication Review Standard Medication Review Consultation Medication Review Follow-Up Medication Assessment Follow Up Assessment MedsCheck Annual MedsCheck Follow-up MedsCheck Diabetes MedsCheck at Home MedsCheck Long-Term Care $60 $70 $15 $60 $20 $60 $25 $75 $150 $90 Nova Scotia Basic Medication Review Advanced Medication Review $52.50 $150.00 New Brunswick NB Pharmacheck $52.50 PEI Basic Medication Review (BMR) Medication Review Follow-Up (BMRF) Diabetes Medication Review (DMR) Diabetes Medication Review Follow-Up(DMRF) $52.5 $20.00 $65.00 $25.00 Newfoundland Medication Review $52.50

While Specific Details Of Each Provincial Program Differ Slightly Patient Eligibility Criteria ( # of meds/ conditions) Follow-ups (#/year, pharmacist decision ) Reimbursement Models Documentation Requirements Billing Methods The Overall Program Goals and Patient Service Provision Are Very Similar

Medication Review Services What is it? Start by stating what it is not meant to be: Not meant for targeting only the most difficult patients Not mean to find and solve all potential drug related problems in one visit Not meant to require excessive amount of time in preparation and in conducting the review

Medication Reviews: Value to Patients? Just as valuable for a patient taking 3-5 Rxs as it is for a patient taking 12 Rxs Teaches patient awareness of: Indication, Adherence, Side Effects Pharmacist has opportunity to: 1) Dispel false assumptions about medications / condition 2) Fill in the gaps- listen, teach, answer questions, reassure Builds a sense of empowerment!

What Happens In A Med Review? It gives pharmacists an opportunity to sit down privately with the patient and: Get to know them better as patients Gather information + better understand their medication regimen Review the entire profile Understand the patient s concerns by listening to their questions Address their concerns Identify and resolve drug related problems Advocate for the patient

It is much more important to know what sort of patient has a disease than what sort of a disease a patient has. Sir William Osler, 1849-1919, often considered the "father of modern medicine

Best Possible Medication Record Delete discontinued medications Clarify dose changes Current prescription medications Add Rxs filled elsewhere Ask /confirm use of non-oral route meds: inhalers, eye drops, topicals etc. Include OTCs, vitamins + herbal meds Include samples provided by physicians State medication allergies/intolerances

This Document Is Important For. Family Physician, Specialists, Dentists, Optometrists, Emergency Room Teams What if you can t speak? As scope of practices for regulated HCP expand, the BPMR will be integral to the patient s continuum of care particularly in the absence of an electronic health record.

We Want To Embrace Expanded Pharmacy Services However

T I M E How do we find it?

Patient Eligibility Identification + Enrollment Opportunities

Seniors in Canada The population of Seniors is growing The number of chronic diseases increases with age Medication use is high www.statcan.gc.ca/pub/91-215-x/2011000/i003-eng.htm. Accessed July 2013 Terner M, Reason B, McKeag AM et al. Chronic conditions more than age drive health system use in Canadian Seniors. http://www.cihi.ca/cihi-ext-portal/pdf/internet/chronic_cond_sys_use_en. Accessed July 2013. Report on seniors falls in Canada. http://www.phac-aspc.gc.ca/seniors-aines/alt-formats/pdf/publications/pro/injuryblessure/seniors_falls/seniors-falls_e.pdf. Accessed July 2013 http://publications.gc.ca/collections/collection/hp25-1-2005e.pdf. Accessed July 2013 https://secure.cihi.ca/free_products/drug_use_in_seniors_2002-2008_e.pdf. Accessed July 2013.

Diabetes in Canada > 9 million Canadians live with diabetes or pre diabetes. Type 2 diabetes dx is increasing dramatically: -The population is aging. -Obesity rates are rising. -Canadian lifestyles are increasingly sedentary Aboriginal people are three to five times more likely than the general population to develop type 2 diabetes. 80% of new Canadians come from populations that are at higher risk for type 2 diabetes. These include people of Aboriginal, Hispanic, Asian, South Asian or African descent. http://www.diabetes.ca/diabetes-and-you/what/prevalence http://www.phac-aspc.gc.ca/cd-mc/publications/diabetes-diabete/facts-figures

Focus on Diabetes It is a chronic, progressive disease that is difficult to manage which requires continual re-assessment. It changes-constant self- monitoring, changes in diet, exercise, disease progression, new meds, new doses, combination therapy, trying to get to target A1c, BP Hypoglycemia management and avoidance Review of proper testing / injection techniques Patient monitoring, diabetes device training and education

Getting Patients to Say Yes! I Want & Need a Medication Review!

Enrollment Strategies In-store posters, leaflets, telephone on-hold messaging, Website Computer generated reports identifying eligible patients Computer generated letters advising patents of their eligibility Making follow-up MedsCheck appointments to ensure patient engagement and attendance One-on-one personal invitations All can be use in combination to enhance enrollment and retention

Explaining the service to a patient during routine prescription counseling.

Scenario One Mrs. Smith, would you like to book a Medication Review (Assessment) appointment? What s a Medication Review (Assessment)? It s a service paid for by the government. You bring in all of your prescription and non prescription medications and I review them all for you.

Scenario Two Mrs. Smith, I d like to take some time and sit down with you privately to review your medications to optimize therapy. I believe you would really benefit from this appointment. We ll go over the names, what they are used for and see if they are all working well together.including your vitamins and over the counter medications. This appointment is called a Medication Review ( SMMA ) and it is funded by the provincial government. At the end of the appointment I ll provide you with a formal document listing all of your current medications, allergies etc and it will be signed and dated by me, your pharmacist this is an important medical document which you can share at all medical appointments.

Utilize Your Dispensary Team Teach them how to describe the service. Make it easy! P - Pharmacist would like to meet with you R - Review Rx Meds and OTC s N No extra charge + is funded by the provincial government S - Signed medical document for you (your wallet ) to share with everyone involved in your healthcare, especially in an emergency. Are there days or times that are better for you?

What do you say when.. No Thanks I had one last year and there really haven t been any big changes in my meds.

Suggested Response: Great! Then it should not take very long. It is a good idea to have this review at least once a year. to review and assess your medications to optimize your therapy. There may be new information about the medications from last year which I can share with you. I will print you a new document and date it with today s date. A list from last year or two year s ago may not be considered up-to-date in the eyes of other healthcare providers. This information is only useful if it is considered current. It is like having any annual physical this is a medication check-up

What do you say when.. No-Thanks! I made my own list for my wallet.

Suggested Response: Perfect! This is excellent Your list will be a great help for the appointment.i wish all patients were like you! During the appointment I will review your medications, add any over the counter and natural health products, see if they are all working well together and answer your questions. The goal is to optimize your therapy. I will then provide you with an up-to-date medical document which has been reviewed, signed and dated by me, your pharmacist a copy of which I would like to send over to your physician s office for her records - with your permission. It also has our pharmacy s contact information for other health care providers to call us if more information is required.

What do you say when. My doctor knows what I m taking. This appointment isn t necessary.

Suggested Response Yes, you are right that your doctor knows this but other doctors + healthcare providers might not. This a great chance for us to sit down together so that I may review + assess your medications to optimize therapy. I ll remind you what they are for.i ll add any over the counter medications + natural health products that you are taking and make sure that they are all working together and answer your questions. I will provide you with a formal document which has been reviewed, signed and dated by me, your pharmacist. You should take this document to all medical appointments including your dentist so that this current information can be shared. Just think about how many times you are asked to list your medications when you go to medical appointments.

What do you say when No thanks I just use the list at the top (or bottom) of my prescription receipt.

Suggested Response.. You re right, the Rx receipt does list most of your medications. I d like to to sit down with you for a private consultation so that I may review + assess your medications to optimize therapy. Then I will be able to create a more detailed and fulsome document with your complete list of medications, including your over the counter meds and vitamins. Once we complete the appt., I sign and date it so that there is confirmation that it has been reviewed by a pharmacist. This is the kind of document that helps other healthcare providers involved in your care you take it to every appt. and they can use it for their records.

Possible Daily Medication Review 1. Pre-op Rx ( bowel prep, eye drops, pre-dental, pre-mri) 2. Vacation supply orders Opportunities 3. Patient RX file transfers in or out 4. Annual official Income tax receipt request 5. Patient relocating to different city or retirement/nursing home 6. Specialist visit or Annual Physical Check Up 7. Patient confused or uncertain of medication names 8. Hospital discharge or planned hospital admission 9. Significant changes made to an existing medication profile or the addition of new medication, 10. Documented evidence of patient non-compliance

Pre-Op Rx.. Whenever you are going in or out of the hospital it is important to have your signed Medication Record with you in case they want to see it.

Opportunities Medication Names Can I have a refill on my little round white pill? I don t know the name of it or what it is for..but you should know you re the pharmacist after all.. And it should be on your files somewhere. Mrs. Smith.I d like to sit down with you and go over your medications, teach you the names and the reasons for taking them.

Opportunities Newly Initiated Medications ( Rx or OTC ) I d like to sit down with you and update your medication record so that we can add these new medications. We can review your current meds and discuss the new ones. It is important to keep this medication record current at all times

Drug Related Problems (Medication Management Issues) Identify in order of priority Concentrate on 1) The most medically urgent problem 2) Followed by the patient s perceived most urgent problem. Formalized Services/Tools available within the framework of Medication Review Services for opportunities to collaboratively communicate and resolve these DRP s The Pharmaceutical Opinion Program- Ontario, Quebec ($15) Medication Review Follow Ups ($15- $25) Medication Review Consultation - British Columbia ($70.00)

Increasing Patient Awareness of Other Expanded Pharmacy Services Smoking Cessation Program (up to $125 - $300) Pharmaceutical Opinion ($15) Adaptation ($6-$20.00) Minor Ailments ( $18) Renewals ($8.60-$20.00) Immunization Service ($7.50 -$20.00)

Team Approach: Who Does What? Remember the pharmacist is the EXPERT. Teach the pharmacy technicians / assistants to: 1.Identify patients, communicate the service and determine the most appropriate appointment time. 2.Print and prepare forms for the pharmacist 3.Greet the patient and start the appointment. 4.Fax, bill and file documents.

Best Times? Determine what works best for you and your team. Overlap is ideal First thing in the morning before the phones start ringing off the hook Wednesday afternoons Evenings Weekends

Can Consultations Be Done Without A Pre-Booked Appointment? For patients who rarely come in.try to take advantage of their presence in the pharmacy. For patients who disclose that they take no ( or very few ) OTCs For patients who have already had a previous Med Review + now qualify for a new one.sometimes their conditions are stable with few med changes but time is well spent on the education side.. Explain that the consultation can proceed and every effort will be made to avoid pharmacist interruptions unless deemed highly necessary

How.? Is it possible to accommodate walk-in appointments or schedule Medication Reviews without pharmacist overlap?

Protected Time Teaching + empowering pharmacy technicians /staff to manage the workflow while the pharmacist is with a patient The pharmacist is in with a patient for a consultation. May I help you at all? Would you like to come back for your prescription (refill) tomorrow or would you prefer that we deliver it to you then? Would you like to make an appointment with the pharmacist?

Use The Team! When a patient arrives, have the technician/staff member greet them and take them into your consulting office/area. The staff member can bring up the patient profile and confirm DOB and Address. Pharmacy team member can prepare patient s initial medication list (from pharmacy computer ) Staff member can phone patient 24 hours ahead to remind them of appointment and that patient should bring all medications and OTCs.

Be Organized Have the following teaching aids easily retrievable: Medication aids, weekly dosettes, snap cap vials, spacers, tablet splitters, tablet crushers, eye drop aids, placebo inhalers etc. Pamphlets + frequently used websites on your Favourites on computer

Watch the Time Consider having a clock in the room which is visible to both you and the patient. We will be finished our appointment by (time) at the latest. As you can see, we have just a few minutes left in the appointment and it would be important to address This subliminally shifts a portion of the responsibility for making the best use of the time to the patient.

Is the Patient Experience Professional?

Is the Patient Experience Professional? Are you proud of the completed document you are handing to the patient? Does it reflect the image of your practice and your business? Is it neat? Is it in a pharmacy folder with other information about your pharmacy and services? Special upcoming events? Have you attached your business card? Does it contain information about the possibility of a follow up appointment?

Bill for the Services Provided Your knowledge, expertise, interventions + time are valuable. Bill for all services provided (where possible ) - maximize each opportunity. Refer to other available pharmacy services that you may offer for additional billing opportunity. Teach the billing process to a pharmacy team member. This is an administrative task. Without proper documentation and billing the services did not occur in the eyes of the payer

Use Your Team!! Create enthusiasm + establish buy-in Consider electing or appointing a MedsCheck Champion from within your team.( not a pharmacist.have them push and motivate the team!) Hold regular staff meeting to evaluate success and identify opportunities for improvement Consider adopting and maintaining a rewards program for the entire team to ensure persistence and consistency. Often, what gets rewarded gets done!

Summary of Key Messages Medication Reviews can be done by all pharmacists you are the experts! Clear consistent communication about the program and it s value to patients - is paramount Many patients are eligible Focus on the Patient and their medications Team work is an essential enabler of the program Logistics/aesthetics are critical to program integration Pharmacists are essential leaders on their teams

Plus the value of.. Improved Patient Safety and Outcomes Improved Prescription Adherence Improved Patient Loyalty Referral to other services Compliance Packaging, Smoking Cessation, Immunization/Injection, Minor Ailments, Home Delivery etc Referral for other products - Blood Glucose Monitors, BP Monitors, Pedometers, Incontinence Products/ Home Health Care, Heating Pads/ Ice Packs, Dry Mouth Products, Vitamin Supplements Vitamin D3, Multiple Vitamins, Cranberry Capsules

Can You Afford To Provide Medication Review Services? Can You Afford Not To?

QUESTIONS?