Integrated Pharmacist Services in the Community A summary of what we have heard Feedback from: the National Stakeholder Forum, November 2015 the local fora held by District Health Boards, February 2016 Prepared by TAS 10 March 2016
Acknowledgement Thank you to everyone who attended the national and local fora on Integrated Pharmacist Services in the Community. Your energy, insights, ideas and the conversations are greatly valued by the District Health Boards (DHBs) in the process of developing the next contract for Integrated Pharmacist Services in the Community. Your input has helped to enhance the understanding of local issues and innovations. Your time and commitment to the process is appreciated, and while your exact words may not have been captured in this document, we hope we have portrayed the intent. Disclaimer While care has been used in the processing, analysing and extraction of information to ensure the accuracy of this report, TAS gives no warranty that the information supplied is free from error. TAS should not be liable for provision of any incorrect or incomplete information nor for any loss suffered through the use, directly or indirectly, of any information, product or service. Copyright Statement The content of this document is protected by the Copyright Act 1994. The information provided on behalf of TAS may be reproduced without further permission, subject to the following conditions: - You must reproduce the information accurately, using the most recent version. - You must not use the material in a manner that is offensive, deceptive or misleading. - You must acknowledge the source and copyright status of the material. Page 2
Table of Contents 1. 2. 3. 4. 5. 6. 7. How the DHBs have been engaging on Integrated Pharmacist Services in the Community... 4 The focus of the meetings... 5 Next Steps... 5 Meetings were structured around questions... 5 National Questions... 5 Recurring feedback falls into key themes... 6 Working with others for integrated care... 6 Access to pharmacist services by the consumer... 7 Consumer empowerment... 9 Safe supply of medicines to the consumer... 9 Improved support for vulnerable populations... 10 Using the pharmacist as a first point of contact within primary care... 11 Enablers of delivery of Pharmacist Services in the Community... 12 Information Technology... 13 Premises / Facilities... 13 Supply chain... 13 Legislation/Regulation... 13 Workforce... 13 Business model... 14 Funding... 14 Better integration in primary care... 14 List of pharmacist services... 15 Page 3
Integrated pharmacist services in the community A summary of what we have heard 1. How the DHBs have been engaging on Integrated Pharmacist Services in the Community On Friday 27 November 2015, District Health Boards (DHBs) held a national stakeholder forum in Wellington. The overarching aim was to start the conversation with consumers and other key stakeholders, including Māori, pharmacy, primary care, aged related residential care, the Ministry of Health and DHBs on Integrated Pharmacist Services in the Community and what that may look like in the next 5-10 years. Importantly, consumers were invited to this forum, as they are at the heart of our goal of developing person-centric pharmacist services in the community. This started the conversation about the future of pharmacist services and the changes needed to keep pace with the changing environment of healthcare service delivery. DHBs are clear that the service model needs to be developed collectively through engaging with a wide range of stakeholders including consumers, pharmacists, general practice and other primary care providers such as residential care providers. Engagement needs to happen locally and regionally, as well as nationally. As part of the process of developing the next contract for Integrated Pharmacist Services in the Community, and due to the success of the November national stakeholder forum, each DHB took the process to their communities and hosted a local forum in February 2016. These fora were designed to include consumers, pharmacists and others involved in delivering health care in the primary setting and encourage discussion on ways the primary care and community services can work better to make the most of pharmacist services in the broader primary care environment. Twenty local fora were held around the country across all 20 DHBs. Excerpts from several of the meetings are available to view on the TAS website. The findings from the both the national and 20 local fora will be fed into the strategic development and service configuration for the next contract for pharmacist services in the community. The resultant new service direction will be developed over the coming months, using a collective engagement process with a wide range of stakeholders, for introduction of the next contract during the July 2016 June 2017 year. Page 4
2. The focus of the meetings Each forum followed a similar format, with scene setting before a range of stakeholders, including consumers, presented their perspectives. Questions were then posed to start discussions about the direction of pharmacist services in the community. The questions focused on: - How to best utilise the skill set of pharmacists? - What mattered to the consumer in the delivery of services by pharmacist, and the health sector in general? - Who could pharmacists be working with to optimise the health of their community? - Where and when could services be delivered? 3. Next Steps The feedback from this series of fora will be used alongside: - the strategic direction provided by: o the New Zealand Health Strategy, and its accompanying Pharmacy Action Plan o Implementing Medicines New Zealand 2015-2020 (the New Zealand Medicines Strategy) - the lessons learned from the financial, process and outcome evaluations of the 2012 Community Pharmacy Services Agreement. The combined knowledge helped to formulate the key themes that will form the basis of the development of the next contract for pharmacist services. The themes were confirmed at the Stakeholder forum held on 3-4 March 2016. There is more information about this forum at http://www.centraltas.co.nz/community-pharmacy/stakeholder-forum. 4. Meetings were structured around questions Seven questions were posed at the national forum, and three at every local forum, with the opportunity for each DHB to add questions with a local flavour if they wished. The local questions built on the feedback from the national questions. The questions are listed below. National Questions 1. Person-Centric Service Delivery. What would it look like if the person is in the centre of pharmacist services in the community? 2. Person-Centric Service Delivery. How can we make the most of pharmacists skills as medicines experts? 3. Integrating pharmacist services in the community/ One Team. How can we integrate pharmacist services with the wider community? 4. Integrating pharmacist services in the community/ One Team. How can pharmacists work more closely with primary care? 5. Accessible pharmacist services in the community. How can community pharmacist services be made more accessible for all New Zealanders? 6. Accessible pharmacist services in the community. What would it look like if pharmacist services in the community could be configured to maximise accessibility? Page 5
7. Strategic Direction. How can pharmacist services be constructed nationally to deliver on government strategies? 5. Recurring feedback falls into key themes The feedback from all the engagement to date lent itself to the following six themes: 1. Working with others for integrated care 2. Access to pharmacist services by the consumer 3. Consumer empowerment 4. Safe Supply of medicines to the consumer 5. Improved support for vulnerable populations, and 6. Utilisation of the pharmacist as a first point of contact within primary care. Feedback was also received about the enablers to delivering services, such as IT support and funding. While the focus of the engagement to date has been on service delivery, these enablers have been captured and a brief summary of these is in section 6. On a similar theme, many innovative ideas and practices have been shared; a selection of these has been provided at the end of each theme section. Working with others for integrated care Most meetings discussed the pharmacist s role in the Multi-Disciplinary (MDT) or Inter-Disciplinary (IDT) teams, with general agreement that the pharmacist as the medicines management expert must be integrated into the team/s. This role and the pharmacists skill set needs to be promoted within the MDT and to consumers, so pharmacists skills can be fully used. You have got to have the same focus and it has always got to be the patient. Pharmacist This idea of integration with the wider team was repeated in relation to people with complex needs. One pharmacist said that competition is getting in the way of collaboration. Another said that services for complex patients needed to be co-designed. Along with promoting the role of the pharmacist, there must be clear expectations on the level and type of service that should be received by the consumer. One door, one story, one team Consumer Other members of the MDT should be able to refer a consumer to a pharmacist for specialist services. Likewise the pharmacist should be able to refer consumers to other members of the MDT. Access to medical records and shared information is essential. (This aligns with comments in the section Consumer empowerment about the Electronic Health Record). Page 6
Innovation through service integration where health systems talk to each other, and better yet health professionals work together to provide the best service so consumers can be confident and informed. Consumer Adherence management support including medicines therapy assessments (MTA) and medicines utilisation reviews (MUR) can be provided by pharmacists. The information from this work can assist the MDT in their support of the consumer. Feedback on innovative approaches included that funding should be via the individual (rather than through dispensing) and for contact with that person. Key groups should be identified through diagnoses / points of vulnerability. PHOs should have more widespread involvement by pharmacists, rather than just at GP practice levels. Pharmacists should be involved in support and education, not just in medicines management. General practitioners (GPs) who attended meetings expressed similar frustrations to pharmacists. Better feedback loops to the GP are needed so the GP knows that the person is getting help with his or her medicines management. There should be a simple way for a GP to annotate a script to say why the script was written that way (e.g. diabetes). GPs said the overall conductor needs to be the GP, but better links between pharmacy and the GP, or with the pharmacy service being provided from the general practice, would free up time for both pharmacists and GPs. Access to pharmacist services by the consumer The concept of pharmacist services being provided only from the traditional bricks and mortar pharmacy was not favoured at any of the meetings. One meeting raised the idea of a pharmacist being able to link virtually with the consumer in his or her own environment. People spoke of services being provided where the consumer needed them, perhaps at a marae, at home, at school or at work, in a residential care facility or be provided as a mobile service. It should be easy for the consumer, and it should be at a point in the health service where the consumer is touching the health service or regularly attends, for example, at the general practice surgery, or at a social service. Services should be closer to home and better integrated in the primary care setting. Pharmacist services could be located in a health hub or be provided as a mobile service. One meeting discussed the pharmacist being a navigator who empowers consumers with multiple points of access to benefit of getting out and providing the service just in a different setting that is safe for the patient Pharmacist Page 7
services, but no wrong door. As well as offering many different points of access, pharmacy services need to be user-friendly, have flexible hours, and have a welcoming environment (for example, with hearing loops). Disabled people need to be able to get in and out of the pharmacy. Consumer There was a strong feeling from consumers that they know their local pharmacist and that their local pharmacist knows them. There is comfort in having their services delivered by someone with whom they have an existing relationship. Consumers also need to be able to easily identify the pharmacist within the pharmacy. Many people spoke about the need for consultation rooms so consumers felt safe and could have a private conversation about their health. Some consumers don t know what services are available. It should be easy for them to find out. Consumers want the right service, in the right place, at the right time. We didn t know that the pharmacist could do all these services. Why doesn t the pharmacy or the DHB tell us? If people knew you could do all these things, they would use you more rather than the doctor. You guys are so accessible and easy to approach and you know us. Consumer Continuity of care was important. There could be incentives for consumers to value the continuity of service from their local pharmacist who knows them, similar to the way patients are enrolled with a general practice. The type of contact with the pharmacist could be triage, treatment and/or referral. The pharmacist resource should be directed towards high-risk activities and low-risk activities could be automated. Services must be affordable for the consumer and the provider. People will go to the place where they receive the most value for money. Innovative ways to support access to pharmacist services could be to: - set up a Clinical Governance Committee to support pharmacists delivering services - improve continuing Professional Development to include Peer Review - support ongoing advancement in peer environment - provide services in the community beyond the bricks & mortar - provide flexible services to meet the needs of the local population. Pharmacists in a particular locality could consider themselves as a collective and collaborate. This could lead to streamlining of services, and could result in more services being available to the consumer closer to home. Page 8
Consumer empowerment Health literacy is vital to empowering the consumer, as are tools for the consumer to manage what matters to them about their health. Health literacy is needed desperately across the board, for all people in our community. Consumer The consumer needs to be a part of multi-disciplinary team discussions, with the focus on what matters to them as an individual. Similarly, the pharmacist must be able to connect with a range of people that are relevant to the consumer, for example, the GP, nurse, other health care providers, as well as social support services, the family and whanau. If each consumer had My List of Medicines along with his or her Electronic Health Record, this would allow the consumer to only have to tell their story once and to own their own story/information. The Electronic Health Record (EHR) could be updated each time the consumer interacted with the health care system. Pharmacists have a key role in keeping the EHR up to date. The pharmacist has a role in providing medicines information to the consumer and in supporting medicines management for the consumer. Pharmacists should provide a medicines information system focused on consumers. In my journey the people who have given me the best advice was actually the pharmacy. Consumer As mentioned in Access to pharmacist services by the consumer, many consumers said they were not aware of the range of services that a community pharmacist could provide. Consumers should be asked how they would like to learn about pharmacist services. People of different ages, ethnicities, and life stages may need to receive information differently. Safe supply of medicines to the consumer Pharmacists would prefer to increase their role in interactions with the consumer, and reduce the involvement of the pharmacist in dispensing activity. (This aligns with a comment made in Access to pharmacist services by the consumer that the pharmacist resource should be directed towards highrisk activities and low-risk activities could be automated.) There needs to be both effective and efficient delivery of medicines to the consumer and access for consumers to the starting points for the supply of medicines, i.e., via prescription, through standing orders, or following triage by a pharmacist. Page 9
One should not have to guess whether the medicine is subsidised Doctors should be able to provide that information accurately when consulting with the patient. Consumer Medicines information such as the identification and communication of side effects is required. The truth is I don t really know anything about medicines and I don t know about the medicines I have been prescribed and I don t really understand what they do. Consumer Medicine wastage needs to be minimised. Pharmacists could use their holistic knowledge of the consumer and of the medication to decrease medicine wastage and save money for the health system. There needs to be a national approach to a new systems process to reduce the risk of multiple prescribers for the one patient. A single patient record should have information on primary care medication prescribing, pharmacy dispensing records and information about what the patient actually takes. Improved support for vulnerable populations There were strong messages that there should be an emphasis on working with vulnerable patients and populations, especially those with Long Term Conditions, the frail and the elderly. These services should be incentivised in order for the pharmacist to effectively meet the needs of their vulnerable populations. Other feedback was that the Community Pharmacy Long Term Conditions Service that provides medicines adherence management support is not working in its current state and needs to change. At-risk populations may need a Care co-ordinator, either a pharmacist or a health care provider better placed to support that person e.g. a nurse. There was much discussion around who may be at risk. The common factors in identifying at risk populations were identified as: - diagnosis newly diagnosed people may need greater assistance and support - transition points when a person is transitioning between areas of care, such as being discharged from hospital, extra support may be required - key life events are challenging health needs may suffer through a life changing event such as the death of a carer or loved one. Comments on supporting high-needs patients mirrored the feedback on the pharmacist s role in the MDT (either an actual team or a virtual team), and the need for the patient to have his or her health record updated each time they touched the health care system. Page 10
Feedback was that when the consumer has complex needs it is even more important for the pharmacist to be connected and integrated, not only to the primary care team, but also to the wider health sector and to social services providers. The linkages made must take account of the need to protect patient privacy. These relationships take trust and time to build. The particular circumstances of high needs patients puts further weight behind the need for services to be provided where the patient needs them. Shared care information, tools and planning systems must recognise that patients are mobile or transient, and must include specialist mental health services. Consideration needs to be given to how to add value every time the person has contact with the health care system. Innovative ideas were to allow pharmacists the ability to refer to other primary care providers in the same way that other health care providers can, for example, St John Ambulance staff in Nelson Marlborough can refer to other providers. Prescribing pharmacists may deter consumer self-diagnosis where a potentially infectious disease is mistaken as a sore throat. Pharmacist In Tairawhiti attendees agreed that patients discharged from hospital should have a series of scheduled follow ups with a range of health professionals (for example, pharmacist one week, physiotherapist the next), to ensure the patient s condition doesn t deteriorate. There was a view expressed that consumers would be alarmed if they knew how poorly coordinated care was, and how entrenched the silos were. Older people generally have the view that their doctor, pharmacist, district nurse, hospital clinicians know all about their needs and treatment. The opposite is true. There should be more use of InterRAI which is the tool used in all New Zealand aged residential care facilities and by District Health Boards to assess the care and support needed by older people living in their own homes. A genuine and successful case management approach to vulnerable elderly people would pay huge dividends in supporting the person to remain as independently as possible in their own home for longer, avoiding costly residential and hospital care. Using the pharmacist as a first point of contact within primary care There was wide feedback that tells us that pharmacists have the skills to act as: - health navigators for consumers - providers of health literacy education - translators into plain English (diagnosis/care plan). The pharmacy is viewed as a community hub or a health Information hub, utilising the site of the pharmacy and the pharmacist s knowledge. Page 11
Pharmacists have the skills to be able to triage, then treat or refer at points of contact, adding extra health value at every contact with the consumer. You need to increase your physical presence in a way that is better for consumers. Consumer Pharmacists can also undertake target population screening, and identify when additional support might be required for a person such as: - the transition from secondary to primary care - a new diagnosis - complex need e.g. CarePlus patients - life events such as the death of carer. The key to success in dealing with at-risk populations is that the service needs to be consumerdriven, the right people have to be engaged in the conversations, and it doesn t have to be medically driven. The current business environment for vulnerable populations can be off-putting. The focus should be on the needs of the consumer, that is: - staff should be under no pressure to sell a product - a comfortable private space to discuss issues must be available - adequate time is provided to check understanding - the pharmacist should be available and clearly identifiable to the consumer. We heard some innovative ideas that included allowing pharmacists to manage and review repeat prescriptions for stabilised patients, for example, repeat dispensing within agreed criteria set by the prescriber, by a standing order 1. Ideally, there would be one full time pharmacist in each general practice, taking referrals, and booked appointments, and providing services such as MUR, MTA, complete therapeutic reviews with care plans and follow ups, similar to a model being used in Australia. Pharmacists offer a unique value proposition in the health sector. However many of the services that could be provided by pharmacists are limited by the fact of pharmacists being tied to their dispensary. 6. Enablers of delivery of Pharmacist Services in the Community Enablers are the things that are needed to be able to deliver the services to improve health in our communities. While the focus of these meetings was about future services, there was discussion on 1 A standing order is a written instruction issued by a medical practitioner or dentist. It authorises a specified person or class of people (eg, paramedics, registered nurses) who do not have prescribing rights to administer and/or supply specified medicines and some controlled drugs. Page 12
how these could be changed or improved to increase pharmacists ability to provide the services. Listed below are the enablers that were discussed most often through the fora. Information Technology Integration Tools - The pharmacist needs access to and the ability to interact with the Electronic Health Record (EHR), and all systems such as EHR, My Health, Test Safe, need to be integrated. - Better links to other data sources, for example, InterRAI, would help in identifying at-risk populations. - GPs should be able to refer via prescription for a pharmacist to contact the patient to counsel, review or discuss a particular need. - There needs to be good baseline data on health outcomes that can be used to set health improvement targets relevant to pharmacist services. - Tools should be used to free pharmacists time, for example, automated payment mechanisms, robotics, point of care testing, mobile phone apps, etc. Premises / Facilities - Premises need to be suitable, comfortable and accessible for the consumer; or provided in a more mobile way, a community hub or a health care hub. - Privacy for consultations is important. The consumer should be able to book time to see a pharmacist. - The provision of premises should reflect the needs of the local environment and the demographic of the population. Supply chain Efficient supply chains for medicines are required: - to the pharmacy - to the patient. Legislation/Regulation Legislation relevant to pharmacy, for example, the Medicines Act and Regulations, should be reviewed to ensure the current and future environments are recognised. The scope of practice must be relevant to the services that pharmacists are able to provide. Workforce The number and balance of staff in a pharmacy may need to change to deliver services, and should have appropriate career paths. Use of technicians could release pharmacists from dispensing activities to allow them to concentrate on the more effective delivery of other services. Other ways to free up workforce time are more use of technology in the dispensing process, eg robotics; better prescription quality, e.g. e-prescribing and original pack dispensing. Page 13
Other primary care professionals may need to work in a different way beside pharmacists. Pharmacists need to be culturally competent and to have communications skills for the demographic they are working in. For example, they must know how to talk to the consumer as an equal (thus removing the power imbalance) and to use plain English. Business model There needs to be a clear direction of travel to allow time for business models to adjust. There must be certainty that there will be a return on the costs of the training required to deliver services. Pharmacists time must be freed up to allow them to deliver services to at-risk populations. Funding The funding model must acknowledge the time required to deliver services and should allow for flexible application of services dependent on need. There needs to be a discussion on how the consumer funds the medicine, including who should pay the co-payment, changes to the pharmaceutical exemption card rules and requirements, and who owns the medicine once a co-payment has been made. This discussion should include other sources of funding for medicine charges and how a pharmacist can access this funding. Better integration in primary care While we heard that there are areas where integration in primary care is working well, generally, there needs to be enhanced connections and communications with General Practice, such as colocation, virtual links, attendance at MDT meetings, and sharing of educational experiences. The link with the GP was cited as the most important link a pharmacist needed. Pharmacists must help General Practice to understand better what pharmacists can do, including how pharmacists help patients better understand and manage their medication. Reducing the barriers between GPs and pharmacy could include co-location; pharmacists working in practices; facilitated meetings of GPs and pharmacists; instant secure messaging technology; pharmacists having access to GPs patient management systems; and shared care tools for complex patients. Page 14
7. List of pharmacist services Through all the fora different services that pharmacists felt they were offering or could offer were discussed. A selection of these has been captured below: - Synchronisation - Reconciliation - Medicines Therapy Assessments (MTA) - Medicines Utilisation Reviews (MUR) - Adherence management and support - CPAMs or other anti-coagulation management services - Point of care testing for other illnesses/screening - Primary screening for disease, for example, melanoma, CVD BP/Cholesterol, Bowel cancer - Bone density - Smoking cessation support - Vaccinations - Gout education and medication support - Renal - Emergency Contraceptive Pill (ECP) and family planning education - Minor ailment services, for example, manage hay-fever/skin infections/rehydration - Equipment advice and support or counselling e.g. use of inhalers. Page 15