Better Outcomes for People Living with Chronic and Complex Health Conditions through Primary Health Care

Transcription

1 Submission: Primary Health Care Advisory Group Discussion Paper (August 2015) Better Outcomes for People Living with Chronic and Complex Health Conditions through Primary Health Care August 2015 Contact details David Quilty Executive Director National Secretariat Level 2, 15 National Circuit, Barton, ACT 2600 Australia PO Box 7036, Canberra Business Centre, ACT 2610 Australia Telephone: Facsimile: Internet:

2 Contents Overview... 3 Theme 1 - Effective and Appropriate Care... 4 Theme 2 Increased use of Technology... 6 Theme 3 How do we know we are Achieving Outcomes?... 8 Theme 4 How do we establish suitable payment mechanisms to support a better Primary Health Care System?... 9 The Pharmacy Guild of Australia August

3 Overview The Pharmacy Guild of Australia (The Guild) is the national peak pharmacy organisation representing community pharmacy. It strives to promote, maintain and support community pharmacies as primary providers of health care to the community through optimal therapeutic use of medicines, medicines management and related services. The Guild welcomes the opportunity to provide a response to the Primary Health Care Advisory Group Discussion Paper, Better outcomes for people living with Chronic and Complex Health Conditions through Primary Health Care. The Guild believes there is a need for genuine primary health care reform in Australia and that better utilisation and investment in community pharmacy should be an integral part of these reforms. Today there are over 5,450 community pharmacies in Australia offering a highly skilled network of primary health care professionals providing quality medicine dispensing, advice and services. Community pharmacies are equitably distributed and highly accessible, and often operate over extended hours: in urban, rural and remote areas. Both well and sick people regularly visit community pharmacies, providing an opportunity to engage people along the health spectrum, including hard-to-reach population cohorts who do not use other health services. This is particularly relevant to rural and remote locations and for Aboriginal and Torres Strait Islander People, in the prevention and ongoing management of chronic diseases, and to support patients with mental health needs. There are ready opportunities to enhance the way that community pharmacies is utilised in the health system. These enhancements have the potential to deliver widespread benefits for patients and funders, with many already in place in comparable health systems overseas. They include a greater focus on utilising community pharmacies for triage and in the treatment of minor ailments, risk assessment and referral, transitional care (including hospital and aged care), point of care testing, chronic disease management, immunisation, telehealth and after-hours care. To date, efforts to better utilise pharmacies have been held back by focusing on individual programs and pilots that tend to come and go, lack scale and duplicate one another. It is becoming increasingly clear that a health system that is overly weighted towards expensive episodic acute medical care is inefficient in dealing with Australia s changing demographics and chronic disease patterns. To deliver meaningful change, the primary health care reforms need to: Equip all arms of the health system (enabled through the use and support of e-health) to work in a coordinated and collaborative way towards quality, patient-centric care, Aim to achieve common measurable health outcomes and ensure ongoing affordability across the system, Highlight the importance of the prevention of chronic diseases, and early intervention assisted by appropriate risk assessment and referral pathways, Focus on the principles of reablement to keep people living in their own homes for as long as possible, with minimal tertiary intervention, and able to participate productively in the workforce and the community following the care received, The Pharmacy Guild of Australia August

4 Promote effective referral systems between all health professionals where expanding skills and roles are embraced rather than resisted, Empower consumers with a strong focus on health literacy and assisted self care, Highlight to patients the services available from the respective health care professionals and providers both now and into the future, and Facilitate a closer alignment and greater coordination between primary health care providers and the Federal government (including across portfolios), State/Territory governments, Primary Health Networks and private health insurers. The Guild also notes the concurrent processes and inquiries underway that are relevant to the work of the Primary Health Care Advisory Group, including: The Medicare Benefits Schedule Review, The Reform of the Federation White Paper process, The Sixth Community Pharmacy Agreement Pharmacy Trial Program, The House of Representatives Standing Committee on Health Inquiry - best practice in chronic disease prevention and management in primary health care, The development of National Strategies into diabetes, asthma, allergies and chronic diseases, and State & Territory Government investigations into the use of community pharmacy in public health. Responses to Questions in the Discussion Paper are addressed below individually. Theme 1 - Effective and Appropriate Care Do you support patient enrolment with a health care home for people with chronic and complex health conditions? The Guild supports a more coordinated, collaborative and integrated approach to primary health care in Australia, recognising that the Quality Use of Medicines (QUM) is a fundamental aspect of patient care that is under acknowledged and under-funded. From a survey of 5,000 Australians aged in October 2012, more than half (54.9%) regularly took at least one prescription medicine. 1 Concepts like patient enrolment and the health care home are worthy of consideration but should not be allowed to be about health practitioners owning patients. Patients need to be empowered and given maximum choice about where and how they will receive the care that best meets their health needs, rather than risk becoming the owned commodities of individual health practitioners. An approach where a single individual practitioner is allowed to control the care of a patient will encourage inefficiencies, result in vertical integration and commercially-driven preferred 1 Medicines Australia; Facing the Health of Australians; Mar 2013 The Pharmacy Guild of Australia August

5 provider models; reduce consumer choice; restrict innovation and competition; and not make effective use of the wider health system. If a coordinated care approach is to be truly patient-centred, patients should have the ability to choose who and how their care will be coordinated; who will lead and participate in their care planning team (should include input from all key care providers); what services they will receive; and where they will access these services. Patients also need to be partners in their health care planning and implementation, with access to the information and knowledge they need not only about their health conditions but also their care options and they role they need to play in taking personal responsibility for maximising their own health outcomes. As long as they are not captured by particular interests, Primary Health Networks can play a key role in developing local patient pathways and coordinated care models; and providing patients with the knowledge they need to navigate the health system and take greater responsibility for their care needs. What are the key aspects of effective coordinated patient care? The primary focus of effective coordinated care should be on delivering the best and most cost-effective outcomes for patients and funders, through the most efficient overall use of the wider health system. As a highly accessible and frequently accessed part of the primary care system, pharmacies can play a key role throughout the continuum of care for patients with chronic conditions, as: o a first point of contact o a place of triage, advice and referral o a provider of health information and health literacy assistance o a risk assessment and early invention point o as medicine management experts as part of a wider management team o point of care testing o lifestyle management, and o ongoing monitoring of and support for patients with chronic conditions. Traditional roles and responsibilities should not be set in stone, but reviewed from a starting point of providing patients with best access to the quality care that is required to maximise their health outcomes, in a way that delivers value-for-money for funders and enables health practitioners to practice at the top of their professions in a collaborative health environment. This approach should not only apply to the management of chronic health conditions, but also to the most cost-effective treatment of minor ailments, thereby reducing the unnecessary use of more expensive care options, which should be focused on more complex and serious health conditions. It is estimated that 15% of all GP consultations are for the treatment of minor ailments. When projected nationally, this equates to 25 million GP consultations The Pharmacy Guild of Australia August

6 annually, or approximately 96,000 GP consultations per day 2. For a significant portion of these minor ailments, treatment may be able to be more cost-effectively provided by other health care professionals such as pharmacists or nurses, enabling GPs to focus more on the diagnosis, treatment and management of chronic conditions which require their skills and expertise. There also needs to be a stronger focus on transition between care settings and developing better local pathways between health care providers. As dispensing medicine experts, pharmacies have a critical role in transitional care issues where medicine misadventure is a frequent cause of avoidable hospitalisations. There are approximately 230,000 medicinerelated hospitalisations a year in Australia with an estimated cost of $1.2bn. 3 Opportunities also exist to implement practical reforms to help improve access to medicinerelated care, in ways which will take greater pressure off other areas of the health system. These reforms, which have been implementing internationally, include: o utilising community pharmacy through enhanced continued dispensing for the management of patients who are not unwell, but require ongoing medicines therapy for their chronic disease/s (e.g. high blood pressure), and o creating a pharmacy formulary to supply one-off medications for select, readily diagnosable minor ailments, enabling consumers to access more timely treatment, whilst freeing-up capacity in other parts of the health system. Effective, co-ordinated care should be supported by access to community pharmacy after hours. As 80% of GP visits result in the issuing of a prescription 4, the funding of GPs afterhours needs also to take into account the increased demand for after-hours medicines, with appropriate incentives to make it viable for identified pharmacies to extend their opening hours. As discussed in Theme 2 (below), effective coordinated care must be enabled by a comprehensive electronic health record to ensure continuity of care and visibility of services. Theme 2 Increased use of Technology How might the technology described in Theme 2 improve the way patients engage in and manage their own health care? There are rapid technology improvements in areas such as remote monitoring, pathology and point of care testing, and DNA analysis. These technologies provide the opportunity to improve access to and efficiency of these services and enable greater choice for patients and increased competition to traditional providers. As highly accessible health destinations, pharmacies are well placed to provide patient access to these technologies, taking pressure off other parts of the health system. 2 Australian Self Medicines Industry Report; The Potential Economic Impact of Expanded Access to Self-Medication in Australia; Sep ACSQH; Literature Review: Medication Safety in Australia; Aug Bettering the Evaluation and Care of Health (BEACH) data, Family Medicine Research Centre, The University of Sydney The Pharmacy Guild of Australia August

7 With the advent of high speed broadband, video conferencing capabilities and high definition health applications, there is the opportunity to use telehealth/telemedicine to provide patients with increased access to clinicians and remote health tests, as well as driving greater collaboration through virtual health teams. These technologies will be particularly beneficial in areas with poorer physical access to services (rural and remote Australia), as well as in reducing avoidable emergency department presentations. Web-based applications are providing patients with greatly increased access to health related information, enabling them to be better informed than ever before about their health conditions but increasing the risk of inaccurate self-diagnoses. Providing patients with access to trusted, evidence-based health information supported by the advice from their local health care professionals, including GPs and community pharmacists, provides the opportunity to give patients the knowledge, expertise and confidence to take more personal responsibility for managing their health conditions. Technologies should also underpin a collaborative team-based care environment, including access to patient care plans, the organisation of patient appointments, and the provision of test results and up-to-date health indicators. Patients should be educated to use these technologies to take greater control and responsibility for their care working with their health care providers. This will also increase choice and competition in the provision of care. The increased use of technology provides the opportunity for patients to utilise alternative care options that may be fee-for-service or funded through private providers such as health insurers. Additionally, these technologies will result in an increasing convergence of the health and the aged and community care sectors. Every effort should be made to ensure that the range of eligible services in consumer directed community aged care and the NDIS provides patients with the support they need to manage their chronic health conditions. What enablers are needed to support an increased use of the technology described in Theme 2 of the Discussion Paper to improve team based care for people with chronic and complex health conditions? A patient e-health record is a critically important tool in the provision of a coordinated, collaborative team-based approach to the care of patients with chronic health conditions. A comprehensive e-medication management system must be a fundamental part of a patient e-health record, accessible by primary health care providers, hospitals and aged care facilities. It should include prescription medicines, over the counter medicines (OTCs) and medicines management support services. Financial incentives to enable the optimal uptake and use of e-health and telehealth services by primary health care professionals, including GPs, specialists and pharmacists, should also be considered. The Pharmacy Guild of Australia August

8 Theme 3 How do we know we are Achieving Outcomes? Reflecting on Theme 3, is it important to measure and report patient health outcomes? It is vitally important to measure and report patient outcomes as well as ensure those outcomes are available to patient care team members as well as the patients themselves. Outcomes based reporting systems need to be developed across the wider health system. In pharmacy there is already widespread electronic recording and systems for reporting medicine adherence outcomes developed. This provides the opportunity to transition to outcome based reporting and funding in appropriate areas of care, including reducing avoidable hospitalisation episodes, measuring and maintaining key health indicators, and delivering on wellness outcomes. There is a need for greater analysis and reporting of health outcomes at the localised level, including developing a better understanding from this data of the models of care and pathways that work most cost-effectively and can be replicated more widely. More broadly, there is a need for a more comprehensive understanding of health needs at a localised level and how existing services and the capacity of health professionals can be most effectively deployed to meet those needs. Primary Health Networks can play a key role in this vital population health work, which should be focused on chronic health conditions. To what extent should patients be responsible for their own health outcomes? Health systems in comparable countries, like the UK, are moving towards an emphasis on supported self-care 5, with patients provided with the knowledge and tools to take greater responsibility for their health care, including through improved access to evidence-based health literacy information and navigation tools to enable them to identify and access the most appropriate service support options for the care they need. As highly accessible and trusted health care professionals, community pharmacists can play a key role in supporting self-care, particularly in locations where there is a lack of timely access to health professionals. Through their first port-of-call and triaging role, community pharmacists can help patients navigate their way to appropriate care settings to meet their needs. 5 NHS England; Community Pharmacy - helping provide better quality and resilient urgent care; Version 2, Nov 2014 The Pharmacy Guild of Australia August

9 Theme 4 How do we establish suitable payment mechanisms to support a better Primary Health Care System? How should primary health care payment models support a connected care system? It is critically important that the central role of quality medicine supply continues to be appropriately remunerated. Otherwise, a fundamental element of the care of patients with chronic health conditions will be undermined. There is a need for a significantly increased investment in medication management in Australia. There is overwhelming evidence that QUM, with the support of dispensing community pharmacists as medicine experts, reduces costs across the wider health system. This is particularly the case with patients with chronic long term health conditions, and is a readily implementable opportunity that must be grasped. Payment systems need to reflect the principle of incentivising the most cost-effective solutions, challenging traditional siloes of service provision and enabling access to the most appropriate and cost-effective sources of care. Access to MBS items should be based on cost-effectiveness and clinical capacity, with a focus on improving access to patients where there is unmet need and where there is established evidence that earlier intervention or care will deliver enhanced health outcomes. In a recent survey by the Consumers Health Forum (CHF), a key finding showed that most respondents believed that pharmacists have a larger role to play in providing primary care services. 6 Caution should be taken in providing care coordinators with lump sum funding (up front or otherwise). Instead, consideration should be given to models that provide patients with access to funding to utilise the health system the way they want: working in collaboration with care coordinators and informing their GP through an electronic health record. Wherever feasible, outcomes based funding models should be trialled and implemented where there is an ability to directly link interventions with health outcomes. The basis of a coordinated, patient-focussed care model is that all members of the patient s care team should be rewarded for delivering health outcomes, including but not restricted to the care coordinators. Personalised medication management service models should be considered for patients where there is clear evidence that an intensive approach to medication adherence will drive substantially improved health outcomes and reduce costs across the wider health system. 6 Consumers Health Forum of Australia. Pharmacists and Primary Health Care Consumer Survey: Results and Discussion, Jul 2015 The Pharmacy Guild of Australia August

10 What role could Private Health Insurance have in managing people with chronic and complex health conditions in primary care? Private health insurers should have a strong focus on preventing and managing chronic health conditions to reduce patients unnecessarily ending up in acute hospital settings or developing longer term health issues. This should include an emphasis on encouraging and rewarding patients for maintaining healthy lifestyles, and working with health professionals such as community pharmacists in areas such as weight management and smoking cessation. Private health insurers have a strong interest in minimising unnecessary hospital readmissions. With clear evidence that medicine misadventure is one of the main causes of avoidable readmissions, private health insurers should be strongly encouraged to work with private hospitals in funding a consistent approach to post-discharge medicines reconciliation and medicines management, focused on at at-risk patients with chronic health conditions, which would be delivered through community pharmacies in close collaboration with GPs. There should be greater ability to mix and match a variety of public and private funding sources in the coordinated care of patients with chronic health conditions. Services should be sourced on the basis of patient need and their capacity to pay. Patients should have the ability to make decisions based on having access to clear information about services and costs. The Pharmacy Guild of Australia August