Breakfast symposium: From hospital to home - the focus on the patient

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1 Breakfast symposium: From hospital to home - the focus on the patient Nadya Hamedi DARZI Fellow UCLPartners and Barts Health NHS Trust in collaboration with North Central London Local Pharmaceutical Committee & Lynne Garforth Clinical Primary Care Pharmacist Ashburton Prescribing Consultants Delivered by:

2 This symposium has been organised and funded by Bayer HealthCare. Xarelto (rivaroxaban) prescribing information is available at this meeting from the Bayer stand. Adverse events should be reported Reporting forms and further information can be found at adverse events should also be reported to Bayer : Tel.: Fax.: L.GB Date: April 2015

3 From hospital to home- the focus on the patient Lynne Garforth Clinical Pharmacist Primary care Ashburton Prescribing Consultants Ltd Nadya Hamedi DARZI fellow Barts Heart Centre/UCLPartners

4 Declaration Funding / speaker fees received from Bayer, Pfizer / BMS, Daiichi- Sankyo, Boehringer Ingelheim

5 Overview What are the risks when a patient moves from the hospital setting back to their home? Who should support the patient? What are the common issues seen by primary care clinicians with a particular focus on the anticoagulated patient? Transferring patients back to the care of their anticoagulation clinic How can pharmacists reduce the risk? How can we improve adherence to anticoagulants? Making an impact on stroke prevention What are the educational needs of pharmacist

6

7 Primary care pharmacy GP practice support Medicines optimisation to support chronic disease management e.g AF reviews Medication reviews Management of repeat prescribing system Post discharge meds reconciliation Anticoagulation clinics Local health trusts GP practice level CCG projects Medication reviews in the vulnerable elderly

8 Medicines reconciliation Medicines reconciliation, as defined by the Institute for Healthcare Improvement, is the process of identifying an accurate list of a person's current medicines and comparing them with the current list in use, recognising any discrepancies, and documenting any changes, thereby resulting in a complete list of medicines, accurately communicated. But who is responsible for ensuring these changes reach the patient? Is it the HCP or does the patient need to be responsible for managing their own care?

9 Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes: NICE Guideline 5 Recognise that medicines reconciliation may need to be carried out on more than one occasion during a hospital stay for example, when the person is admitted, transferred between wards or discharged. In primary care, carry out medicines reconciliation for all people who have been discharged from hospital or another care setting. This should happen as soon as is practically possible, before a prescription or new supply of medicines is issued and within 1 week of the GP practice receiving the information. Organisations should ensure that medicines reconciliation is carried out by a trained and competent health professional ideally a pharmacist, pharmacy technician, nurse or doctor with the necessary knowledge, skills and expertise including: effective communication skills technical knowledge of processes for managing medicines therapeutic knowledge of medicines use. Involve patients and their family members or carers, where appropriate, in the medicines reconciliation process.

10 Medicines reconciliation within the GP practice Safe systems in place - protocols for repeat prescribing management TTO received Read coding Medications added / deleted Prescription issued when patient presents at practice Is this enough? Who is amending the medication lists Is the information clear? Is there a clinical check? Who is engaging with the patient?

11 What about the anticoagulation service? Often no information provided No follow up appointments Patient may have had Their warfarin stopped for a procedure Their dose changed Interacting drugs prescribed LMWH prescribed Warfarin stopped inappropriately

12 Safe systems can fail 84 year old lady discharged with a diagnosis of AF and started on rivaroxaban 15mg od Over 75 med review by pharmacist at the GP practice Medication had been added to the system as per TTO by GP Patient discharged with a supply of medication Dose was incorrect as CrCl 80ml/min clinical check had failed at several stages (hospital and by GP)

13 Patient engagement 77 year old housebound man discharged following an MI Ticagrelor started by hospital in addition to aspirin and other meds Meds updated by GP on clinical system as per TTO 6 weeks later pharmacist carried out med review and noticed all meds had been collected except those added during recent admission Patient not taking ticagrelor Community pharmacy had not received TTO Patient unaware Role of GP practice in communicating changes can be improved

14 The importance of clear instructions on TTO 80 year old lady on warfarin (AF) on admission to hospital Switched to a NOAC during admission NOAC listed on TTO Warfarin not on meds list on TTO but was not mentioned in comments where other meds that had been stopped had been But GP did not remove from repeat prescription Community Pharmacist intervened

15 Communicate with the anticoag service Patient attended usual anticoag appointment INR 1.3 On review, had been in hospital and had been discharged over a week ago on a lower dose than pre admission dose Common occurrence patients told to arrange own appointment, no direct communication with the service Can lead to increase risk especially where there have been dose changes to warfarin and / or interacting drugs added Could lead to patient being at risk for several months if appointment not imminent

16

17 Take every opportunity to counsel the patient 70 year old man with AF, admitted with TIA despite good INR control On discharge warfarin stopped and apixaban started Followed up as a result of missed appointment at anticoag service Was only taking apixaban once daily despite clear labelling Is this just a compliance issue or misunderstanding on behalf of patient?

18 Overcoming the issues Hospitals Improve communication to anticoagulation services Clear instruction as to what to do with EVERY medication patient was admitted on GP Practice Ensure clinical check happens as part of meds rec and challenge where necessary Improve communication channels to the hospitals, patients and community pharmacies Anticoagulation services Encourage patients to communicate med changes / details of hospital admissions etc Educate patients when switched to NOACs Develop interface and / or practice pharmacist roles

19 Improving adherence through good communication Establish the most effective way of communicating with each patient and, if necessary, consider ways of making information accessible and understandable (for example, using pictures, symbols, large print, different languages, an interpreter or a patient advocate). Encourage patients to ask about their condition and treatment. Ask patients open ended questions because these are more likely to uncover patients' concerns. Primary care has the benefit of frequent interactions with patients to support relationship building

20 PRESCRIBE by APC

21 PRESCRIBE by APC

22 Involve patients in the treatment decision Newly identified patients (new diagnosis or previously refused warfarin) Be clear about the risk of stroke and lack of benefit of aspirin Discuss modifiable bleeding risks Offer choice of all anticoagulants - Anticoagulation may be with apixaban, dabigatran etexilate, rivaroxaban or a vitamin K antagonist. NICE CG180 Medication won t work if a patient doesn t take it

23 Conclusion Keep the communication channels open Between HCPs in the different settings Between the HCP and the patient Review current systems such as repeat prescribing management Encourage CCGs to invest in pharmacist led meds reconciliation in primary care Take every opportunity to involve the patient, don t assume someone else has or that the patient has taken everything on board

24 Pharmacist: Making an impact on stroke prevention Nadya Hamedi DARZI fellow Barts Health NHS Trust/UCLPartners

25 Declaration None Bayer sponsoring presentation

26 NICE guidelines for AF (2014) one of the key priorities: personalised package of care for patients support and education practical advice on anticoagulation

27 NICE guidelines for medicine adherence (2009) Enabling patients to make informed choices by involving and supporting them in decisions about prescribed medicines 1/3 to 1/2 of all medicines prescribed for long-term conditions 5% to 8% of unplanned hospital admissions are due to medication issues

28 NICE guidelines for medicine optimisation (2015) Medication review, based healthcare professionals knowledge and skills, including all of the following: Technical knowledge of processes for managing medicines Therapeutic knowledge on medicines use Effective communication skills.

29 Adherence to new medication for chronic conditions Effective treatments Patient Practitioner Optimum outcomes Caro JJ et al., CMAJ 1990, 160: Barber et al., Qual Saf Health Care 2004;13:

30 New Medicine Service (NMS) Conditions Asthma and Chronic Obstructive Pulmonary Disease (COPD) Hypertension Type II diabetes 10% improvement in adherence Antiplatelet/ anticoagulant therapy The service offers patients support within the first 21 days of new medication initiation 1. Patient engagement 2. Intervention 3. Follow up

31 How can pharmacist make an impact on stroke prevention in patients with Atrial Fibrillation?

32 Opportunity for Pharmacists to support anticoagulation needs of patient with Atrial Fibrillation

33 Adherence programme Darzi fellow Referral from 1 o /2 o care Unmet need Capacity of anticoagulation clinics NMS/MURs Educational Needs Atrial fibrillation Anticoagulation CBT Referral Process direct to community pharmacy after NOAC Initiation Patient need Community pharmacy New medicines Evaluation of pathway redesign for patients & professionals

34 Resources and training on oral anticoagulants for pharmacist

35 Resources and training on oral anticoagulants for pharmacist

36 Summary Effective treatments Patient Practitioner Optimum outcomes Co-producing patient-centred approach

37 Interest in joining focus groups? Contact: Nadya Hamedi Tel:

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