Supporting medicines adherence:Developing the pharmacist contribution

Graham Davies | Professor of Clinical Pharmacy and TherapeuticsKing’s College London

Supporting medicines adherence: developing the pharmacists contribution

Professor Graham Davies,Institute of Pharmaceutical ScienceKing’s College London

Content

South London project – supporting patients with diabetes

Supporting community pharmacists to deliver adherence support

Key challenges to future care – the Southwark and Lambeth Integrated Care initiative

Summary

South London HIEC

Richmond174,400

Wandsworth269,300

Kingston150,000

Merton192,300

Sutton180,900

Croydon336,600

Bromley 335, 914

Lewisham284,746

Lambeth329,174

Southwark298,073

Greenwich262,145

.

Bexley233,33311

2

6

5

9

14

12

3

4

15

58

717

13

1

10

24

5

9

8 6

1

10

7

3

16

2

3

4

5

6

7

8

9

10

1

11

12

13

14

15

16

17

Bethlem

Bolingbroke Hospital

Epsom Hospital

Guy’s Hospital

King’s College Hospital

Kingston Hospital

Lambeth Hospital

Maudsley

Mayday Hospital

Oxleas

Queen Mary’s Hospital

Royal Marsden – Sutton Hospital

South London Healthcare

St Helier Hospital

St Thomas’ Hospital

Tolworth Hospital

University Hospital Lewisham

1 Greenwich University

2 King’s College London (The Strand)

3 King’s College London (Waterloo)

4 King’s College London (Guy’s)

5 King’s College London (St Thomas’)

6 King’s College London (Institute of Psychiatry)

7 Kingston University

8 Lambeth College

9 London Southbank University

10 St George’s University

Four key priorities:

• Mental health

• Diabetes• Stroke• Infection

Challenges – UK perspective

Estimated that there are 3.1 million people with diabetes in England. 800,000 of these are not diagnosed (1)

By 2020 an estimated 3.8 million adults, or 8.5% of the adult population, will have diabetes and by 2030 this is estimated to rise to 4.6 million or 9.5% (1)

The NHS in England spends more than £2.3 billion a year on inpatient care for people with diabetes. That’s 11% of NHS inpatient care expenditure (2). Length of hospital stay is 2-3 nights longer than those without diabetes.

Anti-diabetes medicines cost the NHS £725 million/year.

30 -50% of medicines prescribed for long-term illnesses not taken as directed For diabetes, we can estimate at least £200 million/year waste

(1) APHO Diabetes Prevalence Model, http://www.yhpho.org.uk/resource/view.aspx?RID=81090. Last updated 28/09/2010(2) NHS Diabetes report November 2011. www.diabetes.nhs.uk

0%

10%

20%

30%

40%

50%

60%

% o

bes

e

Schools - % Obese Southwark average London average England average

Schools

Reducing Unwarranted Variation

Fourfold variation in the rate of hospital admissions for diabetes in London PCTs

Fivefold variation in Y6 childhood obesity rates across primary schools in Southwark

Tenfold national variation in the % of type 2 diabetics receiving all 9 NICE key care processes

Threefold variation in uptake of structured education across South London with best at 29%

https://slondonhiec.org.uk/sites/default/files/SL_HIEC_Community_Pharmacy_&_Diabetes_Report_FINAL_authors.pdf

Key stakeholders from across south London invited to discuss how community pharmacists could be more specifically involved in supporting people with diabetes.

Participants included representatives from national diabetes organisations, patient representatives, academics, commissioners and healthcare professionals.

Themes identified

Supporting patients’ use of medicines Identifying concerns and facilitating goal setting

Screening for undiagnosed diabetes Risk assessment using trigger drugs

Supporting use of glucose meters and test strips

Communication skills to promote inter-professional working

Signposting eye and foot checks; access to support groups

and structured education (DESMOND)

Patient Perspective

“…I’ve been going to the same place for the past 3 years and they understand my history and if my medication has run out they will phone me to remind me.”

Patient 3

“...I ring up the pharmacist, supplies are getting a bit low, tell them what I want...he will ring the surgery and I will go in about 2 days later and it’s all waiting for me. He will do a delivery service for those who need it.”

Patient 14

Educational support

Raise awareness of common beliefs about illness and treatment held by patients

Enhance consultation skills Provide systematic approach Examples of good behaviours

Develop a proactive versus reactive approach

Focus for education intervention

Endorsed by the Royal Pharmaceutical Society

Key points

Increase awareness about adherence and challenges

Underpinned by evidence: Perceptions and Practicalities model1

Focus on consultation skills using validated framework (MRCF)2

Highlights patient-centred approach to better understand their medicine-taking behaviour

Demonstrates good consultation behaviours which can lead to behaviour change Motivational interviewing

1 Horne, R. & Weinman, J. (1999) Patients' beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illness. Journal of Psychosomatic Research, 47 (6), 555–567. 2 Abdel-Tawab R et al (2011). Development and validation of the Medication-Related Consultation Framework (MRCF). Patient Education and Counseling 83 (3): 451-457.

Interactive

Videos demonstrate different levels of effective practice

Work at your own pace

Reflect on your own practice

Techniques explained in full

Rating exercises to reflect on level of practice

Features & Benefits

Overview of PackagePRE-MODULE ASSESSMENT (Clinical Knowledge)

PART 1: Assessing and addressing adherence in diabetes

PART 2:

Identifying and consulting with non-adherent patients with diabetes

PART 3: Using consultation skills to identify and address patient non-adherence

in diabetes

POST-MODULE ASSESSMENT & REFLECTIVE EXERCISES

Low concerns

High concerns

High necessityLow necessity

Sceptical

AcceptingIndifferent

Ambivalent

Mann et al. (2009)

Integrating care – the adherence challenge

Many people had care for more than one Long Term Condition

The intensity of care for people with LTCs will increase with the growth in the older population

No of Conditions per patient

0 - 4

5 - 9

10 -

14

15 -

19

20 -

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25 -

29

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35 -

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55 -

59

60 -

64

65 -

69

70 -

74

75 -

79

80 -

8485

+0%

10%20%30%40%50%60%70%80%90%

100%

Morbidity (number of LTCs) by Age Group

012345678+

Age Groups (Years)

Pe

op

le (

%)

Key challenges

Co-morbidities with ageing Engagement of different health care

professionals Silo approaches

Poor transfer of information Lack of consistency in messages

Medicines adherence Not routinely assessed or documented Agreed plan or intervention not documented New Medicines Service and MUR a start

Southwark and Lambeth Integrated Care will deliver a bold and radical transformation across health and social care at scale.

Citizens will feel that their health is also their responsibility and will be supported in self management by building community assets, capabilities and skills.We will provide the right care in the right place, at the right time, reliably and proactively by the professional(s), peer support workers or volunteers most suitable to provide care.Ensure we are treating the whole person with integrated care centred around empowered individuals.

Ensure professionals are best able to deliver this new approach, ensure better professional lives for the staff we are working with.

This requires behaviour change by all professionals, citizens and communities.

1.

2.

3.

4.

5.

We need to shift the LTC care paradigm from people being

dependent recipients of care to

enabling and supporting people with LTCs to live

independently and optimally with their

condition.

Doing more of the same better will not be enough

Improving and integrating care for LTCs will not be sufficient – we need a new paradigm to supporting people with Long Term Conditions

Must do better:

• LTCs are under-diagnosed

• Too many people with LTCs die prematurely

• QOF scores for LTC management are well below London average in 7 of 17 LTC diagnoses

The ‘Scissors of Doom’ - Growing demand with less funding

• Population in S&L expected to grow by 18% in next 10 years

• Aging population

• People live longer with LTCs

• Funding for NHS, Public Health and Social Services is falling well behind growth in demand

Key behaviours and support

Undertaking healthy behaviours• Not smoking, Exercising, Healthy eating, Drinking

alcohol in moderation

Keeping home environment safe• Impaired mobility and physical ability to take care of all

activities of daily living• Cognitive decline with impaired ability to run a

household independently• Epilepsy with frequent seizures and risk of injury

Optimising medicines use• Taking medications as prescribed or knowing how to

take PRN medications

Detecting and addressing risks early• Detecting people at risk and stratification• Early effective interventions• Care management

Optimising Medicines Use for LTC

Scoping the key issues, problems and successes

Developed medication adherence screener Piloted in hepatitis C out-patient clinic Adoption by Thrombosis Centre (KCH) -

focus on transfer of warfarin patients to NOAC (time in range <50%)

CCG backing to use screener in GP cluster.

Results

Pilot in 40 patients – over 20% admitted to missed doses in week before clinicThe majority of patients (70%) had concerns about their medicines

Frequency (%)Possible side effects 23 (62)How the medicines may damage my body in the long term 9 (24)Taking too many medicines 9 (24)Whether the medicines will be of any help 4 (11)Whether their effectiveness will wear off over time 4 (11)

Conclusions

• Preliminary results suggest that the screener can be integrated into routine care to identify non-adherence

• Non-adherence appears to be associated with:• Low motivation (as conceptualised by the Modified

Morisky i.e. forgetfulness and carelessness)• Perceptual barriers (only took their medicine when

they felt the need)• Practical barriers (poor planning of medicine-taking

behaviour )• Used by MDT to target inform consultation during

clinic visit

Future

Capture medicines adherence data routinely and make available to: Aid provision of consistent messages Facilitate patient self-management

Training for all HCPs is key Opportunity within Lambeth and Southwark

to design and test a system for LTC which draws on expertise of pharmacists

Need to measure impact of approach on health care outcomes/utilisation/satisfaction

Introduction to a medicines-adherence in diabetes e-learning package

Professor Graham Davies,Institute of Pharmaceutical ScienceKing’s College London