Aplikasi farmasi klinis di sarana

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meningkatkan kesehatan masyarakat 
PROF. DR SYED AZHAR SYED SULAIMAN
PUSAT PENGAJIAN SAINS FARMASI
UNIERSITI SAINS MALAYSIA
KAMPUS UNIVERSITI SAINS MALAYSIA
 Objectives
•Define transitional care and its impact on healthcare outcomes
and expenditures

•Describe the development of clinical pharmacy services for

public

•Identify medication-related strategies to decrease hospital

readmissions

•Review examples of pharmacist-led interventions to enhance

transitions of care
Transitions of Care

“The movement of
patients between
health care locations,
providers, or different
levels of care within
the same location as
their conditions and
care needs change.”

Source: Healthy Transitions Colorado, 2015.

 Transition of Care

• The movement patients make between health care

practitioners and settings as their condition and care needs
change during the course of a chronic or acute illness

Coleman EA, Boult CE. Improving the Quality of Transitional Care for Persons with Complex
Care Needs. J of the Amer Ger Society. 2003; 52(4): 556-557
Why focus on care transitions?

Improve patient safety

and health outcomes

Reduce readmissions
and healthcare costs
 Barriers to Successful Care Transitions

• Number of providers involved in patient’s care

• Inaccurate documentation during hospital stay
• Prescribing errors
• Inaccurate medication profile at discharge
• Polypharmacy
• Inadequate patient education on discharge medications
• Failure to provide patient follow-up
 Medication errors remain the core of hospital
readmission problems

• 60% of all medication errors in the hospital occur at admission, intra-

hospital transfer, or discharge
• Approximately 20% of patients discharged from hospital to home will
experience an adverse event during transition
– 65% to 70% of these events are associated with medications
– 77% of these patients receive inadequate medication instructions
• Anticoagulants, antiplatelet agents, insulin, and oral hypoglycemic agents
account for the majority of medication-related hospitalizations

Institute of Medicine. Washington DC: National Academies Press; 2000

Butterfield S, et al. www.psqh.com/mayjune-2011/838-understanding care transitions.
 Example of problem
• Mbak Nyok Nyet an elderly woman age 65 years
old and coming to your pharmacy to fill in her
medications. She was given ranitidine 150 mg
bd, metformin 500 mg bd, pindolol one tablet a
day, simvastatin 20 mg daily and indometacin
one capsule bd.

• What is/are your comment/s on the

medications given to her?
 Vision for Pharmacy

• Ensuring safe and optimal

use of medicines for the
people in the community
Medicines should
• Integrating Pharmacy into be seen as an
existing and new structures/ investment; not a
services cost
Source: HCUP Statistical Briefs #153 and #154: http://www.hcup-us.ahrq.gov/reports/statbriefs/statbriefs.jsp
 Hospital Readmission Reduction Program
(CMS)
YEAR READMISSION DIAGNOSIS PENALTY

2013* Acute MI, CHF

2015 COPD, TKA, THA

2016 CABG surgery

2017 Aspiration pneumonia, sepsis

* CMS Transitional Care Billing introduced

An army of pharmacists
 Evidence to support the pharmacists’ role
Author/Journal Title Pharmacist Primary outcome Results
Intervention
Jack BM, et al. A Reengineered Clinical Pharmacist Rate of Decreased 30 day discharge by 30% in
hospital discharge at 2-4 days rehospitalization in intervention group
Annals of Internal program to following 30 days in 749 Avg cost savings per discharge:$412
Medicine decrease discharge patients.
hospitalization
(Project RED)

Wong, et al. Medication Clinical Rate of medication 106 of 170 pts had medication
Reconciliation at pharmacists discrepancy at discrepancy at discharge
Annals of Hospital Discharge: performed at discharge and
Pharmacotherapy Evaluating discharge clinical impact on
Discrepancies patients

Schnippner JL, et al. Role of pharmacist Clinical Rate of preventable At 30 days, 1 patient in intervention group
Archives of Internal counseling in pharmacists ADEs within 30 had a preventable ADE vs 8 patients in
Medicine preventing adverse performed at days of discharge the control group
drug events after discharge, then 3-5
hospitalization days later
 The Bottom Line

Poorly coordinated care transitions

Decreased quality of care

Decreased health outcomes

Increased hospital readmissions

Increased costs
 Reduce
hospital
Improve readmission
quality rates
outcomes

Reduce of
adverse
drug events

Transitions of Care Service

 Why Involve the Pharmacist?
• Prevent medication errors
• Address medication concerns
• Avoid Adverse Drug Events
• Provide medication counseling
• Assess medication adherence and efficacy
 Pharmacist Interventions

• Improper drug selection

• Subtherapeutic dosages
• Supratherapeutic dosages
• Medication non-adherence
• Therapeutic duplications
• Therapeutic omissions
• Drug interactions
• Drugs with no indications
• Treatment failures
 Another problem
• Bapak Sukamayun berusia 75 tahun menderita
hipertensi selama 25 tahun, diabetes 30 tahun,
merokok, kegagalan jantung, nyeri akibat gout dan kini
mengalami septicemia akibat Proteus mirabillis.

• Dr Ambon memulakan ciprofloxacin 500 mg BD,

amlodipine 10 mg sehari, simvastatin 20 mg sehari,
frusemide 40 mg bd, thiazide 1000mg daily

• Bagaimana farmasis merawat pesakit ini?

 Metrics
Indicator
1. Volume of patient focussed activity: consultations, medication reviews, patient
queries – per practice pharmacist
2. Medicines information queries
3. GP workload
Anything that pharmacist does that would have been done by GP
% acute prescription requests/month
4. Medication Reviews done as % of all completed
5. Medicines reconciliation for patients discharged from hospital - % of all patients
discharged
6.Disease specific reviews, according to national priorities (e.g. AF, using shared
decision making approach) 
7. Repeat dispensing (Medicines Optimisation dashboard)
8. Patient Experience
9. Antimicrobial Stewardship 
10. Feedback from stakeholders
 So, how’s it going?
• GP Mentor and pharmacist support
• Diverse range of tasks – variation may be an issue!
– COPD & osteoporotic fracture risk
– Asthma reviews and inhaler technique; Q Risk
assessment and prescribing of statins; IHD reviews
– Nursing home/care home reviews
– AF management and developing NOACs/group clinics
– Antidepressant reviews for long term patients; RA
– AF anticoagulation clinics/group clinics
 Local Recognition

http:// “It is really exciting to be at

www.northumberlandgazette.co.uk/
news/pharmacists-right-at-the-heart- the forefront of something so
of-new-model-of-health-care-1-
8222823
new and innovative in the
NHS. To feel like you are
making such a positive
difference by being proactive
in reviewing patients and
helping to avoid any
problems that might with
arise medication in future.”

Alastair Green, F1 GP Pharmacist

THE CORE OF TRANSITION
OF CARE PROGRAMS
 Establish the relationship
• Establish point of contact responsible for quality improvement
for the hospital

• Discuss a potential meeting about value-added services

• Develop a transition of care team in conjunction with the

hospital
 Transition of Care Program Goals
• Provide enhanced patient care services
• Provide a continuum of care from the hospital to home
through community pharmacy care
• Reduce readmission and adverse events
• Reduce cost to the health system and patients
• Ensure regulatory compliance
 Interventions performed by pharmacists
during care transitions
• Contact patient within 24 hours of hospital discharge to establish follow-
up consult
• Detailed review and reconciliation of drug orders between hospital and
PCP
• Analysis of prescription, OTC, vitamins, supplements, herbal remedies
• Comparison of patient’s preadmission and discharge medication lists
• Omissions, discontinued medications, dose changes, therapeutic
duplicates, drug-drug interactions
–Discussion of unintended medication discrepancies with providers for
resolution
 Medication reconciliation during consult
Rekonsiliasi obat selama konsultasi
• Perform comprehensive medication history
• Verify patient’s current medication list
• Provide updated medication list to patient
• Provide patient/caregiver medication education
– Indications for use and importance of adherence to therapy
– Proper administration (self-injection technique, inhaler technique, etc)
– Goals of therapy (A1C, BG, BP, Cholesterol, INR, etc)
– Disease state monitoring
– Potential adverse effects
• Provide interpretive tools to assist patients with barriers to taking
medication
• Ensure patient access to medications – including lower cost alternatives
and insurance formularies
• Medication reconciliation is
the process of comparing a
patient's medication orders
to all of the medications that
the patient has been taking.

• This reconciliation is done to
avoid medication errors such
as omissions, duplications,
dosing errors, or drug
interactions.
Phase 1 – Community Pharmacy Care Package

Transfer from Repeat Prescribing to eRepeat Dispensing (eRD) and the

development of a community pharmacy care package for patients
• Use of electronic repeat dispensing becomes the default prescribing
option where the prescriber wishes to prescribe on a long-term
basis
• The duration of each supply to the patient is determined by the
pharmacist and patient, with guidance from the prescriber, in order
to ensure it is based on clinical need and to seek to avoid
unintended wastage of medicines
• Patients are registered with an individual pharmacy to allow a
patient centred/holistic approach to supporting their use of
medicines
• Funding mechanism for the care package must ensure there is no
drive to dispense prescriptions where the patient has no need for
them
Phase 1 – Community Pharmacy Care Package

• Medicines optimisation support provided regularly

• Synchronisation of patient’s medicines undertaken to
support adherence and reduce waste
• Patient Activation Measure (PAM) and adherence scores would
be used to indicate the impact of pharmacy interventions,
including on the patient’s engagement with their health
• This will assist the targeting of pharmacy engagement with the
patient to improve adherence and optimise use of their
medicines, allowing the patient to set their own motivational
goals
Phase 1 – Inhaler technique checks/coaching

• Offer of an inhaler technique check and coaching

session to patients prescribed inhalers using eRD
at least twice a year
• A formal system for referral back to the prescriber
would be implemented for circumstances where a
referral is clinically necessary
Phase 1 – Prescription
Interventions
• Pharmacies already make interventions on prescriptions
• These are communicated to the prescriber but are not always
clearly recorded in patients’ pharmacy records
• Information on the interventions is not centrally collated and
therefore
the value of these interventions cannot be determined
• Under this proposal such interventions would now be clearly
recorded using a standard classification system and the data
would be centrally collated
• National and local (CCG) guidance would be provided to
pharmacies on target interventions
• Not dispensed interventions would fall within the remit of this
proposal
Phase 1 – Post-discharge MURs/
medicines reconciliation

• Post-discharge education should continue to be

provided
• Numbers should increase as communications
between hospital and community pharmacies
improve
• For some patients a full education may not be
required, but a medicines reconciliation
(conducted by support staff) would be of benefit to
all patients
• Further work is required to determine the
optimal approach to supporting patients post-
discharge and this may be a candidate for
support from the Pharmacy Integration Fund
Phase 1 – Pharmacy First service
Minor Ailments Advice Service & an
Emergency Supply Service
• To effectively implement such a service, review and
implementation would be required in order to
support the referral of more patients to the service
• Further development of IT infrastructure would
also be beneficial to support
• This is an area which the Pharmacy Integration
could improve
Phase 1 – Public Health Campaigns

• Each campaign could run within pharmacies for up

to 2 months
• This approach would allow to deliver a
consistent campaign message across the whole
pharmacy network reaching millions of people
at once
Phase 2 – Enhanced community pharmacy
care package for patients
All pharmacies will need to have access in place and have to provide the national
vaccination service

• Building on the development of the care

package in phase 1, additional elements would
be provided to patients registered to receive
the service
• These elements would support the
development of a pharmacy care plan with
the aim of optimising the patient’s use of
medicines, treatment of their condition and
improvement of their patient activation
score
Phase 2 – Enhanced community pharmacy
care package for patients

• Examples would include assessing for patients with COPD and

asthma, frailty and falls assessments and use of other screening
tools (building on the work of the Community Pharmacy Future
projects)
• Use of these tools would allow the assessment of the
impact of the community pharmacy support on the patient
and their condition
• As appropriate an annual education may be undertaken and
interventions would be provided when patients commence
new therapies
• Most of the interventions would be provided on an ongoing
and regular basis, generally as patients present in the
pharmacy to obtain their next supply of medicines
Phase 2 – Healthy Living Pharmacy or
equivalent accreditation

• In order to support the effective provision of public health

campaigns, pro-active healthy living advice and locally
commissioned public health services, pharmacies will
work towards achieving an HLP equivalent accreditation
• The training of support staff as health champions will
provide them with the skills to effectively support
behaviour change by patients and the public, related to
both healthy living and medicines optimisation
• A deadline by which pharmacies must be accredited
would be set and an ongoing requirement to ensure
that accreditation is maintained
 Phase 3

• During this phase the service developments

proposed in Phase 1 and 2 would continue to be
provided
• Pharmacies would additionally provide support
to specific groups of patients to manage long
term conditions, e.g. hypertension and asthma,
and more advanced support for frail and older
people with multiple conditions
• This would release further GP practice capacity
but it would also require the majority of
community pharmacists to be qualified as
independent prescribers (or for the Alberta
approach to prescribing qualification to be
adopted)
Other service developments and the future

DH has identified the provision of

additional clinical pharmacy support for
care homes as one area that needs to be
taken forward.
Community pharmacy can provide some of the
necessary support required by care homes
and patients living within them, but the
approach to team working with general
practice would need to be explored in order to
maximise the value provided to patients.
.
Overall, the outline proposals on how
community pharmacy teams could make a
more significant contribution to patient care.
Transforming Pharmacy Education For a Sustainable Tomorrow