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Primary Health Care & Health Promotion College of Pharmacy Qatar Primary Health Care-2008 "The Foundation for Health and Wellbeing" The Team Approach in Asthma Management: A Primary Health Care Model from Qatar Nadir Kheir PhD FNZCP MPS Assistant Professor, Founding Chair Clinical Pharmacy & Practice College of Pharmacy, Qatar University College of Pharmacy- NKheir 3rd Nov 2008 1 ! Primary care should be positioned as part of an overall strategy for health promotion, disease prevention and population health. College of Pharmacy- NKheir 5. 6. 7. 3 Ottawa Charter for Health Promotion Primary Health Care Parameters 1. 2. 3. 4. 3rd Nov 2008 The first level of contact with the health system; Accessible and Affordable; Participatory (involves community participation); Empowering (encourages individuals to take more responsibility for their own health); Initiating a continuing health care process which systematically identifies those at-risk and ensures illness prevention, health promotion, treatment, and rehabilitation; Providing service through multi-disciplinary teams; Based on practical, scientifically sound and socially acceptable methods, and encourages appropriate uses of technology. First International Conference on Health Promotion Towards a global public health movement Built on WHO’s “Targets for Health for All”; Defined health promotion as: “ the process of enabling people to increase control over, and to improve, their health”; ! Promoting health is promoting the multidimensional context of health ! ! ! ! Ottawa Charter for health promotion. First International Conference on Health Promotion 1986, Ottawa-WHO/HPR/HEP/95.1 College of Pharmacy- NKheir 3rd Nov 2008 2 College of Pharmacy- NKheir 3rd Nov 2008 4 Medical Care We now know there is: a need for pharmacists to shift their focus a need to target outcomes that matters a need to take responsibility for outcomes ..thereby, a need to provide patientcentered care Physiotherapy Care “The cooperative, responsible provision of drug therapy for the purpose of achieving definite outcomes that improve the patient’s quality of life” 3rd Nov 2008 5 College of Pharmacy- NKheir Geriatric Care Pharmaceutical Care Maternal Care Medical Care Eye Care Surgical Care 3rd Nov 2008 Kheir’s Version 7 Nursing Care Physiotherapy Care Dental Care The Patient xx Pharmaceutical Care The Patient Nutritional Care Hepler & Strand, 1991 Paediatric Care Mental Health Care Pediatric Care Hepler & Strand’s Vision of Pharmaceutical Care: College of Pharmacy- NKheir Dental Care xx • • • • Nursing Care Mental Health Care Geriatric Care Eye Care Nutritional Care College of Pharmacy- NKheir Maternal Care Surgical Care 3rd Nov 2008 6 Strand, Morley, Cipolle, 2004 College of Pharmacy- NKheir 3rd Nov 2008 8 Medication Management Service: A Model for Primary Healthcare Services in Qatar ! ! 1. 2. 3. 4. A range of patient-centered services that improve the use of medicines Patients may be referred to the service by the following: The treating doctor; The pharmacist; A patient may make self-referral Any other healthcare provider Patient Category Pharmacist’s Role 2. Patients with actual or potential DRPs The pharmacist shall follow structured process to identify actual or potential drug-related problems and shall develop a plan to eliminate or minimize these problems and maximize desired outcomes Competence Standards For Medicines Management Services, Pharmacy Council of New Zealand, 2005 College of Pharmacy- NKheir 3rd Nov 2008 9 College of Pharmacy- NKheir 3rd Nov 2008 11 Seven categories of patients who may benefit from the MMS Patient Category 1. Patients on polypharmacy College of Pharmacy- NKheir Pharmacist’s Role "The pharmacist shall check each drug for indication, effectiveness, safety, and compliance. "The pharmacist may suggest reduction of doses or drugs "The pharmacist shall advice on how to minimize adverse effects, and on best timing to take each drug in relation to other drugs, meal times, daily activities, etc 3rd Nov 2008 10 Patient Category Pharmacist’s Role 3. Patients who require education to improve their compliance with drug therapy The pharmacist shall work with the patient to maximize compliance with drug therapy through conducting an interview to gauge the reasons for poor compliance and devising plans to improve compliance and concordance College of Pharmacy- NKheir 3rd Nov 2008 12 Patient Category Pharmacist’s Role Patient Category Pharmacist’s Role 4. Patients on medicines which require the use of devices (asthma inhalers) or who use devices to monitor diseases status (glucometers, peak flow meters) The pharmacist shall identify problems with how the patient use the drug giving devices and provide train the patient on the proper use of theming to maximize the benefit of the drugs. For example, the pharmacist may check inhaler technique 6. Patients who request the use of the service to discuss other drug-related problems and issues Patients may request the use of the service to discuss other issues associated with drug therapy or where they require to speak in private manner with the pharmacist about drug therapy problems College of Pharmacy- NKheir 3rd Nov 2008 Patient Category Pharmacist’s Role 5. Patients on potentially harmful drugs which require education and monitoring (warfarin, steroids, chemotherapy) The pharmacist shall educate the patients on the use of drug with potential for serious adverse effects or for drug-drug or drugfood interactions, and also those drugs which require monitoring to avoid harmful effects College of Pharmacy- NKheir 3rd Nov 2008 13 14 College of Pharmacy- NKheir 3rd Nov 2008 Patient Category Pharmacist’s Role 7. Patients referred by their clinicians Clinicians may wish to refer specific patients to the service when they identify an issue where the pharmacist might have appropriate input College of Pharmacy- NKheir 3rd Nov 2008 15 16 Asthma: A Model A model condition for which there is no Cure Prevalent, and climbing Needing a Multidimensional team approach Has defined treatment protocols, and outcomes Impact on healthcare services & budget Impact on other outcome measures: - Productivity -Schooling ! Severely compromises QoL: -Restrictions on daily activities & work -Difficulties in controlling symptoms -Poor social & psychological functioning ! ! ! ! ! ! College of Pharmacy- NKheir 3rd Nov 2008 Source: BMJ, 1996 17 College of Pharmacy- NKheir 3rd Nov 2008 19 What do we know about asthma status and control worldwide? ! In Australia, 45% of candidates for reliever use are not taking one ! 30% of candidates for a preventor are not taking one ! In New Zealand, 49% of asthma patients are undertreated ! 71% of children with asthma are under-treated ! However, 80-85% of asthmatics are satisfied with their asthma control ! Out of these, 40% of children missed > 5 days of school/yr ! ..and 20% of adults were off work 3-4 days/yr ! ..and 33% had either been in hospital or treated in A&E ! 20% of asthmatics are using >10 puffs/day of reliever & think their asthma is well controlled College of Pharmacy- NKheir 3rd Nov 2008 18 College of Pharmacy- NKheir 3rd Nov 2008 Jenkins, C. An update on asthma management. Internal medicine journal. 2003; 33:365-71 20 Evidence from Research It's not all about inhaler technique ! Patients under-use their preventor therapy ! Patients over-use their reliever therapy ! Patient have poor understanding of asthma ! Patients might be on poly-pharmacy ! Patients may have misconceptions about asthma therapy ! Preventative therapy might be under-prescribed Emmerton L, Shaw J, Kheir N. Asthma management by New Zealand pharmacists: a pharmaceutical care demonstration project. Journal of Clinical Pharmacy & Therapeutics 2003;28(5):395-402. College of Pharmacy- NKheir 3rd Nov 2008 Mehuys E et al. Effectiveness of pharmacist intervention for asthma control improvement. Eur Respir J. 2008; 4:790-9 Community pharmacy-based programs can significantly improve therapeutic outcomes in adult asthma patients Barbanel D et al. Can a selfmanagement programme delivered by a community pharmacist improve asthma control? A randomised trial. Pharm World Sci. 2007; 29(3):228-39 A self-management programme delivered by a community pharmacist can improve asthma control in individuals recruited at a community pharmacy. Pauley TR et al. Pharmacistmanaged, physician-directed asthma management program reduces emergency department visits. The Annals of Pharmacotherapy 1995; 29(1): 5-9. The comprehensive asthma management program reduced the number of ED visits for acute exacerbations of asthma. 21 Community Pharmacy Asthma Self-management Program Final Report December 2005, The University of Sydney, Faculty of Pharmacy Key Elements for Optimal Asthma Management 1. Assessment of asthma severity ! Medication adherence scores in the Intervention Group improved significantly over time (p=0.04), whilst Control Group scores did not (p=0.64). ! Asthma self-efficacy scores in the Intervention Group improved significantly over time (p=0.01) whereas Control Group scores did not (p=0.95). ! Asthma quality of life scores improved significantly for intervention Group over time (p<0.01). (Step 1) 2. Achieving best lung function (Step 2) 3. Identifying and avoiding triggers (Step 3) 4. Optimizing medication (Step 4) 5. Developing an action plan (Step 5) 6. Educating and reviewing regularly Centre for Asthma Monitoring. Health care expenditure and the burden of disease due to asthma in Australia. (Step 6) Australian Canberra: AIHW; 2005. College of Pharmacy- NKheir 3rd Nov 2008 22 College of Pharmacy- NKheir 3rd Nov 2008 24 The Asthma Support Center QP Pharmacy- Doha Healthcare Centre 1 The Multidisciplinary Approach in Asthma Management: The Asthma Clinic and Support Centre QP-MS Philosophy of Practice: ! An important element of optimal asthma management is for people with asthma to practice productive selfmanagement behaviors. Critical Elements ! Adopting a patient-centered approach to the problems patients were encountering with their asthma; ! Applying a structured, stepwise cognitive-behavioral model of asthma self-management; patient education; support; and feedback to facilitate the acquisition of lifelong asthma self-management skills. Nurse: Doctor: Diagnose Prescribe Monitor Referral Pharmacist: Patient education Care planning Monitoring Documenting Referral 1: Kheir N. Proposal for an asthma care centre in Ras Abu Aboud Clinic, QP Pharmacy, CPDP preserntation, RAA Clinic, 2007. College of Pharmacy- NKheir 3rd Nov 2008 25 Appointments Patient education Follow-up Documenting Referral College of Pharmacy- NKheir 3rd Nov 2008 27 Why to refer to a Pharmacist? Aim: 1. To develop a Pharmacy-based referral Asthma Support service in which the pharmacist takes proactive, patientcentered, outcome-oriented role in asthma management. 2. To work collaboratively with the patient, the physician and the nurse to provide comprehensive asthma care College of Pharmacy- NKheir 3rd Nov 2008 26 ! A new healthcare team (patient + carers as one team) ! Limited doctor-patient interaction time ! Pharmacotherapy (education, monitoring, safety) is principal role of the Pharmacist ! Integral part in the move of Pharmacy from robotic dispensing and inventory control to patient care and accountability for outcomes ! We use our training, experience and interest College of Pharmacy- NKheir 3rd Nov 2008 28 … and also, if relevant: Who to refer? 1. 2. 3. 4. 5. 6. Patients newly diagnosed with asthma and for whom initial therapy was prescribed Returning patients with poorly controlled asthma after being examined by the physician Patients with apparent poor compliance with asthma medication Patients with suspected poor inhaler technique Patients who need asthma education (selfreferred) Asthma patients on multiple drugs College of Pharmacy- NKheir 3rd Nov 2008 ! Checks the entire drug & medical history: # # # # # # 29 Comorbidities Drug doses Potential interactions Adverse effects Need for the drug, etc College of Pharmacy- NKheir 3rd Nov 2008 31 Medication history What does the Pharmacist Do? Demographic, Medical, Medicines, Behavioural, Social Plans and institutes education on asthma Teaches inhaler technique Assesses compliance Develops individualized asthma action plan Teaches the use of symptom diaries and Peak Flow Meter ! Makes recommendations to the doctor ! Monitors progress ! Documents intervention and undertake small-scale research ! ! ! ! ! College of Pharmacy- NKheir 3rd Nov 2008 30 Assessment of therapy Identification of drugrelated problems Follow up Goals of therapy met? DRP resolved? Ongoing monitoring Primary-secondary care continuum Report send to GP & Feedback from GP Medication Review Clinic Bringing everything together Documentation Care Plan Establish Goals of Therapy Patient education Verbal and written counselling Followup appt booked Electronic records Audit DRP College of Pharmacy- NKheir 3rd Nov 2008 32 Foundation Other models to follow • Cooperation: team-work and mutual respect • Treating the patient as partner • Assuming and accepting responsibility • Shift of focus • Target: Improving Outcomes • Ability and desire to follow-up ! Diabetes care centre ! Dislipidaemia care centre ! Other services? College of Pharmacy- NKheir 3rd Nov 2008 33 35 ! Asthma is a chronic condition that compromises the patient’s QoL and that has heavy financial cost ! Pharmacists can work in a multi-disciplinary team to improve asthma outcomes ! To provide effective service, the pharmacist needs specialized training in medication management services and Pharmaceutical Care ! Implementing this model would prove costeffective, and would pave the way for extension to other services ! Intensive and directed asthma counseling ! Developing and publicizing Asthma Action Plans ! Conducting asthma management workshops for pharmacists ! Providing training on Pharmaceutical Care principles ! Agree on documentation plans 3rd Nov 2008 3rd Nov 2008 Summary Asthma Care College of Pharmacy- NKheir College of Pharmacy- NKheir 34 College of Pharmacy- NKheir 3rd Nov 2008 36 http://www.scielosp.org/img/fbpe/rpsp/v4n2/4n2a16fpg.gif