15 August 2017

Chronic disease – the search for a better way

Government Pharmacy

The welfare of some 120 chronically ill patients in Victoria could open the way to more primary-care delivery at pharmacies and take the load off GPs in underserviced locations.

An 18-month pilot program will track the progress of patients with at least one of four common chronic conditions, who are under the care of GPs, but using consultant pharmacists for monitoring, follow-ups and medication adjustment.

The commonwealth’s far larger Health Care Homes initiative for chronic disease also seeks to involve pharmacists and other allied-health professionals, but that program has gained little traction due a lack of clear purpose and poor funding. By contrast, the small, narrowly-focussed Victorian trial has struck a chord.

The response from GP-pharmacy partnerships was such that the Victorian government has extended the pilot to four locations, up from three. “Interest has been so strong we have expanded the pilot,” Victorian Health Minister Jill Hennessy told The Medical Republic.

“That means more patients will be able to visit their local pharmacist to monitor chronic conditions and manage medications under the direction of their GP’s care plan.”

The state will give every participating pharmacy and general practice a grant of $21,500 each to compensate them for time spent on the project over the 18-month trial period, beginning in September.

The state will cover the cost of subsidising medications rather than the PBS, so the cost effect on pharmacies and patients will be neutral. The state will also fund the purchasing of relevant point-of-care testing devices.

Nine pharmacists from the four participating pharmacies are midway through a specially designed, month-long training program.

The focus on asthma, hypertension, hypercholesterolaemia and anticoagulation therapy means they will need to prove competence in skills such as spirometry and measurement and interpretation of blood pressure, lipids and INR levels.

The town of Kilmore, 60km north of Melbourne, is one of the four locations where consultant pharmacists will screen, monitor, advise and adjust medications for patients under the direction of GP partners.

Dr Daile Kincaid, principal of Kilmore’s Stepping Stones medical practice, says she jumped at the chance to team up with her local Amcal pharmacy for the pilot program. “I’ve been a GP for 20 years, and there are things that stand out as making good common sense. This is one of them,” Dr Kincaid said.

“It was a simple decision because it wasn’t going to add to my workload; in fact, it’s a really great example of (prioritising) outcomes for patients.”

The great appeal of the trial is its preventative nature, she says.

Under the scheme, up to 30 patients from each practice will have appointments with consultant pharmacists at least once a month according to the care plan.

Dr Kincaid opened her practice two years ago because she wanted to “do things differently” and promote community health.

Kilmore is an idyllic rural community where people get up in the morning and milk their cows, she says.  But like all sites in the pilot, it has high rates of chronic illness and doctors are overstretched.

“We have three GP clinics. T there are a lot of GPs. But it’s difficult to get appointments.”

She says doctors need to be realistic about the need for reinforcement of the education they give patients, one of the roles the pharmacists in the program can perform.

“Asthma is a good example. The technique is completely crucial to the efficiency of the medication.  It’s a serious disease that is often untreated. If we have got the pharmacist trained specifically to deliver the information, it’s a really good idea.

“Education becomes prevention. That’s a really key thing. If we have more education readily available when asthmatics get their scripts filled, we actually will have better management of asthmatics,” Dr Kincaid said.

Dr Kincaid expects to be in closer consultation with her participating pharmacy through the trial, responding to queries and reports while she maintains responsibility for patient outcomes.

“I suspect the training for the pharmacists will cover all the important things. But I guess the reality of how that works in general practice and what actually happens to the patient – I see myself in that role,” she said.

In Kerang, in the state’s far north, pharmacist Simon O’Halloran welcomes the pilot as a “unique opportunity” to close gaps in chronic disease care by having pharmacists and doctors work together instead of communicating through the patient.

“I am already seeing quite a lot of these (chronically ill) patients through the week,” he said. “Rather than them asking questions when something crops up, we are going to be working more proactively, having more formalised patient consultations and documenting and reporting the outcomes directly to the GP, so they have more timely access to any relevant measurements.”

Mr O’Halloran works at Terry White Chemist, Kerang, which has teamed for the pilot with Gannawarra Family Clinic in the Murray River border town. He is also a principal pharmacist at a dispensary over the NSW border and does mobile consulting work.

Among requirements for taking part in the pilot, the GP-pharmacy teams had to demonstrate a strong existing working relationship and the means to relay test results and information instantly using the cloud-based cdmNet system offered by Precedence Healthcare.

“I’d like to see a model where pharmacists and GPs work collaboratively to better manage the patient, as opposed to working somewhat in isolation where the GP sees the patient to assess, diagnose, and manage, and we see them to fill prescriptions and advise on medications,” Mr O’Halloran said.

“A lot can happen between those two points, and if the GPs and the pharmacists are not on the same page there can (be) gaps, and if they’re not working towards a common goal it might fragment care.  That’s where I’d like to see this program bring a distinct advantage, in bringing the patient to the forefront.”

Appointments with the GP-referred patients should be a “manageable workload” on top of walk-in business, as long as management made sure a consultant pharmacist was available at all times, as well as a dispensing pharmacist.

“Effectively, we already have that model of care, with two pharmacists doing professional services such as home-medication reviews, Medschecks and primary point-of-care testing,” Mr O’Halloran said.

He dismissed talk of turf wars with GPs as “silly”, adding many of the functions to be asked of pharmacists in the pilot were things they already did s uch as counselling, triaging and point-of-care tests.

“I think there’s a lot more we can do, and a lot more we can do better. It can’t simply be seen as something that works against doctors. There has to be a distinct benefit to better support doctors and absolutely to support the patient. Patients are the priority.”

As reported in the mainstream media, initial reactions to the Victorian pilot from the AMA and the RACGP a few years ago were prickly.

After the go-ahead was announced in January, RACGP President Dr Bastian Seidel said there were plenty of highly qualified GPs who were capable and willing to manage chronic disease for patients.

Woman on The Back of Scooter

The program is also designed to help reduce the workload of overstretched GPs

He said access to doctors did not seem to be much of a problem.

“The concern really is that sometimes patients are not able to afford to see their GP on a regular basis and that’s a direct consequence of the extension of the Medicare rebate freeze,” he said.

“Pharmacists are not going to offer services for free, either.”

More recently, AMA Vice President Dr Tony Bartone told The Medical Republic the important thing was to ensure the GP remained at the centre of patient care.

The aspect held out as controversial in earlier reports was that, under a GP care plan, a pharmacist would be able to adjust a prescribed medication if a target test measurement was not achieved within a stipulated time and if the GP so directed.

This, according to the Melbourne Age newspaper, would give pharmacists the power to “alter prescriptions” and shift patient care away from doctors.

Professor Jill Thistlethwaite, medical adviser at NPS, said it was important to note that all the pharmacists taking part in the trial were highly experienced and had close relationships of trust with their partner GPs.

Their training will consist of a month of online tuition and tests, and three days of face-to-face practical training at the end of August, related specifically to the tests they will be conducting and interpreting, as well as plans for communicating with GPs and what to do if a problem arises. The trainees are expected to be familiar with course components such as medication history-taking and best communication.

Practical training will be followed by an assessment including an eight-station OSCE, similar that taken by medical trainees, to ensure they meet the mark.

A practising GP and an advocate of inter-professional practice, Professor Thistlethwaite said the teaching of pharmacy had evolved over the past decade to put more emphasis on interactions with patients, adding the benefits of cooperation could flow both ways.

“Working as a GP in the UK, we had a pharmacist in our general practice for two days a week who helped us with our prescribing and looked at the efficiencies of our prescribing and best practice. That was exceptionally helpful,” Professor Thistlethwaite said.

She characterised the Victorian pilot as a “conservative” step into patient-centred chronic disease management which could, nevertheless, help inform the future of the commonwealth’s larger scheme.

Debbie Skinner, director of the Alexandra Medical Clinic, a pilot participant some 140km northeast of Melbourne, says the response of patients will be the key to the success of this particular care model.

As a nurse consultant in diabetes and wound management who works across spectrum of rural healthcare – in hospital, community health, aged care and the medical practice – she has seen a raft of projects designed to wring better results from thin resources.

“This is a way of seeing if the pharmacy-GP model is going to work better than the other things they have tried, such as nurse practitioners and medical assistants,” she said.

“Regular screening for INR and lipids could be fascinating for some patients,” she said, going on her long experience of diabetes management.

“It could be a motivating factor for INR and cholesterol patients to become more engaged in their care.

“However, different people need different motivations. The question is whether this type of pathway captures an audience and makes them more concordant with therapy, by engaging with another person as well (as the doctor). It’s a pilot. Let’s give it a try and see what works.”

Her clinic, which is under demand pressures after the death of her GP husband last year, would benefit from added data. For patients, easier access to health checks could lead to earlier interventions, more conversations and more useful clinical information.

She recalled her husband asking a patient, how are you managing your asthma? The patient said, “Good”. “Then I asked him, but how are you managing it? He said, ‘I don’t get out of my chair because I can’t breathe’.”

The story illustrated the need for “layered conversations” to get to clinical information.

The only urban location in the pilot is Whittlesea, in Melbourne’s northern suburbs, where GP services also appear to be in strong demand.

Dr Brian Murphy, principal of Whittlesea Medical Clinic, was dealing with emergency patients on both occasions we called to hear the circumstances of his involvement in the pilot program.

The project has been designed with input from an external panel, including doctors’ and pharmacists’ groups, the National Heart Foundation and the Asthma Foundation.

Harry Patsamanis, clinical strategy adviser at the Heart Foundation, said the care-plan model would give patients confidence the pharmacist knew what the GP wanted them to achieve and could provide practical help for them reach their blood pressure target.

“We know that the more people know they have high blood pressure and have it managed to target will significantly reduce their chance of having a heart attack. So we certainly see this is an opportunity to better manage people with medicines,” he said.

“The other thing that’s really important is that the care plan can include information about, and access to, lifestyle-behaviour programs – such as exercise and healthy eating – that the pharmacist can provide.”

Mr Patsamanis said pharmacists had the skill to trouble-shoot with patients on adherence issues and side-effects, and the expertise to go ahead with a dose adjustment or a second agent to manage hypertension,

But the pilot was inherently cautious.

“The GP sets the care plan, the GP identifies what the patient needs to achieve outcomes under the plan, the GP enlists support of the pharmacist to provide support as part of that care team.

“It’s a very structured way of assisting patients to better meet the outcomes we want to see as evidence-based practice.”

The CEO of the Asthma Foundation of Victoria, Danielle dal Cortivo, said interventions by pharmacists could help tackle the “disconnect” between how asthmatics were managed by GPs and their medication-taking behaviour, such as over-use of reliever medication.

“The pharmacist may see lots of people going in to get reliever medication, because that’s the only thing that works for their asthma. However, we know that what patients using their medication more than twice a week actually need is to engage with their GP about preventer medication that can manage the asthma.

“Certainly, the Asthma Foundation is very excited about these collaborative-type approaches, because it means people with asthma having access to people who can keep reinforcing key messages and better support them.”

GPs taking part in the pilot can claim the usual MBS benefits, and the enrolled patients will continue to cover their usual care and medication costs.

To be enrolled in the trial, patients must have established relationships with a general practice and a pharmacy, live in the community, have stable medications, no recent hospital admissions, and may not be pregnant or cognitively impaired.

Exclusion criteria also apply to each of the chronic illness categories.

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