CONTINUITY OF MEDICATION AND MEDICATION RECONCILIATION IN

PRIMARY CARE

Dr Charlotte Hespe

GP

TRIPLE AIM FOR PRIMARY HEALTHCARE

Improving the patient experience of care (including quality and satisfaction)

Improving the health of populations

Reducing the per capita cost of health care

PRIMARY CARE SERVICE DELIVERY Patient centred:

Preventive care

Acute care, exacerbation / presentation

Chronic disease / multimorbidity care

Palliative care

PATIENT CENTRED MEDICAL HOME

5 Universal features

•Patient-centred

•Comprehensive

•Coordinated

•Accessible

•Committed to quality and safety

PCMH

Comprehensive care

Coordinated

care

Committed to quality

and safety

Accessible

Patient centred

Template of the future

10.

Comprehensiveness and care

coordination

9.

Continuity of care

7.

Prompt access to care

8.

Population management

6.

Patient-team

Partnership

5.

Team based care

4.

Registration

3.

Data driven improvement

2.

Engaged leadership

1.

10 Building Blocks for quality patient

centred Primary care

IMPROVING QUALITY OF HEALTHCARE

1. Increased delivery of patient centred quality

primary care

2. Achieve accurate Electronic health records

with accessibility of high level data

3. Improved interoperability of IT systems

across the health system

4. Achieve increased levels of Health Literacy

CASE STUDY 1 Mrs B, aged 86. Gold card.

Lives at home (alone but supported by family members on a rostered basis)

Current Diagnoses: CCF, IHD, Prosthetic mitral valve, AF, Severe Renal Impairment, Osteoarthritis,

Osteoporosis, severe GORD, recurrent severe UTI (cause acute delirium), previous Pagets disease, Vertigo

(of unknown origin),bilateral glaucoma and dry eye syndrome.

“Team” includes: GP, Practice Nurse, 6 Specialists (Cardiologist x 2, Renal Physician, Gastroenterologist,

Ophthalmologist, Rheumatologist), 3 Allied Health specialists (OT, Physiotherapist, Podiatrist), Pharmacist for

Webster pack

Multiple medications including Warfarin, high dose Omeprazole and ranitidine, Digoxin, Metoprolol,

Paracetamol, Prochlorperazine, multiple eye drops (Latanoprost and lubricating gels and drops).

Requires weekly INR checks

Multiple allergies including to Sulfa and Penicillin

Over last 18 months has had 14 admissions to local tertiary hospital due to chest pain, UTI, headaches and

unstable BP, severe nausea and vertigo.

Problems:

Differing information re Digoxin dose

Warfarin monitoring and variable dose

Metoprolol

Antibiotics

SYSTEMS

Atul Gawande (TED2012 http://www.ted.com/talks/atul_gawande_how_do_we_heal_medicine)

“Making systems work is the great task of my generation of

physicians and scientists. But I would go further, and say that

making systems work

— whether in healthcare, education, climate change, making a

pathway out of poverty —

is the great task of our generation as a whole.”

SYSTEMS- CLINICAL MICROSYSTEMS

A small functional front-line unit that provides Healthcare

The microsystem includes the people who work together, the defined environment in which they work, the individuals who receive the care, the processes and activities needed to accomplish the work and the Information and IT that supports the work.

CASE 2 Mrs N, 63 yo

Married, lives in apartment with husband

Chronic Low back, hip, neck, shoulder pain (multiple cause but started in 1994)

Laminectomy in late 90’s : Neurosurgeon still overseeing care. Recommended surgery for ongoing pain management. Second opinion from Orthopaedic surgeon x 2 : Hip surgery not recommended

Major depression / Anxiety : Psychiatrist oversees therapy and prescribes SNRI, benzodiazepines x 2 (also known to drink excess ETOH in the evenings)

Underwent double laminectomy – complicated procedure/ pain +++ post surgery/ 2 week admission– discharged to Rehabilitation hospital for 2 weeks. Ongoing severe pain 8/10

Sent to GP for scripts for pain management on discharge home from Rehab

No formal discharge letter from initial hospital / Nurse discharge letter from Rehab.

Medications that patient verbally reported: Endone, Oxycontin SR, Panadeine Forte, Panadol Osteo, Pregabalin, Sertraline, Diazepam, Alprazolam, Temazepam

MEDICATION RECONCILIATION IN PRIMARY CARE Patient

Electronic Discharge letter (timely and hopefully accurate )

-information not always accurate (e.g. if transferred to multiple wards and ICU during admission then medication changes may have been lost in transfer)

Specialist letters

Community Pharmacy

Home visit / Health Assessment / Home Medication Review (partner with Pharmacist)

Family members

Hospital- talk to RMO or Medical records department (can be tricky as they will need patient consent)

Specialist rooms / mobile

INTEGRATED CARE AND INTEROPERABILITY OF DATA

SHARED ELECTRONIC HEALTH RECORD

Key features for useful sharing of electronic health records:

1. ACCURATE UP TO DATE DATA (patient demographics, allergies, vaccinations,

past medical history, current medications)

(Data Cleansing, Data Cleansing, Data Cleansing)

2. Practice policies that ensure the organisation's use of the e-health record system is

secure, responsible and accountable

3. Implement RACGP Computer and information security standards (CISS):

www.racgp.org.au/ehealth/security

4. Use coded IHI (from the Health Identifiers Service at Medicare)

Encourage and teach “health neighbourhood” to join in

HEALTH LITERACY

“the ability to obtain, read, understand and use healthcare

information to make appropriate health decisions and

follow instructions for treatment”

Low health literacy reduces the success of treatment and increases the

risk of medical error: up to half of patients cannot understand basic

healthcare information

ANY QUESTIONS?