Professional Documents
Culture Documents
Contents
1.
Executive summary
2.
Introduction
Review questions
3.
Background
4.
Shadowing the GP
Case studies
5.
10
10
10
11
12
12
13
Category: Diabetes
13
14
Category: Paperwork
14
15
ACKNOWLEDGEMENTS
Thank you to Penny Clark, Clinical Pharmacist at NorthCare, for consenting to being shadowed for two weeks. Penny also
provided the selection of case studies and answered many questions. We are also grateful to Dr Antony Raymont for his
helpful advice on the review and for providing a summary of NorthCare staff feedback (section 8) from the contracted IFHC
evaluation work before it was officially due. We also need to thank Sarah Farmer who is currently a pharmacy student at the
University of Auckland. She was employed by Midland Community Pharmacy Group to be Pennys shadow and gathered the
information used in the activity analysis section.
6.
16
16
Impacts on practice efficiency and quality potential time saving and emergency department
presentation/admission saves
17
Summary
19
7.
20
Method
20
21
22
23
24
25
8.
26
28
29
31
32
34
37
AUTHORS
Jenny West (Midlands Health Network), Janet Amey (Midlands Health Network), Cath Knapton (Midland Community Pharmacy
Group), Sam Illing (Midlands Health Network summer medical student).
SUGGESTED CITATION
Midlands Health Network (2012). Clinical Pharmacy in General Practice: a review of the first nine months. Hamilton.
Information in this report may be used freely provided the source is acknowledged.
1. Executive summary
In 2010, Midlands Health Network presented a business case to the Ministry of Health
that identified a number of strategies to provide better, sooner, more convenient health
care, including a strategy to develop integrated family health centres.
The business case was accepted, a project was established, and a range of health professionals including doctors,
nurses, pharmacists, and other allied staff, designed and developed a new model of care to not only address the key
issues facing the sustainability of health sector, but to also place the patient at the centre of their health care journey.
Five key strategies were developed including an expanded general practice team, improved access to services through
a patient access centre, system initiated contacts to provide proactive health care, virtual consultations, and new
strategies to streamline the patient experience.
Three proof of concept sites in Hamilton were chosen for the initial launch of Midlands Health Networks model of care
NorthCare Grandview Road, NorthCare Pukete Road and NorthCare Thomas Road. The first stage of the model of
care went live in April 2011.
Through the design and development stage, Midlands Health Network partnered with Midland Community
Pharmacy Group to develop one particular component of the model of care the extension of the general practice
team to include an expert clinical pharmacist (CP).
The CP role is designed to support the general practice team, have scheduled appointments with patients to
manage and monitor their medications, provide specialist input into the patients care plan, and liaise with local and
hospital pharmacies to make sure that medication-related information is transferred seamlessly. The CP is full-time
and works across all three NorthCare sites during the week.
Nine months after implementing the model of care at NorthCare, a review of the CP role was initiated to assess its
impact on the day to day operation at the three NorthCare sites.
The review focuses on the following operational questions:
What types of activities has the CP undertaken and what impact has this had on the three practices?
What effects do general practitioners (GPs) and practice nurses report the role of the CP has had on their daily work?
Data for this review was gathered by three main sources:
Data from an activity analysis of 10 days of the CPs work. This was gathered by a pharmacy student shadowing
the CP and classifying and timing all activities;
Data from medicine reconciliation post discharge forms; and
A summary of feedback from GPs and practice nurses regarding the impact the addition of the CP to the
general practice team has had on their daily activity.
The main impacts of the CP identified through this review are:
The CP has become a highly valued member of the general practice team;
The CP saves the GP time by undertaking specific tasks such as medicine reconciliation post discharge, an
activity previously undertaken by GPs, now allowing them more face-to-face time with patients;
The general practice team has benefited from having expert pharmaceutical advice on hand. This has saved
team members from having to do research and/or answer patient medication questions and enabled them to
move onto other patient activities;
Paperwork is often identified as the bane of general practice. The CP has undertaken both clinical and nonclinical-related paperwork leaving other members of the team to undertake other activity;
The CP has potentially avoided emergency department presentation or admission for some patients, or
re-admission post discharge due to timely identification of medication errors;
The CP has improved the quality of the service provided to patients enrolled at all three practice sites; there are
specific examples of harm reduction through the outcomes of timely medicine reconciliation and clinical review;
The CP has played an important role in the practice teams contribution to meeting health targets related to
diabetes and smoking cessation;
The CP has an impact on practice performance as measured through the annual Midlands Health Network Quality Plan;
The CP has improved medication management for patients. There are specific examples of patients identified who
had not been taking their medication regimes optimally the CP has been able to remedy these streamlining
processes for patients and improving quality of life in some cases;
The CP has been available to undertake medication education for patients. This would previously have been
done by GPs or practice nurses. The CP has been particularly useful in difficult cases or where patients have
been non-compliant;
The CP has improved care for those patients with high needs through proactively focusing on auditing patient files
where there has been frequent hospital admission, multiple medications or poor control of chronic conditions such
as diabetes. In addition, auditing has ensured practice alignment with current best practice guidelines.
At the commencement of the role the activities of the CP were left broad in scope. With the results of this review
it is time for the extended general practice team, Midland Community Pharmacy Group and Midlands Health Network
to decide how to configure the role moving forward in order to meet both patients needs and the practices workload.
Figure 1 below shows the summary of impacts (as identified through this review) on individuals, groups and organisations
affected by the introduction of the CP into the extended general practice team.
S av e GP t im e
E xt ra tea m member w or ki ng t o
m eet qual ity pe rformanc e targets
I ncrease GP
billable hours
Whanau / Family
I mp roved medicati on
m an agem ent
I ncreased s en se of
teamw or k in pat ie nt car e
I mp roved
quali ty of li fe
I ncreased a cc ess to
pharm acy ad vice & s ki lls
Patient
T ai lored educatio n
to me et need
Phone, ema il or F 2 F
a vail abilit y
Only on n eeded
m edication
2. Introduction
In 2011, Midlands Health Network introduced a new model of primary health care
at three integrated family health centre (IFHC) proof of concept sites in Hamilton.
Elements of the new model of care began to be implemented from April 2011.
The three NorthCare practices in Grandview Road, Pukete Road and Thomas Road have been developing and testing
the new model of care approaches on behalf of the wider network (see Appendix 1 for an implementation timeline). The
NorthCare sites had a combined total of 15,694 enrolled patients in September 2011 (see the two maps in Appendix 2).
One key strategy of the IFHC model of care is the expanded general practice team. The first phase of this strategy
commenced in April with the addition of a full-time clinical pharmacist (CP) to the team working across all three
NorthCare sites.
Review questions
The main review question was what has been the impact of the implementation of a full-time CP on the day to day
operational activity of the three NorthCare general practice sites. To answer this, the review concentrated on the following:
What types of clinical and non-clinical activities has the CP undertaken and what impact has this had on the
three practices?
What effects do general practitioners and practice nurses report the role of the CP has had on their daily work?
In addition, the CP recorded a number of brief case studies of interest to show real life examples of the role. These case
studies are anonymous and no patient identifying information is included.
3. Background
Adverse clinical consequences and increased economic costs related to medication
misuse, and medication-related problems such as non-adherence and suboptimal
therapeutic outcomes, are widely recognised by clinicians, policy makers, and health
care economists.
In New Zealand, these issues are accompanied by a huge growth in the number and complexity of available prescription
medications and a primary sector facing increased pressures on workforce capacity and capability. The Midland
Community Pharmacy Group has worked with Midlands Health Network to begin addressing these issues through the
development and implementation of the CP role within the IFHC model of care.
The role of the CP in the primary health care setting was designed to provide solutions to clinical consequences and the
economic costs of medicine misuse, medication-related problems, patient non-adherence and suboptimal therapeutic
outcomes. It was envisaged the CP role would provide an additional avenue to coordinate and improve the care transition
for patients as they moved from secondary care episodes back into primary care. The CP role at NorthCare was expected
to allow GPs more time to spend with patients with complex conditions and co-morbidities.
COMMUNITY PHARMACIST
The community pharmacists primary focus is on proving professional care to patients, supported by safe and effective
medication management and medication information. Services are provided based on the pharmacists assessment of
patient situations with the objective of optimising patients health. Community pharmacists in the Midland region are also
involved in implementating many additional health services such as:
Comprehensive warfarin counselling
Smoking cessation counselling
MUR medicine use reviews
Free emergency contraception for under 25s
Flu vaccination campaigns
Waste management and DUMP (Dispose Unwanted Medicines Programme)
Medication counselling for patients initiated on medicines for mild to moderate depression.
CLINICAL PHARMACIST
The discipline of clinical pharmacy requires an obligation to increase knowledge for the purpose of advancing health and
quality of life. Focus is placed on both pharmacologic and nonpharmacologic strategies. 2
Clinical pharmacists assume responsibility and are accountable for managing medication therapy for patients acting in
collaboration with other health care professionals. A CP is considered to be a drug therapy expert. This service helps
to avoid prescribing errors. They must be briefed on a patients medical information in order to provide drug therapy
recommendations to the health care provider.3
www.ehow.com/info_7761792_clinical-pharmacy.html
www.ehow.com/info_7761792_clinical-pharmacy.html
Shadowing the GP
Data regarding the CP role analysis was gathered by shadowing the CP for two weeks (10 working days) and recording
and timing all daily activities. This was undertaken by a pharmacy student (nine days) contracted to Midland Community
Pharmacy Group and a Midlands Health Network funded medical student (one day) using a form for each activity
developed specifically for the review. The CPs activities were recorded and analysed following headings (refer to
Appendix 4 for detailed definitions):
Total activity time and daily activity average;
Source of interaction referring to the person, group or event that triggered the activity, such as CP, GP, patient
or discharge summary (Dx);
Whether any face-to-face interaction(s) had resulted from a patient drop-in without appointment (walk-in), add-on
to an existing PN or GP consultation, or booked CP appointment;
Type of interaction, such as brief advice, medicine advice to staff, medicine reconciliation, paperwork and tests
or support given;
Where applicable clinical significance using the Midland Community Pharmacy Group intervention
classification system:
Very significant intervention(s) that potentially averted emergency medical attention or serious harm. This included
prevention of disability, impairment, damage or disruption in the patients body function/structure, physical activity
or quality of life, prevention of birth defects, prevention of serious drug toxicity or major adverse events.
Significant intervention(s) that avert routine medical attention, either through the improvement in patient care
and/or optimisation of therapy including decreasing length of hospital stays, risk of moderate or adverse symptoms,
preventing the exacerbation of a condition. For example preventing high blood pressure or improving blood
glucose control.
Minor intervention(s) resulting in minor improvement in patient care and/or optimisation of therapy that
includes improvement in quality of life, mobility or comfort, or in symptoms usually left untreated or treated with
non-prescription medicines.
Intervention that had no impact on the patient or their wellbeing.
Interventions harmful to the patient or may have had a harmful or negative impact on the patients wellbeing.
Non-clinical: efficiencies and improved quality;
Bureaucratic save: non-clinical and process focussed tasks that saved another practice team member time and
consequently reduced workload;
Money save: tasks that did or had the potential to save the patient, the practice or the health system money;
Emergency department (ED) save: tasks that did or had the potential to save an emergency department admission;
Save GP time: clinical tasks that did or had the potential to save GP time;
Save practice nurse time: clinical tasks that did or had the potential to save GP time;
Quality: Tasks that directly contribute to the achievement of quality performance indicator targets.
No patient identifying information was collected on the activity analysis forms. Completed forms were provided on a regular
basis to the Midlands Health Network team by the pharmacy student. Data was entered into excel over the two-week period
and analysed.
Case studies
Case studies were selected and provided to the Midlands Health Network team by the CP and no identifying patient
information was included.
Daily source
count average
Source %
CP
174
17
38.4
Discharge summary
105
11
23.2
GP
52
11.5
Practice support
46
10.1
Practice nurse
28
6.2
Patient
23
5.1
Pharmacy
1.5
PAC
0.7
0.2
Other
18
4.0
Grand Total
453
46
100
Source or initiator
10
Medicine Review or
Reconciliation
all
% of
13.6 ity
activ
Medication Issue
of all
4.5% ity
activ
Education and
Information
all
% of
24.1 ity
activ
ACTIVITY TYPE
Number
undertaken
Average time
per activity
Medicine Review
77 activities
29 minutes
Medicine Reconciliation
34 activities
35 minutes
1 activity
95 minutes
Drug interaction
10 activities
27 minutes
Recall
1 activity
95 minutes
Medication change
14 activities
44 minutes
Allergy
1 activity
2 minutes
ADR
11 activities
36 minutes
Advice to patients
53 activities
18 minutes
93 activities
15 minutes
Counselling patients
40 activities
34 minutes
Warfarin education
3 activities
16 minutes
10 activities
28 minutes
5 activities
48 minutes
Diabetes general
11 activities
40 minutes
CVRA
1 activity
25 minutes
Blood Pressure
3 activities
43 minutes
HbA1c
3 activities
62 minutes
Blister pack
3 activities
17 minutes
Labs organised
20 activities
28 minutes
Rx Issued
20 activities
29 minutes
Medication card
6 activities
34 minutes
29 activities
36 minutes
General deskwork
350 activities
11 minutes
SC standalone
11 activities
10 minutes
SC combined
8 activities
24 minutes
Referred
5 activities
19 minutes
Diabetes
of all
1.9% ity
activ
Tests or Support
of all
6.8% ity
activ
Paperwork
all
% of
45.9 ity
iv
t
c
a
Smoking cessation
of all
2.9% ity
activ
11
Medicine Review or
Reconciliation
all
% of
13.6 ity
activ
Number
undertaken
Average time
per activity
Medicine Review
77 activities
29 minutes
Medicine Reconciliation
34 activities
35 minutes
1 activity
95 minutes
ACTIVITY TYPE
The most time consuming activity, by activity average, involved the interventions of comprehensive clinical
medicine review, medication reconciliation and medication change. Changing medication and recalling a patient
to a screening appointment are not in themselves time consuming and records show they occurred alongside
more time consuming interventions.
With having only one comprehensive clinical medicine review occurring during the two week period, it is difficult
to accurately estimate the average duration of a CP medicine clinical review conducted at the NorthCare practices,
although the CPs previous work experience suggests a clinical medicine review takes between one and three hours.
To ultimately improve patient outcomes and to save additional practice time, internal CP referral procedures and
external marketing of CP services could be introduced with a view to increase the number being completed.
Medication Issue
of all
4.5% ity
iv
t
c
a
Number
undertaken
Average time
per activity
Drug interaction
10 activities
27 minutes
Recall
1 activity
95 minutes
Medication change
14 activities
44 minutes
Allergy
1 activity
2 minutes
ADR
11 activities
36 minutes
ACTIVITY TYPE
There were 11 activities to remedy adverse drug reactions (ADR) taking an average 36 minutes (range 10 to
90 minutes) involving either interaction between drugs or with a medical condition. The variance in activity duration
involving ADR was high with a recorded range of 10 to 90 minutes. There was one activity involving an allergy able to
be treated within two minutes.
There were 11 activities involving drug interactions taking an average 27 minutes to remedy.
12
Education and
Information
all
% of
24.1 ity
iv
t
c
a
ACTIVITY TYPE
Number
undertaken
Average time
per activity
Advice to patients
53 activities
18 minutes
93 activities
15 minutes
Counselling patients
40 activities
34 minutes
Warfarin education
3 activities
16 minutes
10 activities
28 minutes
A total of thirteen drug education sessions were held during the two weeks.
Because of the importance for self management and continual monitoring with anticoagulant therapies,
anticoagulant subcategories warfarin, clexane, and dabigatran were included.
Three warfarin education sessions were conducted and took between 10 and 20 minutes (average 16 minutes).
There where no clexane or dabigatran education sessions required, contrary to the numbers noted earlier in 2011
during which time dabigatran was launched onto the New Zealand pharmaceutical market.
10 other drug education sessions took an average 28 minutes ranging from five to 57 minutes in length.
Category: Diabetes
ACTIVITY CATEGORY
Number
undertaken
Average time
per activity
5 activities
48 minutes
Diabetes general
11 activities
40 minutes
ACTIVITY TYPE
Diabetes
of all
1.9% ity
activ
The categories Diabetes General, HbA1c and BG meter (blood glucose meter) involve the health management of,
and education for, patients with either type one or two diabetes. The general diabetes practice level interventions
involving medication advice and/or insulin adjustment averaged 40 minutes and ranged from seven to 95 minutes.
The wide range in time for activities involving diabetic patients reflects the varying levels of medication advice
diabetics can require. This depends on their current level of blood glucose management and the complexity
of their case.
Blood glucose management software enabling the download and reporting of blood glucose monitor data is
available for NorthCare patients to print reports to assist with their diabetes and insulin management. During the
two week task analysis the CP assisted with five blood glucose monitor downloads averaging 48 minutes and
ranging from three to 95 minutes.
13
ACTIVITY TYPE
Tests or Support
of all
6.8% ity
iv
t
ac
Number
undertaken
Average time
per activity
CVRA
1 activity
25 minutes
Blood pressure
3 activities
43 minutes
HbA1c
3 activities
62 minutes
Blister pack
3 activities
17 minutes
Labs organised
20 activities
28 minutes
Rx issued
20 activities
29 minutes
Medication card
6 activities
34 minutes
As a clinician in the therapeutic management of medications, the CP is qualified to take blood pressure
measurements and carry out CVRA.
Most test or support activities included organising labs and issuing scripts.
Category: Paperwork
ACTIVITY CATEGORY
Number
undertaken
Average time
per activity
29 activities
36 minutes
General deskwork
350 activities
11 minutes
ACTIVITY TYPE
Paperwork
all
% of
45.9 ity
iv
t
c
a
Over three quarters of activities (76.6 per cent, 350) had a paperwork component.
Paperwork included normal practice activities such as updating patient notes, amending long-term medication lists,
and disease and smoking coding.
The CP updated 29 patients long-term medicines lists.
14
Smoking cessation
of all
2.9% ity
iv
act
ACTIVITY TYPE
Number
undertaken
Average time
per activity
SC standalone
11 activities
10 minutes
SC combined
8 activities
24 minutes
5 activities
19 minutes
15
Significant
Minor
No. patient
impact
Harmful
to patient
Total
classified
% of
classified
CP
10
18
25
30
83
35.3
Discharge summary
13
15
30
64
27.2
GP
11
27
11.5
Hospital
diabetes nurse
0.4
PAC
0.9
Community pharmacy
2.1
Practice nurse
17
7.2
Practice support
13
5.5
Patient
12
23
9.8
Total Classified
26
55
76
78
235
100.0
% of Classifed
11.1
23.4
32.3
33.2
0.0
100.0
% of Tasks
5.7
12.0
16.6
17.1
0.0
51.4
Activity source
or initiator
16
Table 3: Time spent on discharge summaries (Dx) reviewed and medicine reconciliations
Discharge summary (Dx)
Time (minutes)
Time (hours)
540
416.5
6.9
Total
956.5
15.9
Reviewed
It is important to note that the following saves and improvements report the number of hours the CP spent carrying out
activities that contained elements of both actual and potential time and money saved.
In terms of total activity time, the CP is currently spending an average 5.9 hours per day carrying out activities with
an element of GP time saving (including the time spent on Dx and MRs as noted in table 5 above), and 1.2 hours per
day on activities with an element of practice nurse time savings (refer to Table 4).
Table 4: Number and time spent on activities with an element of time save
and/or quality improvement
Activity number
Activity time
(minutes)
Activity time
(hours)
Activity time
(hours) in
average day
Bureaucratic save
116
1420.5
23.7
2.37
Money save
112
2001.5
33.4
3.34
Emergency department
save (presentation or
admission)
23
739.5
12.3
1.23
GP time save
(including DX and MR)
281
3539
59.0
5.90
Practice nurse
time save
44
720
12.0
1.20
Quality
53
720
12.0
1.20
Save or Quality
Improvement
Note: A single activity may count in multiple categories so totals do not sum.
17
continued
The CP is reducing the non-clinical bureaucratic workload of other practice team members with an average 2.3
hours spent per day on activities with an element that saved another practice member from completing paperwork.
Examples include organising prescriptions, coding smoking status or updating a patients long-term medication
(LTM) or file notes.
Tasks that did or had the potential to save emergency department presentations/admissions and therefore the health
system money averaged 1.2 hours per day (refer to Table 6). Tasks that directly saved or potentially saved either the
patient, practice or health system money totalled 112 and concerned an average 3.3 hours CP hours per day.
Activities that directly saved or potentially saved either the patient, practice or health system money totalled 112 and
concerned an average 3.3 hours CP hours per day.
In addition to saving time and money, the CP is also having a substantial impact on quality improvement. A total of
53 activities involved work towards achieving quality goals that have a financial incentive based on performance.
Over the two weeks, a total of twelve hours or 1.2 hours per day were spent on tasks positively impacting the
Midlands Health Network quality programme. The quality goals most impacted by CP work were Diabetes Annual
Review (DARs), smoking status coding and smoking cessation.
To determine the actual freeing up of billable GP and PN hours for activities other than discharge review and
medicine reconciliation, any future analysis should be designed to measure the specific activity elements that save GP
and PN time.
18
Summary
The CP is improving patient outcomes through optimising treatment and preventing the need for medical attention
and/or serious harm.
Some 235 (51.4 per cent) activities undertaken by the CP since April 2011 were classified using a clinical intervention
classification system developed by the Midland Community Pharmacy Group. Of the total 235 tasks:
11.1 per cent (26) were classified very significant as it potentially or did avert emergency medical attention
or serious harm, or adverse event.
23.4 per cent (55) involved interventions classified as significant in that they averted routine medical attention
by either the improvement of patient care, optimisation of therapy or prevention of the exacerbation
of condition(s).
32.3 per cent (76) were minor in that they resulted in minor improvements such as the optimisation of therapy
to improve quality of life, mobility and comfort, or in symptoms.
Activities classified as having no direct patient impact totalled 78 (33.2 per cent).
There were no activities that categorised as dealing with events or interactions that were harmful or negatively
impacting the patient.
During the two week period, the CP spent an average eight hours per week reviewing discharge summaries and
5.9 hours carrying out medicine reconciliations. These have traditionally been GP activities.
Over the two weeks, CP activities that did or had the potential to save emergency department presentation or
hospital admission averaged 1.6 activities per day.
The CP carried out activities that contain an element of clinical and non-clinical time savings that free up GP and
practice nurse hours. In addition, the CP saves money for either the health system or patients (25 per cent of tasks)
and has a substantial impact on quality improvement (1.2 activity hours per day).
19
Method
Between 21 April and 28 October 2011, the CP analysed 627 discharge summaries (Dx) sent to the practice from Waikato
Hospital. The 627 reviewed by the CP represented those brought to her attention by practice support staff. It is now
operational policy to alert the CP of Dx receipt, but during the period of analysis, this was not the case and it is unknown
what percentage of Dx sent by DHBs the 627 represents. Dx analysed as having issues requiring further investigation had
a full medicine reconciliation completed with results being recorded on a medicine reconciliation post discharge form
(MR form). The MR form categorised reconciliations under the following event headings:
1. Whether completion took fewer or greater than 48 hours to complete from the time the practice received the Dx.
2. Contact(s) in the form of phone, face-to-face, or email required to complete the MR process. Contacts noted
where those made with the patient, GP, pharmacy or other services involved in the case. More than one contact
with a person or service provider and more than one type of contact were noted.
3. Where an error occurred on the Dx they were recorded under discharge summary interventions in one of the
following categories:
a. Medicine missing where the medicine was on the patients MedTech practice notes but missed off the patients
hospital records for the duration of their stay in hospital and at point of discharge;
b. Incorrect medicine doses listed on the Dx;
c. Interactions between known medications on the Dx, or, over the counter (OTC) medications, or known
medical conditions;
d. Error on Dx summary including events where there were Dx double ups, the Dx had not been sent to the practice
or the hospital had not completed one, the Dx was incomplete or contained a lack of information, and when Dx
were received for patients not enrolled at the practice. These errors often required contact with the hospital ward
or doctor, and for patients not enrolled at the practice contact with the correct practice.
4. Practice level interventions noted in response to medication Dx errors where:
a. A medication was not listed on the long-term medication (LTM) section of the patients file, meaning the practice
did not know the patient had been prescribed a medicine;
b. The LTM needed updating, and whether medications were removed and/or added;
c. A further prescription needed to be issued;
d. A laboratory referral was required;
e. Recall inputted meaning the patient required to be contacted to advise or remind them of a follow up or referral.
20
5. Adherence and support services in the form of patient counselling, blister packs issued, or referral to health
support services outside the practice, eg. diabetes clinic.
6. Referrals to pharmacy for:
a. Medicine use review (MUR) where patients with adherence issue or whom require support can be treated and
advised face-to-face by the MUR travelling pharmacist;
b. Smoking cessation support and treatment;
c. Warfarin counselling.
Out of the total 627 discharge summaries (Dx) received by the NorthCare practice, a full medicine reconciliation post
discharge was required for 214 (31 per cent). The Midlands Health Network team collated and analysed the data recorded
on MR Forms using Microsoft Excel 2007.
% of MRs
completed
% of Dx
reviewed
Medication missing
32
13.6
5.1
Incorrect dose
27
12.6
4.3
Medication interaction
11
5.1
1.8
Error on Dx
17
9.9
2.7
Total
87
Error type
21
Table 6: Number and percentage of practice level intervention type required after MR
Number
% of MRs
completed
% of Dx reviewed
51
19.6
8.1
LTM updated
141
65.9
22.5
62
29.0
9.9
82
38.3
13.1
Rx printed
19
8.9
3.0
Lab referral
35
16.2
5.6
Recall inputted
41
19.2
6.5
431
Total
22
Contact
% of all MR contact
Patient
191
89.3
GP
122
57.0
Pharmacy
116
54.2
Hospital
27
12.6
Other services
11
5.1
Table 8: Number and percentage MR requiring one contact or more than one contact by type
One contact
% having one
contact
% Requiring more
than once contact
Patient
169
79.0
22
17.3
GP
120
56.1
1.6
Pharmacy
105
49.1
11
8.7
Hospital
22
10.3
3.9
Other services
11
5.1
0.0
Contact type
23
Table 9: Number and percentage of MRs leading to interventions of support/referral for support
Support Category
Number
Patient counselling
129
60.3
Blister packs
10
4.7
10
4.7
1.4
0.5
Pharmacy warfarin
1.4
156
Total
24
25
26
27
Detail
Mid 2009
Midlands Health Network CEO presents on new model of care to Primary HealthCare Ltd (PHCL) staff
June 2010
October
December 2010
Workshop 1: the model of care; Workshop 2: system initiated contacts; Workshop 3: contact management;
Workshop 4: pre-consult consult
February 2011
28 March
Site blessing
29 March
1 April
4 April
11 April
11 April
Clinical pharmacist joins the general practice team working across all three sites
10 May
30 May
30 May
2 June
July onwards
28
16 August
Re-setting workshop
September
18 October
Rounding begins
7 November
December
Rooming implemented at NorthCare Pukete Road (facility constraints at Thomas Road and Grandview Road sites)
LEGEND
NorthCare Grandview Road
Principal highway
Enrolled Patient
Hamilton city
locality boundary
29
LEGEND
NorthCare Grandview Road
Principal highway
Enrolled Patient
Hamilton city
locality boundary
30
Time:
Charge:
GP request
Source of interaction
NHI:
Pt
Practice support
Pharmacy
Dx - <48h >48h
Nurse request
CP initiated
Reason
F2f info
F2f walk in
F2f add on
Brief advice
Med chg
Counselling
F2f bkd
Smoking
Referred
New Stop
Combined
LTM updated
Med reconciliation
Stand alone
Education
Warfarin
Admin
Rx issued
BP
Labs organised
CVRA
Recall (circle)
Im / Cerv / Flu / DARs / Br
Diabetes gen
BG meter
Clex
HbA1c
Dabigatran
Med card
Blister pack
Allergy
Other
Other
Information
T1
T2
T3
Strategies used
Referred to
GP
PN
Pcy
Other
Advice from
GP
PN
Pcy
Other
Intervention classification
Pt contacts
V. signif
Bureaucratic save
Signif
Money save
Minor
Save ED
No pt impact
Save GP time
Harmful to pt
Phone-Ms
Letter
Txt
31
ii.
iii.
iv.
v.
A comprehensive clinical medicine review usually involving 1-3 hours research to improve patient
outcomes and save practice time in the long-term
vi.
Brief medicine review being a shorter version of the comprehensive clinical medicine review that
is a straight forward review of medication
vii. Administrative tasks that include checking lab test results, updating of patient notes on the patient database
MedTech, sending and receipt of emails, registration with professional
viii. Facilitating Rx issue
ix.
Labs organised
x.
xi.
xii. Recall of patient for immunisation (Im), cervical smear (Cerv), influenza vaccination (Flu), Diabetes Annual
Review (DARs), and breast screening (Br)
xiii. Adverse Drug Reaction (ADR) intervention
xiv. Drug interaction where medication(s) is interacting, either with another medication or condition, to cause
adverse or unintended side effects
xv. Allergy to a drug leading to change of medication
xvi. Smoking Cessation (SC):
1. Patient referred by CP to another party, eg. community pharmacy or practice nurse, for SC counselling
2. SC combined as part of another patient interaction
3. SC provided as a stand alone consultation and primary intervention
xvii. Education in the form of warfarin, clexane and dabigatran information, general diabetes information
including medication and lifestyle factors, and blood glucose meter data downloads for trend analysis.
32
b. Tests or support:
i.
Blood pressure
ii.
iii.
HbA1c
iv.
Medication card containing all patient medications and dosage supplied to patient
v.
vi.
Blood glucose monitor downloading a patients blood glucose tester data to graph trends for disease
or insulin medication management
Tier One task query that requires no research and took less than five minutes
ii.
iii.
Tier Three complex medical query that required significant, eg. 30-120 minutes, research
iv.
Strategies used refers to research sources other than MedTech patient notes, such as literature search
source, contact with pharmacy, specialist advice.
33
Task duration
(minutes)
Average task
duration
Task duration
(hours)
5/12/2011
38
443
11.7
7.38
6/12/2011
34
452
13.3
7.53
7/12/2011
51
540
10.6
9.00
8/12/2011
45
543
12.1
9.05
9/12/2011
55
436.5
7.9
7.28
12/12/2011
54
486
9.0
8.10
14/12/2011
42
493.5
11.8
8.23
15/12/2011
41
515
12.6
8.58
16/12/2011
51
609
11.9
10.15
20/12/2011
46
464.5
10.1
7.74
60
1.00
457
5042.5
11.0
84.04
Date
* Time spent travelling between the three NorthCare practices has been calculated based on one single travel time
recorded to and from each practice site multiplied by the number of times the CP travelled to and from the particular
practice. As the act of travelling has no impact on clinical outcomes the number of trips taken has been omitted from the
total task count, but because travel is required to fulfil the CP role within the three separate practices, it is included in the
overall task duration total.
34
Table C : Type of intervention by activity number and percentage, duration average and
range ranked by highest to lowest activity number
Task type
Number
% of tasks
Average time
Max. time
Min. time
Paperwork
350
76.6
11.2
110
0.5
93
20.4
14.5
90
77
16.8
28.9
110
Brief Pt advice
53
11.6
18.2
70
Counselling
40
8.8
33.9
95
10
Medicine reconciliation
34
7.4
34.5
110
12
LTM updated
29
6.3
35.7
95
Labs organised
20
4.4
28.2
90
Rx issued
20
4.4
28.5
95
Med change
14
3.1
44.4
95
Diabetes general
11
2.4
40.1
95
ADR
11
2.4
35.5
90
10
SC stand-alone
11
2.4
10.1
30
10
2.2
28.2
57
Drug interaction
10
2.2
26.9
90
SC combined
1.8
23.5
50
10
Med card
1.3
34.0
90
BG meter
1.1
48.0
95
SC referred
1.1
18.8
50
HbA1c
0.7
62.3
95
BP
0.7
43.0
95
Blister pack
0.7
17.3
19
15
Education warfarin
0.7
16.0
20
10
Other
0.4
15.5
17
14
0.2
95.0
95
95
Recall
0.2
95.0
95
95
CVRA
0.2
25.0
25
25
Allergy
0.2
2.0
Clexane education
0.0
0.0
Dabigatran education
0.0
0.0
825
100.0
11.0
110
Total
35
Add on
Booked
Walk in
Total
% of Total
CP
28
DX
16
GP
12
PN
Practice support
Patient
36
Pharmacy
PAC
Total
15
25
100
% of Total
24
60
16
100
100
Just under half (12, 48 per cent) of the face-to-face consults involved counselling, and 10 or 40 per cent a brief medical
review. Almost all involved paperwork, usually in the form of updating patient notes and/or long-term medication list.
Five (20 per cent) involved giving medical advice to staff upon request and six (24 per cent) were implicated as a result
of a medicine reconciliation triggered after analysis of a discharge summary (Dx). Further analysis on a larger sample of
face-to-face consultations could be done to validate these results.
Non face-to-face contacts made with patients were mostly made by phone (97.7 per cent), either to have a conversation
(71.1 per cent) or leave a message (26.6 per cent). One (0.8 per cent) email and two (1.6 per cent) letters were written.
36
Number
Percentage
Phone conversation
91
71.1
Phone message
34
26.6
0.8
Letter
1.6
Text
0.0
Total
128
100.0
PATIENT:
Contacts
Time taken
Comments
Patient
GP
Pharmacy
Hospital
Other Services
Dx summary interventions
Med missing (was on prior to
admission but missed off while
in hospital and at discharge)
Incorrect dose
Interaction
Error on Dx summary
Adherence / Support
Patient counselling
Blister packs
Referral to support service
(eg. diabetes clinic)
Referral to pharmacy
MUR
SC
Warfarin
37
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