PROPOSAL OF ESTABLISHING A DIABETES MEDICATION THERAPY ADHERENCE CLINIC (DMTAC) IN HOSPITAL TUANKU AMPUAN NAJIHAH

DIABETES

MEDICATION THERAPY ADHERENCE CLINIC (DMTAC)

PROTOCOL

IN

HOSPITAL TUANKU AMPUAN NAJIHAH,

KUALA PILAH

PHARMACY DEPARTMENT

HOSPITAL TUANKU AMPUAN NAJIHAH

REVISED JANUARY 2013

PROPOSAL OF ESTABLISHING A DIABETES MEDICATION THERAPY ADHERENCE CLINIC (DMTAC) IN HOSPITAL TUANKU AMPUAN NAJIHAH

1. Introduction

Medication Therapy Adherence Clinic (MTAC) is a clinic operated by pharmacists who provides counseling and education to patients with the purpose of helping them to improve their ability in self-managing condition and thus preventing deteriorating in symptoms. The goal is also to ensure seamless transition of patients from in-patient care to the out-patient clinic system (hospital/health community)

2. Objectives

a) To maximize the benefits of medication therapy in diabetic patients.

b) Reduce adverse effects and complications resulting from multiple drug regimen.

c) Assist physicians in the management of patients placed on anti-diabetic therapy.

d) To educate patients about diabetes and its complications, proper self management and the use of medications and self-care devices.

e) To provide consultative services to physicians and other healthcare professionals on diabetes medications and related issues.

f) To reduce the emergency room visits of patients and decreasing the total healthcare costs of diabetes.

3. Justification

To dispose problematic and uncontrolled Diabetes Mellitus patients on medications to the appropriate clinic for continued treatment based on HbA1c readings and Fasting Blood Glucose as measuring parameters.

4. Man Power

a) Consultant/specialist

b) Medical Officer

c) A Pharmacist

d) A Staff Nurse

e) A Laboratory Technician

5. Price Estimation And Specifications

An estimation of RM is needed in establishing a Diabetes Clinic.

5.1 Specifications Needed:

a) A room in MOPD Clinic for pharmacist to conduct counseling sessions (with a suitable table and 2 chairs for pharmacist and patient)

b) Printing materials eg DM booklet, patients recording book, patients profile, flip chart etc.

c) Glucometer and blood glucose testing strips for testing patients Fasting Blood Glucose on day of MOPD visit

d) Cabinet to store documents, records and patients profile

e) Reagent to run HbA1c test every 3-6 months

f) Relevant stationaries

DIABETES MEDICATION THERAPY ADHERENCE CLINIC (DMTAC) PROTOCOL

1. Location

The DMTAC clinic is located in MOPD.

2. Objectives

a) Maximize the benefits of medication therapy in diabetic patients.

b) Reduce adverse effects and complications resulting from multiple drug regimen.

c) Assist physicians in the management of patients placed on anti-diabetic therapy.

d) To educate patients about diabetes and its complications, proper self management, and the use of medications and self care devices.

e) To provide consultative services to physicians and other healthcare professionals on diabetes medications and related issues.

f) To reduce the emergency room visits of patients and decreasing the total healthcare costs of diabetes.

3. Policy

All patients currently managed in the diabetes clinic. As appropriate, other patients may be referred from the medical out-patient department.

4. Diabetes Clinic Implementation

On a typical DM clinic day, a minimum of 1 pharmacist is in the clinic. The DMTAC pharmacist is multitasking duties throughout the day, assessing patients and addressing their needs, documenting actions and plans, giving appropriate education to patients, and doing follow-ups.

DM clinic day of Hospital Tuanku Ampuan Najihah will operate from 8.30am to 1pm every Thursday.

5. Patient Selection

a) Uncontrolled Diabetes

Fasting Blood Sugar (FBS) > 10.0 mmol/l

Random Blood Sugar (RBS) > 15.0 mmol/l

HbA1c > 10%

b) Diabetes with other complications (macrovascular or microvascular)

c) Diabetes with other co-morbidities (eg Hypertension, Hyperthyroid, Asthma etc)

6. Procedure

Enrolling patients into MTAC

1. During the initial interview, the following will be reviewed with the patient:

(a) DMTAC mission

(b) Anticipated benefits to the patients

(c) Goals of patient or care giver

(d) Patient specific drug therapy related need and goals

(e) Patients rights and responsibilities to the program

2. Upon agreement to enroll into the program, patients will be attended to sign an informed consent form, allowing their information to be released to them or shared among healthcare professionals involved in their care for the sole purpose of providing critical information needed for coordination of their care, unless they otherwise direct

Refer DM/HPT/Lipid-MTAC/HTAN/F1

Initial Assessment by the MTAC pharmacist

Refer to DM/HPT/LIPID-MTAC/HTAN/F2(2) Patients pharmacotherapy review form

Refer to DMTAC/HTAN/F2 knowledge assessment

Refer to DMTAC/HTAN/F1 counseling checklist for Diabetic MTAC

3. At the initial visit the pharmacist will perform an initial assessment of the patient. The initial evaluation will entail:

(a) Review of patient medical/medication history

(b) Conduct a baseline assessment:

i. Past medical/medication history

ii. Social/family history

iii. Diet and lifestyle

iv. Allergies (Drug, food etc)

v. Medication knowledge

vi. Medication adherence

(c) Determination of medication related problems and issues

(d) Patient (and/or caregiver) interview

(e) Patients knowledge regarding their diseases and management

4. Patient education (Drugs, HbA1c, complication of diabetes, disease management etc)

5. After the initial interview the pharmacist will schedule their next appointment based on the needs assessment after the initial visit, or other clinic appointments and medication refills or their current health status as it is convenient to the patient. The majority of patients will be seen every 1-3 months, either at pharmacy or during the next MOPD visit.

6. Patient DMTAC visit frequency will be based in multiple issues and scheduled accordingly:

(a) Need to refills (30 or 60 days)

(b) Change in medication

(c) Mentally or physical ability to handle receive one month or greater of medication

(d) Visit schedule at diabetic clinics

(e) Miscellaneous reasons as determined by the pharmacist warranting a visit

7. Assessment will be conducted in accordance to a standard counseling checklist.

Second and Subsequent Visits

Refer to DM/HPT/LIPID-MTAC/HTAN/F2(2) Patients pharmacotherapy review form

Refer to DMTAC/HTAN/F1 counseling checklist for Diabetic MTAC

8. To take place 1-3 months later (depending on patients situation). Assessment of glycemic control and discussion of clinical results will be undertaken.

(i) Glucose level will be assessed in the clinic/pharmacy when necessary

(ii) Readjustment of medication will be carried out according to patients assessment

(iii) Review appointments until blood glucose and other clinical parameters achieve their target goals.

(iv) Compliance, reassurance and reinforcement

9. Health advice given and education undertaken (refer to appendix III) when appropriate and will be noted to doctor/s in clinic for interventions

10. Assessment will be conducted in accordance to a standard counseling checklist.

Missed Visits

Patients will be called by phone after a missed appointment to re-scheduled appointments. If patients have logistic problems, they will then be given appointments following clinic day appointments (namely every 3-4 months)

Pharmaceutical Review

Undertaken by practicing pharmacists at the earliest opportunity based on the patient selection criteria, or after referral of patient by doctors or other healthcare professional.

1) Drug-related problem identification

(a) Carefully assess the patient and obtain all information required to ascertain if any intervention or recommendation has to be made

(b) Identify patient-specific health or drug related problems

2) Drug-related problem solving

(a) Identify available therapeutic alternatives and consider the pros and cons of each alternative with patient

(b) Consider whether non-pharmacological therapy may help to prevent or solve the health or drug-related problem

(c) Formulate a patient specific action plan together with the patient, including identification of specific health outcomes and the means (drug or non-drug) to achieve them.

3) Drug therapy monitoring

(a) Monitor the patients adherence to the plan

(b) Follow up on the patients progress to assure the achievement of desired outcomes, making modifications to the existing plan if necessary

4) Pharmacists recommendations

(a) Offer feedback to the patients physician and discuss about his or her progress with the action plan and ultimately its outcome

7. Medication Dispensing and Counseling

Pharmacists shall dispense the medication and counsel the patient

Follow up counseling during part supply medication collection or during scheduled appointment

8. Documentation

1. All relevant data to be recorded using the designated forms, and stored in the patients profile

2. The documentation will contain the following parts (Appendix IV)

Patient demography and medical/medication history

Lab Values

Assessment of patients medication knowledge

Assessment of patients adherence

Pharmaceutical care issues and pharmacists plan

3. After each visit, a note is placed in the patients profile documenting the patients current status, identified drug relation problems and monitoring results, updating the medication list as needed, allergies, adverse drug reactions, medication adherence, any interventions, and action/plan for each medical condition addressed.

4. All documents can be found in the Appendix

DM/HPT/Lipid-MTAC/HTAN/F1 Enrollment form

DM/HPT/LIPID-MTAC/HTAN/F2(2) Patients pharmacotherapy review form

DMTAC/HTAN/F2 Knowledge assessment

DMTAC/HTAN/F1 Counseling checklist for Diabetic MTAC

9. Discharge Criteria

1. Patients that has completed 8 visits and/or achieve HbA1c 7% or 7.5% (depending on patient condition)

2. Defaulted 6 months or 2 MOPD visit (phone call to patients 2-3 times)

WORKFLOW OF MEDICATION THERAPY ADHERENCE CLINIC (DIABETES)

HOSPITAL TUANKU AMPUAN NAJIHAH

A. Flow Chart For Management of New Case Diabetic Patients (From In Patient)

NURSE

NURSE

MEDICAL OFFICER

NURSE

PHARMACIST

NURSE

PHARMACIST

PHARMACIST

PHARMACIST

WORKFLOW FOR MEDICATION THERAPY ADHERENCE CLINIC (DIABETES)

HOSPITAL TUANKU AMPUAN NAJIHAH

B. Flow Chart for Management of New Case Diabetic Patients (From MOPD)

PHARMACIST

PHARMACIST

PHARMACIST

PEMBANTU TADBIR/NURSE

NURSE

PHARMACIST

PHARMACIST

MEDICAL OFFICERS

PHARMACIST

PHARMACIST

WORKFLOW FOR MEDICATION THERAPY ADHERENCE CLINIC (DIABETES)

HOSPITAL TUANKU AMPUAN NAJIHAH

C. Flow Chart for Management of Subsequent Pharmacy Visit

PHARMACIST

PHARMACIST

PHARMACY ASSISTANT

PHARMACIST

PHARMACIST

PHARMACIST

PHARMACIST

EDUCATION OUTLINE FOR DIABETES PATIENTS

First Visit

Brief diabetes overview

Therapeutic goals, specifically blood glucose (HbA1c, FBS, etc)

Specific discussion of medication use/adverse effects with the patient (insulin and hypoglycemic agents)

Self monitoring blood glucose how, when, why etc (if applicable)

Signs and symptoms of hypo/hyperglycemia, sick day management and course of action to be taken

Patient concern

Visit 2

Other therapeutic goals (BP, Lipid etc)

Benefits, risks and options of improving blood glucose controls

Foot care

Specific drug counseling

Patients concerns

Visit 3

Exercise benefits

Hypoglycemic reactions (reminder)

Basic nutrition (carbohydrate counting)

Patient concerns

Visit 4

In depth discussion of diabetes (macro & micro complications, etc)

Cardiovascular education (Lipids, blood pressure, peripheral vascular disease, set goals)

Prevention, detection and treatment of complications

Patient concerns

Visit 5

Health benefits of good glucose control

Smoking ceasation (if applicable)

Alcohol reduction (if applicable)

How to continue goals, long term plans

Subsequent follow-ups

Revision of treatment goals

Specific drug counseling

Patient concerns

POINTS OF REMINDER

1. All Diabetes patients will be given a DM booklet (in-patient and out-patient)

a. Medical officer in charge will fill in the requisite details in the booklet

Name of patient

HbA1c,FBS reading (if available)

Blood Pressure

Waist Circumference

Weight

Height

Medication commenced (eg insulin, HPT medication, lipid lowering agents, etc)

b. When the patient is recruited into DMTAC clinic, a DMTAC colour sticker will be pasted on the booklet and appointment card for identification.

2. As HbA1c and FBS is the main parameter to be measured in the clinic, patients should be subjected to HbA1c test every 3 months, and measurements of Fasting Blood Glucose, blood pressure, waist circumference, weight and height should be taken on the day of appointment.

3. Patients of DMTAC will be counseled and educated for Self Monitoring Blood Glucose (SMBG) and ultimately Self Adjust Insulin Dose, therefore they will be adviced to purchase a Glucometer when needed. (HbA1c chart and Blood Glucose Recording Book will be provided by pharmacy.

4. Most of the patients will be preferably seen and assessed by pharmacist before being reviewed by the medical officers. Any problems or findings will be documented in patients profile in MOPD clinic. A separate record will be kept in the pharmacy.

5. In the event of patient being referred for follow up in other institution besides HTAN, medical officers are to remind to not refer those patients to DMTAC clinic.

Receiving new diabetic patients with

FBS > 10mmol/l or RBS >15mmol/l

HbA1c > 10%

Triage process Take patients height, weight, waist circumference (WC), BMI, BP and blood sugar level (by Glucometer)

Register, fill up particular in green book (MOPD booklet) and refer to pharmacist

Initial assessment, assessing compliance, take medication history

Perform physical examination, initiate treatment or prescribing drug and order blood investigation

Schedule the date for:

Blood test and next appointment in MOPD clinic

Fundoscopy and neurological examination

Medication dispensing, counseling and MTAC awareness program

Issue a DM booklet and put a DMTAC colour sticker on it

Documentation and set the next MTAC appointment date

Trace patients record from green book

Select patients based on

FBS > 10.0 mmol/l or RBS > 15.0mmol/l

HbA1c > 10%

Put MTAC sticker on patients profile in MOPD clinic

When the patient come on appointment day, register and retrieve of patients profile card at nurse counter

Triage process (Take BP, FBS, weight and waist circumference). Retrieve HbA1c results if not traced.

Pharmacist recruits and reviews patients for MTAC

Patient register at pharmacy counter for medication refill (every one to two months)

Identify patients with DMTAC sticker

Trace patient profile in pharmacy

Medication refill in the pharmacy

Pharmaceutical review and pharmacist intervention

Medication dispensing, counseling diabetes education

Schedule for next appointment

Documentation

Perform examination and review treatment

Medication review upon new prescription. Sticker on prescription for identification

Counseling and Education of Patients.

Documentation and Issue the MTAC booklet to patient

Set the next appointment date. Patients collect medications from pharmacy counter