Collaboration between hospital pharmaceutical service and community pharmacy within the ‘Telémaco’ project. A case report

BACKGROUNDS

Male, widower, smoker of 20 cigarettes / day, 75 years old, who lives alone, goes to the pharmacy to pick up medication. We observe an excess of boxes of metformin in electronic prescription, since it always says “that you still have at home.” It is a patient selected by his reference hospital to be included in the “Telémaco” project, which is a Pharmaceutical Care project that allows evaluating the patient experience with a model of telematic Pharmaceutical Care coordinated between Hospital Pharmacy and Community Pharmacy, measured using the IEXPAC scale (1), being an instrument that allows the evaluation of the patient’s experience and its evaluation after the follow-up period in patients who use hospital medicines, compared to the traditional model.

Patient stratification is the tool that marks the orientation of the new patient centred Pharmaceutical Care model, different from how we knew it until now.

After the stratification of the patient in the Hospital Pharmacy Service of the Lozano Blesa Hospital according to the evaluation scales of the chronic patient (2) and, the evaluation, according to the Permanent Kaiser Model (3), it is observed that the patient is at a Stratification Level 1.

• Therefore, we are facing a:

• Complex patient

• With low activation level

• With cognitive impairment

• Ignorance of hospital medication

• STUDY AND EVALUATION

We provide a multidisciplinary and multidimensional Pharmaceutical Care, according to the Stratification models available within the Strategic Map of Chronic Patient Care (MAPEX project (2), which defines Pharmaceutical Care as “the professional activity by which the pharmacist is linked with the patient (and / or caregiver) and the rest of health professionals, to attend to them according to  their needs, proposing strategies to align and achieve the short In order to improve health outcomes” based on the Capacity-Motivation-Opportunity (CMO) model (4), since the patient has affected, four important dimensions that affect pharmacotherapy (demographic variables, socio-health variables and cognitive and functional status variables, clinical variables and the use of health services, and variables related to treatment):

1. Variable Weight: nutritional risk (the patient presents an involuntary weight loss > 5% in the last 3 months).

2. Mental disorders, cognitive impairment and functional dependence: patient with symptoms of anxiety, depression, and/or psychological discomfort (sadness, worry, anguish.

3. Pluripathology/Comorbidities: The patient has two or more chronic diseases.

4. Related to treatment:

• Polypharmacy: the patient takes 5 or more medications

• Adherence to treatment: there is evidence that the patient is not adherent to pharmacological treatment

We will use a common taxonomy in the registry of pharmaceutical interventions.

The patient has a level of stratification 1 that, according to the model of Permanent Kaiser (3), is a patient who needs medication, under control and lifestyle changes, with the support of:

Precise e-Care (support in technologies and promotion of self-care (5),

Pharmaceutical Care in community pharmacy and,

Coach.

The pharmacotherapeutic objective according to stratification level 1, is to increase pharmacological adherence by 80%.

The initial state of affairs is shown in the annex 1.

INTERVENTION

Intervention Motivational interview is conducted to define objectives with the patient, visualise the future, bring out limitations and look for alternatives to help raise awareness, etc.

We coordinate with the Hospital Pharmacy Service of the Lozano Blesa University Clinical Hospital to “prepare weekly medication trays” since they ask us not to extract the hospital medication from the blister until it is ingestion, and this increase adherence to pharmacological treatment.

In the first visit scheduled by video call that is made in the community pharmacy with the patient and the hospital pharmacist, 8 pharmaceutical interventions are recorded according to the taxonomy of the CMO Pharmaceutical Care model (4): Review and validation, Concomitant review and validation, Review of objectives, Coordination, Planning, Safety, Special Monitoring and Adherence.

The health problem that most worries the patient is the diarrhoea he suffers from due to the medication for hospital use, since it prevents him from being autonomous in his movements. The communication between Hospital Pharmacy and Community Pharmacy allows to detect that, during his visit to Pneumology, the patient did not understand the instructions to alleviate this side effect as it was recorded in the Telemachus software in which the clinical and pharmacotherapeutic history of the patient on whom the project is developed is shared, so he is instructed in the hygienic-dietetic measures (garrob flour), use of probotics and if not controlled, the indication of loperamide.

Another problem is the lack of adherence to treatment with tiotropium bromide, since when it is administered it causes you cough. Our intervention with the primary care physician for the spacer camera indication also solved the problem.

 The control of blood glucose and blood pressure figures is achieved thanks to collaboration with nursing, since the patient did not go to the controls or adhere to pharmacological treatment.

The collaboration of his family increases adherence to treatment with complex pharmaceutical forms: insulin and inhaler.

Monthly the patient continues to be monitored in the Community Pharmacy, and quarterly with the Hospital Pharmacy Service, either face-to-face or at the digital health point, which is the community pharmacy.

RESULT/FOLLOW-UP

The first month that the community pharmacist intervenes in the provision of Pharmaceutical Care to a patient with hospital medication, he achieves the objective set by the Hospital Pharmacy, improving the control of health problems.

For 6 months, the community pharmacist has detected and resolved 6 incidents related to medicines, going from an initial adherence of 30% to 95% (registered in Nodofarma Asistencial (6)):

1. Lack of adherence: non-compliance

2. Inadequate dose: metformin

3. Inadequate guideline: simvastatin

4. High probability of adverse effects: diarrhoea

5. Lack of knowledge of the use of the drug: thiotropium bromide

6. Health problem insufficiently treated: carob flour, probiotics and loperamide

The patient continues in the project and continues to be evaluated. 

Pharmaceutical interventions related to pharmacological treatment generate the following final situation affair (annex 2).

Other dimensions that affect the patient have been worked on: going from being experts in the drug, to being experts in the relationship with the patient and his pharmacotherapy.

CONCLUSIONS

Communication between health professionals with a Multidisciplinary and Multidimensional approach, using the same taxonomy of pharmaceutical interventions, allows detecting failures in the information that the patient receives when passing through different levels of care, allowing the coordination of the multidisciplinary team to manage to control the patient’s health problems.

Table 1. Summary of pharmaceutical interventions

PCD: Primary Care Doctor; HABP: Arterial High Blood Pressure.

The stratification of the patient through this collaborative model of Hospital Pharmacy-Community Pharmacy generates a joint work to achieve the same objectives, giving rise to patients and professionals satisfied with the improvement of the control of the patient’s health status.

APPRECIATIONS

My appreciation is for the Spanish Society of Hospital Pharmacy and the Spanish Society of Rural Pharmacy, and especially for Ramón Morillo for having taught me to see the patient’s pharmaceutical care from a more innovative and more adapted to the future of our profession perspective.

REFERENCES

1. Instrumento de Evaluación de la eXperiencia del Paciente Crónico. Cuestionario IEXPAC. [Internet]. Available from: http://www.iemac.es/iexpac/cuestionario.php

2. Mapa Estratégico de Atención al paciente externo (MAPEX). Modelos de estratificación de pacientes [página web]. Sociedad Española de Farmacia Hospitalaria. Madrid: 2019. [28-05-2020]. Available from: https://www.sefh.es/mapex/cmo-modelo.php

3. Nuño Solinís R. Buenas prácticas en gestión sanitaria: el caso Kaiser Permanente. Rev Adm Sanit. 2007;5(2):283-92. Available from: https://www.elsevier.es/es-revista-revista-administracion-sanitaria-siglo-xxi-261-articulo-buenas-practicas-gestion-sanitaria-el-13107524 

4. Calleja Hernández MA y Morillo Verdugo R. Sociedad Española de Farmacia Hospitalaria. Modelo CMO en las consultas externas de Farmacia Hospitalaria. Euromedice Vivactis. Depósito legal: M-40773-2016 ISBN: 978-84-608-6548-3. Rev. Ene 2017. Available from: https://www.sefh.es/bibliotecavirtual/CMO2/Libro_CMO.pdf

5. Clark CM Jr, Snyder JW, Meek RL, Stutz LM, Parkin CG. A systematic approach to risk stratification and intervention within a managed care environment improves diabetes outcomes and patient satisfaction. Diabetes Care. 2001;24(6):1079-86. doi:10.2337/diacare.24.6.1079

6. Nodofarma Asistencial. [Internet] Madrid. Consejo General de Colegios Oficiales de Farmacéuticos. Available from: https://asistencial.nodofarma.es/Home/Acceso?actionRedirect=Index&controllerRedirect=Home

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