HOME MEDICATION REVIEW
Duration; 14th November 2011
At 14th of November which is Monday, I followed the pharmacist in charge, Mr. Chan Chee Meng (U44) for the home medication review program. We went to the psychiatric ward located outside HTAR which is at Jalan Pegawai, Klang where the Klang Health Clinic and Klang Dental Clinic located about 10am. We were accompanied by a staff nurse Pn. Dermia, a medical assistant En. Amri, and a driver Mr. Kumar. In this program, we will go to the patient’s home to check for his/her compliance towards medicine and their progress. However, some patients went out when we did the visit. Mr. Chan said that they will contact the patients to notify them the next visit to their house. Some patients which are in critical condition will be given Clopixol Depot® 200mg/ml Inj. (Zuclopenthixol Decanoate) intramuscularly by the nurse or medical assistant. Among all the 12 patients visits, I found an interesting case of patient A which her mother complained the patient wake up very late in the morning because she sleep about 2am, and she would’t be able to move her body up after wake up from the sleep. After Mr. Chan checked the medicine dosage while the medical assistant checked the blood pressure and heart of the patient, they discussed with the doctor on phone to change the dosage of clozapine tablet 100mg OM and 500mg ON to 200mg OM and 400mg ON. Propanolol dosage reduced from 20mg BD to 20mg ON. The dosage of fluoxetine remains 60mg. Some patient’s family members really thanked us because patients developing positive progress on their mental health. We ended our visit about 2pm. Then, I followed Mr. Chan to his office and I started to ask him several questions. Next page is the explanation about Home Medication Review (HMR).
Introduction
Home Medication Review (HMR) is a patient-focused process which advocates the optimal and quality use of medication at the patient’s home. It involves systematic assessment of the patient’s medication in order to identify and meet the medication-related needs as well as to identify, resolve and prevent drug related problems.
This service is a continuation of patient’s care from health facilities to their home. It is a comprehensive activity which involves clarification of the indication for use and administration details of all prescription and non-prescription medicines (including nutritional supplements, vitamins, herbal/complementary medicine and other remedies) with access to medication storage.
Pharmacist as one of the important service providers in the health care system, are responsible for provision of information and advising patient or (care giver) regarding medications and therapeutic devices. They play a major role in monitoring and advocating patient’s awareness about safety, appropriate and quality use of medications and encourage compliance, in order to optimize therapeutic outcomes.
Objectives
Primary Objective
The objective of HMR is to improve health outcomes and quality of life of the patient by emphasizing the Quality Use of Medication, which is appropriate, safe, judicious and efficacious. The pharmacist works with the patient, doctors and other health care providers to evaluate medication related information as well as identifying, preventing and optimizing health outcomes. The best outcome of HMR is achieved by reconciling all medication related information including Prescription and Over the Counter (OTC) medicines, traditional medicines, health supplements as well as therapeutic devices and aids.
Secondary Objectives
• To monitor patients’ adherence towards medications especially patient suffering from chronic illness.
• To educate patients and their care givers pertaining to the importance of medication adherence and to address other medication related issues such as side effects and adverse drug reaction
• To ensure the right medication and the right amount are stored properly at patient’s home.
• To identify and resolve possible drug interaction involving all medicines involving all medicines including prescribed medicine, over the counter (OTC) medications, traditional as well as health supplements.
• To counsel patients and their care givers in order to improve their insight towards medication and overall well being.
• To facilitate a cooperative working relationship between the pharmacist and other members of the health care team in order to benefit the well being of the patient,
• To facilitate care givers involvement in the management of patient’s illness
Scope of Service
The HMR service is to be extended to patients who are currently seeking treatment in Ministry of Health Hospitals ans Community Health Clinics only.
Manpower Requirement
All appointments for HMR should be conducted by a qualified pharmacist. The HMR Pharmacist may accompany other health care team members if needed.
Appointment
Appointments or the number of visits for patients under the HMR program will be determined by the Pharmacist conducting the HMR.
Procedures
Patient Inclusion Citeria
The need of HMR lies on the treating doctor but any member of the health care team may trigger a potential need for HMR.
The citeria which may be used to determine the need of HMR are as follows:
• Patient suffering from chronic illness and taking five or more medications for long term therapy.
• Patients who are taking more than 12 doses of medications daily.
• Patients suspected of non-adherence or not managing well with medication-related therapeutic devices (such as inhalers or insulin pen).
• Patients who are managing their own medication but at risk due to language difficulties, impaired insight, confusion/dementia or any other cognitive difficulties such as psychiatric and geriatric patients.
• Patients who are taking medications with narrow therapeutic index or requiring therapeutic drug monitoring such as warfarin, phenytoin,digoxin etc.
• Patients who are recently discharged from hospital with significant change in medication regimen.
• Patients who have defaulted treatment or fail to refill their medication especially for chronic illness.
• Patients attending number of different doctors from the same health facility or receiving treatment from multiple health facilities.
• Symptoms requiring pharmaceutical intervention such as occurrence of adverse drug reaction or sub therapeutic response toward treatment.
Patient Exclusion Citeria
• Patients who are not Malaysian citizens.
• Patients who are homeless.
• Patients who are aggressive.
• Patient’s family who signed the consent form regarding unwillingness to join HMR.
Administrative Requirement
• HMR pharmacist need approval from Head of Department- official letter
• All HMR visits should be conducted after obtaining consent for visit from patient/care giver.
• Risk assessment should be done by the HMR pharmacist prior to visit, especially if the home visit is not to be conducted along with the community home care team.
Activities
ENROLLMENT OF PATIENTS FOR HMR
Pharmacist select HMR patients from the referral form from doctor. Then obtain consent from patient/caregiver to participate by filling up the consent form. Risk assessment applicable if HMR done by pharmacist alone.
PREPARATION BEFORE HOME VISIT
Make appointment with the patient/caregiver. Note down the appointment in HMR Appointment Record. Then prepare medication identification chart based on the patient case record. Then ensure all procedures in the checklist are adhered.
CONDUCTING HOME MEDICATION REVIEW
1. Introduce yourself and explain the purpose of the visit to the patient/care giver.
2. Initial assessment by HMR pharmacist.
3. Medication Adherence Evaluation using Modified Morisky Medication Adherence Scale.
4. Pharmacotherapy review
a) Identify pharmaceutical care issues
b) Plan interventions to address all the identified drug related problems
c) Discuss with the doctor pertaining to any change of regimen or other suggested intervention. To alert patient to come for follow up visit in clinic if needed.
5. Remind patient to attend the clinic on the appointment date with the doctor.
6. Distribute related pamphlets/leaflets to patient/care giver.
7. Remind patient/care giver to bring all the balance medication on next appointment with the doctor and return to pharmacy unit to get new supply based on new prescription.
8. Follow up visit will be held upon another referral from prescriber or when deemed appropriate by the HMR pharmacist.
