Section 2 The Chronic Medication Service
2.1 An overview
The purpose of the Chronic Medication Service ( CMS) is to further develop the role of community pharmacists in the management of individual patients with long term conditions. It is underpinned by a systematic approach to practice, in order to improve a patient's understanding of their medicines and to work with them to maximise the clinical outcomes from their therapy. It facilitates a holistic approach to promoting health, ensuring that disease prevention, health education and health protection are all integral elements of CMS. This model of practice is based on patient need, clinical practice and quality improvement. It is patient centred, supports self management, promotes a partnership approach between the pharmacist, the patient and other healthcare professionals, ensures systems are in place to help minimise adverse drug reactions and address existing and prevent potential problems with medicines. It also provides for structured follow-up and referral interventions as, and when, necessary.
CMS encourages collaborative working between GPs and other healthcare professionals, community pharmacists and patients and puts in place systems to:
- ensure that drug therapy is evidence-based;
- help minimise adverse drug reactions;
- address and prevent potential problems;
- promote health;
- maximise patient safety;
- provide a structured follow-up intervention where necessary;
- reduce wastage; and
- improve outcomes from therapy.
The core objectives of CMS are to:
- underpin the pharmacist's role in improving the management of long term conditions;
- improve patients' understanding of their medicines and their long term conditions, enhancing self-care;
- use a systematic approach to prioritise pharmaceutical care by implementing the CRAG Clinical Pharmacy Practice Framework;
- document pharmaceutical care;
- provide continuity of care;
- ensure that a focus on health improvement is integral to practice; and
- facilitate partnership working.
In order to achieve these aims and objectives it is important that GPs and community pharmacists are comfortable with their respective roles. Figure 1, on the following page, illustrates the patient 'journey of care' when CMS is in place and the resulting information and communications flows between the two healthcare professionals.
Figure 1: The information and communications flows during the patient journey of care
2.2 CMS service outline - the community pharmacy component
There are three stages to the community pharmacy component of CMS as outlined in Figure 2 below.
Figure 2: A summary of the Community Pharmacy component of CMS
2.3 CMS service outline: the General Practice component
There are three stages to the GP component of the CMS as outlined in Figure 3 below.
Figure 2: A summary of the Community Pharmacy component of CMS
2.4 CMS service specification
STAGE 1 PATIENT REGISTRATION
A patient with a long term condition/s registers for CMS with the community pharmacy of their choice. The patient can only register with one pharmacy at any one time. Registration is voluntary and open ended; a person can withdraw from CMS at any time. Patients not registered with a GP practice in Scotland or who have a temporary resident status 9 are not eligible to register for CMS.
A patient is registered electronically for CMS by the national Patient Registration System ( PRS). A CMS patient registration request is generated by the pharmacist's Patient Medication Record ( PMR) system and sent to PRS via the ePharmacy Message Store ( ePMS). PRS will send back a message informing the pharmacist whether registration has been successful or not.
Registering for CMS means a patient must take their serial prescription to the pharmacy where they are registered. They are free to take non-serial prescriptions elsewhere. However, wherever possible, patients are encouraged to use the same pharmacy to ensure continuity of care.
Registration includes an explicit informed patient consent process to allow the pharmacist and GP to exchange any relevant clinical data, where appropriate, to support the shared care element of CMS. The consent is given to the registering pharmacist. Robust systems for secure data exchange to maintain patient confidentiality are provided through the ePharmacy Programme.
- GP patient registration notification
Once a patient with a long term condition/s has registered for CMS with a community pharmacy then the pharmacy PMR system generates an electronic CMS registration notification message which is sent to ePMS. This message is pulled down from the store by the relevant GPIT system which, in turn, flags the patient as CMS registered in the patient electronic record at the GP practice.
This flag acts as a trigger to the GP when they open the electronic patient record so that they know that they can then enter into a shared care arrangement with the patient and their community pharmacist. This arrangement includes the option to generate a serial prescription/s for the patient. This is a prescription for medicines, medical sundries or appliances which is dispensed in instalments for up to a 48 week period. Serial prescriptions are supported by national CMS disease specific protocols which outline common potential pharmaceutical care issues, referral criteria and reporting requirements.
Withdrawal from CMS is also electronically supported in the same way as registration. Again, the GP practice is alerted to a registration withdrawal. If a patient wishes to change their registration to another pharmacy the new pharmacist will be prompted firstly to establish that this is what the patient wants to do. In these circumstances the patient's registration will be withdrawn from the original pharmacy and they will be re-registered with the new pharmacy. A patient registration notification message will be sent to the patient's GP practice to update their record.
STAGE 2 PHARMACEUTICAL CARE PLANNING
Pharmaceutical care planning requires the pharmacist to identify a patient's pharmaceutical care needs, care issues, any desired outcomes and the actions required to deliver the outcomes. These are then recorded in a pharmaceutical care plan. This approach essentially forms a dynamic continuous model of care as identified in Figure 4 below. By undertaking an initial risk assessment, the pharmacist identifies and prioritises individuals who have unmet pharmaceutical care needs and, as a consequence, may be at risk from sub optimal therapeutic management, side effects or poor compliance. This assists the pharmacist in introducing CMS in a planned and achievable manner, using the pharmacist's time effectively to initially target patients most in need of their support.
Figure 4: Pharmaceutical care planning
Pharmaceutical care planning formalises and documents much of what community pharmacists already do in their day to day practice. It promotes a holistic approach by focusing on the whole person, involves the patient in their own care and takes into account co-morbidity as well as disease specific issues. The care planning process also supports the continuity of pharmaceutical care.
- Prioritising pharmaceutical care planning
Prioritising pharmaceutical care planning means: identifying and prioritising individual patients most in need of pharmaceutical care. This is achieved by undertaking an initial risk assessment.
- Pharmaceutical assessment
The pharmaceutical assessment involves identifying and reviewing the patient's pharmaceutical care needs and any pharmaceutical care issues which need to be addressed. The pharmacist undertakes an assessment of the patient and their general health and then builds a medication profile for the patient by assessing all the medicines prescribed for their long term condition/s. They do this by evaluating the therapeutic efficacy of each drug and the progress of the condition/s being treated. The assessment process allows the pharmacist to gauge the patient's understanding of their condition/s and medication and helps to identify any unresolved issues.
- Pharmaceutical Care Planning
Pharmaceutical Care Planning involves generating a pharmaceutical care plan, based on the pharmaceutical care issues identified during the assessment process, and which is agreed with the patient. The patient's pharmaceutical care needs and pharmaceutical care issues are confirmed and prioritised with the patient. This is documented within a pharmaceutical care plan and the pharmacist and patient jointly agree actions to solve any problem/s over a period of time. Some actions may involve other members of the healthcare team and the pharmacist takes responsibility for communicating those actions to the appropriate individual. The plan also states how and by whom this will be monitored. The process of pharmaceutical care planning is described in more detail in Appendix 4.
Monitoring and review describes the implementation of the care plan and includes the ongoing monitoring and reviewing of progress against the plan. The pharmacist and patient monitor and review progress against the actions in the pharmaceutical care plan. Agreement is reached on whether the desired outcomes are being achieved and, if not, the plan is reviewed. Ideally, to assist in this process the patient should be given a personal copy of their pharmaceutical care plan. Pharmaceutical care plans should be open to a process of peer review as part of the quality element of the pharmacy contract.
In order to achieve maximum therapeutic benefit from prescribed medicines and appliances it is important that patients understand their therapy and how to use the products prescribed appropriately. The pharmacist should, therefore, also consider the counselling and advice needs of the patient in relation to their medicines both during the initial assessment and on an ongoing basis. This is underpinned by the CRAG Framework for Counselling and Advice on Medicines and Appliances in Community Pharmacy Practice10. This should complement and reinforce information provided by other members of the healthcare team, present opportunities for the patient to ask questions and assist the pharmacist to play their role as a patient educator.
STAGE 3 SHARED CARE
Once a GP receives a CMS registration notification message they can chose to enter into a shared care arrangement with the pharmacist and patient which allows them to generate a serial prescription underpinned by national CMS disease specific protocols. Ultimately, it is a matter for the GP to determine an individual patient's suitability for this component of the service. The pharmaceutical care plan remains as the basis of the ongoing care for the patient and the national CMS disease specific protocols outline any referral criteria and reporting requirements.
- Ongoing care planning: building on the systematic approach
Stage 3 is also underpinned by pharmaceutical care planning. Where a pharmaceutical care plan is already in place from Stage 2 then the pharmacist continues to monitor the control of the condition/s and symptoms, side effects and compliance. In addition, serial prescriptions provide the opportunity for a more planned and structured follow up by the pharmacist. Where a patient without a pharmaceutical care plan receives a serial prescription, the pharmacist should, if necessary, formulate a care plan as part of the serial dispensing process.
A serial prescription is a prescription for medicines, medical sundries or appliances which is dispensed in instalments for up to a 48 week time period. A GP can choose to generate a serial prescription for a patient through a number of routes; during a patient's annual QOF medication review, during a routine appointment, at a chronic disease management clinic or as a result of a patient or pharmacist request. In doing so the GP takes into consideration the stability of the patient's condition/s, the medicines they consider to be appropriate for serial dispensing and the duration of the prescription. They also select the serial prescription dispensing intervals. In the future, it may be possible to allow the pharmacist and patient to determine the time intervals supported by national guidance. The GP system generates the paper serial prescription and associated electronic prescription message. The electronic message is automatically sent to ePMS.
Once received in the pharmacy, the serial prescription is scanned and subsequently dispensed at the time intervals determined by the GP. This establishes the medication supply arrangements for the duration of the serial prescription. The electronic prescribe message is used to generate the dispensing instalments and associated electronic claim messages for the serial prescription. These messages form the basis of the ePay element of the ePharmacy Programme. In addition, information on items dispensed against a serial prescription, ' dispensing information', is automatically sent via ePMS back to the GP practice after each serial dispensing episode. The final dispensing episode triggers the pharmacist to generate and send an end of care treatment summary to the GP practice. This can include an electronic serial prescription renewal request.
A GP can cancel either the serial prescription or an item on the serial prescription electronically at any point. For example, if a patient's medication has been stopped or altered or if the patient's circumstances have changed - they may have been admitted to hospital or their condition is no longer stable. Once cancelled, the pharmacist can no longer dispense any outstanding instalments for that item/prescription.
- Clinical disease specific protocols
The shared care stage is also supported by national CMS disease specific protocols which outline common potential pharmaceutical care issues, referral criteria and reporting requirements. The protocols complement the pharmaceutical care planning process and help the pharmacist to identify any requirement to refer the patient back to an appropriate healthcare professional over the period of a serial prescription as well as any end of care period reporting requirements. This facilitates partnership working with other members of the primary care team. Evidence from both England 11 and the USA12 has identified that thirteen long term conditions represent the most frequent indications for drug therapy (over 50%). These are detailed in Appendix 5. When considering the disease specific protocols it would seem sensible to start with these conditions initially whilst remembering that they do not occur in isolation; patients have co-morbidities.
If necessary, a pharmacist will refer a patient to an appropriate healthcare professional (usually the patient's GP but may also include other members of the practice team or secondary care colleagues) based on either the referral criteria within the disease specific protocols or their own professional judgement.
Once the last instalment from the serial prescription has been dispensed the pharmacist sends a serial prescription renewal request for a new serial prescription/s to the GP practice. This request can form part of the end of care treatment summary. This summary details any information pertinent to the GP, such as the dispensing history for the serial prescription, relevant QOF data and any recommended actions for the GP to consider. This supports the sharing of information between the GP and pharmacist with appropriate informed patient consent and through secure systems of communication.
The end of care treatment summary, including the renewal request, is queued in the GPIT system for review along with any other relevant patient correspondence, hospital letters and information that the GP needs to consider when reviewing the patient. This establishes a formalised system for follow up. It can also form the backbone of the annual QOF medication review as well as other long term condition reviews. When the GPreviews the shared care arrangement, prompted by the serial prescription renewal request, they can take into account the information in the end of care period treatment summary to inform the review process. They then update or continue the existing package and issue a new serial prescription/s, taking into account any required actions. Any relevant information is recorded and/or updated in the GP system . The QOF medication review marker and any other relevant QOF domains are also updated and stored.
2.5 Summary
Long term conditions require proactive, continuing care as opposed to reactive, episodic care. CMS outlines the community pharmacist's contribution to the care of patients with long term conditions, based on a holistic approach. It builds on the existing strengths of community pharmacy practice; it focuses on the continuity of pharmaceutical care of patients with the right balance between the condition specific elements and the wider overview reflecting the incidence of co-morbidity and the associated polypharmacy aspects. The focus on therapeutic partnerships facilitates the policy of shifting the balance of care for the management of long term conditions and introduces multidisciplinary and collaborative working between healthcare professionals. It also improves the efficiency of information transfer and data capture both locally and nationally. CMS introduces systems to help prevent and solve adverse drug reactions, with structured follow-up and referral if necessary. This should, in turn, improve health outcomes for patients with long term conditions as well as contribute to the Scottish Patient Safety Programme.