Home Medicines Review Program

Home Medicines Review (HMR) is a comprehensive clinical review of a patient’s medicines in their home by an accredited pharmacist on referral from the patient’s general practitioner (GP). It is also called as Domiciliary medication management review. It is designed to enhance the quality use of medicines and reduce the number of adverse medicine events, by assisting consumers to better manage and understand their medicines through a medication review conducted by an accredited pharmacist in the patient’s home.

There are different problems due to irrational medications or medication errors. Irrational medication may lead to hospital admissions, increased morbidity & mortality. These medication errors are due to lack of knowledge about the diseases or ailments & medications. These problems are high in geriatrics with chronic illness, patients on polypharmacy & patients with multiple co-morbidities. These patients require regular monitoring & medication management at home and for that purpose, we take home medication review program. Pharmacist and medical professional provide HMR program, they review the patient, diseases & drug treatment.

HMR involve estimation of disease, evaluating the therapeutic efficacy of each drug, adverse effects, adherence medication & drug interaction. HMR includes a thorough check of medicines taken by patients, prescription drugs & non-prescription drugs.

AIM: To prevent problems related to medication & provide individual drug regimen through the team.

HMR program consists of four steps. They are

1. Assessment of clinical need & referral

2. Interview, review & report

3. Medication management plan

4. Payment (or) Continuity of patient care

1. ASSESSMENT OF CLINICAL NEED & REFERRAL

2. INTERVIEW, REVIEW & REPORT

 

3. MEDICATION MANAGEMENT PLAN

4. PAYMENT (OR) CONTINUITY OF PATIENT CARE

Participation in HMR program

1. Requirements of participation in HMR program: Patient need to accept all the terms and conditions of the program.

2. Patients eligibility criteria: Patients with chronic diseases should go for HMR program.

3. Identifying patients for HMR: The patients with the risk of medication mis-adventure, co-diseases, complex treatment regimens should be selected for HMR program.

4. Patient consent (Acceptance): Patient should accept for the HMR program.

5. Patient interview: Patients interview must occur face-to-face at the patients home except in some circumstances like cultural reasons & safety concerns associated with a visit to the patients home.

Dispensing of Ancillary Substances

 

ANCILLARY SUBSTANCES

Ancillary substances are the products which are dispensed by the pharmacist with main drugs prescribed by the doctor. They include ancillary medicines, parapharmaceuticals including ancillary labels (auxiliary labels).

Ancillary medicines are the drugs which are given in combination with the main drugs, helpful for the treatment. Para pharmaceuticals are the substances like catheters, needles, several laboratory wares, sutures, syringes, sphygmomanometers and costly surgical materials. These provide additional support to the treatment.

It is the duty of the pharmacist to take responsibility for the purchase, stocking and distribution of these ancillary substances. Modern techniques must be utilized in order to maintain proper control over the investment in inventory by the pharmacist. Example of such a modern technique is ‘Economic order quantity’ model. They help in determining the optimum inventory level. This is done by calculating optimum order quantity and reorder points.

Auxiliary labels are the labels stick to the medicines while dispensing and useful for the patient. Pharmacist writes the information about the usage of drugs regarding the time when they should be taken. These auxiliary labels with timings of administration of drugs are written by the pharmacist.

 

Role of pharmacist in dispensing ancillary substances:

Various duties of pharmacist in this aspect are

1. Purchasing and stocking of those ancillary substances, Para pharmaceuticals

2. Inventory control of the ancillary substances

3. Distribution of ancillary supplies to different departments

4. Advisory role in selection of items as he has the knowledge of understanding the use of these ancillary substances

5. Handling and accounting of pharmaceuticals.

Patient Counselling

PATIENT COUNSELLING

Patient counselling and chronic disease monitoring are the two important functions performed by the pharmacist. It is the responsibility of the pharmacist to educate the patient about the medication, adverse drug reactions, drug interactions and problems due to non-compliance.  Patient education in relation to the pharmacy may be defined as a process that aims at imparting proper drug knowledge, ensuring patient compliance and improved therapeutic benefits.

 

Definition:

Patient counselling can be defined as an interactive session designed to educate the patient about the medication, by providing him complete information, identifying and removing the barriers which lead to appropriate therapy.

 

Need for counselling and privacy:

It is a two-way exchange of information between the pharmacist and the patient. The pharmacist has to give information about drugs, their usage in the language that the patient understands. Counselling has to be effective, should be done in a place free of noise, interruption and distractions. Privacy to the patient is of utmost importance.

 

Classification of counselling:

Patient counseling can be of two types. They are:

1. Direct counselling (Face-Face)

2. Distant counselling ( Over telephone/ through the internet)

Determining patient information needs:

Patients seek information from different sources like physicians, friends, relatives, books or magazines and the internet. A pharmacist should identify the desire of the patient, information seeking behavior, patient-specific needs and then tailor the educational approach to patients counselling.

Patient learning and behavior:

Understanding of attitude and health beliefs of patients is important for designing an effective counselling session. It should be easy to understand and the patient should be able to recall the information and be motivated to follow the treatment regimen.

All the drug-related information should be provided to the patient.

1. Medicine’s generic name, brand name

2. Dose, dosage schedule and route of administration

3. Frequency and duration of therapy

4. Indications to be followed

5. Special precautions

6. Possible side effects

7. Storage conditions

8. Expiry date

9. Cost of the medicine

10. Drug interactions

 

Selection of the patients for counselling:

Patients are selected according to the need. Some patients require counselling for a few minutes while others take more time. Patient counselling can also be performed during ward round or during the administration of the drugs. Long counselling sessions are given to

1. Patients with long-term diseases/treatment. Ex: Epilepsy

2. Patients without severe symptoms. Ex: TB

3. Patients using drugs with narrow therapeutic index Ex: Warfarin

4. Patients with a danger of abrupt therapy cessation. Ex: Corticosteroid therapy

5. Patients with potential for non-compliance, abuse or misuse of drugs. Ex: treatment with tranquilizers.

 

Components of patient education:

            Patient education programmed should be designed in a manner that the patients understand that they are suffering from ailments that need attention. A good counselling program includes

1. Relevance: The counselling process should be relevant to the needs of the patient. It should be taken into account that the knowledge level, reading level, beliefs, circumstances and prior experience.

2. Individualization: Programme should be according to the individual needs of the patient as every person has his own problems and capacity for learning

3. Feedback: Getting a response from the patient which helps to assess the degree of understanding by the patient about the information given.

4. Reinforcement:  Giving the reward to the patient by praising him.

5. Facilitation: It includes new methods to reduce barrier to a treatment regimen and can be done by using special containers, reducing the cost.

6. Combination: Usage of all the above techniques.

 

Methods of providing the patient education:

1. Verbal education: Direct method of providing education in which two persons are involved

2. Written information: Package inserts (leaflets) found inside a drug package, labels on cartons of drugs, booklets and special promotion material developed by pharmaceutical companies.

3. Audio-visual methods: Involve use of overhead projectors, slide projectors to improve knowledge and increase retention.

 

Technique of providing patient counselling:

            Counselling should be designed in such a way that any message sent by patient, whether verbal/non-verbal should be easily detection by the counselor. There are number of obstacles present in a counselling session and these barriers should be overcome to have a successful session.

 

Some of the barriers are:

1. Hospital environment: Should be suitable for counselling privacy.

2. Language barrier: Poor people cannot understand English, other languages, technical terms

3. Education level: The patient may not be able to read the label or written instructions or information given.

4. Disabilities of body: Old age people with eye sight inability to hear cannot read or hear the instructions clearly.

5. Patient motivation: If the patient does not listen and learn to the pharmacist, the counseling goes useless.

6. Inadequate time or training: Experienced clinical pharmacists are assigned to the duty of patient counselling. If juniors are assigned, it may affect the quality of counseling.

 

Rules for designing a good counseling session:

1. Dress formally and sit properly for developing a professional image.

2. Having an eye contact with patient and avoid staring.

3. Establishing rapport with the patient by introducing himself and shaking hand.

4. Counsel with predetermined plan which include more number of open ended questions.

5. Counsellor should have clarity of speech and patience.

6. Session should be ended gradually and ample time should be given to the patient to express and clear his doubts.

 

Counseling regarding the proper use of drugs:

1. Before using the drugs: Ask regarding allergic conditions, if any. Drug sensitivity, major disease like diabetes, hypertension, renal failure or liver impairment. If pregnant/ breastfeeding.

2. Storage of drugs: Keep away from children, storing in cool dark place, preventing liquid medicines from freezing, discarding expired drugs. In case of single dose injectables -discard remaining drug

3. Proper use: About dosage form, dose, schedule, directions and precautions.

 

Documentation:

Every step of counselling process should be documented after each counseling session with the patients.

Pharmacy and Therapeutic Committee

Definition:

            It is a committee formed by a group of physicians, pharmacists, medical staff and other healthcare professionals, who formulate the policies regarding the therapeutic use of drugs.

 

Role of PTC:

PTC has a dual role in the hospital.

1. Advisory: PTC assists in the formulation of professional policies regarding evaluation, selection and therapeutic use of drugs.

2. Educational: It assists in various functions designed to meet educational leads of professional staff, physicians, nurses, pharmacists and others for the knowledge of matters pertaining to drugs.

 

Functions and objectives:

1. To serve as the advisory council to the medical staff and administrative persons related to the use of drugs.

2. To compile and develop a formulary of drugs, prescriptions and selected items based on the therapeutic use, safety, cost, etc.

3. It recommends written policies and procedures for selection, procurement, storage, distribution and use of drugs.

3. To establish suitable educational schemes for the hospital professionals related to the usage of drugs.

4. To study problems related to the distribution and administration of the drugs.

5. To make recommendations concerning to drugs to be stopped inwards and emergencies.

6. To advise the pharmacy in the implementation of effective drug distribution and controlled procedures.

 

There are six primary functions of Pharmacy & Therapeutic committee. They are

 

1. ADR MONITORING & ROLE OF PTC IN ADR MONITORING:

Adverse drug reaction is a noxious, unintended reaction of a drug which occurs at normal doses. The cause of it must be thoroughly investigated to prevent such reactions in other patients.

PTC is responsible for monitoring the drug use, to prevent ADR if any and to report the authorities to avoid such ADRs in future. In order to do that efficiently, PTC issues a set of guidelines to the medical, paramedical staff of a hospital with ADR reporting form.

ADR problem can be solved at two levels.

1. By preventing when they occurred in the past

2. To treat them when they have occurred.

All ADR details are reported in ADR reporting form.

An ADR is first reported to the dean or the director of the hospital, then to the reporting authorities of state and central government followed by the state drugs control authorities.

The Drug may be withdrawn from the market on order of drugs control department and other medical fraternity.

2. DRUG PRODUCT DEFECT REPORTING:

A drug is called defective if its packing is inadequate, has confusing labels, is deteriorated or contaminated, is manufactured as a defective dosage form, fill or crown of a drug is inaccurate, faulty drug delivery apparatus etc, These defects are generally due to human errors, machine error or errors in developing techniques. Such defects should be detected by a pharmacist or nurse before it reaches the patients.

The model form of reporting the defective drug product should be filled and sent to manufacturing authorities. Post detection, the report should be sent to the manufacturers, followed by the authorities. Physical inspection of entire lot or batch of the product supplied to the hospital must be performed and necessary action must be taken.

3. PSYCHOTROPIC DRUG USE:

Psychotropic drugs are those, which on longer use produce dependence or addiction and hence these are dangerous to patients as well as the society. These are also called as dangerous drugs.

      PTC develops guidelines to purchase, store, dispense and proper administration of these drugs. The procedure for this is as per ‘Narcotic and Psychotropic substances Act’.

PTC ensures strict adherence to the above act by the hospital staff. In some hospitals automatic “stop orders” are in force whereby, all drug orders for narcotics, sedatives and hypnotics shall be automatically discontinued after 48hrs.

“Stop Orders” will be in action when there is a misuse or mislead of drug use exceeding the guidelines. Narcotic drug usage shall not be stopped unless-

1. Order indicates exact no of doses to be given to a patient

2. Exact period of time for the medication is specified

3. Attending physician should record the medications given to the patient.

4. EMERGENCY DRUGS:

Emergency drugs are the list of medicines which are needed in medical emergencies. PTC prepares the list of drugs and other supplies to be made available in the emergency boxes.

These boxes are kept in all important places in the hospital and given in charge of pharmacists or nursing supervisors of the hospital.

As these medicines are available by the side of beds, they are referred to as bedside pharmacies. Emergency cupboards and boxes are kept in wards or departments of radiology.

It is mandatory that a pharmacist or nursing supervisor should check daily whether there is the constant number of drugs in emergency boxes.

Usually, some 20-30 important life-saving drugs, 10-15 surgical instruments, and dressings including syringes are made available in the boxes.

The list may vary and depends on the need of the hospital.

 

5. DRUG UTILIZATION REVIEW:

 Drug utilization includes prescribing, dispensing, administration of prescribed drugs. Drug utilization review should be organized in a hospital by PTC and it is controlled by the hospital formulary department.

Obtaining the medical history and patient medication profile are the two activities useful to the pharmacists to monitor drug utilization in the hospital.

Medication histories of in-patients are accomplished by personal interview or through a computerized questionnaire. The information is also obtained from patients’ helper or family members in case the patient’s condition is not cooperative.

During interview all the information regarding allergies, idiosyncratic reactions towards food products, lab tests, other ADRs of the drug. This information is passed onto the physician for early correct diagnosis and prescribing.

These services will be useful in the case of patients who require long time therapy and those who continue treatment from their home as outpatient ie diabetes, hypertension, asthma, epilepsy, tuberculosis etc.

 

6. PTC AND SAFE USE OF DRUGS:

Day by day lots of new drugs are introduced by hundreds of manufacturers, increasing the scope for errors in prescription writing, dispensing and administration of new drugs poses a great problem to the pharmacist especially when the chances of drug interaction, ADR & other problems are relatively unknown for a new drug. Hence PTC formulates many policies and guidelines to be followed by all professional while handling both the new drugs and existing drugs.

Procurement & Purchasing

PROCUREMENT

            Procurement is a process of selecting the drug, finding the source, agreeing terms and acquiring medicines. Procurement is defined as a process of acquiring medicines through purchases from the manufacturer, their agents like distributors or from private/ public suppliers. Purchasing starts with framing of buying policies & ends with receiving, stocking & payment.

 

PURCHASE

            An act of getting something by paying money. The basic purpose of the purchase is to ensure a continuous flow of raw materials of right quality, in right quantity, at right price, at right time, form right source, of the right item and it is the main objective. Purchasing procedure avoids duplication and wastage of drug products. In some hospitals, separate department called medical store manages all purchases of pharmaceuticals, medical supplies, equipment and surgical etc. The chief pharmacist prepares an annual budget request for pharmaceutical purchases and places orders for medicines through the medical stores.

 

1. Right Quality:

            Right quality means the quality which is available at the supplier, according to the specifications mentioned in terms of grades, brands, trade names, physico-chemical characters, national standards etc.

 

2. Right Quantity:

            The right quantity is the quantity that may be purchased at a time with the minimum total cost and which obviates shortage of materials and with a continuous supply of materials. “Economic Order Quantity” technique may be followed in order to avoid shortage.

 

3. Right Source:

            Selecting the right source for the purchase of materials is an important consideration in the purchase procedure. The right source for the procurement of materials is that supplier who can supply the material of right quality and in right quantity as ordered, at a right time at which the materials were required to be supplied, at an agreed price with the supplier.

            The supplier should be in a position to honour the commitment without much follow- up. He should have necessary financial resources and adequate man-power to handle the order and  well established with higher reputation and integrity.

 

4. Right Price:

            Right price is that price which brings the best ultimate value of money invested in purchasing the materials. Determining right price is very difficult task and it depends on various factors like quality delivery time, demand and supply curve, after sales services, discount offered, government restrictions, terms of purchase etc.

 

5. Right Time:

            Right time means the time when stock reaches the minimum level. Purchasing department should have lead time information about all the drugs. Lead time is time taken between placing of order and receipt of drugs to the department.

 

6. Right Item:

It is all about purchasing of right item needed in the hospital, without alternative drug.

 

PURCHASE PROCEDURE

Purchase procedure involves different steps for procurement of goods.

 

STEPS IN PURCHASING

1. Determination of requirement

            The materials to be purchased  for particular period are selected and well planned for the purpose of their regular and continuous use. Purchase requisition is generally prepared by departmental heads and provides information of type of material to be purchased, time of requirement, quantity to be purchased, and submitted to chief pharmacist, who processes the purchase.

 

2. Source of supply:

            The pharmacy and therapeutic committee sets adequate standards for the purchase of quality drugs. Procurement of stores is generally done by following sources.

1. Medical store depot

2. Directorate General Supplies and Disposals

3. Direct from wholesellers and Manufacturers

4. By inviting tenders

5. Emergency purchases from Local Market

 

a. Medical store depot (MSD):

            This organisation has six medical store depots (MSD) at Mumbai, Chennai, Kolkata, Karnal, Hyderabad & Guwahati. The items purchased by these organisations are subjected to various in house tests at the testing units in Chennai and Mumbai. It runs on no-profit and no-loss basis.

 

b. Directorate General Supplies and Disposals:

            Directorate General Supplies and Disposals calls for tender and places the order. The payment is made only after the verification of inspection report by the indentor.

 

c. Direct from wholesalers and Manufacturers:

            Direct purchases from wholesalers, manufacturers are done following a proper purchase procedure. Materials are then received and stocked at their relevant places under proper storage conditions.

 

d. By inviting tenders:

            Tenders are invited from various suppliers and generally the lowest bidder is choosen for supplying the order. However price and quality both are considered well.

 

e. Emergency purchases from Local Market:

            Items that are not available at MSD, DGS & D and any emergency drug which is out of stock can be immediately purchased from local market. For this, purchase form is prepared in duplicate, one copy is sent to the department and other copy is retained in the pharmacy. This avoids the department concerned to re-order the same item.

 

3. Purchase order:

            After selecting the supplier, chief Pharmacist or any other suitable authority prepares a purchase order giving detailed description, specification, packaging price and quantity needed etc., Of the items. This purchase order is in written form and it is the evidence of contract between the buyer and the supplier. Number of copies varies from hospital to hospital.

1. The original copy is sent to supplier

2.One copy for accounts section

3. One copy for Purchase department

4. Two copies for the concerned department

5. One copy as history copy

The purchase order should clearly indicate the terms and conditions, i.e., price quality and time of delivery. There should be a regular follow-up of purchase order so that drugs and supplies can be received timely.

 

4. Receipt of acknowledgment:

After placing the order to supplier by sending  a copy of purchase order, the supplier in turn sends an acknowledgment of the order saying that he will be able to supply  the goods with the terms and conditions which are mentioned in the purchase order.

 

5. Receipt of drugs:

On the receipt of drugs, there should be a system in the stores whereby the supply of drugs received in the medical stores from the manufacturer are properly checked by person specially assigned for this purpose. Preferably the same person is responsible for reviewing the stocks, date of expiry, description, quantity, batch number, as mentioned in the order form.

            Random sampling can be done to make sure that products confirm to the tendered specifications like date of expiry and any visible sign of deterioration such as a change in color etc.

            If any deterioration is observed, the matter should be reported to the medical superintendent and local drug inspector. These stocks should never be used until the drugs inspector’s permission is granted and the information should be sent to the manufacturer.

            After the thorough examination of drugs, the above officer should give “ No objection to accept the supply” in writing on hospital copies of delivery challans, invoices by putting signature and date. The invoice received from the supplier is sent to accounts section for accuracy along with price and quantity. After verification, the accounts section certifies and passes, the invoice for payment and on this basis, cashier makes the payment either by cheque/draft.

 

6. Distribution of drugs to drug store and wards:

Drugs should be supplied in the original packing of manufacturers. However if it is not possible to do so, then that should be supplied in clean containers so that the integrity and original properties can be preserved. Name and quality of the drug should be properly labeled. It is always advisable that suitable precautions should be taken to dispose off “ original empty containers” in order to avoid misuse. The containers should be destroyed in the presence of a responsible person with a written statement signed by him.

            The chief pharmacist should visit wards to check whether the drugs are properly stored under special storage conditions like cold storage, cool temperature & room temperature.