Preventing unnecessary hospital admissions for medication could save the NHS a significant part of the £150m “medicine waste” recognised in a Department of Health report, say Nina Barnett and Andrew McDowell.
The need for clinical medication review to optimise therapy is well recognised and, for many, is already embedded in clinical practice. However, to date there has been much less focus on the process following prescription of a medicine, specifically on medication adherence.
Medication contributes to 5 – 8 per cent of hospital admission and readmissions, of which almost half (approximately 4 per cent) are preventable. A 2010 report from the Department of Health estimates that wasted medicines cost the NHS £150m each year with poor adherence to medicines contributing a significant amount to both waste and suboptimal benefit from medicines.
Improving medication adherence address two of the four key areas of the quality, innovation, productivity and prevention agenda – improving quality of care and preventing increased health care utilisation from medicine related problems, including lack of efficacy.
The long term conditions agenda is also of key concern, accounting for 70 per cent of NHS spend. With the advent of evidence based medicine, patients with long term conditions face an ever increasing medication burden. Herein lies the challenge: balancing evidenced prescribing with the inevitable consequence of poly-pharmacy.
There are financial and clinical incentives to improve medication adherence in order to reduce waste, minimise preventable medicines-related problems leading to readmission and maximize return on investment in medicines for patients and the health care system.
In 2009 the National Institute of Clinical Excellence produced guidance around supporting medication adherence. This outlined the need for improved medicine-related communication with patients, the value of patient involvement and the patient perspective in decisions about medicines taking and the importance of communication between health professionals about agreed decisions relating to medicines.
In recent months the New Medicines Service, an evidence-based adherence support service, which captures the essence of this NICE guidance, has been introduced through community pharmacies. The service complements the established support provided by the medicines use review service.
The New Medicines Service is available free to patients who are on certain medications for long term conditions and, through a structured consultation at two and four weeks post initial prescription, uses a concordant approach to support medication adherence, including elements of coaching.
At the heart of the chronic disease management model is the informed, empowered patient with access to continuous self-management support. It has been estimated that around 70–80 per cent of people with long-term conditions can be supported to manage their own condition.
Traditional pharmacy models of consultation focus on the provision of information and education, but most result in directive advice. The need to ensure patient safety through transfer of medicines related information is clear but this activity is by no means a proxy measure of patient engagement or of improved patient outcomes.
We know that education alone is not enough; in fact, patients may be disengaged or passive, and pharmacy consultations that inadvertently fail to actively engage patients miss an opportunity to encourage patients to take responsibility for the management of their own health.
The aim of health coaching is to raise awareness and increase responsibility for health in order to improve patient outcomes. It is our contention that a health coaching approach provides pharmacists with skills that engage patients with the management of their own health.
Health coaching interventions are designed to assist patients to generate greater awareness of their health and increase their sense of responsibility for self-management, thereby motivating them to engage more effectively with their use and management of medicines.
In considering optimising outcomes from medicines, it is critical to understand the importance of improving adherence from a patient perspective. Patients are motivated to adherence to medication regimens because of benefit they perceive from regularly taking the medication, for example, relating this to their lifestyle goals, such as being able to walk the dog, go on a holiday, or play with their grandchildren.
By identifying and working with the patient’s agenda, pharmacists can tap into that individual’s motivation, thereby maximising the opportunity to improve health outcomes. Pharmacists who address this aspect of the personalisation agenda will need to develop skills in behaviour change.
There is a growing body of evidence from the research literature, supported by practical accounts from pharmacists, to promote the use of coaching based conversations to improve adherence, particularly in long term conditions. For example, in the area of smoking cessation, coached participants had higher rates of adherence to pharmacologic therapy and higher quit rates than non-coached participants.
In cardiovascular disease, coached individuals had better adherence rates to prescribed treatment, including pharmacotherapy, than non-coached participants. Similarly, diabetic patients benefitted from coaching through reduction in perceived barriers to medication taking and improvements in HbA1C.
In hospital practice, attention is being paid to reducing preventable admissions and re-admissions, including those which relate to medicines. At North West London Hospitals Trust, there is a pharmacy service which addresses the issue of preventable medicines-related hospital episodes, medicines waste and optimising adherence.
Using evidence from the literature and local experience the Harrow Integrated Medicines Management service was established in 2008 based Northwick Park Hospital, Harrow. Ward pharmacists identify patients with risk factors for preventable medicines related problems and refer them to the HIMMS pharmacy team, who, using an evidence based assessment tool known as PREVENT, manage and follow up these patients during admission and after discharge, including referral to primary care for medicines support as required.
Audit of the service has shown that adherence issues are one of the two most common reasons for referral. Adherence problems can be broadly divided into two categories: unintentional non adherence and intentional non adherence.
Unintentional non adherence refers to two main categories of patients; those with physical impairment and those with cognitive issues. Physical impairment around medicines, such as difficulty opening containers, is usually easily identifiable and amenable to simple measures. For patients who have cognitive issues, for example where there is a question around capacity for medicines taking, additional support from carers may be needed and this often involves multiagency support.
A health coaching approach is most useful for engaging patients who are intentionally non-adherence, such as patients who are ambivalent about medicines taking. These patients are classified as intentional non-adherent as they are exercising choice in not taking their medicines.
They are more difficult for clinical staff to identify and management involves addressing patients’ beliefs and values around medicines taking and the balance of perceived necessity for a medicine against their concerns.
For example, this may be a patient not prioritising taking their medicines because they don’t believe it is worth the effort. These patients represent a significant proportion of non-adherent patients and we suggest, are currently an under recognised group. Pharmacists in this service are developing their skills in the use of health coaching tools to support this group of patients.
Moving towards a concordant approach to medicines taking requires a change in thinking. The current skills gap can be addressed through training in the use of health coaching and for pharmacists this is particularly about integrating an education based approach to medicines support.
By focussing on the patient agenda through the use of coaching tools, pharmacists will improve patient adherence to and therefore outcomes from medicines. The new medicines service is the first step in acknowledging this. The challenge is to develop pharmacist skills further, in order to integrate coaching into every day pharmacy practice.