Passport to Health Managing Your Health Information

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Passport to HealthManaging Your Health
Information

Family MD
Passport to Health
Patient
Pharmacist
Iris Krawchenko R.Ph, B.S. Phm, CGP
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The Original Collaborators

• Dr. R.H

• Iris Krawchenko Dr. R. H. Tytus
• R.Ph. B.Sc. Phm., CGP B.Sc. Phm, MD, CCFP, FCFP

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How Did the Idea Originate?

• Pharmacist/physician collaboration educational
  meeting June 16, 2004
• In discussion, we identified a patient care gap
  in the current medical system and developed the
  program as a solution.
• Care gap identified best possible medication
  record by family physician, appropriate HT
  therapy and patient adherence
• Met once every 2 weeks to develop, implement,
  evaluate and improve the program
• Utilized expertise of others in development

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Pre-Pilot Program

• Enrolled 4 patients
• Medication Reconciliation conducted with very
  startling results
• Fine-Tuned Chronic Disease Management protocols
• Re-evaluated program
• Developed budget and presented program to
  Hamilton Family Health Team
• ACCEPTED

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Passport to HealthEmpowering the Patient
Binder designed to empower patients and engage
patients in their treatment plan. All data can
been stored in one location for review by Family
MD, pharmacist and patient.
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Passport to Health

• Contains..
• CPP (cumulative patient profile)
• Documentation of monthly objective measurements
  and how they relate to the established goals
• Current Comprehensive Medication List
• Module specific Risk Assessment
• Patients
• must bring the passport to every appointment with
  every health care professional.
• are encouraged to provide a copy of their current
  medication record to all health care professionals

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PTH The Big Picture

• Patient Criteria Met
• (e.g., Diabetes Hypertension)
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• FHT Physician rosters patient to program
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• Patient chooses their PTH Pharmacist
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• Patient meets with PTH Pharmacist
• and PTH binder is customized
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• Medication consultation conducted by
• Pharmacist physician communication
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• Disease management action plan
• according to protocol monthly follow-ups

Patient agrees to inform pharmacist of any
medication changes within 48 hrs
Patient presents PTH binder to all allied health
professionals encountered
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Pharmacists Accessibilitygt 10,000 Licensed
Pharmacists in Ontario
Why Not Integrate the Community Pharmacist into
Chronic Disease Management Programs?
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PTH Module 1 CV Disease
Focus on Patients with Hypertension and Diabetes

• Cardiovascular issues responsible for 80 of
  deaths in people with type 2 diabetes
• Only 9 of people with hypertension and diabetes
  have BP under control
• Targeted by Ontario MOH as priority issue
• Physician bonuses available for hitting targets
• Care gap with respect to
• appropriate management
• patient adherence

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Passport to Health with CV module

• At each subsequent monthly visit, the
  pharmacist
• Measures Blood Pressure
• Weighs Patient
• Measures Waist Circumference
• Documents and reviews targets
• Reviews adherence, identifies and discusses any
  drug related concerns
• Updates Medication list.

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Passport to Health

• In follow-up the pharmacist
• Communicates with physician regularly
• Makes recommendations when necessary to try to
  improve getting to goal
• Identifies and re-directs responsibility for
  treatment failure
• Makes other recommendations regarding medication
  management for CV disease
• Updates physician of any changes in the
  medication profile
• Sends physician new list of medications.

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Passport to Health
The pharmacist provides on-going education,
support, reinforcement and counseling for the
patient at every monthly visit.
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Passport to Health

• The first community based project involving
  pharmacist collaboration to be funded by a Family
  Health Team
• In Hamilton, 5 physicians collaborating with 5
  pharmacists with the goal of managing 10 patients
  each (50)
• Recipients of 2006 Commitment to Care Award for
  Physician/Pharmacist Collaboration

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Passport To Health - Challenges

• Patient Enrollment slower than expected.
  Physician driven. Perhaps consider other allied
  health care professionals /or the community
  pharmacist
• Communication with physician mostly paper based
  or verbal. Electronic still pending.
• Patient Information Paper based. Older
  population very comfortable with paper and not
  electronic. Now developing electronic version
  also for patient choice.
• Collaboration in the pharmacy. Must have the
  support of the pharmacy team
• The pharmacy technicians must learn to triage
  and choreograph the activities of the dispensary
  while the pharmacist is involved in comprehensive
  patient care

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Passport To Health - Successes

• Patient acceptance and positive feedback
• Positive physician feedback
• Enhanced and Integrated Role of the Community
  Pharmacist
• The Passport to Health core program lends itself
  to different chronic disease management modules
• Interest and uptake with other FHT
• Easily modified for the specific needs of a
  program
• Program evaluation ongoing

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Passport To Health

• Questions?

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