Outreach Pharmacy Service in Old-aged Homes –-An exploratory program in Tseung Kwan 0

Joseph Lau1; Antony CT Leung1; Tak-yi Chui1; Ngai-sing Ng1; Dolly MY Leung2; Christine Lam3, Eanna Chow4; Anita Chan3

1 Haven of Hope Hospital; 2 HOH Woo Ping Care & Attention Home, 3 HOH Nursing Home; 4 HOH Tsui Lam Day Care Centre for the Elderly


Introduction

In Hong Kong, with an increasing elderly population, many old-aged homes have been established in recent years. In Tseung Kwan 0 and Sai Kung districts alone, there are over 18 old-aged homes. Most of the old-aged home residents receive multiple drugs for multiple diseases. Not infrequently, these elders are required to attend several Hospital Authority (HA) specialist clinics regularly. Besides, private practitioners would also prescribe some medications for them occasionally. This multiple medical consultations raise the potential problems of polypharmacy, compliance, adverse reaction, interaction, financing and drug wastage. Furthermore, the existing law and the code of practice only lay down basic manpower requirements. Without specific legislative requirements and external support, health workers or nurses have to shoulder the responsibilities of drug management in old-aged homes. Variable standards of practice invariably result. The common problems are improper drug distribution and storage system, poor medical/ administration record-keeping, insufficient knowledge on drug handling of staff, which in fact is crucial for the proper and safe drug administration process. This paper reports the exploratory outreach pharmacy service program in four old-aged homes in Tseung Kwan O.

Service Objectives

The objectives of the outreach pharmacy service program in old-aged homes are as follows:
To provide onsite advice to old-aged homes to improve their drug distribution, administration & storage system;
To provide the concerned staff with update drug information and training (e.g.seminars & workshops) to improve their drug knowledge; and
To promote proper drug usage to reduce medication errors, drug wastage and polypharmacy in old-aged homes
To facilitate support and collaboration with Chief Pharmacist Office of HA in the future development and assessment of the drug distribution system in the old-aged Homes;

Service Scope

The first stage of service commenced in January 2002 and lasted for one and half years. Four old-aged homes in Tseung Kwan a district were selected and the services provided were divided into three main parts.

A) Improving the old-aged home's infrastructures regarding drug distribution, administration, recording, storage and drug handling

i) Pharmacist would provide visits to old-aged homes. The facilities and procedures of the following aspects would be evaluated:
· Drug distribution and administration procedure
· Medication record keeping
· Drug storage
· Drug disposal method

ii) After the evaluation, recommendations would be made and discussed
with the administrative party of the corresponding old-aged homes.

iii) A re-visit would be carried out to audit the progress and see whether
further recommendation is required.

iv) A briefing session on the new drug distribution and administration
infrastructure would be held.

B) Improving the drug knowledge of the staff

i) Workshops and seminars would be held with emphasis on the following areas:
· Meter-dose inhaler administration technique
· Common adverse effects
· Correct use of different dosage formulation
· Proper time of drug administration for commonly prescribed drugs
· Drug -Food interaction

ii) Drug quiz would be organized for enhancing their interest and awareness of drug related issue

C) Promoting correct drug usage

Polypharmacy and drug interaction program -the medication profiles of the old-aged home residents would be evaluated. The duplicated drug items and the potential mutually interacted items would be spotted out. The consolidated data is then reported to Community Geriatric Assessment Team (CGAT) senior medical staff/CaS for further actions. The program would be carried out every six months.

Drug utilization program -Psychotropic impact program regarding haloperidol
and thioridazine would be implemented to monitor the drug usage of CGAT.
The cases would then be reported to the senior medical staff for clinical audit
and re-evaluation.

Service progress & Observations

The following were carried out during the period of the program:
One drug quiz competition program was organized to the CGA Told-aged homes' nurses in order to stimulate their interest & enhance their drug knowledge, with participation rate of 40.95%, in Jan 2003
Six separate inhaler technique workshops with emphasis on proper inhaler technique were organized for all four old-aged homes, with participation rate of 97.6 %, in 2002/2003
Drug distribution system audit program- all 4 selected old-aged homes were visited by pharmacist. Recommendations were made and changes on drug distribution system were implemented to ensure safe and smooth improvements in 2002/2003
Polypharmacy and drug interaction monitoring program were carried out in the 4 old-aged homes in March and December 2002 respectively to monitor for the drug usage in the elderly clients as they are susceptible to adverse drug effects.
Drug utilization program (Psychotropic IMPACT program -high risk drug usage: e.g. haloperidol/Serenace & Thioridazine/Melleril, etc.) was implemented & used to monitor the drug usage by Haven of Hope Hospital pharmacy in June 2002.
Two drug education seminars on common psychogeriatric adverse drug reactions were organized, with participation rate of 72.5%, in July 2003 Feedbacks for the 4 homes were good with staff welcoming the training. Participation rate was encouraging. Management staff of the homes were open to be audited and to implement the recommendations of the visiting pharmacist as far as possible. It can be said that outreach pharmacy service is welcomed by old-aged homes and helpful to the staff involved in the drug administration process.

Limitations

Participation in the program by the old-aged homes was voluntary. This could account for the enthusiasm of both the management and frontline staff in all the activities including the audit. However, the homes did not have resources for some recommendations on improvement measures on system. With better available resources, further improvements could have been made.

Haven of Hope Hospital Community Geriatric Assessment Team (CGAT) provided regular visits to these 4 old-aged homes. This meant that many residents were having their geriatric medical follow-up within the old-aged homes, and most of the medications were dispensed by Haven of Hope Hospital pharmacy. This enabled better and more complete drug information retrieval for polypharmacy and drug utilization.

Further study

With confirmation of the feasibility of the pharmacy outreach service, the effectiveness of the service should be evaluated.

Conclusion

All planned programs in the first stage were completed successfully. Feedbacks from the old-aged homes were positive and encouraging. We conclude that the establishment of pharmacy outreach service in old-aged homes is feasible. Pharmacy professional input regarding drug management of old-aged homes, drug regimen review and caregiver/patient education programs are highly recommended and suggested to be carried out on a regular basis. We expect more old-aged homes will be involved in this program next year. A study on the effectiveness of the program is recommended.

Acknowledgements
Acknowledges the contribution of the old-aged homes & community spirit of our co-workers and colleagues.