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Health, Beauty & Fashion

Confused? The pharmacist can help you at home

House calls let the pharmacist check if medicine is stored correctly and if pills interact with vitamins and supplements a patient is taking
The Straits Times - February 9, 2012
By: Lea Wee
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Confused? The pharmacist can help you at home -- ST ILLUSTRATION: MANNY FRANCISCO

An elderly patient with diabetes, Madam Chen (not her real name) was admitted in dire straits to the Changi General Hospital (CGH) 11 times in the first eight months of 2010.

The chain of events leading to each admission was nearly the same every time.

Her blood glucose level would shoot up so high that she would lapse into a potentially fatal condition called diabetic ketoacidosis (DKA). She would become weak and breathless. Once, the 80-year-old fainted at home, a two-room Housing Board rental flat where she lived alone. Luckily, she was discovered by a volunteer visiting her.

In the hospital, doctors could not fully fathom why her blood sugar would spike to such dangerous levels when she had all the necessary medication to control it.

So in August that year, Ms Lee Chai Hoon, a pharmacist from the hospital, visited Madam Chen at home to investigate. Ms Lee found some possible answers to the doctors' conundrum.

Instead of storing the unopened insulin vials for her diabetes in her refrigerator, Madam Chen put half of them in the freezer, rendering them ineffective.

Ms Lee also discovered that Madam Chen had been injecting herself with 16 units of insulin, instead of the prescribed 18 units, because she had misunderstood the doctor's instruction.

As she had to go to the polyclinic regularly to consume her medication there, she thought she had also been given medicine for her other three illnesses - high blood pressure, high cholesterol and deep vein thrombosis. Hence, she did not take medicine for these on the days she went to the polyclinic.

She had also not been taking other medication as she was supposed to, as she thought the polyclinic had given it to her when she went there for treatment - which actually was for a separate illness, tuberculosis.

Madam Chen had not been keeping to the low-sugar diet recommended for diabetics. Instead, she had been scoffing down free food packets containing goodies such as biscuits and three-in-one instant coffee which the community centre nearby was distributing to the poor. These were wreaking havoc on her nutrition.

During the visit, Ms Lee advised Madam Chen on the right way to take and store her medicine, as well as the importance of complying with a low-sugar diet.

She understood and appeared to be cooperative, said Ms Lee.

There are many patients who could do with such guidance, so the Health Ministry's Agency for Integrated Care (AIC) started a two-year pilot project in June 2010 to help them. Ms Lee's home visit was part of the project.

The agency, which was set up by the Health Ministry in 2009 to coordinate care services, mooted the idea after members of its Aged Care Transition Team noticed some patients were not taking their medication correctly after they were discharged from hospital.

The team helps patients, mostly the elderly poor, negotiate a smooth transition from hospital to home.

A study in 2009 by the agency had found that as many as one in five hospital readmissions occurred because of poor compliance with taking medication.

Besides CGH, the project was also rolled out to Tan Tock Seng, Singapore General, Khoo Teck Puat and National University hospitals.

In each hospital, care coordinators roped in pharmacists to go to the homes of patients who were deemed to need their help after they had been discharged.

Between June 2010 and August last year, 308 patients were seen by pharmacists, together with their care coordinators.

The pharmacists found each patient to have an average of three medicine-related problems, the most common of which was not taking their medication as prescribed. This meant they were either not taking their medication or not taking it correctly.

'This can lead to unnecessary deterioration and complications of the medical condition,' said Ms Yasmin Ng, assistant manager of outpatient pharmacy practice at CGH.

Almost all (about 98 per cent) were on five or more types of medicine. More than seven in 10 (or 75 per cent) were on 10 or more types of medicine.

During the home visit, which can take up to two hours, the pharmacist reviews the patient's medicine and assesses if he is taking it as prescribed.

She will also help to sort out the medicine, throw away what has expired and ensure none of the drugs interacts with another to cause harm.

If she sees any adjustments that have to be made, she will contact the doctor - immediately if necessary.

The advantage of doing a medication review in the patient's home is that it offers a unique perspective on his medication use.

'For instance, we can see for ourselves how the medicine is stocked and stored, rather than rely on what the patient tells us,' said Ms Ng.

The pharmacist can also review every drug, herbal supplement and vitamin being taken by the patient and ensure that they do not interact with one another.

In this context, the home pharmacist has a multifaceted role as the patient's advisor, confidante and even advocate with his doctor.

Right now, however, the time allocated for the programme is only 0.4 per cent of the pharmacist's working hours.

She can afford to make only one home visit for each patient most of the time.

The jury is still out on how much good a single visit can do.

For instance, Madam Chen managed to stay out of hospital after the visit - for three months.

After that, she lapsed into her old habits and was hospitalised again.

She has since moved to live in a senior activity centre, where she is under medical supervision.

But the AIC feels the response from patients has been positive enough for the visits to become a permanent fixture for all the hospitals once the pilot project ends next month.

In a survey conducted after each visit by the care coordinator, nine in 10 patients said they were able to manage their medication better.

Details are still being worked out on how the programme might be improved.

The AIC is likely to increase the number of hours each pharmacist spends on the resource-intensive programme.

To sustain the programme, Ms Ng feels it is worthwhile to adopt the cost-effective method of 'health-care hot spotting', by focusing on patients who are unnecessarily high utilisers of health care, for instance, those who have been admitted multiple times for medicine-related problems.

There is potential for the pharmacist to play an even bigger role during the home visit, said Ms Ng.

The CGH pharmacists have been taking along a blood pressure monitor and a glucometer which they use on patients with high blood pressure or diabetes as a quick gauge of whether their medical conditions are under control.

Ms Ng said: 'If the readings are not good, we will write a memo to the doctors to suggest a review of medication, if necessary.'



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