Community Pharmacy In Health Care Homes Trial Program
A Health Care Home is a general practice or Aboriginal Community Controlled Health Service (ACCHS) providing coordinated and flexible care for patients with chronic and complex conditions. Health Care Homes offer coordinated, integrated care that is tailored to patient needs by acting as a ‘hub’ for patient information and assisting with coordinating broader care with other health professionals.
Community pharmacy involvement in the Health Care Homes trial, agreed to last year under the Pharmacy Compact as The Community Pharmacy in Health Care Homes Trial Program, presents an opportunity for community pharmacists to expand their involvement in coordinated and integrated care which is tailored to patient needs.
Participation in the Community Pharmacy in Health Care Home Trial Program is available to all pharmacies that comply with the program rules, however since the Australian Health Care Homes trial is only occurring in 10 of the 26 Australian Primary Health Networks (PHNs) it is more likely that pharmacies in, or close to the boundaries of, those Primary Health Networks will receive patient invitations.
A current list of the participating General Practices and Aboriginal Community Controlled Health Service (ACCHS) is available here
Community Pharmacy Role
The Community Pharmacy in Health Care Homes Trial Program is an initiative funded under the 6CPA to support the incorporation of medication management planning and programs within Health Care Homes. Pharmacies involved in the trial will work in conjunction with the Health Care Home team by delivering patient-centred medication management services until the trials conclusion on 30 November 2019.
Patients are enrolled to the Health Care Homes model of care by their general practitioner or Aboriginal Community Coordinated Health Service (ACCHS). An invitation will be sent from the patient’s care coordinator to the patient’s nominated pharmacy.
Community pharmacy’s role in Health Care Homes is to conduct an initial medication reconciliation of the patient’s medications, and develop a collaborative Medication Management Plan.
Medication adherence and management services may be identified based on clinical need, including dose administration aids, blood glucose monitoring, blood pressure monitoring, and development of an asthma management plan – these services are available to all Tier 2 and Tier 3 patients to help achieve their medication goals.
This will be supported by regular follow-up reviews by the pharmacy to maximise continuity of care and improved chronic disease management.
Shared Care Plan
A central element of the Health Care Homes model is the development of a tailored and electronic Shared Care Plan with the patient, which will be implemented by the team of health care providers. The plan will identify the local providers best able to meet each patient’s needs (including community pharmacy), coordinate care with these providers, and include strategies to help each patient manage their conditions and improve their quality of life.
There are severely different software providers approved by the Medical Industry Software Association (MISA) that a General Practice or ACCHS could be using so the email invitation to participate in a patients Shared Care Plan may come from a number of different sources https://www.msia.com.au/healthcare-homes/
Community pharmacy’s contribution to the Shared Care Plan includes:
Medication reconciliation: Using a systematic approach to reviewing a patient’s currently prescribed, over the counter, and complementary medicines. It also identifies any medication-related issues, including adherence.
Medication Management Plan: The aim of a collaborative Medication Management Plan is to optimise medication management, reduce medication-related problems and medication-related hospital admissions, implement strategies to help patients manage their medications, and provide goals of therapy and patient self-management strategies. As part of the plan, pharmacists and patients may identify supporting services which may assist in improved medication management of adherence.
Supporting services: Supporting medication management and adherence services are available to all Health Care Home patients in Tier 2 and Tier 3 to support the implementation of their medication management goals. These services are offered based on clinical need. Patients in Tier 1 are not eligible for supporting services under the Trial Program. The following medication adherence and medication management services are examples of supporting services that can be offered to patients in Tier 2 and Tier 3:
- Dose administration aid (weekly packing of the patient’s medicines)
- Blood pressure testing
- Blood glucose monitoring
- Athma management planning (includes an asthma control test (also referred to as an asthma score) and device training (ideally reviewed every 3 months).
Follow-up reviews: All patients are eligible for three follow-up reviews conducted in consultation with the patient/carer and Health Care Home, until the end of the trial. Follow-up reviews are designed to measure whether patient goals and targets are being met. The timeframe between the initial consultation and follow-up reviews is at the discretion of the pharmacy, in consultation with the Health Care Home and with consideration of the needs of the patient.
Medication Management Plan and Trial Data Requirements
The development and review of a collaborative Medication Management Plan is the fundamental role of community pharmacy in the Health Care Homes model of care.
A Medication Management Plan must include:
- Goals of medication therapy (i.e. proposed plan of action)
- Person responsible for the identified goal (e.g. patient, pharmacist, general practitioner)
- Identification of medication adherence and management services (e.g. blood pressure monitoring, blood glucose monitoring, dose administration aids, development of an asthma action plan)
- Reconciled medication list
- Next review date
Development of a collaborative Medication Management Plan and medication reconciliation occurs in consultation with the patient/carer and Health Care Home during the initial consultation meeting.
At each follow up-review, the Medication Management Plan is reviewed to assess whether medication management goals are being met, and to measure and report on health outcomes.
The Medication Management Plan is uploaded to the patient’s Shared Care Plan after the initial development, and after each follow-up review. All members of a patient’s Health Care Home team will have access to the plan.
Throughout the trial period, pharmacies must collect health outcomes information for all patients that receive medication management services as part of the Health Care Homes Trial. Data is being collected in order to monitor the HCH Trial’s delivery of health outcomes for patients living with multiple chronic and complex conditions.
Data will be required to be provided at the initial consultation and after each follow-up review conducted in consultation with the patient/carer and Health Care Home.
See the Health Outcomes Data document for information about required data 6CPA_CommunityPharmacyinHeathCareHomes-Program-HealthOutcomesData_Aug2018.pdf (pdf - 248 KB)
Claiming and Payments
Patients are categorised by their Health Care Home based on the complexity of each patient and predicted demand for unplanned acute services.
The following payments are payable by the 6CPA Administrator for provision of Health Care Homes Medication Management services:
|Tier Category||Total per patient capped payment over 18 month trial period||Inclusions|
|Tier 1||$418.75||Initial Medication Management Plan; three follow up reviews; health outcome data collection.|
|Tier 2||$1,372.75||Initial Medication Management Plan; three follow up reviews; health outcome data collection; supporting services (flexible category).|
|Tier 3||$1,642.75||Initial Medication Management Plan; three follow up reviews; health outcome data collection; supporting services (flexible category).|
A proportion of the total payment will be made to pharmacies on a retrospective basis following the development of the Medication Management Plan and submission of health outcomes data and following each review of the Medication Management Plan and submission of health outcomes data. Payment for supporting services is encompassed within the payments, however pharmacies may apply an additional consumer charge for a DAA service at their own discretion.
The Community Pharmacy in Heath Care Homes Trial Programs Delivery and Recording Platform will be provided to all pharmacies participating in the trial soon. This will also include a full suite of training materials to guide you through the preparation and successful delivery of the Community Pharmacy in Health Care Homes Trial.
Should a Health Care Home patient present to your pharmacy prior to the recording platform becoming available contact the 6CPA Health Care Home team at 1300 555 262 or email firstname.lastname@example.org.
Should a Health Care Home patient present to your pharmacy prior to the recording platform becoming available or If you have any queries regarding participation, please call the 6CPA helpline on 1300 555 262 or email email@example.com.