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Chapter FIVE: THE WAY FORWARD
This chapter introduces the concept
of integrated care and advocates the
establishment of an integrated care pilot
based on the principles of the
pharmaceutical care model schemes.
The pilot could apply to prevention
and treatment in relation to the misuse of
illicit drugs, prescribed and
over-the-counter medicines, alcohol and
nicotine. |
Introduction
137. Pharmacists are already involved in many aspects of
the planning and implementation of services for substance
misusers but such involvement is patchy, and the
profession's contribution is constrained because it is
often not included at the early stages of development. The
adoption of an integrated approach, that seeks to combine
and co-ordinate all the services required to meet the needs
of an individual, will enable pharmacists, as equal members
of a team of providers, to become fully engaged in the
development and provision of services for substance
misusers according to local need. This will result in
decisions about the provision of pharmaceutical services to
substance misusers being made with informed consideration
of all the issues involved.
138. Service response needs to be patient-focussed
addressing the wider needs of the patient and his/her
family and not limited by organisational or administrative
practice. Support should be made available for the whole
extent of the patient's journey including rehabilitation
and reintegration into the community. Many informal local
arrangements are already in place but these are not
recognised centrally and do not operate within a clearly
defined system.
The Concept of Integrated Care
139. "Integrated" as opposed to "shared" care is now the
accepted and recognised term to describe a process that
seeks to combine and co-ordinate all the services that are
required to meet the needs of an individual. The change in
terminology has come about because of the existence of
different definitions for medical and social care.
140. Evidence shows that substance misusers do, in many
cases, need help from a wide range of service providers
[see box below]
95,96. No single agency can tackle the diverse needs of
this sector of the population on its own.
Range of Potential Service
Providers for Substance Misusers - General Practitioners and Primary Care
Teams
- Community and Hospital Pharmacists
- Scottish Prison Service (
SPS)
- Providers of
SPS transitional care
arrangements
- Housing services
- Employment and training providers
- Health specialties [A&E
Departments, peri-natal and hepatology
services]
- Religious organizations
- Addiction services
- Social Inclusion partnership
initiatives
- Social Work community care, children
and families services, criminal justice
social work
- Criminal Justice Services (Drug Courts,
DTTOs, Arrest Referral
Schemes, the Police)
- Providers of residential detoxification
or rehabilitation services
- Acute Services
- After-care services
Adapted with permission from
Scottish Executive Effective Interventions
Unit: Integrated Care for Drug Users:
Principles and Practice. Astron: Edinburgh,
2002. |
141. In order to further this development and ensure the
adoption of a consistent approach throughout the whole of
Scotland:
- Formal links should be established between
pharmacists and other agencies, such as Social Services
staff
- The profession of pharmacy should be fully
represented on all Drug Action Teams
- All
NHS Boards should have access to
advice provided by a Specialist Pharmacist in Substance
Misuse (
SPiSM)
- An integrated care model, which would identify and
standardise existing best practice and involve the
pharmacist and other relevant healthcare professionals,
should be constructed to address the needs of all
clients and specific client groups (
e.g. pregnant women, the homeless, those
wishing to withdraw from methadone, employed and
chaotic drug users,
etc.).
An Integrated Pharmaceutical Care Model for
Substance Misusers
142. Pharmaceutical care was first described in 1990 as
the process required to ensure that all the patient's drug
therapy is appropriately indicated, effective, safe, and
convenient and achieving a defined outcome
97. In 1999, The Clinical Resource and Audit Group (
CRAG) Framework for Clinical Pharmacy
Practice in Primary Care
98 recommended that pharmaceutical care needs should
include:
- needs for a pharmaceutical product: a medicine, a
formulation, and a "compliance aid"
- needs for a pharmaceutical service: advice,
simplified regimens, a medication review, monitoring of
drug therapy and health promotion.
143. Pharmacists can help to address an individual
patient's needs by working in collaboration with the
patient, and/or carer, other healthcare professionals,
social work services staff and the acute sector to provide
integrated care.
144.
MEL (1999) 78, entitled Model Schemes
for Pharmaceutical Care
99, provides an opportunity for community pharmacists
to develop services for frail elderly patients, people with
palliative care needs and people with severe and enduring
mental illness through implementation of evidence-based
practice, national guidelines and policy.
145. There is a commitment in
The Right Medicine to develop similar models for
chronic disease management including epilepsy, asthma,
diabetes and coronary heart disease by the end of 2005
1.
146. A Steps Framework has been developed to drive
forward the concept of the pharmaceutical care model
schemes. This stepwise approach breaks the process up into
a number of components, applies evidence-based practice and
guidelines and standardises current practice. This approach
helps professionals to develop their practice, to forge
links with other health and social care providers and to
manage any capacity issues.
147. A worked example of a stepwise approach, adapted to
the provision of services for substance misusers, is given
below.
EXAMPLE OF STEPWISE
APPROACH Step 1 Preparing your Practice Step 1 would standardise best practice and
improve access to information relating to
medication, condition, local support agencies
and integrated care through discharge planning,
improved documented communications and
teamwork. Subjects covered would include: - Potential side-effects and how to
manage them (
e.g. drowsiness and the
implications for driving/operating
machinery)
- Advice on action to be taken if a dose
was missed
- Stocking of self-help leaflets
- Health improvement and harm reduction
information including topics such as safe
sex, diet and smoking cessation
- Multi-agency agreement and sign-posting
to other agencies
- Wound management advice and
referral.
Step 2: Appropriateness and Safety:
Targeted Intervention Working in collaboration with their
colleagues in primary care the pharmacist would
carry out an assessment of the appropriateness
of drug therapy in relation to whether or not
the dose was optimal and assess if the patient
was experiencing any preventable or manageable
side effects or reduction in risk associated
with specific phases of a drug misusers
"journey". The latter might include specific
support for pregnant women, chaotic drug users,
those wanting to withdraw from methadone or
those where a relaxation of daily supervision
would be advantageous (
i.e. employment or study
opportunity). Oral testing, etc would also be a
component. Step 3: Holistic Medication
Review To ensure that all of the patient's drug
therapy was appropriately indicated, safe,
effective, and convenient and that health
promotion needs were being met. |
148. The steps could be provided as packages of care or
as individual components. The principles of the
pharmaceutical care model schemes could be applied to
substance misuse as part of an integrated care model.
149. The goals of care should be as outlined in the box
below.
Goals of Care Direct: - To reduce illicit substance use
- To reduce the risk of the drug-related
disease including the spread of blood-borne
viruses
- To optimise the benefit of harm
reduction programmes
- To improve all aspects of health
- To improve integrated care through the
provision of pharmaceutical care based on
individual need
- To reduce the incidence of drug-related
deaths.
Indirect: - To reduce involvement in criminal
activity
- To improve personal, social and family
functioning
- To improve education and employment
prospects.
|
150. An integrated care model for substance misuse
should:
- Contribute to the planning, design and delivery of
services
- Reserve sufficient time and resource for forging
and maintaining links with other relevant agencies
- Allow adequate training for all members (including,
wherever possible, multidisciplinary and multi-agency
training to promote a mutual understanding of the roles
of different partner agencies)
- Establish an atmosphere where organizational and
cultural barriers can be explored
- Establish components of the pharmaceutical care
plan that would contribute to the single shared
assessment and/or existing multi-disciplinary care
plans
- Establish and agree systems and protocols for
referral, the sharing of information and joint working
between agencies
- Promote evidence-based practice
- Develop systems for clinical effectiveness
- Work with patients to support them through the
provision of pharmaceutical care.
Goals of Care Adapted with permission from
Scottish Executive Effective Interventions
Unit: Integrated Care for Drug Users:
Principles and Practice. Astron: Edinburgh,
2002. |
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