DIABETES

MEDICATION THERAPY ADHERENCE CLINIC

(DMTAC)
PROTOCOL
IN
HOSPITAL TUANKU AMPUAN NAJIHAH,
KUALA PILAH
PHARMACY DEPARTMENT
HOSPITAL TUANKU AMPUAN NAJIHAH
REVISED JANUARY 2013
PROPOSAL OF ESTABLISHING A DIABETES MEDICATION THERAPY
ADHERENCE CLINIC (DMTAC) IN HOSPITAL TUANKU AMPUAN NAJIHAH
1. I!"#$%&!'#
Medication Therapy Adherence Clinic (MTAC) is a clinic operated by pharmacists who provides
counseling and education to patients with the purpose of helping them to improve their ability in
self-managing condition and thus preventing deteriorating in symptoms. The goal is also to
ensure seamless transition of patients from in-patient care to the out-patient clinic system
(hospital/health community)
2. O()*&!'+*,
a) To maimi!e the benefits of medication therapy in diabetic patients.
b) "educe adverse effects and complications resulting from multiple drug regimen.
c) Assist physicians in the management of patients placed on anti-diabetic therapy.
d) To educate patients about diabetes and its complications# proper self management
and the use of medications and self-care devices.
e) To provide consultative services to physicians and other healthcare professionals
on diabetes medications and related issues.
f) To reduce the emergency room visits of patients and decreasing the total healthcare
costs of diabetes.
3. J%,!'-'&.!'#
To dispose problematic and uncontrolled $iabetes Mellitus patients on medications to the
appropriate clinic for continued treatment based on %bA&c readings and 'asting (lood )lucose
as measuring parameters.
/. M. P#0*"
a) Consultant/specialist
b) Medical *fficer
c) A +harmacist
d) A ,taff -urse
e) A .aboratory Technician
1. P"'&* E,!'2.!'# A$ S3*&'-'&.!'#,
An estimation of "M is needed in establishing a $iabetes Clinic.
/.& ,pecifications -eeded0
a) A room in M*+$ Clinic for pharmacist to conduct counseling sessions (with a
suitable table and 1 chairs for pharmacist and patient)
b) +rinting materials eg $M boo2let# patient3s recording boo2# patients profile# flip
chart etc.
c) )lucometer and blood glucose testing strips for testing patients 'asting (lood
)lucose on day of M*+$ visit
d) Cabinet to store documents# records and patients3 profile
e) "eagent to run %bA&c test every 4-5 months
f) "elevant stationaries
DIABETES MEDICATION THERAPY ADHERENCE CLINIC (DMTAC) PROTOCOL
1. L#&.!'#
The $MTAC clinic is located in M*+$.
2. O()*&!'+*,
a) Maimi!e the benefits of medication therapy in diabetic patients.
b) "educe adverse effects and complications resulting from multiple drug regimen.
c) Assist physicians in the management of patients placed on anti-diabetic therapy.
d) To educate patients about diabetes and its complications# proper self management#
and the use of medications and self care devices.
e) To provide consultative services to physicians and other healthcare professionals on
diabetes medications and related issues.
f) To reduce the emergency room visits of patients and decreasing the total healthcare
costs of diabetes.
3. P#4'&5
All patients currently managed in the diabetes clinic. As appropriate# other patients may be
referred from the medical out-patient department.
/. D'.(*!*, C4''& I234*2*!.!'#
*n a typical $M clinic day# a minimum of & pharmacist is in the clinic. The $MTAC
pharmacist is multitas2ing duties throughout the day# assessing patients and addressing their
needs# documenting actions and plans# giving appropriate education to patients# and doing
follow-ups.
$M clinic day of %ospital Tuan2u Ampuan -a6ihah will operate from 7.48am to &pm
every Thursday.
1. P.!'*! S*4*&!'#
a) 9ncontrolled $iabetes
'asting (lood ,ugar ('(,) : &8.8 mmol/l
"andom (lood ,ugar ("(,) : &/.8 mmol/l
%bA&c : &8;
b) $iabetes with other complications (macrovascular or microvascular)
c) $iabetes with other co-morbidities (eg %ypertension# %yperthyroid# Asthma etc)
6. P"#&*$%"*
E"#44'7 3.!'*!, '!# MTAC
&. $uring the initial interview# the following will be reviewed with the patient0
(a) $MTAC mission
(b) Anticipated benefits to the patients
(c) )oals of patient or care giver
(d) +atient specific drug therapy related need and goals
(e) +atients rights and responsibilities to the program
1. 9pon agreement to enroll into the program# patients will be attended to sign an informed
consent form# allowing their information to be released to them or shared among
healthcare professionals involved in their care for the sole purpose of providing critical
information needed for coordination of their care# unless they otherwise direct
< Refer DM/HPT/Lipid-MTAC/HTAN/F1
I'!'.4 A,,*,,2*! (5 !8* MTAC 38."2.&',!
Refer to DM/HPT/LIPID-MTAC/HTAN/F2(2) Patients p!ar"a#ot!erap$ re%ie& for"
Refer to DMTAC/HTAN/F2 'no&(ed)e assess"ent
Refer to DMTAC/HTAN/F1 #o*nse(in) #!e#'(ist for Dia+eti# MTAC
4. At the initial visit the pharmacist will perform an initial assessment of the patient. The
initial evaluation will entail0
(a) "eview of patient medical/medication history
(b) Conduct a baseline assessment0
i. +ast medical/medication history
ii. ,ocial/family history
iii. $iet and lifestyle
iv. Allergies ($rug# food etc)
v. Medication 2nowledge
vi. Medication adherence
(c) $etermination of medication related problems and issues
(d) +atient (and/or caregiver) interview
(e) +atients3 2nowledge regarding their diseases and management
=. +atient education ($rugs# %bA&c# complication of diabetes# disease management etc)
/. After the initial interview the pharmacist will schedule their net appointment based on
the needs assessment after the initial visit# or other clinic appointments and medication
refills or their current health status as it is convenient to the patient. The ma6ority of
patients will be seen every &-4 months# either at pharmacy or during the net M*+$
visit.
5. +atient $MTAC visit fre>uency will be based in multiple issues and scheduled
accordingly0
(a) -eed to refills (48 or 58 days)
(b) Change in medication
(c) Mentally or physical ability to handle receive one month or greater of medication
(d) ?isit schedule at diabetic clinics
(e) Miscellaneous reasons as determined by the pharmacist warranting a visit
@. Assessment will be conducted in accordance to a standard counseling chec2list.
S*&#$ .$ S%(,*9%*! V','!,
Refer to DM/HPT/LIPID-MTAC/HTAN/F2(2) Patients p!ar"a#ot!erap$ re%ie& for"
Refer to DMTAC/HTAN/F1 #o*nse(in) #!e#'(ist for Dia+eti# MTAC
8. To ta2e place 1:3 2#!8, later (depending on patient3s situation). Assessment of
glycemic control and discussion of clinical results will be underta2en.
(i) )lucose level will be assessed in the clinic/pharmacy when necessary
(ii) "ead6ustment of medication will be carried out according to patients assessment
(iii) "eview appointments until blood glucose and other clinical parameters achieve
their target goals.
(iv) Compliance# reassurance and reinforcement
A. %ealth advice given and education underta2en (refer to appendi BBB) when appropriate
and will be noted to doctor/s in clinic for interventions
&8. Assessment will be conducted in accordance to a standard counseling chec2list.
M',,*$ V','!,
+atients will be called by phone after a missed appointment to re-scheduled appointments. Bf
patients have logistic problems# they will then be given appointments following clinic day
appointments (namely every 4-= months)
P8."2.&*%!'&.4 R*+'*0
9nderta2en by practicing pharmacists at the earliest opportunity based on the patient
selection criteria# or after referral of patient by doctors or other healthcare professional.
&) $rug-related problem identification
(a) Carefully assess the patient and obtain all information re>uired to ascertain if any
intervention or recommendation has to be made
(b) Bdentify patient-specific health or drug related problems
1) $rug-related problem solving
(a) Bdentify available therapeutic alternatives and consider the pros and cons of each
alternative with patient
(b) Consider whether non-pharmacological therapy may help to prevent or solve the
health or drug-related problem
(c) 'ormulate a patient specific action plan together with the patient# including
identification of specific health outcomes and the means (drug or non-drug) to
achieve them.
4) $rug therapy monitoring
(a) Monitor the patient3s adherence to the plan
(b) 'ollow up on the patient3s progress to assure the achievement of desired
outcomes# ma2ing modifications to the eisting plan if necessary
=) +harmacist3s recommendations
(a) *ffer feedbac2 to the patient3s physician and discuss about his or her progress
with the action plan and ultimately its outcome
;. M*$'&.!'# D',3*,'7 .$ C#%,*4'7
+harmacists shall dispense the medication and counsel the patient
'ollow up counseling during part supply medication collection or during
scheduled appointment
<. D#&%2*!.!'#
&. All relevant data to be recorded using the designated forms# and stored in the patient3s
profile
1. The documentation will contain the following parts (Appendi B?)
+atient demography and medical/medication history
.ab ?alues
Assessment of patient3s medication 2nowledge
Assessment of patient3s adherence
+harmaceutical care issues and pharmacist3s plan
4. After each visit# a note is placed in the patient3s profile documenting the patient3s current
status# identified drug relation problems and monitoring results# updating the medication
list as needed# allergies# adverse drug reactions# medication adherence# any interventions#
and action/plan for each medical condition addressed.
=. All documents can be found in the Appendi
DM/HPT/Lipid-MTAC/HTAN/F1 ,nro(("ent for"
DM/HPT/LIPID-MTAC/HTAN/F2(2) Patients p!ar"a#ot!erap$ re%ie& for"
DMTAC/HTAN/F2 -no&(ed)e assess"ent
DMTAC/HTAN/F1 Co*nse(in) #!e#'(ist for Dia+eti# MTAC
A. $ischarge Criteria
&. +atients that has completed 7 visits and/or achieve %bA&c @; or @./; (depending on
patient condition)
1. $efaulted 5 months or 1 M*+$ visit (phone call to patients 1-4 times)
WORKFLOW OF MEDICATION THERAPY ADHERENCE CLINIC
(DIABETES)
HOSPITAL TUANKU AMPUAN NAJIHAH
A. Flow Chart For Maa!"#"t o$ N"w Ca%" D&a'"t&( Pat&"t%
(Fro# I Pat&"t)
NURSE
NURSE
MEDICAL
OFFICER
NURSE
PHARMACIS
T
NURSE
PHARMACIS
T
PHARMACIS
T
Receiving new diabetic patient wit!
". F#S $ "%&&'()( '* R#S $"+&&'()(
,. HbA"c $ "%-
Tr&a!" )ro("%% . Ta/e patient0 !eig!t1
weig!t1 wait ci*c2&3e*ence 45C61 #MI1 #P
and b(''d 2ga* (eve( 4b7 8(2c'&ete*6
Regite*1 9(( 2p pa*tic2(a* in g*een b''/
4MOPD b''/(et6 and *e3e* t' p!a*&acit
Initia( ae&ent1 aeing c'&p(iance1
ta/e &edicati'n !it'*7
Pe*3'*& p!7ica( e:a&inati'n1 initiate
t*eat&ent '* p*ec*ibing d*2g and '*de*
b(''d invetigati'n
Sc!ed2(e t!e date 3'*;
i6 #(''d tet and ne:t app'int&ent
in MOPD c(inic
ii6 F2nd'c'p7 and ne2*'('gica(
Medicati'n dipening1 c'2ne(ing and
MTAC awa*ene p*'g*a&
I2e a DM b''/(et and p2t a DMTAC c'('2*
tic/e* 'n it
PHARMACIS
T
WORKFLOW FOR MEDICATION THERAPY ADHERENCE CLINIC
(DIABETES)
HOSPITAL TUANKU AMPUAN NAJIHAH
B* Flow Chart $or Maa!"#"t o$ N"w Ca%" D&a'"t&( Pat&"t%
(Fro# MOPD)
PHARMACIST
PHARMACIST
PHARMACIST
PEM#ANTU
TAD#IR)NURS
E
NURSE
PHARMACIST
PHARMACIST
MEDICAL
OFFICERS
D'c2&entati'n and et t!e ne:t MTAC
app'int&ent date
T*ace patient0 *ec'*d 3*'& g*een b''/
Se(ect patient baed 'n
". F#S $ "%.% &&'()( '* R#S $
"+.%&&'()(
P2t MTAC tic/e* 'n patient0 p*'9(e in MOPD
c(inic
5!en t!e patient c'&e 'n app'int&ent da71
*egite* and *et*ieve '3 patient0 p*'9(e ca*d
at n2*e c'2nte*
T*iage p*'ce 4Ta/e #P1 F#S1 weig!t and
wait ci*c2&3e*ence6. Ret*ieve HbA"c
*e2(t i3 n't t*aced.
P!a*&acit *ec*2it and *eview patient 3'*
MTAC
Pe*3'*& e:a&inati'n and *eview t*eat&ent
Medicati'n *eview 2p'n new p*ec*ipti'n.
Stic/e* 'n p*ec*ipti'n 3'* identi9cati'n
C'2ne(ing and Ed2cati'n '3 Patient.
D'c2&entati'n and I2e t!e MTAC b''/(et
t' patient
PHARMACIST
PHARMACIST
WORKFLOW FOR MEDICATION THERAPY ADHERENCE
CLINIC (DIABETES)
HOSPITAL TUANKU AMPUAN NAJIHAH
C* Flow Chart $or Maa!"#"t o$ S+'%",+"t Phar#a(- .&%&t
PHARMACIST
PHARMACIST
PHARMAC<
ASSISTANT
PHARMACIST
PHARMACIST
PHARMACIST
PHARMACIST
Patient *egite* at p!a*&ac7 c'2nte* 3'*
&edicati'n *e9(( 4eve*7 'ne t' tw'
&'nt!6
Identi37 patient wit! DMTAC tic/e*
T*ace patient p*'9(e in
p!a*&ac7
Medicati'n *e9(( in t!e
p!a*&ac7
P!a*&ace2tica( *eview and p!a*&acit
inte*venti'n
Medicati'n dipening1 c'2ne(ing
diabete ed2cati'n
Sc!ed2(e 3'* ne:t
app'int&ent
D'c2&entati'n
Set t!e ne:t app'int&ent date. Patient
c'((ect &edicati'n 3*'& p!a*&ac7 c'2nte*
EDUCATION OUTLINE FOR DIABETES PATIENTS
F'",! V','!
= (rief diabetes overview
= Therapeutic goals# specifically blood glucose (%bA&c# '(,# etc)
= ,pecific discussion of medication use/adverse effects with the patient (insulin and
hypoglycemic agents)
= ,elf monitoring blood glucose < how# when# why etc (if applicable)
= ,igns and symptoms of hypo/hyperglycemia# sic2 day management and course of action
to be ta2en
= +atient concern
V','! 2
= *ther therapeutic goals ((+# .ipid etc)
= (enefits# ris2s and options of improving blood glucose controls
= 'oot care
= ,pecific drug counseling
= +atients concerns
V','! 3
= Cercise benefits
= %ypoglycemic reactions (reminder)
= (asic nutrition (carbohydrate counting)
= +atient concerns
V','! /
= Bn depth discussion of diabetes (macro D micro complications# etc)
= Cardiovascular education (.ipids# blood pressure# peripheral vascular disease# set goals)
= +revention# detection and treatment of complications
= +atient concerns
V','! 1
= %ealth benefits of good glucose control
= ,mo2ing ceasation (if applicable)
= Alcohol reduction (if applicable)
= %ow to continue goals# long term plans
S%(,*9%*! -#44#0:%3,
= "evision of treatment goals
= ,pecific drug counseling
= +atient concerns
POINTS OF REMINDER
&. All $iabetes patients will be given a $M boo2let (in-patient and out-patient)
a. Medical officer in charge will fill in the re>uisite details in the boo2let
= -ame of patient
= %bA&c#'(, reading (if available)
= (lood +ressure
= Eaist Circumference
= Eeight
= %eight
= Medication commenced (eg insulin# %+T medication# lipid lowering
agents# etc)
b. Ehen the patient is recruited into $MTAC clinic# a $MTAC colour stic2er will be
pasted on the boo2let and appointment card for identification.
1. As %bA&c and '(, is the main parameter to be measured in the clinic# patients should be
sub6ected to %bA&c test every 4 months# and measurements of 'asting (lood )lucose#
blood pressure# waist circumference# weight and height should be ta2en on the day of
appointment.
4. +atients of $MTAC will be counseled and educated for ,elf Monitoring (lood )lucose
(,M()) and ultimately ,elf Ad6ust Bnsulin $ose# therefore they will be adviced to
purchase a )lucometer when needed. (%bA&c chart and (lood )lucose "ecording (oo2
will be provided by pharmacy.
=. Most of the patients will be preferably seen and assessed by pharmacist before being
reviewed by the medical officers. Any problems or findings will be documented in
patients profile in M*+$ clinic. A separate record will be 2ept in the pharmacy.
/. Bn the event of patient being referred for follow up in other institution besides %TA-#
medical officers are to remind to not refer those patients to $MTAC clinic.