s Post- discharge Home Medicines Reviews | I2P: Information to Pharmacists - Archive
Publication Date 29/07/2011         Volume. 3 No. 7   
Information to Pharmacists

Editorial

From the desk of the editor

Welcome to the August 2011 edition of i2P- Information to Pharmacists.
Direct distribution by pharmaceutical manufacturers is back in the news once more.
This disruptive attack on an efficient community pharmacy business model must be checked before it gets too far out of hand.
Neil Retallick discusses some of the issues as does Mark Coleman in the Pharmedia section of i2P.
Read and see what you can do to help.

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News Flash

Newsflash Updates for August 2011

Newsflash Updates

Regular weekly updates that supplement the regular monthly homepage edition of i2P.
Access and click on the title links that are illustrated.

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Pipeline

Pipeline for August 2011

Pipeline Extras

A range of global and local news snippets and links that may be of interest to readers.
Pipeline Extra simply broadens the range of topics that can be concentrated in one delivery of i2P to your desktop.

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Feature Contribution

Pfizer Direct - the Implications as other Manufacturers look at this channel

Neil Retallick

Pfizer is working hard to improve its direct supply model, but no matter how efficient it becomes, it will still wreak havoc in community pharmacies.
It is almost a case of the more effective Pfizer’s logistics become, the more damage their direct supply model will inflict on community pharmacies.
The issue here has never been whether or not Pfizer can supply the right drugs at the right time to the right place.
If they lack the will to make this happen, there is a multitude of logistics experts that can help them achieve efficient supply.
Recent relaxation of order cut-off times is an indicator that Pfizer wants their model to be accepted by pharmacists and is willing to make concessions to meet their needs.

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Pharmacists - where are you when we need you?

Loretta Marron OAM BSc

New parents are congregating  at alternative practitioner clinics for after-hours 'information' seminars, eager to learn anything they can do to improve their families health and wellbeing.  Seniors and major illness patients are attending meetings to learn how to better manage their illnesses.   But what advice are they being given and why is their local pharmacist not there to support them?
People want to feel they are in control of their health.  When they are told about a lecture on lifestyle and health education, they will turn up in droves to listen to what their friendly neighbourhood natural therapist has to say.

Comments: 2

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A conflict between selling complementary medicines and providing evidence based clinical medical reviews?

Dr Linda Bryant (PGDipPharm, MPharm, DPharm(Auck), FACPP, FNZCP, FPSNZ, MCAPA)

First came the randomised controlled trial1,which linked calcium supplementation with vascular events, then there was a meta-analysis linking calcium with cardiovascular events2 and then a further confirmatory meta-analysis of calcium plus Vitamin D and using individual patient data.3
The conclusions were reasonably secure that calcium supplements are likely to increase the risk of a cardiovascular event. It is now advised that people obtain their calcium intake by dietary means – which is feasible even for those who do not consume a lot of dairy products. General practitioners have now stopped prescribing calcium, leaving me confused as to what arguments are being used by the community pharmacists who continue to sell the calcium supplements.

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Post- discharge Home Medicines Reviews

Kay Dunkley - BPharm, Grad Dip Hosp Pharm, Grad Dip Health Admin, MPS, MSHPA

Through the 5th Community Pharmacy Agreement hospital initiated HMRs will now be available for high-risk patients recently discharged from hospital. This is an important step in addressing the fact that patients recently discharged from hospital are at risk of medication misadventure. The question I would like to raise is who is best placed to undertake these HMRs. The traditional model of HMR referral has been through a General Practitioner (GP) to the consumer’s community pharmacy. Under this model the HMR may be undertaken by an accredited pharmacist directly involved with or employed by the community pharmacy or be outsourced to an independent accredited pharmacist. Under the 5th Community Pharmacy Agreement this model has now been modified to enable direct referral from a GP to an accredited pharmacist and also direct referral from a hospital based medical practitioner for a newly discharged patient. The traditional model will continue in tandem with this new model.

Comments: 2

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Make sure your perspective is perceptive

Harvey Mackay

We've reached a point in our country's history where authority and power seem to be manifested by the need to shout down the other person.  Discussion and compromise are words freely bandied about, but they've largely lost their meaning. 
What is really lost is perspective.
Just as there are two (or more) sides to every story, there are plenty of different ideas on how to get things done.  No one person has a corner on that market.

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Fingers crossed as FDA considers drug bar code packaging rule

Mark Neuenschwander

I’ve been thinking about baseball, movies, ambiguous bar codes, and the FDA.
On June 26, 1974, New York Yankee All-Star Derek Jeter was born, two-time Academy Award winner Elizabeth Taylor divorced (for the fifth time), and Sharon Buchanan, a young grocery clerk in Troy, Ohio, was the first ever to ring up a retail purchase by scanning a bar code. On the same day in 2011, I drove from Arlington, Virginia, to Silver Spring, Maryland, to meet with people at the FDA to talk about the future of bar-code labeling on drug packaging.

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More Shocks and Economic Pain

Barry Urquhart

There are more shocks and economic pain on the near-term horizon for taxpayers, small business owners and corporations.
This is a key finding of an extensive and intensive strategic analysis undertaken by Barry Urquhart, Managing Director of Marketing Focus, who will deliver a keynote address on the analysis at the forthcoming annual national conference for the Australian Mining and Exploration Companies Association.
Among the significant points which have been identified are: -

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Marketing Focus: Here's looking at you, kid!

Barry Urquhart

AUSTRALIA'S OWN SILICON VALLEY

"Wealth....Innovation. Creativity. Originality. Dynamism. Growth. Capital. Technology."

Silicon Valley is both a name and locality known throughout the world and is synonymous with each of the above listed attributes. It means and is perceived to be many things to many people.
Since the 1960's Silicon Valley has been the birthplace of many scenario changes, iconic products, services, concepts and business entities. In itself it is a magnet which attracts some of the world's brightest, most enterprising, free thinking and driven entrepreneurs.
The Federal and State governments, in Washington DC and California, have welcomed, encouraged and supported investment in countless large and small, established and start-up businesses to enable them to blossom and to create wealth, employment, education and opportunities.
Financial injections and tax relief/incentives have been provided in abundance.
Everyone, it seems, is a winner.

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No success without access

Harvey Mackay

Over the years I've asked a lot of people what makes a great salesperson, and the answers are fairly predictable:  passion; persistence; personality/likeability; planning; trustworthiness; strong work ethic; drive/initiative; quick learner; goal-oriented; good communications skills; sense of humor; humility; good timing; strong at building relationships; and follow-up (or as I say, the sale begins when the customer says yes).
My own answer is always the same:  hungry fighter.  In many ways, that is the embodiment of all of the above traits.

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E-Health - High cost for very little return

Peter Sayers

Politicians in the UK are starting to wake up to the fact that their Department of Health is unable to deliver its electronic care records system, after investing 2.7 billion pounds sterling in the project without being able to demonstrate a single benefit of the system.
The project has suffered from the same problems that have beset a similar Australian project being developed by the National e-Health Transition Authority (NEHTA).
It is now recognised that the pitfalls and waste might have been avoided in the UK had they consulted a range of health professionals before starting the project.

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Question homeopathy’s remedies but not its approach

Staff Writer

It seems the National Health and Medical Research Council (NHMRC) is likely to follow the lead of the UK and denounce homeopathy as an ineffective and unethical therapy that shouldn’t attract scarce government research funds.
This is within the remit of the NHMRC’s role to provide health advice to clinicians and the Australian public. But the NHMRC also funds the majority of health and medical research in Australia.
And this dual role means the NHMRC – or those looking to it for guidance – may look unfavourably at funding any research involving homoeopathy.
Homeophathy has its shortcomings but researchers still have a lot to learn from studying this practice. 

Written By Jon Wardle:NHMRC Research Scholar, School of Population Health at University of Queensland

Comments: 2

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Saving Lives at Birth

Staff Writer

United States Secretary of State, Hillary Clinton has acknowledged Monash University researchers for a life-saving new drug concept at the Saving Lives at Birth global challenge forum held yesterday in Washington DC.
Following the forum, at which Monash University researcher Dr Michelle McIntosh spoke, the research team received funding to engineer a drug that could save the lives of mothers of newborn children in developing countries.

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UQ Law helps professionals deal with carbon tax challenge

Staff Writer

The University of Queensland is preparing for an increased uptake in post-graduate legal courses as lawyers, consultants and accountants prepare to implement the Government's carbon tax scheme, due to take effect in July 2012.
Head of the TC Beirne School of Law Professor Ross Grantham said he expected a significant demand for specialist skills in areas such as consumer law, contracts, taxation, climate change and policy, and mining and offshore resources law.

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Cholesterol drug may help diabetes sugar levels

Staff Writer

A medicine designed to improve levels of 'good' cholesterol may also help control blood sugar in people with diabetes who are taking cholesterol-lowering drugs, according to a recently published study in Circulation: Journal of the American Heart Association.
The study, led by the University of Sydney's Professor Philip Barter, made the finding while analysing data from a clinical trial on the drug torcetrapib. Torcetrapib is a cholesterol ester transfer protein (CETP) inhibitor, a type of drug that increases levels of high-density lipoproteins (HDLs, or 'good' cholesterol).

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Microsoft grant boosts stroke, cardio disease detection devices

Staff Writer

A $100,000 Microsoft fellowship awarded to a lecturer leading the University of Sydney in the emerging field of bioelectronics will accelerate the development of electrical devices used to diagnose and monitor stroke and cardiovascular disease.

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Indigenous Science Education Program wins national award

Staff Writer

Macquarie University's innovative Indigenous Science Education Program has been recognised with an Australian Learning and Teaching Council (ALTC) Award for Programs that Enhance Learning.
The Indigenous Science Education Program (ISEP) works with Casino, Lismore and Maclean High Schools in northern NSW and Chifley College in Western Sydney and has its origins in requests for help from Aboriginal Elders in addressing the poor completion rate of secondary education by their Indigenous youth.

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Karratha GP Super Clinic to Provide Better Health Services

Staff Writer

Residents of the West Pilbara will soon have better access to GPs and allied health professionals following the signing of a $7 million agreement with the Pilbara Health Network for a GP Super Clinic to operate in Karratha.
Acting Minister for Health and Ageing, Mark Butler, today welcomed the signing of the $7 million agreement as a welcome boost to health care in West Pilbara.
“This GP Super Clinic will deliver better access to health services for locals in a single, convenient location,” Mr Butler said.

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Stopping snoring cuts heart attack risk, researchers find

Staff Writer

Sleep apnoea patients who are successfully treated have lower blood fat levels and a reduced risk of heart attack than people who are left untreated, University of Sydney researchers have found.
Sleep apnoea, a condition in which people stop breathing momentarily while sleeping, affects up to 20 percent of the population. The researchers found treatment with a continuous positive airway pressure (CPAP) device reduced post-meal blood fat (triglyceride) levels.

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New Advisory Council to Boost Disease Prevention Efforts

Staff Writer

Moves to prevent the lifestyle risks of chronic disease in Australia have been boosted with the creation of an expert Advisory Council for the Australian National Preventive Health Agency.
Acting Minister for Health and Ageing Mark Butler today welcomed the appointment of 10 expert members to a new advisory council for the Agency in another significant step forward for national health reform.

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Researchers unveil body clock battle for Blind New Zealanders

Staff Writer

Nearly 3000 blind and partially-sighted New Zealanders could be suffering from undiagnosed sleep timing disorders according to a recent study from The University of Auckland.
The study, which was undertaken in conjunction with the Royal New Zealand Foundation of the Blind (RNZFB), was recently published in the journal PLosOne. It looked at self-reported sleep habits, sleep disruptions and medication use in people completely blind in one or both eyes; partially-sighted and fully-sighted.

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Stone Age Diet May Stop Ageing

Staff Writer

While some people may feel anxious about their body's condition as they age, US academician Professor Michael Rose has no qualms about it; claiming once individuals reach their 90s their bodies stop ageing.
According to Professor Rose, who is an expert in evolutionary biology, “if you are lucky enough to live that long, you stop ageing”.
To reach this point, he suggests adopting a 'stone age' diet when you hit 30 years of age.

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Forum told of seaweed’s bioproduct potential

Staff Writer

Commercial viability of high-value macroalgal (seaweed) bioproducts for human health is a step closer with a research collaboration between Flinders University biotechnologists and Australian Kelp Products.
Under the agreement, Flinders researchers will trial new processes developed at the University to create products for the food, nutraceutical and cosmeceutical industries.
These include marine sugars refined from seaweed that can have applications in anti-viral pharmaceuticals, functional cosmetics, and environmentally friendly agricultural pesticides and fertiliser.

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Flood Relief Funds Distributed – Pharmacists Supporting Pharmacists

Staff Writer

On behalf of the pharmacy profession of Australia, the Pharmacists’ Support Service (PSS) is pleased to announce that financial support for pharmacists affected by the floods, via the funds raised by the joint Pharmacists’ Support Service Inc and Pharmaceutical Society of Australia flood appeal, has now been distributed.  A total of 18 pharmacists were provided with financial assistance which was generously donated by their pharmacy colleagues from around Australia.

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Direct Distribution - the story continues to unfold

Neil Johnston

Editor’s Note: It was expected that other manufacturers would consider a direct distribution model after Pfizer had initiated a system that when developed, would appear to have most of the “bugs” knocked out of it.
The “who” and the “when” would then be the only unanswered questions.
i2P has covered a lot of the earlier discussion regarding this industry-changing decision, and in light of recent commentary, i2P has asked Mark Coleman to give us an update.
His comments appear below the media item in brown text published recently in Pharmacy News.

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Post- discharge Home Medicines Reviews

Kay Dunkley - BPharm, Grad Dip Hosp Pharm, Grad Dip Health Admin, MPS, MSHPA

articles by this author...

Kay Dunkley is a pharmacist who has worked in hospital and organisational pharmacy for over 20 years.  She has a broad experience working in public hospitals and in providing support to health professionals through government funded bodies and professional organisations.  Kay also has a strong interest in the health and well being of health professionals and especially the role of peer support.  Kay first became involved as a volunteer with the Pharmacists’ Support Service, a group which has been providing telephone support for pharmacists in Victoria since 1995.  In 2005 Kay became the Program Coordinator for the Pharmacists’ Support Service and has assisted the service to become an independent organisation which is currently seeking to expand to provide support to pharmacists throughout Australia.  In 2007, when AMA Victoria approached the Pharmaceutical Society of Australia (Victorian Branch) with a view to establishing their own Peer Support Service; Kay accepted an invitation to assist.  The AMA Victoria Peer Support Service commenced operation in February 2008.  Kay currently coordinates both of these services and also works part-time as a consultant pharmacist in Residential Care Facilities.

Through the 5th Community Pharmacy Agreement hospital initiated HMRs will now be available for high-risk patients recently discharged from hospital. This is an important step in addressing the fact that patients recently discharged from hospital are at risk of medication misadventure. The question I would like to raise is who is best placed to undertake these HMRs. The traditional model of HMR referral has been through a General Practitioner (GP) to the consumer’s community pharmacy. Under this model the HMR may be undertaken by an accredited pharmacist directly involved with or employed by the community pharmacy or be outsourced to an independent accredited pharmacist. Under the 5th Community Pharmacy Agreement this model has now been modified to enable direct referral from a GP to an accredited pharmacist and also direct referral from a hospital based medical practitioner for a newly discharged patient. The traditional model will continue in tandem with this new model.

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The advantages of the traditional model are that it builds on established relationships between the GP, the local pharmacy and the consumer.  Even when an independent accredited pharmacist is engaged to undertake the interview and report preparation the referral through the community pharmacy facilitates three way communication as the accredited pharmacist is reliant upon the community pharmacy for background information about a consumer including their dispensing record.  Also the community pharmacy will usually refer to an accredited pharmacist with whom they have an established and trusting relationship.  It is my experience that the consumers associate the interviewing pharmacist with their regular community pharmacy, even when they are not directly employed by that pharmacy.  The disadvantages of this model have been that there may be delays in organising an HMR due to the involvement of a consultant who may not be readily available.  Also, in my opinion it is possible that there is an increased risk of a breakdown in communication when an external consultant pharmacist is involved.

Timing of HMRs in a patient recently discharged from hospital can be critical in preventing medication misadventure.  Hospital discharge is a critical time as a recovering patient and those involved in their care can become confused about changes to medications, especially when generic substitution is involved and medication regimes have been altered.  Sometimes the hospital does not have a complete medication history available or may be unaware of a patient’s idiosyncrasies or factors such as the financial implications of medication changes for an individual which may impact on the patient’s adherence.  Likewise when a consumer first visits their GP after discharge a discharge summary or notification of changes to medication may not be available.  Similarly the community pharmacy may not even be aware that the consumer has been in hospital, let alone that their medications have been altered.  Although work has been done to try and address these issues at the community hospital interface; without timely and accurate electronic communication and good patient education there is a potential for misadventure.

Many large public hospitals have a pharmacy outreach program in place and have pharmacists who contact patients after discharge and organise home visits.  The programs aim to reduce readmission rates for recently discharged patients.  In my experience the reports written by the outreach pharmacist are shared with the GP and the community pharmacy (with the patient’s permission) as well as being incorporated into a patient’s hospital medical record.  Outreach pharmacists are a great bridge between hospital and community care.  However I do not have any figures on the timeliness of outreach visits across the various hospital services.  My personal observation is that visits are often delayed for longer than a week after discharge from hospital for a variety of reasons.  In the private hospital sector pharmacy outreach services are not usually available due to absence of funding incentives.  Many elderly people are treated in private hospitals and are thus not able to benefit from hospital pharmacy outreach program after discharge.  Thus this group of consumers has been totally reliant on the community HMR model.

A recent South Australian study showed evidence that hospital initiated HMRs were conducted sooner than HMRs organised by community processes.1  This study was undertaken at three large teaching hospitals in South Australia over nine months.  High risk patients were identified through a risk stratification instrument.  These patients received HMRs either using existing community processes with GP referral using Item 900 or alternately a hospital initiated HMR was undertaken, sometimes using the community pharmacy and sometimes using a rapid response team of accredited pharmacists.  In all cases a hospital liaison pharmacist was involved in initiating the HMR.  The results showed that patients who had a hospital initiated HMR, without referral by their GP received their HMR sooner than those who were referred by their GP.1  This study also showed that direct referral by the hospital to an accredited pharmacist enabled an HMR to be undertaken sooner than when the HMR was organised through the community pharmacy.  Thus involvement of a community pharmacy also delayed the HMR.1  Thus the model of hospital initiated HMRs which by-passes both the GP and the community pharmacy enabled the fastest route for a recently discharge patient to receive an HMR.

Based on the model from the South Australian research it is likely that public hospitals will engage their own accredited pharmacists to undertake post-discharge HMRs, in a similar manner to current outreach programs.  It is unclear to me at this stage whether the hospitals will be able to be paid directly for the reviews and employ accredited pharmacists to undertake the reviews or whether they will arrange referrals with a range of consultant accredited pharmacists.  What is of concern to me is that the process may by-pass community pharmacists and GPs.  Collaboration is an important part of the HMR process.  Collaboration is not just communication of findings by sharing a report after an HMR.  Collaboration means working together for the benefit of the individual consumer or patient.  Collaboration will improve patient care. The roles of doctors and pharmacists in the community are complementary.2  In a similar manner I believe that the roles of hospital pharmacist, community pharmacist, hospital doctors and GP are all complementary.  I do hope that this does not become a turf war between the various groups of professionals or result in empire building by any particular group, but rather that a suitable model is developed to involve all of these health professionals for the benefit of patients who are discharged from hospital.

Hospital based pharmacists are in a good position to undertake an HMR after discharge as they are able to access the medical record of the patient and consult with the hospital medical team about changes to the medication regime.  They will also be familiar with generic substitution and medication changes made during a hospital stay.  However the community pharmacist may have a well established relationship with a consumer and is more likely to be aware of issues that may impact on the consumer’s ability to adhere to prescribed medication.  They are also more likely to be aware of non-prescription medications the consumer is using.  Together with the GP the community pharmacist is responsible for providing ongoing care to the consumer in their home environment.  In the current Australian healthcare system the GP is also the key care provider who is responsible for co-ordination of care for a consumer; though this may change with the advent of Medicare Locals.  Generally the GP has an established relationship with their patient and will know the full history of that person and often their family as well.

Where does the role of the independent accredited pharmacist fit in this process?  While all community pharmacists are not all able to become accredited, independent consultant accredited pharmacists are essential to the HMR process.  Accreditation is not for all pharmacists.  It is also likely that patients discharged from private hospitals and small public hospitals may benefit from the services of a consultant accredited pharmacist.  It is also my belief that there is a benefit to be had from an independent review as a pair of fresh eyes may see something which has been missed through over-familiarity.

This new model of direct hospital initiated referral will bring benefit to people at risk of medication misadventure after hospital discharge.  I hope that the model developed is truly collaborative and uses the skills and knowledge of all those involved to provide patient-centred care.

Please note all the views expressed in this article are my personal opinion and do not necessarily reflect the opinion or attitude of any of the organisations that I am employed by or associated with.

 

1. Angley M, Ponniah AP, Spurling LK et al. Feasibility and timeliness of alternatives to post-discharge home medicine reviews for high-risk patients. J Pharm Pract Res 2011; 41: 27-32.
2. Rigby D. Collaboration between doctors and pharmacists in the community. Aust Presc 2010;33:191-3.

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Submitted by Manya Angley on Tue, 02/08/2011 - 13:20.

As the project leader of the SA post-discharge medication review implementation trial referred to in this article I would like to clarify that the rapid response team (RRT) of accredited pharmacists used in our study were all independent accredited pharmacists. RRT accredited pharmacists were not employed by the hospitals involved and were directly funded by the project. The RRT was assembled purposefully for the project with the assistance of HMR facilitators. The study methodology was as follows: the patient's GP was contacted in the first instance and organisation of post-discharge reviews for all patients occurred via the HMR pathway whenever GPs were confident the HMR could be conducted within 7 days post-discharge. The community pharmacy was the second port-of-call. Post-discharge review referrals were only made directly to members of the RRT in the event that GPs or community pharmacies were not confident reviews could be conducted within 7 days. In all instances the GP and community pharmacy were kept in the loop because as highlighted by Ms Dunkley the relationships they have with patients are integral to optimum patient care. GPs remained responsible for developing the medication management plan with their patient regardless of the pathway followed. Thus if the model implemented within the fifth pharmacy agreement is based on our study, there is no doubt it will be truly collaborative. What is needed is a flexible model that is both collaborative and patient centered and ensures that post-discharge medication reviews are conducted within 2 to 10 days post-discharge when patients are known to be at the greatest risk of medication misadventure.

Submitted by Kay Dunkley on Sun, 07/08/2011 - 23:40.

Thank you for this clarification. I agree that the model you used is preferable. I hope that a similar flexible and collaborative patient centred model is implemented under the 5th pharmacy agreement.

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