Supporting Your Patients with Diabetes to Get the Most from Their Injectable Therapies

Supporting your patients with diabetes to get the most from their injectable therapies: Community Pharmacy & General Practice working together

“Diabetes is the fastest growing health threat facing our nation. Over 3 million people are living with diabetes in England. If their condition is managed they can live longer and fuller lives. The cost of diabetes to the NHS will continue to rise. In order to control these costs, the Department & NHS must take significant action to improve prevention and treatment for diabetes in the next couple of years.”

Chris Askew Chief Executive Diabetes UK – State of the Nation 2016

INTRODUCTION

The West Midlands Pharmacy Local Professional Network working with the Academic Health Sciences Network and Coventry & Rugby CCG & Coventry Local Pharmaceutical Committee held an implementation event to shape the design and implementation of this exciting Medicines Optimisation project which will be launched in a selection of pharmacies and practices in early January 2017. The project is conducted under a joint working agreement with Eli Lilly &Co and Novo Nordisk and supported by Diabetes UK.

This project will use pharmacy intervention with NMS and MUR to improve knowledge and confidence in the correct injection technique for diabetes patients using injectable therapies leading to improved patient outcomes, reduced waste and greater cooperation between community pharmacy and general practice. Pharmacists will:

·  attend training on the recommended practice for injecting techniques

·  complete Medicines Usage Reviews or New Medicines Service as part of the Advanced Services on patients using injectable therapies

·  collect and submit data in the form of patient questionnaire and pharmacist evaluation forms

·  suitable patients may be identified in the pharmacy or be referred from the GP practice

In Scope:
Patients using insulin or GLP-1 injectable therapy. All requirements defined by the National Services for MUR or NMS must be fulfilled / Out of Scope:
Patients not on injectable therapies. Patients registered with GP practices not part of the pilot

Please note this is not a new service – simply a local agreement to provide pharmacists with additional training to increase their capability and confidence to provide advice to patients using injectable therapies. The success of this project will be determined by reviewing feedback received from patient questionnaires and pharmacist evaluation forms. All requirements relating to the provision of the National services NMS and MURs must be adhered to.

AIMS

It is intended that this work will:

·  Develop an education framework to include safe administration, safety and adherence for both the NMS and MUR consultation for community pharmacists on injectable therapies in diabetes.

·  Enable commissioners to understand the quality of the interactions from pharmacy.

·  Upskill community pharmacists around the pilot surgery sites to deliver patient support for injectable therapies via NMS and MUR.

·  Process map current and future state for MUR service. Measure outcomes to show the value of the interventions.

BENEFITS

Patient benefits (those expected from the NMS and MUR services):

·  Improved patient adherence which will generally lead to better health outcomes

·  Increased patient engagement with their condition and medicines, supporting patients in making decisions about their treatment and self-management

·  Improved patients’ understanding of their medicines;

·  Highlight problematic side effectsand propose solutions where appropriate;

·  Reduced medicines wastage by encouraging the patient only to order the medicines they require

NHS benefits:

·  reduce medicines wastage (on insulin and GLP-1 therapies)

·  reduce hospital admissions due to adverse events from medicines (on insulin and GLP-1 therapies)

·  lead to increased Yellow Card reporting of adverse reactions to medicines by pharmacists and patients, thereby supporting improved pharmacovigilance (on insulin and GLP-1 therapies)

·  receive positive assessment from patients (on insulin and GLP-1 therapies)

·  improve the evidence base on the effectiveness of the service

·  support the development of outcome and/or quality measures for community pharmacy.

Additional benefits:

·  Develop resources which can be used to replicate this work such as a consultation framework for NMS and MUR

·  Integration of pharmacist care in line with 5 year forward view.

·  Improvement of pharmacist skills around injectable therapies through NMS and MUR.

·  Support the use of summary care records.

OBJECTIVES

·  Improve the injection technique for diabetes patients using injectable therapies

·  Increase confidence of pharmacists in conducting consultations involving injectable therapies

·  Integration of advanced services into patient pathways

·  Foster closer relationships between community pharmacy and general practice

KEY PARTNERS

West Midlands LPN Chair – Satyan Kotecha

Coventry & Warwickshire LPN Lead – Andy McKenna

Coventry LPC – Fiona Lowe (Chief Officer)

Project Manager - Yasmin Akhtar

Coventry & Rugby CCGs – Mark Galloway (or replacement)

AHSN – Lucy Chatwin & pharma support Lily and Novo

NHSE – Michelle Deenah (Senior Primary Care Contracts Manager)

NHSE – Gurjinder Samara CSU team – PharmOutcomes support, reports and invoicing

TIMELINE

11th January 2017 Training event at Holiday Inn Coventry, 6.45 for 7.15pm

12th January 2017 Soft launch

1st April 2017 Main pilot period

30th June 2017 End of pilot period

July 2017 Evaluation of pilot

REMUNERATION

·  Remuneration for NMS and MUR to be claimed in the normal way through NHSBSA

·  Each pharmacist who works an average of 2 or more days each week in one of the pharmacies shown (Appendix Six), and attends the training session on 11th January 2017, will receive £100 on submission of the 5th completed patient questionnaire (Appendix Three)

·  By 7th July 2017, all pharmacists who have received the training payment must ensure all completed patient questionnaires and the pharmacist evaluation form (Appendix Two) have been sent to Yasmin Ahktar (). Receipt of these forms will trigger a second payment to the pharmacist for data collection. This will be equivalent to £10 per completed patient questionnaire plus £10 for completion of the pharmacist evaluation form (Appendix Two). Please note this payment will exclude the 5 x £10 for the first five completed patient questionnaires – they are included within the first training payment. There is a maximum £200 total claim per pharmacy

MEASURES OF SUCCESS

The feedback from the pharmacy evaluation forms will be combined with the answers from the patient questionnaires to evaluate the success of the project.

RISKS

·  If a patient has been injecting with poor technique or into fatty lumps (lipohypertrophy) then the intervention may lead to increased insulin absorption and a risk of hypoglycaemia. Please note that one of the pharmacist responsibilities within a Medicines Usage Review is to refer concerns to the GP and this must be done in a timely manner. The patient should be advised to monitor their blood glucose frequently and seek medical attention if required.

·  Before beginning to deliver this pilot, it is recommended that locally participating pharmacists discuss with participating GPs and other key personnel (such as Diabetes Nurses) and agree how to jointly mitigate this risk

REFERRAL

Diabetic patients using injectable therapies may be referred to the pharmacy by the participating GP practices or invited for an MUR or NMS when they present a prescription for dispensing at one of the participating pharmacies.

Please note the patient must be eligible for an MUR or NMS as described by the National service guidelines which includes:

·  Community Pharmacy Contractors must carry out at least 70% of their annual MURs on one or more target group patients. Where a patient is taking four or more medicines and at least one of their regularly prescribed medicines is in the ‘BNF 6.1 Drugs used in Diabetes’ then they fall into the target group: ‘Cardiovascular risk’

·  Community Pharmacy Contractors are funded to complete a maximum of 400 MURs per annum. This pilot will not fund MURs over the 400 maximum threshold

·  Type 2 diabetes is one of the conditions included for the New Medicines Service

INTERVENTION

The pharmacist will invite the patient for an MUR or sign them up for the NMS as appropriate. Patient consent will be obtained as per the National service specification.

When completing a MUR:

The pharmacist will ask the patient questions from the patient questionnaire (Appendix Three).

The pharmacist will proceed to carry out the MUR using their knowledge gained at the January 2017 training event and supported by various documents including the Quality Marker ‘5 star MUR document’ (Appendix Five). As part of the MUR conversation the pharmacist will discuss injection technique with the patient including:

·  Ensure needle and pen unit assembled correctly with new needle every injection

·  Perform 2 unit air shot prior to dialling up correct dose of medication.

·  Mix insulin appropriately if indicated (intermediate and mixed insulins)

·  Correct insertion of needle at 90 degrees and hold in situ for 10 seconds after plunger fully depressed.

·  Rotation of injection sites and prevention of lipodystrophy

·  Advice if lipodystrophy present

·  Correct disposal of sharps as per local guidelines

Depending on the conversation and baseline knowledge of the patient, it may be appropriate to only discuss injection technique or it may be appropriate to progress to other stages of the ‘5 star MUR document’ (Appendix Five). The pharmacist will use their professional judgement.

Flow charts are shown (Appendix One)

A ‘hints and tips’ document is available (Appendix Four) plus various patient information leaflets (Appendix Seven) from Diabetes UK. At the end of the MUR the pharmacist will ensure all questions on the patient questionnaire (Appendix Three) have been answered.

APPENDIX ONE – Flow Charts

Appendix Two – Pharmacist Evaluation Questionnaire

To be completed by each participating pharmacist at the end June 2017 and returned to Yasmin Akhtar by email to between 1st and 7th July 2017.

1. Since attending the training how many MURs have you completed with patients using injectable therapies?
2. Since attending the training how many NMS have you completed with patients using injectable therapies?
3. How easy was it to recruit patients to the service and why?
4. Are you confident in describing the four key steps to good injection technique to patients?
5. How useful did you find the 5 Star MUR document? Are there any of the stages that you would appreciate more information on?
6. How likely are you to actively seek MURs with patients on injectable therapies in the future?
7. Did this pilot result in any discussions/communication between you and the surgery? Please describe briefly
8. Patient feedback was collected via the patient questionnaires. Do you have any particular patient experiences relating to this pilot? Please describe briefly if so.

Appendix Three – Patient Questionnaire (complete during the MUR)

Question / Beginning of consultation: / <1 year / 1-10 years / 10-20 years / >20 years
1 / How long have you been prescribed an injectable therapy
Yes / No
2 / Do you ever forget to administer your insulin at the correct time
Yes / No
3 / Do you ever feel discomfort from injecting?
No. of pens or cartridges:
4 / How many pens or cartridges do you keep at home?
During The consultaion
5 / How many of the key steps to good injection technique did the patient self report? / Yes / No
New needle and correct pen assembly
Insertion of needle at 90 degrees and hold in situ for 10 seconds
Avoidance of fatty lumps when choosing injection site
Rotation of injection sites to prevent fatty lumps
Total score
After consultation
6 / How many of the key steps to good injection technique did the pharmacist teach? / Yes / No
New needle and correct pen assembly
Insertion of needle at 90 degrees and hold in situ for 10 seconds
Avoidance of fatty lumps when choosing injection site
Rotation of injection sites to prevent fatty lumps
Total score
7 / Did you find this review useful?

Appendix Four – Hints and Tips

HINTS AND TIPS

Key Facts:

·  There are approx. 4 million people with diabetes in the UK and around 30% of these are on insulin

·  Insulin is one of the top 3 high risk medicines in the UK and top 5 worldwide

·  There are now over 30 different types of insulin and many devices

·  Prescribers should not use ‘U’ for units as this has led to many errors when it is read as a zero, resulting in 10x the amount of insulin being given

·  Never draw up insulin from a pen using a syringe – this is the cause of many hospitalisations but is still done when people want to share one cartridge between 2 or more people. As well as increasing the error rate it also stops the pen from working!

·  More concentrated insulins are now available (Humalog U200 and Toujeo). Patients still need the number of prescribed units. Some HCPs have halved the patients dose because the insulin is more concentrated

·  GLP-1 RAs are not used in Type 1. Popular with patients as they lose weight on them

·  Children and pregnant women with Type 1 diabetes have a 24 hour helpline. It is crucial that pregnant women don’t have ketones as they can kill the foetus in a few hours.

·  When patients with diabetes have an intercurrent illness they should: increase blood glucose monitoring; maintain some carbohydrates; never stop insulin; increase fluid intake; seek help if necessary. For Type 1 diabetics the priority is to get rid of any ketones (increase the insulin to do this). For Type 2 diabetics the priority is to maintain control

The Forum for Injection Technique (FIT) was formed in 2009 and have recently released the 4th edition of ‘The UK Injection and Infusion Technique Recommendations.’ It can be found at www.fit4diabetes.com

Summary of Rules for Injection Technique:

1.  Insulin and GLP-1 receptor agonists must be deposited into healthy subcutaneous tissue, avoiding the intradermal and intramuscular spaces as well as scars and lipohypertrophy

2.  4mm pen needles are recommended for all adults regardless of age, gender or BMI

3.  Roll and invert cloudy insulins to resuspend and visually confirm no crystal mass remaining in the cartridge

4.  Recommended sites for injection are abdomen, thigh, buttocks and upper arms