​As healthcare increasingly moves into the community, greater collaboration between physicians and pharmacists can improve patient care. Find out how collaborative prescribing in the hospital-to-home service supports general practitioners in caring for patients in the community.

INTRODUCTION

With an ageing population and more complex patient profiles in Singapore, providing the best healthcare remains a challenge. There is also a greater need to move healthcare from hospitals into the community, as this keeps patients away from hospitals and helps them receive care in a familiar environment.

PHARMACIST AND PHYSICIAN COLLABORATIVE PRESCRIBING AT CGH

Changi General Hospital (CGH) was among the first hospitals in Singapore to pioneer a pharmacist and physician collaborative prescribing initiative under the Hospital-to-Home (H2H) programme. This initiative has been approved by the Ministry of Health (MOH) since October 2020.

Under this programme, CGH provides medication reviews, drug optimisation and medication refills for H2H patients using a shared care model involving physicians and pharmacists. Patients can be referred to collaborative prescribing in the H2H service by their general practitioner (GP), home medical doctor or community nurses.

Patients must meet the following eligibility criteria:

• Being of stable condition that requires regular monitoring and titration for chronic illnesses; or
• Having adherence problems that require medication review and coaching

THE EXPANDED ROLE OF PHARMACISTS

The traditional role of the pharmacist has evolved beyond the provision of medications, patient education, and reinforcement of adherence to medication therapy. Pharmacists who have undergone and passed the MOH’s collaborative prescribing programme are able to prescribe medications to patients. With the skills and expertise in evidence-based practice and patient care, pharmacists can now assume new roles with a focus on patient care.

One of these expanded roles is in prescribing medicine. The potential benefits of expanded pharmacist prescribing include:

• Improvement of patient care
• Improved access to medication
• Optimisation of medication management
• Better resource utilisation

COLLABORATIVE PRESCRIBING

Expanded pharmacist prescribing is a new professional practice area for pharmacists. When the pharmacist visits patients at home, pharmacists with their specialised knowledge can monitor the patients’ responses to their prescribed medications and make appropriate dose titration suggestions, where needed.

Medication reviews by pharmacists is the key area of the collaboration with physicians. Medication reviews after discharge from the hospital have reduced morbidity and mortality in patients. The evidence supporting the benefits of home medication reviews continues to expand.

Such reviews can be effective in the identification of medication-related problems among patients receiving treatment for chronic illnesses, as well as assist in the resolution of medication-related problems.

GENERAL PRACTITIONERS IN THE SHARED CARE MODEL WITH THE H2H SERVICE

A typical patient with multiple chronic medical problems can continue to be managed well by a GP with adequate community support and optimal utilisation of resources. Home care also alleviates the issue of commuting. In the context of advanced dementia or immobile patients with a complex medication regimen, the GP plays a primary role in supporting the family’s navigation and coordination of care. The GP’s familiarity with the referral pathway ensures that the patient receives the appropriate care through the linking up to relevant resources in the community.

CONCLUSION

The roles of the doctor and pharmacist are complementary. A collaborative and good working relationship is essential to the delivery of personalised and effective patient services and enabling greater responsiveness to changing patient needs.

Pharmacists have the skills and knowledge to contribute to the quality use of medicines, to minimise medication misadventure and to help patients better manage their medicines. With improved collaboration through improved inter-disciplinary communication and relationships, optimal medication management for the patient can be achieved.

The pharmacist and physician collaborative prescribing initiative is one such inter-professional collaboration in the evolving landscape to meet the medication management and healthcare needs of the community now and in the future.