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INCREASING THE NUMBER OF DMTAC FOLLOW-UP PATIENTS IN PKD MELAKA TENGAH

M. Amiruddin, S. Mohamad Esa, Soo, W. C., N.A. Rusli, Foo, S.Y., N. Mohd Zudin, Chew, P.C., S.A. Woon.

Pejabat Kesihatan Daerah Melaka Tengah

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GROUP MEMBERS

1. Mardhiah Amiruddin KKPeringgit PFUF52

2. Suraya Mohamed Esa KK Peringgit PFUF44

3. Soo Wan Ching KK Jln Gereja PFUF44

4. Nur Asyikin Rusli KK Tengkera PFUF44

5. Foo Swee Yen KK Sg.Udang PFUF44

6. Noorafinah Mohd Zudin KK Ujong Pasir PFUF44

7. Chew Poh Chiong KK Ayer Molek PFUF44

8. Woon Su Ann KK Peringgit PFUF41

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PRESENTATION OUTLINE

Problem identification
Problem ranking
Reason for choosing
Opportunity and problem statement
Cause effect analysis
Verification study
Literature review
Data collection
Process of care
Model of Good Care (MOGC)
Remedial actions
Findings
ABNA
Conclusion
References

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PROBLEM IDENTIFICATION

No.	Problem	Achievement (KPI March 2016)
1	Low number of DMTAC follow-up patients in PKDMT	Standard : 100 % Finding : 55 %
2	Long waiting time in outpatient pharmacy (wait >30 minit)	Standard : 0 % Finding : 10.5 %
3	Increase of insulin returned in outpatient pharmacy	Standard : 0 % Finding : 11.2 %
4	Delayed in supplying SPUB medicines to patients due to delay receiving of medications from referral facilities. (e.g. List A Drug) .	Standard : 0 % Finding : 14%

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PROBLEM RANKING:SMART CRITERIA �

No	TOPIC	VOTE					TOTAL
No	TOPIC	S	M	A	R	T	TOTAL
1	Low number of DMTAC follow-up patients in PKDMT.	24	24	24	16	16	104
2	Long waiting time in outpatient pharmacy.	16	24	24	16	16	96
3	Increase of returned new insulin in outpatient pharmacy.	8	24	16	16	16	80
4	Delayed in supplying SPUB medicines to patients.	16	16	16	8	16	72

Rating scale: 1=low, 2=medium, 3=high

8 Group Members

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REFINED & CHOSEN TOPIC

Increasing the number of DMTAC follow-up patients in PKD Melaka Tengah.

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REASON FOR CHOOSING

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National Health and Morbidity Survey (NHMS) 2011 reported 2.6 million Malaysian adults were diabetics, but only 23.8% of patients were controlled.

Malaysia

Melaka

In 2016, there are 22,285 diabetics, 17% of the patient with HbA1c > 10%.

In 2016, there are 12,815 diabetics, 16% of them with HbA1c > 10%.

PKD Melaka Tengah

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WHAT IS DMTAC?

Diabetes Medication Therapy Adherance Clinic

It is an ambulatory care service offered by pharmacists in collaboration with physicians.

AIM: To help diabetic patients to achieve better medication adherence level and glycemic control.

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WHAT IS DMTAC?

During each visits, patient will receive:

Medication adherence assessment
Drug-related problems identification and management
Medication counseling
Monitoring of clinical outcomes
Diabetes education (4 modules)

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Uncontrolled diabetes patients will be recruited for a multiple number of follow-up to access their knowledge and diabetes management.

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LITERATURE REVIEW

85 DMTAC patients were studied in Hospital Kuala Lumpur, where 9 months of DMTAC follow up resulted in HbA1c reduction of 1.7% compared to 0.6% in control.

(Loganadan et al., 2011).

A study conducted in 14 government health clinics in Kuala Lumpur and Putrajaya showed positive outcome after 4^th visit of DMTAC session, in term of:

Glycaemic control (1.0% of mean HbA1c reduction),
Medication understanding (mean medication understanding score 97.6% compared to baseline 92.2%)
Adherence level (mean MMMAS of 7.4 compared to baseline of 6.5).

(Lee X. Y., 2015)

Continuous follow-up of DMTAC patient is crucial to ensure good glycemic outcome.

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DMTAC CURRENT ISSUE

However, a lot of patients didn’t turn up as early as second follow up and this might affect the intended plan for the patients in DMTAC.

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DMTAC FLOW

INITIAL VISIT

FOLLOW-UP VISIT

Trace patient’s record

Reinforcement, Counselling& Education

Assessment and Review

Medication Refill & Dispensing

Schedule For Next Visit (Appointment)

Documentation

Recruit patients

Counselling & Education

Initial assessment and Review

Medication Refill & Dispensing

Schedule For Follow up Visit (Appointment)

Documentation

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PROBLEM STATEMENT

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CAUSE EFFECT ANALYSIS

LOW NUMBER OF DMTAC FOLLOW UP PATIENTS

Poor documentations

Pharmacist limitation

Poor patients tracing method

Lack of commitment from patients

Not interested with DMTAC

The target set is too high

Lack of communication between health care professional

Elderly – difficult to come for appointment

No tagging on patients record

Time constraint

Lack of trained DMTAC pharmacist

Long waiting time

Lack of counseling tools eg. Glucometer & flip chart

No standardisation in documentation for different facilities

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VERIFICATION STUDY

No	Factor	Method	Standard	Finding
1.	Documentation	Direct observation and data collection from the Patients Registration Book and Appointment record	100%	55%
2.	Tracing method	Direct observation and data collection from the Appointment record	100%	40%
3.	Patients commitment	Questionnaires	100%	65%

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OBJECTIVES

General Objective

To increase the number of DMTAC follow-up patients in PKDMT.

Specific Objectives

To determine the causes and factors contribute to the low number of DMTAC follow-up patients in PKDMT.

To recommend and institute remedial measures on how to increase the number of follow up.

To evaluate the effectiveness of remedial measures taken.

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TYPE OF STUDY

Cross sectional study

(Jan- December 2016)

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INCLUSION CRITERIA

Walk in patient from other facilities
Patient who unwilling to participate in the study

EXCLUSION CRITERIA

Clinics with DMTAC service
Patient with uncontrolled DM (HbA1C > 10%)

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TERMS’ DEFINITION

DMTAC	Diabetes Medication Therapy Adherence Clinic
MMAS score	Modified Morisky Adherance Scale score
DFIT score	Dose, Frequency, Indication and Time score
PRE	Newly recruited DMTAC patients
POST	Follow-up DMTAC patients
Phas-VAS	Pharmacy Value-Added Service (ie: Appointment cards, Ubat Melalui Pos (UMP1 Malaysia), Drive-Through Program.

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PROPOSED INDICATOR & STANDARD

INDICATOR:

Percentage of follow-up DMTAC patients.

No. of follow-up DMTAC patient

Total no. of target follow-up DMTAC patient*

X 100%

No of new DMTAC patient

No of follow-up DMTAC patients

1: 3

STANDARD : 100%

* target set by BPF KKM

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PROCESS OF CARE (FOLLOW UP)

INITIAL VISIT

FOLLOW-UP VISIT

Trace patient’s record

Reinforcement, Counselling& Education

Assessment and Review

Medication Refill & Dispensing

Schedule For Next Visit (Appointment)

Documentation

Recruit patients

Counselling & Education

Initial assessment and Review

Medication Refill & Dispensing

Schedule For Follow up Visit (Appointment)

Documentation

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MODEL OF GOOD CARE (MOGC)-PRE REMEDIAL

Bil.	Process	Criteria	Standard	Pre remedial
1	Trace patient’s record	Check patient name according to DMTAC appointment record. Trace patient record book. Inform diabetes educator to send patient to see DMTAC pharmacist first before seeing the doctor. Trace patient DMTAC file.	100%	75%
2	Assessment and review	Review patient’s compliance, understanding, insulin technique(if applicable), SMBG, HbA1c, BP self-monitoring.	100%	75%
3	Reinforcement, Counselling & Education	Provide counseling according to DMTAC module.	100%	90%

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MODEL OF GOOD CARE (MOGC)-PRE REMEDIAL�

Bil.	Process	Criteria	Standard	Pre remedial
4	Medication refill and dispensing	Patient’s prescription was received and filled Pharmacist dispense medication	100%	78%
5	Schedule for next visit	Schedule for next visit	100%	65%
6	Documentation	Complete patient’s DMTAC Pharmacotherapy Review and appointment record. Send the record and patient to doctor for any intervention done.	100%	55%

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Trace patient’s record

Reinforcement, Counselling& Education

Assessment and Review

Medication Refill & Dispensing

Schedule For Next Visit (Appointment)

Documentation

REMEDIAL ACTION 1

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REMEDIAL ACTION 1

No.	PROBLEM	FACTORS	REMEDIAL MEASURES
1.	Poor patients tracing method	No tagging on patients record Lack of communications between health care professionals	Create: DMTAC tagging sticker (post remedial 1), Appointment Reminder Note and Appointment Name List (post remedial 2) Alert other healthcare professionals the use of referral form and DMTAC tagging sticker through series of CMEs

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DMTAC sticker ,appointment reminder note and name list

Appointment reminder note

DMTAC sticker

Appointment Name List

INNOVATION

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REMEDIAL ACTION 1

No.	PROBLEM	FACTORS	REMEDIAL MEASURES
1.	Poor patients tracing method	No tagging on patients record Lack of communications between health care professionals	Create: DMTAC tagging sticker (post remedial 1), Appointment Reminder Note and Appointment Name List (post remedial 2) Alert other healthcare professionals the use of referral form and DMTAC tagging sticker through series of CMEs

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Trace patient’s record

Reinforcement, Counselling& Education

Assessment and Review

Medication Refill & Dispensing

Schedule For Next Visit (Appointment)

Documentation

REMEDIAL ACTION 2

REMEDIAL ACTION 2 & 3

REMEDIAL ACTION 2

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REMEDIAL ACTION 2

No.	PROBLEMS	FACTORS	REMEDIAL MEASURES
2.	Lack of commitment from patients	Lack of interest 2. Long waiting time	Provide incentives for patients Eg: give needle and pill cutter Prepare medication for the patients in advance (register patient in Phas-VAS program) / provide fast lane counter.

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Incentives for patients who completed at least 4 sessions

Insulin needles

Pill cutter

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REMEDIAL ACTION 2

No.	PROBLEMS	FACTORS	REMEDIAL MEASURES
2.	Lack of commitment from patients	Lack of interest 2. Long waiting time	Provide incentives for patients Eg: give needle/ pill cutter/ pill box Prepare medication for the patients in advance (register patient in Phas-VAS program) / provide fast lane counter.

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REMEDIAL ACTION 3

No.	PROBLEMS	FACTORS	REMEDIAL MEASURES
3.	Pharmacist limitation	Time constraint Lack of trained staffs Lack of counseling tools eg. Glucometer & flip chart The target set is too high (300 patients for 2016)	Set a DMTAC day (based on clinic) and allocate a pharmacist for DMTAC in clinic counter schedule. Echo-training for new pharmacists in DMTAC Requested and obtained counseling tools from Bahagian Perkhidmatan Farmasi Melaka & collaboration with District Laboratory Department for glucometer in each DMTAC clinic. Set target based on the number of PF eligible for running the DMTAC clinic

Clinic	DMTAC day
KK Peringgit	Monday-Thursday (8am-1pm)
KK Ayer Keroh	Tuesday & Thursday (8am-1pm)
KK Tengkera	Monday-Friday (8am-1pm)
KK Ujong Pasir	Tuesday-Wednesday (8am-1pm)
KK Ayer Molek	Monday-Friday (8am-1pm)
KK Cheng	Tuesday-Wednesday (2-5pm)

Example of DMTAC timetable in different clinics

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REMEDIAL ACTION 3

No.	PROBLEMS	FACTORS	REMEDIAL MEASURES
3.	Pharmacist limitation	Time constraint Lack of trained staffs Lack of counseling tools eg. Glucometer & flip chart The target set is too high (300 patients for 2016)	Set a DMTAC day (based on clinic) and allocate a pharmacist for DMTAC in clinic counter schedule. Echo-training for new pharmacists in DMTAC Requested and obtained counseling tools from Bahagian Perkhidmatan Farmasi Melaka & collaboration with District Laboratory Department for glucometer in each DMTAC clinic. Set target based on the number of PF eligible for running the DMTAC clinic

No of DMTAC pharmacist increased from 7 to 14

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REMEDIAL ACTION 3

No.	PROBLEMS	FACTORS	REMEDIAL MEASURES
3.	Pharmacist limitation	Time constraint Lack of trained staffs Lack of counseling tools eg. Glucometer & flip chart The target set is too high (300 patients for 2016)	Set a DMTAC day (based on clinic) and allocate a pharmacist for DMTAC in clinic counter schedule. Echo-training for new pharmacists in DMTAC Requested and obtained counseling tools from Bahagian Perkhidmatan Farmasi Melaka & collaboration with District Laboratory Department for glucometer in each DMTAC clinic. Set target based on the number of PF eligible for running the DMTAC clinic

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Glucometer provided by District Laboratory for all DMTAC clinic

Counseling tools provided by BPF Melaka

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Trace patient’s record

Reinforcement, Counselling& Education

Assessment and Review

Medication Refill & Dispensing

Schedule For Next Visit (Appointment)

Documentation

REMEDIAL ACTION 4

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REMEDIAL ACTION 4

No.	PROBLEMS	FACTORS	REMEDIAL MEASURES
4.	Poor documentation	No standardization in documentation for different facilities Difficult to trace record and understand the plan	Standardized documentation (post remedial 1) - (Approval of printing by Pegawai Kesihatan Daerah) Patient Registration book with standard registration number Appointment book DMTAC referral form DMTAC intervention note Create: next visit plan note (Post remedial 2) Briefing to all DMTAC pharmacists for documents standardization

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Patient registration book

Clinic	Standard registration Number
Peringgit	DMTAC/KKP/Year/No
Ayer Keroh	DMTAC/KKAK/Year/No
Tengkera	DMTAC/KKTE/Year/No
Ujong Pasir	DMTAC/KKUP/Year/No
Cheng	DMTAC/KKC/Year/No
Ayer Molek	DMTAC/KKAM/Year/No
Sri Tanjung	DMTAC/KKST/Year/NO

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Appointment book

Number of patients per day can be set up earlier and therefore preparation can be made in advance.

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DMTAC referral form & intervention note

Referral form

Intervention note

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REMEDIAL ACTION 4

No.	PROBLEMS	FACTORS	REMEDIAL MEASURES
4.	Poor documentation	No standardization in documentation for different facilities Difficult to trace record and understand the plan	Standardized documentation (post remedial 1) - (Approval of printing by Pegawai Kesihatan Daerah) Patient Registration book with standard registration number Appointment book DMTAC referral form DMTAC intervention note Create: next visit plan note (Post remedial 2) Briefing to all DMTAC pharmacists for documents standardization

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Next Visit Plan Note

To ease the next pharmacist on duty to execute next plan for the patient

INNOVATION

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REMEDIAL ACTION 4

No.	PROBLEMS	FACTORS	REMEDIAL MEASURES
4.	Poor documentation	No standardization in documentation for different facilities Difficult to trace record and understand the plan	Standardized documentation (post remedial 1) for all facilities running DMTAC includes: (Approval of printing by Pegawai Kesihatan Daerah) Patient Registration book with standard registration number Appointment book DMTAC referral form DMTAC intervention note Create: next visit plan note (Post remedial 2) Briefing to all DMTAC pharmacists for documents standardization

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Briefing for DMTAC pharmacist

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CONFORMATION TO MOGC

Bil.	Process	Criteria	Standard	Pre remedial	Post remedial 1	Post remedial 2
1	Trace patient’s record	Check patient name according to DMTAC appointment record. Trace patient record book. Inform diabetes educator to send patient to see DMTAC pharmacist first before seeing the doctor. Trace patient DMTAC file.	100%	75%	90%	95%
2	Assessment and review	Review patient’s compliance, understanding, insulin technique(if applicable), SMBG, HbA1c, BP self-monitoring.	100%	75%	95%	100%
3	Reinforcement, Counselling & Education	Provide counseling according to DMTAC module.	100%	90%	95%	100%

15%

5%

20%

5%

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CONFORMATION TO MOGC

Bil.	Process	Criteria	Standard	Pre remedial	Post remedial 1	Post remedial 2
4	Medication refill and dispensing	Pharmacist dispense medication	100%	78%	90%	95%
5	Schedule for next visit	Schedule for next visit	100%	65%	95%	98%
6	Documentation	Complete patient’s DMTAC Pharmacotherapy Review and appointment record	100%	55%	85%	95%

12%

5%

30%

3%

30%

10%

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FINDINGS

No.	Jan – Mac 2016 (Pre-remedial)	July – Sept 2016 (Post-remedial 1)	Oct - Dis 2016 Post-remedial 2
1.	TARGET :
2.	ACHIEVEMENT: New DMTAC patients: 85 Target no. of follow up: 255 Actual no of follow up: 104	ACHIEVEMENT: New DMTAC patients: 100 Target no. of follow up: 300 Actual no of follow up: 201	ACHIEVEMENT: New DMTAC patients: 82 Target no. of follow up: 246 Actual no of follow up: 240
2.	Ratio:	Ratio:	Ratio:
3.	PERCENTAGE :	PERCENTAGE :	PERCENTAGE :
* Standard : Target set by BPF KKM

1 : 1.2

40.8%

1 : 2.0

1 : 2.9

67.0%

97.6%

RATIO 1 new DMTAC patient : 3 follow-up DMTAC patients*

STANDARD 100%

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ACHIEVABLE BENEFIT NOT ACHIEVED (ABNA)-POST REMEDIAL 1

ABNA= 59.2%

ABNA= 33.0%

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ACHIEVABLE BENEFIT NOT ACHIEVED (ABNA)-POST REMEDIAL 2

ABNA= 59.2%

ABNA= 33.0%

ABNA= 2.4%

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WHY INCREASE NUMBER OF FOLLOW-UP IS IMPORTANT?

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DMTAC OUTCOME MEASURES

Glyceamic control

( HbA1c reduction )

Medication Compliance

(Modified Morisky Adherence Score, MMAS≥6)

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NUMBER OF FOLLOW UP VS �% OF HBA1C REDUCTION

HbA1c	Pre remedial	Post remedial 1	Post remedial 2
Baseline	11.5 %	10.6 %	10.5 %
After	10.9 %	9.5 %	9.3 %
Reduction	0.6 %	1.1 %	1.2 %

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NUMBER OF FOLLOW UP VS �% COMPLIANCE

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1^ST PLACE

Oral Category

QA Convention Melaka 2017

We are invited for presentation of our QA project to DMTAC representatives from other PKD and hospitals at state level.

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In the process of implementation to other PKD and Hospital in Melaka.

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THE NEXT STEP

To further improve our study by reducing ABNA from 2.4% to 0%.

Implement strategy of change to other states in Malaysia

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CONCLUSION

Patient’s understanding

Patient’s compliance

HbA1c

Increase number of DMTAC follow-up patients

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GANTT CHART

Task to be performed	Apr 16	Mei 16	Jun 16	Jul 16	Ogo 16	Sep 16	Oct 16	Nov 16	Dis 16	Jan 17	Feb 17	Mac 17	Apr 17
Finalise QA proposal
Finalise QA proposal
Pre-remedial Data Analysis
Pre-remedial Data Analysis
Implement remedial action
Implement remedial action
Compile data from every DMTAC clinics
Compile data from every DMTAC clinics
Preliminary data analysis
Preliminary data analysis
Data analysis and report writing
Data analysis and report writing
Finalise report
Finalise report

Plan

Execution

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REFERENCES

Guariguata L, Whiting DR, Hambleton I, Beagley J, Linnenkamp U, Shaw JE. Global estimates of diabetes prevalence in adults for 2013 and projections for 2035. Diabetes Res Clin Pract 2014;103(2):137–49.
Institute for Public Health. The Fourth National Health and Morbidity Survey 2011 (NHMS IV 2011). Ministry of Health, Malaysia;2011.
Feisul I, Azmi S. National Diabetes Registry, 2009-2012. Putrajaya: Non-Communicable Disease Section, Disease Control Division, Department of Public Health, Ministry of Health Malaysia;2013.
DiabCare Malaysia 2013 Action Plan Workshop. Putrajaya, Malaysia. 13th November 2014.
American Diabetes Association. (2014) Complications (Virginia, USA: American Diabetes Association). http://http://www.diabetes.org/living-withdiabetes/complications/? loc=lwd-slabnav (13 March 2014).
Pharmaceutical Services Division. (2014) Protocol Medication Therapy Adherence Clinic: Diabetes
Loganadan, N., Chin, S.T., Rachel, T., Lim, K.Y., Fudziah, A. (2011). Clinical and Economic Impact of Pharmacist Run Medication Therapy Adherence Clinic Service on Patients with Type 2 Diabetes. Malaysian Journal of Public Health Medicine, 11 (Suppl 5), 42
Lee X. Y., Selvakumari S., Cheah K. Y., Nor B., Gan C. B., Teng J., A. Hafeez, Nazariah H. (2015). Impact Of Pharmacist-managed Diabetes Medication Therapy Adherence Clinic (DMTAC) In Government Health Clinics. Malaysian Journal of Pharmaceutical Sciences Vol. 13, No. 1, 43–51

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ACKNOWLEDGEMENT

Bahagian Perkhidmatan Farmasi Negeri Melaka

Providing counselling tools and incentives for patients

District Laboratory Department PKD Melaka Tengah

Providing glucometers

Pejabat Kesihatan Daerah Melaka Tengah

Printing of new DMTAC document

DMTAC Pharmacist in PKDMT

Full support throughout our study

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THANK YOU !