Pharmaceutical Care

The ageing of the intellectually disabled population, as described in reports of the NIDD over the years, should have a major effect on the future practice of pharmacy with that population group. This increase in the older population with intellectual disability and increasing utilization of medications will pose new demands for expertise in the area of medication therapy management for this population. To date, the need for specialised pharmaceutical care for the ageing population with intellectual disability has not been widely recognised (Flood and Henman, 2010). Poor knowledge and attitudes of healthcare professionals have been cited as one of the reasons why the healthcare needs of people with intellectual disabilities are frequently unmet (Kerr, 2004). Flood and Henman have identified that the Annual Report of the NIDD

Committee 2008 and all previous reports of the committee have been silent about the need for pharmaceutical care provided by pharmacists for this vulnerable population (Flood and Henman, 2010). [QI 7]

In 1990, a new way to look at the responsibilities of the pharmacist and pharmacy services was identified and the term “pharmaceutical care” was used to describe this concept of pharmacists' services (Hepler and Strand, 1990). The philosophy of pharmaceutical care focuses on the responsibility of the pharmacist to meet all of the patient's drug related needs, be held accountable for meeting those needs and assist the patient in achieving his or her medical goals through collaboration with other health professionals (McGivney et al., 2007). In an article proposing a redefinition of

pharmaceutical care, Blackburn and colleagues have proposed that ‘the current definition of pharmaceutical care and its associated care processes need to be modified to ensure the activities of pharmacists are being focused on high-priority patients on a consistent basis’ (Blackburn et al., 2012). They argued that the philosophy of pharmaceutical care (and its associated care processes) should be expanded to make pharmacists accountable to populations of patients at high risk for drug- or disease-induced morbidity. One such population is the population ageing with intellectual disability and behaviour disorders. Williamson and Harvey in a Literature Review/Scoping paper identified some considerations and strategies for improving capacity of disability services to meet the needs of people with a disability in improving

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health outcomes (Williamson and Harvey, 2007). One such strategy related to pharmacists, Box 2.5.

Strategy for Improving Capacity of Disability Services to Meet the Needs of People with a Disability by Improving Health Outcomes

Pharmacist

• Developing a sound relationship with a pharmacist can benefit people with a

disability by being an avenue for advice. People with a disability may regularly require medication and often will require more than one medication.

• The need for medication can increase with age. Advice from a pharmacist can

provide a safeguard against interaction of medication and side effects.

• The pharmacist can support the person and service provider to provide a

regular assessment and monitoring of medication (both prescribed and over the counter) to identify risks of adverse interaction.

Box 2.5 Strategy for Improving Capacity of Disability Services to Meet the Needs of People with a Disability by Improving Health Outcomes

Pharmaceutical care, rational medication use and effective medicines supply management are key components of an accessible, sustainable, affordable and equitable healthcare system, which ensures the efficacy, safety and quality of medicines. HIQA in its National Quality Standards for Residential Care Settings for Older People in Ireland states in Criteria 15.2 of Standard 15: Medication Monitoring

and Review,

‘the condition of the resident on medication is monitored and subject to review at three monthly intervals or more frequently where there is a significant change in the resident’s care or condition’.

Criteria 15.6 also states that

‘each resident on long term medication is reviewed by his/her medical practitioner at least on a three monthly basis, in conjunction with nursing staff and the pharmacist’.

These criteria are the supporting statements that set out how a service can be judged as to whether the standard is being met or not. In contrast, the HIQA National Quality

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Standards: Residential Services for People with Disabilities (HIQA, 2009b) in which

there is no mention of the pharmacist, states in Standard 9: Health, Criteria 9.14 that

“the individual’s medication is monitored and subject to review at regular intervals, appropriate to the individual’s needs”.

The difference in standards expected here is a concern.

The most recent Canadian Consensus Guidelines for Primary Care of Adults with Developmental Disabilities did not include a pharmacist in the consensus process.

Among the 39 participants were practitioners in family medicine, nursing, paediatrics, psychiatry, psychology, occupational therapy and speech-language pathology (Sullivan et al., 2011). This should be a cause for concern for people with intellectual disabilities, their carers and their pharmacists.

Pharmacists and pharmaceutical care are components of the medication use process. Deirdre Madden in her report, Building a Culture of Patient Safety, recognised that

health services are provided by professionals who are dependent on each other to deliver safe, high quality care and treatment to patients (Madden, 2008). Berta and colleagues, who conducted a systematic review of the literature followed by a 2-round modified Delphi consensus process to identify elements of data that have been shown to contribute to continuity of information between primary care providers and medical specialists providing care to adult asthma patients, observed that,

‘The quality of decision making by clinicians is profoundly affected by informational continuity which refers to the use, transfer, and

management of patient information’ (Berta et al., 2008).

Good informational continuity is achieved with the accurate assimilation, timely transfer, and sharing of essential patient information among care providers that includes relevant information on past events and on patients’ personal circumstances (Haggerty et al., 2003). To practice effectively pharmacists require adequate

information. [QI 1, QI 2, QI 7, QI 10, QI 12]

The authors of the Lessons from the Labryinth Report acknowledged that quality issues at any stage of healthcare are notably significant for people with intellectual disabilities, because the impact of poor quality may have serious repercussions for them when compared to people without disabilities (Lennox and Edwards, 2001). It is

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important that care is right for people with intellectual disabilities whose behaviour challenges and TheWinterbourne View Update Report raised questions about

whether people with intellectual disabilities were being given the right medications to improve their condition, or whether they were being over-medicated for the benefit of staff (DH, 2013c). There is consequently a perceived need to improve the quality of the medication use process in this population group.