1. Optimize© -
A Medicines Adherence
Solution
provided by
Green Light Pharmacy
in it’s Stepney branch
commissioned by Tower Hamlets PCT in
2012 & now by NHS England

2. There is no impending pharmaceutical
discovery, surgical innovation or
governmental policy change with
greater potential for improving the
health of patients and efficiency of the
health care system, than simply
increasing the percentage of treatment
plans that patients (are able to) carry
out as prescribed
[Align Map www.alignmap.com ]

3. “Drugs don’t work in patients who don’t take them” C. Everett Koop M.D – Surgeon General
USA 1982-89
It is estimated that 50% of all prescribed medication is not used by patients
as intended by the prescriber [ Sackett D.L., Snow J.C. “The Magnitude of Compliance & Non-Compliance” In:
Haynes R.B. et al (Eds) “Compliance in Health Care” Baltimore, John Hopkins University Press 1979; Nov 22]
It has been estimated that between 20 and 50% of patients are not
adherent to their medication regimeKripalani S, Yao X, Haynes RB. Interventions to Enhance
medication Adherence in Chronic Medical Conditions: A systemic Review. Archives of Internal medicine 2007; 167:540-550
Improving medicine taking may have a far greater impact on clinical
outcomes than an improvement in treatments Haynes R.B., Ackloo E., Sahota N., McDonald H.,
Yao X. “Interventions for Enhancing Medication Adherence” Cochrane Database System Review 2008; (CD0000011)
33-69% of all medicine related hospital admissions are due to poor
medication adherenceOsterberg & Blaschke. New England Journal of Medicine 2005 Vol 353
Only 4 to 21% of patients are receiving the optimum benefit from their
medicines Garfield S, Barber N, Walley P, Willson A, Eliasson L. Quality of Medication Use in Primary Care - Mapping the
Problems, Working to a Solution: A Systemic Review of the Literature. BMC Medicine 2009; 7:50

4. • To support independent living
• To improve patient adherence with therapy by
– Improving understanding
– Identifying practical problems
– Supporting the carer
• To reduce wastage and thus make cost savings by decreasing
the local prescribing budget
• To help people manage their medicines safely & appropriately
• To decrease Preventable Medication Related Hospital
Admissions and thus make cost savings to the CCG’s Hospital
Admissions budget

5. The service focuses on improving,
supporting & monitoring
adherence (how people take their
meds) not simply on the provision
of compliance devices (ie not just
a blister pack, other solutions as
well)

7. It's
intentional
non-compliance

8. Optimize© addresses:
Unintentional non
compliance
• Access (eg over / under
script request)
• Physical issues (using
inhalers, reading
English)
• Adherence solutions
(Blister Packs ,
Reminder Charts,
prompts eg phone call,
text, phone aps )
Intentional non-
compliance
• Cognitive support
• Meds Education Plan
• Patient held meds
record - their
“Medication
Passport”
• Condition Education
Plan
• Adherence Record
• Reward Plan
• Relapse Plan

9. Optimize©:A Medicines
Adherence Solution
Referral
Adherence
Assessment by
AccreditedCP
Support Plan &
Report (SPAR), carried
out by patient’s usual,
localCP.
(Compliance aids;
cognitive support;
use of MAR sheets;
reminders/prompts)
Discharge from
service, but
with on-going
Support Plan
Review
(initially
at 3
months,
then every
6 months)
Evaluation
of Referral
by
Accredited
Community
Pharmacist
(CP)
Patient referred to other health & social
care services and/or contacted by
accredited pharmacist to discuss the
reason for the referral and possible
solutions.
Inappropriate
Referral
Appropriate
Referral
Adherence Evaluation by Accredited
CP (usually as a domiciliary visit)
Adherence MUR Plus by AccreditedCP
Support Plan
Communicated to the
patient, as user
friendly (patient held)
Medicines Passport
Patient carries
on in the service
Annual Report &
Evaluation of Service
to Commissioner by
Service Provider

10. What’s the service?
Adherence Assessment (AA)
followed by a Support Plan
and Report (SPAR). People
requiring ongoing support will
be referred onto Optimize
Adherence Support Service for
tailor-made adherence
support.
Who can refer?
Any CCG / LA approved
body
Which patients need the
service?
Patients with long-term
conditions who have
difficulty taking, or
remembering to take, their
medicines; complex and
high need patients only.
Who provides the
service? – Hub & Spoke
model
• Assessments by
Accredited
Community
Pharmacists (hub)
• The patient’s presant
local (Accredited)
Community
Pharmacist (spoke)
How will we link to other
services (for referral and for
reporting)?
• Community nurses
• GP practices
•Multi-disciplinaryGroups
•Social Care Organisations
• Pharmacy network
• Hospital discharge department
• Pathway design (CCG,
locality/network etc)
What do we report?
• Patient review
• Info the GP requires.
• Cost savings of
recommendations
• Summary of health outcomes
for patients in scheme
• Patient satisfaction surveys
• Assessment of data from
stakeholders
Optimize©: A Medicines
Adherence Solution

11. What we were not commissioned
to provide – but on reflection would
be useful
• IT platform
• Training of Pharmacy Staff in other
pharmacies for roll out of service
• Whole team training (GPs, Nurses, &
other Health & Social Care
Professionals)

12. Optimize© Referral Form
Confusion on taking medication
Remembering to take medication is a problem (eg evidence of missed doses)
Assistance required to physically take medication (eg dexterity issues)
Medications are not synchronised on prescription, requiring extra visits to the Dr / Pharmacy
Difficulty in maintaining supply of medication evident (eg stockpiling or running out of medication)
Patient forgetting to request repeat prescriptions
Health Literacy (eg difficulty understanding & reading medication labels / non-English literate, lack of
understanding of meds or medical condition)
Prescribing Interval to be reassessed (eg patient is on 7 day prescriptions -might imply adherence issues)
Patient has requested help in taking medicines
Intentional non-adherence (ie patient intentionally choosing to not take medication)
High Risk Patient (eg onVirtualWard, Frequent HospitalAdmissions)

13. Optimize© Adherence Evaluation (Part 1)
MMAS-8 Questions.
Note for pharmacist - If repeating questionnaire after 6 month please preference each question with the phrase “since we
last spoke …...”
You are taking medication(s) for your condition. Individuals have identified several issues regarding their medication taking
behaviour and we are interested in your experiences. There is no right or wrong answer. Please answer each question
based on your personal experience with your new medication.
Do you sometimes forget to take your medicine(s)? Yes No
People sometimes miss taking their medications for reasons other than forgetting.
Thinking over the past two weeks, were there any days when you did not take your
medicine(s)?
Yes No
Have you ever cut back or stopped taking your medication without telling your
doctor because you felt worse when you took it?
Yes No
When you travel or leave home, do you sometimes forget to bring along your
medication?
Yes No
Did you take your medicine(s) yesterday? Yes No
When you feel like your condition is under control, do you sometimes stop taking
your medicine?
Yes No
Taking medicine everyday is a real inconvenience for some people. Do you ever feel
hassled about sticking to your medicine treatment plan?
Yes No
How often do you have difficulty remembering to take all your medications? Never / Rarely
One in while
Sometimes
Usually
All the time

14. Optimize© Adherence Evaluation (Part 2)
BMQ Questions.
I would like to ask you about your PERSONAL VIEWS about the medicines prescribed for you.
Note for pharmacist - If repeating questionnaire after 6 month please preference with the phrase “since we last spoke …...”
Please indicate how much you agree or disagree with the following statements about your
medicine by answering the following. There are no right or wrong answers. We are
interested in your personal views.
Tick the appropriate box Strongly
agree
Agree Uncertain Disagree Strongly
disagree
1) My health, at present, depends on my medicine(s)
2) Having to take my medicine(s) worries me
3) Without my medicine(s) I would be very ill
4) My life would be impossible without my medicine(s)
5) I sometimes worry about long term effects of my
medicine(s)
6) My medicine(s) are a mystery to me
7) My health in the future will depend on my medicine(s)
8) My medicine(s) disrupts my life
9) I sometimes worry about becoming too
dependent on my medicine(s)
10) My medicine(s) protects me from
becoming worse

15. Optimize© Adherence MUR Plus (Page 1)
Patient name & address Attach Patient's PMR Bag Label Here DOB Total number of
medicines being used by
patient:
Ethnicity Prescribed
Gender OTC &
complementary
therapies
Pharmacist name: Date:
Suggested questions Complete GLMAS Patient Evaluation Questionnaire Form with patient at start of interview Yes
/
No
1. How are you getting on with your medicines?
2. How do you take or use each of these medicines?
3. Are you having any problems with any of your
medicines, or concerns about taking or using them?
Medicines not listed on the patient’s PMR Dosage Notes (include if OTC or prescribed. If prescribed from GP or Hosp etc)
Consultation notes
List ALL meds patient is on from GP / Hospital etc with prescribed dosages (can attach a copy of patient's Repeat Request Form or PMR record
print out). List actual dosages that the patient takes (can do this on the Repeat Form or PMR print our). List any significant side effects. Can use
codes from GL MUR referral sheet as “short codes”
Group Q4 & Q5 by therapeutic areas
4. Do you think they are working? Prompt: is this
different from what you were expecting?
5. Do you think you are getting any side effects or
unexpected effects?
6. People often miss taking doses of their medicines,
for a wide range of reasons. Have you missed any
doses of your medicine, or changed when you take it?
Prompt: when did you last miss a dose?
7. Do you have anything else you would like to know
about your medicines or is there anything you would
like me to go over again? Prompt: Are you happy with
the information you have on your medicines?

16. Optimize© Adherence MUR Plus (Page 2)
Is a Compliance Aid being used now. Patient's views of it's usefulness.
Prompt: How does the Compliance Aid help you ?
Evidence of intentional non-compliance. Why is patient intentionally non-compliant?
How does person order / collect prescriptions?. Which pharmacy do they use ?
Do they remember to order medicines? What about PRNs & non MDS medication
Is there duplication of medication due to supply from different pharmacies (including hospital) ?
How do medicines get delivered to the patient ?
Is there evidence of stockpiling or running out of meds. (Check patient's actual stock of meds: list
excess meds & quantities of patient's stock)
Does patient order all medicines together or at different times?
Can person read all labels? Yes / No
Can the
person
read
English ?
Yes / No Can they open and close all containers? Yes / No
Dexterity – able to push tablets out of blisters, pick up small tablets, halve
tablets?
Yes / No
Can they
measure
any liquid
medicines
?
Yes / No
Inhalers / eye drops – check technique / able to administer correctly? Yes / No
Are they able to swallow their medicines? Yes / No
Is person
aware of
time (day)
and place?
Yes / No
Assess if any of the following would be helpful (please circle)
Hand written labels, Large print labels, Symbols / colour coding, Easy open lids, Large bottles, Pop blister meds into bottle, Halve
tablets, Haleraid, Spacer , Eye drop dispenser, Different formulation, Measuring cup / oral syringe, Other
What systems do they use to remind them to take their medicines?
Does someone help patient take their medicines? Who?
Does this person prompt or actually administer?
Is this person able to help patient with all doses on all days? (check weekends / evenings)
Does person have a compliance aid already – what type/ who fills it?
Who initiated the compliance aid in the first place ? (GP, Patient, Nurse, CP etc)
What condition is the compliance aid in ? (clean, labelled, legible?)
Adherence to ‘prn’ medicines, medicines unstable in compliance aid, inhalers, creams etc ?
Note to Pharmacist - Remember to take medicines for disposal.
Other issues (eg frequent attendance at Urgent Care Centre, A&E)

17. Optimize© Adherence MUR Plus (Page 3)
Name Strength & Form of
medicine
Approximate
quantity
Approximate cost
(based on present DT
price can be completed
in the Pharmacy)
Reason for disposal RIO score
Please list medicines no longer required taken for disposal
I agree to the above medication being removed for safe disposal by the pharmacist
Signature of patient …………………………...…..…......... Signature of pharmacist ……….....................Date ……
RIO scoring: 1 – no likelihood of preventing an emergency admission, 2 – possibly may prevent an emergency admission, 3
– likely to prevent an emergency admission

18. Optimize© Adherence Assessment & Support Plan,
including Patient’s Medication Passport (Meds
Usage Issues)
Actions required for MedicinesUsage Issue (Assessor to tick which were identified from
assessment):
Improve the patient’s actual use of their medicines
 Improve the patient’s understanding of their medicines
 Improve the patient’s experience of taking their medicines
 Address any issues with any meds with inadequate dosage instructions (ie as directed) & PRN
meds with the prescriber
 Address side effects (patient reported or clinically identified) and drug interactions that may
affect the patient’s adherence with the prescriber
 Recommendations from review of the clinical and cost effectiveness of drugs prescribed. From
review of the clinical and cost effectiveness of drugs prescribed itemise here potential cost
savings. Include proposals for changing brands to generics (& vice versa) if appropriate; non-use
/ under use of meds by patient (eg evidence from meds patient requested for disposal)
 Change existingAdherence Solution to a more suitable one
 Discus with prescriber altering the prescribing interval so patient does not run out / have excess
medication
 Improve the patient’s baseline understanding of their condition(s)
 Improve the patient’s interpretation of a healthy lifestyle
 Address intentional non-compliance issues
 Other -

19. Optimize© Adherence Assessment & Support Plan,
including Patient’s Medication Passport (Meds
Access Issues)
Actions required for Access Issue (Assessor to tick
which were identified from assessment):
 Prescription ordering service
 Prescription Collection service
 Prescription Delivery Service
 Prescription Synchronisation
 Duplication of medication due to supply from
different pharmacies (including hospital)
 Stockpiling (excess stock with patient. Reference-
6 month ordering history from GP records or
Pharmacy PMR)
 Other -

20. Optimize© Adherence Assessment & Support Plan,
including Patient’s Medication Passport (Physical
Issues)
Actions required for Physical Issue (Assessor to
tick which were identified from assessment):
 Use of aids including:
o Hand written labels (ie written in a different
language)
o Large print labels
o Symbols / colour coding
o Easy open lids; Large bottles
o Pop blister meds into bottle
o Halve tablets
o Haleraid; Haleraid
o Eye drop dispenser
o Eye drop dispenser
o Measuring cup / oral syringe

21. Optimize© Adherence Assessment & Support Plan,
including Patient’s Medication Passport (Adherence
Solutions)
Actions required for Adherence Solution Issue: (Assessor to tick which were identified from assessment)
 Simplify dosage regime (discus with prescriber)
 Support carers (formal or informal carers) re medicines oversight. This includes supply of meds & meds education
(eg to enable identification of adverse effects)
 Link medication to daily routine with reminders & prompts
 Supply Medication Reminder Chart (MR Chart) (A list of all meds & when to take) (Use Medication Reminder
Chart specified in SLA)
 Supply MedicationAdministration Records chart (MAR)Chart (use MAR Chart specified in SLA).
o Retain used MAR charts , use to make notes of patient's on-going Adherence
 Provide a reminder mechanism for prompting medication adherence (eg phone calls, texting, e-mails, phone ap).
o Specify reminder mechanism chosen here:
 Supply medication in multi-compartment compliance aid
o Analyse used Blister Packs & make notes of patient's on-going Adherence
 Supply cogitative support: Educational Plan to increase patient/carer understanding of the underlying conditions
 Supply cogitative support: Educational Plan to increase patient/carer understanding how their medication works
 Supply cogitative support : Adherence Record Chart (AR Chart) (similar to a MAR but actually asks the
patient/carer to record the reason why a medication was missed or intentionally not taken)
o Retain used Adherence Record Charts , use to make notes of patient's on-going Adherence
 Supply cogitative support: Reward Plan.
o Details of Reward Plan:
 Supply cogitative support Relapse Plan
o Details of Relapse Plan:
 If patient is not aware of time or place then the patient will need support from informal carer (family / friend , or
formal carers (eg Social Care Support, Community Nurse support) for medication administration.
o Details of Informal or Formal Support :
 Other -

22. Unused Meds, collected from just ONE
patient, prior to joining Optimize©
service

23. Evaluation of Data
Due end July 2013 (from 1st six months of
service)
Evaluation will be supported by UCL

24. Any Questions ?
sanjay@greenlightpharmacy.com
Optimize©
Green Light Healthcare Ltd
January 2012