Most healthcare spending in developing countries is private out-of-pocket. One explanation for low penetration of health insurance is that poorer individuals doubt their ability to enforce insurance contracts. Community-based health insurance schemes (CBHI) are a solution, but launching CBHI requires obtaining accurate local data on morbidity, healthcare utilization and other details to inform package design and pricing. We developed the “Illness Mapping” method (IM) for data collection (faster and cheaper than household surveys).IM is a modification of two non-interactive consensus group methods  to operate as interactive methods. We elicited estimates from “Experts” in the target community on morbidity and healthcare utilization. Interaction between facilitator and experts became essential to bridge literacy constraints and to reach consensus.The study was conducted in Gaya District, Bihar (India) during April-June 2010. The intervention included the IM and a household survey (HHS). IM included 18 women’s and 17 men’s groups. The HHS was conducted in 50 villages with1,000 randomly selected households .We found good agreement between the two methods on overall prevalence of illness  and on prevalence of acute  and chronic illnesses . We also found good agreement on incidence of deliveries , and on hospital deliveries . For hospitalizations, we obtained a lower estimate from the IM (1.1%) than from the HHS (2.6%). The IM required less time and less person-power than a household survey, which translate into reduced costs.We have shown that our Illness Mapping method can be carried out at lower financial and human cost for sourcing essential local data, at acceptably accurate levels. In view of the good fit of results obtained, we assume that the method could work elsewhere as well. A large part of health care spending in developing countries is private and out of pocket (OOP). India is typical: 70% of spending is private, of which 86% is OOP ,2. MoreoOur study is located in Gaya district, Bihar state, India. The main source of data on incidence/prevalence of illnesses and hospitalisations is the Indian National Sample Survey (NSS) . The NSSThis paper contains a description of a cheaper and faster method to derive quantitative estimates of healthcare events through qualitative approaches . The expnon-interacting groups (participants do not interact and discuss with each other during the group process)  to get an overview of the village, its size, social segmentation, and a general impression of its socio-economic status. Using this knowledge, we selected our experts by applying the following criteria:1. They should be living in different parts of the village.2. They should be sociable, outgoing and interacting frequently with their neighbours, so that they would be knowledgeable about people and events in the village. Not surprisingly, participants with higher interpersonal skills have been found to perform better in group discussions .3. Group members should reflect similar social or income groups.In the Illness Mapping facilitators (of the same gender as the participants) guided group meetings to enhance recall of the parameters needed for the calculation of the prevalence of illnesses and utilization of health services. Such facilitated recall procedure does not occur either in the Delphi or the NGT, but publications suggested that compared to unstructured interventions, participants recall the relevant parameters better when procedures are structured during the thinking, visualizing and estimating stage of the interaction with the facilitator ,32. ConsWith each group, we first obtained a rough estimate of the number of households in different parts of the village, the rough household size (i.e. number of family members that ate from the same pot), and the total population of the village. Then we asked the number of persons who had been sick over the last one month, and the nature of their illness. We then asked every participant to name, one after the other, all the illnesses they could remember. To facilitate recall, the facilitator prompted periodically by asking about specific illnesses by name, both common and not so common ones. We also enquired about incidence of hospitalizations and deliveries (during the last 12 months) including information whether the delivery occurred at home or in an institute.Consensus was reached through a structured group discussion of the final tallies, similar to the final round of the NGT. We presented to each group the final tallies of the main illness categories and frequencies of illnesses, hospitalizations and deliveries, and asked for feedback on the illness tallies . Usually participants chose to increase the final cumulative percentage. In the few instances where the group was not able to arrive at a single estimate, we noted the different estimates  and averaged them.Similar to the Delphi method, our facilitator combined all responses and fed those back to the experts, who then ranked all opinions/solutions to obtain a new “agreed value”, which was again combined and distributed. Like in the Delphi, the experts can re-evaluate their ranking and possibly change their original opinions/solutions .As in NGT, our Illness Mapping process occurs in a meeting. And, like NGT interaction is limited in the first part of the process when each expert gives their response to the facilitator (in NGT this is done in writing). A group discussion follows, to clarify and evaluate responses, and reach consensus  ,25.i were recorded; we classified the illnesses reported as acute, chronic, accidents, and undefined. 18 groups from 14 villages provided 8 or more names of illnesses; only these groups were retained for the analysis of illness types. Hospitalizations and deliveries were counted and presented separately.Data obtained in group discussions were recorded on pre-designed data sheets; a second person, other than the facilitator recorded the responses. Names and frequencies of illnessesThe household survey questionnaire included questions on general demographics , socio-economic status (queried through questions on many items of household expenditures) and health status of household members. Following the method of the Indian National Sample Survey Organization , we consWe used Stata (version 11) for a descriptive analysis of the household survey. We used MS Excel (version 2003) for the Illness Mapping data tabulation and analysis.t-test. When comparing the results from the Illness Mapping with the results from the household survey we considered as “good fit” results of the Illness Mapping that were less than two SEM of the household survey data and as “very good fit” the results that were less than one SEM.The incidence of illness and health care utilization derived from the household survey are represented in percentages by dividing the number of cases by the overall number of members of the sampled households. The estimates derived from the Illness Mapping are presented as the mean and standard error of the mean (SEM) of all the group estimates arrived through consensus . We compared information obtained from male vs. female groups to ascertain that familiarity with local illnesses was comparable, and significance of this difference was assessed by Student’s The information on socioeconomic and demographic status of the sampled population in Gaya (one of the districts of Bihar state) is summarized in Table t test).Local prevalence of illnesses is one of the main parameters for designing and pricing health insurance. We compared the estimate of prevalence of illnesses (the percentage of persons ill in the last month) from the Illness Mapping methodology with the conventional household survey Table . The comThe proportion of acute and chronic illnesses in the Illness Mapping and the household survey data is shown in Table The Illness Mapping estimate of incidence of hospitalization was 1.1% ±0.4) and the household survey estimate was 2.6%  for all groups combined, while the household survey estimate was 51.4%  the incidence of illness episodes, and prevalence of hospitalizations and delivery is strongly context-dependent and varies across locations even in the same country  making iWe followed a strategy of soliciting local information from groups rather than from individuals. We were inspired by group techniques, assuming that the small cosmos of a village community could be captured through harvesting the knowledge that is readily available to its inhabitants free of charge. Having failed to find a ready-made suitable method in the published literature, we opted to utilize a combination of established methods and adapt them to our settings. Group approaches such as the Delphi and NGT have been used successfully and with high accuracy for business forecasting as well as for public policy ,39. We aOur method was based on small group discussions with people who were marginally literate and numerate, but nonetheless experts or valid representatives of their village communities. They were chosen (with the help of our partner NGO staff who had prior access to the village) for their social attributes and their knowledge of households in their own neighbourhood in the village. In each village we carefully identified such participants and facilitated their interaction to obtain estimates for the prevalence of illness for the entire village. Other key contacts in the village such as teachers, village head, and health workers could also be recruited to provide similar information if there were no prior links with the village.We organized gender homogenous groups in each village to ensure that both men and women would be able to express themselves freely. We thought that women, who are usually caregivers, might be more familiar with illnesses than men. However we found no statistical difference between the estimates given by men’s and women’s groups. We found it more difficult to assemble men’s groups as men were usually away during the day. From this experience we infer that Illness Mapping could be extracted from interactions with either gender of respondents, and that women’s groups are likely to be easier to assemble than men.Our method had to be adjusted to the field reality of low literacy which meant that written consensus and voting was not the best option and so we employed a strategy which involved everyone in a sequential and structured interaction. Our structure emerged from the motivation, explanations, and facilitation techniques that we used to encourage accurate recall and steer discussions towards final consensus.We examined the potential of our new Illness Mapping method by comparing the results obtained with those derived through a household survey. We compared three parameters which are important for implementation of micro health insurance: (i) prevalence of illness for acute and chronic illnesses, both of which entail cost implications which can be much higher in the case of chronic illnesses , (ii) inoverestimation of hospitalizations in our household survey. In contrast, hospitalizations may have been underestimated in the Illness Mapping method as the group members may have only been aware of the longer duration hospitalizations in their communities and those due to major procedures such as surgeries. They may have omitted the shorter and less severe hospitalizations. This view is supported by prior evidence that longer duration stays and surgeries are more positively associated with recall than other hospitalizations [We obtained a lower estimate of incidence of hospitalization from the Illness Mapping than from the household survey (1.1% (±0.4) from the first source versus 2.6% from the second source). This discrepancy could be the result of two types of memory effects that can lead to erroneous reporting by respondents: errors of omission and of telescoping . While oizations . We do nData obtained either from Illness Mapping or from a household survey would usually be treated by insurers with some reserve, as both methods are less reliable than actual claims data over a long period of time. The Illness Mapping did not, a-priori, show any difference on this count relative to the data obtained from the household survey. In insurance business, it is therefore common practice to include a safety loading in premium calculations, to account for errors in assumptions or inaccuracy of estimates.The main advantage of the Illness Mapping method is that it is cheaper and faster to operate, and could replace a household survey for estimating morbidity and healthcare utilization, especially where local data is needed but not readily available. While we have tested this method in rural settings in India, we have no reason to think that it could not be equally effective in urban settings (e.g. slums), or in other countries. The estimates about morbidity and healthcare utilization are of course essential not only for insurance purposes, but also for health policy choices more generally. Limitations of this method include the need to establish good contacts with the study communities in order to identify the most suitable community experts. Secondly, high quality group facilitation is essential, by facilitators that must speak the local language and understand the local social settings . Finally, as the estimates obtained by both methods are predictive, one powerful way to evaluate the robustness of the estimates obtained would be to examine both Illness Mapping data and household survey data against actual claims data. Such a follow-up examination is needed to validate the accuracy of the Illness Mapping as a generally applicable alternative to household surveys for the data in question.The effort to introduce health insurance among low income persons in areas in the informal economy requires that the benefit packages as well as the premiums payable will be customized to local conditions. Evidence has shown that those local conditions are context-specific and that one-size-fits-all simply will not do. This customization therefore is contingent on obtaining at least some local data on such pieces of information as prevalence of illness, hospitalizations, chronic and acute illnesses, and deliveries. We have explored the Illness Mapping method on the assumption that it can deliver a cheaper and faster resourcing of the essential local data, at acceptably accurate levels. We have shown in this study that the results obtained through the Illness Mapping method were comparable to those obtained through household survey. We have also shown that obtaining these results costs less time and money than conducting a household survey. We therefore conclude that for as long as health insurance solutions must be adapted to context relevant conditions and that these differ from one location to the next significantly, the Illness Mapping method tested in this study and explained in this article may serve the purpose.iThe following conditions were usually included: (i) acute: fevers, diarrheas, body pains, respiratory conditions (not including asthma/COPD), TB and skin problems; (ii) chronic: asthma/COPD, diabetes, hypertension, kidney diseases, and cardiovascular problems.ASHA: Accredited social health activist; HHS: Household survey; IM: Illness mapping; NGO: Non-governmental organization; NGT: Nominal group technique; NSS: National sample survey; SE: Standard error.The authors declare that they have no competing interests.DMD and RK were responsible for the study concept and design. MG was responsible for the Illness Mapping fieldwork and data management; EB was responsible for the household survey fieldwork and data management. MG, EB, RK and DMD analysed and interpreted the data. EB, MG and RK prepared the draft of the manuscript. All authors read, revised and approved the final version of the manuscript.MG was a Post-Doctoral Fellow, and EB a Ph.D. student with the Institute of Health Policy and Management, Erasmus University, Rotterdam, while developing this article. This work represents part of the requirements for the PhD thesis of EB at Erasmus University.DMD, in addition to acting as principal investigator on this grant within his position as hon. Professor at Erasmus University Rotterdam, also acted as supervisor of MG in the Post-Doctoral fellowship and EB in the PhD studies. He is also the Chairman of the Micro Insurance Academy.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2288/12/153/prepub


Cardiovascular risk management is largely provided in primary healthcare, but not all patients with established cardiovascular diseases receive preventive treatment as recommended. Accreditation of healthcare organizations has been introduced across the world with a range of aims, including the improvement of clinical processes and outcomes. The Dutch College of General Practitioners has launched a program for accreditation of primary care practices, which focuses on chronic illness care. This study aims to determine the effectiveness and efficiency of a practice accreditation program, focusing on patients with established cardiovascular diseases.We have planned a two-arm cluster randomized trial with a block design. Seventy primary care practices will be recruited from those who volunteer to participate in the practice accreditation program. Primary care practices will be the unit of randomization. A computer list of random numbers will be generated by an independent statistician. The intervention group (n = 35 practices) will be instructed to focus improvement on cardiovascular risk management. The control group will be instructed to focus improvement on other domains in the first year of the program. Baseline and follow-up measurements at 12 months after receiving the accreditation certificate are based on a standardized version of the audit in the practice accreditation program. Primary outcomes include controlled blood pressure, serum cholesterol, and prescription of recommended preventive medication. Secondary outcomes are 15 process indicators and two outcome indicators of cardiovascular risk management, self-reported achievement of improvement goals and perceived unintended consequences. The intention to treat analysis is statistically powered to detect a difference of 10% on primary outcomes. The economic evaluation aims to determine the efficiency of the program and investigates the relationship between costs, performance indicators, and accreditation.It is important to gain more information about the effectiveness and efficiency of the practice accreditation program to assess if participation is worthwhile regarding the quality of cardiovascular risk management. The results of this study will help to develop the practice accreditation program for primary care practices.This cluster randomized trial is registered at ClinicalTrials.gov nr NCT00791362 Cardiovascular diseases (CVD) remain an important cause of mortality and morbidity worldwide. In public health and in primary care, many efforts have been made to prevent CVD ,2. Althoe.g., a continuing education session or audit without follow-up). To enhance continuous improvement in primary care in the Netherlands, the Dutch College of General Practitioners (DCGP) initiated in 2005 a nationwide comprehensive practice accreditation program for primary care practices. This program consists of a systematic audit on the basis of validated performance indicators for diabetes mellitus, CVRM, asthma, chronic obstructive pulmonary disease (COPD), practice organization, patient experience, educational feedback to practices, the requirement to develop structured improvement plans, and a check on the implementation of these plans after one year. If the procedure is performed, primary care practices receive a certificate that provides accreditation for a time period of one year. While accreditation serves a range of purposes, improvement of professional performance and practice organization are prominent among these [The slow improvement of cardiovascular primary care may be caused by the one-off and condition-specific character of many improvement activities . The DCGP has developed a number of products and activities to implement these guidelines, including a national kick-off conference for general practitioners (GPs) in December 2005, and a supportive package  consisting of educational materials and software for assessment of cardiovascular risk. The practice accreditation program is an important approach to improve primary care, but controlled evaluations of its effect have not yet been done.A substantial number of performance indicators used in the practice accreditation program is related to CVD. These indicators are derived from the completely revised guideline on CVRM that was published by the DCGP late 2005 . The newThe overall aims of the study are to determine the effectiveness and efficiency of the practice accreditation program in primary care, focused on its effect on CVRM.Key objectives are:1. To determine the effectiveness of the program on primary performance indicators for CVRM by comparing practices in the accreditation program that focus their improvement plans on CVRM to practices in the accreditation program that focus their improvement plans on other domains of chronic care. Primary outcomes are documented controlled blood pressure, serum cholesterol, and prescription of recommended preventive medication .2. To determine the potential effect of the program on other indicators for CVRM, self-reported goal attainment in the intervention group, and unintended consequences. Secondary outcomes are all other indicators for CVRM, self-reported goal attainment in the intervention group, and unintended consequences .3. To determine the economic efficiency of the program in the observed period regarding the primary outcomes.4. To explore what factors and mechanisms are associated with change (or absence of change) of performance in CVRM.The study design is a cluster randomized controlled trial with a block design, considering primary care practices as units of clustering.The Medical Ethics committee Arnhem-Nijmegen waived approval for this trial. At follow-up practices will send a letter of invitation and informed consent to 100 patients with established CVD. Patients return their letter with informed consent to Radboud University Nijmegen Medical Centre with permission for audit of their medical records. The privacy of the participating patients will be protected, and all data will be coded and processed anonymously. For the baseline-measurement, mandatory information on indicators for patients with established CVD will be used, collected by practices on behalf of the practice accreditation program.Seventy primary care practices will be recruited from practices in the Netherlands who voluntarily apply to start the practice accreditation program. An invitation letter for the study will be sent as part of the instruction manual for the program. Practices with a clear preference for a specific improvement plan will be excluded from participation in the study while participating practices will be randomized to a group which starts with an improvement plan on CVRM or to a group that does not. This also accounts for practices that participate in regional programs for enhancing disease management.The study focuses on patients with established CVD. This includes patients with angina pectoris, acute myocardial infarction in their medical history, other chronic ischemic heart diseases, transient ischemic attack (TIA), ischemic stroke, peripheral arterial disease, and aneurysma aortae. Selection of patients out of electronic medical records with these conditions will be based on corresponding diagnostic International Classification of Primary Care codes , a worldwide system to label conditions in primary care .General practices will be the unit of randomization. A computer list of random numbers will be generated by an independent statistician and then used to randomly allocate practices to equally sized intervention group or control group. This will be done in a randomized block design in blocks of four practices in order of enrolment. We assume that improvement activities in the control group will not influence cardiovascular care.Visitatie Instrument Praktijkvoering, VIP) [The practice accreditation program is an existing procedure provided since 2005 by an independent body (NPA) that has a license to use the accreditation procedure developed by the DCGP. The DCGP remains responsible for the content and further development of the procedure; it will be responsible for adequate delivery of the practice accreditation program in this study. The practice accreditation program comprises, firstly, of a comprehensive audit  and written feedback to the practice, which covers a range of clinical domains (mainly chronic diseases), practice management, and patient experiences. The feedback, which consists of a comparison with benchmarks of other primary care practices, is discussed with a non-physician observer in a feedback consultation and helps to identify substandard performance. The second obligatory component, the planning of improvements in the practice according to the principles of quality management, is based on this feedback. The practice team is supported by a trained non-physician consultant. Practices that perform the procedure as planned are all accredited, so accreditation does not imply that a certain minimum score has been obtained . In the practice accreditation program, validated instruments are used: the Visit Instrument to asses Practice management  , clinicaThe intervention starts with volunteering for the practice accreditation program. After enrolment for the study, practices will be contacted by telephone for further explanation of the study protocol and to schedule the data collection. After data is collected, practices are randomized. Practices allocated to the intervention group are instructed to focus their improvement plans on cardiovascular diseases in the first year of the program.The control group also starts with volunteering for the practice accreditation program and follows the same routine as described for the intervention group. Practices allocated to the control group are instructed to focus their improvement plans on other domains than cardiovascular disease and diabetes mellitus (they may target CVD later after the study period of one year). They are instructed to focus their improvement plans on other clinical areas than CVD or diabetes.Both intervention and control group receive feedback on CVD indicators as part of the normal practice accreditation program. Practices in the intervention group are instructed to set targets related to process and outcomes of cardiovascular care . All practices will receive a minimum of four hours of support by outreach consultants for no cost, which is available in all regions. Also, the practices are provided with examples of improvement plans, which saves time and would make study participation more attractive.In each practice measurements are done at baseline and at follow-up Figure . At baseThe effect evaluation aims to determine the effectiveness of the program on primary performance indicators for CVRM and to determine the potential impact of the program on other indicators for CVRM, self-reported goal attainment in the intervention group, and unintended consequences.Primary outcomes have been selected from the 20 quality indicators for established CVD , which w1. The percentage of patients in the practice with known established CVD who have systolic blood pressure below 140 mmHg.2. The percentage of patients in the practice with known established CVD who have LDL cholesterol below 2.5 mmol/l.3. The percentage of patients in the practice with known established CVD with a record that aspirin, an alternative anti-platelet therapy, or an anticoagulant has been prescribed.Data concerning indicators are extracted from medical records and will be available at patient level so that linkage to other measures  can be made at patient level.2, measurement of waist circumference, fasting glucose measurement, influenza vaccination, registration of alcohol intake, control and advice for exercise and diet, and comprehensive risk assessment , BMI <25 kg/me.g., home care) and productivity losses, using a one-month retrospective observation period. Also, at follow-up in both groups, time and other resources of practice teams spent on quality improvement in the total period of 18 months will be documented. Data-collection on performance indicators will be done in the follow-up measurement by medical record audit.In follow-up measurements items of use of healthcare will be extracted from the medical records with a retrospective three-month observation period. These items include number of contacts in the practice , use of various types of cardiovascular medication, use of hospital care or other care providers for cardiovascular diagnosis or therapy. Additional information will be collected with patient questionnaires, particularly on other healthcare use . This will be measured in semi-structured telephone interviews.1. Exposure to other quality improvement activities: Both study groups report on their exposure to relevant professional education and practice improvement activities  will be added to measure health outcome . To mease.g., age, multi-morbidity, ethnicity at practice level) and practice characteristics [e.g., availability of nurses, delegation of medical tasks to assistance, practice size). Only factors emerging from previous research are considered to avoid overcorrection in the primary analysis. A logistic regression model will be constructed for each outcome to analyze these outcomes in relation to group  and measurement moment . Identified differences between the groups at baseline will be included in this analysis. Random coefficients will be included to allow for the clustering of data within practices. Each of the secondary outcomes  will also be analyzed in this way. Finally, if an internally consistent scale can be constructed (reflected by high reliability coefficients of the combined score), we will develop an aggregated measure of outcome, and use this in a similar random coefficients linear regression analysis.The study groups will be compared at baseline regarding known determinants of cardiovascular care and its improvement. These include patient factors ,28  and improvement related costs . Units of resources are monetary valued on the basis of prevailing Dutch guidelines  or natioThe process evaluation, the fourth key objective, aims to explore what factors and mechanisms are associated with change (or absence of change) of performance on CVRM indicators. Semi-structured telephone interviews will be held with primary care physician or the quality coordinator of the practice after data collection for follow-up measurement is concluded. Topics of this interview are: practice characteristics; feedback reports; composing improvement plans; and reasons to participate in and experiences with the practice accreditation program. We want to explore if specific elements of the practice accreditation program are the cause of change in CVRM. All interviews will be conducted by the same person and will be audio-recorded. Interviews will be transcribed verbatim. Two researchers will independently review the transcripts. Data analysis will be done according to the framework approach . Topics In the practices in the practice accreditation program up to 2006 (n = 139), the following median values at practice level were found on indicators referring to patients with CVD: 53% for acceptable blood pressure levels; 36% for acceptable cholesterol levels; and 38% for use of anticoagulents . These data suggest that the current scores on the primary outcomes are in the range of 35% to 55%, which imply that substantial improvement is possible in many practices. The proposed study has been powered to detect a difference of 10% (from 55% to 65%), not yet taking control for baseline values into account because of uncertainty regarding the correlation between baseline and follow-up measures.We expected that the accreditation and improvement program will have an effect of 5% to 10% absolute change, which is the median value of effect sizes in a comprehensive review of 235 studies on quality improvement . Other aThe study is planned from September 2008 until September 2012. In months 1 to 18, practices are recruited and included in the project and go through the accreditation procedure. The baseline data collection will take place in these months. During months 3 to 42, practices (in the intervention group) work on improving their management of CVD, practices in the control group on improvements in other areas. In months 18 to 42, follow-up measurements in intervention and control practices are planned. During months 43 to 48, data will be analyzed and reported.The sample of participating primary care practices in this study is composed of volunteers for the practice accreditation program and therefore not nationally representative for primary care practices in the country. This reflects current practice, in which practice accreditation is a voluntary activity. It implies that study results cannot be generalized to the  situation of obligatory accreditation. Furthermore, we only collect data on CVRM; therefore, we cannot make statements about the effects of the program on other chronic illnesses.e.g., involve a practice nurse). We intend to compare the groups with other, independent samples of practices that provide data on cardiovascular care to get an impression of the representativeness of our sample of practices.Because both intervention and control groups start with accreditation, this project cannot pick up non-specific effects of the practice accreditation program. For example, we expect that practices prepare for accreditation by improving their practice ; ICPC: International Classification of Primary Care; PACIC: Patient Assessment of Chronic Illness Care; TSRQ: Treatment Self-Regulation Questionnaire; ICER: Incremental cost effectiveness ratio; CEAC: Cost-effectiveness acceptability curve.MW is Co-Editor in Chief of Implementation Science; all decisions on this paper were made by another editor. EN, JL, EA declare that they have no competing interests. JB is involved in development of the practice accreditation program and receives funding for this from the Dutch College of General Practitioners. MB is an employee at the Dutch College of General Practitioners and is involved with the practice accreditation program.EN is involved in developing instruments, data-collection, analysis, and reporting aspects of the trial. MW, the project leader, is involved in all aspects of the study. JvL and JB are involved in the design of the study, the analysis, and the reporting. MB is involved in the design and reporting of the study. EA will evaluate the economics. All authors read and approved the final manuscript.


While the home is the most common setting for the provision of palliative care in Australia, a common problem encountered here is the inability of patient/carers to manage medications, which can lead to misadventure and hospitalisation. This can be averted through detection and resolution of drug related problems (DRPs) by a pharmacist; however, they are rarely included as members of the palliative care team. The aim of this study was to pilot a model of care that supports the role of a pharmacist in a community palliative care team. A component of the study was to develop a cost-effective model for continuing the inclusion of a pharmacist within a community palliative care service.The study was undertaken (February March 2009-June 2010) in three phases. Development (Phase 1) involved a literature review; scoping the pharmacist's role; creating tools for recording DRPs and interventions, a communication and education strategy, a care pathway and evidence based patient information. These were then implemented in Phase 2. Evaluation (Phase 3) of the impact of the pharmacist's role from the perspectives of team members was undertaken using an online survey and focus group. Impact on clinical outcomes was determined by the number of patients screened to assess their risk of medication misadventure, as well as the number of medication reviews and interventions performed to resolve DRPs.The pharmacist screened most patients  referred to the palliative care service to assess their risk of medication misadventure, and undertook 52 home visits. Medication reviews were commonly conducted at the majority of home visits , and a variety of DRPs (113) were detected at this point, the most common being "patient requests drug information"  and "condition not adequately treated" . The pharmacist made 120 recommendations in relation to her interventions.Fifty percent of online survey respondents (10/20) had interacted 10 or more times with the pharmacist for advice. All felt that the pharmacist's role was helpful, improving their knowledge of the different medications used in palliative care. The six team members who participated in the focus group indicated that there were several benefits of the pharmacist's contributions towards medication screening and review.The inclusion of a pharmacist in a community palliative care team lead to an increase in the medication-related knowledge and skills of its members, improved patients' medication management, and minimised related errors. The model of care created can potentially be duplicated by other palliative care services, although its cost-effectiveness was unable to be accurately tested within the study. Approximately 50 to 90% of cancer patients, and 9 to 16% of non-cancer patients, are referred into palliative care services per 100, 000 population per year in Australia . Home isA common problem encountered in the home is the inability to adequately manage medications, which is a significant issue given that they are used to treat symptoms experienced by the patient, such as pain. Inadequate medication management often stems from poor medication-related knowledge and understanding, in other words, health literacy ,5, and cFurther compounding this problem is the lack of consumer-oriented clinical information on medications. This is especially important as medications that patients needing palliative care take are for reasons and doses different to that described in information produced by pharmaceutical manufacturers, known as consumer medicine information (CMI) in Australia. This information is brand-specific and is based on the manufacturer's approved usage of the medication. However, as it is too complex for patients and carers to understand and does not cater to the educational needs of those from non-English speaking backgrounds ,7, patieSuch problems also result in indirect expenditures, such as psychological, social and economic burdens on patients, carers and the healthcare system, which are generally much greater than the costs of pharmacological and non-pharmacological treatments ,8. The pPharmacists, however, are not widely recognised as members of the palliative care health team ,9,10. ThIn Australia, the role of a pharmacist in a community multidisciplinary palliative care team had not previously been piloted and a model of care to support and optimise this had not been developed and trialled. The overall aim of this study therefore was to develop a model of care that supports the role of a pharmacist as a member of a community palliative care multidisciplinary team  and is potentially cost-effective, to improve outcomes for patients at home and their carers. Specifically, the pharmacist's role was to assist in improving knowledge of medications and their management for the health professionals within the team, and for patients and their carers. A major thrust was to minimise medication misadventure and, where possible, to reduce hospital admissions and lower costs to the service system.http://www.smrpalliativecare-consortium.org.au) in Melbourne, Australia. The service provides specialist palliative care and neurological care in the community, covering a population base of over 500, 000. Patients may be referred by their carers, general practitioners (GPs), other health care professionals, external agencies, or by self-referral. The service admits over 500 new patients each year, with an average of 180 patients on the program at any one time. Patients' ages range from 1-90+ years (median age 65+), and approximately 85% have a malignant diagnosis and 15% non-malignant, including end stage Motor Neurone Disease. Prior to the integration of the pharmacist (known as the "Project Pharmacist" hereon) in to the team, it provided specialist medical, nursing, allied health, pastoral care, and bereavement services with the support of trained volunteers.The team operated within a service that is a member of the Southern Metropolitan Region Palliative Care Consortium  could use and follow when collecting data, collaborating with other members in the palliative care team, and interacting with patients and carers.A literature review was commenced in this phase and continued throughout the study, to provide a framework for the Project Pharmacist's role. Five areas were investigated, the results of which are reported elsewhere : medicatBased on the findings of the literature review and with advice and support from the following people, the Project Pharmacist's role was developed:• Project Team • External Evaluator (S.H) who is a pharmacist with palliative care expertise• Steering Committee that was established• Key stakeholders from various organisations/networksTo assist the Project Pharmacist in undertaking their role, various tools were developed/adapted, based on the findings of the literature review.The Medication review screening tool , or later in the patient's home if deemed appropriate by a team member.Where a patient was discharged from the inpatient service  to home and referred to the Project Pharmacist, she visited the patient prior to discharge and informed them that a home visit could be organised within 7-10 days after discharge. In this scenario, the Project Pharmacist performed an outreach medication review.Where a patient was discharged from another hospital to home and referred to the Project Pharmacist, she contacted the patient or their carer to offer a home visit within the same time frame and conduct an outreach medication review.All referrals were made using a standardised Referral Form that was developed.Following medication review by the Project Pharmacist, the patient's treatment plan was updated and the Project Pharmacist provided feedback to the team, the patient's GP, and community pharmacy as necessary in the form of a Medication Review Report.Patient information leaflets (PILs) on the following nine medications used in palliative care in were developed: clonazepam; cyclizine; fentanyl; gabapentin; hydromorphone; metoclopramide; morphine; oxycodone; and pregabalin.The morphine leaflet was piloted for face and content validity by a sample of patients and carers, doctors, the team and volunteers from the palliative care service (including an ex-pharmacist and people from a non-English speaking background). Based on the information, most patients/carers felt they fully/mostly understood how to take the medication and what to do if side effects occur. Some patients felt they only had a basic understanding, and were not confident, of what to do for side effect management. As these aspects could be explained to the patient/carer by the Project Pharmacist (e.g. during a home visit), the format and content was kept consistent for the remainder of the PILs.Four of the PILs  were translated in to seven languages  frequently encountered in the SMR Palliative Care Consortium. This was done by three translators  who are specialised and experienced linguists. The translated material was independently checked.Audio (MP3) files of the morphine leaflet were also produced in English and in the seven other languages above.The PILs and MP3 files were attached to websites  for use by health professionals to assist patients and carers in understanding palliative care medications.A communication strategy for the Project Team, for within the palliative care service, and for key stakeholders, was developed. The Project Manager and Project Pharmacist met with key stakeholders  to discuss the project, how their organisation/network might be used to facilitate further communication via e-mail, newsletters and articles, and to provide, where relevant, education to their members at information sessions.The Project Pharmacist developed and provided education to the palliative care service involved in the study, as well to as other palliative care services and health professionals (e.g. GPs) within the SMRPCC. Topics covered included neuropathic pain, enteral administration of medications and prescribing in the elderly and in renal and liver impairment.Interprofessional education also occurred informally during daily interactions between the Project Pharmacist and other team members and formally at regular team meetings.The Project Pharmacist also taught patients and carers to use a dose administration aid (DAA) for effective medication management.The objective of this phase was to implement the activities discussed in Phase 1. Where necessary, adjustments were made to these based on feedback from the Project Team, External Evaluator, Steering Committee and key stakeholders. The Project Pharmacist was also clinically supervised, to a limited extent , by a Senior Medical Officer (doctor). Interaction between the Senior Medical Officer and Project Pharmacist involved, but was not limited to: joint community visits, particularly when complex issues were identified; follow up of patients'/carers' concordance to newly implemented medications/changes subsequent to this; education of patients/carers; advice regarding suitable drug formulations ; post-medication review discussions (when the Project Pharmacist had undertaken review separately); development of resource charts ; auditing of patient's current medication regime (e.g. determining whether the medication list was recorded accurately/updated in the last month); and auditing of the process of requesting emergency medications from the GP (e.g. need for anticipatory prescribing to manage symptoms on a 24 hour "emergency" basis and need to have these medications available in the home).The objective of this phase was to evaluate the results of the activities implemented in Phase 2, in order to enable appropriate decision making and policy development by government and the palliative care service regarding the benefits of an ongoing role of a pharmacist in community palliative care services in to the future:Evaluation of the study was grouped in to three categories: process; impact; and outcomes. This meant assessing the success of the process that underpinned each activity implemented in the study in Phase 2; the impact of each activity on the role of the Project Pharmacist in the palliative care team; and the clinical outcomes generated by each activity in terms of the palliative care team's knowledge and understanding of medications, the number of patients screened as well as medication reviews undertaken by the Project Pharmacist with a view to reducing DRPs, and the number of clinical interventions made.In addition to using the three categories above, evaluation of the study was divided in to internal and external arms that are described below.These three categories were studied not just during Phase 3, but also in earlier phases. During Phases 1 and 2 of the study, the Project Manager and Project Pharmacist regularly reviewed and revised its objectives and timeframes as necessary, in consultation with the Project Team and Steering Committee. The External Evaluator also reviewed all of the processes and documents discussed in Phase 1, including statistical data collation and analysis. As well, a 12-item survey was designed in Phase 1 and sent as an online link to other team members (n = 32) in Phase 2, to measure the number of times the Project Pharmacist had been contacted, the type of interactions and the considered value of the role within the team. Open-ended comments could also be made.In Phase 3, the External Evaluator conducted a focus group with the team (not including the Project Pharmacist or Project Manager) to further determine the effectiveness of the study in terms of supporting the role of a pharmacist in a community multidisciplinary palliative care team. The focus group was conducted at the palliative care service, using a semi-structured guide, and was audio recorded.The results of the internal and external evaluations were then combined and are shown in Table On review of the Project Pharmacist's Activity Database, it was demonstrated that the Project Pharmacist undertook the following seven major roles :1. Medication review2. Education for patients/carers e.g. carer training on how to use DAAs and other delivery devices, such as nebulisers and oxygen concentrators.3. Ensuring ongoing access to medications e.g. home delivery of medications in palliative care emergencies4. Information provision/education for team members e.g. on off-label medications, oral chemotherapy or trial medications used by patients 5. Consultation and collaboration with team members e.g. updating medication chart6. Liaison with other health professionals  to ensure continuity of patient care.7. Symptom management protocol  implementation through in-services education.In addition, the Project Pharmacist conducted a combined bereavement visit  for a patient's carer. The Project Pharmacist found the experience to be valuable as it provided the opportunity for interprofessional learning and development of this counselling skill.A 63% response rate was achieved (20/32 team members). 50% of respondents (10/20) had interacted 10 or more times with the Project Pharmacist, during the past three months, for advice/assistance. Only 5% (1/20) had never interacted with the Project Pharmacist; this respondent was a non-clinical staff member who would have been unlikely to have needed this type of contact.The majority of interactions were regarding information/clarification about medications , advice on what medications could be used  or advice on alternative medications . Assistance in decision-making when changing a medication was less commonly sought . Comments made by respondents also indicated that they accessed the Project Pharmacist for other aspects of medication management e.g. impact of medications on functional status, minimising medications."I have been able to provide better, needs-based care".With regards to whether respondents found the Project Pharmacist's role helpful, all (20/20) felt that it had improved their knowledge of the different medications used in palliative care, 90% (18/20) indicated that it had improved their knowledge of medication issues for palliative care patients, and 60% (12/20) thought it had changed their practice with sourcing and providing information to patients/families. One respondent commented: "found it themselves and/or approached the Chief Pharmacist". The Chief Pharmacist indicated that the Hospital Pharmacy rarely received requests from the team for information on medications or medication management since the role of the Project Pharmacist was introduced, and as a result, had "lessened the anxiety" they had felt when providing advice for patients who were deemed to be part of an 'invisible ward' i.e. patients who they had not seen but it was expected that they were to provide information about their medications/treatments.The majority of respondents (95%) said they would be more likely to discuss patients who had potential medication issues with the Project Pharmacist. When asked about how they found out information prior to the role of the Project Pharmacist within the team, the majority "Great resource and help especially when there's a problem in the home, can pick up the phone and ask [her] e.g. unfamiliar drug, doses, calculations" (P4).Six team members participated in the focus group . When asked what they perceived were the benefits of the Project Pharmacist's contributions towards medication screening and review, participants felt that she was readily accessible, approachable and knowledgeable, especially when called on for information during home visits: "confidence-building...helping give better service and better outcomes for patient[s] especially because [they] know [the] patient's background". Another (P3) commented that the Project Pharmacist: "picked up on non-adherence and impact on behaviours", and "made [me] question about why it's not always necessary to prescribe emergency meds, need to be more client-centred, emergency meds cost money. GPs aren't always receptive about emergency meds, and saying you've chatted to the pharmacist helps with adding credibility/authenticity".One participant (P5) stated that the Project Pharmacist was "was participating in team meetings in order to pick up on things and follow up - this is a key component and would need to be maintained in to future services".Participants perceived that the Project Pharmacist's role had few limitations, mainly being that that it made them ignore their own learning as they tended to rely on her. When asked what areas required improvement, participants believed that she should have been given more opportunities to attend home visits and increased time to dedicate to the role. Participants also felt it was important that the Project Pharmacist "experienced and [have] a palliative care approach to the way they think and interact with families". Participants believed that the model of care piloted in the study was sustainable (and needed) as it eliminated a gap in care that existed, was an "essential component of interdisciplinary management for patients being palliated at home", where each component was recognised as being important, and "provided a quality service for patients and families" that involved reducing the risk of medication misadventure and its potential consequences:Aside from attending team meetings, participants thought that to sustain this role in a community multidisciplinary palliative care team, a future pharmacist needs to be "[It's] about providing a safe service and acting quickly e.g. on what GPs are prescribing, not necessarily what's wrong with our service"."Every community service should have a pharmacist"."Can expand positives to other teams, huge loss not to have a pharmacist"."proactive and education-focussed".Finally, to further ensure sustainability, participants indicated that the gap between hospital to community care needs to be bridged but were unsure about how this could be done considering that the Project Pharmacist had been The Project Pharmacist Activity Database showed that screening for patients at risk of medication misadventure was conducted for the majority of patients  referred to the palliative care service, using the MRST. 380 MRSTs were conducted from April 2009-March 2010, during which the following problems were frequently detected by the Project Pharmacist:• 83% (316) took 5 or more medications, or more than 12 doses of medications per day.• 77% (294) took medication requiring monitoring, had a narrow therapeutic index or are high risk.• 62% (238) had other co-morbidities• 55% (208) were recently discharged from hospital• 59% (224) were attending different healthcare providersAllergies/adverse drug reactions were recorded routinely since October 2009 in 185 MRSTs; 24% (44) reported no known allergies/adverse drug reactions; 31% (58) had none recorded; and 45% (83) had data recorded. Similarly, renal function was routinely recorded since December 2009 in 116 MRSTs. There was data available for 49% (57) of patients.Fifty two home visits were undertaken by the Project Pharmacist from June 2009-March 2010, and these were done on a "needs basis" after consultation with other team members. Approximately 6 home visits per month were undertaken by the Project Pharmacist, and on average, a home visit took 54.5 minutes. Where there was no need for a home visit, sometimes care was coordinated by the Project Pharmacist over the telephone, or by other means, which took substantial time; this was not counted as a home visit.Medication reviews were conducted at the majority of home visits , and a report of the findings was generated for all patients seen by the Project Pharmacist, a copy of which was compiled into the patient's medical history and sent to their GP, community pharmacist and other health professionals involved in the patient's care if appropriate.The Project Pharmacist perceived the medication reviews undertaken at home visits to have had a significant impact on patients' care, through reassurance and education around medication management for patients/carers. She felt that the impact of medication reviews on team members was that they were provided with an updated medication list for all patients, and therefore knew exactly what medications the patient was currently taking.The Project Pharmacist made 113 interventions based on the same number of DRPs that were detected, and the most common DRPs were "patient requests drug information"  and "condition not adequately treated" . The Project Pharmacist made 120 recommendations in relation to her interventions, and the most common types were "referral to the prescriber"  and "education/counselling session" .It could not be estimated, however, as to how many recommendations arising from medication reviews were accepted by prescribers, as the Intervention tool was used infrequently, and there was little correspondence from GPs in response to the Medication Review Reports generated by the Project Pharmacist. A lot of the time though symptom management issues were managed by doctors at the palliative care service and scope for GP involvement was small; the purpose of the Medication Review Report was mainly to keep the GP up-to-date with the patient's progress. Also, in many cases the Medication Review report only recorded the patient education activities undertaken by the Project Pharmacist, where no GP intervention was required.A toolkit was developed to assist other palliative care services in developing their own model of care, incorporating the role of a specialist pharmacist in to the team. Four options for sustainability were provided, as well as some "rough" costings for this role in to the future. Pathways/strategies and tools that were developed in this study, such as the care pathway, MRST, Intervention tool and PILs, were also included in the toolkit.This study is the first in Australia to demonstrate that the inclusion of a pharmacist in a community palliative care multidisciplinary team: assists in increasing the knowledge of team members, with respect to medications used in palliative care and their management; leads to improved knowledge of potential problems with medications and how to manage them and to a change in practice for the benefit of patients; enables ongoing education and support from the pharmacist to the team members; allows for in-service education to be provided, as and when required; assists in improving contacts with the GPs and palliative care service for the benefit of the patient and their carer; and assists the patient and carer to better understand the medications prescribed.In particular, the study led to a significant increase and improvement in knowledge of medications and their use by nursing staff. However, this result may in part be influenced by the role of the Senior Medical Officer in the team and their contribution to patients' medication management in concert with that of the Project Pharmacist's. Certainly, improving health professionals' knowledge of, and skills and confidence in medication utilisation has been recognised as key strategy in preventing medication misadventure and improving patient safety ,20, espeThe study findings in terms of number of DRPs detected (113) by the Project Pharmacist are also comparable to those reported by Westberg and Sorensen . In theiThe study presented here is also the first to have reported the utility of a screening tool (MRST) in the palliative care population and therefore the first to present data on the number of patients screened (373/422) for being 'at risk' of medication misadventure. The number of home visits made by a pharmacist to undertake medication reviews for patients requiring palliative care (46/52) is also new data that is currently not available in the literature. This tool and measurement outcome, respectively, can reasonably be used in future studies where a pharmacist is involved, in addition to assessing the achievement of clinical outcomes such as symptom control ,25 and aAlthough the timeframe of the study and the capacity to measure benefits was limited, it was recognised that the inclusion of a pharmacist could also lead to: an increase in confidence of patients/carers in the use of medications; an increase in medication concordance; a reduction in medication errors made by both health professionals and patients/carers; and reduced hospital admissions due to medication errors being averted by a comprehensive patient screening and medication review process, recognising that hospital admissions are sometimes required to improve medication and/or symptom management and can, ultimately, prevent future admissions as the patient's condition deteriorates. This is in line with the findings from a study by Ajdukovic et al, who found that pharmacist elicited medication histories for 'at risk' groups in the Emergency department can reduce medication misadventure and errors .Specifically, this role in the present study alleviated the demand on the hospital pharmacists by having many of the team's queries regarding medications or medication management issues answered by the Project Pharmacist. This was a saving in time and money to this area of hospital operations. However, this also could not be quantified as previous requests for assistance varied in number and complexity. 'Interruptions' to the usual role of the hospital pharmacists also varied depending on whether they were in the pharmacy at the time of the request and so information was on hand, or whether they were on a ward and had to leave the task they were undertaking and return to the pharmacy to seek information to assist.Importantly, this study attempted the development of a potentially cost-effective model of care (incorporating various pathways/strategies and tools), which has not been previously done locally or internationally. The care pathway provided a focus and framework for the Project Pharmacist, the team and the palliative care service, and is freely available to other palliative care services across Melbourne, Victoria for duplication via the toolkit that was developed. This toolkit should be added to the Australian Government Department of Health website for use by community palliative care services across Australia, and if appropriate, to international government websites. Indeed, its encompassing tools became familiar within the study community palliative care service and referrals increased. All patients were screened by the Project Pharmacist on admission to the team, to evaluate triggers for home visits and a more extensive medication review.Although the development of a cost-effective model of service delivery was a component, this premise was unable to be achieved within the scope of the study because the structure of each palliative care service is so different. The community palliative care service was aided by the existence of a hospital pharmacy department that had the capacity to provide back-up to the Project Pharmacist. The pharmacy department and Project Pharmacist complemented each other. This additional support is not available in most community palliative care services. Further, a lack of pharmacists with the high level of knowledge and skills relevant to palliative care of the Project Pharmacist engaged for this study are unlikely to be able to be duplicated, at this point in time, in other community palliative care services.There is the potential, however, to duplicate the model and make a saving on the employment costs by sharing a community pharmacist among a group of palliative care services. This would aid the potential for a cost-effective model because of the reduction in time spent with families once the pharmacist was involved; a lessening in the prescribing of unnecessary and/or ineffective medication; and an improvement in the overall knowledge of the other health practitioners and patients and families in recognising adverse effects of medicines and thus anticipating medication and treatment needs, with a subsequent improvement in the care and support of patients and their families.There would need to be the engagement of more than one pharmacist in one service to more accurately predict a cost-effective model. This study could therefore, more realistically, be viewed as a scoping or feasibility study.Further to the above, the model of care is not a 'one size fits all' paradigm and should be clearly seen in the context of location and requirements. A pharmacist employed in a single palliative care service, for example, may have a different role and structure from other employment models e.g. compared with employment by a palliative care consortium or within a division/network of GPs. Nevertheless, below are examples of recommendations that have been made to sustain the model of care; some or all of these could be considered by policy makers, palliative care services, divisions/networks of GPs, community/specialist pharmacists and pharmacy peak bodies in other states of Australia and overseas.As a result of this study, a number of recommendations and suggestions have been made that would assist decision-making on the efficacy of including a pharmacist within community palliative care services. These include recommendations regarding funding, region-wide or consortia collaborative arrangements and inclusion of a pharmacist within divisions/networks of GPs.It was considered that funding should be made available for a specialist pharmacist to be placed in community palliative care services within Melbourne, Victoria. This would assist continuation of the 'value-add' and lessons learned from this feasibility study across the sector. Inclusion in the palliative care service would provide timely access to expertise, education and advice as well as improve patient medication management and symptom control.Both government and palliative care services themselves should consider how this might be achieved. An agreement between palliative care services could be negotiated within the palliative care consortia or regions to fund a pharmacist position to support the services to improve medication management for their patient group and also knowledge of palliative care medications and their management within their community palliative care teams. A pharmacist placed within a consortium would need to incorporate all the skills required within a single service, but be broadened out in terms of actual tasks undertaken and service operation. This would require the capacity to manage the varying demands of the service within a region, and the compilation of an education information portfolio, including online access to information and support, to assist the various demands upon the time and knowledge of the pharmacist.Alongside this, the pharmacist would need to remain up-to-date with changing referral processes and their relevance to palliative care patients. An essential component of such an arrangement would have to be a willingness by both the services and the pharmacist to be mobile. By its nature, the role of a pharmacist across a consortium or region would be less hands-on than one placed within a single service.To aid improvement in symptom management and control by community palliative care services, there should be an extension of, the current limited funding of Outreach Pharmacy Services within public hospitals and it should ensure that palliative care patients are included within their scope of operation. Outreach Medication Reviews are available at major metropolitan hospitals in Victoria for patients at risk of medication misadventure after discharge from hospital. The Outreach Pharmacist provides counselling on medication and disease state management in the patient's home or specialist outpatient clinic. After a home visit, a report is sent to the patient's GP and community pharmacist. The extension of the capacity of the Outreach Pharmacy Services could provide an avenue for palliative care patients to obtain a medication review in a timely manner after discharge from hospital.Divisions/networks of general practice should also consider incorporation of a specialist palliative care pharmacist within their division/network. The pharmacist's role would be different if located within a division/network of GPs, although much of the above would be required, and it could be assumed that the tasks would be broader than providing palliative care. Inclusion in this forum would allow for improved collaboration between hospitals and community palliative care services within these network areas.At the same time, better links between peak pharmacy and palliative care bodies, with an accompanying improvement in communication between community pharmacists and palliative care services, would greatly assist in the support of patients and their families, especially in accessing, using and managing emergency just-in-case medications. This was recognised as an issue in this study and further research in to prescribing and dispensing of emergency medications is required to prevent duplication and wastage; specifically, to determine whether this results in an accompanying decrease in hospital admissions and what cost savings could be achieved by interventions resulting from HMRs for palliative care patients.The development of a PIL for patients and carers on the use of emergency medications could also assist in alleviating concerns by patients and their families on how and when to take them. A generic document for use by palliative care services could be developed  that can be sent to GPs, which includes all the relevant details required by the GP, including the form, strength, dose and cautions associated with emergency medications and who to contact if patient/family are unsure of how and what to do.The development of a check list for nursing staff on the process of ordering emergency as well as regular medications, including follow-up processes and, an improvement in communication from palliative care services to GPs and patients regarding their use, would all aid better management of symptoms, and could lead to a reduction in hospital admissions and the capacity for patients to die at home if they desire. Anecdotally, however, it is reported that no matter how much planning and information is provided, some patients, carers and families can, understandably, panic and require outside assistance when faced with an emergency medication related problem.Patients or carers were not surveyed with respect to their knowledge (to determine the impact of the Project Pharmacist on this), because often by the time the Project Pharmacist had screened medications and/or visited the patient, their condition had deteriorated to the extent that surveying would have been an imposition. Occasionally, patients had died before the Project Pharmacist had a chance to undertake a home visit.modus operandi, for example, a pharmacist within a single service versus a pharmacist across consortia or one placed within a network/division of GPs.This study showed that the inclusion of a pharmacist in a community multidisciplinary palliative care team has great benefits for the team, patients and carers. There are seven major roles that a pharmacist can undertake, which can lead to an increase in the medication-related knowledge and skills of team members and thereby improve the medication and symptom management of patients and minimise medication errors. To support these roles a model of care is required and was created, incorporating various pathways/strategies and tools that can potentially be duplicated by other palliative care services. A larger, longitudinal study is required to accurately test whether this is a cost-effective model, incorporating a number of different From this feasibility study, it could be extrapolated that the cost-effectiveness of such a model would be demonstrated by the improved knowledge of medications and their use by both professionals and patients/families, and thereby better symptom identification and management, along with improved patient medication information and better communication between palliative care services, GPs, specialists and pharmacists. A foreseeable outcome would be fewer hospital admissions for the palliative care patient and a reduction in prescribing of unnecessary medications.CMI: Consumer medicine information; DAAs: Dose administration aids; DRP: Drug related problem; D.O.C.U.M.E.N.T: Drug selection, Over or underdose; rescribed, Compliance, Untreated indications, Monitoring required, Education or Information, Non-clinical, and Toxicity or adverse reaction; GPs: General Practitioners; MRST: Medication review screening tool; NAATI: National Accreditation Authority for Translators and Interpreters; PIL: Patient information leaflet; SMRPCC: Southern Metropolitan Region Palliative Care Consortium.The authors declare that they have no competing interests.SH drafted the manuscript and made contributions to the conception and design of the study, as well as the collection , analysis and interpretation of data. MB contributed to the design and coordination of the study; the acquisition , analysis and interpretation of data; and revised the manuscript. SS also collected , analysed and interpreted the data, and revised the manuscript. All authors have read and approved the final manuscript.SH graduated from Monash University (BPharm(Hons) in 2001 and PhD in 2007) and was appointed to the position of Lecturer in 2009 at the Faculty of Pharmacy and Pharmaceutical Sciences. She is an Early Career Researcher in Pharmacy Practice with research experience and expertise in professional practice, education and medication safety and use, particularly in the area of palliative care service delivery in the primary care setting. Her PhD research involved the identification of Australian community pharmacists' educational needs in palliative cancer care, and the subsequent development, delivery and evaluation of an educational program to meet these needs. This program will soon be adapted to suit a Masters in Pharmacy Practice program at Monash University for postgraduate students. SH also teaches palliative care to undergraduate students at Monash University along with other topics, and has a strong research interest in women's health.MB was Executive Director of Palliative Care Victoria and on the Palliative Care Australia Council for several years. Her involvement with the palliative care sector has encompassed many roles. Since living in Thailand for some years, Margaret returned to Australia and managed a number of projects, including Development of a Model of Care for People Living with Motor Neurone Disease. She has recently left Australia to live overseas again.SS has practical experience in palliative care in hospital and community settings, and has undertaken postgraduate studies in palliative care. She was a member of the expert group who updated the Therapeutic Guidelines: Palliative Care version 3, 2010. SS has had input in to two projects funded by the Australian Government Department of Health and Ageing, which were aimed at improving the medication management of palliative care patients by educating community pharmacists. She is currently assisting development of the palliative care unit for postgraduate study at Monash University.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-684X/10/16/prepubMedication Review Screening Tool (MRST). This is the tool that was developed in the study for use by the pharmacist to assist them with screening patients who were admitted to the palliative care service to determine their risk of medication misadventure.Click here for fileIntervention form. This is the tool that was developed in the study for use by the pharmacist to assist them with recording drug-therapy problems they detected in patients and recommendations they made to resolve those problems.Click here for file