Innovative Models - Pharmacy Role with Clinical Pharmacist Karyn Dahms

This episode discusses a pharmacist-led program at the Gold Coast Hospital that supports paediatricians in managing ADHD medication. This initiative, which began as a pilot in 2018 has grown significantly, alleviating pressure on paediatricians by handling medication management while also recognising broader patient needs. The program has successfully treated nearly a thousand patients and received positive feedback from families. 

Transcript

Brad 0:09
So I'm Dr. Brad Jongeling and we're at the Australasian Society of Developmental Paediatrics Conference and we've been discussing systems reform this afternoon. And I've got with me here Karyn Dahms, who's a clinical pharmacist at the Gold Coast Hospital. And we going to chat about the role of pharmacy and the new program they've been doing over the last few years, particularly as it relates to ADHD and medication management. So welcome along. Karyn, Can you talk to me a little bit about the program that's been operating and how you see it moving forward? 

Karyn 0:42
Hi, Brad. Thanks for having a chat with me. the program that we've got running is something that sort of evolved over time. We started it back in 2018 as a bit of a pilot and I think at that stage we weren't quite sure what was going to happen with this model, but it's certainly demonstrated its worth since. And we've now grown to four full clinics and doing 27 appointments a week and taking a lot of pressure off the paediatricians. So what we essentially do in their CDS clinics is that we actually do medication reviews, which is the thing that takes up a lot of paediatrician time. So we see patients, 27 patients a week, 45 minutes we spend with them working out whether they've got the right therapy, whether it's been efficacious or whether their tolerance is acceptable and getting the benefit that they need from it. We make medication, recommendations and tweaks and and things like that. And we consult with the paediatricians at the end of our case. 

Brad 1:39
So my understanding, if I can just take you back a little bit, is so the assessments are done by the paediatrician. They'll make the bio psychosocial model, they'll make the diagnosis, and they will make a decision about commencing medication. Yes. But the review at 6 to 8 weeks is with you. Is it is that correct? 

Karyn 1:55
Yeah, that's correct. So we will do the medication review at 6 to 8 weeks. In actual fact, it's evolved so that we probably hold the patient in the pharmacy clinic over the next 12 months so that can look like a few different things. It can either be if they're complex and we're taking a little bit of time to stabilise or the tolerance is sort of not acceptable, we can actually have them three or four times throughout the year to try and get that right before they go back to the paediatrician. So we certainly do hold some of those complex families. We have evolved also to not just be about medication, and sometimes we actually make recommendations to not medicate. And that's not really the issue that we're dealing with. So it's not always medication related. We have become more familiar with some of the other dynamics that are happening and making recommendations about that, too, such as referring to intensive family supports or other things that are contributing to their child's presentation. 

Brad 2:51
So when I heard you speak today, you mentioned that there isn't really any training yet for this, and that's something that you're going to think about down the track. So obviously it requires quite a close working relationship with the paediatricians. I think you mentioned that you do case conference quite regularly with these cases. You just talk a bit about how that's worked. 

Karyn 3:10
Yeah. So the way that our templates work is that we see five patients in the morning and another one or two patients in the afternoon in the middle of the day, we actually have a dedicated hour for case conference, which we can also do virtually or face to face, depending on whether we're all in the same clinic. And we will then present our cases to the paediatrician. Obviously we've written our notes and everything by then and they've got the opportunity to pull those up and look at them as well. And as Dr. Owen said after my presentation, it does require a little bit of trust and this, this expert knowledge comes over time because we don't have that formalised training package. I rely on my pharmacist to do a lot of self-directed learning as well as observational learning. So yeah, it does require a little bit of trust, but we do put that hour aside and they're able to accept our recommendations or even throw some other things in there we might not have thought of and come up with something new or different. Yeah. 

Brad 4:06
So one of the challenges I can reflect on in the kids and I see, when you start a medication, it's usually sometime down the track, but they often come back and the parents will say, Look, I'm really worried about his social skills. Do you think maybe he could have autism spectrum disorder How would that be handled? Because that would be probably something that the paediatricians that work in the service where I work would frequently come across, and that really slows down that process of of dealing with both the medication issue and other other emerging issues. 

Karyn 4:33
Yeah, absolutely. A common scenario that and often when we've treated the ADHD, we do start to see some emerging ASD traits. And yes, we have got lots of concerned families saying do you think you know, we might be dealing with ADHD? Obv the pharmacist isn't going to make a call about that. We might take the history about. So what makes you concerned about that? What sorts of things are you observing? And we will document that and we might have a hunch potentially, but we're certainly not going to say that to the families. And then when we have our case conference, we'll talk to their paediatrician, say the family has got some concerns that ASD might be at play here and we might send out some assessment, some ASRS or whatever, and get those done. We can certainly initiate that from the pharmacy clinic, but we would consult with the paediatrician before that. But we can we can recognise those signs and concerns. Yeah. 

Brad 5:23
So that's great. So that does rely on that support of the paediatrician around the context of that child and the work that you do. So are you also using some online questionnaires to document aspects of side effects and so on, or is it really just come down to that consultation with the family? 

Karyn 5:40
Yeah, no, we actually haven't got any written or online questionnaires. Actually, it just really is a consultation. Pharmacists have a very good skill at drawing information out of people. That's something that we're trained well to do. So I do find it I mean, I've got a fairly relaxed approach with the families and I do find that I'm able to extract a good amount of information that's going to give me enough to go on. Quite often it's obvious that they're not tolerating it or they've had a great response. So no, nothing, nothing formal, just a consultation. 

Brad 6:11
So pharmacists are excellent at managing medications and obviously providing some feedback around titration when when the medications first started. If we talk about stimulants, which might often be methylphenidate, immediate release to begin with, do you provide the advice around the titration of that and is that within something that the paediatrician has advised or do you have carte blanche to be able to make those changes? How does that work

Karyn 6:35
No? We do give them a titration plan. The pharmacist can make that decision based on weight and other things that we think about. We certainly do. We've got fairly good templated titration plans, to be honest. So it's fairly prescriptive. So we certainly do make those plans and we write the titration plans and send those off to the families. But it's it's templated so we don't go too far off that template. And the paediatrician is usually a more conservative than pharmacist. So, so we will tend to tend to do what we think the paediatrician would do anyway. But yeah, we offer that information in a written format. 

Brad 7:14
And what about the decision about moving to a long acting form? You know, where is that made? Is that something that you do at a 6 to 8 week check early or do you wait a bit longer? How does that work in this service? 

Karyn 7:26
I guess for a good percentage of families that have had a good response to a short acting, we would make that call maybe at that 6 to 8 review, but not necessarily, you know, if they're really happy with the way things are and don't want to make a change and happy to do things for a bit longer the way it is. And we can certainly we're quite collaborative with the families as well, you know, a lot of them are nervous, they know actually it's working. I don't really want to touch it and that's totally fine, you know, totally fine to make that call. But we do have the autonomy to make that recommendation. But again, all of our cases are discussed with the paediatrician where we will confirm that that's what they're comfortable to do as well. And then we will follow up with the families, say, yep, as discussed, you know, move to long acting script will be at your pharmacy by the end of the day, whatever, and they can follow up that. 

Brad 8:10
and it's still the paediatrician has to write that script and take responsibility for that. 

Karyn 8:13
or the registrars or Yes but yes, we, we are not prescribers yet. 

Brad 8:18
Yep. So I suppose one of the questions I'm really interested in would be with the children that you say what would be something that would lead you to think, Oh, I better chat with the paediatrician about this. So what are the emerging issues We've touched on one which is a question around ASD issues, but what else may be in response to the medication or side effects or so on might be where you would think, Oh, I better have that chat? 

Karyn 8:39
Yeah, sometimes there's more than one option. You know, I could think of a few different options and I think, okay, well, well, I don't want to just pin it on one option at the moment, so there might be something I would say, What do you think about this? This is what I'm thinking. The other thing that probably emerges a lot is low mood. And so there might be some mood concerns more than attention and focus concerns. And so, I mean, I certainly would have recommendations about what I would do then, but I certainly wouldn't make that call without having a discussion with a paediatrician. And sometimes low mood can be a result of the of the stimulants as well. So we'd drill down a little bit further and if there's increased anxiety and it seemed to have happened when we started the stimulant, then obviously we would, you know, hear those little nuances and make a decision one way or the other but yea low mood and probably some mental health concerns probably do emerge. And we wouldn't make a call without having a chat with the paediatrician in those cases. Yeah. 

Brad 9:33
So it sounds like from the presentation today that this has been really effective. It's given paediatricians another place that those children can be followed up, helping them free up more time to do assessments. I think you talked about you've seen that a couple of hundred kids already through this process, or is it in the thousands where, you. 

Karyn 9:52
Know, we'd be close to a thousand? We Yeah, definitely. It's been since 2018, but only at point eight for a period of time. Point 8 FTE. So yeah 27 patients every week. So yeah I don't know exactly, but it will be close to a thousand if not more. 

Brad 10:07
and the feedback's been good from families. 

Karyn 10:09
The families have just loved it. I mean like I've said, we've had good verbal response. We've only just started gathering some written responses now or written feedback now so that we can actually publish some information about this model. It's generated a lot of interest in Queensland and across Australia, so we certainly are communicating with lots of other health services about how they can implement a model like this. The funding's different obviously everywhere, so it's beneficial for Queensland or for Gold Coast Health Service because we generate more than we cost, but that may not be the case in other areas. So but the families absolutely love it and we've gotten to know a lot of them as well. They move through the families or several of their children move through the clinic. So no, they really, really appreciate the opportunity to be able to touch base with someone, get those little tweaks that are required fairly urgently. They got that other option and they they totally appreciate it. Yeah. 

Brad 11:01
Well, thanks very much. Great to chat to you about how that project works. Karyn And look, I think it's got lots of potential and I think other groups across Australia, as you mentioned, are looking after looking at it. And so we I think in WA, so we'll be really keen to see how that partnership, I think with paediatrics and pharmacists work moving forward. 

Karyn 11:18
if I eventually develop this training package, I'll send it your way so you can get your pharmacy team up and running. 

Brad 11:24
That'd be great. Thanks very much. 

Karyn 11:25
Thanks, Brad.