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Fleetwood Toolkit

The Fleetwood Toolkit provides information about the ASCP Foundation’s Fleetwood Project research initiative, including intervention tools and reprints of relevant articles.

Background

Fleetwood Phase I

Fleetwood Phase II

Fleetwood Phase III

Contents of Fleetwood Toolkit

Fleetwood Alerts

BACKGROUND
The Fleetwood Project® is a three-phase initiative to demonstrate the impact of consultant pharmacist services on patient outcomes and health care costs.

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Fleetwood Phase I
The first pharmacoecomonic analysis of the cost of medication-related problems in US nursing facilities and the impact of consultant pharmacist services on those costs. The study found that consultant pharmacist-conducted drug regimen review increases the number of patients who experience an optimal therapeutic outcome by 43% and saves as much as $3.6 billion annually in costs associated with avoided medication-related problems. Even with this savings, for every dollar spent on medications in nursing facilities, two dollars are spent to treat medication-related problems.

Bootman JL, Harrison DL, Cox E. The health care cost of drug-related morbidity and mortality in nursing facilities. Arch Intern Med 1997;157:2089-2096.

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Fleetwood Phase II
A six-month feasibility study to test a new model for long-term care pharmacy—the Fleetwood Model—which includes:

  • Prospective medication review
  • Direct communication with the prescriber
  • Pharmacist assessment of the patient
  • Formalized pharmaceutical care planning for patients at highest risk for medication-related problems.

Fleetwood Phase II found that the Fleetwood Model could be successfully implemented in long-term care pharmacy, increased the clinical involvement of the internal and consultant pharmacist, reduced the time spent on traditional drug regimen review, resulted in greater recognition of the pharmacist’s contribution to patient care and the interdisciplinary team, and improved communication among the pharmacy staff, between the pharmacists and physicians, and between the pharmacy and nursing facilities.

Fouts M, Hanlon J, Pieper C, Perfetto E, Feinberg. Identification of elderly nursing facility residents at high risk for medication-related problems. Consult Pharm 1997;12:1103-1111.

Harms SL, Garrard J. The Fleetwood Model: an enhanced method of pharmacist consultation. Consult Pharm 1998;13:1350-1355.

Daschner M, Brownstein S, Cameron KA, Feinberg JL. Fleetwood Phase II tests a new model of long-term care pharmacy. Consult Pharm 2000;15:989-1005.

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FLEETWOOD PHASE III
Fleetwood Phase III is a three-year randomized trial to test the effectiveness of the Fleetwood Model in reducing potentially inappropriate medication use, adverse drug events, and the undertreatment of common diseases experienced by nursing facility residents in 26 nursing facilities in North Carolina. In addition, the study will quantify the impact of the Fleetwood Model on the efficiency, productivity, workload, and satisfaction of the participating pharmacists. The ASCP Foundation's research partner for Fleetwood Phase III is the Center for Gerontology and Health Care Research at Brown University. The project is funded by The Commonwealth Fund and the Retirement Research Foundation. The intervention phase was conducted January 1 through December 31, 2004. Results are expected to be published in 2006.

Key Components of Intervention
Risk Screen—A risk screen was integrated into the pharmacy’s software system to identify patients at highest risk for adverse drug events and those receiving potentially inappropriate medications. The risk screen was adapted from published research on risk factors for preventable adverse drug events in nursing facilities.

Prospective Intervention—Dispensing pharmacists review the medication profile of high-risk patients and those receiving potentially inappropriate medications during order verification prior to dispensing the prescription and intervene prospectively to address medication problems identified. The pharmacists communicate directly with the prescriber to resolve medication problems. All interventions are documented in the pharmacy system.

Web-based pharmaceutical care software—was developed and serves as the repository for the documentation of all interventions made by dispensing and consultant pharmacists and the main conduit of information exchange between pharmacists. This shared system allows the dispensing and consultant pharmacists to work from the same patient information and see all interventions and outcomes.

Treatment Algorithms—Algorithms for alternatives to potentially inappropriate medications and intervention letters for specific drugs, which were faxed to prescribers with recommendations for suitable alternatives, were developed for use by the dispensing pharmacists.

Nursing Alert Cards for Inappropriate Medications—were developed for propoxyphene and medications with anticholinergic effects to foster early recognition of potential adverse drug effects. This intervention targets the monitoring stage of the medication use process.

Although not specified in the list of inappropriate medications in the nursing facility regulations, propoxyphene was targeted because of its prevalence of use, high risk for adverse effects, and lack of superiority over more appropriate analgesic medications.

The Alert Cards contain recommendations for monitoring for potential adverse medication effects that should be observed for and reported, as well as RAP problems that may be caused or aggravated by the medication effects. The cards are sent with the medication order and are placed on the front of the patient’s medication administration record. The goal is to reduce new orders for inappropriate medications, increase monitoring for adverse effects, and provide documentation for the survey process. The consultant pharmacist conducted an inservice for nursing facility staff when these procedures were implemented.

For all new orders for propoxyphene products, a letter is faxed to the prescriber with a recommendation for alternative therapy based on the nature and severity of the patient’s pain. For all refills, the nursing alert card is sent with the medication. Anecdotal reports from the pharmacists indicate that the prescriber letter is useful in changing prescribing habits and the Propoxyphene Alert Card enlists nurses in the effort to reduce the use of these products.

Many of the medications inappropriate for use in the elderly are implicated due to their anticholinergic effects. However, for some of these medications there may be no reasonable alternatives, or efforts to prevent their use may not be successful. The Anticholinergic Alert Card is intended to foster early recognition of the adverse effects of these medications so problems can be avoided, managed, or reversed.

Cameron KA, Feinberg JL, Lapane K. Fleetwood Project Phase III Moves Forward. Consult Pharm 2002;17:181-198.

Lapane KL, Hughes CM. Identifying nursing home residents at high-risk for preventable adverse drug events: modifying a tool for use in the Fleetwood Phase III study. Consult Pharm 2004;19:533-537

Christian JB, vanHaaren A, Cameron KA, Lapane KL. Alternatives for potentially inappropriate medications in the elderly population: treatment algorithms for use in the Fleetwood Phase III study. Consult Pharm 2004;19:1011-1028.

Lapane KL, Hughes CM. Job satisfaction and stress among workers providing long-term care pharmacy services. Consult Pharm 2004;19:1029-1037.

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FLEETWOOD TOOLKIT CONTENTS

Articles

Fleetwood Phase I

FW I Bootman Arch Intern Med-Abstract_The health care cost of drug-rel.pdf
Bootman JL, Harrison DL, Cox E. The health care cost of drug-related morbidity and mortality in nursing facilities. Arch Intern Med 1997;157:2089-2096.

Fleetwood Phase II

FW II Fouts Risk Factors tcp97-10.pdf
Fouts M, Hanlon J, Pieper C, Perfetto E, Feinberg JL. Identification of elderly nursing facility residents at high risk for medication-related problems. Consult Pharm 1997;12:1103-1111.

FW II Harms tcp98-12.pdf
Harms SL, Garrard J. The Fleetwood Model: an enhanced method of pharmacist consultation. Consult Pharm 1998;13:1350-1355.

FW II Daschner tcp00-10.pdf
Daschner M, Brownstein S, Cameron KA, Feinberg JL. Fleetwood Phase II tests a new model of long-term care pharmacy. Consult Pharm 2000;15:989-1005.

Fleetwood Phase III

FW III Cameron tcp02-03.pdf
Cameron KA, Feinberg JL, Lapane K. Fleetwood Project Phase III moves forward. Consult Pharm 2002;17:181-198.

FW III Lapane High Risk tcp04-06.pdf
Lapane KL, Hughes CM. Identifying nursing home residents at high-risk for preventable adverse drug events: modifying a tool for use in the Fleetwood Phase III study. Consult Pharm 2004;19:533-537

FW III Christian Algorithms tcp04-11.pdf
Christian JB, vanHaaren A, Cameron KA, Lapane KL. Alternatives for potentially inappropriate medications in the elderly population: treatment algorithms for use in the Fleetwood Phase III study. Consult Pharm 2004;19:1011-1028.

FW III Lapane Survey tcp04-11.pdf
Lapane KL, Hughes CM. Job satisfaction and stress among workers providing long-term care pharmacy services. Consult Pharm 2004;19:1029-1037.

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Fleetwood Alerts
Nursing Alert Cards for inappropriate medications were developed for propoxyphene and medications with anticholinergic effects to foster early recognition of potential adverse drug effects. The Alert Cards contain recommendations for monitoring for potential adverse medication effects that should be observed for and reported, as well as RAP problems that may be caused or aggravated by the medication effects. The Alert Cards are intended to foster early recognition of adverse medication effects so problems can be avoided, managed, or reversed.

Many of the medications inappropriate for use in the elderly are implicated due to their anticholinergic effects. However, for some of these medications there may be no reasonable alternatives, or efforts to prevent their use may not be successful. The Anticholinergic Alert Card is sent with new and refill medication orders and placed on the front of the patient’s medication administration record. The Anticholinergic Alert Form is completed by the consultant pharmacist as part of the drug regimen review.

Although not specified in the list of inappropriate medications in the nursing facility regulations, propoxyphene was targeted because of its prevalence of use, high risk for adverse effects, and lack of superiority over more appropriate analgesic medications. The Propoxyphene New Order Letter is faxed to the prescriber for all new propoxyphene orders. The Darvon Alert Card is sent with new and refill medication orders and placed on the front of the patient’s medication administration record.

The Digoxin Alert Card is sent with digoxin medication orders for doses greater than 0.125mg if there is no diagnosis supporting a higher dose.

Alerts NFs

Anticholinergic Alert Card.pdf
Anticholinergic Alert Form.pdf
Darvon Alert Card.pdf
Digoxin Alert Card.pdf
Propoxyphene New Order Letter.pdf

Alerts Non-NFs
Alert cards can also be used in the non-nursing facility setting. The terminology used in the Non-NF Alerts is appropriate for non-nursing facility settings.

Non-NF Anticholinergic Alert Card.pdf
Non-NF Anticholinergic Alert Form.pdf
Non-NF Darvon Alert Card.pdf

The consultant pharmacist conducted nursing inservice programs before implementing the use of the Alert Cards.

Darvon-ACH Med Inservice.ppt

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