Questions/Answers

Raman Hospital is located among the three-southernmost provinces where the problem of insurgency takes place in the Muslim-majority (96.68%), contested provinces of Narathiwat, Pattani, and Yala in the far south of Thailand bordering Malaysia. For more than 15 years, such chaos become a barrier for patients and healthcare personnel to access the health system. Ninety percentage of the population use Malay language to communicate in daily life but are illiterate in eligible to Malay or Thai language which is the national language. Raman Hospital serves in-patient with an average number of 106 patients per day, of which 50% of patients are elderly patients with chronic diseases and require maintenance treatments. Administration of oral medications during hospital stay in the past provided by nurses according to the scheduled time. This method has brought lacking of awareness for the patients in terms of self-administration and knowledge of one’s own medications. In 2016, the survey by Raman Hospital found that, after discharging from the hospital, only 48% of patients had good adherence of medication, while 12.05% of HIV patients were failed to suppress the viral load. Diabetic and hypertensive patients developed complications; 118 patients with new chronic kidney disease, 101 patients with new cerebral hemorrhage, and 16.09% of the patients readmitted to the hospital and costed 1,953,320 baht for the treatment. The objectives are to increase medication adherence after discharged and reduce the spread of HIV infection by reducing the number of HIV patients who are taking the antiretroviral drugs and unable to suppress the viral load, new chronic kidney disease patients, stroke, readmission rate due to lack of non-adherence and the cost of treatment for readmission. Patients are encouraged to participate in self-administration of medications while in hospital and develop their own medication-assisting tools.

The development of Self-Administered Medication (SAM) by patient participation under the supervision of a multidisciplinary team during hospitalization system is the development of a service that focuses on in-patient with chronic diseases in Yala Province, which the majority is elderly and eligible. Our members of multidisciplinary team were trained and developed tools along with the patients in order to encourage patients to take their own medication correctly while in hospital and in stable disease conditions. As a result, the cost of public services was reduced up to 129,000 baht per year. Meanwhile, all patients were able to give feedback or comments before discharged. Therefore, it is consistent with the comprehensive service types delivering inclusive and equitable services for all.

This initiative was developed for all patients with chronic diseases both communicable and non-communicable diseases requiring long term medications to be well-prepared for self-administration medications once discharged from the hospital. The program encouraged patients to adhere to their own medications and able to control their own diseases to achieve good outcomes. As a result, communicable chronic disease patients such as HIV patients, had the viral load undetectable, thus ending the spread of infection. Patients with chronic non-communicable disease patients had less complications from non-adherence, resulted in less hospital readmissions, disabilities or deaths from cerebral hemorrhage. Therefore, it is in line with the Sustainable Development Goals No. 3 (good health and well-being).

Developing a collaboration between the Raman Hospital, the network sector and the patients to solve problems together to achieve the sustained solutions. Patients had a success in adherence to their own medications and able to control their own diseases to achieve good outcomes, reduce disabilities and have better health. Regarding the environmental dimension, the program reduced Global warming by using the reused boxes instead of plastic bags to take medicine home.

Administration of oral medications during hospital stay in the past provided by nurses who administered the medications according to the scheduled time. It has brought lacking of awareness for the patients in terms of self-administration and knowledge of one’s own medications. The adherence was as low as 50-60% and was part of fatal complications in chronic diseases. This problem had effected the whole health system from the department level of Raman Hospital to the level of three-southernmost-border provinces and could be any other regions of Thailand. The majority of chronic disease patients were the elderly with vision impairment and eligibility especially Thai language. Therefore, this initiative allowed patients to participate in the development of self-administration of medication in order to improve the patient's health and reduce the burden of the government in the long run. The cost of hospitalization and wasting of large quantities of medications were reduced.

Patients with chronic diseases, both communicable and non-communicable diseases, usually need to comply with medication administration throughout life regardless their sex and age. In order to achieve good outcomes, all patient equally has the right to take care of their health conditions at their best with their own responsibility with the guidance of SAM.

Target groups are all chronic disease patients, including communicable diseases such as HIV, Tuberculosis and non-communicable diseases such as diabetes mellitus, hypertension, chronic kidney disease and cardiovascular diseases, where the medications need to be taken consistently or life-long. Most of the time, these medications are started during hospitalization and introduced by the multidisciplinary team with a close monitor to ensure that patients are able to continue them safely after discharged from the hospital. Patients are encouraged to improve their adherence and knowledge of their own medications in order to control their disease conditions. Besides, it is expected to reduce the spread of infection among HIV and tuberculosis patients, including disabilities, deaths, readmission rate and cost of treatment for readmission.

Since 2017, the meeting of multidisciplinary teams and networks was held with the main objective to develop medication administration system while in hospital to be more efficiency. Previously, all medication during hospitalization was given by nurses. With the collaboration with multidisciplinary team, the patient then became the medication self- administrator. Medications were all organized in the personal box individually as if patients were at home. Patients were encourage to co-develop medication aid tools with the multidisciplinary team. The innovative resulted in pictorial labels to help patient taking medication correctly and the alarm to notify medication administration time (before meal and after meal). Every medication was counseled by ward pharmacist to all in-patients during hospitalization. Each meal, the nurse supervised the medication administration from patient's medication box to see if it was according to physician’s order. The physician examined the patient's medication intake during a daily examination. Patients who administered medication correctly and were in stable condition would be discharged by the physician. Before discharge, all patient knowledge in terms of medication would be evaluated. Instead of plastic bags, personal medicine box would be given to the patients and must be taken to the hospital every time. Several days after discharged, the Village Health Volunteer and community nurse visited the patient’s home and re-evaluated medication adherence. The pictorial label had been applied to 12,000 chronic disease patients in the outpatient department. In 2018, in order to improve medication adherence, tablet cutting tools were provided to the patients who was prescribed with a quarter or a half tablet. Patients with nasogastric tube were provided with a small mortar to crush tablets. By the year 2019, every hospitals in Yala province followed the campaign and patients in need were all provided with the medication aid tools.

At the beginning of program, obstacles were from health care personnel especially the nurse who though that SAM system would increase the workload. This misunderstanding was overcome by executive meeting with multidiscipline leaders to clarify the reason and long term benefit of changing the previous system to SAM system. Meanwhile, the patients and caregivers needed to be acknowledge about advantages of SAM system as well. In addition, pictorial labels became the effective solution to improve medication adherence, since there were a number of elderly and eligible patients.

Developing the SAM system by patient participation under the supervision of a multidisciplinary team during hospitalization is patient-centered with the concept of sustainable way to prepare patient with chronic diseases, both communicable and non-communicable diseases, during hospitalization, to enhanced medication adherence with the collaboration of multidisciplinary teams and network partners. Pictorial labels were developed for our patients in three-southernmost-border provinces of Thailand to overcome language barrier in order to achieve treatment outcomes.

This initiative is inspired by Lam P et al research which found that self-administered medication while in hospital significantly increased knowledge about medications. Lowe CJ et al. also showed that patient adherence was significantly higher when compared to administration by the nurse. Richardson et al. found that patients were highly satisfied with the SAM system at the level of 90-100%. In addition, the concept from Drowse and Ehlers suggested that the use of pictorial labels is a solution to increase knowledge and adherence in elderly patients or cannot read medication label, which is similar to the context of Raman Hospital.

In 2017, the pictorial label was applied to outpatients with chronic diseases and expanded the use in the primary care unit (PCU) in all 16 locations in Raman District, Yala province. Then, the work process and outcome were shared in the national event with the attendees at the national HA Forum. In 2018, there were visitors from other hospitals e.g. Narathiwat, Pattani and Phatthalung Province. In 2019, the innovative won the first place winner award of Academic Expo in Health Service Area 12, Public Sector Excellence Awards (PSEA) and to be shared at the HA Southern Regional Forum. Self-Administered medication by patient participation under the supervision of a multidisciplinary team during hospitalization system applied to the entire province (7 hospitals) by the Yala Provincial Public Health Office agreement. Moreover, it is the main poster presentation at the "Pharmaceutical in Future" conference, the annual national medication management safety conference.

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The development of SAM by patient participation under the supervision of a multidisciplinary team during hospitalization system used financial resource approximately 16,800 baht. Tablet cutting tools were provided by drug companies and small mortars for grinding medications were from generous donors (5,000 Baht per months). Multidisciplinary team were composed of 120 nurses, 7 pharmacists, 13 physicians and 88 Village Health Volunteers who were trained and collaborated with the patients.

With the result in achievement of patient adherence by SAM, sustainable financial supports were from pharmaceutical companies and monthly donations. So, the medication aid tools were adequately provided for the patients in need. SAM has created the circle of collaboration between patients and Raman hospital health care personnel with understanding and trusts.

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Raman hospital internal assessment form was used to assess medication knowledge when patients discharged and evaluated medication adherence at the follow-up visit. The external surveyors were Yala Provincial Public Health Office, the Healthcare Accreditation Institute (Public Organization), the Association of Hospital Pharmacy (Thailand), the Association of Community Hospital Pharmacist and Yala Medication Management System Team. All four organizations assessed according to medication safety standards. There were also research studies and patient satisfaction assessment conducted by the Faculty of Pharmaceutical Sciences, Prince of Songkla University.

The Primary internal indicators were the percentage of medication adherence at the follow-up visit after discharged. The secondary internal indicators were the percentage of HIV patients taking the medication unable to suppress the viral load, the number of new chronic kidney disease, the number of stroke patients, the percentage of readmission due to non-adherence, and the cost of treatment for readmission. Indicators for external agencies include medication knowledge before discharged from the hospital, medication knowledge at follow-up visit, medication adherence at follow-up visit and medication errors during hospitalization.

The results were the comparison between 2016 and 2019 by internal evaluation. The primary outcome as patient adherence was increased from 48% to 93.2%. The secondary outcomes were percentage of HIV patients taking the medication cannot suppress the viral load decreased from 12.05% to 0.9%, the number of diabetes mellitus and hypertensive patients developed complication of chronic kidney disease was reduced from 118 to 21 cases, the number of new case stroke patients due to non-adherence was reduced from 101 to 33 cases, percentage of readmission from the non-adherence was decreased from 16.09% to 3.00% and the cost of treatment for hospitalization and re-admission due to non-adherence was decreased from 1,953,320 to 385,408 baht. The medication management safety standard evaluation from 4 external organizations were all passed. The research from the Faculty of Pharmaceutical Sciences, Prince of Songkla University found that medication knowledge before discharged from the hospital increased from 6.4 points to 8.56 points (total 10 points) with no medication errors occurred during hospitalization. The patient satisfaction was at 80-100%. In addition, internal and external assessment results were used to improve SAM system every year.

The Raman Medication Management System Team is an organization which controls, coordinates, and collaborates with other relevant departments such as pharmacy department, nursing organization, and medical organization. All 3 organizations have professional roles in acknowledment, supervising, and examining medication intake of patients while in hospital. The Information Technology Department plays a role in supporting the computer program, providing automatic amplifying speakers to alert patient of medication dosing at each meal and available to encounter the technical problems. Procurement department plays a role in procuring the purchase of patient medication boxes, materials for pictorial labels, and small mortars. Community nurses play a role in visiting patients’ home and coordinate with nurses in the hospital, as well as the Village Health Volunteer in the area, who make a regular home visit. For patients returning home but still unable to take medication as prescribed, The Village Health Volunteer will visit, monitor, evaluate and report the patient's medication adherence results after discharge. Emergency medical services (EMS) provide services to transfer patients between home and the hospital for patients with disabilities or severe illness throughout the time of insurgency in the area.

Raman Hospital has a policy of developing drug administration system while in hospital, from nurse-administered medication to Self-Administered Medication (SAM) by patient participation under the supervision of a multidisciplinary team. Changing this system to establish patient-centered teamwork and patient engagement mechanism in the design of SAM system and tools in order to solve problems that are relevant to chronic disease patients in long term. Harn Thai Pharma (2508) Co., Ltd. supports tablet cutting tools which are one of important keys for medication adherence. The Fund for The Underprivileged Patients of Raman District supports the budget for procuring small mortars for patients with nasogastric tube. The Village Health Volunteer in the area visit home to assess the patient's medication adherence after discharged from the hospital. The Yala Provincial Public Health Office has supported and launched the policy to apply the system to all hospitals in Yala Province. The Medication Management System Team monitors and evaluates the system monthly for further development and sustainability.

The key lessons learned were changing the medication administration system from traditional routine that medicine administration was provided by nurse to the patient-centered system that patients take part in medication management. This required cooperation between the multidisciplinary team, patients, caregivers, network partners and the private sector to be involved. It also helped multidisciplinary team to recognize the patient's medication problems that may had at home, leading to problem solving and improvement in medication adherence at the follow-up visit, reduce spreading of infection by reduce number of HIV patients who unable to suppress viral load, reduce the number patients with chronic disease complications, re-admission rate due to non-adherence, and reduce the cost of treatment for re-admissions. In addition, the goal of applying this initiative to other contexts is to expand the results by implementing the Self-Administered Medication (SAM) by patient participation under the supervision of a multidisciplinary team during hospitalization to hospitals in the three-southernmost-border provinces and other hospitals in Thailand to achieve good treatment outcome sustainably.