We wish her and her family peace.
1.Distribution of Ostomy Supplies:
Early in July, 1995, I received information that the Manitoba Society of Pharmacists was lobbying our Provincial Government to give up it's distribution of Ostomy supplies through the Home Care Depot and let pharmacies handle it. I confirmed my information then set up a meeting with the Minister of Health, Hon. Jim McCrae. On August 30/95,Henry Cormack (1st Vice) and myself met with the Minister where he confirmed he had received a letter from the Society of Pharmacists. We expressed our concerns, on behalf of the WOA, as follows:
I take great pride in playing an active role in the WOA and I also recognize that not everyone is able to be an active participant. Our association consists of three levels of volunteers:
The Manitoba Society of Pharmacists is coming out to our November 15th general meeting to discuss their proposal to assume responsibility for the delivery of ostomy supplies and ostomy counselling in the province. In preparation for this, what follows is a critique by the editor of this proposal.
By way of history, the Winnipeg Ostomy Association was formed in 1972, with the primary goal of improving the availability and cost of ostomy supplies and the introduction of proper medical counselling to ostomates in the province. These were achieved in 1974 with the introduction of the Manitoba Ostomy Program (MOP). Distribution of ostomy supplies was assumed by the provincial government through the Home Care Depot and trained nursing staff were introduced in conjunction with the delivery of the supplies. The distribution from a single source has kept prices here the lowest in Canada and the ET nurses have provided excellent support to ostomates in the province. In short, the system has been both cost effective and beneficial to ostomates.
From the inception of the MOP, the ostomy supplies, minus certain non-essential items, were provided at no cost to ostomates in the province. In 1993, the Provincial Government instituted a cost sharing measure under which the ostomate and the government share the cost of supplies up to $600.00, with the government covering all costs above the $600 level.
At present, ostomy supplies are ordered over the telephone. The rural areas use a 1-800 number. Payment can be made over the phone using charge cards and the supplies are shipped out, usually the next day. The executive of the Brandon/Westman Ostomy Association have also expressed their support of the current MOP, in the light of recent proposals. The depot keeps all items in stock resulting in few delays. The inventory listing of the MOP consists of 400 separate stocked items because:
2. Product Selection
ET nurses keep up to date on current ostomy supplies and run product trials on an ongoing basis when new products appear on the market. If the items are judges to be medically effective and cost- efficient they are added to the program. Many technological advances have been made since the program was instituted in 1974 and the current inventory listing at the Home Care Depot reflect these improvements. The ET nurses are available for consultation when appliance related problems arise.
Further product information is available through the Winnipeg Ostomy Association and its publications. The major ostomy manufacturer's products are all available through the MOP and many Manitoba ostomates use other, less well known, appliances which they obtain from the MOP after consulting with the ET's.
Again, it is difficult to envision that any given pharmacy can have in stock the array of products ostomates may request, especially given limited shelf lives and stocking costs.
Counselling is presently available through an ET nurse. The ET Nurse requires a Baccalaureate degree in nursing, and completion of an Enterostomal Therapy Education Program, recognised by the Canadian Association of Enterostomal Therapy. (see Definition of Enterostomal Nursing.). The VON service the rural areas by giving regular clinics i.e. monthly in Brandon and giving in-service training to hospital and care home staff, thereby training qualified medical staff on site to meet ostomates needs. They are also available for consultation with medical personnel province wide when specific problems arise. The MOP outlines these roles quite clearly.
The current pharmacists' proposal states "The patient would benefit from professional pharmaceutical counselling." Pharmacists are not qualified to give ostomy counselling, neither do they have the necessary knowledge to handle the task.
4. Pharmaceutical Care.
Pharmaceutics is the science of preparing and dispensing drugs. Ostomy appliances are not pharmaceutical products and pharmacists get no training in proper use of equipment or counselling of ostomates. At present, the ostomate has access to a team of professionals who consult on the total ostomy care of the patient. Pharmacological needs are on the fringe of the primary needs of the ostomate. To transfer the centralization of meeting an ostomates needs to the realm of pharmacology makes no medical or business sense.
The current financial arrangement is beneficial to both government and ostomate.
The proposal states "The volume discounts available to government are equally available to community pharmacy." In a letter from Elizabeth Lindner, General Manager of Hollister Limited, one of major manufacturers of ostomy supplies, she states about the MOP "the depot purchases in extremely large quantities, two/four times per year. Consequently, it is able to benefit from manufacturers' best discounts. A retail store would purchase in much smaller quantities, much more frequently. The overall cost to the manufacturer of supplying the retailer is higher; therefore, the retailer pays a higher price for products."
Current costs of ostomy supplies in Manitoba are the lowest in Canada. The bulk purchasing power of the Home Care Depot, the largest single purchaser of ostomy supplies in Canada, puts the prices here at 20 - 30% less than manufacturer's list prices. We are given to understand that the MOP covers the cost of running the ostomy part of the Home Care Depot with the prices it sets. The government and ostomate share in this saving under the current arrangement. The proposal also states: "Provision of services by community pharmacists could reduce the nursing workload for redeployment elsewhere." The hospital-based ET Nurses are essential for pre- and post-operative duties, while the VON-based ET Nurses are essential for rural and long term counselling to ensure good quality of life. The move to community pharmacists is not likely to reduce the nursing workload. On the contrary, if appliances are not supported with proper counselling, the increase in skin and other related appliance problems will require increased nursing involvement.
Adding the profit factor into the cost effective and efficient present system is in neither the 1800 odd Manitoba ostomates nor the co-funder's best interests.
Presently Manitoba is the only province to centrally warehouse ostomy products. In all other provinces these products and associated professional services are provided by community pharmacy and/or home health supply stores. In Manitoba the patient is required to pay 50% of the cost of the supplies up to $300.00 per fiscal year (total $600), above which the government pays 100% of the cost.
The existing program, whereby patients are required to obtain their supplies from a single location in Transcona, or to pay for mail delivery, is disease-state or condition-based rather than income tested and is similar to the Life Saving Drug Program (LSDP). Given that the service delivery of the LSDP is in the process of being transferred to community pharmacy to gain the benefits of professional pharmaceutical counselling in the community, there are advantages for a similar transfer of ostomy supplies and counselling to community pharmacy.
The Transcona location is open only from 8:30 a.m. to 4:30 p.m., Monday to Friday, awkward hours for anyone who works a regular workday. Community pharmacies, on the other hand, are generally open 12 hours a day, 7 days a week,for rural patients,there would be no worry of mail delays.
2. Product Selection
The patient has no option to purchase alternate products - either upscale or ones that better meet their specific needs - and no way to determine what products are available. In community pharmacy they could purchase the product they feel best suits their lifestyle needs, and pay the difference if it is more expensive.
The patient would benefit from professional pharmaceutical counselling that would be available to them. We understand approximately five nurses, operating from the Health Science Centre, St. Boniface Hospital and Manitoba Public Health/VON manage the needs of over 2,000 patients province-wide. These nurses travel to selected rural communities about once every second month. We have had discussions with representatives of this nursing group who spoke favourably of patient support being available in the community.
4. Pharmaceutical Care
Community pharmacists will better be able to manage the total health needs of each individual patient and to provide accessible consultation. Some pharmacies presently carry some of the "non-essential" ostomy products for which the government does not pay and would prefer to carry the entire line. Government
Payment can easily be managed through the Drug Programs Information Network (DPIN). The co-payment by the patient need not change. Payment to pharmacies would be weekly Electronic Funds Transfer.
The volume discounts available to government are equally available to community pharmacy.
Provision of services by community pharmacists could reduce the nursing workload for redeployment elsewhere.
The Manitoba Society of Pharmacists.
Eligibility is based on the following criteria; persons who: are residents of Manitoba; and are registered with Manitoba Health Services Commission; and have lost the normal function of the digestive or urinary system ecessitating ostomy or fistula management; or have drainage from the respiratory or lymphatic system in a quantity necessitating use of an ostomy appliance.
A person is registered with the program at the time of hospital discharge or contact with an ET Nurse. Once an assessment by an ET Nurse has been completed, decisions are made regarding the type and quantity of supplies. Products then may be ordered on a monthly basis. If a new item is requested, an ET Nurse must order the item the first time to monitor the quantity and combination of supplies being used. Clients who are noted to be using large quantities of supplies are reassessed by the program ET Nurse.
Efforts are taken to avoid duplicating services already available to the client. For example, if a person is being seen by a VON or Home Care Nurse, then contact is made with this primary caregiver to review their assessment and determine if ET services are required. Registrants are encouraged to initiate contact with the program's ET if they are experiencing questions or concerns. Rural clinics are held in seven locations throughout the province at various intervals to meet with clients on an individual basis, complete hospital visits, conduct staff inservice sessions and attend rural UOA chapter meetings. Health professionals are contacted annually in writing to notify them about the clinic dates and locations, encourage their referral of clients as needed and remind them of the availability of staff development resources.
Products trials are conducted with the hospital-based ET's on an ongoing basis when items are deemed as cost-effective alternatives. Hospital supplies are reviewed upon request and suggestions are forwarded; a priority in the regard, is the use of products in hospital that are available per MOP to the client once home which promotes continuity in terms of learning. It has been demonstrated that the purchase of supplies on a volume basis is more cost efficient per person, when compared to retail or reimbursement systems.
This study will investigate how many patients have this disease in the Province of Manitoba, and the number of patients with newly diagnosed disease in the past 10 years. Furthermore, the study will also look for any particular characteristics that make some people more likely to have this disease; i.e. age, sex, where they live, their martial status, their ethnic group, etc. Patients with this disease may be contacted in the near future and asked to fill out a questionnaire.
Anyone with a diagnosis of inflammatory bowel disease (Crohn's disease or ulcerative colitis) who would like to fill out the questionnaire or anyone with questions about this study can contact: Trish Rawsthorne, R.N. at (204) 787-2060.
Patients with the following ostomies were visited in September and October:
Colostomy - 5
Ileal Conduit - 3
Ileostomy - 2
Pelvic Pouch - 1
Continent Urostomy - 1
Total = 12
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