Long Term Conditions Service

The Long Term Conditions (LTC) Service is designed to support patients with identified medicine adherence issues become self-managing through the delivery of a pharmacist medicines management service.

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Who is eligible for the LTC Service

What you need to know to deliver the LTC Service

Visiting LTC Service Users and proactively sharing information for patient safety 

How to write brief practice notes 

LTC Service Patient Case Studies


 Who is eligible for the LTC Service

The eligibility of a patient to the service is managed through the LTC Service Eligibility Assessment Tool, which sets a nationally consistent set of criteria for entry to the service.
Eligibility to the LTC service is based on a pharmacist-led eligibility assessment which applies a standard set of agreed criteria.

The assessment is used to identify factors that contribute to a patient’s adherence with their medicine regime and the actions that the pharmacist and the patient will work together to address the adherence issues.

Eligible patients will also benefit from the pharmacist working more closely with the prescriber to enhance the patient’s medication use and adherence of medicines. Pharmacist recommendations made to prescribers may also improve the clinical or cost effectiveness of treatment.

Registered patients will be encouraged to use one pharmacy for dispensing, but may still receive medications from another pharmacy.

What you need to know to deliver the LTC Service

LTC Service Protocol
Guide to the Long Term Conditions Service
Quick version of the Guide to the LTC Service
Eligibility and Assessment Tool
Mental Health Criteria
Patient Registration Form


Visiting LTC Service Users and proactively sharing information for patient safety 

People registered for the Long Term Conditions Service may have reasons for visiting another pharmacy. Generally, it is to get medicine for ‘acute instances’ when a person is discharged from hospital or has had a specialist appointment. Either way, it can complicate the care the registered LTC Service pharmacy provides, as it is impossible to know that there has been a change to the Service User’s medicines regimen.

How you can help improve safety of those registered with the LTC Service

Should a new Service User present at your pharmacy with a hospital discharge or specialist prescription for an ongoing condition please use the diagram below fpr the best practice ways to minimise future complications for them.

Visiting LTC Service Users Diagram


How to write brief practice notes using the SOAP format

SOAP stands for Subjective, Objective, Assessment and Planning. The SOAP format is used by clinicians to structure notes that sufficiently articulate their professional activity and for recording and communicating to the members in the team.They can support you to articulate and record your cognitive process.  

What you need to know about writing SOAP notes
SOAP Note Examples


Where to store SOAP notes in LOTS

Toniq provided a template for a SOAP style note with the November 2014 medicine update. This can be used as the basis of a consolidated patient note that spans patient history.

Make sure your Toniq templates are up to date:

  • Check latest templates are downloaded on the updates and downloads page, then 7.
  • Update Toniq notes templates to make them effective.
  • The new template is called TQ SOAP note.

Instructions on the template itself detail how the note, once present in a patient history can then be copied forward to form a consolidated or longitudinal note across the entire patient history.

Use your F4 Green Papers function key to find and read see Toniq’s green paper on this SOAP template. 

Where to store SOAP notes in LOTS

  1. Enter the notes in the patient’s ‘Event Audit’ as per SOAP format
  2. To collate the notes into a single longitudinal report, go to ‘Reports’, ‘Patient Reports’, ‘Person Audit Report’, under ‘Person Details’, select  ‘Patient below’
  3. Type in the patient’s name
  4. Select the patient
  5. Change the date range if required
  6. Click on ok
  7. The report with a list of the notes (events) will come up. In a future update, you will be able to access this report via Dispensary.  


LTC Service Patient Case Studies

Anthony's Story

Anthony was a patient with HIV and diabetes who managed to stabilise his T-Cell count. His doctor got in touch with Anthony’s community pharmacy because they realised he was eligible for the LTC Service and would benefit from the extra support the pharmacy could give him to keep him taking his medicines as prescribed in order to maintain his T cell count. Because of his diabetes Anthony was also on other medications which when combined with the side effects of his HIV meant he had associated liver problems.

What actions were taken?

Once registered in the LTC Service, the pharmacist synchronised Anthony’s medicines and he began getting his other prescriptions faxed directly to that pharmacy.

Initiatives developed for Anthony’s LTC Medicines Management Plan

  • Diary reminders were set up in an online calendar shared by the community pharmacy team to ensure Anthony was contacted by phone well before he ran out of medicine.
  • The pharmacist had a list of questions which they used to make sure these conversations were going to help him remain adherent E.g. When is your next scheduled blood test?
  • Each conversation was noted in the community pharmacy’s Pharmacy Management System
  • Regular prescription collect enabled the pharmacists to:
    • find out more about his medicines usage
    • provide guidance and tips on how he should be taking the medicines. 

How has the LTC Service helped Anthony?

Since registering for the LTC Service Anthony has maintained a stable T- Cell count and his pharmacists hasn’t had to dispense antibiotics to him to treat infections. The feedback from Anthony’s doctor and specialist has been positive and acknowledged how the pharmacist had been a key adherence tool within the multi disciplinary team keeping Anthony healthy. 

More LTC Service Patient Casestudies


For more information please contact: pharmacy@dhbss.health.nz