The chronic disease conditions like diabetes, hypertension and obesity are on the rise due to life style changes and diet. All these conditions are complex by nature. In their treatments, Patient compliance and adherence to therapy are posing as major hurdles in the effective management leading to increased burden of morbidity and mortality. Disease management of HIV, hypertension, diabetes and tuberculosis which are usually associated with poly pharmacy with prolong medication, calls for a strict monitoring of compliance and medication adherence. Patient’s lack of knowledge about the drugs (i.e. usage and dose), cognition deficiency, incapacitated and aged patients are some other worth mentioning elements which compromise the dosing of the prescribed drug through appropriate route and time. To respond to this concern, stage supply service (SSS) for the prescribed medicines can be initiated which can flourish the issue of patient adherence. This tool is already field tested in developed countries and has been proved to be a successful approach in optimizing patient care and adherence. SSS has emerged as an effective approach in the changing scenario of disease management from hospital model to ambulatory and home care. SSS is developed on the principles of supply chain management in which a clear line of process along with possible bottle necks were identified before hand and appropriate measures were planned to overcome them. Further, this concept is blended to match the requirements of an individual patient as per the pharmaceutical care model suggested by FIP-WHO module.  

SSS refers to an arrangement where the pharmacist dispenses and supplies the prescribed medicines to the patient in instalments e.g. daily, every second day, weekly, fortnightly or as otherwise committed. All the dispensing of medication undertaken in SSS should comply with legislative requirements, including, where relevant, those applicable to controlled drugs. The SSS offers a wide range of benefits such as, reminders for the time and type of medication, the route of administration, prevents the misuse of medication, monitor and increase adherence, decrease rate of drug abuse and help in providing suitable conditions for the storage of medicines. The preliminary requirements to initiate this tool are human resources and IT infrastructure. The orientation and training of SSS comprises of creating awareness about team goal, individual roles along with skills of communication with human and IT interfaces. The community pharmacist together with fellow health care team members sets up the domains  like, scope or any limitation in providing the extent of the service, installation of a separate consultation area, maintaining privacy and confidentiality of the patient’s illness and records (date, time and quantity supplied).

The SSS can be initiated by the prescriber, pharmacist (or any other healthcare provider), patient or their caregiver (see Fig 1 for complete process). When the service is started by prescriber, they usually begin by requesting for SSS by annotating the prescription to the pharmacist which includes: Patient details, medicine details, and dosing schedule. If the prescriber makes any change in the prescription he/she will have to notify the pharmacist as early as possible. Whereas on the other hand, if the service is initiated by the pharmacist (or any another healthcare professional) or on request of the patient or their caregiver should communicate with the prescriber along with details of the service to be provided. The patient will be referred back to the prescriber by the pharmacist if they regularly miss doses, issues related to their safety, or circumstances demand a change in the prescription. It is the responsibility of the pharmacist to bring in notice of the prescriber if the patient fails to pick up the dose. Beyond the matter of professional courtesy, interaction with the prescriber for constituting the lines of communication required for ongoing management of the service is also important.



Fig.1. Stage Supply Service (SSS): Objective, Benefits, Suitable for, Components of the service.

An important legal aspect of this service is stage supple service agreement which forms a part of SSS. This agreement is signed between the pharmacist and patient or their caregiver with both parties keeping a copy of the agreement. The agreement outlines few important terms of the service which will include; the name and contact details of the pharmacy (providing the SSS), the prescriber and patient or caregiver. It also includes various other, mandatory aspects of the service like how often and when the medicines will be collected, type and quantity of the medicines are to be supplied, procedure to be followed in case of doses missed or lost and the period for which the balance of supply will be held by the pharmacy if the service continuity is broken. The pharmacist has the authority to discuss matters with prescribers (or any other health care professionals) relating to patient's care, service termination or transfer if required and the record of supply (on demand) of the medication after dispensing.

After the agreement is made between both the parties, another area which needs special supervision is “documentation”. Documentation of individual prescriptions of patients, their allergies and adverse drug reactions is very important. Stage supply record should be maintained for every single patient. accurate and timely recording of each medicine should be implemented. The stage supply service record comprises of three parts: For single medicines (when only one medicine being supplied) such as, hormonal therapy in cancer treatment; For multiple medicines (when more than one medicine being supplied) as in tuberculosis; For communication record (regardless of either form described above, it is used as a means of communication among prescriber, patient or their caregiver). The record should also contain the amount, type and quantity of drug supplied, signature of the pharmacist as well as the Patient, instances of missed or lost doses, payment arrangements and prescription requests. In some exclusive cases, when patient moves away or goes for some time on vacation, he/she should have a prior notification made to the pharmacist so that alternative arrangements can be made. These arrangements can either be contacting the prescriber regarding transfer to another pharmacy (if available) or provision of additional supplies to fill the gap period. In some exceptional cases, the service can be discontinued at any point of time after the exercise of the professional judgement of the pharmacist. These cases include; when the patient fails to comply as per the agreement of the service, behaves or communicates in an unprofessional manner with any other pharmacy personnel, disrupts the normal functioning of the pharmacy due to dishonesty in deals and payments.