Transcript Document

Medicines Adherence
Support Service
Pilot Project
Community Pharmacist
Training
Dr Susan Patterson,
Pharmacy & Medicines Management
Adviser, HSCB
Jo Gribben,
Pilot Lead, SE Trust
Caroline Johnston,
Pilot Lead, Northern Trust
What problems do older
people have with
medicines?
“Transforming Your Care”:
more older people will be
managed at home
36% of over-65s take 4 or
more medicines for
prevention of chronic
disease
10% (approx) hospital
admissions are due to
medication-related
problems
50% of people do not
adhere to prescribed
medication
The only medicine that works is the one that the person takes
Barriers to medicines
taking
• Limited organisational skills
• e.g. forgetting to take medicines
• Difficulty taking
• Visual impairment
• Limited dexterity – arthritis
• Patient belief
• e.g. Poor understanding
Potential solutions
• Simplify regimen
• Encourage active family/caregiver
involvement
• Calendar /blister packs
• Reminder charts/cards
• Reminder text messages, phone-calls
• Easy - open containers
• Large print, audio labels
• Audio PILs, translations
• Appropriate information
• Education, aids
• Domiciliary Care
SOUTH EASTERN TRUST
VERONICA CLELAND
RESIDENTIAL, DAY CARE AND
DOMICILIARY CARE MANAGER
The Challenges
• Increasing older population
• By 2019 the population of older people
between 65 and 84 is projected to grow
by 32%
• The population of 85 and over is
projected by 2019 to rise by 45%
• Four Localities within South Eastern
Health & Social Care Trust:
– North Down
– Ards
– Down
– Lisburn
• Localities are divided into geographical
patches and staff work in GP aligned
Integrated Primary Care Teams.
Care Managers
District Nurses
GP
MHSOP
(CPNs)
Assistant Care
Managers
Social Workers
Open Referral System into
Local Office
• Referrals allocated to appropriate Service
– Signposted out to Community / Voluntary sector
– Reablement
– Care Manager / Assistant Care Manager Integrated
teams
• The majority of Service users should be
referred to Reablement unless they have no
Reablement potential
Reablement
• Reablement – focuses on the client’s
strengths and abilities to help them regain
their independence, re-learning daily living
skills or gaining new ones. Packages of care
are focused on the short term with the client
moving to other forms of Care Providers if
further support is still required.
Care Management
• Care Management Is a concept which
embraces the key functions of: case finding,
care screening, undertaking proportionate,
person-centred assessment of an individual’s
needs, determining eligibility for service(s);
developing a care plan and implementing a
care package; monitoring and reassessing
need and adjusting the care package as
required.
Source: DHSS&PS Circular HSC (ECCU) 1/2010 March 2010
Assessment
• A person-centred process whereby the needs of an
individual are identified and their impact on daily living
and quality of life is evaluated, undertaken with the
individual, his/her carers with the individual, his/her
carer and relevant professionals.
Source: DHSS&PS Circular HSC (ECCU) 1/2010 March 2010
• Service users assessed Using - NISAT – (Northern
Ireland Single Assessment Tool)
Care Plan
• A description of what an individual needs will
be met.
Source: DHSS&PS Circular HSC (ECCU)1/2010 March 2010
Care Package
• A combination of services designed to meet a
person’s assessed needs
Source: DHSS&PS Circular HSC (ECCU)1/2010 March 2010
Domiciliary Care
• The mechanism for the delivery of domiciliary
care is outlined by DHSSPS (2003) and
states that people should be helped to live
independent lives with safety and dignity in
their own homes.
• All agencies providing Domiciliary Care must be
registered with RQIA and operate in accordance
with regulation.
The Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order
2003 (the Order).
• Article 38 of the Order confers powers on DHSSPS
to prepare, publish and review statements of
minimum standards applicable to all services
including regulated services.
• Domiciliary Care Agencies Minimum Standards
updated August 2011
http://www.rqia.org.uk/cms_resources/domiciliary_care_standards-%20Aug%2011.pdf
Care Providers
• NISRA figures survey week in Sept 2013
• 4715 service users received domiciliary care
services in the SETIn SET
• 15 / 85% split in care provision
•
http://www.dhsspsni.gov.uk/domiciliary_care_services_for_adults_in_northern_ireland_20132.pdf
Management of Medicines
• Standard 7:
• The agency has arrangements in place to ensure that
care workers manage medicines safely and securely.
•
http://www.rqia.org.uk/cms_resources/domiciliary_care_standards%20Aug%2011.pdf
• Requires that staff are both trained and competent to
administer medications.
Issues
• Receiving current up to date lists of medication at
referral
• Updating medication lists/ new prescriptions /
transcribing whose responsibility??
• Multiple forms of medication administration and
competency of staff.
• Withdrawal of MDS
• Environmental issues
• Relatives and informal carer’s giving medication along
with formal carer’s
• Dual medications in homes (Husband & Wife)
• 2 or more providers
Currently in SEHSCT
• Domiciliary care workers in the statutory
sector are not trained to administer
medications, can prompt / remind / assist
under direction of the service users
• Need to address issues of transcribing /
updating MAR
• Safety of service users and protection of staff
is paramount.
At present we are rolling out a programme of
training for the topical administration of
medications
Approx 526 domiciliary care staff require training
Training and on-going competency of staff RQIA
mandatory standard –3 yearly
On- going work from Regional perspective,
Any Questions?
Medicines Adherence Support Service
Aim: To improve outcomes
from prescribed medicines by
ensuring safety and quality in provision of
adherence support for older people
who are living in their own homes
NICE CG 76 (2009): Supporting Adherence
Assess adherence
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provide further information on
medicines
discuss with patient
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Intentional? Discuss beliefs / concerns
Non-intentional? Address practical problems
if there is a specific need
consider case by case
address concerns and needs of the
individual
Service Model Tested in Pilot Phase 1
Assessment
• From all health
• & social care
settings to pilot
pharmacist
Referral
• Pilot lead pharmacist
assesses patient at
home, identifies
adherence issues and
recommends
solutions.
• Solutions
implemented by
patient, family,
pilot lead
pharmacist &
other health &
social care
professionals.
Solutions
Monitoring and follow up
Referral Criteria
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Aged ≥ 65 years old
On four or more regular medications
Living at home
Attending pilot GP + community
pharmacist
Suspected/actual adherence issue
Phase 1 Locations
Northern Trust:
• Ballyclare & Ballymoney
South Eastern Trust:
• Hillsborough & Lisburn
Total – 8 GP Practices, 22 Pharmacies
Referrals (n=143)
Community Pathway (118)
Hospital Pathway (25)
GPs
83
Pharmacists
21
Community Pharmacists
23
Staff nurses
3
Social Care Team
3
OT
1
Re-ablement / Community
rehab
District Nurse / Diabetic
Nurse
Other
2
4
3
Reasons for Referral
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Problems removing tablets from packaging
Confusion / confused about medications
Problems with ordering/collecting medications
Recent hospital discharge
Not taking medication as prescribed
Requesting Monitored Dosage System (MDS)
Non-Intentional Non-Adherence Issues
Clinical
Inadequate knowledge of medication regime
Inadequate knowledge of dose/correct technique
Access
Ordering issues
Storage & Disposal issues
Delivery / collection issues
Day to day
Cognitive / memory issues
Dexterity issues
Vision problems
Poor swallow
Solutions Implemented
Resolution of clinical query
Medication List
Education (specific)
Disposal of medication
Sign post /referral to other teams
Synchronisation of prescriptions
Ordering solutions
Altering medication timings
Provision of a device
New / altered care package
Phase 2
Why conduct a phase 2 pilot?
Outstanding issues from phase 1:
•
Supporting medicines adherence in a wider
population
• Developing a better follow up model
• More referral pathways
•
Commissioning solutions
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Medicines lists
Accessibility
“Making it Better through Pharmacy
in the Community”
DHSSPS 2014
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Helping people gain better
outcomes from medicines
Helping people live longer,
healthier lives
Helping people safely avail of
care closer to home
Helping people to benefit from
advances in treatment and
technology
Phase 2 - Locations
Integrated Care Partnership Areas
South Eastern Trust - Lisburn
Northern Trust – East Antrim
Community Pharmacy Pathway
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Attend training!
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Service Specification & Guidance
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Sign contract (HSCB)
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Obtain items on stock list
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Complete & submit stock claim form (+ receipts)
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Organise pharmacy – staff / premises
Stock List
Community Pharmacy Pathway
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Identify patients
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Patient enrolment
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Pre-assessment preparation
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Assessment (Community Pharmacy Assessment Form)
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Implement Solutions
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Monitor & Review
Identifying patients - Criteria
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Aged ≥ 65 years old
On four or more regular medications
Living at home
Attending pilot area GP
Suspected/actual adherence issue
Identifying patients
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Patients self-refer
PMR - identify from erratic ordering / poor
management
Relatives / friends / staff voice concern
Health / social care worker voices concern
Referrals from pilot lead
Patient Enrolment
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Information leaflet
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Consent form
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Arrange appointment
 In pharmacy or domiciliary visit
 Family / carer present if appropriate
 Patient to bring all medicines & compliance aids
Patient Information Leaflet
Consent Form
Community Pharmacy
Assessment Form
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Pre-assessment information (medication)
Confirm medicines
Assessment of adherence
Current support arrangements
Issues identified
solutions
Monitoring & follow-up
Pre-assessment information
Obtain an accurate list of patient’s medication
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GP record
•
Pharmacy PMR
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Recent hospital discharge letter
Complete demographic information
Pre-assessment information
Assessment (1)
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Verify medication list with patient/carer
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Reasons for discrepancies (intentional ?)
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Assess patient’s knowledge
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Identify side effects / other issues
Assessment (2)
15 questions
3 themes
NISAT Format
(patient-centred)
 Access
 Adherence (day to day management)
 Clinical & patient attitude
Complete to reflect assessed person’s
perspective:
“I am able”
“I am able with difficulty”
“I am able with assistance”
“I am not able”
 Assessor & Carer perspective
Assessment (2)
Assessment (3)
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Current arrangements
Summary of Issues identified
Possible solutions, consider with patient
Solution Grid
Assessment (3)
Implement Solutions
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Education
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Advice on storage
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Disposal of medications
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Synchronisation
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Family involvement
Stock Solutions
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Complete stock solution claim form
Pill popper
Pill splitter
Haleraid® / Turbogrip®
Eye drop applicator
Re-usable compliance aids (range of sizes)
Personalised
(List-based solutions)
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Monthly Claim Form
Medicines Reminder Card/list
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Medicine Administration Record (MAR Chart)
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* NB for patient/family/informal carer use only
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Monitored Dosage System
MUST confirm accuracy of list
Medication Reminder Card
Medication Reminder Card/List
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Ensure patient / informal carer can use
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Check monthly, against prescriptions
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Manage changes
Monthly
Interim
Medicine Administration Record
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For patient / informal carer use only
Assess if suitable for patient
Record of medications taken / given
Issued monthly against prescriptions
Manage changes - New chart
Supplementary Chart
Monitored Dosage System
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Ensure patient can use
Check stability of medications (Guidance)
Issue weekly against monthly scripts
Inform GP - record can be annotated
Arrangements for medications not in MDS
Procedure for changes
Remove old medications from house
PSNI standards - Consultation
Information/referral to other HCPs
GP- send summary if relevant
• Clinical teams (if known)
• Social Care
• Pilot lead
Telephone / written information
•
Must make it clear if action needed,
and by whom
Referral to other HCPs
Monitor and Review
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Follow-up - Approximately 1 month & 3
months post –assessment (page 4)
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Changes to circumstances
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Solutions still working / appropriate?
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Document actions / referrals / changes
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Forward completed form to pilot lead
Monitor and Review
Payment model
Attendance at training, set up of in-house
standard operating procedures, provision of
evidence of purchase of the minimum
MASS stocklist items and signed contract.
Pre assessment preparation.
Payment per
contract
£150
Payment per patient
£20 per new patient who meets the eligibility criteria
and gives consent to participate*
Medicines adherence assessment.
Completion of community pharmacy MASS
assessment tool.
Provision of Solutions
A. directly from the dispensary medicines
adherence stock list
and/or
B. if the solution is a personalised (listbased) solution, it must be based on an
accurate list of medicines.
£28 per patient*
Monitoring and Follow Up
£10 per patient for monitoring at 1 month and 3
months (or appropriate intervals) and providing data to
pilot lead pharmacist.
Payment model
A. Reimbursement for stock items provided. Please
see section below.
OR
B.£40 per patient per month for checking accuracy of
the patient’s medicines list against the new
prescription** and providing an appropriate
personalised (list-based) for a maximum of 6 months
or the duration of the pilot project.
Stock solution claim form
Assessment claim Form
Example
Promote service in pharmacy
- Poster
- Leaflet in medication bag
Patient identified (daughter concerned)
- recently discharged from hospital
- a lot of medication in the house
Recruitment
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Patient information leaflet supplied
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Patient agrees
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Appointment arranged
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Patient and daughter to attend pharmacy
Pre-assessment information
Assessment
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Consent form signed
Medications – including those started in
hospital
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Assessment completed
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Changes to medication noted
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Assessment
Assessment
Solutions
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Education on new medications
Removal of discontinued medications (form)
GP – change Atorvastatin to morning
Written list of medicines?
Synchronise script quantities and dates –
daughter to order meds monthly
Re-usable compliance aid – daughter will fill
Solutions
Actions
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GP – synchronise scripts, amend
Atorvastatin
Claim forms
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Pre-assessment preparation
Assessment
Stock solution (compliance aid)
? Personalised MASS solution
1st and 2nd Follow up
Thank you for listening
?
Any questions
Caroline Johnston, [email protected]
jo
Jo Gribben, [email protected]
Susan Patterson, [email protected]