Transcript Helen Whiteside - Pharmacy Management National Forum Workshop

Medicines
Optimisation
in Care Homes
Learning and Practice
Development
Helen Whiteside MRPharmS IP
Medicines Optimisation Pharmacist
Pharmacy lead for older people, care
homes and dementia
Previously
Clinical Care Home Pharmacist
Learning Objectives
This session will
1. Summarise the key elements of national guidance and standards
2. Summarise the guidance on optimising medicines use in older people with
multimorbidities and polypharmacy
3. Describe the key aspects of the NHS Leeds West CHAMOIS model which
optimises medicines for care home residents through a cost effective medication
review service linked to the CCG strategic priority health goals in areas including
cardiovascular, respiratory, diabetes, mental health and dementia
4. Describe some of the challenges with medicines safety in care homes for the
elderly –a very vulnerable group of people.
5. Use case examples and data to illustrate how the service incorporates best
available evidence to tackle some of these challenges and has been a driver of
change in the local commissioning arrangements for care home residents
6. Share the learning and resources from the service to support similar initiatives
Polypharmacy in a nutshell
Paracelsus
(1493-1541)
This is what
medication
guidance
in older people is
all about…
• “All substances are poisons;
there is none which is not a
poison.
• The right dose differentiates
a poison from a remedy.”
Polypharmacy –
Is it appropriate or problematic?
• Appropriate Polypharmacy
– Prescribing for an individual for complex
conditions or for multiple conditions in
circumstances where medicines use has
been optimised and where the
medicines are prescribed according to
best evidence.
• Problematic Polypharmacy
– Prescribing of multiple medications
inappropriately, or where the intended
benefit of the medication is not realised
Deprescribing Tools
Background
• August 2013
• 2.4 WTE 8a pharmacists
• Employed to carry out medication
reviews in older persons care
homes
• By July 2014 – just 1.8
• By December 2014 – just 0.8
Our MO interventions focussed on…
• Personalised and holistic reviews
• CCG priority disease areas
• Specific high risk medicines
• Deprescribing of less beneficial medicines
• Appropriate monitoring
How we started
Leeds West CCG
Standard Operating Procedure
for Care Home Pharmacists
providing a medication review service
to care home residents
• CCG aim – invest to provide savings for
medicines budget
• 3 pharmacists with 3 different backgrounds
– rounded team
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List of care homes (>1 yr out of date!)
SOP and standard letters written
Checklist for care homes / practices
Introduction leaflet for practices/care homes
Patient leaflet
No standard review template - PREVENT
Data collection tool created
Smartcards and ICE forms
CHAMOIS
Project
Meet
Doris
2014
Show Doris video
10 mins
Year 1 data – 460pts
25%
40%
45%
14%
End of 2 year project
No. of patients reviewed
680
No. of follow up reviews
435
Net cost saving
£ 124,804
Saving per patient
£ 184
No of medicine changes
3.75 per patient
(2562)
No of tests required
>2 per patient
(1440)
Referrals needed in
1 in 4 patients
27% (183)
Clinical Data
Drug Class
% of patients
% Acceptance rate
of recommendations
Calcium & Vitamin D (before /after review)
39 / 53
90
Cardiovascular
60
88
Diabetes
10
94
Respiratory
13
95
Opioids
20
94
Benzodiazepines
9
87
Anticholinesterases
24
58
Antipsychotics in Dementia patient
5
76
Antipsychotics NOT in Dementia patient
4
50
Anticholinergics
23
82
40
93
ONS
6
90
LT antibiotics for UTI
2
n/a
PPIs
45%  or ; 14%
 or 
Thanks, you've been a great
help to us!
I’ve enjoyed working with you
and hope to be able to
continue in the future
What makes our day…
Now that you
have stopped
Margaret's’
medicines she is
more alert,
socialising in the
lounge with other
residents and has
put on weight as
her appetite has
improved.
Thank you
Just dropping you a
line about my mum.
Since you came 3
months ago she has
had no falls. This is
the longest in two
years she has gone
without a fall.
Thank you
The End Result…
MOP Medication Reviews
New residents & post discharge LWCCG
Integrated Care Home Scheme
Four permanent Band 8a
Medicines Optimisation Pharmacists
Medication Reviews
Polypharmacy/Care Homes
Scenarios
• 15 mins then feedback
Scenarios Feedback
• 15 mins
Right Medicine
– Safe Systems
Medication
Review
MAR
& other record keeping
Rx.
system
set
up
Prescribing
Storage and Waste
Disposal
Administration
Medicine Receipt
Order Medicine
Prescription printed
& GP practice systems
Receive Rx. & reconcile
with order
Dispensing
& delivering
NICE guidance and
quality standards
•
Managing medicines in care
homes
– Guidance
– Quality Standard
– Support for commissioning
•
Local government briefing: Older
people in care homes
Improved standards
for LCC inspections
Implement
• ALL guidance/ standards
• or
• 1 at a TIME?
Commissioning- what
should be in your contract?
•
Medicines listed on day of transfer
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Discharge summaries sent WITH person
•
1st Self administration
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Prescribing – Safe repeat prescribing systems
– Comprehensive instructions for ALL medicines
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Medication Reviews as part of MDT
– At least annually
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Covert medicines
– NOT until FORMAL best interests meeting has been
held with CH staff, Rxer and family/advocate
– Consider training
Learning – 1
Standard
- review checklist
- review template or
- data input?
or not?
Learning 2 – know
your baseline Rx data
• LWCCG = £180 per patient / year
• In long term annual reviews drops to £100
• Long term business case
• NH vs. residential homes – impact on £
• Other influences to these residents care
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Eating and drinking team
Admission avoidance scheme
Winter planning schemes
Care coordinators
Antipsychotic reviews / audits & care pathways
Learning 3
Solving the problems –
Connecting and working
together
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Feedback to teams
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Prescribing and GP practice issues
Issues with communications/ medicines supplies
from mental health teams, community and acute
provider pharmacy departments
DATIX incidents and medicines safety team /LCC
Connecting to other clinical leads / commissioners
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CCG Diabetes /Long term conditions
CCG Quality managers/ LA Contract managers
CCG QI leads
CCG Primary care team – practice intelligence
Learning – 4
Care coordinators
Learning 5 –
Medicines Safety
• 200 incident reports completed
• Medicines Safety
– Knowledge and skills
– Decision making
– Practices, processes and systems
• At different levels
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National guidance
Inspections
Commissioners
HCPs
Health and Social Care Providers
Yorkshire contributory
factors framework
1.
BMJ Qual Saf 2012;21:369e380. doi:10.1136/bmjqs-2011-000443
Learning 6Quality Improvement for
Patients
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Ensuring appropriate care and monitoring
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Reduced problematic polypharmacy
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Ensuring accurate diagnosis
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Identifying personal medicine preferences, non
adherence and agreed and actioned solutions
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Feeding back issues with transfer of care to ward based
teams / lead pharmacists to lead improvement in Trust
Learning 7 –
Education, Training
and Peer Review
•
Clinical pharmacy in the community Pharmacists
and Technicians meet
•
2-3 a year in London and North (Leeds/Manchester/ N’castle)
• In the South
• next date is 4th Dec and you can contact the
administrator Sam at [email protected]
•
Now in the North!
– Lead by Heather Smith Consultant Pharmacist- Care of Older
People and Interfaces of Care at Leeds Teaching Hospital
NHS Trust for more information
– email [email protected]
– Next meeting :
– Monday 12th October 2015 1pm-4pm
– Venue: Martin OE meeting room (Neurology Seminar
room), Level E, Martin Wing, Leeds General Infirmary
Key areas 1 –
Improve Knowledge and Skills
•Prescribers/ Nurses
– Up-skill Primary Care Professionals in frail elderly medicine,
pathophysiology and effect on medicines, prescribing choices and
processes and monitoring
•All heath care providers
– Safe medicines administration and record keeping
•Initiate proactive care / admission avoidance plans INC. medicines /
monitoring section
•End of Life - Use of GSF and EPaCCS records
•Commissioners
Key areas 2 –
Practices, processes and systems
•My role is to facilitate teams to work together
– Care Home
– GP practice
– Pharmacy
•Medicines safety team role is to provide and ensure
– Good practice guidelines / effective policies and safe processes
in the system
•Commissioners
– To be aware of current patient groups needs
– Set standards and put safety measure in place and monitor
Key areas 3 – Medicines Safety
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Medication Errors- record record record – learn learn learn
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New Residents / New care episode / New meds from other team
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Repeat Prescribing
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Repeat person, disease and drug monitoring
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Medicines Plans
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Deprescribing
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Safely record
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Contracts
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Human Factors
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End of Life- key meds, anticipatory prescribing
GRW 80 yr old female in a care home
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Aspirin 75 OD
Bisoprolol 1.25mg OD
Furosemide 80 OD
Ramipril OD
Digoxin 125 OD
Pravastatin OD
Clopidogrel 75 OD
Falls, Sleepy, Constipated, lethargic, dry skin,
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Tramadol 100 QDS
Pregabalin TDS
Metformin 850 BD
Gliclazide 80 BD
Citalopram 40 OD
Trazadone 100 ON
Salbutamol MDI
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Aspirin - here secondary prevention, stop if primary prevention
Cardiac drugs
– what indication?
– What monitoring? BP pulse, U&Es
Bisoprolol – for HF titrate
Digoxin - any symptoms of toxicity? Dig level needed?
Rosuvastatin
– why on this – not 1st line – had others?
– Still need a statin, if so what cholesterol level
Clopidogrel
– Indication? Duration? Why on this and aspirin? Benefit / Safety
Doses of drugs in renal impairment Cr Cl
– Tramadol, Metformin, Gliclazide, Statins etc
Tramadol and Pregabalin
– What indications?
– Appropriate dose or x a day?
Pain control
– Tramadol full dose but no paracetamol – not in line wth pain guidance
– On opiate, diuretic and anticholiinergic drugs – no laxative – needed?
Diabetes drugs
– Check HbA1c and adjust if necessary
– Other alternative drugs – fit local and national guidance?
Mental Health
– Dose of citalopram ok for age / mood?
– Indication for trazadone?
– FU by MH team recently to review Tx?
Salbutamol
– Indication?
– How often using? -Can patient use? – need aids?
– On therapeutic Tx – need steroid etc
Side effects of any drugs?
80 care home – housebound or outside? – Ca & vitamin D needed for OP # risk –
renal impairment – use alfacalidol
If CKD 3-5 – had ACR assessment?
Aspirin and SSRI, >80 and chronic conditions but no PPI cover – Rx?
Risk and falls review – what can be stopped?
Admin times – anything change? BD pt gets out of bed at lunchtime
Tired, depression, constipation, dry skin – elderly or hyprothyroid? Check TFTs
Answers
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Aspirin
Bisoprolol 1.25mg OD
Furosemide
Ramipril
Digoxin 125 OD
Rosuvastatin OD
Clopidogrel
Tramadol 100 QDS
Pregabalin TDS
Metformin 850 BD
Gliclazide 80 BD
Citalopram 40 OD
Trazadone 100 ON
Salbutamol MDI
Patient StoryMonitoring for safety and effectiveness
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PEG fed patient not had bloods done for >18 months
FU of care from specialist – case management from dietetics every year
Sodium 161 Digoxin >1.3 (0.5-1.0 microgram/L) Urea and Creatinine high
Dehydrated – insufficient fluid in PEG regimen – AKI
Even stable CrCl too low for Rx medicines (DO NOT USE eGFR for drugs
doses)
Poor wound healing – related to high HbA1c
HbA1c excess – insulin and oral meds
Contraindications- stricture but prescribed alendronic acid
Memory drug FU missing
• Need standard PRESET annual (6/12)
monitoring systems
Change Agent
“if you want to go fast,
go alone. If you want
to go far, go
together”
African proverb quoted
by Al Gore
•
Start with myself
• Work out what might
help others to
change
• Build alliances
• Don't be a martyr
Medicines systemscare homes and EPS
• Any top tips for successful
implementation?
For more
information go to…..
• http://www.leedswestccg.nhs.uk/news/l
eeds-care-home-patients-benefitmedication-review-service/
• 0113 84 35528 or 0113 84 35470
• [email protected]
• @NHSLeedsWestCCG
• [email protected]
Thank you for
listening
Any Questions?
References 1
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Managing medicines in care homes (2013). NICE. London
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NICE Good Practice Guidance. http://www.nice.org.uk/guidance/sc/SC1.jsp
Quality Standards https://www.nice.org.uk/guidance/qs85
Commissioning support http://guidance.nice.org.uk/sfcqs85
Local authority guidance http://publications.nice.org.uk/lgb25
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NHS Scotland. Polypharmacy Guidance. March 2015
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http://www.sehd.scot.nhs.uk/publications/DC20150415polypharmacy.pdf (accessed 11th September 2015)
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Welsh Deprescribing Guidance
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http://www.awmsg.org/docs/awmsg/medman/Polypharmacy%20%20Guidance%20for%20Prescribing%20in%20Frail%20Adults.pdf
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Kings Fund Deprescribing
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http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/polypharmacy-and-medicines-optimisationkingsfund-nov13.pdf
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East and South East England Specialist Pharmacy Service.
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A patient-centred polypharmacy (incorporating 7 steps to deprescribing). Version 12 Updated July 2015
http://www.medicinesresources.nhs.uk/en/Communities/NHS/SPS-E-and-SE-England/Meds-use-and-safety/Service-delivand-devel/Older-people-care-homes/Polypharmacy-oligopharmacy--deprescribing-resources-to-support-local-delivery/.
(accessed 11th September 2015)
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New approaches to Polypharmacy, oligopharmacy and deprescribing. London: 2014.
http://www.medicinesresources.nhs.uk/upload/documents/Communities/SPS_E_SE_England/Presn_OPNet_19Nov13_Ne
w_approaches_Polypharm_Oligopharm_and_deprescribing_NB_LO.pdf (accessed 11th September 2015).
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All others accessed 26 04 2015
References 2
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Care Quality Commission. Managing patients’ medicines after discharge from
hospital. October 2009
Polypharmacy and Medicines Optimisation – Making it safe and sound (2013).
The Kings Fund. London. Authors M Duerden, T Avery and R Payne.
Accessed 7 4 14
http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/polypharma
cy-and-medicines-optimisation-kingsfund-nov13.pdf
Making our health and care systems fit for an aging population (2014). The
Kings Fund. London. Authors D Oliver, C Foot, R Humphries.
http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/makinghealth-care-systems-fit-ageing-population-oliver-foot-humphries-mar14.pdf
Accessed 7 4 14
Quest for Quality (2011). BGS Joint Working Party Inquiry into the Quality of
Healthcare Support for Older People in Care Homes: A Call for Leadership,
Partnership and Quality Improvement
http://www.bgs.org.uk/campaigns/carehomes/quest_quality_care_homes.pdf
Accessed 19 12 13
British Geriatric Society (BGS) Commissioning Guidance. High quality
healthcare for older care home residents (2013)
http://www.bgs.org.uk/campaigns/2013commissioning/Commissioning_2013.p
df Accessed 19 12 13
Fit for Frailty. British Geriatrics Society
http://www.bgs.org.uk/index.php/fit-for-frailty accessed 26 04 2015
References 3
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Care Home’ use of medicines study (CHUMS): Prevalence, causes & potential harm of
medication errors in care homes for older people
http://www.birmingham.ac.uk/Documents/collegemds/haps/projects/cfhep/psrp/finalreports/PS025CHUMS-FinalReportwithappendices.pdf
Accessed 19 12 13 and also published as
Barber ND, Alldred DP, Dickenson R et al. Care homes’ use of medicines (CHUMS) study:
prevalence, causes and potential harm of medication errors in care homes for older
people. Quality and Safety in Healthcare 2009;18:341–346
Safety of Medicines in Care Homes. National Care Forum (2013)
http://patientsafety.health.org.uk/sites/default/files/resources/safety_of_medicines_in_the_
care_home_0.pdf Accessed 19 12 13
Clinical Medication Review. A Practical Guide. NHS Cumbria 2013 Accessed 4 4 14
http://www.cumbria.nhs.uk/ProfessionalZone/MedicinesManagement/Guidelines/Medicatio
nReview-PracticeGuide2011.pdf
Task Force on Medicines Partnership and the National Collaborative Medicines
Management Services Programme. Room for Review. A guide to medication review: the
agenda for patients, practitioners and managers. 2002
Report and Action Plan of the Steering Group on Improving the Use of Medicines (for
better outcomes and reduced waste). Improving the use of medicines for better outcomes
and reduced waste: An action Plan. October 2012
Royal Pharmaceutical Society of Great Britain. Moving Patient, Moving Medicines, Moving
Safely – Discharge and Transfer Planning. March 2008