Transcript Sheffield Integrated Care Service A co

Sheffield Integrated Care Service
Integrated support for complex
patients.
Sarah Alton Head of Medicines Management
Janet Smith Community Matron
Sheffield
Combined Community and Acute Pathway Integration Our patient pathways span the provision
of health services across community and acute, including older people, stroke and palliative care.
This has provided the opportunity to consider how the delivery of care could be configured and
redesigned in the future to transform patient pathway
Integrated Community
Care
Four Integrated Care Teams
(ICTs) covering:
ICT Nursing 24/7
ICT Therapy
ICT Pharmacy
Active Recovery (Rehab)
Falls Service
Podiatry (including forensic
and acute)
Flexible Workforce
Primary Care &
Interface Services
Active Recovery incl:
Assessment Team & Rehab
Assistants
Rapid Response
IV Team
Phlebotomy
Transfer of Care Team incl:
Front Door Response
Ward Transfer of Care
Care Home Liaison Placement
Macmillan Case Management
Primary Care:
GP Collaborative
Single Point of Access
Telehealth
Active Programmes (incl
MH Resp)
Assessment and Rehab
Centre (ARC)
Acute Therapy Services
Integrated Geriatric
& Stroke Medicine
Therapeutics &
Palliative Care
Integrated Stroke:
Acute Stroke Unit (RHH)
Stroke Intermediate Care
Beds (Beech Hill)
Community Stroke Team
Palliative Care:
Palliative Care Unit
Hospital Support Team
Intensive Home Nursing
Bereavement Service
Geriatric Medicine:
Care of Elderly wards
Frailty Unit
Intermediate Care Beds
(General, EMI and Ortho)
Outpatients
Lymphoedema Service
Continence
Tissue Viability
TB
Therapeutics:
Chaplaincy
Dietetics (acute/community)
Psychological Services
SLT (acute/community)
Medical Illustration
Plus host for:
CCA Research
Professional Leadership
The Integrated Care
Pharmacy Team
Pharmacist Team
Lead 0.8FTE
Clinical
Pharmacists
2.0FTE
Care Home
Support
Pharmacist 0.4FTE
Pharmacy
Technician 1.0FTE
Referral Criteria to Pharmacy
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Compliance issues
On 10 or more medications
Difficulties with swallowing
Recently discharged from hospital
or intermediate care facility
At risk of falls
Pain review needed
On high risk medicines
Medication related concerns
Activity to date: Reviews
• Over 500 referrals
Apr 14 to March 15
for domicillary review
• Approx 50:50
clinical:adherence
• 76% clinical reviews
for patients with
complex long term
conditions
Medicines Optimisation
MDT working
to improve
medicines
management
and patient
outcomes
Social care
GP practice
Hospital
The
medicines
optimisation
hub.
Community
pharmacist
Nurse
COPD Initiative
• From October 2015 to April 2016
• All patients with diagnosis of moderate to
severe COPD in one Community nursing team
• Initial review and CAT assessment , follow up
at 3 and 6 months
• Evidence based
– GOLD criteria
– Isle of Wight initiative
Education and Training
• Medicines management training as part of
core clinical skills for all community staff
• Ad hoc training on medicines issues
• LTC medicines management training provided
– Heart Failure
– COPD
– Diabetes
Case Study 1:
• Patient referred due to poor compliance with her monitored dosage
system (MDS)
• A home visit from the Integrated Care clinical pharmacist was
arranged.
• Patient had carers in morning to assist with showering and dressing
• The patient had good compliance with her morning meds however
this was poor at lunchtime and hit and miss with evening meds.
• The medications she was non-compliant with included furosemide,
lansoprazole and simvastatin. The patient explained she went out
shopping , going to coffee mornings and lunch clubs.
• The patient was taking two beta-blockers, one had been
discontinued during a recent hospital admission and alternative
started, but this had not been updated at the GP surgery.
Questions
• What factors would be considered on first
assessment of this patient?
• Who should be involved in discussions
regarding this patient?
• What recommendations might be made to
support this patient?
Actions Taken
• Discussion with patient to find out her needs, community
pharmacist , GP and carers
• Discontinue one of the beta-blockers
• Furosemide discontinued,nurses to monitor
• Rationalise medications to once a day in the morningsimvastatin switched to atorvastatin
• Carers to prompt with meds in the morning
• Second visit planned to coincide with delivery of updated
MDS. Patient counselled on the changes to her meds.
• Third visit arranged after a few weeks to assess
compliance with the new MDS.
• Patient’s compliance was much improved.
Case Study 2
• Patient referred to the pharmacy team
• Patient receiving ongoing district nurse visits
for the application of a Fentanyl patch every 3
days.
• The patient had an existing care package and
received four care calls a day to administer
medications, excluding Fentanyl
Questions
• What factors would be considered on first
assessment of this patient?
• Who should be involved in discussions
regarding this patient?
• What recommendations might be made to
support this patient?
Actions Taken
• Home visit from clinical pharmacist
• Medication review of all meds
• Discussion of options with patient and assessment of
circumstances- a little persuasion resulted in the
patient agreeing to the care company taking over the
application of the fentanyl patch
• Contact care company superviser to request
application of Fentanyl patches was included in the
meds admin package.
• Reduced need for a nurse visit.
Benefits of Joint Working
Wider Skill Mix
Broader input into Long Term
Condition Reviews
MDT approach adds value
and improves outcomes for
patients
Better understanding of each
others roles
Members of the team linked
to localities leads to improved
communication and improved
rapport
Shared knowledge and skills
“Better than a BNF”
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Changes to nursing teams
Changes to pharmacy team
Small team spread thinly
Taking time to refer
Communication across teams
Capacity
Future Developments
• Greater input into LTC reviews
• ICT pharmacy team caseload and management of
patients
• Increased input into palliative care and end of life
patients
• Prescribing
• Widening referrals
• Increased integration with social care and locality
working
Without
change there
would be no
butterflies”
“