East and North Herts CCG has developed a Care Home service from a designated pharmacist – this short film provides insights into the rationale for the service development and the outcomes and benefits for care home residents and the wider health economy.
|VANGUARD: East & North Hertfordshire Enhancing Healthcare in Care Homes (ECCH) Vanguard|
|Case study & Toolkit:||Implementing Medication Reviews in Care Homes to reduce polypharmacy , improve safety, deliver improved health outcomes and promote cost-effective prescribing.|
|What it is:||The Context
East & North Hertfordshire has 92 nursing and residential care homes taking part in the EHCH vanguard. The vision of the ENHerts EHCH vanguard is:
“To deliver an enhanced model of health and social care to support frail elderly patients, and those with multiple complex long term conditions in the community in a planned, proactive and preventative way”.
To achieve this the vanguard has 4 delivery workstreams:
1. Confident staff in care homes – upskilling staff to feel more confident about supporting residents’ health and wellbeing
2. Multidisciplinary teams (MDT) – support and advice from pharmacists, dieticians, geriatricians, mental health professionals, doctors, therapists and nurses
3. Rapid response – a range of services including a frailty vehicle delivering expert care, supported by teams of healthcare professionals, doctors and nurses
4. Effective technology – GP access to patient information when they visit them in their care homes and data analysis
One aspect of the MDT workstream is to make optimal use of pharmacists expertise to improve care home resident outcomes, reduce A/E attendances and to reduce admissions to hospital by ensuring medicines are handled in a safe and appropriate way in line with NICE guidance https://www.nice.org.uk/guidance/sc1.
Why medication reviews in care homes?
Care home residents take an average of 8 different medicines a day and with up to 70% of home residents incurring medication errors http://www.birmingham.ac.uk/Documents/college-mds/haps/projects/cfhep/psrp/finalreports/PS025CHUMS-FinalReportwithappendices.pdf
As part of a whole package of interventions within the overall programme, the vanguard has established clinical pharmacist medication reviews ( level 3) and closer working with GPs for care homes. The ENHerts ECCH vanguard has already implemented ‘aligned GPs’ to all 92 care homes across 6 localities.
|Purpose:||1. To reduce medication errors and improve medication safety in care homes, leading to:
· Reduction in ambulance callouts and conveyances to hospital
· Reduction in A/E attendances
· Reduction in hospital admissions
2. To reduce the cost of medicines prescribed for residents in care homes by minimising polypharmacy and reducing medicines waste
3. Optimise medication use ensuring all prescribed medication is appropriate and beneficial
|How it works:||What was done?
East and North Herts CCG had already implemented ‘aligned GPs’ with their care homes. This means that each care home have a linked practice who conduct weekly ward rounds as part of an enhanced service.
4 clinical pharmacists (2.6 wte) band 8a and one (0.8 wte) band 5 pharmacy technician have been employed by ENHerts CCG to work with the care homes in the 6 localities involved. More appointments are planned to fully cover the 6 localities with a sustainable workforce once the business case is proved.
The care home pharmacist and technician are part of the wider CCG medicines optimisation team and consequently are aware of the other medicines management objectives that the CCG are working towards and work closely with the locality pharmaceutical advisers.
Once appointed, the pharmacists and technician underwent an induction that included getting to know the key people in the CCG and local adult care services that work with care homes, such as the quality team and safeguarding leads. They also met with locality GPs, key members of the community service, mental health clinicians, local geriatricians and members of the care providers association.
The team developed their own procedures and processes including how interventions are recorded and reported to ensure all data collection is consistent.
The process for a medication review taking place with a care home is:
Ø Care homes are prioritised for a review (starting with the 11 homes in the first wave in the EHCH vanguard Complex Care Premium (CCP) programme, followed by those with quality or CQC concerns, GP request, high hospital admissions/ crisis service use). From this a planned list of care homes has been developed for the team to work through during the year. This list will and can be adjusted as priorities change.
Ø Letters and introductory engagement visits with the care home and the aligned GP are carried out so everyone understands what the medication reviews are about and everyone’s role in the process is clear.
Ø Dates for medication review visits to a care home are set up with both the care home and with the aligned GP’s practice manager for that home. It is crucial that the aligned GP has the commitment and time booked for them to take part in the review so as to update prescriptions in light of the agreed pharmacist’s recommendations, otherwise the medication review by the pharmacist and the care home team is a wasted exercise.
Ø GP system access is secured for the pharmacists, for those care home residents with the aligned GP practice via Smartcard – hence they are authorised to check primary care records.
Ø Clinical Pharmacists base themselves in the care home so they can review for each resident :
o The GP records in SystmOne accessed via remote laptops/tablets whilst in the care home. ( Emis Web can only be accessed from the GP practice at this stage due to IT limitations.)
o The medical notes and care plans in the care home.
o The Medication Administration Record (MAR).
o The team also discuss medicine related issues with resident where able and if not carers/relatives.
o The technician observes medication rounds and provides feedback to care staff. The technician also attends the MDM to inform the pharmacist/ GP / care staff of issues that could be addressed to improve adherence, waste, safety or efficiency.
From this review and following discussion with the GP and care staff, medications may be changed/altered
Ø As the GP has remote access to the patient record they update this at the time of review.
Ø MAR charts are amended and the ‘professionals page’ in the patients care plan is updated by the pharmacist to ensure that carers have access to information related to any changes made.
Ø Any medication changes are discussed with the patient and with patient’s family where appropriate.
Ø The Clinical Pharmacist will also contact the local Community Pharmacy responsible for dispensing the care home’s prescriptions, so they are also fully informed of any changes made.
Ø The Clinical Pharmacists also record their own activity to maintain ongoing audit of their work and record clinical and financial outcomes
Ø Summary reports of outcomes including financial savings and number of medicines review / stopped are sent to GP practices along with action plans for care homes and / or GP practices if necessary.
Ø The service also sends questionnaires out to both the aligned GP practice and the care homes to monitor their satisfaction with the service provided
Medication Reviews have now been taking place in care homes since December 2015.
It has been found that on average it takes a pharmacist 30-40mins per resident ( including approx. 5 minutes / patient of GP time) to complete all the aspects of a review visit to care home, review of MAR and resident’s records, discussions with GP and carers, record keeping. This needs to be factored in when planning the completion of reviews in care homes, especially when many care homes have large numbers of residents
How we engaged with Care Homes and GPs:
It has been vitally important to ensure acceptance and buy-in from the care homes and from their aligned GPs in order to get the medication reviews implemented for maximum benefit. This is particularly so as this requires time from the care home staff and from the aligned GPs to take part in the reviews.
The programme has engaged with primary care and the care homes in the following ways:
· Workshops and meetings and visits to care homes with HCPA, Hertfordshire Care Providers Associate, to explain what the reviews are, and what is required of the care home and what care and business benefit these reviews would be for the homes
· Information leaflets, letters, visits and presentations at primary care meetings, with GP practices to explain what the reviews are, and what is required of the aligned GP and what the benefits would be for the practice
· Initial explanation and discussion at locality meetings and progress updates at bi-monthly prescribing meetings.
|The Impact:||By end of June 16: medications reviews had been completed on:
· 16 care homes (17% of the 92 homes)
· covering 506 residents/patients in total
· of the 4,600 medications reviewed from those 506 patients:
o 578 (13%) of medications were stopped
o 87 of these ceased medications had falls risks attached to them
· An average of £132 has been saved per patient due to stopping meds, resulting in the equivalent of £67,000 savings per annum on medication costs from those reviewed thus far.
|It has been found that on average it takes a pharmacist 30-40mins per resident to complete all the aspects of a review (visit to care home, review of MAR and resident’s records, discussions with GP and carers, record keeping notifying community pharmacist of any changes). This needs to be factored in when planning the completion of reviews in care homes, especially when many care homes have large numbers of residents. .|