Pharmacist Operating Guide Barnsley Health & Social Care Medication Policy for Domiciliary Care May 2008
CONTENTS Section Number Guidance Page Number 1 Barnsley Health & Social Care Medication Policy for Domiciliary Care 3-4 2 Barnsley Health & Social Care Medication Procedure for Domiciliary Care 5-12 3 Barnsley Health & Social Care Medication Processes for Domiciliary Care 13-16 4 Definition of the Three Stages of Medication Support 17-18 5 Business Process Flow - Initial Service User Assessment & Service Establishment 6 Business Process Flow Remind, Assist and Controlled Administering of Medication 7 Barnsley Health & Social Care Medication Operating Practices for Domiciliary Care - Pharmacy Procedural Flow 19 20 21 8 Medication Management System (MMS) Process 22 9 Protocol for Assessment by Community Pharmacist of non-daily Medications prior to inclusion in the Medication Management System and supporting MDS 23 10 Responsibilities of the Pharmacist 24-25 11 General Roles & Responsibilities 26 12 Medication Plan 27-30 13 How to complete the Medication Plan 31-32 14 Medication Plan Example 33-36 15 Home Care Services Approved Moisturising Creams 37-38 16 Community Care Teams Contact Details 39-40 2
Section 1 Barnsley Health & Social Care Medication Policy for Domiciliary Care The Medication Policy governs all home care service provision throughout the Borough of Barnsley and has been developed in collaboration between Service Providers, Care Management, Health and Pharmacists. The Policy has been developed to enable home carers to support the reminding, assisting and controlled administration of service user s medication in a manner that promotes their safety, independence, choice and control. Care managers will promote service user independence by working closely with them to overcome the barriers to self medication in partnership with pharmacists by offering solutions such as large print labels or easy to open bottle tops. Where service users are unable to self medicate largely as a result of cognitive decline pharmacists will undertake medication use reviews (MUR) in the homes of service users or at the pharmacy where service users have the ability to travel, in advance of medication regimes being established through a medication management system, with the aim of implementing a controlled safe environment where home carers are able to carry out assisting and the controlled administration of medication that meets the specific needs of service users. Participating Pharmacists will have the appropriate CRB Check for working with vulnerable adults. Medication Management Systems will be developed in full consultation with service users as part of the medication use review process, to meet their individual needs and choices. Monitored Dosage Systems (MDS) will be utilised in many cases and/or Medication Administration Records (MAR) for recording purposes, (particularly where medication is deemed unsuitable for MDS such as liquid medication) as the core elements of the medication management system. To ensure that the environment is as safe as possible home care providers will only undertake assisting and the controlled administration of medication where a medication management system has been established with medicines replenished by a qualified pharmacist supported by a Medication Plan. Service users being discharged from hospital who are unable to self medicate will receive a visit from a community based pharmacist who will undertake a medication use review and establish a medication management system prior to home care service provision of medication support. Pharmacists will complete medication reviews by weeks12/13 with the purpose reviewing the medication regime with the service user and/or family members or representatives where appropriate to ensure that it is meeting the needs of the service user and will consult where appropriate with the service users GP. Replenishing and disposal arrangements will be discussed and agreed with the service user and/or family as part of the medication use review with the pharmacists ultimately responsible for the replenishment and disposal of medication excluding sharps such as needles which will be removed for disposal by the Council s Clinical Waste Department. 3
Home carers will be prohibited from collecting prescriptions and returning unwanted or out of date medication to pharmacists for service users due to health & safety and legal implications around controlled drugs. Where prescriptions cannot be collected or medicines returned by the service user or their family/representatives participating pharmacists will arrange to deliver/collect. On completion of the medication use review a Medication Plan will be forwarded by the pharmacist to the care management team who will dispatch them to their home care providers along with the care plans. Secure Medication Cabinets with key pad entry systems will be utilised funded by the service user or family with their requirement identified from the medication use review by the supporting pharmacist. Medication Plans completed as part of the medication use review will be stored by home care providers in the service user s communication log located in their home to enable home carers to reference the information. Pharmacists will complete annual medication use reviews to ensure that the medication is meeting service user s needs with regular monitoring support provided by home carers during their visits particularly where medication is being reminded with changes in need communicated to home care management for discussion with the community teams who in turn will inform pharmacists where medication use reviews are required. Changes in medication will be communicated by the GP to the supporting pharmacist who will take the necessary steps to incorporate the new medication into the MDS and/or MAR Chart systems. The medication policy is supported by a clearly defined business process with supporting procedures and underpinned by a robust training plan refreshed every three years to ensure that all contributing parties have the appropriate skills and knowledge to discharge their duties and responsibilities. All home care providers will be encouraged to ensure that their home carers taking the NVQ 2 Award in Care complete Unit 221 Assist to take Medication and that their Senior Home Carers/Team Leaders complete the Safe Handling of Medication training. 4
Section 2 Barnsley Health & Social Care Medication Procedure for Domiciliary Care INTRODUCTION This procedure has been identified to ensure that Home Care Services adhere to and comply with safe working practices, in line with the Commission for Social Care Inspection guidelines, and in conjunction with the policy, business process, training plan and Home Care provider s responsibilities. The Medication and Healthcare Activity Guidance notes have been devised to provide details of these responsibilities. SCOPE This procedure applies to all persons responsible for managing Home Carers and Home Carers themselves. TRAINING REQUIREMENTS Home care service providers will ensure that home carers due to take the NVQ2 Award in Care complete Unit 221 Assist to take Medication, with their Senior Home Carers/Team Leaders completing the Safe Handling of Medication training. All home carers as part of their induction will receive training in the Medication Policy, Procedures and supporting Business Process and be required to provide refresher training every 3 years. CONSENT The Law states that medication support may only be given with the written consent of the Service User. This is obtained at the time of assessment when the Care Plan detailing the activities to be undertaken by the appropriately trained Home Carer(s) is completed and subsequent documents such as the Service User Plan and Medication Plan are produced ahead of services commencing. Where consent is unable to be given by the Service Users themselves, consent should be obtained from an authorised person acting on behalf of the Service User eg Guardian, 3 rd Party, Next of Kin. In situations where consent is refused, the refusal should be should be reported to the Care Manager/Social Worker and no medication support should be provided to that Service User. DEFINITION OF MEDICATION Medication for the purpose of this guidance only includes products prescribed for the treatment of Service Users, which are taken by mouth or applied externally in line with approved Medication and Healthcare activities. 5
ORAL MEDICATION Taking prescribed/non prescribed tablets or medicine is the responsibility of the Service User. Where a Service User is living alone and is unable to perform this activity safely then, following a medication review by a pharmacist, a Home Carer can undertake the controlled administering of medication as detailed on the Care Plan and the Medication Administration Record. (MAR) REMINDING (OCCASIONAL REMINDER OR PROMPT) - THE DEFINITION Reminding for the purpose of these guidelines means an occasional reminder or prompt from the Home Carer for the Service User to take their medicines after checking that the medication is required (refer to Work Roster Communication Log/Care Plan). Having reminded the service user to take their medication the Home Carer will complete the document titled Record of Medication Reminded by Home Carer located in the Communication Log and make an appropriate record in the Daily Record of Care. A persistent need for reminders may indicate that a Service User does not have the ability to take responsibility for their own medication and should trigger a review of the Care Plan, which may result in a Medication Use Review taking place and a Medication Management System being established. The Home Carer must notify their Manager immediately so that they can request that the Care Plan be reviewed and record the notification in the Daily Record of Care. The Home Care Manager will then notify the Care Manager by completing a Contact Assessment form immediately to ensure suitable provision is made at the earliest opportunity by the Care Management team. The Home Care Provider should await confirmation that the Care Management team have made alternative arrangements for support with medication and notify Home Carers accordingly. Home Carers must not undertake assisting or controlled administration of medication until such time as the supporting documentation is received (ie Care Plan and Medication Plan). HOME CARE MEDICATION MANAGEMENT SYSTEM The above is implemented once the pharmacist has completed a Medication Use Review (MUR) and is detailed in the Medication Plan with Monitored Dosage Systems (MDS) and/or a Medication Administration Record (MAR) established. The Medication Management System (MMS) is implemented in full consultation with the service user to ensure that it meets their needs and individual choices. The system establishes a safe environment in which assisting and controlled administration of medication can be undertaken by Home Carers in line with the regulations and standards stipulated by the Commission for Social Care Inspection. 6
Pharmacists will visit service users to undertake additional Medication Use Reviews (MUR) no later than 12/13 weeks after the initial system has been implemented and every 12 months. It is important that Home Carers review the Medication Plan held within the Communication Log during each visit as the Plan may change as a result of the Medication Use Reviews. (MUR) Under the control of the Medication Management System Home Carers who have received the required training will be able to assist with medication or undertake the controlled administration of medication. Assist with medication is defined where a Home Carer removes the tablets out of a MDS or other container using a non touch method and passes them to a service user along with a drink of water. Controlled Administration of medication is defined where a carer removes the tablets from a MDS or other container and with the previous written consent of the service user or advocate provided through the Care Plan and Medication Plan places them on his/her tongue and encourages the service user to swallow the drugs by offering a cup of water to his/her lips. The above may also be defined where a Home Carer measures out a dose of liquid medication as instructed by information detailed in the supporting MAR Sheet. Having completed both the assisting or controlled administration of medication from a MDS the Home Carer will complete the document titled Record of Medication Assisted or Controlled Administering by Home Carer located in the Communication Log and make the appropriate record in the Daily Record of Care. Where medication has been assisted or administered from the originally prescribed packaging the MAR Sheet should be completed and the appropriate record placed in the Daily Record of Care. Where a service user is no longer able to take medication as part of the existing Medication Management System with assistance, the Home Carer after approval from his/her Line Manager, can undertake controlled administering of medication until such time as the Medication Plan has been updated by the participating Pharmacist. The Line Manager once notified of the above by the Home Carer must complete a Contract Assessment ASAP to request through the Community Care Team that a Pharmacist complete a MUR and provide an updated Medication Plan. GENERAL FORMS OF ADMINISTRATION OF PRESCRIBED MEDICATION AND HEALTH RELATED ACTIVITIES o From Monitored Dosage System (MDS) o From original container (when it cannot be placed in MDS) o Liquid medication o Creams / gels Refer to Approved Moisturising Cream List o Inhaled medication* o Eye, ear and nose drops* o TED and compression stockings* * The above activities may NOT be undertaken by a Home Carer without current appropriate 7
training by a District Nurse who confirms that the Home Carer is competent to undertake the activity. This confirmation must be in written form and must be kept by the organisation. FROM MDS / ORIGINAL CONTAINER AS DETAILED ABOVE: Always follow instructions for administration issued on the MDS o Check the Service User s identity. o Check that the medication is for the correct Service User and the MAR sheet relates to the correct Service User. o Confirm that this activity is detailed on the Care Plan. o Check the communication log and MAR to ensure medication has not already been taken. o Check the time indicated on the MDS is the actual time assisting and controlled administration is taking place. o Check how the medication has to be given (eg after food, not with certain drinks). o Undertake the controlled administration of the medication in line with Care Plan/ Medication Plan. o Record on MAR. o Where antibiotics have been prescribed, record in ink the full instructions from the originally prescribed packaging on a blank MAR Sheet and into the appropriate record in the Daily Record of Care. Home carers MUST NOT assist/administer controlled drugs e.g. Warfarin, Methotrexate or Morphine. These should be administered by either a family member or District Nurse. Where medication is found in the home which is not detailed on the MAR Sheet, Home Carers should: Contact their line manager for guidance. The Home Care Manager should contact the participating Community Pharmacist immediately to establish whether or not the medication should be given and agree arrangements for the Pharmacist to include the medication as part of the Medication Management System ASAP if it should be taken. The Home Care Manager should advise the Home Carer of the decision made. Home carer to record the outcome on the Daily Record of Care in the Communication Log and, if medication is to be given, on the Service Users Medication Record and the Blank MAR Sheet provided, until such time as it is included within the Medication Management System if it is required to be taken on an ongoing basis. LIQUID MEDICATION o Check the Service User s identity. o Check that the medication is for the correct Service User and the MAR Sheet relates to the correct Service User. o Check that the medication is still in date & stored in accordance with manufactures instructions. o Record in ink on the container label and in communication log the date the container was opened if you are opening it for the first time. 8
o Confirm the dosage on the label is the same as detailed on the MAR Sheet. o Confirm that this activity is detailed on the Care Plan. o Check the documents in the service users Communication Log and MAR Sheet to ensure medication has not already been taken. o Check the time indicated on the MAR sheet is the actual time being given. o Check how the medication has to be given (eg after food, not with certain drinks). o Measure out the correct dosage using the measuring container provided by pharmacist. o Undertake the controlled administration of the medication in line with Care Plan/Medication Plan. o Record on MAR Sheet. CREAMS / GELS Moisturising skin creams should by applied ONLY, on the basis that it is not part of an ongoing treatment for a skin condition. Refer to the list of Approved Moisturising Creams in your Home Carer Operating Guide. Always check with your Line Manager prior to applying creams which are not detailed on this list. o Check the Service User s identity. o Check that the cream is for the correct Service User and the MAR relates to the correct Service User. o Check that the cream is still in date & stored in accordance with the manufactures instructions. o Record in ink on the container label and in communication log the date the container was opened if you are opening it for the first time. o Confirm that this activity is detailed on the Care Plan. o Check the communication log and MAR Sheet to ensure the Cream has not already been applied. o Always follow your organisation s infection control procedures when applying creams. o Apply as detailed on the container and MAR Sheet o Record on MAR Sheet INHALED MEDICATION This may not be undertaken by Home Carers without current appropriate training by a District Nurse who confirms that they are competent to undertake the activity. This confirmation must be in written form and must be kept by the organisation, and updated annually. Where oxygen is to be provided, any risks relating to Control of Substances Hazardous to Health (COSHH) should be recorded on the Environmental Risk Assessment undertaken by the Locality Manager. In addition to this, further guidance regarding oxygen is provided by the installing contractor. o Check the Service User s identity. 9
o Check that the medication is for the correct Service User and the MAR Sheet relates to the correct Service User. o Check that the medication is still in date. o Record in ink on the container label and in communication log the date the container was opened if you are opening it for the first time. o Confirm that this activity is detailed on the Care Plan and Medication Plan o Check the communication log to ensure medication has not already been taken. o Check how the medication has to be given. o Assist with the inhaler as detailed on the MAR Sheet, Medication Plan and Care Plan. Care must be taken to give the inhaler in the order stated if there is more than one. o Record on MAR sheet. If there is more than one inhaler the care worker should record the order in which they were given. EYE, EAR AND NOSE DROPS Controlled administration of these may not be undertaken by a Home Carer without current appropriate training by a District Nurse who confirms that the Home Carers is competent to undertake the activity. This confirmation must be in written form and must be kept by the organisation. Refer to the list attached for details of examples of acceptable drops. o Check the Service User s identity. o Check that the medication is for the correct Service User and the MAR relates to the correct Service User. o Check that the medication is still in date. o Record in ink on the container label and in communication log the date the container was opened if you are opening it for the first time. o Confirm that this activity is detailed on the Care Plan and/or Medication Plan. o Check the communication log to ensure medication has not already been taken. o Check how the medication has to be given. o Always follow your organisation s infection control procedures when instilling drops. o Instill as detailed on the container and MAR Sheet. o Record on MAR Sheet.. TED / COMPRESSION STOCKINGS Fitting of these may not be undertaken by a Home Carer without current appropriate training by a District Nurse who confirms that the Home Carer is competent to undertake the activity. This confirmation must be in written form and must be kept by the organisation. This activity must also be detailed in the Care Plan. DISPENSING AND STORAGE OF MEDICATION Medication should be stored in a safe but accessible place which should be detailed in the providers Service User Plan and in accordance with the manufacturer s instructions. 10
Where a Medication Plan states that a secure box is necessary, the access code and location of the box should be detailed in the Service User Plan as part of the initial service establishment visit. The copy of the Service User Plan held within the Communication Log in the service users home should have the access code deleted or obscured to prevent the service user from accessing the Secure Medication Cabinet. DISPOSAL OF UNUSED, OUT OF DATE AND NO LONGER NEEDED MEDICATION Unused, out of date or no longer needed medication should be returned to the pharmacist in line with the Medication Plan provided by the pharmacist. Home Carers are prohibited from returning medication, where service users and family/representatives are unable to return medication participating pharmacists will collect. Arrangements should be made to return unused PRN medication to the Pharmacist each Month to prevent stock piling. When stated on the Medication Plan Home Carers should contact the Council s Clinical Waste Department by telephoning the number detailed on the Medication Plan to arrange for sharps such as needles to be collected for disposal, these items should not be returned to the pharmacist. COLLECTION OF PRESCRIPTIONS Arrangements for the collection of prescriptions will be detailed in the Medication Plan provided by the pharmacist. Home Carers are prohibited from collecting prescriptions, where service users and family/representatives are unable to collect participating pharmacists will deliver. NEW PRESCRIPTIONS Home Carers must notify their line manager by telephone immediately when discovering new prescriptions left by GPs in the homes of service users and record the telephone conversation in the Daily Record of Care located in the Communication Log. The Home Care Manager will request that a Senior Home Carer/Team Leader visit the service user s home at the earliest opportunity to collect and deliver the new prescription to the participating pharmacist. ENVIRONMENTAL RISK ASSESSMENT In line with the Commission for Social Care Inspection regulations a comprehensive Environmental Risk Assessment is carried out by the Home Care Provider prior to services commencing, which includes assessment of any risks associated with the Service User s medication. A copy of the Environmental Risk Assessment is available within the body of the Communication Log held in a safe place within the Service User s home, as a key reference point for all Home Carers. The original document is maintained in the Service Users file at the Home Care providers Headquarters. The levels of risk associated with medication will be reviewed and monitored on an ongoing basis. Home Carers must notify their Line Managers immediately of any incidents relating to medication 11
that my be harmful to the service user or themselves and record the incident in the Daily Record of Care. HOME CARERS MUST NOT: Undertake controlled administration of any medication unless a Medication Management System has been implemented and is replenished by the pharmacist. Give injections Make up measured dosages boxes Apply or change any dressings Apply creams other than moisturising products Undertake treatment baths as part of wound care or where there is exacerbation of skin disease Administer any other forms of medication or homely remedies Give any rectal suppositories Give insulin Administer through PEG Change stoma, colostomy or ileostomy bag Change catheters Administer controlled drugs e.g. Warfarin, Methotrexate or Morphine 12
Section 3 Barnsley Health & Social Care Medication Processes for Domiciliary Care Home Care Medication Management Process Initial Assessment The process enables a controlled environment in which a Medication Management System can be implemented to meet the needs of Service Users enabling the reminding or controlled administering of medication by Home Carers in line with the regulations & standards stipulated by the Commission for Social Care Inspection COMMUNITY CARE TEAMS Care Managers undertake the initial assessment (FACS) and identify medication needs. YES Service User is able to self medicate NO COMMUNITY TEAM Dispatch outcome based Care Plan to Home Care Services with instructions to REMIND Service User to take medication COMMUNITY TEAM Request agreed adaptations from the supplying Community Pharmacist COMMUNITY TEAM Identify barriers to self medication by offering solutions such as easy to remove bottle tops or large print on labels FORM 1 MCAF HOME CARERS Remind Service Users to take medication providing verbal support only and complete Medication Reminded Documentation in line with CSCI COMMUNITY TEAM It is anticipated that in the majority of cases agreed adaptations to medication to promote self medication and where appropriate Medication Management Systems will have been established prior to home care services commencing, with pharmacists working to a maximum of 10 days to complete the initial MUR and a total of 15 days to establish a Medication Management System. Should home care services be required to commence prior to the above arrangements being established the Community Teams will provide the Care Plan to providers to enable services to begin with the exception of medication until the above solutions are in place. Administering of medication will be the responsibility of the Service User and/or Family or Friend or in exceptional circumstances Health until the appropriate solutions are in place. The Home Care Providers will not be responsible for reminding or administering medication without the appropriate arrangements in place. YES Barriers Identified/ Overcome NO COMMUNITY TEAM Fax a Contact Referral (sections service user/gp details and medication requirements) supported by a telephone request that a Medication Review be undertaken by the participating Pharmacist with the aim of developing a Medication Management System for implementation within a maximum of 15 Days to enable Home Carers to administer medication in a controlled environment Community team members when referring should request Pharmacists identify opportunities to consolidate medication times where for example there were only 3 home care visits required each day for other activities where medication was required to be taken 4 times a day COMMUNITY/REVIEWING PHARMACIST Completes the Medication Review and establishes a Medication Management System 13
Home Care Medication Management Process Establishing the Medication Management System The process enables a controlled environment in which a Medication Management System can be implemented to meet the needs of Service Users enabling the reminding or controlled administering of medication by Home Carers in line with the regulations & standards stipulated by the Commission for Social Care Inspection COMMUNITY CARE TEAMS Refers service users that are unable to self medicate HOSPITAL SOCIAL WORK TEAM Refers service users that are unable to self medicate prior to hospital discharge SECURE STORAGE BOXES Where the need for a secure box is identified the reviewing pharmacist will notify the Community Team at the earliest opportunity so that they can liaise with the Service Users family to recommend a product with a key pad entry system and offer supplier details and make arrangements for the Service Provider to receive details of the location and access code. The purchasing of the Storage Box will be the responsibility of the Service User or family. COMMUNITY TEAM Registers the Medication Plan and dispatches to the Home Care Service Provider. Where changes are made to the original Medication Plan such as where service users are now able to self medicate with or with or without reminding support the Care Plan is updated accordingly and submitted to the Home Care Service Provider COMMUNITY/REVIEWING PHARMACIST Arranges to meet the service user and/or Next of Kin to undertake a medication user review with the aim of establishing a controlled environment that meets the needs of the service user whereby controlled administering of medication can be undertaken by home carers. Typically through the use of MDS and/or MAR Charts Establishes delivery or collection arrangements. Takes control of repeat prescriptions. Produces the Medication Plan, which includes details of medication and disposal arrangements along with the need if required for a secure storage boxes. Sharps such as needles should be disposed of by contacting the Councils Clinical Waste Section either by the service user, family or home carer (where no support was available) this will be stated in the Medication Plan along with contact details. In circumstances where the Service User is identified with cognitive decline the pharmacist will recommend the use of a secure storage box with a key pad entry system. Dispatches Medication Plan to the Community Team and where appropriate the Community Pharmacist with an instruction to commence supply COMMUNITY PHARMACIST Commences supply of the medication to the service user in line with the information received HOME CARE PROVIDER Places Medication Plan in the Service Users Communication Log and commences services in the controlled administering of Medication COMMUNITY/REVIEWING PHARMACIST Visits the Service User in week 12/13 to evaluate the Medication Management System, where changes are made, the Medication Plan is updated and dispatched to the Community Team and supplying Pharmacist with unused medication with the exception of sharps such as needles removed for disposal HOSPITAL SOCIAL WORK TEAM Administering of medication will be the responsibility of the Service User and/or Family or Friend or in exceptional circumstances Health until the appropriate solutions are in place. 14
Home Care Medication Management Process Requests for Reassessment and Reviews The process enables a controlled environment in which a Medication Management System can be implemented to meet the needs of Service Users enabling the reminding or controlled administering of medication by Home Carers in line with the regulations & standards stipulated by the Commission for Social Care Inspection HOME CARE PROVIDER Identifies Service Users needs increased no longer able to self medicate completes a contact referral and dispatches to Community Team Registers the risks associated with the fact that no further services in respect of medication will be provided until such time as a Medication Management System has been implemented on their Environmental Risk Assessment HOSPITAL SOCIAL WORK TEAM Should there be any changes to an existing service users ability to self medicate as a result of hospital admission or a change to their medication the Hospital Social Work Team will send a request to the Community/Reviewing Pharmacist to to undertake a Medication Review prior to discharge COMMUNITY/REVIEWING PHARMACIST Identify during annual Medication Review that medication requires changing. Updates Medication Plan and dispatches to the Community Team for registration. The annual review takes place in month 11 to enable the coordination of activity with the Community Team who undertake reviews in month 12 COMMUNITY TEAM Complete the assessment and identify barriers to self medication by offering solutions such as easy to remove bottle tops or large print on labels FORM 1 MCAS COMMUNITY TEAMS Request agreed adaptations from the supplying Community Pharmacist COMMUNITY CARE TEAMS Refers service users that are unable to self medicate to the Community/Reviewing Pharmacist COMMUNITY/REVIEWING PHARMACIST Arranges to meet the service user and/or Next of Kin to undertake a medication review with the aim of establishing a controlled environment that meets the needs of the service user whereby controlled administering of medication can be undertaken by home carers. Typically through the use of MDS and/or MAR Charts Establishes delivery or collection arrangements. Takes control of repeat prescriptions. Produces the Medication Plan, which includes details of medication and disposal arrangements along with the need if required for a secure storage boxes. Sharps such as needles should be disposed of by contacting the Councils Clinical Waste Section either by the service user, family or home carer (where no support was available) this will be stated in the Medication Plan along with contact details. Dispatches Medication Plan to the Community Team and where appropriate the Community Pharmacist with an instruction to commence supply COMMUNITY TEAM In exceptional circumstances the Community Teams may Identify that Service Users needs have increased during the annual review with Service Users no longer able to self medicate. These needs in the majority of cases would be communicated through from the Home Care Providers. Care Managers who identify increased need will dispatch a contact referral to the Community/ Reviewing Pharmacist. COMMUNITY TEAM Registers the Medication Plan and produces a new Care Plan dispatching both documents to the home care service provider HOME CARE PROVIDER Places new Care Plan & Medication Plan in the Service Users Communication Log and commences services in the controlled administering of Medication COMMUNITY PHARMACIST Commences supply of the medication to the service user in line with the information received 15
Home Care Medication Management Process Community Based Changes to Medication The process enables a controlled environment in which a Medication Management System can be implemented to meet the needs of Service Users enabling the reminding or controlled administering of medication by Home Carers in line with the regulations & standards stipulated by the Commission for Social Care Inspection GENERAL PRACTITIONER Prescribes new medication typically Antibiotics/Steroids for Service User HOME CARE SERVICE PROVIDERS Where the GP leaves a new Prescription at the home of a Service User the Home Carer must inform their line manger immediately by telephone who in turn should contact a Team Leader/Senior Home Carer and request that they deliver the Prescription to the supporting Pharmacist at the earliest opportunity. The Home Carer must log the incident in the Daily Record of Care held within the Communication Log SERVICE USER/FAMILY SUPPORT Present prescription to Community Pharmacist. COMMUNITY PHARMACIST Pharmacist builds in the new supply of medication through the use of a MDS or MAR Chart the following week, supplying a MAR Chart in the first instance if immediate supply is required If the GP has previously provided medication to the home guidance will immediately be sort from the supplying pharmacist. 16
Section 4 Definition of the Three Stages of Medication Support The Barnsley Health & Social Medication Policy for Domiciliary Care has been developed within the Guidelines stipulated by CSCI however there are minor differences due to the unique nature of the partnership between Health & Social Care with the Community Pharmacists being an integral partner, which differs from the vast majority of social care environments. Home carers will be unable to assist service users to take their medication through the use of compliance aids which have not been established or replenished by the supporting Community Pharmacists due to the risks associated with the provision or dosage of inappropriate medication. Stage 1 Remind Service User to take Medication The service user is able to self medicate initially or with advice from the Community Care Team on how to overcome the barriers to self medication for example; with the removal of child proof tops or larger print labels. These will be provided by the Community Pharmacist on request by the Community Care Team. The Care Plan will state Remind to take Medication and will also be displayed on the home carers Weekly Work Roster. The Community Pharmacist is not required to undertake an MUR in these circumstances as there is no need for a Medication Management System. The home carer provides an occasional reminder to the service user without any active involvement with the medication, for example a reminder may be given in the lounge with the medication kept in the Kitchen or Bathroom. The carer will inform her manager immediately if she/he believes that the service user is unable to continue to self medicate and may require a Medication Management System. Stage 2 Assist Service User to take Medication The service user is unable to self medicate with the Community Pharmacist at the request of the Community Care Team completing a Medication Use Review prior to implementing a Medication Management System supported by a Medication Plan which states Assist to take Medication under the Support Required Section. The Care Plan will state Medication Management System with the home carers Weekly Work Roster stating Assist to take Medication. The compliance aid (MDS) or originally prescribed packaging will be supplied and replenished by the Community Pharmacist with the carer taking the soluble medication from the container and placing it on the palm of the service user s hand prior to passing them a drink of water to aid swallowing. Stage 3 Controlled Administering of Medication The service user is unable to self medicate with the Community Pharmacist at the request of the Community Care Team completing a Medication Use Review prior to implementing a Medication Management System supported by a Medication Plan which states Controlled Administering of 17
Medication under the Support Required Section. The Care Plan will state Medication Management System with the home carers Weekly Work Roster stating Controlled Administering of Medication. The service user or guardian where required will have signed both the Care Plan and Medication Plan in advance of controlled administering to give consent. The compliance aid (MDS) or originally prescribed packaging will be supplied and replenished by the Community Pharmacist with the carer taking the soluble or liquid medication from the container in the correct dosage as stipulated on the Medication Plan and placing it in the mouth of the service user. The Community Care Team will inform the Community Pharmacists of the number of daily visits from home carers to enable them through the Medication Use Review to safely consolidate dosages with the permission of the service user thus eliminating the need to put out medication to be taken by a service user on their own at a later time. Key Note: Home carers under no circumstances will provide assisting or controlled administering of medication until such time as a Medication Management System has been implemented within the home of the service user, with Community Pharmacists contracted to complete the process within a maximum of 15 days from the point of referral. District Nurses will provide services until such time as the medication management system is implemented where families or representatives of service users are unable to provide short term support. 18
Section 5 - Business Process Flow Initial Service User Assessment & Service Establishment Community Care Team Screen referral/complete assessment Service User is able to self medicate? Yes No Community Care Team Submits Care Plan to Home Care Service Provider Remind to take Medication Community Care Team Faxes Contact Assessment to Pharmacist to request Medication Management System Family or District Nurses provide medication support until Medication Management System established Home Care Service Provider Completes service establishment visit producing Environmental Risk Assessment and Service User Plan with Remind to take Medication detailed as an activity on the carers Weekly Work Roster Home Care Service Provider Home carer provides appropriate support notifying manager immediately of problems identified or request for re-assessment if needs change Community Pharmacist Completes Medication Use Review, establishes Medication Management System, produces Medication Plan detailing; Medication regime MDS and/or MAR Requirement for either Assisting or controlled administering of medication Replenishment arrangements Disposal of unwanted medication Need for Secure Medication Cabinet Faxes Medication Plan to Community Care Team Community Care Team E-mail Medication Plan and Care Plan Medication Management System to home care service provider Home Care Service Provider Completes service establishment visit producing Environmental Risk Assessment and Service User Plan with Assist or Controlled Administering of Medication detailed as an activity on the carers Weekly Work Roster 19
Section 6 - Business Process Flow Remind, Assist and Controlled Administering of Medication Remind to take Medication Home Carer reminds service user to take medication without any active involvement Medication Management System Established by a Pharmacist in the home of the service user following a referral from the Community Care Team Home Carers play a crucial role by reporting changes to service user needs to their managers to enable them to request the Community Teams to undertake reviews and re-assessments in partnership with the Community Pharmacists Assist to take Medication Home Carer removes medication from packaging and passes to service user for he/she to take Medication Plan produced following a Medication Use Review detailing Assist or Controlled Administering of Medication Controlled administering of Medication Home Carer places medication in service user mouth and administers water A service user may after a period of re-enablement, be able to self medicate with or without reminding support A service user s needs may increase preventing them from self medicating with a medication management system required established by a Community Pharmacist and supported by a Medication Plan A service user s needs may increase which will require the need for controlled administering of medication A service user may after a period of re-enablement, be able to take their medication with assistance 20
Section 7 Barnsley Health & Social Care Medication Operating Practices for Domiciliary Care - Pharmacy Procedural Flow Step 1a Request made from either patient, family member or GP. Refer this request into the Medication Management Scheme by contacting the appropriate Community Care Team. Refer to section 16 Pages 39/40 Step 1b Referral received from Community Care Team. See Pages 39/40. Step 2 MUR to be arranged with Service User within 10 days Step 3 MUR conducted (at Service Users home or in pharmacy) and Medication Plan established. Step 4 Copy of Medication Plan sent to Community Care Team Step 5 Support as per medication plan supplied within 15 days of referral Step 6 Identify changes to medication from interim prescriptions received/information gathered from carer/family/gp. Where antibiotics supplied mid week please state on Daily Record of Care in the Communication Log to flag up to home carers. Step 7 Continue support and claim fee monthly Step 8 Review medication plan after 12/13 weeks via MUR Step 9 Forward reviewed medication plan to Community Care Team and supply adjusted support (as appropriate) Step 10 Continue to supply and claim fees (any information following hospital discharge will be forwarded by hospital pharmacy dept) Step 11 Review medication plan annually via MUR (or earlier if circumstances necessitate) and forward new medication plans to Community Care Teams after each review 21
Section 8 Medication Management System (MMS) Process Community Care Team, pharmacy or another similar source refers service user into the MMS. On hospital discharge, if the service user has previously been in receipt of MDS they will be discharged on one, if they have not and are identified as being unable to self medicate, they will be referred to their regular pharmacy (if participating in LES) and enough medication will be dispensed to see the Service User through to the end of the assessment period. Details of the discharge will be faxed to the pharmacist and GP, along with a named contact at the hospital to ease discharge. For service user s referred into the MMS by the Community Care Team, they will conduct an initial assessment of ability of SU to self medicate. If the Community Care Team identify simple barriers to self-medicating, they have a summary of how these can be tackled without further referral into the MMS. If the barriers cannot be overcome, the service users will be referred to their regular (participating) pharmacy, by fax, containing all relevant information. If the service user s regular pharmacy is not undertaking the MMS LES, the service users will be referred to a participating pharmacy local to them. Follow the Pharmacy flowchart to describe actions within the pharmacy. Once the Medication Plan has been completed it is placed on the service user s care plan and is accessed by all carers involved in the Service users care (as appropriate). Service users may be cared for by a number of different carers. MAR sheets and other documentation is used by carers to record their activity in relation to the administration/reminding support outlined in the Medication Plan. 22
Section 9 Protocol for Assessment by Community Pharmacist of non-daily Medications prior to inclusion in the Medication Management System and supporting MDS 1 Identify medications not prescribed for daily use. (e.g. once weekly) 2 Establish which day(s) this medication is to be taken on. 3 Pharmacist to make a judgement as to the clinical appropriateness of inclusion in MDS (e.g. methotrexate and warfarin would not normally be appropriate for patient safety reasons) Typically administered by District Nurses NOT Home Carers. 4 Where a drug may be included, consider the practical aspects of the dosage regime for that drug (e.g. risedronate must be taken 30 minutes before first food, drink or other medication of the day). Ensure that this is recorded clearly on the Medication Plan, and sufficient notes are made and attached to the Service Users PMR. These notes must incorporate all the necessary information to allow the Carer to be aware of how this drug is taken safely. 5 Consider the need for additional labelling to clarify any special instructions. As a minimum this should include a note in the dosage field stating Check the Medication Plan. 6 Ensure that the Service User and/or carer receive adequate counselling to explain both the adjusted regimen and the reasons for this. This is likely to involve the issue of a patient information leaflet for the relevant drug. 23
Section 10 Responsibilities of the Pharmacist This acts as a summary of the key responsibilities of the participating pharmacist (this includes the staff under their supervision) in the execution of the LES. On receipt of a valid referral, to contact Service User and/or the appropriate Next of Kin/representative to arrange a MUR at either the pharmacy or the Service User s home within 10 days of the referral. Conduct the MUR and devise an appropriate Medication Plan within 10 days of receipt of the referral. As part of the MUR, establish any problems that the Service User is experiencing which prevents them from self-medicating. This includes reminding issues. Transmission of the completed Medication Plan to the relevant Care Team. Deliver the level of support indicated by the Medication Plan within 15 days of the receipt of the referral. When dispensing the Service User s medication, pay particular attention to labeling needs, so that the Service User and their carer is able to understand any special precautions/instructions with any of the items involved. When supplying a MAR sheet, ensure a label is attached to any MDS pack stating, Please see MAR sheet for medication not supplied in this pack. Consider the level of Home Care available (as stated on the referral), and investigate the need to consolidate dosage regimes to fit in where possible. Consider the impact of any special precautions of particular drugs, and make changes to dosage times as appropriate. Ensure NPSA guidance is followed in respect to drugs such as Warfarin and Methotrexate. The ordering and processing of prescription. Monitoring changes to the Service User s medication through mid-cycle changes and interim prescriptions (where this is possible). Liaising with the Service User s surgery as necessary. Putting changes into place to account for discharges from hospital (using details provided by the hospital pharmacy). Liaising with care staff to ensure appropriate supplies continue. 24
To review the Medication Plan 12-13 weeks after establishment, and annually thereafter; and as necessary should there be significant changes to the Service User s condition/treatment/circumstances. Forwarding updated Medication Plans to the relevant Care Team after each review. Arranging mutually beneficial delivery schedules with Service User. Forwarding details of how to purchase secure medication storage boxes where this is appropriate. Maintaining appropriate records within the pharmacy to ensure safe and effective continuity of support. Ensure that support staff are appropriately trained. Submit monthly claims by the 5 th working day of each month. 25