Implementing QIPP in care homes Hounslow PCT approach - Delivering positive clinical and cost effective outcomes Unoma Okoli Care Home Pharmacist, Hillingdon PCT unoma.okoli@nhs.net
Background CHUMS-Care Home Use of Medicines Study report (October 2009) raised significant issues in care homes that additional support could improve care, reduce risks and improve cost effectiveness. Hounslow PCT issues Limited medicines management support solely to care homes. Higher Cost/APU for GP practices with care home patients leading to pressure on their prescribing budgets. Key drivers being Specials, dressings and oral nutritional supplements. How best to support care homes and GP practices manage patients with complex medication needs. How to deliver QIPP in care homes.
Business Case Proposal To recruit a Care home pharmacist for one year. (0.6-0.8wte) Care home pharmacist role: medication reviews for patients in care homes in partnership with the patient s GP practice, other healthcare professionals and other stakeholders. support the development and delivery of QIPP initiatives in care homes. Funding- top sliced from the prescribing budget. Key Performance indicators primary & secondary outcomes and measures
Medication Review Outcome Background 12 Nursing homes with 520 residents covered by Hounslow GPs. 88% of the residents are under the care of 5 GP practices and reside in 8 nursing homes. 7 nursing homes (334 patients) reviewed. The residents are mixed client groups; whilst the majority of the residents in these care homes are frail and elderly, a proportion are the elderly mentally ill, high dependency & those requiring palliative care.
Medication Review Outcome Care homes Patients notes reviewed Total* interventions actioned Annualised prescribing savings Average savings per patient reviewed NH 1 51 124 11,150 219 NH 2 77 210 19,692 256 NH 3 54 206 48,120 891 NH 4 50 175 46,230 925 NH 5 33 129 15,539 471 NH 6 55 177 16,849 306 NH 7 14 65 4,998 357 Total 334 1086 162,578.95 486.76 Note:* Total intervention actioned represents 60 85% of total interventions recommended RIP & respite patients are excluded from data
Medication Review Outcome Some practical examples
NH 1 NH 2 NH 3 NH 4 NH 5 NH 6 NH 7 Medication Review Outcome 250 200 150 100 50 0 8 24 92 Intervention levels by care homes 8 52 39 150 9 4 19 158 152 * RIO scoring method developed by Croydon PCT was used to measure the effect of the interventions on potential unplanned hospital admission 9 25 95 8 29 140 0 13 52 Level 3 Level 2 Level 1 Scoring system* Level 1- Intervention unlikely to have avoided a future hospital admission. Level 2- Intervention may have avoided a future hospital admission. Level 3- Intervention has probably avoided a future hospital admission. It assumes that 1 in 10 of level 2 interventions would have resulted in hospital admission, hence 10% of the number of level 2 s are counted as level 3 s Of the 334 medication reviews actioned, there were 839 level 1 interventions 201 level 2 interventions ( equivalent to 20 level 3) and 46- level 3 interventions
Medication Review Outcome Results 1086 interventions were actioned with an annualised savings of 162,578 ( 486/patient) Approximately 70% of the interventions accounted for the annualised savings while 30% relates to quality and safety issues. Additional 16,002 estimated savings for rationalising inappropriate use of dressings in two of the nursing homes. Estimated cost of hospital avoidance is 51,282-234,498 ( based on average cost of 2-7days stay)
Emerging themes Risk due to varying levels of nursing skill and competence. Nurses unable to change catheters leading to A&E attendance. Patients on BP drugs - GP not informed despite BP readings of 150/90 & greater or 95/60 & lower. Medicines stored in fridges with temperatures out of range for up to 1 year and recorded.( 11-26 0 c) Inadequate or lack of relevant information provided to GP during home visit. Poor MAR recording and documentation. Lack of clarity on dressings used per resident.
Emerging themes Drugs related and GP prescribing issues Lack of implementation of MHRA drug safety updates. e.g. domperidone risk of VA or sudden death, strontium risk of VTE, citalopram greater than 20mg in over 65yrs Reluctance to challenge the continuation of medications initiated in Hospital e.g. 2-3 antidepressants in dementia, memantine combined use with AChEIs( not approved) Reluctance to initiate trial stoppage of antipsychotics or sedatives without support of CPNs or specialist. Low BP leading to unplanned hospital admissions due to falls BP 94/53 and patients on Atenolol 10mg od and amlodipine 5mg od. Long term prescribing of silver dressings (3-6 months)
Emerging themes Drugs related and GP prescribing issues Multiple use of emollients, barrier creams, PPIs + H2 antagonist+ gaviscon, laxatives sometimes leading to loose stool and request for antidiarrheal. Patients prescribed incontinence medications and using pads. Inappropriate prescribing of Specials - some initiated in hospital. Inappropriate prescribing of ONS/SIP feeds. Post prescribing of incontinence appliances and stoma products.
Emerging themes Drug incidents/errors Same drug given twice as stated on MAR ( versicare and solifenacin) Double dose of risperidone administered in error as stated on MAR. Paracetamol and codydramol administered leading > 2g paracetamol /day. Midazolam prescribed PRN for seizure Fentanyl patches with 2 different dosages for same patient. Oramorp oral solution omitted on MAR yet administered.
Emerging themes Poor Nursing home processes leading to wastage Inadequate check by NH and practice staff involved in the repeat prescribing process. Continuous reordering of PRN medications despite non adherence e.g. laxative, analgesics etc No clear protocol for ordering incontinence and stoma appliances leading to wastage. Ordering of dressings in isolation of the review periods. Others NH and GP s not always aware of specialist services that are available to residents in the community. NH nurses not aware of training provided by PCT- incontinence specialist nurse training etc.
Challenges Care home pharmacist role what is the remit? Managing expectations of stakeholders. Lack of clarity on how to resolve issues uncovered as there may not be protocol/procedure to refer to. Dealing with multiple stakeholders and multidisciplinary teams who may at times be defensive. Uncharted terrain with uncertainties. Balancing cost pressure and quality issues. Continued pressure to justify the role of care home pharmacist. Pressure to resolve all incidents and issues identified. Sometimes feeling of working in isolation and not adequately supported.
Successes Cost effective outcomes: annualised savings of 162,578 from review of 334 patients. 16,002 estimated savings for rationalising inappropriate use of dressings in two of the nursing homes. estimated cost of hospital avoidance is 51,282-234,498 CCG to fund the role of care home pharmacist for an additional 3 years fixed term. GP LES commissioned for the local authority funded residential home due to care home pharmacist work which identified medicines management and clinical risks. LA care home service specifications to be amended to reflect the recommendation from the care home medication reviews outcome Routine minimum training for nurses in nursing home Medicines reconciliation and review for new residents or on discharge from hospital with timeline by pharmacist/gp or nurse LA to review monitoring standards for care homes.
Impact and Benefits Support additional capacity to provide quality medicines management initiatives within care homes. Target top 10 prescribing areas by utilising the work undertaken by East and South East England Specialist Pharmacy Services in relation to implementing QIPP in medicines management in Care Homes. Deliver net value savings and support End of Life Care. Support implementation of the MHRA drug safety Alert. Reduce the risk of inappropriate hospital admissions and support planned discharge.
Impact and Benefits Support good practice across Outer North West London. Support CHUMS report recommendations. Support Service redesign- care home in reach specialist service for dementia? Partnership working with local authority to reduce medication errors in care homes.
Integration into the wider health care Support additional capacity to provide quality medicines management initiatives within care homes. Local Authority engagement Influence service redesign/ specifications e.g. community stoma care nurses, in reach specialist services in care homes Support National priorities NSF for Older People published in 2001. Specifically, standard 2, Person Centred Care. Government s 2008 white paper Pharmacy in England: Building on Strengths - delivering the future. Compliance with the 16 regulations (out of the 28) that come within Part 4 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010
Tips Write a Business Case Define the care home pharmacist remit process or clinical review or both? Pharmacist right skills, knowledge and experience willingness to learn Know the Evidence Engage and work closely with the GPs with homes Work closely with other stake holders local authority, tissue viability, incontinence nurses, dieticians, CPNs, dementia specialist in secondary care etc. Work closely with MMT- identified prescribing trend in care home is likely happening in the general GP population as well.
Tips Understand what governance process is in place within the organisation and how incidents identified will be handled. Medication review process Agree the process and how interventions will be actioned with the GP prior to commencing the reviews. no blame and non judgemental approach required. Balance cost benefit vs quality. Balance time spent on administrative vs clinical reviews. Professional support shadow other colleagues and clinicians. join the RPS care home group. Share your findings with key stakeholders. A learning organisation culture facilitates success.
My Experience Community pharmacist PCT Practice Pharmacist Pharmaceutical Adviser Former PCT NPC Associate Pharmacovigiliance and pharmacoepidermology certification - LSHTM CPD s ongoing Updating my clinical skills. relevant courses, training, shadowing etc literature review and journals
Appreciation Sangeeta Sharma, Senior Commissioning Medicines Adviser, Hounslow PCT and Medicines Management Team. Cherise Howson, Senior Care Home and Practice Support Pharmacist Croydon PCT. Lelly Oboh, Consultant Pharmacist, Care of Older People, Guys & St Thomas Community Health Services East and South East NHS Specialist Pharmacy Services.