New Care Models Pharmacy Services in Care Homes Pauline Walton
East & North Hertfordshire Background By 2030 the number of older people with care needs is predicted to rise by 61% 2,000 extra carers needed year on year to meet increase in demand Rising pressure on care homes: Unplanned use of health services (e.g. GP, 999) Delayed Transfers of Care Staff pressures Poorer resident outcomes
Care Homes in East & North Hertfordshire 62 older people s care homes Of which.. providing.. 3,475 beds 37 are residential homes (1786 beds) 23 nursing homes (1550 beds) 2 have dual registration (139 beds) 79% of homes are rated by CQC as 'Good', 19% as 'requires improvement 3% and as 'Inadequate'.
2013-14 2,794 visits to A&E 1,744 admissions to hospital from care homes The A&E attendance rate is 0.96 per 100 population in the over 65 age group residing in care homes. This compares to 0.34 A&E attendances per 100 population of the general over 65s population. 454 hospital stays of less than one day 23hrs 5.76M 7 Care home patients on average have 7 prescribed medicines Nationally, on any given day 70% patients experience at least one medication error (Barber ND et al 2009) Pharmacist visits to care homes can reduce reported errors
One in six people aged 85 or over are living permanently in a Care Home. Yet data suggest that had more active health and rehabilitation support been available, some people discharged from hospital to care homes could have avoided permanent admission. NHS Five year Forward View, October 2014 50 vanguards across the country 6 focusing on care homes Became a Vanguard site August 2015
Confident Staff Up skilling staff to feel more confident about supporting residents health & wellbeing Multidisciplinary Teams Support & advice from pharmacists, dieticians, geriatricians, mental health professional, doctors, therapists & nurses Rapid Response A range of services including a frailty vehicle delivering expert care, supported by teams of healthcare professionals, doctors and nurses Effective Technology GP access to patient information when they visit them in their care homes and data analysis Enhanced GP care Targeted support Impartial Assessor Tech in Care Homes Early Intervention vehicle Care Home pharmacist /technician Red Bag HomeFirst Community linked geriatric team Complex Care training End of Life care
Care Home Pharmacy Team
Medicines Optimisation overview A person-centred approach to safe and effective medicines use, to ensure people obtain the best possible outcomes from their medicines. Monday to Friday 9am to 5pm 1. Identify Care Home 2.Arrange access to care home and aligned GP practice/s and Community Pharmacist 3. Liaise with practice to gain access to system. 4. Medicatio n Review 5. Systems and processes 6. MDT meeting 7. Follow up Expert deep dive into residents medication Recommendations made to care home s aligned GP. Decisions actioned. Multidisciplinary working & Partnership working Reduced duplication Secure GP development Benefits: Improved safety Improved health outcomes Reduction in costs and waste Adhoc training opportunities Best practice shared & embedded Implementation of guidance Support with CQC preparation and action plans
Medicines Optimisation more details For each patient look out for: Monitoring Inherited prescribing, allergies Any medicines with no clear indication Documents e.g. Mental health reviews Identify how often medicines are requested/ repeated and any PRN medicines Any resident with dementia is READ coded correctly Identify if patient is taking ONS and review against local guidance / MUST score Collate all information from: 1. Recent CQC reports 2. Quality team to identify common medicines related issues and themes that have resulted in hospital admissions 3. Community pharmacist to identify medicines system related issues Patients with concerns: Recent hospital discharge/new admissions Frequent fliers, polypharmacy High risk medication Poor medication adherence Multiple co-morbidities
Definition Systems and Process - RiO scoring Developed by NHS Croydon, based on the Hospital Avoidance Scale within the RiO system and adapted to provide a simplified health intervention scoring tool. A qualitative assessment is made of the potential impact of each intervention allowing the assignment of a value of likelihood with regard to the prospect of the intervention preventing a hospital admission. Scoring Recommended that interventions are peer reviewed to ensure consistency of approach. Reviewed within our own pharmacy team and externally with HVCCG and HCT pharmacists. Used in several areas across the country and has been incorporated into the RPS document Supporting use of pharmacists in care homes. Average cost of hospital stay for this pt group is 2,600 Level 1 Lifestyle advice Compliance aid to remove medication from a blister Unnecessary food supplement stopped Level 2 Long term steroids; bisphosphonate started Spacer device added for patient with asthma with poor inhaler technique Crushing of modified release medication stopped. Level 3 Insulin instructions changed; resident was being given novorapid despite low blood glucose levels Elderly patient prescribed SSRI and aspirin, gastro protection started Diazepam rectal added for patient with poorly controlled epilepsy Concerns: Subjective Not been academically reviewed/ validated.
Impact so far
Key high impact themes Quality Stopping medicines that may cause falls Reducing ACB Stopping concurrent anti-coagulants Review and replacement of Trazodone Documenting allergies Costs Best practice repeat ordering systems introduced with Community Pharmacists Review of ONS and use of nutritional review, checking weights, use of MUST tool Promote Food First
Based in care homes One Care Home one GP practice IT solutions to viewing notes there and then Effective GP engagement through face to face in situ discussions Previous evidenced pilot work Vanguard integrated working Enablers
How did we identify patients Future At the Start Data from recent CQC reports, CCG Quality team, relationship with Care home and GP Currently Vanguard Targeted Support project identified homes who needed extra support (from a range of data) Risk Stratification using efi and STOPP/START tool within SystmOne
Completed Dietetic Support More written support materials Involvement in providing CPPE training In progress Recruit pharmacy technician Develop pharmacist independent prescribers Prescqipp Care Home medicines management e learning package Ambitions for the future Improved templates within GP clinical systems for med reviews Linking with GP based practice pharmacists to cascade and develop workforce In the future AKI training for care home staff Antibiotic and treatment of UTI training Community Pharmacy workforce development Spread across STP Expanding the scheme to cover more care homes Apply programme principles to home care services for our vulnerable housebound residents Evaluate outcomes more systematically
A day in the life of https://www.youtube.com/watch?v=5xbg-havwfw
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