East & South East England Specialist Pharmacy Services East of England, London, SouthCentral & South East Coast Medicines Use and Safety Community Health Services Update: NICE Managing Medicine Care Homes SC1 Focus on Recommendations 1.2 & 1.15 Lelly Oboh Consultant Pharmacist, Care of older people 20 th Nov 2014
Care homes Over 18,000 homes care for ~ 460,000 adults in England 1 95% are over 65 years 2 and average age is mid 80s 3 Most common conditions dementia, stroke, degenerative neurological conditions, advanced cardio-respiratory disease, cancer and painful arthritis 3 Residents are frail, vulnerable with complex health and social care needs and take many medicines Relatively short life expectancy Av. length of stay 1-2 years male, 2-3 years female 1. CQC.2009 The quality and capacity of adult social care services: An overview of the adult social care market in England 2008/09 2. Age UK. Later Life in the United Kingdom June 2013. accessed 12/4/14 http://www.ageuk.org.uk/documents/en- GB/Factsheets/Later_Life_UK_factsheet.pdf?dtrk=true 3. British geriatric Society. Quest for quality. 2011. http://www.bgs.org.uk/campaigns/carehomes/quest_quality_care_homes.pdf
Residents have additional health needs vs. those in domiciliary care 1 78% had at least one form of cognitive impairment. 64% were confused or forgetful. 20% exhibited challenging behaviour. 19% described as depressed or agitated 71% were incontinent. 27% were immobile, confused and incontinent. 76% immobile or required assistance with mobility 3 x more likely to fall than those living at home and 10 x risk of hip fracture 2 1.Data obtained from BGS Quest for quality 2011 (Help the Aged, Quality of life in care homes, A review of the literature, 2007,96-97) 2. DoH 2009. Falls and factures: Effective interventions in health and social care. www.dh.gov.uk/en/publicationsandstatistics/publications/dh_103146
Background NICE Social Care Guidelines Since April 2013, NICE s role expanded to include social care. Opportunity to apply an evidence-based system to decisionmaking in the social care sector Guidelines will promote better integration between health, public health and social care services They are not mandatory To be used in conjunction with existing frameworks and regulation (e.g CQC) already in place Medicines management in care homes (CH) is first topic referred to NICE by DoH Provides practical support to improve the quality of care Underpin development of Quality Standards
NICE Quality Standards (QS) Concise set of statements that describe high-priority areas for measurable quality improvement in an area Support the Government's vision for a health and social care system focused on delivering the best possible outcomes for service users 1 Social care QS focus on the services and interventions to support the social care needs of service users Not targets, not mandatory but must be considered when planning and delivering services Must have a good reason to ignore Aspirational, but achievable standards 1. Health and Social Care Act (2012).
NICE SC1 2014 Managing Medicines in care homes Residents should have the same involvement in decisions and right to access appropriate services and support as those in domiciliary care Audience: Health and Social care providers and commissioners and others involved with decisionmaking about medicines in CHs Recommendations about the systems and processes that need to be in placeto ensure the safe and effective use of medicines for all residents
Patient centred care Medicines related interventions must Take into account the individuals needs and preferences (patient centred) Involve others who the patient wishes to be involved Keep residents free from harm, abuse or neglect (safeguarding)
NICE: 17 Recommendations 1. Develop and review policies for safe and effective use of medicines 2. Support informed decision making 3. Sharing medicines information 4. Record keeping 5. Identify, report, review and learn from incidents 6. Safeguarding 7. Accurate medicines list (medicine reconciliation) 8. Medication review 9. Prescribing 10. Ordering 11. Dispensing and supply 12. Receipt storage and disposal 13. Self administration 14. Administration (monitoring) 15. Covert administration 16. Homely remedies 17. Training skills and competencies of care home staff
Related Quality Standards (Consultation, due Mar 2015) Statement 1. Care homes have a medicines policy that is regularly reviewed. Statement 2. People who live in care homes are supported to self-administer their medicines unless a risk assessment has indicated that they are unable to do so. Statement 3. People who live in care homes have an accurate listing of their medicines made on the day that they transfer into a care home. Statement 4. People who live in care homes have details of their medicines shared with their new care provider when they move from one care setting to another. Statement 5. GP practices have a clear written process for prescribing medicines for their patients who live in care homes. Statement 6. People who live in care homes have at least 1 multidisciplinary medication review per year Statement 7. Care homes have a documented process for the covert administration of medicines for adult residents
1.2 Supporting residents to make informed decisions and recording these decisions Residents have same opportunities to be involved in decisions about their treatment/care as those in domiciliary care (HSCP) And they get the support they need to do so Prescriber or CH staff records a resident's informed consent in the care record. (consent not needed for every administration) CH staff record the circumstancesand reasonsfor a refusal in record and MAR (if given) unless a pre agreed plan exists HSCP notify prescriber and supplying pharmacist of ongoing refusals (if resident agrees). HSCP identify and record anything that may hinder a resident giving informed consent considered and reviewed. Mental health problems, lack of (mental) capacity to make decisions Problems with vision, hearing, reading, speaking or understanding English and cultural differences. HSCP: care home staff, social workers, case managers, GPs, pharmacists and community nurses
1.2 Supporting residents to make informed decisions and recording these decisions Prescribers should Assume there is capacity to make decisions If there are any concerns about ability to give informed consent, assess resident's mental capacity in line with appropriate legislation Record assessment of mental capacity in the resident's care record HSCP to ensure that residents are involved in best interest decisions, in line with legislation Find out about their past and present views, wishes, feelings, beliefs and values Involve them, if possible, in meetings Talk to people who know them well, within and outside CH
Process for Involving patients in decision making about their medicines NICE CG 76. 2009 NICE 2014
National Care Forum Patient Record http://www.nationalcareforum.org.uk/medsafetyresources.asp
Example of a protocol for refused medicines Gives clarity about when refusal needs to addressed. And how urgent Critical medicines Symptomatic control, hormone replacement Certain drugs or all drugs
Examples of processes Include questions/prompts as part of medication review process/protocol e.g. Can the patient be involved in decision making process? Does the patient want to be involved? To what extent can they be/do they want to be involved?
1.15 Care home staff giving medicines to residents without their knowledge (covert administration) Health and social care practitioners No covert if the resident has capacity to make decisions about their treatment and care Covert administration In context of existing legal and good practice frameworks to protect both the resident and CH staff Process must include: Assessing mental capacity, Holding a best interest meeting involving CH staff, prescriber, pharmacist and family or advocate Recording the reasons for presuming mental incapacity and plan Planning how medicines will be administered without resident knowing Regularly reviewing whether covert administration is still needed. Commissioners and providers to establish wider policy several health and social care organisations
Pharmacist s role Develop process and policy Capacity can fluctuate, can medication wait until resolved Explore if genuine reason for non adherence Holistic and objective review of medicines to determine that they will prevent deterioration of physical or mental health maintain physical or mental health save life Combine evidence, with expert experience, patient circumstances, experience and values Regular medicines that are only needed prn can disguise as refusals e.g. laxatives! After long periods of non adherence, gradually re introduce medicines at low dose if need be Advise on best formulation, stability and administration methods
NHS Scotland Polypharmacy Guidance 2012 The GP should write a statement clearly outlining medication to be given covertly, & This must be kept in the service users care plan, together with an explanation of the rationale for this action. http://www.central.knowledge.scot.nhs.uk/upload/polypharmacy%20full%20guidance%20v2.pdf
Case Scenario Mr A Dementia, hx BPSD, wandering at night Sleeps all day and awake at night Nurses give his medicines in a cup but he wants to look through so he can take the Nitrazepam 5mg out He doesn t want to take it Nurses not too pleased because if he doesn t take it, he is awake all night, walking up and down, disturbing everyone and banging on exit doors Nurse asks if they can give it covertly?
Covert or not?
Key points Assume patient has capacity to give consent unless there is evidence to suggest otherwise. Capacity is not an all or none situation and people may have capacity for some decisions and not others Dementia doesn t always mean lack of capacity The fact that a patient is supported physically to take their medicines does not mean they haven t got mental capacity. It cannot be assumed that a patient lacks capacity just because of their age, conditions, disability, behaviour or because they make a decision you disagree with Family views cannot override patients in isolation Intentional non adherence is usually to do with patient s fears, values and experience of medicines try to address!
Thank you