Care Home support and medicines optimisation: Community Pharmacy National Enhanced Service 1
1. Introduction Back in 2006 the National Service Framework for Older People in Wales 1 highlighted the problem of medication administration errors stating administration errors especially non-administration occur relatively frequently both in hospital and care settings. Care home residents should theoretically be protected from medication administration errors under The Care Homes (Wales) Regulations 2002 2 which state, The registered person shall make arrangements for the recording, handling, safe keeping, safe administration and disposal of medicines received into the care home. In addition the Governments in Wales and England have introduced minimum standards which must be met by care home providers. In her 2014 report A Place to Call Home? 3 the Older Person s commissioner for Wales concluded that too often, there is an acceptance by organisations and the system of an overall level of care that is simply not good enough. Much of what is now considered to be acceptable should be considered unacceptable in 21st century Wales and falls below the standard that older people have a right to expect. The report identifies the importance of patient centered care which underpins this service. In addition the service incorporates the relevant aspects of the 2014 Trusted to Care review. NICE Managing Medicines in Care homes SC1 4 was published in March 2014. The purpose of this guideline was to provide recommendations for good practice on the systems and processes for managing medicines in care homes. This guideline is written for both health and social care staff with over 100 recommendations. There are 2 specific recommendations for the supplying pharmacy but many recommendations for pharmacists depending on their role within the care home. In 2016 the Royal Pharmaceutical Society (RPS) Wales published Improving medicine use for care home residents 5. This publication recommended that all care home residents should have a review of their medication by a pharmacist at least annually. The Professor Andrews report Trusted to Care report 6 identified a number of serious concerns about the standards of fundamental care and the treatment of frail elderly patients in general, and those with delirium and dementia in particular. A number of the concerns were related to medicines prescribing and use. Growing concern around medicines in care homes is being driven by concern over unacceptably high error rates, and growing awareness of potential overprescribing and waste. These are important aspects of the Prudent Healthcare policy in Wales, which identifies care homes and transitional care as key elements of the healthcare 2
strategy for Wales References 1. Welsh Assembly Government. National Service Framework for Older People in Wales. Available from: http://www.wales.nhs.uk/documents/nsf%20for%20older%20people.pdf [Accessed 16 th August 2017]. 2. National Assembly for Wales. The Care Homes (Wales) Regulations 2002. Available from: http://www.legislation.gov.uk/wsi/2002/324/made [Accessed 16th August 2017]. 3. Older Peoples Commissioner for Wales. A Place to Call Home? Available from: http://www.olderpeoplewales.com/libraries/uploads/a_place_to_call_home_- _A_Review_into_the_Quality_of_Life_and_Care_of_Older_People_living_in_Car e_homes_in_wales.sflb.ashx [Accessed 16th August 2017]. 4. National Institute for Health and Care Excellence. Managing Medicines in Care Homes. Available from: https://www.nice.org.uk/guidance/sc1/resources/managing-medicines-in-carehomes-pdf-61677133765 [Accessed 16th August 2017]. 5. Royal Pharmaceutical Society Wales. Improving Medicines Use for Care Home Residents. Available from: https://www.rpharms.com/portals/0/rps%20document%20library/open%20acce ss/policy%20statements/improving-medicines-use-for-care-home-residents- (wales).pdf?ver=2016-10-13-162139-760 [Accessed 16 th August 2017]. 6. Andrews J, Butler M. Trusted to Care. Available from: http://gov.wales/docs/dhss/publications/140512trustedtocareen.pdf [Accessed 16th August 2017]. 3
2. Service aims The skills and expertise of pharmacists and their teams as the experts in medicines have much to contribute to the optimisation of medicines use in care homes and supporting the reduction of waste. The service starts with the resident and their needs for pharmaceutical care and is built on the foundation of safe and efficient supply, supported by an appropriate level of medicines optimisation. The service is also built around the Prudent Healthcare principles and in particular remodeling the relationship between the user and provider on the basis of co-production. Patient benefit: Improved clinical outcomes through better treatment choices and compliance Effective use of medicines Improved safety through identification and reduction of risks. Care home benefit: Introduction of a more systematic and streamlined medication ordering and administration process. Education and training for staff managing medicines; signposting to accredited medicines training programmes. Assistance and advice in communications with prescribers and dispensing pharmacists. Compliance with the requirements of CSSIW. This service will be commissioned, under the Directions, as an enhanced pharmaceutical service and will provide commissioners of care with assurance relating to the standards of medicines management in the care home. 4
3. Service Outline 3.1 Level 1 Support: Care home visit, medicines management tool and waste audit The provision of a systematic review of all medicines management processes in the care home and working with the home on the development of protocols & procedures to facilitate the safe ordering, supply, storage and administration of medicines and appliances and reduce avoidable waste. 3.2 Level 2 Support: Patient Outcome Medicines Safety Indicators (POMSI s) and Medicines Reconciliation. The purpose of this level is to highlight and review therapeutic risk areas of prescribing which have regularly shown to occur in care homes. By using the POMSI s the pharmacist can ensure pharmaceutical scrutiny of prescribing for care home patients and benchmark this against prescribing standards. 3.3 Level 3 support: Medication Review To provide Level 3 of this enhanced service the dispensing pharmacy is expected to work with the residents GP to conduct a full medication review with the resident, utilising the GP patient record. This element of service directly links with the GMS Directed Enhanced Service for Care Homes requirement to undertake a medication review and can only be provided in agreement/partnership with the GP practice. 4. Scheme Eligibility 4.1 Only those pharmacies providing this service to care homes located within NHS Wales and commissioned by the health Board will be eligible for payment for the service. 4.2 The service can only be provided by a pharmacy that has applied to participate in the Care home support & medicines optimisation enhanced service. 4.3 The service is commissioned on an individual care home/community pharmacy basis, i.e. each care home serviced will require individual applications. 4.4 Any pharmacy entering into a contract with the Health Board to provide this service must complete and submit form PS/ES/5 CONTRACTOR LISTING. 5
4.5 The pharmacy providing the service will normally be the pharmacy providing prescription dispensing services to the home. Pharmacies not supplying prescription dispensing services may provide the service at the discretion on the health board. 4.6 The pharmacy providing the service will jointly sign an agreement form with the care home (appendix 1). It is expected that this agreement form would last for three years from the date of signing with a review every 12 months. 5. Service descriptions & specifications 5.1 Level 1: Support medicines management tool and waste audit 5.1.1 The pharmacy and the care home will jointly produce procedures and protocols for the ordering, supply, and safe storage of all medicines and appliances. These will be reviewed on an annual basis. These will be available to the Health Board on request. Copies should be retained by the pharmacy and the care home. The pharmacy will provide the home with details of a named contact for enquiries and medication advice. Protocols and procedures should follow national standards and best practice (NICE Guideline 4, RPS guidance 5 ) 5.1.2 The contracted pharmacy will undertake scheduled visits twice a year (at a minimum of 4 months between visits) and complete the medication audit support tool and provide advice on medicines management to staff within the care home. The pharmacy should send a copy of the Support Tool kit (appendix 2) to the care home prior to the visit, in order for them to be aware of the areas covered within the visit. 5.1.3 Following the first visit the pharmacy will provide the home with a copy of the completed toolkit / report containing recommendations for improvement if required. Resulting actions for the care home will be entered by the community pharmacy service provider onto Visit Outcomes Report section of the support tool and an action plan generated and provided to the care home within 10 working days of the visit. The care home will agree the content of the report within 28 days of receipt and a signed copy will be returned to the pharmacy. In the exceptional circumstances that the care home does not agree the content of the report the pharmacy should liaise with the Health Board for advice. Following the second visit, the Action Plan will be updated indicating whether or not the care home has completed the actions recommended after the first visit. A copy of this update will be left with the care home. 6
The pharmacy will liaise with the GP and other healthcare professionals as appropriate to seek to resolve any issues identified following a visit. This will form a duty of care service provided to the home where the pharmacy will accept a responsibility to identify and resolve any issues identified to the best of their ability. If issues cannot be resolved the pharmacy should seek advice from the Health Board. 5.1.4 The pharmacy will liaise with the GP and other healthcare professionals as appropriate to seek to resolve issues identified following a visit. If during any visit the pharmacy identifies any concerns or patient safety issues these must be reported to CSSIW, the Health Board and the GP practice where appropriate. 5.1.5 The pharmacy will be required to maintain a register of the care homes to which they provide a dispensing service. This is defined as the monthly dispensing of repeat medicines to the home. 5.1.6 The pharmacy must have a searchable register of care home residents, which may or may not be the current patient medication record (PMR) system. This register will enable the quick identification of all residents within a care home and the medicines that are being supplied. 5.1.7 The pharmacy will provide advice on appropriate adherence support for residents self administering medicines. 5.1.8 The pharmacy will undertake ongoing audit, every 6 months, on waste/returned medicines from the care home, or from the disposal book if a nursing home. The pharmacy will identify the top 10 returned items, by total quantity; from the care home over a one month period (if the home does not return unused medication on a monthly basis then this should be done in line with the homes return protocol/cycle). The pharmacy will use this information and improvement methodology to identify opportunities to reduce waste and recommend actions to prescribers and the care home. A summary of these actions and estimates of savings made will be reported as part of the care home service visit report to the Health Board. The dispensing pharmacy providing this service will enter details of identified waste medicines on to the national waste medicines reporting tool via NECAF. 5.1.9 Level 1 services can be provided by any qualified member of the pharmacy staff (e.g. pharmacist or qualified pharmacy technician) 7
5.1.10 Care Home Electronic Medication Support Systems Welsh Government is currently reviewing technological solutions within care homes and producing an approved requirement framework for medication support systems, including emar, in care homes within Wales, with a view to widespread use of these systems. Once this review is complete a pharmacy contractor providing an electronic system from the approved NHS framework contract to all the residents of the care home being supplied will be reimbursed the agreed NHS framework price for that system. The pharmacy contractor cannot charge the care home for provision of this system. 5.2 Level 2 Support: Patient Outcome Medicines Safety Indicators (POMSI s) and Medicines Reconciliation 5.2.1 The dispensing pharmacy will undertake twice yearly searches (at a minimum of 4 months apart) of their care home resident register (as outlined above), and report against agreed Patient Outcome Medicines Safety Indicators (POMSI s) (appendix 3). These will be reported as part of the care home service visit report to the health board. 5.2.2 The care homes POMSI performance will be reported to the Health Board on a twice yearly basis, via NECAF. 5.2.3 The pharmacy will work with the patients GPs, Practice Pharmacy team, care home staff and HB to review and if possible facilitate improvements in the care home performance against the POMSI s. 5.2.4 It is expected that level 2 services will be provided by a pharmacist 5.2.5 For residents transferred from another setting (from their own home, another care setting or secondary care), a Discharge Medicines Review (DMR), should be completed to ensure the resident is receiving the correct medication. The pharmacist must satisfy themselves that the list of medicines available is reliable, accurate and up-to-date; this should include discussion with the resident or their carer in order to establish a complete picture of the medicines being taken by the resident. Where the medicines prescribed following a transfer of care do not, in the opinion of the pharmacist, correspond to those the patient should be receiving, the pharmacist must bring this to the attention of the patient s current GP and, where appropriate, other professionals responsible for the care of the patient in order to resolve any discrepancy. 8
5.2.6 The usual DMR process should be followed and payment will be made via the normal DMR process. 5.2.7 Pharmacies will need to conduct a DMR where appropriate (or state no new residents have been admitted in the claim period) to receive Level 2 payment except in exceptional circumstances where agreed. 5.2.8 If the care home DMR claims result in the community pharmacy reaching the annual limit for DMRs extra DMRs can be commissioned at the discretion of the commissioning Health Board. These will be commissioned and reimbursed as an enhanced service. 5.3 Level 3 support: Medication Review 5.3.1 The GMS Directed Enhanced Service (DES) for Care Homes contains a requirement to undertake a medication review of each resident and states: The GP, as the lead clinician in the multi disciplinary team, may commission a medication review to be undertaken by a pharmacist. A GP employed pharmacist, or cluster based health board employed pharmacist, or community pharmacist providing services to the relevant care homes will undertake at least one medication review, with particular reference to polypharmacy, antipsychotic prescribing and other high risk medicines, for each resident in the care home. Further medication reviews will be undertaken by pharmacists as clinically appropriate. 5.3.2 To undertake level 3 the pharmacist must work with the GP practice to ensure that access to the resident s medical records can be arranged alongside the process for review and recording of recommendations and changes within the patient record. This level can only be provided in agreement/partnership with the GP practice whether or not the DES is provided for that practice and may be commissioned via a local enhanced service (LES). 5.3.3 It would be expected that the review would be undertaken in the care home with the resident (or representative) and the nurse/carer for the resident. It is also expected that the pharmacist has accessed and reviewed the full GP record in preparation for the visit. Competency The pharmacist should familiarise themselves with the resident's history and current medicines/treatment before the review to ensure they are able to confidently identify and discuss any medicine related issues, such as 9
potential side effects, incorrect dosing schedules, device technique, etc, during the review. Information should be obtained from the PMR in the pharmacy, GP records, hospital patient notes (including bedside data), prescription/mar charts, test results, discharge prescriptions, etc. As a minimum the pharmacist conducting the review should be competent and confident - To identify and take action to minimise harm from side effects, interactions, therapeutic duplication and inappropriate doses To ensure that the resident/carer knows what to do if their symptoms change or a problem persists To provide additional counselling or lifestyle advice to the resident/carer To identify and reduce medicines wastage To highlight the importance of any monitoring requirements and discuss when monitoring was last carried out, including blood tests and physical monitoring To arrange /carry out diagnostic tests, e.g. blood tests, blood pressure, peak flow, x-ray, scans, etc To clinically assess the patient where appropriate e.g. blood pressure, peak flow measurement, etc Update patient medication record (PMR)/patient medical notes within the GP practice Discuss any issues raised in the review with the prescriber (i.e. any concerns, suggestion for improvement, etc) that cannot be rectified by the pharmacist To explore the evidence that all medication is effective and is achieving the desired outcome. This can be based on what the resident/carer reports or available clinical data e.g. blood pressure readings, test results, etc The pharmacist should not undertake or agree to undertake Level 3 unless they are confident with the above competencies. 6. GENERAL SERVICE SPECIFICATIONS & REQUIREMENTS 6.1 A pharmacy contractor wishing to provide this service will need to apply to the Health Board. Only those pharmacies commissioned by the Health Board to provide a Care Home Service will be eligible to receive payments under this scheme. 6.2 In order to provide levels 1 & 2 of the service the pharmacy must be the dispensing pharmacy to the care home, unless there are exceptional 10
circumstances where the Health Board can locally commission another community pharmacy to provide this service. A pharmacy can provide level 1 service only, but cannot provide level 2 unless level 1 service is provided. If there is more than one pharmacy providing dispensing services to the home then the service will be commissioned from the pharmacy dispensing the majority of prescriptions unless otherwise agreed by the local health board. Level 3 services can be provided by any provider. 6.3 The Health Board will enter into a Service Level Agreement (SLA) with all pharmacies commissioned to provide the service (appendix 4). 6.4 A national framework for the recording of relevant service information for the purposes of review and the claiming of payment will be developed. 6.5 The pharmacy contractor will participate in any reasonable publicity of the availability of the service required by the Health Board. 6.6 The pharmacy contractor has a duty to ensure that pharmacists and technicians involved in the provision of the service have relevant competency, skills and knowledge and are appropriately trained in the operation of the service including ongoing training and CPD, and have completed the National Enhanced Services Accreditation via WCPPE. 6.7 Pharmacist and technicians providing any level of the service have until 31 st March 2019 to complete NESA accreditation. 6.8 The pharmacy contractor will participate in any Health Board organised audit of service provision. 6.9 The pharmacy contractor will co-operate with any locally agreed Health Board-led assessment of service user experience. 6.10 The pharmacy contractor will ensure that there is a Standard Operating Procedure for the service will be in place. This will be reviewed biannually or when there is a change in service specification. 6.11 Monitoring and review of the service specification will be undertaken during the Contract Monitoring Visits. Post Payment Verification (PPV) will be undertaken by Health Board officers or its representatives as required to meet external audit requirements and ensure proper use of public funds. 11
7. Fees & Claiming Fees will be paid on an annual basis Level 1: 234 per annum per care home (two visits per annum and waste audit twice yearly) Level 2 fee per POMSI report (two reports per annum) 1-30 beds: - 168 / report = 335pa 31-60 beds: - 335 / report = 670pa 61-90 beds: - 503 / report = 1005 pa 90+ beds: - 5.58 per patient / report Level 3 local agreement This would be determined by the pharmacy providing the service and the commissioner. A minimum fee of 57 per patient is recommended. 8. Equality & Human Rights 8.1 The Provider will ensure that the service it offers does not discriminate against service users on the basis of their race, disability, gender, age, sexual orientation, religion/belief or non belief. 8.2 The provider will ensure that it is able to respond to any communication needs and access requirements of service users. 8.3 Service users will be treated with dignity and respect at all times in accordance with the Health Boards commitment to promote and give effect to the Human Rights Act. 9. Local Health Board Responsibilities 9.1 The Local Health Board shall enter into a Service Level Agreement (SLA) with all pharmacies commissioned to provide the service. 9.2 The Local Health Board will also have in place reasonable measures to ensure that pharmacies and other stakeholders are aware of local service provision and where appropriate publicise the availability of this service. 9.3 The Local Health Board, or its authorised officer, shall support the resolution of difficulties so far as they relate to issues within the control of the Local Health Board. 12
9.4 The Local Health Board, or its authorised officer, shall support the handling of any complaints or issues relating to the service so far as they relate to issues within the control of the Local Health Board. 10. Definitions 10.1 Pharmacy means any premises where drugs are provided by a pharmacist as part of pharmaceutical services 10.2 Pharmacy contractor (or contractor) means a person lawfully conducting a retail pharmacy business. 10.3 Pharmacist means a person who is registered in Part 1 of the GPhC register or in the register maintained under Articles 6 and 9 of the Pharmacy (Northern Ireland) Order 1976 10.4 Pharmacy Technician means a person who is registered in Part 2 of the GPhC register. 10.5 The home should be located within the boundaries of the Health Board and registered under the provisions of the Care Standards Act 2000 to provide residential or nursing care to residents of the home 10.6 The Definition of a Care Home is outlined in the Care Standards Act 2000. This abolished the distinction between nursing and residential homes under the term Care Home. This states:3.(1) For the purposes of this Act, an establishment is a care home if it provides accommodation, together with nursing or personal care, for any of the following persons. They are- persons who are ill or have been ill persons who have or have had a mental disorder persons who are disabled or infirm persons who are or have been dependant on alcohol or drugs But an establishment is not a care home if it is- a) a hospital b) an independent clinic 13
c) a children s home d) Or if it is of a description excepted by regulations. 121 (9) - An establishment is not a care home for the purposes of this Act unless the care, which it provides, includes assistance with bodily functions where such assistance is required. This includes both short-term and long-term residents Appendices 1. Care Home/Community Pharmacy Agreement form 2. Medicines Management Review tool 3. Patient Outcome Medicines Safety Indicators 4. Service Level Agreement 14