Organisation implements annual medication reviews for reducing risk of harm to frail residents in care homes, uncovering serious incidents and implying 6,166 quality interventions

Outline:

In order to ensure that care home residents throughout Norwich were receiving annual multidisciplinary medication reviews, Norwich CCG approached Arden & GEM’s medicines optimisation team to support their locally commissioned service (LCS) for care homes. By working in partnership we have designed and delivered a consistent and effective care home medication review service, run by pharmacists and pharmacy technicians with a range of experience and expertise across both primary and secondary care.

By continually adapting the service, over four years, to meet evolving local need the team has been able to increase the appropriateness of medications and reduce problematic polypharmacy. Since 2014, the service has completed 2,693 person-centred, evidence-based medication reviews which have resulted in 6,166 quality interventions.

As well as ensuring that Norwich care home residents are prescribed medication in line with NICE guidance, the service has also directly delivered cost savings of £80k. Additionally, the team has compiled and maintained a library of best practice and identified areas for improvement which have increased alignment between care homes and GP practices, and enhanced communication and information flows across the wider health and care system. The service has improved the quality, safety and appropriate use of medicines.

Challenges:

As older people are being encouraged to stay in their own homes for longer, people entering care homes are generally frailer, more likely to be affected by multiple health problems and are often being treated with polypharmacy and hyper-polypharmacy.

It is essential that the medicines being administered are regularly reviewed to ensure they remain safe and effective. The NICE ‘Medicines management in care homes’ quality standard suggests that this should take place annually, as a minimum, and be conducted by a multidisciplinary team.

Within Norwich Clinical Commissioning Group (CCG), there are 31 care homes delivering LCS with capacity for over 1,000 patients. The CCG’s LCS for care homes needed support to design and deliver a holistic medication review programme that would improve the quality, safety and appropriate use of medicines.

The aims of the service are to:

• Check whether a patient still needs to take all of their medications

• Find out whether the medicines are being taken as intended and are helping

• Ensure medicines aren’t causing harm or risk, including any issues with side effects or reactions

• Explore whether additional medicines should be offered

• Answer any questions or address any concerns of patients and/or carers.

Outcomes:

Improving quality Between April 2014 and March 2018, we:

• Completed 2,693 patient reviews

• Undertook 6,166 quality interventions

• Delivered cost savings of £80,916.

We have increased the appropriateness of medicines and reduced polypharmacy. Interventions are categorised to identify trends, themes and areas for development. The top three intervention types are: confirm or update allergies, add or amend dose instructions and delete obsolete medication. Our technicians ensure patient records are accurately updated, with changes followed up in writing with care homes and supplying pharmacies.

During 2017/18:

• 278 patients reviewed had medication stopped

• 168 were referred to specialists.

We have had a direct impact on patient safety Including uncovering serious incidents e.g one patient was discovered to be receiving a strong opioid treatment both orally and via patches when one should have been substituted for the other.

Practice alignment After a year of service delivery, we identified that care homes were often looked after by multiple practices, with up to three or four GPs visiting at the same time. It was difficult to build professional relationships and offer continuity of care. This led to a city wide realignment project providing care home residents with continuity of care.

Spread:

We have compiled and maintained a suite of information, signposting and best practice guidance on a dedicated area of ‘Knowledge Anglia’ – the region’s extranet system. We regularly add content on a wide range of topics such as homely remedies and secondary dispensing.

We have endeavoured to share best practice and project outcomes with the wider healthcare sector and pharmacy profession:

• Paper accepted by the Journal of Medicines Optimisation which shares the aims, process and results from the initiative as well as discussing the benefits for patients, clinicians and the wider local health economy. This will be published in March.

• Case study written and published on the Arden & GEM website and circulated via social media and our monthly enewsletter.

• Regular contributions to the Norfolk and Waveney care homes newsletter and Norfolk County Council’s website.

We have proactively used our experience to identify recurring issues in care homes (feeding into the pan Norfolk Care Home Steering Group) and GP practices to improve communication and information. For example, we liaised with local hospital sites and ambulance services to develop a list of appropriate information to send with residents who attend hospital, which was then circulated to care homes.

Value:

This responsive and patient-focused service has improved the quality, safety and appropriateness of medicines use for care home residents in Norwich.

Outcomes for patients:

• Between April 2014 and March 2018, we completed 2,639 reviews, with 6,166 quality interventions covering patient safety, quality and cost effective prescribing.

• Patients are offered a full holistic annual review covering medication, nutrition, falls, blood monitoring and chronic disease management. The patient, or their representative/carer, is able to ask questions about any aspect of their care, not just medication.

Use of resources:

• Increased awareness of the medicines optimisation team’s expertise – as a provider of information and education to care homes and practices

• The practice realignment project has improved continuity of care for patients

• In some homes this has resulted in a significant reduction in ad-hoc GP visit requests, allowing clinicians to use their time more effectively. Care home staff and patients are now aware that a GP will be visiting once a week so can often save less urgent cases until then as appropriate.

• Conducting all reviews as a multidisciplinary team (MDT) session offers the chance for clinicians to build stronger relationships with patients and care staff.

Involvement:

The service is designed to provide holistic, multidisciplinary, person-centred reviews. Involvement and engagement with clinicians, care staff and, where possible, patients and families is key.

• Patient and families are always given the opportunity to participate in medication reviews, although uptake is rare. We are working with care homes to increase involvement by giving as much notice of visits as possible and providing information in accessible formats. Patients and families were actively consulted as part of the GP realignment process.

• Practices: Every April, the medication review timetable is circulated to practices for comment, with flexibility around times and dates to accommodate their needs.

• MDT: All interventions are agreed with the MDT at face-to-face meetings and then communicated to the home, supplying pharmacy and registered practice to ensure timely implementation.

• Care homes: annual visits are arranged to discuss any medication issues and offer support with CQC visits and NICE recommendations. This visit also forms part of the medication review process as MAR charts are checked.

The service has ensured good communication about medication between health and social care practitioners, care home residents, family members or carers. There is also much greater collaborative working with specialist healthcare professionals.