In Sheffield we have developed a care pathway within the Sheffield locality which accepts referrals from health and social care practitioners and makes use of the skills of the dispensing community pharmacy and enables them to support the management of at-risk patients. The care pathway is an example of implementation of a care plan by the community pharmacist, including goals agreed with the patient, following initial assessment by a medicines optimisation team. This service is an example of implementation of a number of recommendations within the NICE guideline 5 but in particular those recommendations in section 1.4 about medication review and section 1.8 about medicines-related models of organisational and cross-sector working.
Aims and objectives
Our aim is to develop an integrated medicines optimisation pathway across Sheffield accessible to health and social care professionals and ultimately available to patients to self-refer to.
Reasons for implementing your project
There is currently a gap in the provision of domiciliary medicines review services in Sheffield. There is no commissioned service through community pharmacy and unless a patient is already known to community services teams there is no direct pathway for referral for a domiciliary medicines optimisation service. A small pilot study in 6 Sheffield GP practices in 2013 demonstrated the benefits of a domiciliary medicines optimisation service to which health and social care professionals could directly refer patients into. This project was joint-funded with by health and social care. Significant savings were made in social care as a result of a reduced need for care calls for medicines administration. There were also savings in health care due to reductions in the use of potentially inappropriate medication. In addition a number of significant interventions were made which potentially avoided a hospital admission for those patients. The next step was to determine how this could be scaled up across and to utilise the skills of community pharmacy for the ongoing management of patients.
How did you implement the project
We identified key stakeholders for the project. The concept was supported unanimously and there was real enthusiasm for the project however we did face a number of challenges along the way:
- The project would be time limited and could only run for 6 months meaning we had to hit the ground running to get results.
- Staff recruitment: we needed to recruit an assessment team quickly however due to staff shortages within the NHS and winter pressures secondments were not an option. We overcame this by offering part time staff additional hours and recruiting across the CCG acute STH and community staff.
- Community Pharmacy concerns about workload and releasing staff from the pharmacy for home visits. We developed a local service specification in agreement with the LPC which included funding ongoing management of patient and an additional fee to release staff to carry out home visits. This enabled pharmacies to come on board with the project.
- Engaging GPs and raising awareness of the project presented a further challenge- we needed to make an impact in a short period of time.
- We promoted the project to practice managers, practice pharmacists at locality meetings.
- We produced patient information leaflets for practice reception staff to hand out.
- We attended MDT and care planning meetings in the GP practices involved.
- We promoted the service to social service colleagues and targeted patients receiving care calls for medicines administration.
- We held a coffee morning in a sheltered accommodation complex to promote the service to residents.
Implementation of the project was supported by the use of the PharmOutcomes system. The community pharmacist will register the patient to the system and in doing this they are agreeing to provide the service as per the referral. As well as being used to record all the data necessary to demonstrate the benefits, PharmOutcomes is also being used to trigger payments to pharmacies. Use of the web-based reporting system simplifies data reporting, benefit evaluation and management of payments. Pharmacies appreciate the simplicity of the system.
We monitored progress by recording all the referrals and interventions made by the assessment team during the project. Community pharmacists recorded their activity on pharmoutcomes and were asked to report progress against goals set and details of any interventions made.
- 137 at-risk patients were referred into the scheme. Twenty GP practices and twenty community pharmacies actively participated.
- Reduction in the use of inappropriate medication (14 medications stopped and 21 started , using the STOPP-START criteria), 5 care calls stopped, reduced medicines waste; and improved understanding of medication.
- 91% success rate on goals set.
- 20 follow-up home visits undertaken by Community Pharmacists.
- 26 compliance aids provided ranging from compliance charts, to monitored dosage systems. - Provision of a direct referral route for health and social care professionals - freeing GP time and reducing delays.
There is significant potential to further develop this work to involve community pharmacy more in the management of patients with long-term conditions to improve patient safety and reduce hospital admissions. The scheme has been very popular with healthcare professionals in the community and patient feedback has been overwhelmingly positive. We used the friends and family patient test to assess our service.
Key learning points
Top tips for someone looking to implement a similar project:
- Involve key stakeholders from the start to help plan and develop the project
- Identify willing people to work with ( those with an interest in the area / willing to get involved)
- Understand the constraints: work, time pressures etc. and provide sufficient resources to enable the project to happen
- Keep going
- Be flexible and able to overcome barriers quickly as they arise
- Get the admin in place early
The funding for the service is through GP locality freed up resources held by Sheffield CCG. The assessment team comprise STH employees and CCG staff. The community pharmacists are funded through the CCG.