General Practitioners employing Pharmacist Independent Prescriber to jointly optimise care of our care home patients

Our Aim

To improve health outcomes and the wellbeing of our care home patients by:

• Clinical review and assessment by the GP – akin to ward round

• Discussing patient’s wishes for future care with them and/or their carer/family

• Optimising medicines prescribed

• Identifying and Reducing Risks eg adverse effects, drug interactions, polypharmacy, stopping medicines if no longer indicated withdrawing any treatments no longer appropriate

• Ensuring appropriate drug monitoring where relevant

• Minimising waste of medicines

• Reviewing patients in a proactive manner to reducing risk of an unplanned admission

Prior to the initiative the doctors were constantly being called out to see patients in care homes to manage acute situations – this approach was quite reactive but time pressures did not allow for much further intervention, or holistic proactive management (as we would have desired). Doctors had to manage 4-5 acute visits between morning and afternoon surgery.

Why have we done this?

It is a documented fact that clinical medication review alongside GP assessment has obvious benefits for frail elderly patients and helps decrease hospital admissions.

Care home residents on average:-

• receive up to four times as many prescription items as older people living within their own homes

• are older people who are more likely to be at risk from polypharmacy and adverse drug reactions which is often a cause of hospital admission.

• In the UK between 5-17% of hospital admissions in over 65s may be due to inappropriate drug therapy and up to half of those admissions may be preventable.

• In February 2006 CSCI (Commission for Social Care Inspection) produced a report highlighting that nearly half of all care homes fail to meet the national minimum standard for medication. Staff training alongside ongoing medication review was identified to take steps towards addressing this issue.

With admissions avoidance high on the commissioning agenda, this work allowed us to incorporate an approach that is over and above what is expected through GMS, and allowed our practice to lead and direct the required work, based on needs and demands. It was a proactive innovative way of working that was far removed from the reactive pressurised approach that is often demanded and expected of GPs in relation to managing care home patients.

NICE have published their first Social Care Guidance: Managing Medicines in Care homes (SC1). This has helped shape and formalise this work as it includes specific recommendations for GPs, GP practices, health professionals prescribing medicines. Our findings in fulfilling these recommendations are captured in Appendix 1, attached to this document as supporting material.

What did we do?

• 16 multi-disciplinary sessions involving the GP, our Pharmacist Independent Prescriber and care home staff reviewed our patients across 8 different sites – both nursing and residential care homes

• Sessions were completed at the care homes between February – September 2014 (allocated sessions were dedicated)

How did we do this?

A multidisciplinary approach led by our GPs and Pharmacist Prescriber worked alongside CPNs, consultants and care home staff to optimise our patient care . Potential barriers identified included Pharmacists not being directly employed by the practices and the clinical governance implications this could have including lack of relationship with the GPs and with the practice as well unfamiliarity with the pressures faced in both settings .

Additionally, in order to proactively effect change and make it happen, we felt the pharmacist had to be an independent prescriber with a wealth of local experience and intelligence. We overcame this barrier by having our own Pharmacist who is employed directly by the practice lead this work. The Pharmacist knows the nuances of GP and practice operations/pressures and is astutely and acurrately aware of NHS pressures. The pharmacist has a long standing relationship with the practice and homes, and is familiar with their relationship/pressures within care homes as well as awareness of what best practice and national guidance looks like. Our practice services a population of 18000 and we have the highest percentage of over 80 -year olds within the CCG.

The costs incurred were that of the GP time/Pharmacist Independent time/admin time to organise the visits. The costs reflected the 16 sessions outlined below. Part of our funding was received from the CCG following successful submission of our plan.

We present a sample of interventions from 4 out of the 16 visits  we completed. We monitored and evaluated our results for just a sample of visits which we felt could be extrapolated to all 16 visits as it was quite labour intensive capturing the interventions and we had no additional support to do this. This data represents 48 patients that were reviewed. On average, each person in a care home is prescribed 8 or more medicines. Our interventions are captured in the results table attached as supporting material but some key elements to highlight are:-

• 134 medicines that were prescribed as an acute and were still found to be needed were moved to the patient’s repeat list of medicines
• 20 medicines were stopped after discussion with carers
• An additional 63 medicines were removed from active repeat medicine to history as they were no longer needed

The results of the  data  exceeded our expectations from when we  started this project  and we were pleasantly surprised. However we were aware that this was an area where we could make improvements, the scale of which was unknown when we embarked on the journey. The key benefits to patients as demonstrated by this data  are amplified by the fact that we tailored our review to each patient,  one size approach does not fit all. The approach we took was tailored, informed and targeted to individual patients and care homes needs. Patient benefits include: administration of the tablets at the right time, in the right formulation that most suited that person (for 81 items of medicines), less admissions to hospitals because we stopped medicines that were no longer needed and increased monitoring of drugs and relevant pathology eg renal function.

It is also important to highlight that it is not just about the medicines , we were able to optimise the  care of our patients as well e.g. some patients would be ‘lost to the system’ when they were moved from one setting to another e.g. it may have meant that their dementia review wasn’t reviewed as planned by the secondary care team, or medicines had changed when patients were discharged from hospital but this was not actioned (which we were able to rectify). As a prescriber I personally was able to build a relationship with the home, the carers and patients and develop that trust that was required to implement that changes that were needed to optimise the care of the patient.

This work illustrates an example of innovative, quality focused and value for money which we feel should be further supported as this brings GPs, other clinicians and health partners together to improve services and patient care by widening the scope of primary care, beyond traditional GMS and PMS service. Challenges are everywhere in the NHS: patient demand, increasing target and time pressures, silo working and lack of knowledge of real life implications that all this creates.

Being innovative, thinking differently and working within a multi-disciplinary team saves time and money for the NHS and optimises patient care. GPs directly employing Pharmacist Independent Prescribers can be beneficial but the Pharmacist must be competent, highly skilled and have a great relationship with the practice and a true understanding of all pressures within the NHS.