Improving Medicines Optimisation for Care Home Residents and Providing Medicines Management Support to Care Homes - The Wigan Borough CCG Approach

The aim of this initiative is to review prescribing, implement the principles of medicines optimisation for care home residents and support overall medicines management processes in care homes in line with NICE guidance and Care Quality Commission (CQC) requirements.

Objectives:

Ensure that all residents in care homes have a structured medication review by a medicines management pharmacist to ensure prescribing is evidence-based and cost effective and ensure appropriate monitoring is being carried out.

• Ensure appropriate management of patients with conditions commonly associated with increasing age such as dementia (NICE Key Therapeutic Topic (KTT) 2017), osteoporosis (NICE QS149) and atrial fibrillation (AF) related stroke (NICE NG196) and review inappropriate polypharmacy (NICE KTT 2017) and those medications commonly known to increase the risk of falls.
• Work with care home staff to ensure the overall safer use of medication by reviewing policies, providing education on medicines administration and storage and reviewing ordering procedures to reduce waste (NICE SC1, Recommendation 1.14.11).
• Work collaboratively with Local Authority Market Oversight and CCG Quality Teams to support homes to ensure that improvements in service provision are maintained going forwards.

Wigan Borough has a total population of 322,000 of which approximately 3.75% are aged over 65 and live in a care home. Wigan has 53 care homes (32 residential and 21 nursing homes), with a total of 2223 care home beds within the Borough. According to NICE guidance (NG56), two-thirds of people aged 65 years or over have multimorbidity, and 47% have three or more conditions and it has been reported that care home residents are prescribed an average of 7.2 medicines per day, with 69.5% of patients experiencing at least one error. The Royal Pharmaceutical Society recommends that every care home resident should receive a pharmacist led medicines review at least once a year, with NICE defining this as 'a structured examination, with the objective of reaching an agreement with the person about treatment, optimising impact, minimising medication‑related problems and reducing waste' (NG5).

The Medicines Management Team of Wigan Borough CCG had a desire to improve medicines optimisation for care home residents through improving the quality and safety of prescribing and improving patient outcomes. The quality areas selected included those identified in the CCG Medicines Optimisation Quality, Innovation, Productivity and Prevention (QIPP) plan. This was a new area of work for the medicines management team as there was little previous local experience of carrying out medication reviews in this setting or of providing support to care homes.

Additionally, feedback from GP Practices, the Local Authority and safeguarding referrals indicated that care home staff required support around the safe use and handling of medicines. This was further evidenced by CQC reports which specifically highlighted concerns with medicines management in a number of homes within Wigan Borough. The technician role was intended to specifically address the implementation of NICE guidance (SC1) and to collaborate with care home managers, the Local Authority Market Oversight Team, (who monitor care homes locally), and CQC inspectors to develop the skills and knowledge required such as the legalities and practicalities of healthcare within care homes.

To secure funding, a business case was developed and within this outcome measures and cost savings on the prescribing budget were identified.

In April 2014 the CCG secured funding from the Better Care Fund to employ 2 full time pharmacists for 1 year to support GP Practices to undertake medication review for care home residents. Initial findings identified that care home staff required support with the safe use and handling of medicines. Consequently, the skill mix within the team was reviewed and funding secured to recruit 1.8 WTE care home technicians who in addition to supporting the pharmacist reviews, would support the implementation of NICE guidance for Managing Medicines in Care Homes (SC1). Funding was secured to make all posts permanent as a result of the project achieving the pre-specified outcomes in May 2016.

The pharmacists within the team carry out medication reviews informed by the patient, their carers and their medication record. The medication reviews allow structured examination of a patient's medicines with the objective of reaching an agreement with the patient (or their carer) and their GP about treatment; aiming to optimise the impact of medicines, minimise the number of medication‑related problems and reduce waste

Face to face discussions are the preferred option of communication as recommendations are more likely to be accepted when discussed directly; however, arranging face to face discussions has been a challenging aspect of this project. Where practices are unable to accommodate this approach, written recommendations are provided for the GP to review. Changes are recorded in the GP record and communicated to the care home, patient and community pharmacy. A ward round approach is currently being evaluated.

Overall, savings were calculated as the difference in cost between the previous and the adjusted (or stopped) medication and were calculated for a 12 month period.

Demographic data and records of interventions made for a number of key quality and polypharmacy outcomes are collected via an access database.

Care home support is based on the initial NICE baseline assessment, the outcome of CQC inspections or information provided by the Local Authority Market Oversight Team. Key areas include ordering processes, storage, documentation, record keeping, administration, medication review, information sharing, self-administration and covert administration.

The team also contributes to the development of Service Improvement Plans (SIPs) and provides support to ensure recommendations are implemented.

Between August 2014 and March 2017 the care home team completed medication reviews for 749 care home residents and achieved savings of £710k on prescribing costs alone.

Staffing levels during this time period varied, with the maximum staffing level being 2 whole time equivalent (WTE) band 7 pharmacists August 2014 – March 2017 and 1.8WTE band 5 pharmacy technicians September 2015 - March 2017.

Based on actual staffing levels and midpoint salary plus on-costs from 2016/17 Agenda For Change (band 7 = £45389 and band 5 = £30053) staffing costs for the project were £259,193.

The return on investment for this project is therefore 2.7 based on the prescribing savings achieved. This does not reflect any secondary savings due to prevention of events eg falls, fractures and stroke which have not been calculated as they are very difficult to quantify.

Overall 2947 recommendations have been made to prescribers as a result of this initiative (average 4 per patient), of which 2515 have been accepted (85%).

In total 1626 medications (regular and when required) were stopped, 543 medications had a dose reduction, 42 medications had a dose increase and 676 medications were initiated.

A summary of the outcomes from the key quality areas reviewed is in the table here.

Care home team support to implement NICE guidance has been offered to 31 care homes with 29 homes (94%) accepting this support. Seven care homes have been supported more intensively in conjuection with a local authority SIP.

A summary of support can be viewed here.

Management of 'when required' and topical medication has required intensive support across most homes. Support has since been developed to include observed medication rounds as it has been found to be a valuable way of reviewing procedures and reducing variability between staff.

13 homes have shown improvement in their CQC ratings following support from the team. In addition to the positive feedback received from home managers following input from the team, CQC have also directly acknowledged the support provided by the team following inspections.

The team are currently developing guidelines and training programs to ensure that improvements in service provision are maintained in the future.

Think about the skill mix within the team to ensure a more enhanced level of support can be provided to both GP practices and care home staff.

Raise awareness of the role of the team and secure engagement from GPs by sharing examples of good practice and positive outcomes.

Where possible, encourage face to face meetings as the preferred option of communication between the GP practices and team as this supports informed discussion around the suggested interventions and enables the pharmacist to provide additional detail and context if required, especially if they also have access to the patient’s notes.

Collaborative working helps to build relationships and encourage sharing of information between all key health and social care stakeholders involved in the delivery and monitoring of residential and nursing care.

Ensure all healthcare professionals involved in individual residents’ care, including community pharmacists are updated to ensure changes are communicated across interfaces.