Integrated Care Clinical Pharmacist for Frail Older People: Case Management and Enhanced Rapid Response

The ICP role has been developed to cater for frail older people, recognising that current disease-focused therapeutic approaches are often ineffective and positive outcomes result from addressing the interactions of the whole rather than discrete aspects of medicines use. In line with growing evidence of what works in this group, care provided by the ICPs is organised around the patient’s holistic needs and integrated within the care pathway. Guy’s and St Thomas’ NHS Foundation Trust has more than 2 million patient contacts a year including 866,000 in community health services. This service is provided across the London boroughs of Southwark and Lambeth. The scope of the ICP role is to:

• Reduce inappropriate polypharmacy and adverse effects.

• Improve adherence and patients’ understanding of medicines

• Reduce utilisation of emergency services through better therapeutic control of multi morbidities

• Receive referrals from GPs, nurses, therapists and geriatricians to undertake domiciliary medication reviews for patients with complex therapeutic needs during vulnerable periods (i.e. peri or post discharge, when a rapid response is needed to prevent a hospital admission) or patients with frequent hospital admissions

• Attend and present complex cases at geriatrician led community multidisciplinary team meetings and safeguarding meetings

• Increase knowledge and skills among community health and social care providers to optimise medicines use

• Facilitate partnership working across agencies to tackle barriers and improve medicines use during care transitions

• Actively support community pharmacists, community health and adult social care providers to deliver personalised interventions and care packages that support older people/their carer’s with medicines taking

• Actively integrate the role of the community pharmacist (named) into the patient care pathway by bridging the gap and facilitating collaborative working between local community pharmacists and GPs.

In early 2008, a senior Pharmacist and Community Matron piloted specialist Medicines Management input for case managed patients. This enhanced model of case management was positively received. One patient was on a type of medication which resulted in extreme dryness of mouth making eating and drinking very painful. The effect on her everyday life was so severe, that she experienced suicidal thoughts. In the pilot, following a comprehensive medication review the pharmacist switched her to an alternative drug regime, thus resolving the issue.

This enhanced model of case management was evaluated in 2008 (Evaluation of Case management-Lambeth PCT 2008). Patient views illustrated the impact of this model of care on clinical outcomes and highlighted a number of areas for improvement. The current ICP project built on the findings from the evaluation and further enhanced this model of care, through expansion both in expertise i.e. medicines management and facilitation of improved joint working between agencies.

Evaluation of data from the first 143(n>350) reviews from community matrons caseloads show that patients had an average of 7 long-term conditions and 14 medicines. Cardiovascular, respiratory, pain and diabetic conditions were the most prevalent and over 60% patients were prescribed drugs linked with high risk of hospital admissions.

The emerging picture is that of very vulnerable patients, mainly over 75 years, with complex therapeutic needs, frequent hospital admissions, dynamic health status, living alone in the community and struggling to manage their medicines independently as a result of a combination of functional impairments, health and psychosocial needs.

The ICP input is time limited. Once the identified complex medicines need or acute crisis has been resolved the patient is discharged from the pharmacist’s caseload. In order to continue providing pharmaceutical care specific to this frail older population, a model which utilises a named community pharmacist to provide ongoing support identified in the care plan and reduces reliance on unplanned or emergency services is being explored.

These community pharmacists will work closely with the GP, other generalist health and social care practitioners to support and monitor adherence, promote self -management and independence, monitor drug effects and patient response and reduce wastage.

The first element of the project involves the ICP addressing complex pharmacy needs and developing a care plan. The second is the development of long-term strategies enabling provision of appropriate support within the community for this patient group, particularly enhanced roles for community pharmacists and care workers.

Step 1:

Using locally developed screening or assessment tools community health service staff (mainly community matrons, therapists and nurses within enhanced rapid response teams) proactively identify patients with a real or high risk of medicines related problem and refer to the ICP. The ICP also proactively finds patients from the community matrons’ caseload and receives referrals via the CDMT, GPs and geriatricians in certain localities. (Commitment from CCG to commission enough posts for full coverage)

Step 2:

Prior to the patient visit, the ICP gathers information from a range of sources including community services health records (RIO), hospital based electronic prescribing record, discussions with the referrer and by accessing the clinical letters/records at the GP practices. The ICP undertakes an in depth medication assessment using a locally developed tool focused on 3 areas of medicines related needs: access, adherence and clinical issues.

The pharmacist discusses these needs with the patient, taking into account their values, beliefs and experiences around taking medicines. They jointly formulate a care plan to achieve the desired outcomes. Adherence issues and solutions are discussed with the patient to determine practical ways to resolve the challenges they face, with appropriate follow up.

Step 3 & 4

The pharmacist coordinates the implementation of the various aspects of the plan by liaising with the referrer, GP, community pharmacist, a range of other health and social care professionals, carers and informal carers as appropriate. Solutions are agreed with all parties, and appropriate follow up monitoring and assessment arranged. The ICP will follow up with telephone calls and further visits to ensure that agreed changes are actioned and the patient is responding and coping appropriately, until they are safe and stable to be discharged from the ICPs active caseload.

Step 5

This project identified and tested a role for a named community pharmacist to actively lead medicines optimisation in the stable frail older person following input from the ICP.

The evaluation showed that patients benefited from the ICP input project in the following ways:

• Improved quality of life, health and emotional well-being e.g. improved functionality, symptom control

• Improved personal dignity e.g. ability to perform personal care and simple tasks, resolving incontinence problems

• Holistic approach to care referral and improved access to other services e.g. dietetics, OT, home repairs/adjustments

• Improved co-ordination of care and reducing gaps in service provision e.g. medicines supply and delivery

• Greater understanding of medication regimen, enabling greater patient choice and control e.g. improved adherence, supporting and safe-proofing the existing innovative and bespoke ways to self-manage medicines

• Reduction in adverse drug reactions and unplanned emergency admissions and unscheduled episodes of care

• Reduced medicines waste and cost effective prescribing e.g. decluttering and disposal of unwanted/expired medicines

• 20 (n32) respondents to the patient satisfaction surveys (n35) found the pharmacist’s visit either very helpful (75%) or helpful (25%). 90% of patients were satisfied with the outcome of the visit. 45% of the respondents felt that their health had improved following the pharmacists visit. 95% of patients felt their views and opinions about their medicines were taken into consideration and 80% felt involved in decisions about their medicines. 90% of patients felt that they had a better understanding of their medicines following the discussion with the pharmacist.

Staff have benefited from this project in the following ways:

• More effective joint working between different agencies and teams

• Increased knowledge of medicines issues amongst Community Matrons, GPs and the wider primary care team

• Holistic approach to patient care encouraged

• ICPs, now integral and valued members of the community multi-disciplinary team, are receiving referral requests from other healthcare and social care providers.

The wider NHS has also benefited in the following ways:

• This model has been adapted and successfully replicated by other NHS organisations

• Learning has been widely shared and disseminated across NHS and the profession

• Case studies from the project have been used for facilitated peer support meetings and clinical supervision for other community based clinical pharmacist across SE and East of England NHS.

The ICP routinely applies the following key principles when delivering care within this service:

Personalised

– Organised around the patient, not disease or service

– Involve patients, practitioners and carers

– Describe circumstances in which needs exist as well as priorities

Co-ordinated

– Must be part of co-ordinated care vs stand alone

– Allow information sharing and reduce duplication

Outcome focused

– Must result in a personalised care plan that meets the needs identified. A means to an end!

– Focus on meeting needs vs. just providing a service In order to ensure patients receive a consistent service we have developed a comprehensive medicines assessment tool.

The ICP uses this assessment process with every patient that is referred to the service.

Integration: The ICP liaises with a wide range of health and social care practitioners as well as sharing records across the healthcare team allowing the timely transfer of information about the patient in a timely manner.

Leading and co-ordinating all aspects of the patient’s medicines related needs to ensure that the recommendations in the care plan are implemented and outcomes achieved.

The ICP pharmacist acts as an advocate for the patient in relation to their medicines needs. i.e helping to remove barriers and facilitate access to a range of support services to meet their individual needs.

It is vital that recommendations are not only implemented but that the patient is reviewed by the ICP within appropriate timescales to ensure interventions have had the intended outcomes and patient’s goals have been achieved.

Easily accessible clinical supervision from a consultant pharmacist to address complex situations commonly encountered when dealing with vulnerable older patients particularly where there is uncertainty or paucity in the evidence base. Also to unblock the professional and organisational barriers encountered as part of working within multidisciplinary team across organisations.