Medicines Optimisation for Older People in Care Homes and the Intermediate Care Setting: Developing and Reproducing new Models of Care

The aim of this project was to refine, test and scale up a regional model for medicines optimisation in older people in intermediate care and care home settings within the Northern and Western Health and Social Care Trusts.

The objectives were:

1. To deliver this innovative and new consultant pharmacist led pharmacy service seamlessly to older people throughout identified points in their care pathway which may originate in the acute care setting, intermediate care facilities and/or care homes, continuing through to care within the community/primary care setting.
2. To build upon the pharmaceutical care of older people case management projects carried out between 2012-2014 in the Northern and Western HSC Trusts and demonstrate that the models of pharmaceutical care successfully implemented in each Trust (in Nursing Homes in the NHSCT and in Intermediate Care in the WHSCT) were reproducible in the other Trust. This work would then also serve as a platform to deliver on the following:

• A scalable model for medicines optimisation in older people in intermediate care and care homes across Northern Ireland
• A business case for regional roll out of this model from 2016/17
• A regional policy for medicines optimisation in older people in all settings.

The WHSCT is a geographically large trust serving a mainly rural population of 300 000 people. The NHSCT is a neighbouring trust serving a more urban population of 475 000 people.

The WHSCT intermediate care case management model was originally delivered in Waterside Community Hospital, a 48-bed reablement facility for older people. Prior to the pilot work in 2012, the pharmacy service to Waterside was ‘supply only’.  The model, informed by a process mapping event with a multidisciplinary stakeholder group, required the consultant pharmacist to assume pharmaceutical care responsibility for patients throughout their stay in intermediate care and for 30 days post-discharge when case management was completed via a follow-up telephone call. 

This model yielded £68k per annum drug cost savings.  The consultant pharmacist made an average of 2.5 clinical interventions per patient during their stay in intermediate care; these can potentially lead to prevention of medication errors and adverse drug events.The School of Health and Related Research at Sheffield University (ScHARR) has defined the costs related to these errors; application of the ScHARR model yielded potential savings of £63-144k pa. In 2015, the WHSCT service continued in Waterside Hospital and was introduced to two new similar facilities in the NHSCT (Robinson and Dalriada Hospitals).  Evaluation of the NHSCT and comparison to the WHSCT would establish whether the model could be reproduced with similar outcomes.

The care home model developed in the NHSCT required the consultant pharmacist to conduct case management clinics with older people in care homes. Once all patients had been reviewed, a ‘wrap-up’ meeting was held with the GPs and care home staff where key findings were highlighted.  Educational sessions were delivered to care home staff as identified or requested.  Over a 12-month period, in 16 homes, 727 patients were reviewed and an average of 2.9 clinical interventions made per patient. Over the project duration, the average number of hospital admissions from these homes dropped from approximately 3.5 to 1.5 per month.  A&E presentations to the main acute facility reduced by 14%. Total drug cost savings were estimated at £107k pa. In 2015, the care home model was introduced to the WHSCT to test for reproducibility of outcomes.

Work from 2012-14 has been published (refer to the supporting material).

The original models were developed prior to publication of the NICE guideline in 2015, but recognising that these aligned with implementation of recommendations 1.2, 1.3 and 1.4 within the NICE guideline for older people in care homes and intermediate care. The funding to test and scale the models for reproducibility and robustness was sought and obtained from the Department of Health (NI) Change Fund.

Two case management pharmacists were recruited into the intermediate care model, one in each of the two trusts who delivered the case management model under the mentorship of the consultant pharmacists. Three further case management pharmacists were recruited into the care home model, again under the mentorship of the consultant pharmacists. Two of these pharmacists were based in the Northern and Southern sectors of the WHSCT where they not only introduced the model of care, but also tested different methods of communication and actioning of recommendations with GPs.  The different routes of communication were:

1. Letter to the GP and actions followed up by the pharmacist
2. Teleconference/meeting with GP and recommendations agreed and actioned
3. Pharmacist had direct access to the GP system and implemented recommendations according to a pre-agreed three-tiered protocol.

One further part-time pharmacist was employed in the NHSCT to revisit homes six months post-review to determine levels of maintenance of recommendations and need for further review.

To ensure the models of care could be integrated into existing systems, process mapping events were held in both trusts with focus either on intermediate care (NHSCT) or care homes (WHSCT). These were attended by multidisciplinary stakeholders and ensured buy-in at early stages of implementation. Trust-specific issues were identified and an action plan agreed by all attendees at these events.

The trust teams held joint team meetings on a monthly basis where clinical interventions and use of data collection tools was peer reviewed. This included review of application of the Eadon criteria to clinical interventions (a scale from 1 to 6 reflective of quality of pharmacist care) and use of the Medications Appropriateness Index (MAI). This added a quality assurance element to the project ensuring all pharmacists were working to an agreed standard. 

The MOOP steering committee met on a monthly basis where issues and risks could be highlighted and discussed; advocacy groups attended as required.

Quarterly reports were provided to the Department of Health’s Regional Innovations in Medicines Management Programme Board who were overseeing the work.

For references please see the supporting material.

Quantitative Evaluation

Data were collected over a 12-month period from September 1^st 2015 with 90-day follow-up of all patients case managed within both models of care. A preliminary analysis was performed in March 2016 to inform an interim report to the Department of Health. Full and ongoing analysis is being conducted in 2017.

Tables of results for the intermediate care setting comparing the original pilot outcomes to those achieved in 2015/16 are included in the supporting materials. The case management pharmacists worked with patients on a full-time basis (the consultant pharmacist role in 2012-2014 was 50% patient-facing) achieving further improved outcomes including:

• Improved medication appropriateness from admission to and discharge from intermediate care at a statistically significant level
• The majority of clinical interventions being Eadon grade ≥4 reflecting an improvement in the standard of quality of care for patients
• Further improvement in drug cost savings, the majority of which would be from the primary care drug budget
• A potential invest to save return of £2.01 to £3.68 per £1 invested.

Care home outcome data analysis is ongoing with the following noted to date:

• Statistically significant improvement in appropriateness of prescribing
• A statistically significant reduction in A&E presentations and unplanned hospital admissions 30 days post case management completion
• Drug cost savings of £141 - £180 per patient p.a
• A statistically significant reduction in GP call outs and A&E presentations at 90 days post case management completion.

Qualitative Evaluation

The charity Age NI run a unique programme where older people are recruited and trained in facilitation, listening skills, and report delivery. Once trained, facilitators are engaged in carrying out bespoke, facilitated sessions with older people on key issues including health and social care so that their views and experiences can be used to influence and shape policy and practice on ageing issues. 

In early 2016 Age NI conducted an independent evaluation of this work. Sixteen patients, one carer and 11 staff from both care settings were interviewed. In their final report and conclusions, Age NI supported the person centred approach demonstrated by the pharmacy teams, and believed this to be a fundamental aspect in the delivery of excellent care to older people. Age NI believe it is crucial to include older people and carers in discussions about medicines and this project demonstrated the benefits of this approach.

The key to success of work like this is to ‘win hearts and minds’ at the earliest possible stage. Engagement with stakeholders began when preparing the original business case in 2010/11. However, as pharmacy was moving into a new sector, and creating a new role (these were the first consultant pharmacist posts in Northern Ireland), it was initially not clear who all stakeholders might be. 

Process mapping events proved to be invaluable as all potential stakeholders were invited to participate, issues identified and action plans created collaboratively. Assumptions should not be made as to how systems and patient care pathways currently work.

The ‘test and scale’ approach has proven to be invaluable. The two trusts tested the two models, overcame obstacles within their own geographic area and used the learning to inform the other trust on how best to overcome presenting barriers. 

Extensive data collection and analysis was time-consuming but proved to be essential in moving the work forward and building capacity. The team, as it grew, ensured the project and results were disseminated extensively at both conferences and awards events. There was a lack of funding in 2014/15, but based on data from 2012-14, local commissioners continued to support the consultant pharmacists until Change Fund money was secured.

Strong project management with a clear organisation structure and communication management strategy is essential for success.

In March 2016, the Minster for Health in Northern Ireland announced the transformation fund; £2.3 million of this was devoted to Medicines Optimisation. A decision was then taken to permanently support and fund the older people work and to roll out both the intermediate care and care home consultant pharmacist led case management models across all five trusts in Northern Ireland in 2017. Evaluations will continue as the models are further developed and integrated into the pharmacy services in each trust.