Neighbourhood Integrated Medicines Optimisation Team: Improving medicines use at home

Aims of the service:

• To provide a consistent approach to medicines review for patients with complex needs identified by MDTs within the target populations
• The service will be based within East Cheshire Trust (ECT) community services and form part of the wider ECT clinical pharmacy service
• The service will take referrals from the GPs, other healthcare professionals and also identify patients proactively using a combination of methods

Objectives of the service:

• To conduct a medication review on patients registered with

  Eastern Cheshire Clinical Commissioning Group (ECCCG) practices within 4 weeks of admission to a care home, resolve any issues identified and contribute to the patient’s care plan where indicated

• To review medication in patients with long term conditions eligible for proactive care to reduce avoidable admissions, at the request of the referrer (e.g. following significant events such as a medicines safety incident, an admission or a fall, or when the referrer has identified a specific issue with medicines such as poor adherence or polypharmacy), resolve any issues identified and contribute to on-going case management.

It is recognised nationally that patients with a long term condition (LTC) account for more than 50% of all GP appointments, 65% of all out patient appointments and over 70% of all in-patient bed days.

It is estimated that by 2025 there will be:

• 18 million people in England with a LTC
• 3.3 million people aged 65 and over with an LTC with:

o          2.4 million receiving informal care at home

o          450,000 people in care/residential homes

• A forecast rise in total LTC expenditure to £26.4 billion, equivalent to a rise from 1.4% to 1.8% of Gross Domestic Product (GDP).

Despite the massive expenditure on LTC management it is estimated that up to 50% of medicines are not taken as intended by the prescriber.

East Cheshire Trust piloted the NIMO Team as part of the work on improving management of LTCs in 2013/14. This project involved 2 pharmacists and a pharmacy technician employed by East Cheshire Trust to contribute to the care of patients with LTCs by:

• Following up patients identified as needing further support with their medicines during an admission to ECT
• Liaising with the practice-based multidisciplinary teams (MDTs) in Knutsford and Macclesfield to provide advice on medicines issues
• Working with individual patients referred to the service by members of the MDTs in Knutsford and Macclesfield.

This service was well received by GPs, community matrons and patients and demonstrated the potential of pharmacists to contribute a unique perspective to the MDT.

Enhancements to the pilot service have since been developed by peer groups and CCG commissioners. These include:

• NIMO team covering the entire Eastern Cheshire CCG footprint
• Access to patient GP records via EMIS
• Extension of the service to include patients in care homes

The Royal Pharmaceutical Society highlighted issues associated with medicines in their publication Medicines Optimisation: Helping patients to make the most of medicines. Good practice guidance for healthcare professionals in England (May 2013). This document was used to support the initiation of this service, however, during the service review which is due March 2017, the NICE guideline, Medicines Optimisation: the safe and effective use of medicines (2015), will be incorporated into the service specifications aims and objectives to ensure the service is up to date with current recommendations.

The NIMO service is a team of 2 clinical pharmacists and one pharmacy technician. We promote our service to GP’s, community matrons, social services, district nurses and Macclesfield District General Hospital (MDGH) Pharmacy team and wards as we wanted to take referrals from all healthcare professionals involved in patient care.

We provide medication reviews for patients in their own homes liaising with the relevant GP and keeping the initial referrer up to date also. The medication reviews involve compliance checks, INH technique training, BP readings, and discussions regarding social and personal habits, e.g. smoking cessation, healthy eating advice. Suitable patients for our service are high risk/care home patients, patients with 3 or more recent medication changes, recent initiation of a critical medication or increased re-admissions to hospital. We have an office at MDGH which proves very useful as we have access to discharge letters, bloods, SCR’s and the frailty team who we communicate with regularly and they also validate our cost saving tool at a quarterly peer review panel meeting.

Initially we reported back to the CCG with a monthly report outlining the number of referrals, trends of referrals and our cost savings but now we are established we a provide quarterly report and planned meeting with our managers and commissioner to discuss the next quarter. The Medicines Management Team also provides us with the latest cost effective medications’ and formulary updates so that we can incorporate those into our reviews where appropriate.

When we receive a referral we put it into our EMIS system which also allows us to check PMH, recent bloods, prescription information and all consultations and gather all relevant information. The pharmacist does a clinical check of the patient’s medications and arranges a visit, with the patients’ consent, for themselves or the pharmacy technician to attend.

After our medication review visit, we would liaise with the GP and provide recommendations where necessary. We work closely and have built good relationships with most community pharmacies in our area and again liaise where necessary. If the recommended changes are prescribed or stopped, we would always follow up with the patient to ensure compliance.

As a service, we used to review care home patients but found that they had already been reviewed by the GP for that home before we had go around to seeing them , so instead of duplicating workload, we would do a clinical check for these patients and advise as needed.

As a team we received 850 suitable referrals into the service during the 2015-16 financial year. Of these 384 were from GP practices, 382 from Macclesfield District General Hospital and 141 from other healthcare professionals such as district nurses, dementia re-ablement services and social services. We also handled a total of 1077 telephone calls. These referrals led to 617 patient home visits and a total of 730 interventions. Proactive and detailed communication is maintained in our team as we aim to create a seamless care pathway between our referrers and patients and ensure that the referrer is informed of the outcome of our assessment within 48 hours.

GP’s were issued with a questionnaire on the service. The final question asked if they thought it would be useful if the NIMO pharmacists were non-medical prescribers, of those who answered the question, 73% said yes.

Also found in questionnaire results was;

• 100% said they would refer to the service again
• 100% said they felt they were provided with adequate feedback from the NIMO team
• 100% said their concerns and queries were resolved with the NIMO team.

The interventions we have made have resulted in patients having an increased understanding of their medication, ensuring that patients receive their medication in a timely manner and a way that promotes compliance and have estimated that we have prevented some hospital admissions because of our interventions. Due to our interventions we have saved over £37,000 in the 2015-16 financial year and, due to the new cost saving tool outlined above, have estimated cost savings for the 2016-17 financial year to rise to £90,000.

The response from patients and our referrers has been positive with some GP practice referral numbers increasing three-fold over the 2015-16 financial year. The future aims of the service are to increase referral numbers from all sources, increase the number of patient visits undertaken, prevent more hospital readmissions and increase cost savings further.

• It is important to prioritise patients at an increased risk of hospital admission
• It is important to keep updating key stakeholders to ensure that they remain aware of the service
• Local CCG initiatives must be taken into account when recommending prescription changes for medicines optimisation or medicines management purposes
• Cost savings can be determined much more effectively if a risk stratification tool is used to determine the impact of the service on each individual patient
• The EMIS Web system makes communication with other community healthcare professionals much easier and allows for faster resolution of problems. It would be worthwhile avoiding setting up the service if EMIS Web is not an option as faxes and emails take far too long to meet the key performance indicators that will likely be drawn up for the service
• Progression for the pharmacists and technicians, for example by way of clinical diploma, is paramount as an enhanced clinical knowledge was found to be extremely beneficial.