Refer-to-Pharmacy is an electronic tool that allows bedside referral of patients to their community pharmacist for a post-discharge medicines adherence consultation, or to update a patient’s pharmacy record with medication changes to improve safety. Pharmacies are also informed of hospital admission for particular patient cohorts so they can stop dispensing to reduce wasted medicines.
Refer-to-Pharmacy (R2P) is THE tool that let’s hospitals meet one of the requirements of NICE’s NG5 Medicines Optimisation guidance which states “a consenting person’s medicines discharge information should be shared with their nominated community pharmacy where possible”.
Refer-to-Pharmacy makes this possible. Refer-to-Pharmacy was developed to meet an obvious safety and service need. By the end year 1 (October 2016) such referrals are now routine from our hospital, with high acceptance rates from local community pharmacies. There is much interest in spreading the development into other health economies.
Aims & Objectives
The main aim was to develop an effective hospital to community pharmacy referral tool that could also be spread to other health economies, and there were several other objectives to achieve this: Financial & Technical.
Funding was gained via three-way arrangement with ELHT, Blackburn with Darwen and East Lancashire CCGs.
Development of the actual software could not commence until a validated copy of the e-discharge letter was available as this was a key component.
Behavioural Changes - Hospital: It took nearly 2 months to train all ward based pharmacists and technicians (90+). Using the system was easy with training focusing on identifying eligible patients.
Community Pharmacy behavioural change: On-line training was provided as well as some SOPs and a user guide. The LPC have supported mechanisms to aid acceptance rates of referrals Patients: A patient-facing film was made to show patients on their bedside TVs explaining why the system exists and how they will benefit from being referred.
Twitter and Facebook accounts were created for health professionals and patients to interact with. Raising awareness - A ‘referral toolkit’ has been developed with the Royal Pharmaceutical Society, there have been articles written for journals, social media has been used to raise awareness in the profession, the local AHSNs have been engaged with, and R2P has been discussed at numerous meetings and conferences. A regular newsletter also keeps interested parties informed of progress.
During the consultation for NG5 guidance a submission was made that led to part of the guidance stating that patients’ discharge letters should be shared with community pharmacies where possible: Refer-to-Pharmacy makes this possible, and does so reliably and consistently. ELHT’s Comms team create branding with a logo and strapline: Get the best from your medicines and stay healthy a home. A mobile phone app was developed to inform people of development and news (bit.ly/r2pharm).
Finally R2P has won two awards: a Patient Safety Award in July 2016, and from Building Better healthcare in November 2016. Evaluation – Manchester University School of Pharmacy was engaged with early in the technical development; this led to the software being ‘research-friendly. They’re close to publishing a qualitative study about the introduction of Refer-to-Pharmacy, and are working closely with the Trust to evaluate the trend in readmissions reduction. In built audit tools also allow performance monitoring.
Hospital to community referral was simply not happening before the project. We had tried signposting patients and quickly determined this approach was ineffectual. Data from the NHS local area team supported this view with very low numbers of post-discharge MURs (only 0.14% of the 365,200 hospital admissions in 2013/14 resulted in a post-discharge MUR). We serve a population of about 500,000, the Trust has about 1,000 beds and discharges about 120 people/day.
Our baseline was effectively zero, however subsequent activity reveals the most vulnerable patients are being referred compared to all discharges (average age 78 years versus 49 years; length of stay 9 days versus 4 days).
Initial key stakeholders were community pharmacists engaged with via the Local Pharmaceutical Committee and kept informed via newsletters before and after go-live. CCGs were engaged with to help fund initial development. Newsletters and posters have been used to raise awareness. A patient-facing film was developed to inform potential referable patients on their bedside TV (viewable via www.elht.nhs.uk/refer).
Between go-live on 29th October 2015 and 31st December 2016 referrals from hospital totalled 6,543 (and this was from a standing start; projections for Year 2 are closer to 15,000). Community pharmacists are reporting that the system is saving them dispensing time and reducing medicines waste. For the 5 weeks to the end of September 2016 they reported: 602 referrals had saved them time, and 628 had reduced medicines waste. In the same period pharmacists reported that 762 referrals had no likelihood of readmission.
Very shortly we will have a reporting tool that will compare readmissions rates for referred patients as the Refer-to-Pharmacy database and ELHT’s PAS database are compared. This is being developed in conjunction with Manchester University in order to make sense of the information as there is no control group to compare against. An early signal for the first 6 months of 2016 (while the system was in its nascency) was a reduction in readmissions (at 28 days and for the same diagnosis) from 3.8% to 3.2% which equated to 60 fewer patients. The system is saving the hospital pharmacy team time too.
What used to be a 5 minute phone call to verbally communicate changes to blister packed medicines has been replaced with a 20 second referral, and with 1953 blister pack referrals made in Year 1, that’s a lot of time saved and invested back into patient care.
The development of Refer-to-Pharmacy and of NG5 have occurred in parallel. ELHT went live with Refer-to-Pharmacy about 6 months after NG5 was published. As mentioned above during the consultation period of NG5 a submission was made to NICE to promulgate the sharing of discharge letters with community pharmacists. Gaining development funds was a challenge, but a good business case and effective persuasive skills worked. Developing the software and keeping it on track was the biggest challenge. It took several months as the process needed mapping out at a very detailed level, and then developed and tested.
There was a hiatus whilst the third-party provider of our e-discharge letter system sorted out providing a copy of patients’ discharge letters. There was a lot of testing to ensure the software worked as intended, interfaced with the patient administration system (PAS), coped with the complexity of merged patients, deceased patients; but it was worth the wait. The system behaved as designed and was ultra-quick to use, meaning referrals take seconds to make, meaning there is no encumbrance to staff using the system.
The next challenge was creating the cultural change required to adopt the new working practices to make it work; reporting tools aided this with a lot of communication with system users.
The current challenge is creating the desire to spread the innovation; a communications strategy is driving this. No services were discontinued as a result of Refer-to-Pharmacy – it has innovated a new service model, and actually saved time at the hospital and community ends, improving productivity, patient safety, medicines adherence, and empowering pharmacy professionals allowing joint working which was previously unimaginable.
The project required funding to set up; a tripartite agreement between ELHT and our two CCGs funded the development and annual maintenance fee; with extra investment from the software developers. ELHT’s Comms team funded the development of branding and the film. Future sites would not require the same costs as the system now exists.
Results and evaluation
Driving the use of the system has been achieved with reporting tools which came on line at various points in Year 1.
The Hospital Summary report shows from which wards and from which staff referrals have been made. This allows individual conversations to take place to praise or encourage virtuous behaviour with our philosophy being: Every Eligible Patient Referred.
The Outcome Report shows which pharmacies (for a chosen period) have accepted, rejected, or have yet to accept a referral. This is used initially by the LPC to drive up acceptance rates and since September outstanding referrals are chased up weekly by the hospital pharmacy team as a few pharmacies can be called split amongst many people more quickly.
The acceptance rate in October 2016 was 85% which means there’s still some work to do to meet the community philosophy: Every Referred Patient Accepted.
On go-live a simple process outcome was captured by community pharmacists for each referral type. Based on their feedback this was changed to make it easier to use which had the benefit of capturing more outcome data including likelihood of readmission, time saved and reduced medicines waste. These data capture tools will shortly be enhanced to improve the depth of data obtained.
It took a few months to meet expectations while we understood what was required to create the right culture to get people to routinely make and receive referrals. Information on this can be found on the mobile app bit.ly/r2pharm.
Key learning points
The most important thing is to get in touch so they don’t reinvent the wheel. Refer-to-Pharmacy is the “Ronseal of Referral Systems”, it’s the world’s first fully integrated hospital to community pharmacy referral system so don’t waste time and resource starting from scratch.
Be persistent with your vision to deliver an effectual referral solution and never give up. The Royal Pharmaceutical Society has produced a toolkit to help spread the concept. Its content was heavily influenced by the development experience of creating Refer-to-Pharmacy and contains evidence to inform business cases and an implementation checklist (www.rpharms.com/referraltoolkit).
Subsequent experience at ELHT would inform people further about what works and doesn’t work. A strong communications campaign is essential to keep all key stakeholders informed. This needs to cover all health professionals involved, and separately local media and patients.
The campaign never ends and is needed to sustain interest and involvement by all parties. Every year new users come along who need inducting into how the system works and what makes patients eligible for referral; and every year new patients are admitted to hospital who need educating on their medicines and how community pharmacists can help them get the best from their medicines and stay healthy at home.
The software that enables Refer-to-Pharmacy was created to ELHT Pharmacy department's specification but is owned by the developer Webstar Health.