The project integrated a clinical pharmacist within the Islington social services re-ablement team to provide proactive support around medication management. This involved carrying out medication reviews with service users who were identified as having a medication related need, with the aim of optimising therapy, avoiding adverse drug effects, increasing knowledge and supporting individuals to manage their medications.
The project demonstrated implementation of the key principles of the NICE Medicines Optimisation (MO) guidance (NG5), specifically by addressing; polypharmacy (Recommendation 1.2.6), optimising medications and improving safety (Recommendation 1.1.8).
Aims and objectives
- To provide domiciliary medication reviews to Islington residents receiving intermediate care input - To show that by providing proactive support that medications can be optimised and potential adverse effects and hospital admission from sub-optimal use of medicines could be avoided.
Our objectives were:
- Safety: To reduce medication errors at transition of care.
- Quality: To optimise medication for older people living in Islington to improve clinical outcomes and reduce medicines-related harm.
- Co-creating health: To create an environment where individuals feel empowered to express their views so that shared decision making can occur.
- Integrated care: To strengthen links between primary, secondary and voluntary sectors in relation to medication optimisation.
- Integrated care: To develop specialist pharmacist input into multidisciplinary social services and intermediate care services in Islington.
Reasons for implementing your project
As the service developed the following steps have provided opportunity for improved efficiency and productivity of the service:
- Shared IT systems - access to social care IT systems saves time as they provide direct access to information. Access to GP IT systems would further increase efficiency as at present the pharmacist has to request medical summaries via fax or email for each review performed
- The use of iPads to record interventions and outcomes during reviews. Previously, reviews were recorded on paper then typed at a later point which was a time consuming process. The following areas have been identified as opportunities for cost savings as a result of the domiciliary reviews
- Reduced medication wastage through optimisation of medications and improved compliance
- Reduction in number of social service visits needed for medication prompting through optimisation of medication dosages and timings
- Reduction in the need for district nurses to administer medications because an individual has regained independence with medication management post discharge from hospital
How did you implement the project
To combat this, referrers were instructed to explain the purpose and reasoning for a medication review to obtain informed consent before sending referral forms to the pharmacist. A simple leaflet about medication reviews was also put together which is now provided to all individuals receiving input from Re-ablement regardless of whether they are referred for review. Access to social services IT systems took a long-time to achieve. If a similar service was going to be set up we would recommend that this is provided prior to service roll out. Having access to background information that may influence an individual's ability to manage their long-term conditions and medications can help steer the approach taken during the reviews and the types of interventions made. In line with the NICE MO guidance, medication reviews were carried out in a systematic way ensuring that all aspects of medicines management were examined. This includes access to medicines, compliance and clinical issues.
- Removal of old medications worth over £1500
- Rationalisation of prescribing; Mrs X was prescribed duplicate drugs within therapeutic groups including; statins, PPIs, Vitamin D supplementation and antibiotic prophylaxis
- Avoidance of ADRs - anti-hypertensives stopped in hospital had been continued by GP upon discharge without any BP monitoring and anti-diabetic medications had not been reviewed despite significant weight loss and reduced dietary intake.
Mrs X was not compliant with taking all of these medications because she felt they made her unwell. After the pharmacist's education session, Mrs X felt that she would be able to manage her medications independently. As increasing service user independence with medication management was a key aim of the service a formal evaluation of service user opinion was conducted in April 2014 on a sample of individuals. Thirty-four service users who had been seen by the Re-ablement Pharmacist in the preceding six months were interviewed by telephone to ascertain their satisfaction with the service. The median age of interviewees was 74 (range 48-95 years); 62% were female. Overall, participants valued the service, and the pharmacist's visit exceeded their expectations and promoted their independence with taking medication. (Full results of evaluation are available on request). It is recognised that the outcomes of the service have not been evaluated in a validated way. This is currently being reviewed by members of the Whittington pharmacy team and UCL School of Pharmacy, and we plan to capture outcome data that demonstrates the multivariate impact of these reviews.
Key learning points
Finally, the success of the service is proving to be a limitation. A continual rise in the number of referrals has led to the service almost reaching saturation point. From the outset, plans to ensure sustainability need to be in place. Locally, outcomes from this work have led to the commissioning of further innovative pharmacists' posts. Two further clinical pharmacist posts have been funded to conduct medication reviews in domiciliary as well as nursing and residential homes for complex older people.