Whittington Health Pharmacy Re-ablement Service

Our aims were:
- 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.

Re-ablement is a package of care provided to domiciliary patients by Health & Social Services. Anecdotal reports suggested that medication-related problems were frequently encountered during re-ablement carer visits. These problems included insufficient medication information and lack of assessment of patients' medication-related needs on discharge from hospital, multiple supplies of different medication and service users' inability to manage their medications independently. Traditionally, there was no pharmacist input to the social services teams in Islington. In 2012, the results of a six-month pilot indicated the potential value of the addition of a pharmacist to the Re-ablement team as assessed by medicines optimisation interventions and team member feedback. Following the success of this pilot, a pharmacist was recruited into the Re-ablement team. Referral criteria for the service were expanded from Re-ablement service users to any adult receiving input from Islington Social Services, AgeUK or the community matrons. Local population demographics are summarised in Table A.

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

The service was established as a six-month pilot in March 2012, from which funding was extended following a positive evaluation. Currently the cost of the service is the salary of a band 8a wte clinical pharmacist, (approximately £60,000 with on-costs). Initially, there were less regular referrals to the service. It was felt that this might be due to the lack of knowledge around what this new service could provide. To increase visibility and awareness of the service, the pharmacist started attending and contributing to bi-weekly Re-ablement meetings. This allowed her to review all patients on service, allowing both health and social needs to be considered together. Also, at times the pharmacist was co-located with the team in social services buildings. This integration of the pharmacist into the Re-ablement team provided a source of expertise for social care colleagues who had medication related queries. Visibility and promotion of the service was essential for success. When the pilot began there was a higher incidence of service users refusing a domiciliary medication review when they had been referred by another member of the team providing in their care.

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.

Service uptake was monitored by reviewing the number of referrals to the service. Since the pilot began in April 2012 until 31st December 2014 there have been 253 referrals to the service and 203 domiciliary reviews have been conducted. Data from these reviews have been analysed up to March 31st 2014 when 139 reviews had taken place. As a result of these reviews 573 interventions have been recommended by the pharmacist (Table 2). Activity data from April 2014 is currently being reviewed. The impact of the service is best demonstrated through a case study. Mrs X is a 70 year old lady who was referred to Reablement after a hospital admission for an infective exacerbation of bronchiectasis. During the medication review a total of eighteen interventions were made.

These included:
- 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.

Integration of health and social care teams is essential for a service like this to have maximum benefit. Visibility and promotion of the service is essential and is best achieved through the multidisciplinary meetings (MDMs) and co-location with social services. Medicines optimisation has to be on the agenda of all professionals involved in an individual's care. Working closely with social services, the Re-ablement pharmacist has fostered a greater understanding within the team of how to manage medications appropriately in a patient's home, and how to support their independence with medication. Subsequent avoidance of medication related problems has the potential to reduce the hospital admissions. Access to social service records is extremely useful, it helps the pharmacist make appropriate interventions but it also alerts other professionals that a pharmacist is involved which facilitates joined-up working. Conducting medication reviews at a patient's home means that they are likely to be more relaxed and volunteer more information than they would in a healthcare setting. This allows in-depth discussions about medications but also wider discussions around health and unmet social needs, allowing lifestyle behaviour change interventions and referrals to an appropriate service to be made. It also permits the identification of duplicate supplies of medications from different health care providers.

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.