Independence Well- being and Choice 2005, Our health, our care, our say 2006, Strong and Prosperous 2006

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2 Medicines Op+misa+on Outcome focused approach to safe and effec+ve use of medicines that takes into account the pa+ent s values, percep+on and experience of taking their medicines Important Outcomes for adults Improved quality of life Making a posi8ve contribu8on Improved health and emo8onal wellbeing Personal Dignity Control and choice Economic wellbeing Freedom from discrimina8on Independence Well- being and Choice 2005, Our health, our care, our say 2006, Strong and Prosperous Communi@es 2006 h3p:// pharmacy- pdfs/helping- pa8ents- make- the- most- of- their- medicines.pdf

3 Older people and medicines Op8mising medicines use can have a high impact on pa8ent experience, health outcomes and costs Naylor S et al. Kings Fund Transforming our health care system: Ten priori8es for commissioners h3p://experienceinvest.com/tag/healthcare- property/

4 Frail Older People 10% of over 65s and 25-50% over 85s 1 Take more medicines (mostly repeats) Higher risks of adverse drug events (ADEs) Frequent hospital admissions and longer stays Higher users of primary care and social care resources Many will manage be@er at home in crisis with the right support to meet their needs (BGS Fit for Frailty 2014) Young et al. Lancet

5 Frailty Age- associated decline in physiologic reserve and func+on across mul8- organ systems leading to increased vulnerability for adverse health outcomes (Fried et al 2001) A dis8nct health state where a minor event can trigger major changes in health from which the pa8ent may fail to return to their previous level of health (Bri8sh Geriatric Society) Co- morbidi+es Acute illness Adverse outcomes Social vulnerability Ageing Progressive condi8on, with episodic deteriora8ons

6 Poor resilience to stressors

7 Frailty markers Frailty Phenotype ( 3) Weakness Slowness Low level of physical ac8vity Self- reported exhaus8on Uninten8onal weight loss (Fried et al 2001) Acute Illness oten present as frailty syndromes Falls Immobility Delirium Incon8nence Suscep+bility to ADEs

8 Focusing community services on those with frailty rather than on those at highest risk of hospital admission might improve quality of pa8ent care and reduce hospital bed usage BGS Fit for Frailty 2

9 Premises underpinning frailty services 1. Interven8ons across health and social care aimed at improving physical, mental and social func8oning to avoid adverse events like hospitalisa8on vs strictly disease- orientated biomedical approach 2. Individualised treatment and interven8ons 3. Sustained support over a long 8me that con8nues even through intervening crises and adverse events. 4. Interven8on plan that enables par8cipa8on of the older person. 5. Engagement with the family and/ or carers BGS Fit for Frailty

10 Evidence: Pharmacist led interven+ons reducing hospital admissions No evidence of impact of medica8on reviews on hospital bed use (Philp I et al IJIC 2013) Systema8c reviews and Meta analysis (Thomas R Age and Ageing 2014) Interven8ons led by hospital pharmacists reduce unplanned hospital admissions in older pa8ents with heart failure (3RCTs) Interven8ons led by hospital or community pharmacists for the general older popula8on do not reduce unplanned admissions (16 trials) Many interven8ons that might be expected to avoid admissions, including home based medica8on reviews do not (Kings Fund 2010) Bo3om line No robust evidence that pharmacist led interven8ons reduce hospital admissions in older people

11 Adverse Drug Event (ADE) or Drug Related Problem Adverse drug reac8ons (ADRs) i.e. unwanted or harmful effect of medica8on failure by the pa8ent to take the medicine as intended, Medica8on errors e.g. prescribing, dispensing or administra8on errors Inappropriate or over treatment being prescribed Failure to prescribe an indicated treatment Medica8on discrepancies i.e. unexplained differences in documented medica8on regimens, par8cularly at transfer of care

12 General points ADEs can cause serious harm to pa8ents and lead to hospitalisa8on or death Terminology used in literature vary : ADRs are one cause of ADEs Rates of drug related hospital admissions vary widely 0.1% to 45% Clinical coding captures some ADRs but, generally underes8mate. Coding will not capture ADEs Not all ADEs or ADRs are preventable Highest risks: elderly pa8ents with mul8ple co- morbidi8es and receiving mul8ple medicines Medicines Related problems on Admission to Hospital - The Evidence h3p:// Medicines_related_problems_on_admission_the_evidence_Apr14Vs1_JW.pdf

13 WeMeRec. Medicines- related admissions.2015 At least 5% of hospital admissions are medicines related 80% are due to ADR Root causes of MRAs are complex Successful interven8ons to reduce the scale of the problem will need to involve primary and secondary care, as well as pa8ents.

14 Medicines- related admissions (WeMeRec 2015) Pa+ent- related risk factors Impaired cogni8on Four or more diseases in pa8ent s medical history Dependent living situa8on Impaired renal func8on before hospital admission Non- adherence to medica8on regimen Age > 65 years (more likely to experience an ADR)

15 Medicines- related admissions (WeMeRec 2015) Medica+on- related risk factors General Polypharmacy ( 5 medicines at the 8me of admission)* New medicine started within the last 7 days Complex medica8on regimens at hospital admission (Predic8ve of re- hospitalisa8ons for ADRs) Specific drugs An8coagulants An8platelet agents Diure8cs NSAIDs ACE inhibitors

16 Causes of PDRAs (Qual Saf Health Care 2008) Problems at mul8ple stages in the medica8on use process Prescribing, dispensing, administra8on, monitoring, help seeking Main causes of problems irrespec8ve of associa8on Communica8on failures (between pa8ents and healthcare professionals and different groups of healthcare professionals) Knowledge gaps (about drugs and pa8ents medical and medica8on histories). Conclusions The causes of PDRAs are mul8faceted and complex. Technical solu+ons to PDRAs will need to take account of this complexity and are unlikely to be sufficient on their own. Interven+ons targe+ng the human causes of PDRAs are also necessary for example, improving methods of communica+on.

17 Causes of PDRA (Howard et al BJCP 2006) Systema8c review of 13 papers Range %( mean 3.7) PDRAs Associated with prescribing problems (30.6%) adherence problems (33.3%) monitoring problems (22.2%) 50% of PDRAs involved four groups of drugs; an8- platelets (16%) diure8cs (16%) NSAIDs (11%) an8- coagulants (8%).

18 PDRAs and readmissions (Davies EC et al BJCP 2010) Small UK hospital study (n91) Approximately 20% of pa8ents readmi3ed to hospital within a year of discharge were re- admi3ed due to a suspected ADR 57% definitely or possibly avoidable. In 30% (n=11/37) of pa8ents readmi3ed within 28 days of discharge the causa8ve drug had been ini8ated in during the index admission.

19 Managing ADE in the community is Everybody s business: A mul+disciplinary approach is needed Suppor+ng self- medica+on Administering medicines Adverse drug reac+ons (ADRs) Monitoring medicine effects Pa8ent outcomes Non Adherence Polypharmacy Medicines reconcilia+on and Transfer of Info (De) Prescribing & Medica+on reviews (health only) 19

20 PDRAs in the real world.

21 Pa+ent centred pharmaceu+cal care to reduce avoidable drug related readmission Blagburn J et al EJHP 2015 Socially isolated pa8ents and/or on high- risk medicines Older people s medical ward x 1 year plus control Readmission rates 12mths before and 12 mths of interven8on period (retrospec8vely) Readmission rate was significantly lower on the interven8on ward (69/418) vs control ward (107/490); 17% vs 22%, p<0.05 Person- centred risk assessment and risk management for older people and their medica8ons in hospital may reduce the likelihood of 30- day readmission by 40%. Using a monitored dosage system for medicines at home may be a significant risk factor for hospital readmission.

22 Hypothesis and Interven+on Prac88oner behaviors and/or pa8ent- specific factors (medical condi8on & adherence) may be more accurate predictors of hospital readmission risk than the individual s epidemiological grouping Person- centred pharmaceu8cal care during and ater a hospital admission, that meets each individual s need for informa8on, risk management or support to take their medicines may reduce readmissions caused by non- adherence or troublesome side effects. Consulta+on Clinical pharmacists and pa8ents encounters moved from giving informa8on to pa8ent led conversa8ons, with shared treatment decisions and joint solu8ons to problems iden8fied Interven+ons Medicine reconcilia8on, shared decision making, mo8va8onal interview techniques, real- 8me discharge communica8on, assessing a person s usual support network for suitability, providing person- centred informa8on

23 Pharmaceu8cal Care bundle

24 Pharmacy- led integrated medicines management (IMM) project NWLH NHS Nina Barne3 et al Managing Preventable Medicines Related Readmission (PMRR) Parallel cohort study (836 pa8ents) Used PREVENT tool to iden8fy high risk pa8ents- 3 domains medicine- specific, clinical and social risks Causes of preventable readmission are mul8factorial Working within MDT to iden8fy/minimise the PMRR is cri8cal. The most frequent reasons for referral to the service Adherence issues (69%) Compliance support requests (29%) Pa8ents with cogni8ve impairment requiring help (29%) Pa8ents taking high risk medicines without appropriate monitoring or review in place (20%). Some pa8ents were referred for more than one reason.

25 Interven8on and results Referral to the IMM pharmacist team for medicines reconcilia8on & review, discharge planning and post discharge follow up Innova8ve coaching approach to consulta8on Collabora8on across MDT health & social care teams Readmissions within 30 days discharge 16% (IMM service site) vs 18% (standard service site) PMRR 0.3% (IMM site) vs 4.4% (standard service site) sta8s8cally significant reduc8on (P=0.002). Saving: 3 for every 1 spent on an IMM pharmacist Future work pa8ent experience, coding to iden8fy high risk pa8ents on admission, linking with primary care to iden+fy and manage pa+ents in the community

26 Integrated Medicines op+misa+on on Care Transfer (IMPACT) project Leeds teaching Hospital. Heather Smith et al 2013 Iden8fy older people at high- risk of med. related problems- started with PREVENT, used clinical judgement Medicines- related need iden8fied and medicines care plan (MCP) added to the pa8ent's discharge communica8on. Interven8ons Specific advice on medicines follow up post- discharge. Pa8ents (and or carers) educa8on Care planning, referral and sign- pos8ng to primary care and technician visit if needed Collabora8on CCG pharmacists for f/up medica8on reviews in domiciliary or care home seyngs Collabora8on with Adult Social Care: Medicines support assessments for pa8ents with re- ablement post discharge Pa8ent Needs: 86% clinical, 36% medicines support Re- admission within 30 days: 16%MCP vs 22% non- MCP

27 Community Health Services New Services and Innova+ons in Healthcare A Pragma@c approach Aim: Pharmacists take lead to iden+fy, resolve and co- ordinate medicines related care Reduce inappropriate polypharmacy and adverse effects. Improve adherence and understanding of medicines Reduce u+lisa+on of emergency services through be3er therapeu8c control of mul8ple morbidi8es Facilitate partnership working across agencies and improve medicines use during transi+ons of care Increase medicines related knowledge and skills among general prac8ce/community teams Inves8gate and develop methods of collabora+on with community pharmacy

28 New model of care: A pharmacist- led approach to op+mising medicines use for frail older in the community Pa8ent Centred, Co- ordinated, Con8nuous and Collabora8ve Frail older person during vulnerable periods & deteriora+ng health e.g. post discharge Receives GSTT Consultant/Advanced level clinical pharmacists input in the community Stable frail older person Receives generalist pharmacists ongoing input STEP 5 Community Pharmacy team implement specific long term goals within care plan. **Case management, Community MDTs, GPs, Enhanced Rapid response, Teams Liaise with GP (??Prac8ce based pharmacists) & mul8disciplinary teams Featured in the RPS Now or Never Report 2013: h3p:// of- care/models- of- care- in- ac8on.asp Winner : PresQIPP awards 2014 Shared decision making category Runner Up: Clinical Pharmacy Congress 2014: Best innova8on category 17

29 Moving towards medicines op+misa+on Pa+ent iden+fica+on Moving from drug related factors to pa8ent centred, real need vs. poten8al need Most frail elderly have high risk factors! Find the group, find the drugs! Assessment- approach and scope Moving from drug assessment to holis8c and pa8ent centred including social vulnerability, func8on as well as drugs and disease Including evidence base, then individualising drug therapy according clinical judgement and pa8ent narra8ve Interven+ons General fixed solu8ons to individualised jointly agreed solu8ons Working in silo as pharmacists in one seyng to collabora8ve and MDT/ integrated working Pharmacist to pharmacist referrals Care coordina8on- led by pharmacist as expert in use of medicines How can we make this rou+ne prac+ce?

30 FUTURE: Pharmacist- led medicines op+misa+on across secngs Social care Nurses Pharmacists in hospitals Medics Social care Carers AHP Pharmacists in community Pharmacists in primary care & community Social care providers and care homes Commissioners Research Professional bodies and regulators Educa8on

31 Learning so far. There a clear role for ALL pharmacists Need long term commissioning strategy with pharmacy workforce leading medicines op8misa8on across ALL seyngs Enable/skill up wider workforce incl. pa8ents, carers and social care Need realis8c outcomes/gains measured across the local economy Need innova8ve ways to gather research evidence research Training and clinical supervision for clinical pharmacists in community (domiciliary care/care homes) Need pharmacy champions to wn herats and minds

32 Summary Increasing numbers of frail older people Increasing pressure to deliver care closer to home for pa8ents with complex needs Polypharmacy, ADEs and support to take medicines are main issues Pa8ent experience and perspec8ve is a MUST! Many medicines related problems start at home Current clinical pharmacy exper8se and resources in community don t match need ð need a shit, closer to home In the real world.. Gathering the evidence (narra8ve) that pharmacists leading medicines op8misa8on across seyngs can reduce risks of ADE, PDRA and improve pa8ent outcomes

33 #pharmanforum Ques+ons?