Medicines Optimisation the opportunities and challenges Christina Short Medicines Optimisation Project Manager
The remit:- Clinical Pharmacy input into the Locality Model Proposal: To contract a senior pharmacist to work with the Bexhill locality to test various models of how to provide medicines optimisation services within a locality. Start date 3 rd Nov 2014
The project: Test models of provision of:- Pharmaceutical advice to practice MDTs or to receive referrals from MDTs MDT ward rounds to carry out medication reviews in care homes Domiciliary medication reviews for housebound frail elderly patients Explore other opportunities to provide pharmaceutical support to locality based services Model the workforce requirements for widespread implementation of these services
Identify champion East Sussex Better Together - Locality Working Group 3 rd Dec 2014 Why are we here? How do we feed this into ESBT locality work stream? Answer Complete a
Project charter Prepared By: Date: Executive Sponsor Project information: Project Aim: Rationale: Key Area of Focus: Start Date: (Provide reason for the project. Identify the problem to be addressed.) Projected End Date: Project Objectives (SMART): (Statements of specific, measurable, relevant, timely outcomes) 1. Project Scope IN: Expected Benefits: Measure: Project Scope OUT: Stakeholder: What is the benefit? What is the measure? Who benefits? Key Milestones: (stage of project plan) Milestone: Start Out Define & Scope Measure & Understand Design & Plan Pilot & Implement Sustain & Share Target Completion Date:
Project charter cont. Project Team: Role: Time Commitment: Additional Resource Requirements: Additional Information:
Project Scope What project will achieve What it will not achieve Focus on project delivery NOT delivering the service! Stating what s not included avoids confusion & appearance of project failure in eyes of sponsor. Project Scope IN: Test model of provision of pharmaceutical advice to practice MDTs or to receive referrals from MDTs Test model of MDT ward rounds to carry out medication reviews in care homes & intermediate care beds Test model of provision of domiciliary medication reviews for housebound frail elderly patients Project Scope OUT: Clinical pharmacy in Community Hospitals Prescribing support in GP practices beyond the frail elderly and care homes Operational and technical medicines management services to care homes e.g. ordering and supply processes, medicines policies and procedures etc..
Tools NETWORKING:- OK wrt. pharmacy contacts in & outside CCGs Challenging in other CCG/ASC disciplines Phone, phone, phone Notebook (Dictaphone)
Resources used++ http://www.medicinesresources.nhs.uk/en/co mmunities/nhs/sps-e-and-se-england/ Polypharmacy Resource Jan 2015 UKCPA website (membership required) CoE page & documents NICE Managing Medicines in Care Homes BMA Quality First: Managing workload to deliver safe patient care
Examples of Pharmacy Led Solutions - Care Homes SHINE (Northumbria) - 1.7 drugs stopped/resident pill burden = QoL & 2.38 saving/ 1 invested Croydon CCG - 3 month pilot antipsychotics 26%, hypnotics 33.3% Hounslow PCT - 334 reviews - Rx cost 162,578/yr & emergency admissions = 234,498 Lambeth pilot - 488 reviews - Rx cost 288/pt/annum East Sussex - 988 reviews - 814 safety and quality interventions + 240 prescription queries - Rx cost 160/patient/yr Brighton & Hove CCG IRx Solutions - Rx cost 130-200/patient
Example of Pharmacy Led Solutions - Domiciliary medication reviews Croydon CCG 322 reviews emergency admissions = 234 000/annum Boots, Lloyds & Rowlands (Wigan) polypharmacy pilot UEA estimates > 470m for 11,000 pharmacies in England Western Health and Social Care Trust NI - 1,122 interventions, 84% QoL readmissions & inappropriate prescribing = 120,000 + /annum NHS Lothian - 186 patients 135 drugs stopped (33% high risk) 29 drugs reduced (48% high risk) = 135/patient/annum
Business Case 1. Executive Summary 2. Introduction 3. Strategic Context 3.1 National Context 3.2 Local Context 3.3 Health Needs Analysis 3.4 Reasons for Service Change/Innovation 4. Proposed Service Model/Change/Innovation 4.1 Approach to Options Appraisal 4.2 Options for Future provision 4.3 Options Appraisal 4.4 Recommended Service Model/Change/Innovation 5. Commissioning Approach 5.1 Approach to deciding upon the Commissioning Model 5.2 Commissioning Model Options and Analysis 5.3 Recommended Commissioning Model 5.4 Approach to deciding upon the Commissioning Method 5.5 Commissioning Method Options and Analysis 5.6 Recommended Commissioning Method 6. Financial Context 6.1 Current Activity and Cost 6.2 Investment 7. Anticipated Impact on Local Health and Social Care Economy
Business Case cont. 13 pages! 8. Engagement and Communications 9. Equality Impact Assessment 10. Privacy Impact Assessment 11. Project Plan 12. Governance Arrangements 13. Assessing the Risk 14. Conclusion and Recommendations GLOSSARY APPENDICES
Requirements Management BC broken down into separate files Information drop boxes Clarity around where information sits Reduced duplication Referencing
Challenges ID people Facts & figures matching demographics Roving Geriatrician Trying to appoint F/T physician to free more time, limited domiciliary visiting ICC federation ACP project phase 2 delayed until nurse in post Seaford & Alfriston unfortunately we currently don t have a GP to continue in this post, it would helpful to recruit to this post before starting a new project.
MDT reviews 2/12 completed 15 patients reviewed Number of regular, repeat medications 1 15 Changes in medication numbers post MDT:- by 1 4* No Change 8 by 1 1 by 3 1 by 4 1 *2/4 resulting from secondary care referrals (post # NoF bone protection, neurological intervention) Decreases in number are not all stopped medications but may show stopped medications with additions of others. 94 year old man, on 5 repeat medications possible deprescribing opportunity wrt. antihypertensive & lipid lowering medication. One patient 3 prescriptions for levothyroxine, 1 x 50mcg + 2 x 25 mcg. Notes & prescription records = 75mcg/day. No pattern of issuing one or the other of the 25mcg prescriptions. Medication review documented as completed
MDT reviews cont. One female patient, with swallowing difficulties identified as a known non-complier with medications - possible medicines optimisation opportunity wrt. exploring reasons for this & possible solutions. A second lady struggling to manage her medications was referred for carer support/administration - possible medicines optimisation opportunity wrt. exploring reasons for this & possible solutions. One patient noted to be on 3 prescriptions for atorvastatin, one for 40mg & 2 for 20mg tablets, all of which from a brief review of prescription appeared to be issued on a monthly basis. 95 year old man co-prescribed PPI & H2 blocker - possible deprescribing opportunity. Encouraging to note the GP call to the dispensing pharmacy wrt. the stability of a new drug in the blister pack (MDS)
Ups! Seaford & Alfriston:- Thank you for your phone call & email, we are interested in involving pharmacists in our nursing home project. Also there is wider work in East Sussex looking at care home in reach, which involves medication reviews. Roving Geriatrician:- Ideally pharmacists visits linked to visiting consultant Preferably NMP pharmacists deprescribing & optimising prescribing.
Ups cont. ICC Federation Building searches to compare prescribing in care homes of 4 practices & ID trends. Feeds Hypnotics Antibiotics for UTIs Opiate patches Diuretics only in heart failure MDT reviews clearly show need for clinical pharmacy medication reviews Business Case document is now 27 pages long & still incomplete! (executive summary key!)
Thanks for listening All tips & wrinkles most welcome! Any questions?