Reviewing Medicines in at risk patients care homes Clinical Medication Reviews by Pharmacists in Collaboration with GP Surgeries across Brighton and Hove CCG Liz Butterfield FRPharmS 19th April 2016
NICE: Managing Medicines in Care Homes, March 2014 This is the first NICE clinical guideline that applies across both health and social care. NICE (draft) Quality Standards highlight areas of improvement required in managing medicines in care homes: Recommend GP practices have a written protocol on prescribing for care homes Recommend directions on prescriptions to be in full by GP practices Care homes to have a policy on medicines management, covert administration and risk assessments for self-administration Medication Reviews for each patient
Commissioning, Delivering & Continuation Need for medication reviews in vulnerable care homes residents Specific contract with number of reviews defined and structured reporting Liaison with all GP surgeries with supportive feedback Multimorbidity and polypharmacy depresrcibing
Summary of success 2012-13 2013-14 No.of Care Homes 90 110 No of Reviews 1600 2000 No. of interventions 4000 6000 Annual cost savings 354,573 330,000 *Potential hospital cost savings Not calculated 380,450
Commissioning, Delivering & Continuation Now in its third year the project has delivered clinical benefits and cost savings Focus on sip feeds, continence products, reduction of risk of Acute Kidney Injury plus deprescribing where risks outweigh benefits Overall the project has provided savings of around three times cost
Outcomes Achieved Safety, quality, cost effectiveness Rx Reduction in pill burden Increase in deprescribing Sustainable Changes Financial Savings LESS MORE Waste Prescription errors AKI? Inappropriate medication
Reducing the Risk of Harm to Patients from Prescribed Medicine Using National Patient Safety Agency Risk Assessment Tool: Brighton Care Homes Medication Review Project Pharmacist led medication review has an impact on reducing harm to patients from prescribed medication and associated potential hospital admissions or referrals. This has been demonstrated by adopting the National Patient Safety Agency Risk assessment tool (www.nrls.npsa.nhs.uk). Post completing the reviews, one single pharmacist then used the NPSA risk assessment tool to evaluate the impact of pre and post medication review. Reviews were completed by a number of pharmacists.
Case Study Countdown 25 to 5 1. Buprenorphine patch 10mcg + 5mcg 1w for long standing back pain 2. Paracetamol 500mg 2 QDS for osteoarthritis. Both knees and shoulders replaced 3. Cardicor tablets 2.5mg 1od for blood pressure 4. Indapamide 1.5mg 1od for blood pressure and ankle swelling 5. Lansoprazole 15mg 1od for dyspepsia started post naproxen which is now stopped 6. Gaviscon Advance 2 x 250mls prn for dyspepsia 7. Macrogol sachets 1 od for constipation 8. Pregabalin capsules 25mg om for heel pain and pins and needles of leg 9. Pregabalin capsules 75mg on 10. Solifenacin tablets 5mg for urge incontinence; also uses a pad. Dry mouth and sedated. 11. Quinine tablets 300mg on for cramps due to long term PPI and hypomagnesium 12. Magnesium tablets 1od (OTC) to prevent cramps 13. Aspirin dispersible 75mg 1 od for primary prevention recommended by pharmacist 30 years ago 14. Ibuprofen Gel 5% prn for leg pains 15. E45 Cream 2 x 350g prn for dry skin. 16. Viscotears prn for dry eyes 17. Salivex Pastilles prn for dry mouth 18. Lactulose prn for constipation 19. Calcichew D3 forte tablets for bone strength and prevention, but has high intake in dietary calcium 20. Vitamin B12 injection every 3 months recent levels are sky high 21. Ferrous Sulphate tablets 1 tds levels are good, and no longer feels tired 22. Donepezil 5mg tablet taken only when forgetful plus caused rectal incontinence 23. Zopiclone 7.5mg tablets help her sleep, but she has no trouble falling asleep but wakes up early at 6am. Also sleeps in afternoon 24. Tubigrip Size G for knee to support and reduce pain 25. Alendronic acid weekly has had for about ten years
Case Study 25 to 5 Medicines 1. Buprenorphine patch 10mcg 1w 2. Paracetamol 500mg 2 QDS prn 3. Cardicor tablets 2.5mg 1od 4. Indapamide 1.5mg 1od 5. Macrogol sachets 1 od Plus prn: gaviscon suspension
Benefits to patient, carers & the NHS Feels more alert, Memory loss improved significantly Reduced errors in prescribing, dispensing and administration. Less falls Reduced anticholinergic side effects Understands medicines Back to self medicating Prepares own pill box Knows who to contact for help or information Visit to GP reduced from 12 a year to 1 Financial savings
For the frail vulnerable patient & ALL involved in their care
References BEERS recommendation: The initial Beers criteria identified medications whose risks outweigh their benefits and those that should be avoided or used with caution in adults 65 and older. First published in 1991 by Mark Beers, MD, and colleagues, the criteria were subsequently updated in 1997 and 2003 and were recently revised and updated by AGS in 2012. STOPP: Screening tool for older people's potentially inappropriate prescriptions START: Screening tool to alert doctors to right/appropriate treatments. Feb 2013 Anticholinergic Burden Score. A list of medicines and associated anticholinergic scales. Evidence for this has been reviewed by the National Prescribing Centre. Guidance for Prescribing in Frail Adults : All Wales Medicines Document published in September 2014 Suggestions of Drug Monitoring in Adults UKMI document published in February 2014