Integrated approaches totackling polypharmacy to help reduce hospital admissions

Claire Vaughan- Head of Medicines Optimisation, Salford CCGLindsay Harper- Director of Pharmacy, Salford Royal Care Organisation

Polypharmacy - What’s the problem?The NHS spends £16.8 billion a year on medicines (£1 in every £7 spent) and they are the most common treatment in the NHS. Medicines help a lot of people to get well, but:

• Use of multiple medicines is increasing• One third of over 75s now take at least six medicines • over 1 million people now take 8 or more medicines a day

• Medication safety continues to be a serious issue• A person taking ten or more medications is 300% more likely to be admitted to hospital • 6.5% of hospital admissions are for adverse effects of medicines and this rises to 17% in the

over 65 age group• Over 70% of hospital admissions for adverse reactions to medicines could be avoided

• Up to 50% of people do not take their medicine as intended by the prescriber, meaning their health is affected

• There is poor public awareness of the harm caused, or the impact on health services, from problematic polypharmacy.

Examples

Safer prescribing for patients living with frailty, including deprescribing. yhahsn.org.uk

Mo video produced to encourage patients who take several types of medicine to book a review with their local pharmacist.wessexahsn.org.uk

Me + My Medicines, developed by patients and supported by clinical staff, CCGs and AHSNs to empower patients to learn more about their medicines. meandmymedicines.org.uk

Medicines Optimisation INN

Polypharmacy is one of the four themes of the AHSN Network’s Medicines Optimisation Innovation

National Network (INN).

The other themes are

• PINCER

• Transfer of Care Around Medicines (TCAM)

• Patient and public engagement around medicines

Traction

• Polypharmacy data - AHSNs led the development of national data set and are now playing a wider role in

addressing this.

• Links forged with key stakeholders in public engagement as part of polypharmacy, but will require a

further work up. E.g. Richmond Group of Charities has a strong interest in co-morbidities and

polypharmacy

• PINCER and TCAM well worked up with a strong evidence base

Quotes from Salford

Brenda ( 89 years old)

‘ I try to take all my medicines but it is a full time job!’

‘ the chemist did not put how to take my medicines on the tablets –that is not right. How will I know which to take?’

‘ really confusing when the box changes. I know what to look for’

Salford Community Pharmacist

‘ I am supposed to get a copy of compliance aid discharge scripts. They never seem to come. I am left in the dark!’

Salford GP Practice Pharmacist

‘ the discharge scripts often only tell us half the story’

‘at least in Salford we can see the hospital electronic record’

The Safer Medicines programme aims to identify innovative ways to improve medicines optimisation in collaboration with patients and professionals from across the health and care system.

NICE Recommendations for Polypharmacy(2015)• Systems for identifying,

reporting and learning from medicines-related patient safety incidents

• Medicines reconciliation

• Medicines-related communication systems when patients move from one care setting to another

• Medication review

• Self-management plans

• Patient decision aids used in consultations involving medicines

• Clinical decision support in electronic systems

• Organisational and cross sector working

Integration and learning from Safer MedicinesAim: to ensure medicines are always correct at any point in the patient journey➢Currently measure at entry to Salford Royal Foundation Trust

➢Currently measure at entry intermediate care entry

➢Starting to measure at return to primary care

➢Starting to measure in care homes

Aim: Shared understanding of safety across the health economy with medicines➢Health economy medicines safety group

➢Integrated workforce

Medicines reconciliation within 24 hours at entry into SRFT on Admissions Unit

Medicines reconciliation within 72 hours at entry into Salford Intermediate Care Homes

Neighbourhood Integrated Practice Pharmacists in Salford• Team of practice pharmacists employed by SRFT and Salford Primary Care

Together GP Practice commissioned by Salford CCG.• April 2018

• 28 pharmacists( 20 wte)• Now supporting all 44 Salford GP practices.

• Menu of services provided to GPs• Medicines Reconciliation post discharge/ holistic reviews• Poly pharmacy reviews- frailty or themed for a particular condition• High risk medicines reviews- increased number of practices meeting

targets

• Future work areas:Respiratory , Mental Health, Pain Reviews

Neighbourhood Integrated Practice Pharmacists in Salford• In 17/18 – 25,000 medication reviews completed by team

• Including polypharmacy and frailty reviews

• Deprescribing of medicines

• The Broughton Team (5 pharmacists- 50,000 population)• saved 680 hours of GP time

• Improved blood pressure control in CKD and diabetic patients

• Completed reviews of COPD patients to improve compliance with GMMMG guidelines

• Demonstration of reduced drugs spend

Improvement on the medication safety measures included in the University of Manchester Dashboard (SMASH)

1. Improvement on the medication safety measures included in the University of Manchester dashboard (SMASH)

Medicines Related Admissions

• SRFT Clinical Pharmacists identifying if a patient’s admission is related to medicines

• Recording it on the EPR and alerting the clinical team

• Automatic email to SRFT Medicines Information pharmacist to enter yellow card

• Referral made to the relevant GP practice pharmacist for post discharge medicines review

• SRFT pharmacists identifying ~ 40 a month

• Challenge- correctly coding the admission and the medicine involved.

SRFT Medicines related admissionsThe role of the medicine in the admission was confirmed in 132/305 (43%) cases.

Improving accuracy of information regarding medicines on discharge prescriptions

• Audits completed on the % accuracy of documented medication changes on two wards

• Improvements seen on medical ward but not surgical ward

• Training delivered to junior doctors by GP and pharmacy staff

• Discharge checklist developed for junior doctors

• Test of change- to enter whether medicine- new, dose changed or stopped on electronic prescriptions

Electronic Pharmacy referral systems• Working with GM AHSN, GM LPC and GM LPN.

• Generic specification written to include referral to GP practice pharmacists and community pharmacists, two way communication

• Develop a system that can be spread across GM (Workstream 1- Public Health- seamless care)

• Awarded to Pharmoutcomes after procurement process. Going live Oct 18

• Referral orders will be built into Allscripts EPR for hospital pharmacists to refer to GP practice pharmacist and community pharmacist

• Electronic copy of discharge attached for community pharmacists

• ? Extended to new Integrated Care Organisation pharmacy teams

Future roles for Pharmacy StaffSalford Together(ICO) have included pharmacists and pharmacy technicians in the plans for:

➢Falls team

➢Urgent Care team

➢Enhanced Care Neighbourhood teams

Ensuring medicines optimisation and safety is at the centre of the new systems we are developing in Salford

Prescribing Pharmacist role within Enhanced Care Team(Enhanced care team take over care of at risk patients for six weeks)

Pharmacist is:-

• Taking an active role in the weekly MDT; discussing care plans for patients including any changes to medicines

• Delivers structured medication reviews to support the effective use of medicines

• Using non-medical prescribing qualification and skills as a clinical pharmacist to optimise medicines, involving patients to improve the use of medicines

• Providing advice and assessment for patient’s conditions for example BP, pulse, peak flow and inputting into clinical management plans used to directly manage patient care

• Liaising with local community pharmacies to ensure medication changes are actioned in a timely and accurate manner.

Thoughts of the Salford Integrated TeamPositives• Increased opportunities to

improve medicines safety across the health economy

• Effective team working between SRFT, CCG and community Pharmacy Teams

• The support of the CCG with innovation money

• Excellent electronic systems

Challenges• Data sharing

• Recruitment of staff

• Traditional boundaries

• Sharing our learning

•TIME!

Safer medicines report summary