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Preventing admissions in the frail elderly
Cherise Howson,
Care Home Pharmacist,
Croydon CCG
Objectives for this session
Background
Key learnings
Challenges
Practical examples
BackgroundThe Health Foundation January 2015 report, Focus on: Hospital admissions from care homes Older people living in a care home postcode had 40 - 50% more
emergency admissions and A&E attendances than the general population of the same age,
Certain conditions were over three times more common in areas that had more care home residents. These include: • pneumonia • pneumonitis • Alzheimer’s disease • dementia • epilepsy
Care home patients were also less likely to be admitted for heart disease and circulatory system problems
BackgroundIn a 2004 UK study, the most common drug groups associated with admission due to adverse drug reaction were: NSAIDs (29.6%) Diuretics (27.3%) Warfarin (10.5%) ACE (7.7%) Antidepressants (7.1%) Beta blockers (6.8%) Opiates (6.0%) Digoxin (2.9%) Prednisolone (2.5%) Clopidogrel (2.4%)
Reactive vs ProactiveReactive behaviour Proactive behaviour
No interventions until a problem occurs Care protocols /pathways
Not routinely assessing high risk patients
Routine assessments /reviews
A&E attendanceProlonged
hospital stays
Increased morbidity/mortality
Reduced hospital
admissions
Healthcare savings
Increased healthcare
costs
Improved morbidity/mortalityIncreased
QoL
Croydon approachIntegrated into the GP enhanced LES as a MDT approach to medication reviews
• Time efficient
• Less paperwork
• Decisions agreed on MDT basis
• Rolled out from May 11
Key learnings A multidisciplinary team approach with direct GP
involvement in the reviews results in the greatest interventions and enhances the knowledge of all involved.
It requires a two – pronged approach, review of both processes and systems as well as a clinical review
Engagement - Positive working relationships are integral
Challenges
Hospital admissions
Patient and Relatives
Care Home Staff
Other services
GP
Health intervention scoring The Hospital Avoidance Scale within the RiO healthcare
management system adapted.
Interventions are assigned by the Clinical Pharmacist.
The score is determined by the probability that an adverse event would have occurred in the absence of an intervention
Scores are then used to calculate cost avoidance.
Interventions are examined for reliability.
Analysis of interventions
Date:
No of interventions Level of intervention 1 2 3
Information on medicines/PILs
Information on Illnesses
Responding to Symptoms
Lifestyle advice
Compliance advice
Compliance aid recommended
Side effects advice
Inhaler technique
Formulation advice
Problem with supply of medicines
Smoking cessation
Optimising current therapy
Overdose avoidance
Identification of interaction Incorrect /inadequate directions
BP check
BMI measurement
Falls Prevention
Medicines administration/recording
Medicines storage
Cold chain
Unnecessary medicine
Monitoring
Identified previously unmet need
Synchronisation of quantities-reduce waste
Medicines reconciliation post hospital discharge
Other: Medication Policies -Medication Audits -Medication Reviews
ScoringLevel 1 = no likelihoodLevel 2 = possibleLevel 3 = likely
Examples of RIO interventionsLevel 1 Lifestyle adviceUnnecessary food supplement stopped Level 2 Long – term steroids; bisphosphonate startedSpacer device added for patient with asthma with poor inhaler techniqueLevel 3 Insulin instructions changed; resident was being given novorapid despite low blood glucose levelsDiazepam rectal added for patient with poorly controlled epilepsy
A cost avoidance figure of £2,800 is attributed to each potentially saved hospital admission.
Assigned to each level 3 intervention.
Estimated that 10% of those receiving level 2 interventions would be considered likely to avoid a hospital admission.
Economic evaluation
Drug cost savings Based on DT tariff costs for that month
Annualised
Medication reviews with one GP practice 89 residents reviewed 168 interventions made
• level 1 – 156• level 2 – 9• level 3 - 3
Top 5 types of interventions• Unnecessary medicines (32%)• Optimising current therapy (17%)• Side effects advice (15%)• Incorrect/ inadequate directions(11%)• Synchronisation of medicines to reduce waste(5%)
Annualised drug cost savings of £8K
OVER TO YOU…….
Example of RIO scoringMedication
Seretide 250 inhaler 2p bdSalbutamol inhaler 2 p prn Ipratropium 2p qdsSenna 2 nocteCitalopram 20mg odClopidogrel 75mg odAmlodpine 5mg odSimvastatin 20mg nocteOTC - ibuprofen Metformin 500mg 2 bdGlicazide 80mg od
Interventions RIO score ?
Inhaler technique checked. Correct technique demonstrated. Spacer device added Advice on re-ordering and cleaning Advised MAR to include salbutamol Senna changed 1 or 2 at night prn Senna original pack as now prn dose Ibuprofen changed to prn paracetamol Alcohol use – advice given as open door policy, monitor lager in room Lansoprazole 15mg started Advised on benefits of flu vaccine – at risk group Advice given to carers on using diabetic diagnostic device
Example of RIO scoringMedication
Seretide 250 inhaler 2p bdSalbutamol inhaler 2 p prn Ipratropium 2p qdsSenna 2 nocteCitalopram 20mg odClopidogrel 75mg odAmlodpine 5mg odSimvastatin 20mg nocteOTC - ibuprofen Metformin 500mg 2 bdGlicazide 80mg od
Interventions RIO score ?
Inhaler technique checked. Correct technique demonstrated. Spacer device added Advice on re-ordering and cleaning Advised MAR to include salbutamol Senna changed 1 or 2 at night prn Senna original pack as now prn dose
1
21111
Ibuprofen changed to prn paracetamol Alcohol use – advice given as open door policy, and lager in room Lansoprazole 15mg started Advised on benefits of flu vaccine – at risk group Advice given to carers on using diabetic diagnostic device
22
3
21
Case StudyEC is a 89 year old female who has been at the care home for 3 years. Metformin 500mg 2 bdGliclazide 80mg 1 bdHydroxine 25mg nocteOmeprazole 20mg Ramipril 5mg 1 odAmlodpine 10mg 1odAtorvastatin 40mgCavilon durable barrier cream to be applied to sacral areaAquacel dressing 10cm sqCetraben emollient apply dailyCitalopram 10mg maneCitalopram 20mg maneOxybutynin 5mg bdWarfarin 1mg, 3mg and 5mg asdLatanoprost eye drops 1 drop affected eye(s) at nightDocusate 100mg 2 nocteLoperamide 2 initially then one after each looseDigoxin 125mcg dailyAdcal D3 1 bd
List the interventions you would make and assign a RIO score.
