Marianne Price explains how a scheme employing dedicated pharmacists in care homes is saving Nene Commissioning £100,000 a year.
The NHS Northamptonshire Care Home Advice Pharmacists (CHAP) team was set up in 2008 by GPs in the Nene PBC group.
Nene Commissioning had already introduced a scheme linking individual GP practices to homes in order to improve care, communication and cut the number of care homes that practices needed to visit from upwards of 20 to an average of 2.3.
This closer working created the impetus to develop a more holistic approach to medicines review.
Evidence suggests that, on average, patients in care homes are higher users of medicines than those who are not. This, coupled with high turnover – both of staff and patients – in care homes can cause problems.
Dedicated pharmacy advice
The scheme initially began as a pilot in October 2008 with one pharmacist funded by the PBC consortium who was appointed by and managed as a member of the PCT's pharmacy and prescribing team. Between December 2008 and April 2009 the pharmacist visited six care homes, prioritised by GPs, undertaking detailed reviews of 125 patients. The number of interventions suggested by the pharmacist and acted upon by GPs was high and resulted in considerable improvements to the quality and safety of care for a large number of individual care home patients.
In April 2009, a business case for permanent funding was agreed by the PCT. This investment meant that a further 10 care homes were visited between April and September 2009 and 254 additional patients were reviewed. In addition, during 2008 the PCT redesigned its community pharmacy care home advice service, which released sufficient funding for a second care home advice pharmacist. As a consequence, two additional part-time pharmacists were appointed at the end of 2008, bringing the team to three individuals (two whole-time equivalents).
How we work
We begin by making personal contact with the care home manager and allied GP surgery. We're granted access to the records held by both the GP and care home and, with our pharmaceutical knowledge, we effectively reconcile the two sets of information, ensuring that the patient is taking the correct drugs, at the correct time, in the correct dosage. In other words, we look at what the care home is doing, which is not always what GPs think it is doing.
We also check that any monitoring needed for a particular drug regime is up to date. We identify whether the individual circumstances or condition of the patient has changed since the prescriptions were made and whether there are any side-effects or adverse reactions from multiple medications. Relevant blood tests or any required monitoring is also suggested to the GP for investigation.
Any suggestions are then recorded on an individual record for each patient and returned to the GP in paper form. Click here to download this form. These suggestions, fully annotated and evidenced, might include the recommendation to stop or start a particular drug, to change medication where an alternative would be more efficacious, to change dosage because of changed circumstances or to change the method of administration where a patient has a particular difficulty – for example, with swallowing.
The GP then accepts or declines these suggestions (in writing using the original written form) and this is returned to the pharmacist who then ensures that relevant actions are implemented. The pharmacist takes responsibility for ensuring that every action is followed up, documented in the patient's record and clearly communicated to the care home (and the patient and relative as appropriate).
The thoroughness of the review process allows us to develop a positive relationship with each care home visited, which often means that further advice is requested (on issues such as medicines storage and disposal). We also give advice on reducing waste through efficient ordering of drugs and recognition of expiry dates.
Non-pharmaceutical issues such as communication between the various parties often come up and we can help resolve those.
The process takes quite a lot of time – which most GP don't have at their disposal. Because patients have moved around quite a lot, perhaps between respite care, care home and home, they've often had a change of GP too. We spend quite a lot of time catching up with the various discharges. On a typical day I might review only five patients.
We have produced a care home information pack, which includes answers to the most frequently asked questions, relevant patient information leaflets, ‘how to' guides on the administration of medicines such as eye drops and inhalers and templates that the care home staff have found very useful.
Because our detailed reviews can uncover a range of clinical issues connected to the administration of a patient's medication, we are often in a position to liaise with other specialists such as dieticians, tissue viability nurses, Parkinson's specialist nurses and community psychiatric nurses.
Outcomes and savings
Between December 2008 and April 2011, we visited 44 care homes, undertaking 1,192 detailed medication reviews. In 85% of patients reviewed, at least one suggestion was made to the GP to revise an aspect of a patient's medication regime.
The pharmacist has usually identified a potentially more clinically appropriate or cost-effective approach rather than a previous error. However, if we discover an error we are in a position to resolve it immediately.
A total of 3,907 suggestions were made for this cohort of patients overall, or around three suggestions per patient reviewed, of which 85% were agreed by the GP and subsequently actioned.
Over the course of these three years, a total of 836 drugs were stopped, 1,168 drugs were changed and 95 new drugs started. As well as contributing to the quality of care for these patients, these interventions contributed to an annual saving from the prescribing budget of over £100,000 – or around £98 per patient per year.
The box above gives examples of suggestions made.
We estimate there are 262 care homes in Northamptonshire, including homes for patients with mental health problems and learning disabilities, so we've probably only seen a quarter of the patients that we could.
Care home patients tend to be a forgotten cohort. But because we are a dedicated service, we are able to deliver a gold standard service to every one of them.
Marianne Price is care homes advice pharmacist to NHS Northamptonshire
Examples of pharmacists' suggestions to GPs
• Recognising the need to restart treatment temporarily stopped for a patient who had had multiple hospital admissions
• Temporarily stopping the administration of drugs for trial periods for patients who had been taking the medication continuously for a number of years
• Reducing doses of drugs with a view to stopping them for indications that were no longer apparent
• Helping care homes to find a way to administer medication to patients with a feeding tube where crushed tablets were inappropriate
• Helping homes to reduce the number of dementia patients on antipsychotics that were no longer felt to be appropriate. Click here to download the audit form.
• Contacting the drug manufacturer to find an appropriate dose in a sachet formulation for a patient with swallowing difficulties who had been prescribed a modified-release tablet
• Reducing medications implicated in falls
Initiative: Dedicated pharmacists who undertake a review lasting one or two hours with care home patients to ensure their medication is at the optimal level of quality.
Suggestions sent to GPs and then implemented by pharmacist
Staffing: Two whole-time-equivalent pharmacists
Results: More than 85% of recommendations made by pharmacist accepted by GP. Some £98 in medication costs saved per patient seen. Better working relationship with care homes who have tapped into pharmacists' knowledge to ask about medication storage and ordering.