Improved outcomes in care homes – an integrated journey

Wasim BaqirNational Pharmacy Lead (Care Homes), NHS England

Louise BateAssociate director, Medicines Education, NICE

Glen GarrodPresident of the Association of Directors of Adult Social Services (ADASS), and Executive Director of Adult Care and Community Wellbeing, Lincolnshire County Council

Melanie WeatherleyChair, Lincolnshire Care Association

Improved outcomes in care homes –an integrated journey

• Why do we need to improve outcomes?

• How can we do this?• Lincolnshire experience

• Support from NICE

• NHS England initiatives

• Q and A

• Other local examples

Medication Errors

• 41.7% of 237 million errors in care homes

• Medicines Optimisation• Prescribing errors (3%)

• Monitoring errors (6.9%)

• Care Home Systems• Administration errors (92.8%)

• Other• Dispensing errors (3.6%)

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http://www.eepru.org.uk/wp-content/uploads/2018/02/medication-error-report-revised-final.2-22022018.pdf

PREVALENCE AND ECONOMIC BURDEN OF MEDICATION ERRORS IN

THE NHS IN ENGLAND Policy Research Unit in Economic Evaluation of

Health and Care Interventions

Medication Errors

Medicines Waste

Silo working

Excess medicines (unnecessary/ inappropriate)

Lack of structured review

Rare patient involvement

Improved outcomes in care homes –an integrated journey

• Lincolnshire experience

Growing trust leads to growing complexity and willingness to take risks – with greater returns

Care Home Trusted Assessor

Medication Support in Care Homes

Productivity across the Residential Sector

What about Homecare?

Key Stages of the Programme• Accept the challenge – together we can achieve!

• Identify key stakeholders -this group may grow as the programme progresses

• Find Best Practice or Evidence Base (e.g. NICE guidelines)

• Define the root problem and which aspects affect which stakeholders

• Establish Governance and Reporting – regulatory as well as local

• Develop the Plan• Check back to best practice• (Pilot) and Implement• Evaluate

• Report back to stakeholders

• Write up and share

Medication Management Example

Initial Challenge – Rationalisation of Medication and Oral Nutritional Supplements

Secondary Issue – CQC comments on Medication Management

Serendipity – NHSE Medicines Optimisation in Care Homes Funding

Golden Rules

• Accept that you might not be right first time

• Don’t focus on the money, but don’t forget it either

• Do not “do unto” any group

• Be prepared to leave some issues for another day

• Think outside the box

•Be Brave

Improved outcomes in care homes –an integrated journey

• Support from NICE

• For people and organisations involved with managing medicines in care homes

• Aims to promote the safe and effective use of medicines in care homes by advising on processes for prescribing, handling and administering medicines

• Recommends how care services relating to medicines should be provided to people living in care homes

People who commission/monitor how

care is provided in care homes

People who provide care

in care homes

People who provide services to care homes (GPs, pharmacies etc.)

Residents living in care homes, their

families and carers

NICE guideline SC1: Managing medicines in care homes

SC1 Managing medicines in care homes: key points

• People living in care homes have the same rights in relation to NHS care as the rest of us, as set out in the NHS Constitution

• Care homes residents should have the opportunity to make informed decisions about their care and treatment

• Person-centred care is important

• Helping residents to look after and take their own medicines helps them retain their independence

• When a person moves into a care home, staff should assume they can manage their own medicines, unless indicated otherwise

• Each resident should have an individual risk assessment to determine the support they need to manage their own medicines

• Care home providers should have a medicines policy which includes written processes for the safe and effective use of medicines

https://www.nice.org.uk/guidance/sc1/resources

http://www.nationalcareforum.org.uk/medsafetyresources.asp

Shared learning case studieshttps://www.nice.org.uk/guidance/sc1/resources/shared-learning

Quick guides for social carehttps://www.nice.org.uk/about/nice-communities/social-care/quick-guides

Improved outcomes in care homes –an integrated journey

• NHS England initiatives

Next Steps on the Five Year Forward View

Deliver improvements in the priority areas: • cancer • mental health • primary care• urgent and emergency care

A national move towards integrated care.Learning from the vanguards is integral to Sustainability and Transformation Plans

The Medicines Value Programme

The NHS wants to help people to get the best results from their medicines – while achieving best value for

the taxpayerSavings will be reinvested in improving patient care and providing new

treatments to grow the NHS for the future

The NHS policy framework that governs access to and pricing of

medicines

1

The commercial arrangements that influence price

2

Optimising the use of medicines

3

Developing the infrastructure to support an efficient supply

chain

4

A whole system approach….

• NHS England, NHS Improvement, NHS Digital, Health Education England

• Regional offices link with STPs, ACSs, CCGs, and providers

• Nationally coordinated with AHSNs, Getting It Right First Time, NHS Right Care and NHSCC

Following the Next Steps on the NHS Five Year Forward View and Carter Report

Seven care elements• Enhanced primary care support

• Medicine reviews

• Multi-disciplinary team (MDT) support including coordinated health and social care

• Reablement and rehabilitation

• High quality end-of-life care and dementia care

• Joined-up commissioning and collaboration between health and social care

• Workforce development

• Data, IT and technology

Integrating Medicines Optimisation: Enhanced Health in Care Homes

• 240 Pharmacists and technicians working across care settings to support care homes

o Medicines optimisation (including deprescribing)

o Care home systems and staff (reduce errors, waste)

o Antimicrobial stewardship

• Training pathwayo HEE commissioned training provider – CPPE

o 600 Pharmacists and Pharmacy Technicians

o Independent Prescribing

• Infrastructureo Networks, IPACS, Data & Metrics, Polypharmacy Support

Care Homes Offer to STPs

STP offered funding

STP

- Lead CCG

- Submit Plan

Regional Moderation

Lead CCG commissions

local providers

Monitoring(Population

Health Dashboard/

Metrics)

Funding process

35 STPs and 10 ICSs offered fundingBased on indicative care home populationPlans submitted and approved from 45/46 STP/ICSs

Proposed plans from STP/ICSs

• Scaling up medicines optimisation in care homes

• Risk stratification

• MDT working

• Shared decision-making

• Specific Care Settings

• LD, Mental Health

• Cross sector

• Hospitals, community trusts working with primary care

• Community Pharmacy

• Strategy to eradicate poor medicine use in care homes

Improved outcomes in care homes –an integrated journey

• Q and A

Case Study:Northumberland Vanguard

• Pharmacy team work across primary and secondary care

• Support network between Mental Health and other local pharmacy services

• Team works closely with community pharmacy, general practice, social care and voluntary sector

89y old lady admitted to A&E following epileptic fitAssessed on A&E: decision to increase Lamotrigine

Discharged back to care homePharmacist liaised with A&E and prescribed

Community Pharmacy supplied

Admission to ward avoided

Mrs. B is prescribed

21 medicines

Amlodipine 10mg tablets (BP)

Bendroflumethiazide 2.5mg tablets (BP)

Doxazosin 4mg tablets (BP)

Clopidogrel 75mg tablets (blood thinning)

Quetiapine 200mg tablets (antipsychotic)

Zopiclone 7.5mg tablets (sleeping tablet)

Folic Acid 5mg tablets (vitamins)

Alendronic acid 70mg tablets (bone protection)

Adcal D3 1.5g/10micrograms (bone protection)

Paracetamol 500mg tablets (pain)

Naproxen 500mg tablets (pain)

Ferrous Sulphate 200mg tablets (iron)

Simvastatin 40mg tablets (cholesterol)

Codeine Phosphate 30mg tablets (pain)

Rivaroxaban 20mg tablets (blood thinning)

Donepezil 10mg tablets (dementia)

Memantine 20mg tablets (dementia)

Mirtazapine 15mg tablets (antidepressant)

Morphine sulphate 10mg/5ml (pain)

Laxido (laxative)

Docusate Sodium (laxative)

Decisions in Silo

Lack of Shared Decisions with

residents/families

Fragmented Care

Working better together

• Shared decisions with family

• Support from Psychiatry of Old Age Services

• Linked in with community pharmacy

• Care home staff and GPs involved

• 12 Medicines stopped

• Antidepressant dose increased

• Laxative PRN

Medicines optimised! ☺

Amlodipine 10mg tablets (BP)

Bendroflumethiazide 2.5mg tablets (BP)

Doxazosin 4mg tablets (BP)

Clopidogrel 75mg tablets (blood thinning)

Quetiapine 200mg tablets (antipsychotic)

Zopiclone 7.5mg tablets (sleeping tablet)

Folic Acid 5mg tablets (vitamins)

Alendronic acid 70mg tablets (bone protection)

Adcal D3 1.5g/10micrograms (bone protection)

Paracetamol 500mg tablets (pain)

Naproxen 500mg tablets (pain)

Ferrous Sulphate 200mg tablets (iron)

Simvastatin 40mg tablets (cholesterol)

Codeine Phosphate 30mg tablets (pain)

Rivaroxaban 20mg tablets (blood thinning)

Donepezil 10mg tablets (dementia)

Memantine 20mg tablets (dementia)

Mirtazapine 15mg tablets (antidepressant)

Increased to 30mg dailyMorphine sulphate 10mg/5ml (pain)

Laxido (laxative) PRNDocusate Sodium (laxative) PRN

Case Study: Blackpool & Fylde Coast

• Pharmacists and pharmacy technicians supporting medicines optimisation and management

• Medicines optimisation @ patient level

• Supporting care homes (medicines systems, waste, education & training)

Medicines waste logs assessed by pharmacy technicians Waste and reasons identified • Education, Systems change & MO

• Initially the average monthly waste/home was £554.86

• After 9 months, average monthly waste/home: £280.56

• % reduction in medication waste: 50.6%

Integrated working is hard….… but worth the pain!