Medicines Adherence Support Service

Pilot Project

Community Pharmacist Training

Dr Susan Patterson, Pharmacy & Medicines Management

Adviser, HSCB

Jo Gribben, Pilot Lead, SE Trust

Caroline Johnston, Pilot Lead, Northern Trust

What problems do older people have with medicines?

“Transforming Your Care”: more older people will be managed at home

36% of over-65s take 4 or more medicines for prevention of chronic disease

10% (approx) hospital admissions are due to medication-related problems

50% of people do not adhere to prescribed medication

The only medicine that works is the one that the person takes

SOUTH EASTERN TRUSTSOUTH EASTERN TRUST

VERONICA CLELAND

RESIDENTIAL, DAY CARE AND DOMICILIARY CARE MANAGER

The ChallengesThe Challenges

• Increasing older population

• By 2019 the population of older people between 65 and 84 is projected to grow by 32%

• The population of 85 and over is projected by 2019 to rise by 45%

• Four Localities within South Eastern Health & Social Care Trust:– North Down– Ards– Down– Lisburn

• Localities are divided into geographical patches and staff work in GP aligned Integrated Primary Care Teams.

District Nurses Care Managers

MHSOP(CPNs)

Assistant Care Managers

GP

Social Workers

Open Referral System into Open Referral System into Local OfficeLocal Office

• Referrals allocated to appropriate Service– Signposted out to Community / Voluntary sector– Reablement– Care Manager / Assistant Care Manager Integrated

teams

• The majority of Service users should be referred to Reablement unless they have no Reablement potential

ReablementReablement

• Reablement – focuses on the client’s strengths and abilities to help them regain their independence, re-learning daily living skills or gaining new ones. Packages of care are focused on the short term with the client moving to other forms of Care Providers if further support is still required.

Care ManagementCare Management• Care Management Is a concept which

embraces the key functions of: case finding, care screening, undertaking proportionate, person-centred assessment of an individual’s needs, determining eligibility for service(s); developing a care plan and implementing a care package; monitoring and reassessing need and adjusting the care package as required.

Source: DHSS&PS Circular HSC (ECCU) 1/2010 March 2010

AssessmentAssessment• A person-centred process whereby the needs of an

individual are identified and their impact on daily living and quality of life is evaluated, undertaken with the individual, his/her carers with the individual, his/her carer and relevant professionals.

Source: DHSS&PS Circular HSC (ECCU) 1/2010 March 2010

• Service users assessed Using - NISAT – (Northern Ireland Single Assessment Tool)

Care Plan

• A description of what an individual needs will be met.

Source: DHSS&PS Circular HSC (ECCU)1/2010 March 2010

Care Package

• A combination of services designed to meet a person’s assessed needs

Source: DHSS&PS Circular HSC (ECCU)1/2010 March 2010

Domiciliary Care

• The mechanism for the delivery of domiciliary care is outlined by DHSSPS (2003) and states that people should be helped to live independent lives with safety and dignity in their own homes.

• All agencies providing Domiciliary Care must be registered with RQIA and operate in accordance with regulation.

The Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003 (the Order).

• Article 38 of the Order confers powers on DHSSPS to prepare, publish and review statements of minimum standards applicable to all services including regulated services.

• Domiciliary Care Agencies Minimum Standardsupdated August 2011

http://www.rqia.org.uk/cms_resources/domiciliary_care_standards-%20Aug%2011.pdf

Care ProvidersCare Providers• NISRA figures survey week in Sept 2013

• 4715 service users received domiciliary care services in the SETIn SET

• 15 / 85% split in care provision

• http://www.dhsspsni.gov.uk/domiciliary_care_services_for_adults_in_northern_ireland_2013-2.pdf

Management of MedicinesManagement of Medicines

• Standard 7: • The agency has arrangements in place to ensure that

care workers manage medicines safely and securely.• http://www.rqia.org.uk/cms_resources/domiciliary_care_standards-

%20Aug%2011.pdf

• Requires that staff are both trained and competent to administer medications.

Issues•Receiving current up to date lists of medication at referral•Updating medication lists/ new prescriptions / transcribing whose responsibility??•Multiple forms of medication administration and competency of staff.•Withdrawal of MDS •Environmental issues•Relatives and informal carer’s giving medication along with formal carer’s •Dual medications in homes (Husband & Wife) •2 or more providers

Currently in SEHSCTCurrently in SEHSCT• Domiciliary care workers in the statutory

sector are not trained to administer medications, can prompt / remind / assist under direction of the service users

• Need to address issues of transcribing / updating MAR

• Safety of service users and protection of staff is paramount.

At present we are rolling out a programme of training for the topical administration of medications

Approx 526 domiciliary care staff require training

Training and on-going competency of staff RQIA mandatory standard –3 yearly

On- going work from Regional perspective,

Any Questions?Any Questions?

Medicines Adherence Support Service

Aim: To improve outcomes from prescribed medicines by

ensuring safety and quality in provision of adherence support for older people who are living in their own homes

NICE CG 76 (2009): Supporting AdherenceAssess adherence• provide further information on

medicines• discuss with patient

• Intentional? Discuss beliefs / concerns• Non-intentional? Address practical problems

if there is a specific need

• consider case by case• address concerns and needs of the

individual

Monitoring and follow up

Service Model Tested in Pilot Phase 1

Referral Criteria Aged ≥ 65 years old On four or more regular medications Living at home Attending pilot GP + community

pharmacist Suspected/actual adherence issue

Phase 1 LocationsNorthern Trust:•Ballyclare & Ballymoney

South Eastern Trust:•Hillsborough & Lisburn

Total – 8 GP Practices, 22 Pharmacies

Referrals (n=143)

Community Pathway (118) Hospital Pathway (25)

GPs 83 Pharmacists 21Community Pharmacists 23 Staff nurses 3

Social Care Team 3 OT 1

Re-ablement / Community rehab

2

District Nurse / Diabetic Nurse

4

Other 3    

Reasons for Referral

Problems removing tablets from packaging Confusion / confused about medications Problems with ordering/collecting medications Recent hospital discharge Not taking medication as prescribed Requesting Monitored Dosage System (MDS)

Non-Intentional Non-Adherence Issues

ClinicalInadequate knowledge of medication regime

Inadequate knowledge of dose/correct technique

Access

Ordering issues

Storage & Disposal issues

Delivery / collection issues

Day to day

Cognitive / memory issues

Dexterity issuesVision problemsPoor swallow

Solutions Implemented

Resolution of clinical queryMedication ListEducation (specific)Disposal of medicationSign post /referral to other teamsSynchronisation of prescriptionsOrdering solutionsAltering medication timingsProvision of a deviceNew / altered care package

Phase 2

Why conduct a phase 2 pilot?

Outstanding issues from phase 1:

• Supporting medicines adherence in a wider population• Developing a better follow up model• More referral pathways

• Commissioning solutions• Medicines lists• Accessibility

Helping people gain better outcomes from medicines

Helping people live longer, healthier lives

Helping people safely avail of care closer to home

Helping people to benefit from advances in treatment and technology

“Making it Better through Pharmacy in the Community” DHSSPS 2014

Phase 2 - Locations

Integrated Care Partnership Areas

South Eastern Trust - Lisburn

Northern Trust – East Antrim

Community Pharmacy Pathway Attend training!

Service Specification & Guidance

Sign contract (HSCB)

Obtain items on stock list

Complete & submit stock claim form (+ receipts)

Organise pharmacy – staff / premises

Stock List

Community Pharmacy Pathway Identify patients

Patient enrolment

Pre-assessment preparation

Assessment (Community Pharmacy Assessment Form)

Implement Solutions

Monitor & Review

Identifying patients - Criteria

Aged ≥ 65 years old On four or more regular medications Living at home Attending pilot area GP Suspected/actual adherence issue

Identifying patients

Patients self-refer PMR - identify from erratic ordering / poor

management Relatives / friends / staff voice concern Health / social care worker voices concern Referrals from pilot lead

Patient Enrolment Information leaflet

Consent form

Arrange appointment

In pharmacy or domiciliary visit Family / carer present if appropriate Patient to bring all medicines & compliance aids

Patient Information Leaflet

Consent Form

Community Pharmacy Assessment Form

Pre-assessment information (medication) Confirm medicines Assessment of adherence Current support arrangements Issues identified solutions Monitoring & follow-up

Pre-assessment information

Obtain an accurate list of patient’s medication• GP record• Pharmacy PMR• Recent hospital discharge letter

Complete demographic information

Pre-assessment information

Verify medication list with patient/carer

Reasons for discrepancies (intentional ?)

Assess patient’s knowledge

Identify side effects / other issues

Assessment (1)

Assessment (2)

15 questions

3 themes

Access Adherence (day to day management) Clinical & patient attitude

NISAT Format(patient-centred)

Complete to reflect assessed person’s perspective:“I am able” “I am able with difficulty”“I am able with assistance”“I am not able”

Assessor & Carer perspective

Assessment (2)

Assessment (3)

• Current arrangements• Summary of Issues identified • Possible solutions, consider with patient

Solution Grid

Assessment (3)

Implement Solutions Education

Advice on storage

Disposal of medications

Synchronisation

Family involvement

Stock Solutions- Complete stock solution claim form - Pill popper- Pill splitter- Haleraid® / Turbogrip®- Eye drop applicator- Re-usable compliance aids (range of sizes)

Personalised (List-based solutions)

• Monthly Claim Form• Medicines Reminder Card/list

• Medicine Administration Record (MAR Chart) * NB for patient/family/informal carer use only

Monitored Dosage System

MUST confirm accuracy of list

Medication Reminder Card

Medication Reminder Card/List Ensure patient / informal carer can use

Check monthly, against prescriptions

Manage changes Monthly

Interim

Medicine Administration Record For patient / informal carer use only Assess if suitable for patient

Record of medications taken / given Issued monthly against prescriptions Manage changes - New chart

Supplementary Chart

Monitored Dosage System Ensure patient can use Check stability of medications (Guidance) Issue weekly against monthly scripts Inform GP - record can be annotated Arrangements for medications not in MDS Procedure for changes Remove old medications from house PSNI standards - Consultation

Information/referral to other HCPs

• GP- send summary if relevant• Clinical teams (if known)• Social Care• Pilot lead

Telephone / written informationMust make it clear if action needed,

and by whom

Referral to other HCPs

Monitor and Review Follow-up - Approximately 1 month & 3

months post –assessment (page 4)

Changes to circumstances

Solutions still working / appropriate?

Document actions / referrals / changes

Forward completed form to pilot lead

Monitor and Review

Payment model

Payment model

 

Payment per contract

Payment per patient

Attendance at training, set up of in-house standard operating procedures, provision of evidence of purchase of the minimum MASS stocklist items and signed contract.

£150  

Pre assessment preparation. 

  £20 per new patient who meets the eligibility criteria and gives consent to participate*

Medicines adherence assessment. Completion of community pharmacy MASS assessment tool.

  £28 per patient*

Provision of SolutionsA.directly from the dispensary medicines adherence stock list and/orB. if the solution is a personalised (list-based) solution, it must be based on an accurate list of medicines.

  A. Reimbursement for stock items provided. Please see section below.

  OR B.£40 per patient per month for checking accuracy of

the patient’s medicines list against the new prescription** and providing an appropriate personalised (list-based) for a maximum of 6 months or the duration of the pilot project.

Monitoring and Follow Up 

  £10 per patient for monitoring at 1 month and 3 months (or appropriate intervals) and providing data to pilot lead pharmacist.

Stock solution claim form

Assessment claim Form

ExamplePromote service in pharmacy

- Poster

- Leaflet in medication bag

Patient identified (daughter concerned)

- recently discharged from hospital

- a lot of medication in the house

Recruitment

Patient information leaflet supplied

Patient agrees

Appointment arranged Patient and daughter to attend pharmacy

Pre-assessment information

Assessment

Consent form signed Medications – including those started in

hospital

Assessment completed

Changes to medication noted

Assessment

Assessment

Solutions Education on new medications Removal of discontinued medications (form) GP – change Atorvastatin to morning Written list of medicines? Synchronise script quantities and dates –

daughter to order meds monthly Re-usable compliance aid – daughter will fill

Solutions

Actions GP – synchronise scripts, amend

Atorvastatin Claim forms

Pre-assessment preparation Assessment Stock solution (compliance aid) ? Personalised MASS solution 1st and 2nd Follow up

?Any questions

jo

Thank you for listening

Caroline Johnston, Caroline.Johnston@northerntrust.hscni.netJo Gribben, Josephine.Gribben@setrust.hscni.netSusan Patterson, susan.patterson@hscni.net