The London Older People The London Older People Service Development Service Development

Program (LOPSDP)Program (LOPSDP)

The ‘Medicines Management’ Project

(January to July 2003)

Lelly ObohProject Co-ordinator

Integrating medicines management Integrating medicines management into the Single Assessment Process into the Single Assessment Process

(SAP)(SAP)

Patient Case SelectionSocial services staff, Nurses, Occupational

therapists, etc

Initiate SAPSocial services or health staff

Continued Care

Case manager or care coordinator (health or social service staff)

The Medicines Management ProjectThe Medicines Management Project

In-depth Medication AssessmentAssessing Pharmacist

Provide Pharmaceutical Care PackageCommunity Pharmacist

Nurse GP Carer

London OP ProgramLondon OP Program

Referral Pathway

ObjectivesObjectives To pilot trigger medicines questions and an

in-depth assessment tool with the SAP To develop a referral pathway To develop a communication pathway

between the older person’s case manager (care coordinator, pharmacists and others

To identify, train and support a cohort of pharmacists to undertake detailed medication assessments and provide pharmaceutical care packages

To develop a monitoring and review process To achieve improved medication outcomes

for older people

4 medication trigger 4 medication trigger questionsquestions

• I need help getting a regular supply of my medicines

• Sometimes I do not take my medicines the way the doctor wants me to (I can swallow and use all of my medicines and get all of the medicines out of their containers)

• There are some medicines that I cannot get out of the containers

• Realistically I think some of the medicines I take could work better

1. KEY FINDINGS - 4 Trigger Questions 1. KEY FINDINGS - 4 Trigger Questions (4Qs)(4Qs)

4Qs are appropriate to identify vulnerable OP with pharmaceutical care needs within SAP

4Qs can be adapted to suit needs of OP and assessor

None of the 4Q identifies those with swallowing problems

Trained SAP assessors can refer appropriately to a pharmacist

Using district nurses works well

A&E not a suitable place to ask 4Q

Incorporate 4Qsinto contact and overview assessments

Revised 4Qs Adequate training is

required for those who carry out initial assessments

4Qs can be used as part of discharge plan

2. KEY FINDINGS - Developing referral 2. KEY FINDINGS - Developing referral and communication pathwaysand communication pathways

OP care organisers can contribute positively to the SAP

A multidisciplinary approach to the SAP process is beneficial

Faxing or posting standard forms/letters work well.

The care plan is a useful way to communicate the OP’s needs and proposed action plan between all concerned

Role of OP care coordinator is vital to ensure adequate communication

Contact and communication protocols with the OP, care organiser, GP, community pharmacist (CP) social service should be developed prior to launch

Communication loops should be closed

The care plan should be sent to those involved as needed

3. KEY FINDINGS - Pharmacist 3. KEY FINDINGS - Pharmacist undertaking the in-depth assessmentundertaking the in-depth assessment

Primary care and community pharmacists (CP) with the specified competencies can carry out the in-depth assessment using the appropriate tool

Good communication, and organisational skills and local knowledge are essential

Further training and support is needed to fully achieve competencies

CPs need more clinical input

PCT should resource specialists OP pharmacist to carry out in-depth assessment, train and support other pharmacists

Train/support local network of pharmacists to deliver integrated Medicines management services (MMS)

4. KEY FINDINGS – in-depth Assessment 4. KEY FINDINGS – in-depth Assessment tool 1tool 1

User friendly, thorough and appropriate

Identifies OP/carers needs, determines priorities and allows development of a care plan to meet needs

Care organisers can contribute to the development of the care plan

Identified that majority of OP assessed had a form of visual limb or memory impairment or swallowing difficulties and complex social needs

OP’s home is an ideal place to conduct assessment

Assessor must have skills to reflect on assessment to ensure that care plan will help to meet identified needs

Care packages must be developed to provide practical solutions to problems

Assessments must be carried out in suitable environments, not in the dispensary

4. KEY FINDINGS – In-depth Assessment 4. KEY FINDINGS – In-depth Assessment tool 2tool 2

OP relied heavily on good will of care organisers

No adequate backup systems in place if unavailablerisk

Majority not taking medicines at all or as prescribed

Gap in knowledge of why and what medication is fornon compliance

Medication issues identified in all areas highlighted in OP NSF medicines document

Support CPs to provide backup systems to reduce risk

Develop local systems for regular medication review

Develop systems for CPs to regularly monitor OP knowledge and compliance with medication

5. KEY FINDINGS - Community 5. KEY FINDINGS - Community pharmacists providing packages of pharmacists providing packages of

carecare Care package can be

developed from care plan Assessing pharmacist

liasing with CP to develop care package works well

Most OP had a good relationship with a local CP and preferred to use their services

CPs were already providing a certain level of MMS

Variation in structure and reimbursement

Minimal training required for CP to provide care package

Vulnerable OP with a package of care OP advised to register with a local CP

PCTs to ensure there are protocols to ensure MMS are delivered to appropriate standards

PCTs to explore innovative approaches to ensure capacity within community pharmacy to deliver care packages

6. KEY FINDINGS - Indentifying unmet 6. KEY FINDINGS - Indentifying unmet needs and better outcomes for OPneeds and better outcomes for OP

Identified met and unmet pharmaceutical care needs in the 4 areas

Analysis of assessments and evaluation show benefits to OP- supported services, better understanding of their medicines, informed decision making, feeling respected, improved prescribing

Partnership with OP and their carers and among professionals

Further evaluation of outcomes for OP

Systems for more effective sharing of this information among health and social care

RECOMMENDATIONS - Training RECOMMENDATIONS - Training

Develop multidisciplinary training packages to enable

PCT to secure funding to support care packages, understand

the value of MMS and risk of not providing MMS

PCTs develop protocols for good communication systems

between OP and those involved in their care

OP to access/engage in new services and work in partnership

with health and social care personnel

Care organisers to know where and how to get help, access

medicines information and resolve simple medicine problems

Social services and voluntary organisations to realise the cost

effectiveness of domicillary care, role of pharmacists in

medicines management and understand the health system

RECOMMENDATIONS - TrainingRECOMMENDATIONS - Training

Develop multidisciplinary training packages to enable

SAP assessors to understand the principles behind the 4Qs to identify OP with pharmaceutical needs and the role of pharmacists in medicines management

CP to identify unmet needs, access expert support, time management, access funding for new service, understand local support networks for OP

Specialist pharmacist to reflect on assessment and identify own needs to meet competencies

GPs to realise benefit of team working, understand MMS and how to access

RECOMMENDATIONS- Next stepsRECOMMENDATIONS- Next steps

Propose a model of spread and sustainability that would fit into existing local medicines management initiatives

Explore options and support the 3 sites with roll out strategy engage key people in PCTs and social services responsible for

implementing OP services Disseminate learning across London through the London Older

People pharmacy network (OPnet) along with other networks and organisations

Gather the views of older people, carers and key individuals Carry out an evaluation to measure outcomes for OP Develop a communication strategy to ensure that the findings

and learning from the project are disseminated to the relevant individuals and organisations identified

Write full report by November 2003 (include outcomes for OP)

RECOMMENDATIONS- The FutureRECOMMENDATIONS- The Future

Validate 4Qs

Validate pharmacist competencies framework

Accreditation for SAP assessors and in-depth

assessors

Electronic assessments

Link with new pharmacy contract, LPS, repeat

dispensing

Full integration of pharmacy into SAP