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NHS England’s National Pharmacy lead for Care Homes explains how the Vanguards are reducing the risks of medicine-related complications and unplanned hospital admissions:
I know a woman in a care home, let’s call her Dorothy.
Dorothy is happy in her care home; she has a loving family, good care and makes her own choices. Dorothy is fully involved in decisions about her medicines and only takes what she feels is important to her at this point in her life.
Sadly, Dorothy is the exception rather than the rule when it comes to medicines use by care home residents.
Following publication of the Care Homes Use of Medicines Study (CHUMS) in 2009, a number of other high profile organisations – including NICE and The King’s Fund – have published reports highlighting the poor quality of care and risk of harm in these cases.
In short, if you live in a care home you’re likely to take multiple medicines, have little say in what medicines you are given and not have a regular, detailed review of your medicines.
Quite often residents take prescribed medicines that are no longer needed, which can impair overall quality of life, sometimes severely, and may even cause harm.
It’s not all doom and gloom; there is emerging evidence that pharmacy teams – pharmacists and pharmacy technicians – are well placed to improve medicines optimisation for care homes and their residents.
The Northumbria Shine Shine project project showed that when you undertake a patient-centred review of medicines, you not only improve quality and safety but can release healthcare resources and funding. We, and I have to declare an interest here, it was my project before I joined NHS England, managed to stop one-in-five medicines because they were either no longer indicated, unsafe or the patient made an informed decision not to take the medicine.
Learning from the six NHS England Care Home Vanguards and the Northumberland Integrated Primary and Acute Care System (PACS) Vanguard, further showed that pharmacy teams embedded within the system and integrated across social, primary and secondary organisations, can prevent hospital admissions, facilitate faster discharge, and make a big impact on safety, quality and health/ social care expenditure.
There are a number of tools and guidelines to support pharmacists, however, it ultimately comes down to asking some common sense questions:
Does the medicine have a purpose/indication? Is the medicine appropriate or safe?
Is there medicine missing that the patient could benefit from? What are the patient’s or family and carers’ views and wishes?
An action plan is then drawn up with the patient and family or carer as well as the wider multi-disciplinary team and actioned once the patient/family/carer has agreed. There’s a follow up a few weeks after the review and nurses monitor patients.
Patient involvement is key and quite often put in the ‘hard to do’ box, with clinicians giving reasons such as poor cognition and frailty. We developed a patient involvement framework:
Patients should be involved in all decisions. If this is not possible then…
The family should be fully involved. Where the family want no involvement…
A letter outlining discussions and interventions made by the team is sent to the family, with option for them to comment or reverse any changes made.
In cases where the patient has no family then advocates are asked to challenge and ask questions.
The care homes arena has also been the ideal place for pharmacy technicians to show what they are capable of achieving in the NHS. Pharmacy technicians in care homes broadly have three roles: clinical (medicines reconciliation, medicines review, patient counselling, follow up), technical (medicines waste management, supporting supply and ordering) and training (care home staff, community pharmacy, general medical practice teams).
In fact, pharmacy technicians working for the Northumberland PACS Vanguard are currently doing traditional pharmacist roles in supporting and reviewing medicines with some low-risk patients, allowing pharmacists more time to work with the more complex, frailer patients.
There is a step before all this; to make medicines optimisation work well, we need good relationships with the care homes, general practices, community pharmacy, care home/community nurses, the allied health professionals who also support the care home, and, most importantly, the resident and their family.
The key learning from our Shine project was that you could achieve more if you worked better with your local professionals and support teams. For example, in Northumberland, we created better links between experts in old age psychiatry and general practice, so decisions that ordinarily wouldn’t have been made (such as stopping ‘specialist’ medicines such as antipsychotics in dementia patients) could be openly discussed.