a domiciliary medication review service – ‘mesh’ su wood – prescribing support services...
TRANSCRIPT
A domiciliary medication review service – ‘MESH’Su Wood – Prescribing Support Services
Aim to:
Understand what the Bradford MESH service is Know how the referral system was developed Understand the service delivery Know the impact the service has had and the economic
benefit to the NHSLook at a domiciliary medication review service in
relation to the NHS England pilot scheme
Plan
Overview of the current pharmacist led MESH service Challenges in running the service Opportunities for MESH service development National context MESH: supporting the CCG objectives/vision Group discussion Feedback and Q&A Summary
What is the problem?
What happens to a prescription once it has been issued?
Who knows?An unmet need
What is the problem?
A typical case
Excess medicines found in a home
Included
- 58 insulin pens,
- 15 boxes test strips & 17 boxes lancets
- 34 bottles of Sno tears (many half used or out of date),
- 9 Seretide 125 inhalers & 10 Ventolin inhalers
What is the problem?
50% of patients with chronic diseases in the developed world are non-adherent.
The magnitude and gravity of non-adherence is such that greater worldwide health benefit could be gained through improving adherence to current medicines than developing novel treatments.
The consequences are waste, morbidity and hospital admissions.
World Health Organisation. adherence to long term therapies. evidence for action. Geneva: WHO; 2003
What is the problem?
So that could mean for 50% of prescriptions:Likelihood of clinical benefit reducedRisk of harm increasedHigh cost for the NHS
How can a pharmacist in primary care help?
Who are we?
Prescribing Support Services: a multidisciplinary team providing a range of medicines management and optimisation services in primary care
‘MESH’ – MEdicines Support at Home – care home and domiciliary medication review.
Domiciliary review service model
Referral from GP, integrated care , Social service.
BRI. Virtual ward or community
service providers 10 or more
meds, high risk
medicines or multi morbidity
Computer based level 3
medication review
Identification of key priorities
Arrange face to face review
Undertake domiciliary or
care home review
Complete action plan including
holistic interventions ..liaison with
specialist nursing teams, social
services, primary care, family & carers
Follow up key actions :
engagement with service providersFocus on patient
safety /admissions avoidance
DISCHARGE
REFERRAL
High quality medication review delivered by experienced clinical pharmacists To comprehensively review complex polypharmacy patients
To support prescribers with deprescribing agenda
To review a patient’s medicines holistically addressing and discovering:
Why and when medicines were started
Clinical issues – interactions, doses, monitoring, approprtieness of tx, untreated indications
Adherence issues – unintentional/intentional? Understanding patients health beliefs/attitudes towards medicines
Ordering, supply and waste reduction of medicines
To ensure the medication reviews are informed by current policy and guidance on medicines – MHRA/NICE/Safety alerts
To enable clinical priorities to be addressed, such as antipsychotics in dementia, reducing anticholinergic burden, inhaler issues, “Dosette” box issues
Outcomes – dependent on resource put in Bradford Districts
CCGBradford City CCG
population 330,115 118,567
Pharmacist resource 1.6FTE 1.4FTE
Net annualised savings
£150,000 £140,000
Number of dom reviews
772 957
Adherence issues 36% 32%
Reducing risk of harm
544 tests ordered30 antipsychotics in dementia stopped58 sedatives stopped/ reduced76 anticholinergic burden reduced12 NSAIDs stopped/ reduced
550 tests ordered16 antipsychotics in dementia stopped42 sedatives stopped/ reduced255 anticholinergic burden reduced29 NSAIDs stopped/ reduced
Cost savingDependent on the resource put inAnnualised drug cost saving reportedNot reported savings on
- Reduced hospital admissions
- GP time
- Nurse time
- Social care time
- Carer burden
Recurring themes - inhalers Example – ‘Approx 5-6 inhalers in use including Flixotide 125mcg, Seretide
125/25, Clenil 200mcg, Salamol 100mcg & Ventolin 100mcg mdi using 1 puff, four times a day of each inhaler.’
Photo ‘excess’ inhalers – lost clinical benefit and waste value £1,400
140/191(70%) technique corrected, 37/191(20%) inhaler device changed
How the MESH pharmacists are tackling this- Informing GPs or respiratory nurses of non-adherance
- Educating patients on inhaler technique
- Providing written instructions to aid memory
- Follow up visits to check corrections are being maintained
- Involving relatives and formal or/informal carers in supporting patients
Recurring themes – ‘Dosette Box’ issues
Photo: multiple boxes in the home with only the odd dose taken out of any of them
How MESH pharmacists are tackling this- Ensuring that an ‘MDS’ is appropriate and the best way to help the patient manage their medicines
- Using the medication review as an opportunity to rationalise medications and
implementing deprescribing where appropriate
- Making links with community pharmacy, social care and GP surgeries to ensure good
communication around medication issues
- Practices now encouraged to ask the MESH pharmacist to review before starting a
Dosette box where capacity allows
Recurring themes – ‘Waste’ - Excess medications in patient’s own home
£58,000 of excess meds found last year How MESH pharmacists are tackling this- Patient/family/carer education when excess medicines removed.
- Working with patients to run down stocks and implementing a system
for evaluating if more medicines are needed.
- Removing items from or adding messages to repeat templates indicating excess stock and date item next needs to be ordered.
- PSS waste poster being developed to put up in GP surgeries/pharmacies.
- MESH pharmacists’ contact details supplied to community pharmacists and GP receptionists if they identify medication over-ordering or potential hoarding
Stakeholder feedback
Patient:
“It’s much easier now only taking things once a day, I get them all out of the way in the morning and I haven’t forgotten once”
“The reminder chart really helps and it’s handy on the fireplace”GP
“Excellent job. Now why did we not acquire your services a long time ago. Carry on good work.”
Challenges in setting up this service: workforceExperienced clinical pharmacistsClinical training and experience essentialCommunication with patients/ carers and other
HCPsTeam workLone workingAdequate resourceGovernanceSafeguarding
Challenges: how do we find patients?GP practice – known patients, searches (e.g. ≥ 65yrs, 10
or more meds, inhalers, housebound)Referrals (S1 task and email to MESH pharmacist) are
received from:• GP• Integrated care service• Community pharmacists• Social services – assessment team• Social services – provider team• Hospital – BRI• Home for Hospital• Virtual ward• Pulmonary rehab• Physio/ OT
Challenges: multi-disciplinary communicationIn the review process, MESH pharmacists work with:
• Patients• Relatives/carers• Community pharmacists• District nurses• Heart failure nurses• Social services – assessment team• Social services – provider team• Hospital ward staff• Hospital consultants• Hospital medical secretaries• Respiratory• Elderly care discharge• Virtual ward• Interface
Challenges: KPIsData collection: cost saving and clinical
parameters, error reporting and patient ‘stories’Reporting: quarterlyClinical benefit outcomes: risk reduction markers,
patient storiesCost saving outcomes: annualised drug cost savingPatient and NHS stakeholder feedback
Challenges going forward
‘Over 85 population in Bradford has grown by 17% and will grow by 44% in the next 5 years’ – inevitable increase in polypharmacy patients
Increased resource needed for equity to all practices, to manage increased referrals from primary care, to manage increased in-reach/ out-reach requirements from secondary care.
Integrated care groups – aiming to a greater presencePolypharmacy and de-prescribing agenda
Fits with national context
Focus on integrated careAdmissions avoidancePolypharmacy and de-prescribing agendaNICE guidance on medicines optimisation
MESH supporting the CCG agenda
Frail elderlyPatient-centred careSelf-careIntegrated careAdmissions avoidancePolypharmacy and de-prescribing
Discussion in groups
What experience is there is the group, if any, of this type of service?
How do you see a domiciliary medication review service in your area?
What are the challenges to setting up a domiciliary medication review service in your area?
How would a domiciliary medication review service be good for a General Practice Pilot Site?
Summary – domiciliary review for the pilot scheme
Improve medicines safetyImprove patient outcomesImprove management of long term conditionsReduce GP workloadImprove communication between pharmacists, GP
practices, social care etcIncrease patient confidence in pharmacistsIncreasing roles of practice pharmacists
Summary – why you need to have a domiciliary medication review service
There is an unmet need
There is no point in prescribing
and issuing medicines if they are not
taken, both clinically and financially