Developing a Regional Medicines Optimisation Model for Older People in

Care Homes: The Journey

Hilary McKee

Consultant Pharmacist

Northern Health and Social Care Trust

There are 2,000 attendances per year at Antrim Hospital Emergency Department from Nursing Homes

There is evidence that intervention in care homes reduces hospitalisation

Medicines optimisation improves patient quality of life.

Nationally it is estimated that around 5% of hospital admissions are due to adverse drug reaction (ADR)

Background

Background

• American researchers tested a programme called Interventions to Reduce Acute Care Transfers (INTERACT 11)

• This programme comprises three main aspects;• Identifying, assessing, and managing conditions to prevent

them from becoming severe enough to require hospitalisation,

• Managing selected conditions, such as respiratory and urinary tract infections

• Developing palliative care plans as an alternative to acute hospitalisation.

Difficulties of Prescribing in the Older Person

• Demographic trends are shifting towards an increased number of older people in the population

• Global Projections estimate 392 million people over 80 years in 2050, 830 million in 2100

Difficulties of Prescribing in the Older person

Age related changes in pharmacokinetics and pharmacodynamics cause increased sensitivity to the side-effects of drugs and increased unpredictability of how a patient will respond to that drug

Lack of clinical trials means poor evidence base for clinical decision making

Difficulties of Prescribing in the Older Person

• With age comes more chronic conditions, more medicines (polypharmacy)

• Specialists can follow a “single disease approach” to prescribing

• Adverse drug reactions misinterpreted as symptoms requiring treatment resulting in a “prescribing cascade”

Difficulties of Prescribing in the Older Person

• Polypharmacy linked to potentially inappropriate prescribing

Difficulties of Prescribing in the Older Person

Can result in increased drug reactions, increased drug interactions, increased falls, increased hip fractures, increased hospital admissions, increased length of stay in hospital, increased readmission rates, increased mortality

Project began in 2012

• Two Consultant Pharmacist posts established in Elderly Care in two trusts.

• Northern Trust…. Care Homes

• Western Trust….. Intermediate CAre

Aims of the outreach clinics

• The service was developed to support nursing and residential homes in their management of residents with complex needs, and to reduce dependence on secondary care services where possible.

• Series of weekly clinics held in the home by a Consultant Geriatrician and Consultant Pharmacist, reviewing the management, medication and care planning of residents.

• A number of homes also have visits from Consultant Pharmacist only.

Practicalities

• Initial meeting with Nursing Home managers and senior staff, Consultant Geriatrician and Pharmacist to outline aims of the clinics

• Identified patients’ GPs and sent letters outlining the project

• Informed relatives and gave opt out clause

• Commenced weekly clinics – 6 patients per clinic

• Each patient was discussed with the Senior Nurse involved in their care, outlining medical, functional and behavioural problems

• Patients were examined where appropriate

• Medications were reviewed

• Recommendations were made and communicated to GP by letter and if urgent, by fax.

Number of medications per patient

• No patients on no medication

• Very few patients on less than 5 medications

• Most patients on 10 - 15 medications

• Considerable number on 16- 23 medications

Initial considerations

• Some of the general things we need to consider are:

• How long they have been a resident, type of unit they are in, age, medical history, recent problems, recurrent problems, recent GP call outs, OOH call outs, attendances at ED, admissions, mobility, falls risk, bowels, continence, weight, eating and drinking habits, sleeping habits, mood, excessive drowsiness, overall health, recent bloods, recent obs.

Kardex considerations

• When looking at the kardex we need to consider:

• Does each drug have an evidence based clinical indication?

• Does the benefit of each medicine outweigh the risk?

• Is dose and frequency correct?

• Is kardex clear?

Kardex considerations

• Is there any drug class duplication e.g. two concurrent NSAIDs, loop diuretics, ACE inhibitors, anticoagulants?

• Are there any drugs prescribed that are known to predictably increase the risk of falls e.g. benzodiazepines, antipsychotics, vasodilator drugs known to cause hypotension such as alpha blockers, calcium channel blockers, long acting nitrates, ACEIs, ARBs or hypnotics such as zopiclone, zolpidem, zaleplon?

Kardex considerations

• Is there a drug or dose prescribed which is potentially inappropriate for older patients with acute or chronic renal impairment

• Is there a drug prescribed that is unsuitable based on other blood results or obs?

• Are there any drug – drug interactions?

• Are there any adverse drug reactions?

• Are there many anticholinergic drugs?

• Is the drug form suitable for the patient?

• Is the patient compliant?

What is being prescribed?

• Analgesia

• Laxatives

• Antidepressants

• Proton pump inhibitors

• Nutritional products

• Night sedation

• Dementia drugs

• Bone protection

What changes were made?

Total number of patients seen 727

Medications stopped 1165

Medications started 202

Blood tests requested 300

Information requests 27

Dose adjustments 1301

Product changes 92

In sixteen nursing homes

• Reviewed 727patients

• Made 2134 interventions

• Many kardex amendments

• Onward referrals e.g. community OT, Physio

Types of Intervention made

• Stop bone protection when patient becomes immobile

• Strontium - risk of DVT in immobility

• Iron, folic acid, thiamine - may not always be necessary when patient is on reasonable diet

• Iron will contribute to constipation

• PPIs - use lowest dose - associated with C.diff

• UTIs - ask GP to consider prophylaxis

• Poor inhaler technique - change to nebules

• Adjust insulin levels for better control

• Switch anti-depressants - taper and cross over in some instances

• Increase pain relief

• IV antibiotics ordered

• Commence anti-epileptic drug in patient with re-current seizures

Education

• “Wrap-up” meeting at end of visits

• Analysis of prescribing patterns in that home

• Educational needs of nursing staff identified.

• Presentations made to staff at a later date;

• “Kardex writing”

• “Medications and peg tubes”

• “Medications and food”

• “Wound Care”

• Nursing colleagues now becoming involved.

Meanwhile, back at the ranch….

• Hospital admissions from nursing homes are analysed by elderly care pharmacist.

• Development of consultant pharmacist case load of patients who are followed up on discharge back to the nursing home.

• Monitor admission rates from the homes we have been involved with.

• Emergency department attendances by nursing home residents are examined.

• Falls clinic being established

Did we reduce admissions?

Decrease in admissions

• A conservative estimate of preventing two admissions per month via outreach clinic review from each of 12 homes (i.e. one home review per month) could realise annual savings in the range of £61k - 104k. This represents a potential percentage reduction of 14.4% in admissions to NHSCTs secondary care from nursing homes (based on 2000 annual admissions )

Drug cost savings

• Drug costing prior to and after the outreach clinics yielded projected annual cost savings of £299 per patient.

• Total drug cost savings for the two year project were therefore estimated at £212,900

Conclusions

• Outreach clinics well received by nursing home staff and GPs alike

• Improved medicines management with improved medicines appropriateness

• Reduced hospital admissions? Admissions are multifactorial.

• Estimated drug cost saving of around £213k in the sixteen homes presented.

• Consultant Pharmacist remains the link between the nursing home and hospital

The next steps

• Was this data reproducible?...Nursing home model was replicated in Western trust using Band 8a pharmacist under guidance of consultant pharmacist

• On going to new nursing homes in Northern trust and revist homes previously covered…aim to decide optimum time interval between reviews

• Intermediate Care Model replicated in Northern Trust

• Aim was for eventual regional roll out of the model.

Many awards, poster presentations, publication

• Chairmans Quality Award in Northern Trust

• Runner up in Pharmaceutical Care Awards, 2015

• Hospital Pharmacy Team of the Year

• Abbvie Patients as Partners Awards 2017

• Presented at many conferences… BGS, FIP, Pharmacy Management, Pharmacy North-South Conference, ICIC conference

Publication

• European Journal for Person Centered Healthcare 2016 Vol 4

Issue 4 pp 650-655 650

• Nursing Home Outreach Clinics

show an improvement in patient

safety and reduction in hospital

admi

Current Position in Northern Ireland

Five Trusts

Five Consultant Pharmacists

Three 8A Pharmacists in each trust

Pharmacy technician in each trust

Collaboration with Nursing Staff “In reach project”

Three workstreams

• Nursing Home Clinics

• Intermediate Care

• Medicines Adherence

Other innovations in elderly care

• Case management of nursing home patients admitted to hospital and follow up if required on discharge

• Education for nursing home staff… ECHO programme etc

• Parkinsons medications…get it on time

Thank you for listening..any questions?