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Pharmacists offer a clinical service to vulnerable care home residents

NICE advice about medicines in care homes was due to be published as The Journal went to press. Debbie Andalo looks at how pharmacists currently support residents

Pharmacists in west Leeds are reducing waste and improving disease management in care home patients as part of a £107,000 pharmacist-led project.

Helen Whiteside, who has a background in hospital pharmacy and care of the elderly, is one of three pharmacists employed by Leeds West Clinical Commissioning Group as part of the clinical care home pharmacists project. The initiative was launched in August and runs until July this year when it is expected to be continued or expanded depending on the results of its evaluation.

Ms Whiteside is confident that it will become a permanent fixture: “I am 100 per cent sure that it will continue because it has already proven to be such a success. I think there is now national recognition that medicines management needs to be in place in care homes. Guidelines from [the National Institute for Health and Care Excellence] about managing medicines in care homes are due out this month and people are going to have to be in place to help and support that happening,” she says.  

The three pharmacists are responsible for managing the medicines of patients in 1,700 beds in 100 residential, nursing or learning disability homes in the west of the city. The patients are registered with 38 local practices. The pharmacists are systematically working with the practices to identify those patients living in a care home. Seven months into the project they are about half way through.

The pharmacists are given electronic access to patients’ records and carry out a medicines review. “Our role is to reassess whether they still need the medicines, what symptoms they have and what illnesses they have now. Then we consider the dose they need after looking at their test results. It’s a risks and benefits assessment where we consider all the evidence about their medicines,” explains Ms Whiteside.

A pharmacist will then visit patients in their care homes and review their medicines admissions records and allergy status. All their findings are talked through, either with the residents or their carers. The pharmacist then discusses the results of their review and their recommendations with the patients’ GPs. “It really is a one-stop medicines service to optimise the use of their medicines at their time of life,” says Ms Whiteside.

Any changes are also discussed with the care home and the local community pharmacist. In addition, the pharmacy team has links to the local elderly care consultants and hospital pharmacists at Leeds Teaching Hospitals NHS Trust in a bid to spread best practice in medicines management for this vulnerable group of patients.

Ms Whiteside says it is not unusual to find older frail people living in care homes who are prescribed nine medicines a day. This means that some residents, often in their 90s, could be taking as many as 30 tablets or more every day. “It’s very complex and these numbers are just averages,” she says.

It is hoped that the project will not only reduce the number of inappropriate drugs being given to older people in care homes but also help improve the medicines management skills of those who are caring for them. Ms Whiteside explains: “Improving the skills and knowledge of carers is a side line. It’s opportunistic. The main purpose of the scheme is around reviewing people’s medicines but we also give advice on anything that we pick up on, such as skin care and the best creams to use to prevent residents getting contact dermatitis.”

Ms Whiteside says the focus of the project is not to save money; often any money saved by reducing medicines wastage is reinvested in the use of preventive medicines or changing formulation.

An analysis of the project’s first two months shows the pharmacists are already making a difference. The management of dementia, depression, cardiovascular disease, pain and constipation have all been improved following a medicines review, according to the CCG. Medicines and other product waste has also been reduced, especially the use of painkillers, laxatives, topical preparations, lancets and test strips, and inhalers and nebulisers, it adds. 

The risk of falls has gone down because of improved medicines monitoring and management, and there has also been a reduction in the use of “inappropriate polypharmacy”.

Ms Whiteside is confident that the model being developed in west Leeds could be copied elsewhere. “Definitely. It’s very straight forward — it’s about having somebody in place who can consistently take the same review of all medicines.

“Most people who are resident in a home … end up being prescribed medicines by an increasing number of different prescribers. What is often lacking is having somebody who has an overview of all a person’s medicines and who can give that perspective.” 

Pharmacists in Leeds are not the only ones tackling the issue of medicines management in care homes. Others in Northumberland and North Tyneside are also taking a lead.

Research and development pharmacist Wasim Baqir, at Northumbria Healthcare NHS Foundation Trust, is involved in a project designed to involve care home residents, and their families and carers, in prescribing decisions as part of a medicines management scheme.

The project involves 15 care homes and 400 patients and their families within the district covered by North Tyneside CCG.

A team of four pharmacists — who are also prescribers — review the patients’ medication records and carry out medicines reviews. They consider issues such as whether a medicine is still performing a function and whether it is still appropriate when other co-morbidities are taken into account. Medication safety is also addressed as well as whether there are other medicines that the patient should be taking or if there are any non-pharmacological alternatives. 

The pharmacist’s recommendations are taken to a multidisciplinary team meeting, which includes an old age psychiatric consultant, GP and nurses from the care home. Significantly the patient — or the patient’s relatives or carers — is also invited to attend so he or she can contribute to the final decision about medication. If the patient or carers are unable to attend then they are asked by letter for any comments.

Any medication changes are then regularly reviewed and the care home nurses are encouraged to inform the pharmacist of any adverse events. 
Dr Baqir says the project’s main purpose is to increase the involvement of care home residents in decisions about their medicines and challenge traditional thinking.

“In a care home, residents don’t have the luxury of intentional non-adherence, which they would do if they still lived at home. One of the criticisms made is that you would never get care home patients involved in decisions about their medicines because of the type of patients that they are.

“But what we have found is that 17 per cent of the patients involved in the project did have the capacity to make decisions and up to 50 per cent of families wanted to be involved. So we can’t say that these patients are too old or too frail [to be involved in decision-making]. Many may lack the capacity but their families want to be involved — they like to be asked.”

It is also important, according to Dr Baqir, that the pharmacists involved in the project are prescribers, which means they can act autonomously in making decisions about medicines without having to go back to a patient’s GP for approval. “It’s about using that skill mix properly,” he says.

Early results from the project show that this way of managing care home medicines can save money. The volume of prescribed medicines has fallen by 15 per cent and there has been a net saving of £62,000 on the drugs budget.

Nurse time has also been saved, according to Dr Baqir. “Nurses tell me that it can sometimes take 15 to 20 minutes to administer one tablet, so just reducing one tablet for one patient can save them time.”

Both the Leeds and Northumbria pharmacists have been involved in helping to shape the NICE good practice guidance on medicines management in care homes so it is possible that both models could be adopted more widely in the future.

Dr Baqir says: “I was part of the NICE development group so hopefully what we are doing is what NICE wants.” 

But whatever NICE recommends, the Northumbria model is already on the way to being copied elsewhere. Last month it was named winner of the personalisation of care category in the national Patient Experience Network awards. The project is also part of the Health Foundation’s Shine 2012 national programme, which supports innovation in healthcare aimed at improving quality of care.

Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2014.11135788

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