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Take on MR?MOP and clean up medicines use in care homes

By Jayesh Shah, DipClinPharm, MRPharmS, Priti Shah, BPharm, MRPharmS, and Ulrike Lukas

Monkey Business Images/Dreamstime.comOur population is ageing and more and more older people are entering residential or nursing homes for care. In January 2010, the Department of Health issued an alert in response to the “Care homes use of medicines study”, asking primary care organisations to review the safety of local prescribing, dispensing, administration and medication monitoring arrangements for older people in care homes.

At that time, NHS Surrey already had a care homes project underway, which had begun in November 2008. That project stemmed from the recognition that many of our 9,000 care home residents (including children and adults with learning difficulties or disabilities, as well as older people) had complex medical issues and were receiving a large number of medicines. The project — known as “MR MOP” (explained below) — had two key outcomes:

  • To ensure that a clinical medication review (MR) is undertaken for each patient and to discuss the outcome with his or her GP
  • To improve the medicines ordering process (MOP), by ensuring that all stages of the process are performed in an efficient and timely way, and to minimise waste.


To do this, NHS?Surrey developed a “care-homes pack” that would be used by the primary care pharmacists and pharmacy technicians in the medicines management care home team (MMCHT). The pack contained resources such as: sample letters introducing the MR?MOP?project to GP surgeries and care homes, action plans, a list of care homes, data collection forms (eg, medication review sheets), guidance on the use of specials and savings calculators.

Training

Each member of the MMCHT was  trained on the MR?MOP project.  

In workshops the aims of the project were discussed, the care-home pack was explained and participants worked through case studies. Further workshops were held on topics such as calcium and vitamin D supplementation for osteoporosis and collecting data about prescribing, dispensing and administration errors. All staff were given time to complete the “Supporting care homes” package provided by the Centre for Pharmacy Postgraduate Education.

Implementation

When they had completed training, members of the MMCHT approached GPs (either face to face or by email or letter) offering to review their care-home patients. After GPs provided written consent for patient review, the care home managers were informed and a list of residents from each care home obtained. For each resident a member of the MMCHT:

  • Undertook a clinical MR using the medical notes on the GP’s computer system and the medication record at the care home
  • Had meetings with care-home staff to review medicines management (eg, ordering processes, waste, storage)


Once the MR form was complete, a meeting was organised with the responsible GP in which the reviewed patients were discussed in detail. Any proposed changes were explained and the GP’s agreement (or lack of agreement) and any other comments were noted. Recommendations that were agreed with the GP were communicated to the care home manager and changed in the GP’s record (by the GP or a member of the MMCHT). Urgent changes were annotated on the current medication record by the pharmacist as soon as possible.

The community pharmacist who dispensed the care home’s medicines was visited next and informed of any changes. This was also an opportunity to discuss any issues the pharmacist had regarding the drug ordering process or medicines waste.

Spreading the word

We were concerned that we might encounter some resistance to our project, but most care home managers and staff welcomed us from the start. After completion of the first few MR?MOP reviews, we found that word of the project had spread — care-home managers, nursing staff and GPs welcomed our reviews. We were careful to explain that our aim was not to criticise the current systems, but to provide advice and recommendations that would help the care homes provide high-quality care, which would be of benefit when they were assessed by the Care Quality Commission.

Data collection

In January 2010 we developed a system to collate and code the clinical interventions made by the MMCHT. Interventions are initially coded for their type (eg, a pharmaceutical intervention, recommendation for monitoring or referral to another healthcare professional) and significance (eg, no direct impact, significantly improves standard of care, very significant impact on patient care).

To date, a wide range of clinical interventions have been recorded. Examples include changing an expensive, unlicensed special of clobazam liquid to tablets for a patient who could swallow the tablets, and stopping bisphosphonate therapy for an elderly, bed-bound patient who was unlikely to fall and was suffering from the side effects of the medicine.

We also collect data on cost savings made during the review process (eg, through stopping medicines or changing patients to more cost-effective options). See the Box below for some data collected by the MMCHT.

Benefits

In addition to optimising medicines use and saving money, there have been other benefits, which will result in higher-quality patient care.

Improved communication

Now that primary care pharmacists and technicians are helping to link care home staff, GPs, community pharmacists and patients (or their carers), communication has improved. Also, each GP surgery has a named member of the MMCHT who they can contact to discuss medicines-related issues.

Anecdotally these arrangements have been welcomed by patients, carers, and the health and social care professionals involved. Members of the MMCHT have also helped care-home staff to improve their knowledge of medicines and of how prescriptions are processed. 

Reduced waste

Medicine supply has been synchronised so that all patients in a particular care home start their “medicine cycles” on the same day each month and all cycles last for 28 days. This has reduced the waste in several homes and substantially reduced the need for GPs to process ad hoc requests for prescriptions from care homes. We have produced a “mid-cycle medication calculator” that can be used if a medicine is started mid-cycle, to work out the quantity required to last until the start of the next complete cycle.

Staff from care homes have been educated about the shelf-life of creams and liquid medicines so that, where appropriate, these items are not discarded every month. The quantity and use of “when required” medicines have been reviewed, contributing to a considerable reduction in waste.

Education has been provided to staff in care homes about ordering appropriate quantities of expensive items (such as dressings, appliances and nutritional supplements).

Networking

NHS Surrey has formed a “Care homes network group” to share and discuss ideas and new ways of working in care homes. There are currently around 40 members, including some carers. Education and training for nurses and carers is high on the agenda of this group, as is reducing medicines-related admissions to accident and emergency departments. This network has enabled the MMCHT to engage with several forums run through the Surrey Care Homes Association.

In summary

The NHS Surrey MR?MOP project has been successful in improving quality of care and reducing medicines waste in care homes. It has also improved communication between staff in care homes, GPs, community pharmacists and the primary care medicines management team.

The project has been well received and the MMCHT now takes requests from GPs and care home managers to review their residents’ medicines and deliver training to staff.

Intervention data 

The following data were collected by the medicines management care home team as part of the MR?MOP?project. Savings are attributed to reduced waste, changing medicines to more cost-effective options and stopping unnecessary medicines. The figures do not include savings made from reducing hospital admissions or use of out-of-hours services, etc.

  • Between April 2009 and March 2010, 750 patients were reviewed in 34 care homes, with £123,137 in annual recurring savings achieved
  • Between April 2010 and March 2011, 821 patients were reviewed in 32 care homes, with £81,865 annual recurring savings achieved
  • On average three recommendations or interventions were made per patient
  • Stopping a medicine accounted for 30% of interventions
  • Providing advice or improving instructions for administration accounted for 9% of interventions
  • When categorised by British National Formulary chapter, interventions were mainly for CNS medicines (24%), followed by gastrointestinal (16%) and cardiovascular (16%)
  • Depending on the care home, up to 7% of interventions were classed as “very significant” and may have prevented hospital admissions

At the time of writing, Jayesh Shah was lead primary care pharmacist and Priti Shah was a bank pharmacist, both at NHS Surrey. Ulrike Lukas is a senior pharmacy technician at NHS Surrey.
E: jayesh.shah@surreypct.nhs.uk

Citation: Clinical Pharmacist URI: 11083299

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