Integrated strategies will work best

Medicines are the second highest expenditure in the NHS and optimising the use of medicines is key to maximising resources and improving patient outcomes. To deliver this a shift is needed from cost cutting exercises alone to more transformational changes to ensure medicines optimisation in the longer term.

In Sheffield a community intermediate care service (CICS) is commissioned to maintain and promote independence and keep patients in their own homes, thus reducing admissions and allowing for quicker discharges. CICS is provided by a multidisciplinary team and its pharmacy service is valued as a specialist service that assesses, addresses and resolves medication needs for patients in intermediate care, from medicines reconciliation and clinical medication review to managing a patient to self-administration (pharmaceutical re-enablement).

Method

This evaluation was undertaken in order to assess the impact of the pharmacy service within CICS, on the following three outputs: admissions avoidance, medicines adherence and pharmaceutical reablement. The project period was three months and the pharmacy team recorded their interventions for every patient assessed (305) in this period.^[1]

This tool identifies potentially inappropriate medicines (PIMs) in older people, for example, there is an increased risk of falls with benzodiazepines. Previous research shows that 11 per cent of patients admitted to hospital had a PIM as a contributory factor to admission.^[1]

Within this evaluation, the team identified the number of PIMs patients were taking when they joined the service and the number of PIMs a patient was taking post pharmacy assessment, thus enabling an assessment of PIMs reduction.

Medicines adherence was measured through consultations with patients and identifying tools to improve adherence using specific interventions to overcome practical problems where a specific need was identified (in line with National Institute for Health and Clinical Excellence 2009 guidance on medicines adherence). It is recognised that evidence for which tools improve adherence is inconclusive.

Results

Admissions avoided Medication review by the CICS clinical pharmacists reduced PIMs by 62 per cent (190 patients had a medication review and 61 PIMS were identified, 38 of which were stopped). Since PIMs have been shown to contribute to hospital admissions their reduction should lead to a reduction in admissions. This suggests that the use of the STOPP criteria to identify PIMs by clinical pharmacists in the community could have an impact on admissions avoidance but further research is needed in this area.

Clinical interventions

Medication review resulted in significant clinical interventions, including rectifying and reporting medication errors, initiating evidence based medicines, preventing unintentional overdoses and rationalisation of analgesia.

Medicines adherence

Medicines adherence is led by pharmacy technicians, who review patients’ adherence and implement systems and strategies to improve it. Strategies included monitored dosage systems, compliance or tick charts and provision of information. Solutions were tailored to patients’ needs and 35 per cent (107/305) of patients assessed were issued with a tailored solution to improve adherence. These patients will be followed up to measure whether actual changes were achieved in their medicines use in the longer term.

Eighty-two per cent of patients (37/45) achieved their goal to be independent with medicines administration; 20 per cent of patients visited (24/117) to assess ability for self-medication resulted in a social care package not being needed (24 packages at four calls per day) or the frequency of calls being reduced — a saving of £115,000 for social services, in the project period, which equates to a potential annual saving of £460,000.

Outcomes and recommendations

The pharmacy service within CICS improves patient care and medicines safety. Its actions have consequences wider than the traditional medicines management agenda and its work has highlighted that patients whom it reviews are less likely to be on a PIM and therefore less likely to experience an adverse drug reaction or a medication-related hospital admission. It also demonstrates that patients benefit from patient counselling and goal setting techniques and the impact on the individual patient in terms of promoting independence should not be underestimated because this reduces the need for social care packages at a time when local authorities are facing even greater financial pressures than the NHS.

Strategies to work in an integrated way, crossing boundaries from acute to primary/community care and social services need to be pursued if real transformational change in relation to medicines optimisation is to be achieved.