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Pharmacists can help reduce avoidable hospital admissions in the community

The inclusion of a pharmacist as part of an integrated care model of health and social care professionals could help prevent avoidable hospital admission. Gemma Dowell explains

By Gemma Dowell

The inclusion of a pharmacist as part of an integrated care model of health and social care professionals could help prevent avoidable hospital admission. Gemma Dowell explains

We know that the frail, elderly and those with complex needs go into hospital unnecessarily most often. We also know that people living with one or more long-term conditions who would be better supported in their own homes in the local community are too often admitted to hospital.

In order to make the community the default safe place of care, supported by high quality hospital services, an integrated way of working is being commissioned by the Coastal West Sussex Clinical Commissioning Group — entitled “proactive care”.

This involves multidisciplinary teams (MDTs) of health and social care professionals working to ensure a seamless and integrated approach to community care, treating patients as a whole person and not just a symptom.

Within this model of care, which is based on the successful “Torbay model” (one of the first areas in England to use a successful model of integrated care and the subject of a paper commissioned by the King’s Fund1), an innovative pilot has been conducted within Coastal West Sussex to build on this further and demonstrate the added value that clinical pharmacists can bring to avoiding potential medicines-related adverse events and admissions to hospital, and, ultimately, improving patient care.

Although the current literature demonstrated reductions in prescribing costs when pharmacists have undertaken clinical medication reviews, the additional benefits and the benefits within this model of care were unproven.

Consequently, I designed, implemented and closely managed a six-month, pharmacist-led pilot with the aim of proving that not only would pharmacist inclusion within a proactive care MDT be cost-effective, but it would also deliver numerous additional qualitative benefits.

Pilot

During the pilot, a pharmacist worked with a proactive care MDT, covering four surgeries (approximately 30,000 registered patients), including social workers, physiotherapists, occupational therapists, a team co-ordinator, community matrons and GPs, for one day each week.

In addition to undertaking domiciliary clinical medication reviews for patients referred by colleagues, time was also spent identifying patients with known risk factors for medicines-related admissions2 through specifically designed searches built into the GP practice clinical system.

This ensured that patients most likely to benefit from a review — using the skills and expertise of a clinical pharmacist to optimise their medicines — were targeted.

Furthermore, participation in meetings to discuss the holistic management of patients suitable for proactive care proved beneficial. During the pilot, estimated savings of £14,000 over and above the cost of providing the service were achieved (based on a total of 31 reviews being undertaken and 98 recommendations being implemented).

In fact, the costs were covered by the reduction in prescribing costs alone and additional savings came from potentially avoided hospital admissions attributed to the proactive care pharmacist’s interventions. This was determined by using risk-scoring methodology from the National Patient Safety Agency based on the likelihood and potential consequence of patient harm (see Panel 1). All scores were validated by a senior pharmacist and the GP clinical lead for proactive care.

Panel 1: Risk Score

How to risk score:

  1. Consider each of the scenarios presented
  2. Identify the worst consequence that could occur as a result and assign a score between (and including) 1 and 5, relating to the effect that this consequence could have on the patient (5=catastrophic — includes death or severe disability; 4=major — usually results in hospital admission; 3=moderate — moderate impact on the patient but does not require hospital admission; 2=minor — minor impact on the patient; 1=negligible — negligible impact on the patient).
  3. Thinking about the likelihood of this consequence occurring, assign a likelihood score between (and including) 1 and 5 relating to how likely it is that this consequence will happen to the patient in this scenario (1=rare; 2=unlikely; 3=possible; 4=likely; 5=almost certain).
  4. Using the consequence and likelihood scores, refer to the National Patient Safety Agency table (available at www.npsa.nhs.uk in the NPSA document “A risk matrix for risk managers”) and find where these two scores intersect. This is the total risk score for this scenario. Make a note of this.
  5. For any scores that are red (between and including 15 to 25), would a pharmacist’s intervention reduce this score to <15? Mark “yes” or “no” for each.

 

Findings

By extrapolating the results from the pilot, we can estimate that annual savings of £364,000 could be achieved across the CCG to be reinvested in additional high quality healthcare for local patients. This is likely to be an underestimate because a significant period during the pilot was initially spent building relationships and maximising engagement with local prescribers to ensure that recommendations were respected, valued and, most importantly, implemented in order to achieve the required outcome for patients.

Benefits

After this initial investment in effective relationship and change management, feedback from local prescribers, practice managers, and health and social care professionals working within the proactive care pioneer site practices has continued to be extremely positive and has highlighted that the service is meeting a previously unmet need for the local population. This is further reflected by the direct referrals to the proactive care pharmacist that are now being received from local prescribers.

Examples of some high-risk clinical issues identified and resolved by the proactive care pharmacist included:

  • A patient with a diagnosis of dementia was prescribed an antipsychotic, which was not clinically indicated. The Medicines and Healthcare products Regulatory Agency has concluded that there is a clear increased risk of stroke and a small increased risk of death when any antipsychotic is used by elderly people with dementia.
  • A patient was prescribed three different preparations of calcium or calcium and vitamin D on repeat prescription (as Fultium D3, Adcal D3 and Calcium carbonate 1.5g + colecalciferol 10µg). Too much calcium and vitamin D can cause nausea, mild cognitive impairment, kidney stones, disturbances in heart rhythm, inflammation of the pancreas and coma.
  • Metformin was prescribed at a dose too high in relation to a patient’s kidney function. This can be associated with lactic acidosis, a rare but serious metabolic complication, which can result in disturbances of heart rhythm, multiorgan failure and death. This is more common in patients with impaired kidney function because the drug is excreted renally.
  • Despite a repeat prescription for warfarin being issued and dispensed each month, a patient was identified as not having attended the clinic for relevant monitoring and had a low international normalised ratio result, putting her at risk of a blood clot.
  • A patient, having had a “mini-stroke”, was not prescribed modified-release dipyridamole and aspirin when this was clinically indicated. People who have had one event like this are at an increased risk of another or more serious stroke and these drugs are known to reduce the risk of this occurring.
  • A patient was prescribed the wrong drug: a tiotropium Respimat device was prescribed instead of a glyceryl trinitrate spray for exercise-induced angina.
  • Patients were prescribed medicines that put them at an increased risk of falls, including one elderly patient prescribed four different antihypertensives even though the recorded blood pressure was 120/52mmHg.
  • A patient had difficulty swallowing alendronic acid and was at risk of severe oesophageal reactions (including inflammation, ulcers and erosions) because he or she was struggling to comply with the special instructions for taking this medicine.

In addition to the estimated reductions in costs and medicines-related hospital admissions, numerous other benefits of the service have been demonstrated, including:

  • Waste reduction
  • Medicines optimisation and a reduction in polypharmacy
  • Reduction in the likelihood and consequences of patient harm
  • Resolution of discrepancies on discharge from hospital
  • Promotion of the self-management of long-term conditions
  • Providing an accessible source of advice for the proactive care team
  • Improved communication with community pharmacists
  • Improved patient concordance with prescribed treatments
  • Provision of education for GPs around medicines

Lessons and themes

Panel 2 lists the breakdown of pharmacist interventions made. Lessons and themes identified from pharmaceutical interventions made as part of this work are also being used to inform local guidance on optimising medicines, including stopping medicines that are no longer effective or are causing side effects, or where the benefits no longer outweigh the risks.

Panel 2: Interventions

Below is a breakdown of pharmacist interventions made:

  • Drug no longer indicated, stopped or changed because of a safety risk (42 per cent)
  • Non-compliance identified (21 per cent)
  • Stockpiled drugs returned to a pharmacy for destruction (18 per cent)
  • Excessive quantity on repeat prescription for patient’s needs (6 per cent)
  • Preventive drug not prescribed in line with national guidance (4 per cent)
  • Doses of medicines missed because not aligned with daily carer visits (4 per cent)
  • Patient prescribed wrong drug (2 per cent)
  • Concerns raised about potential abuse of Controlled Drugs (1 per cent)
  • Incorrect monitoring (1 per cent)

 

The exciting potential to demonstrate the benefits of medicines optimisation in this context has resulted in a commitment that a dedicated clinical pharmacist would be included as a core member of each MDT, rolled out in line with the wider proactive care programme within Coastal West Sussex CCG in order to meet the needs of local patients.

This pilot has demonstrated the significant benefits that a clinical pharmacist can bring to an MDT of health and social care professionals as part of an integrated model of care, working together to improve patient outcomes from their medicines.

Gemma Dowell, MPharm, PGDipPrescStudies, was a pharmaceutical adviser for Coastal West Sussex Clinical Commissioning Group.

References

  1. Thistlethwaite P. Integrating health and social care in Torbay: Improving care for Mrs Smith. March 2011. The King’s Fund. Available at: www.kingsfund.org.uk (accessed 19?August 2013).
  2. NHS Scotland and the Scottish Government. Polypharmacy guidance. Version 2. October 2012. Available at: www.central.knowledge.scot.nhs.uk. (accessed 19 August 2013).

Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2013.11128324

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